Ticu ^n \^c^^ (Eoluutbta llmn^rfiity in ti|f (Utty of N^m fork iAtftxtnct ICthrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practiceofmedici1903tyso THE PRACTICE OF VIEDICINE /TEXT-BOOK FOR PRACTITIONERS AND STUDENTS WITH SPECIAL REFERENCE TO DIAG- NOSIS AND TREATMENT BY JAMES TYSON, M.D. lOFESSOR OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA AND PHYSICIAN 10 THE HOSPITAL OF THE UNIVERSITY; PHYSICIAN TO THE PENNSYLVANIA HOSPITAL ; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA ; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC. THIRD EDITION THOROUGHLY REVISED AND IN -PARTS REWRITTEN lUitb 134 lillU5tration5 INCLUDING COLORED PLATES PHILADELPHIA P. BLAKISTON^S SON & CO I I 2 WALNUT STREET 1903 GIPT Copyright, 1903, by P. Blakiston's Son & Co. ^. Q^ci^-i^^AAXi^ THE MERSHON COMPANY PRESS, RAH WAY, N. J. PREFACE TO THE FIRST EDITION. I HAVE no apology to make for preparing this book. I have long con- templated it, and have finished it after several years' labor. It has taken some time, because it represents almost purely personal work, which has been frequently interrupted. It does not pretend to be based on my personal prac- tice only. In these days of specialized work this would be impossible, though with most of even the rare forms of disease in every section I have had some experience. To fill in the gaps of my own knowledge I have used that of others, but have always sought to make suitable acknowledgment to the proper source, and if this has not been done in any case, it has been a matter of oversight. I had not, at the outset, expected to illustrate the work, but, as it pro- gressed, a certain number of illustrations seemed necessary, not only to explain the text, but also, in a few instances, to render clearer the treatment described. Thus the number of charts and other drawings has grown to nearly a hundred, all of which, it is hoped, will be found useful. In expec- tation of the ultimate adoption of the metric system for the measuring of doses, these have been indicated throughout the book in the metric and Eng- lish measures. Acknowledgment is due to Dr. Joseph P. Walsh and Mr. M. A. Morin for suggestions after reading the text, to Dr. William Schleif for material assistance in Section XV, and to my son, Dr T. Mellor Tyson, for assistance throughout the work and especially in preparing the index. 1506 Spruce St., Philadelphia, October i, 1896. PREFACE TO THE THIRD EDITION. In preparing the third edition of the Text-Book of Medicine, I have sought to make its contents represent, as far as possible, the present state of modern medicine. The subject is an extensive one and it may be that some important points have escaped notice, and I will be indebted to readers who may call my attention to them. It is not easy to point out the sections in which additions and changes have been most numerous, but as the infectious diseases are those of which our knowledge is being most enlarged and modified, a good many alterations and additions will be found in the pages devoted to them. So numerous have they been in all parts that the entire book has been reset. I have again had the advantage of a careful revision of the Section on Nervous Diseases by Dr. W. G. Spiller and I believe it will be found fully abreast of the times. The subject of Dysentery has been carefully revised and partly rewritten by my colleague. Dr. Simon Flexner, whose studies on this subject have made him an acknowledged authority. I have had much valuable assistance from my son, Dr. T. Mellor Tyson, in various ways. 1506 Spruce St., Philadelphia, September, 1903. CONTENTS SECTION I. INFECTIOUS DISEASES. Typhoid Fever, . Paratyphoid Fever, Mountain Fever, Typhus Fever, Relapsing Fever, Malta Fever, The Malarial Fevers, Clinical Varieties, .... Intermittent Fever, Remittent Fever — Estivo-au- tumnal Fever, . . ■ • Pernicious Malarial Fever— The Congestive Chill, Irregular Forms of Malarial Fever, Malarial Hematuria or Hemo- globinuria o r Intermittent Hematuria — Blackwater Fever, Malarial Cachexia or Chronic Malaria, Yellow Fever, Dengue, Cholera, Dysentery, . . . - Acute Catarrhal Dysentery, Amebic or Tropical Dysentery Bacillary Dysentery, Chronic Dysentery, The Plague, . Measles, Rubella, . Scarlet Fever, Diphtheria, . Smallpox, Vaccine Disease, . Chicken-pox, Whooping-cough, Mumps, Influenza, Cerebrospinal Fever, Erysipelas, Septicemia and Pyemia, Hydrophobia, Tetanus, Anthrax, Glanders and Farcy, Actinomycosis, Foot and Mouth Disease, Milk Sickness. Syphilis, The Gonorrheal Infection, Gonorrheal Arthritis, 17 54 54 55 59 63 65 7Z 72, 76 77 78 79 79 83 90 91 104 104 109 106 113 114 118 122 124 132 145 152 156 157 161 162 167 177 181 184 190 194 197 198 200 201 202 210 210 PAGE Croupous Pneumonia, . . . 212 Bronchopneumonia, .... 228 Chronic Interstitial Pneumonia, . 22,z Embolic Pneumonia, .... 235 Embolic Non-septic Pneumonia, . 235 Embolic Septic Pneumonia, . . 237 Tuberculosis, 238 I. General Etiology and Invasion, Morbid Anatomy, . . . 238 II. Acute Tuberculosis, . . . 244 1. General or Typhoid Form, . 245 2. Pulmonary Form, . . . 247 3. Meningeal Form. Tubercu- lous Meningitis, . . . 249 III. Chronic Tuberculosis, . . 252 Pulmonary Tuberculosis, . 252 Chronic Ulcerative Phthisis, . 254 Fibroid Phthisis, . . . 265 Treatment of Tubercular Phthisis, . . . . 266 IV. Tuberculosis o f Lymphatic Glands, 279 V. General Tuberculosis of the Serous Membranes, . . . 281 Tuberculosis of the Pleura, . 281 Tuberculosis of the Perito- neum, . ... 282 VI. Tuberculosis of the Genito- urinary Organs, . . . 283 Tuberculosis of the Kidney, . 283 Tuberculosis of the Pelvis of the Kidney, Ureters, and Bladder, 284 Tuberculosis of the Ovaries, Fallopian Tubes, and Uterus, 285 Tuberculosis of the Testes, Prostate Gland, and Seminal Vesicles 285 VII. Tuberculosis of the Mam- mary Glands 286 VIII. Tuberculosis of the Heart and Blood-vessels, . . . 286 Leprosy, 287 Rheumatic Fever, .... 289 Infectious Diseases of Doubtful Na- ture ^97 Ephemeral Fever— Febricula, . . 297 Protracted Simple Continued Fe- ver 298 Weil's Disease 300 Miliary Fever 30i Glandular Fever, . . . • 302 Vlll CONTENTS. SECTION II. DISEASES OF THE DIGESTIVE SYSTEM. Diseases of the Mouth, The Coated Tongue, Dc-angement Due to Dentition, Stomatitis, .... Simple Acute Catarrhal Stoma titis Aphthous Stomatitis . . Mycotic Stomatitis. Ulcerative Stomatitis, Treatment of Different Forms of Stomatitis, .... Cancrum Oris, Glossitis, Glossitis Desiccans, . Eczema of the Tongue, . Leukoplakia Buccalis. Mucous Patches. Diseases of the Salivary Glands, Functional Derangements, Inflammation of the Salivary Glands, .... Angina Ludovici, Diseases of the Tonsils and Pharynx Quinsy, Follicular Tonsillitis, Chronic Tonsillitis and Hyper- trophy of the Adenoid Tissue of the Pharynx, Simple Circulatory Derangements of the Pharynx, Acute Catarrhal Pharyngitis, Chronic Catarrhal Pharyngitis Ulceration of the Pharynx, Phlegmonous Pharyngitis, Postpharyngeal Abscess, Diseases of the Esophagus, Exploration of the Esophagus with ;he Bougie, Esophagitis, Spasm of the Esophagus, Cancer of the Esophagus, Stricture of the Esophagus, Dilatation of the Esophagus, Diseases of the Stomach, . Diagnostic Technique. External Examination. Internal Examination or Chem- ical Examination of Gastric Contents. Acute Catarrhal Gastritis. Chronic Catarrhal Gastritis Phlegmonous or Suppurative Gastritis, . ... Traumatic and Toxic Gastritis, Diphtheritic Gastritis, Mycotic Gastritis, Nervous Dyspepsia, Atonic D^'spepsia, Gastralgia. Hyperchlorhydria. Anorexia Nervosa. . Nervous Vomiting-. Gastric and Duodenal Ulcers Cancer of the Stomach, Dilatation of the Stomach, Visceroptosis, . PAGE 304 304 304 306 306 307 307 308 310 311 311 312 312 312 313 313 313 3^3 314 315 315 316 317 320 320 321 322 322 323 323 323 324 324 325 326 326 329 329 329 332 342 343 349 349 350 350 350 352 353 354 357 357 359 366 373 376 Diseases of the Intestines, Simple Acute Catarrhal Enteritis, Chronic Catarrhal Enteritis, . Cholera Morbus, Diarrheas of Children, Acute Dyspeptic Diarrhea, . Acute Entero-colitis, Cholera Infantum, The Celiac Affection in Children Pseudo-membranous Enteritis, Phlegmonous Enteritis, . Hemorrhagic Infarct of the Bowel Ulceration of the Bowel, Tubercular Ulcer, Embolic Ulcer, Syphilitic Ulcer, Appendicitis, .... Recurring and Relapsing Appen dicitis — Chronic Appendicitis Intestinal Obstruction, . I. Internal Strangulation, II. Intussusception — Invagina tion, .... III. Twists and Knots — Volvu lus, .... IV. Obstruction by Abnormal Contents or Foreign Bodies, . . . . V. Strictures and Morbid Growths, VI. Fecal Obstruction, Constipation, .... Dilatation of the Colon, Nervous Affections of the Bowel, I. Derangements of Motion, II. Derangements of Sensibil- ity, III. Secretion Neuroses, Carcinoma of the Bowel, Hemorrhoids, Diseases of the Liver, Abnormalities in the Shape and Position of the Liver, Diseases of the Bile Passages and Gall-bladder, . Jaundice, or Icterus, Icterus Neonatorum, Simple Catarrhal Jaundice, Cholelithiasis, . Acute Impaction, Chronic Impacted, Acute Infections, . Cancer of the Gall-bladder, Carcinoma, Stenosis, Cicatricial Contraction, Parasites, Diseases of the Blood-vessels of the Liver. Hyoeremia, Passive Hj-peremia — Red At- rophj". Active Hyperemia. Thrombosis and Embolism, Pylethrombosis, Pylephlebitis, CONTENTS. IX. Diseases of the Blood-vessels of the Liver : Fatty Liver, .... Fatty Infiltration, Fatty Metamorphosis, The Amyloid Liver, Cirrhosis of the Liver, . Suppurative Hepatitis, Perihepatitis, .... Glissonian Cirrhosis, Acute Yellow Atrophy of the Liver, .... Morbid Growths of the "Liver, Carcinoma of the Liver, Sarcoma, .... Syphilis of the Liver, Parasites of the Liver, Echinococcus Disease or Hyd atid Cyst of the Liver, Other Parasites of the Liver, Diseases of the Pancreas, . Acute Pancreatitis, Chronic Pancreatitis, Diseases of the Pancreas: Cancer of the Pancreas, . 455 Sarcoma of the Pancreas, 456 Cysts of the Pancreas, 457 Pancreatic Cellulitis, 457 Diseases of the Spleen, 458 Splenitis, ..... 465 Perisplenitis, .... 468 Abscess of the Spleen, 469 Rupture of the Spleen, The Amyloid Spleen, 469 Atrophy of the Spleen, 471 Hemorrhagic Infarct of the Spleen 471 Neoplasms of the Spleen, 471 Echinococcus of the Spleen, . 475 Wandering Spleen, . 477 Diseases of the Peritoneum, Acute Peritonitis, 477 Chronic Peritonitis, 481 Local, Circumscribed, or Chronic 481 Adhesive Peritonitis, 482 Diffuse Chronic Peritonitis, . 483 Cancer of the Peritoneum, Ascites, . . . . 483 484 484 485 485 485 485 485 485 486 486 486 486 486 486 487 487 491 491 492 492 495 SECTION III. DISEASES OF THE RESPIRATORY SYSTEM. PAGE Diseases of the Nose, . . . 497 Rhinitis, 497 Chronic Nasal Catarrh, . . 498 Hay-fever, 501 Diseases of the Larynx, . . . 503 Examination of the Larynx, . . 503 Acute Catarrhal Laryngitis, . . 505 Spasmodic, Catarrhal, or False, Croup 506 Simple Chronic Catarrhal Laryn- gitis, 508 Tubercular Laryngitis, . . ■ SH Syphilitic Laryngitis, . . . 513 Edema of the Glottis, . . .513 Paralysis of the Laryngeal Muscles, 514 Diseases of the Trachea and Bron- chial Tubes 517 Acute Bronchitis 5^7 Chronic Bronchitis, . • . 5i9 Bronchiectasis, or Bronchial Dila- tation, 524 Diseases of the Trachea and Bron chial Tubes : Bronchial Asthma, . Plastic or Fibrinous Bronchitis, Diseases of the Lungs, Emphysema, .... Vesicular Emphysema — Pseudo hypertrophic Emphysema, Tumors of the Lung, Diseases of the Pleura, Acute Pleurisy, . . . Chronic Pleurisy, Hydrothorax and Hematothorax, Pneumothorax, Morbid Growths of the Pleura, Mediastinal Disease, . Mediastinal Tumors, Mediastinal Abscess, Simple Lymphadenitis, 526 530 531 531 532 537 539 53^ 547 548 54^ 551 .551 553 556 557 SECTION IV. DISEASES OF THE HEART AND BLOOD-VESSELS. General Symptomatology of Cardiac Disease, .... Cardiac Asthma. Di=;eases of the Pericardium, Pericarditis, .... Other Pericardial Affections, Hydropericardium, Hemopericardium, Pneumopericardium, 'AGE PAGE Diseases of the Endocardium, . . 507 558 Endocarditis, 567 558 The Mild or Simple Form of 559 Acute Endocarditis, . - 568 559 The Severe or Malignant Form 566 of Acute Endocarditis, . . 570 566 Chronic Valvular Defects, . . 574 566 Mitral Insufficiency 57» 566 Mitral Stenosis, . . . • 57^ CONTENTS. Diseases of the Endocardium : Mitral Insuflficiency and Stenosis, Aortic Insufficiency or Incompet- ency, .... Aortic Stenosis and Insufficiency, Tricuspid Regurgitation, Tricuspid Stenosis, . Pulmonary Insufficiency or Incom petency, .... Pulmonary Stenosis, Congenital Defects, . Relative Frequency of Valvular Defects, .... Associated or Combined Valvular Lesions, .... Diseases of the Myocardium, Hypertrophy and Dilatation — Atro phy, Hypertrophy of the Heart, Dilatation of the Heart, Atrophy of the Heart, . Brown Atrophy, Degenerations of the Cardiac Mus- cle, Diseases of the Myocardium : 582 Parenchymatous or Albuminoid Degeneration, 582 Fatty Degeneration or Fatty 587 Metamorphosis, 588 Fatty Infiltration or Fatty Over 589 growth, .... Amyloid Infiltration, 589 Calcareous Infiltration, 590 Myocarditis, .... 590 Chronic Myocarditis or Fibro myocarditis, 591 Acute Suppurative Myocarditis. Aneuryism of the Heart, 592 Rupture of the Heart, 599 Neuroses of the Heart, Nervous Palpitation, 599 Tachjxardia and Bradycardia, 600 Irregular Pulse, 603 Angina Pectoris, or Stenocardia, 608 Diseases of the Blood-vessels, 608 Arteriosclerosis. Aneurysm, .... 608 Aneurysm of the Thoracic Aorta, 608 608 609 610 610 610 610 612 613 613 614 614 615 616 620 624 624 627 628 SECTION V. DISEASES OF THE BLOOD AND BLOOD-MAKING ORGANS. PAGE Diseases of the Blood, . . . 641 Minute Structure of the Blood, . 641 The Anemias, 644 Secondary or Symptomatic Ane- mia, 645 The Primary or Essential Anemias, 648 I. Chlorosis, .... 648 II. Progressive Pernicious Ane- mia, 652 The Primary or Essential Anemias : III. Leukemia, .... IV. Lymphatic Anemia — Pseudo- leukemia — Hodgkin's Dis- ease, ..... Status Lymphaticus, V. Splenic Anemia, or Splenic Pseudoleukemia, 658 664 667 668 SECTION VI. DISEASES OF THE THYROID GLAND. Goitre, Simple Goiter, or Struma, Exophthalmic Goitre, Myxedema, .... Congenital Cretinism, PAGE 670 670 672 676 678 Sporadic and Endemic Cretinism, Neoplasms of the Thyroid. Diseases of the Suprarenal Capsules, Addison's Disease, .... PAGE 678 680 681 681 SECTION VII. DISEASES OF THE URINARY ORGANS. General Remarks on Albuminuria, Extrarenal Albuminuria, Renal Albuminuria, General Remarks on Albuminuria : Physiological or Functional Al- buminuria, .... CONTENTS. XI General Remarks on Albuminuria : Tests for Albumin and Globulin, Renal Dropsy, Uremia, Tube-casts, .... Diseases of the Kidney, Derangements of Circulation, Active Congestion, Passive Congestion of Cyanotic Induration, . . . . Acute Parenchymatous Nephritis, Chronic Parenchymatous Nephri- tis, Chronic Interstitial Nephritis, Lardaceous Kidney, Suppurative Interstitial Nephritis, and Pyelonephritis, . Abscess of the Kidney, Paranephritis or Perinephric Ab- scess, Nephrolithiasis (Stone in the Kid- ney), . . Tumors of the Kidney, Cysts of the Kidney, Anomalies of Form and Position of the Kidney 686 687 688 690 693 693 693 696 707 716 726 730 735 735 736 742 744 746 Diseases of the Kidney : Normal Situation of the Kidney, 746 Congenital Absence of the Kid- ney, 746 Congenital Absence of One Kid- ney, 746 Lobulated Kidney, . . . 747 Horse-shoe Kidney, . . . 747 The Movable or Floating Kid- ney, ...... 747 Idiopathic Hematuria, . . . 749 Hemoglobinuria, .... 750 Toxic Hemoglobinuria, . . 751 Paroxysmal Hemoglobinuria, . 751 Chyluria, 752 The Relation of Heart Disease to Kidney Disease, . . . 753 Diseases of the Bladder, . . . 759 Cystitis, 759 Stone in the Bladder, . . . 765 Neuroses of the Bladder, . . 765 Paralysis of the Bladder, . 765 Muscular Spasm of the Bladder, . 766 Hemorrhoidal Veins of the Blad- der, 769 Morbid Growths of the Bladder, 769 SECTION VIII. CONSTITUTIONAL DISEASES. PAGE Rheumatism, 771 Muscular Rheumatism, . . . 771 Chronic Articular Rheumatism, . 77^ Joint Affections Simulating Rheuma- tism, 775 Arthritis Deformans, . . . 775 1. Multiple Arthritis Deformans, 777 2. The Partial or Monarthritic form, 778 Gout, 780 Lithemia, 793 Diabetes Mellitus, . . . -795 Diabetes Insipidus, .... 817 Obesity, .... . 821 Rickets, .... . 824 Osteomalacia, . 829 Purpura . 831 Symptomatic Purpura, - 831 Scurvy, .... . 832 Infantile Scurvy, . 834 Arthritic Purpura, . . 834 Purpura Hsemorrhagica, . • 835 Hemorrhagic Diseases of the ^lew- born . 836 Hemophilia, . 837 SECTION IX. DISEASES OF THE NERVOUS SYSTEM. General Introduction, .... Histology of the Nervous System, General Symptomatology (Investi- gation of a Case of Nervous Disease, I. Phenomena of Motion, . II. Sensory Phenomena, III. Sensory Motor Phenomena, . IV. Vasomotor and Trophic Phe- nomena V. Mental Phenomena, PAGE 840 General Introduction : PAGE 840 VI. Alterations in Vision and Hearing, 865 VII. Alterations in Breathing and 843 Pulse, .... 866 843 Affections of the Peripheral Nerves, 867 860 Neuritis 867 86s Localized Neuritis, 867 Sciatica, .... 870 863 Multiole Neuritis, . 872 865 Endemic Neuritis, 878 xu CONTENTS. Afltections of the Peripheral Nerves: Malarial Neuritis, Beri-Beri. the Kakke of Japan, Leprous Neuritis, Neuralgia, Varieties Depending upon the Nerves Involved, Tumors of Nerves, . . . . Affections of the Spinal Cord, . Localization of the Functions of the Segments of the Spinal Cord, Affections of the Membranes of the Cord, Spinal Pachymeningitis, Spinal Leptomeningitis. . Hemorrhage into the Spinal Mem- branes, .... Affections of the Substance of the Cord, .... Secondary Systematic Degenera- tions of the Spinal Cord. . Acute Affections of the Spina Cord, Disturbances of the Circulation of the Spinal Cord, Hemorrhage into the Substance of the Cord, .... Caisson Disease, Diffuse Myelitis (Acute and Chronic), Myelitis of the Anterior Horns (Acute Poliomyelitis Anteri- or), . . . . . Acute Poliomyelitis in Adults, Subacute and Chronic Poliomveli- tis, ' Acute Ascending Spinal Paralysis Chronic Affections of the Spinal Cord Spastic Spinal Paralysis, Tabes Dorsalis, ... Hereditary Ataxia, . Cerebellar Hereditary Ataxia, Progressive Interstitial Hypertro phic Neuritis of Childhood, Toxic Sclerosis, Ataxic Paraplegia, . Syringomyelia, .... Morvan's Disease, . Compression of the Spinal Cord, Tumors of the Spinal Cord and Membranes, Lesions of the Cauda Equina and Conus Medullaris, Spina Bifida Progressive Bulbar Palsy, Acute Bulbar Palsy, Pseudoparalytic Mayasthenia, Amytropic Lateral Sclerosis, . Progressive Spinal Muscular Atro- phy, . . . Diseases of the Brain, Localization of Cerebral Disease, I. The Motor Areas of the Cor tex, .... II. Sensory Areas of the Cortex and Sensory Paths, Cortical Areas Covering Speech, The Various Forms of Aphasia and their Anatomical Lesions, 878 879 «8i 886 900 901 903 904 90.5 908 908 908 910 911 918 921 921 922 924 924 926 937 938 938 939 939 941 943 943 946 949 950 951 954 954 956 958 963 963 964 970 972 972 PAGE Diseases of the Brain : The Physical Basis of Thought — Apraxia, 973 Aphasia, or Loss of the Faculty of Speech, 975 Derangements of Speech of Irrita- tive Origin 980 Cortical Areas Whose Function is Unknown or Uncertain, . . 981 Tracts Within the Brain — Centrum Ovale, Internal Capsule, Cen- tral Ganglia, Corpora Quadri- gemina, 983 Cerebellar Disease 984 Diseases of the Cranial Nerves, . 987 Olfactory Nerve, .... 987 Optic Nerve and Tract, . . 987 1. Affections of the Retina, . 987 2. Affections of the Optic Nerve, 989 3. Lesions of the Chiasm and Tract, 992 4. Lesions of the Tract and Cen- ters, 994. Symptoms of Lesions of the Optic Nerve Chiasm, Tract, and Optic Cortex, .... 995 Lesions of the Motor Nerves of the Eyeball, 998 Third Nerve, .... 998 Fourth Nerve, .... looa Sixth Nerve, .... lOOi Phenomena in General of Paral- ysis of Motor Nerves of the Eye), looi Ophthalmoplegia, .... 1002 Treatment of Ocular Palsies. 1003 Lesions of the Trifacial, or Fifth Nerve, (Trigeminus), . . 1004 Lesions of the Facial Nerve or Sev- enth Pair, 1006 Lesions of the Auditory or Eighth Nerve, 1013; Diseases of the Crariial Nerves — Le- sions of the Auditory or Eighth Nerve: 1. Loss of Function; Nervous Deafness, 1013 2. Auditory Hyperesthesia, . . 1015 3. Irritation of the Auditory Nerve — Tinnitus Aurium, . 1016 4. Disturbance of Equilibrium Associated with Defect of Hearing, Labyrinthine Verti- go, Meniere's Disease, . . 1017 Lesions of the Ninth or Glossophar- yngeal Nerve, '. . . . 1018 Lesions of the Pneumogastric or Vagus Nerve, the Tenth Pair, 1019 Lesions Involving the Nucleus and Trunk of the Pneumogas- tric and Branches, . . . 1019 Lesions of the Pharyngeal Branches 102a Lesions of the Laryngeal Branches 1020 Spasm of the Larynx. . . . 1023 Lesions of the Cardiac Branches, 1024 Lesions of Gastric and Esopha- geal Branches 1024 Lesions of Pulmonary Branches, 1024 CONTENTS. xiu Lesions of the Eleventh Pair or Spinal Accessory Nerve, . Symptoms of Paralysis of the External Branch of the Spinal Accessory, Symptoms of Accessory Spasm, 1. Congenital Torticollis, or Fixed Wry-neck, ... 2. Spasmodic Wry-neck, Lesions of the Twelfth Pair or Hy poglossal Nerve, Diseases of the Spinal Nerves, . Cervical Plexus, .... Affections of the Phrenic Nerve, . Lesions of the Brachial Plexus, . Of the Combined Plexus, . Lesions of Individual Nerves, Of the long Thoracic or Pos- terior Thoracic — Serratus Pal- sy, Nerves of the Arm, Lumbar and Sacral Plexuses Diseases of the Membranes of the Brain, .... Pachymeningitis, . _ . _ . External Pachymeningitis, Internal Pachymeningitis, . Purulent and Pseudomembran ous Pachymeningitis, Hemorrhagic Pachymeningitis, Leptomeningitis, Affections of the Blood-vessels of the Brain, Hyperemia, Anemia, Edema, Apoplexy, . I. Cerebral Hemorrhage, II. Embolism and Thrombosi; of the Cerebral Vessels, . Morbid Changes due to Throm bosis and Embolism, . • Affections of the Blood-vessels of the Brain : Thrombosis of the Cerebral Sin- uses and Veins, Intracranial Aneurysms, The Cerebral Palsies for Children, Infantile Hemiplegia, . . Bilateral Spastic Hemiplegia, . Spastic Paraplegia, Sclerosis of the Brain, . PAGE 1026 1026 1027 1027 1028 1030 IO3I IO3I 1031 1032 1032 1032 1032 1033 1036 1038 1038 1038 1038 1038 1038 1040 1045 1045 1046 1047 1048 IQ48 1056 1057 1 061 1062 1062 1063 1066 1067 1069 Intracranial Aneurysms : Multiple Sclerosis of the Brain and Spinal Cord, Dementia Paralytica, .... Tumors of the Brain, Suppurative Encephalitis, Encephalitis without Abscess, . Chronic Hydrocephalus, . General and Functional Diseases : Neuroses, . Acute Delirium, Paralysis Agitans, . Other Forms of Tremor, Acute Chorea, . Choreiform Affections, I. Simple Tic, II. Tic with Explosive Utter- ances, Coprolalia, Echolalia, etc., III. Complex Co-ordinated Tic, . IV. Spasms of the Muscles of Respiration and Deglutition, . V. Chronic Progressive Chorea, General and Functional Diseases: VI. Chorea Major, VII. Postchoreal Paralysis and Postparalytic Chorea, Epilepsy, Reflex Convulsions of Children, . Migraine, Occupation Neuroses, Writers' Cramp, .... Athetosis, Tetany, Hysteria, ...... Neurasthenia, . . Traumatic Neuroses, Other Forms of Functional Paraly- sis, Abasia-atasia, . . _ . Family Periodical Paralysis, Vasomotor and Trophic Derange- ments, . • • Acute Angioneurotic Edema, . Raynaud's Disease, Progressive Facial Hemiatro- phy, Acromegaly, Scleroderma, . . . . Morphea, . . . Ainhum, Syphilis of the Nervous System, . 1069 1070 1074 1081 1083 1084 1087 1087 1088 1091 1091 1097 1097 1098 1099 1099 1099 IIOI 1 102 1 102 iiii 1112 1115 1115 1119 1119 1121 1 129 1 132 1133 1133 1 136 1 136 1 136 1138 1 139 1141 1 142 1143 1144 SECTION X. DISEASES OF THE MUSCULAR SYSTEM. Myositis, Rheumatic Myositis (Acute and Chronic), . . Infectious Myositis, Progressive Ossifying Myositis. . Idiopathic Muscular Atrophies. Pri- mary Myopathic Forms of Muscular Atrophy, L Pseudohypertrophy of Mus- cles, PAGE 1 150 iiSo 1 150 1 150 II5I II?,I Idiopathic Muscular Atrophies: Erb's Form of Juvenile Hered- itary Atrophy HI. The Facio-scapulo-humeral Tyoe of Juvenile Palsy, . IV. The Peroneal Type of Pro- gressive Atrophy, Myotonia Congenita (Thomsen's Disease), . . ^ • ■ PAGE 1152 1153 IIS3 IIS3 XIV CONTENTS. SECTION XI. THE INTOXICATIONS. Alcoholism, ii55 Acute Alcoholism, . . . • ii55 Chronic Alcoholism, . . . ii55 Delirium Tremens, or Mania a Potu 1158 The Morphin Habit— Morphinism. . 1161 Chloralism, 1163 Cocainism, 1163 The Tobacco Habit, . . • .1164 PAGE Bisulphide of Carbon Poisoning, . 1164 Lead Poisoning 1171 Arsenical Poisoning, .... 1170 Ptomain and Leukomain Poisoning, 11 71 Grain Poisoning, .... 1173 1. Ergotism, 1173 2. Pellagra. . . . . . 1174 3. Lathyrism, or Lupinosis, . . 1174. SECTION XII. EFFECTS OF EXPOSURE TO HIGH THOUGH BEARABLE TEMPERATURE. Heat Exhaustion, PAGE II75 Thermic Fever — Sunstroke, Coup de Soleil, 1 176 SECTION XIII. ANIMAL PARASITES AND THE CONDITIONS CAUSED BY THEM. or Flat I. Protozoa, II. Platyhelminthes, Worms, . . . . . A. Trematodes or Flukes', . B. Cestodes, or Tape-worms, . IIL Nematodes, or Round Worms, . A. The Ascarides, B. Trichiniasis, . . . . C. Anchylostomiasis Uncinari- asis, . . . . , PAGE II79 1 180 1 180 II81 1 189 1 189 II9I 1 193 III. Nematodes, or Round Worms : D. Filariasis, .... 1194 E. Other Nematode Worms, . 1198 IV. Acanthocephali — Thorn-head Worms 1 198 V. Arthropoda, 1199 A. Arachnoidea, .... 1199 B. Insecta, 1200 SECTION XIV. Summary of Symptoms Following Overdoses of Poisons, and the Treatment OF their Effects. To which is Added a Table of Minimum Dose which HAS Caused Death and Maximum Dose Followed by Recovery, . . . 1204 APPENDIX. Tables for the Con\t:rsion of the English Into Metric System, and the Reverse, ^-^^ INDEX. 1219 CHARTS AND ILLUSTRATIONS FIG. I. PAGE Temperature Chart of a Typical Case of Typhoid Fever Uninfluenced by Treatment, -r ' •' i tV " u ' ' o^ 2. Chart Showing Drop in Temperature Incident to Intestmal Hemorrhage 27 3. Chart Showing Anemia of Typhoid Fever, / -, ^ t,' , ^Colored) 30 4 Chart Contrasting the Drop in Temperature after the Bath Early and Later m ... the Disease, 43 5. Burr's Portable Bath-tub, 44 6. Temperature Chart in Typhus Fever, • . ■ ^\ §; 7 Temperature Chart of Relapsing Fever, Showmg Relapses . ■ ■ ■ Oi 8. Chart Showing Morning and Evening Temperature m Malta Fever— 1 wo Distinct Relapses are Shown, . . .... •.,-.• "4 Q Plate Illustrating Different Forms of the Malarial Organism with Their Stages of Development, . . ■ ■ .• : ^ {Colored) 68 10. Temperature Chart in Intermittent Fever, Showing the Paroxysms and Intermission, . • • • ' r.,' • ' / t." ' 'a 11. Temperature Chart in Intermittent Fever, Showing the Paroxysms and Intermission, ...••• 75 12. Fountain Syringe for Hypodermoclysis, joi n. Temperature Chart of Measles, . • • ' ,^ • ., ,• c \ % ' v ■ ' IJi Plate Showing Pathognomonic Sign of Measles (Koplik s Spots), . Facmg 1^0 14. Temperature Chart of Scarlet Fever, 127 15. Temperature Chart of Smallpox, '(Colored) 163 16. Chart of a Case of Influenza, :^ {Colored) 03 17. Method of Puncture for Spinal Drainage, . ^/^ 18. 19- Syphilitic Teeth, _. . • • • ' • '217 20. Chart Showing Crisis m Pneumoma, _ . • • p ; •^. Succeeding 24. Tempfrature'chart'of a Case of Tubercular Consumption without Fever, . 262 25. Pasteboard Spit-cup, . • ^ ' r^. [, ^o"; 26. Diagram Showing Eruption of Milk Tee h . . 305 %: |l;l"p\tir„?F^irTeTrSra°{.fy:terF..een, Who Had Ta.en kucH ' Mercury in Infancy, :^ g 20 Arrangement for Auto-lavage, . . • •. ■ ' c' i ' ' iln S' Oppler Boas Bacillus from Contents of a Carcinomatous Stomach . . 369 3?" Temperature Chart of Appendicitis, Showing Temperature Maintained by 32. Chart^on^Vn^Sti^ShL?^^^^ to Normal, Incident to Perforation, 33 Vertical and Transverse Sections of an Intussusception 411 34. Giant Congenital D^'-^-^'-" ^^ Human Colon 423 35. The Cystic Duct in iA Giant Coneenital Dilatation of Human Colon. . . • • 35: The Cystic Duct in Section, with Part of the Gall-bladder and Hepatic and Common Bile-ducts, . . ■ • • • • ' , ' T>>-£r' I '^'^^ 36 Comparative Enlargements of the Liver, Corresponding to the Different Morbid Growths, " "^Js 37. Tenia Echinococcus, . . • • .-, ^- ,■ \ ' " ' ' 1^^ 38. Section through an Echinococcus Cyst with Brood Capsules 479 39^ So-called " Ovarian Cells," - _ .- 495 40. Technique of Rhinoscopic Examination 49^ 41. Technique of Laryngoscopic Examination, 504 42. Natural Size of Image of the Vocal .Apparatus, 505 43. Cadaveric Position of the Left Vocal Cord . . •. • . • • . • ^'^ 44. Complete Both-sided Abductor Paralysis of the Posterior Cnco-arytenoid 45. Paralysis of 'the Internal thyro-arytenoid Muscles, 5i6 XV xvi CHARTS AND ILLUSTRATIONS TIG. PAGE 46. Paralysis of the Transverse and Oblique Interarytenoid Muscles, . . 516 47. Bilateral Paralysis of the Thyro-arytenoids Combined with Paresis of the Arytenoid 5i6 48. Curschmann's Spirals, 528 49. Section through Frozen Thorax at Second Interspace in Front, Looking from Above Downward, 552 50. Section through Frozen Thorax at Second Interspace in Front, Looking from Below Upward. . . 552 51. Pulsus Paradoxus, 562 52. Temperature Chart. Malignant Endocarditis, 572 53. Tracing of Pulse of Mitral Insufificiency, 578 54. Tracings of Pulse of Mitral Stenosis 580 55. Tracings of Pulse of Aortic Regurgitation, 583 56. Pulse-tracing of Aortic Stenosis, 586 57. Normal Pulse-tracing, 618 58. Pulsus Bisferiens. • • • • 619 , 59. Tracing of Pulse of High Arterial Tension . . 619 60. Sphygmogram of an Atheromatous Vessel, 626 61. Aneurysm of the Aorta. Showing Sites of Election, . . • . . . 629 62. Chart.^Showing the- Blood in Simple Anemia {Colored) 646 63. Chart, Showing Blood in Chlorosis {Colored) 650 64. Liver Lobules in a Case of Pernicious Anemia, . . . {Colored) 653 65. Cells from Liver in Pernicious Anemia, {Colored) 654 66. Chart. Showing Blood in Pernicious Anemia, .... {Colored) 655 67. Colored Plate, Showing the Different Forms of Colorless Corpuscles in the Blood of Leukemia {Colored) 661 Plate Showing Degeneration of Blood Corpuscles in Leukemia, . Facing 662 68. Epithelial Casts and Compound Granule Cells 691 69. Pus Cast, 691 70. Blood Casts, 661 71. Hyaline Casts, 691 72. Hyaline and Granular Casts, Illustrating the Formation of the Former, . 691 73. Dark Granular Casts, Casts Partly Hyaline, Containing Oil-drops and Granular Matter, 693 74. Waxy Casts, 692 75. Oil Casts and Fatty Epithelium, 693 76. Cylindroid or Mucus-casts, 693 77. Hilus of Kidney with a Large and Small Renal Calculus, Showing How Precipitation and Aggregation Take Place, 738 78. Diagram Showing Probable Plan of the Center for Micturition, . . . 766 79. Heberden's Nodosities, yyj 80. Tophacious Gout, 786 81. Deformed Skeleton from a Case of Rickets, 825 82. Outline of Rickety Chest, 826 83. Diagram of an Element of the Motor Path, 841 84. Diagram Illustrating Crossed Paralysis, 844 85. Diagram Illustrating the Possibility of Paralysis of Arm on one Side and Leg on the other, 845 86. Diagram Showing Probable Plan of the Centre for Micturition, . . . 848 87. Motor Nerve Points on Face and Neck 853 88. Motor Nerve Points on Upper Limb, Flexor Surface, ..... 854 89. Motor Nerve Points on Upner Limb, Extensor Surface, .... 855 90. Motor Nerve Points on ThigTi. Anterior Surface, 856 91. Motor Nerve Points on Lower Limb, Posterior Surface 858 92. Motor Nerve Points on Leg, External Surface. . . . . . . 859 93. Diagram Showing Relation of Vertebral Spines to their Bodies and to the Nerve-roots, 889 94. Diagram Showing Relative Size and Shape of the Cord and Gray Matter at Different Levels 889 95. Section of Spinal Cord in the Cervical Region, 890 96. Diagram of Sensory Skin Areas Corresponding to the Different Spinal Seg- ments, Anterior Surface 891 97. Diagram of Lesion Showing Brown-Sequard's Paralysis. .... 895 98. Schema Showing Chief Symptoms in Left Unilateral Lesion of the Dorsal Cord, 895 99-100. Diagram of Sensory Skin Areas Corresponding to the Different Spinal Segments, Posterior Surface . 896-897 loi. Secondary Descending Degeneration of the Pyramidal Tracts in a Primary Lesion of the Left Half of the Cerebrum, go5 CHARTS AND ILLUSTRATIONS xvii FIG. PAGB 102. Diagram of Descending Degeneration of the Pyramidal Tracts due to a Lesion in the Left Internal Capsule, . 907 103. Secondary Ascending and Descending Degeneration in a Transverse Section of the Upper Dorsal Region, 907 104. Section through the Cervical Enlargement in Anterior Poliomyelitis, . . 919 105. Transverse Section through the Lumbar Region in Tabes Dorsalis, . . 927 106. Transverse Section through the Thoracic Region in Tabes Dorsalis, . . 928 107. Transverse Section through the Cervical Region in Tabes Dorsalis, . . 929 108. Transverse Section through the Lumbar Region in Beginning Tabes Dorsalis. 930 109. Sarcoma of the Lower Cervical Cord, 946 no. Sarcoma Compressing the Cervical Cord, 946 111. Situation of the Cranial Nerves, 951 112. Bird-Claw Hand. 959 113. Lateral Aspect of the Brain, 964 114. Aspect of the Median Surface of the Cerebrum as it Appears when the Two Hemispheres are Separated, 965 115. Lateral Aspect of the Brain, 966 116. The Motor Tract, 967 117. Sensory and Motor Paths in the Spinal Cord, . . . {Colored) 968 118. Primitive Speech of the Child in Mechanical Repetition of Words, . . 973 119. Wernicke's Schema, Showing the Association of the Various Partial Con- ceptions to Form the Whole Conception or Word Image of an Object, 974 120. Simplification of the Schema of Voluntary Speech, 975 121. Diagram of Seats of the Lesions of Word-deafness, Word-blindness, Motor Aphasia, and Agraphia, 976 122. The Left Hemisphere, with the Fissure of Sylvius Drawn Apart in Order to Show the Convolution in Island of Reil, 977 123. Simplification of Wernicke's Schema of Voluntary Speech, .... 980 124. Transverse Section through the Crura Cerebri in Secondary Degeneration of the Right Pyramidal Tract, 983 125. Commencing Optic Neuritis from a Case of Caries of the Sphenoid Bone with Secondary Meningitis, qqq 126. Diagram Showing Course of Optic Nerve-Fibers, 993 127. Situation of the Cranial Nerves, (Colored) 1000 128. Schema for Central Innervation of the Facial Nerve, ..... 1007 129. Simplified Drawing of the Peripheral Distribution of the Facial' Nerve, .,.•..„.. {Colored) 1009 130. Wnst-arop m Musculospmal Paralysis, 1034 131. Position of Wrist, Hand, and Fingers in Ulnar Paralysis, .... 1035 Circle of Willis and Arteries of Brain, Facing 1046 132. Focal Symptoms of Brain Tumor, 1077 133. Left Facial Hemiatrophy, 113Q 134. Temperature Chart from a Case of Sunstroke Treated by Ice-water Baths and Frictions. Recovery, . , . . jj^^ PRACTICE OF MEDICINE. SECTION I. INFECTIOUS DISEASES. TYPHOID FEVER. Synonyms. — Typhus abdominalis ; Enteric Fever; Pythogenic Fever; Gas- tro-enteric Fever; Nervous Fever; Autumnal Fever; Slow Nervous Fever. Definition. — Typhoid fever is an acute infectious fever due to the implantation and proHferation of the typhoid bacillus — the bacillus of Eberth. It is especially characterized anatomically by hyperplastic and ulcerative lesions of the lymph-follicles of the intestine, of the mesenteric glands, and by enlargement of the spleen. Historical. — The disease is probably coeval with civilization, and is easily recog- nizable in the descriptions of Hippocrates (B. C. 460-357) and Galen (A. D. 130-200); and in more modern times in those of Adrianus Spigelius (1624), Thomas Willis (1659), N. Hoffmann (1699), Thomas Sydenham (1685), and others in the seventeenth century and in the next. Noteworthy are the writings of E. Gilchrist (1734), John Huxham (i739)> J- C. Riedel (1748), and R. Manningham (1746). Doubtless Huxham's "slow nervous fever," described in his "Essays on Fevers," was the typhoid of the present day, and his "putrid malignant" the rarer typhus of to-day. But Huxham regarded typhoid as a variety of continued fever rather than as a distinct and separate fever, and it was not until 1813 that Pierre Bretonneau, of Tours, described it under the name dothieninterite and Petit and Serres as fievre etitero-rndsentirique. It was, however, the writings and teachings of the great French physician, Louis, which did most to disseminate a knowledge of the true nature of typhoid fever — to which he gave the name it bears. His great work was published in 1829.* Among his pupils, who came from every country, was a coterie of brilliant young Americans, including William W. Gerhard and C. W. Pennock, of Philadelphia, and James Jackson, Jr., of Boston. The first, after his return to America, had the opportunity, in conjunction with Pennock, of studying the disease in the wards of the Philadelphia Hospital in the spring and summer of 1836, and of contrasting it with typhus fever, of which there was an epidemic then prevalent in Philadelphia. These two observers were the first to point out the difference between the two diseases. This they did in the "American Journal of the Medical Sciences" in 1837. Their publications were followed in 1838 by a paper by James Jackson, Sr., entitled " Report on Typhoid Fever," and another Tjy Enoch Hale " On the Typhoid Fever of New England," which probably had their impulse in the information furnished by the younger Jackson to his father on his re- turn from Paris. Thus it came to pass that Elisha Bartlett's work on the " Diagnosis and Treatment of Typhus and Typhoid Fevers," an American text-book published in 1842, contained the first separate description of the diseases. For up to 1838 only typhoid fever was known in Paris. At this time Alfred Stille, who had been the house physician of Gerhard and Pennock in the Philadelphia Hospital, and had learned there the distinctive features of typhus and typhoid, went to Paris, and in 1838 read a paper Taefore the Societe M6dicale d'Observation pointing out the differences between them. George C. Shattuck had been similarly trained in Boston, and contributed a paper to the same society. Shattuck also went to London at Louis' request, and at the Fever Hospital there saw the two distinct affections, on which he reported to the Society on bis return to Paris, f He insisted on the existence of two fevers in Eneland * Louis, P. C. A., " Recherch. anatom., patholog., et therapeutiques sur la maladie connue sous lesnoms gastro-enterite, fievre putride," etc., Paris, 1829. t " Amer. Med. Examiner," February i, March, 1840. I8 INFECTIOUS DISEASES. In Germany, J. V. Hlldenbrand had pointed out differences between typhoid and typhus as early as iSio, but also regarded them as varieties of the same disease, and not distinct diseases. These views were maintained for many years in Germany, but since 1S59, at least, correct notions have prevailed. In Great Britain, in 1835, Peebles, of Glasgow, who had observed the rubeoloid eruption in the contagious typhus of Italy, pointed it out to Drs. R. Perry and A. P. Stewart. The former, according to Stewart, was the tirst to contend for the difference between the eruptions of typhus and typhoid. His writings, as quoted b}' Murchison, do not show this. Stewart, how- ever, separated the two affections in a paper published in 1840.* In England it was not until 1849-51 that Sir William Jenner, f by his experiments and observations, clearly demonstrated their difference, and about the same time definite ideas were arrived at in France. Since 1S50 the two diseases have been everywhere recognized and described as distinct and separate, except in German^', where the recognition came a few years later. ^ Etiology. — The bacillus typhosus, to which prevaiUng views ascribe typhoid fever, was discovered by Eberth in 1880 in the intestine of a case of the disease. This observation was promptly confirmed by Klebs, Eppinger, Koch, V. Meyer, Friedlander, Gaffky, and others, who found it in the intestines, lymphatic system including the mesenteric glands and spleen, in the liver and the kidneys, the blood and bone-marrow, and even in bile and urine, as well as in the rose-colored spots. It was secured in pure culture from the spleen and infected lymphatic glands by Gafifky in 1884. The bacillus is described as a short, rod-like bacterium, whose length is three micromillimeters, breadth one micromillimeter. Thus its length is about one-third the diameter of a red blood-disc, and its width one-ninth of the same, though its size and shape vary somewhat with the culture-medium and the age of the bacillus. Its ends are rounded, and sometimes there can be seen toward them, dark, glistening, round bodies. These were at one time believed to be spores, but recently this germ has been classed among those that do not produce spores. § Early observations have been rendered somewhat unreliable by the very close resemblance of this bacterium to the bacterium coli. Several methods, all more or less successful, have superseded that suggested by Eisner || for differentiating the two bacilli. The bacillus stains readily in a saturated watery solution of methyl- blue. Cultures may be made from the lecal discharges on the tenth day of the disease or later, but with difficulty, and are often negative ; probably because the bacilli are not numerous. E. Frankel and ]\I. Simmonds*' early injected pure cultures of the typhoid fever bacillus into the blood of mice, rabbits, and guinea-pigs, with fatal results, which are now ascribed to toxins thus introduced. By introducing the cultures into the duodenum. Klem- perer. Levy, and others caused lesions similar to those of typhoid fever, though more recently similar intestinal lesions have been produced by other bacteria, including the bacterium coli commune. The resisting powers of the typhoid bacillus are very great. It thrives at room-temperature. The thermal death-point is given by Sternberg at 156° F. (69° C). According to Klemperer and Levy, the bacilli remain vital for three months in distilled water, though in ordinary water the com- moner and more vigorous saprophytes consume them. When buried in the upper layers of the soil, they retain their vitality for nearly six months. Cold ♦"Edinburgh :\Ied. and Surg. Jour., ■ April, 1840. „ , • t Jenner, "Med. Chir. Trans.," vol. xxxiii.; " Edinburgh Mo. Jour, of Med. Sci., vols. ix. and X., 1840-31 , " Med. Times," vols, xx-xxiii., November. 1840. to ]March, 1851. JFor an interesting and verv much more complete historical sketch of the development of our knowledge of typhoid fever, see Murchison's treatise on the "Continued Fevers of Great Britain," ?d ed.. London.' 18S4. § Sternberg. "Tour, of Am. >red. Assoc," August 22, t8qi, p. sqo. 1 " Zeitschrift fiir Hygiene und Infectionskrankheiten," January, i8g6. 5 Von laksch, '' Kiinische Diagnostik," 1892, S. 213. TYPHOID FEVER. 19 has no effect upon them, for repeated freezing and thawing fail to kill them. They have lived upon linen for from sixty to seventy-two days, and on buck- skin from eighty to eighty-five days. Sternberg has si^ceeded in keeping alive hermetically sealed bouillon cultures for more than one year. John S. Billings and Adelaide Ward Peckham, in some experiments in the Labo- ratory of Hygiene, University of Pennsylvania, dried bouillon cultures on threads and found that typhoid bacilli lived in a vacuum two hundred and seven days ; in a desiccator over sulphuric acid, two hundred and three days ; in a closet, two hundred and twenty-eight days, and proved more resistant than the bacillus coli communis or staphylococcus aureus. One-tenth to 0.2 of one per cent, carbolic acid added to a culture-medium is without effect upon the growth of the bacillus ; 0.5 of one per cent, strength of car- bolic acid and 0.05 of one per cent, corrosive sublimate solutions are, how- ever, fatal to it. Of all agents except high heat, sunlight seems to be among the most powerful to destroy it. The experiments of Billings and Peckham,* just alluded to, go to show that insolation for two hours destroys 98 per cent, of the germs, and in three to six hours kills all. This very important observation, made first by Janowski in i890,f has been confirmed by Dieu- donne.ij: L. Brieger announced in 1885 that the pathogenic action of the typhoid bacillus was due to a specific product of the bacillus, a soluble toxin, but later studies led by R. Pfeiffer have shown that these bacteria do not yield a soluble toxin, but store up the poison in their bodies, whence it goes over in very small quantities into the fluids in which the bacilli are cultivated. The bacillus itself most frequently enters the blood through the stomach in drinking-water or milk, in both of which it has been found during epi- demics. There is reason to believe also that it may be inhaled. It has been found in water-filters by Harold C. Ernest and T. M. Prudden. It is quite well settled that the bacilli find their way into food and drink through the careless disposition of alvine discharges from typhoid fever patients, and more than likely that food may be contaminated by contagion conveyed from these discharges by the common house-fly. An oyster bed may be infected by sewage ; green vegetables, by polluted water sprinkled upon them. Whether the bacilli multiply outside the body in the water of wells or rivers to which they have obtained access is not well settled, but, judging from the large number of persons sometimes infected from those sources, it is not unreasonable to conclude that such multiplication can take place. A most noteworthy instance was the epidemic of 1885 at Plymouth, Penna., U. S. A., where 1200 persons were attacked and 130 died, all the cases starting from a single subject, whose discharges contaminated the water- supply. The recent epidemic (1897) at Maidstone, England, furnishes another illustration of the effect of contaminated water-supply. Within two weeks after the outbreak, about the middle of September, 509 cases were reported; by October 2y, 1748 cases; November 17, 1848 cases; in all, about 1900 in a population of 3=^,000. The bacilli develop rapidly in milk and in the soil. The relatively infrequent communication of tvphoid fever to physicians, nurses, and others in close communication with the disease is explained by the fact that the contagion escapes from the patient in the * "Influences of Certain Agrents in Dei5troying the Vitality of the Typhoid and Colon Bacillus," " Science," February !■;. iSo";. + " Zur Biologic des Tvphus-Bacillus." "Centralbl. f. Bakteriol.," viii., i8qo. t " Reitraere zur Benrtheilunp der Einwirkung- des Lichtes auf Bacterien," " Arbeiten aus dem kaiserlichen Gesundheitsamte," Band ix. , S. 405, 1894. 20 INFECTIOUS DISEASES. stools alone, and as these are commonly promptly disposed of, the chances for the dissemination of the poison are correspondingly few. Carelessness in the disposition of these discharges, as the result of which they are allowed to dry on linen, whence the bacilli pass into the air of the room, does sometimes occasion the infection of nurses and physicians and others attending on typhoid cases. The inadvertent drinking of water from a bath used in tubbing typhoid fever cases is said to have caused the disease in a nurse. Predisposing Causes. — Experience fails to establish definite pre- disposing causes of typhoid fever, but new-comers are more likely to be attacked than old residents, as early shown by the French physicians in Paris. It certainly often attacks the strong and healthy as fiercely as the feeble and delicate, while allowance must be made for the more frequent exposure of the healthy. Thus caused, typhoid fever is unlimited in its distribution by climate or civilization, but it may be complicated by disease peculiar to certain localities, pre-eminently malaria. Typhoid fever is a disease of adolescents and adults under thirty, although it may occur at any age. Less common in children, perforation has been found in a child five days old, while not a few cases have been reported in sucklings. Infection in utero is claimed as possible because of successful cultures of bacilli from the fetus. In the young the duration of the disease is short and the prognosis singularly favorable. It has oc- curred at the age of seventy-five, eighty-six, and even ninety. More men than women have typhoid fever (71 per cent, of 444 cases collected by Reginald H. Fitz), probably because of their more frequent exposure. The assertion that the pregnant state seems to protect against typhoid fever is not substantiated by experience in Philadelphia, in evidence of which I may state that within two months there were received in my wards at the Hos- pital of the University of Pennsylvania three pregnant women with typhoid fever. Typhoid fever is more common in the late summer and autumn months than at any other time of the year, whence one of the names, " autumnal fever." Heat has probably to do with the ripening of the cause, but the relation of moisture to such maturing is not so well settled. It has, however, been observed that hot and dry summers are followed by more cases than hot and moist summers. Buhl and Pettenkofer have shown that more cases succeed seasons when the ground water is low — that is, when the springs are low and the upper layers of the soil comparatively dry — than when the ground water is high and the soil is saturated with moisture to a point nearer to the surface. Under the latter condition of high ground water the germs are retained in situ. When the ground water is low, on the other hand, the constant circulation between the air in the loose soil and that above it conveys the germs upward, and they pervade the air accord- ingly. The hot and dry summer furnishes identical conditions. While it is not impossible that the germs may be transmitted through the air, and the disease acquired by inhalation, it is scarcely likely that this is a frequent occurrence, since it has been shown by German© that in completely dried air-currents the bacillus soon dies. Liebermeister prefers to explain the relation of typhoid to the hot and dry season by the fact that at this season the Quantity of solid matter in springs is relatively larger; that the poison, in other words, is more concentrated, and therefore more virulent. Special epidemics may occur at any season. Thus the epidemic of typhoid fever at TYPHOID FEVER. 21 Plymouth, Penna., alluded to, began April 10 and raged with greatest fury during May and June. Other epidemics illustrate the same truth. Morbid Anatomy. — The characteristic morbid anatomy of typhoid fever includes the changes in the lymphatic structures so constantly asso- ciated with the disease. These are more striking in the solitary glands of the ileum and their agminations known as Peyer's patches. The glands are enlarged by the accumulation of outwandering and proliferated leuko- cytes that develop to the stage of epithelioid cells, when they become necrotic and disintegrate. The acme of this process prior to disintegration is known as medullary infiltration, and is reached from the eighth to the tenth day of the disease. In a recent autopsy made after death on the eleventh day typical medullary infiltration was found. The disintegration is either molec- ular or massive. The former is followed by a corresponding absorption ; the latter, by a massive discharge of the dead cells into the bowel, resulting in the well-known typhoid ulcer. This, when it represents a single follicle, is small and circular, not more than from three to six millimeters (1-8 to 1-4 inch) in diameter; large and elliptical when an entire Peyer's patch is involved. Such a patch is usually opposite the mesenteric attachment, has its longest diameter parallel with the length of the bowel and its shorter trans- verse, thus reversing the relations of the tubercular ulcer. Much larger ulcers are sometimes formed by the union of others, especially toward the lower end of the bowel. The borders are commonly raised. The floor of the ulcer is usually the submucosa, or the muscular coat of the bowel, but it may be the peritoneum, and even this is sometimes sphacelated, appearing as an opaque white membrane that sooner or later breaks and the bowel is per- forated. The discharge of its contents into the peritoneal cavity is followed by peritonitis, usually fatal. More commonly, the ulcer heals, and the patient recovers, but the normal glandular structure of the gut at the seat of the ulcer is not restored. Necropsy discovers ulcers in different stages of healing, sometimes all healed except the single fatal spot that has become the seat of perforation. The large intestine is also invaded in probably one-third of the cases, and the process may terminate here also in perforation. Ulcer- ation may extend to the appendix, where, too, perforation sometimes takes place. Similar infiltration of the lymph nodules and lymph cords of the mesenteric glands and of the spleen may occur, contributing to the enlarge- ment of these organs. In the spleen it is associated with an active hyperemia that contributes to further enlargement, generally recognizable during life. The organ may reach twice or three times its normal size — i. e., 435 to 650 gm. (14 to 20 ounces). There has even been rupture of this organ. Hemor- rhagic infarcts have been found in the spleen in from four to seven per cent, of cases coming to autopsy. Abscess of the spleen has been found. Perforation has been noted at necropsy in 5.7 per cent, of cases — that is, 114 out of 2000 autopsies in Munich; by Osier, in 2.48 per cent, of 685 cases. Schultz found peritonitis from intestinal perforation in 1.2 per cent, of 3680 cases in Hamburg in 1886-87 ' Liebermeister found perforation in 1.3 per cent, of over 2000 cases at Basle between 1865-72; Holscher, in 6 per cent, of 2000 cases; and Murchison, 11.38 per cent, of 1721 cases. In 4680 cases collected by R. H. Fitz the deaths from perforation were 6.58 per cent., which may be said to represent about the proportion actually occurring, since up to the date of his report nearly all died. It occurred in only one of 105 soldiers treated at the University Hospital in the fall 22 INFECTIOUS DISEASES. of 1898. The range of percentage of perforation may, therefore, be put down at from 1.2 to 11.38 per cent. As to the location of perforation, Hawkins found it in 61 of y2 cases in the ileum, 3 in the cecum, 3 in the appendix, and 5 in the colon, most of the latter being in the sigmoid flexure. In 167 cases collected by Fitz the ileum was perforated in 136, the large intestine in 20, the appendix in 5, Meckel's diverticulum in 4, the jejunum in 2. The number of perfora- tions is usually i, but Fitz reports out of 167 cases, 2 in 19, 5 in 3, 4 in i, several (sic) in 4, and 25 to 30 in 2. The accident is most frequent in the third week, or close to the third week. It is more frequent in men. The liver, among organs more rarely affected, shows cloudy swelling, granular and fatty degeneration of its cells, lymphatic nodular areas, and even liver abscess with pylephlebitis, and acute yellow atrophy. Abscess of the liver was found 12 times in the Munich necropsies, and acute yellow atrophy 3 times. Pylephlebitis has followed abscess of the mesentery and perforation of the appendix. Typhoid bacilli are often found in the gall- bladder in fatal cases; in Chiari's reports* 19 out of 22; in Simon Flex- ner's, 7 out of 14. Perforation of the gall-bladder is sometimes met, and Keen has collected 30 cases in his book on the " Surgical Complications and Sequels of Typhoid Fever," 1898. .Nine cases of abscess of the spleen were collected by Keen, who also reports a leukemic spleen that seems to have been caused by typhoid fever. In the kidneys there may be cloudy swelling and granular degenera- tion of renal cells, more rarely acute nephritis, which may even be hemor- rhagic ; also miliary abscesses in which typhoid bacilli have been found. Diphtheritic and catarrhal inflammation of the pelvis of the kidney and catarrhal inflammation of the bladder are occasionally present. Changes in the respiratory organs are often found. Among the rarer of these are edema of the glottis, ulceration of the larynx, and even necrosis of the laryngeal cartilages. Hypostatic congestion of the lungs is quite common ; pneumonia is more infrequent. Even gangrene of the lungs was found in 40 of the Munich cases ; abscess, in 14 ; and hemorrhagic infarction, in 129. Pleurisy and empyema are rare events. Dr. Arthur V. Meigs f has described changes of a hemorrhagic character in the lungs, and others in the muscular and nervous systems, the essential relation of which to typhoid fever remains to be demonstrated. In the circulatory system there may be thrombosis of veins, especially of the femoral, causing the not very rare symptom of milk leg ; more rarely there is thrombosis of the femoral artery, which may be preceded by embo- lism. Endocarditis and myocarditis may be present. The latter condition is attested by a yellow, soft, and flabby muscle seen after death. As to the nervous system, notwithstanding the intensity of the nervous symptoms at times, meningitis is a rare event, though both serious and purulent forms have been met, typhoid bacilli being found in loco as the apparent cause ; also thrombosis of cortical veins and parenchymatous changes in nerve-trunks, even when there have been no symptoms of neuritis. Abscess of the brain has also been found with the bacillus typhosus in loco. In the muscular system granular and hyaline transformation of voluntary muscle may occur, as in other fever processes. Abscesses in the parotid gland are a familiar complication ; more rarely, abscesses in the intermuscular tissue. General invasion of all organs and * • Prager medicinische Wochenschrift," i8q^. No. 22. t "Proceedings of the Pathological Society of Philadelphia," 1890. TYPHOID FEVER. 23 of the blood by the typhoid bacillus was found once in William Osier's wards at the Johns Hopkins Hospital by Simon Flexner. Typhoid Fever unthout Enteric Lesions. — A few years ago typhoid fever without enteric lesions would have been considered an impossibility. This can no longer be claimed. Cases have been reported by Sidney Philips, J. W. Moore, Simon Flexner, and others, without these lesions. In doubt- ful cases the Widal reaction and the presence of bacilli as determined by cultures must be appealed to, such examinations being suggested by other symptoms. Symptoms and Course. — A certain period of incubation is necessary after the successful implantation of the bacillus before typhoid fever arises. This varies from a week to two weeks and even longer. The period of incubation is usually without symptoms, but a sense of weariness and indis- position to exertion, the latter often overcome by force of will, may be present ; so may a want of appetite and a slight coating of the tongue. These symptoms, more strictly speaking, belong to the prodrome, and are in turn not sharply separated from those of the disease itself, which usually sets in very gradually, and is often quite advanced before suspected, — indeed, sometimes well advanced, constituting the " walking "" or '' ambulatory " typhoid. In children the onset is less gradual. There may be headache, anorexia, a furred tongue, nausea, chilliness, but only rarely a decided rigor. The disease may be ushered in by pain in the back or legs or muscles and nosebleed. The latter has always been considered characteristic, and yet I meet it less frequently than might be expected from the text-book state- ments, yiore common is looseness of the bozvels. All this time there is slight fever, and the patient feels wretched. The fever and the discomfort increase, and finally he goes to bed. The tendency to looseness of the bowels and epistaxis, more than any other symptoms of this group, justify strong suspicion of the existence of typhoid fever. Yet one or both are quite often absent. Certain epidemics are more apt to be attended by diarrhea than others. The abdomen soon becomes slightly distended and tympanitic, and pressure in the right iliac fossa will usually elicit tenderness with gurgling. At times there is colicky pain of varying severity independent of pressure ; at others the gastric symptoms are marked and there are nausea and zvni- iting. Usually about the eighth day, rarely later and sometimes a little earlier, rose-colored spots make their appearance on the skin of the abdomen and chest, more rarely elsewhere on the body. These call for further description. They are usually bright red in color, and are well compared to a fleabite. They are very slightly, if at all, raised above the surface and disappear on pressure, to return instantly after its removal. Their number varies greatly. Sometimes they are very numerous, oftener there are four or five to ten. again one or two, most rarely none. When numerous, they occur in suc- cessive crops, each crop lasting from two to four days. Histologically, they are circumscribed, actively hyperemic areas, the hyperemia being excited by some irritant, which may be the typhoid bacillus itself, since it has been found in the spots. Only in the most malignant cases is there any blood found outside of the vessels, and when this occurs, the spots can be made to disappear but partially on pressure. The association of roseolar spots is so intimate with the disease that they have been regarded as pathogno- monic. Rose-colored spots are much more uncommon in children. In addition to rose-colored spots, sudauiina are often present in large 24 INFECTIOUS DISEASES. numbers on the skin, especially when the disease is associated with much sweating, but their occurrence is by no means constant, and their association with Other diseases in which there is perspiration is well known. More rarely, petechia: and t'ibices are noted in adynamic forms of the disease. An erythema is quite often found on the skin of the chest and abdomen. Peliomatous patches — the tache hleuatre — sometimes are found on the skin of the thorax, abdomen, and thighs ; also the tache ccrebrale — a red line, produced on drawing the finger-nail over the skin, — but neither have any symptomatic significance. Herpes is so rare that it is often spoken of as. negatively pathognomonic. Jaundice is occasionally seen, and may be the result of an obstructive cholangitis excited by the bacillus. Enlargement of the spleen is an almost constant clinical feature of typhoid fever. If the vertical dullness exceeds the depth of two ribs and an interspace, enlargement is present. Not only may such enlargement be recognized by percussion, but by palpation as well. Clinicians generally lay great stress on palpation, and enlargement may sometimes be detected by it when the organ eludes percussion by reason of tympany. Hermann Eichhorst advises the following method of examination : Put the patient in the right diagonal position, and lay the finger gently between the anterior ends of the eleventh and twelfth ribs, when the enlarged organ can almost always be felt with every deep inspiration of the patient, in spite of meteo- rism. At times the outline is indistinct, at others both the tip and anterior edge of the organ can be distinctly located. Strong pressure should not be exerted by the fingers, for in this way the spleen may be insensibly pressed backward into the excavation of the left hypochondrium. Enlargement can generally be detected at the end of the first week or in the first half of the second week, when the organ may reach twice or three times its normal size. By the end of the third week it begins to diminish in size. The enlargement may be accompanied by tenderness. Enlargement of the spleen is less fre- quent in cases occurring late in life. Early, too, in the disease the patient may have a slight cough, unasso- ciated with physical signs, or at most those of a mild bronchial catarrh. The fever is at once the most important and characteristic symptom, and from the temperature alone a diagnosis can be made. During the increment of the disease it exhibits a peculiar, tide-like evening rise and morning fall, while the temperature of each morning and evening is from one and a half to three degrees higher than that of the previous morning and evening. The patient isjarely seen at the very beginning of this first stage, but should he be, it will be found to last commonly a week. Fre- quently it is succeeded at the end of four or five days by the acme or fasti gium, in which are continued the evening rise and the morning fall, but the evening and morning difterence is less marked, the tidal character is no longer present, and the temperature is high throughout. The average duration of the fastigium is five to eight, rarely ten days, being longer in severe cases and shorter in milder ones. It is during it that we meet the maximum temperature, quite often 105° F. (40.5° C.) or a little above, more rarely 106° F. (41.1° C). A temperature of 106° F. is not infre- quently followed by recovery, but while 107° F. (41.6° C.) and 108° F. (42.2° C.) and even 109° F. (42.7° C.) are met, such cases have invariably, in my experience, terminated fatally. The fastigium is succeeded by the third stage, or period of decrement or decline, in which the reverse of the initial stage is shown by an evening TYPHOID FEVER. 25 temperature lower than that of the previous evening, and the morning temperature lower than that of the previous morning, but with the evening temperature still higher than that of the morning of the same day. This decline continues until the normal is reached, and from one to two weeks are consumed before that is attained. The whole is much better shown and more easily understood from a chart than from a description in words. Such a chart of the temperature uninfluenced by treatment is seen in figure I, although the rise and fall are not always as regular as indicated. In a typical case one might safely place the first stage at four days to a week ; the second, or fastigium, at seven to ten; and the third, about as long as the second, the shorter period corresponding to a mild case and the longer to a severe one. The fever does not always reach the higher temperature shown 1ST WEEK 2D WEEK 3RD WEEK 4TH WEEK I s; 1: i Fig. I.— Temperature Chart of a Typical Case of Typhoid Fever Uninfluenced by Treatment. in the chart, and sometimes the maximum never reaches 102° F. (38.9° C). On the other hand, there is sometimes a difference of three or four degrees in the morning and evening temperature, and the latter may drop to the normal. In ordinary cases the evening temperature falls to the normal in the course of the fourth week, but in severe cases the temperature keeps up during the fifth and even sixth week, these cases having almost invariably extensive ulceration with great tenderness of the abdomen and meteorism. Many of them terminate unfavorably by hemorrhage or perforation. When the disease begins with a chill, — a rare event, — the temperature rises more rapidly in the beginning. Sudden falls of a decided character 26 INFECTIOUS DISEASES. may occur in consequence of hemorrhage from the bowels or the nose or from collapse after perforation of the bowels. Sudden rises are produced by indiscretion in diet and overexertion or the supervention of some acute in- flammatory affection, as pneumonia, or ptomain absorption. Copious szi'catiiig characterizes some cases of typhoid fever, though the skin is more commonly dry. Sometimes, during the reaction after a cold bath, there is perspiration. The profuse sweats first alluded to are not attended by a reduction of temperature. On the other hand, they are some- times present when the temperature is highest. Cases of recurring paroxvsms of chill, fever, and sweat are reported, which simulate intermittent fever, and may reasonably be mistaken for it. The pulse is only moderately frequent, 90 to 120 being the usual range, while a proximity to 100 is quite frequently maintained. In grave cases it becomes more frequent. 14c or more; when, if maintained, it is a rather unfavorable symptom, due to high temperature or complications. Temperature and pulse do not always increase pari passu. Dicrotism may occur with frequent pulse, but dicrotism also occurs in the early stage, when it is regarded by some as diagnostic. During convalescence the pulse gradu- ally resumes its normal character, and sometimes becomes abnormally slow, falling to 30 or less. I have recently had a case in which the pulse fell as low as 18, and continued for one day between 20 and 36. The breathing rate commonly advances with the rate of the pulse, but is sometimes increased in frequency by temporary causes and rarely is dispro- portionately slow. In a very striking case of my own at the University Hos- pital the rate fell to twelve in a minute, and continued thus for an hour. The heart-sounds, at first natural, grow less loud as adynamia pro- gresses, and the first sound may even disappear in grave cases. Sometimes a soft systolic murmur develops at the apex, usually at the end of the second week. Sometimes it acquires greater intensity. It has been especially studied by M. G. Hayem,* who ascribes it not to an endocarditis, but to a relaxation of the muscle which results in imperfect apposition of the valves and a consequent regurgitation. This murmur disappears as recovery takes place, and the heart-muscle growls strong. As the disease advances, the tongue, previously furred, tends to become dry and brown, clearing, however, at the edges and tip as the case improves. In severe cases, especially if the mouth is not kept clean, stomatitis with fissures and bleeding may occur, and sordes may collect on the teeth, while the lips become covered with black crusts, constituting the " fuliginous coat- ing." These phenomena are almost unknown with the bath treatment. Mild grades of pharyngitis, producing difficulty in swallowing, sometimes usher in the attack, more particularly in certain epidemics. The diarrhea of typhoid fever has been alluded to. Usually correspond- ing in severity with the extent of the local lesion, it is seldom troublesome or difficult to control, and is sometimes absent throughout. The stools may be grayish yellow, and about the consistence of pea soup. Meteorisiii in moderate degree is an almost constant symptom. The dis- tention by gas is commonly ascribed to atony of the bowels. Its presence in high degrees adds to the seriousness of the case, since it corresponds usually with the extent of bowel lesion, and soon succeeds perforation. Hemorrhage from the bowels, also a consequence of intestinal ulceration *M. G. Hayem. " Des manifestations cardiaques de la fievre typhoid," " Le Proyres Mfedical," 17 Juillet, 1875, p. 401 et seq. TYPHOID FEVER. 27 and the separation of sloughs, is a serious symptom, but by no means always fatal, though large quantities of blood are sometimes discharged per amtm, The occurrence of such hemorrhage is followed by a rapid reduction of the temperature, as shown in the appended chart, and a pallor and faintness such Ui T r — \ \ S 1 UI i k t E T re 81^ UI X iffi^' >a t s •Kl V^ , ^ t S •wv l> UI ^^ > t E •Ai-ye^ *■' Ul • n • vg a , V* t S ■vl w p^» UJ M 3:r"^ X t E •W dfV., UI ■lAi d ?>, a t E •wd e> UI NpON 'f\jr''' X t E ™ wi.ii " "' i " UI j ~irvT®» « t S •W-V9.-- UI •w-y£-f t t E ^i-IAI ZMr- N UI vi-d 1 J 1 « t E • t • 1^ t ¥^ CO E •IM K) 2' ^ UI .„-U> C t. S •VI 'V ^ UI "t — — jk aSsr •t E _,,..,.,, . '.w-dSKd;' UI •w: 1* ^ t S wd frrf Ul •^m t t E 4^5U5. UJ i >lf §.?_ - __ _ _ _2 1; t r- E •f i^Lg- ^ T UJ :^s^'4 t t E ■w JTf >~^ UI ::::::::::::::::::::::Tm ■J^ t t £ •'W 'd ^» Ul •w|'d ZiTj ^ t E 1WV l't» — L :::::_::: UI 1 'i^l v 8p* t i5. I— E •W 'V ^1 '■ ''^ |:| ="1 °—i '0 °o5 °s A °S; 1 S ' ■" ' „■ < Q bO a '% o bO as are common to large hemorrhages elsewhere. As stated, very profuse hemorrhages may be followed by recovery, and it is barely possible that a favorable influence may sometimes be exerted by them. Very rarely a patient will bleed to death. Hemorrhage was a cause in 1 1 out of 56 deaths In 28 INFECTIOUS DISEASES, Osier's 685 cases. It occurred 99 times in 2000 cases in Munich, and 8 times in 105 soldiers under my care after the Spanish-American war. Perforation is attended by sudden acute pain in the abdomen, and symp- toms of collapse. The pain is rarely circumscribed, but radiates through the abdomen ; and I well remember a case when it was so high up that it seemed in the thorax and I mistook it, for a time, for that of pleurisy. It occurs most frequently in my experience in the third or fourth week, but it has happened as early as the eighth day and as late as the sixth week. In Fitz's cases it occurred in the third or fourth week in 46.5 per cent. ; in four cases in the first week and one in the sixteenth week. (See also Morbid Anatomy.) Delirium is less constantly present in typhoid fever than in typhus, and may be absent throughout. It may, however, be very active, requiring the patient to be carefully watched to prevent him from leaving his bed and seri- ously endangering his life. More than one victim has leaped from a window with fatal results under such circumstances. In certain cases, especially when the initial headache is very intense, this symptom continues, and to it are added fever and delirium so extreme that meningitis is simulated,, though the true form of this disease rarely occurs. Such cases illustrate the " nervous form " of the disease. A tendency to drowsiness, and even to stupor, suggested the common name " typhoid," but it is less character- istic than in typhus. Muscular tremor is a symptom in severe cases, when it would seem to indicate a muscular weakness or exhaustion, which may be an effect of high temperature or of the specific poison of the disease. Carphologia, or " picking at the bedclothes," is a symptom of which the unfavorable import has been somewhat exaggerated, probably because of the popular familiarity with Dame Quickly's interpretation in Falstaff's illness. Concurrently with these " typhoid " symptoms, the tongue reaches its maximum dryness, and may be dark and leathery in appearance, while sordes may collect on the teeth. Bed sores are among the dangers of protracted cases. Hiccough is an infrequent, but sometimes obstinate symptom. Apart from an initial bronchial catarrh, which sometimes ushers in the disease, the typhoid patient sooner or later acquires a slight cough, due to hypostatic congestion of the lungs, but it is easily kept within bounds by fre- quent changes in the position of the patient. Occasionally, the cough is quite severe, but seldom requires more active treatment than this. The initial bronchial catarrh, too, sometimes assumes severity, while more rarely the symptoms and signs of pneumonia usher in the disease. Changes in the Urine. — The urine is always dark-hued and concentrated, with a correspondingly high specific gravity. Often when the fever is high the urine contains a small amount of albumin. When complicated with nephritis, there is more albumin, and tube-casts are present. Recent French statistics place albuminuria, regardless of its cause, at over twenty per cent. While such albuminurias are found in grave cases, they do not appear to add greatly to the seriousness of the case, and recovery is by far the more usual termination. More rarely, nephritis in a mild form may develop during con- valescence. Most rarely, it may be the initial symptom of the disease, con- stituting a nephrotyphoid analogous to the pneumotyphoid, when it may even mask the true disease by the severity of its symptoms. It is well named by the French — fievre typhoide a forme renale. Only the Widal test, the intes- TYPHOID FEVER. . 29 tinal symptoms, and the spots clear up the diagnosis. Such nephritis may rarely be hemorrhagic. The toxic properties of urine are said to be in- creased during typhoid fever, especially while the cold baths are being used. The urine may contain bacilli of typhoid fever, generally associated with albumin. The following summary from Norman B. Gwyn's paper in the " Johns Hopkins Bulletin," June, 1899, condenses our present knowledge. " I. In quite a high percentage, perhaps from twenty to thirty per cent., ■of all cases of typhoid fever typhoid bacilli may be present in the urine. " 2. When present, they are usually in pure culture, often so numerous as to make the freshly voided urine turbid, and may then be detected by a cover-slip examination, " 3. Appearing generally in the second and third week of illness, the •organisms may persist for months or years, probably multiplying in the bladder, the urine being apparently a suitable medium for their growth. " 4. Though often showing evidences of cystitis and marked renal in- Tolvement, the urine containing bacilli has usually only the characteristics of an ordinary febrile urine; the presence of bacilli has no prognostic impor- tance, and their disappearance or persistence, without having induced local change, is the rule. "5. Lastly, as shown by Richardson, irrigation of the bladder with "bichlorid of mercury and the internal administration of urotropin — a com- pound of ammonia and formaldehyde — seem to be safe methods of remov- ing the bacilli ; thirty to sixty grains of the latter quickly removing all bacilli in six cases." The so-called diazo reaction of urine, to which attention was first called "by Ehrlich in 1882, is so constant in this disease as to be deservedly regarded as a symptom. It was found by John Hewetson in 136 out of 196 cases, and by Arthur R. Edwards in 128 out of 130 cases, and by Simon in 22 out of 26 cases. I have never found it absent when the test was made sufficiently early. Three solutions are kept in separate bottles : 1. A five per cent, solution of hydrochloric acid saturated with sul- phanilic acid. This solution should be fresh. 2. A half of one per cent, solution of sodium nitrite. 3. Ammonium hydrate. When it is desired to make the test, 40 c.c. of (i) andc.c. of (2) are mixed. The hydrochloric acid, acting on the sodium nitrite, liberates nitrous acid, which in its nascent state combines with the sulphanilic acid, producing diazo-benzine-sulphonic acid. Equal parts of this mixed solution and urine are thoroughly shaken ; enough of the ammonia is then allowed to flow carefully down the side of the tube to form a colorless zone above the urine mixture. At the junction of the two fluids a dark-garnet or cherry- Ted ring will form if the reaction takes place, and if the tube is well shaken, a uniform red color is imparted to the entire fluid, which, when allowed to stand for some hours, shows a characteristic olive-green precipitate, the tipper layer of which, as a rule, has a still darker-green color. The reaction occurs about the time of the appearance of the ras'h and usually continues until the tzventy-second day, but it may disappear before the end of the second week. It is, as stated, symptomatic and not diagnostic, certainly not pathognomonic, as it occurs in many diseases with high fever, among which measles and miliary tuberculosis are conspicuous. It may, however, be 30 INFECTIOUS DISEASES. regarded as negatively pathognomonic — that is, its absence is strongly pre- sumptive against the presence of typhoid fever. Changes in the Blood. — The state of the blood in typhoid fever early claimed attention, and even the earliest observers, beginning v^ith Le Canu in 1837, noted a diminution of red hlood-corpiiscles. This observation has been DEC. 1890 . 19 22 26 28 311 3 6 9 JAN. 1891 12151B212427 SO^a 5 FEB. B 1114 7 20 23 26: 1 MARCH t 7 10 131618 90^ 80% 4,000,000 f \ / 70^ / / > 60^ 3,000,000 1 1 1 1 50^ / } ^ '^ / y -^ 40^ 2,000,000 \ 1 > A \ / «- " r^ 30SS \ \ y ' / / V ,'' ;^ ■^ * 20^ 1,000.000 • 10% 500,000 10,000 8,000 A \ 6,000 *^s ^V .^ \ / / to 4,000 \ / 'w 2,000 > / / V- "* _. Black — Red Corpuscles. Red— Hemoglobin. Blue— Colorless Corpuscles. Fig. 3. — Chart Showing Anemia of Typhoid Fever, — {From Thayer's ^' Monograph.") essentially confirmed by the "most recent studies with modern accurate methods, among vi^hich those by Ouskow,* by Khetagurow, f and by W. S. Thayer % are conspicuous. At the beginning of the fever the number of red blood-corpuscles is nor- mal and even at the upper limit of normal, because the patients are apt to be young and strong, while in some instances the initial diarrhea or pronounced sweating may cause slight concentration of the blood. During the first two weeks the number of red corpuscles gradually falls, though but slightly. With defervescence they fall off more rapidly, reaching a minimum usually about the first week of convalescence, after which there is a gradual rise to the normal, followed again by a possible slight fall when the patient gets up. *"The Blood as a Tissue," St. Petersburg:, i8qo. t" Pathological Changes in the Blood in Typhoid Fever," Inaug. diss., St. Petersburg, 1891. X " Two Cases of Post-typhoid Anemia, with Remarks on the Value of Examination of the Blood," vol. iv., "Johns Hopkins Hospital Reports," 1895. TYPHOID FEVER. 31 The fall in the number of red corpuscles, while relatively slight, bears usually a direct relation to the severity of the case. The hemoglobin is always reduced and the reduction is relatively greater than the corpuscular loss, with an even slower return to the normal. Extreme anemia, with a blood count as low as 1,300,000 corpuscles in a cubic millimeter and hemoglobin as low as twenty per cent., has been met. The number of leukocytes in a cubic millimeter, normal at the begin- ning, tends also to diminish slightly throughout the disease, reaching a mini- mum toward the end of defervescence, increasing again with the beginning of convalescence, and reaching the normal after several weeks. More defi- nitely the change consists in a diminution in the percentage of multinuclear or overripe elements, with a relative increase in the large mononuclear or ripe elements. Thayer regards the absence of leukocytosis of real diagnostic value, being in marked contrast with the distinct increase in the number of colorless corpuscles and overripe elements (multinuclear cells) characteristic of most other infectious processes. Typhus fever is unattended by blood changes, and while in a few cases of malignant pneumococcus infection there may be no leukocytosis, there is no diminution in the leukocytes, as in typhoid. The condition of the blood in malarial fever is practically the same as in typhoid fever, but the presence of the malarial parasite in the former is distinctive. In pure miliary tuberculosis unassociated with local inflammatory processes there is also an absence of leukocytosis. It is impor- tant to remember that cold baths have the effect of producing a decided tem- porary increase in the proportion of leukocytes, probably rather, as Thayer thinks, in consequence of an accumulation of white cells in the vessels of the surface than as the result of a true leukocytosis. More rarely, the leuko- cytes are increased. Cabot refers to four cases in which they reached 11,000, and in one 17,000, with no lesions other than those common to typhoid. Very interesting is the effect of suppuration on this reduction in the number of leukocytes. It is replaced by an increase as shown by counts after per- foration, phlebitis, and otitis. Especial value is claimed for leukocytosis as a warning of impending perforation and peritonitis. Unusual Modes of Onset. Unusual Symptoms. Atypical Forms. — It has been mentioned that while slight chilliness is often an initial symptom, severe rigor at the same stage rarely occurs. It does, however, happen, as in 13 out of 79 of Osier's cases. More frequently, chills have been observed in the course of the disease from some one of the following causes : 1. At the onset of a relapse. 2. As a result of treatment, especially by antipyretics internally, guaiacol externally, or of a hypodermic injection of a sterilized culture of typhoid bacilli. 3. At the onset of complications, such as pneumonia or pleurisy or thrombosis. 4. From sepsis during convalescence in severe and protracted cases. Under these circumstances chills may be frequent, severe, and of grave import. 5. From concurrent malaria. In epileptics who acquire typhoid fever the latter disease is very apt to be ushered in by an unusual number of epileptic convulsions, which continue frequent until the fever becomes established, then diminish, and finally cease, often not recurring until some time after recovery, causing the victim and his friends to believe that the chronic malady has disappeared. It returns, 32 INFECTIOUS DISEASES. however, sooner or later. The same is true of choreic attacks. Rarely, the ■disease is ushered in with convulsions in children. In diabetes the sugar may disappear during the fever. Among the more unusual modes of onset should be mentioned cases be- ginning with severe bronchitis ; those with the initial symptoms of pneu- monia, including chill ; those with initial symptoms of nephritis or with intense nervous symptoms, suggesting cerebrospinal meningitis. Among the latter are intense headache and photophobia, combinations rapidly pass- ing over into active deUrium, with muscular twitching and retraction of the head, constituting the nervous or meningeal form. In accordance with recent views these varieties may be considered as representing forms in which the organs especially involved are the primary and chief seats of attack by the bacillus as contrasted with the more usual intestinal form. In certain long and severe cases septic infection occurs, manifested by fever, sweats, and local abscesses in various parts of the body, including the perirectal and perinephric regions. Among irregular forms is the so-called abortive form. This doubtful form is said to be more sudden in its onset, beginning with shivering and fever of 103° F. (39.4° C.) or higher. The rose-colored spots appear at from the second to the fifth day. The fever falls at the end of the first week or beginning of the second, commonly by crisis with a sweat, after which fol- lows convalescence. The hemorrhagic is a grave variety characterized espe- cially by cutaneous and mucous hemorrhages, and is fortunately rare. The mild form is sometimes so mild as scarcely to be recognized as typhoid fever and is often called gastric fever or simple febricula. There is, however, no more important lesson for the inexperienced practitioner to learn than that some cases beginning as a mere febricula may pass over into forms of great ■severity, and may even terminate fatally. A very rare form is the tonsillar typhoid, in which whitish elevations appear on the tonsils, subsequently becoming ulcers. Complications and Sequelae. — The recent Spanish-American war has <:onfirmed the possibility of the coexistence of typhoid ever and of malarial iever, since a number of cases from among the soldiers have been reported in which not only all the necessary clinical features of typhoid fever were present, but also the Widal reaction, in which, too, the malarial organism was found in the blood. Such coexistence occurred in two of the cases •under my own care in the Hospital of the University of Pennsylvania. It is, however, an infrequent event. On the other hand, a mongrel disease that is the product of the two causes, as was once supposed to be the case, and known as typhomalarial fever, does not exist. The term should be dropped, as it is confusing and gives rise to erroneous impressions. Persons with tuberculosis, diabetes, epilepsy, and other forms of chronic nervous disease are as liable to typhoid fever as others, while scarlet fever, diphtheria, measles, chicken-pox, rheumatism, and especially erysipelas, may iDefall a typhoid case. Typhoid fever in diabetic cases is especially apt to be attended with low temperature. Typhoid fever itself predisposes to tuber- culosis, and not a few patients recover from the former disease only to be attacked by the latter. Thrombosis of the femoral vein, more frequently the left, resulting in phlegmasia alba dolens, or milk leg, is a complication that often greatly delays convalescence. It occurs, according to Murchison, in one per cent, of all cases. It sometimes invades both legs in succession, and may extend TYPHOID FEVER. 33 into the iliac veins and vena cava, thence even into the right auricle, caus- ing death from syncope. Unless the latter event occurs, however tedious the recovery, it takes place ultimately almost without exception. Very rarely there may be suppuration. Bacilli have been found in the thrombus. IMore or less phlebitis is always present. The question as to the primary event, whether thrombosis of phlebitis, is seemingly settled by this finding of bacilli, in favor of the former. Arterial as well as venous thromhosis may occur, and the former may start with embolism ; femoral arterial obstruction is most common, resulting in gangrene of the leg and foot. Embolic abscess may occur in the kidney and lung. Parotitis, commonly going on to suppuration, is an occasional symp- tom. It is the result of infection by Steno's duct. Xoiiia. or gangrenous stomatitis, has appeared as a complication or sequel in children. A\'. W. Keen records nine cases of w^hich five proved fatal. Gangrene in other situations occurs more rarely, as in the vulva in females and in the perineum and about the anus in both sexes. This may be due to arterial thrombosis. Perineal fistulae may follow in these cases. It has been mentioned that pneumonia may usher in the disease, and :a few words may be said here of the relation of the two conditions, pneu- monia and typhoid fever. The term typhoid pneumonia is one in common use by many who have no definite notion of its meaning, and, like the term typhomalax-ial, has occasioned confusion. In the first place, the case may begin as a lobar pneumonia, the intestinal symptoms appearing at the end of the first week or later, at which time also the spots may appear, establishing the diagnosis, while the usual crisis of pneumonia fails to make its appear- ance. Again, a pneumonia may supervene in the second or third week of a typhoid fever as a complication in which the true relation is less difficult to determine. Finally, there may be a true pneumonia, to which stupor, a dry tongue, and general adynamia may be added, without the distinctive lesions of typhoid fever. This is true typhoid pneumonia, which it may not always be easy to separate from the typhoid fever beginning with pneumonia. Both of the forms of pneumonia may be caused by the typhoid bacillus or the pneumococcus. Hypostatic congestion has been referred to. Many cases formerly thus named are really instances of catarrhal or lobular pneumonia iDelonging to the class of inhalation pneumonias. Such may terminate in abscess and gangrene. When pleurisy occurs, it has the same relations to the disease as pneumonia. It is. however, more rare, but may also be puru- lent. An initial nephritis has been mentioned on page ^2. Certain suppurative processes sometimes included as symptoms should be regarded rather as complications than symptoms. Of these those about the ear are the most serious. They are, however, less frequent in typhoid than in typhus fever. They are most common in the parotid gland, where, how- ever, the inflammatory process does not always terminate in suppuration, occasionally resolving itself with or without local treatment. The duct of Steno is probably the route of infection in these cases by the pus organisms that find conditions favorable to their work. The middle ear may be invaded, producing otitis media. Here the Eustachian tube becomes the route of infection. Sometimes abscesses are m.ultiple. Not infrequently convales- ence is delayed by numerous bods, the effect of which in keeping up the temperature must be remembered. The bladder may be a seat of suppuration, and pyuria is not infrequently present. George Blumer found it in 10 out of 60 cases, or nearly 17 per 34 INFECTIOUS DISEASES. cent., of a series admitted to the Johns Hopkins Hospital. I have met it only once in a pronounced form in a series of 41 cases, but also in isolated cases more frequentl}- since my attention has been called to its possibility. It is probably caused by the typhoid bacillus. The inflammation may extend to the pelvis of the kidney or start therefrom. Orchitis and epididymitis are also occasional symptoms during convalescence. Thompson S. West- cott collected 32 cases for Keen's book, " Surgical Complications and Sequels of Typhoid Fever," 1898. Cardiac complications, including pericarditis, endocarditis, and myocar- ditis, are sometimes present. The latter may be a cause of sudden death. Neuritis is an occasional complication or sequel in both the local and multiple forms. Osier found it, however, m but 4 of 389 cases. The pain may be severe and associated with the usual tenderness of the nerve trunks. I recall one patient who made a splendid recovery under the tub-bath treat- ment, but had the exquisitely tender toes first described by Handford. The tenderness is often so great that the bedclothing must be kept raised by a cradle. I find neuritis, too, more frec|uent since I have been watching for it. Even cases of optic neuritis with atrophy of the optic nerve have been reported, but it is probable that these are sequelae of meningitis mistaken for typhoid fever. Tetany sometimes succeeds typhoid fever. Two sequelae of typhoid fever, neither of frequent occurrence, are con- spicuous by their symptoms. They are insanity and tubercular phthisis. The former is often typical acute mania, requiring the utmost vigilance to- prevent the patient from injuring himself and others, or from escaping from the house or jumping from a window. Although this form of insanity is often prolonged for many weeks, the prognosis is singularly favorable, and recovery, sooner or later, takes place. Tubercular phthisis, when it occurs, has its predisposing cause in the lower tone of cell life, favoring the suc- cessful implantation of the specific bacillus, and is followed by its usual consequences. Post-typhoid hone lesions are surprisingly common. Sir James Paget, Alurchison, W. W. Keen, Haywood, Harold C. Parsons, and others have collected many cases. They include osteitis, necrosis, and periostitis. The tibia is the favorite seat, — 91 times out of 216 of Keen's collec- tion, — next the ribs 40 times, the femur 22 times, the ulna 15, and the humerus 11. Ebermaier, in 1887, obtained from two cases of suppura- tive post-typhoid periostitis the bacillus of Eberth in pure culture, and since then quite a number of cases have been reported : whence pyogenic properties of this bacillus may be inferred. Other bacilli — viz., the staphylococcus, streptococcus, and pneumonococcus — are, how'ever, at times associated. Golgi also produced suppuration by injecting pure typhoid bacilli subcu- taneously at a distance from the fractured ends of a long bone in a lower animal. The pus showed in culture only typhoid bacilli. Perichondritis appears to be a frequent complication in Germany, as- shown by the collections of Keen, Liining, and Westcott — 169, 13, and 14 respectively. Keen's and Liining's lists include the same cases. The disease is certainly less common in England and America. Necrosis of the carti- lages, as \vell as ulcers, are frequent results. . All of these surgical compli- cations are easily explained since the recognition of the bacillus. The typhoid spine, to which attention was called by Gibney of New York in 1889, is a sequel of undetermined nature. There is sever pain in the back, commonly aggravated by motion. The pain may be throughout the TYPHOID FEVER. 35 whole spinal region or limited to the cervical, dorsal, or lumbar por- tions. From the latter it may extend toward the hips. It may be a spondylitis, but is probably a pure neurosis. Allied to this condition is perhaps an obstinate periostitis of the sternum or the crest of the ilium or front of the spinal column after typhoid fever, alluded to by William Pepper in the " Text-book by American Teachers." These conditions are rare and sometimes, at least, may be coincidences. Cholelithiasis is now a well-recognized sequel, Dufourt having reported it in 19 patients who had their first attack after typhoid fever. Further interest attaches because there is every reason to believe that the bacilli in the gall-bladder are the initial cause of the process which results in stone, Bernheim first called attention to this possibility in 1889, and is sustained by Dufourt, Milian, Hanot, Maurice, H. Richardson, Mason, W. H. Welch, and W. W. Keen. Polyuria is a rare complication. A remarkable case Avas reported by Dr. James C. Wilson, at a late meeting of the Section on Medicine of the Col- lege of Physicians of Philadelphia. Such excessive polyuria must be due to an irritation by bacilli of the urinary center in the medulla. Relapses. — These occur readily, succeeding, it used to be taught, upon premature relaxation of diet. The demand of the convalescent for change in food, and especially for solid food, is often well-nigh irresistible, but should be denied until the temperature has been normal for a week. With our present views as to the etiology of typhoid fever relapses cannot be thus explained ; for, while such indiscretion in diet might reasonably be expected to renew intestinal lesions, it would not be expected to revive the life of the original cause, the bacillus. Accordingly, we must look elsewhere. As long ago as 1871 Hamernjk, quoted by Murchison and Maclagan,* suggested that the relapse is really a reinfection of the large intestine from the small by the passage of sloughs over healthy lymphoid follicles. Hugh Stewart t reiterated this suggestion in 1894, but Murchison early noted that the fresh lesions are sometimes higher up in the ileum than those of the first attack. Liebermeister believed that a part of the typhoid poison remained latent somewhere in the body, awaiting some exciting cause to bring it into activity. G. Fiitterer | claims to have been the first to discover the typhoid bacillus in the gall-bladder in 1888; § also that he was the first to express the opinion that relapses are caused by typhoid bacilli entering the intestines with the bile. Dupre || and Chiari ^ were among the first to find typhoid bacilli almost constantly present in the gall-bladder of those ill with typhoid fever, and suggested the possible responsibility of these bacilli for relapses. They may be discharged into the small intestine without harmful result after immunity is secured. Prior to this period, however, the patient may suffer a relapse. Thus may be explained the occurrence of relapses after indiscretions in diet, which stimulate the action of the liver and cause more bacilli to be poured into the bowel, thus increasing the chances of infection. Chiari's experience leads to further confirmation, since in three cases of relapse the number of bacilli in the gall-bladder was very large. B. Curshmann, in his paper on tphoid fever in Nothnagel's ♦"Edinburgh Med. Jour.," vol. xiv., part ii. p. 865, 1871. t "Practitioner," vol. liii. p. 185, 1894. i " Medicine."' Noveinber. 1898. § "Miinchener mad. Wochenschrift," No. ig, 1888. |l "Les infections biliaires," "These de Paris," 1891. , „ ..™ ^- ^■. ,. ^ if"Prager medicinische Wochenschrift," 1893, No. 23. See also Brannan, ' Twentieth Century Practice of Med.," vol. xvi. pp. 678 and 679. 36 INFECTIOUS DISEASES. " Encyclopedia of Practical Medicine," says of relapses : " Undoubtedly their development is to be attributed to the re-entrance into the circulation of living typhoid bacilli which, after the primary attack, were left behind in various organs ; and associated with this, more or less complete development of the local and general typhoid lesions occurs.'"^ It has been usual to regard as necessary to the diagnosis of relapse the presence of those symptoms essential to the primary diagnosis — ^ viz., the characteristic spots, a return of the tidal or step-like tem- perature, and, scarcely less so, the enlarged spleen, and all of these after complete defervescence. In my experience this dare not be insisted upon. The attack is, however, usually less severe, the duration shorter, and recovery the rule. Relapses are to be distinguished from recru- descence, which is a simple return of fever, often induced by numerous ca.uses, including lapses in diet, too much excitement, and the like. Relapses may be multiple. Transverse markings on the finger-nails incident to multiple relapses are sometimes noted. The number of relapses varies greatly in the experience of different observers — from one to eighteen per cent. Of 112 cases admitted to the Hospital of the University of Pennsyl- vania from the various military camps of the country, in the fall of 1898, there was a percentage of 10.7. Certainly it is smaller with the bath treat- ment. Relapses are more frequent in young persons than in older ones. Diagnosis. — Typhoid fever is usually easily recognized by the fairly well-trained medical man, while the experienced hospital physician may even know the disease by the dull, dusky facies. At other times diagnosis mav have to be delayed until the distinctive signs appear. The peculiar range of temperature is the most distinctive symptom, and from it alone the diagnosis may be made. The rose-colored spots, occurring about the eighth day, are conclusive if present, but they are occasionally absent. Diarrhea is less constant, and in my experience nosebleed still less so, but more char- acteristic. Both, however, require to be weighed in association with other symptoms. No one symptom is pathognomonic. The resemblance of typhoid fever to certain cases of rapid consump- tion has long been recognized, but the modern temperature chart has greatly diminished the difficulty of distinguishing them. Certain cases of malarial fever, especially the autumnal type, also very closely resemble typhoid, but here, too, the temperature diagram is not identical, while the usually easy recognition of the malarial jorganism completes the solution. Where the two diseases are concurrent, as is sometimes the case, the difficulties are increased. Mention has been made of the close resemblance of the so-called nervous variety of typhoid fever to cerebrospinal fever, and it is sometimes so mis- interpreted. As the disease progresses, however, the distinctive signs develop and the correct diagnosis is gradually made. Further, unless an epidemic of cerebrospinal meningitis prevails, the probability that this com- bination represents the early stage of typhoid fever is far greater than that it is cerebrospinal meningitis. The popular term, " brain fever." now pass- ing into disuse, doubtless included many of the cases of nervous typhoid. More misleading, e^-en though less frequent, are the cases beginning *The term recrudescence is not alwa^'s similarly used. Thus Curschmann. in the article alluded- to, regards relapse and recrudescence as due to the same cause and calls it relapse if it succeeds upon a perfectly afebrile period, and recrudescence if the reascent occurs during the period of involution before the declining temperature has coiriDletely returned to the normal. I prefer to retain the distinction given in the text, which is also that adopted by Osier. TYPHOID FEVER. 37 with decided pulmonary symptoms suggesting pneumonia rather than typhoid fever, and unless the physician is awake to the possibilities of such a beginning and watches further developments the case may be regarded as one of typhoid pneumonia. Doubtless some cases that are still regarded as lobar pneumonia are typhoid fever. Such a mistake might have been made in the case reported by Osier in the third edition of his " Text-book/' when only the symptoms and morbid anatomy of pneumonia w€re found, but in which pure cultures of the typhoid bacillus were isolated from the lungs, liver, kidneys, and spleen. Xo lesion of the intestine and no other organisms were present. Certain cases of concealed suppuration resemble typhoid fever in the symptoms produced, and may for a time mislead. But again the tempera- ture chart, after a few days' observation, will solve the question. It is in such cases that a study of the blood is of value — the presence of leukocytosis pointing to suppuration, and its absence, to typhoid. Of specific aids to diagnosis the isolation of the bacillus is attended with many difficulties, since the tapping of the spleen is not considered justifiable, and cultures from the blood and feces are difficult to obtain and uncertain. The serum diagnosis, or the JJldal or JVidal-Griibler reaction, which depends upon the fact that the diluted serum of a patient suffering from typhoid fever will cause actively motile typhoid bacilli to lose their motility and to become aggregated into clumps, is the best aid at hand. The active principle underlying this reaction is the presence in the blood of a substance termed agglutinin. In many diseases this substance is present, and it is found to be specific in its reaction to the causal bacterium. However, in some normal sera a non-specific agglutinin is found, which will produce the agglutination of several varieties of bacteria. The test may be said to be pathognomonic, but, because of conditions to be spoken of later, not always applicable as an aid to the immediate diagnosis of a doubtful case. Kneass and Stengel * report that in 2383 cases of typhoid fever the reaction was present in 95.5 per cent, of the cases, and that in 1365 non-typhoid cases it was absent in 98.4 per cent, of the cases. Taking these statistics. the absence of the reaction in 4.5 per cent, of the typhoid cases may be due first, to faulty clinical diagnosis, for at the present time there is reason to believe that there are infections caused by bacilli of the typhoid-coli group, the sera of which will only agglutinate these modified types, Avhich have been termed paracolon and paratyphoid infections. Second, it may be due to the fact that in these cases the test was not applied continuously during the supposed attack of typhoid fever, since from statistics collected by Hermann Biggs, of the Health Department of New York City, the serum of typhoid patients gave the reaction during the first week in about 70 per cent. ; during the second week in about 80 per cent. ; and during the third and fourth weeks in about 90 per cent, of the cases. Thus in cases clinically typhoid the test should be made every tw^o or three days during the disease before it can be said that the reaction is absent. This late reaction, of course, is of little practical value, since the diagnosis will have been made much earlier by the more usual methods. The reaction has appeared for the first time as late as the forty-second day. and in a few isolated cases has rem.ained absent throughout the course of the disease. Indeed the reaction has been found as long as eight years after recovery, f •Gould's "Year-book," i8q8. + "Clinical and Scientiric Contributions upon the Value of the Widal Reaction, based upon the Study of Two Hundred and Thirty Cases," Philadelphia Med Jour., vol. iii. p. 778. 38 INFECTIOUS DISEASES. The presence of the reaction in i.G per cent, of non-typhoid cases is due either to faulty technique, /. c, the dilutions were not high enough since the agglutinin found in some normal sera will agglutinate the typhoid bacilli in insufficient dilution ; or to the fact that the patient may have passed through a tvphoid infection some months previous, because the reaction has been found in some cases to be present many months after the recovery from the disease. It may occur as early as the third day, but is usually observed about the seventh day. It gradually becomes more marked as the disease progresses, and is commonly present in the blood of convalescents, and for months after recovery, though in some cases it disappears before the end of the disease. It is also true that the severer the infection, the more marked the reaction, and vice versa. Pleural and pericardial efifusions, the bile, the milk, and to some extent, the urine of typhoid fever cases, as well as the blood serum, possess this agglutinative property for typhoid bacilli. Widal, in his original communication, described the reaction as it occurred in vitro, as follows : " The blood or serum to be tested was added to either a young bouillon culture, or to sterile bouillon which is at once inoculated with the bacillus. In the former case the reaction with the typhoid serum appears usually within two or three hours, and consists in the clarifi- cation of the previously turbid fluid and the formation of a clumpy sediment composed of accumulated bacilli. In the latter case the tube is placed in the incubator, and within fifteen hours the reaction is manifest in the growth of the bacilli in the form of a sediment at the bottom of the tube, the fluid remaining nearly or quite the same." This method, of course, is impracticable from a clinical point of view, nor is there any attention paid to the degree of dilution or to the time necessary for the agglutination to take place. There are several details in the technique of this test which require attention, in order to make it of value as an aid to diagnosis. I append the method employed at the A\'illiam Pepper Laboratory of Clinical Medicine, because experience has proved its accuracy. A strain of typhoid bacilli is selected which by experiment is known to be easil}- agglutinated by sera from undoubted cases of typhoid, and which gives little or no reaction to normal sera. The stock culture of this strain of bacilli is preserved on slanted agar at room temperature, and sub- cultures made once a month. For the test, a sub-culture eighteen to twenty-four hours old is used. From this culture an emulsion is made in physiological salt solution. This emulsion is examined in the hanging drop with a power of 800 to 1 000 diameters, and should be entirely free from clumping, the bacteria should be actively motile, and the number of bacteria to the field should not be too great. If any clumping is present, the emulsion should be filtered through a sterile filter paper. The blood is collected in a sterile capillary tube having an enlargement in the middle. After it is collected the ends of the tube are sealed in the flame. One drop of the clear serum is diluted in five drops of a physiological salt solution (dilution i to 5). One drop of the prepared emulsion of typhoid bacilli and one drop of the diluted serum are then placed on a cover glass and examined as a hanging drop. If no agglutination takes place within ten minutes the reac- tion is said to be negative; but, if agglutination does take place within that time, it may or may not be positive, since normal sera may agglutinate the typhoid bacilli in the dilution i to 10. A dilution i to 50 is then made : one drop of the diluted serum (dilution i to 5) is added to 10 drops of TYPHOID FEVER. 39 the bacterial emulsion in a watch glass. A drop of this mixture is then examined in a hanging drop; and if agglutination takes place within an hour and there is no clumping in the control, it is said to be positive ; otherwise it is said to be negative. This method furnishes a means for accu- rate dilution, but is, of course, less practical than the dried blood method suggested by Wyatt Johnson, of Montreal, because of the necessity of having at hand a glass capillary tube. In the dried blood method the same technique may be followed as that described above. A drop of the dried blood, which has been collected on absorbent or smooth paper, or on a piece of glass, is diluted with five drops of a physiological salt solution, making an approximate dilution of i to 5. The test should then be carried out in the same manner as in the serum method.* Diagnosis of Perforation, — In view of recent increased success of operation for perforation, an early recognition of this accident becomes important, to which end a close watch should be kept for warning symp- toms. Among the latter is hemorrhage from the bowels, for, while by no means always followed by perforation, it precedes this accident in a certain number of cases. Its occurrence should, at least, excite increased vigilance in looking for the signs of perforation, and particularly suggests a count of the blood with a view to discovering leukocytosis. To this end frequent counts should be made. If leukocytosis be found, there is additional evidence of impending perforation, though it is to be remembered, too, that abscess in the parotid and otitis media also produce leukocytosis. Perfora- tion itself is usually ushered in by sharp pain, tenderness, rigid abdomen, lowered tempera«Lure, frequent pulse, followed later by meteorism, vomiting, the pinched features, and cold, clammy skin of collapse. If the perforation is in the appendix, the symptoms are those of perforation succeeding appendicitis. It may occur in the mildest cases, and in such especially, the appearance of localized pain and tenderness may also be regarded as a warning. Tympany is not always present, while it is often evident when there is no perforation. In a second class of severe cases where there is delirium or stupor, abdo- minal distention may be the only symptom. In a few instances there are no evident signs and the perforation may be first found at autopsy. This occurs commonly in cases of unusual gravity, where the event is masked by the severity of the symptoms. Prognosis. — The mortality of typhoid fever varies so much in dififerent epidemics and under different circumstances that statistics are of doubtful value in measuring fatality. Extremes of mortality claimed are as low as one per cent., and even less by the Brand bath method as carried out on the continent of Europe, and as high as fifty-five in army practice during cam- paigns and among negroes. The average of all may be put down approxi- mately at from ten to thirty per cent, before the Brand cold tub treatment was instituted. Prior to this, hospital treatment appeared less successful than that of private practice. Since its introduction, because of the greater ease with which that treatment can be applied in hospitals, this can hardly be said to be the case. In private practice a decided majority get well, fully 80 per cent., with rest, liquid diet, and family nursing. With skilled nursing, judicious feed- ing, and symptomatic treatment, a larger proportion of recoveries takes place. * See also a paper on the " Principles Underlving the Serum Diasfnosis of Typhoid Fever and the Method of Its Application," by Prof. W. H. Welch, "Jour. Am. Med. Assoc..' August 14. iSOT- «-a interesting resume of the development of our knowledge of the subject will also be touna tnere. 40 IXFECTIOUS DISEASES. sav 90 per cent. In hospitals where the Brand method is correctly carried out there is an easy reduction of mortality to 7 per cent, and less. In this- country the results have not been quite so satisfactory as on the continent of Europe. The mortality of \Mlliam Osier's cases at the Johns Hopkins Hospital, Baltimore, has been j.t, per cent. My own. at the Hospital of the University of Pennsylvania and at the Philadelphia Hospital, has been 7.3 ; that of James C. Wilson and others at the German Hospital, up to January I. 1896, 7.25 per cent. — astonishingly uniform results.* Brand's own mor- tality has been but i per cent. Of my own cases treated by the Brand method all who died perished through perforation or hemorrhage of the bowels. Among the soldiers under my care at the Uniyer5!ty Hospital in 1898-99 treated by the Brand method the mortality was 4.5 per cent. Among causes which have contributed to reduce percentage of deaths is the including of mild cases as determined by more accurate diagnosis. U)i favorable synipfoins are persistent high temperature, above 105^ F. (40.5^0.), low muttering delirium, extreme tympany, hemorrhage from the bowels, and the signs of perforation. Walking typhoid has been almost always fatal in my experience, exhaustion being apparently caused by the continued muscular effort during fever. Sudden death by syncope occasionally occurs, sometimes when least expected, during convalescence, or it may happen during the acme of the fever. In either event the immediate cause is not always discoverable, evident lesions being wanting in most cases. Pulmonary thrombosis and myocarditis have been found at autopsy in these obscure cases. Sudden death is much more frequent in men than women, — 114 to 26, according to Dewevre's statistics, — a surprising and almost incredible difference. The prognosis in children under fifteen is especially favorable. Recovery takes place in them with few exceptions, while I have been struck with the number of fatal cases in young people from eighteen to twenty-two. Then follows a period favorable to recovery, but after forty the mortality again increases. The dangers at this older age appear to be from com- plications, especially pneumonia, as the symptoms peculiar to the disease are not increased in severity. The prognosis in pregnant women is grave. In the first place,, the pregnant woman usually aborts in the second week. This is. how- ever, not invariably the case. Dr. G. H. B. Terry reporting i a case of undoubted typhoid fever occurring in a woman during the fourth month of her third pregnancy. She recovered, and on April 5 following gave birth to twin girls, healthy and weighing respectively six and seven pounds. According to L. Brieger, the mortality was 20 per cent, of cases treated by other than the bath method. The results of the bath treatment seem to be better. I recently had under my care two pregnant women at the end of the fifth and sixth months respectively, now recovered, who were treated throughout by cold tub-baths without accident. Under any circum- stances more women die of typhoid than men — this, too, though the disease is more frequent in men than in women. Fat persons bear the disease badly. Hemorrhage and perforation seem to be in no degree diminished by the Brand bath treatment. On the other hand, careful investigation shows that these accidents are not more frequent, as has been alleged. * These are the figures published in my first edition. In his third edition Osier reports the mor- tality up to date fi8g8) at the Johns Hopkins Hospital 7.1 per cent.— a trifle less than that to date of his second edition. + " Medical News," February 16, 1901, p. 263. TYPHOID FEVER. 41 Death in typhoid fever may be the result of any of the following causes : exhaustion incident to prolonged illness, hemorrhage, peritonitis, shock due to perforation, intoxication by the toxin of the disease, or complications such as pneumonia or nephritis. As already intimated, sudden death sometimes occurs inexplicably. Treatment. — Rest and Diet. — The primary conditions of a successful treatment of typhoid fever are rest in bed and a liquid diet, of which milk is the type. No one questions the necessity of putting the typhoid fever patient absolutely at rest in bed and not permitting him to rise for any purpose until convalescence is thoroughly established. That the diet should be liquid is as little disputed, while milk is generally conceded to be the safest form. It should be given at stated intervals, say once in two hours, in doses of from four to six ounces ( 118.28 to 177.42 c. c.) or even eight ounces (236.56 c. c), as circumstances determine. Very rich milk is not desirable, hence such milk should be diluted with water or carbonic acid water, Vichy, or lime- water. The stools should be closely watched for undigested fragments of casein, and when these are present the milk should be reduced in quantity or further diluted. If there is diarrhea, the milk should be boiled while this lasts, and in obstinate cases peptonized. Animal broths of mutton or of chicken, also beef-peptonoids, may be associated with milk when change is demanded, but they are not as convenient, while beef -tea and essences are harmful. When the stomach is very irritable, albumen water may be sub- stituted, in the proportion of the whites of two eggs to a pint of water, to which may be added a little lemon, or whisky or brandy if stimulants are indicated. Wine whey may be associated or substituted where, for any rea- son, milk cannot be used. In extreme feebleness of digestion peptonized milk may be administered by the rectum, but this is rarely necessary. Not more than four ounces of any nutriment should be administered at one time by the rectum, for this organ soon becomes intolerant of large doses. While the nourishment above described fulfills also the indications for free ingestion of liquids, with a view to favoring elimination by the kidneys and bowels, plain water may also be freely given in the intervals between nourishment. There can be no reasonable objection to enlarging the dietary of ordi- nary cases of typhoid fever by any easily assimilable albuminous saccharine or amylaceous food. It is a mere matter of convenience. Typhoid fever does not dififer from other cases of fever in demanding simple and easily assimil- able food. It matters not much what it is, of the kinds referred to. It may be that we have been needlessly restricted in the past. Many cases are so ill that they can with difficulty be made to take any food, and whatever they will take most easily is best. On the other hand, it is evident that in the emergencies of hemorrhage and perforation a minimum amount of nourish- ment should be given, and I sometimes allow such patients to go many hours without food. In this disease, as in others, we must treat the patient and not the disease. The list of articles named by Shattuck * and embodied in the footnote includes foods that may be added to or substituted for milk. The Brand Bath Treatment. — In addition to rest and liquid nourishment the treatment that my own experience and a careful study of the experience * The following list, by Frederick C. Shattuck (" Diet in Typhoid Fever," "Jour. Am. Med. Assc," 1897, xxix. p. 51), includes many allowable articles : ,,. . " I. Milk, hot or cold, with or without salt, diluted with lime-water, soda-water, ApoUinaris, or Vichy ; peptonized milk : cream and water {i. e.. less albumin) ; milk with white of &%%, buttermilk, kumiss, matzoon, milk whey, milk with tea, coffee, cocoa. , , "2. Soups: Beef, veal, chicken, tomato, potato, oyster, mutton, pea, bean, squash; carefully strained and thickened with rice (powdered), arrowroot, flour, milk or cream, egg, barley.- ' 42 INFECTIOUS DISEASES. of others place easily at the head, in every case when it can be carried out, is the cold tub-bath treatment, commonly known as the Brand treatment. Our method in the Hospital of the University of Pennsylvania is as follows : Before the bath the patient is first encouraged to empty the bladder, and if sweating, he is wiped dry. He is then covered loosely with a sheet and gently lifted into the bath sufficiently filled with water at 70° F. (21" C), provision being made to rest the head upon an air-cushion or platform. Un- less very weak, he may at first step from the edge of the bed into the tub, which should be lower than the bed. During the bath he is vigorously rubbed by the nurse, and encouraged also to rub himself. A compress wrung out of ice-water or an ice-cap is kept upon his head, or water at the same temperature is poured at intervals upon it, say, three times in the course of the bath, or the head is sponged with cold water from time to time. This is important in severe cases with decided nervous symptoms. At the end of fifteen minutes he is lifted on the bed, which has been previously protected with a mackintosh and blanket. The wet sheet is replaced by a dry blanket, and the patient is rubbed dry. When this is accomplished, the under blanket and mackintosh are withdrawn and he is comfortably covered. As soon as the patient ceases to shiver after his removal from the bath, which is usually in twenty minutes, the temperature is taken with a view to determine the effect of the bath. If delayed longer he may be in a restful sleep, and to wake him for the purpose of taking his temperature is needlessly disturbing. After this the temperature is not again taken until three hours after the bath. If then it exceeds 102° F. (39° C), the bath is repeated. If the temperature is between 101° F. (38.2° C.) and 102° F. (39° C), it is taken again in an hour; if between 100° F. (37.8° C.) and loi' F. (38.3° C), in two hours; if below 100° F. (37.8° C), not until three hours, but when- ever the temperature exceeds 102° F. (39° C.) the bath is given, provided three hours at least have elapsed since the previous bath. This makes more than eight baths in the twenty-four hours impossible. The effect of the bath upon the temperature varies with the stage of the •disease ; the reduction during the first week being often less than one degree, while toward the end of the second week and in the third week a fall of two or more degrees is quite usual. Fig. 4 shows these effects very nicely. In addition to the lowered temperature the immediate effect of the bath is to add strength to the heart and volume to the pulse. The shivering, which begins from five to ten minutes after the immersion, is not allowed to interfere with the continuance of the bath, and it very rarely happens — indeed, scarcely ever — that anything occurs to interrupt the bath. It would be wrong, however, to say that there are no conditions under which it should be discontinued and the patient at once returned to bed. Such conditions would be an almost absolute pulselessness with a blue, cyanosed appearance of the skin. Should this occur, hot-water bags should be applied to the feet and legs after the patient is put to bed. The more remote effect of the bath may be said, in a word, to be milden- "3. Horlick's food, Mellin's food, malted milk, somatose. " 4. Beef-juice. " 5. Gruels ; Strained corn-meal, crackers, flour, barley-water, toast- water, albumin-water with lemon-juice. " 6. Ice-cream. " 7. Eggs, soft boiled or raw, egg-nogg. " 8. Finely minced lean meat ; scraped beef ; the soft part of raw oysters ; soft crackers, with milk or broth ; soft puddings, without raisins ; soft toast, without crust ; blanc mange, wine jelly, apple sauce, and macaroni " I should be disinclined to allow ice-cream, apple-sauce, minced meat, scraped beef, or even soft toast, while there is fever. TYPHOID FEJ^ER. 43 ing of the symptoms in every particular. Delirium and stupor are scarcely known. The dry tongue is very much more infrequent, and diarrhea rarelv demands other treatment. In the majority of cases I give no medicine, but do not hold myself bound to such course, meeting whatever symptoms seem to demand it by appropriate treatment. For a time I used to give the patient a little whisky and water during the bath. Recently I have discontinued this, unless there seems some special reason for it. There is, however, no harm in it, and it serves to entertain and comfort him. I do not give a preliminary DAY OF MONTH 18 19 ^ 20 31 K 3 < DAY OF DISEASE 7 8 9 10 -< time!" A.m. 1 -Js e|>-: ^ 5 i' s id 1 1 ! 3 2 E j 1 1 2 2 u = sj5 2\ ZCO DAy[ P.m. = 13 5 i 1 1 1 3[., - 'S '-;5 V\ If. s =^- 5 5 J J ?i ! ^ ' 15 -t3 TEMP 1 1 i ) " 1- o < 1 1 ; — U- 1 1 - - 1 ^ 107 ■ 1 V ij X 'V- _I LX_ X X. 1- 1- -? X 1- .1 I I 1 1- T X _i : -Q^ — +- ■S — §- — — QT ■□ — a a S— _ 1 / 1 H T 1 \ f \ • 1 ( I \ 1 \ _ \ « f^ t f i \ 1 \ ■^ / \ r,' ff r ■^ A 1 / \ n / ^ \ , \ ''V A / \ \ / w 1 \ / * - \ V \ / \ / 1 / \ 1 \ V V \ A J.-02- \ / \ /^-* \ / , / V \ 4 \ 1 . ^i— \ \ i \ \ I \ 1 d \ \t \\ \ T — f r * \ \ / 1 "V j \ 1 4 — — f- _ -401- — r - 1 1 f - V i ( 1 1 J 100 \ 1 f I ; . 1 [ I -■ I _ ■OSWA, , j 1 1 ; - \ 1 1 - 97- ■ 1 1 i - . 1 i , UJ — - 1 1 (- 1 1 1 i - E 1 1 1 - : 1 . - — i,- 1 ; - 1 1 1 ^:Si ' 1 ' 1 1 1 1 ( Fig. 4. — Chart Contrasting the Drop in Temperature after the Bath Early and Later in the Disease. dose of calomel, as recommended bv some, as there seems nothing gained by it. None of the complications except hemorrhage from the bowels is allowed to interfere with the carrying out of this treatment, nor is menstrua- tion or even pregnancy. The baths are discontinued during hemorrhage, lest the necessary movements of the body should re-excite it ; but with the portable bath-tub to be described thete need be no interruption even during hemorrhage, should the baths be indicated by the temperature. It is not claimed that the baths shorten the illness, they simply milden it. ^^'hile it is 44 INFECTIOUS DISEASES. probably trvie of typhoid fever, as of pneumonia, that it may abort sponta- neously, we cannot cause it to abort by any means we possess. In private practice the difficulties of the Brand treatment are greatly increased — unfortunately, sometimes are insuperable. They consist chiefly in the difficulty in arranging the bath and the strain on the attendants. By means of a portable tub devised by Dr. A. H. Burr, of Chicago, a very large part, if not the whole, of these difficulties is removed. Dr. Burr's tub con- sists, first, of a large rubber sheet, with rings attached near its margins by elastic tapes ; second, of a light wooden crib, with fastenings along the lower rail by which to attach the sheet. This frame folds by two movements into a compact bundle. The accessories are a siphon-shaped piece of hose and a Bath-tub Completed, Showing Siphon for Drawing off the Water. Fig. 5. — Burr's Portable Bath-tub. bath thermometer. In using, the sheet is first slipped under the patient^, brought up over the pillow, and tucked up alongside of the body. The frame is unfolded and placed down over the patient, resting on the mattress, and surrounding patient and pillow. The edges of the sheet are then drawn up and over the top rail of the crib down to the lower rail, and fastened by its rings. This completes a light and perfect tub, capable of holding twenty gallons of water. It can be emptied by the siphon in four minutes ( See Fig. 5).* If the ordinary tub be used. — and in hospital service this is usually more convenient, — the same water, if it remains unsoiled by discharges, as it should, may serve for several baths. Other Methods of Reducing Teuiperature. — As contrasted with the Brand bath, other methods of securing the good efifects of hydrotherapy seem trifling ; yet, as it may be impossible to carry out this treatment, such methods must be considered. Sponging is one of the most usual, and if rightly carried out may be quite efficient. It should be resorted to, as is the bath, when the temperature exceeds 102° F. (39° C), and continued for fifteen minutes, or until the temperature falls. An important condition of success- *The Burr bath-tub is sold by E. H. Sargent & Co., io6 Wabash Avenue. Chicago, Ul. Another tub, as convenient and as easily managed, has been devised by Dr. S. Clifford Boston, who dispenses witli the framework, substituting strong iron supports, made by Jones, Leopold & Co., southwest corner Ridge Avenue and Fairmount Avenue, Philadelphia. TYPHOID FEVER. 45 ful sponging is often overlooked. A thin film of water should be left on the surface sponged, as it is the evaporation of this, rather than the temperature of the water, which is effectual in cooling the body. Temperatures that can- not be thus controlled can often be kept down by a partial wet-pack, which I have found very efficient : The patient's trunk is enveloped from the axilla to the thighs in a folded sheet, which is kept constantly wet, or as much so as is required to control the temperature, by the continual addition of cold water. Antipyretics, including antipyrin, antifebrin (acetanilid), phenacetin, and others of the same class, which act by producing copious perspiration, are no substitutes for the baths, for, while they reduce temperature, their effect is but temporary, and their continuous employment too depressing to the patient. Moreover, th-ry are purely antipyretic, and lack the tonic influ- ence to the nervous and muscular systems which characterizes the cold tub- baths. Quinin. formerly used in massive doses for its antipyretic effect, has "been replaced by the more modern agents. Guaiacol, locally applied, is undoubtedly an efficient antipyretic, and has a warm advocate in Horace G. McCormick in the treatment of typhoid fever. After washing the skin, from one to ten minims are rubbed into it, and the part covered with oiled silk. The fall iia. temperature is prompt. Some rather alarming symptoms of collapse are, however, reported from its use, and it has failed to secure a permanent footing. The Expectant-Symptomatic Treatment. — Where the difficulties in the way of the Brand method are insuperable. I prefer to place the patient in bed on the diet described, combat the temperature by sponging or wet-packs, and for the rest adopt what may be termed the expectant-symptomatic method, meeting the symptoms as they arise in accordance with the fol- lowing : (a) Indications for Alcohol and Other Stimulants. — I prefer to reserve alcohol until called for by signs of waning strength. That it is a remedy of the greatest value I fully admit, but it is also true that mild cases may be carried to a favorable termination without it. On the other hand, I favor its liberal use when needed, giving sometimes as much as an ounce (30 c. c.) of whisky or brandy every hour, though such doses are rarely needed. More frequently, a half ounce ( 15 c. c.) every four or two hours is quite suffi- cient, even where there is considerable adynamia. A low, muttering delirium, feeble, dicrotic pulse, and dry tongue are among the indications which imperatively demand alcohol ; a high temperature does not contra-indi- cate it, as an antipyretic effect also follows the use of large doses, and delirium is sometimes calmed by it. Other diffusible stimulants which may be used in conjunction or alternation with alcohol are the aromatic spirit of ammonia and the carbonate of ammonium, while digitalis and strychnin may tide a feeble heart over a period of weakness. From five to ten minims (0.333 to 0.666 gm.) of the tincture of the former, and 1-30 to 1-20 of a grain (0.00216 to 0.00324 gm.) of the latter may be given as demanded, while their hypodermic use may be availed of. At the Hospital of the University of Pennsylvania we have found hypodermic injections of camphorated oil i grain (0.066 gm.) to 15 minims (i gm.) very useful in tiding over extreme adynamia. The injections may be repeated once in four hours or oftener. Transfusion or, what is more practicable and as efficient, hypodermoclysis of normal salt solution (0.8 per cent, sodium chlorid) may be availed of in the extreme adynamia which sometimes attends protracted typhoid fever. 46 INFECTIOUS DISEASES. {b)Treafmciif of Special Syiiiptoiiis. — Methods more directly adapted to control dcliriiini are an ice-cap to the head, the bromids, spirit of chloro- form, chloral, and Hoffmann's anodyne. With the cold-bath treatment they are rarely necessary. Occasionally, meningeal symptoms are so violent that leeches may be used to the temples or behind the ears. I have seen an almost magically quieting effect thus produced. Blisters are useless. Little difficulty is commonly experienced in controlling the diarrhea of typhoid fever. As stated, with the cold bath treatment very little special treatment is necessary. Simple preparations of opium, either alone or in combination with bismuth or nitrate of silver or acetate of lead, or salol, are usually sufficient. Specific action has been claimed for nitrate of silver. I have not been convinced of this, yet it is, in combination with the extract of opium, 1-4 of a grain (0.0162 gm.) of each, my favorite remedy for the diar- rhea. Similar specific effect, more particularly in healing the ulcers, has been claimed for the oil of turpentine. The impression made by the teach- ings of the late George B. Wood on the profession of the United States as to this effect has not yet been effaced. He held that the dry, leathery tongue so often presented in this disease is the indication for its use. Whether such view was correct or not, few who have used the oil of tur- pentine have failed to see the coated tongue clear up under its use. Tur- pentine is also useful as a stimulant. It should be administered in doses of ten minims (0.66 gm.) in mucilage of acacia every six or eight hours. Constipation, especially during convalescence, is not infrequent, and should not be too hastily interfered with. If it is necessary to interfere, it should be by simple enema only. Aperients by the mouth in this stage are dangerous, and I am confident I have seen at least one life sacrificed by purgatives thus administered, having been succeeded by perforation, peri- tonitis, and death. On the other hand, indifference to the condition of the bowels sometimes leads to fecal impaction, which can only be relieved by the finger. Such a state of affairs should be averted by watchful care. Hemorrhage from the bowels should be treated by absolute quiet wdth cold to the abdomen. Food should be reduced to a minimum and should be of the blandest character, as represented by peptonized milk and liquid beef-peptonoids. The administration of food may be suspended for some hours without risk. In severe cases the foot of the bed should be raised, and a hypodermic injection of 1-8 to 1-4 of a grain (0.008 to 0.016 gm.) of morphin given at once. In such cases, where prompt and decisive action is necessary, a syringeful of a filtered fluid extract of ergot may be injected hypodermically, and repeated later, if necessary, in half the dose. In mild cases astringents, such as tannic acid or gallic acid and the acetate of lead, may be given by the mouth, the former in doses of 10 to 15 grains (0.666 to I gm.) hourly until some hours have elapsed without a hemorrhage. The acetate of lead should be given in one to three grain (0.066 to 0.194 gm.) doses every three hours, combined with extract of opium, 1-4 of a grain (0.016 gm.). Turpentine is highly valued by some in the treatment of hemorrhage from the bowels. In cases of extreme weakness ether and digitalis may be given hypodermically. Tympanitic distention of the abdomen is often a distressing symptom. It is usual to treat it with turpentine in ten-minim (0.666 gm.) doses every four to six hours. The rectal tube should be cautiously used if the meteorism is great, and large quantities of gas are sometimes thus disengaged from TYPHOID FEVER. 47 the large intestine. The quantity of food should also be reduced to a min- imum, as its fermentation and decomposition contribute to the gas. Pain induced by meteorism or otherwise may be allayed by turpentine stupes over the abdomen, though sometimes it may be necessary to rein- force the stupes by small doses of opium, or a light, warm poultice may be substituted. Sudden, sharp pain, similar to that produced by tympanitic dis- tention of the bowel, is also caused by peritonitis, of which tympany is like- wise a symptom, and the two often occasion many anxious moments to the physician necessarily in doubt as to whether this serious complication may occasion them. If a peritonitis is the result of extension of inflammation bv continuity and not of perforation, — a possible condition, — recovery mav take place. Such recovery is favored by absolute rest of the bowel, best secured by hypodermic injection of morphin, 1-4 grain (0.016 gm.), re- peated if necessary. Even such movement as is necessitated by the use of the bed-pan is of questionable propriety. It is much better to permit the discharges to pass into a soiled sheet. Perforation is the most serious accident which can happen to the typhoid fever patient, though it is claimed that recovery has taken place where peritonitis has been thus caused. Indeed, according to ^lurchison, 10 per cent, of all cases recover, 5 per cent, if general peritonitis supervenes. Even this seems a large proportion, for in my experience no case of undoubted perforation has recovered. On the other hand, recent results after operation have been so favorable as to make it imperative that the propriety of this treatment should be considered in each case. It is impor- tant to remember that early operations are those attended with largest success. In a recent and exhaustive paper ("Jour. Am. Med. Assoc," January 20, 1900) on the " Surgical Treatment of Perforation of the Bowel in Typhoid Fever," A\\ W. Keen collected 158 cases and summarizes as follows : Oct of 158 Cases of Operation for Perforation. When Done. Total. Died. Recovered. Percentage of Recoveries Within 4 hours, In 4 to 8 hours, In 8 to 12 " In 12 to 18 " In 18 to 24 ■ ' ' 44 38 6 13.63 39 27 12 30.74 After 24 hours, Not given, . . I S.33 \ '9-^^ ) '5 Uc „ 16 12 4 25 / ( ^5-35 25 17 « 32 - 30.76 \ 29.09 14 10 4 28. 57 ) ) Total 15S 121 37 23.41 Keen also formulates the rule that // the operation is not done within about tzi'eiitx-four hours after the perforation, there is probably no hope of a recoverx. A surgeon should therefore be immediately called, and if col- lapse is not too profound laparotomy should be done. For sleeplessness the milder soporifics usually answer; 10 to 15 grains (0.666 to one gm.) of sulphonal generally furnish the required rest. Chlo- ralamid 30 grains (two gm.), trional 15 to 30 grains (one to two gm.), or chloral 10 to 15 grains (0.666 to one gm.) may be used. If these rem- edies are insufficient, morphin must be used, 1-4 grain (0.016 gm.) being given by the mouth or half as much hypodermically, or more if necessary. Bed^ sores can generally be averted by scrupulous attention to cleanli- 48 INFECTIOUS DISEASES. ness, the thorough drying of the patient after washing, removing thus " ' traces of urine or other discharges, and by sponging the patient daily with alcohol or whisky. Above all, his position in bed should be frequently changed and all inequalities in the bed clothing should be smoothed out, while the bed should be kept clear of crumbs and other irritating particles. Should a sore appear it must be antiseptically dressed, while the part should be protected from pressure by pads and air-cushions. For liiccough the more ordinary measures commonly effectual are counter-irritation by mustard, dry cupping, or blistering ; the various anodyne measures, including Hoffmann's anodyne, chloroform, and the hypodermic injection of morphin. The anti-spasmodics, including sumbul, the oil of amber, and especially musk, have been useful. Cannabis indica is also recom- mended. In an obstinate case under my care after all measures had failed, including musk, the hypodermic injection of one grain (0.06 gm.) of camphor dissolved in oil, 15 minims (0.5 gm.) repeated hourly, relieved the case in six doses. A second case has been relieved in the same hospital by like treatment. In other cases I have found musk useful when all else failed, but it is a most costly remedy and its use is thus necessarily limited. The dose is 5 to 10 grains (0.3 to 0.6 gms.). The cystitis sometimes present in typhoid fever is commonly easily relieved by washing out the bladder with boric acid solution, say a dram (4 gm.) to a pint (0.5 liter) of sterilized water; or instead of this salol may be given in five-grain (0.3 gm.) doses four or five times a day, as a urinary antiseptic. The best remedy is urotropin, which is a derivative of formalde- hyd and is said to be non-toxic and non-irritating. According to Mark W. Richardson daily doses of 30 grains (2 gm.) will remove typhoid bacilli permanently from the urine in a week. The Management of Convalescence. — In no disease is watchfulness dur- ing convalescence more important. The effect of indiscretion in diet in pro- ducing relapse and recrudescence has been referred to. But there are other clangers during convalescence. It is to be remembered that the complete healing of intestinal ulcers is often delayed after all other symptoms have disappeared except a slight elevation of temperature ; that a deep-seated ulcer may thus remain with the thin peritoneum for its floor, rendered weaker by reason of imperfect nutrition. Such a membranous floor is known to have been torn by simply reaching over for a book and to be followed by a fatal peritonitis. These are reasons, too, for putting off the use of solid food until the temperature has maintained the normal for a considerable time, certainly a week. Then the diet should be changed most gradually, first permitting a soft-boiled egg or poached egg in the morning, and awaiting developments. If no fever follows, it may be continued daily. The next step is to allow some thoroughly softetied milk toast, then a small quantity of well-boiled rice, with a suitable interval after each first trial until sure that no harmful results follow. Finally, tender meat may be •allowed, and then soft vegetables one after another. Emotional disturbance is a well-recognized cause of recrudescence, and should be carefully guarded against. I have already referred to constipation and the importance of correcting it by enemata only. During convalescence the hair is very apt to fall out, but usually returns in a natural way. It may be desirable to cut it close, though scarcely neces- sary to shave the head, as some recommend. TYPHOID FEVER. 49 Special Forms of Treatment. The Antiseptic Treatment. — The antiseptic treatment of typhoid fever is based upon the idea of destroying the germs of the disease in the intes- tinal canal, and thus cutting off their harmful influence. If I mistake not, it is not claimed that it is possible to destroy the bacilli elsewhere in the economy — that is, in the blood, the spleen or other lymphatic tissues, or wheresoever they may be present. In addition to the localized effect on the ■specific bacilli in the intestine, this treatment claims also to arrest fermenta- tion arid check the activity of the commoner intestinal bacteria, which, it is alleged, are fanned into virulence by the presence among them of typhoid bacilli. The claims of the adherents of the method do not altogether agree, but its more moderate supporters hold only that it renders the disease milder and diminishes its mortality, urging it more particularly in those cases where for any reason the Brand treatment cannot be carried out. Among the remedies employed for their antiseptic eft'ect are calomel, betanaphthol, carbolic acid, chlorin water, naphthalin, salol, and tincture of iodin. Calomel has long been used by various physicians in the treat- ment of this disease. Its popularity is partly due to the fact that it is also an excellent and safe laxative. It had the early support, in the treatment of typhoid fever, of Liebermeister, who claimed that under its use the dura- tion of the disease was shortened and its intensity lessened. His plan was to give three or four doses of 7 1-2 grains (0.5 gm.) each, in the first tw^enty-four hours of treatment. I have said that some of the supporters of the Brand treatment prefer to precede that treatment by such a dose of calomel. It can certainly do no harm. Betanaphthol is another efficient and non-toxic germicide. It is held that doses sufficient to produce an antiseptic effect are not irritating. These doses are 5 to 10 grains (0.33 gm. to 0.66 gm.) three times a day in a wafer, capsule, or tablet. It is sometimes combined wath salicylate of bismuth if there be diarrhea, or salicylate of magnesium if there be constipation, as suggested by Bouchard. All the advantages of this treatment are claimed for it, including dimin- ished abdominal pain, diminished meteorism, a clean and moist tongue, inodorous stools, rapid convalescence, and less tendency to secondary com- plications. Another one of these remedies is a compound of carbolic acid and iodin, — I part of the former and 2 of the latter, — given in doses of i to 3 drops, well diluted, three to six times a day. Chlorin water is also an old remedy recommended by Sir Thomas Watson and by Murchison, and recently revived in the treatment of typhoid by Burney Yeo, who claims that it cleans the tongue quickly and removes the fetor of the evacuations within twenty-four hours ; that it reduces the temperature and shortens the, attack ; while the physical strength and mental clearness of the patient are maintained, together with a greater power of assimilating food and, conse- quently, rapid and complete convalescence. Yeo even claims a general antiseptic influence for this treatment. He adds to 12 ounces (360 c. c.) of chlorin water, 24 to 36 grains (1.584 to 2.376 c. c.) of quinin and an ounce (30 c. c.) of syrup of orange-peel, and gives an ounce (30 c. c.) every two, three, or four hours, according to the severity of the case. Salol is recommended for the s^me antiseptic purpose ; 40 to 50 grains (2.5 to 3.25 gm.) in the twenty-four hours, in capsules, w^afers, or tablets, in doses of 5 to 10 grains (0.3 to 0.66 gm.). Thymol is recommended in 50 INFECTIOUS DISEASES. the same doses. All these doses in my judgment are so large that I fear their harmful effect would more than equal any possible advantage. The Eliminative and Antiseptic Treatment. — This treatment is in- tended to add to the antiseptic eft'ect a prompt removal from the bowels of the bacillus and its toxic products. The first it is sought to accomplish on the principles previously described ; the second by thorough datfly evacuations of the bowels by means of purgatives, large quantities of fluids being given at intervals to replace the liquid carried off in the discharges. This treat- ment is especially associated with the names of Woodbridge, of Cleveland, and Thistle, of Toronto. The former published a book on " Typhoid Fever and its Abortive Treatment." in which he claims that if this treatment is instituted sufficiently early, not only is the disease aborted, but the patient need not go to bed or be restricted in diet, debarred from social enjoyment, or even be required to neglect or omit his business. With- out commenting further upon these claims, I will state that a trial of the Woodbridge treatment was made during 1898 and 1899 in the wards of the New York hospitals and the United States Army Hospital at Fort Meyer, Va. Of 14 cases treated in New York 4 were under the personal care of Dr. Woodbridge. Thirteen cases recovered and i died, the fatal case being one under Dr. Woodbridge's personal care. The cases were treated with antiseptic and purgative tablets prepared by Parke, Davis & Co., according to Dr. Woodbridge's formulse.* The remaining cases were treated at Fort Meyer by Dr. Woodbridge. Of these, 4 patients died, 3 of intestinal hemorrhage and i of exhaustion, giving a mortality of 10.5 per cent, for the 38 cases, as compared with the rate of 9 per cent, among the cases treated in the other wards of the hospital. Thistle's method is much simpler and more easily carried out. Calomel is given daily in fractional doses, 1-2 grain (0.033 S^^-) every half hour, until three grains have been taken, followed three hours later by Epsom or Rochelle salts in half-ounce (15 gm.) doses, sufficient being given to secure from 3 to 5 movements daily. To compensate for the withdrawal of so much fluid from the body as well as to eliminate the poison through the kidneys, the ingestion of large qviantities of water is enjoined. For intestinal anti- sepsis salol is given in five-grain doses, every three hours, with 8 ounces (236.56 c. c.) of water. Thistle is not so extravagant in his claims as Woodbridge, alleging, however, that hemorrhage and perforation are both more infrequent. He reports in a recent paper 172 cases treated by himself and other physicians in Toronto, with 5 deaths — a mortality of 3 per cent. Of the fatal cases 2 died of pneumonia in early convalescence, 2 of intestinal hemorrhage, and i of hemorrhage from the stomach and nose with general purpura in all parts of the body. , In view of the fact that typhoid fever is a general and not a local infec- * The formulas are three in number, designated No. i. No. 2, and No. 3. No. i, a tablet, contains podo- phyllin resin, i-g6o grain ; calomel. 1-16 grain ; guaiacol carbonate, 1-16 grain ; mentliol, 1-16 grain ; eucalyptol, q. s. Immediately on the appearance of fever, and before the diagnosis is made, one of these tablets is given every fifteen minutes during the first twenty-four hours, and in larger doses, if necessary, in the second twenty-four hours, until not less than five or six evacuations are secured each day. On the third or fourth day tablet No. 2, consisting of the same ingredients in precise pro- portion, with 1-16 grain thymol added, is given every one or two hours at first, the size and frequency of the dose of both tablets being regulated to allow 'the movements to become gradually less fre- quent until the temperature drops to normal and the passages are reduced to one or two a day. On the fourth or fifth day, formula No. 3, composed of guaiacol carbonate, gr. iij., thymol, gr. j.. men- thol, gr. ss., eucalyptol, m. v., in capsule, is given every three or four hours, alternating with the tablet. The medicine is to be washed down with copious draughts of distilled or, if necessary, some laxative or diuretic mineral water. I am indebted to the admirable paper, by John Winters Brannan, on "Typhoid Fever." in vol. xvi. of the " Twentieth Century Practice of Medicine," for the facts here presented on the antiseptic and eliminative treatment of this disease. TYPHOID FEVER. 51 tion and that the local lesions in the bowel are only a part of the local mani- festation, the antiseptic and eliminative treatment does not seem to rest on a thoroughly rational basis, while the extravagant claims, especially of Woodbridge, discredit his results. These claims have finally been over- thrown by his own experience in New York City and at Fort Meyer. On the other hand, it does seem reasonable that sloughing and extensive ulcera- tion in the bowel may cause secondary sepsis. Toward an effort to prevent such infection the antiseptic treatment may, therefore, be permitted if the dosage be not excessive and otherwise harmless to the patient ; but not with a view to eliminating the poison. Theoretically, one might object to purgation by calomel, because the unloading of the gall-bladder may be attended by a copious discharge of bacilli capable of reinfecting the bowel. Serum Treatment of Typhoid Fever. — The practical studies and appli- cation of the serum treatment by Dr. A. E. Wright, of Netley, and his pupils, and of Chantemesse in Paris, have given a decided impulse to this method of treatment because of the seemingly satisfactory results obtained. These results include immunity as well as cure. Of the several methods of procedure, Wright adopted that of inoculating the subject with measured quantities of dead, but still poisonous, micro-organisms. He prepared an antityphoid vaccine from agar cultures of typhoid bacilli, grown for 24 hours at blood heat. The cultures thus obtained are emulsified by the addi- tion of measured quantities of sterile broth. The resulting emulsion is sterilized by raising it to a temperature of 140° F. (60° C.) and keeping it at that temperature for five minutes. The local and constitutional symptoms succeeding the injection of the vaccine vary in degree with the dose used. Local symptoms include tender- ness two or three hours after injection at its site, gradually increasing in severity and extending upwards into the armpits and downwards into the groin. There is also commonly seen a patch of congestion about the site of inoculation with red lines of inflamed lymphatics, extending upwards into the armpits. These symptoms disappear about 48 hours after injection. Constitutional symptoms include some degree of tenderness, beginning gen- erally two or three hours afterwards. There is loss of appetite, while nausea and even vomiting may supervene. Rest is disturbed and there is some fever in all cases. These symptoms also pass away in a couple of days. In three only out of eleven cases tested did the health seem to be shaken for three weeks. As was to be expected, the blood of persons thus inoculated was found to immobilize and agglutinate the typhoid bacilli. Moreover, Wright's observations go to show, in harmony with those of Pfeififer, that the immu- nity acquired by undergoing an attack of actual typhoid is not greater than that which is acquired by an inoculation of typhoid bacilli. There are. however, limitations the consideration of which is scarcely in place in a text-book, and the student who is further interested is referred to the admi- rable papers by Wright upon this subject.* A summary of the statistics prepared by Prof. Wright as to results of antityphoid inoculation f in India, South Africa, and England, go to show, 1st, a decided reduction of incident cases in the inoculated; 2d, a reduced death-rate in the inoculated who acquired the disease as contrasted with the uninoculated who acquired the disease ; 3d, that the duration of immunity * "Remarks on Vaccine against Typhoid Fever," byA.E. Wright, M. D., and Surg.-Maj. D. Semple, M. D.. " British Medical Journal," January 30, 1897. t The " Lancet," September 6, 1502, page 256. 52 INFECTIOUS DISEASES. thus obtained varies from five months to two years, as determined by the duration of the agglutinative reaction; 4th, that double (successive) inocula- tion is more efficiently protective than single inoculation. In a letter received from Professor Wright while printing this edition he says he usually com- mences with 5oo,ooo,ocxD typhoid bacilli and gives ten days later 1,000,000,- 000 dead typhoid bacilli. He also writes that he never attributed any cura- tive value to antityphoid inoculations. In France Chantemesse has prepared an antityphoid serum, as con- trasted with the antityphoid vaccine, which he claims to be curative and prophylactic. In his latest publication * he shows from a review of the statistics of the various hospitals of Paris, excepting that under his own direction, a combined mortality of 19.3 per cent., and that, while there were natural variations, the lowest recorded mortality in any hospital exceeded 12 per cent. Under the serum treatment, which had been received by 356 patients up to the time of his report, only 17 died, a mortality of 4.7 per cent. At Toulon, out of 151 patients 13 died, the addition of this mor- tality making 6 per cent., as contrasted with the German Army statistics, which gave a mortality of 9.5 per cent. It may be mentioned in passing that the reduced mortality thus claimed is but 1.4 per cent, less than that obtained by the tub-bath treatment by physicians in the United States. In this country Drs. William Royal Stokes and John S. Fulton,t fol- lowing Abel and Loeffler, produced an antityphoid serum by injecting gradu- ally increasing doses of a 48-hour-old virulent culture obtained from the Johns Hopkins Hospital Laboratory into the subcutaneous tissues of the abdomen of the hog, which was subsequently bled, the serum drawn and trikresolized. It was found that guinea pigs given subcutaneous injections of this pro- tective serum were rendered immune against a peritoneal injection cf a viru- lent typhoid bacillus. More precisely, that a subcutaneous injection of the serum in doses of from 1-600 to 1-800 of the body weight will protect guinea pigs against four times the minimum fatal dose of intraperitoneal injection with the typhoid bacillus. The injection of 1-3000 to 1-4000 of the serum by weight iiito the abdominal cavity will protect against five times the mmi- mum fatal dose, and a dose of 1-600 to 1-800 of the body weight will protect against seven times the minimum fatal dose of the typhoid bacillus. Thus far only 18 cases have been treated by Drs. Stokes and Fulton's serum, and although they admit that so few cases lead to no conclusion and perhaps no very reasonable inference, they are encouraged to continue their experiments and think they have shortened the duration and intensity of the fever in most of the cases, while none were lost.+ Prophylaxis. — Most important in the management of typhoid fever is the disinfection of the excreta, which are the contagium bearers, through the careless handling of which the disease is communicated to others. The same is perhaps true of the vomited matters. Among the most suitable disinfectants, on account of its cheapness, harmlessness, and effectiveness, is chlorinated lime or bleaching powder, also called chlorid of lime, which contains from 25 to 40 per cent, of * " Pi'esse Medicale," December 24, iqo2. t "Maryland Medical Journal," August, tqo2. t In explanation of the imperfect results thus far obtained bv antityphoid sera, allusion should be made to the observations of Ehrlich, Bordel and Wasserman to the effect that bacteria are de- stroyed in artificial immunity by the joint action of two distinct substances, one the intermediate or immune body produced in the blood when animals are immunized bv the injection of non-fatal doses of various bacteria. The second is called the complement or end body, and'is a sort of digestive fer- ment always present in the blood. It is destroyed by a temperature of 60° C. (160° F.) while the im- mune body is not. TYPHOID FEVER. 53 available chlorin. A solution made in the proportion of 4 to 100 of water, containing, therefore, at least i to 1.5 per cent, of chlorin, is suffi- ciently strong. Some of the solution is placed in the chamber vessel before it is used, and the remainder, in all say a pint, is added afterward. Thorough admixture should be made, and an hour allowed to elapse before the stool is thrown into the privy well or water-closet, if disposed of thus. In the country the disinfected stool may be buried. Solution of chlorinated soda, or Labarraque's solution, is a more elegant but not more efifective disinfectant. As it contains about 2 per cent, of chlorin, it is nearly equivaflent, when undiluted, to the above solution of chlorinated lime. Chlorinated lime rapidly loses its chlorin, and should be kept in tight vessels. Carbolic acid, in the proportion of one part of the commercial acid to ten of water, is an efficient disinfectant for this purpose. The same method as that described for chlorinated lime must be employed, and an exposure of twenty minutes to half an hour maintained. Quite as good a disinfectant for intestinal evacuations is milk of lime or ordinary " whitewash," composed of lime in solution and in suspension. This should be thoroughly mixed with the evacuations until the mass is distinctly alkaline, and should remain in contact for one or two hours, since it is slower in its action than chlor- inated lime or carbolic acid, and much longer exposures are required to destroy the bacillus. It is particularly adapted to the disinfection of privy wells and latrines, into which it m^ay be thrown, freshly prepared in the pro- portion of I part by weight of recently burned calcium hydrate to 8 of water, or about 12 per cent. It is not harmful to water-closet pipes in such quan- tities as required to disinfect the stools of a single case of typhoid fever. Acidulated solution of corrosive sublimate i to 500 is an admirable disinfectant for stools, but is not altogether harmless to plumbing, whence it is less satisfactory when excreta are thrown into city water-closets. Sulphate of iron or copperas is a good antiseptic and deodorant, but not a true disinfectant. An antiseptic prevents the growth of bacteria without necessarily killing them, while disinfectants do both. Above all, it must not be forgotten that simple hot w^ater thoroughly mixed with the fecal discharges is an efficient disinfectant. Most important in the prophylaxis of typhoid fever is drainage. It seems to be now definitely settled that the fever originates in every instance from the ingestion in some way of the typhoid bacillus commonly in drinking-water or milk, or in food contaminated with it, more rarely by inhalation. Hence, it is of the greatest importance that the sources of water used in domestic economy should be protected against contamination by discharges containing the specific bacilli, which sometimes find their way into wells and other sources of water-supply. Nurses should be enjoined to guard against their own infection by due attention to cleanliness after caring for the discharges of a patient and even after tubbing, while watchful care should be taken not to carry the hands to the mouth during the bath. On the other hand, the infection is one of the easiest controlled, and the spread of typhoid fever can be efifectually prevented if the precautions advised are followed. Moreover, it cannot be too strongly insisted upon that any infected water or milk may be rendered thoroughly harmless by boiling and filtration. Physicians should lose no opportunity to inculcate this truth as well as that' limpidity of a water does not guarantee its innocuousness, while it may even be slightly turbid and yet harmless. Boiling is the most important treatment, far more important than filtration. 54 INFECTIOUS DISEASES. Paratyphoid Fever. Definition. — A form of infectious fever presenting a clinical picture identical with that usual to typhoid fever, but due to a bacillus whose char- acteristics are intermediate between the typhoid and colon groups, and called therefore, the paratyphoid or paracolon bacillus. Symptoms. — The symptoms are those of typhoid. Differences observed are, in general, greater mildness and more favorable prognosis ; greater fre- quency of diarrhea and more frequent termination of fever by crisis. Myositis and purulent arthritis, very rare in typhoid fever, are among the complications. Absence of intestinal ulceration is characteristic. The dis- ease does not respond to the Widal test, but the serum reacts upon fresh cultures of the paracolon or paratyphoid bacillus. Treatment is in no way different from that of typhoid. Mountain Fever. Synonym. — Rocky Mountain Fever. Definition. — A form of fever met in the mountain regions of Western United States, characterized by its moderate temperature, ioi° to 103° F. (38.2° to 39.3° C), a duration of from two to four weeks, and generally mild course. Mountain fever has come to be pretty generally acknowledged as a variety of typhoid fever, modified by the combined factors which go to make up the influence of high altitudes. Certain it is that if a careful study of the cases reported by various observers is made, the clinical picture differs no more from the typical picture of typhoid fever than the abortive forms of typhoid occurring at low altitudes. It must be admitted, however, that this view is not unanimous, and it should be mentioned that Surgeon Charles Smart,* of the United States Army, in a careful review of the subject, in 1878, in a paper entitled " On Mountain Fever and Malarious Waters," concluded the disease was typho-malarial fever. Such a view implies a separate specific disease, typho-malarial fever, which is not admitted at the present day by the best authorities. The lesions of typhoid fever in the ileum have been found in at least two of the very few fatal cases reported, f An enlarged spleen is also found. Finally, Woodruff's J studies of the serum reactions in this form of fever have furnished all necessary proof of the identity of the disease wkh typhoid fever. Epistaxis occurs. So far as I am aware, however, no spots have been reported except a " doubtful tCicIie rouge " by Roland G. Curtin § in one of four cases seen by him in 1868 in Wyoming Territory. Diarrhea has been noted, but there is a tendency rather to constipation — not infrequently the case in typhoid fever. Tympanites also occurs. The other symptoms are those incident to all fevers, such as debility, headache, and frequent pulse. Doubtless many imperfectly studied instances of other forms of disease are classed by indifferent observers as mountain fever, as in a case mentioned by Curtin. * " Am. Jour. Med. Sci.," January, 1878. + One is reported by Siirgreon Ho'ff, U. S. Army, " Am. Jour. Med. Sci.," January, 1880; the speci- men from another is in the United States Armv Medical Museum. Washington D. C. X Woodruff, C. E., " The Form of Typhoid "Fever Called Mountain Fever; Widal's Test; Afebrile Oases," "Jour. Am. Med. Assoc," 1808, vol. xxx, p. 75:5. § "Rocky Mountain Fever." Reprint from the "New York Med. Jour.," January 8, 1887. TYPHUS FEVER. 55 Mountain fever is not to be confounded with mountain sickness, another condition incident to unusual exertion at high altitudes. In it there are dyspnea, frequent pulse, dizziness, and bleeding at the nose ; also great prostration on exertion, and sometimes slight elevation of temperature. Treatment. — The treatment of mountain fever, mainly symptomatic and roborant, would be, so far as any special measures are needed, that of typhoid fever. TYPHUS FEVER. Synon'Yms. — Typhus Exanthematicns ; Pctchial Fever; Pestilential or Putrid Fever; Ship Fever; Jail Fever; Camp Fever. Definition. — An acute, highly contagious fever, favored by closely crowding human beings ; especially characterized by sudden onset of high fever, by a petechial eruption, typhoid symptoms, and short duration as com- pared with typhoid fever ; terminating suddenly at the end of the second week. Historical. — It is commonly conceded that the plague of Athens, so graphicall}'- described by Thucydides (B. C. 470 to 400), was the same as the typhus fever of to-day, though it has also been held identical with the Oriental or bubonic plague, which, like typhus, until recently has been regarded as growing very rare. It is also possible that what is so often mentioned in the Scriptures as pestilence may have been typhus, although this too may have been Oriental plague. The same is true of numer- ous epidemics which prevailed during the first fifteen hundred 3-ears of the Christian era, many of which were undoubtedly typhus, especially in Spain and Italy. Among the names were La Pourpre in French, Tabafdiglio in Spanish, Petecchie in Italian, Fleckfieber \Vi German, all of which meant "spotted." It was called pestilential, putrid, malignant, petechial, and " jajd " fever in England, and also " the plague' until 1760, when the name typhus was given it by Sauvages. The history of its sepa ration from typhoid was given under that disease. Etiology. — Though of acknowledged infectious nature, no organism has as yet been isolated that can be held responsible for typhus fever,* "but several non-distinctive bacilli have been isolated from the blood and tissues of patients. Fostered by close crowding, filth, and famine, it each year becomes more infrequent as the conditions favoring it are eliminated, and there is reason to believe it will ultimately be stamped out. Thus, in 1897 there were only three cases in all the London fever hospitals. Ireland has been its home for centuries, but filthy and crowded sections and the alms- Tiouses of large cities have at different times furnished seats for its lodgment. My own experience with the disease is limited to two mild epidemics in the Philadelphia Hospital in 1866 and 1883. and another quite serious in the Camden County (Xew Jersey) Almshouse in the winter of 1880-81. Quite a serious epidemic prevailed in New York City in 1881-82, and a milder one in 1892-93. Sporadic cases rarely occur, but its spontaneous origin is scarcely possible, though such possibility was admitted by Murchison, whose judg- ment on fevers was at one time regarded as almost infallible. Typhus fever is eminently contagious, and cases should be promptly isolated. Nurses and others in constant attendance upon typhus patients are more liable to be attacked than those who, like the physician, merely visit them daily, although perhaps no disease in the past has included among its victims so many medical men. It is not known precisely what the contagium bearer is. It may be all the exhalations and discharges from the body, but it is not especially the bowel discharges. f * For a summary of the observations thus far made on the " Micro-organisms in T.vphus Fever." see a paper with this title by J. B. Byron and Egbert Le Fevre, in vol. ii., "Researches of the Loomis Laboratory," New York, i8g2, p. 130. 56 INFECTIOUS DISEASES. Morbid Anatomy. — As to the morbid anatomy of this disease, there is reallv nothing distinctive. Rigor mortis is apt to be delayed. The petechial eruption remains after death, and gangrenous bed-sores may be found on the body. The most constant lesion is moderate enlargement of the spleen, and in this enlargement the liver and kidneys may share, and their cells be the seat of cloudy swelling due to fever heat. Indeed, all the tissues, includ- ing the heart muscle, may be granular from this cause. The splenic enlarge- ment is mainly due to vascular engorgement, but there may also be some hyperplasia of lymph-cells. The lymph-follicles of the intestine may be enlarged from the same cause, but there is no ulceration of these or of Peyer's patches. The blood is dark and liquid. Hypostatic congestion of the lungs is very frequently found ; likewise bronchial catarrh. The permanence of F 105° 104° 103° 102° lor 100° 99° 98° Days of Disease Pulse Jiesp. M E M E JiJ^ E M E M E M E M E M E IVI E ME m!e ME m!e mIe M E M E M E C ' K A / ' /T K /\ 1 , '1 A 1 \ A \/ P A \ v/ \j \ A j Y 1 /\ V Y /^ 1 \/ L 1 V / K V V V, \ Y j ' V Y f \ 1 \, SI 1 1 1 1 A 1/ 1 1 1 1 / A / ^ ^ A V 1 2 3 4 5 6 S 9 10 11 12 13 14 15 16 ■H - K g ^ 1 s ^ 1 i; S p 3 S 3 3 3 s S 5 o a 3 i S § => o S § S S g s s — S S 2 s - ?, ?! ?1 => ?, s ^, ?, SI S S5 S ?! o - g ?i S s 3 a s 3 3 S " s 3 I- 41 = 39 = 38 = 37 = 36 = Fig. 6. — Temperature in Typhus fever (" Pepper's American Text-book of Medicine.") the eruption after death is in strong contrast with that of typhoid fever,, which disappears after death. Symptoms. — The period of incubation is usually about twelve days. It may be less. There is seldom any prodrome, the invasion being sudden,. announced by a chill or chills followed by headache and great mitscular pain, especially in the back, and by high fever, the temperature rapidly rising to 103°, 104°, 105°, and 106° F. (39.4°, 40°, 40.5°, 41.1° C.) without any of the tidal-wave rise characteristic of typhoid fever. The pulse is at first full and strong, but soon weakens and becomes frequent — 120 and more. There is extreme debility. Almost characteristic are the red, congested con- juncti'c'ce, the dusky face, dull expression, and lozv, muttering delirium, which contrasts strongly with the sometimes active delirium of typhoid. The' tongue is early coated and becomes rapidly dry. The bowels are constipated. On the third to the fifth day the eruption presents itself ; it is of tzvo- TYPHUS FEJ^ER. 57- kinds. The petechial, or more characteristic, is at first not unhke that of typhoid fever, but is darker in hue and disappears less readily on pressure ; a little later it is barely influenced, and still later does not respond at all to pressure. It has become hemorrhagic, petechial — the blood is without the vessels. There may be spots exhibiting each one of these stages. This eruption is also more scattered than that of typhoid fever, appearing all over the body, while that of typhoid is limited to the chest and belly. In addition to the petechial eruption there is also a peculiar dark mottling of the skin, an alternation of purple blotches with others of a light hue, generally capable of being influenced by pressure, but these blotches, too, may become blood extravasations. With the beginning of the second zceek all of the symptoms deepen: The tongue becomes dry, fissured, and leathery ; sordes collect on the teeth ; stupor deepens, there are subsultus and nystagmus, coma vigil, — the patient is unconscious, but the eyes are wide open, — and picking at the bed-clothes. At this time, too. the peculiar disagreeable odor said to be characteristic of typhus fever makes its appearance. It is variously described : by Gerhard, as pungent, ammoniacal. and offensive ; by the late George B. Wood, as like the odor of badly ventilated rooms, in which a number of persons are col- lected ; and by others, as like the odor given off by rotten straw or the urine of mice. Gerhard and ^^lurchison both held that its degree was propor- tionate to the degree of contagiousness of the case. The breathing becomes more rapid, the pulse weaker, scarcely appreciable, and the patient may die of adynamia ; or at the end of the second week a crisis occurs, he falls asleep, the temperature declines as rapidly as it rose, and often after a long sleep the patient wakes up refreshed and with a clear head. Convalescence now progresses, and although it may be slow, relapses rarely occur. A few symptoms require special allusion : First, the fever. The skin is burning hot and the tem.perature rises to 106^ F. (41.1° C.), and even 108° F. (42.2'' C. ) and 109' F. ( 42.7° C. ) toward a fatal termination. It is the calor mordax. There is always hypostatic congestion of the lungs and, along with this, a great deal of bronchial catarrh and cough. Such catarrh may pass into a broncho-pneumonia, which may terminate in gangrene of the lungs. The urine is concentrated, as in all high fevers, and urea and tiric acid are relatively increased. Albuminuria is also common, but there is not usually any organic change in the kidney beyond the cloudy swelling referred to. Retention of urine on account of the mental hebetude may occur, and should be guarded against by frequent examination and catheterization. Bed-sores are common, and there may e^-en be gangrene of the extremities. Instances of the ambulatory form of typhus fever are much more rare than of typhoid, but they are occasionally met. Diagnosis. — How does typhus fever differ from typhoid fever? I have referred to the dift'erences in the eruption in the two diseases. But the tem- perature of typhus fever is quite as characteristic as that of typhoid fever. In the latter disease we have the peculiar tidal-wave course described. In typhus fever, in the first place, the average maximum temperature is higher : for, while a temperature of 106' F. (42.1" C. ) is not uncommon in typhus fever, 105° F. ( 40.5^ C.) in typhoid is quite high. The temperature in typhus quickly reaches the maximum, usually from the third to the fifth day, con- tinues with light remissions until the twelfth or fourteenth, then there is a sudden decline. The ascent is steady and continuous, and only marked by 58 INFECTIOUS DISEASES. slight morning remissions, while in typhoid fever the morning remissions are decided. The pulse, during the first three days, is usually about loo ; after that it becomes more frequent and feeble, running up to 120 or higher, until the drop in temperature, when there is a corresponding fall in the rate of the pulse. It is seldom dicrotic, as in typhoid fever. Typhus fever more fre- quently begins with a chill than does typhoid: the important symptoms, including the eruption, appear earlier. In isolated cases, however, there may be difficulty in diagnosis. Malignant measles, hemorrhagic smallpox, cerebrospinal fever, and "bubonic plague are diseases for which typhus fever may be mistaken. The eruption of malignant measles is not unlike that of typhus fever, and it appears first in the face. The extreme adynamia and the typhoid symptoms are very similar. There is bronchitis in both, but the coryza and acute nasal catarrh are not found in typhus, while concurrent with the case of malignant measles are others of a milder and more typical nature. The latter fact also aids the diagnosis in variola, where, too, in the malignant form the hemor- rhagic tendency is more marked and occurs early in the disease. Cerebrospinal fever has often been mistaken for typhus, and in the early stage the suddenness of onset, the eruption, and the nervous symptoms are all calculated to mislead. One has to wait but a few days, however, before the courses of the two diseases diverge. Bubonic plague has been confounded with typhus, but it seems to have been a very difterent disease, resembling typhus only in its fatality. Bubonic plague, as described to us, — for our knowledge is from descriptions, — is characterized by the same suddenness of ■onset, the chill, high fever, and prostration, as is typhus fever ; but the erup- tion appears earlier, and quickly becomes carbuncular. while the course of the disease is much shorter. Prognosis. — The mortality of typhus is high, but different epidemics vary in this respect. During the epidemic at the Camden County Almshouse (1880-81) referred to, 103 of the officers and inmates were attacked. Of this number 2;^ died, giving a mortality of a little over 22 per cent. I might add that of the officers of the institution, 7, including an attending physician, the steward, the matron, the assistant matron, and 2 nurses, together with the builder of a new hospital building, were attacked, and all died. In some epidemics the mortality is even greater, reaching 50 per cent., but it is com- monly put down at from 12 to 20 per cent. The disease attacks either sex at any age. One of the modes of death is by acute fatty degeneration of the heart, and the peculiar dusky complexion sometimes seen may be due to the inability of a weak fatty heart to propel the blood through the capillaries. Sudden death is not unusual. It is more than likely that with the improved nursing and hygiene of the present dav the mortality of typhus would be less. Treatment. — Whenever possible. typhus fever should be treated in the open air ( in tents ) . as the safety of attendants as well as recovery of patients is favored thereby. There is no reason why hydrotherapy should not be as serviceable in typhus as in typhoid, but it is absolutely necessary that free stimulation should be associated with any treatment. We know that the greatest danger lies in the asthenia, which can be met only by stimulants. If there is one disease in which the free use of alcohol is indicated more than in another, it is typhus fever. The quantity required, of course, must be gov- erned by the condition of the patient. In some case.s it may be necessary to give an ounce (30 c. c. ) every hour. Quinin is also strongly indicated, as are digitalis and strychnin as heart strengtheners. When the temperature RELAPSING FEVER. 59 becomes high, if the cold bath be not used, sponging of the body in the way described under typhoid fever may be substituted. The same objection exists to phenacetin and antifebrin as in typhoid ; that is, they dare not be rehed upon as an exclusive means of reducing temperature, but they may be used as adjuvants. Other symptoms should be treated as they arise. . Specific anti- septic treatment has proved to be Vi-'ithout peculiar advantage. After the crisis, which, as has been said, is strikingly well marked in this disease, it is simply necessary to treat symptoms as they arise. The accompanying bronchitis is treated, if it requires treatment, like any other bronchitis, but the ammonium salts are especially indicated on account of their stimulating qualities, while the aromatic spirit of ammonia is an espe- cially convenient preparation for these purposes. Alcohol, ammonia, and camphorated oil may be given hypodermically to tide over emergencies. The patient should be nourished as in typhoid fever — by nutritious liquids, including milk, milk punches, egg-nogg, and nutritious broths. RELAPSING FEVER. Synonyms. — Febris rccurrens; Famine Fever; Seven-day Fever; Typhus ict erodes. Definition. — Relapsing fever is an acute infectious disease, character- ized by two or more febrile relapses separated by periods of total remission, and caused by the inoculation and multiplication of the spirochaeta of Obermeier. Historical. — Like typhus and typhoid fevers, relapsing fever is not a new malady, for a disease corresponding very closely to it was described b}^ Hippocrates as pre- vailing two thousand years ago on the island of Thasus, off the coast of Thrace. Typhus and relapsing fevers often prevailed together, and many of the older reports of typhus with relapses doubtless referred to relapsing fever. Strother, in 1729, speaks of frequent relapses; also Lind, in 1763. John Rutty, however, in 1770, gave the first clear description of relapsing fever as it prevailed in Dublin in 1739, 1741, 1745, 1748. After this many epidemics of what is evidently relapsing fever were re- corded until 1817. It was still regarded as a modification of typhus, even in 1817-19, and, according to Christison, " there was a very general impression that the relapsing fever could produce the common typhus." After iSiythe disease almost disappeared until 1826, when another epidemic of both typhus and relapsing fevers broke out. Then for the first time a distinction was drawn between the two fevers, especially by Dr. O'Brien, who published an account of the epidemic as it appeared in Dublin. Numerous epidemics appeared from time to time since that date in Great Britain and Ireland and on the continent of Europe, but it has been growing less as cleanliness and hygiene improved. It prevails, also, as might be expected on account of the defective sanitary conditions, in India and Eastern Europe. It made its first appear- ance in America in 1844 in an emigrant ship from Liverpool to Philadelphia, and was described by Dr. Meredith Clymer. It was especially studied in India by Vandyke Carter, of Bombay. In September, 1869, it again visited Philadelphia, and New York in November, and a somewhat extensive epidemic prevailed in the former city, in which I had some experience with it. Etiology. — That the specific cause of relapsing fever is a bacterium of the group spirobacteria, genus spirochaeta, is now generally acknowledged. Plrst discovered by Obermeier in the blood of victims, it is known by his name as the spirochceta Obermeier. It is a narrow spiral about 0.025 to 0.05 mm. (i-iooo to 1-500 inch) in length — that is, its length is three to six times the width of a red blood-disc. It is found floating among the blood-discs during the fever. Before the crisis and in the intervals the organism is not found, but small, glistening spherules, said* to be its spores, take its place. Confir- mation of the contagious nature of the disease is found in the fact that it bas been communicated from one human beinsf to another by inoculation of 6o INFECTIOUS DISEASES. blood, and to monkeys in the same way. It may be supposed that the organ- ism is given off in the breath or from the skin. The operation of the cause is undoubtedly favored by overcrowding, by filth, and by destitution. Yet the disease is not confined to the poorly fed. This was especially proved in the Philadelphia epidemic of 1869, when a considerable number of fairly well-to-do persons were affected, although they always resided in crowded districts. Neither age, sex, nationality, nor season is a factor in its causation. Morbid Anatomy. — There is no essential morbid anatomy, and such as is found corresponds with that of typhus. Most conspicuous is enlargement of the spleen. Symptoms. — The period of mcubation varies greatly, so that it is put down at from two to fourteen days. According to Murchison, there may actually be no interval between exposure and the invasion. The latter is sudden by a chill, fever, intense pain in the back and limbs, with dic::iness. This abrupt invasion is a distinctive feature, and in perhaps none of the con- tagious diseases is it, as a rule, so marked. Exceptionally only is there a short period of malaise with loss of appetite. On invasion the temperature rises rapidly and quickly reaches 104° F. (40° C.) The patient cannot retain his feet, and promptly takes to his bed, feeling very sick, rather than pro- foundly weak. There may be nausea and vomiting and even convulsions in the young; the pulse rises rapidly, more rapidly than in typhus, reaching 140 on the second day, and later 150 and 160. The patient may be delirious^, but the typhoid symptoms are not usually so profound as in typhus and the tongue remains moist. laundice appears in a certain number of cases on the third or fourth day, usually in one out of every 12 cases, occasionally as often as one in every four or five. The temperature during the paroxysm fluctuates slightly, being higher in the evening. Szvelling and sudaniina are often present, and occasionally petechice, but there is no characteristic eruption. Rarely, Murchison says in 8 out of 600 cases, a roseolar rash appears, or there may be a mottling like that of typhus, which, however, always disappears on pressure, and disappears entirely in three or four days — dift'er- ing in these respects from the similar eruption of typhus. Herpes may be present. There is occasionally abdominal tnderness in the epigastric or iliac region, and the enlarged spleen may be easily detected, but there are no active intestinal symptoms. The liver may be also slightly enlarged, extending lower than in health. The spirillum is to be found in the blood and should always be looked for. It may readily be detected with a power of 500 diameters without any special preparation of the blood, care being simply taken to secure a thin film. Crisis. — If the invasion of relapsing fever be sudden, its termination is no less so. It is by crisis, beginning usually with sweating. After five or six days of unabated fever sweating sets in, which soon becomes profuse, the temperature falls rapidly to normal or even subnormal, the various discom- forts fade away, and in the course of a few hours the patient is apparently well. Rarely, the crisis may be ushered in by a diarrhea, an epistaxis, or the appearance of menstruation. The crisis does not always take place at the same stage of the disease. It may occur as early as the third day or not until the tenth, or even the fif- teenth, but most commonly on the seventh. While the crisis is ordinarily followed by some relaxation and faintness, there soon ensues a rapid recovery of natural and healthful feeling. Occasionally, however, the depression is RELAPSING FEVER. 6i '■ ^ c i s s o — 1 g" — 1 o 1 — i i r 1 p 2o CO > m < go ^ - ^ — - H* ■ ~ ~ - - - > t« < < ^ ..^ sc < -" -^ 1 — ""■ "> ^ >~. ►^ -- -- ^ S :k Oi «= _ — L_ - — — — -\ ^ _ Ci - A < J M < ^ \, ^ oc ( ^ " ^ 5» "^ k ^ -J « s \ > HI J— ^ ^ - ■* — _ t« ~ - ^ ~" — -^ ? 09 / — — ' \l X^ > «= ~ ^ - St J N ^ 05 ^ ^ -4 -1 — — — ~ — \ " •^J ■* N \ ^ "v > O , r^ _ 62 INFECTIOUS DISEASES. greater and a sensation as of collapse occurs, especially in delicate or elderly persons. Relapses. — Again, in a week from the crisis, generally on the fourteenth day from the primar}' chill, another occurs, or a series of them, with fever, and the paroxysm repeats itself, to be again succeeded by a crisis at a some- what shorter interval. There may be a third or even fourth and fifth paroxysm ; more commonly they are limited to two or at most three. Each succeeding attack is shorter than the previous one. Occasionally there is no relapse, the disease terminating with the first crisis. Convalescence, usually rapid, is sometimes prolonged, and the duration of the entire illness may be put down at from eighteen to ninety days, and the patient rarely returns to work within six weeks. One attack does not secure immunity from another. Complications. — Among the complications may be mentioned bronchitis, pneumonia, nephritis, and hematuria. The spleen may enlarge until it rup- tures. It may attain a weight of 4 1-2 pounds (10 kilos.), and may be the seat of infarcts. Albuminuria occurs as in other fevers characterized by high temperatures. Pregnant women usually abort in the relapse, and the child, if not still-born, survives but a few hours. Postfebrile paralysis may occur, and troublesome ophthalmia succeeds in some epidemics. Diagnosis. — In its early stages relapsing fever is not unlike typhus. In suddenness of onset, rapid rise of temperature, habitat, and subjects, the resemblance is close. The readiness with which a patient takes his bed is characteristic of each, but in relapsing fever the adynamia is not so great as in typhus, and it is rather because of a dizziness that he cannot keep about. The crisis cuts short all doubt on this point of confusion with typhus. In the intense muscular pains, especially in the back, relapsing fever resembles smallpo.r, but the eruption in the latter disease sets doubt at rest. Malarial fever may be suggested by the relapse, but the presence of an organism in the blood of each of these affections, widely different in appear- ance, permits the settlement of such confusion by the microscope. The preva- lence of an epidemic is, of course, of great assistance in the diagnosis between relapsing fever and any of the diseases with which it may be confounded. Prognosis. — The prognosis of relapsing fever is not unfavorable. The higher mortality reported in some of the earlier epidemics in Great Britain and Ireland was doubtless due to an admixture of typhus. An average for several years in a number of cities in Great Britain and Ireland, according to Murchison, has been 4.3 per cent. ; in the epidemic at Bombay in 1877-78, Vand3'ke Carter estimated tha^mortality at 18.02 per cent. ; while in the Phila- delphia epidemic the studies of William Pepper and Edward Rhoads found it 14 per cent. I am sure that in private practice during this epidemic the mortality was not so great. There are some accidents, which have been already alluded to, that are responsible for a few deaths. Thus, the spleen has ruptured from extreme congestion. Pneumonia sometimes causes a fatal termination. It has been said that the crisis sometimes terminates in collapse with its characteristic clammy coldness, pulselessness, unconscious- ness, and fatal end. A fatal nephritis occasionally complicates the disease, death being preceded by ursemic convulsions. Certain cases associated with jaundice, called by Griesinger " bilious typhoid," are often fatal. Some striking cases of this kind were noted by Pepper at the Philadelphia Hospital in the epidemic of 1869-70. Treatment. — The febrile paroxysm demands much the same treatment as in typhus — careful nursing, sponging or cool bathing, nutritious, easily MALTA FEVER. 65 assimilable food, and stimulation, although the latter is less important than in typhus. No drug has the power to prevent the recurrence of the relapse, although quinin is indicated, and, as in other adynamic fevers, is useful as a roborant. It is reasonable to expect that phenacetin, antifebrin, or antipyrin will relieve the muscular pains. Should they not suffice, morphin, hypoder- mically, can be relied upon. MALTA FEVER. Synonyms. — Mediterranean Fever; Neapolitan Fever; Rock Fever; Undulant Fever. Definition. — An anomalous fever, characterized by irregular remis- sions and relapses, copious sweats, and rheumatoid pains, caused by the micrococcus melitensis. Distribution. — The various names of Malta fever indicate its distribu- tion on the Mediterranean littoral, outside of which it has been thought infre- quent; but in 1898 J. J. Kinyoun * suggested its presence on the Southern Atlantic coast of America and the islands of the Gulf of Mexico, a suggestion confirmed by the report by J. H. Musser and Joseph Sailer of a case originat- ing in Cuba.f Etiology. — The cause of this peculiar fever, the micrococcus melitensis^ has been studied by Bruce, whose researches have been confirmed by Hughes. Its morphological and biological features have been accurately studied by H. E. Durham. It is found in large numbers in the spleen, but has not been isolated from the blood. Pure cultures have been obtained, the disease has been reproduced in monkeys, and the micrococcus isolated from the infected animal. It has been regarded as a form of typhoid, malarial typhoid, and in consequence of enlargement of the mesenteric glands, noted by Italian observers, called adenotyphoid. It has also been thought to be an anomalous form of malarial fever, and ascribed to " chronic poisoning with fecal accu- mulation." On the other hand, it does not give the Widal typhoid fever reaction, while A. E. Wright and F. Smith have shown that the blood of Malta fever patient reacts with pure cultures of the micrococcus melitensis. This would seem to settle its independent nature. The disease attacks mostly the young. Morbid Anatomy. — Our knowledge of the morbid anatomy of Malta fever is not definite. Thus, Bruce says no characteristic lesion of typhoid fever is found, while Perry says of " rock fever " that in 100 autopsies made during four years' residence in Gibraltar, the typical lesions of t3'phoid were present without exception. Hughes also says the spleen is enlarged. Symptoms. — There is usually a period of incubation of from six to ten days. The onset is gradual, with headache, sleeplessness, and thirst, loss of appetite, zvithout chilliness or high fever at first. There is no diarrhea; spots are not found. These symptoms, more or less pronounced, last from three to four weeks, when the first remission sets in, simulating convales- cence. It lasts a few days only, when the first relapse appears, this time with rigors, high fever, and often diarrhea, and the symptoms of the first attack intensified. This relapse lasts for from five to six weeks, to be fol- lowed by another remission of from ten days to two weeks. Then follows the second relapse, when recur the^symptoms of the first relapse, to which * " Gaceta de Caracas," July 15, i8g8, and " Philadelphia Med. Jour.," January 14, iSag, p. 63. + " Philadelphia Med. Jour.," December 31, i8g8. •64 IXFECTIOUS DISEASES. THE MALARIAL FEVERS. 65 are superadded great debility, night-szvcats, pain in the larger joints, includ- ing hips, knees, and ankles, and in the testicles — one or both — lasting three or four weeks. Then follows a third remission, which may last for a month or six weeks. Then a third relapse of shorter duration, adding to the other symptoms a heavily coated tongue, a high temperature, 105° F. (40.5°' C.) and above in the evening, but normal in the morning, the night-sweats, and especially the rheumatice pains, being markedly severe. All the joints now seem to be involved, and motion is an agony. The fibrous tissues are also often involved in this relapse, especially the tendo Achillis and fibrous struc- tures about the ankle ; also the lumbar aponeuroses and sheaths of the nerves from the sacral plexus. Diagnosis. — The rarity of the disease and the peculiarity of its symp- toms may cause it to be overlooked for some time. The serum reaction is, however, characteristic, cultures of the specific bacillus responding to the serum of the blood of the disease as in typhoid fever. Prognosis, — This is generally favorable, not more than two per cent, perishing. Treatment. — This is symptomatic, being directed to the relief of the symptoms and the support of the patient against the exhaustive effects of the disease. A case seems to have been successfully treated with Malta iever antitoxin by Fitzgerald and Ewart.'^ THE MALARIAL FEVERS. Synonyms. — Ague; Fever and Ague; Chills and Fever; Mars'h Fever; Swamp Fever; Paludal Fever; Miasmatic Fever; Intermittent, Remit- tent, and Pernicious Remittent Fever; Bilious Fever; Estivo -autumnal Fever. Definition. — An infectious fever, of intermittent or remittent type, due to an organism known as the Plasmodium or hematozoon of malaria. A chronic cachectic condition due to the same cause is known as " chronic malaria " or " malarial cachexia." Chronic malaria has really a more definite morbid anatomy than the acute malarial fevers. The term " malaria " — meaning, in the Italian, bad air — was originally applied to the supposed specific cause of the fever, but it is also used to express the con- sequences of such cause. Varieties of Malarial Fever. — The malarial fevers are intermittent or remittent. The former is characterized by paroxysms of fever, between which there are total intermissions. In the remittent form there are remis- sions or abatements in the fever, but not intermissions. The remittent fevers exhibit much less regularity than the intermittent fevers, even in their remissions, and in consequence of their prevalence in the later summer and fall have recently among other irregular types been included under the head estivo-autumnal. This term embraces also all the malignant types, which are rarely seen in the spring months. The term " irregular " malarial fevers is quite as distinctive and perhaps more accurate. The paroxysms of fever may come on daily at the same hour, when they are called quotidian; they may occur every other day, when they are known as tertian; or they may OQCur every third day, — that is, skip two days, — when they are called quartan. More rarely occur quintan, sextan, * " The Lancet," April 15, iSgg. 66 INFECTIOUS DISEASES. septan, and octan fevers, with intervals of four, five, six, and seven days,, respectively. It will be noted that in naming these periods the day of the paroxysm and that of the following paroxysm are both counted. The " double tertian " is a fever in which paroxysms occur each day but at dif- ferent hours, the hours on alternate days corresponding with each other. In these cases the alternate paroxysms may also be of dift'erent intensities. In like manner there may be double quartans and even double quotidians. Although the parox}sms in true intermittent fever commonly occur at the same hour, they may happen a little earlier each day, when they are called " retarding." The former is apt to occur when the disease is becoming more severe, the latter when it is abating. The paroxysm varies in length in the different varieties. In the quotidian form it lasts from ten to twelve hours, in the tertian six to eight hours, and in the quartan four to six hours. Malarial cachexia referred to in the definition, also known as chronic malaria, will be fully considered later. Etiology. — The malarial fevers are to-day believed to be caused by a protozoon known as the Plasmodium malarice hematasobn, or hematomonas malaria:. These fevers have ever been a field which seemed to promise reward to the seekers after such a cause. In the days of Hippocrates (B. C. 460-357) it was recognized that marshes breed malaria. John K.. Mitchell,* an eminent American physician, was, however, the first to sug- gest, in a scientific manner, the parasitic origin of malarial fever. This was in 1849; in 1859 John K. Barnes,f of the United States Army, also called attention to such a mode of origin. In 1869 Binz, the pharmacologist,, declared that the cause of malaria M^as an ameboid protozoon, because of the specific action of quinin on ameboid organisms. Alassy, Basa, Wiener, Polk, Holden, Salisbury, and others, all suggested a fungous origin of malaria on more or less unstable foundations. It was not until 1879 ^^^'^ Ed. Klebs and C. Tommasi-Crudeli succeeded in isolating a germ which they called bacillus malarice, from the low-lying atmosphere over marshes and from the soil itself, the inoculation of which into rabbits, they alleged, produced malarial paroxysms with enlargement of the spleen and pigmenta- tion. No permanent impression was, however, made by this announcement. The very next year, 1880, A. Laveran, a French army surgeon, discovered the Plasmodium referred to, and announced the discovery to the Paris Acad- emy of Medicine in 1881 and 1882. His researches were made in Algiers, and in the course of the next three years he published numerous papers. His results were confirmed by Richard in 1882. E. Marchiafava and A. Celli published, in 1885, their observations on the same organism in the blood of malarial patients in Rome. These observers were the first to insist upon the ameboid property of the intracellular form. From this time our knowledge has been enormously extended by many observers, among whom may be especially mentioned Golgi (1885-92) and Canalis (1893) in Italy; Vandyke Carter (1887) and Patrick Alanson (1893-96) in England; in this country A. C. Abbott, W. T. Councilman (1885), Surgeon General Sternberg and William Osier (1886), Walter James (1888), George Dock (1889-92), William Sydney Thayer and John Hewetson as authors of a mastrely monograph in 1895, and James Ewing in 1900; Patrick Manson (1894-96), Surgeon Major Ronald Ross (1895-96), and Daniels (1899) in England from their India studies; Grassi, Bignami, and Bastianelli (i^ * " On the Crvptog-amic Oriarin of Malarias and Epidemic Fevers," "American Journal of the Medi- cal Sciences," Philadelphia, 1849. t " U. S. Army Reports," 1859, p. 163. THE MALARIAL FEVERS. 67 99) in Italy, and W. G. AlacCallum and Eugene L. Opie in this country, have developed the mosquito theory to a positive demonstration that malaria may be conveyed from the mosquito to man, and from man to the mosquito. To Study the Malarial Organism. — The malarial organism ^ is best studied as follows : A drop of blood is taken from the finger or lobe of the ear of a case of ordinary tertian intermittent fever during the chill, or an hour or two previous, while the temperature is gradually rising. It should be suitably spread on a slide and carefully examined by the microscope. There will prob- ably be found a number of pale, mulberry-like bodies analogous to those in figure 9, A„, A\, made up of from twelve to twenty segments, massed about a clump of black pigment granules. Careful focusing will show that this body lies within a red blood-corpuscle, whose delicate walls and pale sub- stance surround it. If, now, a little solution of gentian-violet or fuchsin be successfully added to the preparation, the stain will impart itself to each of the little segments, differentiating a deep-tinted central nucleolus and more lightly stained surrounding protoplasm. In the same slide may be seen other similar bodies (-B,, B„_,), uninclosed in the ring of hemoglobin, loosely arranged, apparently falling apart ; also small, pale spherules ( C j, C 2) floating alone in the liquor sanguinis, apparently derived from the same source. If the blood be taken during the chill, careful searching may also discover certain red corpuscles (D^, D „,) on which are imposed minute pale spots (epicorpuscular) which exhibit ameboid movement. These also take a stain which may develop a central nucleolus and lighter surrounding area, deepening in color at its periphery. The colorless intermediate area is usually interpreted as a bladder-like nucleus, the deeper-stained dot at one side representing the nucleolus which is not apparent in the unstained speci- men. Sometimes there is more than one disc-like body. A few hours later, after the chill, none of the free bodies described is visible, but within * These organisms are readily seen with a power of 500 to 600 diameters, but are best studied when magnified 1000 times, say by an oil immersion Tjth. For more precise study take from the finger- end, or better, the lobe of the ear, thoroughly cleansed, a drop of blood and place on a sterilized cover-glass, which should then be allowed" to fall gently on a glass slide, without pressure. If the. study is prolonged, the edge may be sealed with paraffin, or a ring cf oil. Staining maj' be practiced as follows : A thin layer of blood is spread on several clean cover slips, which are first left to dry in the air for a few minutes, and then placed in absolute alcohol to fix the blood corpuscles and parasites. After 13 to 20 minutes the cover-slips are dried and are ready for staining, although the last stage may be deferred indefinitely. They may be stained with saturated solution of methylene blue, which, as shown by Celli and Guarnieri, is best dissolved in blood serum or ascitic fluid. Double staining, which, if successfully performed, gives brilliant results, should be done by Ehrlich's method, as modified and improved by Romanowsky, i8go; Ziemann in 1898, and Nocht in i8qq. The staining fluid is a mixture of a one per cent, solution of eosin •with a saturated solution of methylene blue, which develops a third stain that colors the chromatin. The eosin stains the red discs pink, the methylene blue stains the hemosporidea blue, while the third stain colors the chrom- atin a violet tint. To prepare the Xocht-Romanowsky staining fluid, Ewing directs as follows. Make first the following three solutions: (i) Polychro7}ie Methylene Blue Solution.— To i oz. of polychrome methylene blue (Grubler) add 5 drops of 3 per cent, solution of acetic acid (U. S. P. 33 per cent.) to neutralize the undue alkalinity. (2) O'rdinarv .Methvletie Blue Solution.— yisike a i per cent, (saturated) watery solution of methy- lene blue, prefe'rably Ehrlich's rectified, or Koch's, by aid of gentle heat. This solution improves with age and should' be at least a week old. (3) Eosin Solution. — A i per cent, solution in water of Griibler's aqueous eosin. Then to 10 c. c of water add 4 drops of (^). 6 drops of (i), and 2 drops of (2I, mixing well. To Use.— Ttie specimens fixed bv alcohol or heat are immersed for two hours specimen-side down, and will not overstain bv twentv-four hours' immersion. They should be then washed in distilled water, dried slowl v over the flame and mounted, if desired, in Canada balsam. The density af the blue may be varied to suit individual fancv, nor need the proportions be rigidly followed, but most important is the accurate neutralization of the polvchrome solution. Preliminarv studies mav be made of the drepanidiutn ranarutn, a similar parasite in the red corpuscle of the frog (Osier." " Canadian Lanaet." Xo. 7. 1882); or on the hematozoa of birds._ (See papers by W. G. MacCallum and Eugene L. Opie in " Tour, of Experimental Medicine," vol. 111. No. I, 1808; see also Angelo Celli's admirable book on " Malaria," 2d ed.. translated by John Joseph Eyre, London, iqoo, where the whole subject is treated most interestingly and fully.) 6S INFECTIOUS DISEASES. Af Ai BZ CI aj^fo, 0^ pt £i' ,f ^./^^^' 'V '!^ G ^ ^2 ■^' .-Y"/ Fig. g.— Illustrating Different Forms of the Malarial Organism with their Stages of Development. Au --^3, As, Ai. Sporulation stage. Bi, B^. Sporules separating. C C^. Free sporules. Dx, D^. Epicorpuscular forms. E^, E^, E%, E^. Intracorpuscular forms. Fx, F^. The large extracorpuscular body. Gx, d, Hs. The flagellate forms. Hi, H^, Hz, Hi, H^, H^. The crescent-shaped parasite and forms result- ing from its evolution. Drawings in the upper part of the plate from the blood of a case in the wards of the Hospital of the University of Pennsylvania, those in the lower portion selected. THE MALARIAL FEVERS. 69 the corpuscles are seen actively moving ameboid bodies (£3, E^, ) of con- siderable size, constantly changing shape, and sending out pseudopodia into the substance of the blood-corpuscle. These intracorpuscular bodies stain with the same differentiation as the smaller disc-like bodies, but the nucleus is larger and less distinct. Many of them contain one or more dark granules in active motion. Still later, toward the next paroxysm, the pale body fills the entire corpuscle, its ameboid movement ceases, while the pigment granules are more numerous and stationary. It has, moreover, lost its nucleus and nucle- olus. The pigment now tends to mass itself into clumps or radiating lines, and just before, or at the time of the chill, the picture first described, of rosettes or loosely attached and free spherules, is seen. The same cycle of successive steps is kept up from paroxysm to paroxysm. The conclusion reached by all observers is that the large intracorpuscular body (Fig. 9, A^) is the mature parasite ready for sporulation, and the mulberry mass presents the sporules perfectly formed, which a few seconds later become free spher- ical spores. These attach themselves to the red discs, penetrate them, and grow at the expense of the hemoglobin, leaving the black granular residue as excrementitious substance, which is let loose in the blood at the time of sporulation. As a consequence of this, the presence of pigment in the blood and tissues is one of the most characteristic features of malaria. The time required to attain the perfect growth, from the free sporule to the last stage of sporulation, varies in the different varieties of malarial fever. During this period certain groups, perhaps numbering myriads of cor- puscles, pass through the same stages, and the final sporulation of such a group of parasites is always followed by the malarial paroxysm. This is probably due to some toxic substance developed at the time of sporulation. Thus, with the typical quotidian type, sporulation takes place every day at the same hour, with the tertian type every other day, the quartan type every seventy-two hours, and so on. If, however, two groups ripen at different hours, we have the double forms, be it double tertian or double quartan. Or two groups of tertian parasites may mature on alternate days, causing a quotidian paroxysm, though at different hours. A paroxysm may be expected at once in the tertian form, if radiating lines appear in the organism with concentration of pigment. The cycle of existence of the estivo- autumnal type has an undetermined duration, and probably varies from twenty-four to forty-eight hours. The irregular ripening of different groups would explain the irregularity of the estivo-autumnal forms of fever, which may begin as regular types. Attempts are further made to differentiate the parasite of the different types of fever by its dimensions, rapidity of ameboid movement, size and number of pigment granules, number of segments in sporulation, etc. Thus the full-grown parasite of tertian fever is about as large as a normal red blood-corpuscle, beginning its cycle of development as a much smaller hyaline ameboid body. It acquires rapidly fine, brown pigment granviles formed at the expense of the surrounding blood-disc, which, becoming gradually decolorized, becomes larger and more indistinct until it disappears. The granules exhibit active movement. In the sporule stage the segments number from fifteen to twenty, or even more. The parasite has a cycle of 48 hours. The parasite of quartan fever is very similar, but it is smaller; its ameboid movements are slower, and the pigment granules coarser, darker, 70 INFECTIOUS DISEASES. and less active in motion. The red corpuscle embracing it, instead of becoming larger and paler, shrinks about the parasite and assumes a deeper, greenish hue. The sporulation segments are fewer, only from five to ten in number, and arranged with great regularity about the central pigment (Fig. C), A „). Its cycle is y2 hours. The parasite of the estivo-aiitiimnal fever is still smaller, being, when fullv developed, often less than half the size of a red blood-corpuscle, and tlie quantity of pigment is much smaller. Only the early stages of its development, represented by small hyaline bodies, often with one or two pigment granules, are found in the peripheral circulation, the later stage being seen in the blood of internal organs, such as the spleen and bone- marrow. The fewness of the pigment granules is characteristic. The corpuscles containing the parasite are also apt to become shrunken, crenated, and brassy in color. After a week or more, the larger crescentic ovoid and round bodies to be described make their appearance, and are characteristic of this form of fever. The cycle of this parasite is about 48 hours. The large extracorpuscular body {F ^, F^,), which presents the same pigmentation and other features of the intracorpuscular body, is the latter escaped from the corpuscle. The event of its escape may sometimes be observed while studying blood taken about the time when most of the intracorpuscular bodies have disappeared by sporulation. Such escape, it is thought, does not take place in the living blood, since the corpuscle is not found in preparations, dried or "" fixed." immediately after the removal of the blood from the body. It is found, however, in preparations watched with the microscope for some minutes after being taken. The crescejit-shaped parasite (Fig. 9, i7,, H.,, H^, H^, H^, H^,) is also a striking object, far less frequently met, at least in the vicinity of Philadel- phia, than the ordinary pigmented form. Unlike the large extracorpuscular form already described and the flagellate form to be next described, it is apparently a constituent of living blood, and, according to the studies of Thayer and Hewetson. as well as the earlier ones of Marchiafava and Celli, appears in most of the cases of estivo-autumnal fever after a certain time, generally during the second or third week, and not in the cycle of development of tertian or quartan fevers. The crescent develops in the interior of the red corpuscle from the small hyaline forms, which gradually increase in size, lose their ameboid movement, and assume a crescentic shape, while pigment granules collect in a group at the center. The cor- puscle itself gradually becomes decolorized and ultimately destroyed, though for some time a delicate line can be seen running between the horns of the crescent, a shell, as it were, of the corpuscle in which the parasite is developed. The crescents in turn change into elliptical, ovoid, and finally round forms. When the round form is assumed the pigment starts into active motion, and sporulation may take place. Such sporulation may also. according to Canalis, Manson. and Ross, be by flagellation. The flagellate organism ( G^, G„) may also com.e into view on the slide some fifteen or twenty minutes after the blood is mounted, but is never seen on slides " fixed '" immediately after the blood is drawn. It develops from the full-grown tertian and quartan parasites and from the round bodies with central pigment in estivo-autumnal infections. It is a very interesting object, the tentacle-like prolongations lashing about the central mass and agitating the surrounding corpuscles in a seemingly violent manner, throw- ing the latter and its own melanin particles into a state of extreme commo- THE MALARIAL FEVERS. 71 tion. Sometimes portions of these tentacles break loose and float away in the blood plasma. It will be noted that no quotidian parasite is described. It is not thought that a special form causing this variety of intermittent fever exists, but that the quotidian paroxysm is due to the maturation on successive days of two swarms of the tertian parasite. Though the mosquito theory of malaria is by no means new, it was not imtil 1894 that Patrick Manson gave it definiteness by suggesting the mos- quito might be the intermediate host for the extracorporeal forms of the parasite, that the flagellate form is the first extracorporeal stage, and that the flagella, breaking off from the residual body, may penetrate the cells of some organ of the insect. He first claimed that the crescentic form of estivo-autumnal malaria and the tertian and quartan spherical forms from which develop flagella are the " extracorporeal sporulating homologues of the intracorporeal organism ; that the flagellum is the extracorporeal homo- logue of the intracorporeal spore." Both types of sporulating plasmodium possess the same function, — the propagation of the parasite, — one in the human body ; the other, outside of it. Surgeon Major Ronald Ross, whose studies were stimulated by Manson, found the flagellate form in the stomach of mosquitos that had fed on subjects suffering with estivo-autumnal fever whose blood contained large numbers of crescents, confirming Manson's observations. Again, Daniels, working in Calcutta under Ross' direction, was able to confirm all the latter 's observations. Angelo Celli, while admit- ting that Ross partly saw the first stages of development of the estivo- autumnal parasites in the body of a dapple-winged mosquito, holds that Grassi, Bastianelli, and Bignami have given us all the details of its develop- ment.* W. G. MacCallum demonstrated in his observations on halteridium of Labhe, a malarial parasite of birds, that the flagella represent male sexual elements. Favoring Causes and Geographical Distribution of the Malarial Fevers. — Such is the belief as to the immediate cause of malarial fever at the present day, evidence being strongly in favor of the view that inoculation is the only mode by which the infection is carried from the mosquito to man and from man back to the mosquito. Indeed, most recent studies by the Italians, Bastianelli and Bignami, have determined the species of mosquitos that are capable of producing two forms of infection. They are the anopheles claviger and anopheles pictns (dapple-winged mosquito of Ross), both conveying the estivo-autumnal form, while the former is the conveyer of tertian infection. These views are further confirmed by the conditions which favor malarial fever, and these conditions, notwithstanding exceptions, are hot climates and hot seasons plus decomposing vegetable matter, low river banks frequently covered and uncovered with water and exposed to the sun — in a word, conditions that favor the breeding of mosquitos. Wherever these conditions occur, malaria is rife. Especially are they found in the southern borders of the north temperate zone, as in Southern United States, Southern Italy, and along the lower Danube ; the northern border of the south temperate zone, in the tropics, as Central America, the West Indies, Central Africa, and Southern Asia. A freshly upturned soil may furnish, under a sufficiently high temperature, a min- imum of 60° F. (15.6° C), as favorable a focus almost as a marshy river bank. All ages are susceptible, but children are especially liable to take the * Celli, "Malaria," 2d ed. Translated by John Joseph Eyre, London, igoo. 72 INFECTIOUS DISEASES. disease on exposure. More men have it than women, for evident reason. Currents of air carry the disease to localities in which it is not primarily engendered, only by carrying the mosquitos laden with the extracorporeal forms. Water ingested cannot be a cause of malarial infection, according to modern views. Morbid Anatomy, — The morbid anatomy of malaria includes mainly changes in the blood, the liver, and the spleen, — changes that vary with the duration and intensity of the disease, to which, however, they do not always correspond. As to acute malaria: In the true intermittent fevers there is a loss,, sometimes considerable, of red corpuscles after each paroxysm, which is made up during the intermission. In the estivo-autumnal form the blood losses are greater and more permanent. The absence of leukocytosis is characteristic. In remittent and pernicious malaria — the latter a form char- acterized by the intensity of the poison and severity of the symptoms — the morbid changes may not be very striking if the patient die in the first attack, but more marked after a second. The blood is described as hydremic,, the serum is sometimes tinged with hemoglobin, and the corpuscles, while containing the parasite, present all stages of destruction. The spleen is enlarged, but not nearly so much as in chronic recurring forms of malaria. It is, m.oreover, soft and its pulp is dark from accumulated pigment in the intervascular cords. The liver is enlarged and dark-hued, sometimes described as bronze and sometimes slate-color. Even when not visibly altered to the naked eye, there may be no difficulty in recognizing the excess of pigment within and without the small vessels, some of which may be occluded. In fact, by the aid of a microscope, almost all the tissues may be found abnormally pigmented, even the brain, some small vessels of which may also be occluded. The kidneys are the seat of pigment deposits, and their cells of cloudy swelling. In chronic malaria the blood changes are even more marked. There is a positive secondary anemia in which, as usual, the hemoglobin is de- creased rather more than the corpuscles. The leukocytes are almost invari- ably diminished, the polynuclear leukocytes most, while the larger mono- nuclear forms are relatively increased. Pigment deposits are abundant, especially in the spleen, which is enlarged and hard. In chronic malaria, of whatever form, the enlarged spleen is the most characteristic morbid product. It may weigh as much as ten pounds (4.5 kilos.) and measure ten inches ^(25 cm.) long and four (10 cm.) to six (15 cm.) in width; its capsule is thickened, its substance firm, and the tra- beculse prominent. Pigmented areas abound, due to the plugging with pigment of the intercommunicating lymphoid spaces of the pulp, and in- some cases the melanosis is general. The pigment particles resulting from the disintegration of the hemoglobin in the vessels are retained in the spleen,, as by a filter. The liver is also enlarged, to a less degree, however, than the spleen. It is indurated and presents various degrees of pigmentation, which may reach a slate-gray tint. The pigment is contained in the portal canals and beneath the capsule. The kidneys may be similarly pigmented, the pigment lying about the smaller blood-vessels and the Malpighian bodies, and in the cells lining the tubules. In protracted cases of malarial cachexia other tissues may be pigmented. Thus, the small vessels of the brain may be surrounded by INTERMITTENT FEVER. 75, pigment and even occluded, so that hemorrhagic infarcts may occur. Even the mucous membrane of the stomach and the peritoneum may be pig- mented in extremely chronic cases. Malarial poisoning is included among the causes of chronic nephritis, but, in considerable experience with renal diseases, I can recall but one or two cases of nephritis doubtfully traceable to this cause. CLINICAL VARIETIES. The chief varieties of malarial fever admit of easy separation by their symptoms. Intermittent Fever. Definition. — This form of malarial fever is characterized by a total remission of fever between paroxysms. Symptoms. — This, the well-known fever and ague, characterized by distinct paroxysms of chill, fever, and sweat, has a distinct period of incuba- tion, which mav be as short as twenty-four hours or even less, though usually it is from a week to fourteen days. Sometimes it is very nmch longer, and even months are said to elapse after exposure before the first paroxysm sets in. The paroxysm is usually preceded by a prodrome of uneasiness and dis- comfort, sometimes languor and yawning, sometimes headache, sometimes nausea, which forewarns the patient of its coming. As often as not there is no such prodrome. The paroxysm consists of the chill or cold stage, the fever, and the sweat. The chill commonly begins gradually. First there is a creep, then another a little more severe, then another, each growing in severity until the teeth chatter and the body shakes violently. There is, however, great dif- ference in the severity of the chill. It may be a barely noticeable creep or such a chill as will cause the bed and even the windows of the room to shake. At the same time the patient's lips are blue, his face is pale and pinched, and he looks very cold. Yet he has fever. Even before the chill there is a slight rise in temperature, and during it the latter may reach 105° F. (40.5 C.) and 106° F. (41.1° C.) in the axilla or mouth. A surface thermometer may show a lower temperature of the skin, but the internal heat is in strong con- trast with the apparent coldness. There may be nausea or vomiting and severe headache. The pulse is small, hard, and frequent. The hands are pale, cold, and the nails blue. The urine is increased, light-hued, of low specific gravity, though before the chill it may be concentrated and the specific gravity high. The duration of the chill varies from a few minutes to an hour or more. To the chill succeeds the fever. The skin is intensely hot and dry and the face flushed. There is intense thirst. The mouth is dry, the tongue coated, the breath foul. There is no mistaking this stage any more than the first. Yet the actual temperature is but little higher than during the chill. This is well shown in the appended chart, in which it will be seen that the temperature during the chill at two successive observations was 104.2° F. (40°C.) and 104.4° F- (40.18° C.) ; during the succeeding fever it reached at the first observation 104.8° F. j,40.4° C), and at the second, 105° F. ('40.45° C). The duration of this stage is from half an hour to four or six hours. The siveating stage follows, with the appearance of drops of sweat on 74 INFECTIOUS DISEASES. the face, whence it extends all over the body and is various in quantity. With it comes relief to all the symptoms. Indeed, a sense of great comfort super- venes. It may be a mere suggestion of moisture, or it may be very profuse, drenching the patient's clothing and even wetting the bed. It is commonly proportionate to the severity of the chill. During the sweat the temperature falls rapidly, but if the paroxysm is severe several hours elapse before it attains the normal. It lasts for half an hour to tzvo hours, after which the patient feels comfortable and well. It is not easy to give a satisfactory rationale of the three stages. The F. 107 T ^ ^ Iz i - - E - h Z E - z E - - -: 6 J z- — - z - E r E.-S_ - - 106° 105' lOf 103° 102° 101° 100° 99° -9- :E -z - — -1- -S E E E h E E E E - E E: h — - E E — E -o ^ -■ .a. X _ ;■-< — ^iE E E _ -i - _< I ■zU ; — I C o E E E E E E ^ E - ~ — c C i- a 3-1-1 ~ - E ~ ~ .Sig_ _ i-Q — E E n.z IZ ~i t z z z z z z — z: - - Zi i^- '_ - - - z z — 0|z z z — 0-- - — — - — — - - — — — - - — - -^-\ - — - — - — — i - L c.^- -- - \ r- - - - - ^ - - - — .^[ -J rrr - ^ - ^ - - - L ~* 1 CM \ ol s E .- Q- - |— ii -■ \ ' ■ 1 1 f^ 1 ^ V / I .1 irr j \ c / \ . ^ r s z _J s _ _ _ _ _ , _ 5 •\ n' _ _ __ oIX --r _ .^ — - - — -^ — - S — -^ — -1 — — — — — / - - — ^ ^ ^ — - — 2"r' - f — — — -s- — T — -' — q — - o^ — — - - — — - — - —-, - - -- LO- 5 f^i — — — — ^— - - t — — — r- 1 — — — — ' -j — — — — — — — — — — 1 — — — — '\ — — — — — 7 " - \ — — =/ ~~t ] / j / / \ r 11 f E: 1 i :~ r St ^ \ "< < -^ E A^ ■i < ^ s <- - :E E s \^ i - i L - s- t .< ^ if -(1- 98° ->■ 97° ~z i < TO- < - i: ~ — — E ~ dr_ ^ r E i -< < I ^ ? 1 1 E z — -*- 5 _2 tl ~ E i ^ ._ Pig. 10. — Temperature Chart in Intermittent Fever, Showing Paroxysms and Inter- missions. It will be noted that the temperature has been taken during the chill, and during the fever just after the chill, and that although, as is well known the fever is very high during the chill while the patient feels cold, it is still a little higher during the fever just after the chill. first and second are undoubtedly the direct result of the same cause — a toxin generated by the plasmodium, since the actual fever which characterizes both is irritative. The superficial coldness and sense of cold of the first stage may be the result of vasomotor spasm contracting the blood-vessels of the surface and due to an irritation of vasomotor centers by the toxin ; the second stage to a derangement of the heat-regulating centers. The third stage is probably a reactive vasomotor paralysis, with the usual leakage from the skin inci- dent to it. The total duration of the paroxysm is from eight to tivelve hours, and usually between the paroxysms the patient feels perfectly well. During the paroxysm the spleen becomes enlarged and the malarial patient has often herpes labialis, a symptom which is almost pathognomonic of malarial fever. The size of the spleen subsides after the paroxysm, although with its repe- tition there is a disposition to permanent enlargement, resulting finally in the ague cake. INTERMITTENT FEVER. 75 The types of the paroxysm so characteristic of intermittent fever have already been referred to. The order of frequency is quotidian, tertian, and quartan ; the first being by far the most frequent. Diagnosis. — The diagnosis of intermittent fever is most easy, and a typical case should be easily recognized after the second paroxysm, if not after the first. If the case be less typical and the chill omitted or so slight as to escape recognition, a certain resemblance between such a paroxysm and the hectic fever of tubercular consumption, with its subsequent sweat, must be admitted, and it not infrequently happens that such fevers are Fis; II.— Temperature Chart in Intermittent Fever, Showing the Paroxysms and Intermissions. declared to be malarial by the attending physician — more frequently, it is to be hoped, for the sake of comforting the patient than as a matter of accurate diagnosis. Still more close is the resemblance of the paroxysm to the chills, fever, and sweats of septicemia and pyemia, while suppuration is frequently ushered in, and its progress associated with like symptoms. Other conditions cal- culated to produce these symptoms may generally be discovered on careful inquiry, though they may escape notice for a time. In addition to suppura- tion, surgical operations, catherization, puerperal fever, the incidence of empyema, and the like, all produce chill, fever, and sweat. The so-called 16 INFECTIOUS DISEASES. nervous chill is easily distinguished, because with it there is no rise of tem- perature — at least nothing at all comparable to that of the malarial chill. The possible combination of malaria with other causes of chill and sweats is to be remembered. A search for the hematozoon, scarcely necessary for diagnosis in typical cases, may under such circumstances prove extremely useful. Prognosis.— The prognosis of simple intermittent fever is always fav- orable. Very frequently, if the disease is not treated by medicine, it will exhaust itself in a couple of weeks and disappear, v.'hile the administration of suitable doses of quinin always puts an end to it. The worst that can happen is the conversion of the disease into chronic malaria or the malarial cachexia. This may occur when treatment is neglected, or when constant exposure to the cause operates to produce such a state notwithstanding suitable treatment. Remittent Fever — Estivo-autumnal Fever. Definition. — Remittent fever is the form of malarial fever characterized by a continued fever with paroxysmal exacerbations. It is also known as bilious fever. It has become rare at the present day in the North Atlantic States of America, and is confined mainly to the South, to Italy, the lower Danube sections in Europe, and to tropical countries. It occurs in the late summer and fall, and hence is included among the estwo-autiimnal fevers. Symptoms. — It generally begins with a chill after a period of incuba- tion analogous to that of intermittent fever. It is more likely to be preceded by prodromal symptoms than is intermittent. There are malaise, intense headache, a coated tongue, and often obstinate nausea and vomiting. Vomit- ing of bilious matter is a conspicuous symptom. These gastric symptoms, formerly ascribed to gastritis, are probably caused by central nervous irrita- tion due to the toxin. There may be jaundice resulting from obstructing cholangitis ; the liver may be tender on pressure. The chill may be less severe, and the other stages of the paroxysm less characteristic. The fever does not pass off, but continues with a full, bounding pulse and a tempera- ture of 102° to 103° F. (38.9° to 39.5° C). There are daily remissions, as in typhoid fever, but they do not follow the same rule of tidal rise. Yet the two diseases are very similar, and often thoroughly try the diagnostic skill, even of those who are accustomed to meet bilious remittent fever. The tem- perature rises quite as high as in typhoid fever, and the patient is usually very ill. The two diseases occur a-t the same time of the year — the autumn. It is not impossible for them to be concurrent. There is little else that is peculiar in the symptomatology of the common forms of remittent fever besides the prodrome, the malarial organism, and the peculiar paroxysmal character. In prolonged remittent fever the typhoid state is sometimes assumed, manifested by dry tongue, hebetude, stupor, and feeble, frequent pulse. The urine is high-colored, with high specific gravity, depositing a copious sediment of urates, and sometimes contains biliary coloring-matter. Not infrequently it contains blood-corpuscles or hemoglobin. Diagnosis. — As intimated, it is with typhoid fever that remittent fever is most likely to be confounded. Occasionally in the South there has been confusion with yellow fever. To us who study typhoid fever in the North it seems surprising that there should be any confusion with this disease. It is ordinarily so easy, after watching the temperature chart for a few days, to PERNICIOUS MALARIAL FEVER. yy recognize typhoid fever. In the South it is, however, different, and, before the discovery of Laveran's plasmodium,, the therapeutic test — administration of quinin — was frequently needed to settle the question ; for remittent fever, like intermittent fever, yields to quinin. In such cases a successful search for the hematozoon will settle the question promptly. This is the variety in which we have the small, actively motile hyaline forms of organism, while the larger crescentic, ovoid bodies are to be looked for as soon as the disease has existed over a week. An unsuccessful search may still leave the matter in doubt, but if the nasal hemorrhage, the typhoid spots, the diarrhea of typhoid, and the temperature are not sufficiently characteristic, the quinin test ought to put an end to all doubt. The Widal test has come to our aid, also, of late, and if responded to affords conclusive evidence of the presence of typhoid fever. Although it may seem presumptuous for one who has not practiced in the South to say it, such study as I have been able to give to the subject impels me to say, with Osier, that all of the continued endemic fevers of the South may be resolved into typhoid or malarial fever. The diagnostic distinction between remittent fever and yellozv fever will be given when considering the latter disease. Prognosis. — This is usually favorable when treatment can be promptly applied. Pernicious Malarial Fever — The Congestive Chill. Definition. — This variety of malarial fever is characterized by the extreme severity of its paroxysms. Occurrence. — It still presents itself occasionally in the North, but is much rarer than it was fifty years ago. Up to a few years ago it was not uncommon to hear of the death from this cause of a prominent citizen at his country seat on the banks of the Delaware above Philadelphia. Later, the cases became confined to the servants and others out late at night or early in the morning, and, more recently still, even such cases as these are seldom reported, although the milder forms of malaria prevail. It is still prevalent in the Southern United States, in Italy, the lower Danube, the Niger delta, and other parts of tropical Africa. According to the Italian observers, per- nicious malarial fever is associated with the small plasmodium. Two principal types present themselves — the comatose and the algid. Other forms, named from special features more or less characteristic, are the hematuric, the bilious and the asthmatic types. As malarial hematuria is not confined to the pernicious variety, it will receive separate consideration. The bilious type is that of the ordinary severe form of remittent fever, while asthma characterizes the comatose and algid types. I. The comatose type may or may not begin with a chill, but in its more serious forms the chill is a conspicuous feature, being severe. To it suc- ceeds the comatose state, whence the term congestive chill often used in the South, where the popular notion prevails that if the first paroxysm does not kill, the second will. This is an exaggerated idea of its seriousness, although it is certainly a very grave affection and often terminates fatally. A low, muttering delirium may supervene, the eyes are bloodshot, the skin is hot and dry, the temperature rising to 105° or 106° F. (40.6° or 41.1° C). The comatose condition is probably a toxic one, and lasts until a partial elimi- nation of the poison has taken place, usually from twelve to twenty-four hours later. The patient may, however, perish without return to conscious- 78 INFECTIOUS DISEASES. ness, or consciousness may return to be followed in a short time by fatal relapse. 2. The algid type is characterized by gastric symptoms, extreme nausea and vomiting, which are mostly followed by collapse, for there is intense prostration, with coldness of the surface and extremities. The symptoms are, indeed, comparable to those of the collapse of cholera. There are the same small, feeble pulse, frequent, shallow breathing, cramps, vomiting, purging,, husky voice, and thirst wath suppressed urine, and with these the same clear- ness of intellect until death steps in — the last scene in the drama, in which asthenia also plays a leading role. In these cases there may or may not be a chill, yet the patient feels cold and the surface temperature is never high, rarely exceeding ioi°F. (38.3° C), and falHng as low as 96° F. (35.6° C). The internal temperature is, however, high. Diagnosis. — Pernicious malarial fever is to be distinguished in its comatose form from typhoid fever, and in its algid type from yellozv fever.. The presence of the plasmodium and pigment in the blood are the distinctive features to be carefully sought. Irregular Forms of Malarial Fever. It sometimes happens that the paroxysm in intermittent fever omits one or more of its stages. Especially is this the case with the chill in which event the disease has received the characteristic name of " dumb ague." Frequently, however, what receives the name of " dumb ague " is something altogether different. The " malarial cachexia," for instance, is sometimes spoken of as " dumb ague." Like malarial cachexia " dumb ague " is found among the older residents of a malarial district. Quite often it happens that the malarial paroxysm consists of nothing but a state of drowsiness, which recurs at regular intervals and is very char- acteristic. The temperature in these cases is elevated, but not very high, 100° F. (37.8° C.) or perhaps 101° F. (38.3° C.) ; there may be slight delirium. Another irregular form is intermittent neuralgia, which is clearly malarial, the proof of it being the facility with which it is broken up by quinin. Usually there is no fever ki this variety. The nerve commonly involved is one of the branches of the trigeminal. The intercostal nerves are also the seats of such an attack, giving rise to one of the forms of pain in the chest, but any nerve-trunk or its branches may be affected, as the sciatic or brachial. The term latent intermittent fever is applied to a combination of symp- toms affecting persons living in malarial districts — consisting in a weary, languid feeling, associated with want of appetite, headache, nausea, vomit- ing, constipation, and coated tongue. Sometimes the so-called " bilious attacks," which exhibit the above symptoms in an aggravated form, espe- cially the headache and vomiting, are malarial in their origin, and may be broken up with quinin. Such attacks may be called malarial migraine. Irregularity of fever or chills, or both, may be caused by infection with more than one group of the same kind of parasite occurring at different times, or there may be infections of different kinds of parasite maturing at their own specified time. MALARIAL HEMATURL4. 79 Malarial Hematuria^ or Hemoglobinuria, or Intermittent Hema- turia — Blackwater Fever. This form of hematuria is the direct result of malarial poison. The first account of it in this country was published by George Troup Maxwell in the " Oglethorpe Medical and Surgical Journal," Savannah, Ga., volume iii. pages 12-18, July, i860. While it is a very frequent symptom ot the pernicious or malignant type of malarial fever, it also occurs as a symp- tom, and, indeed, sometimes the sole symptom, of the milder varieties of malaria, such as occur in the Middle States of the United States. I have met a number of these cases. Rarely are they accompanied by a chill, and there may be no symptoms whatever except the bleeding. More frequently there is a cold feeling, the tips of the nose and of the fingers become cold, and the lips become blue, immediately after which the urine is found to be bloody. Microscopic examination of the urine will recognize in some instances blood- discs, in others no corpuscles can be found. It is a hemoglobinuria:^ The hemorrhage occurs daily or on alternate days, more rarely at longer intervals. Sometimes it is continuous, with exacerbations at regular intervals. In all cases of unexplained hematuria the blood should be examined for the mala- rial organism. When a symptom of pernicious malarial fever, the condition is more apt to be hemoglobinuria than hematuria ; it is more aggravated and more con- tinuous, although still intermittent. It may also be associated with hemor- rhages from the nasal and oral mucous membranes, and even from the stomach, which add much to the gravity of the case. To such a grave form of malarial fever occurring in the Niger delta m. Africa the name blackwater fever has been given. Chronic Malaria and Malarial Cachexia. Definition. — This is a condition which often supervenes in cases imper- fectly or ineffectually treated, or in persons living in malarial districts where there is constant exposure to the cause and consequent repeated attacks. Symptoms. — The most striking symptom of this condition is anemia of a peculiar kind. The incident changes in the blood have been referred to on page y2. The skin exhibits a dirty-yellow or sallow appearance, often erroneously characterized as " bilious," as though it were a form of jaundice,, which it is not, although there may be sometimes slight jaundice also. Such persons have, in addition, deranged digestion. The tongue is pale, flabby, and coated, and the breath sometimes foul. The bowels are constipated. The hands and feet are cold, the circulation is generally bad, and the tempera- ture is subnormal, though it may alternate with the feverish state. In con- sequence of the hydremic blood there is sometimes edema of the feet, and even general anasarca. The spleen is enlarged, often extending as low as the ilium. Some very unusual symptoms are included in the symptomatology of this form of malaria — as, for example, paraplegia and orchitis. The former *The presence of hemoglobin can be easily shown by making Teichmann's hemin crystals in the following manner: The earthy phosphates are precipitated, filtered out, and a small portion placed on a glass slide, and carefully warmed until completely dry. A minute granule of common salt is carried on the point of a knife to the dried mass and thoroughly mixed with it. Any excess of salt is then removed, the mixture is covered with a thin glass cover, a hair being interposed, and a drop or two of glacial acetic acid allowed to pass under the cover. The slide is then carefully warmed until bubbles begin to make their appearance. After cooling, hemin crystals can be seen by aid of the microscope. These, though often verv small and incompletely crystallized, are easily recognizable by an amplification of 300 diai_i&ter3. They are, chemically, hydrochlorate of heniatin. So INFECTIOUS DISEASES. condition may be the result of deranged circulation in the spinal cord, but it is difficult to regard the latter as anything except a coincidence. A remark- able case of malaria with symptoms of disseminated sclerosis was reported by Dr. William G. Spiller in the " American Journal of the Medical Sciences " for December, 1900. The autopsy disclosed sclerosis of the right crossed pyramidal tract throughout the spinal cord, not intense, but unmistakable. The plasniodinin is found in this form of malaria also, and the crescent is said to be the form more or less characteristic of it. The recognition of the organism is of value in the diagnosis of this from other forms of anemia, although the history of the case and the presence of enlarged spleen are also important factors in diagnosis, especially as the plasmodium may elude detec- tion altogether, and malaria still be present. It is to be remembered, how- ever, that in leukemia there is also enlarged spleen, but the microscopic examination of the blood reveals at once in the latter disease the excess of colorless corpuscles. Prophylaxis of Malarial Fever. — Much may be done to avert malarial infection. It is not considered possible for the organism to enter the system by the stomach or respiratory passages. This being established, prophylaxis must consist in measures to destroy the mosquito or escape its bite. To exter- minate the adult mosquito is manifestly impossible. Yet it is not chimerical to look forward to the possibility of destroying the insect in the larval state as it exists in pools and ponds. While all the more common species of mos- quito belong to the genus culex or genus anopheles, Ross has shown that up to the present only mosquitos belonging to the genus anopheles have been found to contain malarial parasites. The larvae of this genus live, not in artificial collections of water, but in natural ponds in rural regions. Ross believes that, if future experiments show that malaria is confined to the genus anopheles, the task will be much more simplified, and there would be a chance of exterminating the whole genus in a given locality. In the meantime our prophylactic measures must consist in protecting against mosquito bites by netting, and in making the blood as uncomfortable a habitat for the Plas- modium as possible by charging it with quinin. To this end a few grains of quinin, say five to ten (0.333 to 0.666 gm.), should be taken daily, especially by newcomers and by all residents at times. It seems pretty well founded, too, that the cause of malaria is more active after nightfall. This is not inconsistent with the mosquito theory. Hence, exposure at these times should be avoided. It is also a notion with residents in malarial districts that exposure while the stomach is empty is apt to invite the poison. This is probably erroneous. Should it be true, exposure while fasting should i)e avoided. In this matter, as in others, it may be necessary to give lip a good many of our old notions, but until the new theories are thoroughl}- established it may be just as well to adhere to practices justified by ex- perience. Treatment of the Different Forms of Malaria. — The treatment of ■intermittent fever is preeminently by quinin. Not only does it promptly break up the paroxysms, but it causes also the rapid disappearance of the Plasmodium, which is responsible for them. The dose required varies, but fifteen to thirty grains (i to 2 gm.) are usually sufficient for an adult. Sometimes larger doses may be needed in inveterate cases. It does not matter very much how the drug is administered, but there is a best way for each case. I prefer, as a rule, to give an hourly TREATMEXT OF MALARIA. 8i dose of three to five grains, beginning long enough before the expected paroxysm to get the quantity previously decided upon into the blood at least two hours before the chill is expected. If the dose first selected fails, the second should be made larger. It is to be remembered, however, that quinin, like other drugs, acts more efficiently after a free aperient, while constipation decidedly interferes with its prompt and efficient action. Some prefer a mercurial, as eight to ten grains (0.05 to 0.666 gm.) of blue mass, or six to ten grains of calomel, but provided a free movement is secured, it does not matter much how it is accomplished. Having broken the paroxysm, it is well to continue the quinin for a few days in smaller doses, and to anticipate the seventh day subsequent to the last chill by another full dose of the drug, and to do so at intervals of seven days for some weeks. Under ordinary circumstances the freshly prepared pill of quinin made with aromatic sul- phuric acid is to be preferred. This is easily soluble and is not so unpleasant to take as the solution, which is, however, more readily absorbed. The sugar-coated and gelatin-coated pills are not so certainly efficient, as they sometimes, especially with deranged digestion, pass through the bowel undissolved. Some physicians prefer to administer quinin during the decline of the fever. This was the practice of Sydenham in giving the bark. Among modern physicians disposed to follow this method are Bacelli, A. Plehn, Maclean, Alanson and other East Indian physicians : and in this country George Dock. The treatment of the paroxysm itself is by measures calculated to combat each stage. During the chill, to satisfy the patient, artificial warmth should be supplied, though it does no good and the temperature is already a fever temperature ; during the fever, if the temperature is above 102° F. (38.9° C), the body may be sponged to reduce the heat, and during the ^' sweat '' the patient should be carefully dried. If there be any reason why quinin should not be exhibited, the other alkaloids of cinchona, as cinchoni- din, are equally effectual in doses about one-fourth larger. Xo substitute for cinchona or its alkaloids has ever been suggested which has stood the test of trial. The treatment of remittent fever is essentially that of intermittent fever. It is in this form that the mercurial aperient is deemed especially valuable as a preliminary by those having wide experience in its treatment. The continued nature of the fever, and the tendency to a typhoid state which often develops, demands a liquid diet, with the careful addition of stimulants. The pernicious forms of malarial fever are treated by quinin, as are the other varieties of the disease. In the congestive variety advantage must be taken of the first lucid interval to push the drug in very large doses. Sixty grains or more may be necessary, and advantage may be taken of rectal or even hypodermic injections, but abscesses are almost sure to occur if the latter be used. Extreme cases, however, demand extreme remedies. Soluble salts should be used, such as the bisulphate, hydrochlorate, and hydrobromate. of which 15 grains (i gm.), dissolved in distilled water, are a dose. Double this dose may be given. The bisulphate of quinin may also be administered hypodermically with tartaric acid, 30 grains (2 gm.) of the former to 5 grains (0.333 §.^'^-^ of the latter. The muriate of quinin and urea may also be given hypodermically in ten-, fifteen-, or tAventy- 6 82 INFECTIOUS DISEASES. grain (0.666, i, and 1.33 gm.) doses. It is especially commended by Solo- mon Solis-Cohen, who advises, as soon as the diagnosis is established, and without reference to the time of paroxysm, a single injection of from 10 to 15 grains (0.66 to i gm.) of the salt, dissolved in a syringeful (20 to 30 minims) of boiling water. Should a paroxysm recur at the following period, a second injection is given, and should further paroxysms occur, injections are given in corresponding number; otherwise but three injections are given during the first seven days, and two injections during the second seven days. My experience in the hypodermic use of this drug has been satisfactory from the therapeutic standpoint, but I have not escaped abscesses. It may also be given by the mouth in capsules in the same doses. Even the intravenous injection of quinin has been recommended in intractable cases, and for this purpose the soluble bimuriate is most suitable. Fifteen grains (i gm.) with one grain (0.066 gm.) of sodium chlorid are dis- solved in two drams (8 c. c.) of distilled water and injected. In addition to the use of quinin, prompt measures must be taken to com- bat all symptoms which add to the dangers of the situation — stimulants for the asthenia ; artificial heat for low temperature ; morphin hypodermicallyv to relieve the pain and allay nausea ; cool sponging or bathing to' reduce the temperature, and saline cathartics to relieve congestion in the comatose form. The treatment of the milder varieties of hematuria is most satisfactory.. The administration of quinin in almost any way, say three grains (0.19 gm.) every three hours for several days, will effectually break up the paroxysms,, and its use in smaller doses for some time longer will prevent a return- All practitioners, even those residing where it is most prevalent, are not agreed upon the treatment of the graver forms of malarial hematuria met in southern latitudes. While some still urge quinin, others strongly object to it and hold even that it precipitates hemoglobinuria. Only so long as sporulating parasites are present in the blood would they use it, and the actual presence of hematuria contra-indicates it. At most it must be used tentatively in doses as small as a grain, and if the urine redden or a chill supervene, they omit it. If well borne, the dose may be increased. Treatment is otherwise symptomatic — usually eliminative and restora- tive. Elimination is obtained by water-drinking and salt solution ingestion, the latter by enteroclysis, hypodermoclysis, or even intravenous injection.. The skin must be kept active b}L, cautious doses of pilocarpin, by woolen cloth- ing and avoiding draughts. In urgent cases pilocarpin may be cautiously used, but the hot pack is a safer measure. Morphin in small doses may be used to control vomiting, and for its general tranquilizing effect. Strychnin and diffusible stimulants, ammonia, brandy, and champagne, are often neces- sary. Strychnin may be given hypodermically. Stimulating diuretics are strongly disadvised. It is in chronic malaria especially that arsenic becomes a useful remedy, Fowler's solution being the best preparation. It should be given in ascending doses. Iron is often advantageously associated with it, and for such a combination the solution of the chlorid of arsenic and the tincture of the chlorid of iron are especially suitable. Here, as elsewhere, I am disposed to believe that needlessly large doses of iron have been given and that the constipating effect of iron, so justly complained of, would be YELLOW FEVER. 83 obviated by giving doses little in excess of what can be absorbed. For it is this excess remaining in the alimentary canal that works the mischief. Five minims (0.333 S^^^-) of the tincture of the chlorid, combined with as many of the solution of the chlorid of arsenic, are a proper dose, but the arsenic should be increased until a slight puffiness of the face results. The carbonate of iron or the reduced iron sulphate may be given in doses not exceeding one grain (0.066 gm.). A modified Blaud's pill containing in addition to the carbonate of iron arsenic in 1-25 grain (0.0026 gm.) doses is a very efficient and con- venient remedy. The administration of iron should be kept up a long time. Q it in ill should not be omitted in this form of malaria, but there is no advantage in giving it in large doses. Strychnine and mineral acids are also useful remedies for the gastric derangement, while constipation may be treated by an occasional mercurial purge, say a couple of grains (0.132 gm.) of blue mass, to which may be added as much compound extract of colocynth, and as much extract of hyoscyamus, or 1-8 grain (0.008 gm.) of extract of belladonna. Very popular in the hands of some physicians is Warburg's Tincture, and it does seem that it succeeds where quinin alone fails. Besides quinin, it contains aloes, rhubarb, and a number of aromatics. One formula omits the aloes, so that in prescribing one should say with or without aloes. It usually proves a powerful sudorific. It is given in half-ounce doses, repeated after two or three hours. The action is similar to that of antipyrin, phenace- tin, etc. YELLOW FEVER. Synonyms. — Febris flava; Bilious Remittent Fever (Rush) ; Kendall's Fever; Barbadoes Distemper; Indies occidentalis ; Elodes icterodes; Typhus icterodes; Typhus tropicus. Definition. — Yellow fever is an acute infectious disease, characterized by a febrile paroxysm succeeded by a brief remission and a relapse. It is associated more or less constantly with jaundice, and tendency to hemorrhage especially into the stomach, whence the blood is vomited constituting " black vomit." Neither jaundice nor black vomit is essential to the disease. History. — The birthplace of yellow fever is unknown. It appeared in Barba- does in 1647; prevailed in Jamaica in 1671; at St. Domingo in 1691; Pernambuco, in Brazil, from 1687 to 1694; in Martinique in 1690; in Boston Harbor probably in 1692; Philadelphia and Charleston in 1692: Rocheford, France, in 1694; and Philadelphia again in 1699, when a severe epidemic prevailed. Philadelphia was again visited in 1741 and 1762; New York in 1791, and Philadelphia in 1793, during which time there reigned one of the most frightful epidemics history records, 4040 dying out of a population of 40,000. After 1793 the disease prevailed more or less every j^ear in the United States until 1S05. From 1805 to 1820 the epidemics were limited or only isolated cases oc- curred, until 1820, when Philadelphia was again severely attacked. After 1820 there was a period of comparative immunity, but not without cases and small epidemics in various cities of the United States, until 1853, when there raged a violent outbreak through the southern cities of the Union. In New Orleans alone in that year nearly 8000 died. In 1867 and 1873 there were other epidemics of moderate severity, and in 1878 another severe epidemic appeared, chiefly in Louisiana, Alabama, and Mississippi, during which nearly 1600 died. This was the last severe epidemic. In 1897 there were several local outbreaks in the Gulf States. In New Orleans alone, between September 8 and December 11, there were 1902 cases, with 288 deaths, according to the Marine Hospital Reports. Thus, it is in a sense an American disease, and except in Spanish ports it has been limited in Europe to ports to which it has been carried, its spread from these having been also prevented. It is, however, endemic at the present day on the west coast of Africa as well as in the West Indies. 84 IXFECriOUS DISEASES. Distribution. — John Guiteras makes three areas of infection : ( i ) The focal zone, in which, up to 1901, the disease was never absent, including Havana, Vera Cruz, Rio de Janeiro, and other Spanish-American ports. (2) Perifocal zone, or region of periodic epidemics, including the ports in the tropical Atlantic, in America, and Africa. (3) The zone of accidental epidemics, between the parallels of 45 degrees north and 35 degrees south latitude. A very interesting fact in connection with yellow fever is its limitation to the sea and the seacoast, as it rarely invades interior cities or altitudes higher than 1000 feet (300 meters). Etiology. — The analogy between yellow fever and the other forms of contagio-infectious disease, in its origin, spread, and conditions, renders it more than likely that it, in common with them, is the result of a specific organism. Domingos Freire, of Brazil ; Carmona, of Mexico ; Gibier at Havana, and others have described organisms as possibly responsible, all of which have been rejected. In 1889 Surgeon General Sternberg, U. S. A., discovered a bacillus in the tissues of yellow fever patients, which he called bacillus X. In 1896 Sanarelli,* Director of the Institute of Experimental Medicine at Montevideo, isolated a bacillus, which he called bacillus icterodes. These, Sternberg says, are identical, but the late Dr. Walter Reed and Dr. James Carroll, after a careful study, concluded that the bacillus X belongs to the colon group, and the bacillus icterodes to the hog cholera group.f N"otwithstanding the fact that Sanarelli's bacillus has been found by a number of observers in from thirty-three per cent, to fifty per cent, of cases examined, conclusive evidence that it is the specific germ of yellow fever is w^anting. On the other hand, the most recent studies of Reed and Carroll go to show that it is probably an ultra-microscopic organism in the blood of the infecting person. I As to the propagation of the disease, the same observers with Aristides Agramonte, all of the United States Army Aledical Depart- ment, § have placed the moscjuito theory of the origin of yellow fever on so substantial a basis that it would seem that further discussion of other theories may as well be laid aside. This theory, which, it will be remembered, makes the mosquito the host of the unknown parasite of yellow fever, was first advanced by Carlos J. Finlay, of Havana, as far back as 1881, || but made little impression. The studies of Reed and his colleagues, made in the island of Cuba in 1900, are most convincing. They included two divisions: First, the exposure of immunes to the bites of mosquitos which had bitten yellow fever subjects : and second, exposure of the same to fomites by handling ind sleeping in clothing saturated with the discharges of yellow fever patients. Their conclusions are as follows: i. The mosquito — Stegomyia fasciatus — serves as the intermediate host for the parasite of yellow fever. 2. Yellow fever is transmitted to the non-immune individual by the bite of a mosquito that has previously fed on the blood of those sick with this dis- ease. 3. An interval of about twelve days or more after contamination appears to be necessary before the mosquito is capable of conveying the infection. 4. The bite of the mosquito at an earlier period after contamina- tion does not appear to confer any immunity against a subsequent attack. * " Annalesde I'lnstitut Pasteur," xi. 438, 18Q7. + " Tournal of Experimental Medicine," vol. v. No. 3. December, iqoo. i "EtioloRv of Yellow Fever: A Supplemental Note." "Am. ^Med.," February 22, igo2. § "Etiology of Yellow Fever," " Philadelphia Jledical Journal," October 27, igoo. "Etiology of Yellow Fever: An Additional Note," Journal of American Medical Association," February 16, igoi. f " Annales de la Real Academia," vol. xviii., 1881, pp. 147-169. YELLOW FEVER. 85 5. Yellow fever can also be experimentally produced by the subcutaneous injection of blood taken from the general circulation during the first and second days of this disease. 6. An attack of yellow fever produced by the bite of a mosquito confers immunity against the subsequent injection of the blood of an individual suffering from the non-experimental form of this disease. 7. The period of incubation in thirteen cases of experimental yellow fever has varied from forty-one hours to five days and seventeen hours. 8. Yellow fever is not conveyed by fomites, and hence disinfection of articles of clothing, bedding, or merchandise supposedly contaminated by contact with those sick with the disease is unnecessary. 9. A house may be said to be infected with yellow fever only when there are present within its walls contaminated mosquitos capable of conveying the parasite of this disease. 10. The spread of yellow fever can be most effectually controlled by measures directed to the destruction of mosquitos and the protection of the sick and well against the bites of the insects. 11. While the mode of propagation of yellow fever has now been definitely determined, the specific cause of this disease remains to be discovered. It is evident that many of the older views, so long accepted, must be given up if this theory is adopted. On the other hand, many well-known facts are more satisfactorily explained. Among these is this, that freezing weather terminates the activity of the disease, but does not destroy it. Yellow fever attacks all races, both sexes, and all ages except the very young. Yet it is through the young that the disease is maintained in a native population, because protection is secured by a previous attack or long residence in a locality in which it is endemic, and it is the young who. as they grow up, furnish the pabulum for fresh cases. The negro and the Creole, although not immune, are comparatively so. More males are attacked than females, because of their frequent exposure. Strangers are especially liable. Morbid Anatomy. — Intense yellozu coloration and hemorrhagic extra- vasations under the skin are present. The yellow coloration is due to a mixed hepatogenous and hematogenous jaundice. The serum of the blood is red-tinted, because of its containing dissolved hemoglobin. The liver is the organ which has always been regarded as exhibiting the most char- acteristic change. Yet this is not always so. It becomes ultimately fatty, when its color resembles the yellow of admixed coffee and milk — a cafe ait lait appearance — as contrasted with the more bronzed appearance of the liver of remittent fever. Earlier in the disease the organ may be slightly enlarged from hyperemia. It may be a nutmeg liver. The liver-cells pre- sent various stages of fatty degeneration, with necrotic masses in and be- tween the liver-cells, described by George M. Sternberg. The gall-bladder is generally empty. The kidney may exhibit cloudy swelling or even acute nephritis, and pale, fatty areas may be seen at the bases of the pyramids. Various bacteria are found in the liver and kidney. The stomach after death contains more or less of the " black vomit." which is a mixture of transuded serum and altered blood pigment. The mucous membrane of the stomach is hyperemic and more or less swollen, and there are blood extravasations. Surgeon Eugene Wasdin,* in a paper on the postmortem findings of yellow fever, says the morbid appearances postmortem cannot be regarded as sufficiently distinctive to admit a diagnosis from them alone. * " United States Marine Hospital Reports for the Fiscal Year i8g8." 86 INFECTIOUS DISEASES. Symptoms. — Yellow fever has a period of incubation of from twenty- four hours to five days, very rarely exceeding the latter. It is usually three or four days. (See Reed and Carroll's conclusions.) After this follows the stage of invasion or febrile stage, with sudden onset and generally a chill, promptly followed by headache and severe pain in the back and limbs. The patient may be seized at any time, day or night. Surgeon R. D. Murray,* of the United States Marine Hospital Service, emphasizes the fact that yellow fever usually begins at night when the patient is relaxed, while malarial fever attacks him more frequently when at work. The fever rises rapidly to 102° F. (38.9° C.) and as high as 105° F. (40.5° C). The pulse corresponds. The skin feels hot and dry, but less pungently so than in typhus. Even on the first day the face is flushed, the eyes are injected, the lids perhaps slightly tumid, the tongue furred but moist, the throat sore, the bowels constipated, the urine is scanty and often albuminous, though albuminuria does not generally appear until the evening of the third day. So, too, at this early stage there may be slight jaundice, and Guiteras says this " early manifestation of jaundice is undoubtedly the most char- acteristic feature of the facies of yellow fever." There may be nausea from the beginning, but it is not until the second or third day that it is aggravated and the characteristic " black vomit " makes its appearance. This resembles an infusion of coffee, and deposits a sediment comparable to coffee grounds, and which consists of broken-down red corpuscles and hematin. In the worst cases the vomited matter may be tar-like in appearance and consistence. On the other hand, " black vomit " is not always present, being generally confined to the severe cases. In some, the vomited matter is watery or bilious. This stage lasts from a fezv hours to tzvo or three days. Then follows the second stage, or stage of calm, in which there is a decline in the fever and of the other symptoms generally. This may be the beginning of convalescence in the mild cases. But in severe cases this stage is of short duration, — from a few hours to one or two days. Then the third stage, or stage of febrile reaction, sets in, lasting one, two, or three days. The temperature now rises again, although the pulse may continue to fall; the nausea and vomiting return — the latter becomes hemorrhagic and may be accompanied by abdominal pain. Black and offensive stools occur. Jaundice, if not previously present, now makes its appearance ; the tongue becomes dry and brown, and there may be bleeding of the gums — indeed, from all the mucous membrances. To albuminuria may be added hematuria. ^The strength rapidly fails, the pulse grows weaker, there is nervous trembling, suppression of urine, mental wandering, convulsions or stupor, and death. Such, however, is not always the termination, even when there has been " black vomit." The symptoms may all gradually subside and the patient recover, although the jaundice may persist for a long time. In mild cases the calm stage, as stated, may be succeeded by convalescence. Guiteras f regards as the three characteristic symptoms of yellow fever: First, the facies, including especially early jaundice. Second, albuminuria, which, he says, is rarely so early in other fevers, unless of an unusually severe type. " Even in the mild cases, that do not go to bed — cases of ' walking yellow fever ' — on the second, third, or fourth day of the disease albuminuria will show itself," though it may be quite transr- * " Marine Hospital Reports," iSgQ, p. 303. t " Diagnosis of Yellow Fever," " U. S. Marine Hospital Reports for the Fiscal Year 1898." YELLOW FEVER. By €nt. Third, a peculiar slowing of the pulse, with a steady or even rising tem- perature. This symptom was first pointed out by Faget, of New Orleans. It is noted more particularly on the second or third day, when the fever is still keeping up, that the pulse begins to slow, dropping as much as twenty beats, while the temperature has risen i 1-2° to 2°. On the evening of the third day there may be a temperature of 103° to 104° F. (39.4° to 40° C), with a pulse running from 70 to 80. During defervescence the pulse may become still slower — down to 50, 48, 45, or even 30. Diagnosis. — The three characteristic s3'mptoms of Guiteras above pointed out should be borne in mind, viz., facies, early albuminuria, and slow pulse. As to differential diagnosis, yellow fever is most likely to be con- founded with severe fever of bilious or malarial remittent type. Indeed, the resemblance is sometimes very close, especially when the latter is accom- panied by hematuria. But the remission occurs earlier in remittent fever and the chill is of much longer duration, while the presence of Laveran's Plasmodium in the blood settles the question in favor of the latter. Acute ycllozv atrophy of the liver is a disease more insidious in its approach and less febrile. The urine in acute yellow atrophy is loaded with bile. Relapsing fever resembles yellow fever only in the s3'mptoms of the relapse, but this occurs much earlier in yellow fever. The similarity of the mild forms of yellow fever to thermic fever has been emphasized by Guiteras. As to dengue, or break-bone fever, increased importance has recently attached to the diagnosis between this disease and yellow fever because of the dispute as to whether certain cases in the epidemic of 1897 in the Southern United States — as at Galveston, for example — were cases of dengue or of yellow fever. The question is one which presents difficulties, for both jaundice and hemorrhage, including black vomit, have been in the past credited to dengue, while in the disputed cases black vomit, at least, was wanting. In favor of yellow fever were the authoritative names of Guiteras and H. A. West, of Galveston. The following table of contrasted symptoms was kindly prepared for me by Dr. West : Yellow Fever. Dengue. 1. One febrile paroxysm, character- i. Usually one febrile paroxysm, but ized by a steady rise and lasting usually sometimes two, a steady rise of temper- about three days. The temperature rises ature until the acme is reached; a short rapidly, the acme is often reached within stadium, followed by a remission, then a few hours from the onset. not infrequently a second rise. Duration four to eight da^^s. 2. The pulse rate is characterized by 2. The pulse usually increases in abnormal slowness and want of corre- rapidity with rise of temperature, though spondence with the temperature; while an abnormally slow pulse ma}^ sometimes the latter is rising from three to four be observed. degrees the pulse continues to diminish in frequency. 3. There are cutting pains through the 3. Headache is more or less intense, forehead, the eyes ache, the muscles of the pains in the limbs and back are severe and back, loins, thighs, and calves are sore and apparently involving the bones and joints often ache severely, even in mild cases. The latter are not only painful and stif- Thepain is muscular rather than articular, fened, but in many instances swollen. 4. There is no glandular involvement. 4. The Ij'mphatic glands are enlarged with varying degrees of frequency in dif- ( ferent epidemics. 5. The face is turgid, not infrequently 5. The face is generally flushed, the a dusky red. The upper eyelid is often eyelids swollen, the eyes injected and swollen. The appearance is that of watery; there may be a slight jaundice, typhus or of measles before the eruption, but this symptom 'is extremely suspicious with the addition of slight or well marked of yellow fever. INFECTIOUS DISEASES. jaundice. The conjunctivae are congested and shiny with a slight yellow tinge, the eyes sometimes intensely red and sensi- tive to light. The jaundice becomes more distinct after the first or second day, the skin showing the same combination of capillary stasis with an icteroid hue as the eyes. As the case progresses, jaundice may become intense. 6. The tongue is whitish in the center, with red tip and edges, and is pointed; gums swollen and disposed to bleed. Epigastric tenderness and pain, nausea and vomiting are common; in the stage of depression black vomit is not infrequent; it is alarming and often of fatal import. 7. Eruption absent, or extremely rare and insignificant. 8. Urine scanty, albumin usually found within seventy-two hours ; there may be only a trace in the evening urine. In the second stage albumin may be abundant and accompanied by all the evidences of a severe nephritis, the pres- ence of casts, hematuria, disposition to anuria and uremia, /n eve7'y sez>ere case nephritic complicatiojis doviinate the clitiical picture. 9. Tendenc}' to hemorrhages common, from nose, gums, bowels, uterus, kidneys, and stomach, the last often fatal. 10. Disease often fatal. 11. One attack protects from another. 12. Not protective against dengue. 6. The tongue at first is covered with a white fur; it is swollen and the edges are red, and as the case progresses the coating increases in thickness and be- comes a dirty yellow. In man^' cases there is nausea, but vomiting is rare. 7. An eruption occurs in quite a large number of cases; it may be a simple ery- thema or resemble that of scarlatina, measles, lichen, or urticaria. 8. The urine, except in rare instances, is free from albumin; if present at all, it is evanescent. There is no evidence whatever that serious kidney compli- cations belong to the pathology of dengue. 9. Hemorrhages from mucous mem- branes, nose, gums, intestines, uterus and kidneys not infrequent, but rarely of serious import. 10. Prognosis proverbially favorable. 11. One attack does not protect from another. 12. Not protective against yellow fever. Prognosis. — Yellow fever is a grave disease, and in its severe forms one of the most fatal of the infectious diseases. The mortality ranges from 15 per cent, to 85 per cent. Among the dissipated, the worn-out, the poor, and in hospitals the mortality is higher ; it is less in the colored race. " Black vomit " is not necessarily a fatal symptom. Many malignant cases terminate in a couple of days. Modern studies go to show the ravages of yellow fever will be greatly diminished in the near future, emphasized by the statement of Dr. Guiteras at the Sanitary Conference of American Republics, held in Washington, D. C, in December, 1902, to the effect that " not a case of yellow fever has originated in Cuba for fourteen months." Treatment. — There is no specific treatment for yellow fever, and the symptoms are to be met as they arise. The practice quite general in the Southern United States to give an initial dose of castor oil is justified. Some prefer calomel five to ten grains (0.33 to 0.66 gm.) ; others compound cathartic pills, one, two, or three at a dose followed, if necessary, by a saline such as cold citrate of magnesia, Epsom salt, or Glauber salt. The last is preferred by some who have had the longest experience. These measures are followed by efiforts to cause perspiration, in which the hot foot-bath is included. Quinin is not recommended by those of wide experience for any specific effect, though it may be given for its antipyretic effect. The latter is, however, better accomplished in the early stages by the coal-tar derivatives antipyrin and acetanilid. Seven and one-half grains (0.5 gm.) may be given hourly until relief is afforded. Recent views as to the etiology YELLOW FEVER. 89 of the disease would seem to justify a return to quinin for its original purpose. We may seek to stop vomiting by ice internally and externally and hypodermic injections of morphin, by cold dry champagne and cold efifervescing waters. Food should be withheld for from three to five days, and then be of the simplest kind, of which a mixture of equal parts of milk and Vichy is the type. The hemorrhagic tendency may be combated by astringents, including iron. Washing out the rectum by warm soap and water and enemas, carried high up in the bowel, is highly recommended by Marine Hospital Surgeon H. D. Geddings. * Two or three pints must be used. Normal salt solution may be thus used with a view to its being retained and absorbed. The failing strength is to be supported by alcohol, strychnin, and digitalis ; the high temperature reduced by sponging and cool baths. Nutrient enemas are to be relied on when vomiting is uncontrollable. The following line of treatment laid down by Surgeon-General Stern- berg appears to have been especially satisfactory in cases treated in United States, Cuba, and Brazil, with a mortality, according to Carroll, of only 7.3 per cent. In addition to sodium bicarbonate 7 1-2 grains (0.5 gm.), mer- cury bichlorid 1-60 grain (0.001 gm.) every hour, he advises a hot mustard foot-bath during the first 24 hours, cold sponging, cold applications to the head, protection from currents of air, sinapisms over the stomach and lumbar region, the promotion of perspiration, withholding of food during the first three days, and stimulants, in the form of iced champagne or good brandy, after the fourth day. If the stomach be irritable he advises milk and lime water, and if these do not agree, nutrient enemas. Later on he allows milk punch, ale, porter, etc. Good judgment should be exercised in discriminating against the over- use of drugs. Prophylaxis is more efficient than direct treatment, but modern etiology has overthrown rules formerly supposed well established and resolved it chiefly into (i) Guarding non-immunes against infection by the mosquito. (2) Screening the house of the infected person against the insect in order to prevent the spread of the disease. (3) The destruction of as many mos- quitos as possible, by drainage, by covering breeding places with insecticides and larvicides. Among these may be mentioned tobacco leaves, chrysanthe- mum powder, the anilin dyes, and petroleum. (4) Depopulation of infected places — that is, the removal of all susceptible persons whose presence is not necessary for the care of the sick. Sermn Treatment. — Recent attempts at protective inoculation have not been followed by satisfactory results in yellow fever, though success for this treatment was claimed by W. L. de Humboldt as far back as 1854, Caromon in 1 88 1, and Freire in 1884. Sanarelli has used the " antiamarylic " serum of a horse inoculated with gradually increasing doses of the icteroid bacillus for eighteen months. He treated eight cases subcutaneously, of whom two died. He also treated fourteen cases by intravenous injection, of whom four died.f * " United States Marine Hospital Reports for Fiscal Year i8q8." + Sanarelli, " Annales de I'lnstitul; Pasteur," vol. xii. p. 348, i8g8. 90 INFECTIOUS DISEASES. DENGUE. Synonyms. — Break-hone Fever; Dandy Fever. Definition. — Dengue is an epidemic, infectious, possibly contagious ■disease, characterized by paroxysms of extreme pain in the joints and muscles, accompanied by fever and sometimes eruptions on the skin. Historical. — Dengue was recognized as a distinct disease in the latter part of the ■eighteentli centuiy, lirst in Spain in 1764-68. It prevailed in Cairo and Java in 1779. In 1780 an epidemic prevailed in Philadelphia, which was described by Benjamin Rush under the name of bilious intermitting fever. In 1824 it prevailed in Calcutta, in 1827 and 1828 in Charleston, Savannah, and in New Orleans, U. S., and in the West Indies, and was described by the late Professor S. H. Dickson, then of Charles- ton. Since then there have been numerous epidemics, for the most part south of the thirty-second parallel of latitude. It is said that in Galveston, Tex., in 1897, 20,000 were attacked in two months. Etiology. — J. W. McLaughlin, of Texas, has found in the blood of a dengue patient a micrococcus, which he holds accountable for the disease, but the eflfect of inoculations requires to be studied. Analogy would lead us to suspect such an organism, while experience justifies a like conclusion. Dengue spreads, as do diseases thus caused, by the routes and means of travel. It attacks both sexes and all ages, regardless of season, although warm climates are its natural habitat, and it is rather more common in sum- mer. It is not usual to have more than one attack. No morbid anatomical changes have been found associated with the disease. Symptoms.— Dengue is usually sudden in its onset, after a period of mctihation lasting from three to five days, at the end of which there may be some sense of discomfort (more frequently there is not), headache, and even chilliness. Suddenly, often at night, the patient is struck with pain in the muscles and joints, and especially the muscles of the back and loins. The pain is searching, as though extending into the bones themselves. The small as well as the large joints are affected, and the pain is aggravated on motion. The suffering is extreme, and it may be said that the patient is literally racked with torture. Simultaneously there are headache and fever, the former severe and the latter quite high, rising rapidly to 102°, 103°, 105° F. (38.9°, 39.4°, 40.5° C), and even 106° or 107° F. (41.1° or 41.6° C), reaching its maximum from the second to the fourth day, then declining, reaching the normal about the fifth day. The face is flushed, the conjunctivae are congested, commonly less so than in yellow fever ;^the pulse is frequent, 100 to 120, rising and ialling with the fever. Delirium is not a marked feature, save in children. The tongue is coated and red at the tip and edges, there are loss of appetite, slight nausea, and extreme thirst, scanty urine, and constipation ; at times, liowever, the urine is copious and clear. Hemorrhage from the nose and •gums has been noted, and both Eugene Foster and D. C. Holliday have seen black vomit similar to that of yellow fever ; and in one case copious hemor- rhage from the bowels, which persisted three months and terminated in ■death, was observed. The paroxysm lasts three or four days, at the end of which the tem- perature falls, the pain subsides, and a short period of comparative comfort, though one also of great prostration, succeeds that of great suffering. It is during this remission that an erythematous rash makes its appearance on the face, neck, and shoulders, and thence over the whole body in two or three days. At the same time the lymphatic glands at the back of the head CHOLERA. 91 and neck, in the axillse and groins, swell, with some return of fever. The eruption is not constant or always uniform. It lasts from a few hours to a couple of days, when it subsides with the beginning of the second febrile movement, which is milder and shorter, after which true convalescence sets in. The eruption may also reappear, though rarely. Diagnosis. — On account of the joint involvement, associated, as it often is, with redness, dengue has not inexcusably been mistaken for acute rheu- matism; but the decided remission in tAvo days, the altogether short dura- tion of the disease, and its epidemic character, should soon extricate the physician from such confusion. The absence of any glandular swelling or eruption in rheumatism and the more close limitation of the pain to the joints aid in the discrimination. After rheumatism, influenza is perhaps the next disease with which dengue may be confounded. It, too, is epidemic, and is attended often by extreme and sudden muscular pains, but the sudden intermission charac- teristic of dengue does not occur in influenza, nor does the eruption or glandular swelling. The resemblance of dengue to yelloiv fever has been referred to under the latter disease, where, too, the two conditions are contrasted. Prognosis. — Notwithstanding the extreme suffering, recovery is the invariable rule. Treatment. — Nothing can be done to cut short the disease. The most satisfactory method to control the pain is by the hypodermic injection of morphin and atropin. One-fourth grain (0.016 gm.) of the former and 1-150 grain (0.00044 gm.) of the latter may be given, supplemented by phenacetin and antipyrin, in doses of ten grains (0.66 gm.) of the former and five grains (0.33 gm.) of the latter, every two hours, when the hypo- dermic injection may be repeated if relief has not been obtained. The coal-tar derivatives are also the best remedies for the fever, but they may be supplemented by sponging with cool water, or the cold bath in extreme cases. Prostration must be met by alcoholic preparations. CHOLERA. Synonyms. — Cholera asiatica; Cholera algid a; Cholera maligna; Cholera infectiosa; Epidemic Cholera. Definition. — Cholera is an acute infectious disease caused by the invasion and toxic action of the comma bacillus or spirillum of Koch. It is characterized especially by vomiting, purging, painful cramp, and collapse. Historical. — Cholera is a disease long endemic in certain localities in India, whence it has made periodical visitations to Europe, and in 1S31-33 for the first time- to North America. It invaded the United States in 1832 by two channels of immi- gration — first, from Great Britain b)^ way of Quebec and the Great Lakes, reaching the then limits of settlement, the militarj^ posts'of the upper Mississippi; second, by way ■of New York. In 1835-36 another visitation occurred, and in 184S another by way of New Orleans and the Mississippi Yalle5% extending even to California. In 1854 a severe epidemic raged through the United States, for which immigration was also responsible. In 1865 Arabia and Egypt were severely visited in the spring, Constanti- nople in July, and thence all Europe. In> 1866 it a'gain appeared in Egj-pt, spread over all Europe, reaching the United States the same summer, during which there were quite a number of cases, some of which came under the observation of the author in the Philadelphia Hospital. An extensive outbreak prevailed in Europe in 1884, extending to Italy, Spain, and France, but it did not reach the United States._ Much more serious than any of the more recent epidemics was that of i8g2, which 92 INFECTIOUS DISEASES. started in March or April in the northwestern provinces of India, attacking with great violence the pilgrims at the great Hurdwar Fair, near the source of the Ganges, and extending thence through Cashmere and Afghanistan to Persia, where it arrived in May or June. Thence it crossed the Caspian Sea and spread rapidly thi-ough Euro- pean Russia into Prussia, seating itself most stubbornly and savagely in Hamburg in August. Havre, Antwerp, Berlin, Vienna, and especially Budapesth in Hungary, were also visited. A few cases occurred in Southampton, London, and Liverpool, and it reached New York Harbor in September, 1892. A few cases were also reported in New York City, but there was no further spread. Etiology, — It is now generally acknowledged that cholera owes its existence to the comma bacillus or spirochseta, a semispiral rod-bacillus dis- covered by Koch in 1884. It is thicker, but not more than half so long as the tubercle bacillus. Sometimes, by the apposition of two bacilli, an S- or a corkscrew-shape is produced. Its multiplication is favored by heat, mois- ture, and filth. It is easy of destruction, even by weak acids and a tempera- ture of 140° F. (60° C). It can produce cholera only when it is taken in by the stomach, where, however, a normal gastric juice is always able to destroy it, while weak digestion induces a vulnerability that is promptly availed of by the bacillus, which quickly passes into the intestine, where the alkaline reaction of the secretions favors its development in enormous num- bers. Bacilli are rarely found in vomited matters, but are numerous in the fecal discharges, and are found in the intestines after death. They may invade the follicles and intestinal wall, but some time is required for this,, and such invasion does not occur in cases speedily fatal. Medium of Infection. — Drinking-water and contaminated food are the acknowledged media through which the bacillus is commonly introduced into the human organism, but it may be conveyed in clothing or food, on the hands, and may even enter the mouth while floating in the air. The postal service is regarded as a means of infection. It frequently follows in the train of moving masses of human beings, such as emigrants and pilgrims, but it prefers the sea-level and lower altitudes, especially less than 1000 feet (30.5 meters) above the sea. While at the present day the views of Koch as to the origin and spread of cholera are largely dominant, it should not be overlooked that an authority so high as that of Pettenkofer, of Munich, still holds that the germ of cholera develops in the soil-water of the earth during the heated months, and rises in the atmosphere as a miasm. He claims that the conditions peculiarly favorable to its development are a low-ground water, associated with por- osity, moisture, and a contamination with organic matter, especially sewage. A. Rubino, in his article in "^ajous' Annual," volimie ii., 1899, says that both theories are in accordance with fact, and Asiatic cholera must there- fore be regarded as a contagious and miasmatic disease. As stated, anything that enfeebles digestion favors its permanent lodg- ment and multiplication. Hence, general ill-health, fatigue, the alcoholic habit, depression of spirits, fright, or anxiety, any one or all may be predis- posing causes. All ages and sexes are liable to be infected, but young chil- dren seem most vulnerable. Morbid Anatomy. — The appearance of a man dead of cholera may present no peculiarity. More commonly, there is a shrunken aspect of the whole frame, the skin of the exposed and non-dependent parts is gray or ashen hued, while the dependent portions are livid. The eyes are deeply sunken, the temples hollow, the nose is pinched, and the skin clings closely to the bones beneath it. The appearances of such a body, in brief, are those of a wasted cadaver long immersed in the pickling vats of the dissecting room. CHOLERA. 93 Very striking are the postmortem elevations of temperature and the phenomena of postmortem muscular contraction. The former has reached 109° F. (42.8° C.) and higher. The latter include movements of the lower jaw, rotation of the eyes, contraction of the arms and legs, sometimes start- lingly life-like. On section of the body the subcutaneous tissue is found dry, the blood in the vessels thick and dark. The condition of the stomach and bowels differs somewhat with death at different stages of the disease. If death takes place early the stomach is commonly, but not always, filled with a turbid liquid grayislvwhite in color, resembling rice w^ater. In this the microscope may recognize columnar epithelial cells, isolated and in flakes ; also the remnants of partially digested food, such as disintegrating muscular fasciculi and oil globules. The mucous membrane of the stomach appears congested, and the course of the larger vessels can be readily traced in consequence of their teing full of thick blood. A populated appearance ascribed to enlargement of the solitary follicles is often present. The epithelium is detached in places ; in others, intact. The mucous membrane of the sjnall intestine may also be much con- gested; the bowel is filled with rice-water fluid. On its surface lie numerous patches or flakes of detached epithelium, while the papillated appearance pro- duced by the enlarged lymphadenoid follicles is everywhere present. The villi are largely denuded of epithelium, but in places they are intact. If death takes place during imperfect reaction, the gastro-intestinal mucous membrane is still more congested and dark-red in color from hyper- emia and blood extravasation. At such times, too, the solitary glands are conspicuous and cause also a papillated appearance even more striking than that in the stomach. Peyer's patches may also be raised, and the same denu- dation of epithelium from the villi and elsewhere is present. The signs that suggest an inflammatory process are a slight cellular infiltration of the intes- tinal walls and the enlargement of the solitary follicles ; also, at times, a diph- theritic exudate. The liver is natural in size, but may be congested and darker hued than in health, while the cells exhibit cloudy swelling, and in places small areas of fatty change. The spleen is usually small, certainly not enlarged. The condition of the kidneys is interesting, and varies with the stage at which the patient dies. If early in the disease the organ, superficially, is not much altered ; it may be somew^hat enlarged. The veins are slightly over- filled, but there is no marked capillary injection. There may be a few white or yellowish patches, where the epithelium is found compressed, cloudy, and fatty. The lumina of the tubes may, in places, be blocked with granular matter or well-formed casts, and there may be a few hemorrhagic foci, the changes starting from the pyramids. If death takes place later, after reaction has set in, the kidney is enlarged. The changes are chiefly in the cortical substance, in w^hich are seen grayish- white and yellow patches, alternating with normal-hued portions. In these altered places the tubes are opaque, with granular and fatty debris. Hemor- rhagic infarcts may also be found in the cortical substance. The ^lalpighian capsules, with their included glomerular capillaries, are intact. These changes correspond in the two stages' with the phenomena described by Cohnheim several years ago as the results of ligation of the renal artery, — the first to those following ligation of short duration, the second to those following ligation of longer duration. 94 INFECTIOUS DISEASES. The heart is normal in size, but its walls flaccid. The right cavities are commonly filled with dark, liquid blood ; the left cavities, empty. In many instances the Iiuigs also present an appearance more or less characteristic, being shrunken and small, lying back in the thorax, as though collapsed. Like the other tissues, they are empty of blood except in their dependent portions, which are the seat of hypostasis. They have been com- pared by Parkes to fetal lungs. Sutton found the two organs to weigh but 20 ounces (600 gm.), as compared with 45 ounces (1350 gm.), when death occurred after reaction had been established — that is, after the blood had again occupied the pulmonary artery and its branches. Collapse may be interfered with by adhesions, in which event it is only partial. Such appearances could, of course, occur in death from hemorrhage and^ after all, the only distinctive condition is the presence of the rice-water fluid in the stomach and intestine, or in both, containing the " comma " bacillus and desquamated epithelium. The latter, to which the earlier descriptions attached great importance, is now generally regarded as postmortem in origin. The flakes thus produced are also what the older authors described as patches of lymph. Symptoms. — After a period of incubation ranging from thirty-six to fifty-six hours, rarely five days, the symptoms of cholera commonly present themselves sufificiently gradually to admit of arrangement into three distinct groups or stages : 1. The stage of preliminary diarrhea. 2. The stage of collapse. 3. The stage of reaction. The stages are by no means always recognizable, and the severity of the symptoms varies greatly, such variations being reasonably ascribed to the varying quantities or virulence of the specific poison. Mildness in a given case is no guarantee against virulence in another caused by it. 1. The stage of preliminary diarrhea * is characterized by moderate diarrhea, which is characteristically painless, but may be associated with colicky pains. The stools are yellow or yellowish throughout this stage, and are alkaline in reaction. Xausea and vomiting are not usual in it, and the patient may feel but slightly indisposed. There is generally a feeling of rest- less discomfort and depression, to which headache may contribute. The temperature remains normal. The first stage may last for a week or longer, or for a few hours only, or it may be entirely absent. 2. In the stage of collapse the diarrhea has become profuse. The dis- charges have lost their yellowish color and resemble thin gruel or rice-water. The fluid gushes out with great profuseness and apparent force. There may be griping or tenesmus, but more characteristic are the very painful muscular cramps, which usually begin in the fingers and toes and extend thence to the calves of the legs and abdominal walls. Vomiting, bilious at first, is soon added to the diarrhea. The fluid vomited soon assumes the rice-water char- acter, and gushes from the mouth as from the bowel, in enormous quantities. Extreme weakness and exhaustion are by this time present. The skin is blanched and shrunken, the lusterless eyes are sunken and bounded below By great circles of blue. The nose is pinched, the lips are thin, the cheeks hollow, and the countenance pallid to bluish grayness. The extremities and entire body become clammy and cold, the superficial temperature falls 5° or * To this stage the term cholerine has also been applied, but this word is now more commonly used to indicate a mild form of cholera. CHOLERA. 95, 6°i while that of the rectum rises to 103° and 104° F. (39° and 40° C). Speech is husky, whispering, and labored. The pulse is feeble or frequent, or absent at the wrist, and the patient appears to be dying. Even the heart- beat and sounds are almost gone, but the breathing continues. Through all this, consciousness may be maintained to the end or coma may supervene. Death commonly occurs in this stage. On account of the scantiness of blood certain secretions cease and there is neither urine nor saliva, while power to perspire, and even the lacteal secre- tion in nursing women, remain. A more close examination of the rice-water vomited matters and bowel, discharges reveals flakes of epithelium, mucus, and granular debris, and, with sufficiently ,high powers and suitable preparation, the cholera bacillus together with numerous other bacteria. Occasionally a little blood is present. The fluid is albuminous and contains the salts of the blood, among which sodium chlorid is conspicuous. Sometimes, however, there may be no vomit- ing or purging, whence the term cholera sicca. In these cases, however, the stomach and bowels are commonly found containing the characteristic fluid after death. This second stage is generally of shorter duration, commonly a few hours only, but it may be prolonged to twelve or twenty-four. The disease is some- times ushered in with the symptoms of this stage. It has been ascribed to the action of a toxin produced by the bacilli, which, when absorbed, produces the systemic effects of this stage, but it is likely that the flux is the principal factor in its production. 3. The stage of reaction is characterized by the return of warmth and color, the latter more slowly, and the re-establishment of secretions. Espe- cially favorable is the return of the urinary secretion. Along with these changes the vomiting and purging occur at longer intervals. Such improve- ment is, however, often delusive. The diarrhea may return, the collapse repeat itself, and the patient die. Or there may supervene cholera typhoid, a state characterized by a frequent, feeble pulse, dry tongue, delirium, and sometimes an erythematous or roseolar eruption on the extremities. This may end in recovery. Or there may be superadded symptoms of nephritis^ including uremia, coma, and death. Or there may be inflammation, diph- theritic or catarrhal, of the bowels. Diagnosis. — In the matter of the diagnosis it is well known that, so far as symptoms are concerned, cases of cholera morbus, cholera nostras, or sporadic cholera, as we may prefer to name it, have occurred with symptoms absolutely identical with those of true cholera, including the fatal termi- nation. There is one very important etiological difference between cholera mor- bus and true cholera, which is also of great diagnostic value, and that is that almost invariably cholera morbus is traceable to a severe and irritating excit- ing cause, such as a meal of indigestible fruits or vegetables, or imperfectly cooked or decomposing fish or shell-fish, while cholera comes on without any such cause, or succeeds trifling derangements of digestion, which in other than cholera seasons pass away without harmful results. As a rule, too, the symptoms of cholera morbus are much more severe at first than those of true cholera, and the substances first vomited are undigested articles that have acted as exciting causes, succeeded by green, bilious matter. The discharge from the bowels is first also of a more bilious character, and above all, the mortality is much less serious ; indeed, recovery is the rule. Yet these dif- 96 INFECTIOUS DISEASES. ferences are not to be relied upon. (See, also, Appendix to Section on Cholera, p. 102.) By bacteriological investigation only can a given case be identified with absolute certainty. The agglutinative reaction is the most ready method. It is similar to the Wldal test for typhoid fever, and depends on agglutina- tion of the bacilli in a culture of cholera vibrios, produced by the blood-serum of the infected case. Some hours are, however, necessary to complete such a bacteriological diagnosis. Further, such investigation can be made only b}' those who are expert and provided with proper facilities. Such expertness and facilities, moreover, are not found in the hands of the general prac- titioner, and the bacteriological investigation is, therefore, of limited appli- cation. Doubtless, should occasion demand, the authorities in the large cities, at least, will furnish the same assistance they now do in the case of diph- theria and typhoid fever. As to the microscopic examination of the dejecta, which is more feasible for the practitioner, it may be said if the examination reveals a preponder- ance of curved bacilli, comma-shaped, and sometimes joined end to end, so as to form figures somewhat resembling the letter S, and again appearing in long threads, we may feel justified in considering the case one for careful study by bacteriological methods. Although there are found in the alimen- tary tract other bacilli, the morphology of which is much like that of the cholera bacillus, they are not numerous. The bacillus of Prior and Finkler, found in the stools of cholera morbus, while closely resembling the true comma bacillus of Koch, is larger and thicker. i\Iore easily distinguished are the cultures. The Prior and Finkler bacillus grows more rapidly and the shape of its culture is saccular, while that of the cholera bacillus is conical. It also liquefies the gelatin much more rapidly. How, then, shall we know a case of vomiting, serous diarrhea, severe colicky pain, followed by collapse, to be a case of cholera ? In this country, w^here such a thing as endemic cholera is unknown, it goes without saying that any isolated case, even if fatal, cannot be one of true cholera unless there be traceable some connection with an acknowledged focus of cholera elsewhere. Second, such communication must have taken place within the period of incubation required for the development of the case, say within six davs. Of course, such communication need not be a personal one. It may be by clothing, merchandise, and probably even letters. These conditions being fulfilled, the patient suffering with the symptoms of cholera must, for the time being, be regarded as a case of the true dis- ease, and isolated until the bacteriological investigation can be made, but the rapid occurrence of similar cases increases the probability of its being true cholera, and finally establishes its certainty. Yet local epidemics of cholera morbus do sometimes take place, severe and grave in character, due to local causes, and favored by extreme and long-continued heat. Thus it is still the question whether the epidemic of cholerine that prevailed in Paris in May, June, and July, 1892, was true cholera or cholera morbus, and there seems much reason to believe it to have been the latter, notwith- standing the prevalence of true cholera elsewhere in Europe. Symptoms similar to those of cholera arise from poisoning by cor- rosive sublimate, tartar emetic, arsenic, mushrooms, and ptomains from various sources, but their symptoms are rarely confounded with those of ■cholera. Prognosis. — The prognosis, always grave, varies with the stage of the CHOLERA. 97 epidemic. It is well known that in the beginning a very large proportion of cases die, fully 80 per cent., but as the epidemic is prolonged the ratio of deaths to persons attacked grows less, the mortality falling to 30 per cent, or less. The habits and morals of the patient have an important influence. Intemperance and dissipation diminish greatly the powers of resistance, as do also fatigue, indigestion, fright, and fear. Treatment. — The treatment of cholera is very appropriately divided into prophylactic and medicinal ; the former, when properly carried out, being more effectual than the latter. Prophylaxis. — In the first place, it has been sho^^^l that a certain degree of immunity from cholera is secured by a first attack. This was the con- clusion of a collective investigation directed by the Academy of Medicine of Paris in 1884, and by Edward O. Shakespeare from information collected by him during his residence in Spain in 1885, appointed by the United States Government to investigate the subject. From this standpoint Ferran and others sought to secure immunity by inoculation of protective virus. The former, using a pure culture in bouillon of the comma bacillus, prac- ticed the method in Spain during the epidemic of 1885, but a French com- mission appointed to investigate it reported unfavorably, and it fell into disuse, although Dr. Shakespeare in his " Report on Cholera in Europe and America " is inclined to believe there are possibilities in Ferran's method which make it scorthy of further trial. Gamaleia, Lowenthal, Brieger,* and Wassermann secured immunity in animals, by blood seram from others treated with injections of from o.i to I c. c. of cholera bacilli sterilized by heat, and G. Klemperer t obtained results which went to show that immunity could be conferred on man by the same treatment; also by the subcutaneous injection of the milk of immu- nized goats, though the immunity is considerably less by the latter than by the former. A. Lazarus showed (1892) that the blood of man, after recovery from an attack of cholera, has the property of protecting guinea- pigs from fatal infection when injected in very small quantities into the peritoneal cavity along with intraperitoneal injections of cholera vibrios. Issaefif, in 1894, confirmed the latter observation, but showed that the prop- erty was temporary. Lazarus regarded this effect antitoxic, R. Pfeiffer as the direct result of bacteriolytic or lysogenic action of the serum. Pfeiffer's studies on immunity from Asiatic cholera were published in con- junction with Issaeff in 1894. He showed that the destruction of living cholera bacilli quickly takes place in the peritoneal cavity of the immunized guinea-pig, if at the same time a minute quantity of the serum from an immune animal is injected. This constitutes Pfeift'er's " serum reaction." or phenomenon, and was demonstrated by him and Kolle for typhoid fever infection, and was one of the steps that led to recognition of the importance of the agglutinating reaction of sera. L'p to the present time, apparently but three cases of cholera have been treated by subcutaneous injections of blood-serum from persons who recently sufifered attacks of cholera. Of these, one died and two recovered. The results of protective inoculations by cultures by 'SI. Haff'kine's ♦Brieger's exp°riments ■were upon guinea-pig's, which he succeeded in making _ immune to virulent cultures of cholera bacilli. The method consisted in making intraperitoneal injections of comma spirilla cultures prepared in watery extract of calves' thymus or in beef-bouillon. — "Deutsche med. Wochenschrift," i8q2. No. 31. (•"Berliner klin. Wochenschrift," 1892, No. 39, S. 969; " Med. News," Philadelphia, October 2g, 1892, p. 496. 98 INFECTIOUS DISEASES. method are more practical. His researches at the Pasteur Institute, pub- Hshed in 1892, started with inoculation of the animal in the peritoneal cavity and exposure of the resulting exudate to the open air for several hours. A transfer of this to the peritoneum of another animal secures an " exalted " or " fixed "' vaccine, the subcutaneous injection of which secures anticholeraic immunity, but with necrosis of the cutaneous tissues. This necrotic effect is removed by cultivating it at a temperature of 39° C. (102.2° F.) in an atmosphere constantly aerated. Successive inoculations result in an attenua- tion of cultures, which, injected under the skin of animals, even in an exag- gerated do'^e, produces only a passing edema, while it leaves the animal immune to the " exalted " or " fixed " virus. The same harmlessness attends its inoculation under the skin of men, where the microbes die and disappear, setting free a substance which acts upon the organism and confers immunity on it. The same result follows the injection of their dead bodies only. Thus he was enabled to prepare vaccine, preserved in weak solutions of carbolic acid, which remains efficacious for six months, and may be used by persons without bacteriological training. From the summary of cases, some 32,000 treated by his method in India during 1 893- 1894, published by AI. Haffkine in January, 1895, we note a reduction of mortality from 6.51 per cent, in cases not treated to 3.8 per cent, of those treated. Xo other method has been tested by anything like as many cases, and though the correct treatment may not yet have been arrived at, it seems reasonable to believe that we are in close pursuit of one which is . most promising of results. More recent inquiry into results of Haffkine's treatment in Calcutta during two years by Simpson (" Indian Med.-Chir. Rev.," July, 1896) shows a reduction of mortality of 72.47 per cent. Until these processes are perfected we must be satisfied with a proph- ylaxis which, in point of fact, is little, if at all, less efficient in securing immunity than the most successful inoculation methods as yet suggested. By means of it cholera has been virtually kept out of England and the United States since 1873, though brought to certain ports where it has been held at quarantine. It consists mainly in the isolation of the patient and in certain precautions against the spread of infection by sterilizing the dis- charges. To this end : 1. The vomited matter and the discharges from the bowels are to be gathered in carbolic solution, i to 20, or chlorinated lime, i to 10, some of which should be in the vessels before it is used. After use, more should be added. The matter thus collected should be gently stirred and allowed to remain twenty minutes before being poured into the water-closet hopper. Where the excreta can be thrown into a pit, or even, as may be done in the country, on the manure pile, milk of lime, or what is the same thing, ordinary whitewash, is a very efficient and cheap medium with which to disinfect them. 2. After vomiting, the mouth of the patient should be rinsed with a solution of hydronaphthol, i to 5000, care being taken that none is swal- lowed. After each evacuation from the bowels, the buttocks, thighs, and anus should be washed with soap and water. 3. All body and bed linen soiled with the discharges should be imme- diately moistened with carbolic solution, i to 60, and removed in a covered vessel from the apartment, placed in a wash-boiler, and boiled for half an hour in a one per cent, solution of washing soda. ■CHOLERA. 99 4. Xapkins, towels, and table linen should be placed in a similar vessel or canvas bag for removal and similarly boiled. 5. All dishes, knives, forks, spoons, etc., used by the patient should be boiled after each meal in a one per cent, solution of soda. 6. The remains of meals should be thrown into a vessel containing milk of lime or whitewash, and removed at the end of the day. 7. Door-knobs are liable to be soiled by the hands of one carrving out excreta, and should be carefully washed and cleaned and sterilized, lest they, in turn, communicate the infectious material to another person handling them. 8. In case of death, the body, without being vrashed, should be wrapped in sheets wet in a solution of bichlorid of mercury, i to 1000, and allowed to remain until removed for prompt burial. Special Directions to Nurses: 1. In like manner nurses of cholera patients should not hold any direct communication with others during attendance on such cases. 2. They should, under no circumstances, take their meals in the sam.e apartment with the patient, and before leaving the room the hands should be cleansed with soap and bichlorid solution, and such portion of the dress as is liable to be soiled should be changed. The hands should be again rinsed in bichlorid solution, i to 1000, after leaving the patient's room. A very convenient plan is to wear a slip or '" overall " with a hood to cover the hair, which can be easily thrown aside before leaving the room. A canvas slipper or overshoe, readily removed, should also be worn in the sick-room. 3. The food of the nurse should be wholesome and plain, freshly cooked, and served hot. Xo uncooked vegetables should be eaten. ]\Iilk should be boiled and, if desired, cooled before using. Cold drinks should be taken moderately, if at all. Coffee and tea may be taken hot. 4. Teeth should be cleansed after each meal, as the mouth affords a peculiarly favorable nidus for decomposing matters and a favorable nidus for the multiplication of pathogenic fungi. A daily bath in warm water, with the use of soap, should be taken by each nurse. 5. Care should be observed to keep the body from being chilled by drafts or other cool exposures, and to this end woolen underclothing should be worn. 6. Courage and cheerfulness are amply justified, because it is really almost impossible to take cholera if the above precautions are carried out. The Treatment of the Attack. — The indications in the management of cholera, apart from isolation of the patient and the sterilization of the dis- charges, are. in the ^rst stage, to check the diarrhea, combat the multi- plication of bacilli, and neutralize their toxic influence. In the second stage, to relieve the cramp and pain and check the flux. I. — The former is to be attained by the judicious use of opiates and acids on the one hand or opiates and antiseptics on the other ; for antiseptics and acids can scarcely be used together, and the physicians must decide on which of the germicides he proposes to fely. Any of the mineral acids, such as hydrochloric, nitromuriatic, and sulphuric acids in doses of 10 to 15 minims (0.66 to i c. c.) of the dilute acid wdth as much tincture of opium or a corresponding dose of paregoric or deodorized tincture of opium loo INFECTIOUS DISEASES. properly diluted, may be given every two hours. Or a lemonade of tartaric or citric or lactic acid, 2.5 drams to i quart of water (9.5 gm. to a liter),, may be used in conjunction with the opiate. In addition, the rectum may be washed out by the warm solution of tannic acid in water or camomile tea, to be again referred to on page 10 1. It has long been the practice to prescribe in cholera, as well as cholera morbus, a mixture of stimulating aromatics and irritants with opiates, and there is no doubt that in the early stages of cholera such combinations may be of value. The following is one of them : IJ Tr. opii, ^ Tr. capsici, { J^-^i'^gj^' . Ua f3ss(2c. c.) Sp. menth. piper., ^ \ / Sp. chloroformi, | Sp. camphoras, J Sp. vin. rect q. s. ad f rij (60 c. c.) M. Sig. — Teaspoonful in hot water or black tea every fifteen minutes until relieved. Paregoric, in one-dram doses (4 c. c), similarly administered early in the disease, is often sufficient to control the symptoms. The following is the well-known cholera mixture or diarrhea mixture of Squibb, which is given under the same circumstances : ^ Tr. opii, ^ Sp. camphorge, |- aa . . . . . . f^j (30 c. c.) Tr. capsici, ) Chloroformi pur f 3 iij (12 c. c.) Alcohol. . q. s. ad f 3 v (150 c. c.) M. Sig. — Teaspoonful every hour or every two hours. Instead of the acid solutions, antiseptics may be given for the same purpose. Of these, salol is a favorite, and may be given in doses of 10 to -1 5 grains (0.66 to i gm.) every two or three hours, and it may be combined with subnitrate of bismuth in large doses, with wine of opium or deodorized tincture. The greater or less usefulness of calomel in cholera, as attested by experience in so many epidemics, beginning in 1885, may be ascribed to its antiseptic qualities, although it is probably as efficient in con- trolling vomiting as any other drug. The plan pursued at the New Hamburg Hospital and at the ^loabit Hospital in Berlin was to give an initial dose of four to seven grains (0.3 to 0.5 gm.), after wdiich 1-3 to 3-4 grain (0.02 to 0.05 gm.) was given every two hours through the first and second stages. A portion of the calomel becomes changed in the intestine to corrosive sublimate ; and as corrosive-sublimate solutions have a fungus-destroying action, in a strength of i to 30,000, it is reasonable to suppose that the bacilli in the intestine are directly killed by the calomel. II. — The indications in the second stage are to relieve the painful cramp, to continue to try to check the discharges, and to compensate for the loss of liauid by the vomiting and purging. For the relief of cramps morphin hypodermically is to be preferred, because of the promptness of its effect and because absorption from the gastro-intestinal mucous membrane is much hindered, if not altogether pre- vented, in true cholera, while the vomiting is a further obstacle to the administration of medicine by the mouth. Full doses should be given, 1-6 to 1-4 grain (o.oi to 0.016 gm.), which may be repeated, if necessary. If circumstances compel the administration of anodynes by the mouth, chloro- dvne is one of the best, and is well administered in brandy or whisky. CHOLERA. lOl Such administration, too, fulfills any indication for opium to control the bowels. Some difference of opinion exists as to the propriety of checking the- discharges in this stage, the chief reason assigned being that the bacilli, whose presence is directly or indirectly the cause of the flux, are thus retained. But such objection is offset by the fact that the flux itself is the greater source of danger and that, if it can be controlled, the bacilli in the bowel are comparatively harmless. Unfortunately, in the later stages, when the flux is established, nothing avails to control it, and the opiate may as well be limited to that hypodermically administered for the relief of pairi. I quite agree with those who hold that, notwithstanding the oppo- sition to it, opium will retain its place among the chief weapons against the disease. The effect of the copious discharge is to produce the intense exhaus- tion referred to under symptomatology, and it is imperative to counteract this, if possible, by stimulants freely administered. Champagne, brandy, and ammonia, combined with ice and carbonated waters, are suitable. If not retained by the stomach, whisky, ether, and the aromatic spirit of ammonia may be given hypodermically in thirt^'-minim (2 gm.) doses frequently repeated. The hope of benefit from these remedies is justified, if reaction once sets in. More serious still is the drainage of liquid from the tissues, and the most serious consequences ensue from the resulting stagnation in the blood. To restore its liquidity is, therefore, of the greatest importance. Transfu- sion of watery solutions suggests itself, but the difficulty and delay involved in practicing are opposed to its use. Hypodermic injections of hot saline Fig 12. — I. Rubber reservoir and. tube o£ fountain syringe for hypodermoch^sis. 2. Attachment for cannula. 3. Soft rubber rectal tube. 4. Needle. 5. Cannula. solutions or hypodermoclysis, also enemas or enteroclysis of similar fluids, slightly astringent, were practiced successfully by Cantani in Italy in 1892, and have been continued with various results in Europe, and in a more limited manner, with satisfactory results, at Swinburne Island in New York Harbor. The method practiced at the latter place, as described by Judson Daland, is as follows: Water at 40° C. (104° F.) previously steriHzed, and containing 0.8 per cent, of sodium chlorid and one per cent, of brandy, was 102 INFECTIOUS DISEASES. Introduced under the skin in the midaxillary hne in the region of the floating ribs, through a long hypodermic needle and cannula attached to the tube of a fountain syringe or Davidson syringe. The former is preferred, because the pressure may be neatly regulated by raising or lowering the bag. One or two quarts may be introduced, thirty to forty-five minutes being required, in favorable cases for the former quantity. When absorption is slow, it may be facilitated by manual manipulation at the seat of the swelling that results at the point of injection. In unfavorable cases a much longer time is required to introduce this quantity, as much as four hours, whence the rate of absorp- tion becomes of prognostic value. The operation may be repeated in two hours, or in severe cases one quart may be injected in each flank, repeated as soon as absorption is complete. The quantities to be used may be laid down at, for an adult, two pints ( i liter) ; an adolescent, one pint (0.5 liter) ; and an infant, 1-2 pint (0.250 liter). Other sites may be selected for injec- tion, as the buttocks, inner surface of the thighs, or below the pectoral muscle. The neighborhood of the neck should be avoided because of the possible edema of the larynx, such an accident having occurred at Swin- burne Island. The benefit derived from the use of this measure under other circumstances, — as, for example, succeeding large hemorrhages and uremia, — together with the facility with which it can be carried out, com- mend it strongly. A heaping feaspoonftd of common salt to a quart of sterilised zvater furnishes zvith suffieient nearness the proportion desired. Whenever the discharges have been so copious as to make it reasonable that the vessels are becoming drained, hypodermoclysis is indicated, and may be repeated every two, four, or six hours as required. Enteroclysis is made with a one or two per cent, solution of tannie acid at a temperature of 45° C. (113° F.). For an adult 2 quarts (2 liters) may be administered; for an adolescent, i quart (i liter). It is introduced slowly, by a fountain syringe or Davidson syringe, through a rectal tube with lateral outlets but closed at the end. The tube is introduced gently by a combined rotary and pushing motion to the depth of 10 inches, when the fluid is allowed to enter slowly, consuming not less than ten minutes. The patient should, of course, be encouraged to retain the fluid, and may be aided by pressure on the anus witli a napkin. Enteroclysis is said to be useful in any moderately severe case of cholera, and may be given night and morning, more frequently in severe cases. According to Daland, experiments made at Swinburne Island in the autumn of 1892 showed conclusively that when thus introduced fluid can be "made to pass through the ileocecal valve into the small intestine. In fact, several patients vomited the solution. It is in the algid stage that this treatment is more particularly used, but other means must be taken to keep up the warmth of the body. To this end the patient is immersed in the hot bath at a temperature of 38° to 42° C. (100° to 107° F.). In favorable response the warmth of the body returns, the pulse is fuller and stronger, the respiration deeper. Hot-water bottles, hot-w^ater bags, and hot bricks may be applied alongside the body. III. — In the third stage, that of reaction, indicated by the return of warmth, pulse, and heart-beat, and especially the establishment of the urinary secretion, restorative measures are continued with the addition of judicious nutriment, preferably in the shape of peptonized foods, especially peptonized milk. Great care must be exercised lest diarrhea be induced by too liberal feeding. Convalescence is necessarily very slow in serious cases, and relapses are prone to occur. CHOLERA. 103 Appendix. — The Examination for Cholera Bacillus. I add the method practiced for this purpose in the Bacteriological Insti- tute at Berlin furnished by Dr. Louis Fischer. The articles necessary are : 1. A microscope with Abbe's condenser and an oil-immersion lens of 1-12 inch focal distance. 2. A solution of fuchsin i gm. in 90 c. c. distilled water and 10 c. c. alcohol. 3. A few pipettes, glass rods, cover-glasses, and slides. 4. A few platinum wires melted or soldered to the ends of glass rods. 5. A few " hollow " slides. 6. Ten to 12 glass plates or glass panes, about 12 cm. long and 9 cm. wide. 7. About a dozen ordinary flat plates. 8. An alcohol lamp or gas, preferably a Bunsen burner. 9. A number of test-tubes with sterilized gelatin. 10. A number of test-tubes with sterilized nutrient bouillon. 11. A few Erleymer's glasses, about one-third filled with i per cent, peptone solution — i gm. peptone, 0.5 gm. chlorid of sodium, 100 gm. dis- tilled water. 12. Concentrated sulphuric acid. The dejecta of the suspected patient are scattered in as thin a film as possible on a glass plate, and this is carefully examined by the aid of a plati- num wire for a mucous flake (" Schleimflocke "), which is laid on the edge of the plate and isolated. From this is taken a piece the size of a pinhead by means of a platinum loop sterilized by drawing it through a Bunsen burner. The fragment is rubbed on a cover-glass until it is evenly divided ; super- fluous material is removed by pressing another cover-glass over it ; the two are separated, and allowed to air-dry. The glass cover is then drawn three times through the flame of the Bun- sen burner in the same manner as for the examination of sputum for tubercle bacilli, and by means of a pipette a few drops of fuchsin solution are placed on it, allowed to remain one or two minutes, and then washed off in distilled water. A drop of water is put on the cover-glass, which is laid on a slide and examined with the oil-immersion system. If it be desired to preserve the specimen, after staining with fuchsin solution wash off the excess of stain with distilled water, allow it to get thoroughly air-dry, add Canada balsam, and mount. In some of the fulminating cases where the intestinal contents are color- less or have a pale-red color, with slimy flakes or with a flour-soup mass, especially in the period of reaction, the cases running a slow course, no mucous flakes will be found, but large quantities of blood. Here may be found, besides cholera bacilli, numerous other micro-organisms, while the cholera bacilli are but sparingly present. To render a diagnosis absolutely positive in such cases, " cultures " are necessary. Cultures can be made in " hollow slides " by smearing the border with vaselin, then bringing a small drop of, sterilized bouillon into this hollow groove of the slide by means of a platinum-wire loop, and inoculating the bouillon with the smallest possible particle of the suspected mucous flake. The cover-glass is carefully laid on the vaselin, which serves to render the groove air-tight, and also prevents evaporation of the drop of sterilized I04 IXFECTIOUS DISEASES. bouillon. The slide is then laid aside at a temperature of 20" to 22° C. (68° to 70° F.)- The room can be heated, if the temperature is below this. In about twenty-four hours the bouillon becomes turbid, and the slide can be examined with the oil-immersion lens without disturbing the culture. The best place to examine is the border line, and even if but few cholera bacilli were originally present, they grow so rapidly that they can be easily recognized by their curved shape. Culture Method by Scliottelius. — Take 100 to 200 c. c. of the suspected dejecta from the intestinal contents and place them in a beaker glass contain- ing 250 to 500 c. c. of mild alkaline meat-bouillon, and mix thoroughh' ; then let this mass stand twelve to twenty-four hours at a temperature of 30° to 40° C. (86'' to 104° F.). After this time the cholera bacilli have usually increased in numbers, and are found on the upper layer of the fluid. Intro- duce at the upper layer a platinum loop, take out a small drop the size of a lentil seed, rub it on a cover, and allow it to dry thoroughly in the air ; then stain, as previously described, with the fuchsin solution. Postmortem Tests. — To examine suspected intestinal contents, open the abdominal cavity carefully and ligate at two places with stout twine a piece of the ileum well filled with fecal contents, about three to four centi- meters in length, and taken from near the cecum. A double ligature should be applied at each end and the cut made between the two, so that the intestinal contents will not be spilled in the abdominal cavity. It is well also to cut out a piece of the intestine three to four centimeters in length from the upper portion of the ileum, and to lay the excised portions in ordi- nary water until ready for examination. The method is the same as has been described — that is. take a small piece of nocculent mucus the size of a pinhead. etc. Gelatin stroke and stick cultures, and also potato cultures, can be made for examination. The spirilla also grow on blood-serum and agar. Cholera bacilli require for their growth a mild alkaline nutrient medium, and are very quickly destroyed by mineral acids. They do not develop readily in ordinary water, owing to the presence of other bacteria, which destroy them ; they do develop, however, very rapidly in sterilized water. DYSENTERY. Syxoxym. — Bloody flux. Definition. — The term dysentery, derived from the Greek w^ords for difficult and bowel, is applied to inflammations of the large and sometimes, although to a less extent, of the small bowel. The condition can be best considered under three heads which represent varieties or different forms of the disease. These are: ist, catarrhal, 2d, bacillary, and 3d, amoebic dysentery. Catarrhal Dysextery. Definition. — Catarrhal dysentery is the simplest and most common form of the disease met with in temperate climates. It is characterized by an increased mucous secretion associated with desquamation of the epithelium covering the gut. together with a variable involvement of the solitary lym- phatic nodules of the large intestine and of both the solitary and agminated nodules of the small intestine. DYSENTERY. 105 Etiology. — This form occurs more frequently as an accompaniment of other diseases of adults than as a simple uncomplicated process. It attends the specific intestinal lesions in typhoid fever and tuberculosis and is com- monly associated with the acute infectious exanthemata and not infrequently with diphtheria. It is the form of dysentery caused by simple irritants, of which unripe and indigestible food forms a liberal source. In children, especially during the hot summer months, but to a certain extent through- out the entire year, this form is met with. As in adults, it may be the result of the ingestion of indigestible food or other irritants, but in young and nursing children it forms a part of the so-called entero-colitis of the summer months. In the better characterized entero-colitis of children Duval and Bassett have obtained the bacillus of Shiga from the dejections and from the mucous membrane of the intestines in fatal cases. Morbid Anatomy. — Changes in the affected intestine are of dift'erent grades. In the lighter forms there is merely an excessive secretion of mucus associated with desquamation of the epithelial cells, exudation of more or less serum, and the emigration of a small number of leukocytes. The mucosa is swollen and congested. In severer forms the surface of the gut is covered with mucus, streaked with blood. The mucosa is much injected, bleeding points or ecchymoses can be made out, and the lymphoid nodules are enlarged and prominent. Not infrequently small defects in the mucosa exist in connection with the nodules, constituting small ulcers. The latter rarely extend beyond the limits of the nodules, and pseudo-membrane never occurs in connection with them. Symptoms. — Catarrhal dysentery is usually ushered in by diarrhea, the first stools being copious and painless. Soon, however, these are replaced by small mucous discharges streaked with blood and accompanied by crampy abdominal pains, technically known s^s tormina (twisting pains) and strain- ing or tenesmus. The latter is exceedingly trying, causing a constant feel- ing of unsatisfied desire for stool, so that the patient is disposed to sit con- stantly on the closet or to go back repeatedly many times in a single hour, experiencing at the same time intense burning pain at the anus. Yet the total quantity discharged in the twenty-four hours is not large. From 28 to 42 ounces are a full amount. Sometimes a chill is the initial symptom. The tongue is furred and at first moist ; later it may become dry. There may be nausea and vomiting. There is always more or less fever, sometimes very slight, at others decided, the temperature seldom exceeding 103° F. (39.4° C). There are the thirst and acceleration of pulse usually attending fever, and sometimes the former is extreme. The abdomen may be tender, but not necessarily so. It may be tumid or flat and hard. In addition to the characteristic features of the stools already mentioned, scybala or hard fecal masses may be present at first. Later the stools are frequently green in color, from the presence of bile — bilious dysentery — and increase in their transit the burning feeling already mentioned. In addition to blood-corpuscles and leukocytes the microscope recognizes large round and oval epithelioid cells containing fat-drops and vacuoles; also at times the ccrcomonas intcstinalis. Until recently no specific organisms w^re found in the simple catarrhal form of dysentery. F. C. Curtis has found the bacillus pyocyaneus in an epi- demic of dysentery at Harlwick, N. Y. The milder cases of catarrhal dysentery are self-limiting, terminating usually in a week, when the character of the stool changes. Other cases io6 INFECTIOUS DISEASES. are more intractable and resist even judicious treatment for a long time, becoming even chronic. Diagnosis. — The diagnosis of acute catarrhal dysentery is very easy. The tormina and tenesmus with the frequent blood-stained mucous stools occur in no other affection. ^Malignant disease of the rectum is sometimes mistaken for chronic dysentery. Examination of the rectum should be made in all prolonged cases. Prognosis. — The prognosis is generally favorable. As intimated, many mild cases get well without treatment, and when judiciously handled unfavorable termination is rare. Favorable termination is not, however, invariable, and cases sometimes end unfavorably after a prolonged course, or thev become permanently chronic and incurable. Emaciation and exhaus- tion are rapid, and even a mild attack rapidly reduces the strength of its victim. Bacillary Dysentery. Definition. — The form of dysentery most commonly present in tem- perate and tropical regions, appearing in a variety of forms. Under it are to be included : First, pseudo-membranous, croupous, or diphtheritic. Sec- ond, ulcerative. Third, chronic dysentery. Etiology. — The lower part of the large intestine is most frequently the site of the lesion, but the entire large and more rarely the small gut may be affected. The difference between the acute, pseudo-membranous, and chronic forms are striking, notwithstanding which, the evidence at hand tends to connect them to one causative factor. Beginning with the researches of Shiga in Japan, in 1898, which were followed by the investi- gations of Flexner and Barker carried out in Manila, in 1900, and after- wards by Flexner in this country, and Kruse and others in Germany, the evidence has grown in favor of the B. dysenterise (Shiga) as being the specific cause of this variet}' of dysentery. The Bacillus dysenterice is a well-characterized micro-organism belong- ing to the colon typhoid group of bacilli, which can be distinguished by its cutural and other characteristics. In morphology it differs only slightly from the typhoid bacillus, with which it has certain cultural properties in common. It grows upon ordinary culture media readily, and brings about little change in milk excepting to cause a slight alkalinity. It is slightly motile when first isolated, but quickly loses its motility on artificial cultures, but this can be restored by pas^ge through experimental animals. Flagella surrounding the body of the bacillus have been demonstrated by Vedder and Duval, of the University of Pennsylvania. The organism is pathogenic for a wide series of laboratory animals, and when injected into the intestine of cats, or fed to them after alkalinization of the gastric juice, it is capable of setting up an inflammation of the gut from which the bacillus may be recovered. Taken into the stomach of man it rapidly sets up a severe colitis. There are two instances on record of its action on man : The first, reported by Flexner, in which a small quantity of a culture was accidentally aspirated into the mouth by one of his assistants, the intestinal symptoms appearing within forty-eight hours ; the second, reported by Strong, in which a Filipino prisoner voluntarily swallowed a portion of a culture of the bacillus, in which case the symptoms quickly developed and were of marked severity, the bacillus being recovered from the stools. The man finallv recovered. DYSENTERY. 107 Bacteriological Diagnosis. — Diagnosis of this form of dysentery can be established in two ways : First, by recovery of the specific organism from" the stools ; second, by obtaining the agglutination reaction with the blood of the patient and the specific bacilli in a manner similar to that of the Widal test in typhoid fever. In the acute disease the specific bacilli are abundant, and can be sep- arated without great difficulty from the dejecta. For this purpose solid contents are avoided and mucus or blood-stained mucus is selected for examination. Plate cultures upon agar-agar are made and incubated for twenty-four hours. The colonies which have developed at the end of this period are not chosen for further study, but are carefully marked with a blue wax pencil and the plates returned to the incubator for another twenty-four hours. The second crop of colonies usually contains a large proportion of the dysentery organisms, which grow more slowly than the colon bacillus in the mixtures of the two organisms. Transplantations from the second crop of colonies are made into glucose agar tubes, which are incubated for a day and all gas-forming colonies excluded as being non-dysenteric. The tubes which show no gas are then further examined, and among them the specific organism will be found. (Duval.) The agglutination test with the blood of persons ill of bacillary dysen- tery is easily obtained. For this purpose cultures, twenty-four hours old, upon agar-agar, are employed, from which suspensions are m.ade in bouillon. In using the blood, it is preferable to employ the wet method by which the blood is obtained in capillary tubes, from which the serum can be col- lected. After proper dilution of the serum the tests are carried out in the usual manner. Positive reactions may be obtained in dilutions varying from 1-20 to I- 1000 in a period of from one-half to one hour, and as early as from the third to the fourth day of illness. This method is applicable to the study of all cases of dysentery, as well as the entero-colitides of children. Morbid Anatomy. — The anatomical features of bacillary dysentery vary with the form and duration of the disease. The most acute cases are those running a rapidly fatal course and involving the entire large gut and a variable length of the lower small intestine. The mucous membrane is greatly swollen, suffused with serum and blood, presenting a pulpy appear- ance, but without visible false membrane. These are the forms which result fatally in 48-72 hours, and which are met with in tropical countries, and sometimes in institutional and other epidemics in temperate climates. The usual form of bacillary dysentery is the pseudo-membranous. In this the extent of the lesion varies, sometimes appearing in the rectum and sigmoid flexure, and sometimes extending throughout the large gut. The membrane, which is grayish-white in color, presents a granular surface, and appears first upon the elevations of the mucosa corresponding to the inser- tion of the bands of longitudinal muscle and the transverse lines of the colic pouches. As the condition progresses in severity the intervening mucosa is covered with pseudo-membrane. The entire mucosa is injected, swollen, and covered with blood-stained mucus, beneath which bleeding points may be discerned. Upon mi^croscopical examination the pseudo- membrane is found to consist of a filarinous and cellular exudation which lies upon the surface and penetrates into the substance, for a variable distance, of the mucosa. The glands of Liberkiihn undergo necrosis and become invaded by pseudo-membrane. Large numbers of micro-organisms io8 INFECTIOUS DISEASES. are present in the dead tissue, and the blood-vessels of the mucosa are extensively occluded by thrombi. A demarcating inflammation "takes place at the limits of the living and necrotic tissue, causing separation of the latter, which upon exfoliation leaves behind defects which constitute the acute dysenteric ulcers. The dis- ease may come to an end at this stage or an earlier one, and. the integrity of the mucosa be restored, or the necrosis may extend more deeply and involve the depth of the mucosa and be associated with marked inflamma- tory changes in the submucous and muscular tunics. In these instances iflceration may extend through the mucosa and invade the submucosa, and even penetrate more deeply, and in the subsequent process of repair new tissue develops in the submucosa which leads to the permanent thickening of the intestinal wall. It is this form of dysentery which tends to pass into the chronic disease, in which ulceration is deep and persistent, and much new tissue develops in the submucosa, in the mucosa, and even in the muscular coat. Owing to the persistence of the ulceration and possibly to the interaction of secondary micro-organisms, including the pyogenic cocci, always present in the intestinal canal of man, the ulceration extends not only mOre deeply, but tends also to heal slowly and imperfectly, whence arise the symptoms characterizing chronic ulcerative dysentery. That the specific organism persists throughout long periods, where these pathological conditions are present, is shown by the acute exacerbations of the disease and by the association of the chronic ulcerative with fresh pseudomem- T^ranous inflammation met with not infrequently at autopsy. It is during the exacerbation that the specific bacillus is to be sought in the dejecta and the blood reaction looked for. Among the consequences of the tissue production in chronic dysentery, polypoid outgrowths are met with. These consist of portions of the mucosa and submucosa, in which an overplus of new tissue is developed, and which come to project into the lumen of the gut. Partially through the action of gravity and through other causes they tend to lengthen, whence they come to be attached by narrow pedicles to the wall of the gut. Depressed scars, over which the mucosa is atrophied, also mark the site of healed ulcerations. The new formation of connective tissue throughout the coats of the gut may be so extensive as to bring about, after its contracture, serious deformation and narrowing of the lumen. Inflammation sometimes extends to the peritoneal coat, whence adhesions to the neighboring parts take place. Only rarely does ulceration proceed so rapidly, or fail to be attended by connective tissue formation, as to perforate the peritoneal coat. Symptoms. — The symptoms of bacillary dysentery are those of the simple catarrhal form greatly intensified. The fever is higher, the pain is greater, the tormina and tenesmus are more severe, the stools are more l)loody, and the adynamia is more profound. Delirium is often present, and the tongue may be dry. The abdomen is tender and swollen, and typhoid fever may be simulated. The symptoms in the secondary form are less severe than in the primary. Complications and Sequelae. — The complications in this form of ■dysentery are more numerous. Abscess of the li-vcr is one of them, and is ascribed to thrombotic extension from the seat of inflammation along the vessels of the portal system into the liver, or to emboli carried from the primary focus to the liver. Perforation of the bowel is not a very rare com- plication, having been found by Woodward, in a study of the statistics of DYSENTERY. 109 the late Civil War in America, 11 times in 108 autopsies. This accident is followed by a peritonitis, which is usually fatal, the local symptoms of which. vary with its exact seat. If in the neighborhood of the cecum, perityph- litis ensues ; if lower down in the rectum, a proctitis. A peritonitis may also arise by extension of the inflammation from the mucous lining of the bowel. The same opportunities enabled Woodward to show the undoubted association of malaria with dysentery, though it is likely that the " chills " referred to in older reports were sometimes septic and due to the dysentery. The same is true of the joint szvelling described by the older authors, among whom was Sydenham. They may be a part of pyemic processes. Paralysis, commonly paraplegia, as a sequel, is attested by Woodward and Weir Mitchell. Pleurisy, pericarditis, endocarditis, and Bright's disease are among sequelae reported. Diagnosis. — The same diagnostic symptoms that enable us to recog- nize the other varieties of dysentery attend this in severe degree, but it is the occurrence of successive cases that gives the stamp by which we recog- nize the diphtheritic type. (See also bacteriological diagnosis, page 107.) Prognosis. — The prognosis of this form of dysentery is the most un- favorable of all the varieties. Most cases perish, death being preceded by extreme adynamia and other symptoms of the typhoi-d state, including dry tongue, stupor, emaciation, and the cadaveric countenance. Consciousness is sometimes painfully persistent to the end. Amcebic Dysentery. Synonyms. — Aniochic Enteritis; Tropical Dysentery. Definition. — An ulcerative inflammation of the large intestine due to anioeha coli. This form has sometimes, incorrectly, been termed tropical dysentery. It occurs in the tropics, but also in temperate regions, while the commonest form of the disease in the tropics would appear to be bacil- lary dysentery. Etiology. — The studies of Kartulis in Egypt, of Councilman and Lafleur in America, and Kruse and Pansini in Italy, have established amoeba coli as the cause of this variety of dysentery. The organism was, however, first described by Lambl in 1859, and later by Losch, but its relation to tropical dysentery was first clearly established by Kartulis. The amoebae are found in the dejecta, in the intestinal ulcers, and in secondary liver abscesses of the disease. The organism varies from 15 to 20 microns in diam- eter and is actively motile when examined in the living state. It consists of two portions, an outer ectosarc and an inner endosarc. Its movements are brought about through the propulsion of the former, after which the granular inner substance flows into the pseudopodia. The amoeba is phagocytic, taking up foreign substances from the intestine, etc., and especially englobing the red corpuscles. At present two varieties of amoebje are distinguished as occur- ring in the stools : the first non-pathogenic — amoeba coli mitis — and the sec- ond pathogenic — amoeba coli. The former has been found repeatedly in healthy stools, and it does not exhibit phagocytic properties for red cor- puscles. In this country amoebic dysentery has been found to occur as a sporadic disease, especially in the Southern States, but also in Pennsylvania, New York, and the New England States. Morbid Anatomy. — The intestinal lesions are usually limited to the no INFECTIOUS DISEASES. large intestine ; rarely they are found in the ileum. The characteristic lesion is ulceration, involving the mucosa and submucosa. In early ulcers a small defect only is found in the mucosa ; more rarely the muscular coat is invaded, and rarest of all, the peritoneal coat. In the course of the ulceration the submucosa becomes infiltrated with a grayish, gelatinous material, the ex- foliation of which gives rise to the ulcer. In this material there are few preserved cells, but it consists chiefly of necrotic material, in which only a few pus cells can be made out. Amoebse may be discovered in the necrotic tissue, as well as in the adjacent portions of the mucosa and submucosa. In the immediate neighborhood of the ulcer proliferation of the connective tissue takes place which, in favorable cases, may completely restore the defect, and in chronic cases brings about permanent changes in the gut similar to those described in chronic bacillary dysentery. Pseudo-membrane is never present in uncomplicated cases, but instances of combined amoebic and bacillary dysentery, in which pseudo-membrane has been present, have been described. Microscopical Diagnosis. — Detection of the specific amceb^ in the stools, or of secondary liver abscesses, confirms the diagnosis of the disease. Great care should be exercised to obtain fresh material for microscopical examination, and bits of mucus, rather than fecal material, should be chosen for study. The mucus or pus is slightly pressed out, but not too firmly, under a cover-glass, and the slide slightly, but carefully, warmed up to body heat, before examination. Inasmuch as desquamated epithelial cells sometimes take on a round form and simulate amoebae, it is desirable that a definite movement be detected before passing upon the nature of the suspected cells. Living amcebge, especially those enclosing red corpuscles, are taken to indicate the nature of the pathological condition of the intestine. Symptoms. — The symptoms of amoebic dysentery are similar to those of catarrhal dysentery, but much more irregular and prolonged. The onset is usually less sudden, but may be equally so. The stools are less numer- ous, and are apt to be more liquid and more copious. They abound in the amoebae coli. The straining at stool is less severe and persistent, while there may be several days of relief, to be followed by the usual train of symptoms. The fever may be severe or mild. Complications. — The most common and serious complication is abscess of the liver, which is now believed to be due to the w-andering amoeba dysenterica, which reaches the liver through the blood-vessels. The abscess may be single or multiple. In the former case it may be of large size, in^'olving fully half of the bulk of the liver. The multiple abscesses are smaller in size and superficial. The abscess walls are peculiar, being ragged from the presence of necrotic projections. Only occasionally, in the older abscesses, are there firm, smooth, fibrous walls. Next to the iniieniiosf necrotic ::oiie is a zone of cclhdar infiltration encroaching upon and destroy- ing the liver-cells, and external to this again a zone of intense hyperemia. The contents of the abscess are not pure pus. In fact, the paucity of the pus-cells here is as significant as in the inflammatory infiltration of the mucosa, indicating a similarity in the etiology. The pyoid material consists rather of fatty and granular debris and the amoebae, which are also found in the walls of the abscess. These abscesses sometimes break into the lungs, carrying the amoebae with them, which are sometimes, under these circum- stances, found in the expectoration. In addition to the abscesses described there are found also in the liver DYSENTERY. m in amoebic dysentery patches of circiimscrihed necrosis, scattered through the Hver as the result of the action of the amoebae. Diagnosis. — The diagnosis is rendered easy by the recognition of the amoeba coli in the stools, which should be examined by the microscope in every case of dysentery as directed under microscopical diagnosis. Prognosis. — The prognosis is much more serious than that in the catarrhal variety. The course of the disease is always prolonged, and a fatal issue is much more frequent. It would seem that the patient must outlive the organism before he can recover, and even then recovery is delayed by the exhausted condition into which he has fallen in the struggle with his microscopic guest. When the termination is most favorable, cases of amoebic dysentery last from six to twelve weeks. Treatment of Dysentery. — The first measure of treatment of catarrhal dysentery duly recognized should always be a purgative. No aperient is better than castor oil. An ounce of oil (30 c. c), guarded by 10 to 20 drops (0.66 to 1.33 gm.) of laudanum, is the proper dose for an adult. The saline treatment, especially when there is high fever and no marked adynamia, is also efficient, working a rapid cure in many cases. Two drams (8 gm.) of sulphate of magnesium, or 1-2 ounce (16 gm.) of Rochelle salts dissolved in water, should be given every hour until copious watery purgation results.* When this end is obtained by either remedy, an opiate may be given. Plain opium in doses of one grain (0.066 gm.) every three hours, or 1-2 grain (0.033 gi"-) of the extract, is the favorite. Or the drug may be combined with bismuth subnitrate in ten-grain (0.66 gm.) doses, or with one of the astringents, tannic acid in two- to five-grain (0.132 to 0.33 gm.) doses, or the acetate of lead, one- to two-grain (0.066 to 0.132 gm.) ; or with salol. Very comforting in quieting rectal irritation is an opium sup- pository containing one grain to two grains (0.066 gm. to 0.132 gm.) of opium, or 1-2 grain to a grain (0.033 g™- to 0.066 gm.) of the extract. Hope's camphor mixture is an old remedy which sometimes acts well, especially in cases disposed to become chronic. Dr. Hope's formula, origi- nally suggested in 1826, is as follows: I^ Acidi nitrosi, f 3 j (4 c. c.) Mist, camphorje f § viij (240 c. c.) M. et adde tr. opii, gtt. ,xl ( 1.2 c. c.) Sig. — A fourth part to be taken every three or four hours. The Hope's camphor mixture of the shops; made with nitric acid in- stead of nitrous acid, should not be substituted. It goes without saying that the food should be liquid and of the blandest kind : boiled milk, better still peptonized, light animal broths, and beef-juice, not beef-teas, are the type. Barley or rice may be added to such broths, and should be thoroughly cooked. The first consideration in the treatment of hacillary dysentery is a hland and non-irritating, hnt nourishing, diet, one that leaves as little residue as possible. The peptonized foods, such as peptonized milk and beef-pepto- * The following- striking- results -would seem to jiustify the saline treatment : Day treated 60 cases of dysentery, 25 of which received ipecacuanha and opium; the remaining 35 were treated with magnesium sulphate. Under the former method of treatment the death-rate was 32 per cent, and under the latter 2.q per cent. The recoveries occurring- under the former treatment were slo-\v and accompanied by frequent relapses; under the latter they were complete and rapid, but it was always found advisable to continue one-dram doses of magnesium sulphate three times daily for a couple of days after the stools had ceased to be dysenteric. 112 IXFECTIOUS DISEASES. noids, in addition to beef -juice and somatose, are the types. To these, stimu- lants should be freely added. Opiates are needed to relieve the pain, and their hypodermic use is sometimes especially efficient for this purpose. When, the necrotic membrane is removed, an extensive ulcerated surface remains to be healed. Such healing is favored by the restrained peristalsis that opium produces. The same purpose may be served by the use of ipecacuanha, if the effect claimed for it by the East Indian physicians is produced. Directions for its administration are given below. On the other hand, it is doubtful whether soluble remedies intended for the direct healing of the ulcers ever reach these surfaces in an active state, when administered by the mouth. Nitrate of silver, when administered,, does sometimes, however, reach the lower bowel. Bismuth, being largely insoluble when administered in large doses, undoubtedly reaches the bowel, and mav produce some healing eitect. ]\Iore promising is the use of iodo- form, which may be also expected to reach the part affected, and which is not onlv more healing in its action, but is also antiseptic. It may be given in a pill or capsule, in doses of 1-2 grain to 3 grains (0.0324 to 0.194 gm.}. The same indication as to diet exists in the atnccbic as in the other forms of dysentery. It is apparently in this form, of which only isolated cases are met in temperate chmates, that the ipecacuanha treatment of the East Indian phvsicians has been so successful. It is claimed to act as a muscular sedative and secretory stimulant ; by its effect the former allays the exag- gerated peristaltic activity so characteristic of the disease, by the latter it augments the secretion cf mucus as well as stimulates the activity of the liver-cells in bile formation — a function which in dysentery is in abeyance. Great stress is laid on the mode of administration. A preliminary dose of laudanum is given, and in half an hour afterward from 20 to 60 grams (T.332 to 4 gm.) of ipecacuanha. For three hours after the first dose only a little ice should be sucked, and after that a little iced soda-water and milk administered. Beef-tea or bread or light foods are fatal to the favorable action of ipecacuanha, and to the use of such foods failures are ascribed by the advocates of the treatment. On the second day the drug is administered in reduced quantity, supplemented by salicylate of bismuth, quinin, naphthoic and opium, while milk should form the staple food. Later, farinaceous foods and soups may be carefully given, but no solids should be permitted for a long time. Warm injections of quinin, i to 5000, i to 2500, and i to 1000, have been employed at the Johns Hopkins Hospital with good results, the amceb^e being rapidlv destroyed by them. Perhaps ipecacuanha acts similarly. For the relief of pain opiates must also be administered, preferably by the rectum in suppository or small starch-water enemas; or morphin may be given hypodermically if the stomach be sensitive. Seniin Therapy. — The immunizing protective effect of vaccines against the dysentery bacillus and the protective and curative effect of antidysenteric sera demand allusion. Their availability has received fresh support from recent experimental studies by Simon Flexner and Frederick P. Gay.* D\senter\ vaccines were made of dead cultures as described in Gay's paper. Guinea pigs which received one or more subcutaneous injections of subminimal lethal doses showed a marked protection against multiple * "Vaccination and Serum Therapv against the Bacillus of Dysentery An Experimental Study.'" By Frederick P. Gay, " University of Pennsylvania Medical Bulletin," November, 1902. DYSENTERY. 113 intraperitoneal lethal doses of the living organism. It is interesting to note that while protection afforded by a given vaccine against its own strain of bacillus dysenterise was absolute within limits, it was found that under simi- lar condition such protection may not be secured against other strains, sug- gesting the advisability of combining several strains of bacilli after their cultivation in the preparation of vaccines. Antidysenteric scrum, was obtained from the horse after immunization. It was found to possess agglutinative properties for bacillus dysenteriae. This serum also had protective and curative properties against multiple fatal intraperitoneal doses in guinea pigs. Gay concludes that this protective power may be regarded as proven beyond peradventure. The effect of antidysenteric sera in the cure of dysentery in the human being is as yet limited to the serum treatment of Japanese dysentery, as reported by Shiga. Of 250 cases thus treated the mortality aver- aged 10 per cent, as against 36 per cent, in cases treated by ordinary methods. Chronic Dysentery. Any one of the forms of dysentery described may become chronic, but bacillary dysentery is the more usual form. Morbid Anatomy. — All the lesions described as occurring in the dif- ferent varieties of dysentery may be present. The most common is ulcera- tion, which is variously extensive and exhibits also efforts at healing. On the other hand, cases of chronic dysentery are met with in which there are no ulcers whatever. The coats of the bowel are thickened, especially the sub- mucosa and the muscularis, while patches of black and slate-gray discolora- tion are scattered through it, the result of blood extravasation and dis- integration. Puckering, pseudopolyposis, and cystic degeneration may be present as described under Morbid Anatomy of bacillary dysentery. Treatment. — The patient should be put to bed on a diet easy of assimi- lation and furnishing a minimum of waste. Its quantity should be just what is needed and no more. From what has been said it may be inferred that I have little confidence in methods of treatment the object of which is to get remedies to the diseased bowel by way of the mouth. Bismuth in large doses, iodoform, and even nitrate of silver may, however, be tried for the purpose. One-half to i dram (2 to 4 gm.) of bismuth should be given at a dose, so that from 12 to 15 drams are administered in the course of a day. Iodoform may be given as above directed. The topical treatment of chronic dysentery by way of the rectum is that on which most reliance is placed at the present day. Its object is to get remedies to the diseased part. To this end they are dissolved and their solutions are introduced into the lower bowel. Nitrate of silver is the fav- orite remedy, but alum, sulphate of zinc, sulphate of copper, and acetate of lead are also used in the same doses. Twenty to 30 grains (1.3 to 2 gm.) are dissolved in a pint (1-2 liter) of water, and from 3 to 6 pints (1.5 to 3 liters) are injected at one time through a long tube gently introduced well up into the bowel, but at the onset weaker solutions and smaller quantities are injected. The patient should be p^aced on his back with the hips ele- vated by a pillow, so that there may be the cooperation of gravity. I have had many opportunities to use this treatment in the wards of the Hospital of the University of Pennsylvania, and confess to disappointment in the 114 INFECTIOUS DISEASES. results. My cases improved to a certain point, but none got well. The treatment is sometimes painful. Very decided counterirritation to the abdomen, by iodin and even by blisters, is sometimes of decided advantage. At least these measures seem to mark the turning point in the disease. THE PLAGUE.* Synonyms. — The Bubonic Plague; Oriental Plague; Black Death; Black Plague; Pcstis Hominis. Definition. — The plague is a febrile infectious disease, characterized by a tendency to buboes or carbuncles, in addition to the usual phenomena of the typhoid state. Historical. — It has already been said that the historical plague of Athens, described by Thucj'dides, corresponded rather with the typhus of to-day than with the Oriental plague, which still occurs in Asia, and of which a grave epidemic is now (1903) raging in the East Indies and China, the last previous epidemic having oc- curred in Hong-Kong, China, in May, 1894, from which 2500 died in three months. The plague of the sixth century, Justinian era, the Justinian Plague, is believed to be the bubonic plague of to-daj^ as was also " the black death " of the fourteenth cen- tury, in which perished a fourth of the population, and the plague of London in 1665, which destroyed 70,000. With the improvement of hygienic conditions it has been growing rarer, until the last outbreak occurred, which has practically prevailed since September, 1896, with certain abatements and exacerbations. From that date to January 13, iSgg, in the Bombay Presidency, 214,197 had the disease, and 169.240 died. This epidemic has spread to Japan, Honolulu, and to Portugal. A few cases also occurred in San Francisco, U. S. A., in the first half of 1900. According to J. F. Payne, there are Jive independent endemic centers of the disease: (i) The province of Tripoli; (2) Southwestern Arabia; (3) A large section of Asia, including Mesopo- tamia, Persia, and Kurdistan; (4) The districts of Kumaon and Gurwhol in northwestern India; and (5) Southwestern China. Robert Koch considers there are three endemic main plague foci in Asia — viz., Mesopotamia, Thibet, and Assia, while he places the primary source of the disease in the English territor}^ at Uganda (" Sajous' Annual," vol. v., 1900). In addition to the recent epidemic in China the region of the lower Volga and neighboring Turkey was visited as recentlj^as 1878 and 1879. Etiology. — The epidemic of 1894 gave the opportunity of isolating the specific germ of plague which was discovered by Kitasato and later by Yersin. It is a short rod with rounded ends, and resembles the bacillus of chicken cholera. It is found in the blood, glands, and other viscera, and in no other disease excepting the plague. Obtained in pure cultures, it can produce in inoculated animals the same effects as in human beings. It obtains entrance through the respiratory and digestive tracts, but especially by way of excoriations. It occurs generally in pure culture, but may be associated with pus-forming bacteria, which enter the system with it or after it and are responsible for the suppuration. Filth is a potent predisposing cause, as the description of Dr. Aoyoma, who was a member of Kitasato's expedition and himself fell a victim, vividly portrayed. The rat is a medium of transmis- sion from house to house, while man in his travels is the agent of transmis- sion through long distances. Flies, fleas, ants, and other insects may trans- mit the disease, while almost any of the lower animals are subject to it. Plague is a disease of hot countries and of hot seasons, but it may break out in midwinter. It attacks all ages and classes, but the poor, who live in * For an admirable series of papers on the Plag'ue see "British Med. Jour.," October 27, 1900; also. " Bubonic Plague," by Simon Flexner, M. D., "University of Pennsylvania Medical Bulletin," November, 1902. THE PLAGUE. 115 crowded quarters and amid unfavorable hygenic surroundings, are its favorite victims. The fact that small animals such as monkeys, squirrels, rats, and mice die in great numbers during epidemics and seem, indeed, to be the first victims, suggested that the specific organism is of telluric origin. At any rate, the bacilli have been found in the soil and dust of houses inhab- ited by its victims. In this respect it is similar to anthrax and tetanus. Persons who live in upper stories are less frequently attacked than those who live on the ground floor. The boating population of China, which lives mostlv on the water, is comparatively exempt. Body linen, bed clothing, carpets, rags, and baggage are frequent media of communication. On the other hand, virulent as is the plague, its contagium appears to be more controllable than that of such diseases as smallpox and scarlet fever, as evidenced by the fact that with ordinary cleanly precautions few phvsi- cians, nurses, or others attendant on the sick acquire the disease, and even those employed to guard and disinfect infected houses commonly escape. In the epidemic in Canton, during which upward of 30,000 Chinese died, not one of 300 American and English residents was affected. Morbid Anatomy, — There is no morbid anatomy to the plague beyond the buboes and internal suppurating processes, which seem to be essential symptoms, the cutaneous and other hemorrhages, and the various tissue alterations that attend high fevers generally. The liver and kidneys are congested and the spleen is enlarged to two or three times its normal size. Varieties of the Disease. — Three principal forms are easily separated : (i) Pcstis mijior, abortive or larval form, which commonly appears before the outbreak of an epidemic. It is also the form which is endemic. It is characterized by moderate swelling of the lymphatics, little fever or other constitutional disturbance, and usually terminates favorably at the end of about two weeks. (2) The bubonic form is the more common severe epi- demic form — the malignant adenitis of James Cantlie. Until recently all plague was called " bubonic," but it is now known that only about 70 per cent, of cases are accompanied by glandular enlargement. (3) The septic ccmic form, also known as toxic, fulminant, or siderans, a severe form, in which death may occur in twenty-four hours with associated hemorrhages, but in which glandular enlargement is slight : the time between the onset and the fatal termination being too short to allow its development. Prostration is extreme. (4) The pneumonic form, in which no buboes appear on the surface, but the force of the disease is spent on the lungs, the spu- ttim swarming with bacilli. The processes in the latter organs are septi- cemic. Symptoms. — Of the bubonic or ordinary form. — A period of incubation of from two to seven days usually precedes the appearance of the intense weakness which is one of the earliest characteristic symptoms of the plague. A second period or period of prodrome may follow the incubation, though it is not common. It is short, from a few hours to a couple of days, and includes headache, prostration, marked nausea, vomiting, vertigo, and rarely lumbar pain. A chill is not usual, but there may be chilliness, after which the usual fever of the infectious diseases sets in with great severit}^ and with its accompaniments, among which severe headache, backache, delirium, and the typhoid state are conspicuous. The temperature rises rapidly to 102'' and 104° F. (39° and 40° C.) and even higher. The pulse ranges from 90 to 120, of fair volume, often dicrotic. Before the fever sets in great weak- Ii6 INFECTIOUS DISEASES. ness is manifest. The patient reels like a drunkard, with weakness and vertigo. He breathes hurriedly and is anxious, restless, and depressed. The features are drawn and haggard. Petechia:, vibices,—i\-it plague-spots of the Bible, — albuminuria, hematuria, and even hematemcsis may be included. Slight enlargement of the spleen is present. Pre-eminently characteristic is the bubo or suppurating gland. It appears on the second or third day, if the patient live to it. It occurs in order of frequency in the glands of the groin, the armpit, the neck, or in the pop- liteal region. It commonly reaches the size of a walnut or egg, when it rup- tures, if not opened with the lance. It may, however, subside without dis- charging. Suppuration is a desirable termination. It is painful and tender, as buboes commonly are. Coincident with the appearance of the bubo the fever subsides, a profuse szveat breaks out, and the pulse falls to 90 or 100. In addition to the bubo, carbuncles may also be present in the lower extremi- ties, the buttocks, or in the neck. In some epidemics hemorrhages are common, and even the buboes may contain blood. In the pneumonic form there are the usual symptoms of pneumonia,, chill, high fever, severe pain in the side, dyspnea, cough, rusty sputum, and physical signs of consolidation,* and marked prostration. In the septicemic form the patient is stricken by a virulent poison and the prostration is extreme. The glands are enlarged, but there are no buboes. The enlargement is slight and may only be detected at necropsy, but it is gen- eral. Hemorrhages from the nose, bowel, and kidney are most frequent in this form. Apyrexia is not uncommon, fever reaction being impossible because of the extreme depressing influence of the disease. The delirium is of the typhoid type. Diagnosis. — In its fever, its intense prostration, its petechise and vibices of the early stages the plague resembles typhus. No other fever is charac- terized by such intense prostration. The bubo and the carbuncle seem to be the distinctive signs, although they are said to be sometimes absent in the milder cases of a declining epidemic, as well as in the intense pestis siderans. The diazo reaction of the urine is usually absent. Prognosis. — The plague is said to be the most fatal of all diseases, 70 to 90 per cent, perishing, districts and towns being half depopulated, while whole families have been annihilated. Death occurs from the second to the fourth day, and if recovery take place it is delayed by the slowly healing buboes and carbuncles. These may, however, heal rapidly. Treatment. — Free stimulation, nutritious food, as in the most adynamic forms of typhus and typhoid fevers together with cool baths to combat the fever, are the measures indicated. Antiseptic treatment of the buboes and abscesses should be practiced, and may shorten the duration of these plagues of the skin as compared with the older treatment. Morphin should be given to produce sleep and relieve pain. Kitasato's general directions, scv often quoted, can hardly be improved. They are as follows : " The disease prevails under faulty hygienic conditions ; it is, therefore, urged that general hygienic conditions be carried out. Proper receptacles for sewerage should be provided, a pure water supply afforded, and streams cleansed ; all persons sick of the disease isolated ; the furniture of the sick- room washed with a two per cent, carbolic solution in milk of lime ; old clothes ajid bedding are to be steamed at 100° C. (212° F.) for at least one * For reports, see " Sajous' Annual," vol. v., igoo, article "Plague." THE PLAGUE. 117 hour, or exposed for a few hours to sunUght. If feasible, all infected articles should be burned. The evacuations of the sick are to be mixed with milk of lime, and those who die of the disease are to be buried at a depth of three meters (about 12 feet) or, preferably, cremated. After recovery the patient is to be kept in isolation at least one month. All contact with the sick is to be avoided, and great care exercised with reference to food and drink." Instead of carbolic acid and milk of lime for the disinfection of buildings, Haffkine suggests sulphuric acid in the proportion of i to 200 of water. Serum Therapy. — Preventive inoculation was introduced by Yersin, Calmet-te, and Borrell conjointly in 1895. Dead cultures of plague bacilli were injected subcutaneously into rabbits and guinea pigs and found to convey a certain degree of immunity against plague. Haffkine extended this method of preventive inoculation to man. The dead bacilli, suspended in bouillon, are injected subcutaneously. These injections were first made upon lower animals, notably m.onkeys, with the result of protecting them against subsequent inoculation with virulent plague bacilli ; then upon human beings in India and China. The results of these inoculations are more definitely stated in the fol- lowing conclusions reached by the Indian Commission: " (i) Inoculation sensibly diminishes the incidence of plague attacks on the inoculated popu- lation, but the protection which it affords against attacks is not absolute; (2) Inoculation diminishes the death-rate among the inoculated population. This is due not only to the fact that the rate of attack is diminished, but also to the fact that the fatality of the attacks is diminished ; ( 3) Inoculation does not appear to confer any great degree of protection within the first few days after it has been performed; (4) Inoculation confers a protection which certainly lasts for some considerable number of weeks. It is pos- sible that the protection lasts for a number of months. The maximum duration of protection can only be determined by further observation; (5) The varying strengths of the vaccine employed have apparently had a great effect upon the results which have been obtained from inoculation. There seems to be a definite quantum of vaccinating material which gives the maxi- mum amount of protection; and provided that this quantum can be injected in one dose, and provided also that the protection turns out to be a lasting one, reinoculation might with advantage be dispensed with." * As contrasted with preventive treatment Yersin's antipest serum t and Lustig's serum are intended for curative purposes, after the manner of diph- theritic antitoxin. The former is prepared by injecting the horse, first, with dead and then with living plague cultures. The serum, to insure sterility, is heated to 60° C. (140° F.) before being sent out. Lustig's serum is pre- pared from the horse after injection with a substance derived from bacilli by treatment with alkali and precipitation by hydrochloric acid. Small animals have been rescued from infection by plagtte germs by Yersin's serum, but in human beings the results have been less conclusive, Arnold % claiming that it reduced the mortality of cases 70 to 90 per cent., w^hile Cremow § denies any therapeutic value. Calmette and Salimbini claim to have shown from their observations and experiments during the plague epidemic in Oporto, Portugal, that much larger doses of the antipest serum * See Dr. Simon Flexner's paper on " Bubonic Plague, its Nature, Mode of Spread, and Clinical Manifestations," "' University of Pennsylvania Med. Bulletin," November, igo2. + " Sajous' Annual," vol. v. p. 491. t"Med. News," January i, i8q8. § " London Lancet," May 6, 1899, Ii8 INFECTIOUS DISEASES. may be used, and are sometimes demanded, than have heretofore been deemed sufficient. Their report also shows that, while the use of the Haft- kine prophylactic may be attended with danger among those who have been exposed to the infection of the disease prior to inoculation, the use of a pre- liminary immunizing dose of antipest serum, followed by an injection of a dose of Haft'kine's proph3dactic, removed the element of danger and con- ferred an immunit}- of probably longer duration than would be produced by the exhibition of the serum alone. Notwithstanding the seeming inconclusiveness of these observations, the Indian Commission reports that " though the method of serum therapy as applied to plague has not been crowned with a therapeutic success in any way comparable to that obtained in the treatment of diphtheria, nevertheless, the method of serum therapy is in plague, as in other infectious diseases, the only one which holds forth the prospect of success." ^^^alter Wyman, Supervising Surgeon-General United States ^Marine Hospital service, has directed that between i6o and 200 c. c. of antipest serum should be given during the first forty-eight hours of the disease. In severe cases, 20 to 40 c. c. of this amount should be injected into a vein. In immunizing with the serum, use 5 to c. c. every fifteen days. In case the Haffkine prophylactic cannot be administered on account of exposure to the disease, the mixed plan of immunization may be used. This consists of giving 5 to 10 c. c. of antipest serum, and, three days later, i c. c. of the Hafifkine prophylactic."^ MEASLES. Syxoxvms. — Rubeola; MorbilU. Definition, — ^Measles is an acute, highly contagious disease, character- ized especially by a mottled eruption and nasobronchial catarrh. Historical. — Measles and smallpox are first recognized in the writings of Ahrun, a Christian priest and physician of Alexandria, A. D. 610-641. It was, however, first ac- curately described bj- Rhazes, A. D. 900, and Avicenna, A. D. 9S0-1037. Rhazes is ac- credited with distinguishing it from smallpox. It continued, however, to be confused with the latter disease as late as the middle of the seventeenth century. The two were clearh' separated by AVithering as late as 1792. The distinction of having separated the disease from scarlet fever was awarded to Thomas Sydenham about 1665, but this separation is also said to have been made one hundred years earlier — that is, in 1563 — by Forestus, of Holland. Rhazes and Avicenna described it under the name hhasbah. The term rubeola or its equivalent in Arabic is said to have been first used by the Arabian, Haly Abbas, in the latter part of the tenth century, but was replaced bj- the Italian word viorbilli, meaning little disease, up to the middle of the eighteenth centurj^ when Sauvages reapplied the name rubeola, which was adopted by Cul- len and Willan. AYithin the last few years some English writers have reapplied the name morbilli. The disease has prevailed in Asia and Europe for centuries, and was imported into the United States with the first settlers. Etiology. — ^Measles is in all probability due to a micro-organism, which, however, has not as yet been isolated, although micrococci have been found in the blood and tracheal mucus by Babes and by Klebs. ]\Iore recentlv, 1892, P. Canon and W. Pielicke f found with considerable con- stancy a bacillus in the blood, the expectoration, and nasal and conjunctival mucus of cases of measles. Whatever it is, it is very unerring, since the dis- * "Philadelphia Medical Journal," February lo, icoo. t " Berliner klin. Wochenschrift," vol. xxix. 377. MEASLES, 119 ease is more unfailingly communicated to those unprotected by previous attacks than is scarlet fever. Nor is the contagium-bearer definitely known, but it is likely to be the nasal and bronchial discharges, and probably also the tears. The contagium has been transmitted by the inoculation of mor- billous blood and nasal mucus, and it is most active when the breath is its medium. It is communicable by a third party and by fomites ; though more active and unfailing than the contagium of scarlet fever, it is less so than that of smallpox. It is not, however, so tenacious as the causes of these. Measles is a disease of childhood, but adults often get it, and that very severety. Repeated attacks are possible, but as other eruptive affections resemble it and diagnosis is often careless, some of the repeated attacks may be thus explained. It is milder and rarer in sucklings under six months, while the age during which the disease is more commonly contracted is from one to five years. Morbid Anatomy. — There is no essential morbid anatomy of measles beyond the nasal and bronchial catarrh, and the signs of these generally dis- appear with death. When death occurs it is usually the result of complica- tions, and the morbid anatomy of such is present. The most frequent com- DA/ OF DISEASE HOUR 85858568U6i:8.2 63[28 8L!38iaS8l2 6Sl!6S6 1!886 12 63asl2 8aSl2 6SI2 35U861i66[26 + PC i » • fll / I ^ lUd JJ.5 \ / . ,„ 4 l^ - -i *i3 tU T 12 vt -iju 1 ** ^1 jti onn _ --t kf._r__±i J I = s i 1 '! f J •• f - 4- f ^"w 38-0 " ir, ^ " : : "" : "" " " i^ 1^ - • i J - J. f 8 -^ S7.5 - : _ — — I "" . ■ « t t •J'.O _ ' a^k /"':.*". -J- - 1 / ^ f p -u * d \t 1 I- '' ' I ^rr . t ir » T " 36.5 -Tj ^ t 't: I t Jt, : " " .. r t n ^ / t I " " -rn V 1 ' 1 ' T r oG.O . " _ ^ __ __ ---i- X 60.0 1 I 1 1 1 1 * Fig. 13. — Temperature Chart oi Measles— (E/c/^/iors/). plication is bronchopneumonia. There may be lobar pneumonia, and among the morbid phenomena are to be included sometimes those of collapse of the lung. In those rare instances of hemorrhagic or " black " measles there is the usual discoloration of hemorrhagic extravasation. Rarely also the morbid states of intestinal catarrh are found. Symptonis. — The period of incubation of measles varies, but is com- monly between seven and fourteen days. Rarely it is a day or two longer. A prodrome, if present, in measles is of short duration. It may be manifested by sneezing, fretfulness, chilliness, and feverishness ; or, if the child is old enough to express itself, by headache. Then comes, on the first day, the initial or prodromal fever, a peculiarity of which is a remission on the second day. This is shown by the appended cut from Eichhorst. But very early. I20 INFECTIOUS DISEASES. and even almost suddenly, coryza, with red and watery eyes, and photophobia present themselves, closely followed by troublesome cough and correspond- ing feverishness reaching 103° and 104" F. (39.4° and 40° C). Much less frequently than in scarlet fever is there vomiting, but the tongue is apt to be furred : the cough is sometimes croupy. Convulsions very rarely usher m the disease. On the fourth day from the onset the eruption makes its appearance. It appears first in the face in the form of papules and blotches, which coalesce more or less imperfectly, leaving sometimes islands of white skin between them. Under any circumstances the boundary between the eruption and the sound skin is uneven and crescentic. The eruption is somewhat raised above the surface, and the W'hole effect is to make the face appear swollen. This elevation of surface at times becomes distinctly papular and even shot- like, resembling closely the papular stage of smallpox. In fact, this appear- ance has quite often led to a diagnosis of smallpox, which twelve hours later had to be withdrawn. From the face the eruption spreads to the neck, thorax, abdomen, and extremities. It is bright red, as a rule disappearing on pressure. Sometimes, however, even in mild cases, there are petechise, and in malignant cases the extravasations are extensive. At the same time, the mouth and fauces are bright red in color, and not infrequently there is diarrhea, as though the eruption extended throughout the entire mucous tract as well as over the skin. At the maximum of the eruption there may be slight swelling of the cervical lymphatic glands. At the end of two or three days after its appearance the rash fades gradually, first from the situa- tions in w^hich it appeared earliest, and a fine, branny desquamation occurs, easily overlooked. The fading takes place in the order of invasion. The typical rash may be accompanied by sudamina. In 1896 Henry Koplik * called attention to a sign that seems likely to be of real value in the diagnosis of measles. It is the appearance, on the first day of invasion, on the buccal and labial mucous membrane, of a scat- tered eruption consisting of small irregular spots, bright red in color, in the center of which is a minute bluisJi-zi'liite speck. They have been found 45 times in 52 cases and 31 times in 32 cases. The spots somewhat resemble those of thrush, from which they are distinguished by their roundish shape and their color, as contrasted with the more yellozcisli center of those of thrush. ^M'lile thoroughly discrete in the beginning, later in the disease the spots may coalesce, and the characters of a discrete eruption or spotting disappear, producing^ an intense general redness, " which is simply dusted over with myriads of these bluish-white specks." They can- not be wiped off, but the whitish portion can be removed by forceps without causing pain or bleeding. Tliey consist of thick layers of epithelium in a state of partial fatty degeneration. They require a good light for their demonstration. (See plate opposite.) The other symptoms described continue until the eruption begins to fade — that is, on the fifth or sixth day. when they abate. The cougJi, except at times, often hangs on quite stubbornly, especially in scrofulous children, and sometimes even persists as the catarrhal symptom of a tuberculosis, the development of w^hich seems peculiarly favored by the disease. Hence, the cough of measles should never be slighted, and early exposure to cold and dampness should be guarded against. * " Archives of Paediatrics,'' December, 1896, and " Medical Record," April g, 1898. Fig. 2. OffllK Y" Fig. 3. Fig. 4. /esicles are even found with turbid contents, producing scarlatina miliayis. The eruption is sometimes entirely absent from the face ; hence no conclusion should be based upon inspection only. The thorax and inner surface of the thighs are more favorable sites. The eruption, when severe, is constantly accompanied by an itching or burning more or less intense, and there is a feeling of slight roughness at times. The tongue is red at the edges and tip, furred at the center, but through the fur the papillae stand out in distinct points, producing an appearance that is regarded as more or less characteristic. This has been called by some the strazvbcrry tongue. So I did in my first edition, but further examma- tion into the subject leads me to adopt the view that the strawberry tongue is the red and raw-looking tongue with enlarged papillae, as originally held by the late Dr. Flint,* who wrote as follows : " In the progress of the dis- ease the coating exfoliates, leaving the surface of the tongue reddened ; and the papillae being enlarged, the appearance is strikingly like that of a ripe strawberry." The term raspberry tongue is also applied to this condition. The rest of the mouth, including the roof and the palate and tonsils, is bright red, as though the eruption extended to it, as it doubtless does. With the abatement of the eruption comes desquamation, and it is gen- erally proportionate to the intensity and extent of the former. It sets in about the tenth day, and continues in bad cases for two or three weeks and even longer. When the eruption is slight, the little scales are scarcely noticeable, and the closest examination is necessary to discover them, while, where there is a vivid and extensive eruption, the amount of desquamation is enormous. Glove-like casts of the fingers, including the nails, are some- times exfoliated, and the bed contains each day numerous flakes of epiderm that have come off, while many days are required for complete separation of the dead skin. Great care should be taken in gathering it up, for in the desquamation resides the contagium. On the other hand, when slight it should be carefully sought for, as it has great diagnostic value. At the same time it should not be regarded as something peculiar and confined to scarlet fever, for every dermatitis is followed by desquamation, as especially exemplified in the exfoliation that follows an attack of erysipelas on the face or irritation by iodin or mustard. The urine from scarlet fever proper is like that of fever cases generally — scanty, high-colored, and precipitating uric acid and urates on cooling. The chlorids are diminished during active fever. The duration of simple uncomplicated scarlet fever ranges from three to fourteen days, according to the degree of severity. Its decline is, how- ever, gradual as compared with the suddenness of onset. Such is a general picture of scarlet fever in its simple, uncomplicated form, so characteristic that early in its history it received the name scarla- tina simplex; owing to further combinations of symptoms, there have been * For an interesting paper containing the views of various authors on this subject see he Strawberry Tongue in Scarlet Fever," by M. H. Fussell, M. D., " University Med. Magazine, Phila- delphia, May, 1897. SCARLET FEVER. 127 128 INFECTIOUS DISEASES. added three other varieties; the anginose form, or scarlatina anginosa; the malignant form, or scarlatina maligna, and the hemorrhagic form. In the angi)iosc variety the throat symptoms are conspicuous and severe. In no well-developed case is there an absence of throat redness. On the other hand, there may be intense soreness with swelling of the fauces and tonsils, giving rise to extreme dysphagia. The neck may be so swollen as to fill up the depression beneath the jaw. There may be a false membrane involving the fauces, the posterior pharynx, the nasal cavities, the trachea, and the bronchi. The throat may present all the features of a severe diphtheria. Abscess and destructive ulceration ma}' result, which may proceed even to perforation of the carotid artery, and rapid death ensue therefrom. The inflammation almost certainly ascends the Eustachian tubes, producing severe ear symptoms. The false membrane is usually the result of the intensity of the inflammatory process, due to the specific cause of the disease and not to that of diphtheria, but there may be true diphtheritic membrane containing the Loefller bacillus. Especially is this true of the cases in hos- pitals for infectious diseases. The streptococcus pyogenes is perhaps the most frequent cause of the throat inflammation. It has been found also in the skin, the blood, and the glandular organs in fatal cases. Scarlet fever has, indeed, been called a streptococcus infection. Follicular tonsillitis may also be one of the forms of sore throat. In the malignant variety there is an overwhelming intensity of the cause which may result in almost immediate prostration and death of the patient, giving no time for the development of the usual symptoms, or these may be so feebly manifested that they present no distinctness. When the disease is not immediately fatal, there is intense adynamia, the heart and pulse sharing it. The breath is rapid ; the capillary circulation is feeble ; the skin dusky ; the eruption is imperfectly developed ; the temperature is very high, reaching 105" to 108° F. (40.5° to 42.2° C.) ; there is delirium, which may pass over into coma, and convulsions may occur. The pulse ranges from 120 to 150. In the honorrhagic form there are more or less extensive hemorrhagic extravasation, epistaxis, and hematuria. It attacks, for the most part, the feeble and badly nourished, and, like the previous variety, is almost invari- ably fatal. Epidemics of scarlet fever vary greatly in severity. In some all the cases appear to be mild, in others all are of extreme severity. Families of children may be exterminated. Again, a mild case may give rise to one of the most intense forms. ^ Complications. — Acute nephritis is the most frequent complication of scarlet fever. It makes its appearance usually after desquamation is more or less complete — in the second, third, or fourth week. A slight album.i- nuria. which is common at the height of the fever, is not to be confounded with that of nephritis, and probably does not predispose to it, although the cells lining the tubules are at this stage in a state of cloudy swelling. The rationale of its production is not precisely understood. It used to be ascribed to cold or a draft of air upon the skin, w^hich is young and tender after the desquamation. But vdien it is remembered that the mildest cases are as susceptible as the most severe, and probably more so, and that chil- dren have been found barefoot in the street with the eruption upon them, and yet have escaped Bright's disease, it must be admitted that we do not know all about it. The fact that the complication is usually more severe the earlier it appears, would go to show that the specific toxin or bacillus has SCARLET FEVER. 129 something to do with it. It is true, too, that with the skin functionally dead the complemental work thrown upon the kidney increases its susceptibility to the ordinary causes of nephritis, of which cold is one. It is to be remem- bered also that other diseases in which the skin is seriously affected predis- pose to nephritis. This is pre-eminently true of burns and scalds. However it may be brought about, the result is generally a typical example of parenchymatous or tubal nephritis, although instances of acute interstitial inflammation are also found. Every grade of severity is met, but early recognition increases our power to control this severity. The majority of cases thus recognized get well, and I have, known recovery to take place after suppression of urine has lasted for a week. The clinical picture is that of acute nephritis otherwise caused, and its consideration may be deferred until that disease is studied. This complication was for- merly often overlooked, but in modern times cases are more closely watched for it. The possibility of Bright's disease without albuminuria must be borne in mind. Adenitis producing a moderate degree of glandular enlargement occurs in almost all cases of scarlet fever, but in severe cases it becomes a painful and grave complication. A majority of cases subside, but some go on to extensive and destructive suppuration, of which I have known ulceration through the carotid artery a consequence. Arthritis ensues in a certain number of cases, and closely resembles that of acute rheumatism. The term rheumatism is justified as much as the term gonorrheal rheumatism, and no more. Each is the result of the specific cause of the disease, and not of the cause of rheumatism. It occurs usually at defervescence, and recovery is almost invariable. Suppuration in the joint has, however, occurred. Otitis is one of the most serious and permanently harmful of the com- plications. It is commonly considered the result of an extension of inflam- mation from the throat through the Eustachian tube to the middle ear, and is associated with the streptococcus. I have known it to occur after recover}^ was supposed to have taken place, immediately after a child had been sitting on a cold step. On the other hand, it sometimes happens quite early in the disease. Suppuration and perforation of the membrane of the tympanum are common, and more rare is destructive suppuration of the mastoid cells. As a consequence of one or both of these, it almost always leaves impaired hearing or total deafness. The facial nerve may become involved in the disease of the labyrinth, producing facial palsy, while thrombosis of the lateral sinuses may be another result of the same condition. Meningitis and death may be later consequences. Meningitis may arise independently of otitis ; in fact, scarlet fever is the most frequent cause of meningitis, after cerebrospinal fever, tubercu- losis, and syphilis. Various other nervous affections develop as rare complications. Among these may be mentioned chorea, convulsions, hemiplegia ; and Osier mentions two cases of progressive paralysis of the limbs due to ascending spinal paralysis or multiple neuritis and subacute ascending paralysis as coming under his observation. ' Of thoracic complications endocarditis and pericarditis not infrequently develop during convalescence from scarlet fever. Endocarditis is nor always discovered, and a few unexplained chronic valvular defects may have originated in this way and thus be accounted for. Pericarditis is less likely I30 INFECTIOUS DISEASES. to be overlooked. Malignant endocarditis is not so frequent as might be expected from the virulence and widespread character of the responsible germ. Pleurisy may also occur, and more rarely pneumonia. Diagnosis. — The diagnosis of scarlet fever is easy if the symptoms are well developed, for it is the mild cases that escape detection. In the absence of the eruption in a distinctive form, it is sometimes impossible to aver the presence of the disease. If there be a doubt as to the eruption, close watch- ing will sometimes discover signs of desquamation in the shape of branny scales beneath the underclothing or in the stockings. In the absence of this the question must occasionally remain forever unsettled. At others the unfortunate development of a nephritis sets the matter at rest. If there has been exposure to the contagion, it is best to regard every case of sore throat as a possible case of scarlet fever, and treat it accord- ingly. While the throat affection of diphtheria closely resembles at times that of scarlet fever, where this symptom is at all conspicuous in scarlet fever the eruption is not generally wanting, or is, at least, present to such extent as to permit recognition of the disease. The fact that the one or the other of the two diseases is prevailing may settle the ques- tion. It must be admitted, too, that the two aft'ections may succeed each other, and even, perhaps, coexist, both events being, however, exceed- ingly rare. The diagnosis of diphtheria is rendered certain by obtaining a successful culture of the Klebs-Loefifler bacillus. The facilities furnished at the present day by the municipal laboratories to this end make it easy to obtain this test. The coryza and cough in measles characterize the stage of invasion, while the eruption occurs later than in scarlet fever. When it does come it is very different, being at first, at least, in patches bounded by irregular and crescentic outlines, more uneven and elevated, and is conspicuous in the face, where the scarlet fever eruption is faintest. The absence of sore throat is distinctive of measles, though its occasional presence in mild degree must be admitted in the latter disease. Rofheln, or rubella, has an eruption more like that of scarlet fever than is the typical measles eruption, but it is not usually followed by desquama- tion. There are no uncomfortable throat symptoms, and the constitutional disturbance is much less. It is also of much shorter duration. It is pos- sible, too, that these affections may succeed each other, as is true of real measles and scarlatina. Acute exfoliating dermatftis resembles scarlet fever during the eruption, but the exfoliation in the former is not like that of scarlet fever. As in erysipelas, it has more the appearance of scales and crusts before it is thrown off, and there is more apt to be a moist surface left behind, followed by a second exfoliation. There are no throat symptoms, and the tongue char- acteristic of scarlet fever is wanting. The eruption caused by belladonna, both on the skin and throat, resembles that of scarlet fever, but it is of short duration and without constitutional symptoms. Prognosis. — The prognosis of scarlet fever varies greatly in different epidemics. There are epidemics of great severity, in Avhich the mortality is large, and certain fulminating cases are beyond treatment. Yet most physi- cians of large experience in surveying their work will recall that the per- centage of deaths in their scarlet fever cases has not been large, and that it has been greatest among the very young. The percentage of deaths is put down at from 5 to 10 per cent, in mild epidemics, and 20 to 30 per cent, in SCARLET FEVER. 131 severe ones. The mortality is greater in hospitals than in private practice. In the fulminating cases death takes place before a chance for treatment is offered ; but in the next grade of cases, characterized by high temperature and severe throat symptoms, a survival of five or six days generally means recovery, unless the supervening complications carry off' the patient. Among these, nephritis and glandular swelling passing over to abscess are conspicuous, but even of those so afflicted a majority recover. Treatment. — After isolation and protection in bed against changes of temperature, the treatment of scarlet fever is, in the main, a symptomatic one, associated with a vigilant nursing that will guard against complications. The patient should be isolated, if possible at the top of the house, and all communication with those of the family who have not had the disease inter- dicted. The temperature of the room should be uniform, while effective ventilation should be secured. The diet should be liquid as long as the fever persists, and the best of all liquids is milk, though light broths are allowable and an abundance of water. If the fever is high, say above 103° F. (39.4° C), cool sponging may be resorted to, but it is to be remembered that high temperature in this disease is usually of short duration and not likely, therefore, to produce the mischief it may cause in long-continued febrile diseases like typhoid fever. Very high temperature, such as 105° F. (40.5'' C), with meningeal symptoms, may require the tub-bath or cold pack, but the temperature of the tub-bath should not be so low as that used in typhoid fever. It is safer to put a patient in a bath at 90° F. (32.2° C.) and gradually reduce the temperature. The warm bath allays the itching of the skin, but this is as well accomplished by inunc- tion with cold cream or sweet oil, and this unguent is important for another purpose as soon as desquamation takes place, to keep the scales from flying about and spreading the contagium. An ice-cap may be applied to the head if the temperature be high, and especially, if there are head symptomis. While cool applications are allowable during fever, they are positively con- tra-indicated in its absence, as they may act in the development of complica- tions of nephritis and otitis. Fever is best controlled by these measures, but it is desirable to give medicines which tend to the samic purpose, especially if they dispose to diure- sis as well. Hence, the officinal solution of citrate of potassium or of the acetate of ammonium combined with the spirit of nitric ether, or a couple of drops of aconite with a little flavoring syrup, is useful. Constipation should be guarded against. The throat symptoms require to be treated according to the degree of their severity. Iron and potassium chlorate may be added to the above mixture. If more active local measures are needed, the throat may be sprayed frequently with peroxid of hydrogen (i to 3) or with a weak bichlorid of mercury solution (i to 5000) or carbolic acid spray (i to 60). The first is the best. Cold water applications, and even ice to the exterior of the throat, are very comforting to the patient. Very efficient and soothing is a bandage for the throat with pockets opposite to the tonsils, into which pieces of ice are placed and the whole covered with a dry towel ; or little india- rubber ice-bags may be similarly usedt In adynamic cases stimulants and restorative treatment in general are indicated. Due regard should be had to the tendency of the disease in severe forms to produce degeneration of muscle and the liability of the heart to share in this. The proper treatment of the throat tends to save the ear, but should the 132 INFECTIOUS DISEASES. middle ear become involved, the membrane should be watched daily, and if the tension be extreme, perforation practiced, even more than once, if needed. Too little attention has been paid to this complication, and if cir- cumstances permit, an aural surgeon should be called in. The prophylaxis against nephritis should be most careful. Whatever may be the immediate cause of the renal involvement, it is certain that cold often becomes its exciting cause. Hence, the patient should be scrupulously guarded against drafts, and, tedious as it may sometimes seem to mother and child, " six weeks in the room " is a precaution which will avert many a case of nephritis. In addition to the milk diet, which is an efficient prophy- lactic against nephritis, I am in the habit of giving a moderate dose of digi- talis, say three to five minims (0.333 to 0.666 gm.), tw^o or three times a day, to aid in maintaining a free movement of the blood through the kidney. The treatment of complicating nephritis is the treatment of that afiPec- tion under other circumstances, and the reader is referred to the appropriate section on it. Serum Treatment. — An important addition to the treatment of scarlet fever has been made by Paul Moser * who suggested the use of antistrep- tococcic serum, not with a view to combating the disease itself, but the complications which are the result, not of the scarlatinous, but of the strep- tococcic infection. G. A. Charlton,t of Montreal, and W. R. Hubbert, of Detroit, have reported Moser's treatment with gratifying results. Dr. Charl- ton says that he employed it in 15 cases, the majority of which would, in his judgment, under ordinary treatment, have termdnated fatally, or, at leasts have suffered from lingering and troublesome complications. There were thirteen prompt recoveries and two deaths, one case having been in a dying condition and the other complicated by pneumonia wdien they came under treatment. The frequency of mixed infection is shown by Moser's state- ment that in 99 cases of scarlet fever streptococci were obtained from blood 63 times. The injections should be made early in the disease. The usual dose is 20 c. c, but in those cases in which the severity of the attack would seem to indicate a larger quantity, the dose may be repeated. After the injection of the serum a rapid subsidence of the pyrexia supervenes, also a corresponding decrease in the pulse rate, with improvement in its tension and rhythm. This seemingly harmless treatment demands a prompt trial for the relief of the dangers of this serious disease. " DIPHTHERIA. Synonyms. — Membranous Croup; Angina nmligna; Angina membranacea; Cynanche contagiosa; Diphtheria faucium. Definition. — Diphtheria is an acute, contagious, inflammatory disease, caused by inoculation with the Klebs-Loeffler bacillus, and especially char- acterized by the formation of false membrane and by secondary constitu- tional infection. It may attack any mucous membrane, and even the skin, but, as usually employed, the term means diphtheritic inflammation of the oral, faucial, nasal, laryngeal, tracheal, or bronchial mucous membrane. The term diphtheroid is applied to such membranous inflammations as are not due to the Klebs-Loeffler bacillus. * "Ueber die Behandlting des Schaiiachs mit einen Scharlachsstreptococcenserum," "Wiener klinische Wochenschrift," October g, igo2. t "Montreal Medical Journal," October, igoa. DIPHTHERIA. 133 Historical. — Diphtheria has prevailed endemically and epidemically since the days of Hippocrates (406 B. C). D'Hauvanture, an East Indian physician living at the time of Pythagoras (probably 500 B. C), described a disease bearing strong re- semblance to diphtheria. The first tracheotomy is said to have been performed by Asclepiades, who lived probably more than a century before Christ. Diphtheria was recognized hj Aret<£us of Cappadocia (100 A. D.), who has left the oldest clear and concise description of this disease, which he called " Syriac ulcer." Galen also de- scribed the disease in the latter part of the second century. Paralysis of the soft palate was recognized as one of the consequences of diphtheria in the fourth century by Coelius Aurelianus, and in the fifth or sixth century by ^tius. During the Middle Ages no accurate descriptions were given, although important epidemics are recorded that no doubt were diphtheria. Ballonius, of Paris, in 1659, gives the earliest re- corded/eference to the pseudo-membrane of diphtheria. The disease appeared in this country, in New England, in the seventeenth century. The earliest American literature on the subject appears to be a reference to a number of children that "died from bladders in the windpipe," found in the work of Sibley, of New England, in 1659. An admirable account by Samuel Bond was published in the " Transactions of the American Philosophical Society," at Philadelphia, in 1770. The disease was epidemic for the first time in New York city in 1771. Samuel Bard, in a paper written at that time, described it under the name of "Angina suffocativa," known in common parlance as " sore throat distemper." We owe the name by which the disease is now generally known to Bretonneau, who applied it in a paper read before the French Academy of Medicine in 1821, wherein he declared, also, that " Angina suffocativa," " Cynanche maligna," "putrid" and other forms of sore throat were one and the same thing.* The first distinction between catarrhal, croupous, and necrobiotic types of laryn- geal diphtheria was made by Virchow in 1847. Etiology. — The specific organism which by common consent at the present day is the cause of diphtheria is the so-caUed Klebs-Loeffler bacillus, •a bacillus, non-motile, slightly bent, with rounded ends, 2.5 to 3 microns f in length, and from 0.5 to 0.8 micron in thickness. It stains readily by Loeffler's methylene alkaline blue in cover-glass preparations and in sections. Its cultures in blood-serum are small, round, grayish-white colonies that are characteristic. These, with the clubbed ends of the bacillus and clear spaces in its interior, giving it an appearance as if broken, suffice for its recognition. It grows on all the usual culture- media, but ceases to grow at a temperature below 20° C. (68° F.). If inoculation cultures are practiced on the lower animals, the nature of the virus is declared by the exudation, the bacilli, the swelling of adjacent h'mphatic glands, and the invariably fatal results of such inoculation. The bacillus produces in its growth a potent toxic substance, or tox- albumin, the absorption of which from the seat of local infection causes the general symptoms of the disease, which are therefore due to this toxin and not to an invasion of the blood by the organism producing it. The toxin is an albuminous substance, but its composition is unknown. When injected into animals, it produces paralysis, nephritis, and albuminuria. Roux and Yersin were the first to show, in 1888, the pathogenic property of cultures that had been filtered through porcelain. The successful implantation of the bacillus of diphtheria is, however, dependent on various circumstances. Certain temporary states of the indi- vidual doubtless favor it, while others retard it. While general weakness or feeble resisting power may be one of these conditions it is likely also that purely local states, such as uncleanness of the mouth, teeth, and fauces, as well as chronic inflammatory conditions, may act as predisposing causes. Enlarged tonsils and nasopharyngeal catarrh predispose. It has been shown that there are different degrees of virulence in the contagious organism itself. The bacillus of diphtheria is associated with other pathogenic bacteria, * The history of diphtheria is one of the most interesting- chapters in medicine, and isrnore fully ■considered in the classic paper of Abraham Jacobi in the "System of Medicme by American Authors," Philadelphia, 1885. t A micron is a xijVi) millimeter, or TiSiiss inch. 134 INFECTIOUS DISEASES. such as streptococcus pyogenes and stapJiyloeocciis albiis and aureus, micro- coccus lanceolatus, and bacillus coli communis, which are probably responsi- ble for suppurative processes often associated, as well as for certain deep- seated inflammatory conditions and certain forms of pseudo-diphtheria, which often complicate the disease and are sometimes mistaken for it. The streptococcus is probably the most active. It was formerly believed that defective drainage, and to a less extent also the upturning of soil, were conditions favoring the production of diph- theria, but such views are not sustained by modern studies. On the other hand, army statistics seem to show that foul air causes simple follicular sore throat, which in seasons of epidemics makes an excellent nidus for the growth of the diphtheria bacillus. The contagion is communicated, as a rule, through the air and not by fluids ingested, although epidemics have been traced to milk, in which the bacillus multiplies. In the vast majority of instances the source of the contagion is the throat or nose of another individual affected, whence it is propelled by acts of coughing or expecto- ration. Hence it happens that the physician and nurse are not infrequently infected. Perhaps in this disease, more than any other, excepting typhus, are doctors and nurses the victims of contagion. Much may, however, be done to secure protection by caution during such ministrations, as by keep- ing the mouth closed and carefully cleansing the hands after contact. The practice of examining throats through a plate of clear glass is a further pro- tection against inoculation of the examiner. The contagion is less tenacious than that of scarlet fever, but is still highly so, having been found to live on blood-serum for one hundred and fifty-five days ; dried on silk threads, one hundred and seventy-two days ; and in gelatin, for eighteen months. It has been found on a child's toy that had been kept in a dark place for five m.onths, and in the hair of nurses. It resides also in the healthy throats of immune persons, in simple catarrhal angina without membrane, and in simple lacunar tonsillitis ; whence it is plain how the disease may arise without apparent cause in certain sporadic cases. It is believed by some that diphtheria affects the lower animals, espe- cially the cat, and may be transmitted from them tO' children. It is said, also, that such an affection attacks calves and heifers, and is from them com- municable to man. The disease is much more common in children than in adults, though no age is exempt. It is rare in very young children, and more girls are attacked than boys. Abraham Jacobi, ^whose experience has been very large, has seen only three cases in the newly born. Several cases in children about six months old have come under my notice. Epidemics vary in severity, and winter is the season in which the disease is most prevalent. While crowding in cities favors it, it is often widespread and virulent in the country. Morbid Anatomy. — The morbid anatomy of diphtheria consists, on the one hand, in the presence of the false membrane and of the more ordi- nary phenomena of inflammation, most of which latter disappear after death ; in the deep-seated ulcerative processes that sometimes result ; and in the results of the complications and sequelae to be considered later. The paralyses do not furnish palpable morbid products. Under morbid anatomy the constitution of the false membrane is suit- ably considered. At its first appearance it is yellowish-white, but later may assume a grayish hue. Whether superimposed on a mucous membrane or DIPHTHERIA. 135 set into it as in a frame, depends much upon the character of the epitheUum with which the surface is normally covered. To squamous epithelium the membrane is more deeply and thoroughly attached; to columnar epithelium, such as lines the larynx or bronchi, it is more loosely adherent; but in both situations it tends to become looser with the lapse of time. The membrane itself is to-day considered a product of what is known as coagulation-necrosis, our knowledge of which is based on the studies of Wagner, Weigert, and especially of Oertel. The mechanism of its produc- tion is as follows : The diphtheritic poison, probably admixed with fibrin from the blood, infiltrates the wandered-out leukocytes and the epithelial cells of the part, especially the more superficial, causing first their death and then a hyaline transformation, and simultaneously coagulation. The result- ant, is a plate of necrotic tissue and coagulated fibrin. Hence the word " coagulation-necrosis." The membrane presents, also, a laminated structure, probably due to the involvement of successive layers of tissue and wandering cells. If forcibly separated, especially when recent, it is apt to leave a bleeding surface, on which new membrane is generally promptly deposited. The process proceeds from without inward, and. though usually superficial, may extend more deeply, invading lymphatic glands and adjacent tissue, producing foci of necrosis, which may be extensive. Blood-vessels may also be invaded, especially capillaries. Bacilli are everywhere present, but they do not directly produce the mischief. It is caused by the toxin they generate. The same results may be produced experimentally. Inflammatory membrane of this kind is not the product of the toxin of diphtheria only. Any intense irritant is capable of producing it. Such are corrosive poisons like nitric acid and ammonia, although the necrotic product is here partly the result of the direct action of the agent itself on the tissue. Similar in its effect is the organism of scarlet fever, whatever it may be, which often produces a pseudo-membranous angina difficult to dis- tinguish in its coarser characters from that of diphtheria, but in which is not, as a rule, found the Klebs-Loefiler bacillus. In this membrane have been found streptococci, staphylococci, and diplococci. The microccus of sputum-septicemia, and the oidium albicans may produce such false mem- brane. The streptococcus is probably the most frequent cause. Such false membranes may be called diphtheroid. Symptoms. — ^The period of incubation varies from two days to twelve, seldom exceeding one week. According to what may be the primary or principal seat of invasion we may speak of the pharyngeal, laryngeal, and nasal forms of diphtheria. In the pharyngeal variety, fever and sore throat appear simultaneously, sometimes preceded by a chill or chilliness. Both increase rapidly. There may be aching or a sense of weariness. More rarely a convulsion ushers in the attack. At times at the beginning, at others on the second or third day, an erythematous eruption more or less extensive appears on the skin and may lead to the diagnosis of scarlet fever. Usually, as soon as attention is called to the throat, white patches are found on one or both tonsils, which spread with varying rapidity. It is this spread from the original focus by which the disease is especially characterised as something distinct from fol- licular tonsillitis. Commonly, the extension is anterior, over the anterior half-arches to the uvula, and to the palate or up into the nasal passages, or both. With the invasion of the uvula and palate, commonly reached about the fourth dav, the diagnosis becomes certain, even without the bacteno- 136 IXFECTIOUS DISEASES. logical examination. ^lore serious is the extension backward into the larynx, producing croup. The temperature rises to 103' or 104° F. (39.4^ or 40° C.J, but is not characterized by extreme or persistent elevation. The pulse, which ranges from 120 to 140, is never very full and strong, but tends early to smallness and w^eakness. Delirium is rarely present. Deglutition becomes more and more painful, and is increased by external glandular szcclling, involvmg the Ivmphatic and salivary glands, although this swelling is not invariably present. As the nasal passages become involved, breathing becomes more and more obstructed, until, finally, it is possible through the mouth onl}\ The Eustachian tube, middle ear, and even the antra may be invaded. So, also, there may be diphtheritic conjunctivitis, and even keratitis, and, though rarely .indeed, dermatitis. Sh.ould there be, however, excoriations or ■wounds, these may be invaded by the diphtheritic pseudo-membrane. Such false membrane may, however, be due to the streptococcus, which requires a bacteriological examination for its recognition. As intimated under the head of morbid anatomy, the ulcerative process may extend much more deeply, producing destruction of tissue and even gangrene, resulting, as in scarlet fever, in a fatal erosion of blood-vessels. Usually, the membrane gradually disappears from the fauces as convales- cence is established, or is coughed up if deeper in the respiratory passages. Sometimes, on the other hand, it remains on the tonsils for some days after all constitutional disturbance has disappeared. If the inflammation and membrane formation extend downward, laryngeal cough and the signs of laryngeal obstruction become superadded — in a word, the sym.ptoms of pseudo-membranous croup supervene. Or if the process begins in the larynx — primary laryngeal diphtheria — we have croup at the outset, which differs from spasmodic croup in being less sudden in its onset. The seriousness of the disease is greatly aggravated by the pos- sibility of complete obstruction and suffocation unless averted by operative interference. Not the larynx alone, but the trachea and bronchi may be invaded by false membrane, ^\'hile the onset is slov."er than that of pharyn- geal diphtheria, the course is more rapid. To the phenomena of congestion and membrane formation with resulting obstruction are added those of spasm, which brings on at intervals the alarming paroxysms that add to the terrors of this horrible aft'ection. Nasal diphtheria, in which the nares are especially invaded by the false membrane, requires special allusion. It is more apt to succeed upon acute nasal catarrh with little secretion than on chronic catarrh. The eft'ect of the invasion is to increase any previous discharge, which is also rendered acrid and irritating. In this form glandular swelling of the deep faucial glands at the angle of the jaw is particularly prone to occur, probably on account of the richness of this locality in lymphatics, and persists as induration, while a chronic pharyngeal and nasal catarrh may persist a long time after disap- pearance of the membrane. Jacobi, who also especially emphasized the diagnostic value of this peculiar glandular swelling, called attention to the fact that this form of catarrh is not only liable to be a focus of fresh attacks, but may also be a source of spread to others. Suppuration in these enlarged glands rarely occurs. In three to five days after the onset, if the case is one of ordinary severity, the phenomena of constitutional infection m.ake their appearance in extreme adynamia, feebleness of pulse and heart-beat, while a sense of DIPHTHERIA. 137 intense zveariness is complained of. From this time a new period of danger begins, the danger of death from heart failure. This is a distinct and separate cause from heart paralysis due to neuritis of cardiac nerves. At times in diphtheria, as in scarlet fever, the signs of constitutional poisoning appear at the outset, and the patient is struck down as by a blow, but this is less common than in scarlet fever. In such cases the temperature may not rise, and may even be subnormal. Constitutional poisoning is not so prone to take place in primary laryngeal croup as in secondary croup. This lesser tendency to constitutional poisoning together with the more gradual onset, the spasm, the slighter contagion, the shorter duration, and more serious mortality, constitute the chief clinical features of the laryngeal variety. Complications and Sequelae. — The most frequent complication of diphtheria is nephritis, which pursues a course somewhat similar to the nephritis of scarlet fever, but is less frequently accompanied by dropsy, and generally terminates more favorably. On the other hand, albuminuria is present in almost every severe case. There may be the other signs of nephritis — viz., blood-casts, epithelial casts, scanty and even suppressed urine. Capillary bronchitis and hronchopneumonia are serious complica- tions, especially if the results of inflammation of the virulently laden mem- brane. Endocarditis and arthritis sometimes occur. The most important sequel of diphtheria is paralysis. This is now gen- erally regarded as the result of a toxic neuritis. It may come on as early as the seventh or eighth day, or as late as the second and third w'eek, when con- valescence is apparently established. It is quite as likely to follow mild cases as severer ones. It may even follow wound-diphtheria. It most frequently affects the palate, producing nasal speech and permitting the passage of fluids into the posterior nares and through the nose. There is simultaneous anesthesia of the pharyngeal mucous membrane, destroying reflex excita- bility. Next in frequency of involvement are the muscles of deglutition; more rarely, the eye muscles, especially those of accommodation, which is thereby rendered defective. There may be also ptosis and strabismus, or paralyses of the distribution of the facial nerves. Still more rarely the nerves of the lower extremities are involved, producing paralysis, partial recovery from which leaves lameness that may last through life. Generally, however, recovery takes place in the order of involvement, usually in two or three weeks. Sometimes there are ataxic synvptoms, with loss of the tendon reflexes, and no involvement of sensation. The most serious of the local palsies is that of the heart, due to neuritis of the cardiac nerves. In this there may be bradycardia and tachycardia, but the most frequent result is the sudden cessation of the heart's action, and this tragic termination may take place during convalescence. Indeed, the event is more frequent during convalescence, and is often as late as the sixth or seventh week. At other times the phenomena of heart failure are more slow in their development. The pulse may become weak and rapid, or more rarely become slow, while the extremities become cold, the temperature falls, and there supervene in a few hours all the signs of collapse. A most strik- ing instance of bradycardia in diphtheria was met by Baumgarten, wherein, toward the close, the pulse fell to 25, though very regular. Diagnosis. — The only two conditions with which diphtheria is liable to be confounded are, first, the different forms of diphtheroid faucitis, includ- ing follicular tonsillitis, and, the faucitis of scarlet fever. The difficulty in deciding between the former condition and diphtheria at the outset is some- 138 INFECTIOUS DISEASES. times extremely great, and time or the bacteriological investigation may alone settle it. The primary fever, constitutional disturbance, and dysphagia are often equally as great in follicular tonsillitis due to streptococcus or some other cause of infection. As a rule, however, the follicular exudate remains limited in size — it does not spread, and in the second or third twenty-four hours is apt to drop out, leaving a clean-cut ulcer that heals rapidly, while the constitutional symptoms disappear with equal rapidity. In the form of follicular tonsillitis attended by multiple white spots on the tonsils the local resemblance to diphtheria is even greater, but the white spots remain isolated, while those of diphtheria spread. Sometimes, however, the mass of desquamated epithelium, fibrin, and fungous filaments, which make up the contents of the follicles in follicular angina extend outside of the follicles and over the surface of the tonsils. Then it becomes more difficult to decide. It does not, however, pass the boundary of the tonsils. The follicular fungi are said to stain bluish-red with an iodopotassic iodin solution. Further certainty is secured by mak- ing cultures from the membrane, a small portion being removed by the sterilized platinum loop or cotton swab, and planted in gelatinized blood- serum. In the course of twenty-four hours characteristic colonies will develop, and the microscope will confirm the diagnosis. From scarlet fever, diphtheria is usually easily distinguished by the absence of eruption, although this aid is wanting in those few cases of scarlet fever in which there is no eruption, and in those of diphtheria where there is an erythematous redness. Under these circumstances the distinction becomes more difficult if the throat symptoms be similar, as they sometimes are. The prevalence of an epidemic of one or the other disease aids in the decision. Later on, the desquamation that takes place in scarlet fever, but not in diphtheria, also settles the question. Diagnosis is sometimes delayed or the disease entirely overlooked by concealment of the membrane in localities not easily open to examination, as in the nasal chambers. Hence, in all obscure cases these should be examined. Indeed, it is not impossible that diphtheria may exist without membrane, as evidenced by prompt recovery after the use of antitoxin in certain obscure throat cases with continued adynamia and fever. The larger cities in the United States now offer, through their health bureaus, to make bacteriological examinations for physicians in all cases of possible diphtheria. Outfits ^are left at stations. They consist of a box containing a tube of blood-serum and another containing a sterilized swab. The following directions are issued by the Philadelphia Board of Health : " Inoculations should be made by rubbing the cotton swab attached to the end of the wire contained in the test-tube gently, but freely, against any visible exudate, and then drawing it over the surface of the culture-medium without breaking the surface of the latter. The swab should then be replaced in the tube from which it was taken, and both tubes be replugged and put back into the box. Return the box to the station from which it was obtained as soon as possible, or bring it directly to the laboratory. The tubes will be collected every afternoon, examined the following morning, and reports will be mailed by one o'clock p. m. The attending physician can obtain information, however, by telephoning directly to the laboratory after that hour." PrognosiSo — The introduction of the serum treatment for diphtheria, DIPHTHERIA. 139 which may be dated April, 1893, when the first 30 cases treated by Behring's normal serum w'ere reported,* marks an era prior and subsequent to which the prognosis of diphtheria presents very different aspects. Even prior to 1893, while the prognosis was so unfavorable as to justify a wholesome dread of the disease the world over, many moderately severe and most mild cases got well. Allowing for the great variation in the percentage of fatal cases in different epidemics, and especially at dift'erent ages, the verv careful and reliable studies of Professor William H. \\'elch,t of Johns Hopkins Hospital, make it safe to put such mortality at a minimum of 40 per cent. Where the larynx was involved, it amounted to almost 100 per cent. Of the remaining non-laryngeal cases probably one-third died. Since the introduction of the antitoxin treatment the studies of the same observer (Welch) show a reduc- tion in mortality of between 50 and 60 per cent. This improvement affects all classes of cases, including those operated upon as well. As near as it ma)' be possible to put it, the mortality since the introduction of antitoxin has been from 8 to 25 per cent. This is attested from many sources. For example, in the report of collective investigation by the American Pediatric Society w^e have the following: " Formerly, 2j per cent, approximately repre- sented the recoveries, while now 27 per cent, represents the rate of mor- tality " ; also " Formerly, only 10 per cent, of laryngeal cases did not require operation, while now vrith antitoxin treatment 17 per cent, do not require this procedure." Finally, the most remarkable results are shown in the " Bulletin of the Departmicnt of Health,'" city of Chicago, for February, 1899, which reports that out of 4071 cases of bacterially verified diphtheria, 3705 recovered and 276 died, giving a mortality rate of but 6.77 per cent. In New York City for 1899 there were 8240 cases reported with a mortality of 1087, or 13 per cent. During thirteen months ending October, 1896, 1972 patients w^ere treated with antitoxin at the Boston City Hospital, and of this number post- diphtheritic paralysis occurred in 5.8 per cent., which percentage is smaller than that of cases not treated wdth antitoxin. A fair ratio of the causes of death in 25 fatal cases prior to the use of antitoxin was given in a paper by William P. ]\Iunn ± as follows : from septic intoxication 8, laryngeal stenosis 7, cardiac paralysis 6, hemorrhage from the bow^els i, nephritis i, unknown 2 ; total 25. Thus the chief causes of death are adynamia, laryngeal obstruc- tion, heart paralysis, or suft"ocation from paralysis of deglutition ; more rarely, nephritis and bronchopneumonia. Hemorrhage from an eroded blood- vessel is a possible cause of death. ]\Iorse analyzed 366 deaths occurring in 1972 consecutive cases treated since 1895 in the Boston City Hospital, and "found the miortality only 18.5 per cent. Seventy of these cases died on the day of admission, and 38 on the following day; in other words, 100 were moribund on admission. The following are the causes of death: sepsis, 107; bronchopneumonia, 91; cardiac complications, 52: exhaustion, 13; tubercu- losis, i; empyema, i; typhoid fever, i; moribund when adiiiitted, 100; total. 366. Under the use of antitoxin the average duration of an ordinary case may be put down at about five days and of a very bad" case ten days. It is impor- *The prior trials of immune serum in the treatment of human diphtheria, made in v. Ber?- mann's clinic in Berlin in iSgi. and by Henoch and Huebnerin Berlin in iSg2, were tentative and made ^vith weak serum and in insufficient doses. , , ■ ^• + " The Treatment of Diphtheria bv Antitoxin." Reprint of paper read before the Association of American Phvsicians, Mav .^i, 183=;. and published in the " Transactions " for that 3-ear. t "Diphtheria: a Clinical Studv," " Medical News," Philadelphia, JIarch 25, 1893. I40 IXFECTIOUS DISEASES. tant to remember, however, that actively growing bacilH can be cultivated from the throat of cases treated early with antitoxin, two weeks after the membrane has disappeared. Treatment. — In the management of every case of diphtheria there are two principal indications : first, to combat the toxin and thereby neutralize constitutional infection; second, to co-operate with this object by suitable supporting treatment. I. To combat the toxin and to prevent constitutional infection. This is accomplished (a) by serum therapy, that is, by antitoxin; {b) by local anti- septic measures. (a) Antitoxin. — The treatment of diphtheria by antitoxin should be associated with the general and local treatment to be described. It is based on the facts that animals may be made immune to diphtheria by the injection of diphtheria toxin, and that the serum from such animals is antitoxic to the toxin of diphtheria. This was shown by Behring in 1891, after some preliminarv experiments had been made by Frankel in the same year. In 1892 Behring and Wernicke employed this method successfully in immu- nizing sheep, and also ascertained the second important fact mentioned that blood-serum from an immune animal could be used with success m arresting diphtheritic infection in susceptible animals. To this was added the further important fact that a smaller amount of serum is required to produce innnunity than is necessary for the cure of an animal already in- fected. If the injection be made immediately after infection, from one and a half to tzvic'e as much is required; eight hours after, three times as much, and tzcenty-four to thirty-six hours after infection the dose required is eight times the immuni::ing dose. In obtaining a uniform standard of strength Behring produced first his normal therapeutic serum, which when injected into guinea-pigs, in the proportion of i to 5000 of body weight, saves the animal from the fatal efifects of ten times the minimum dose of a two-day-old culture fatal to a control animal not thus treated. One cubic centimeter of this nornml serum he calls an antitoxin unit. The serum prepared by this method he labeled three strengths : Xo. i is 60 times the strength of the normal serum : Xo. 2, 100 times as strong ; and Xo. 3, 140 times as strong. Behr- ing claims that 10 c. c. of his Xo. i serum is sufficient to arrest the progress of the disease in a child under ten years, and effect a cure if given within two or three days after the onset of the attack. This older method of Behring has been replaced- by other modern methods.* One of the objections to the serum treatment at first was the necessar rily large bulk of the injection. This has, however, been reduced by in- creasing the strength of the serum, so that the dose now- injected gives no more discomfort than a hypodermic injection of morphin. Reliable prepa- rations are now made in this country, notably by the ]\Iulford Company, in Philadelphia, and by Parke, Davis & Co., in Detroit, ]\Iich., and in some cities by the official authorities under direction of the city board of health. Two strengths of serum are made by these firms, the " standard " and " concentrated " serum. The latter is more bulky, 1000 units being * The method of the Mulford Co. is briefly as follo^\'s: Determine by trial on a larure number of gruinea piars the smallest sureU' fatal dose of toxin. Take other guinea pigs and determine the smallest fraction of a cubic centimeter of serum that will protect the guinea pig against loo times the fatal dose of toxin. This fraction of a cubic centimeter ■will then contain one unit, and there are in one cubic centimeter as many units as the fraction will go into the ^vhole cubic centimeter. Thus if ji^ of i c.c. is the smallest quantity that ■p'ill protect, then the serum has 250 units per c.c. DIPHTHERIA. 141 represented by 5 to 10 c. c, while 1000 units of the concentrated are rep- resented by 2 c. c. Technique of the Aduiinisfraiion of Antitoxin. — Antitoxin should be administered at once if there is a reasonable probability of the presence of diphtheria, without waiting for the bacteriological diagnosis. Antitoxin does no harm where the disease is not diphtheria, and delay in a true case may be fatal. The begmning dose is 1000 units for ordinary pharyngeal diphtheria. The " concentrated " form is preferred on account of its small bulk, which gives no more pain than a hypodermic injection of morphin. If, for any reason, the concentrated form cannot be procured, the " standard " may be used, which is cheaper and just as efficacious, but gives much more pain because of its greater bulk. One thousand units of this is indicated also. The bulk of 1000 units, concentrated form, is 2 c. c. ; 1000 units, stan- dard form, 4 c. c. A large hypodermic syringe is used for the administration. The syringe must be made sterile by boiling for five minutes just before being used. Always test the syringe with water before filling with serum. After the administration the syringe should be washed out with clean cold water. The injection is given in the back just below the scapula or in the flank or buttock, the skin being cleaned with soap and water followed by alcohol. It is pinched up and the injection made immediately beneath it. If the smaller bulk be used, it can be injected quickly. If the larger bulk be used, inject slowly in order to avoid injury to the underlying tissues by too rapid stretching. Immediately after the injection there is an occasional rise of temperature, which need give no concern. In favorable cases, after twenty-four hours have passed, the tempera- ture will not have risen ; the pulse will be slower ; the membrane will not have spread ; the mucous membrane at the edge of the exudation will be bright red in color. There will be a feeling of diminished discomfort and revival of spirits. These are favorable signs, and a second dose need not be administered. A second dose is administered after twenty-four hours if the temperature has risen, if the membrane is spreading, and if the gen- eral condition of the patient is not so good as at the previous injection. As might be expected, improvement is more rapid in mild cases. In laryngeal diphtheria (membranous croup) the initial dose is 2000 units. The same beginning dose is also given in bad cases of the pharyngeal or nasal form that have lasted some days. In these forms a second dose should also be administered, if there is not improvement in twehe hours. For Immunisation. — For producing immunity to those subject to infec- tion from diphtheria, immunizing doses should be administered. These range from 200 to 500 units, according to the age of the person to be pro- tected. Infants and very young children are easily protected by the smaller dose. Adults, especially those in attendance upon the sick, should receive the larger dose. Persons who have been exposed and probably are already infected should receive 500 units. The throat irritation so common in those who are attending diphtheria is said to have yielded promptly to a dose of 500 units. If suspicious symptoms have appeared, not less than loco units should be given. Immunization cannot be too strongly insisted upon. The protection afiforded by one dose will last for at least three or four weeks, at most 142 IXFECTIOUS DISEASES. not more than eight or ten weeks ; within which time, with proper means of disinfection, the source of infection should be ehminated. Behring and others declare that the diphtheria antitoxin has no injuri- ous effect upon animals in the largest dose in which it has been employed, and that, aside from its antitoxic powers, its properties are entirely negative, as far as human beings are concerned. This is essentially true ; yet there is evidence to the contrary, notably, a fatal case reported in the " Journal of the American Aledical Association,"' April 4, 1896, that of a healthy boy, five years old, who received an injection of Behring's fresh serum as a proph- ylactic and died within five minutes : also another case, in Berlin, referred to in the " ^Medical Xews," April 18, 1896, page 443. The daughter of a friend of the author died suddenly in Switzerland after receiving an injection of antitoxin. {b) Antiseptic Local Treatment to Prevent Constitutional Infection. — Germicides and disinfectants are best applied, when possible, by the spraying apparatus at intervals of an hour, or, at most, every two hours. If the spraying apparatus cannot be used, as is often the case with children, a swab of cotton wool or a soft sponge may be employed. The most satisfactory solution in my hands for this purpose has been equal parts of pcroxid of hydrogen and Dohell's solution. The spraying should be continued five minutes, if possible. Bichlorid of mercury is also a suitable solution for spraying, of strengths of i to 4000, or even, in extreme cases, i to 2000. The most efficient bichlorid solution is that with tartaric acid i to 500,* with which the throat ma}- be swabbed once in six hours, or even, in severe cases, once in three. The objection to the corrosive sublimate solution is its extremely unpleasant taste. Carbolic acid may also be used in 2 1-2 to 3 per cent, solution, in equal parts of glycerin and water. The stronger soltttions are better applied by a swab than by the spray apparatus, while with chil- dren it is often impossible to use the spray. Solutions of albumin solvents are also highly recommended by some, such as trypsin and papoid, in the strength of 30 grains to i ounce (2 gm. to 30 c. c.) or lactic acid in the same proportion. Salicylic acid, i to 200: thymol, i to 2000; chlorin li'ater; boric acid in saturated solution ; saturated solution of iodoform in ether or 5 per cent, suspended in equal parts of glycerin and water, are all useful local applications. Loefl^er's toluol solution is highly praised. It is com- posed of menthol, 10 gm. dissolved in enough toluol to make 36 c. c. ; sesqui- chlorid of iron, 4 c. c, and absolute alcohol, 60 c. c. Still another solu- tion is tincture of the perchlorid of iron, i 1-2 drams (6 gm.) ; glycerin and water, each i ounce (30 c. c.) ; carbolic acid, 15 to 20 minims (i to 1.3 c. c). Where there is laryngeal diphtheria, the patient should breathe an atmos- phere saturated with the vapor of slaking lime. The comfort derived from such breathing is often very great. \^^hile iron and the chlorate of potash have lost some of their former reputation, they are still, in my judgment, indispensable, and I always comi- bine them with any other treatment I may care to use. As held by Jacobi, they are, at least, useful in the conctirrent pharyngitis and stomatitis that invariably attend the disease. The chlorate of potash in saturated solution may be used as a simple mouth-wash. Gargling is an ineffectual method of reaching the throat, and has given place to spraying. Still it may be *A tablet consisting of 3.75 grains C0.25 gm.") bichlorid of mercury to 1Q.25 grains (1.25 gm.) of tartaric acid, dissolved in 4 ounces (120 c.c.) of water, makes a i to 500 solution- DIPHTHERIA. 143 used with advantage by adults. i\Iuch depends upon a certain facility in using it, which may be cultivated. Jacobi recommends that in children too young to use the gargle the local effect of the chlorate of potash be secured by frequent administration of small doses. Thus, regarding i 1-2 to 2 drams (6 to 8 gm.) as a suit- able twenty-four hours' quantity for an adult, 30 grains (2 gm.) for a child two or three years, and 20 grains (1.33 gm-) for a baby a year old, he pre- fers the whole amount to be given in 50 or 60 doses rather than 8 or 10, giving the weaker dose every hour or half-hour, or every fifteen or twenty minutes, being careful to give no water immediately afterward, for obvious reasons. But I have seen the thing overdone : I have seen a little child, exhausted for want of sleep, aroused every fifteen minutes for the adminis- tration of medicine, when what it wanted was sleep more than medicine. 11. The second object includes measures which also have for their purpose, first, checking the spread of the membrane, its loosening and solution, and, second, maintaining the strength of the patient against the depressing action of the absorbed toxin, (a) The former is accomplished by the preparations of mercury. Of these, I prefer the bichlorid of mer- cury in doses of 1.48 grain (0.0027 gm.) to 1.12 grain (0.005 S'l'^-) for an adult, in conjunction with tincture of the chlorid of iron and the chlorate of potassium, every two hours, taken freely diluted. The former dose makes 1.4 grain (0.0162 gm.) of the bichlorid in twenty-four hours, but as much as one-half (0.032 gm.) may be given in that period. These doses are given to adults, and they need not be much reduced for children. There need be little fear of poisonous effects from the bichlorid, as bowel irritation, pain, and loose movements give a warning before any more serious consequences supervene. When these symptoms appear, the bichlorid should be dis- continued or the dose decidedly diminished. The calomel treatment is preferred by some. The drug is given in hourly doses of 1.6 or 1.8 grain (0.016 or 0.008 gm.) until spawn-like stools are produced. Both remedies are supposed to have the effect of loosening the membrane. (h) Iron is also useful in supporting the strength of the patient. For this purpose quinin is indispensable in doses of 10 to 24 grains (0.65 to 1.5 gm.) in the twenty-four hours. Stimulating, nourishing, and easily assimi- lated food is necessary. Milk is to be preferred to all else, fortified with full doses of whisky or brandy, 2 drams to i ounce (8 to 30 c. c), every two hours, being required in all cases of severity, and propor- tional doses for children. The milk may, of course, be alternated with nutritious animal broths or beef-peptonoids. In extreme cases of difficult deglutition nutrient enemas may be useful, but nourishment by the stomach- tube, if possible, is more efficient. For enemas, peptonized milk is the most suitable. To this brandy or whisky may be added, if needed. Rectal alimentation has som.etimes to be discontinued because the enema is made too large and is too frequently administered. Once in four hours is often enough, and 4 ounces at a time are as much as the rectum will commonly bear. Smaller quantities should be used for children. Treatment Demanded by Special Forms. — Where laryngeal obstruction is imminent, intubation or tracheotomy , should be performed. Lives have been saved by both of these operations. Intubation may precede tracheotomy, as its use does not preclude the more serious operation at a later date, if the obstruction increases. Such cases should breathe an atmosphere charged with the vapor of slaking lime. 144 INFECTIOUS DISEASES. In the nasal variety of diplitJicria special means must be employed to disinfect and cleanse the nasal passages. The solutions recommended to spray the throat may be used for such cleansing. Gentle injections into the nostril may be more efficient than the spray, precaution being taken to keep the mouth open, by which the entrance of fluid into the Eustachian tube is guarded against. The injections should be continued until the fluid has free exit either by the other nostril or th: ough the mouth. Jacobi has seen cases where he has been compelled to bore a pas- sage with a silver probe through a mass of membrane filling the nasal cavi- ties, and then apply carbolic acid to remove the denser portions before injecting. He recommends that when about to bring the injection to a close, the nasal cavities should be pressed together for an instant with the fingers, as in this way the fluid is forced backward into the pharynx and swallowed or ejected through the mouth, thus washing both at the same time. The Treatment of Complications and Sequelae. — Complications are treated as the same conditions under other circumstances, and the paralysis so frequently succeeding upon diphtheria alone requires special allusion. The prognosis is, on the whole, good, and time, under favorable circum- stances, mainly effects the cure, and during this the most important meas- ures are those that save the patient from accident. Thus if there is paralysis of the muscles of deglutition, liquid food only should be used, and it may be necessary to nourish for a time by the rectum or by means of the stomach-tube. So,' too, undue exertion should be avoided. Electricity and tonics, especially strychnin, are indicated. The former is applied to wast- ing muscles, and may be advantageously associated with massage. Strych- nin should be given in full doses, ascending gradually to 1-20 grain (0.003 gm.) three and four times a day, with appropriate reduction for children. Iron and quinin should also be given. The electrical treatment for paralysis of the pharyngeal muscles is applied in the following manner : An electrode is placed at the back of the neck and a very small electrode is touched to the velum palati, and a rapidly interrupted faradic current of moderate strength applied. Galvanism may be similarly used. A specially constructed electrode is also applied to the throat. Prophylaxis Against Diphtheria. — Most important are the precau- tions necessary to prevent a spread of the disease. To this end the patient should be isolated, all carpe,ts and unnecessary furniture and hangings should be removed from the room, and all utensils used in treatment should be kept apart and separate for the patient's own use. Spoons and tongue depressors should be kept in carbolic acid solution, or, better, thrown into water kept boiling. All bed linen and clothing removed from the patient should be boiled, being immersed in water before removal from the room. Mattresses, pillows, and woolen garments too good to be destroyed should be exposed to superheated steam in establishments provided for the purpose in the cities ; or they may be disinfected at the same time with the apartment oc- cupied by the patient. They should be opened and suspended in this apart- ment, of which all the doors and windows must be closed tightly and the room fumigated with formaldehyd gas, of 2 to 4 per cent, volume strength, for not less than twelve hours. Suitable lamps are provided for this pur- pose. If formaldehyd is not available, sulphur may be used. The sulphur, in the amount of 2 pounds to every 10 feet (2 kilos to every 2.5 meters) SMALLPOX. H5 square, should be placed in iron pans and these supported by bricks in washtubs containing a little water. The sulphur is then ignited by glowing coals or by burning alcohol. The room should be kept closed for twenty- four hours. After this fumigation the articles of clothing should be hung out in the open air for several hours, and the doors and woodwork washed well with a solution of corrosive sublimate, i to looo, while the walls should be wiped down with a similar solution. Finally, physicians and nurses in attendance on the patient should carefully wash their hands before leaving the room, first in soap and water, and finally rinse them in corrosive sublimate solution, i to lOOO. Nurses in constant attendance should wear an overdress of washable material, vvhich should be slipped off before leaving the room, and the physician while in the room should be similarl}' covered and should treat his hands as described. As the bacillus has been found to multiply in milk, it is safer to use sterilized milk during an epidemic. The convalescent patient should also be kept isolated until thorougiily disinfected. This is accompHshed by giving first a hot water and soap bath, then washing the body of the patient with a solution of bichlorid of mercurv, i to 2000, or 2 per cent, solution of carbolic acid, or, what is m.ore agreeable, 25 to 50 per cent, alcohol. This should be done two or three days in succession. The hair should be cut or similarly washed with these solutions. The regulations of the Board of Health of Philadelphia do not permit the children of a family In which diphtheria has been present to return to school until thirty days after the Board's physician has declared the patient's recovery SMALLPOX. SvxoxYM.— Fan'o/cr. Definition. — Smallpox is an acute contagious disease especially char- acterized by an eruption which passes through the successive stages of pap- ule, vesicle, pustule, desiccation, and desquamation. Historical. — Smallpox Avas first accurately described by Rhazes. an Arabian pby- sician, in the nintli century of the Christian era, anddistin.c:uishedby him from measles; but it is believed to be the same as t\\e pesf a mag-7ta descriheAhy Galen (A. D. 130-200.) Itprevailed also in China many centuries before the Christian era. It isknown tohave prevailed in the sixth centurv and again during the Crusades. The disease is believed tohave been introduced into America by the Spaniards, having first appeared most fatally in :Mexicto in 1520. and in Massachusetts in 1633. I^i evidence of the virulence of the disease it mav be mentioned that in Iceland in 1707, 18.000 perished out of a population of 50.000'. In Mexico three and a half millions v/ere suddenly smitten. Svdenham's classic description Avas made in the seventeenth century. The imraunitv secured bv a previous attack suggested to Lady Mary Wortley Montagu the idea of inoculation for the purpose of protection, the practice of which was introduced in England in 171S Long before this the Brahmins had discovered that the inoculation of smallpox produced the true disease in a milder form, so that the maladv proved fatal onlv to i in ico, or under most favorable circumstances, i m 300. It was. moreover, practiced for centuries in China and other Asiatic countries. The effect of inoculation was. however, to spread the disease, though in a milder- form, and it was not until the discovery of vaccination by Jenner in 1798, that control over the disease was obtained. In I7g6 Juncker wrote that 400.000 lives were Tost vearlv in Europe by smallpox. In 1803 King Frederick William of Prussia, in an edict, stated that 40.000 die annually in Prussia of the disease. As already mentioned, inoculation of smallpox was mtro- 146 INFECTIOUS DISEASES. duced. into England, in 171S, by Lady Mary AVortley Montagu, the wife of the British Ambassador to Turkey ; into Germany in 1721. but was not popular until 1740. The peasantry in various parts of the world, particularly in England, believed that sores on the hands of persons who milked cows affected with cowpox conferred immunity from the disease. It is said that a Dorsetshire English farmer successfully vaccinated his wife and two sons as early as 1774 from a cowpock on himself. In 1791 Plett, a Holstein schoolmaster, vaccinated three children, in one case on the finger-tips, which caused in- flammation of the arm and deterred him from repeating the expveriment. These three children escaped the epidemic in 1794. Edward Jeuner, while a student, learned of the traditions on this subject and mentioned them to his preceptor, John Hunter. He settled the question, Maj' 14, 1796, when he vaccinated a boy, James Phipjis, with matter from akinepock on the hand of a dairymaid. Sarah Nelmes, and on July ist intro- duced into this boy pus from a smallpox pustule without effect. Two years later — Tune, 1798 — he published "An Inquiry into the Causes and Effects of the Variolae Vaccinae," illustrated by four plates, and within a year or two vaccination became general over the continent of Europe. Vaccination was introduced into the United States July S, 1800, b}' Benjamin Waterhouse, Professor ofPhysick at Harvard Universitj', who vaccinated his own children, and into Philadelphia b\' John Redman Coxe, who vaccinated his oldest child about the same time, and then tested the experiment by exposing him to the influence of smallpox. The reliance on the protective power of vaccination in America was strengthened materially by this bold act. President Jefferson was instrumental in introducing vaccination in Southern United States. Once introduced, the practice spread rapidly, but not without some opposition, some of which prevails even at the present da}^, although it is as certain as an}"- demonstrable fact that thousands of lives have been saved by vaccination, and that a thorough and continuous practice of the operation would, sooner or later, blot out smallpox from the face of the earth. Publications in connection with the Jenuer Centenary in iSgS have added greatly to the literature on vaccination, especially the centenary number of the " British ^ledi- cal Journal." See the Report of the Royal Commission on Vaccination, the compre- hensive article by T. D. Ackland and Copeman in " Allbutt's System," and the mono- graph by Cory. Also " Facts about Smallpox and Vaccination," leaflets issued bj- the British Medical Association (" British Medical Journal," 189S, vol. i. p. 632). See, also. Moore's " History of Smallpox," London, 1S15. It is impossible to follow the history of numerous epidemics of smallpox which have prevailed from time to time, even since the ravages of the disease have been ar- rested by the agencj^ of vaccination. The latest epidemic characterized on the one hand by its widespread distribution, and its comparative mildness on the other, is that which commenced in the L^nited States, at the close of the Spanish-American Avar in 1899, spread over almost every State of the L'nion, and is not, at this writing, com- pletely arrested Soon after the period above mentioned there appeared in the Southern States and elsewhere a disease which did not accord with the classic descrip- tions of smallpox, and was variously regarded as chicken-pox, smallpox, impetigo contagiosa, Cuban itch, and as an hitherto undescribed dermatosis. In manj^ cases the mildness of the illness was such that the patient could pursue his usual occupation. As a consequence of failure to recognize the true nature of the disease, it spread widely. Thus, there were reported in the L'nited States to the Surgeon General, Public Health, and Marine Hospital Services in YE.\R 1898, 1899, 1900, I9OI, 1902, Total 135,668 4514 The mildness of the epidemic is shown by the fact that the mortality for this period, and enormous number of cases, was only 3.3 per cent. In the city of Philadelphia there were in the YEAR CASES DEATHS 1900, ...... 27 O I9OT, II59 156 1902, ...... 1342 231 Etiology. — The contagmm of smallpox, probably the most unfailing of all the contagia in its effect tipon the unprotected victim, has not yet been isolated. It is conveyed in the secretions and exhalations of the body, including those of the lungs. The pus of the pustule is its most fertile CASES DEATHS 2,633 27 10,453 458 20.362 819 48,206 II27 54,014 2083 SMALLPOX. 147 source, and the dust derived from the dried pus scales is the more usual medium of its distribution. No other pathogenic organisms than those of suppuration have been isolated from the disease. The degree of mild- ness or severity of a case does not influence that of another caused by it; the severest cases being at times followed by the mildest, and vice versa. The contagium is very tenacious, and may be dormant for months in clothing or furniture or hangings. No age nor sex nor race is exempt, but the number of cases in successive decades diminishes because of the immunity furnished by a previous attack. The foetus in utcro may acquire the disease from the mother, and the child may be born with the eruption on it. Certain individuals are invulnerable even though unprotected by vaccination, while the mortality in aboriginal races is very great. Many alleged immunes respond to a proper vaccination. Some difference of opinion exists as to the period at which smallpox is contagious. Welsh and Schamberg, in their forthcoming book on Con- tagious Diseases, make the following statement, which may be considered as embodying the most recent views : " Smallpox is undoubtedly infectious in all stages characterized by symptoms. It is alleged by some that the disease is even infectious during the period of incubation, but we think there is very little reason to believe that such is the case. " The disease is least infectious during the initial stage, and most highly so during the suppurative and early period of the desiccative stages." Morbid Anatomy. — The essential morbid anatomy of smallpox is that of the eruption as represented by its various stages and modifications, in- cluding hemorrhagic infiltration. To the anatomy of the eruption is added that of the complications that may occur. . 15, — Temperature Chart of Smallpox — {Eu'/ikorsf). The histology of the pustule shows that it starts in the rete mucosum, close to the true skin. The center is a focus of coagulation necrosis, and- about it the reticular spaces are filled with serum, leukocytes, and fibrin filaments. As long as the process does not extend deeper, healing takes place without a scar. In the more severe cases the papillae of the true skin are invaded to various depths and destroyed by the infiltration, producing a loss of tissue constituting the pit. Among other morbid phenomena may be mentioned a hardness and firmness of the spleen. Cloudy swelling of the secreting cells of the liver and kidney occur, as in other fevers with high temperature. True nephritis is rarely present. J 48 INFECTIOUS DISEASES. Symptoms. — After a period of incubation of from seven to twelve clays, and sometimes longer, the victim is seized with violent muscular pain, especiallv in the back. Often a cliill or chills usher in the disease, and in children a convulsion may be the initial symptom. Intense headache is also present. Fever sets in rapidly and the temperature reaches 103° to 104"^ F. (39.4° to 40° C.) the first day. The pidse is rapid, hard, and strong at this stage. Delirium may be present and is sometimes very violent. About the second day the initial rashes make their appearance. These have been especially studied by Theodore Simon, '^' Knecht, f Scheby- Busch, J: and William Osier, § although they are mentioned by some of the older authors, including Sydenham, Wood, Watson, Niemeyer, Trousseau, Marson, Munro, and others. Thev include a diffuse scarlatinous rash and a macular or measly form, dark red in color and occupying a variable extent of surface. Either ma)- be associated with petechial ecchymoses. Sometimes they are general, but as a rule they are limited to the abdomen, the inner surface of the thighs, or the lateral region of the thorax and axilla. Among Osier's cases was one of a true urticarial prodrome. While it is to be remembered that the coexistence of smallpox and measles and of smallpox and scarlet fever is possible, it is more than likely that the eruptions on which the diagnosis was based were really the initial rashes of uncomplicated smallpox. On the fourth day of the disease, the distinctive eruption makes its appearance in the shape of snmll red spots, first on the forehead and wrists, whence it extends rapidly over the face and extremities, becom- ing quite general in the first twenty-four hours. At this stage the eruption is not unlike measles, but in another twenty-four hours it is decidedly different. The papules have acquired shot-like hardness. With the appearance of the eruption the fever falls and the patient feels com- fortable. On the fifth or sixth day a clear or slightly turbid scrum makes its appearance. Coincident with this a depression is seen in the middle of each vesicle. It is umbilicated, and this umibilication is the most char- acteristic feature of the eruption. Frequently, a hair follicle passes up through the center of it. By the eighth day the turbidity has increased until it is bright 3'ellow and the umbilicus has disappeared. The pustule is complete. The maturation takes place in the same order as the eruption appeared. With the appearance of suppuration the fever again returns, knovvn as the secondary fever, and with it elevation of temperature and other signs of fever. There is a good deal of pain in the inflamed parts because of the tension. On the tenth or eleventh day the pustules become dry, and by the fourteenth are converted into crusts, which drop ofif, leaving in mild cases a simple discoloration, in severe a more or less deep ulcer, or, if cicatrization be complete, a simple pit. The eruption may be found on the tongue and buccal mucous membrane and even in the pharynx, larynx, and esophagus, and pustules have been found in the stomach and rectum. In the trachea and bronchi there may be ulcers ; also on the cornea. Sore throat, nausea, hoarseness, vomiting, and diarrhea may be consequences. With the drying of the eruption the fever disappears. This description is typical of the course of the eruption in the simple =■■ "Das Prodromal-Exanthema der Pocken." "Arch. f. Dermatol, und Syph.," Prag. Ileft iii. iZ-jn. 7.6; 1871. Heft ii. 242; Heft iii. 30Q; 1872. Heft iv. 541. + " Arch. f. Dermatol, und Svph.." Heft iii. 75:72, 372. i " Arch. f. Dermatol, und Sj-ph.," Heft iv. 1872. ;o6 5 " The Initial Rashes of .Smallpox," " Canada Med. and Surg-. Jour.." 187J. SMALLPOX. 149 discrete variety. It may be variously modified. The attack may be so virulent that the patient dies before the eruption makes its appearance, or it may be arrested at any stage. Sometimes blood forms the contents of the pustule, and there may be subcutaneous infiltration of blood in addition. Along with this there may be hemorrhage from the mucous surfaces of the nose, stomach, or bowels, or there may be hematuria. The pustules may be so close to each other that they join, when the case is confluent ; or they may be separate and distinct, producing the discrete form.. The variety with bloody infiltration is called hemorrhagic. The diagnosis as to whether the confluent or discrete form is present is generally made by an examination of the face, for it is an interesting fact that nowhere are the pock-marks more abundant than upon the face. Sydenham early called attention to the fact that in the confluent variety the eruption appears earlier (on the third day), and its early appearance, according to him, is an indication that the case will be one of that variety. All the symptoms are much more severe. There is not the abatement of fever described as occurring on the appearance of the eruption. The face, hands, and feet present an almost continuous pus-vesicle, which often bursts in places, and the pus partly drying, there results a picture which is revolting. Such pronounced morbid changes must produce wide systemic exhaustion, as is manifested on the tenth or the eleventh day by the growing weakness of the patient, an adynamia that frequently terminates in death. When recovery takes place, the secondary fever is the more prolonged the more widespread the suppuration. The hemorrhagic variety of smallpox is still more severe. Two forms of it are described : One, the purpura variolosa, or hemorrhagic variola, in which the hemorrhagic symptoms appear early in the shape of a hemorrhagic rash while hemorrhage takes place from the mucous surfaces, generally on the evening of the second or third day. The patient dies in from two to six days, sometimes before the eruption makes its appearance. In the second form, variola h(smorrhagica pustnlosa, the case progresses at first like any other, and it is not until the vesicular or pustular stage that blood makes its appearance in the pocks. Varioloid. — A third variety of smallpox is varioloid, which is variola modified by vaccination or a previous attack of smallpox. In general, varioloid is smallpox bereft of all its serious features, each symptom being milder. The initial fever is less, the eruption is less general and may abort -in its development, the secondary fever is less marked, and convalescence sets in earlier. Yet it has happened that both classes of individuals referred to, those having had smallpox and those having been vaccinated, have had very severe attacks, from which, indeed, the patients have perished. Gen- erally, the longer the interval between the attack and vaccination, the more severe the former is. Similar is the mildness which characterizes a small- pox produced by the direct inoculation of an individual from the pus of another, though the attack thus caused is more severe than that which follows vaccination. Other names given to less important varieties are variola; sine varioUs, or variolous fever without eruption ; ' the crystalline pock, in which the eruption continues vesicular ; and the " stone pock," " horn pock," and '' wart pock," in which the vesicles dry up into tuberculated or warty elevations. Complications. — Among complications of smallpox may be mentioned laryngitis with fatal edema of the glottis, bronchopneumonia, parotitis. I50 INFECTIOUS DISEASES. vomiting, diarrhea, albuminuria, but rarely nephritis. Prolonged delirium, and even insanity, have supervened, while neuritis may occur during con- valescence ; so may arthritis. On the skin may be boils and painful acne. A troublesome and painful conjunctivitis used to be the result of indifferent care of the eyes, but it is now less common because of greater care in this respect. Myocarditis and pericarditis sometimes occur, and most rarely endocarditis. Diagnosis. — With the appearance of the perfect papule all doubt in the diagnosis of smallpox generally ceases. Ignorance of the initial rashes, measly and scarlatinal, has often led to errors of diagnosis. On the other hand, the resemblance of the eruption of measles to smallpox has also given rise to errors the result of which has been no less serious, because in conse- quence cases of measles have more than once been sent to smallpox hospitals with disastrous results. Never in measles is there such severe pain in in the back as in smallpox, while the early cough and coryza are found only in measles. The lesson taught is to defer a positive diagnosis, because less serious mischief can result from an error thus occasioned than as the result of an opposite course. The possibility of relapsing fever being taken for smallpox has been alluded to in considering the former disease. Cerebro- spinal fever may also be simulated by the hemorrhagic form of smallpox. Pustular syphilids and accidental croton-oil eruption have been mistaken for smallpox, as has also chicken-pox. Prognosis. — Smallpox is a serious disease, and the death-rate is always relatively large. It varies, however, at different ages, in different races, and in different epidemics. The young die almost always. Thus, in the Montreal epidemic of 1885, 86 per cent, of the deaths were children under ten years. The African and American Indian and native Mexican have perished by thousands. The range of the mortality in different epidemics is put down at 25 per cent, to 35 per' cent. The recent epidemic in the United States was an especially mild one, the mortality being but 3.3 per cent. The hemorrhagic cases are always serious; those of purpura variolosa all die, and although some cases of variola pustulosa hemorrhagica get well, the majority are usually fatal on the seventh, eighth, or ninth day. The preg- nant woman usually aborts and perishes, but not always. The complications of pneumonia and laryngitis are serious. From the statistics of Dr. Gregory, based Upon London hospital prac- tice, most die on the eighth day ; but in private practice, according to the experience of the late George B. Wood, the greatest number of deaths occur between the twelfth and eighteenth da)'s. Treatment. — ^It is not possible to cut short a case of smallpox. The patient should be isolated and taken to a smallpox hospital, if possible. If at home, an uppermost room should be selected, all hangings and carpet removed, and communication with the rest of the house cut off by closed doors fortified by a sheet dampened with a solution of carbolic acid, i to 60. Separate dishes and utensils should be provided, and nurses should hold no communication with other members of the family. All clothing removed from the patient should be put in scalding water, and sweepings should be burned. The nurse should wear an overall, to be removed on leaving the room, and her head should be covered with a close-fitting cap. The treatment must consist in combating the symptoms. Morphin, or or in less severe cases phenacetin, acetanilid, or antipyrin, must be given to control the pain in the back. Nourishing liquid food and stimulants are SMALLPOX. 151 required in adynamic cases. The fever is treated by sudorifics including acetanilid, antipyrin, phenacetin, and thermol, and by aconite, or by cool sponging or even by cold baths, as in typhoid fever, if the temperature be high. Cool drinks should be permitted ad libitum. The complications must receive the treatment appropriate to them. Tracheotomy may be demanded by edema of the larynx. It has always been the object of the physician to find some means of preventing the disfiguring scars which so invariably remain after very severe cases. No one method is always successful. It has long been thought that the absence of light favored healing without pits. For the painful oph- thalmia that so often attends smallpox, darkness is certainly a comfort, but that it diminishes tlie pitting I have much doubt. It is a comforting fact that even the deepest and ugliest pits gradually lose their distinctness as time passes, and that much of the marking disappears in the course of a few years. The surface should, however, be anointed with vaselin, cold cream, or similar substance, as they allay the burning and itching, keep the scabs moist, and prevent the contagium from spreading through the air. The odor, which is often intolerable, is perhaps best covered by adding carbolic acid to the vaselin or other unguent employed, say 10 grains (0.666 gm.) to the ounce (30 gm.) ; or a watery solution of carbolic acid may be made of the same strength and applied on cloths. Bichlorid of mercury, i to 2000, may be used in the same way. These preparations appHed cold on lint are sooth- ing and comforting. Dr. Schamberg, the assistant physician to the small- pox hospital in Philadelphia, says that, as the result of his experience in the epidemic of 1901-1902 in Philadelphia, painting with iodin seems to be more efficient in averting pitting than any other treatment. J. F. Romero claims to have used with most satisfactory results picric acid as a local measure to prevent pitting. He advises a lotion made mth 2 grams (30 grains) picric acid, 15 grams (half an ounce) alcohol, and 185 grams (six and a half ounces) water. An ointment may be made instead. He suggests that the picric acid may destroy the pyogenic germs that may find their way into the pustules. The eyes, nose, mouth, and throat should be kept clean, all crusts being carefully removed. This may be accomplished for the eyes by cold com- presses frequently changed, while the nose, mouth, and throat should be cleansed with borated gargles and lotions. As soon as convalescence is established the patient should bathe daily, using carbolic soap, the bathing being kept up until the skin is perfectly smooth, because only then does the patient cease to be a source of infection. Special Modes of Treatment. — As in the case of the other infectious diseases, smallpox offers encouragement to similar specific modes of treat- ment. The bacterium of smallpox, whatever it may be, does not seem to develop a toxic substance so virulent as that of diphtheria. The exhaustive effect on the system is that of the extensive inflammation and suppuration of the skin. The internal administration of antiseptics has been recom- mended, but seems to have furnished no results that particularly commend it. The substances tried are the usual ones — namely, sodium salicylate, salol, mercuric chlorid, carbolic acid, creasote,' the sulphites, and sulpho-carbolates. Upon the same plan as the serum treatment for diphtheria, serum from vaccinated subjects, both human beings and lower animals, and from smallpox patients in the advanced stage of the disease, has been used by Kinyoun, Lundmann, and Beclere. Analogy would lead us to expect 152 INFECTIOUS DISEASES. similar results to those obtained b}' antitoxin in diphtheria, but such has not been the case as yet. Special modes of external treatment, as by baths impregnated witli antiseptics, have also been used and brilliant results claimed. Galewouski '•' used solutions of potassium permanganate of such strengths as to make the baths a rose-red color. He claims reduction of temperature, disappearance of pustules, and speedy recovery. Talamon j recommends external applica- tion of mercuric chlorid spray to the skin, using a solution made up of cor- rosive sublimate and tartaric acid, each i gm. (15 grains) ; 90 per cent, alco- hol 5 c. c. (fo 1.25) ; ether, enough to make 50 c. c. (f5 1.33) ; spray three or four times daily for a minute, being careful to protect the eyes. The treatment is commenced on the first day of the eruption, being preceded b\' thorough washing of the face with soap, which is rinsed off with boric acid solution, and the skin then dried with absorbent cotton. After the spray lias been used the face should be covered with a layer of 50 per cent, of glycerolate of mercuric chlorid to keep the skin antiseptic. After the fourth day the number of spra3-ings is gradually diminished, and after the seventh day they are discontinued, though the glycerolate dressings are kept up. Talamon also recommended in the confluent and grave forms of the disease mercuric chlorid baths lasting from three-quarters of an hour to an hour, Vv^ith internal treatment including tlie usual supporting measures. These treatments commend themselves to reason and common sense, and as being disinfectant and cleansinsr at least. VACCINE DISEASE. Synoxyms. — Vaccinia; Vaccina; Cozvpox: Kincpox. Definition. — A'accinia is an infectious disease produced by inoculation of man with lymph from the vesicle of Idnepox. It is characterized by local and general sj-mptoms. Persons successfully vaccinated are, in the vast majority of cases, immune from smallpox. The local product of such vac- cination is the vaccine vesicle, the contents of which, when again inoculated, are capable of producing the same disease with immunity in another person not previously vaccinated. It is pre-eminently characteristic of vaccine dis- ease that it can be communicated only when introduced directly into the blood. Historical. — See History of Smallpox. There can be no doubt that, if vaccination were thoroughly carried out, smallpox could be stamped out. This is, however, not done, and in point of fact, a few cases occur annualh'- everywhere except in Germany, while at intervals an epidemic of greater or less severity occurs. A false sense of security leads to indifference about vaccination and revaccination, and thus gradually accumulate a number of susceptible persons who are liable to the disease. Nature of Vaccinia. — Two views as to the true nature of vaccinia are held — the English, that it is smallpox modified by transmission through the cow ; the second, or French view, that it is a separate disease distinct from * '• >red. Press and Circular," 1850. + ''Jour. Ol Cutaneous and Venereal Diseases," February, iSgi, " Gazetta medica Lombarda," i8go. VACCINE DISEASE. 153 smallpox. Each side claims that its own view is sustained by experiment. The form.er view is probably correct — that vaccinia is smallpox modified by passing" through the cow. Lymph in Use. — At the present time it is almost the universal practice to use animal lymph or the lymph directly from the cow, although human- ized lymph, that from another person having vaccine disease, can also be successfully used. The chief reason for using animal lymph is that all dan- ger of communicating other affections, especially syphilis, is thus avoided, although there is reason also to believe that protection is more certainly secured by animal lymph. For securing the cow-lymph numerous farms exist in this country and in Europe, where, under the most perfect sanitary precautions, inoculation is practiced on the udder of heifers, whence the lymph is gathered and distributed. In Belgium the heifers are slaughtered after the lymph is taken, and if they are found diseased, the lymph is not used- In this country the m.ore usual method is to allow the lymph to dry on ivor}* points or quills, or to collect it in capillary tubes. Before the use of animal lymph became general the crusts, or scabs, from vaccinated arms were pre- served and iiYoistened to the consistence of pus before inoculation. Bacteriology. — The inoculating element of vaccine virus has not been isolated. Analogy leads us to expect some organism will ultimately be found in the fluid of the pock. Quist has cultivated micrococci from vac- cine lymph, which, he claims, produced in the child a typical vesicle ; while Harold Ernst and Martin, of Boston, have isolated from bovine lymph a germ which grows on culture-media and produces, when inoculated in the heifer or children, characteristic vesicles. Klein and Copeman have each found a bacillus, and Pfeiffer and Ruffer bodies regarded as psorosperms. Peculiar ameboid bodies have been niet in the blood of vaccinated persons. Operation. — The operation of vaccination is variously performicd. I prefer, after thorough cleansing, to scrape the skin of the arm or forearm with a lancet until the cuticle is removed and a moist surface results, due to the transuded lic[Uor sanguinis. On this is expressed from the capillary tube the virus, or the ivory point is rubbed, slightly moistened. Prolonged fric- tion is desirable to secure success. I am confident I have been more invari- ably successful since I have used capillary tubes instead of ivory points. It is a disadvantage to have the surface bleed much, as it interferes with absorption. Another method, handed down by the late Professor George B. Wood from his predecessors, and available only with liquid lymph, is to make three slight punctures obliquely under the cuticle and work the lymph into each. The punctures should be about a line apart and at the angles of an equilateral triangle. Very convenient instruments of various kinds are made to scratch the surface, which are especially useful when a large number of vaccinations is to be made and celerity is desirable. At the present day it is quite the fashion to inoculate on the leg, especially in the case of girls, in order to avoid an unsightly scar on the arm. In infants there is no objec- tion to this, but I have known young girls to be very seriously disabled for a time by vaccination upon the leg. Another advantage of inoculation on the leg of infants is that there is less liability to injure the afifected limb in nurs- ing or carrying. The same thing is nearly as well accomplished by vacci- nating the forearm, but this makes the resulting scar needlessly conspicuous. Another favorite situation is the region of the insertion of the deltoid muscle. The Phenomena of Vaccination. — Immediately succeeding the opera- tion a slight inflammatory redness appears, which usually subsides rapidly, 1 5 4 ^ A^^^£ C TI US DISEA SES. and sometimes has entirely passed away before the tirst phenomenon of the vaccine disease appears. Thus, there is a true period of incubation, after which, usually on the third day, but often two or three days later, a slight red elevation makes its appearance. By the iifth or sixth day this has already become an umbilicated vesicle tilled with a transparent viscid fluid, surrounded by a delicate red areola. The vesicle presents a shining" silvery appearance; by the eighth day it becomes a lustrous silver-gray, and by the tenth day the vesicle and areola have both reached their maximum. The pock is by this time 1-3 inch in diameter (about i an.), one to two lines in height, umbilicated at its center, and presenting frequently a minute brown spot or scab in the same situation. The areola is quite angry looking, often two inches (5 cm.) or more in diameter, and shows under a magnifying glass numerous minute vesicles on its surface. At this stage, too, it itches and burns to a degree which causes in adults an almost irre- sistible desire to scratch, while in the child it gives rise to fretfulness and peevishness and to slight fever. Even in the adult there is slight rise of temperature. On the eleventh or tzvelftJi day the disease begins to decline. The areola narrows and becomes less bright, the lymph more turbid and begins to dry. By the end of tzvo -weeks the vesicle has been converted into a dry, brown scab, which generally drops off on the twenty-iirst to twenty-fifth day. A scar remains, which is very distinct at first, but gradu- all}' assumes even a whiter hue than the surrounding integument. The course described is the typical one in a healthy vaccinated child. In other cases the amount of local irritation is much greater, with a cor- responding degree of constitutional disturbance. There is often adenitis in adjacent glands. Sometimes, in ill-conditioned children, deep, tmhealthy ulcers supervene that are very slow to heal, while erysipelas and gangrenous ulcerations have even occurred and been followed by death. Even tetanus has succeeded upon vaccination and it has been claimed that the bacillus of tetanus has been inoculated with the germ of vaccine resulting in the simul- taneous development of tetanus, but, so far as I know, none of the claims as to this combined inoculation have been substantiated. Tetanus resulting from simultaneous inoculation should appear 5 to 9 days after its introduc- tion, whereas, in tlie cases commonly reported, 3 to 4 weeks have elapsed before tetanus developed. This seems to have been the case witli the epi- demic in Camden, N. J., in the fall of 1901. Since the incubation period of vaccination is shorter than that of small- pox, the prompt vaccination bf a person exposed to smallpox may protect him, or at least modify the disease. Vaccination Rashes. — In certain cases, especially when vaccination is done with the liquid lymph from the cow, a general eruption of vesicles takes place, constituting vaccinia bullosa; associated with miliary vesicles it is called vaccinia miliaria. At times a roseolar eruption is associated, — roseola vaccinalis, — not unlike the roseolar eruptions of syphilis. The vesicles may be filled with blood — vaccinia hcenwrrhagica. Revaccination. — Should a considerable time elapse after vaccination, a revaccination will generally be more or less successful. Usually, the entire set of phenomena is less characteristic, although it sometimes happens that the same typical course is repeated. Such successful vaccination is regarded as evidence that immunity from smallpox is no longer present, and the per- son, if exposed to smallpox before vaccination, would have taken it. Such an attack is almost invariably less severe, and presents the modified symptom- VACCINE DISEASE. 155 atology known as that of varioloid. The period of exemption after vac- cination varies greatly. It is often perpetual. More frequently, it lasts from ten to twelve years, and every person should be revaccinated at ten to fifteen years, and thereafter whenever an epidemic of smallpox is raging, unless he happen to have been successfully vaccinated within a few years. At times, even in first vaccinations, an abortive result obtains, the vesicle drying and dropping off much too early. Should this occur, the operation should be repeated. Possibility of Transmitting Disease by Humanized Lymph. — It has already been said that the possibility of transmitting disease by vacci- nating with humanized lymph has been a potent influence in stimulating the employment of animal lymph. Syphilis seems the only disease that can be thus transmitted, although it has been claimed also for tuberculosis. It is, nevertheless, important that every precaution should be taken against such accidents. If humanized lymph be used, as it sometimes must be, only that from children of healthy parents, free from syphilis or tuberculosis, should be selected, and under all circumstances lymph admixed luith blood should be rejected. Lymph should be taken from fully matured and perfect vesicles on the eighth day. It is exceedingly important that the physician should have at hand the data of discriminating between the ulcer of vaccinosyphilis and of vaccina- tion ; and between secondary vaccinosyphilis, the vaccination rashes, and hereditary syphilis occurring about the tim.e of vaccination. Such data are found in the following table compiled by C. S. Shelly from Fournier, in Fowler's " Dictionarv of Medicine " : Vaccinosyphilis or Vaccino-Chancre. Chancre developed on the site of usually one or two only of the vaccination punctures. Inflammation is slight. Loss of substance superficial only. Suppuration scanty or absent, scabs, or crusts. Border of chancre smooth, slightly ele- vated, gradualljr merging into floor. Surface of floor smooth. Induration"parchment-like," and specific, not merely inflammatory. Inflammatory areola very slight. Gland swelling constant, indolent [syph- ilitic] bubo. Complications rare. Chancre never developed before the fif- teenth day after vaccination; usually not until after three to five weeks; it is still in its earlier stage twenty daj'S after vaccination. Secondary Syphilitic Eruption due to Vaccinosy'philis. Appears, at the earliest, nine or ten weeks after vaccination. Requires, in every case, the pre-existence of a specific ulcer [chancre] at the site of vaccination. Vaccination Ulcers. Ulceration affects all the punctures, as a rule. Inflammation and ulceration severe. Ulcer deeply excavated. Much suppuration. Margin of iilcer irregular, as in " soft chancre." Floor of ulcer uneven, suppurating. Induration inflammatory only. Areola inflammatory and er3'sipelatous. Gland swelling often absent; if present, merely inflammatory. Complications — sloughing, erysipelas,etc. — often present. Ulceration is present twelve to fifteen days after vaccination and is fully developed the twelfth day after vacci- nation. Vaccination Rashes. [Including roseola vaccinalis, miliaria vac- cinalis, vaccinia bullosa, vaccinia hsemorrhagica; also accidental erup- tions — rubeola, scarlatina, lichen, , urticaria, etc.] A true vaccinal rash appears between the ninth and fifteenth day after vacci- nation. Absence of inoculation chancre. J 50 IXFECTIOi'S DISEASES. Exhibits the character of a true specific Eruption does uot exhibit specific char- eruption, acters. Fever often slight. Fever always present. Lasts for a long time. Usually acconi- Evanescent, panied by specific appearances on mucous membranes. Vaccinosyphilis Hereuitary Syphilis, Showing Iisel? AJoUT THE Ti.Mi-: of Vacclnaiiox. Begins with local infection chancre and No chancre; begins with general phe- indolent bubo. noniena. Typical development in four stages — viz.. Has no typical development in connection incubation, chancre, second incuba- with vaccination, tion, generalization [secondary erup- tion], etc. Never appears earlier than the ninth or Time of development quite independent tentii week after vaccination. of vaccination. Is attended by the characteristic syphilitic bodily as- pects. Other manifestations of he- reditary syphilis may be present. The history may indicate syphilis. Some idea of the efficiency of vaccination may be obtained from the faci: that through it smallpox has been blotted from the German army, P\irther, it was early shown by Marson that of those who have acquire J smallpox after vaccination, the disease is vastly less severe than in those who have primary smallpox. This is confirmed also by the statistics of \Y. jM. Welch, Physician-in-charge of the ^Municipal Hospital of Philadelphia, From a study of 5000 cases, he showed that where there were good cicatrices, only 8 per cent, died ; with fair cicatrices, 14 per cent. ; with poor cicatrices, 27 per cent. ; unvaccinated cases, 58 per cent. CHICKEX-POX. S vxox YM. — [ 'aricella. Definition. — Varicella is an acute contagious disease of children, char- acterized by an eruption of vesicles with pearly contents and attended with little or no constitutional disturbances. Etiology, — The disease is eminently contagious, but no specific causal organism has been isolated. It is almost purely a disease of chUdhood, occurring most frequently between the second and sixth year. It is a dis- tinct and separate disease from smallpox, an attack bringing no exemption from that (lisease. Symptoms. — The period of incubation is from ten to fifteen days. So slight is the constitutional disturbance that very commonly the appearance of the eruption is the first notification of the child's illness. At tiir.es there are slight prodromal peevishness, restlessness, and fcverishness; at others there is a slight chill followed by fever. Some muscular pain may be present. A prodromal scarlatinal rash may rarely present itself, but for the most part the suddenness of the eruption is distinctive. It presents itself m the shape of isolated pimples scattered over the body within the first twenty- four hours after constitutional disturbance. They may then appear first on the trunk, but are apt to be seen first on the face. In another twenty-four hours they are pearly pustules, as a rule, without um.bilication or areola ; and by the end of the third day they begin to dry up, and in another day are WHOOPING-COUGH. 157 converted into clark-brownish crusts, which drop off, usually leaving no scar. Sometimes, however, a distinct pit is left, especially if the pock be scratched by the child, as it sometimes is, because of the irritation it excites. Occa- sionally, too, the pustule is distinctly umbilicated and may also have a pink areola. The pustules appear in crops, so that on the fourth day they can be seen in all stages, but at the end of a week again all have disappeared. Rarelv are there more than half a dozen on the face, though they may be quite numerous and the victim well dotted over. They occur also on the scalp. I have never seen any complications with varicella, and in most cases under my observation the disease would have been overlooked but for the eruption. It is said, however, that hemorrhagic pocks sometimes occur accompanied by hemorrhage from the mucous membranes; that nephritis and even gangrene — varicella gangrccnosa — have occurred, and infantile paralysis has developed during an attack of the disease. Diagnosis. — The diagnosis should not detain one long. The trifling constitutional disturbances, the rapid, almost sudden, development of the pustules, the absence of umbilication and of areola — all distinguish the dis- ease from smallpox. Prognosis. — This is invariably favorable, except in rare cases of vari- cella gangrenosa. Treatment. — Usually none is needed save the application of a simple lotion or ointment to allay the itching. The principal need of the physician is to make the diagnosis. I conclude the section on the eruptive diseases with the following table, somewhat modified, from T. M. Rotch, wdiich may be helpful in diagnosis : Scarlet Fever. Measles. Variola. Varicella. Rubella. Incubation, . . . Prodrome, . . . Efflorescence, . . Two to four days. Two da^-s. Erythema. Seven 1 fourteen days. Three daj-s. Papules. Seven to twelve days. Three days. Macules, pap- Ten to fif- teen days. A few hours. Vesicles. Fourteen to t wen tj'- one da^'^s. Afewhours. Papules. Desquamation, Lamellar. Furfurace- ules, vesicles, pustules. Lar^e crusts. Small crusts. Complications and sequelae, . . . Kidney, ear, and heart. Eve and lung. Larynx, lungs, eyes. WHOOPING-COUGH. Synonyms. — Pertussis; Hooping-cough. Definition. — Whooping-cough is an infectious disease, characterized by spells of coughing accompanied by a long-drawn inspiration producing the " whoop," whence the disease is named. Historical. — While the writings of Hippocrates, Galen, and Avicenna containex- pressions that point to the existence of a specific disease like whooping-cough, it is still disputed as to whether this disease was known to the Greeks. The fi_rst pub- lished account appears to be bv Baillou, in 1578. He described an epidemic occurring in Paris and spoke of it as a disease not previously known. A hundred years later, Willis wrote of /ussz's pnerorum coiivjilshia, evidently the. disease under consider- ation, which has since become omniprevalent. 158 INFECTIOUS DISEASES. Etiology. — It is interesting to note that Linnaeus ascribed whooping- cough to the larvae of insects in the nose. No specific organism has been generally agreed upon, though a number of candidates for this important role have been brought forward. Thus, in 1887, Afanassieff found in sputum from the disease a short bacillus, of which he has succeeded in mak- ing cultures, inoculations from which into the tracheae of animals have pro- duced catarrhal conditions. Letzerich also found a micrococcus in the sputum with which he claimed he was able to produce the disease in animals by introducing the sputum into the trachea. Koplik's bacillus seems better accredited, and is apparently the same as that described by Czaplewski and Hensel, as found in mucous clumps in the sputum.* Koplik found it in 13 of 16 cases. It is faculative anaerobic, and is not stained by Gram's method except in pure culture, in which it can be separated from other bacilli found with it. It is pathogenic for mice. It is found free and in pus-cells of mucus. It is not found in sputum during the prodromal stage. Whooping-cough attacks children of all ages not rendered immune by previous attacks, though it is most usual between the first and second denti- tions ; nor is it a very rare affection in adults, in whom it may become serious. It is said to be more frequent in girls. Its epidemics are more common in the spring and winter, and often precede or follow those of scarlet fever and measles. The disease is generall}^ communicated from one child to another, and few escape who are exposed. Sporadic cases also occasionally occur. The delicate and those suffering with bronchial and nasal catarrh are more vulnerable. Some, persons are immune. Morbid Anatomy. — There is no morbid anatomy peculiar to whoop- ing-cough beyond the catarrhal inflammation. According to Myer-Huni and V. Heroff, this is most marked in the mucous membrane of the nose, larynx, and trachea down to the bifurcation, but especially on the posterior wall of the pharynx, and in the interarytenoid region — the so-called " cough region." The morbid states found after death are those of the complica- tions — viz., bronchitis, bronchopneumonia, and collapse of the lung. Vesicular and interstitial emphysema are sometimes present, the former from over-distention of the air-vessels, and the latter from their rupture. Symptoms. — Whooping-cough has a period of incubation of from seven to ten days. There is no prodrome separable from the preliminary stage, beginning with cough which is in no way peculiar, being that of an ordinary cold with slight fever and without expectoration. There may be corysa and injection of the conjunctiva. This cough may go on for a couple of weeks and, if there be nothing in the history to suggest the nature of the disease, may occasion no suspicion. Toward the end of this period, how- ever, the observing mother will have noted that the cough is gradually grow- ing worse and becoming paroxysmal, that it occurs " in spells." Then sud- denly a " whoop " is noted and the nature of the disease is suspected. The paroxysmal stage has replaced the catarrhal, and soon the diag- nosis is plain. The paroxysms become more frequent and more severe. Each one begins in a succession of short expiratory coughs, which grow in intensity. All efforts lie in the direction of expiration, and all the expiratory muscles are brought into play to this end. The chest is compressed laterally, and bulges in the sternal region. As the result of such efforts, the face is flushed, the eyes are injected and bulging, the tears start, and the nose dis- * For an exhaustive review of this siihiect with some original observations pointing: to this con- clusion, see a paper on " The Etiologfy of Pertussis," by Joseph Walsh, in " Contributions from the William Pepper Laboratory of Clinical Medicine," Philadelphia, iqoo, p. 450. WHOOPING-COUGH. 159 charges. Finally, the paroxysm termmates or is interrupted by a loud, whooping inspiration— -that is, it may end for the time or be immediately succeeded by another similarly concluded paroxysm. Severe paroxysms commonly terminate in an act of vomiting, which brings up considerable mucus, which often collects before the paroxysm begins and seems to be its exciting cause. The number of paroxysms in the twenty-four hours varies greatly. They may be as often as every half-hour or only four or five times in the day. Emotion will precipitate a paroxysm, as will the inhalation of irritant matters. The little patient resists the paroxysms as long as possible, and when the inevitable comes it will run to the basin or bowl, knowing full well what is to happen. The demure method pursued by little children under these circumstances is often at once touching and amusing. I have known each one of a family of a half-dozen children to have its own cup ready for seizure at a moment's notice. Rupture of a conjunctival or nasal blood-vessel sometimes occurs and occasionally an involuntary urination. An ulcer may form at the frenum of the tongue, said to be due to the press- ure of that part of the organ against the incisor teeth. The termination of the paroxysm is followed by temporary relief. The paroxysmal stage, if uncomplicated, is unattended by fever, and physical examination of the chest is barren of results as compared with the severity of the cough. The percussion note is clear, clearer during inspira- tion. Auscultation may discover a few moist rales soon after a paroxysm ; but during it, nothing. Even during the whoop the vesicular murmur may be absent, because of the slowness with which the air enters the chest. The length of the paroxysmal stage is usually from four to six zveeks, although in mild cases it may be shorter. Indeed, there are mild cases of whooping-cough in which the paroxysms are scarcely noticeable and would not be noted except for an occasional " whoop." Toward the end of this period the paroxysms become less severe and less frequent, and soon the stage of decline or convalescence is established. In the course of it the paroxysms become still milder and less frequent, and finally subside alto- gether. They are, however, liable to be renewed for a time if the patient takes cold, and even digestive disturbances are said to have a similar effect. The other phenomena of the stage of convalescence are return of appetite, weight, and strength. The period of convalescence occupies another four weeks, so that the entire length of an ordinary attack of whooping-cough is from ten to twelve weeks, and even longer. Complications and Sequelae. — The complications that attend whoop- ing-cough are bronchitis, bronchopneumonia, collapse of the lung, pleurisy, and interstitial emphysema. The bronchopneumonia is apt to be of the insufflation kind. Collapse of the lung may succeed it. Interstitial emphysema and even pneumothorax may result from rupture of the air- vesicles, and it is apt to become general and serious. In a case of this kind under the care of my friend, Horace Williams, which terminated fatally, an abscess formed at each point at which the emphysema approached the sur- face. Cerebral palsy and death from subdural hemorrhage are said to have occurred in whooping-cough. Among sequelae may be mentioned, as a rare event, tubercular consumption ; also permanent changes in the shape of the chest including the so-called pigeon breast, sometimes the result of a pro- longed attack of whooping-cough. Diagnosis. — The diagnosis cannot be delayed after the appearance of the whoop, and it is scarcely possible without it. Spasmodic cough may i6o INFECTIOUS DISEASES. occur from other causes, but it is not whooping-cough unless there be the Avhoop. Prognosis. — Xotwithstanding the enormous number of children who have whooping-cough and get well of it, many of them without any treat- ment whatever, it is not so harmless a disease as many suppose. At the same time I cannot believe that the position assigned to whooping-cough by Thomas AI. Dolan,* of being third among the fatal diseases of children in England, is true of this country. The chief danger is from the complica- tion of bronchopneumonia. The younger the child, the greater the danger. As already stated, cases in which interstitial emphysema occurs from rupture of the air-vesicles may terminate fatally. The disease is more serious in the negro race — more than twice as fatal as in whites. Treatment. — The treatment of whooping-cough is one of the opprobria of medicine. Xotwithstanding the claims of many to the contrary, it remains a fact that we possess no means of cutting it short. We may, however, pal- liate the disease by diminishing both the freciuency and the severity of its paroxysms. The remedies to this end are the opiates, chloral, and antispas- modics. The former two, as a rule, should be reserved for night, though in severe cases chloral in doses sufficient to secure somnolence is recom- m.ended by Willoughby.f Of the latter, the most efficient are belladonna, the bromids, and asafetida. Belladonna should be given in full doses. It is difficult to name them, and they must for the most part be arrived at by trial. We may begin with i minim (0.066 gm.) of the tincture every tw^o hours to a child of six months, or 1-12 grain (0.0055 ^'^•) of ^^^^ extract, and increase the dose until the characteristic redness of the skin is produced. The bromids, preferably of sodium, should be given as often, in doses of I or 2 grains (0.066 to 0.132 gm.) for every year of age. I am confi- dent, too, asafetida is useful. I use it in the shape of a freshly spread plas- ter, large, so as to cover the whole of the front or back, and bandaged to keep in place. It should be renewed often. The odor is soon endured. Antipyrin has acquired some reputation and has been especially recom- mended by F. J. Taylor.J and \"on Genser. The former says in many cases its action is little short of marvelous. He recomniends beginning with a small dose, increased until a child of two years is taking two or three grains every three hours. The bromids of potassium, sodium, and ammonium may be combined with it. The same writer recommends alum to check excessive secretion in the later stages, three grains, every three or four hours, to a child two years old. Von Genser recommends two grains a day for each year of age and reports recovery m 24 davs. The intervals between the paroxysms at night may be prolonged by the judicious use of paregoric, deodorized tincture of opium or codein com- bined with the antispasmodics, including belladonna and the bromids. The inhalation of germicidal solutions suggested by the probable germ origin of the disease has not as yet produced any results. Carbolic acid. 5 to 1000, corrosive sublimate, i to 4000, and the peroxid of hydrogen diluted with two parts of Dobell's solution may be used in this way. The remedies pr° better used with the steam atomizer, as the steam itself has a soothing effect. * " WhooDini^-congh.'" London. 1882. + "Am. Joiir. Obstetrics." Jiir.e, tSoS. i " Annals of Gvnaecolog-y and Paediatrics " Tulv. i8oq. See also very full paper, giving: the ex- pori"°nce of many phvsicians', in "Gazette Hebdom'. de TMed. et Chirurg."," October 22, 1896, bv Le Goff. Abstracts in " New York Med. Jour.," November 14, 1896. MUMPS, i6i Parents should be enjoined to protect their children from undue expo- sure, because it is this that causes complications, and it is the complications that are dangerous. Such complications, and other symptoms which arise in the course of the disease, should be treated by appropriate remedies. The possibilities of serum therapeutics extend to the treatment of whooping-cough, and Dr. Walsh, in the paper alluded to, refers to results ■obtained by him which encourage further trial. MUMPS. Synonym. — Epidemic Parotitis. Definition. — Mumps is an acute infectious disease characterized by inflammation of the parotid gland, sometimes of the submaxillary. Etiology. — Although a bacillus parotidis has been described, it is gen- erally conceded that the real contagium of mumps has not been isolated. Children and adolescents are its favorite subjects, the very young as well as adults being equally exempt. More boys are attacked than girls. The disease is more common in the spring and fall. It is more commonly epi- demic, but may be sporadic. It may be associated with measles and whoop- ing-cough. One attack protects against a second. Morbid Anatomy. — The swollen and hardened salivary gland is the sole morbid product. The swelling is mainly due to serous infiltration. Symptoms. — From seven to fourteen days intervene between exposure and the invasion, which is ushered in by moderate fever, rarely exceeding 101° F. (38.33° C), although 103° and 104° F. (39.44° and 40° C.) have been noted. The first symptom is usually pain helozv and in front of the ear, but pain in swallowing may be first experienced. Simultaneously, there may be sivelling about the ear, which extends rapidly in front of the ear and below it until the entire neck in this vicinity is involved. The maximum swelling is reached in about forty-eight hours, after which the involvement of the other side begins and extends with equal rapidity. The most prominent point is in front of the ear! The swelling does not, however, subside as fast as it comes on, but persists from seven to ten days. At the height of the disease the pain and difficulty in swallowing are extreme, the former extending often to the interior of the ear, producing earache, and the hearing may be affected. The parts are so tense and swollen as to make opening of the mouth almost impossible, mastication equally difficult. Suppuration is an exceedingly rare event. In cases of great severity delirium is sometimes present for a short time. Complications. — The most frequent complication is orchitis, and occur- ring, as it commonly does, after inflammation of the salivary glands has sub- sided, it has been regarded as a metastasis ; but this is probably not the case, since both conditions may be the result of the same cause, as originally held by Niemeyer. The swelling may affect one or both testicles, the duration being longer in the bilateral form. The organs are heavy and painful, but not so much so as in gonorrheal orchitis.' The inflammation lasts for three or four days and then subsides gradually. Usually, the gland itself is involved, but occasionally there occurs acute epididymitis with acute "hydrocele . and edema of the scrotum. Atrophy is said to have supervened. i62 LYFECTIOUS DISEASES. Inflammation of the mammary glands and of the vulva sometimes occurs in girls, and more rarely of the ovaries. Otitis media with resulting deafness, meningitis, and facial palsy are occasional complications. Diagnosis. — The diagnosis usually presents no difficulties, and any doubt is commonly cleared up by the acuteness of the attack. Certain enlargements of the cervical lymphatic glands resemble contagious parotitis, and in scrofulous children the swelling in mumps is sometimes pro- longed, but the physiognomy in this disease is different and distinctive. There is more swelling in front of the ear in parotitis, and in the first stage a triangular shape is produced with the apex downward, while the lobe of the ear is raised in a characteristic manner. Prognosis. — The prognosis is favorable, no fatal cases of uncompli- cated mumps being recorded. Treatment. — No means of shortening the duration of the disease exists. The patient should be kept uniformly warm, and to this end the bed is desir- able. It is usual to anoint the gland with some simple ointment, as cold cream, and it may be that the feeling of drawing and tension is thus relieved. No commensurate advantage results from leeching. It is thought by some that the so-called metastasis is occasioned by exposure to cold, and if this be true, there is even better reason for keeping the patient warm. Warm applications are generally better borne than cold. Cotton or wool or flannel,, warmed and greased, gives a sense of comfort. Fever should be treated by appropriate remedies and other symptoms met as they arise. Secondary Parotitis. — This term is applied to parotitis occurring as a complication in acute infectious diseases, typhoid fever, typhus fever, and pneumonia being the most frequent. It may be a complication of pyemia, phthisis, and carcinoma. Except in pyemia, when it is metastatic, it is proba- bly caused by the bacteria of decomposing matters in the mouth, which reach the gland through the duct of Steno. It is a much more serious affection than mumps, and often terminates in suppuration. Facial paralysis may result from destruction of the facial nerve, or there may be deafness from invasion of the middle ear. The treatment of secondary parotitis is that of phlegmonous inflamma- tion elsewhere. INFLUENZA. Synonyms. — Cdtarrhal Fever; Grip ; Fr., La Grippe: Definition. — Influenza is an acute infectious disease characterized by fever, by catarrhal irritation of any or all of the mucous tracts, especially the respira- tory, by muscular pain, and by great prostration. It is commonly epidemic. Historical. — Although influenza appears to have prevailed as early as 1173 in Italy, Germany and England, it was not until 15 10 that it was recognized in its true light as an epidemic or pandemic disease. Since that date it has recurred at intervals of from four years to one hundred 3'ears. Up to 1870 more than a hundred epidemics had been described. It first appeared in the United States in 1627, in Massachusetts and Connecticut, and extended thence over South America as far as Chili. Since i88(^ there has been an epidemic extending almost around the world. It usually begins in the east and travels westward. The last epidemic started in Bokhara, in May, i88q, reached St. Petersburg in October, Berlin in November. London in December, and the eastern cities of the United States by the middle of December. While its rate of travel is rapid, it is not more so than travel itself. Its spread is not influenced b}?- the direction of prevailing winds. It travels as rapidly against the wind as with it. some observers say more rapidly. A district invaded in the fall of the year is apt to be in- fected more or less for several months. Since the epidemic of 1S89 there has been some influenza each winter in the epidemic form in many American cities. INFLUENZA. i6- Etiology. — In 1892 Pfeiffer discovered in the pus-cells of tracheal mucus an organism which he regarded as that of influenza. It is 0.8 to i GRAPHIC CLINICAL CHART. MARK PULSE-nn- RESP; -^^ TEMP. Name, Age, -Residence, Disease, Case. No., Date, DAY OF MONTH "* 2 S s s s s s ?! S5 5; c5 s DAY OF DISEASE « ^ >c ^ - «> 3S = 2 2 ^ »o TIM DA EJ'A.M. c ^ « C5 ■a ^ ^ Si SI 00 - -A 2 2 a, - W 00 y\ P.m. •^ 22 ^ 2 N 0, * •^ = « - 0, »o §1 *o liiill. =- -46- -r- = - -::- -£- -=- -r- -=- S" ■=J -=- s -- S -=- -J -=- .=- -'- % ■r- -:- ■:- -s- -0 ^=- 'J- -=- -=- i- --:^- - — ^^ 1 , ' ' '^ '-N '-•< cvj bi c - -=- -C- ^ -=- -s- ■5 4 -::- < — p^- — ± ^ -s- -=- ^ < '*1 :- § p^ < rt (i f: < a

•- 03 SI •4i\ ^ ^^^^ -^ ■|= ^ .o_ 22 -0 ■2 :n -O -y , S-| ^- 2 i>. Is. ts- >8^ r> loO^ ' 11 1 ^JJ 1 ^';l^ E _JJ,Q 1 f 1 t 1 f\ l-iO \i\ 1 - a n 1 " M - r ■^ /) > r 1 y -IH|- . I y .,SII- v 4 -,-11- ' 4^ -HI- _ . mm ^ 1 _ . , ^ ^ _ Fig. lb. — Chart of a Case of Influenza — Medical Student. micron long and o.i to 0.2 micron broad — i. e., about the same width as the bacillus of mouse septicemia and half as long. It forms colonies on glycerin agar twenty-four hours after inoculation, visible under the microscope as clear, water-like drops. These drops do not coalesce, but remain separate. The bacilli are best stained in dilute Ziehl-Neelsen solution of carbol fuchsin or hot Loeffler methylene blue solution. Later studies tend to sustain Loeffler's claim. The bacilli are very numerous in the nasal and bronchial mucus, whence they are conveyed to others, constituting a true contagiura. P. Canon has even found them in the blood. The contagious nature of mfluenza is further sustained by the fact that it travels only as fast as people travel, even contrary to the direction of prevailing winds. The fact that inoculations have thus far been unsuccessful in transmitting the disease i64 INFECTIOUS DISEASES. is, however, against its contagious nature. The compHcations and sequelae of the disease — pneumonia, pleurisy, endocarditis — may be the result of a toxin, or the bacillus may be transmitted in the blood to the seat of secondary infection. One attack does not, however, protect against a second, and I know persons who have had an attack each winter for several winters. Varieties. — There is much carelessness at the present day in the appli- cation of the word " grippe." Commonly, when a person is said to have " grippe " it means that he has a bad cold in the head, with more or less bronchial catarrh. This seemingly is what Leichtenstern calls endemic inUuensa nostras, pseudo-influenza, or catarrhal fever, a special disease of unknown etiology, which bears the same relation to the true influenza as cholera nostras to Asiatic cholera. In addition, Leichtenstern makes two other divisions — (i) epidemic inflnenza vera, caused by Pfeiffer's bacillus; (2)£'ndemic influenza vera, which often develops for several years in suc- cession after a pandemic, also due to Pfeiffer's bacillus. Morbid Anatomy. — The anatomical changes are those of the compli- cations. Whatever alterations are the direct result of the disease itself for the niost part promptly disappear after death. Symptoms. — Influenza has a period of incubation of from two to three days or longer. It attacks all ages, infancy less commonly, more frequently persons from twenty to fifty years old. The mode of onset is by no means the same. The attack may be ushered in by a chill or continued chilliness. Most frequently, perhaps, there are coryza and sneezing, with or without watering of the eyes. To this succeeds cough, to which is commonly added, very soon, copious expectoration. The cough may be paroxysmal and be attended with prostration at the end of the spell. It is often per- sistent, while the bronchitis may pass into bronchopneumonia or a croupous pneumonia may supervene. Less frequently, there may be faucitis, simple, however, and not accompanied by ulceration or white patches. These symp- toms are more or less associated with muscular pain, although not invariably. At other times the attack begins with severe pain in the back or back of the head, the chest zvalls, the extremities, or throughout the muscular system. Such pain is sometimes severe and sudden. Severe headache may be associated. Another mode of onset is by an extreme and sudden prostration. I have known a man to step from a railroad station, apparently well, and in the course of a few hundred yards become so weak as to have to take a car to reach his home, though not distant. This prostration is apt to be pro- longed even in mild cases far beyond what seems reasonable. Mental depression is a frequent symptom, and suicide and even manslaughter have been said to be its terminal acts. There is always more or less fever. Commonly, it is slight at first, but sometimes very high, ushering in the febrile variety of the disease. I have known it to be 106.2° F. (41.2° C.) at the first observation of a patient. More frequently, it does not exceed 103° F. (39.4° C), and it is often but slightly above normal. During convalescence the temperature may become subnormal, and in the patient alluded to there was a fall from 106° F. (41.1° C.) to 96° F. (35.6° C.) in a very short space of time. Further, the temperature chart may exhibit fantastic changes, as seen in that of the case of a medical student who made a good recovery after twenty-eight days' illness (see Fig. 16). Delirium is sometimes associated with the fever, and may come on suddenly and actively. The pulse is usually cor- INFLUENZA. 165 responding!}' frequent, but some cases of uncommonly slow pulse have fallen under my observation. While pulmonary catarrh is perhaps the most frequent catarrhal mani- festation, it is by no means always present, even when there are pulmonary symptoms. I recall an obstinate case of bronchial spasm without any secre- tion whatever. In the epidemic, especially of 1893-94, in Philadelphia and vicinity, gastric catarrh was frequent, producing distressing nausea with vomiting, and adding greatly to the physical weakness. Severe vomiting may even usher in the attack, especially in children. More rarely there is diarrhea. Herpes is sometimes present. According as one or another set of symptoms predominates, the disease is said to belong to the respiratory, nerv- ous, gastro-intestinal, or febrile form of influenza. Complications. — The most serious complication is pneumonia. It is often invited by exposure during convalescence or in the attempt of a patient to fight out the disease without giving up. In these events it is usually ushered in by a chill and extends rapidly through the whole of one lung or even both lungs. When a part of the primary attack, the pneumonia is more apt to be catarrhal and circumscribed, creeping from the bronchi into the air-vesicles, and is less serious, although it may also be fatal, espe- cially in old persons. At other times the inflammation is confined to the minute bronchioles, and we have the physical signs of a capillary bronchitis. It may be associated with pleurisy. Of cardiac and vascular complications endocarditis, pericarditis, irregularity of the heart unassociated with evident endocarditis or pericarditis, may arise. Sudden heart failure is to be remem- bered as a possible cause of death, as I have reason to know from experience. Of nervous lesions meningitis and encephalitis have been noted, even abscess of the brain ; also neuritis and optic neuritis ; in fact, almost every form of nervous disease, though some of the conditions must be referred to errors of diagnosis, cerebrospinal fever being probably responsible for some. Herpes, when present, is probably a result of neuritis. Mention should not be omitted of venous thrombosis — phlegmasia alba dolens — as a complication of influenza, Leyden and Guttmann having collected 28 cases.* A most important fact to be remembered in this connection is the tend- ency of influenza to develop latent disease into active disease, and to make slight grades of organic affections more serious. This is particularly seen in connection with heart disease and kidney disease. A small albuminuria with no other symptoms may become, after an attack of influenza, an in- curable and rapidly fatal Bright's disease.f A mild cardiac affection, scarcely noticeable by its symptoms, may become a grave illness with degeneration of muscular substance and dilatation of the cavities. Diagnosis. — The diagnosis is ordinarily easy, although doubtless during an epidemic many cases are called influenza that are cases of simple bronchitis, faucial angina, or nasal catarrh. The diagnostic features in addi- tion to the catarrhal factor are the suddenness of attack, fever of short dura- tion, extreme disproportional prostration. Muscular rheumatic pains are characteristic, but not always present. Cerebrospinal fever and inUiienza are sometimes confounded. The distinction will be considered when treating of the former. I have more than once tjhought of a case in its incipiency that it was going to be one of typhoid fever, but the suddenness of onset, absence of the typical temperature of typhoid, of epistaxis, of diarrhea, * " Deutsche med. WochenschriEt," No. 6, iSgy. t See a paper by G. Baumgarten on " Renal Affections Following Influenza," in " Transaction of the Association of American Physicians," vol. x., 1895. i66 INFECTIOUS DISEASES. together with the shorter duration of the iUness, turned the scale in favor of influenza. Prognosis. — The prognosis is generally favorable, especially if the patient goes to bed at once, or at least houses himself. Such a one is almost sure to be well in three, four, or five days. It is possible, however, for one attacked to fight through the disease without losing a day's time. But especially unfortunate is he if he fails in this attempt because of taking cold or inability to hold out longer against the debilitating effect of the dis- ease. In the former he is apt to have pneumonia, in the latter he has to contend with extreme prostration. The prostration of the epidemic variety is something peculiar. The weakness is extreme, and the slightest effort, physical or mental, promptly convinces the patient of this. The duration of the weakness may be greatly prolonged, months being sometimes neces- sary to overcome it. Treatment. — The treatment in the majority of cases is very simple. Rest in bed, without medicine, answers for a large number. Beyond this the treatment is mainly symptomatic, phenacetin, acetanilid, or antipyrin being generally sufficient to subdue the pains when present. Quinin is necessary in many cases to keep up the strength. In ordinary cases requir- ing such treatment I am in the habit of giving 5 grains (0.324 gm.) of phenacetin every four hours, alternating with 2 grains (0.120 gm.) of quinin as often, omitting the former when the pain has disappeared, but continuing the quinin. When the pains are very severe, the phenacetin may be given more frequently and even in larger doses. When headache is present caffein should be added in doses of i 1-2 to 3 grains (o.i to 0.3 gm.). Larger doses of quinin may be needed. A favorite prescription at the Hospital of the University of Pennsylvania is a capsule of 2 1-2 grains (0.16 gm.) each of Dover's powder, salol, and phenacetin, every two or three hours. Another prescription is phenacetin and salol, of each 21-2 grains (0.16 gm.), and pilocarpin, 1-12 grain (0.005 g^i-)- Still another is phe- nacetin and salicin, of each 21-2 grains (0.16 gm.) and powdered camphor, 1-2 grain (0.035 gm.). The cough may be treated with turpentine stupes and sinapisms to the chest ; and when there are positive laryngeal symptoms, " Dobell's solu- tion," sprayed into the larynx, is very useful. It may also be sprayed into the nasal passages, or cocain may be applied locally. Internally, the officinal solution of citrate of potassium in half fluid ounces (15 c. c.) doses every two or three hours, is-.helpful. When the cough is disturbing, small doses of morphin or heroin may be necessary ; and if secretion has set in, ammonium chlorid in 5- to lo-grain (0.324 to 0.648 gm.) doses, with 15 minims (i gm.) of syrup of squills and 2 drams (7.4 c. c.) of compound licorice mixture are sufficient to answer the purpose. If more stimulating effect is required on the secretion, the aromatic spirit of ammonium in half- dram doses (2 gm.), or carbonate of ammonium in doses of 5 to 10 grains (0.324 to 0.648 gm.) may be substituted. Opium may be given in large doses, or morphin in corresponding doses, to relieve pain, if required. For the prostration, supporting measures are necessary, and stimulants may be called for. Whisky and milk are efficient. The entire absence of appetite and the complaint that all things taste alike are to be ignored, and the patient must be encouraged to take food, which should be made as attractive as possible. Strychnin is an admirable heart tonic, and may be given, 1-30 grain (0.00216 gm.), every six hours, increased, if necessary. CEREBROSPINAL FEVER. 167 Treatment for the pneumonia, often so grave a complication, is at times -extremely difficult. In a few cases " pneumonia fulminans " strikes the patient down so suddenly and violently as to make all treatment unavail- ing. Referring the reader for details to the section on pneumonia, it may be said that, as a rule, in the pneumonia of influenza, stimulating and restor- ative measures of a very positive character, rather than depressing agents, are indicated. The free use of alcohol and ammonia is especially necessary. Dry-cupping is never out of place, for it can do no harm, if no good. It may be repeated and should be followed during convalescence by a jacket of wool, to maintain warmth and a uniform temperature, but this is of doubtful propriety during the height of fever when we need measures to dissipate heat rather than to retain it. One need not wait for the physical signs of pneumonia to present themselves before beginning the treatment. Given a chill after exposure, with no other cause to explain it, a pneumonia is almost inevitable. Often- times a pneumonic focus in the center of a lung does not furnish any physical signs, while to wait until it approaches the surface causes a fatal delay in the treatment. Other complications of influenza are treated as when they are simple diseases. Overmedication should be avoided. CEREBROSPINAL FEVER. Synonyms. — Epidemic Cerebrospinal Meningitis; Spotted Fever; Petechial Fever. Definition. — An infectious disease of sporadic and epidemic occur- rence, microbic in origin and especially characterized by inflammation of the membranes of the brain and spinal cord. Historical — Cerebrospinal fever is a disease of modern recognition, for a long time confounded with typhus fever, and even with our present knowledge at times difficult to distinguish from it. Its distinct recognition dates back no farther than 1805, when Vieusseux, in Geneva, pointed it out as a separate disease, under the name fievre cerebrale ataxigtie, although there can be little doubt that it existed previously. Sir John Pringall describes in his work on " Diseases of the Army," published in 1752, a hospital or jail fever that resembled cerebrospinal meningitis. In his history of " Epidemic Pestilences " Bascome speaks of a local epidemic in the autumn of 1802 at Roettinggen m Franconia. Symptoms that almost conclusively point to this disease are described in the histories of the great epidemics of Europe from the thirteenth century on. It appeared in 1806 in this countr}- as an epidemic at Medfield, Mass.; in Canada in 1807 ; in Virginia, Kentucky, and Ohio in 1808 ; in New York and Pennsylvania the year after ; at Grenoble and Paris, France, in 1814 ; again at Metz in 181 5. ' It disappeared on both sides of the Atlantic in 1816. It reappeared at Vesoul, France, in 1822-23, prevailing more particularly in barracks, whence it extended to other places more or less until 1849. It prevailed in Italy from 1839 to 1845, and in Algiers from 1839 to 1847. In 1844 a short epidemic visited Gibraltar ; a longer one, Denmark in 1845-48. It occurred in a mild form in Great Britain in 1846, and malignantly in Sweden in 1854 ; in Norway in 1859-60 ; in Holland brief!)' in 1860-61. Northern Germany was again invaded in 1863, Southern Germanj' in 1864, and Baden and Hesse in the sarne year ; Austria and Russia mildly a year or two later, and in 18&8 Turkev and its adjacent possessions mildly. In the United States another visitation occurred in 1822-23 in Middletown, Conn., and in 1828 at Trumbull, Ohio ; again in Middletown in 1842 , since whichtime it has prevailed more or less in all the States, being especiallj- severe in 1863-65 in Philadel- phia and throughout the State of Pennsylvania. It has lingered in Philadelphia ever since, isolated cases being annuall^^ reported. The number of deaths in thatcity from 1863 to iSgi inclusive, as collected by Alfred Stille and completed by William Pepper, was 2575. Since i8(_|i cases have occurred each year as follows : 1S92, 22 cases ; 1893, 35 cases ; 1894, 18 cases ; 1895, 17 cases ; 1896, 7 cases ; 1897. 10 cases ; 1898, 24 cases ; 1899, 146 cases; in 1900, 29 cases; in 1901, 9 cases; 1902, 4 cases. An epidemic prevailed in Maryland in 1892, in New York in 1S93, and in Boston in 1897. i68 INFECTIOUS DISEASES. Etiology. — The direct cause of cerebrospinal fever is believed to be a micro-organism not altogether undisputed, possibly of more than one variety. It includes a special lancet-shaped diplococcus resembling the pneumococcus discovered by Weichselbaum in 1887, and called by him nien- ingococcus or diplococcus intmcellitlaris meningitidis. It lies within the polynuclear leukocyte. Weichselbaum's observations were confirmed by Heubner * in 1891, by Jaeger in 1895, and by Councilman,! Mallory, and Wright in 1898, and Osier % in 1899. In general these observers favor the view that this organism is the exciting cause of the disease. On the other hand, A. Xetter takes strong exception, and says (volume xvi.,' "Twentieth Century Practice of Medicine," p. 191): "The pneumococcus- can, without doubt, cause meningitis, and in spite of Heubner's experience, tlie role of the pneumococcus has been most surely established experi- mentally." He regards the meningococcus as a degenerate form of the pneumococcus. Osier § also says : " That a primary cerebrospinal menin- gitis may be due to the pneumococcus is universally acknowledged." Mixed infections undoubtedly occur as attested by all observers. Other bacteria found with it are staphylococcus pyogenes, aureus, citreus, and albus, the streptococcus pyogenes, pneumococcus, the bacillus coli communis, and bacillus lactis aerogenes. While the disease may be regarded as contagious, it is not highly so, being somewhat like tuberculosis in this respect. That the infectious agent is always derived from an infected person is at least doubtful, the disease not being, as a rule, traceable to another having it,, but appearing to arise rather in certain houses or localities where the neces- sary conditions prevail. Xeisser has shown that the bacillus is transmissible by feeble atmospheric currents. || Predisposing causes are — cold, moisture, exposure, defective sanitation. Crowded buildings, barracks, and tenements have been favorite localities, especially in Europe. Depressing influences and the fatigue of long marches favor it. During the Civil War in America both armies suffered from the disease, but the mortality was not large. Sometimes the diseasee prevails in the country rather than in the city. It is more common in the young, attacking even infants of less than a year old. Sex and race seem to have no influence on the etiology. Morbid Anatomy. — The external appearance of the body after death is not peculiar. Most characteristic are the remnants of the eruption, petechial or herpetic, but they are not constant. The brain and spinal cord are naturally the seats to which we look for morbid changes, and we find every degree of inflammatory condition, from slight hyperemia, such as may be found in any form of infectious disease, to intense congestion with injection of the pia-arachnoid, and finally a stage in which pus and fibrinous deposits, more particularly in connection with the pia mater, are abundantly present. Higher degrees of hyperemia involve even the calvarium as well as the dura. The arachnoid spaces may contain serum and pus, but * "Jahrbuch fur Kinderlieilknnde," i8qi. and "Deutsche med. Wochenschrift." iSg?- + " Epidemic Cerebrospinal Meningitis," "Report of the State Board of Health of Massachu- setts, Boston. 18:8." i Cavendish Lecture, " On the Etiology and Diagnosis of Cerebrospinal Fever," " West London Med. Tour.," iSgg. § Ibid. i| The follovsring are the characteristic features of this bacillus : It occupies a position within the polynuclear leukocytes, whence the adjective term intracelliilaris. It takes the usual stains, and is decolorized by the "Gram method. It "forms on Loeffler's blood-serum "round, whitish, shining, viscid-looking colonies, w^ith smooth, sharplv defined outlines, which attain a diameter of i to i 1-2 mm. in twenty-four hours " (Councilman). It is found in the cerebrospinal exudate, and has been isolated from blood, from pus from the joints, from pneumonic areas in the lungs, and from nasal mucus. CEREBROSPINAL FEVER. 169 it is under the pia mater that we look for the inflammatory products — serous, fibrinous, or purulent, especially at the bottom of the sulci in the longitudinal and Sylvian fissures and at the base over the pons, the chiasm, and cerebellum. To a less degree the convexity of the brain is also involved, and even the brain substance may share in the hyperemia, while actual softening has been noted. Adhesions between the pia and the cortex are common, removal of the pia carrying the substance of the cortex with it. More rarely there is an effusion into the ventricles and the choroid plexus is congested. The walls of the ventricles may be softened, and in cases of long standing there is even hydrocephalus. The cranial nerves, especially the auditory and optic, may be the seat of a neuritis, or bathed in pus infiltrating the lyrnph-sheaths. The muscular and trophic phenomena resulting from such involvement may be per- manent. The spinal membranes are similarly hyperemic, even to the extent of extravasation of blood at times. The same inflammatory products are found upon them as on the meninges of the brain. They are more fre- quently seen on the posterior aspect of the cord, but may be general. Ounces of pus have been removed from the spinal canal. Even the central spinal canal has been found dilated and filled with pus. There may be likewise inflammation of the substance of the cord. The roots of the spinal nerves may be compressed by exudate, producing localized paralysis, or may be themselves the seat of a neuritis, whence the characteristic clonic muscular contractions often present, while the irritation of the sensory roots gives rise to more or less intense pain. Certain malignant cases are of so short duration that there is no time for morbid changes to occur. In such the results of necropsy are negative. Minutely examined, the exudate consists of polynuclear leukocytes inclosed in a fibrinous mass in which also diplococci are found. The brain and cord may also be infiltrated with pus-cells. In the more chronic cases there is thickening of the meninges, with scattered yellow patches represent- ing exudate. As to other organs, there is no characteristic involvement. The spleen may be normal in size or, if the illness has lasted some time, it may be slightly enlarged. There may be congestion of the liver, kidney, stomachy and intestines, and even extravasation of blood. The same is true of the lungs, in which there may be bronchitis or pneumonia, the latter not very rarel3^ Endocarditis and pleurisy are sometimes found. Symptoms. — Cerebrospinal fever does not present an unvarying pic- ture in its symptomatology, and to attempt to portray every unusual symp- tom would occupy undue space. Several varieties are described, viz., (i) the ordinary form, (2) the malignant form, (3) the mild form, (4) the abortive form, (5) the intermittent form, (6) the chronic form. Only the most char- acteristic symptoms will be given, first of the ordinary form and then of the most important modifications of it. I. The Ordinary Form. No definite time of incubation is known. A prodromal period of short duration with headache and pain in the back or headache and vertigo may precede, but, sudden onset is characteristic, often associated with a decided chill. Projectile vomiting is also a frequent early symptom. Headache and pain in the hack of the neck and back promptly appear. Though usually severe, this pain is sometimes so slight as to cause the real condition to be overlooked. It is sometimes so sudden and severe- 170 INFECTIOUS DISEASES. as to be compared to the sting of a bee. The muscles are rigid, and pain is increased on motion. There is fever, but the temperature does not usually exceed 102° F. (38.9° C). There is nothing characteristic in the fever, and the graphic chart shows no regular evening rise and morning fall. On the other hand, it is extremely irregular. Hpyeresthesia of the skin is a characteristic symptom. It is sometimes extreme, and as the disease increases in severity rigidity of the muscles of the neck and back becomes more marked. This muscular contraction may cause backward curvature of the head and even opisthotonos. Clonic spasm may also occur, though less frequent than tonic contraction. It is more common in children, in whom it may amount to convulsion and take the place of the chill. Spasm of the muscles of the face may occur, and of the eye-muscles, causing strabismus. Strabismus in any febrile case of doubtful nature should always lead to suspicion of meningitis. On the other hand, there may be paralysis of the face and eye-muscles, producing inequality of pupils, nystagmus, di- plopia, and ptosis. More rarely there are paralysis and wasting of trunk muscles, including those of respiration. The auditory nerves may be involved, affecting the hearing, and intolerance of sound is a characteristic symptom, as is also photophobia due to hyperemia of the retina. Delirium is very frequent, occurs early in the disease, and may pass into stupor or coma. The delirium may be maniacal, considerable effort being necessary to control the patient. It has been stated of the temperature in this disease that it is rarely high. In some of the earliest descriptions of the disease — and there have been most interesting ones written almost a century ago — the writers speak of the skin as being cool. This was before the days of the clinical ther- mometer and the accurate measurement of temperature growing out of it. High temperatures do occur, though rarely, 105° F. and 106° F. (40.5° and 41.1° C.) being noted, and others even higher just before death. There is, however, no constant type. The temperature chart of the intermittent form resembles somewhat that of remittent fever, while sometimes the chart resembles that of the fastigium of typhoid fever in its spike-like delineation. The pulse goes hand in hand with the temperature — that is, it is not very frequent at first, at least in adults. As the disease advances it grows more feeble and more frequent as the result of increasing debility of the patient. So, too, the breathing rate is not apt to be markedly influenced unless there be a lung computation. The urine, as in other infectious fevers, may be scanty and albuminous ; but it may also be increased because of the involvement of the nervous system. For a like reason there is sometimes glycosuria, and occasionally in ^severe cases Cheyne-Stokes breathing. Another characteristic symptom is the eruption, although it is not present in more than one-half the cases. It is of at least two kinds — herpetic and petechial. Herpes labialis, although not always present, is nevertheless more frequent than in pneumonia. The herpes may be noted elsewhere than on the face — viz., on the trunk and extremities, extending exceptionally even to the ends of the fingers. The contents of the vesicles may be purulent ; they may coalesce and break and dry, forming crusts. The petechial eruption is more general. It is an extravasation, and, like the similar eruption in typhus, does not disappear on pressure. The number of spots varies greatly ; there may be only a few, or they may be very CEREBROSPINAL FEVER. 171 numerous, fully justifying one of the names of the disease — spotted fever. It will not do, however, to exclude the disease by reason of the absence of these skin symptoms. The petechial eruption seems less common in the sporadic than in the epidemic form. Other eruptions, as erythema, urticaria, sudamina, rose-colored spots like those of typhoid fever, pemphigus and ecthyma, have been noted. Gangrene of the skin has occurred as the result of pressure. Some trophic influence may, however, be responsible for it. Arthritis is not infrequent, varying in different epidemics, reaching nearly 20 per cent, of the severe cases in the epidemic described by S. Flexner and L. S. Barker.* The arthritis is deforming and is analogous to the arthropathies more or less common in spinal cord diseases. Sometimes the disease sets in with diarrhea, though more commonly there is constipation. The tongue is less apt to be dry than in typhus, prob- ably because the patient is less disposed to breathe through his mouth. Jaundice has been met with, and may be due to infectious inflammation of the bile-ducts. Leukocytosis is a constant symptom, increase being chiefly of the mul- tinuclear variety of white cells. Vacuolation of blood cells has also been noted. Kernig's Sign. — Kernig, of St. Petersburg, called attention to a symp- tom which is at times a valuable aid to diagnosis in meningitis where the spinal membranes are involved. It is tested for in the following way : The patient is propped up in bed in a sitting posture, with the thighs flexed upon the abdomen and the legs partially flexed upon the thighs, — a position commonly assumed by patients with prolonged spinal meningitis. An attempt is then made to extend the leg, when it will be found to be resisted by contraction of the flexor muscles, preventing its full straight- ening. In the recumbent position the leg can be straightened. When the patient cannot sit up in bed, the thigh may be flexed upon the abdomen and then an attempt made to extend the leg, which again fails if meningitis be present. Friis found the sign in 53 out of 63 cases, Netter in 45 out of 50, and J. B. Herrick in 17 out of 19. f It is said to be present in all cases of spinal meningitis, but is especially characteristic of the acute cerebro- spinal form. It is apparently no measure of the degree of intensity of the disease. Netter explains it as follows : " In consequence of the inflamma- tion of the meninges the roots of the nerves become irritable, and the flexion of the thighs upon the pelvis when the patient is in the sitting posture elon- gates and consequently stretches the lumbar and sacral roots, and thus increases their 'irritability. The attempt to extend the knee is insufficient to provoke a reflex contraction of the flexors while the patient lies on his back with the thighs extended upon the pelvis, but it does so when he assumes a sitting posture." The Babinski or extension toe reflex (see p. 849) may be sought, though it is inconstant and occurs in hemiplegia and other results of lesions of the motor tract. II. Malignant Form. — The malignant form of cerebrospinal fever is characterized by the suddenness of its onset and severity of its cardinal symptoms, — the chill, headache, coma, ,collapse, — followed by early fatal termination. There is little or no fever; indeed, the temperature may be subnormal. The pulse is feeble and slow, falling to 50 or 60 a minute, increas- * " Am. Jour, of the Med. Sci.," i8q4, vol. cvii. t '■ Am. Jour, of the Med. Sci.," July, iSgg. 172 INFECTIOUS DISEASES. ing, however, in frequency as the disease progresses. The breathing is labored. The urine is scanty and albuminous. But for the prevalence of the epidemic such fulminating cases could not be distinguished from like attacks of other infectious diseases. Such cases may, however, occur even sporadically. They may last but a few hours. They are more frequent in the beginning of an epidemic. The malignant form of smallpox is similar, and the presence of an epidemic of one or other disease must settle the question. 11 L The mild form presents a corresponding mildness of symptoms, and only the presence of an epidemic leads to its recognition. IV. The abortive form terminates abruptly after a sharp development of characteristic symptoms. V. The intermittent form is characterized by remissions and exacer- bations in the fever every day or second day, without, however, the reg- ularity of intermittent fever, for which it is sometimes mistaken. The fever resembles rather that of pyemia. VI. Finally, the term chronic form is applied to cases prolonged beyond the usual duration, in which the headache, gastric irritability, and vague neuritic pains reduce the patient to such an extremity of exhaustion and emaciation that he welcomes death as a relief to his suffering ; or partial recovery may take place with crippled motion, defective senses, and severe pains, which are a source of constant discomfort. On the other hand, some remarkable recoveries, even in these advanced stages, are reported, so that one should not be discouraged from continuing therapeutic effort. Complications and Sequelae. — Of the complications of cerebrospinal fever, croupous pneumonia has already been mentioned as not infrequent as well as that it is sometimes difficult to say which disease is primary. The initial chill and herpes are characteristic of both affections, and close attention to other conditions must be given, such as the presence or absence of an epidemic, the order of appearance of the symptoms, the nervous and muscular preceding in cerebrospinal fever, and coming on later in pneu- monia. Other complications are those which not infrequently accompany infectious diseases, including pleurisy, endocarditis, pericarditis, polyarthritis with possible suppuration, and others. Of the sequelae the most important are blindness due to optic neuritis' and more rarely keratitis, deafness from disease of the labyrinth, paralysis more or less extensive, invading especially groups of muscles, including those of the face. There may be aphasia and defective articulation. There may be also persistent headache, shooting muscular pains, and mental weakness. Next to scarlet fever cerebrospinal meningitis is the most fre- quent cause of deafness. Even chronic hydrocephalus and abscess of the braiih are included among sequelae. Von Ziemssen says the former is indi- cated by " paroxysms of severe headache, pain in the neck and extremities, without vomiting, loss of consciousness, convulsions, and involuntary dis- charges of feces and urine." He also says that of the deaf and dumb in the institutions of Bamiberg and Nuremberg, in 1874, a majority of the pupils had become deaf from cerebrospinal meningitis. N'asal catarrh may be an early symptom, and Striimpell suggests it may precede and be the starting point of the invasion. The discharge often contains the meningococcus, as in ten out of fifteen cases in the Boston epi- demic alluded to. Diagnosis. — The diagnosis in epidemic cases is usually easy, although CEREBROSPINAL FEVER. 173 it is more than probable that under such circumstances some cases are classified as cerebrospinal fever when they are really something else. Dur- ing epidemics typhus fever is the disease with which it is most frequently confounded, especially as epidemics of typhus and cerebrospinal fever sometimes prevail jointly. The difficulty is greatest at the beginning of the attack, for as time passes the diseases diverge in symptoms. Typhus fever is not characterized by the severe pains in the head and back of the neck, nor by opisthotonos, both of which may, however, be absent in cerebrospinal fever, or be so slight as not to attract attention. In typhus fever the spots are more constant and numerous than in cerebrospinal fever. Herpes does not occur in typhus. The typhoid state may be equally pro- nounced in both, but in general it may be said to be more marked in typhus. The two diseases differ in their duration, typhus having a pretty definite duration of about two weeks, whereas cerebrospinal fever is either shorter or longer. Among the diseases which embarrass is muscular rheumatism; more frequently than with typhus fever, perhaps, is it confounded at the onset with this disease. The muscular pains are similar, but the headache in cerebrospinal fever is a point of difference. Hence, too, as the disease advances, the diagnosis becomes plainer. The joint complications not infre- quently associated also cause a resemblance to articular rheumatism, which may lead to confusion at first. The isolated cases give most trouble. Typhoid fever, especially the meningeal form of typhoid, in which there is extreme headache and active delirium, simulates cerebrospinal fever in the beginning not a little, and I have known consultants to hold different views for some days. With the lapse of time, however, the diagnosis may generally be made. The onset of typhoid is also slow ; as a rule, there is no vomiting nor severe muscular pain. Pneumonia is another source of confusion, especially as the two •diseases are sometimes associated, and it is almost impossible to say which is primary. Should it prove that the meningococcus is the sole cause of primary cerebrospinal fever, and the pneumococcus characterizes only the secondary form associated with pneumonia or one of the sporadic primary forms, the bacteriological examination will be of great assistance. The meningeal complications in pneumonia are more apt to invade the convexity, whence there arise muscular contraction and tremor, but not retraction of the head. Tubercular meningitis presents some resemblance to cerebrospinal fever. While usually less sudden in its development, it is not always so. Delirium and stiffness of the neck, retraction, and even opisthotonos occur. It is, however, scarcely ever primary, and there are no skin symptoms. The termination of tubercular meningitis is invariably fatal. The presence of a focus of tuberculosis is a great aid to diagnosis. Influensa, too, in one of its many forms occasionally simulates cere- "brospinal fever, at times very closely. Extreme muscular pain is character- istic of both, and when influenza is associated with actual cerebrospinal meningitis, with delirium and stupor, as it sometimes is, one may be excused for being in doubt. Although both ai;e diseases of short duration, influ- enza spends its fury earlier, and is thus a shorter disease unless prolonged lay one of its complications. This feature, if other characteristic symptoms are wanting, may help us to a decision. Quincke's lumhat' punctw'e may be necessary to establish a diagnosis. 174 INFECTIOUS DISEASES. The operation is done with the patient lying on the right side, with knees drawn up, and the left shoulder turned forward. The needle of a large h}-poderniic syringe or antitoxin syringe is introduced midway between the third and fourth or the fourth and fifth lumbar vertebrae, below the spinous process, a little to one side of the median line, the thumb of the left hand of the operator being placed between the spinous processes as a guide. The needle should enter one centimeter from the median line on a level with the thumb. Fig. 17. — Method of Puncture for Spinal Drainage. A. Quincke's site. B. Maxfan's site. C. Chipault's site. — {Chipault.) and be directed slightly upward and inward. At the depth of two centi- meters in infants and four to six in adults it should enter the canal. The syringe should be unscrewed and the fluid allowed to fall, drop by drop, into a sterilized test-tube, care being taken not to allow it to run down the side of the tube. Five to fifteen cubic centimeters should be withdrawn, for chemical, bacteriological, and microscopical examination. A faint trace of albumin is found in normal cerebrospinal fluid. It may be increased in cere- brospinal meningitis. A cloudy fluid is almost always present in epidemic meningitis ; rarely, it may be clear, or the fluid from an upper puncture may be clear, and from a lower turbid. In tuberculous meningitis it is clear. Blood may be present in the former. Prognosis. — Cerebrospinal fever is a grave disease, but the mortality varies greatly in different epidemics, ranging from 20 to 75 per cent, according to Hirsch, while v. Ziemssen places it for mild epidemics at 30 per cent., and for severe ones at 70 per cent. The death-rate is higher for children, those under two years almost invariably perishing, while few under five survive. The old likewise succumb easily. Of few diseases is the course more variable and uncertain. From a duration of two to three days only it may be prolonged to weeks and even months, and its consequences may be permanent. Usually, ho\\^ver, improvement may be looked for if the patient survives five days, more than half the deaths occurring within this period. A remission of symptoms may take place on the third day, to be followed after a very short time by a relapse. This often misleads and gives the illusive hope of permanent CEREBROSPINAL FEVER. 175. improvement. Convalescence is characteristically slow, the symptoms, yielding gradually. If the termination be fatal, the cardinal symptoms like- wise gradually subside, but are replaced by growing debility and exhaus- tion. Relapses are prone to occur, prolonging the case indefinitely, while a. chronic or protracted form, to which reference has been made, is probably due to the presence of one of the persistent or progressive lesions above referred to. Sporadic Cerebrospinal Fever. — This form of cerebrospinal fever requires a separate, though brief, consideration. It has been already said that such cases occur at intervals, and more especially at odd times succeed- ing the prevalence of an epidemic in a city. Osier, in his Cavendish lec- ture, 1899, has taken some pains to analyze the cases of cerebrospinal meningitis treated at the Johns Hopkins Hospital, Baltimore, with a view to ascertaining what proportion was strictly sporadic and non-complicating. He finds that after eliminating pneumococcic meningitis complicating pneu- monia and pneumococcic meningitis due to local infection and streptococcic cases of the same class (surgical cases), there remained a few primary cases, due to the pneumococcus, a few of miscellaneous meningitis — i. e., caused by unidentified bacilli — and a few due to the diplococcus intracellularis. The whole question is, however, unsettled because of the confusion that has. existed until more lately of the pneumococcus with the diplococcus intra- cellularis. Treatment. — The treatment of cerebrospinal fever is symptomatic and supporting. Quiet and the absence of disturbing causes, such as excess, of light, too much company, are absolutely essential. The food should be simple and liquid, with an abundance of water. The symptom demanding the promptest relief is pain, and for this there is no substitute for opiates^ and of these the best preparation is morphin, and the best mode of adminis- tration is by hypodermic injection. Doses sufficient to accomplish their purpose should be given, say 1-4 grain (0.016 gm.) to 1-2 grain (0.032- gm.), night and morning, for an adult. The tolerance for the drug is. great. It may be combined with 1-150 grain (0.00054 gm.) to i-ioo grain (0.00064 gm.) of atropin. The same preparation may be given by the mouth if the hypodermic administration is not convenient, but the deodorised tincture of opium may be better borne, and where the more frequent admin- istration of opiates is necessary, as hourly or bihourly, this preparation is to be preferred because of the possible harmful effects of the too frequent use of the hypodermic syringe. The action of the drug is, of course, to be carefully watched. Phenacetin, antipyrin, salicylic acid, and this class of drugs are no substitute for opium in this painful malady. Hot baths may be employed for the same purpose. When there are spasms or convulsions there is no remedy equal to chloral. If it cannot be administered by the mouth, a dram (4 gm.) dis- solved in 2 ounces (60 c. c.) of water may be given to an adult, without hesitation, per rectum. In extreme cases chloroform or ether may be inhaled for the same purpose. The bromids may be used as adjuvants in mild cases, but of themselves are altogether inefficient. Cold may be applied to the head for the headache and other meningeal symptoms, and is best used in the shape of an ice-cap or ice-bladder or Leiter's coil. Cold may also be applied to the back of the neck and spine, and according to James Barr over the splanchnic region. These measures 176 INFECTIOUS DISEASES. must be discontinued when the temperature falls to normal. Counter irrita- tion to the back of the neck and spine has long been employed, chiefly by blisters. At the present day it is regarded as of doubtful value. The Paquelin cautery, which has been of late much recommended as a substitute for the blister, can do no harm applied to the back of the neck. The incon- venience is less than is commonly supposed, and the ulcer heals rapidly. Cupping and leeching in the same localities, followed by warm fomentations, may be useful. They relieve the pain for a time at least. General bleeding is not recommended. Free movements of the bowels must be maintained by castor oil or calomel, and the bladder watched. Qninin may be given in tonic doses of six to eight grains (3.8 to 5.9 gm.), but not for any specific end, while large doses are harmful, causing cerebral irritation. Measures of a very decided character to reduce the tem- perature are not, as a rule, needed. Simple sponging suffices for the most part. Should this be insufficient, however, tub bathing may be used as in typhoid fever. The nourishment should be of the best, including animal broths and milk, and where, as is frequently the case in the early stages, they cannot be tolerated by the stomach, they may be given peptonized per rectum, not more than 4 ounces (120 c. c.) at one time. I have thus nourished for several days until the stomach became retentive a case despaired of, which ultimately recovered. Forced alimentation by the stomach-tube is recom- mended by Heubner. Alcohol is contra-indicated in the early stages unless there be unusual adynamia. Later, when exhaustion begins to show itself, it may be used and pushed as under similar conditions in other diseases. There are no specifics that have sustained the efficiency claimed for them. The bichlorid of mercury and iodid of potassium have been most praised, and the former drug may be administered from the onset with some reasonable expectation that it may be useful in doses that need not be harm- ful if not beneficial. Such doses would be 1-24 grain (0.0027 gm.) every two~ or three hours for an adult, suitably reduced for children. Mercurial inunctions, which have been much used, are still recommended by v. Ziems- sen, although he admits them to be of doubtful efficacy. Inunctions of iodo- form ointment, 10 per cent., are advised by D. R. Brower.* The iodids and mercury are indicated in the later stages when there are symptoms of exudation. The lumbar puncture is strongly recommended by Williams, Brower, W. Cuthbertson, t and others, as a curative measure ; Wentworth is doubt- ful ; Osier admits possible benefit therefrom. Laminectomy and local therapeutics, including drainage, have not furnished encouraging results at the Johns Hopkins Hospital.:}: The resulting paralyses should be treated by massage and electricity, and as already suggested we should not be discouraged from persisting, as remarkable cures have been accomplished. Recently I have used with the most satisfactory results the subaqueous treatment recommended by Goldscheider § to which my attention was called by Dr. William G. Spiller. It consists in active movements by the patient while submerged in a bath at a comfortable temperature. The move- ments are not passive, but active and voluntary. * "Clinical Rev.," September, i8og. t "Chicago Med. Recorder," June. i8qq. t Osier, "Cavendish Lecture," June, iSqo. § "Ueber Bewegungstherapie bei Erkrankungen des Nervensystems," Goldscheider, " Deutsche tnedicini.sche Wochenschr.," January 27, 1898. ERYSIPELAS ly-j ERYSIPELAS. Synonyms. — The Rose ; St. Anthony's Fire. Definition. — An acute, contagious, primarily local disease, character- ized by dermatitis with the usual signs of inflammation — swelling, heat, pain, redness, and a peculiar disposition to spread. Historical — Erj^sipelas was described b}' Hippocrates (B. C. 480), who had a remarkably clear conception of the disease. Its parasitic origin was first maintained by Henle (1840). Trousseau first asserted, in 184S, that an abrasion of the skin is an invariable condition of its origin. Hueter, in 1S76, was especially conspicuous in claiming that the disease owes its existence to a micro-organism residing in the blood. Billroth and Klebs held similar views, but it was reserved for Koch, in 1880, to settle the question by finding the specific streptococcus in the lymph-vessels and lymph- ;spaces of the skin, though not in the blood. Fehleisenmade the same discovery inde- pendently of Koch in 18S1, isolating and cultivating the erysipelococcus and inoculat- ing man with it. Orth had previousl}' made experiments of the same kind on animals. Etiology.— The streptococcus erysipelatis of Fehleisen is a minute, cleft fungus, a micrococcus in the narrow sense, three to four microns in diam- •eter, arranged in pairs (diplococci) or chains (streptococci) of from six to twelve cells. The erysipelococcus resembles very closely the streptococcus pyogenes of Rosenbach — in fact, cannot be distinguished from it micro- scopically, while even the cultures of the two organisms resemble each other very closely. The streptococcus pyogenes grows more slowly and less uniformly, according to Hofifa, than that of erysipelas, and presents also a brownish discoloration in the middle of its colony. They behave very simi- larly when inoculated in animals. Simon asserts that the micrococcus of ■erysipelas is identical with that of pyemia. Klebs suggests that more than one organism may be concerned in the causation of erysipelas. The organism probably operates as a local irritant producing the der- matitis. From this as a focus constitutional infection is set up, as in diph- theria, probably through the influence of a toxin generated by the micrococ- ■cus. The bacterium is found in the lymph-vessels and lymph-spaces of the periphery of the inflamed area, and not in the center, by which fact the peripheral spread of the disease is explained. The organism is transferred from one person to another by direct con- tact, or by the intermediation of a third person, or through the atmosphere. It cannot be said, however, that the disease is highly contagious in the •absence of surgical injury, for in my early experience as a hospital interne ■at the Pennsylvania Hospital, and later as a visiting physician in the Phila- delphia Hospital, though it was the custom to keep the erysipelas cases in the ordinary medical wards, I cannot recall a single instance where the disease was communicated to another patient in the ward. It was very different, however, in the surgical wards, where the disease would spread rapidly from i3ne patient to another, showing the importance of the open surface as a con- dition of the spread. The lying-in woman is very readily inoculated, so that no physician should attend a case of labor while attending one of erysipelas. Certain kinds of wounds, as lacerated wounds and scalp wounds, are espe- cially prone to erysipelas. Clean-cut wounds in other locations suft"er less frequently. Leech-bites, vaccination punctures, the wounds of the cupping scarificator and of the subcutaneous syringe, are also favorable starting points. Chronic inflammatory processes and skin diseases may also have erysipelas engrafted upon them. Erysipelas is prone to occur in the epidemic form, more especially in 12 178 INFECTIOUS DISEASES. the spring * of the year in old and unclean hospitals, but such epidemics have become much rarer in the last twenty years. This is doubtless one of the results of antisepsis, now so generally practiced. The feeble, the intem- perate, and those having Bright's disease or other affections weakening- natural resistance, are more prone to the disease. An interesting case of Bright's disease under my care in the Philadelphia Hospital had frequent attacks of facial erysipelas, always accompanied by hematuria. Relapses and recurrences of erysipelas are prone to occur, and a person once attacked by erysipelas, far from being protected, is rather predisposed to a second attack. A family predisposition to erysipelas may exist. Morbid Anatomy .^Like all acute inflammatory states of the skin,^ erysipelas fades away after death and leaves Httle, if anything, to be seen unless it has proceeded to the formation of blebs or abscesses. Swelling and corresponding deformity of the part, especially of the face, when extensive,, may remain, but even this subsides with the lapse of time after death and may totally disappear. Minute examination finds the cocci in the lymph-vessels and spaces at the periphery of the inflamed area, as already stated, and even in the unin- flamed tissue beyond the margin. Various complications attend erysipelas and add their morbid anatomy to that which is more essentially that of the disease. The most important of these are pyemic abscesses of internal viscera and hemorrhagic infarcts of the lung, spleen, and kidneys. The kidneys are especially apt to be con- gested, and the lesions of acute or subacute nephritis are sometimes found. Symptoms. — The form of erysipelas which more particularly concerns the physician is the so-called idiopathic erysipelas, which arises inde- pendently of any apparent traumatic lesion, but since all erysipelas implies some lesion, however minute, the term is a misnomer. The fact remains, however, that the physician is most frequently called upon to treat the form of erysipelas in which there is no discoverable local lesion. There is a period of incubation of from one to eight days, after which this variety of erysipelas begins at times with a chill or succession of chills associated with a loss of appetite and feeling of general discomfort. At other times the chill is wanting. In either event there soon appears a small, red, burning spot a few lines in diameter, usually on the face, oftenest on the bridge of the nose or on the chin. It spreads rapidly, and as soon as sufficient size is attained there is a very characteristic elevation of the patch above the surrovmding tissue^^which can be recognized by carrying the finger across it. This is of diagnostic value. The future extension of the process is upward over the forehead and laterally toward the ears until the whole face, and more rarely also the neck, is invaded. The eyes become closed by szvelling, the features are distorted, and the sum of changes produces an appearance not soon to be forgotten. In other parts of the body, as the arms and legs, the same process may go on, but there is not the unsightly distortion found as in the case of the face and head. In some cases the process proceeds to suppuration, and deep-seated abscesses form. These * The influence of the seasons is very well set forth by James M. Anders in a paper on "Seasona Influences in Erysipelas, with Statistics," wherein he has' shown, as the result of an analysis of 2010- cases collected from different sources, that the various seasons of the year exercise a potent influence upon the frequency of this affection. Thus, month by month the cases increase, in slightly varying ratio, from August to April, the latter montli giving the greatest number, and then there is a rapid decrease from April to August, when we find the smallest number. Again, one-half of all the cases occur during the months of February, March, April, and May ; and 15.9 per cent, during the month of April alone. It was found that a low barometer and mean relative humidity invariably correspond with the annual period in which the greatest number of cases occur, and that the highest percentage of relative humidity corresponds with the months affording the fewest cases. ERYSIPELAS. iy(^ must result from mixed infection with other pyogenic organisms, unless indeed the organism be the same as that of suppuration. Blehs form, par- ticularly oq the lobes of the ears and on the eyelids, while little vesicles are always visible through a lens. From these a serum may exude and dry on the skin. As the dermatitis extends to new areas, the earlier spots dry up and desquamate. The disease seldom lasts more than four days in one spot, although it may revisit the same spot during one attack. There may be erysipelas of the mucous membranes, which may extend to the skin, or the reverse may take place-^extension from the skin to the mucous membrane. Fever probably always precedes, though not noted in the beginning, and it rapidly becomes higher, reaching as high as 105° F. (40.5° C). There is a corresponding frequency of pulse, associated with headache and some- times delirium. The fever continues as long as the disease continues to spread. Often a sudden drop, a crisis, occurs on the fifth to the seventh day, followed by another rise if the disease takes a fresh start. In more serious cases fever and delirium may be followed by drozmi- ness and stupor and a coated, dry tongue — all the symptoms, in fact, of a typhoid state. The urine is scanty and a febrile albuminuria may be present, — in fact, to a degree, may be said to be constant,* — and nephritis sometimes results, while a pre-existing nephritis may have an acute exacerbation engrafted upon it. Mention has already been made, under the head of etiology, of hematuria occurring in these cases. Gangrene may be associated with the deep-seated varieties, constitut- ing gangrenous erysipelas. Complications and Sequelae.— The possible complications are numer- ous, but in practice are really not often encountered. The most frequent is meningitis, the result of extension by continuity through the openings of the cribriform plate of the ethmoid bone or by contiguity from the scalp through emissary veins of the skull, but I have never seen such a case. Wil- liam Osier, however, traced the extension from the face along the fifth nerve to the meninges, causing an acute meningitis and thrombosis of the lateral sinus. Edema of the glottis is the result of extension of the disease to the mucous membrane of the glottis. It is promptly fatal, unless relieved. Malignant ulcerative endocarditis is also with comparative frequency secondary to erysipelas, three cases out of twenty-three being sequelae of this disease. Of cardiac complications, pericarditis, endocarditis, and myo- carditis ; of pulmonary, bronchitis, pneumonia, and pleurisy may be men- tioned as possible ; also jaundice, dysentery, and hemorrhages from the nose and bowels. Purpura is an occasional complication. Nephritis of hemor- rhagic variety has already been mentioned, and even glycosuria has been noted, possibly an accidental association. Septic and pyemic complications do, however, occur and are among the causes of death. Among the sequelse may be mentioned a loss of hair. Cicatricial nezv formations replace the parts destroyed by gangrene and may produce deformity by their contraction. On the other hand, hyperplastic new forma- tions resembling elephantiasis Arabum may result. Hyperesthesia and neuralgia of the involved areas, anesthesia with which atrophy of the skin may be associated, symmetrical gangrene of the fingers, and painful affections of the joints have all occurred as sequelae. * See paper by J. M. Da Costa on "The Internal Complications of Acute Erysipelas," " Am. Jour, of the Med. Sci.," October, 1877. 1 80 IX f EC nous DISEASES. Erysipelas may be associated with other infectious diseases, such as tvphoid and typhus fevers, diphtheria, scarlet fever, and the hke. Diagnosis. — The diagnosis of erysipelas is usually not difficult, although many conditions are called erysipelas by the ignorant which are not of this nature. The acuteness of the disease, the rapidity of its spread, the constitutional disturbance and fever distinguish it from other conditions that superficially resemble it. Prognosis. — The prognosis, in the vast majority of instances, is fav- orable. Onlv in the aged, the intemperate, and those of broken health from other causes does it prove fatal, as a rule. Complications, especially menin- gitis and septic states, are causes of death. On the other hand, erysipelas is said to exert a favorable influence on certain acute diseases, such as acute rheumatism, choroiditis, and even morbid growths. It has even been sug- gested to inoculate erysipelas for the cure of such affections. Treatment.— The patient should, of course, be isolated. It is more than likely that a decided majority of cases of idiopathic erysipelas would get well without any treatment whatever. In other words, the disease is self-limiting. As the disease is exhausting, internal treatment should be restorative and supporting. Quinin. iron, nutritious food, and stimu- lants are indicated, while the patient should be kept at rest. The tinc- ture of the chlorid of iron is used throughout Xorth America because of some supposed specific influence over the disease, and doses as large as a dram every three or four hours have been given. I have always given iron, but never in such doses, and I am doubtful whether it exerts any specific eflfect of the kind claimed. The natural duration of the disease is short, and the eitect claimed from the iron is no prompter than that which nature brings. Ten minims (0.666 gm.) every two or three hours are a sufficient dose, and it is exceedingly doubtful whether larger quantities than this are absorbed. Where debility is marked, alcohol in some of its forms should be freely administered. J. M. Da Costa first suggested the use of pilocarpin in the treatment of erysipelas, more particularly in the early stages. J. L. Salinger,* A. A. Eshner, and S. D. Barr also report favorably on the same treatment, which should, how-ever, be employed cautiously. It is recommended that 1-6 grain (o.oi gm.) be administered hypodermically every three hours until free sweating ensues. After this the interval is increased to four or six hours. Of late, evidence is accumulating to show that diphtheria antitoxin pos- sesses curative properties for diseases other than diphtheria. Among these is erysipelas. In all, five cases of successful treatment have been reported by Russian physicians. Presumably it is used as in diphtheria, which see. An infinite variety of local measures has been suggested to arrest the spread of the disease, all of which are useless to this end, although some of them are useful in allaying the burning. For this purpose I know noth- ing better than the old-fashioned mixture of lead-water and laudanum in the proportion of four parts of the liquor plumbi subacetatis dilutus, U. S. P., to two of laudanum. Or a mixture may be made of acetate of lead I 9 (1.3 gm.), powdered opium 90 grains (6 gm.), and water 6 f ^ (180 c. c. ) . Lead-water alone is an efficient local application for this purpose ; so is cold water. In the military hospitals in Philadelphia during the late Civil War a cranberry poultice was a favorite application, and it was cer- tainly a pleasant, cooling measure, but a waste of a useful fruit. Dusting the * " Therapeutic Gazette," March 15, 1894. SEPTICEMIA AND PYEMIA. i8i surface with finely levigated oxid of zinc or subnitrate of bismuth also has a soothing effect. Of late, ichthyol has become a popular local dressing. It should be added to glycerin or collodion in the proportion of 2 drams (8 c. c.) to the ounce (30 c. c.) of glycerin or collodion. A rational measure would be, as has been suggested by Heuter, the hypodermic injection of a 2 per cent, solution of carbolic acid, or a weak solution, say i to 4000, of corrosive sublimate, just beyond the edge of the advancing dermatitis, but it has never seemed to me necessary, while it is painful and annoying to the patient. There can, however, be no objection to using these antiseptics as dressings to the part. SEPTICEMIA AND PYEMIA. Synonym. — Bacteriemia. Definition. — Pyemia and septicemia are general febrile conditions caused by the entrance into the blood of pathogenic micro-organisms. They are distinguished from sapremia, which is the condition of local develop- ment of micro-organisms associated with the entrance of their toxic products into the circulation but not of the organisms themselves. Septi- cemia and pyemia are sometimes included under the single designation of bacteriemia. They are in man caused usually by the entrance of pyogenic organisms — streptococcus pyogenes and staphylococcus pyogenes aureus or albus — into the blood. In septicemia the development of the organisms is not associated with a special localization of the micro-organisms in the inter- nal organs with the production of abscesses, whereas in pyemia the presence of secondary pus foci in different organs of the body constitutes the distin- guishing characteristic of the condition. Etiology, — While the pus organisms have been heretofore held respon- sible for the majority of intoxications of the blood by their pathogenic products or toxins, from the medical standpoint the term septicemia may be applied to the toxic condition produced by any of the pathogenic bacteria which invade the blood and tissues with or without a visible site of infection. The proportion of these last has of late enormously decreased, because of the antisepsis practiced by surgeons, while the medical septicemias have not much diminished. Illustrative cases of the more usual form of septicemia are puerperal fever following retained placenta, infection by scarlet fever or erysipelas or during difficult labor involving laceration, and the poisoning by a dissecting wound. Among medical septicemias may be mentioned those arising from typhoid fever, pneumonia, diphtheria, and gonorrhea. These are all pri- marily local infections. The symptoms set in in from three to four hours to three or four days, more frequently within twenty-four hours. The same essential cause lies at the bottom of pyemia as of septicemia, but associated with the former as important etiological factors are thrombosis and embolism. To this association Virqhow first drew attention, and it is to thrombosis or embolism that the pyemic abscesses are due. Fragments of a venous thrombus due to phlebitis at the seat of putrid inflammation are broken off and carried in the circulation until a lodgment is effected. These fragments swarm wdth bacteria, causing intense inflammation which goes 1 82 INFECTIOUS DISEASES. on to abscess formation, prodncing the metastatic or embolic abscess. Emboli may be multiple and there will be as many abscesses as lodged emboli. A frequent source of multiple abscesses is the interesting disease, malignant or ulcerative endocarditis, itself a specific inflammation caused by some pathogenic organism floating in the blood and lodging on the heart valves, where it excites a septic valvulitis. The vegetations produced by this may be broken off and become emboli. These are carried through the arterial system to points of lodgment and constitute the arterial pyemia of Wilks. Osteomyelitis is also a cause of pyemia. The term idiopathic pyemia is applied to that form in which multiple abscesses coexist with the other symptoms of pyemia, but no infective focus is discoverable. It will be remembered that the non-infectious embolus produces simple hemorrhagic infarct. The scats of election for abscess in pyemia in their order of frequency are as follows : The lungs, liver, spleen, kidneys, brain, and joints, the sub- cutaneous connective tissue, and subperitoneal connective tissue, including pelvic connective tissue. The marrow of long bones and the parts about the cavity of the middle ear are also seats. Abscesses occur in the lungs when the septic emboli originate in osteo- myelitis or in inflammatory affections of the periphery; in the liver, when they arise from septic foci in the portal area, especially in the intestines ; the pelvic connective tissue, when they start in the uterus and its appendages ; in the spleen, kidneys, and brain, if the emboli arise in the left heart, or are so small that they can pass from the right heart through the lungs to the left heart. Suppuration is not limited to the agency of streptococci and staphylo- cocci. The gonococcns, the bacillus coli communis, the typhoid bacillus, the bacillus laiiccolatns, and others are equally capable of producing suppuration. Symptoms. — A rapidly rising fez'cr is the first symptom of pyemia and septicemia, often so closely followed by a chill that its pre-existence is not suspected. The severity of the chill corresponds with the intensity of the infection and the degree of inflammation resulting from it. The tem- perature during the chill reaches 103° to 104° and 105° F. (39.4° to 40° and 40.5° C.) and is followed by a szveat and fall of temperature, after which the latter again rises to a point even higher than that first attained. Then follows another sweat and fall and thereafter a succession of intermissions, variable but quite characteristic. The rise is generally toward evening, and thus there is a certain resemljlance to typhoid fever, while the rigors and sweats suggest malaria. The evening rise is by no means constant, and irregular fluctuations in the temperature are characteristic. There are other symptoms of fever — viz., thirst, loss of appetite, and nausea. The strength of the patient rapidly wanes, he soon sinks into a condition of exhaustion and semiconsciousness, from which, however, he may be aroused to take medicine and nourishment. The various local involvements cause localised symptoms. Emboli in the lungs cause cough and hurried breathing, but there may be no dis- tinctive physical signs ; in the liver, they may cause tenderness and enlarge- ment with jaundice ; if in the kidney, there may be no sign or there may be albuminuria and hematuria ; if in the intestines, diarrhea ; if in the skin, superficial abscesses ; if in the joints, swelling, tenderness, and fluctuation ; if in the brain, little is added to the existing nervous symptoms. There may also be secondary abscesses of the parotid gland and pancreas, the former SEPTICEMIA AND PYEMIA. 183 producing hard, painful swelling and the latter deep-seated pain in the epi- gastric and umbilical regions. The abscesses contain the pyogenic bacteria, which are responsible for them. Diagnosis. — The diagnosis is not usually difficult, though sometimes the disease is overlooked and the symptoms ascribed to some other cause. Reference has already been made to its resemblance to typhoid fever and malarial fever, but the physician should not be long in doubt. A careful study of the case will show marked differences in history, while the status prcesens exhibits only a superficial resemblance. There are no rigors fol- lowed by sweats in typhoid fever, as a rule, and the temperature chart in pyemia is much more irregular. The suddenness of the pyemia is char- acteristic, though it is by no means invariable. In remittent fever the chill, fever, and sweat are more regular, the prostration is not so extreme, and, above all, it is promptly cured with quinin. The plasmodium, if found, definitely settles the question as to the malarial fever, and the Widal test that of typhoid fever. There should be no confounding of pyemia with simple intermittent fever. The complete absence of symptoms between paroxysms is in no way comparable to the evident desperate illness despite the temporary absence of fever in pyemia. Among the causes of pyemia that have been overlooked is osteomyelitis. Gunshot injuries of bones and compound fractures, if followed by suspicious symptoms, should lead to investigation. Malignant or ulcerative endocar- ditis is often overlooked, and not without reason, as it is so often over- shadowed by other symptoms. A cardiac murmur, with irregular temperature and sweating and unusual prostration, should excite suspicion. Gonorrhea and prostatic abscess are occasionally causes, as are also tuberculosis of the kidney and calculous pyelitis, the last two, perhaps, more frequently than the first two. Prognosis. — The prognosis is very grave. Even when recovery takes place in comparatively mild cases, it is with shattered health. Alore fortu- nate are the rarer instances of recovery after puerperal pyemia, which, when they do occur, are more apt to be complete. When calculous pyelitis and even tuberculous pyelitis are causes, operation often furnishes prompt relief more or less complete. Not all fatal cases are promptly so. There is a form of chronic pyemia lasting for months, in which the symptoms are less distinctive and in the history of an infected wound may be the only cue to its real nature. One such case came under my observation, that of a young physician who received a dissecting wound from which the symptoms started and which terminated fatally with meningitis after many months' illness. Treatment of Septicemia and Pyemia. — First remove, if possible, the primary surgical focus and relieve secondary foci as they appear. After that the symptoms are to be combated and the strength supported to the utmost. To the latter end the most nutritious and easily assimilable food, quinin in liberal doses, alcohol freely, and strychnin are the sheet anchors. To these may be added sponging to lower the temperature. To check sweating, atropin, oil of erigeron in do^es of 10 to 30 minims (0.65 to 2 gm.) in a capsule or on sugar ; ergot 15 to 30 minims (i to 2 gm.) ; agaricin i to 2 grains (0.06 to 0.13 gm.) ; the dilute mineral acids, 15 to 30 minims (i to 2 c. c. ) . Antipyretics may be used to reduce temperature, but it is better to accomplish the same thing by hydrotherapy. i84 INFECTIOUS DISEASES. Among the more favorable cases, in which operative treatment is fol- lowed by prompt and sometimes more than temporary relief, are cases of septicemia originating in vesical and prostatic disease and calculous and tuberculous pyelitis. " In tuberculosis of the kidney, as tuberculosis else- where, especially illustrated in the peritoneum, exposure to the air seems to- have a destructive influence upon the bacillus. If the source of the infec- tion cannot be reached by surgical measures, antistreptococcic serum should be used without hesitation. Twenty to 30 cubic centimeters should be injected every six to eight hours until decided improvement in symptoms takes place daily, after which the interval between injections should be in- creased. Smaller doses may be injected in milder degrees of the poisoning. Prophylaxis is much more efficient than treatment, and with modern aseptic surgery and antiseptic obstetrics septicemia and pyemia are becom-^ ing much more infrequent. HYDROPHOBIA. Synonyms. — Rabies; Lyssa. Definition. — Hydrophobia is an acute infectious disease of animals,. communicable to man, and characterized by intense tonic spasm beginning in the larynx. Historical. — The disease was known to the ancients, including the East Indians, Egyptians, and Israelites, but is not mentioned by Hippocrates (B. C. 4^30-357), though Democritus. living about the same time (B. C. 470-362). is said to have considered it a nervous affection allied to tetanus. Aristotle (B. C. 384-322), however, rec- xjgnized it in dogs. According to Celsus, who wrote about the date of the Christian era, it was named i^pu^oSia^hy the Greeks. The Latin poets, Virgil, Horace, and Ovid, mentioned it, as did also the historian, Plutarch (about A. D. 50-106). and Galen (A. D. 130-200), while Ctelius Aurelianus (fourtli century A. D.) discussed it. William Youatt first described it with accuracy in the lower animals and man.* Pasteur first showed its infectious character, and ascribed it to a toxin developed by a micro-organ- ism as yet undiscovered. The disease is rare in this country and Germany, not infrequent in England and France, and common in Russia. Etiology. — All animals are subject to the disease. The dog is the most frequent victim, and it is from him that it is almost invariably com- municated to man. The wolf, cat, and skunk are also frequent subjects, and may communicate the disease to human beings by their bites, that of the wolf being especially virulent. In such cases, whatever the contagium may be, its bearer is conceded to be the saliva of the animal. The contagium is a fixed and not a volatile one. ^The researches of Pasteur go to show that it is also contained in the central nervous system, especially the medulla and brain. Klebs suggested that the disease is caused by a bacterium found in the salivary glands of those affected with hydrophobia. Gibier, Fol, and Babes claim to have found micrococci in the brain-substance, but these claims have not been confirmed by others, though their experiments have- been repeated. There can scarcely be a doubt that an organism is the medium of infection. The period of incubation is extremely variable, ranging from one week to two months or longer. Even two years are said to have elapsed before symptoms set in. The average may be put down at from six weeks to two months ; but by no means all persons bitten take the disease, a most impor- tant point to be remembered in estimating the efficacy of supposed curative * " Canine Madness," being a series of papers published in " The Veterinarian," 1828, 1829, 1830.. London, 1830. HYDROPHOBIA. 185 measures. Not more than 15 per cent, of those bitten by dogs, according to Horsley, become affected. Various causes contribute to this. Thus, the saHva may be wiped off in the transit of the tooth through the clothing, and such removal of virus may reduce the danger of the second bite of the same animal, even though it be on the unprotected skin. Again, the young are more susceptible. Bites on the face and hands are more frequently followed by infection than those on the lower extremities and remainder of the body. Statistics by Watson, in America, and by Bollinger, in Germany, show more cases to have resulted from bites in the upper extremities, while, according to Horsley, wounds about the face and head are more apt to cause the disease than those on the hands, which are second in order, and after these come bites on other parts of the body. A much larger proportion of those bitten by wolves perish, from 40 to 80 per cent., according to different authorities. To a very important practical cjuestion, How long after a bite may the dreaded suspense of an expected outbreak last? accurate answer seems- scarcely possible. Yet, notwithstanding the fact that cases are recorded of an outbreak after an interval of two years, it may be said with confidence that if three months have elapsed, the victim may feel assured that he is safe. Morbid Anatomy. — The morbid anatomy of rabies, so far as recog- nized, is limited to the upper spinal cord, medulla, pons, and cortex of the brain, and is revealed only by the microscope. The blood-vessels are dilated and congested, the perivascular sheaths are invaded with leukocytes, and there are even small hemorrhages. There is hyperemia of the pharynx, larynx, trachea, bronchi, and even of the mucous membrane of the stomach, which may be covered with blood-stained mucus. Often there are no dis- coverable changes. During the year 1900, important discoveries in the minute morbid anatomy of rabies were announced by Van Gehucten and Nelis. The changes, were found in the peripheral ganglia of the cerebrospinal and sympathetic systems, and are especially marked in the plexiform ganglion of the pneumo- gastric nerve and Gasserian ganglion. In the normal state these ganglia are composed of a framework of tissue in the meshes of which lie the nerve cells, each one inclosed in a capsule made up of a single layer of endothelial cells. The rabic virus stimulates these cells to proliferation leading to the ultimate destruction of the normal ganglion cell and replacing it by a collection of round cells. The ganglion cells are sometimes only slightly altered, at others destroyed, the extent of the process varying in different animals, being most pronounced in the dog and less so in man and rabbit. These changes are claimed to be especially valuable in diagnosis, since the examination can be completed within six hours after the death of the animal. It is important, however, that the animal should be allowed to die and not be killed prematurely. The ganglion selected for examination is by preference that of the pneumogastric nerve. The laboratory of the State Live Stock Sanitary Board of Pennsylvania was the first in this country to take up this method, under the direction of Dr. Mazyck P. Ravenel, bacteri- ologist to the Board. Fifty-two cases were examined between May, 1900, and July, 1901, without a single failure. Symptoms. — Rabies is usually diyided, corresponding to the promi- nence of symptoms, into two varieties — furious or convulsive and dumb or paralytic rabies. Professor W. H. Welch, of Johns Hopkins University, suggests a third form of mixed rabies, representing a combination of con- vulsive and dumb rabies. The variety common to human beings is 1 86 INFECTIOUS DISEASES. the furious or convulsive, though paralytic rabies also occurs in man, espe- cially after bites on the lower extremities, and would seem to be increasing in proportion to the convulsive form. So, too, in dogs furious rabies is the more usual, while in rabbits the paralytic form is more common. It is true, also, that a sharp distinction cannot always be made between the two forms, while a stage of excitation and a stage of paralysis may be made out in the same case, and it amounts largely to this : that in the furious form, the stage of paralysis may be short or wanting, while in the paralytic form the stage of excitement may be short and may be manifested only by acceleration of breathing, elevation of temperature, and symptoms referable to irritation of the vagus nerve. The most reliable observations go to show that there is no difference in the quality of the virus producing the two forms, but that the differences are due rather to peculiarities in the individual, the seat of inoculation, or perhaps the quantity of the virus. The iirst or premonitory stage succeeds upon the period of incubation and lasts about twenty-four hours. The cicatrix of the bite, wdiich has been for some time healed, may become painful or the seat of radiating pain, or become livid, or even break out again. The patient is morbidly depressed or irritable, is feverish, loses appetite, and is sleepless; there is hoarseness or huskiness of voice. A feeling of intense anxiety and a moodiness are very characteristic, his probable fate being the sole subject of contemplation. There is an increased excitability, as a result of which the banging of a door or a flash of light causes the patient to start. The second or 'spasmodic stage is the true hydrophobic stage, setting in usually after the first twenty-four hours. It is also called the furious stage. The sum of its symptomatology depends upon an exalted irritability of the imtscles of the larynx, as the result of which they contract upon the slightest irritation in their vicinity, the act of swallowing being the most frequent exciting cause. Attempt at swallowing is followed by the most potverful contraction associated with dyspnea, even when the glottis is open or tracheotomy has been performed ; whence the fear of zuater, the contact of which with the throat is followed by such frightful spasm of the muscles of the larynx and elevators of the hyoid bone. Even the saliva, which is secreted in increased quantity, cannot be swallowed without exciting parox- ysms. Hence it is discharged from the mouth, sometimes forcibly, giving rise to the popular idea that the patient is frothing at the mouth. A breath of air or the slamming of a door may produce a paroxysm. The paroxysm may be associated with maniacal excitement in which the patient is sometimes uncontrollable, rolling his eyes, striking about with his arms, and making snapping noises with the mouth, which are compared to the biting of dogs. These noises are altogether due to uncontrollable spasmodic shutting of the mouth. On the other hand, between the parox- ysms, when the mind is clear and the reason sound, there is often found a touching concern on the part of the patient lest he does some harm to those whom he loves. There is more decided feverishness in this stage, the tem- perature rising as high as 103° F. (39.4° C), while the pulse is frequent and sometimes irregular. Albuminuria and glycosuria have both been found in this stage. The second stage lasts from one to three days, some- times a little longer. In the third or paralytic stage the patient has become exhausted. There are no more paroxysms and he is quiet. His heart gradually fails, and he dies by syncope, although he may die in a convulsion or in asphyxia. This HYDROPHOBIA. 187 stage usually lasts from six to eighteen hours. Happily, the disease is one of short duration, ranging from two to six days, notwithstanding its long period of incubation. Diagnosis. — Hydrophobia most resembles tetanus. Yet the diseases are very different. Hydrophobia has a long period of incubation, while tetanus has a short one, from three to ten days. Tetanus begins with trismus and is associated with opisthotonos. Neither of these symptoms is present in hydrophobia. Tetanus has no laryngeal symptoms, no spasms in swallowing. The mental depression so characteristic of hydrophobia is wanting in tetanus. More difficult is it to distinguish hydrophobia from the imaginary con- dition known as pseudophohia or lyssopJwbia, numerous cases of which have been reported, and the occurrence of which doubtless furnished the founda- tion for the belief by some that there is no such disease as hydrophobia, and that all cases are lyssophobia. The resemblance is often very close, especially the depression and mania, and it is even said that strong men have been so overcome by this fear that they die as a consequence. The condition, how- ever, generally passes away. Especially is this the case when it transpires that the biting dog was not rabid. Hence, the usual practice of immediately killing the dog supposed to be rabid is not a wise one, since it makes it impos- sible to settle the question conclusively as to its madness. It is better to con- fine the animal until the possibility of recovery is settled. If the dog be killed, inoculations from the medulla should be made under the dura mater of rabbits and results awaited. If true rabies, the paralytic form of the dis- ease will be developed in from fifteen to twenty days. A much more rapid method of diagnosis is that recently announced by A'an Gehucten and Xelis, for which see Morbid Anatomy. Prognosis. — The prognosis once established of hydrophobia, is, unfor- tunately, totally unfavorable. The possibility of spontaneous recoverv can- not be denied, but it is certainly exceptional. The preventive treatment is more successful. The claims of Pasteur will be considered under treatment. Youatt's success by cauterization with nitrate of silver is also there referred to. Bollinger's statistics go to show that out of 134 cases in which the bite was cauterized, 92, or 69 per cent., were attacked, while 42, or 31 per cent., died of the disease ; of 66 not cauterized 83 per cent, died of the disease. Treatment. — The curative treatment consists first in prompt measures to eliminate the poison. Suction is the promptest measure available and should be practiced, if possible, by the victim himself, as it is not without danger to a second person. An abrasion in the mouth or a carious tooth may be the medium of inoculating such person with the dreaded virus. If suction be practiced, the mouth should be promptly rinsed. It is doubtful if the cupping-glass is as efficient, even if at hand. Next in availability is cauterisation, which should be practiced by a glozving hot poker or other instrument of the kind, a galvanocautery or Paquelin's cautery. In the absence of such means silver nitrate or caustic soda should be used and thoroughly applied. Youatt considered nitrate of silver amply sufficient, having failed once only out of 400 times, and in this instance he declared that the patient died of fright. He himself was bitten seven times and in each instance used this agent. In the absence of these caustics pure carbolic acid may be used or corrosive sublimate, i to 500 or to 1000. When the symptoms once set in, palliation alone is possible. The sore should be kept open. 1 88 INFECTIOUS DISEASES. The paroxysms should be controlled by inhalations of chloroform, and averted as far as possible by full doses of opium, preferably, as a rule, mor- phin hypodermically. Chloral may at first suffice. As light and noise excite paroxysms, the patient should be kept quiet and secluded, and even in a dark room with two attendants. Water and nourishment may be given by enema. Pasteur's Treatment by Attenuated Virus. — This is of the nature of preventive treatment. Pasteur discovered that the virus of hydrophobia is located in the nervous system, especially in the brain, medulla, and spinal cord. He then ascertained that inoculations by virus from this source in rabbits produced a virus of such increased virulence that after 25 successive inoculations there resulted a virus that acted after a period of incubation of eight davs ; and after 25 additional inoculations in seven days. The virus from the medulla of rabbits, with this short period of incubation, is called, " fixed " virus as contrasted with the " street " virus. Now, although the spinal cords of such animals contain the virus in a state of great intensity Pasteur ascertained that its intensity was greatly reduced by preserving the cords in dry air. and that it disappeared altogether in two weeks. The desic- cation is practiced in sterilized glass vessels in which are placed pieces of caustic potash. If. now, dogs are inoculated with an emulsion of such medullas of reduced virulence, say, cords preserved from twelve to fifteen days, and then with the cord preserved for a shorter period — that is, with progressivelv stronger virus — they acquire immunity from inoculation by the fresh cord of the- rabid rabbit. Pasteur availed himself of these facts to inoculate human subjects who had been bitten. He used an emulsion of rabbits' cords that had been kept fourteen days, and on successive days made 12 more inoculations from cords preserved a shorter time, until those only one day old were used, after which immunity was secured. Later. — that is, in 1886, — Pasteur reported to the Academv of Sciences the so-called " intensive method," consisting in inocu- lations from cords of increasing virulence in more rapid succession, which is the method now commonly adopted in the various institutes. A careful examination of the results of this treatment by the most exact and conscien- tious observers, such as Victor Horsley, of London, and William H. Welch, of Johns Hopkins University, as well as the records of the numerous Pas- teur institutes throughout the world, goes to show that the treatment is a powerful agent in saving life. In illustration it may be said that the treat- ment was commenced at the Pasteur Institute in Paris in 1886, at the end of which year the percentage of deaths was 0.94, while by the end of 1891 it had been reduced to 0.25 per cent., and for 1895 it was 0.13 per cent., or a mortality of 2 out of 1520 inoculations. In consequence of the difficulties in the way of carrying out the treatment it is practically available only at the Pasteur institutes referred to. of which there is one in New York City., one in Baltimore, and in almost all the large cities in Europe. In the Xew York Pasteur Institute 1608 cases were treated in the 12 years expiring January i. 1902, of which 10 died — a percentage of 0.62. At the Pasteur Institute of Lyons 372 cases were treated from Novem- ber I. 1897. to November i. 1899; 26 persons had been bitten on the face (6 per cent.) ; 203. on the hands; 143. on other parts of the body. In 58 cases (15.5 per cent.) the animal had been proved rabid; in 207 cases (55.6 per cent.) it was very probably rabid: in 107 cases hydrophobia was sus- HYDROPHOBIA 189 pected. Among the 372 persons treated there was but one death (0.27 per cent.)- At the Institute of Marseilles 1460 persons have been treated since its •opening, five years ago. Six deaths occurred (0.40 per cent.). In 307 cases (21 per cent.) the animal inflicting the bite had been proved rabid; it was very probably so in 789 cases (54 per cent.). At the Athens Institute 797 persons were treated from August, 1894, to the end of 1897. Two deaths were recorded (0.25 per cent.). Further- more, the treatment failed in one case when a w^olf had inflicted the bite. Among people not treated at the latter institute, 40 died of hydrophobia. In 2y cases the period of incubation was from twenty to one hundred and twenty days ; in two cases it was from five to six months, seven months in one case, and twelve months in another. The following directions have been issued by Paul (jibier, the Director of the New York Pasteur Institute, for the benefit of persons bitten: Cauterisation. — Theoretically, the immediate application to all the recesses of the wound of any agent that destroys protoplasm should suffice to kill any germs lodged therein and remove all danger of a general infec- tion. Practically, such application cannot be made, and a later cauterization not only does no good, but does harm in lending a false sense of security to the minds of the patient and of his friends. Treatment of the Wound. — It is best, then, to treat the w^ound as one would treat any infected wound. When Should the Patient he Sent to the Pasteur Institute? — At once. It is not a hypothesis, but a demonstrated fact, that every day of delay adds to the uncertainty of a favorable prognosis. It is better to be inoculated for a disease that one has not contracted than to wait for a biological confir- mation of infection, and then find that this delay is irremediable. The inoculation is, in itself, harmless to a non-infected person, and is also pro- tective (like vaccination) for a period of several years. What Should he Done zvith the Dog or Other Animal? — Whenever the animal can be confined and kept with perfect safety under observation, this should be done until he dies or recovers. As full notes as possible should be made and forwarded after the patient's departure to the Pasteur Institute, as a valuable part of his history. If keeping the animal is attended with unavoidable danger, it should be killed, the head separated from the body with an aseptic knife, and with a smaller aseptic knife a small piece of the medulla oblongata should be carefully extracted from the base of the skull. This should at once be placed in a clean, small, wide-mouthed bottle, con- taining a solution of equal parts of pure glycerin and water that has been sterilized by boiling. The bottle should then be sealed and forwarded to the Pasteur Institute for examination by animal inoculation, the results of which may not manifest themselves before three weeks. In addition, the stomach should be opened and examined as to the presence in it of food or ■of foreign bodies, and the details of this examination noted and forwarded as part of the patient's history. How to Reach the Pasteur Institute. — The Institute is situated at 313 West Twenty-third Street, New York City. It is within easy access of the Sixth and Ninth Avenue elevated roads (nearest station at Twenty-third Street) ; the Eighth Avenue electric cars pass the other end of the block, and the Twenty-third Street cross-town cars pass the door from the Penn- sylvania and the Erie Railroad Stations (Hudson or North River). iC)o INFECTIOUS DISEASES. The Pasteur Department of the Baltimore City Hospital is at the corner of Saratoga and Calvert Streets. Length of Treatment.— It is necessary in all cases for the patient to remain under treatment for fifteen days. During this time two inoculations are given dailv. If the case is more grave— that is, if treatment has been begim late— or if the wounds are on the head or face, from four to six inoculations are given daily. Beyond these measures th€ treatment of the disease is the treatment of the symptoms. TETANUS. Synonym. — Lockjaw. Definition. — Tetanus is an infectious disease characterized by parox- ysms of tonic spasm, repeating themselves with increasing severity. It is a disease of human beings and lower animals. Etiology. — The specific cause of tetanus is a bacillus, which was isolated by Nicolaier in 1884 and obtained in pure culture by Kitasato in 1889. It is a slender rod with rounded ends, develops at ordinary tempera- tures, and is found in the soil, in pus, and putrefying fluids of wounds, sometimes forming threads, sometimes irregular masses. It is non-mobile, anaerobic, refusing utterly to grow in the presence of oxygen; develops spores within itself, though when studied early in pus is often sporeless. It is one of the most invulnerable of bacilli, its spores resisting a temperature of 176° F. (80° C), while the bacilli retain their vitality in the dried con- dition for months. According to G. M. Sternberg, they resist a five per cent, carbolic solution for ten hours, but will not grow after fifteen hours' immersion. If five per cent, hydrochloric acid be added, they are destroyed in two hours. They are destroyed in three hours by a i to 1000 bichlorid solution, but when five per cent, hydrochloric acid is added the spores are destroyed in thirty minutes. Exposure to passing steam for from five to eight minutes kills the spores. The toxin, on the other hand, is rapidly destroyed by heat and light, being unable to resist a temperature above 140° to 149° F. (60° to 65° C). In the dark in a refrigerator it can be kept indefinitely. Cultures of the tetanus bacillus in all media give off a peculiar characteristic odor — a burnt-onion smell with a suggestion of putrefaction. The bacilli do not, however, pass into the blood, but at the site of the wound manufacture with great rapidity a ptomain or toxin, which is ab- sorbed and excites the disease.* This was first shown in 1890 by Kitasato, who found that the bacteria-free filtrates of bouillon cultures of the tetanus bacillus produce the same symptoms as inoculation with cultures containing the bacillus, including ultimate death. Indeed, Brieger in 1886 isolated from impure cultures three ptomains, which he called tetanin, tetanotoxin, and spasmatoxiu. The first of these causes the characteristic symptoms of tetanus ; the second, tremors, convulsions, and subsequently paralysis ; and the third, intense tonic and clonic spasms. More recently, Kitasato and Weyl obtained Brieger's tetanin and tetanotoxin from pure cultures ; while Brieger himself, with Frankel and Kitasato, has succeeded in isolating from tetanus cultures a far more deadly ptomain, foxalbuinin, which was purified by Brieger and Cohn, who have shown that it is not a pure albuminous body. * Hochsinger alone claims to have found the bacilli or their spores in the blood of tetanic cases. TETANUS. 191 Brieger has also isolated such poisons from the organs of those dead of tetanus, and Xissen has demonstrated toxin in the blood of those ill of tetanus. Further, it has been shown by Behring and Kitasato that there exists in the blood of animals immune to tetanus a substance with opposite prop- erties, therefore called antitoxin, and by the gradual introduction of the toxin into animals these observers have been able to produce in their blood a potent antitoxic substance. Such serum is prepared by Behring and bv Roux abroad, and by the ^lulford Company in Philadelphia. The method for it§ production is similar to that for diphtheritic antitoxin, but slower. Tizzoni and Cantani have successfully prepared it in a solid form, in which, it is claimed, it can be kept indefinitely and shipped as wanted, and applied it to treatment of cases of traumatic tetanus with success. Six cases have been thus treated up to December 24, 1892. " The Lancet," for August 10, 1895, contains a review of 35 cases treated at all stages with antitoxin, 23 successfully. ^^lore recently, Gooderich collected 153 cases with 63 per cent, of recoveries. Predisposing Causes. — The excitation of tetanus is favored by cer- tain conditions. Wounds, particularly contused and punctured wounds, especially of the hands and feet, are favorite foci, whence the term traumatic for such cases of tetanus, and idiopathic for cases not thus caused. A simi- lar focus is the badly cared-for umbilical cord, whence tetanus neonatorum, affecting especially the colored race. In certain parts of the West Indies it is said that more than half the deaths among negro children are due to this cause. It is probably because the contused wound affords a more favorable nidus for the growth of the bacilli rather than that there is any peculiar laceration of nerves, as formerly thought. It is more common, too, in hot countries, and in places and seasons where there are decided alternations of heat and cold. It affects both sexes and all ages, but it is more frequent in men for obvious reasons, the average percentage of cases, according to F. X. Dercum,* being 22. Idiopathic tetanus is much more rare than traumatic, and it constantly happens that close examination in cases of apparent idiopathic tetanus results in the discovery of a previous undiscovered trauma. Exposure to cold, especially damp cold, is one of the recognized causes of idiopathic tetanus. It can only produce a condition favorable to the lodgment and multiplication of the bacillus. That tetanus should occasionally prevail in epidemics is one of the natural results of its mode of causation. Morbid Anatomy. — There is no essential morbid anatomy of tetanus. There may be congestion, extravasations, and perivascular exudates due to impediment of the movement of the blood during spasm, granular changes in cells from modified nutrition — all results rather than causes of symptoms. Symptoms. — A period of incubation of from ten to fifteen days is required for the operation of the specific cause of tetanus. Occasionally only does a chill precede the other symptoms. There appears first usually a stiffness in the neck and jan's and the patient opens his mouth with diffi- culty, but not with pain. Then the stiffness extends to the back and abdom- inal muscles and to the legs, which may be fixed in extension, more usually during a paroxysm. The result is that the abdominal muscles feel like a board and the whole trunk is inflexible. If an attempt be made to flex the * Article " Tetanus," Keating's " Cyclopedia of Diseases of Children," vol. iv. p. 913, 1890. 192 INFECTIOUS DISEASES. thighs on the abdomen the whole body comes up in a single piece ; if the body is turned over, it is like turning over a wooden man. There is, in a word, orthotonos. Again, as in a striking case of my own, the symptoms may begin in the abdomen and by its intermittent character simulate cramp.* These symptoms are present in various degrees, less marked in the mild cases, more so in the severe ones. In severe cases the jaws become locked, in milder ones they may partly yield to forcible extension. The eyebrows may be raised and the angle of the mouth drawn out, producing the rijus sar- donicus, or tetanic grin. In the so-called head tetanus described by E. Rose, there may be paralysis of the facial muscles and difficulty of swallowing, with violent spasm of the pharynx and esophagus. It is associated more par- ticularly with injuries to the fifth nerve. All the symptoms are further increased during the paroxysm, which is excited by various sensory impressions, sometimes exceedingly trifling, as a breath of air or the contact of a dress, a footfall, or the slamming of a door. The muscles of the trunk contract more strongly, and if the patient be on his back, the body may be so bowed that only the back of the head and heels touch the bed — opisthotonos ; or the side of the face and leg, producing pleu- rosthotonos ; or the abdominal muscles may bend the body forward — emprosthotonos. Spasmodic closure of the jaws sometimes causes the tongue to be bitten. The paroxysm may then relax, and during its relaxa- tion the patient will be able to walk about. In severe cases the spasm may involve also the muscles surrounding cavities, as the thorax, compressing as in a vise their contents, causing extreme pain. Indeed, pain is almost every- where an accompaniment of these spasmodic contractions, and the perspira- tion stands out in great drops on the face and covers the body. An attempt to speak is transformed into a fit of crying. The frequency of the spasms varies greatly ; they may occur every couple of minutes or almost incessantly or once in several hours. The temperature is generally, but slightly, if at all, elevated, rising to loi° F. (38.3° C.) and more rarely to 102° F. (38.9° C). At times, how- ever, it rises higher, to 105° to 106° F. (40.5° to 41.1° C), and it is said also in fatal cases to reach 108° to 110° F. (42.2° to 43.3° C). In a case reported by Joseph P. Tunis f it fell as low as 96.6° F. (35.5° C), reaching a maximum of only 101° F. (38.3° C). The pulse is generally frequent, 130 to 150, respirations 30 to 45. There is often constipation, which is a more serious symptom in severe cases, because the efforts to relieve it are apt to bring on spasm. Among the rare events have been the rupture of muscles and spasmodic closure of the glottis, producing fatal asphyxia. Generally, death is produced by exhaustion, the mind remaining unclouded throughout. Diagnosis. — Tetanus is liable to be confounded with strychnin poison- ing, cerebrospinal meningitis, and hydrophobia. Strychnin poisoning dififers from tetanus in the absence of rigidity between the paroxysms and of tris- mus, and in the more marked involvement of the extremities, as well as the history of the case. In hydrophobia there is no trismus, and while con- vulsive dysphagia occurs sometimes in tetanus, it is very rare. As in strych- nin poisoning, too, the individual paroxysms are more distinct. Cerebrospinal meningitis produces a rigidity similar to that of tetanus, T)Ut the cerebral symptoms give it its stamp, and fever is a much earlier * " Philadelphia Med. Times," vol. i., 1871. p. .' be responsible for complica- tions and modifications of the ordinary pneumonic process. Streptococcus- pneumonia has come to be recognized as a variety of pneumonia having a more or less distinct clinical picture that will be again referred to. Nature of Pneumonia, — Thus caused, pneumonia may be regarded from two standpoints. First, it may be a general disease with a local expression in the lungs, analogous to the inflammation of Peyer's patches in typhoid fever ; or it may be a local disease, which, like diphtheria, infects the' general economy and produces the constitutional symptoms character- istic of it. As in the case of typhoid fever, there were facts which pointed to the infectious nature of pneumonia long before the discovery of any organism that could be regarded as its specific cause. The occurrence of pneumonia in epidemic form was recognized by Laennec and Grisolle, and since their day innumerable epidemics have been described : house epidemics, including those in which a number of individuals, from three to ten or more, have been attacked under the same roof, and general epidemics, invading institutions, ships, and garrisons, in which large numbers of persons are congregated. Out of a ship's crew of 815, 410 were attacked in rapid succession, and out of 720 attacked, 298 perished. While the state of knowledge at the present day seems to demand that we consider croupous pneumonia as an infectious disease due to the action of a specific organism, we cannot ignore the operation of causes, such as damp- ness and cold, which until recently have seemed sufficient to account for a large number of cases. Thus an overworked man is exposed to cold for a long time, and becomes thoroughly chilled. A few hours later he is seized with a rigor, and twenty-four hours afterward the physical signs of a pneu- monia have developed. The lowered vitality consequent on the exposure in each case must be regarded as a predisposing cause, preparing the system for the operation of the ever-present organism as the exciting cause. The operation of cold is further seen in the influence of the seasons, pneumonia being much commoner in the winter months. Other predisposing causes are : a previous attack, fatigue of mind or body, and debilitating conditions of all kinds, such as previous or present illness, especially a chronic com- plaint, such as Bright's disease. A patient of my own had four attacks and succumbed to a fifth. Heredity is also said to be a factor, and injuries of the chest have long been regarded as predisposing causes. Morbid Anatomy. — The lung in croupous pneumonia exhibits three distinct stages : 1. Congestion or engorgement, 2. Red hepatization. 3. Gray hepatization. Pneumonia seeks, by preference, the lower lobes of the lungs, and the right lung more than the left. Pneumonia of the apex, however, not infre- quently occurs, more often in children than in adults. The Stage of Congestion. — In this stage the lung is engorged with blood, yet permeable to air. The capillaries surrounding the air-vesicles are CROUPOUS PXEUMOXIA. 215 turgid and intrude upon the lumina of the air-vesicles. There is a small amount of transudate, in which ma}- be found a few exfoliated alveolar cells and red blood-discs. The part of the lung invaded is redder than normal and heavier, but not nearly so heavy as in the next stage. On section, blood transudes from the cut vessels and bathes the surface. The Stage of Red Hepatization. — In this the lung is dark red in color, hard, and very much heavier than in health — as much as three and four times the normal weight. A piece dropped in water rapidly falls to the bottom. The lung pits on pressure, and in consequence the marks of the ribs are often seen on it after removal. On section the aptness of. the name red hepatiza- tion is at once apparent. The surface is darker in color than in the first stage, and it has the appearance of a section of liver. On passing the. finger over it, innumerable little hard spots like grains of sand are felt. These are air- vesicles filled with the croupous exudate. Corresponding to this, a granular appearance is recognized by the eye. the distended air-vesicles appearing as gHstening points. By scraping, little plugs of fibrin and cellular detritus mixed with serum can be removed. The lung, though thus hard, is never- theless friable, and may be broken up by the fingers. Histologically, the air-vesicles are found to contain a delicate reticu- lum, the meshes of which are tilled with red blood-discs, and with alveolar cells in different stages of degeneration, including numerous granular fatty cells or compound granular cells. The vesicular walls are found infiltrated with lymphoid cells, which extend even into the interlobular tissue beyond them. Plugs of fibrin may sometimes be traced into the smaller bronchi from the air- vesicles. The diplococcus of Frankel and pneumococcus of Friedlander may be demonstrated in cover-glass preparations made from the exudate. They may be associated with the streptococcus and staphylococcus. The Stage of Gray Hepatization. — This is also well named, the cut lung exhibiting a grayish-white coloration. It is still dense and heavy, but much moister and softer, and even more friable. The granulations are, however, less distinct, and on microscopic examination the alveoli are found filled with white blood-corpuscles, while the red corpuscles and fibrin filaments have disappeared. Sometimes all three stages are seen alongside of one another. A stage beyond gray hepatization is sometimes spoken of as a stage of yellozv hepatization. In this stage the lung has assumed a more yellowish appearance, it is much softer, almost liquid in consistence, and more like pus. On minute examination the air-vesicles are filled with pus-cells, the points of greatest softness constituting small abscesses as large as a pin's head and larger. The stage of gray hepatization is the stage of beginning resolution, while that of yellow hepatization represents the same stage in which the pro- portion of leukocytes undergoing fatty degeneration is larger. If recover}- takes place the contents of the air-vesicles liquefy, the product being partly expectorated, but probably mostly absorbed. The pleura adjacent to the inflamed lung is almost always inflamed, the most distinctive sign of this being a plastic deposit. There may also be thickening and some serous efifusion. , After death from pneumonia, the heart is found In a typical pathological condition. The left cavities are generally found empty or nearly so, while the rieht are distended with firm coagula. which often extend into the branches of the pulmonary artery. The spleen is often enlarged. The cells 2i6 INFECTIOUS DISEASES. lining the renal tubes are often found in a state of cloudy swelling; rarely there is nephritis. Symptoms. — Perhaps no other disease except malarial fever is so invariably ushered in by a eliill as is croupous pneumonia, and often a chill of great severity. It may come on at night, waking the patient out of a deep sleep. It may or may not be preceded by a day or two of prodromal discom- fort, with headache, which may be very severe. Almost immediately th.ere succeeds a high fever, in which the temperature rises rapidly to from 103° to 105° F. (39.4° to 40.5° C). A significant Hush on each check is character- istic, occasionally more marked on the affected side. The pulse is full and strong, resisting pressure, rate 100 to 120. There is thirst, and the urine is scanty and high colored, sometimes albuminous. Equally promptly ensues a pain in the side, which may be dull, but is often also sharp and severe, caused in the latter instance by involvement of the pleura. The respirations rise rapidly in frequency, and there is cough, at first dry and hard. It is often restrained on account of the pain it occasions. Soon there is a small amount of mucous expectoration from the coincident bronchitis, but usually in twenty-four to forty-eight hours after the chill the sputum exhibits dis- tinctive characteristics. It is tenacious, light red in hue, — " rusty," — and is ejected from the mouth with difficulty. At other times it is much thinner and darker, and has received the name " prune- juice " expectoration. The amount of blood and the degree of coloration vary greatly. The respira- tions are exceedingly rapid — 50, 60, and even more in the minute. I have known them to be 82, and in a child they may reach 100. The appearance of a patient at this stage is very striking. The face is flushed, the eye is brilliant, the breath is rapid, the als nasi move with each, breath, while a frequent short cough, held back until irresistible, increases at times the already anxious expression of the patient. This state of affairs continues unchanged for from five to nine days, when, if recovery takes place, a sudden drop in the temperature occurs, accompanied often by free perspiration, while a state of comparative comfort succeeds to one of great distress, to be further followed oftentimes by a long and refreshing sleep. This is known as the crisis. It may be preceded by a fall of temperature a day or two earlier, w^hich is again followed by a rise, whence such fall is called the pseudo-crisis. The accompanying temperature chart (Fig. 20), from a case seen in consultation with Alfred Stengel, illus- trates the actual crisis. The fall in crisis is sometimes as much as 7" F. (12.6° C.) in twenty-four hours, and the minimum is quite often slightly subnormal, whence it rises rapidly to the normal. From this point onward convalescence is rapid, and in four or five days more the patient is seemingly well, the temperature and pulse-rate normal, the breathing natural. A muscular weakness and vulnerability, however, remain, which demand care for a time longer. The duration of the stages may be roughly stated as twenty-four hours for the first, five to eight days for the second, and a few days to several weeks for the third. Physical Signs. — The physical signs of a typical pneumonia are very distinctive. The first, or stage of congestion, in which the air-vesicles are still open, is of short duration, terminating within the first twenty-four hours, and may therefore be overlooked. Inspection shows the face flushed, increased fre- quency of respiration, with restricted movement upon the affected side and CROUPOUS PNEUMONIA. 217 increased extent of motion on the sound side. The patient Hes by prefer- ence on the affected side because of the greater comfort it gives him. This posture not only diminishes the pain by hindering the motion of the affected side, but also lessens the dyspnea by permitting unrestrained expansion of the side that is doing the work. Palpation at first may even find vocal fremitus diminished on account of the relaxation of the air-vesicles, but it becomes decidedly increased as the latter fill up. The skin is hot and the pulse is frequent, full, and strong, as a rule. Percussion obtains but slight, if any, impairment of resonance. In fact, tympany, or the vesiculo-tympany of Flint, — Skoda's resonance, — may be present in this stage as a result of the relaxation of the partially filled air- vesicles, giving resonance by immediate relaxation. In the Letter part of the first stage there is, however, impairment of resonance. Auscultation in the very earliest stage may find the vesicular murmur feeble, but very soon is heard the distinctive physical sign of pneumonia, the crepitant rale at the end of inspiration. If there be coincident pleurisy, — pleuropneumonia, — the closely simulating friction sound may be added. Under such circumstances it may be difficult to distinguish these two physi- cal signs. Over the normal part of the lung there is exaggerated vesicular breathing. MARK. /'J„ ^r^^ 20 Q^'9:-M^odiy/^c^^ Pittsburg, Pa. OAYOF-ONTH 4 5 (j 7 8 9 10 11 . 12 D.YOFD,SH.SE 2 3 4 .5 6 7 8 9 10 Tl flef A.M. i-H 6'S 10 5]7 9J11 l|5 > 9 11 13 5 7 9 11 I 5 7 9 11 6 8 12 2 8 S y| P.m. i(i| I 1579 11 1 lacr 9 11 1 3 S 7 9 13 7 9 11 1 7 IJ 7 18 ' "-" ^ J =f- — — = == m?. , : -..^ ' _J — ^ — ^ — — 1.05 J ; : — 1.04 _ — TSJ 1 1 — 1 Wj^ + * ^ -j^ nit- J-? — Ft 3= -zz. = ;^-^^-^^=^^E-=^^= ^ = ^5^EE|-hl=EEEEEEE: - = =: = ^EEE^E^EE5^E^=i=?EE e^eee?ee^eee§=eeee|: , c^ --s: — __± zft — dr — : ^ ■zz 1-00 1 1 .99 |EEEEEEEEEEEEE5?I^EEE = = ■98 .9.7L \ i_. <-^, mM-jjg y. 1 ■ -'- — «— 334 30i 30 32 28 29 URIH ^•f— f WM BOWELS. Ill 1 1 1 1 1 WEIGHT. Fig. 20. — Showing Cri&is in Pneumonia. But all these physical signs, even if carefully sought for, may be want- ing if the pneumonia be central and deep-seated, as is not infrequently the case. They appear as the surface is approached, or they may not be recog- nized at all if the disease remains central. The second stage, or stage of red hepatization or solidification, lasting four or five days, furnishes unmistakable signs. All the signs pneumonia 218 INFECTIOUS DISEASES. reveals to inspection in the first stage are intensified in the second, and the breathing is markedly abdominal. To palpation, vocal fremitus is now intense, the skin is hot and dry, and the pulse continues frequent. Mensu- ration almost always and even inspection may recognize an enlargement of the involved side, the former to the extent of 0.5 to 2.5 cm. Percussion gives absolute flatness over the solidified area, with high pitch and short duration, except in those very rare instances where the extreme consolidation throws the column of air in the trachea and bronchi into vibration, producing tympany. This explanation is perhaps the only one when tympany occurs in the upper lobe. In a lower lobe, tympany may result in the same way, from the proximity of an air-distended stomach. Over the adjacent normal areas, also, resonance is exaggerated, not so much, perhaps, in consequence of supplemental function, as from relaxation of the adjacent air-vesicles — Skoda's resonance by mediate relaxation. Even cracked-pot sound may be produced by percussion over the solidified lung as a result of the sudden expulsion of air from a large bronchus leading to the solidified area. • Auscultation discerns high-pitched bronchial breathing over the solidi- fied lung. Indeed, these are the circumstances that give the typical bron- chial or tubal br,eathing. The air-vesicles are obliterated, and the resulting excellent conducting medium brings the tracheo-bronchial blowing to the ear. In very rare instances, when the larger bronchi are filled with exudate, there may be no bronchial breathing. The ausculted voice gives us typical bronchophony and occasionally even pectoriloquy, as well as whispering bronchophony and pectoriloquy. The heart-sounds are also heard with great distinctness over the consolidated lung, owing to the improved conduction, while the sounds of a concurrent bronchitis are similarly intensified. A lin- gering crepitant rale may also be heard. The tJiird stage, or stage of gray hepatization or resolution, occupies six to ten days. It repeats largely, to inspection, palpation, and ausculta- tion, the phenomena of the first. Resonance continues impaired for some time. The normal manner of breathing gradually returns, the temperature of the skin is notably less, the crepitant rale returns, technically known as the " crepitans redux," and is finally replaced by the normal vesicular breathing sound, by which time the dullness has disappeared. Croupous pneumonia may rarely terminate in abscess or gangrene; in either event the signs of the second stage continue and the temperature does not fall — in a word, the crisis does not occur. The signs of a cavity, which might naturally be expected, are rarely present, and it is rather by the general symptoms, viz., the failure to recover, the continued high temperature, the expectoration of pus, and, in the case of gangrene, the intensely disagreeable odor, that we are informed of the issue. These issues probably represent on a large scale what takes place in every instance in minute areas in the third stage of all pneumonias which terminate favorably. The occasional termi- nation in tubercular phthisis exhibits a similar arrest of the resolving process in the second stage, and the phenomena of catarrhal or fibroid phthisis supervene. The obscuring efifect of a thickened pleura upon all these signs is to be remembered, and too much stress cannot be laid upon the fact that we may have a central deep-seated pneumonia that may give no physical signs ; also that in old persons the physical signs of a pneumonia are very apt to be delayed from one to three days. CROUPOUS PNEUMONIA. 219 Careful differential percussion and palpation may recognize a moderate enlargement of the spleen. The heart should be carefully watched in pneumonia. The sounds, at first loud and clear, become less so as the disease progresses and the lungs become engorged. The pulmonic second sound is particularly sharp as long as the heart is strong, and its failure is an unfavorable sign, as it means that the right ventricle is failing in power and may be yielding to distention. Modifications in Symptoms and Special Symptoms. — The foregoing is the course of a typical case of pneumonia, perhaps of three-fourths of all cases, and the symptoms mentioned suffice for a diagnosis. All of them are, however, subject to modifications. Thus, the chill may be absent or imperfectly developed, in which case all the symptoms arise more gradually. The temperature, especially in old persons and drunkards, may not be nearly so high ; in children it may be higher. The same is true of the respirations, which may be increased to 100 to the minute in children. Pain is especially absent in old persons, cough and expectoration also, so that a careful physical examination of the lungs should be made in all ailments in the old and in drunkards also, as it not infrequently happens that pneumonia is overlooked in them. The pulse is often feeble and rapid instead of full and strong. Nay, more, even the physical signs may he absent in the old, and they are especially apt to be delayed in their development. It is unsafe to say of an old person at the first visit, after a negative physical examination, that he has not pneumonia, for the physical signs may not make their appearance until the second or third day and even later. It would seem, too, that central pneumonia is more common in the old than in the young, while even an afebrile pneumonia is a possibility in the old. Even in younger persons the appearance of physical signs is sometimes delayed three or four days. The expectoration varies a good deal when present, especially as to the quantity of blood. Sometimes it is bright red and quite liquid, almost like a hemorrhage. More frequently it is viscid and glutinous, simply stained with blood. The term " prune- juice expectoration " has long been associ- ated with pneumonia, and sometimes, when it is thin and dark-hued, the com- parison is an apt one. Under the microscope the sputum is found to con- tain blood-discs, leukocytes, and alveolar epithelium in various stages of degeneration, including numerous compound granule-cells, also ciliated epithelium. Fibrinous bronchial coagula, sometimes large enough to be seen by the naked eye, are also met with in the expectoration, and, after suitable staining, diplococci. Should gangrene supervene, the expectora- tion becomes very fetid. The urine is especially characterized by a reduced amount of chlorids, which are often absent until the crisis is passed, when they reappear. It is supposed that during this period they are transferred to the exudate in the lungs. A trace of albumin is often present and it presents the other features of febrile urine. There is sometimes marked jaundice. It may even be the first symp- tom. It may be a catarrhal or a hematogenous jaundice. The cases attended by it are rather more serious., Various explanations have been sug- gested. According to one, it is due to a catarrh of the bile-ducts ; according to another, it is due to a reabsorption of the hemoglobin derived from dis- integration of the red blood-disc of the exudate in the air-vesicles; and according to still another, it is due to a congestion of the liver. All these 220 INFECTIOUS DISEASES. views are speculative. Recently G. Mante * ascribes it to a hemolytic action of the diplococcus lanccolatus. His conclusions are based upon experiments going to prove that such hemolytic action takes place. The blood exhibits usually a leukocytosis, the number of corpuscles being increased from 6000 per cubic millimeter to 19,000, or more. As many as 68,000 have been found. The increase is almost alv^ays in the poly- morphonuclear cells. The proportion of fibrin is also increased from 4 to 10 parts in 1000. This increase of fibrin shows itself also on the micro- scopic slide in the shape of filaments of fibrin. According to Hayem, the blood-plaques are increased. Herpes is very common on the lip — present, it is said, in from 12 to 40 per cent, of all cases. It may occur elsewhere, as on the nose and genitals. Phlegmasia alba dolens, or milk-leg, is a rare sequel. J. M. Da Costa f collected nine cases, of which three were his own. The complication occurs late and has been more frequent in the left leg. When typhoid fever coexists with croupous pneumonia the tongue is coated, and becomes dry and leathery. Constipation is usual, but occasion- ally there is diarrhea, especially in epidemics. Except in typhoid cases delirium is not common, but may be very active in the young. In old per- sons it may be low and muttering. In drunkards, in whom the disease is common and very grave, especially after a debauch, the delirium may be taken for mania a potu, or the two may coexist. Such a patient may rise from his bed and wander out into the city or to another hospital that he pre- fers, having just intelligence and strength enough to accomplish this pur- pose, and will die after its attainment. Streptococcus pneumonia has been mentioned, with the statement that it presents some clinical features different from those of the ordinary croup- ous pneumonia, at least at times recognizable. I must say, however, that I am not myself confident of being able to recognize such pneumonia by these symptoms, since many of them are the same as those heretofore regarded as peculiar to bronchopneumonia as ordinarily caused. In the first place, it is held that the serious form of pneumonia, which often com- plicates influenza, is thought to be a streptococcus pneumonia. Such pneu- monias, like bronchopneumonia, commonly begin obscurely, are atypical, while the local signs are slow to develop. The rusty expectoration is delayed ; in like manner the crisis, Avhich may be substituted by lysis ; or death supervenes instead of crisis. The physical signs also rather resemble those of bronchopneumonia, \yhile it is said :|: that the disease is more fre- quently found in the upper lobe, not at its apex, but in its lower part between the inferior angle of the scapula and the axilla. It may also be irregularly migratory. The sputum may be mucopurulent at the outset, and is always less conspicuously red or rusty. Like bronchopneumonia, it is also insidious in its onset, the fever is irregular, and there is often chilli- ness or actual rigor with sweats ; in a word, septic symptoms are prominent. Termination. — When the pneumonia terminates favorably, promptly after the crisis is passed, it is said to terminate by : I. Resolution, by which is meant that the inflammatory product lique- fies, is absorbed or expectorated, and the lung resumes its natural state and normal physical features. The time at which these events are thoroughly * "Centralblatt fiir Bakteriologie," etc., December lo, i8q6, p. 849. + "Philadelphia Med. Jour.," vol. ii., 1808, p. 510. t G. Baumearten, "Variations in the Clinical Course of Croupous Pneumonia," "International Clinics," vol. ii. Sixth Series, i8q6. CROUPOUS PNEUMONIA. 221 established varies greatly, and if there happens to have been associated pleurisy, with resulting thickened membrane, impairment of resonance may last a long while. On the other hand, it may terminate spontaneously even earlier than the periods named for the crisis. In such event the pneumonia is said to abort. This promptly favorable termination does not always take place. Resolution may be unduly delayed and yet ultimately take place. Such cases naturally occasion anxiety, for resolution may not take place at all, in which event one of five unfavorable terminations may occur. These are: ^ (a) Death from cardiac failure. (&) Abscess. (c) Gangrene of the lung. {d) Interstitial or fibroid pneumonia. {e) Tubercular phthisis. 2. Abscess of the lung is a termination of pneumonia in about 4 per cent, of fatal cases. Flint, Sr., found it in 4 out of 133 cases recorded. When this occurs, the interstitial tissue of the lungs becomes infiltrated with pus cells, small foci of leukocytes aggregate to form larger, until a large abscess results, which may occupy a whole lobe or even a whole lung. In such cases the fever continues high, there is expectoration of pus containing elastic tissue of the lung, and the physical signs of a cavity may rarely be present. It is not impossible, however, for such a process to be arrested by a reactive inflammation, by which a tough protective layer of embryonic tissue is formed about the abscess. 3. Gangrene of the lung occurs in about 3 per cent, of fatal cases. It is especially prone to occur where the pulmonary vessels become so engorged that the circulation is arrested, and where, as a consequence, the hemorrhagic element is conspicuous. Bronchiectatic cavities in an inflamed lobe that are swarming with putrefactive bacteria are an important predis- posing cause. It is recognized by the sickening fetor, which pervades a whole ward, and which, once met, is never forgotten. The expectoration is thin and similarly fetid, and contains large quantities of elastic tissue from the lung. The lung is converted into a gray-green, fetid pulp, in which cavities with ragged walls arise, from disintegration and expectoration of lung tissue. Gangrenous portions may be surrounded by a zone of true inflammation, contrasting by its red color with the gray of the gangrene. Such sloughs have been successfully excavated by surgical treatment. 4. In fibroid induration or cirrhosis, which is occasionally met with, there is also invasion of interstitial lung tissue, but instead of being infil- trated by such an excess of leukocytes as to produce pus, only as many wan- der out as can undergo organization and conversion into permanent tissue. Sometimes this results from the lung failing to expand after resolution and absorption of the exudate, the walls of the unexpanded alveoli collapsing and uniting. In other cases there is partial absorption of the exudate, repeated infiltration takes place into the alveolar septa, and organization takes place in both. The fibrinous plugs may also be transformed into con- nective tissue. Three successive stages may be present. In the first the cirrhotic patches are gray, grayish-Ved, or grayish-yellow, and a small amount of turbid exudate can be here and there squeezed out of them. In the second stage, where the formation of the fibrous tissue in the alveoli or their walls has set in. the lung is dense, firm, airless, and fleshy, whence the term carniUcation. In the third stage the fibroid transformation is com- 222 INFECTIOUS DISEASES. plete; the tissue is tough and slate-gray in color. Such induration is gen- erally in bands and patches that merge gradually into the normal vesicular structure. 5. Tubercular phthisis is another termination of pneumonia. It results from infection by implantation of the tubercle bacillus. Pneumonia of the apex terminates thus most frequently. Complications. — The most frequent complication is pleurisy. It is probably always present to a certain extent, except in the central forms. It manifests itself in the first stage more by the characteristic severe cutting' pain than by physical signs, as the friction sound characteristic of that stage is commonly obscured by the physical signs of the pneumonia. Should the stage of effusion be reached, the physical signs of the pneumonia subside. In severe cases a pleurisy may surround the entire lung and bind it to the chest-wall. A pneumonia on one side and a pleurisy on the other is a pos- sibility. That very interesting pathological state known as pleurogenic pneumonia is sometimes seen in the human being as a form of tubercular pleurisv. In it the lung becomes partitioned oft" by an interstitial frame- work starting from the pleura. It has its typical anatomical product in the pleuropneumonia of cattle. The extension takes place chiefly by way of the lymphatics. Endocarditis is a comparatively frequent complication. William Osier especially called attention to this fact in his Gulstonian lectures for 1885. He ascertained that of 209 cases of malignant endocarditis 54, or over 25 per cent., occurred ' as complications of pneumonia. It is more prone to attack persons with old valvular disease, and to involve the left heart. There is good reason to believe that the specific lancet-shaped bacillus is responsible for this form of valvulitis as a complication of pneumonia. The endocarditis constantly escapes detection, since physical signs are sometimes absent, at others deceptive, but it may be suspected : 1. When the fever is protracted and irregular. 2. When signs of a septic condition arise, such as irregular temperature with chills and sweats. 3. When embolic pneumonia develops. 4. When a loud, rough murmur, especially a diastolic aortic murmur, develops in the course of the disease. Meningitis is another complication to w^hich Osier has called especial attention, finding it in 8 per cent, of fatal cases. It usually comes on at the height of the fever, and may b». confounded with delirium. It is often asso- ciated with endocarditis, and it may he accompanied by cerebral embolism, producing hemiplegia. Neuritis is a- possible complication. Parotitis occasionally occurs, commonly in association with endocarditis. In children middle-ear disease is not an infrequent complication. Diagnosis. — The diagnosis of a case of typical pneumonia is easy. The chill, the rapidly developed fever, and the physical signs are, as a rule, easily recognized. It is to be remembered, however, that the physical signs may be delayed or not appear at all in the central varieties. Pleurisy is the disease from which pneumonia has most frequently to be distinguished. The resemblance between the friction sound and the crepi- tant rale is often very close, while there is impaired resonance to percussion in both. Most valuable in diagnosis is vocal tactile fremitus, which is invariably increased in pneumonia and as invariably diminished in pleurisy of any variety. In the not very rare instances of pleurisy with effusion CROUPOUS PNEUMONIA. 223 attended by bronchial breathing the same sign is pathognomonic, tactile fremitus being diminished, whereas it is increased in pneumonia. Com- monly, too, in this stage of pleurisy we have a change in the line of dullness as the patient changes position, though this is not invariable. The exploring needle, if needed, may also help settle that question. Frequent examination of the lungs should be made in alcoholism, in chronic valvular disease of the heart, in diabetes, and in Bright's disease, since all these affections are prone to become complicated with insidious forms of pneumonia. Typhoid fever and pneumonia are sometimes confounded. The former is apt to become associated with hypostatic congestion of the lungs, and pneumonia with a typhoid state. The hypostasis, however, occurs late in typhoid fever ; the dullness in pneumonia sets in early. A more excusable error is made in the case of acute tub erculo pneumonic phthisis, which may begin with a chill, while the resemblance is otherwise very close, especially in physical signs. Microscopic examination of the sputum should recognize the bacilli of either disease. This should always be made where an apparent pneumonia is prolonged beyond two weeks without a crisis. In pneumonic phthisis the appearance of bacilli is generally late. Prognosis. — Pneumonia is a treacherous and uncertain disease at any age. Young, robust men of twenty-five, taken mildly ill with every reason- able expectation of recovery, sometimes die suddenly and unexpectedly. On the other hand, while in the old and intemperate it is especially danger- ous, old men and women over seventy often recover completely. The intem- perate are less fortunate, yet even among them some surprising recoveriesi are observed. The mortality ranges from 20 to 40 per cent., or about one in four or five die. It is the most fatal of the acute infections of adults in temperate climates. Children recover often, even when desperately ill. The disease seems to be more fatal in cities than in the country, and is cer- tainly so during epidemics, or in ships or other crowded places. The seriousness of an attack varies more or less with the extent of lung involved, pneumonia of a whole lung being more dangerous than that of a part, double pneumonia more than that affecting one lung, while massive pneumonias are always fatal. Meningitis is invariably fatal, but its presence must not be inferred from every violent delirium. Endocarditis is almost as fatal. Death is usually by heart failure, the right ventricle becoming stretched by the accumulated blood, and the valves and columnse carneas embarrassed by fibrinous coagula. which may extend from auricle to ven- tricle and even into the branches of the pulmonary artery. The conclusion h apparently unjustified by a study of statistics,* but it does seem to me that pneumonia is a more fatal disease now than when I began practice thirty-five years ago. Treatment. — A fundamental principle which experience has established is that no single plan of treatment dare be recommended for pneumonia, but that each case is a law unto itself. This is more or less true of all diseases, but it is especially so of pneumonia. Undoubtedly cases occur that are best treated by general blood-letting, while many more do not require it, and a few may be harmed by it. Pneumonia may be a general disease and not a local one, and the lung involvement may be secondary : at the same time the patient often dies from the direct effect of such local involvement. It is the * For an excellent analytical examination of the statistics of pneumonia the reader is referred to a paper in the " Medical News," July 27, 1889, by Drs. Townsend and Coolidge, Jr., based on a study of the cases treated in the Massachusetts General Hospital. 224 INFECTIOUS DISEASES. obstruction to the movement of the blood through the hmgs which strains and wears out the right heart. The blood-letting, if it is done early, lessens this congestion, and thus relieves the right heart. More frequently per- haps at the present day the patient dies of the efifect of the toxin on the heart and nervous system. What are the indications for blood-letting? There are two periods in a pneumonia where blood-letting may be of advantage : First, in the first stage and early part of the second stage, and, second, where there is engorge- ment of the right heart. The indications in the first period include ( i ) great dyspnea; (2) full, bounding pulse; and (3) sharp, pleuritic pain. The relief to all of these symptoms is often magical. The amount of blood taken at such time should not be less than 16 ounces (480 c. c), but not the quantity of blood so much as the relief to the symptoms should be the sign to stop the bleeding. The same results may be accomplished by wet-cups, provided a sufficient amount of blood be taken, and cupping has the appear- ance of being less formidable, although it is actually more painful and dis- turbing to the patient. After the removal of the cups a poultice or warm cotton jacket is comforting. If doubt is entertained as to the propriety of either of these two methods of bleeding, the affected lung should be covered with dry-cups, and after the removal of these the hot poultice or hot jacket applied. Even by this method the relief to the pain and dyspnea is often very great, but it is more likely to be temporary. Dry-cupping may, how- ever, be repeated daily, if it affords relief. While there are cases in which the adynamia is so great as to make blood-letting in any form of doubtful propriety, there can be no possible objection to the dry-cups. Bleeding, besides relieving the symptoms referred to, hastens the crisis and shortens the disease. The indications in the second period are rapid breathing with cyanosis and laboring pulse. At this stage the removal of 10 to 16 ounces of blood is often of signal service, and I believe I have seen life saved by such a blood- letting. These measures may also relieve the cough, but usually something addi- tional is required. Until expectoration sets in. opium is pre-eminently the remedy, and no preparation is so good as morphin in doses of from 1-16 to 1-12 grain (0.004 to 0.005 S^'^-) for adults every two hours in 1-2 ounce (15 c. c.) of the solution of citrate of potassium flavored with lemon or other syrup. Doz'cr's pozvdcr in full doses sometimes acts favorably. It is best given in pill form. Expectorants are rarely needed at the outset, but auiuwuium cJiIorid in doses of 5 to 10 grains (0.32 to 0.65 gm.) in brown mixture, also combined with morphin if necessary, will meet the indications. If a still more stimulating expectorant is required, the carbonate of amuionimn may be used in doses of 5 to 10 grains (0.32 to 0.65 gm.) fre- quently repeated. It is an important fact, often overlooked in prescribing diffusible stimulants, that to get a desired effect they should be frequently repeated, and it is better to give small doses often than large doses at longer intervals. Pneumonia calls very soon, sometimes from the very outset, for alco- holic stimulants, which act not only on the heart, but also as antipyretics. Half an ounce or even an ounce ("15 to 30 c. c.) hourly, in cases of extreme adynamia, may be necessary. The index of sufficiency or the reverse is the state of the pulse and heart. Whisky or brandy, as selected, should be givenJ in milk, which is the most suitable nourishment. From 4 to 8 ounces (12a CROUPOUS PNEUMONIA. 225 to 140 c. c.) of milk every two hours, containing the proper dose of stimu- lant, may be given. Strychnin is an invaluable heart tonic in pneumonia, and may be given in doses of 1-30 grain (0.002 gm.) or more, every four to six hours, com- bined with 8 to 20 grains (0.52 to 1.30 gm.) of qiiinin in the twenty-four hours, as may be required. Digitalis is a remedy much used in pneumonia, and it is a useful drug, but it is not always judiciously ordered. To whip up a flagging heart to increased effort to drive blood through a lung almost as solid as a stone is like whipping up a jaded horse to an effort beyond his strength, and is about as ineft'ectual. On the other hand, such a stimulus may tide over an obstacle which is not insurmountable, but which might remain in the way unless removed. On the whole, I prefer to give digitalis in moderately full doses, 5 to 10 minims (0.3 to 0.6 c. c. ), as an adjuvant to alcohol rather than in very large doses. Occasionally in sudden adynamia very large doses, say I dram (3.7 c. c), hypodermically, may turn the tide toward recovery. Aromatic spirit of ammonia is an important adjuvant in straits like these, and may be substituted with advantage for the carbonate. Inhalation of oxygen is of undoubted advantage in relieving the dyspnea and thus comforting the patient. Whether it is curative is much more doubtful. High temperature may be reduced by sponging, though the tempera- ture itself in pneumonia cannot be regarded as dangerous per se. Should ive ever blister in pneumonia f A blister in pneumonia some- times does much good. It is especially useful in delayed resolution, late in the disease, where the crisis has been imperfect and convalescence does not set in. It may even take the place of a local or general blood-letting, espe- cially when these have been deferred too long or are impossible from any cause. When a blister is applied, let it be an effective one. A large blister is no more painful than a small one, and neither is it so painful as is com- Tnonly supposed. In mild cases turpentine stupes may be sufficient to relieve pain. I am well aware that pneumonia is regarded as a self-limiting disease, reaching its crisis in from five to nine days, and that many think the only indication is to sustain the patient until the crisis is reached. In many cases this is true, but I believe that the fury of the disease may be diminished by treatment, and that a prompt bleeding at a suitable time will not only lessen the suffering, and so spare the strength of the patient, but may also hasten the crisis. Another stage at which a blood-letting is sometimes serviceable is where the right heart, from its ineffectual efforts to propel the blood through the lung, becomes distended. Such a stage is indicated by intense cyanosis and gasping orthopnea. The use of veratrum viride is warmly recommended by some instead of bleeding in the earliest stages of the disease. It diminishes the force of the heart, furnishes a diverticulum for the excess of blood, and, as my col- league, Horatio C. Wood, says, " The patient is bled into his own circula- tion." I have never felt comfortable in relying upon it. The treatment of pneumonia by "ice-cold applications has lately been gaining favor. Its most ardent supporters in this country are Simon Earuch. of New York City, and Thomas J. Mays, of Philadelphia. My experience has not been large, but it has been such as to encourage me to •continue it. Further experience since the first edition of this book appeared 15 226 IXFECTIOUS DISEASES. confirms mv favorable impression. I prefer the method, recommended by Baruch, of enveloping the chest in a suitably fitted linen or muslin jacket (the ordinarv cotton jacket answers well), wet in cold water at 60° F. ( 15.5' C.) and covered by a flannel bandage an inch wide and longer; direct- ing that the jacket be removed and substituted by the dry cotton jacket whenever the temperature falls to 100° F. (37.7° C), and renewed if the MARK SE5P. OR TEMP. ^^ 20 ^/ Q^e^od^/^ce,. ^(J.c^f,^EimimimiiL C^a^it, (?fc "yjQafc, April Fig. 21.— Showing Drop in Temperature in a Case of Pneumonia Succeeding the Application of the Cold, Wet Jacket. The figures opposite resp. in upper left portion indicate the breathing rate, which was- too rapid on admission to be indicated in the usual way by the chart. temperature rises. In this way all danger is averted. Baruch recommends a preliminary dose of 15 to 20 grains ( i to 1.33 gm. ) of calomel. Appended is the temperature chart of a case admitted to the University Hospital under my care, breathing at the rate of 58 a minute, and of whose recovery I had no expectation, but which passed to rapid convalescence after the applicatiorL of the cold, wet jacket. CROUPOUS PNEUMONIA. 227 Dr. Mays prefers to surround the affected area with ice contained in bags that are wrapped in towels ; but they are difficult to keep in place, espe- cially when more than one bag is required, which is the case if more than a limited area is involved. He says, also, that if the temperature falls to the normal, or near it, with a tendency to remain there, the ice is to be gradu- ally removed. The fever is, of course, a mere index of the severity of the disease, and it is not for the direct effect on it that the ice is applied, but to arrest the process. The effect of the ice is almost immediately to cause the tempierature to fall. Such fall must not be mistaken for the crisis. If induced by the ice, it rises soon after its removal. Hypodermoclysis of normal hot saline solution was used in desperate cases of pneumonia in the Philadelphia Hospital by Dr. Frederick P. Henry as early as the spring of 1889. Dr. Henry's first publication upon the subject, however, was made in January, 1900.* A few months earlier than this. Dr. Clement A. Penrose j published a paper on " Infusion of Salt Solution," etc., in pneumonia. The injection is made in the usual way, under the skin, at any stage in bad cases of pneumonia, from one-half pint to a pint (236 to 473 c. c. ) of a .6 of one per cent, solution being injected daily. Dr. Penrose added that the treatment is more efficient when given in connection with oxygen inhalations associated with blood- letting if there is distention of the right heart as evidenced by cyanosis, flagging pulse, and sharp accentuation of the second pulmonic sound. The effect is that of a respiratory stimulant, reducing the pulse and breathing rate, as well as of a diluent for the toxins in the blood. Dr. Pen- rose also describes a method of inhaling oxygen which appears to be very satisfactory. In place of the usual delivery nozzle, a glass funnel is substi- tuted, held about two inches from the face by a framework resting on the bed or an adjoining table. In this way oxygen is supplied to both mouth and nostrils without interfering with the breathing. These measures cer- tainly merit a trial in desperate cases, the more especially as they are at least harmless, and add in no way to the discomfort of the patient, while the results claimed by both Dr. Henry and Dr. Penrose are most encouraging. Serum Treatment, — Pneumonia was one of the first diseases the treat- ment of which by serum engaged attention. The subject was studied by the brothers G. and F. Klemperer, who utilized for prophylactic and curative purposes the antitoxin derived from the blood of immunized animals. Immunity is obtained by subcutaneous or intravenous injection of filtered bouillon cultures of the pneumococcus, cultures sterilized by heat or anti- septics. Such immunity is limited to six months, but the young born within this period are also immune, while the serum of the blood of such animals has the power to immunize other susceptible animals. Nay, more, these fluids, when introduced into the blood of animals already infected, were found capable of curing them. Thus, in such ani- mals with a body temperature of from 104° to 106° F. (40° to 41° C.) the fever fell to normal in twenty-four hours after the injection of the serum. It is held by these experimenters that the pneumococcus pro- duces a poisonous albumin or pneumotoxin, which when introduced into the circulation of an animal causes a rise of temperature, and later an antipneu- motoxin, which has the power of neutralizing the poisonous albumin formed _*" Treatment of Pneumonia by Hypodermoclysis," "International Clinics," vol.' iv., Ninth Series. looo. t "Johns Hopkins Hospital Bulletin," Julj', iSgg. 228 IXFECTIOUS DISEASES. by the bacteria. During the pneumonia the pneumotoxin produced by the bacteria in the kuigs is constantly being absorbed into the circulation. In natural recover}- this continues until enough antidotal substance is gener- ated in the circulation to exert its effect when the crisis occurs. Thei bacteria are not destroyed, nor is their ability to produce poisonous products, but these latter are neutralized by the antitoxin, the presence of which has been demonstrated in the serum of the blood of pneumonia patients after the crisis. Klemperer first injected this serum into infected animals, with the effect of curing them. Finally, he injected into persons ill with pneu- monia the blood serum from others convalescent from pneumonia, with a view to hastening the crisis. In six cases there was a decided reduction in temperature in from six to twelve hours after injection of from 65 to 95 minims (4 to 6 c. c.) of the serum. The pulse and respirations also fell. The serum has no effect when injected into healthy individuals. Pneumonia antitoxin has continued to be used, from time to time, since its introduction by the Klemperers, but it has not established a reputation as a remedv superior to other methods of treatment in common use. It is made. by the Mulford Company, in Philadelphia, whose dose is 20 c. c, or three dessertspoonfuls, beneath the skin, repeated in from four to six hours while the temperature exceeds 103' F. (38.3^ C), after which it should be given twice a day for several days. If the temperature is below 103° F. and there is severe constitutional disturbance, the injection should be con- tinued more frequently until there is marked improvement. This serum is produced by a method used by Pane, Washburn, de Renzi, Lambert, and McFarland by immunizing animals to increasing doses of live virulent cultures. ]\IcFarland has secured in the horse a tolerance to 100 c. c. of a very virulent culture. From such an antipneumococcus serum is obtained. I have used this serum in some 19 unselected cases, but am unable as vet to draw any conclusion horn my observations. BROXCHOPXEU^IONIA. Synonyms. — Catarrhal Pneumonia; Capillary Bronchitis; SuifO'Cative Catarrh; Lobular Pneumonia; Aspiration Pneumonia; Deglutition Pneumonia. Definition. — Bronchopneumonia is an inflammation of lobular or patchy areas of lung tissue caused by microbic or other irritants that find their way to it through a bronchus. Etiology. — The effects of recent studies go to show that the broncho- pneumonias of children are the result of the same causes as the lobar pneu- monias of adults, producing however in the latter lobar consolidation and in the former lobular or patchy consolidation.* Usually bronchopneumonia succeeds a bronchitis of the terminal bronchus leading to the part. Some would consider bronchopneumonia and capillary bronchitis one and the same thing, but the latter term is best restricted to what it actually indicates — inflammation of the smallest bronchioles. It often precedes, and is often asso- ciated with, bronchopneumonia. Parts of a lobule, a whole lobule, or scattered * See Samuel West, " Clinical Lecture on Bronchopneumonia," to show that pneumococcal pneu- monia in a child takes the lobular and not the lobar form. Reprinted for the author from the "British Med. Jour.," May 28, i8q8. BRONCHOPNE UMONIA. 229 groups of lobules are thus affected, and may unite to form larger areas. Thus, while a bronchopneumonia is primarily lobular, we may have even a lobar bronchopneumonia if all the lobules of a lobe are simultaneously affected. Aspiration pneumonia is a bronchopneumonia caused by the irri- tation of inhaled or indrawn particles, including bacteria, among which must be included also streptococci and staphylococci, as well as pneumococci and tubercle bacilli. Tubercular bronchopneumonia is one variety of this. Syphilitic bronchopneumonia is a rare, but possible, affection. The recognition of bronchopneumonia as a separate disease is usually credited to Barthez and Rilliet. Simple bronchopneumonia is pre-eminently a disease of the very young and the old. In the young it occurs as an idiopathic affection, though it is also a frequent complication of the infectious fevers, measles, whooping- cough, scarlet fever, diphtheria, and smallpox. In adults, especially the old, it occurs during influenza, erysipelas, typhoid fever, and all debilitating affections, including Bright's disease and organic disease of the heart. The inhalation variety especially occurs in comatose states, however induced. William Pepper laid especial stress on vesicular emphysema as a predispos- ing cause. In both young and old it may succeed a simple bronchitis from cold, but it is as a coniplication of the infectious diseases named that it becomes during the first five 3'ears of life a very common, serious, and fatal disease, causing, it is said, more deaths among children than any other disease except infantile diarrhea. Diarrhea itself and rickets are also to be included as predisposing causes. All influences depressing to life, such as overwork, fatigue, the air of badly ventilated and crowded houses, insufficient food, and defects of hygiene act similarly. Collapse of the lung is at once a cause and a consequence of bronchopneumonia. Another cause of bronchopneumonia more common in adults and the aged is the inhalation of fine irritant particles or the aspiration of particles of food. In comatose states from any cause the sensibility of the larynx is benumbed, and minute particles of food are permitted to pass beyond the rima glottidis to enter the larynx, and thence the smaller bronchial tubes, where they excite inflammation. Hence the term aspiration or deglutition pneninonia. Glossopharyngeal palsy is often associated with deglutition pneumonia, which may follow tracheotomy and cancer of the larynx and esophagus. The inflammation thus excited is sometimes so intense as to cause suppuration and even gangrene. Stone-cutting, steel-grinding, and coal-mining become causes through the irritating particles inhaled in these occupations. Francis Delafield, in the section on bronchopneumonia, in his " Studies in Pathological Anatomy," says the extension is not from the bronchus to the air-vesicles that are connected with it, but to those that sur- round it. Thus he says, " It is as if a red-hot needle were thrust through the lung, making a track of charred tissue around it." He refers more par- ticularly to the bronchopneumonia that succeeds bronchitis. Morbid Anatomy. — The morbid anatomy of simple bronchopneumonia is quite definite, yet somewhat complex and difficult of description. The lungs may be superficially unaltered or they ma}^ be large and heavy. On the exterior, especially at the base, may be seen a mottled appearance, due to an alteration of dark-blue or bluish-black depressed areas with project- ing portions more natural in hue. The depressed areas represent col- lapsed lung, and can, for the most part, be reinflated. In places they are continuous, forming large patches. Where there is much of this dift'use 230 INFECTIOUS DISEASES. pneumonia, corresponding patches of fibrin may be seen on the puhnonary pleura. On section the surface of the king is dark red in color and from it pro- ject reddish-gray spots, representing areas of bronchopneumonia. These may be separated by tracts of uninflamed and collapsed tissue, or may unite to form more extensive inflamed areas. A section made transverse to the lobule will be found penetrated by a central bronchiole filled with muco-pus, while if the section is parallel with the length" of the bronchiole, the central alveolar passage with its alveoli may be readily recognized, being rendered distinct by the same muco-purulent contents. Around the bronchus, to the extent of from i-8 to 1-5 inch (3 to 5 mm.) or more, is an area of grayish- red consolidation elevated above the surface, usually slightly granular to the touch, but still lacking the hard, shot-like feel of croupous pneumonia. On pressure, a mixture of pus and desquamated cells may be squeezed out, which, at a later stage, becomes almost pure pus, appearing as white points in the non-depressed tissue. Surrounding the imperfectly hepatized areas and at a lower level is a smooth, dark, airless tissue, representing collapsed lung, which may be the seat of beginning inflammation. At a later stage, if the patient survives, especially in adults, the inflammatory areas may assume a darker hue, even that of gray hepatization. Still later, in the per- sistent forms, the areas may contain foci resembling miliary tubercles, from which they may be always distinguished by the fact that the white droplets can be squeezed out, while tubercle remains firm. These areas may be con- verted into cirrhotic patches. During the progress of a bronchopneumonia the air-cells in the adjacent lobules are found dilated, and the edges of the lung and upper portions have also become emphysematous. The bronchioles themselves are also dilated in places. The uninflamed areas are generally congested. The contents of the bronchioles and air-vesicles are pus-cells and swollen exfoliated epithelium. The walls of the bronchiole and of the air- vesicles are thickened and infiltrated with leukocytes. Rarely do they con- tain blood or the fibrin-network characteristic of lobar pneumonia. Occa- sionally, minute extravasations of blood may be found. The phenomena in the aspiration form of bronchopneumonia are more intense in every respect than in the other forms, the infiltration of the air- vesicles with leukocytes leading sometimes to suppuration or even to gangrene. Symptoms. — The initial symptoms vary with the precursory disease. In a child — and here the disease has its greatest practical interest — there may have been measles or whooping-cough or diphtheria, in which con- valescence may or may not have set in. To incipient or aggravated cotigh decided fez'er is added, a temperature of 102° F. (38.9° C.) and higher being attained; the cough becomes more severe and painful, the breathing becomes rapid, and an easily visible, distressing dyspnea supervenes. The embar- rassed breathing grows worse, the fever is higher, the lips and face become cyanosed, the short, incessant cough is inefifectual in the raising of expecto- ration, and the little sufiferer is a picture of pitiable distress. For such a state of afifairs the term suffocative catarrh given by the older authorities is well chosen. Happily, as the disease advances and the blood becomes charged with carbon dioxid, sensibility wanes, the suffering abates, and the cough grows less ; but the frequent breathing, often 60 to 80, the lividity of the face, and the frequent pulse show that the fury of the disease is not spent, BRONCHOPNE UMONIA. 23 1 but will probably terminate only in the death of the little sufferer, which is -directly due to exhaustion of the muscle of the right ventricle. At times, Jiowever, and even when least expected, a favorable turn takes place and a surprisingly rapid convalescence sets in. In adults, as in children, the symptoms vary with the mode of origin. In the idiopathic form, which is recurrent in some old persons, there are fever, a burning spot in the cheek, and shortness of breath, but a cough less troublesome than would be expected. The physical signs rather than the symptoms determine the diagnosis. There are fine moist rales, with harsh breathing rather than bronchial breathing, and relatively clear percussion. The symptoms in a case of deglutition pneumonia are very similar. In the inhalation pneumonia of miners, stone-cutters, and steel-grinders the symptoms are slower in their development and resemble more those of tubercular phthisis. Physical Signs. — These are by no means as distinctive as those of croupous pneumonia. Though I think it best to separate capillary bron- chitis from bronchopneumonia, the association is so close that, given the fine subcrepitant rales of the former, unaccompanied by impairment of reso- nance, we may infer that bronchopneumonia is at hand. Further signs, liowever, of actual involvement of the lung-substance are moderate impair- ment of resonance and liarsh breathing, rather than true bronchial breath- ing, though more rarely the latter may be present, especially when the bases of the lung are involved. Inspection may recognize retraction of the car- tilages and lower sternum during inspiration, indicating defective expan- sion of the lung. Diagnosis. — The diagnosis of bronchopneumonia is usually easy. High fever, cough, mucous expectoration, fine rales, and slight impairment •of resonance, following one of the infectious diseases in a child under five years, and developing gradually, admit of but one interpretation. When a number of small foci unite to form a large area corresponding to the whole or a portion of a lobe, the physical signs are more like those of a lobar pneumonia, and the absence of expectoration in children increases the diffi- culty of diagnosis. Lobar pneumonia develops more suddenly and resolves more rapidly. The similarity in the morbid anatomy of persistent bronchopneumonia and tuberculosis has been referred to, and the clinical resemblance is even greater, so that it may be impossible to say of a given condition in a child which it is. The presence of signs at the apices is to be sought for, and, if found, tuberculosis may be suspected ; but the correct diagnosis is sometimes made only on the autopsy table. Prognosis. — The prognosis varies with the etiology, but broncho- pneumonia is always a serious disease. From 30 to 50 per cent, of all chil- dren perish from it. In fatal cases in children death may '^ccur in twenty-four hours. When recoverv takes place, the disease lasts from five to ten days, and as many more are required for complete restoration to health. More rarely a chronic interstitial pnemnonia, what Delafielql calls a persistent bronchopneumonia, develops, which may last for months or years and finally give rise to miliary tuberculosis. Yet, as mentioned under symptomatology, some remarkable recoveries take place. In adults it is about as serious as croupous pneumonia. The 232 IXFECTIOUS DISEASES. deglutition variety is almost always fatal, and is the usual cause of death in glossopharyngeal palsy. Some cases pass into tubercular consumption, even in children. Treatment. — The indifiference of parents and the carelessness of nurses are responsible for many cases of bronchopneumonia occurring during con- valescence from measles, diphtheria, and whooping-cough which, with proper care, might have been averted. Among the causes thus responsible are exposure of children with uncovered heads at open doors and windows, insufficient clothing during sleep, overheated rooms, and drafty corridors. Restorative measures are indicated in this disease from the outset. Nauseating expectorants are rarely demanded and often do harm by lower- ing the vitality of the young patient. Blood-letting, undoubtedly useful in some cases of croupous pneumonia, is not called for in catarrhal. Opiates to quiet the cough and relieve the pain are the strongest indications in the earlier stages of the disease and sometimes throughout it. They should be associated with diaphoretics and febrifuges, among which the solution of acetate of ammonium, the solution of citrate of potash, and sweet spirit of niter are the best. The tincture of aconite in small, but often repeated, doses is extremely valuable if the temperature is high and the pulse full and rapid. When secretions become free and a stimulating expectorant is required, there is none better than the aromatic spirit of ammonium, which fulfills every indication and spares the stomach more than the chlorid or carbonate of ammonium. If the accumulation of mucus become troublesome, it may be dislodged by a mineral emetic, such as alum, of w^hich the dose for a child is a heaping teaspoonful ; or sulphate of zinc, in doses of lo to 30 grains (0.65 to 2 gm. ) ; or the syrup of ipecac, more likely to be at hand, may be used. At this stage, alcohol, in the shape of whisky or brandy, becomes an important adjuvant. It should be added to the nourishment, of which the best form is milk, although nourishing broths are also indicated. As digestion is likely to be feeble, the milk is better peptonized. Quinin, and especially strychnin as a respiratory stimulant, are useful tonics. In the way of local treatment counterirritation by mustard and tur- pentine is especially useful. The former should be used in the shape of a weak plaster, one part of mustard to five or six parts of flour or flaxseed meal. If white of egg and glycerin be used to mix it instead of water, the plaster is less painful and may be kept on continuously. One of the best modes of applying turpentine is by the St. John Long liniment, which may be made by mixing thoroughly a teacupful of vinegar, a wineglass of turpentine, and one egg. This may either Idc rubbed thoroughly on the chest or it may be applied on flannel. It may be that the turpentine is absorbed and acts as an expectorant. Blisters are not to be recommended. The poultice is a measure of treatment for catarrhal pneumonia which is variously valued. It is undoubtedly useful in children if properly employed, but great care should be taken that it does not become cold. It should be lightly made and changed often: and when changed, it should be done rapidly, a fresh, hot pouhice being at hand to replace the one removed. When poultices are not used, the cotton jacket should be substituted, as it insures a uniform temperature of the body. This should be further fav- ored by maintaining a uniform room-temperature of 70° F. (24.5° C.) and averting drafts by screens. If the temperature be ven- high, it may be reduced by sponging, or, better, by the wet-pack at a temperature of 75° F. (25° C.). The child CHRONIC INTERSTITIAL PNEUMONIA. 233 does not, however, die of the effects of high temperature, but rather, finally, of a failing right heart. The bath is, nevertheless, very calming to the nervous system, and should be used for this reason. The same measures may be used with appropriate modifications in the catarrhal pneumonia of adults, and also in the variety known as deglutition pneumonia. As this last form of pneumonia is, however, generally the beginning of the end in some other serious condition, treatment avails but little. CHRONIC INTERSTITIAL PNEUMONIA. Synonym. — Cirrhosis of the Lung. Definition. — A chronic inflammatory disease consisting in a gradual invasion of a lung by fibroid tissue, with a corresponding reduction in the vesicular structure of the lung. According as it involves limited or more extensive areas it is local or diffuse. Etiology. — Interstitial pneumonia is mainly a secondary affection. There are few chronic affections of the lung which do not cause a certain amount of fibroid overgrowth. Especially is this true of tubercular con- sumption and bronchopneumonia. A form of the latter is the so-called. pneumoconiosis, a fibroid induration succeeding a bronchopneumonia due to the irritating effects of minute particles arising in the occupations of coal- mining, stone-cutting, steel-grinding, and iron-working in general. To the form associated with tuberculosis the term fibroid phthisis is applied, and it has received separate consideration. The seat of a healed tuberculosis is also occupied by fibroid tissue, which may be regarded as an example of interstitial pneumonia. Less frequently it succeeds croupous pneumonia as fibroid induration, which has been considered on page 221 and constitutes an important product in pleurogenic pneumonia mentioned on page 222. Even abscesses of the lung may excite it, while the various forms of morbid growths, as sarcoma, carcinoma, chondroma and hydatid cysts, are causes of. it, and are surrounded by fibroid growths. Especially does the fibroid change occur in a lung that has been long in a state of compression, as by a pleuritic effusion. Since the majority of cases of chronic interstitial pneu- monia are directly or indirectly the result of microbic agents, it has appeared to me best to retain its consideration in this section, even though some cases, may be due to other causes. Morbid Anatomy. — Pathological Histology. — In bronchopneumonia the fibrosis usually starts from the outer sheath of the bronchi, invading the alveolar walls and converting the entire lobule into grayish fibroid tissue, .in which no lung structure is distinguishable. This form is frequently associated with dilated bronchus, of which the fibrosis is probably the direct cause, its contraction drawing the walls apart. The line of demarction between interstitial pneumonia on the one hand and tuberculosis on the other is often not very sharp. , In interstitial pneumonia after croupous pneumonia a gradual organiza- tion takes place of the fibrinous plugs in the air-vesicles : the alveolar walls themselves become thickened by a new formation, at first cellular and sub- sequently fibrillated. Death usually occurs in these cases in one to three 234 IXFECTIOUS DISEASES. months after the onset of the disease. The whole of the part primarily invaded may become thus altered. Macrosco[>ic Morbid Anatonuy. — The chest-walls of the side affected are often depressed, and on opening the thorax, the lung, or as much of it as is involved, is found retracted ; it may be drawn back into the spinal gutter. If on the left side, the heart may be retracted with it. Commonly the two pleurae are found united, but not always. On section the lung is hard and tough. It is gray, fibrous, and the alveolar structure has, to a varying extent, disappeared. The bronchi and the blood-vessels, however, remain, the former being often dilated, to produce the so-called bronchiectatic cavity, of which there may be a number. The pulmonary artery may be atherom- atous. In the phthisical variety there may also be a cavity at the apex, and a recognition of this before death will be an aid to diagnosis. Other- wise a careful study is often necessary to distinguish the two varieties, unless the tubercle bacillus has been found. The uninvolved lung is usually enlarged and emphysematous in pro- portion to the degree of contraction of the afitected lung. The right ven- tricle, which has increased work imposed upon it in forcing the blood through the contracted lung, becomes hypertrophied and may become ulti- mately dilated. Symptoms. — The principal symptom is cough, which starts with the condition causing the fibrosis and continues to the end. It varies greatly in its severity, being sometimes trifling, at others very troublesome. The expectoration is as variable as the cough ; more copious as the cough is more troublesome. Persons thus affected have the appearance of delicate health, and are commonly regarded as phthisical, although they have often con- siderable strength and can pursue some occupation. In non-tubercular inter- stitial pneumonia there is less fever than is present as a rule in phthisis, but the recognition of the tubercle bacillus is the crucial test, for otherwise the symptoms are very similar. In both conditions there is paroxysmal cough, with copious expectoration of muco-purulent matter. The resemblance is still more close if there is bronchiectasis, when the usual emptying of the cavity by cough takes place, commonly in the morning, sometimes twice a ■day, and even oftener. The expectorated matter of the bronchiectatic cavi- ties may be fetid from decomposition. There is usually less dyspnea than in true phthisk. and except where the disease is the sequel of true pneumonia, the fatal termination is longer deferred than in tuberculosis — it may be for years. Physical Signs. — The chest is more or less retracted, its circumference diminished. Its movements are restricted and its topography altered. When the left lung is extensively aft'ected. a pulsation is often seen in the second, third, and fourth interspace, very similar to what is sometimes seen in the right of the sternum, when a pleuritic eft'usion on the left side pushes the heart over to the right. It is probably the result of rhythmic retrac- tion and relaxation of the interspaces corresponding to the cardiac action due to adhesion. In high degrees of the disease the shoulder is drawn down and the spinal column laterally curved, just as in recovery after empyemic pleurisy. The unaffected side is more prominent than in health. The tactile fremitus may be diminished or increased according as the pleural membrane is thickened or not. The same is true of vocal resonance. Percussion gen- erally elicits impairment of resonance over the affected lung, though there may be high-pitched tympany and even amphoric resonance over a dilated EMBOLIC PNEUMONIA. 235 bronchus. The king on the sound side furnishes hyperresonance. To aus- cultation the breathing sounds may be feeble, but there may be broncho- vesicular or bronchial and even amphoric breathing of the most intense kind. There is usually sharp accentuation of the second pulmonic sound because of the forcible effort of the right ventricle to push the blood through the contracted lung; and when the right ventricle begins to yield, cardiac murmurs may develop at the tricuspid valve. Diagnosis. — Chronic interstitial pneumonia is mainly to be distin- guished from fibroid phthisis, which is often impossible without an examina-' tion ni the sputum for bacilli. The history and duration of the case may be of assistance. Prognosis. — Recovery is impossible, yet cases last many years — ten, fifteen, and even longer. Treatment. — As intimated, treatment for the fibrosis is unavailing, though lung gymnastics should be practiced with a view to developing lung expansion. Intercurrent bronchitis may be helped by the usual remedies for that disease. Antispasmodics, belladonna, and hyoscyamus are often useful adjuvants to the cough medicines. Patients are generally better in summer and in a warm climate, where they should dwell, if possible. They should be fed with an abundance of rich, nutritious food, and surrounded by the most favorable hygienic conditions. EMBOLIC PNEUMONIA. Definition. — An embolic pneumonia is a pneumonia caused by an ■embolus, or, more rarely, by a thrombus formed in the pulmonary artery. Embolic pneumonia is either non-septic or septic. Embolic Non-septic Pneumonia. Synonym. — Hemorrhagic Infarct of the Lung. Etiology. — The non-septic hemorrhagic infarct of the lung is the result of embolism, more rarely of thrombosis, of the pulmonary artery. The emboli come from the right side of the heart, where they either originate as fragments of thrombi or have entered from the systemic veins. Emboli usually lodge at the bifurcation of the branches of the pulmonary artery. The usual transudation of blood takes place in a cone-shaped area. Not every embolus is followed by an infarct. An embolus may be so large as to cause death before an infarct can be formed. Nor is every hemorrhagic infarct followed by a pneumonia. The ultimate consequences of non- infectious emboli depend on their size. A large embolus and a corresponding infarct with free extravasation of blood are liable to be followed by gangrene of the lung, which may excite intense reactive inflammation in its neighbor- hood, and the aspirated blood may cause pneumonia. When the lodged particle is small, the hemorrhagic infarct is small, and the transudate is a diapedesis rather than a hemorrhage. , From this, true embolic pneumonia results only when there is no collateral circulation — that is, when it is supplied by an end-artery.* * All the large branches of the pulmonary artery are end arteries, and many of the smaller branches also. 236 IXFECTIOiS DISEASES. Morbid Anatomy. — The infarct thus caused is conical in shape with its base toward the pleura, and varies in size from that of a cherry-stone to that of a hen's egg. The pleura over the infarct at first projects above the surrounding surface, and is at first smooth, but later is roughened by a film of Ivmph. The infarct when recent is dark reddish-brown in color, and on section rises also above the surrounding surface. This transudation is the preliminary of a peculiar reactive inflamma- tion — the embolic pneumonia under consideration. Succeeding a slight preliminary contraction there takes place an immigration of leukocytes from the contiguous vessels which accelerates the reabsorption of the blood. To the disintegration and absorption of the red blood-discs succeed a more rapid paling and contraction, until no color' remains, or there may be a hard- ening of the pulmonary tissue, with a cicatricial-like contraction, into which the pleural membrane is drawn, producing fibroid thickening with radiated prolongations. Such hardening is partly due to a condensation of the lung and partly to an organization of the cells in the infiltrated alveoli and alve- olar walls. Such remnant is slate-gray from the residue of hematin derived from the extravasated blood, or it may be dark red, owing to hematoidin crystals throughout it. If the infarct is large, a part may break down into reddish inodorous pulp, which may be absorbed, or a part may make its way into a bronchus and may be expectorated. In the event of so large an infarct the residue of cicatricial tissue is larger. Caseation and calcifica- tion of the remains are possible results. The embolus itself is in like manner removed, a few filaments or slight wrinkles in the walls of the vessel being the sole residue. Symptoms. — There may be no symptoms, or these may be confined to a transient pleiiritk pain in the pleura covering the embolus. With the increase in size of the infarct such pain increases, and mav be associated with some sJwrtiicss of breath, due to destruction of the aerating surface. To this may be added expectoration of blood if the eft'used blood gets into the bronchus. If the infarcted area be sufficiently large, there may be dullness on percussion, increased vocal fremitus and resonance, crepitant and subcrepitant rales, bronchial breathing, and bronchophony. Further characteristics are the absence of fever and suddenness of onset and the presence of intravascular disease. It has been mentioned that the embolus may be so large, and cut oiT so large a supply of blood to the lung, that death will take place before an infarct can form. Diagnosis. — Embolic non-septic pneumonia is often overlooked. The foregoing symptoms, suddenly occurring in conection with states leading to thromboses in the veins or the right heart, may be suspected to be due to non-septic embolic pneumonia. Infarcts that form in the lung from non- infectious emboli arising in the left heart or arterial system must be so small as to escape detection, since the emboli themselves must be so small as to pass through capillaries into the veins, thence into the right heart, and thence to the lung. Prognosis. — The prognosis of non-septic embolic pneumonia is favor- able unless the embolus is so large as to stop up a large vessel, producing a correspondingly large infarct. An embolus plugging one of the largest branches of the pulmonary artery is fatal before an infarct can form. Treatment. — Nothing can be done actively to relieve an embolic pneu- monia of this kind. A patient in whom it is suspected must, of course, be EMBOLIC PNE UMONIA. 237 kept absolutely at rest. Counterirritation may be applied to the chest-wall over the area involved. Anodynes should be used to a degree required to relieve pain. Embolic Septic Pneumonia. Synonym. — Metastatic Abscess. Etiology. — The cause of septic pneumonia or metastatic abscess of the lung is a septic embolus. Such a septic embolus may originate in a thrombus at a seat of putrid inflammation or suppuration, such as the wound of an operation or a compound fracture, or in the uterus after childbirth. The veins of such a focus are filled with thrombi, which extend into the larger branches, where they soften and break up into fragments, some of which may pass into the right heart, thence into the pulmonary artery and its branches, until one is reached small enough to resist its further transit. Such an embolus, which is probably swarming with bacteria, is an intense irritant, and inflammation sets in that invariably terminates in abscess, as contrasted with the simple indurative irritation caused by a non-septic embolus. Thus caused, septic pneumonia is one of the anatomical features of pyemia. Morbid Anatomy. — Should it be our fortune to see this form of pneu- monia in its first stage, the same dark-red color as that seen in the hemor- rhagic infarct of non-septic pneumonia may be noted, except that the blood extravasation is more copious. Such extravasation is a further irritant, and soon an intense inflammation sets in, which may also be divided into two stages. In the first stage the alveolar spaces and the connective tissue of the alveolar and infundibular w^alls are infiltrated with pus-cells. The latter furnish a white-gray ground, on which may be seen, with the naked eye, •delicate red lines and circles, which represent infundibula whose vessels are still pervious to blood. In the next stage abscess-formation rapidly suc- -ceeds, when the hepatized area melts into a creamy pus, in which float a few fragments of elastic tissue representing broken-down alveolar walls and blood-vessels. The abscesses thus produced may be multiple, but are mostly of small size. If the abscess is subpleural, there will be suppurative pleuritis with empyema, and possibly perforation of the lung. In case a very large vessel is obstructed and a corresponding part of lung cut off, say a fifth of a lobe, the area thus deprived of pulmonary- arterial blood is rapidly filled from the veins, and a condition analogous to a hemorrhagic infarct occurs, to the border of which the inflammation is confined, where finally the necrotic mass is dissected loose. Symptoms. — The symptoms are those of pyemia (see p. 181), of which the lung abscesses form a part A chill succeeding a surgical operation of occurring: during the lying-in state, followed by siveatiug and high fever, are significant symptoms. Successions of these are even more conclusive. Treatment. — Treatment should be supporting and stimulating. Ouinin should be administered in largfe doses, and whisky as in a low fever. The physician should watch for an opportunity for surgical interference, although such opportunity rarely occurs. 238 INFECTIOUS DISEASES. TUBERCULOSIS. I. General Etiology and Invasion. Morbid Anatomy. Definition. — Tuberculosis is a general or local infectious inflammatory disease, the result of the implantation and proliferation of the tubercle bacillus. The action of the tubercle bacillus is peculiar in that it stimulates the cells of the body wherever it may lodge and grow, to the formation of little masses of new tissue which are called miliary tubercles. A miliary tubercle may, therefore, be defined as a nodule of new formation around an irritated point, the focus of which is the tubercle bacillus. The tubercle bacillus is a short rod-bacterium three to four microns in length, equal to about 1-3 the diameter of a red blood-disc, and 1-6 to 1-5 as broad as it is long. When successfully stained and viewed with high power it presents at times a beaded appearance once ascribed to the pres- ence of spores, but now, I believe, regarded as the result of unequal stain- ing. It can be studied satisfactorily only when stained by one of the anilin dyes.* Etiology. — Although the evidence in favor of the bacterial origin of tuberculosis may be regarded as conclusive, the readiness with which the bacillus lodges and grows varies greatly; indeed, the number of instances in which it fails to take root doubtless vastly exceeds that in which it does. Hence, the contagiousness of tuberculosis is slight and, although there appears to be no difficulty in transmitting the disease from one domestic * Of the various methods of staining tubercle bacilli that by the carbol fuchsin solution of Ziehl- Neelsen, with or without Gabbet's counter-stain of methyl blue, continues to be, on the whole, the most satisfactory. By this method the bacillus takes a bright-red color from the fuchsin, the mor- dant being carbolic acid. The carbol fuchsin solution is made as follows : Powdered fuchsin i part Alcohol 10 parts •i per cent, solution carbolic acid loo parts Mix and filter. The older the solution the better. A rapid and a slow method are practiced with this staining fluid, the former being more commonly- used for diagnostic purposes. 1. The Rapid Method ivith Carbol Fuchsin, with or without Counter-staift, by Methylene Blue.— A very small caseated clump of the sputum (care being taken that a bit of food is not taken by mis- take) is selected with forceps or a platinum loop and laid on a clean cover-glass. Another cover- glass is superimposed and the two are rubbed together until the specimen is thoroughly smeared over both. Thev are then separated, two specimens being thus obtained. When dry, one of them is passed, sputum side up. three times over the flame of a spirit lamp or Bunsen burner, by which the albumin is coagulated and the specimen is fixed. The cover-glass is then completely covered with the staining fluid and held over the flame until the solution begins to vaporize, care being taken to keep all parts of the glass thoroughly covered. At the end of one minute it is washed in water. It is then decolorized in acidulated alcohol, 8 to lo gtt. of HClor sgtt. of HNOjtoa watch crystal of alco- hol, and examined. For this a 1-12 oil imjnersion lens and Abbe's condenser are best suited, but after a little experience an ordinary dry system of 350 diameters" amplification, or higher, will easily reveal the bacilli, which are stained a handsome red. The preparation is more brilliant and its study rather less trying to the eyes if counter-stained by a Gabbet's acid blue, composed of — Methylene blue 2 parts 25 per cent, solution sulphuric acid 100 jjarts After being washed in water the specimen is immersed for one-half to two minutes in the acid blue, washed off in water, dried between folds of filter paper, and examined in water. 2. Slower Method ivith Carbol Fuchsin and Counter-stain by Gabbefs Acid Blue.— This slower method is always more satisfactory, if time permits, and should alone be used for permanent prep- arations. . . The steps are the same until the staining stage is reached, when the cover-glasses containmg the specimen are placed in the carbol fuchsin solution, say at five or six o'olock in the evening, and allowed to remain until next morning. They are then washed in water, counter-stained by Gabbet's acid blue solution, washed in water, dried between folds of filter-paper, and studied in water ; or, if it is desired to movnt the specimen permanently, it is passed through alcohol, xylol, or oil of cloves into Canada balsam. Specimens stained in anilin colors should not be mounted in glycerin, as this gradually withdraws the stain. When bacilli are very few, in viscid sputum, the centrifugator may be used, or Biedert's method pursued. Fifteen c. c. of the sputum are mixed with 75 to 100 c. c. ("about two teaspoonfuls) of water. ^ to 8 gtt., according to the density of the fluid, of liquo'r potassse are added, and the whole boiled. If still very viscid, add gradually, while boiling, 4 to 6 teaspoonfuls more of water, until a thin fluid results. The mixture is allowed to stand in a conical glass for two days, when the supernatant fluid is removed and the sediment is examined as before. It is to be remembered that bacilli treated with alkalies .stain slowly, and longer immersion in the staining fluid may be necessary on this account. TUBERCULOSIS. 239 animal to another, it is with extreme rarity that a case of tuberculosis in a human being can be traced to another. In an experience of thirty-five years, including large general hospital service, I can recall but a single instance of probable communication of the disease, and this was from a husband to the wife who was his faithful nurse for years. It would seem, however, that the contagium is more active than such experience would lead one to suppose. Thus, Cornet studied the records of certain institutions whose inmates are devoted to nursing, and discovered the fact that a large pro- portion of these (62.8 per cent, in twenty-five years) died of phthisis; also that of 100 nurses 63 died of this disease. It is to be remembered, however, that the life of the Sisters in convents is unw-holesome from too close con- finement. On the other hand, the statistics of the Brompton Hospital for Consumptives in London is decidedly against any conclusion that contact with patients peculiarly endangers the lives of doctors, nurses, or attend- ants. This, too, though they cover a period when no precautions were taken to destroy the bacillus. Flick's studies also point to a greater activity of the contagium than is usually admitted. He examined all of the houses in a ward in Phila- delphia where there had been deaths from consumption, and found that 33 per cent, of such houses had more than one case, that 25 per cent, of these houses had been infected prior to 1888, and that more than 33 per cent, of the deaths which occurred since 1888 took place in them. These observations accord with the results of Cornet's experiments, which demon- strated that the scraping from the walls of phthisical wards inoculated into the lower animals produced tuberculosis. A truly remarkable experience of Reich is related by Eichhorst.* In the town of Neuenburg, containing 1300 inhabitants, the midwifery cases were about equally divided between two midwives. One of these contracted consumption. She was in the habit of blowing from her mouth into the air passages of the new-born children, with a view to clear away the mucus. Within two years ten of the children delivered by this woman died of tuber- cular meningitis, while of the children delivered by the healthy midwife none showed any sign of tuberculosis. The conditions which favor the growth and multiplication of bacilli have been carefully studied, but have been only partially determined. One of the best recognized of these. Heredity, is much more influential when both parents have the disease than when one is affected. It seems to be true that the child resembling a tuberculous parent is more liable to the disease than one who resembles the healthy parent. A second favoring condition is scrofiihsis. or the " delicate constitution." The peculiar enlargement of the lymphatic glands, formerly known as scrofula, is now^ regarded as true tuberculosis of those glands. There remains, however, a condition called scrofulosis, characterized by paleness,, softness, and translucency of the skin of its subject, in whom inflammations run a slow course, and tend to resolve slowly and to terminate in cheesy products. To this some, and notably Rindfleisch, would still apply the name scrofulosis or the tuberculous di,athesis. In these the tubercle bacillus finds a favorable soil. On the other hand, there is a tradition that persons affected with tuberculosis of the lymphatic glands are less prone to tuber- culosis of the lungs than others. * " Patliologie und Therapie," vol. i. p. 559. 240 IXFECTIOUS DISEASES. Defective and insufficient food, especially when associated with imperfect ventilation, privation, grief, and overwork, are also conditions which favor the growth of the bacillus. Frequentlx recurring bronchial catarrh by lowering the vitality of the mucous membrane engenders a soil favorable to the growth and multipli- cation of the tubercle bacillus. Any of the causes that produce such catarrh may be included among predisposing factors. Particles of dust in- haled in the pursuit of various trades and avocations, as in coal-mining, 5tone-cutting, and steel-grinding, are well known to have this effect. ^leasles, whooping-cough, and typhoid fever with bronchial complications are sometimes followed by it. Damp localities favor the development of tuberculosis, and the very interesting observations of H. P. Bowditch, made a number of years ago, show that in houses thus situated case after case occurs, and whole families have been swept away. It is more than likely these results are dependent on a vulnerability engendered by the " colds " and catarrhs which such localities induce. No race is exempt, but the colored race is especially predisposed, as is also the American Indian when brought under the influence of civilization. Tuberculosis appears to be spreading among the Indians, even in districts ■ in the Rocky ]\Iountains where the disease is rare among the whites. It has been said that tuberculosis aft'ects in the shape of the mild or severe form of pulmonary tuberculosis one-half of the whole human race, that it causes the death of one-seventh of all persons w^ho pass away, killing one- third of those who perish between the ages of fifteen and forty-five. The Irish race in this country is also susceptible and many die of it. On the other hand, the Russian-Polish Jews are remarkably exempt, and next to them are the native American whites. I am indebted to W. A. King, Chief Statistician of the United States Census Bureau, for the following advance figures as to the nationality of victims of this disease : Six 3-ears Calendar 1884-1891 year iqoo. Total 3q8.8 259.6 White, 385.1 250.6 Colored, 774-2 654.1 White persons having mothers born in: United States, 205.1 151. 8 Ireland, 645.7 526.1 Germany, ......... 328.8 214.2 Russia and Poland, . . - . . . . . g8.2 88.5 Over 6000 die annually from tuberculosis in Pennsylvania alone ; while in the United Kingdom of Great Britain and Ireland 60.000 die annually from tuberculosis, and it is probable that at least three times this number are suft"ering from one form or another of the disease. Climates characterized especially by frequent rapid changes of tem- perature favor the development of tuberculosis. Such are the temperate zones. Tuberculosis is less common in the frigid and torrid zones, but these climates are not exempt. Age is doubtless a predisposing cause, the susceptible period for pul- monary tuberculosis being between twenty and thirty-five; for meningeal tiiberculosis, between two and seven; while the lymphatic glands, includ- ing the mesenteric and bronchial, are prone to involvement in the first ten vears of life. The mesenteric glands are more commonlv infected during; TUBERCULOSIS. 241 the first five years of life, including the nursing period and that during which the child is nourished on milk. The shape of the chest has long been regarded as influencing the de- velopment of tuberculosis, and a form of body peculiar to phthisical sub- jects was described by Hippocrates (B. C. 460-357) ; Galen (A. D. 130- 200) described the same type of chest. At the present day two varieties of chests are described as phthisical, the alar and the Hat. The former is narrow, shallow, and long, the angles of the scapulae projecting like wings behind, the proper ratio between the antero-posterior and transverse diame- ters-being, however, preserved. The ribs droop or are unduly oblique. The throat is prominent, the neck long, and the head bent forward. In the flat chest the antero-posterior diameter is disproportionately short, owing to the absence of convexity in the cartilages, which are sometimes even depressed, carrying with them the sternum and producing a form of chest which, on ■section, is kidney-shaped. In this form there is not the increased obliquity •of the ribs characteristic of the alar chest. Traumatism is also an agency of acknowledged importance in favoring the lodgment of the tubercle bacillus. This is more particularly seen in the development of tuberculosis of the joints succeeding injury. It is true, also, that contusion of the chest, without apparent laceration of the lungs or fracture of a rib, has been followed by tuberculosis. Mode of Invasion and Spread. — The bacillus of tuberculosis is probably omnipresent in the atmosphere, being derived from the drying and pulverization of expectorated sputum. The entrance into the body in the -vast majority of instances is by the respiratory tract. Hence the great fre- quency of tuberculosis in the lungs and bronchial glands, which are the first tissues open to its approach. It is possible, however, for it to enter by the skin, causing lupus or skin tuberculosis. It enters more readily by open wounds. Through the alimentary canal we have an undoubted route of in- fection. This happens most frequently in children from the use of the milk of tuberculous cows * ; in adults, from the swallowing of sputum. It is not necessary that the cow should have tuberculosis of the udder to render her milk tuberculous. This has been conclusively shown by Bollinger and con- firmed by Hirschberger and Harold Ernst. The boiling of milk destroys its infective qualities. Tuberculous meat is less frequently the cause of tuberculous infection by the intestine because it is almost invariably cooked iDefore eating, and also because striated muscular tissue is an infrequent seat ■of tuberculous lesions. The tubercle bacillus having once invaded an organ produces localized tuberculosis, which may or may not become generalized in a manner to be presently described. More rarely, tuberculosis may become general from the onset without any local initial lesion being discoverable. This consti- tutes one of the varieties of acute tuberculosis. Once established, tubercu- losis spreads by contiguity and through the lymphatic system and blood. In the former the tubercle grows by the addition of miliary tubercles at its periphery. Through the lymphatic system tuberculosis spreads to the lymphatic glands, and thence to the adjacent serous membranes. The bar- rier of the lymphatic glands once passed, the blood becomes the medium of a general infection. In the vast majority of cases generalization takes * At the meeting of the Association of American Physicians. Washington, May, 1806, Theobald "Smith, in a noteworthy paper on "Two Varieties of Tubercle Bacilli from Mammals," said he thought infection of the human subiect through the milk of cattle decidedly questionable, and that the subject should be reinvestigated. 16 242 IXFECTIOUS DISEASES. place from a focus of tubercle somewhere in the system, as the lungs, or a tubercular lymphatic gland, from which the bacilli start their migration. The favorite seats of tuberculosis are the lymphatic glands, lungs, liver, kidney, spleen, intestinal canal, urogenital mucous membranes, the brain (especially its membranes and blood-vessels), the bones and joints. In fact, no tissue or organ is exempt, the salivary glands and pancreas being least frequently invaded. Anatomy and Histology of Tubercle. — The miliary tubercle is the beginning of all tubercular deposits. It is itself a compound body com- posed of smaller submiliary tubercles, of which from lo to 50 unite to form a miliarv tubercle. It is about the size of a millet seed, hence the name miliarv. By actual measurement it ranges from i to 5 millimeters (1-25 to 1-5 inch) in diameter. In its young state it is a translucent gray granula- tion, especially characterized by its want of vascularity. The typical submili- ary tubercle is about 0.4 millimeter (1-60 inch) in diameter, and contains a giant cell in its center, surrounded by a close infiltration of lymphoid cells or a higher tissue of the lymphadenoid connective-tissue type, in the meshes of which are lodged loose lymph corpuscles or larger epithelioid cells. The giant cell may be wanting, and the whole tubercle may be a mass of lymphoid cells, among which the tubercle-bacilli are scattered, or the bacilli may be found in the giant cells, in the epithelioid cells, or even in the lymph cells. When isolated the miliary tubercle is found surrounded by a dense con- nective-tissue network, welding it firmly to the other tissues in which it is imbedded. The miliary tubercle is further characterized by its want of vascularity. In thin sections of an injected preparation it will be found that the blood-vessels go up to the tubercle and there terminate abruptly. Ta this lack of vascularity the tubercle owes its tendency to cheesy degeneration, in the course of which it assumes an opaque white color. When this hap- pens, the center exhibits under the microscope a granular, ground-glass appearance, while macroscopically tubercle in mass assumes a yellow color. In certain situations, especially in the lungs, the miliary tubercle forms larger foci, which gradually increase in size and constitute tubercular infil- tration, the yellow or crude tubercle of Laennec (1819?) and Louis as contrasted with the miliary or gray tubercle. According to these and other observers during the first thirty or forty years of the present century, gray and yellow tubercles were simply differing forms of tubercle. Later, how- ever, the influence of Mrchow, Buhl, and Niemeyer (1857-70) caused it to be quite generally accepted that the only tubercle was the gray granulation or miliary tubercle, while yello\v or crude tubercle was nothing but cheesy inflammatory matter. The subjects of this were still regarded as having phthisis, but not tuberculosis, whence the celebrated declaration of Niemeyer (1866), "The greatest danger to most phthisical patients is the develop- ment of the tubercle." * Even before the discovery of the bacillus by Koch, in 1882 — a discovery that resulted in the re-establishment of the unity of phthisis — the view began to gain ground, especially through the teachings of Buhl and Rind- fle.isch, that cheesy matter may be metamorphosed true tubercle, or it may have been primarily scrofulous inflammatory deposit, either of which might produce tubercle by an auto-inoculation. In the meantime, in 1865, Villemin announced the inoculability of tubercle. The discovery of the bacillus by Koch, in 1882, completed the overthrow of the duality of * Niemeyer's "Lectures on Phthisis," New Sydenham Society's Translation, 1870, p. 11. TUBERCULOSIS. 243 phthisis, the final result of which was the proposition, now generally admitted, that all phthisis is tubercular. The histogenesis of tubercle is in no way peculiar. We have only to remember that the bacillus is an irritant. The same response occurs to it as to other irritants. The wandering leukocytes flow from the adjacent vessels and form the lymphoid cells that constitute the bulk of the tubercle. The stabile cells of the connective tissue, the endothelial and perithelial cells of the blood- and lymph-vessels, the epithelium of the serous mem- branes, proliferate and enlarge, forming the epithelioid cells, and, in some instances, the giant cells, in both of which bacilli may be imbedded. The bacilli seem, however, to vary inversely with the giant cells. Thus, in lupus, joint and lymphatic gland tuberculosis, giant cells are numerous and bacilli scanty, while in lung tuberculosis bacilli are numerous and giant-cells scanty. The reticulum of connective tissue, usually more or less present at the periphery of the miliary nodule, is formed just as is connective tissue in ordinary non-specific inflammation, by the fibrillation of the protoplasm of cells and the rarefaction of the resulting matrix. The origin of giant cells has been much discussed, but it seems likely that any one of the connective-tissue cells named is capable of developing into a giant cell. It may also perhaps arise from the fusion of individual cells. It contains from 4 to 20 nuclei, commonly arranged in the periphery of the cell. Another form in which the tubercle presents itself is the solitary tubercle, which is not made up of united miliary nodules, but consists of a single large, cheesy mass varying in size from that of a pea to that of a human fist. It is almost invariably secondary to primary tuberculosis some- where else, commonly in the lungs. It is made up chiefly of round cells, in which are found also tubercle ba.cilli. In the peripheral layers a tissue of more fibrous structure prevails, which in certain tubercles becomes so abundant as to give rise to the term " fibrous tubercle." In addition to caseation the solitary tubercle is subject to puriform liquefaction, forming the so-called tuberculous abscess, and also to calcification. The two proc- esses last named may be associated in a single solitary tubercle. Some- times it is encysted. An especially favorite seat for solitary tubercle is the brain in children, especially the cerebellum at the border between the white and gray substance. The nodules are sometimes multiple. It is found also in the spinal cord, the spleen, the liver, and the heart. Degeneration of Tubercle. — Tubercle is subject to changes, of which the most frequent and characteristic is caseation. It is a regressive change, whereby the primarily transparent tubercular tissue is converted into an opaque yellowish substance of various degrees of consistency, resembling certain varieties of cheese, whence the name. The process is a form of coagulation necrosis, beginning in the center of the tubercle. The cells lose their outline, their nuclei are no longer demonstrable by ordinary stain- ing methods, and a confused granular mass results. Bacilli are, however, present. At times, on section, a quasi fibrillation appears in the caseated tubercle that is not to be mistaken for a true fibrous matrix. It may be the result of compression. Caseation is nol limited to tubercle. Cellular inflam- matory products and even cancer-cell masses may undergo the cheesy change. Most frequently caseation is followed by softening. The precise condi- tions necessary for this are not known, though commonly, as soon as a 244 INFECTIOUS DISEASES. caseated mass reaches a certain size, it breaks down into a pyoid product which is not histologically pus, but consists of a number of fat drops, gran- ular debris, and shriveled, formless cells. In the broken-down material the tubercle bacilli are exceedingly numerous, much more so than in the dry caseated tubercle. From this circumstance it is held by some that the caseation and subsequent softening are the effect of the bacilli, the action of which is compared to that of bacteria of decomposition. It seems much more reasonable to ascribe these degenerative changes to defective nourish- ment of the new formation. This view is sustained by the fact that softening does not take place until the tubercular mass acquires a certain size, com- monly a half to one centimeter (0.2 to 0.4 inchj in diameter. The more rapid the formation the earlier does softening set in. iMore rarely caseated tubercle becomes infiltrated with lime sahs and undergoes cdikareous change, by which a sort of healing is accomplished. The calcareous infiltration of tubercle is more especially prone to occur in lymphatic glands, but also happens rarely in the lungs. Finally, a tubercle — and especially the miliary tubercle — may undergo a Hhroid change, or sclerosis. Under these circumstances the new formation is converted into fibroid tissue. A certain more limited degree of cheesy metamorphosis takes place at the same time, but the product is a firm, tough nodule. This fibroid change is more prone to occur in tuberculosis of the peritoneum. Secondary Inflammatory Processes. — So much for the change in tubercle itself. It is, however, capable of exciting retroactive inilammation in its own neighborhood. Thus, in the lungs a catarrhal pneumonia invol- ing adjacent acini is often produced. In other instances an overgrowth of interstitial tissue ensues. Sometimes it is excessive and results in the so-called fibroid phthisis. ]More frequently this form of consumption is the result of a coincident irritation by another cause, such as the irritant parti- cles encountered in such occupations as steel-grinding, stone-cutting, and mining. Associated with tubercular processes, especially in the lungs, is constantly found true suppuration, the result of mixed infection — whence the admixture of pus in the expectoration of pulmonary consumption. It is held by some, and apparently by Koch himself, that the tubercle bacillus is also capable of exciting suppuration in the absence of other pus-producing organisms. II. Acute Tuberculosis. Synoxyms. — Diffuse General Tuberculosis ; Acute Miliary Tuberculosis. Definition. — The simultaneous comparatively sudden development of miliary tubercles in different parts of the body as the result of an irruption of bacilH into the blood or lymph channels. It is the most emphatic expres- sion of the infectious nature of tuberculosis. The infection is in almost ever}' instance an auto-inoculation, of which the source is a nodule of softening tubercle in some part of the body. In 300 cases of miliary tuberculosis examined by Buhl such a source was found in all but ten, while Simmonds in 100 cases found the caseating focus in everv instance. The most common seat of such a nodule is the lungs, next a tubercular lymphatic gland, especially a tracheo-bronchial gland. After this there is less constancy, but tubercular joints, a tubercular pleurisv, tubercular peritonitis, and even a skin tuberculosis may be held TUBERCULOSIS. 245 responsible. Such a nodule may break directly into a vein, furnishing an instance of true embolic infection. Acute tuberculosis occurs most frequently in young persons between twelve and twenty years of age, but adults are not exempt. Any tissue or organ may be involved, but very seldom do we find all the organs of the body affected, though it is quite common to find lesions in more than two, as, for example, the lungs, the pleura, the membranes of the brain, and the peritoneum. The first three are favorite locations. Clinical Varieties. — Three principal clinical forms of acute tubercu- losis are recognized, one presenting signs of acute general infection without special localization, another exhibiting, in addition, easily recognizable pul- monary symptoms, and the third, cerebral and spinal symptoms. I, GENERAL OR TYPHOID FORM OF ACUTE MILIARY TUBERCULOSIS. Morbid Anatomy. — This is the anatomy of tuberculosis in the dififer- ent organs and tissues of the body, and so far as not already described will be given when treating of the disease in these organs. Symptoms. — The general or typhoid form of acute tuberculosis has long been recognized as resembling in a startlingly close manner the symp- toms of typhoid fever, and many mistakes have been made in diagnosis because of this resemblance. Since the use of the clinical thermometer in diagnosis, however, such mistakes have been less frequent. As in typhoid fever, a prodrome of several days, and even weeks, of ill-defined sickness often precedes the taking to bed. Fever, with its height- ened temperature and frequent pulse, is present, as are also the dry tongue, hebetude, and delirium of typhoid. Yet fever is not always present, and afebrile cases are reported by Reinhold and Eichhorst. If differences are sought in the fever of the two diseases, it will be found that the pulse and respiration may be unduly frequent as compared with typhoid fever, but above all, the temperature will be found to differ in its course from that of typhoid fever. There is an absence of the characteristic " tidal wave " rise of temperature of typhoid. There is an evening rise and a morning fall ; and an occasional inversion, with lower evening and higher morning tempera- ture, takes place, which is held to be characteristic. The range is between 101° and 103° F. (38.3° and 39.4° C), but may reach 104° or 105° F. (40° or 40.5° C). The countenance is apt to be more dusky than in typhoid. Excessive sweating is a symptom more characteristic of acute tuber- culosis than of typhoid fever, and may result in sudamina, which also char- acterize the latter disease. Herpes is, however, often present, while it is almost a negatively pathognomonic sign of typhoid. These two symptoms — /. e., sweating and herpes, together with the intermitting fever — con- stitute a resemblance to malarial fever. Waller and Eichhorst have found rose-colored spots on the abdomen and breast, but they are certainly infre- quent, and they do not occur in crops as in typhoid fever. Enlargement of the spleen is often present and even hemorrhage from the hoivels has been noted. Small alhnminuria is a frequent symptom, not due, as might be expected, to a tubercular involvement of the kidney, but to the fever process. Repeated examinations of the lisings fail to discover physical signs indicating disease of these organs, and thus the conclusion that there is no lung involvement is apparently confirmed. Later, however, pulmonary S3^mp- toms may set in, also meningeal symptoms, the duration of which may lead to a suspicion that the disease is not typhoid fever. 246 INFECTIOUS DISEASES. In view of the general possibilities of acute miliary tuberculosis, there may be pleural or pericardial friction and other symptoms of pericarditis and pleurisy, as well as those of peritonitis and meningitis. Tuberculosis of the choroid coat of the eye has been frequently met in acute miliary tuberculosis, more particularly in cases where there has been the widest dissemination. Notwithstanding the difficulties that attend the investigation, the instances in which tubercle bacilli have been found in the blood have been so numerous that in doubtful cases it should be examined. Rutimeyer suggests that the blood be taken for this purpose from the spleen by means of a hypodermic syringe, since it has been shown that the blood of this organ may be especially rich in bacilli. On the other hand, bacilli are rarelv found in the sputum in acute general tuberculosis, even if there be involvement of the lungs, because in this form of tuberculosis the tubercles are situated not in the open air-passages so much as in the interstitial tissue of the lung and in the blood-vessel walls. Diagnosis. — As stated, acute miliary tuberculosis resembles especially typhoid fever, but a carefully kept temperature chart will soon exhibit a dif- ference in the two diseases from this point of view. If bacilli are found in the blood and tubercles on the choroid the question is settled at once. The duration of the disease, though short, is usually longer than that of typhoid fever, and before the clinical thermometer gave us its valuable information the first suggestion that something else than typhoid fever was present came about from noting an absence of the usual defervescence. The Widal reac- tion in typhoid fever and its absence in tuberculosis are valuable aids in the diagnosis. It is well known that typhoid fever is characterized by a negative leuko- cytosis, that is, a diminution rather than an increase of leukocytes in the blood. Precise systematic studies of the blood in the typhoid form of acute miliary tuberculosis are wanting, but from such observations as have been made, it appears reasonable that in true, uncomplicated miliary tuberculosis, there is also wanting an increase in the colorless corpuscles of the blood over the normal. So soon, however, as there becomes associated with the tubercu- losis any catarrhal or suppurative condition of the parts involved, a leuko- cytosis presents itself. It cannot, however, be said that leukocytosis is char- acteristic of true, miliary tuberculosis as contrasted wdth a diminished num- ber of leukocytes characteristic of typhoid fever. The resemblance to intermittent fever has been noted. Here, too, a close study of the temperature will soon show the difference, while a search for the hematozoon of malaria should be made. The failure of quinin to cure will settle the question against a malarial cause for the fever. Prognosis. — The course is invariably toward an unfavorable issue. Scarely ever less than four weeks in duration, it is often eight and even longer, although cases are reported to have terminated at the end of two weeks and even twelve days. Such must, however, be extremely rare. The relative shortness of duration, nevertheless, constitutes it one of the forms of galloping consumption. Acute miliary tuberculosis always terminates fatally sooner or later, although delusive improvements often raise hopes that are not realized. Treatment. — Treatment for acute tuberculosis can only be symptomatic. To our present knowledge a cure has never been accomplished. Antipyretics may be used in moderate doses ; three to five grains of antipyrin, antifebrin, TUBERCULOSIS. 247 or phenacetin, the last probably the best, frequently repeated, abate the fever. Anodynes to quiet cough are also necessary. Supporting food and stimu- lants are indicated. 2. PULMONARY FORM OF ACUTE TUBERCULOSIS. (a) Miliary Tuberculosis Succeeding on Chronic Bronchitis, Chronic Tuberculosis, Whooping-Cough, Measles, etc. ' Symptoms. — This form succeeds in adults on chronic tuberculosis of the lung, on prolonged bronchitis, on whooping-cough or on measles in children. An irruption of miliary tuberculosis the result of infection takes place throughout the lung with or without bronchopneumonia. The tubercles may be scattered throughout the lung, distributed by the blood, and may be found in the walls of the vessels, or radially arranged around the primary focus. It is this event which gave rise to Xiemeyer's dictum, " The greatest danger to most phthisical patients is the development of the tubercle." To the pre- vious cough and physical signs are added higher fever, increased cough, and extreme dyspnea associated with marked cyanosis. The last symptom is very striking. The physical signs may not be altered ; there may be sonorous and sibilant' rales or there may be signs indicating deeper involve- ment of the lung, including small areas of impaired resonance, crepitant rales, and bronchial or bronchovesicular breathing (bronchopneumonic foci). On this account there may be rusty expectoration, rarely hemoptysis. The dull areas may alternate with areas of hyperresonance — hyperresonance due to re- laxation (the Skodaic type) — or it may be due to localized emphysema. On the front of the chest, especially in some cases of miliary tuberculosis of the lungs, there may be unusual resonance. As the disease progresses moist rales become general all over the chest. Again there may be friction crepitation due to tubercular pleurisy. Diagnosis. — The diagnosis is made by recalling the symptoms detailed. Choroidal tubercle should be looked for. Especially important are the dis- proportionate dyspnea and cyanosis associated with the signs of diffuse bronchitis. Leukocytosis is here present. Prognosis and Treatment. — The disease is often rapidly fatal and treat- ment is of little avail toward cure. It must consist in efforts to make the patient comfortable, but as the diagnosis can perhaps never be made with absolute certainty the treatment to be detailed later for the cure of chronic tuberculosis should be carried out. {b) Pneumonic Phthisis — Bronchopneumonic Phthisis. This more unusual form of tubercular phthisis constitutes one variety of "galloping consumption," or phthisis Horida. In it the tubercular infil- tration is by a rapid peripheral invasion inciting to active inflammation. This is manifested as a bronchopneumonia, by which the air-vesicles and bronchioles are variously blocked with cheesy matter. The result is the dis- semination through extensive areas qf lung tissue of opaque, white foci one- fifth to one-half inch (5 to 12 mm.) in diameter. These areas are usually separated by others of a more or less congested but still crepitating tissue, contrasting strongly with the white of the tubercular bronchopneumonic foci. These tend to soften with var>"ing rapidity, resulting sometimes in numerous 248 INFECTIOUS DISEASES. little abscess cavities throughout the lung. At other times the broncho- pneumonic foci are more widely separated or may be limited to the apices, in more rare instances the condition may succeed on croupous pneumonia, forming continuous areas which may also extend throughout a lobe or entire lung. The process is truly pneumonic ; the results resemble, indeed, more a lung in the second stage of croupous pneumonia. As in it, too, the lung is heavy and airless, sinking rapidly in water. There is, however, a greater tendency to disintegration than in croupous pneumonia, and cavities form rapidly in the apices and elsewhere. There may also be enlargement of the bronchial glands in either of these forms, but more particularly in the first — the rapid peripheral extension. Symptoms. — The broncho pneumonic form of consumption occurs most frequently in children as a sequel to measles or whooping-cough. In such seemingly ordinary cases of bronchitis, with fever, obstinate cough, and shortness of breath, physical examination will reveal submucous and sub- crepitant rales throughout the chest with or without limited areas of con- solidation. Tubercle bacilli and elastic tissue appear in the sputum. The fever continues and may become hectic, with sweats. The child emaciates rapidly, and death ensues in from three to eight weeks. Other cases originate more suddenly and with less apparent cause as cases of simple bronchial catarrh, which assume the graver picture described. Such children may inherit a predisposition to phthisis. In adults the attack begins as an ordinary cold in a person with a pre- disposition to tuberculosis, though apparently healthy or run down with over- work. The cough is harassing, and soon becomes loose, expectoration muco- purulent. There are high fever and rapid ivasting, and hemorrhage may set^ in to the surprise of everyone concerned. Then there may be a lull in the storm, but for a short time only. The symptoms, and especially the burning fever, wear out the patient. Bacilli and elastic tissue will now be found in the sputum and the diagnosis is settled. The patient may perish in three weeks. On the other hand, a reactive effort toward improvement may take place and after a time be followed again by decline and perhaps again by improvement, with the effect of prolonging the disease, but not of altering the termination. The physical signs are the same as in children, submucous and subcrepitant rales throughout the chest with or without limited areas of consolidation. The pure pneumonic form succeeding what seemed to be croupous pneu- monia is more an affection of adults. More rare, still, than the bronchopneu- monic form, it may be also rapid in its course. It begins with a chill fol- lowed by fever, often after exposure to cold, with pain in the side, cough, dyspnea, mucous and rusty sputum, impairment of resonance, bronchial breathing, increased vocal fremitus — in fact, all the symptoms of a pneumonia of the whole or a part of a lung, which may be an upper or lower lobe. If the lower lobe, it is probably regarded as a pneumonia until the absence of the signs of resolution call attention to the fact that something unusual "is going on. Later, softening and the signs of a cavity may present themselves at the apex, and bacilli and elastic tissue be found in the sputum. The case may last for three weeks or three months, or even pass over into a chronic phthisis. Diagnosis. — In the bronchopneumonic form it is difficult to make the diagnosis early from simple bronchitis and bronchopneumonia. The tempera- ture in phthisis is probably more irregular and higher. Where the disease lasts more than three weeks, the sputum should be examined carefully for TUBERCULOSIS. 249 bacilli. The diagnosis in the pneumonic form can never be made in the beginning, because the symptoms of the first and second stages of this form are identical with those of the first and second stages of true pneumonia, and it is only when the type of the latter disease is departed from that phthisis can be suspected. The fever in true pneumonia should abate by the ninth day or twelfth day at latest, and if it continue after that time pneumonic phthisis should be suspected and the expectoration should be examined for bacilli. Prognosis. — The prognosis is very unfavorable in this form of con- sumption, death being inevitable in from a few weeks to a few months. Rarely, patients live a year or longer. Treatment. — Treatment of the acute stage is symptomatic. After the acute stage it is that of chronic phthisis. 3. MENINGEAL FORM OF ACUTE MILIARY TUBERCULOSIS. TUBERCULOUS MENINGITIS. Synonyms. — Tuhercnloiis Leptomeningitis ; Basilar Meningitis; Acute HydrocepJmlns; Water on the Brain. Definition. — An acute inflammation of the pia mater due to an irrup- tion of miliary tubercles on this membrane and on the blood-vessels proceed- ing from it, extending also at times to the corresponding membrane of the spinal cord. HistoricaL — We are indebted to Dr. Robert Whytt for the first accurate informa- tion of this disease in his " Observation on Dropsy of the Brain," Edinburgh, 1768. In 1827 Guersant applied the term grafiular mennigztzs to this form of inflammation of the meninges, and in 1830 Pavoine showed the nature of the associated granules- and called attention to their concurrence with tubercles in other parts of the body. In February, 1834, W. W. Gerhard, of Philadelphia, published in the " American Journal of the Medical Sciences" a paper on "Cerebral Affections of Children," based on a study of the disease made in the Children's Hospital in Paris. These studies included autopsies as well as clinical reports, and ^.he descriptions of the lesions found in the former are so accurate that they can scarcely be improved upon. To Gerhard more than anyone else are we indebted for a proper location and classifi- cation of the disease. Etiology. — I have said that the disease consists in essentially an irrup- tion of miliary tubercles on the pia mater, with the resulting inflammatory product. To this end there must be somewhere in the body a tubercular focus whence the bacilli start. Tuberculous bones and joints may furnish such a focus, but it is most frequently located in the bronchial or mesenteric glands. Such focus cannot always be found, even when present. The bare possibility of a primary tubercvflar meningitis may, how^ever, be admitted, in which event the cribriform plate of the ethmoid is the most likely route of bacilli inhaled from the external atmosphere through the nose to the brain. The disease is most common in children between the second and fifth years, though it is not very rare in adults Ions: the subjects of tuberculosis. Morbid Anatomy. — The pia mater at the base of the brain is the most frequent seat, whence the common term basilar meningitis. Particularly are the neighborhood of the optic chiasm, the Sylvian fissure, the interpeduncular space and pons varolii involved. In addition to the miliary tubercles are seen turbidity of the membrane increasing to opacity, the whole smeared over with fibrin and ous. The medulla oblongata and base of the cerebellum may be covered. More rarely the inflammation may extend to the lateral and convex surfaces of the brain. Especially do we find-tbe adventifia-sheaths of the blood-vessels invaded bv the tubercles, which are seen in bead-like rows 2 50 INFECTIOUS DISEASES. when the vessels are withdrawn from the substances of the brain. These vessels are better examined when spread on a dark background, with a low magnifying power. Sections of blood-vessels should be made also, because there may be tubercular infiltration of the intima, causing narrowing and obliteration of the vessel. The cerebral convolutions are softened to a slight depth by the invasion, the blood-vessels dragging a portion of the brain- substance when drawn out. Thus there is really a meningo-encephalitis. The lateral ventricles contain a varying quantity of limpid or turbid fluid, a dram to several ounces, the ependyma is softened and swollen ; the septum lucidum and fornix are disrupted. The convolutions may be flat- tened because of the pressure exerted between the dilated ventricles and un- yielding cranium. More rarely there is a chronic process like that described, but slower in its course. As already mentioned, the pia mater of the cord may be involved, resulting in the same turbid picture. Symptoms. — The symptoms of tubercular meningitis are varied and irregular in their course. At times, the beginning, at least to the superficial observer, is sudden. At others, there are many weeks of ill-health with ill- defined symptoms that go to make the child unhappy, restless, and an evident sufferer. In the course of such weeks the child's appetite is poor, its tongue coated, its bowels are constipated or the reverse, and it loses weight. The sudden events alluded to are a coiiriilsion, obstinate vomiting, or headache. Such a child may have been convalescent from measles, whooping-cough, bronchitis, or other ills of childhood. An attempt has been made with more or less success to divide the symp- toms of the disease into stages, of which the first may be called irritative ; the second, that of subsiding irritation; the third, paralysis. The symptoms most constant in the irritative stage are headache, fever, and vomiting, of Vv-hich the latter may be first. As has been stated, convulsions may usher in the attack, and these convulsions may intermit and be separated by periods of some length. Sometimes an accident, as a fall, may be an exciting cause, and the first vomiting may be excited by a meal of food unsuited to the child's age. The three symptoms mentioned as more constant grow in severity, especially the headache, which becomes more or less incessant and intense, so that the child is never free from it. Yet there may be a lull in the pain as the result of treatment or other cause, followed by an acute exacerbation, which probably causes the peculiar short cry known as the " hydrocephalic cry." In other cases there is constant screaming, which points to the degree of suf- fering. The child rarely sleeps more than a few minutes at a time, tmless under the influence of powerful anodynes. There is always fever in this stage, though it may not be very high, 103° F. (39.4° C.) being commonly the maximum. There is more or less dehrium. The piilse is rapid, even rapid disproportionately to the temperature, while the breathing rate is little altered, furnishing a symptom of some diagnostic value. Evidences of nerv- ous irritation may occur early, more commonly late in this stage. The con- vulsion has been alluded to. The pupils may be contracted or irregular, there may be strabismus, or twitching of the muscles of the face from involvement of the facial nerve. In the second stage delirium yields to coma, though convulsions may continue. There may be localized rigidity of the muscles of one limb or of half the body. The head may be retracted. Headache is not complained of, though the child still may occasionally cry out. The pupils are dilated or irregular and squint is more marked from oculo-motor or third-nerve paraly- TUBERCULOSIS. 251 sis ; the bowels are constipated ; the abdomen is retracted — scaphoid. The temperature tends to be lower, but is variable. There is often a patchy red- ness of the skin and tache cerebrale may be brought out by drawing the finger-nail across the skin. In the third period, or stage of paralysis, the stupor increases and may be profound. Convulsions, however, still occur. They may be localized in a group of muscles or those of one limb, or the convulsion may be unilateral. On the other hand, there may be absolute paralysis of the oculo-motor nerves, and even hemiplegia. As a result of the former the pupils are dilated, the eyelids partially closed, and the eye turned upward. Hemiplegia is more apt to occur when the fissure of Sylvius is invaded, when, too, there may be aphasia. Optic neuritis is sometimes present in this stage, usually occurring late, due to invasion of the optic nerve within the skull. The facial nerve may be involved in basilar cases, producing slight facial paralysis ; so may the fifth, producing anesthesia, and atrophic changes in the cornea if the Gas- serian ganglion be involved. Hyperesthesia of the special senses may also be present, though this is rather a symptom of the first stage. Toward the end a typhoid state may supervene, characterized by dry tongue, muttering delirium, and involuntary discharge of urine and feces. The temperature at this stage may be subnormal, falling as low as 93° F. (33.9° C). On the other hand, the temperature sometimes rises just before death to 106° F. (41.1° C.) or more. The entire duration of the disease is from two to three weeks. The blood examination fails to find a characteristic leukocytosis. Diagnosis. — In the diagnosis we have first to recognize the presence of a meningitis, and, second, to separate the tubercular meningitis from menin- gitis due to other causes. The former is commonly easy, yet mistakes are often made because so many of the head symptoms are simulated by head symp- toms in dyscrasic conditions, of which cholera infantum is a type, while retraction of the head may result from rheumatism of the muscles of the back of the neck ; but optic neuritis and paralytic symptoms are confined to menin- gitis. The presence of tuberculosis elsewhere strengthens other signs. The other forms of meningitis that may give similar symptoms are meningitis due to internal ear disease, traumatic meningitis due to blows and injuries, and syphilitic meningitis. In meningitis due to ear disease the history of the case should prevent a mistake. Traumatic meningitis, especially with abscess, might simulate the symptoms described, but here, too, the history of the acci- dent would be helpful, but in absence of a knowledge of the cause there might be confusion. Syphilitic meningitis is usually chronic, rarely acute, although it affects the base of the brain ; also, the lesion is more apt to be limited in area and confined to one side. Basal headache and signs pointing to localiza- tion are present. Often the history does not help us because the patient denies the existence of the specific cause. Syphilitic disease involves the con- vexity more frequently than does tubercular, causing the symptoms of cortical lesions, including focal convulsions. The diagnosis is most conclusively established if tubercles be detected in the choroid. Prognosis. — The prognosis of tuberculous meningitis well established is invariably fatal. On the other hand, the chances of error in diagnosis are so many that it is not wise to be too confident. It has happened to me more than once to have had cases in children recover where I had thought the dis- ease present, but where the ultimate result proved the diagnosis erroneous. Treatment. — Curative treatment is, therefore, futile, but for the same reason should be persevered in. The cases whose recovery has surprised me 252 INFECTIOi'S DISEASES. have invariably been those in which I used cod-hver oil inunctions. These should, therefore, be persisted in. In addition to this all other supporting measures possible should be used with such treatment of symptoms as will secure the least suffering to the little patient. III. Chronic Tuberculosis, I. PULMONARY TUBERCULOSIS. Synonyms. — Phthisis pulmonalis; Pulmonary Consumption; Consumptiovir of the Lungs. The Greek ttvmcpdiffi^is an admirable word, meaning literally wasting, which is almost, if not quite, the most characteristic s}-mptom of the disease known technically as phthisis pulmonalis. Definition. — Pulmonary tuberculosis is an infectious disease due to the lodgment and proliferation of the tubercle bacillus in the lung substance. Etiology. — The dependence of tubercular consumption on the tubercle bacillus and its various favoring elements has been fully considered under the head of General Tuberculosis, page 238. There are two possible routes of invasion of the lungs, one by the air-passages, — inhalation tuberculosis, — the other by the blood. The former is by far the most common for ordinary forms of consumption, while the latter produces usually miliary tuberculosis. Morbid Anatomy. — Inhalation Tuberculosis. — The bacillus, notwith- standing its probable detention at various points in its journey, rarely obtains a fruitful soil until it reaches the ultimate ramifications of a bronchus or its termination in the alveolar passages, infundibula. and air-vesicles. It is in the septa forming these that it locates itself by preference, multiplies, and excites secondary inflammatory processes, the sum of which constitutes the tuber- cular nodule. A correct understanding of what is to follow may be facilitated by a review of the drawing on p. 253, showing a single lung lobule 1.5 cm. long and I cm. broad, magnified ten times. The principal bronchus is seen enter- ing the lobule and dividing into seven smaller bronchioles, and each of these into two still smaller ones. These smaller bronchioles open directly into a group of from three to five branching alveolar passages, with their infun- dibula beset with air-vesicles. These form the equivalent of an acinus in a racemose gland, and may be teamed lung acini, a more constant unit of lung structure, as Rindfleisch truly says, than the lobule, at least as far as size is concerned, since as few as two of these may unite to form a lobule, or as many as 20 to 30. The figure in the text is made up of 14. In pathological proc- esses other than tuberculosis, the lobule is the more important element, since each is determined by the distribution of the blood-vessels and interstitial connective tissue. Emboli, infarcts, and abscesses therefore light upon the border of the lobules, while the miliary tubercle is found between the bron- chioles and within the alveolar septa, where the bacillus secures lodgment and the tubercle its growth. This favorite position may be seen by making a section across one of the smaller bronchioles after it passes into the acinus, when we will meet the circular edge of a bronchiole and an entire system of partitions between three and five alveolar passages. Under the irritating influence of the bacillus, these septa undergo cellu- lar infiltration, which results in their thickening and encroachment upon the TUBERCULOSIS. 253 liimina of the air-passages. By this process is produced a Httle granulation that corresponds at first in size to an acinus, and enlarged by the implication of other acini until a lobule is finally involved, producing an irregularly rounded or oval body assuming somewhat the shape of a lobule, ranging in diameter from one millimeter to six millimeters (1-25 to 1-4 inch) — the tubercle granulum. On section such a granule is found perforated by one or more minute openings or slits corresponding to the air-passages, one for each of the roundish subdivisions which make up the nodule. In vertical section the appearance is more definite, having a central stem with branches. The area is whitish-yellow in color, surrounded by a ring of hyperemic tissue. The microscope shows the periphery of the bronchiole or air-passage infil- trated with concentric layers, of which the external is made up of small Fig. 22. — Lobule of Lung, Showing Acini and Alveolar Passages — {after Rindfleisch). lymphoid, the middle of large epithelioid cells, and within this again a third zone in which no cells are differentiable, these having lost their contour and become fused into a homogeneous mass — in a word, having become caseous. The lumen of the tube itself is plugged with cheesy matter. The blood- vessels stop short at the edge of the tubercle, as it is thoroughly avascular. By suitable staining methods, tubercle bacilli may be demonstrated among the cells of the tubercle granule in moderate numbers at its periphery, but not in the cheesy center, where they do not seem to thrive until softening takes place, when they are found in great numbers. Thus begin most cases of pulmonary phthisis as a localized tuberculosis of the smallest air-passages at the apex of one of the lungs. The apices are attacked first, because here the unfoldmg of the lungs, in the act of breath- ing, is more limited, the blood moves less freely and tends rather to stagnate — ^conditions which favor the retention of secretion, favor the lodgment, and encourage the srrowth of the bacillus. 254 INFECTIOUS DISEASES. On the other hand, the view so long entertained that the left apex is more frequently affected than the right seems to be erroneous in the light of modern studies. Thus, William Osier out of 413 cases found the right apex involved in 172; the left, in 130; both, in iii. Pension examinations furnish an opportunitv for obtaining information on this subject, and my friend, Theodore G. Davis, of Bridgeton, X. J., took occasion, as examiner in a pen- sion board, to note the cases of tubercular phthisis which passed before his board, with the following results : Out of 897 males, whose ages ranged from forty-five to seventy-one years, 94, or about 10 1-2 per cent., had pulmonary tuberculosis, more or less pronounced. Of these, 39 were markedly worse on the right side and 29 on the left ; both sides were affected in 26 — ^proportions very like those of Osier. From this usual starting point the disease spreads with varying rapidity to other parts of the lung. Two principal varieties, however, result, based upon the rapidity of the spread of the disease. The first includes the ordinary chronic form of consumption, or chronic ulcerative phthisis, and an allied slow form characterized by a special involvement of the connective tissue, known as fibroid piuhisis; the second is pneumonic phthisis, one of the forms of galloping consumption, which has already been considered. (a) Chronic Ulcerative Phthisis. Syxoxym. — Sloiu Consumption. Morbid Anatomy. — This most usual form of consumption, beginning with the tubercle granulum and associated with more or less catarrh of the apex, extends thence slowly downward. The deposit in the beginning is not actually in the very apex, but a little below it, and usually the first point at which physical signs are found is on the middle of the clavicle or just below it. Sometimes, however, the extension is rather backward, so that the physi- cal signs are first manifested in the supra-spinous fossa, whence the impor- tance of always insisting on the posterior examination. From this initial focus, usually toward the anterior face of the lung, the disease extends more or less throughout the lobe, or it may pass to another lobe. If the disease be on the right side, from the upper it may extend to the middle lobe and thence into the lower lobe about an inch blow its apex, corresponding also to a point on the surface opposite the fifth dorsal spine. On the left side, the extension is directly from the upper to the lower lobe. From its previous focus the tubercular infiltrate travels centripetally along the bronchi from smaller to larger as a tuberculous peribronchitis. As E. Rindfleisch aptly expresses it : " The white berries acquire a stalk of the same nature and color. The stalks unite with each other and thus form a radiat- ing or rudely stellate focus of larger extent." These stalks are bronchioles the walls of which are infiltrated with tubercle. Larger and larger branches become implicated with the intermediate parenchyma, but usually it does not extend beyond the cartilage-ringed bronchi of the second order, forming tubercular masses of corresponding size. The infiltration is not limited to peribronchial tissue. It extends also inward toward the lumen of the tube, invading the submucous tissue, where it may be seen as whitish or cloudy patches on slitting up the bronchi and washing off the adherent muco-pus. Thus uncovered, the mucous membrane is found also red and inflamed, contrasting strongly with the whitish patches TUBERCULOSIS. ■ 255 referred to. As we penetrate deeper, these enlarge and intrude upon the lumen of the tube, while the hyperemic areas grow smaller. Such intrusion becomes finally complete occupation, associated, sooner or later, with an ex- coriation or rupture of the mucous membrane. This is the beginning of ulceration, which assumes an important place in facilitating subsequent de- structive process, and is the foundation of the term adopted for this form of phthisis, chronic ulcerative phthisis. The pathological processes referred to, and the destructive effects of which they are the cause, give to the lung in a state of chronic phthisis a varied- picture that is not always found in a single case, nor, indeed, would the lesions of two or more cases always cover this picture. They include the following : 1. The caseous tubercular masses^ formerly called crude tubercle. They embrace single or compound peribronchial foci perforated by the central bronchiole, itself plugged with cheesy matter. Thus- constituted they form grayish-yellow masses from a couple of millimeters to four or five centimeters (1-12 to 2 inches) in diameter. They have the composition already described. Though usually massed toward the apices of the lung, they may also be disseminated through the remainder of the organ, and around them there may also be found scattered true miliary tubercles. 2. The second anatomical feature of the phthisical lung is the cavity. As soon as a tuberculous area reaches a certain size, the tendency to break down is increased, though such tendency does not depend altogether on extent. The bronchial wall, weakened by the tubercular infiltration and the ulceration referred to, is the initial invitation. The wall yields to the pressure which it formerly easily resisted — the inspiratory and expiratory strain inci- dent to coughing, — the bronchus dilates, the gap of the ulcer widens, and the texture of the bronchus gradually yields. The free access of air to the already necrotic caseous matter causes it to soften, break down, and a cavity results. Small foci unite with others and thus larger cavities form, occu- pying the greater part of a lobe, or even a whole lung in very rare instances. Large cavities have usually smooth walls and are lined by the so-called pyogenic membrane, into which, however, often protrude blood-vessels of large size, as thick as a crow-quill, and exhibiting also at times aneurysmal dilatations. Rarely such vessels pass directly across a cavity, and when eroded they may give rise to fatal hemorrhage toward the end of a case of chronic phthisis. On the other hand, these vessels may also become thor- oughly occluded by an obliterating endarteritis. The surface of these smooth- walled cavities is constantly producing pus, while muco-pus is being added by communicating bronchi. Such cavities may be more or less completely emptied by expectoration. They are also surrounded by a consolidated lung tissue, which gives a dull percussion note and thus often prevents the tym- pany natural to a cavity. Small cavities have rough and ragged walls, from which there is constant breaking down, adding elastic tissue, pus, granular debris, and bacilli to the matter expectorated. There may be a number of these small cavities, and if under the pleura one may rupture into the pleural sac, producing pneumo-thorax. Other cavities form by the softening of the center of a caseous area. Others still may be purely bronchiectatic, being limited by bronchial walls. It is more particularly the bronchi of medium size that are thus involved, weakened also bv tubercular infiltration. The form of dilatation mav be cylin- 256 INFECTIOUS DISEASES. drical or globular. The small tubes especially may be the seat of cylindrical dilatation. 3. Pleurisy is constantly associated with tubercular phthisis. It is found in four forms : {a) As an adhesive pleurisy in the immediate neighborhood of tubercular infiltration, causing a collateral hyperemia and intlammation of the pleura. ( b ) There may be perforation from a cavity into the pleura, exciting a purulent pleurisy and a pyopneumothorax. (c) A pleurisy may be lighted up by cold in a favorable focus of col- lateral hyperemia. (d) Finally, the pleura may be the seat of a tubercular pleurisy, result- ing in a thickened membrane, which may be limited or may encase the whole lung and cement the lobes in a continuous inseparable mass. 4. Pulmonary concretions are also found in the phthisical lung, usually about half as large as a pea, smooth or lobulated. They represent calcareous infiltration of alveoli * of the lung, filled with tubercular bronchopneumonic products. They are a medium of one form of healing of tuberculosis. Those retained in the lung are commonly surrounded by a ring of hyper- plastic connective tissue. At times they are expectorated, being released by a sequestrating suppuration into an adjacent bronchus, whence they are brought up by coughing. Sometimes a good many are coughed up. They are something different from bronchial calcuH, which are always smooth, spherical, or elliptical, and are found in small bronchic static cavities. 5. Other evidences of attempts at healing seen in the phthisical lungs are of the nature of reactive inflammation. They may occur : (a) In the initial stage as the result of treatment and favorable hygienic surroundings, when the initial granule is replaced by a cicatricial-like pucker- ing of fibrous tissue or a hard cartilaginous mass of connective tissue. (b) There may be a sequestration or encapsulation of a cheesy nodule, which may or may not undergo calcareous infiltration. (c) Even a cavity of moderate size may heal, in which event, the cavity being cleared out, its walls unite by adhesive inflammation and thus a band of cicatricial tissue takes the place of the cavity. Larger cavities may be reduced in size by a contraction of the cicatricial tissue surrounding them, or several small cavities may be thus surrounded. Quite small cavities sur- rounded by connective tissue and communicating with a bronchus w^ere called cicatrices fistuleuses by Laennec. • 6. The neighborhood of a tubercular infiltration is often the seat of a pneumonia which may be siniply reactive or due to the irritative effect of the bacillus — /. e., a tubercular bronchopneumonia. The area is hyperemic, hard, consolidated, and the air-vesicles filled with exfoliated epithelium. The latter may exhibit various stages of fatty degeneration. It may be complete w^hen an appearance indistinguishable from that of tubercular infiltration is present. In fact, it is tubercular infiltration plus catarrhal pneumonia. 7. When a subject dies of tubercular phthisis, other organs should be searched for tubercles. Tuberculosis of the larynx is common and is not infrequently associated with destruction of the cords and epiglottis. The bronchial glands are usually involved, swollen, inflamed, or tubercular, and when tubercular may become caseous and sometimes calcareous. Other glands are also affected, such as the cervical, mediastinal, and post-peritoneal. * If macerated in hydrochloric acid the lime salt.s can be dissolved out, and the actual elastic ■tissue framework of an alveolus, with its infundibula and attached air-vessels, be left. TUBERCULOSIS. 257 It is now recognized that the so-called " scrofula " of the neck is a tubercu- losis of lymphatic glands. After the bronchial glands the organs most affected are the intestine ; next, the spleen, kidneys, and brain in nearly equal proportion ; then the liver and the pericardium. 8. The only remaining morbid states which may be considered as having any essential relation to tubercular consumption are the amyloid and fatty irMtration. The former is found affecting the kidneys, liver, spleen, and mucous membrane of the intestines ; the latter, especially, the liver and kidney. Symptoms. — The onset of tubercular consumption is by no means uniform. Xotwdthstanding the fact that its insidious nature is well recog- nized, its initial stadium is often overlooked. The victim is scarcely appreci- ably ill. Yet he may lose flesh and strength continuously. He may even say that he has no cough, while close questioning will ascertain that he has had a slight hacking •cough for some time, worse in the morning. Soon the symptoms are plainer, there is evident z^'astijig, an intermittent fever, a bright eye, and the cough zuith expectoration is a conspicuous symptom. Yet dur- ing all this the patient is cheerful and denies that there is much the matter with him. In another instance an individual is " subject to cold " ; he takes cold repeatedly, and each attack, while passing away, yields more stubbornly than the previous one, and finally one comes that persists. There is daily fever which abates to return again, emaciation is evident, and the bright eye and burning cheeks and night-szveats again attest the arrival of the dread disease. Another case may begin with hoarseness, due probably to tubercular laryngitis, not infrequently the initial symptom. Again, after a stubborn attack of bronchitis in a person previously healthy a hemorrhage of the lungs unexpectedly makes its appearance, or such a hemorrhage may set in without previous warning, although, again, careful inquiry may find that cough has been present for some time. The patient has, perhaps, previously been overworked, or lived under unfavorable hygienic surroundings, or may possess a hereditary tendency. In still another instance a patient may consult the physician without sus- pecting that he is very ill, and the signs of advanced disease of the apices will be found present, and there may be but a few more months of life remaining to the unsuspecting victim. A certain number of cases of consumption begin as tubercular pleurisy, which invades the lung by contiguity or by blood infection. One of the most convincing facts in favor of the infectious theory, which seemed established prior to the discovery of the bacillus, was the frequent occurrence of pleurisy as a forerunner of phthisis. It was held that the caseous product of the pleurisy furnished the infectious virus, which, entering the blood, caused tubercle formations in various parts of the body. Thus, one-third of the 90 cases of pleurisy followed up by Bowditch terminated in phthisis. Inveterate dyspepsia is associated with many cases and is as often a pre- disposing cause as a symptom. A great loss of appetite and indisposition to take food are often symptomatic, and their presence does much to diminish the efficiency of remedies and nutrimen1;s so essential to successfully combat the disease. Physical Signs. — Given the suspicion of the existence of tubercular con- sumption from the presence of the above symptoms, whatever others may be superadded, or whatever modification may occur in them, the diagnosis is 17 258 INFECTIOUS DISEASES. completed by a physical examination. The physical signs, therefore, will be next studied. While it is not always easy to separate the clinical history of a case of consumption into three sets of symptoms corresponding to the three separate stages in the morbid anatomy, the physical signs corresponding with these stages are tolerably definite. They are : 1. The incipient stage, or beginning deposit. 2. Stage of complete consolidation. 3. Stage of softening and cavity formation. 1. Inspection, in the incipient stage, is as often negative as not. A slightlv diminished expansion in the infraclavicular space, as compared with the opposite side, may be present, and more rarely a slight flattening of the same region. The clavicle becomes correspondingly conspicuous. The body may continue well nourished or slightly emaciated, or the heart-beat in the normal position may be somewhat accelerated, while the respirations are likely to be more frequent than in health. Palpation may recognize increased vocal fremitus in the same situation, although not always, while the physiological difference in favor of the right side is to be remembered. Percussion in this stage gives slightly higher pitch and impairment of resonance, which may be noted above, on, or below the clavicle. Dullness may sometimes be brought out by directing the patient to iiold his mouth open during percussion or to hold his breath at expiration. To auscultation above or below the clavicle, we have the first evidence of abnormality in a prolongation of the expiratory murmur and harshness in the inspiratory sound — in a word, in bronchovesicular breathing. Theoreti- cally, this should be preceded by a diminished intensity in the inspiratory sound, owing to the interference of the newly-deposited tubercles with the entrance of air into the air-vesicles, but practically such diminished intensity is rarely encountered, and even if present is not of distinctive significance. Increased vocal resonance is a constant accompaniment of these modi- fications in the normal breathing-sounds, but it, as well as the vocal fremitus, may be masked by a pleuritic thickening, and the physiological dift"erence so often referred to must be remembered. J. M. Da Costa also calls attention to the fact that in a certain number of cases, at this stage, there is a blowing sound in the subclavian or pulmonary artery, and that a murmur is some- times present in these vessels before any other physical sign is noted. There are frequently concurrent with these signs those of a bronchitis more or less acute. 2. In the second stage the changes discoverable by inspection are more easily recognized. There is evident loss of flesh, depression of surface, and impaired range of respiratory movement. The hectic flush is intermittingly present. Palpation may even discover an increased warmth of skin. The increased vocal fremitus is now plainly recognized unless obscured by a thickened pleural membrane. Dullness on percussion is positive and easily elicited. To auscultation there is increased vocal resonance. The bronchial factor in the breathing now becomes conspicuous, showing itself by the harshness and relative shortening of the inspiratory element, with the decidedly prolonged and blowing expiration ; also a gradual diminution of the vesicular factor, until the latter disappears entirely, when we have the typical bronchial breathing of extended areas of tubercular infiltration. This sign will now be found in the supraspinous fossa posteriorly as well as anteriorly. The conduction of the normal heart sounds to the area of infiltration, if at TUBERCULOSIS. 259 either apex, is a very frequent and significant sign. The high degree of vocal resonance known as bronchophony is also superadded as a valuable confirma- tion of the presence of complete consolidation. The auscultation signs of a concurrent bronchitis may also be present in this and in the next stage. 3. In the third stage the information furnished by inspection is still more positive. Emaciation is marked, breathing and the pulse are rapid, and the face is often flushed. There is flattening over the affected area, and the excursion of respiratory movement is still more limited. In this stage the superficial veins over the involved area may be prominent, partly from emaciation and partly from obstructed circulation. There may be visible pulsation in the second, third, and fourth interspaces to the left of the sternum because of the retraction of the lung, while the heart may even be drawn up if this retraction be of the left upper lobe. This is seen more particularly in the variety known as fibroid phthisis. To palpation the vocal fremitus is still more marked, and even remains distinct over cavities, because of the consolidation around them, unless there be some obstruction to the entrance of air into the bronchus leading to the involved area. Rhonchal fremitus may be added if adventitious sounds be present. The skin is hot and dry, nnless succeeding one of the sweats that characterize this stage, when it may be moist and clammy. Dullness on percussion is always to be found in the third stage, but to it is often added some one of the varieties of tympanitic note — viz., pure tympany, the " cracked-pot " sound, or amphoric resonance, due to cavities. These require sufficient size and superficial situation on the part of the cavity. On the other hand, resonance may even be normal over a cavity some dis- tance from the surface, especially if the percussion be lightly made, while the consolidated tissue which almost invariably surrounds a cavity often permits only a dull sound to be elicited. Wintrich's change of note should be sought — a change of note produced during percussion over a cavity on opening and closing the mouth, the pitch being higher when the mouth is open. Auscultation in this stage may continue to recognize the bronchial l)reathing of the second, but to it are superadded first small bubbling sounds or subcrepitant rales indicating liquefaction ; later, may be added the dis- tinctive signs of a cavity. These signs are cavernous breathing, cavernous voice, pectoriloquy, either whispering or loud speaking, amphoric breathing, and amphoric voice. To these are often added the large bubbling sounds known as gurgling, caused by the air bubbling through fluid in a cavity. Metallic tinkling may be added to these phenomena, caused by the bursting ■of bubbles in a cavity with amphoric conditions. " Cavernous breathing," strictly speaking, is any modification of the normal breathing sounds due to the air passing in and out of a cavity. When high pitched it becomes tubal or amphoric. The amphoric sound is supposed to occur in cavities with firm walls that best secure the " echo- ing," which is the condition of amphoric breathing and amphoric percussion. Over more yielding walls the breathing is lower pitched, and to this the term " cavernous " is especially applied. Special Symptoms. — The cough of consumption varies greatly. It is at first very slight, and may continue ,so even in advanced stages. As a rule, however, it grows in severity with the progress of the disease. It is caused by the irritation of intercurrent bronchitis or bronchopneumonia or the accumulated contents of cavities. When a cavity becomes more or less ifilled with secretion it must be emptied, and a spell of coughing comes on 26o INFECTIOUS DISEASES. and continues until the cavity is cleared out, whence the paroxysmal char- acter so often assumed by the cough when this stage is reached. The expectoration of tuberculosis varies with the stage of the disease. At first scanty, and in no way characteristic, it grows more copious and becomes puriform as the disease progresses. A more or less circular shape is finally assumed, which is somewhat distinctive, and is called " num- mular," from its resemblance to a coin. The quantity of expectoration varies greatly, from 1-2 ounce (15 c. c.) to 1-2 pint (250 c. c.) in the twenty-four hours. It generally has a sweetish, unpleasant odor, but is rarely offensive. It is sometimes tinged with blood, and may contain Charcot's crystals (p. 265). Minutely, the expectoration is made up chiefly of pus-corpuscles, among which may, however, be found epithelial cells from the mouth and lung alveoli, elastic tissue from the air-vesicles, more rarely from the bronchial tubes or blood-vessels, oil drops, particles of food, generally innumerable tubercle bacilli, and at times blood-discs. The elastic tissue is most easily demonstrated by boiling the sputum in a test-tube with an excess of solution of potash or soda, the effect of which is to thin the sputum and permit the elastic tissue to fall to the bottom of the tube; whence it is easily carried by the pipette to the glass slide and recognized under the microscope by its wreath-like or circular shape, if derived from the air-vesicles. Care must be taken to eliminate fibers of elastic tissue that may be derived from food. To this end the mouth should be carefully rinsed before collecting spu- tum for examination, and it is further to be remembered that particles of food containing such tissue may remain in the mouth for two or three days. The elastic tissue from the bronchi occurs in the shape of elongated or reticular fibers. That from blood-vessels is similar; more rarely it is fenestrated membrane. The alveolar epithelial cells are round and oval, mononucleated, highly granular, nearly twice the diameter of a pus-corpuscle. The bacilli, which are an unfailing sign of tuberculosis, are demon- strable only by special staining methods, of which that by carbol fuchsin, with or without Gabbet's counter-stain of methyl-blue (see p. 238), is recom- mended. One of the most unpleasant consequences of the cough is the vomiting which it induces, more especially in the last stages of the disease. It is not unusual to throw up a meal immediately after it is taken as the result of a paroxysm of coughing. Such vomiting is probably a reflex act, excited by irritation of the pharynx in coughing. Fortunate is the patient who can immediately thereafter take another meal, since this meal is generally retained, because the accumulated muco-pus which caused the coughing spell is also thrown up with the food in the first act of vomiting, and the cough ceases for a while. Pain is not inherent to tuberculosis — that is, the seat of a tubercular infiltration is not usually a seat of pain. Pain is, however, a frequent sec- ondary symptom. It is most severe as the result of a concurrent pleurisy, when it is usually sharp and cutting at the site of the pleurisy. Pain also results from inveterate cough. Such pain is usually in the lower part of the chest and is mainly caused, I believe, by the motion to which this part of the thorax and the diaphragm are subjected in the act of coughing. Fever is a symptom of all stages of pulmonary consumption. At the onset there may be fever of an irritative kind, due to the deposition of the tubercle and to inflammation. This is a fever of a continued type with TUBERCULOSIS. 261 5 E 1 >0 udioOqoo o-n 15 1 1 r - _ 1 1 ^ f-l-r 4 u _ - - -]~" - 9 A.M. _1 1 1 ■~ ■"■ ~ ^ 1 (J.M ^ ■^ S ■^ \ 'tr 16 _1 1- = ~ - - - — — ~" — ■" - — _ - — — ~ - ~ " - - _ - - - 3 A.M. - 17 95.4 - - _ - - - - - - - - — - - T - — — - - -H- 6^.M. - _ - — L. = — "" "■ "■ 1 1 _ 1 — - - - J — — _ - - 9 A.M. 1 i ! _ ~ _J t^ — " U r L, = — ^^ — ^ " " — *«= - ■^ ~ - " = ^ = -J »_ - - 1 ^IVI. - 19 :: ■" - s =^ \ 6^.^i ( H _ _ _ - - ^ - - - r — ~ ■" (A.M. ~ ~ ~ — - - - - - — _ _ _ 1 1 P. M -1 ^ > P.M. 20 ^ _ - "" - — "■ '^•f s \. 1 1=. M. 21 95.4 ■" ~ — - - — ^ -4 • 6 P.M. 1 1 £■ J - - - - - - — ~" ■" "~ 1 A. M. ■■ - - - - 1- _ -K )- 1 (f. M. ■~ ~ - - _ _ Hi u 3 fj. M. 22 ( V- _ __ - - - - — "" 9 A.M. \ IK 12 NOON 23 ~ ~ — - - — H ( 6 P. M . 1 1 1' » _ — - - - — — — ~ ^ 3 A.M. ~ — ~ — — - - — -, L _ ■5^ 1 1 P. M. H J i P.M. 1 2i •- _J - - - - - ~ — S A. I\i. 1 1 "■ ~ - - — - - - _ ■i L. 1 i^. M. 35 ~r" ~" z = SI L_ 8 P.m. -J-4-1— J ^ = = z z - "~ = I ^ - - - J r - ~ ~ - - - 3 A.M. - - - - - - - - - - - - _ - - - - - ■A < ^ ^ ?1 L - - - ~ - - 6 P. M - 26 1— _ ^ - - - - 9 A.M. j f f« L - " ' 'l*'^ 27 1 — — ~ — - . 1 ^ -4 1 A .1. "■ r^ ri'T' >« _ - - _ - - - — — ^"' 9 A.M. ■■ ■~ —i l~ 1 P.M. 1 ■" ■~ -- - - _ H t SP.i. 3S < f= _ _ - -r "■ "" 1 / .M 1 *^ "- ^ ■fj~ IP X 23 - - - ■4 1 _l 6F .J,. f ^ - - - — - "~ ■■ 9 A. M. * ■" -- - -- — — -4 1 P. M. 1 S b* 6y.M. 30 A „ _ - - — ^ 1 1 • (T ««- ^ 1 Ij'.M. 31 "^ ^ > 6 P.M. { r«s - '' ~^9 A.M. ^ - - ^ -1 y. 1 P.M. *" -■ - •^ - - •4 » 6 f 1 A .M. .M. - 1 ( \m „ _ _ -J - - — ■" u ( ^ — - L. - ^ 1 Ij'.M. 2 ■■ - -J ■1 1 6^.M. jd h- _ — _ — - - -\- 1\ - ~ " 9 /i. M. - 4 r' y 1 P.M. ^" — - - - - - _ _ _ 7^ 1 B P.M. 3 J ^ - -^ r 9A.M. *-. - - ,y.M. 1 t- - - - _ - - _ — - - - n - - - Bl - - - - e A.M. 1 1 1 - bo 262 INFECTIOUS DISEASES. slight evening increments, often overlooked, until it becomes associated with hectic fever, which is a septic fever occurring during softening and cavity formation. Hectic fever is one of the most interesting symptoms of con- sumption, adding often a picturesqueness that increases the sadness of the situation. Coming on usually toward the end of the day, the maximum point is reached at no fixed hour, but generally occurs between 2 and 6 P. M., though it may be as late as 10 P. M. The minimum, usually noted MONTH 25 36 28 1 3 * 5 6 7 s 9 !•) n 12 13 14 15 16 time(A.M. .-> 5 5 5 5 5 5 5 5 5 5 ' 5 5 5 5 5 5 5 0*l'(p.M. 4: 4 i 4 i i 4 4 4 i i i i 4. 4 i 4 4 4 4 4 99 ^ORMAU 98 9f 96 94' ; 1 j 1 1 j 1 . _ n 1 1 if / \ It / 1 /' r ijf \ K _ r r^ 1 7 / 7 1 n / 7 t \ '-^ ■V, n n n 1 _ A / » / 1 A j -j- -i -j— [f \t- V jj -^ i^ if d^ =;^ pA ^ — A f- V— -/- rt— t \\ \t \\i ^ ~ ^ ^ h/ ^ rf ^ F t^ ^ V^ 2i~ / , \ • \ V 1/ V u V — 1 i 1 — > j 1 _ ^ __ ^ « _^ ^ ». _i_ ^ , 1 Fig. 24. — Temperature Chart of a Case of Tubercular Consumption without Fever, long under treatment at the Hospital of the University of Pennsj^vania. between 2 A. M. and 6 A. J\I., may occur as late as 12 noon. Hence, fre- quent observations of temperature should be made during the day and night, two in twenty-four hours being inadequate. Once in four hours is not infre- quently desirable, and where careful study is desired, once in tv/o hours may be necessary. The chart (Fig. 23), on page 261, shows extreme range of temperature in hectic fever. There is, however, no greater mistake than to suppose that every case of consumption must have fever throughout. It probably always has fever in the beginning — the fever of onset; but with the disease once established it frequently happens that there is no fever in any part of the twenty-four hours. Appended is a chart of such a case (Fig. 24). In the course of a caae of consumption it constantly happens that periods occur of various duration, from one to seven days, in which the fever is higher than usual with moderate remissions, say of one degree, and attended with increased localized pain. These are explained by the occur- rence of new patches of bronchopneumonia, which may be either simple or tubercular. The fever of hectic is generally followed by siveating, sometimes lim- ited to the head or the neck. The occurrence of sweats in the night, or rather toward morning, has given rise to the term " night-sweat." They are not, however, confined to the night, but may occur at any time, especially during sleep. The pulse is always frequent in tubercular consumption, and gradually grows feebler as the disease progresses. Hemorrhage from the lungs is a symptom everywhere associated with the idea of consumption. There are two periods in which it occurs — one TUBERCULOSIS. 263 early and one late. The early hemorrhages are usually moderate and are due to the rupture of blood-vessels weakened by tubercular infiltration. They are sometimes the very first announcement of the presence of the disease, at others they are a means of relief to a certain feeling of oppression in the chest which precedes them. Their greatest danger is production of an insuf- flation pneumonia by the inspiration of small particles of clot that act as irritants. When the hemorrhages are small the blood is often admixed with mucus, constituting the true hemoptysis. In such cases the blood probably comes from the mucous membrane of the bronchial tubes. The hemor- rhages' late in the disease are commonly large, sometimes enough to cause immediate death. The amount of blood lost in such a fatal case has reached four pounds (1.8 kilos) . Yet enormous hemorrhages are sometimes survived. They are due to ulceration into a large blood-vessel, often one of those described as traversing the wall of a cavity or bridging it from side to side. Diarrhea is a frequent symptom late in the disease. It is commonly due to tuberculosis of the bowel and is often exceedingly obstinate. Not every diarrhea, however, in tuberculosis is tubercular. The cluh-fingcr was noted by Hippocrates, and has long been asso- ciated with consumption — though not peculiar to it. It is a condition found in other chronic diseases, as emphysema, chronic bronchitis, chronic cardiac disease, and aneurysm. The end of the finger is bulbous, quite like a club, and the nail curves over the end. It may involve some of the fingers only. Tuberculous meningitis may be added toward the close of the disease. In it there is extension of tuberculosis to the membranes of the brain, pro- ducing symptoms such as pain in. the head, delirium, acute mania, vomiting, fever, and finally convulsions and coma. The symptoms vary a good deal with the seat of the involvement, and have been considered in detail when treating of tubercular meningitis. If the inflammation is in the fissure of Sylvius, there may be aphasia and even hemiplegia ; if at the base, retraction 0:f the head and palsies of the cranial nerves from pressure, also optic neuritis ; if on the convexity, delirium is more decided, and there may be local convulsions with hemiplegic weakness. Ventricular efifusion — acute hydrocephalus — adds little to the specialization of symptoms. There may be co-involvement of the membranes of the brain and spinal cord, pro- ducing symptoms of cerebrospinal meningitis. The relation of pulmonary consumption to cardiac disease has always been an interesting one. It is commonly thought that affections of the heart and lungs are never concurrent. Occasionally such concurrence is observed, but whether such relation is any but an accidental one is doubt- ful. Osier reports 12 instances of endocarditis in 216 autopsies on cases of consumption. The rarity of lung tuberculosis succeeding chronic valvular heart disease must still be admitted. It has been ascribed to hypertrophy of the unstriped muscular structure about the smaller bronchioles and their acinous terminations, which keeps the alveoli evacuated of such secretions as favor the development of phthisis. Chronic nephritis and amyloid kidney are frequent complications of chronic phthisis. From these causes alhumimiria may result. There may be simple febrile albuminuria. Or albi^minuria may be due to pus, if there is tuberculosis of the bladder or kidney. Tubercle bacilli should be sought for in purulent urine. The liver is often enlarged from fatty infiltration. Diagnosis. — The diagnosis of chronic tubercular consumption may be 264 INFECTIOUS DISEASES. difficult in tiie early stages, but later, when the physical signs have devel- oped, it is easy. Even in the early stages the finding of the bacillus removes all doubt. Occasionally, however, the sputum is very scanty and difficult to get. If such an examination is not possible, or furnishes negative results, some days may elapse before a positive diagnosis is obtained. For the physical signs in the early stages cannot always be relied on, while there occur cases in which, even months after bacilli have been found in the spu- tum, the physical signs are confusing and inconclusive. Due regard must be paid to the fact that in health the expiratory sound below the right clavicle is longer and rougher than in a corresponding position on the opposite side, while the percussion note may also be somewhat higher pitched. The presence of fever more or less constant, the bright eye, and crimson flush in the cheek, with or without emaciation, should excite suspicion and lead to careful physical exploration and examination of the sputum, if not already made. The search of the sputum for elastic tissue is relatively less valu- able, because bacilli are usually found much earlier. In doubtful cases the tuberculin test may be made. I have found it very reliable in a number of cases, and believe it is without danger. E. L. Trudeau, of Saranac Lake, confirms this by his large experience, and says further, that tuberculosis of so moderate an extent as not to give any positive symptoms probably exists in 30 per cent, of individuals who have no reason to suspect its presence. One milligram of pure tuberculin is injected hypo- dermically, and if there be no febrile reaction in 10 to 12 hours, twice this quantity is used two or three days later, and gradually increased at intervals until five milligrams have been injected at a dose. If there be no rise in temperature within ten to twelve hours the patient may be considered free from tuberculosis. The usual rise is from two to four degrees F. Tuber- culin should not be used where the diagnosis can be made without it.* I cannot refrain from adding a word on the importance of securing the physical examination under favorable conditions early in the study of a case. Especially is this true of cases in which there is a hereditary tend- ency. It goes without saying, that the physical signs of incipient con- sumption may easily escape detection when an examination is made with the clothing on, while they would be easily recognized if the patient were stripped to the skin. Too frequently, also, an examination is deferred because of a fear that the patient will be needlessly alarmed thereby. So- called " hemorrhages from the throat " should be carefully investigated, as should also any continued hacking cough. Many of these coughs are now known to be due to tonsillar trouble, but this should not be taken for granted, and a careful examination of the throat should be associated with a physical examination of the chest. A habitually frequent pulse and rapid breathing should also excite suspicion. We should not omit either to examine the posterior part of the chest in the supraspinous fossae, for it sometimes hap- pens that physical signs are here detected before they are recognizable in front. * Tuberculin is the concentrated glycerin extract of tubercle bacilli, and is made by evaporating a luxuriant glycerin bouillon culture of the bacillus to one-tenth of its volume. This is known as crude tuberculin, and while used as such for bovine inoculation must be greatly diluted for use upon the human subject. The crude extract is on the market, being prepared in Koch's laboratory in Berlin and by dilTerent commercial firms in this country. Dr. Ravenel, of the Laboratory of the Live Stock Association of Pennsylvania, prepares from the crude article made by him a stock solu- tion for human inoculation. One cubic centimeter of this solution contains o.i gram of crude tuberculin in a one per cent, solution of carbolic acid. The latter is added in order to preserve the active properties of the tuberculin and to keep the preparation sterile. At the time of using, one part of the stock solution is diluted in twenty parts of sterile water, and then one cubic centimeter (15 minims) will contain 0.005 gram or 5 milligrams. Further dilution necessary to obtain the smallest quantity desired may be made at the time of using. TUBERCULOSIS. 265 Prognosis. — The prognosis of chronic ulcerative phthisis varies greatly w^ith different cases. Its duration extends over periods of from a few months to years. A more important practical question is that of its possible curability and our power to defer the unfavorable end. That occasional cures from consumption take place cannot be denied ; that there is such a thing even as spontaneous recovery must also be admitted. That such recoveries are infrequent and even rare does not alter the fact that they do occur. That much may also be done to put off the fatal ending of this very sad disease admits of even less dispute. Sooner or later, however, it is usually fatal. But we should not be deterred by this fact from using our best endeavors, not only to put off the end, but also to seek an ultimate cure. {h) Fibroid Phthisis. Definition. — This term is applied to a form of pulmonary consumption in which the lung, in addition to being the seat of tuberculosis, is permeated by an overgrowth of fibroid tissue. Its course is much slower, and while it often begins as an inhalation bronchitis in those exposed to the inhala- tion of fine particles of dust from various sources, it may also begin as an ordinary ulcerative or catarrhal phthisis. Symptoms. — Its symptoms, on the whole, are less aggravated than those of ordinary phthisis. The cough is less severe, less exhausting, though more apt to be paroxysmal, and the patient has less fever and emaciates less rapidly. He is often able to pursue some occupation. Bacilli are less numerous and are found with greater difficulty. Expectoration is often, however, as copious, usually arising from cavities or dilated bronchi, and is more frequently fetid. It may contain fat crystals and Charcot's acicular crystals. There may also be hemorrhage. With the addition of these symp- toms, and the presence of bacilli in the sputum, the clinical history is scarcely different from that of simple non-specific cirrhosis of the lung, from which it is, indeed, often separated with difficulty. As in this affection there may be hypertrophy of the right ventricle, induced by the extra effort' demanded of the right heart to move the blood through the fibroid lung. Fibroid phthisis is especially characterized by its prolonged course, which may extend over years. Physical Signs. — The degree of retraction of the chest wall as noticed by inspection is greater than in the ulcerative form, more easily recognized, and not always confined to the vicinity of the apices of the lungs. The heart is frequently dislocated and its apex correspondingly awry, sometimes to an extreme degree. If on the left side, owing to retraction of the lung, there may sometimes be seen a distinct cardiac pulsation in the second, third, and fourth interspaces. The intercostal spaces are often narrowed and the dia- phragm may be drawn up. Modifications of vocal fremitus as revealed to palpation are not nearly so constant, being masked by the retraction and pleuritic complications, and may be absent. There is often little or no eleva- tion of temperature. Percussion is more constant in its results, there being marked dullness and a wooden-like resistance. The hypertrophy of the right ventricle re- ferred to may extend the normal cardiac dullness in positive degree toward the right edge of the sternum. Auscultation most frequently notes bronchial breathing and exaggerated 266 INFECTIOUS DISEASES. voice sound, but both of these may be lessened in intensity by a thickened pleural membrane. A dilated bronchus is frequently present, yielding the signs of a cavity, which may be found in the middle or even at the base of the lung. To the signs of the fibroid state in one part of a lung are frequently added those of emphysema in the remainder or in the other lung. Prognosis. — This is perhaps no better, so far as cure is concerned, than for the chronic ulcerative phthisis, but, as has already been stated, the duration of the disease is much longer, and under favorable circumstances much more can be done for the patient by the same treatment. Treatment of Chronic Tubercular Phthisis. — There is no disease of like importance in which treatment must for various reasons differ so much in different cases. This is owing partly to the fact that curative measures must be adapted more or less to the circumstances of the patient, and partly to the varving peculiarities of the patient himself. In the following pages I will advise first, regardless of the patient's circumstances, the treatment which experience has shown to be most efficient, then recommend such measures as are useful or necessary under any circumstances. The fundamental principle of a successful treatment of a case of tuber- cular consumption is early diagnosis and corresponding promptness in the application of remedial measures, supported by the belief that consumption is not a hopelessly incurable disease.^ 1. Climate Treatment. — Immediately after its recognition, or even, if possible, when the disease is threatened, the patient with tubercular con- sumption should be sent to a suitable climate, provided always that other necessary conditions of a wholesome and happy life can be secured. To discuss at length the relative value of such places would occupy more space than is justified in a text-book, but the following may be laid down as truths reached by those who have specially studied the subject: f 1. Tuberculosis is relatively rare in the following localities in the order named, viz. : On certain sea-coasts, such as that of southern California, in- cluding Santa Barbara, San Diego, Coronado Beach, and somewhat further inland, Los Angeles and Pasadena; on certain islands enjoying a nearly pure ocean climate, such as the Madeiras and Canaries ; in desert places of wide extent, such as are found in the interior of continents, including the Nile Valley and Algiers ; in polar regions ; and, finally, it is rarest at high altitudes, its frequency diminishing with increasing altitude. The elevated plains of Colorado and New Alexico furnish pre-eminently the best condi- tions. 2. Animals successfully inoculated with the bacilli of tuberculosis de- velop the disease rapidly when confined, while those kept in the open air may escape entirely. 3. Damp, especially cold and damp soil, favors the development of tuber- culosis, as do also variations in dampness when conjoined wath changes in temperature. 4. ]\Ioist heat has no influence in producing the disease, but cases origi- nating in tropical countries where the disease is prevalent progress rapidly. 5. Dryness of air is a positive advantage to the consumptive, while variability in a comparatively dry air has no prejudicial influence. Humidity * For evidence of the correctne<;s of this dictum see a paper by S. Edwin Solly, "Neglect of the Early Dias^nosis and Treatment of Pulmonarv Tuberculosis," " Aled. News," February 4, i8q^. t'See S. E. Solly's article "Climate," in Hare's " System of Therapeutics," vol. i. p. 415, Philadel- phia, 1801. TUBERCULOSIS. 267 apart from other factors is apparently without effect, either in causing the disease or curing it; for, although benefit has been received in a humid or sea climate, Solly considers it " probable that it is mainly due to greater purity of the air or the elimination of unsanitary conditions and hurtful occu- pations, as when an overworked citizen takes a sea voyage, or a Bostonian is sent into such a climate as the Isles of Shoals, or a Philadelphian to Atlantic City." Whatever the cause, the beneficial influence of a sea voyage to the consumptive is undoubted. Where low climates are characterized b}- infrequency of phthisis it is by reason of dryness and uniformity of temperature, as is the case in lower Egypt and the Valley of the Nile in Central and Upper Egypt, and in the interior of Algiers as contrasted with the coast belt of that country, with Java, with the Gulf States of America, Mexico, Guiana, and some of the West India Islands. That elevation is unfavorable to the development of consumption and favorable to its cure is abundantly attested, but there is some difference in opinion as to the degree of altitude at which these qualities are manifested, some placing it as low as 1500 feet, the majority at 2500 feet. The latter is probably the more correct, though there is reason to believe that different individuals as well as different stages of the disease may be differently influenced in this respect. For the most part dryness goes with altitude, so that the two conditions are commonly associated. How altitude operates independently of dryness is not easy of explanation, although it is probable that diminished atmospheric pressure is the potent factor. The method of its action is perhaps not precisely understood, but the immediate effect is increased breathing-rate and pulse-rate; next, an increase in the depth of each respiration, followed by cardiac expansion and by hypertrophy ; and later, by a fall in the rate of breathing and pulse to the normal, as the depth of the respirations and the amount of blood passing through the heart at each contraction are increased. The following classification, by G. A. Evans,* of the climates resorted to by consumptives may be found useful in making a selection of climate for a particular case: 1. Climate Cool and Moderately Moist, general elevation 2000 feet — Western slope of the Appalachian chain, Adirondacks, Catskill, Allegheny, and Cumberland Mountains. 2. Climate Moderately Warm and Moderately IMoist. — Western North Carolina, Asheville, elevation 2250 feet ; Western South Carolina, Aiken ; Georgia, Marietta and Thomasville. 3. Climate Warm and Moist. — Florida, Southern California, coast region. 4. Climate Warm and Moderately Dry, elevation about 2000 feet. — Southwestern Texas, Southern California, inland. 5. Climate Cool and Moderately Dry, elevation about 1000 feet. — yiin- nesota, Nebraska, Dakota. 6. Climate Cool and Dry, elevation from 4000 to 7000 feet. — Montana, Wyoming, Colorado, Northern New Mexico, and Western Kansas. In this group are to be placed Davos and St. Moritz, in Europe. 7. Climate Warm and Dry, elevation 3000 to 5000 feet. — Southern New Mexico and Southern Arizona. A further division of resorts in accordance with altitude is into !ozv_, * "Handbook of Phthisology," New York, 1888. 268 JXFECTIOL'S DISEASES. mediiun, and elevated. In the first of these fall naturally Florida, Georgia,, and Southern California ; in the second, places with an elevation of from 1500 to 2500 feet, including Asheville, the Adirondack and Catskill Aloun- tains; in the third, altitude of 5000 feet and above, including the slopes of the Rocky ^Mountains from Wyoming down to Arizona in this country and Davos and St. ]\Ioritz in Europe. As to the permanence of the curative results of treatment at high alti- tudes, it is a common impression among the laity that persons to retain the advantages gained in such climates must remain there. Of this Solly says : " I am firml}- of the belief that persons cured in elevated countries have at least as good a chance of keeping well after returning home as those cured at sea level, and owing to the decided increase in general and pulmonary vitality imparted by the climate, probably a much better one." The usefulness of sanitaria for consumptives has of late been conclu- sively demonstrated. Late observations would seem to show that less impor- tance attaches to location of these sanitaria than has heretofore been believed, although it is reasonable to suppose, that sanitaria at high altitudes will fur- nish the most satisfactory results. The keynote of success in tJiese is the stringent hygiene and open air life. II, Hygiene Treatment. — The following should be carried out as far as possible in every case, whether the patient is enabled to make the change of climate advised or compelled by the force of circumstances to remain at home: Secure a habitation wholesomely located, free from dampness, avoid- ing low ground. The apartments occupied should be those accessible to sunlight for as many hours of the day as possible. In this latitude a south and west exposure obtains this condition. Provide the best possible ventila- tion for day and night. Especially at night should sleeping chambers be thoroughly ventilated, as during the day the patient secures the efifects of change of place, while at night he is compelled to remain in a single room. The more nearly the air of the sleeping chamber approaches that of out- doors the more likely is the patient to improve. \^entilation should be secured without subjecting the patient to drafts of air. A low temperature at night may be rendered less harmful than drafts of warmer air, since its effects may be counteracted by extra covering. In addition to availing himself of a proper location and ventilation, the patient should spend as much time as possible out-of-doors, and except dur- ing active fever, in the practice of moderate exercise, due regard being had to its effect on the heart and breathing. No sudden or forced efforts should be made. For the most part the patient should be kept moving, although, if the weather is suitable, he may also sit for a time. Sunlight rather than shade should surround him in his outdoor life, and the temptation to sit down long for rest in cool, shady places should be resisted. Daily bathing of the most thorough kind should be insisted upon, it may be wath cool though not with very cold water. It should be followed by active friction, so as to maintain the skin functions at their highest point.. Cold sea-bathing is not to be recommended, because the reactive power of consumptives is very feeble, and a chill of the body may be followed by permanently harmful results. The body should be clothed in wool next the skin by day and by night, winter and summer. At night nothing is better or more convenient than a long flannel night-gown extending almost to the feet. III. Food should be abundant and of the best and most nutritious kind. TUBERCULOSIS. 269 Meats, including especially fats, poultry, game, oysters, fish, rich animal broths prepared in the most tempting way should be provided, because the quantity taken should be as large as can be digested and assimilated. Milk and cream, cheeses, and the like are eminently suitable. Koumiss or zoolak may be substituted for milk. What shall we say of alcohol? It is in the majority of cases an efficient adjuvant in consumption, if properly used. That it is at times abused and that the alcoholic habit is sometimes acquired does not alter the fact that it is useful. The physician should watch its use as he does that of mor- phin. A moderate amount with meals in the shape of whisky improves digestion and increases appetite, while combined with milk and cod-liver oil it helps the assimilation of the latter and contributes to fat production — an acknowledged advantage to the phthisical patient. He should be limited to a couple of glasses of sherry or as many tablespoonfuls of whisky at dinner, while a half-ounce morning and evening with a glass of milk will be as use- ful as a larger amount. The whole purpose of the measures recommended under this heading is the production by improved nutrition of a soil prejudicial to the growth of the bacillus of tuberculosis. The effect of unhealthy location, dampness, bad ventilation, darkness, deficiency in fresh air and sunlight, filth of body, chilling influences, colds, improper clothing, and insufficient food is to favor such growth. The treatment of consumption by suralimentation, as suggested by Debove, may be considered at this point. By it is meant surcharging the stomach with food through the stomach-tube. While it is true of the victim of consumption, as of no other disease, that he should be fed, the method does not seem reasonable. The introduction of food far beyond what the appetite calls for is usually attended sooner or later by a rebellion of the stomach. At the same time some happy results are reported. The method, as recommended, is to wash out the stomach with cold water and then introduce a liter ( i quart) of milk, an egg, and 100 gm. (about 3 1-2 ounces) of very finely powdered meat. This is done three times a day. It is much more rational to secure a natural appetite by fresh air and outdoor life. If, on the other hand, there be reason to believe gastric catarrh is present, an occasional washing out of the stomach may stimulate the appetite whole- somely. Or the vegetable bitters may be used for this purpose. Of these, the tincture of nux vomica in 20- to 30-minim (1.3 to 2 c. c.) doses before meals in cold ws»ter is one of the best. The compound infusion or tincture of gentian in two-dram (8 c. c.) doses is also excellent. IV. Medicinal Treatment. — As to medicines, the remedy that has undoubtedly been of more use in the treatment of consumption than any other is really a food — cod-liver oil. When cod-liver oil is well borne it should be administered to every such case of consumption. When it is not well borne, that is, when unpleasantly eructated or causing indigestion, loss of appetite, or diarrhea, it should at once be discontinued, and if a cautious attempt to return to it is met with a similar experience no further trial should be made. In my hands the best method of administration is to place in a wineglass from two teaspoonfuls to, a tablespoon ful of whiskv and overlay it with the same amount of cod-liver oil. It is then " tossed " into the back part of the throat, and after a little experience this is accomplished with great facility, while nothing is tasted but a pleasant rpsidue of whisky. The maximum dose should be a tablespoonful twice a day. The best time is 2^0 INFECTIOUS DISEASES. immediately after breakfast and on retiring at night, although experience may determine more suitable seasons. The various compound preparations and emulsions, consisting of cod- liver oil, other tonic substances, gums, and flavors to cover up the taste do not meet with much favor with me. At best they are but half oil, they are costly, and as a rule, in my experience, are no better borne than the pure oil. Occasionally they are better tolerated, and under such circumstances they should be administered. It should be remembered that the chief purpose of the whisky is not so much to cover the taste of the oil and to render easy its administration as to favor its assimilation and efficiency. After cod-liver oil, more frequently in conjunction with it, I value creasote or its derivative creasotol. Creasote is not a specific for consump- tion, but it relieves the catarrhal symptoms and diminishes the cough and expectoration. There are various modes of administering it. One drop, as dropped from an ordinary bottle — not a dropper— equals very nearly 1-2 minim, and a minim weighs almost exactly a grain. A convenient shape is a gelatin-coated pill, of which 1-2 grain (0.03 gm.) pills and i grain (0.065 gm.) pills are made. Beginning with i grain after each meal and increasing 1-2 grain a day, a dose of 6 to 7 grains (0.39 to 0.45 gm.) three times a day is very easily attained, as a rule. I do not often exceed 5 grains (0.32 gm.) or 10 drops three times a day, lest the stomach be upset. One should seek, however, to reach at least this dose and keep it up with occasional intermis- sions. Another excellent mode of administration is in hot water immediately after meals, beginning with two drops or a minim at a dose and increasing up to 10 drops, which correspond very nearly to 5 grains (0.32 gm.). It may also be given in one of the bitter tinctures, or in any mixture with alcohol, or in emulsion, or with sherry wine. Cod-liver oil and creasote ma}^ be given conjointly — that is, the creasote may be incorporated with the oil before using. Still better than creasote, though more expensive, is creasotol or car- bonate of creasote. It has the great advantage of being unirritating and can therefore be given in larger doses. I begin with 10 minims (0.66 c. c.) and increase to 30 minims (2 c. c.) after meals, omitting it for a time at the end of every six weeks. It is conveniently given in capsules. Among those who report favorably on it is the Berlin clinician, Leyden. Duotol or guiacol carbonate is similar in its effect and is said to be better borne at times than creasotol. It is given in doses of 0.2 to 0.5 gram (3 to 7 1-2 grains) three times daily in capsules or wafers or dry on the tongue, followed by a mouthful of water." I have never been able to secure happy results from the use of creasote by inhalation. It may, however, be employed in combination with chloro- form and alcohol, to which tincture of conium is sometimes added to miti- gate the irritating qualities of the vapor. A mixture of equal parts of each may be made and a few drops placed on the sponge of a Burney Yeo's inhaler, and inhaled as long at a time as possible ; or 10 to 20 drops (0.6 to 1.3 c. c.) may be added to 7 drams (26.25 c. c.) of water and i dram (4 c. c.) of glycerin, and used in one of the numerous excellent forms of nebulizer now in use. Or it may be placed on the surface of steaming water, with the vapor of which it may be carried to the mouth by a suitable appliance. A little glass tube, open at both ends and filled with small pieces of pumice on which the substance to be inhaled is dropped, also serves the purpose fairly well. It is probable that the inhalation at a single sitting has not been long TUBERCULOSIS, 271 enough continued. The following, recommended by Clement A. Penrose,* has impressed me — creasote, oil of turpentine, each four drams (16 c. c.) ; comp. tr. benzoin, three ounces (90 c. c.) ; one dram to a pint of hot water. As the patient becomes accustomed to the fumes, more of the creasote and oil of turpentine is gradually added until the mixture consists of equal parts of the three ingredients. The inhalations, to be effective, should be systematic and of from ten to fifteen minutes' duration each. The above inhalation mixture may be combined with steam alone, with steam and oxygen, or with steam at home and with steam and oxygen at the office. lodin has long been a popular remedy employed by inhalation. A good way is to dissolve a few grains in an ounce of ether and to inhale the vapor with the mouth or nose over the vial for a few minutes at a time. The fol- lowing combination may be used in the little pumice-loaded tube referred to : Compound tincture of iodin, glycerole of carbolic acid, tincture of conium, each a dram (4 c. c.) ; spirit of chloroform, enough to make an ounce (30 c. c). The carbolic acid may be omitted, if desired, and other changes made. S. Solis-Cohen recommends the use of ethyl iodid placed simply in an ounce- vial, over which the patient places his mouth or nose and inhales for five minutes at a time. Or glass capsules containing five minims of the drug may be crushed in a cloth and then inhaled. He regards it as especially use- ful in ulcerative laryngitis and as assisting in the disinfection and healing of pulmonary cavities. Iron is indicated in all consumptive cases, and it is generally well borne, but it should be given in much smaller doses than is usual. The bane of iron is its constipating effect, and this counteracts all the good it otherwise does, and in my experience the various preparations of iron do not differ materially in this respect. Such effect is not produced, however, if a proper dose is given, and if it constipates in the dose administered, this should be reduced until no such effect results. When this is attained it should be kept up with occasional intermissions. Five or six drops of the tincture of the chlorid of iron thus administered and kept up for a long time go a great way toward keeping up the strength and counteracting the tendency to anemia so characteristic of consumption. Other preparations of iron are: reduced iron, carbonate of iron, which may be given in the shape of Blaud's pills, and the sulphate of iron. The vegetable salts of iron, the citrates and malates, are elegant preparations, and the same principle should be observed in their administration. Arsenic is often useful in consumption and may be combined with iron or alternated with it. Many consider arsenic more beneficial than iron. It is not desirable to give very large doses, and five minims of Fowler's solu- tion are a sufficient maximum dose. It is especially useful in small doses where there are gastric symptoms, and may be continued in moderate doses for a long time. Strychnin is a drug that is very valuable in pulmonary consumption, more especially as a heart tonic. It should also be continued over long periods in doses of 1-30 to 1-20 grain (0.0022 to 0.0032 gm.) three or four times a day. Ouinin is also at tim^es very useful, especially when there is fever. V. Serum Treatment of Tuberculosis.— The late J. T. Whittaker * * " Johns Hopkins Hospital Bulletin," November, i8qo. t "Theory and Practice of Medicine," New York, 1893, p. 158. 272 LXFECTIOUS DISEASES. correctly said : " The discovery of tuberculin established the first real epoch in the treatment of tuberculosis, as it constitutes the first actual address to its cause." This is none the less true in view of the fact that the first essays with it appeared to be absolute failures. There is reason to believe, how- ever, that the continued use of it and antitubercle serum by certain coura- geous therapeutists — Whittaker, of Cincinnati, just quoted, Dennison, of Colorado, Trudeau, of the Adirondack region in Xew York, Karl v. Ruck, of Asheville, ]^Iaragliano, and E. A. de Schweinitz — may be followed by results that promise more than the earlier trials immediately succeeding Koch's announcement. This expectation is reasonable in view of the acknowledged efficacy of the serum treatment of other diseases, notably diphtheria. Referring to the refined tuberculin of Koch, the " modified " tuberculin prepared by Trudeau, the watery extract of tubercle bacilli by von Ruck, or the antituberculin serum by de Schweinitz in Washington, the pros- pect of benefit to be derived from it is the greater the earlier its use in the dis- ease, the more localised the process, and the less general the infection. It is contra-indicated in cases with decided fever, also when there is hemor- rhage. The dose of tuberculin administered should be short of that sufficient to produce a febrile reaction. The primary dose should be 0.2 mgm. hypo- dermically on alternate days, increased with every other administration o.i mgm. until a 2 mgm. dose is attained, when it may be increased more rapidly, say 0.5 mgm. every two or three days. After a 15 mgm. dose is attained the increase may be more rapid according to the effect produced until 0.05 to o.i gm. dose is attained, when it should be decreased by halving the dose at every injection and discontinue altogether at o.oi mgm. The injection is best given in the back between the shoulders. The general guide as to dose is the body temperature, which should be taken for a week before treatment as a basis for comparison. A slight rise (1-2° to 1° F. ) six to twelve hours after the injection is the signal that enough has been given, and the dose should not be repeated until the temperature again falls to the standard deter- mined, after which the dose last given is repeated until it produces no fever. The object aimed at is to get in as much tuberculin as possible, say up to O.I gm., so gradually as to produce only a little local and as little gen- eral reaction as possible. It is to be remembered that tuberculin can influ- ence favorably only the tubercular element of phthisis and is powerless and probably injurious where any extensive and generalized complicating strep- tococcus infection has taken place. On this account the previous or con- current use of antistreptococcus serum has been practiced with results some- what encouraging. The injections of 10 c. c. are made at much longer inter- vals, say a week or ten days. The antitubercle serum of de Schweinitz may be injected in doses of I c. c. on alternate days. By either remedy the treatment should be con- tinued for six months, unless the disease is earlier arrested, or unless harm- ful results appear earlier. Late experience seems to show that the serum is to be preferred to tuberculin.* VI. Pneumotherapy. — Where for any reason the advantages of high altitude are not available, some benefit may be derived from artificial pneu- * See " Some Statistics upon Sero-Therapy in Tuberculosis." Bj- J. Edward Stubbert, " Medical News," March n, i8gq. TUBERCULOSIS. 273 motherapy, by which it is sought to modify the air breathed, more especially as to density, although such therapy may also include modifications in tem- perature, humidity, and chemical composition. The simplest application as applied to density is the producing of conditions by which the patient may be immersed in a compressed or rarefied air which he likewise breathes. The more usual application at the present day is, however, that of " pneumatic differentiation," by which the patient inhales air different in density from that which surrounds him. In the dift"erential method the object is also to facilitate inspiration or expiration, or both. Inspiration of compressed air favors inspiration, as does also expiration into compressed air. Expiration, on the other hand, is favored by inspiration of rarefied air and expiration into rarefied air. These objects are accomplished by the pneumatic cabinet, and very satisfactory results are claimed by some observers. The treatment is truly rational. But whether it be the result of inherent difficulties in the use of the apparatus or failure to accomplish what was expected, the use of it does not seem to grow in favor, and I doubt whether as many cabinets are in use to-day as ten years ago. To be efficient the apparatus should be used two or three times a day, with intervals of rest between, and unless the patient have it at his own home or be in a hospital provided with one, it becomes almost impossible to avail himself of it. VII. Treatment of Special Symptoms. — Naturally, the first of these is cough, and there is no symptom that requires more judgment in its management. A slight cough is often best let alone, because it is an effort to remove secretion, the retention of which may be harmful. If a cough becomes harassing, so as to keep the patient awake or otherwise wear him out, it should be controlled. This should be done, if possible, by coun- terirritation. A simple capsicum plaster, or painting with iodin, or iodin with a little croton oil added, or a mustard plaster, or a turpentine stupe may answer the purpose when the cough is not too severe. As to cough medicines, creasote and creasotol may be classed among the curative measures for this symptom, as they diminish secretion and thus relieve cough. Moderate cough is often easily controlled by simple syrupy remedies, such as syrup of wild cherry and syrup of tolu, to which some dilute hydrocyanic acid may be added, two to four minims (0.12 to 0.24 c. c.) to the dose. If these measures are not sufficient, an opiate becomes indispensable. It does not matter much what preparation is used. A teaspoonful of pare- goric in the beginning is often sufficient, acting like a charm, or deodorized tincture of opium, if a stronger preparation be needed, will answer better because of its smaller bulk. For this reason, too, sooner or later, the alka- loids of opium are indicated. Codein is the best of these to start out with in doses of 1-4 grain (0.0165 gm.) increased. Heroin is the most recent and is much commended. It is given in doses of 1-20 grain (0.0033 gm.) or more. Morphin, however, becomes ultimately the best remedy in the majority of cases. When this stage is reached the wiser course is not to order it at stated intervals, but at such times as the cough needs especially to be controlled, as at night on going to bed, or once during the night. In the morning the patient should be allowed to cough for a time to get up the accumulated secretion. The dose essential for this purpose must vary, any- thing from 1-2 A to 1-4 grain (0.00275 to 0.0165 gm.). Sometimes it may be combined with advantage with a syrupy preparation, which facilitates expectoration, and to this may be added a few drops of a mineral acid, as the 18 274 INFECTIOUS DISEASES. aromatic sulphuric. A cough medicine of this kind, long in use in Phila- delphia, is as follows : ^ Morphinaj sulph gr. ss-ij (gm. 0.033-0.066) Potass, cyanid grs. iij (gm. 0.2) Ac. sulph. aromat f 3 j-ij (c c. 4-8) Syr. prun. Virginian q. s. ad 1 1 iij (c c. 95) M. et Sig. — Teaspoonful as often as necessary to quiet cough. In the morning when a patient has to contend with a cavity full of pus it is better to give him a tablespoonful of whisky or a milk punch, to aid in coughing up the accumulated matter, than to give a sedative cough mixture. The ammonium preparations, chlorid and carbonate, are rarely useful in the cough of consumptives, while their effect is to derange the stomach and destroy the appetite. Sometimes, however, where there is much loose phlegm, the use of the former for a short time may be beneficial. Under the same circumstances terebene is one of the best medicines given in doses of 5 to 10 minims (0.3 to 0.6 c. c). It taxes the stomach, however, some- what severely. Terpin hydrate may be substituted in doses of 3 to 6 grains (0.2 to 0.4 gm.). The fever of consumptives rarely demands special measures. Should the temperature exceed 103° F. (39.4° C.) there is no more satisfactory or harm- less measure than sponging, allowing to remain on the surface a thin film of water, the evaporation of which produces the refrigerating effect. Or 3 grains of antipyrin or acetanilid or 5 of phenacetin (0.2 to 0.33 gm.) may be given, the effect watched, and the drug repeated two or three times if necessary. The high fever of phthisis rarely lasts long and of itself does little or no harm. It is merely a symptom of a more uncontrollable septic process. Night-sweats do demand special measures. By far the most reliable therapeutic agent is atropin ; i-ioo to 1-60 grain (0.00066 to o.ooii gm.) at bedtime usually suffices. It may be combined with morphin, if the latter is necessary. Sponging at bedtime with a saturated solution of alum in alcohol is often efficient when atropin fails, or sponging with simple hot water may answer. Agaricin or agaric acid in doses of 1-8 to 1-4 grain (0.0082 to 0.0165 gm.) is a modern remedy for night sweats. Camphoric acid, 20 to 30 grains (1.32 to 2 gm.) in a capsule at bedtime, is another remedy highly recom- mended. So are muscarin, 5 minims (0.3 c. c.) of a i per cent, solution, and picrotoxin, 1-60 grain (o.ooii^ gm.). An old remedy is the aromatic sul- phuric acid, and it is certainly a good tonic, which, administered in doses of 10 to 20 drops (0.6 to 1.3 c. c.) before meals, may also aid in checking the sweats. Or the following lotion may be used : Balsam of Peru, i part ; formic acid, 5 parts ; chloral hydrate, 5 parts ; trichloracetic acid, i part ; absolute alcohol, 100 parts. Hemorrhage is an alarming symptom and must be treated, although it is probable that most hemorrhages stop of their own accord. The patient should be immediately put to bed at rest, with the shoulders raised. Ice, suitably encased, may be applied to the chest, or cloths wrung out in cold water. A hypodermic injection of 1-4 grain (0.016 gm.) of morphin to an adult is a useful measure to secure quiet. Indeed, I almost always begin treatment with it. If the pulse is full and bounding, 3 drops of the tincture of aconite may be given hourly until some effect is produced. Gallic acid may be given in doses of 15 grains (i gm.) every half hour while the TUBERCULOSIS. 275 hemorrhage lasts. The domestic remedy, common salt, is probably useful by exciting reflex contraction. A teaspoonful swallowed is the dose. When the hemorrhage persists hypodermic use of ergot is recommended. The best preparation for this purpose is a good quality of the fluid extract, of which 30 minims or a dram ( 2 to 4 c. c. ) may be injected at one time, twice in the twenty-four hours. What is known as ergotin is probably a solid extract, of which I grain (^0.065 gm.J is equivalent to 5 minims (0.3 c. c.j of the fluid extract. Gelatin is as efficient in the treatment of hemorrhage of the lungs as in other hemorhages. A very promising method is to administer hypoder- mically loc c. c. of a 2 per cent, solution at a temperature of 110° F. (43° C). The gelatin is also advised by the stomach, although it would seem that the effect of digestion would tend to destroy any hemostatic properties. Good results are, notwithstanding, claimed for it. It is certainly an easier and much less painful mode of administration. I am in the habit of ordering the usual homemade gelatin as prepared for the table, in wineglass doses every two to four hours. Suprarenal extract is also recommended in doses of five grains to the powder every two hours. Strapping is very highly recommended by William Gilman Thompson. He directs that pads of cheese-cloth be placed in the axillae and over the femoral veins, and buckle- straps drawn over them tight enough to prevent venous return, but not to prevent arterial flow. It is best to strap but three extremities at one time, loosening one strap every fifteen minutes and re-applying it to the unstrapped limb. The compression may be maintained for an hour or two. Care should be taken not to loosen all the straps at one time. The diarrhea of consumption does not generally become troublesome until tuberculosis of the bowel develops. Slight degrees seem often to relieve the cough. When there is tuberculosis of the bowel it is exceedingly diffi- cult to control. Sufficient doses of bismuth are on the whole the best remedy — sufficient, because at first the smaller quantities, say 10 grains (0.66 gm.) answer, while later much larger doses are necessary. Opium is, however, often necessary, and sometimes the mineral astringents, as the acetate of lead, nitrate of silver, and oxid of zinc, act well in combination with it. Tannic acid is also efficient in combination with opium, and changes must be rung on these various remedies, as any one is apt to lose its effect. VIII. Prophylaxis against Tuberculosis. — Accepted views as to the nature and causation of tuberculosis have raised the question of prophylaxis into one of paramount importance. Careful analysis of accumulated evi- dence in favor of the communication of tuberculosis goes to show that sputum dried and disseminated with dust in the atmosphere is by far the most impor- tant medium. After this the meat and milk of tuberculous cattle, though most recent studies, already referred to- on page 241, go to show that it is doubtful whether tuberculosis was ever caused by the drinking of milk. The perspiration of the affected subject must be acknowledged to be a possible medium, since inoculation of animals by it has resulted in tuberculosis, while the sweat collected after washing and the use of proper antiseptics failed to produce the result. Kissing and the use of wind instruments and pipes pre- viously used by tubercular subjects arp possible media. It is claimed of meat and milk that they infect through the alimentary canal and the form of tuber- culosis resulting from them is usually glandular, especially of the adjacent mesenteric glands. In like manner the tuberculosis traced to kissing has been in the silands about the neck. The discharges from skin tuberculosis 2/6 INFECTIOUS DISEASES. or lupus are also vehicles of infection. Mainly, however, we have to guard against sputum as an agent of infection, the other causes being comparatively easy of escape. The first and most important measure is, therefore, the disinfection of tl-i£ sputum. To this end a spit-cup should always be used when possible, and it should contain a germicide that will destroy the bacillus. The best of these germicides is corrosive sublimate, dissolved in water in the proportion of I to 1000 or 1-2 grain to the ounce (0.033 to 30 c. c), and a small quantity of this solution should be placed in the spit-cup. In consequence of the fact that corrosive sublimate coagulates albumin, the tartaric or citric acid subli- mate should be used. Next in efficiency is carbolic acid in proportion of i to 30 or 24 grains (1.6 gm.) to an ounce (30 c. c.) of water. A strong solu- tion of soda or potash may be used. As already stated, sputum becomes prac- tically active only when dried, pulverized, and carried into the air as dust. It is evident, therefore, that even water in the cup will render it harmless for the time being, while, if scalding water be substituted, its permanent destruc- tion is secured. The first-mentioned methods are most efficient and should be practiced when possible. Such vessels should be further washed with scalding water and more germicide solution added at least once a day. Under no circumstances should the patient be allowed to expectorate upon the floor, in cars or other public conveyances, or even, if possible to prevent it, in the street. In order to meet these necessities as well as those of other situations in the house where temporarily the use of sterilizing cups is impossible, the handkerchief is indispensable, but it should consist either of old pieces of muslin or linen, which can be burned after use, or of porous paper to be similarly disposed of. The so-called Japanese handkerchiefs answer the purpose admirably. Dettweiler's pocket spit-cup, invented for use in the street or elsewhere as a substitute for the handkerchief, is an admirable invention. It is made of blue glass, is flat, and holds about three fluid ounces, or 90 c. c. There are two openings, one at the top and one at the bottom, both provided with Fig. 25. — Pasteboard Spit-cup. metallic screw-caps. The upper and larger opening receives a polished metal funnel extending half way down into the flask, and the whole is closed tightly with a spring cover or cap. The funnel acts like a similar appliance in certain ink bottles and prevents the spilling of the contents of the flask, even if the cap be left open. The lower opening is intended to facilitate the thorough cleansing of the flask. It is said that it can be made at a cost of less than 50 cents, and can be easily kept clean. The pasteboard spit-cups, supported in a rim of steel, recommended by the New York City Health Department, intended to be burned after use, are correspondingly inexpensive and answer the purpose very well. To the same end, diminution of the possibility of harboring dried bacilli, TUBERCULOSIS. 277 umvashable curtains and superfluous upholstering should be banished from the rooms occupied by tuberculous patients. There should either be no car- pets, or they should be replaced by rugs that can be frequently taken up and shaken. The sleeping-car, with restricted air space per caput, its costly upholstery and curtains, used year after year, becomes a possible source of infection, especially in routes toward health resorts, but is less serious than it might be because of the short time that it is generally occupied by the tuberculous and healthy alike. The state-room of the ocean steamer stands a greater chance of being a medium of infection from its longer occupation. When it is remembered how easy it is with ordinary intelligence and simple means to render completely innocuous the bacillus of tuberculosis, I do not myself believe it can be any more efficiently accomplished by the assistance of Boards of Health, and I see nothing to be gained by reporting tuberculosis as an infectious disease, like scarlet fever and diphtheria. I do not object to reporting consumption to Boards of Health, for statistical pur- poses, but am opposed to it with a view to surveillance by such Boards, because I believe it unnecessary, that nothing is gained by it, and that need- less inconvenience, to say the least, is occasioned to victims and their families. The second source of infection, the milk of the tuberculous cow, if it he a source, is avoided by boiling the milk, which is thus rendered thoroughly sterile. There are, however, objections to boiling milk. In the first place, the taste of boiled milk is not always agreeable, but of greater importance is the fact that it is constipating, especially when it is the only food, as in the case of children. It is desirable for this reason, therefore, to be able to use milk unboiled. That this is possible without harmful results was shown by some interesting experiments of Gebbard, who ascertained that the virulence of tuberculous milk is destroyed by dilution with the milk of other cows. Thus, milk from the udder of tuberculous cows was found to have lost its virulence when diluted in one instance 40 times, in another 50, and in a third 100 times. On the other hand, the dilution of sputum 100,000 times was found not to affect its virulence, while pure cultures do not lose virulence when diluted 400,000 times. An important practical conclusion is deduced from these experiments of Gebbard — viz., that a time-honored practice as to "hand-fed babies of using only the milk from one cow is more dangerous than the mixed milk of a herd. For the chances of infection with such are much greater. Practically, the use by adults of raw milk mixed with other food cannot be regarded as dangerous, but with children fed exclusively on milk precautions should be taken to render it sterile by cooking, or if it must be used uncooked it should be the mixed milk of a number of cows. The milk of a cow known to be tuberculous should be invariably condemned and the animal slaughtered. The products of milk — that is, butter and cheese — are, of course, not amenable to the treatment to which milk can be subjected. Safety from infection from these sources can only be secured by a rigid in- spection of cows, and by measures to prevent the development of tuberculosis in these animals. Infection by tuberculous meat is still rarer. In the first place, the flesh of tuberculous animals may not itself be tuberculous, and, in the second place, the cooking to which meat is subjected must kill bacilli. On the other hand, that the communication of tuberculosis by tuberculous meat when carelessly used is possible is shown by the fact that tuberculosis has been produced in animals by the introduction of the juice of the meat of 2/8 INFECTIOUS DISEASES. other tuberculous animals and even from tuberculous human beings. The use of raw or half-cooked meat should therefore be prohibited. In consequence of what has been said of the experimental production of tuberculosis by the inoculation of sweat as well as the increased possi- bilities of getting into the mouth portions of tuberculous sputum, no one should sleep with a tuberculous patient. Dishes and utensils used by such patients should not be used by others unless first scrupulously cleaned, and this is best accomplished by thorough boiling. The patient should himself be taught to prevent his hands, face, and bedding from becoming smeared with sputum. Precautions against auto-infection are scarcely less important than those against infection of others. It has been said that if it were not for auto- infection most cases of tuberculosis, except those within the cranium, would get well. Be this as it may, it is certain that new foci of tuberculosis are constantly being developed in the same patient, which aggravate his com- plaint and hasten his death. Such a focus is tuberculosis of the intestine, which probably often has its origin in swallowed sputum. Patients should therefore be enjoined against the practice of swallowing sputum. The close dependence of tuberculosis upon predisposition, hereditary or acquired, chiefly the former, has long been recognized. As to whether this or infecti'on is the more important factor in the production of the disease cannot be regarded as settled. Thus, one authority, \^olland, in 1892, de- clared that the greatest amount of good will be done by such treatment early in life as will correct any possible constitutional taint. Behrend, on the other hand, claims that our principal efforts are to be directed against the dangers of infection. Under the circumstances, a due amount of attention paid to both factors cannot be amiss. It goes without saying that a tuberculous mother should not nurse her infant, but what should the child or adult predisposed to consumption do to avert the evil? The residence is the first consideration. If possible, the person should be reared in a country of high altitude. Such a course is much more likely to prevent tuberculosis than to cure it, if once acquired. Above all, he should avoid residence in houses situated in low, damp, and shaded localities. Bowditch's observations many years ago, already alluded to, showed conclusively that consumption is favored by these conditions. Further, such person should not reside in a house where many cases of con- sumption have preceded. And if it is impossible to avoid this the walls and floors should be thoroughly ckaned with the germicide solutions already mentioned. The rooms of the house should be large, airy, and well ven- tilated. The predisposed individual should sleep at night with windows and even doors open, due precaution being taken against drafts. Outdoor life should be sought under all circumstances, avoiding, how- ever, especially damp, cold exposure. Riding and driving should be prac- ticed. Judicious athletics, such as develop all parts of the body in good proportion and especially such as secure expansion of the lungs, should be encouraged. Frequent inflation of the lungs should be practiced several times a day. Practice with dumb-bells and clubs of moderate weight is pre- eminently calculated to empty the deeper recesses of the lungs of retained mucus, and to cause the blood to move more rapidly through the more remote parts where the circulation is naturally sluggish. The treatment of acute or pneumonic phthisis is supporting and stimu- lant, symptomatic and palliative. There is no advantage to be derived by TUBERCULOSIS. 279 taking the patient away from home. Food and stimulants are required to combat the exhausting effect of the disease and its fever. The fever itself may be lowered by sponging and the cautious use of such apyretics as phenac- etin, acetanilid, and the like, because in this form of the disease it is more apt to be continuous and exhaustive in character. The cough must be con- trolled by opiates, and such other measures must be taken as wdll make the patient comfortable and mitigate the sadness with which an inevitable fatal prospect is more or less associated. If it should happen that the disease assumes an unexpected chronicity, it may fall into a class of cases in which the treatment laid down for the more chronic forms of consumption is available. IV. Tuberculosis of Lymphatic Glands, Syxonyms. — Scrofula, or the King's Evil ; Tuberculous Lymphadenitis. Etiology. — Even before the discovery of the bacillus of tuberculosis by Koch in 1882, it was generally conceded that what has been known as scrofula, or the King's Evil, was a true tuberculosis of lymphatic glands. The minute study of these glands showed the presence of miliary tubercles, and since Koch's announcement the bacillus has been found in them. The bacillus may be regarded as the immediate cause of the specific inflammatory process. Tuberculous lymphadenitis is most common in children and young adults, but may occur at any age. Symptoms. — The glands most frequently affected are those of the neck, which appear in various degrees swollen and tender, in many instances sup- purating and rupturing when not opened by the surgeon's knife. The sub- maxillary glands are usually the first involved, but those in the posterior cervical triangle are also frequently invaded on one or both sides, though commonly on one side more than the other. The cervical and axillary glands may be conjointly involved, forming a continuous chain behind the clavicle and pectoral muscles. The bacillus usually attacks the glands nearest its point of entrance, and presumably the cervical glands are infected by bacilli, which enter by the way of the nasal or naso-pharyngeal passages. The vul- nerability of these mucous membranes to the bacilli is, of course, increased by any inflammatory state present. As a rule, there is little or no 'consti- tutional sympathy in such a degree of invasion. There may, however, be slight fever. Alore rarely there is involvement of all the lymphatic glands of the body. Such cases are sometimes met among negroes. In them are swelling, pain, and tenderness of all the visible glands, including the cervical, sub- maxillary, and axillary glands, while autopsy discloses the involvement of bronchial, mesenteric, and retroperitoneal glands. In such cases there is more or less continuous fever, but death is usually the result of some inter- current disease, or of pressure upon the respiratory passages. In addition to the visible pictures described, the bronchial glands are often involved without visible enlargement, the condition being first found at autopsy, when it may or may not be associated with lung tuberculosis. The enlargements may, however, reach such a size as to form a recogniz- able mediastinal tumor, which may or may not produce the signs of pressure. The bacilli which invade these glands filter through the respiratory passages. 28o IXFECTIOUS DISEASES. Tabes Mcscnterica. — When the mesenteric or retroperitoneal glands are especially involved the disease is called tabes mesenterica, or ahdom-inal scrofula. These cases occur among children. The trunk and limbs are puny, wasted, and anemic, while their little bellies are prominent, partly because of the enlarged glands and partly from tympany, producing a striking pic- ture. The tympanitic distention often predominates, making it difficult to feel the enlarged glands. In these cases, too, there is often diarrhea, with thin, offensive stools, yet the bowels are not generally the seat of tuber- culosis. There may be tuberculosis of the peritoneum, which may also give rise to an uneven, nodular, tender, and painful enlargement easily recognized by palpation. The disease prevails among poorly fed children in the slums and badly drained and ill ventilated houses of the poor. There are fever, fretfulness, and a general aspect of abject misery. Death generally takes place through exhaustion; or some acute intercurrent disease, such as ente- ritis, carries off the little sufferers. ]\Iore rarely adults may be affected with tabes mesenterica, either as a primary disease or as secondary to pulmonary tuberculosis. I well remember a case associated with peritoneal tuberculosis in which the diagnosis between this condition and carcinoma was difficult, the autopsy determining the question in favor of the former. While tuberculous glands of the neck, and even of the axilla, tend to suppurate, the retroperitoneal and mesenteric glands more frequently caseate without suppuration, and especially characteristic is a tendency in the latter to calcify, furnishing a mode of healing of tuberculosis. The bronchial glands are also less prone to suppurate, but caseate and, at times, liquefy. The easier accessibility of the external glands to the pyogenic organisms may explain the greater frequency of suppuration in them. Diagnosis. — The diagnosis of tuberculous lymphadenitis requires its differentiation from lymphadenoma (Hodgkin's disease), lymphatic leu- kemia, and simple lymphoma. The aft'ected glands in tubercular lymph- adenitis are usually more tender than those in Hodgkin's disease ; they are more closely adherent to each other and the adjacent tissues, and are, there- fore, more fixed and immovable than the glands in Hodgkin's disease. Again, tuberculosis rarely invades more than one group of glands, is asso- ciated with caseation and suppuration, while the lymphadenoid growths do not suppurate. Xotwathstanding this, the tubercular process is slower. Tuberculosis affects the young — those of either sex under twenty — w^hile Hodgkin's disease occurs at any age, is less frequent in the young, and is more common in males. From lymphatic leukemia tuberculosis of lymph-glands is easily recog- nized by the absence of leukocytosis characteristic of the former. Simple lymphoma also affects a single group of glands, and is doubtless often mis- taken for scrofulosis of the glands about the neck. The glands are. how- ever, harder and less tender, less painful than tubercular glands, and there is less constitutional involvement, less anemia. Sarcoma involves groups of glands, and spreads rapidly, invading also adjacent tissues, while carcinoma is always secondary to primary cancer somewhere else. Prognosis. — The prognosis except in tabes mesenterica is generally favorable unless systemic infection occur, recovery being sometimes spon- taneous. This is favored by suitable conditions to be mentioned under treat- ment. In former times " scrofula " was regarded as a protective against consumption. At the present day it is looked upon as a menace because of TUBERCULOSIS. 281 the danger of systemic infection through it, and it is said that three-fourths of the cases of acute tuberculosis owe their existence to it. Under the cir- cumstances we must regard cases of recovery from tubercular lymphadenitis in childhood as instances of a survival of the fittest. Certainly our present knowledge demands a prompter attempt to eradicate the local condition than was formerly practiced. Treatment. — The general management of a case of tuberculosis of the lymphatic glands is similar to that of a case of tuberculosis of the lungs. The patient should be surrounded by the most favorable hygienic conditions, have T:he best of food, take cod-liver oil and the iodid of iron. The local use of iodin is undoubtedly efficient at times in dispersing" these glandular swellings, probably by exciting an inflammatory process destructive to the bacillus, which in a general way is similar to the reactive effect of tuber- culin. When suppuration has set in it is best to open an exposed abscess with the knife, because if allowed to open itself there is apt to result an unhealthy sinuous ulcer, very slow to heal, and when healed causing marked disfigura- tion by unsightly cicatrices. The access of air permitted by the opening seems also to be antagonistic to the life of the bacillus, for with the healing of the abscess the tubercular process stops in that particular gland. Counter- irritation by any means seems to act similarly, although iodin appears to be the most efficient. V. Tuberculosis of the Serous Membranes. General tviberculosis of the serous membranes is a rare condition, and is recognized chiefly by the signs of tuberculosis of the peritoneum and, so far as they exist, of the pleura, these being the two serous membranes of greatest extent and importance. Tuberculosis of the Pleura. Tuberculosis of the pleura may be suspected when, along with the phys- ical signs of tuberculosis elsewhere, there appear the signs and symptoms of a dry pleurisy. (See p. 542.) This is rendered still more likely if there be added the signs of pyothorax with fever, flatness on percussion, and the auscultatory signs of such effusion. (See Physical Signs of Pleurisy with Effusion.) Tuberculosis of the pleura manifests itself — 1. As an acute primary inflammation characterized by a sero-fibrinous or purulent exudate. The onset of such an inflammation may be like that of ordinary acute pleurisy or it may be insidious in its development, like that of the latent form of pleurisy to be described under diseases of the pleura. It may immediately precede pulmonary tuberculosis, be associated with it, or succeed it. 2. As an acute pleurisy the result of extension from an adjacent tuber- culous lung, and as such it may be ^circumscribed, adhesive, or may con- stitute an extensive sero-fibrinous or purulent pleurisy. 3. A chronic, adhesive, proliferative, tuberculous pleurisy characterized by great thickening and adhesion of the pleurae, with tuberculous infiltration of the thickened product. 282 INFECTIOUS DISEASES. The symptoms and physical signs are in no way different from those to be described in connection with the non-specific forms of pleurisy. Treatment. — Some time often elapses before an absolute diagnosis is made, after which, if the disease is at all extensive, its treatment is mainly surgical, consisting in drainage and washing out of the pleural sac. In some instances its complete success is secured only by excision of one or more ribs. In addition the usual restorative and hygienic measures employed in tuberculosis of the lungs should be carried out. Tuberculosis of the Peritoneum. Synonyms. — Tubercular Peritonitis; Tabes Mesenterica. Tuberculosis invades the peritoneum in two ways : 1. As a more or less diffuse deposit of miliary tubercles over the visceral and reflected layer, unattended by active inflammation. 2. As a tubercular peritonitis when the tubercular deposit is associated with an inflammatory proliferation more or less abundant. In a simpler variety of the lattef, the diffuse adhesive, the peritoneal cavity is obliterated, the coils of intestine being matted together and adherent to the abdominal walls. In a second variety, known as proliferative peritonitis, there is marked thickening of the peritoneal layer with less tendency to adhesion and obliteration of the cavity. The omentum is sometimes an inch in thickness and composed of tubercular tissue in various stages of degeneration. The mesentery is similarly infiltrated and shrunken, drawing the intestines to- gether into a ball-like mass or tumor as large as a child's head. The coats of the bowel, especially the large gut, also show localized areas of similar morbid changes. Tubercular peritonitis is sometimes associated with cir- rhosis of the liver, whose capsule and that of the spleen may be infiltrated to enormous thickness. There is often in this form considerable effusion, which may be serous or purulent, at times bloody. Symptoms. — The symptoms include those of chronic peritonitis, except that the abdomen is apt to be harder and more tender. Indeed, a stiff and rigid abdomen is quite characteristic of tubercular peritonitis. Later, how- ever, is added, particularly in the upper part of the abdomen, the tympany so characteristic of peritonitis. In connection with this must be taken the history of the patient, his appearance, the condition of the lungs and the presence of tuberculosis there and elsewhere, particularly in the pleura and bowel, whence extension to the peritoneum is easy by the lymphatic vessels. Four-fifths of all cases of tubercular peritonitis are said to succeed primary tuberculosis of the lungs. In children tubercular peritonitis is frequent as a part of a general miliary tuberculosis. By primary tuberculosis of the peritoneum is meant simply a tuberculosis in which no primary focus has been found elsewhere. Diagnosis. — To the symptoms above described may be added, if needed for the purposes of diagnosis, the information to be derived from a test injection of Koch's tuberculin and an examination for tubercle bacillus of the fluid obtained by tapping. The rise of temperature succeeding the injection is almost infallible evidence, due antiseptic precautions being taken, of the presence of tuberculosis. TUBERCULOSIS. 283 Treatment. — The treatment for tubercular peritonitis is the general treatment for tuberculosis, with such operative interference as may be deemed appropriate after a careful study of each case. The results of operation thus far have been quite sufficiently satisfactory to justify its repetition in suitable cases. VI. Tuberculosis of the Genito-Urinary Organs. This includes tuberculosis of the kidney and its pelvis, tuberculosis of the ureters and bladder, and tuberculosis of the ovaries. Tuberculosis of the Kidney. Morbid Anatomy. — Tuberculosis presents itself in the kidney in two forms : 1. In the shape of miliary granulations, which are a part of a general tuberculosis, giving rise to no special local symptoms. 2. As primary foci of localized tuberculosis, which in time may fuse to form larger areas that undergo caseation and liquefaction, transforming the whole kidney at times into a sac of purulent or cheesy matter. Such tuber- culosis may start in the prostate gland, bladder, ureter, or pelvis of the kidney, and may extend also into the testicle and epididymis in men, and the ovary and fallopian tubes in women. Symptoms. — The first form is without special symptoms. There may be none at all or they may simulate closely those of nephro-lithiasis. Those of the second, so far as the neighborhood of the kidney is concerned, are not distinctive or constant. There ma}^ be none or there may be fullness, tenderness, and even in extreme cases fluctuation. Frequently, subjective symptoms are reflected to the bladder, and they include frequent micturi- tion, pain, and tenderness in the region of the bladder. There is also puru- lent urine, but commonly this differs from that of cystitis. It is more uni- formly acid in reaction, and contains pus less admixed with mucus. Blood is much more frequent than in simple cystitis, and correspondingly albumin. Tube casts are very rarely found. Cheesy masses are sometimes present in the urine and with them the tubercle bacillus, which is the only pathognomonic sign. It should always be sought. The method for its rec- ognition is the same as for the tubercle bacillus in sputum. It should not be confounded with the bacillus found by Malterstock, Travel, and Alvarez in the preputial and vulvar smegma. Hence, these parts should be carefully cleaned preliminary to the search. A negative result does not, however, exclude tuberculosis. In such event Damsch suggested inoculation with the pus from the urine into the anterior chamber of the rabbit's eye. At the end of three weeks tubercular nodules should make their appearance if the pus be tubercular. Sometimes, also, shreds composed of white fibrous and elastic tissue representing the disintegrating kidney or mucous membrane are found in the urine, but are not diagnostic, since they may be found in other varieties of destructive disease of the organ. The features of the urine described are almost characteristically intermittent — that is, the urine is sometimes almost or quite clear and again becomes purulent. In the absence of such conclusive proof as bacilli in the urine, the pres- ence of tubercle elsewhere, as in the lungs or nearer parts, as the testicles and prostate in men or the ovaries and fallopian tubes in women, affords 284 INFECTIOUS DISEASES. suggestive evidence. The latter may be investigated through the vagina and rectum, while catherization of the ureters may also be practiced in women and stenosis of the ureter due to tubercular infiltration of the pyelo- uretal wall thus recognized. Even in men the thickened ureters may rarely be felt through the abdominal wall. In other cases where the lungs are not primarily tubercular they may be secondarily invaded. Hydronephrosis, it is said, may result from complete obstruction of the ureter by tubercular infiltration. Treatment. — Beyond the general restorative and palliative treatment useful in general tuberculosis there is no medical treatment of tubercular kidney. As soon as the diagnosis is made the surgeon should be called and nephrotomy done. Life is almost invariably prolonged by it, and if the operator be so fortunate as to find only a few isolated nodules on sec- tion, they may be scraped away. I have such a patient, a woman, thus operated upon six years ago by Dr. J. \\'illiam White, who remains up to the present time quite free of a return of the disease. In cases in which the whole organ is involved a persistent renal fistula must be expected, if the kidney be not removed. Exploratory operation may even be justified under circumstances that must be determined in each case. Tuberculosis of the Pelvis of the Kidney, Ureters, and Bladder. It is not always easy to separate tuberculosis of these parts of the urinary tract. So far as symptomatology is concerned, outside of the bac- teriological examination, the symptoms of tuberculosis are those of simple inflammation. If the disease is advanced there is tenderness, but this is the case also when there is impacted stone or pyelitis from other causes. The invasion of the bladder produces symptoms like those of cystitis, including frequent micturition and purulent urine in which there may be a small amount of blood. These symptoms, again, are not peculiar to tuberculosis, and the examination for bacilli again becomes necessary. This is much easier since the centrifugating apparatus has come into use. It must be remembered, however, that the presence of the bacillus in the urine tells us no more than that there is tuberculosis of this tract. AVe are still as much in want of information as to whether it comes from the pelvis of the kidney, the ureter, or the bladder. Cystoscopic examination may help us to locate the disease, but as often it does not do so. In women the catheterization of the ureter, if negative in one or the other ureter, tells us that the disease is probably located in the obstructed ureter. It is very important to remember that sometimes tuberculosis, and, indeed, any form of inflammation of the pelvis of the kidney, produces the same frequent desire to pass water as the same condition of the bladder, and that, too, when the bladder is entirely normal : so that we must not be too positive from the presence of this symptom that the bladder is the seat of infection, while, if there be tenderness in the kidney region and in the course of the ureter, these latter are more likely to be the seat of the disease. The diagnosis by ex- clusion may be of service. Thus, if we can exclude calculus and infection of the bladder and ureters by gonorrhea, or in women by the milder in- fections which sometimes attend child-birth, the probabilities are increased that we have to do with tuberculosis. Suspected cases of tuberculosis of these parts are rendered more probable if the patient is a subject of pul- TUBERCULOSIS. 285 monary tuberculosis. Primary tuberculosis of these organs is, however, possible. Tuberculosis of the Ovaries, Fallopian Tubes, and Uterus. A good deal of attention has been paid of late to tuberculosis of the ovaries by Wolff, Charles B. Penrose, Kynoch, and others. The ovaries may be the seat of miliary tubercles or may contain large cheesy masses. Ovarian tuberculosis is commonly associated with tuberculosis of the fallo- pian t-ubes. The symptoms of the former are in no way different from those of ovaritis from other causes. Fallopian salpingitis produces a hard and thick infiltration of the fallopian tubes, which may be recognized by the usual method of examination for disease of these organs. The uterine ends are commonly closed, while the intervening portion may be dilated and contain mucus, pus, and cheesy material. Tubal tuberculosis is commonly double. Tuberculosis also invades the uterus, infiltrating it by miliary tubercles, which coalesce, soften, and break down, producing metritis and ulceration, discharges from which may contain the bacilli. Uterine tuberculosis usually begins in the region of the orifices of the fallopian tubes, and is really an extension of the disease from the tubes. It may, on the other hand, extend from below, from a tuberculosis of the vagina. The symptoms of the result- ing metritis are the same as those of metritis from other causes. Tender- ness and moderate enlargement may be named. Other symptoms, such as hectic fever and sweats, usually occur only when tuberculosis of these organs is a part of general tuberculosis. The disease makes its appearance more frequently during the period of greatest sexual activity, but it has been found in young children, and in them the ovaries and uterus have been found involved without participation of the fallopian tubes. It should be mentioned also that tuberculosis may extend from these organs to the peri- toneum as well as from the peritoneum to them. Wolff * especially believes tuberculosis of the ovaries is not so rare as commonly supposed, since in 17 women who died of tuberculosis he found five in which the genitalia were invaded, and in three tuberculosis of the ovaries on both sides could be demon- strated. Tuberculosis of the Testes, Prostate Gland, and Seminal Vesicles. Tuberculosis of the testes and prostate is not infrequent. It presents itself as cheesy infiltration, which more frequently does not liquefy. More rarely, the vesiculae seminales are invaded. The enlarged vesiculse semi- nales may be felt through the rectum. The symptoms of this form of prostatic disease are in no way different from those of other diseases of the prostate with enlargement, until rupture takes place. Tuberculosis of the testes is not such a rare affection. It is commonly secondary to that of the bladder and prostate, whence the bacilli travel along the vas deferens into the epididymis, which may be converted into a cheesy mass surrounding the testicle. With the invasion of the testicle further enlargement results with softening, ulceration, and fistulous burrowing. The walls of these fistulse are infiltrated with tubercles. This malady is char- acteristically painless. * " Centralblatt fiir Gynakologie," No. 46, 18 286 INFECTIOUS DISEASES. The treatment of these conditions is mainly surgical, although the gen- eral measures usual in tuberculosis elsewhere are also suitable. VII. Tuberculosis of the Mammary Glaxds. The mammary gland, though rarely invaded by tuberculosis, is never- theless an occasional seat, Warden having collected 58 authentic cases in literature, nearly 90 per cent, of whom were females. Most cases developed in the third decennium. Others have found the disease more frequent dur- ing the child-bearing period. The bacilli causing the disease are probably carried by the blood from adjacent or surrounding organs. The special local product is a cheesy nodule in the gland, which softens, breaks down, and breaks through to the surface, often through the skin, with resulting fistul^e. Sharp, lancinating pains radiating into the arm are said to be char- acteristic. The tubercular nodules may be more deep-seated and hard or soft in consistency. Adjacent axillary lymphatic glands may be invaded by the infiltration. The finding of the bacillus is, of course, the crucial evidence, although the association of fistulse and ulcers in connection with tuberculosis elsewhere suggests this disease. VIII. Tuberculosis of the Heart and Blood-Vessels. History. — As far back as 1814, D. F. L. Kreysig,* in Berlin, said " Tubercular tumors of the heart walls, while met with ver}' rarely, are ver}' probable." In 1826 Laennac said the heart muscle is subject to tuberculosis. In 1832 Townsend, of Dublin, recorded a case wherein a large tuberculous nodule started from the left au- ricle and compressed the pulmonarj- vein. Virchow originally announced that tubercle differed from gumma in that it was not capsulated, but later Fuchs has shown that true tubercle may also become surrounded with a capsule. f It is prob- ably more common than is supposed. Tuberculosis of the Heart. — Tuberculosis of the heart presents itself in the shape of miliary tubercles scattered throughout the substance of the heart, more frequently in the membranes, causing tubercular peri- carditis. The latter may be acute or chronic, more commonly acute, caused by sudden invasion. Both are usually a part of a general tuberculosis. Very rarely is the acute form primary. Tubercular pericarditis is followed by exudation of fibrin, and sometimes of blood and pus. Tubercular pericarditis is found sometimes in old persons in whom it promptly causes death. In cardiac tuberculosis it is supposed that the bacilli arise from long latent foci of tuberculosis of the bronchial or mediastinal lymphatic glands. The latter, on the other hand, may be secondarily invaded from the cardiac tuberculosis. Such pericarditis is also commonly adhesive, and is not distinguishable by physical signs and symptoms from the other forms of pericarditis. Tuberculosis also occasionally occurs in the papillary muscular sub- stance of the heart. Tubercles are sometimes found on the valves of the heart. Tuberculosis of Blood-Vessels. — Tuberculosis may also invade the blood-vessels of a part attacked, and in tuberculosis of the lungs hemor- rhages are commonly due to such invasion, which weakens the vessel and ultimately perforates it. * " Tuberculosis of the Heart Muscle," " Edinburgh Medical Journal," September ii, igoi. t " Krankheiten des Herzens," Berlin, 1816. LEPROSY. 287 LEPROSY. Synonyms. — Elephantiasis GrcEcorum. Definition. — Leprosy is an infectious disease, due to the bacillus leprce, characterized by a subcutaneous and submucous nodular infiltrate, or by similar infiltration of nerve-trunks. The former constitutes tubercular lep- rosy ; the latter, anesthetic leprosy. History. — The disease is identified with the early history of Egypt and India, and is described in the Books of Moses, who gave many rules for its recognition, the isola- tion of victims, the test of recovery, and rules to be complied with before the con- valescent could mingle with his people. It prevailed in Europe in the jNliddle Ages, but has become almost extinct there, except in Norway and Sweden, Hungarj-, and Roumania. In Greece and Turkey, Palestine, Syria, E'gypt, India, China, Siam, the Sandwich Islands, and West Indies it is still ende'mic. Etiology. — The bacillus of leprosy was discovered by Hansen in i! and subsequently clearly described by Neisser, and is especially character- ized by its close resemblance to the tubercle bacillus. The bacilli are delicate rods whose length equals 1-3 to 1-2 the width of a red blood-disc. They are for the most part found in the interior of cells, rarely outside of them. Some of these cells are of large size and known as lepra cells. In the interior of these cells the bacilli often form clumps. They are exceedingly numerous in leprous tissue. They stain readily in anilin colors, but not in vesuvin, differing in this respect from tubercle bacilli, and also in that they liquefy coagulated blood serum, while tubercle bacilli do not. In the fresh condition the lepra bacilli exhibit active movement. While the disease is contagious, its spread, under circumstances the most favorable, is exceedingly slow, the most intimate contact, as that be- tween parent and child, being often unattended by inoculation. Experi- mental inoculation was, however, successfully performed on a Hawaiian convict by Arning, as well as in rabbits by IMelcher and Artmann. Accord- ing to IMorrow, in the majority of cases the disease spreads by sexual inter- course, but cracks and fissures in the skin also favor the lodgment of the bacillus. In certain countries, especially the tropical, its spread is more rapid. Such are India, where there are said to be 250,000 lepers, and the Sand- wich Islands, where, in 1889, there were iioo in the settlement at Molokai. In the West Indies there are also many cases, and some remarkable morbid specimens from Trinidad were exhibited by Dr. Beaven Rake at the Pan- American Medical Congress, held in Washington, \J. S. A., in September, 1893- In this country the cases are for the most part isolated ones that enter by the seaports of the Pacific and Atlantic coasts. In Tracadie, on the Gulf of St. Lawrence, there is, however, a leper settlement, the disease having been brought from Norway in the latter part of the eighteenth century. The number of cases is being graduallv reduced, there being in 1896 but 18 as compared to 40 a few years ago. This is apparently the result of segre- gation, which is now generally practiced where possible. All ages and sexes are liable to th;s disease. Animals are not subject toi it, although guinea pigs have been successfully inoculated. A curious im- pression has arisen that the disease is caused by eating spoiled fish or vege- tables. To this view Jonathan Hutchinson has given the weight of his opinion. In view, however, of the acknowledged bacillary origin of the 288 INFECTIOUS DISEASES. disease, this can only be considered as a predisposing cause that lowers vitality by altering nutrition. Morbid Anatomy.— Tubercular leprosy is characterized by its nodular outgrowths on the skin, the nodules being made up of a small-celled infil- trate, maintaining itself for a considerable time, after which it breaks down and ulcerates. The ulcers may heal, producing cicatrices. The mucous membrane is also invaded, particularly that of the eyelids, the conjunctiva, cornea, and larynx. Lymphatic glands, cartilage, liver, lungs, and spleen are also at times affected. The lepra nodes- are vascular, differing in this respect from tubercles. The morbid anatomy of the anesthetic variety will be included in the anatomical changes of the skin to be described in the symptomatology of that type of the disease. Symptoms. — Nothing is known of a period of incubation. The outbreak of the disease is apt to be preceded by an intermittent febrile movement, which has been mistaken for intermittent fever and which may last for one or two years. There is often an erythematous redness of the skin, which in places becomes pale and in others assumes a brownish tinge. From this appearance the name macular leprosy has been applied to certain cases which go no farther. From these spots the pigment may also disappear, leaving perfectly white anesthetic areas — lepra alba. In the tubercular form, which is the more common, an infiltration of the skin with tubercular nodules takes place. These remain for a long time intact, without degenerating, but sooner or later, as a rule, though often only after many years, softening and ulceration take place. Some of them, on the other hand, gradually disappear without ulceration. The number of nodules varies greatly. Some of them are pediculated, others are a simple thickening of the skin, which is conspicuous in such portions as the eyelids, nose, and ears, parts of which may disappear by ulceration. Even the cornea and conjunctiva may be the seat of nodules, and blindness may result. The same development may take place in mucous membranes produc- ing obstruction of the respiratory passages, including the nose and larynx. There may also be leprous deposits in internal organs, including the liver, spleen, lungs, and lymphatic glands. In the nervous or anesthetic form the peripheral nerves become infil- trated wiih the leprous growth and are converted into thickened cords that may even be felt under the skin. These are at first painful, but later become anesthetic. Trophic phenomena of a striking character result, pro- ducing dryness, smoothness, and tightness of the skin with a total absence of nodules. Atrophy and wasting ensue from the same cause, and toes, fingers, and even larger limbs drop off. Great vesicles also sometimes form. Subsequently are added signs of weakness and exhaustion which gradually increase until the patient succumbs. Diagnosis, — ^The diagnosis of the tubercular form is not difficult. The anesthetic variety resembles closely certain forms of scleroderma, but the trophic changes are more extensive. The resemblance of the early stage to intermittent fever has been referred to. The diagnosis may be made absolute by the detection of lepra bacilli in portions cut out for the purpose of study. The anesthetic or nervous form of leprosv and syringomyelia bear a close clinical resemblance. The characteristic differences are thus pointed out by Laehr :* Leprosy is an infectious disease due to the bacillus leprce, begin- * "Deutsche med. Wochenschrift," January 17, 1897, p. 45. RHEUMATIC FEVER. 289 ning with a febrile movement and primarily seated on peripheral nerves. Synngomyelia is a non-febrile or slightly febrile developmental disease, with its seat in the upper spinai cord, m leprosy the circumscribed anesthesia, muscular atrophy, and vasomotor-trophic disturbances of the skin, bones, and joints appear upon the face, trunk, and upper extremities and simul- taneously or earlier in the lower. In syringomyelia the upper extremities are first affected, the lower very late, if at all, the face escaping, as a rule, completely. Sweating is absent in leprosy, but characteristic of syringo- myelia. The wasting in leprosy involves first the muscles of distal parts of the extremities, while that of syringomyelia begins in the proximal portions. The anesthesia in leprosy includes pain sense, temperature sense, and tactile sense, while tactile sensibility is rarely involved in syringomyelia. In leprosy the anesthetic areas vary in form and extent, and, as a rule, are scattered over the entire body. In syringomyelia sensory changes show themselves on the trunk in the form of a girdle. The sensory disturbances correspond to the portions of the cord involved, while the anesthesia of lep- rosy depends upon local cutaneous disease and occasionally upon disease of the peripheral nerves. As a rule, it is possible to detect spindle-shaped thickenings of the peripheral nerves, especially of the ulnar and the peroneal, before the manifestations of neuritis are apparent. Altogether the symptoms of syringomyelia are similar to those of anesthetic leprosy, but in the latter disease the trophic changes are more marked, the phalanges often drop- ping off. Prognosis. — The course of the disease is almost always prolonged, and the patient may die from intercurrent disease. In some cases death results from the gradual exhaustion of the system, which is more rapid in the ulcer- ative forms. From the nervous form of leprosy recovery does sometimes take place, though the secondary changes resulting remain permanent. Treatment. — So far as known, treatment is unavailing. Segregation should be practiced whenever possible, for such a course is invariably accom- panied by a falling off in the number of cases, and the continued practice of this method must ultimately result in the disease being stamped out. Among the remedies that have been recommended are mercury and iodin by inunction. Internally are advised iodid of potassium, creasote and salicylic acid, chaulmoogra oil, and gurjun oil. The chaulmoogra has most reputation, and is regarded by Danielson after forty years' experience with it as distinctly useful. It is used in doses of two drams (8 gm.) every two hours, and gurjun oil in doses of ten minims (0.66 gm.). The latter may also be used by inunction. RHEUMATIC FEVER. Synonyms. — Acute RheumaHsm; Acute Articular Rheumatism; Inflam- matory Rheumatism. Definition. — An acute febrile, jinfectious, but non-contagious fever, characterized by arthritis, usually multiple. Etiology. — While no distinctive bacterium has as yet been isolated, Hermann Sahli found in diseased joints in which there was no suppuration a bacterium closely resembling the staphylococcus citreus, and Leyden a 19 290 INFECTIOUS DISEASES. cliplococcus differing from that of pneumonia. Drs. F, J. Poynton and F. A. Paine with the diplococcus isolated from rheumatic fever have obtained in rabbits results which go to show that the organism with which they experimented is able to produce lesions of rheumatic fever, namely, mitral valvulitis, pericarditis, and polyarthritis. The diplococcus experimented with was obtained from the joints, from the throat in a case of rheumatic angina, from the bladder, and after death from the morbid product of rheu- matic pericarditis and endocarditis. Again, by injecting a young rabbit with the organisms from the blood and cerebrospinal fluid of the infected rabbit they also produced polyarthritis and endocarditis in the second ani- mal. Some of the animals recovered and others perished. In addition to the symptoms mentioned, there were wasting and involuntary clonic move- ments like those of chorea and the animal was also very nervous. With the chorea there was valvulitis.* In another instance the micrococcus lanceo- latiis was found. In view of the fact that several organisms have been, found associated with rheumatic polyarthritis it may be true, as Flexner and Barker \ suggested, that acute articular rheumatism has no etiological unity, but may be brought about by the entrance into the blood of one of several different pyogenic organisms under circumstances incompatible with the development of the phenomena of a general septicemia, but which may give rise to an inflammation of one of the several serous membranes, includ- ing the synovial, as well as the meninges, pleura, pericardium, or endo- cardium. A predisposing cause seems, however, to be necessary in the majority of cases, and exposure to cold is the most common, although epidemics of acute rheumatism occur quite independently of such exposure. While sud- den changes in temperature, also, often afford the needed conditions, the continued action of moderate degrees of cold, especially when accompanied by moisture, is almost as frequently responsible. If to these be added a lowered vitality due to insufficient food, fatigue, overwork, or all these com- bined, we include the majority of predisposing causes. The winter and spring, being the seasons in which the conditions of temperature and moisture operate most strongly, are those in which the disease is most prevalent. For a like reason it is more common in the temperate zones, the extreme North as well as the extreme South being for the most part exempt. In my own experi- ence, the late spring finds many cases due to the cold and dampness of houses where fires have been prematurely dispensed with. It is a disease especially of young adults, being rare before fifteen and after fifty; w4iile the exposing occupations, including those" of driver, servant, and laborer, favor its development. It may be still in place, in connection with the newer etiology, to men- tion two of the older theories of acute rheumatism. According to the meta- bolic theory, a morbid material is developed in the economy as the result of defective assimilation. Prout early named lactic acid as the peccant material, and more recently P. W. Latham has suggested a combination of lactic acid with other substances. The nervous theory was suggested by the late John K. Mitchell in 1831. t According to it. the nerve-centers are affected by cold, and the local lesions are trophic in character, or defects of * Communication to the Pathological Society of London, Tuesday, October i6, 1900 ; published in the " British Med. Jour.," October 20, 1901. t "Am. Jour. Med. Sci.." 1804. % "Am. Jour. Med. Sci.," viii., 1831, p. 53. RHEUMATIC FEVER. 291 metabolism result from the primary nervous lesion, whence arises lactic acid, which accumulates in the blood. Acute rheumatism is a disease simulated by other affections not infre- quently called rheumatic. Thus, scarlet fever is often accompanied by a painful swelling of the joints due to the specific cause of that disease, and called rheumatic, when it should be spoken of as scarlatinal synovitis. The same is true of the so-called gonorrheal rheumatism, which is not a rheu- matism, but a gonorrheal synovitis due to the gonococcus, and not a rheu- matism accurately speaking. ^Morbid Anatomy.— There is little to be added to what will be de- scribed in treating of symptoms, and to w^hat is furnished by the compli- cations, whose morbid anatomy will also be considered in connection with the diseases that constitute them. The synovial membrane is hyperemic and swollen, and in some cases the fluid in the joints is increased, is turbid, and contains flakes of lymph, rarely pus. There may be slight erosion of the cartilages. The fibrin of the blood is usually increased. Symptoms. — While rheumatic fever is seldom ushered in by a chill, there is more frequently a short prodrome of a day or two, during which the patient feels uncomfortable or has an unpleasant aching feeling in his joints. More often, however, the painful arthritis, which is the first symptom to attract attention, develops rapidly, coming on in a single day or night, or seemingly in a much shorter time, making locomotion at once difficult or impossible. The joint aft'ection has some peculiarities. In the first place, the involvement is almost always multiple, and generally includes the larger joints, such as the knee, ankle, elbow, wrist, shoulder, and hip, although none are exempt, and the phalangeal and metacarpo-phalangeal articulations also suffer. The toe-joints escape most frequently. It rarely happens that a single joint is involved, but its occasional occurrence must be admitted. More rarely, if ever, does it happen that all are affected, although even the vertebral articulations must sometimes be included. The joint-inflammation is further characterized by a tendency to fly from one joint to another. Now it will be the elbow, then the wrist ; again, the knee, and then the ankle or shoulder or hip, either on the same side or the other; but while there will be a reduction in the degree of inflammation, and correspondingly of pain in the relieved joints, the relief will not be total. On another day, again, the pain will have returned to the joint which had been temporarily relieved. While the joint-affection always includes a synovitis, the process is by no means confined to the synovial membrane. The adjacent structures, including the capsular and lateral ligaments, and the tendons, with their sheaths, coursing over the joint, and even muscles, are all the seat of involvement, contributing to the swelling and to the pain by the exudation pervading them. Comparing two hands, one of which is involved and the other not, one can often see the depressions between the metacarpal bones in the former obliterated by swelling, while they maintain their usual dis- tinctness in the latter. It is for such reasons that I prefer the name acute rheumatism to that of acute articular rheumatism, which would limit the process to the joints. Rheumatic fev.er is probably the best term. Finally, mention should not be omitted of the non-articular rheumatic fever to which Kohler * has called attention, in which there are no joint- symptoms. ^^___ * " Zeitschrift f. klin. Med." Bd. xix. i8qi. 292 INFECTIOUS DISEASES. The pain is almost always extremely severe, making all motion an agony, while jarring of the bed, or even the weight of bed clothing, may cause the patient to cry out with pain. To diminish the tension, which aggra- vates the pain, the patient is disposed to lie with all the limbs semiflexed. From the beginning there is fever, but being seldom high at this stage, it is not commonly the first symptom to attract attenion. Later, it usually increases proportionately to the extent of joint involvement, but only in the meningeal form is it extremely high. Nor does it pursue a course at all distinctive. In one case, for example, the temperature remained at 102° F. (38.8° C.) and a fraction, night and morning and throughout the day for a number of days. ]\Iore rarely it rises to 104° F. (39.9° C.) Occasionally, however, there is intense hyperpyrexia, w'hen the temperature rises rapidly from 104° F. to 110° F. (39.9° C. to 44.3^ C), and even higher. With this are associated cerebral symptoms of an alarming and dangerous kind, intense headache, and delirium — symptoms otherwise rather unusual in acute rheu- matism. To these are often added unconsciousness, pulselessness, and cyanosis, rapidly followed by death, unless the temperature is promptly reduced. The sudden onset of these symptoms adds to their alarming char- acter. This combination of severe symptoms is known as the meningeal form, or rhcuniaiisui of the brain. The pulse in rheumatic fever is rapid, often disproportionately so to the fever, probably because of the nervous demoralization caused by the acute suffering. Next to the fever and joint-inflammation, the most distinctive symptom of acute rheumatism is the szi'eatiiig, which is copious and usually acid in reaction, sometimes even to such an extent as to impart an acid odor to the air of the room. Sudamina are a frequent consequence of such profuse sweating. Discolorations of the skin, varying in intensity and character, make their appearance in certain cases. There may be a simple diffuse erythema, or it may be papular or tuberculated or marginate. There may be true urticaria, or there may be extravasations of blood, purpuric patches of such extent and depth as to result in sloughing of the tissues, hemor- rhages from the mucous membranes, and hematuria. In one case under my observation there ensued permanent blindness from extravasa- tion into the retina. These cases of peliosis rheuniatica are not acknowl- edged by all to be truly rheumatic, the joint-affection being declared to be of a different nature, analogous to that of scorbutus and hemophilia. The urine is also somewhat characteristic. It is scanty, of high specific gravity, very acid in reaction, and deposits a copious sediment of pink-hued mixed urates. Very interesting and characteristic are certain subcutaneous nodules, attached to tendons and fascia, which have long been observed as occasional events in connection with acute rheumatism, and have been especially studied by Barlow and Warner. They vary in size from a shot to that of a pea, and may be numerous or but few. They occur on the fingers, hands and wrists, elbows, knees, scapulae, spines of the vertebrae, and more particu- larly after the acuteness has passed away. They may last a few days or for months, and are more common in children than in adults. Disposition to recurrence must be mentioned as a characteristic feature of acute rheumatism. Quite rarely does a person who has had one attack escape another, and it is these successive attacks which, augmenting pre- RHEUMATIC FEVER. 293 vious cardiac lesions, finally cripple the heart until its work is greatly ham- pered. The intervals between successive attacks are various, — from a year to four or five years, — and they are the more frequent and more liable to occur the younger the subject. Complications. — Very interesting in connection with acute rheumatism is the frequent involvement of the serous membranes other than those of the joints, such as the pleural membranes and the peritoneum. The involve- ment of the former simulates pleurisy and the latter peritonitis, and I well remember a case of my own, a girl of eight years, in whom for days I thought I was dealing with peritonitis, when a few doses of salicylate of sodium relieved my anxiety by promptly arresting the disease. In rheu- matism of the pleura the absence of physical signs aids in the diagnosis. These phenomena are easily explained with the modern views of the etiology of rheumatic fever, since we have only to suppose the infectious material circulating in the blood to lodge upon the serous membranes instead of the joint tissues. Of the same class is a much more common complication, cardiac dis- ease, including endocarditis and pericarditis, the former being by far the more frequent, and confined almost exclusively to the left heart. Again, the mitral leaflets are much more frequently attacked than the aortic. While the cardiac involvement bears some relation to the severity of the disease, the mildest cases may become complicated as well as the severest. Hence, the heart should be daily examined, and for the further reason that the approach of the disease is often exceedingly insidious. On the other hand, cardiac oppression and palpitation may occur without actual structural change, and even a functional murmur ma}^ be present in acute rheumatism, and this, too, not only at the base, but also at the apex of the heart, an unusual site for such a murmur. The proportion of cases in which cardiac complications occur, though difficult to estimate, is not less than 25 to 33 per cent, for endocarditis, with 10 per cent, more for pericarditis, making in all 35 to 43 per cent., while some estimate even a larger proportion.* Young subjects are more vulner- able than adults, and Fagge mentions an interesting difference in the sexes after adult life, which is, that pericarditis is more frequent in men above twenty-five than in women of the same age, probably because at this age men work much harder than women. The variety of endocarditis is usually the verrucose, or warty, ulcera- tion, laceration or perforation of the valve flaps being very rare. The malig- nant form of endocarditis does, however, occur. While the endocardial murmurs in the endocarditis of acute rheumatism are commonly soft, the pericardial murm_urs are often loud, rough, and rasping, and the vibration resulting from the friction may even be communicated to the hand laid upon the precordium. Both conditions may result in complete recovery, but the former more commonly is the beginning of a chronic valvular defect. Acute myocarditis is a fatal, but fortunately rare, complication of rheu- matic fever, occurring alone or in association with endocarditis and peri- carditis. It is commonly first discovered at the autopsy, though severe epigastric or precordial pain, embarrassed respiration, and cyanosis may suggest it. It probably occurs more frequently than is reported, although the facts do not substantiate it. *De Lancey Rochester in a paper published in the " Tour, of the Am. Tiled. Assn.," December 15, 1900, says 60 per cent, for endocarditis and 10 per cent, for pericarditis. 294 INFECTIOUS DISEASES. Other complications of rheumatism are probably also the direct result of the poison. They include the inflammation of the serous membranes mentioned, bronchitis, and, more rarely, pneumonia. Convalescence from the latter is said to be slow. The sequelcs directly traceable to acute rheumatism are also few. Chorea, acute nephritis, and exophthalmic goiter are among those so regarded. The nephritis is, perhaps, better considered a complication result- ing from the same cause, just as are the endocarditis, pleurisy, and peri- tonitis. Among sequelae should be included the more unusual one of chronic arthritic changes identical with those of chronic articular rheumatism and even rheumatoid arthritis. Diagnosis. — The diagnosis of acute rheumatism -is seldom difficult, the multiple painful involvement of the joints, the fever, and sweating seldom mean anything else; but pyemia and scarlatinal and gonorrheal arthritis must be remembered as possible events. It is the monarticular variety which demands most discrimination in its determination. Traumatic synovitis, tuberculosis or white swelling, and the so-called nervous arthropathies are to be eliminated. It is not ahvays easy at a first visit to distinguish gout from acute rheu- matism, but the most serious possible error in diagnosis is to mistake a pyemic arthritis for a rheumatic arthritis. This is not an uncommon mis- take where there is no evident surgical lesion to suggest it. Osteomyelitis is said to be the most common cause of such pyemias ; but other bone-diseases, puerperal sepsis, and gonorrhea are also causes. Prognosis. — The course of acute rheumatism is characterized by many fluctuations independent of treatment, and its duration is various. Sooner or later recovery generally takes place, although it may be with a crippled heart and a susceptibility to return. ^lore rarely the attack passes over into a subacute condition which makes the patient a sufferer for a long time, while still more rarely true chronic rheumatism is the result. It used to be said the cure for inflammatory rheumatism is " six weeks," and though this is not true of every case, many are prolonged to quite this length. Subacute Rheuinatisin. This term is applied to forms in which all the symptoms are less marked and more prolonged. The fever is not so high, ranging from 99° to 101° F. (37.2° to 38.3'' C). The inflammation of joints is not so intense and the joints involved are less numerous. It exhibits the same " flying " tendency. It may also be associated with the cardiac complications, especially in chil- dren. It may pass into the chronic form. Treatment. — ^Whatever may be the drawbacks to a successful treat- ment of acute rheumatism, — and they are many, — it is certain that most of those who had to treat this disease a quarter of a century ago now attack it with much more confidence than they did in that day. The drug which is responsible for this feeling is salicylic acid, and very few physicians think of any other at the outset of a typical case. The introduction of salicylic acid as a remedy for acute rheumatism is commonly ascribed to Buss, of Basle, some time prior to 1876, but attention was first prominently drawn to it in the latter year by Dr. Strieker, of Traube's clinic in Berlin. Salicylic acid and salicylate • of sodium are equally efficient, but the former has been largely superseded by the latter, because less irritating and RHEUMATIC FEVER. 295 easier of administration. Still better borne is strontium salicylate. Which- ever is used, there is one necessary condition of its efficiency, and that is its constitutional impression. The aim in the administration is, of course, to relieve the patient, but this effect is seldom obtained, or, if obtained, is of fleeting character, until the peculiar ringing in the ears is secured. To do this in the adult i 1-2 to 2 drams (5.8 to y.y gm.) of salicylic acid and from 2 to 3 drams {y.y to 11.6 gm.) of the sodium salicylate in the first twenty- four hours are required. If the salicylic acid is given, it should be in cap- sules. or compressed pills containing 7 1-2 to 10 grains (0.49 to 0.65 gm.) every two hours, followed by a little water or milk. The salicylate of sodium may be given in doses of 10 to 15 grains (0.65 to i gm.) in solution every two hours, or every hour if the pain be severe, until relief comes, after which it should be kept up until the toxic effect is produced, when the dose should be diminished, but the drug continued ; or the interval may also be prolonged. Others would give the salicylate of sodium, i to i 1-2 drams (5.8 to y.y gm.), in a single dose, but in my experience few stomachs will submit to such quantities. The doses laid down may be pushed more rapidly if the suffer- ing is extreme, but I have seldom found it necessary. Under this treatment the pain fades away, the swelling diminishes, and the anxious expression of the patient is changed to one of comfort in from twenty-four to forty-eight hours. Those who object to the salicylate treatment do so on the ground that the relief is not permanent, and it must be admitted that relapses do occur. I am confident, however, that this is often due to the fact that the remedy is discontinued too soon. As stated, the drug, while it should be cut down with the appearance of relief and toxic effect, must be continued for some time after relief is obtained. Salicin, first used by T. J. Maclagan, appears to be about as efflcient as salicylic acid, given in 20-grain (1.33 gm.) doses every two hours, in suspension or dissolved in warm water. It is much less irritating than salicylic acid, but has not superseded it on this account. We should not, however, rely wholly upon the treatment by salicylates. Warmth is commonly a useful adjuvant, and to this end the joints and limbs should be kept surrounded by warm flannels or carded wool or cotton. The patient should, further, sleep between blankets and in a flannel gown so made that it may be easily removed, with split sleeves and split skirt, because of the extreme sensitiveness of the sufferer. The bed, if possible, should be narrow because of greater convenience in handling. The opposite plan, treatment by cold, is also recommended by some. Sometimes the salicylates cannot be tolerated by the stomach, even in the smallest doses likely to be useful. They may then be given by injection as follows : The rectum is washed out with warm water, and after a short rest, 20 to 40 grains (1.3 to 2.6 gm.) or more of sodium salicylate in solu- tion are injected well up into the bowel. This may be done once in six hours with the happiest result, as I can attest from personal experience. If larger doses are thus given, 90 to 120 grains (6 to 8 gm.) being recommended by some, it is well to guard them with a little tincture of opium. But the salicylate treatment is not always successful, and sometimes the drug is not well borne in any shap'e. Then the oil of wintergreen, which contains 90 per cent, of salicjdate of methyl, may be tried, in doses of 10 to 15 minims (0.6 to i c. c.) ever\' two hours, in capsules or in emulsion. Or it may be alternated with the salicylate, if it be a question of tolerance of the latter, the gaultheria being usually better borne for a time by the stomach. I 296 INFECTIOUS DISEASES. say for a time, because, however pleasant wintergreen is at first, its continued use is apt also to excite disgust. Oil of gaultheria is also used locally, at times with excellent results. It mav be used as an embrocation in the proportion of one part of oil of gaul- theria to two parts of olive oi'. More usually it is applied. to the affected joint on lint, which is thoroughly moistened with the oil, wrapped about the joint, and surrounded by gutta-percha, oiled silk, or other impermeable covering to prevent evaporation. This is further prevented by bandaging the whole limb. That the salicylate of methyl is thus absorbed is seen from the fact that salicyluric acid appears in the urine a few days later, while the usual evidence of the physiological action of salicylates — viz., headache or fullness of the head with ringing in the ears — takes place. In view of the gastric disturbances w-hich the salicylates cause in some persons, this mode of admin- istration should not be overlooked. The alkaline treatment of acute rheumatism, most relied upon before the salicylic treatment came into vogue, is a treatment which is by no means worthless. This, originally instituted by Sir A. Garrod, received an addi- tional impulse from the late Dr. H. W. Fuller, who insisted upon the admin- istration of such doses as secured and maintained an alkaline reaction of the urine. This is accomplished by sufficient doses of almost any of the alkaline salts, as potassium citrate, potassium acetate, sodium carbonate ; or liquor potassce may be used. Twenty grains (1.33 gm.) every two hours of the first three are generally sufficient, or 20 minims (1.3 c. c.) of the last. The dose may then be reduced, but enough should be given to maintain the alkalinity of the urine. Failing for any cause in the treatment with salicylic acid, the alkaline treatment, or what is called the " mixed " treatment, may be employed. By this is meant the combined alternate use of the salicylates and alkalies. This may be tried, for example, where sufficient doses of the salicylates are not well borne by the stomach, when they may be supplemented by alkalies. While using the alkaline treatment before the salicylates came into use, it was quite usual to combine with it the " flying " blister, one of small size, — say an inch square, — and to apply it now to one joint and then to another. That this practice is efficient in relieving pain there can be no doubt, while there is also reason to believe that it sometimes cuts short the inflammation in the joint treated. It is more than likely that this treatment has been too much neglected since the salicylates have become popular. In the subacute and chronic stages of the disease counterirritation by blisters or iodin is also of service. For the relief of pain, opium or its derivatives is sometimes necessary, but less frequently than before the introduction of salicylates. Here, again, the hypodermic injection of morphin, 1-4 grain (0.016 gm.), is most com- forting, but the Dover's powder in lo-grain (0.6 gm.) doses is often efficient. Phenacetin. acetanilid, and exalgin may be used for milder degrees. It is soothing to have the joints enveloped in cotton or wool. The treatment of the hyperpyrexia of acute rheumatism must be prompt and energetic, as the danger to life is imminent, the extraordinarily high temperatures thus encountered being inevitably fatal in a few hours. There is but one treatment. It is the application of cold. The bath is to be pre- ferred, although in its absence afifusions of ice-cold water and rubbing the head and body with ice may be substituted. As soon as the temperature begins to mount rapidly above 105° F. (40.5° C.) it should be used, and if EPHEMERAL FEVER. 297 delirum or unconsciousness is associated with such temperature, its need is even more imperative. When time permits, the apphcation of cold may be more gradual. Thus the patient may be put in the bath at 70° F. (21° C.) and the temperature further reduced, if necessary, by the addition of ice or colder water. As stated, there seems now to be no doubt about the pro- priety of this treatment. Numerous cases of recovery have been reported, some even where the temperature had reached 107°, 108'', and even 109° F. (41.6°, 42.2", 42.7° C). With the reduction of temperature, the cerebral symptoms gradually disappear. As the disease becomes more subacute or chronic, the necessity for more active local associated with tonic treatment becomes urgent. It would seem that at such stage the pathogenic cause has exhausted itself, and the disease has become more a local one, maintained by the dyscrasic state of the blood, itself brought about by the prolonged suffering. Hence roborant treatment with iron, arsenic, cod-liver oil, wine, and nourishing food becomes necessary. Indeed, the patient with acute rheumatism should be well fed throughout. Counterirritation by iodin or by blisters should be kept up with appropriate intermissions, although the results are often slow in appearing. Massage is especially valuable, and often surprisingly soothing ultimately, even although at first somewhat painful, while by it the mobility of the joints may be gradually restored. There results sometimes in the muscles in the neighborhood of the joint, and especially in the case of the shoulder, a paretic state, which is also benefited by massage, especially when associated with electricity. Allusion may be made to remedies now more or less obsolete which have had some reputation in the treatment of acute rheumatism. Ni- trate of potassium was among the most popular of the older remedies. As much as 2 drams (8 gm.) of the latter were given by Brocklesby three and four times a day. It was revived by Basham, who applied it locally to the inflamed joints. It is diuretic and diaphoretic. Guiac is also one of the older remedies still used in chronic rheumatism, which see. The bromid of ammonium had the indorsement of J. M. Da Costa in the quantity of i to I 1-2 drams (4 to 6 gm.) in twenty-four hours. It should be mentioned also that no less eminent authorities than Sir Alfred Garrod and the late Austin Flint, Sr., thought acute rheumatism was self-limiting, and that it terminated about as quickly without medicines as with them. Diet in Rheumathc Fever. — The diet of the patient with rheumatic fever should be simple and easily assimilable, but nourishing. While there is fever the food should be liquid, but the rule of conduct should be : feed well — do not starve. INFECTIOUS DISEASES OF DOUBTFUL NATURE. EPHEMERAL FEVER— FEBRICULA. Synonyms. — Irritative Fever; Gastric Fever; Simple Continued Fever. Definition. — A fever of short duration, depending on a variety of irri- tative causes. A febrile movement, lasting twenty-four hours and disappear- ing, may for convenience be called ephemeral fever; if of three or four days duration, febricula. 298 INFECTIOUS DISEASES. Etiology. — The most frequent cause of this form of fever is probably the irritation of foods difficult of digestion, either by their inherent qualities or by reason of some temporary functional derangement of the stomach. In a word, indigestion is perhaps the most frequent cause of such a fever. This is especially the case with children, in whom the condition is often spoken of as gastric fever. Another cause is probably exposure to cold insufficient to produce a bronchitis, tonsillitis, or other affection, too slight to be recognizable by the usual signs. Undue exposure to the sun, too, may produce it, or even fatigue. The inhalation of noxious gases is a possible cause, though somewhat dis- credited by recent studies;'^ also, the absorption from the stomach and intestine of lower toxic albumoses from putrid or decomposing foods — auto- intoxication by ptomains. It is possible, too, that the germ of an infectious disease or its toxic products may enter the economy in quantity insufficient to develop the specific affection which is its usual result. Possibly the poison of rheu- matism or malaria may operate in this way. Symptoms. — The symptoms of irritative fever are those usual to fever in mild degree, /. e., moderate elevation of temperature, rarely above 103° F. (39.4" C), frequent pulse, headcrche, a sense of lassitude and weariness, loss of appetite, nausea, and restlessness; in children perhaps delirium. The fever is apt to terminate suddenly by crisis on the second or third day. Diagnosis. — The diagnosis resolves itself into this : where a careful search fails to reveal the action of a cause, save one of those referred to, and no symptoms develop characteristic of any of the recognized diseases, the affection is irritative fever. Prognosis. — Always favorable. Treatment. — Rest in bed, a simple aperient, a fever mixture consist- ing of solution of citrate of potash, sweet spirit of niter, solution of acetate of ammonium or aconite tincture, will suffice to break up the fever and insure recovery. PROTRACTED SBIPLE CONTINUED FEVER. Definition and Etiology. — It seems necessary for the present to con- tinue this term for a feverish process of a longer duration than ephemeral fever or febricula, — a fever that is not typhoid, not influenza, — lasting from two weeks to three months, and without definite lesions. Knowing, how- ever, what we do know, and littiited as our knowledge still is of infection, it is more than likely that some day a specific cause will be found for each of a motley group of such fevers, which will give them a definite name, just as cases formerly thus grouped are now relegated to typhoid fever. Some of these cases, too, may belong to the group covered by the term cryptogenetic septicemias, suggested in 1878 by W. v. Leube — cases of gen- eral septicemia with concealed local infection undiscoverable even at necropsy, characterized by a fever that persists for weeks. Many of these recover completely, including cases in which the natural doubt as to whether they are of malarial or tubercular origin is settled in the usual way, against malarial by the inefficiency of quinin. and against tuberculosis by reason of recovery. J. ]\I. Da Costa well described such cases in a paper on " Pro- tracted Simple Continued Fever. " f Some of the more serious forms have * Abbott, A. C, " Effects of the Gaseous Products of Decomposition on the Health," etc. " Trans, of the Assoc, of Am. Phj-sicians," vol. x., 1803. t " Trans, of the Assoc, of Am. Physicians," vol. xi., 1896. PROTRACTED SIMPLE CONTINUED FEVER. 299 been traced after death by the aid of the bacteriological examination, to the streptococcus, staphylococcus, and even pneumococcus infection. Cases of prolonged fever, succeeding pneumonia and pleurisy, which subsequently recover may well be ascribed to any of these organisms. Symptoms. — It can scarcely be said of the symptomatology of the milder forms of these fevers, to w^hich reference is here intended, that it includes more than a mild fever, seldom reaching 103° F. (39.4° C), with slight morning remission and evening rise, and the usual high-colored urine; it may be, with mild gastro-intestinal derangement, such as a slightly coated tongue, but no diarrhea, no lung complication, nothing essential but the mild fever. The latter is, however, rarely high, and there is occasionally enlarge- ment of the spleen. These fevers admit, moreover, of a certain classification, based on locality and perhaps on modifying local cause. This would be the case with the thermic fever of the South, described by John Guiteras, characterized lay wakefulness, great nervous excitement, and disordered muscular function, but without eruption or other symptoms of typhoid fever, and lasting for several weeks. This, as suggested by Da Costa, is probably also the ardent fever of the older writers ; in its severer form, the inflammatory fever, described by Copeland. On thermic fever, Guiteras tells me he has changed his views and is forced, in the light of modern studies, to ascribe it to some unknown infectious cause. To this, he says, he has been led by two facts, first, that he finds it farther north than he originally thought it occurred — ■ his original studies w^ere made at Key West — and, second, its occurrence in more than one member of a family. Such, too, may be the " Asthenic Fever " of Murchison, and the " Star- vation Fever," described by Da Costa ;* the " Atypical Continued Fever of Nashville," described by Cain ;t " Simple Continued Fever," described by Baumgarten,$ of St. Louis ; the " Malta " or " Rock Fever." already described ; the " Innominate Fever " of Goodhart,§ who says in his paper, " There is too great a tendency to label all continued fevers by some definite name"; and the " Inexplicable Fever," of Hale White. || Diagnosis. — The cases are to be distinguished, above all, from irregu- lar and mild forms of typhoid fever, similar forms of intermittent and remittent fever, miliary tuberculosis, the fever which sometimes attends chlorosis, hysteria at times, and some other nervous disorders. Da Costa emphasizes a feverish state caused by lithemia ; another in rapidly advancing spinal sclerosis, which may be recognized by other distinctive signs, usually evident when sought for. In cases where there is enlargement of the spleen the resemblance to typhoid is closer, and the diagnosis may have to remain in doubt until settled by the Widal test or by time. The tubercle bacillus should always be sought for in doubtful cases ; also the plasmodium of malaria. Prognosis. — This is generally favorable, except in some of the severer cases ultimately traceable to true infection. Some cases of the so-called thermic fever, reported by Guiteras, died and came to autopsy without defi- nite lesions being discovered. Treatment. — The treatment of simple continued fever of longer dura- * " Trans, of the Colleg-e of Physicians of Philadelphia," Third Series, vol. v., 1881. + " Southern Practitioner," December. i8gi. J "Trans, of the Assoc, of Am. Phj'sicians," vol. viii., 1893. § " Guy's Hospital Reports," xxx.," 1888. II "Brit. Med. Jour.," vol. ii., 1886. p. 1096. 300 INFECTIOUS DISEASES. tion, as well as of the shorter forms, is symptomatic, and remedies for the relief of symptoms are for the most part alone indicated. With continued fever there is always a tendency to weakness, and supporting measures are indicated, including quinin, strychnin, and small doses of iron. Due atten- tion to the bowels should be given, as the effect of constipation in keeping up fever is well known. WEIL'S DISEASE. Synonyms. — Acute Febrile Jaundice; Bilious Typhoid. Definition. — An acute infectious disease, characterized by jaundice and fever, described by Weil in 1886. Etiology. — The cause is as yet undetermined, but it affects males in preference to females, especially butchers, laborers, and brewers, and its subjects are from twenty-five to forty years of age. A few cases have occurred in this country, two having been reported from the Philadelphia Hospital by J. H. Musser and John Guiteras. Weiss considers that the symptoms and lesions most resemble the bilious typhoid described by Gries- inger, while the latter has been claimed to be identical with the typhoid icterodes of Egypt. It occurs commonly in the summer months, and nearly always in groups of cases. But for the last fact I should regard the disease as catarrhal jaundice. Symptoms. — The disease sets in suddenly, after exposure to cold, as in a beer vault, most frequently with a chill and without prodrome. There is fever, with temperature of 102° to 104° F. (38.9° to 40° C.), headache, muscular and joint pains, and epigastric pain, which is characteristic. There is especially tenderness in the calf muscles. Jaundice promptly makes its appearance. The fever lasts usually from ten to fourteen days, and is char- acterized by decided remissions. The liver and spleen are both enlarged; the former may be tender. Associated with the jaundice are the usual clay-colored stools of obstructive jaundice. Beyond the epigastric pain, which may be hepatic in origin, gastro-intestinal symptoms are not marked, though the tongue is coated, and there may be vomiting and diarrhea. There may be dizziness, confusion of mind, and even delirium. The urine con- tains biliary coloring-matter ; sometimes albumin with casts and even blood. After a duration of from eight to fourteen days, convalescence sets in, usually slowly, and it may be prolonged. Diagnosis. — The conditions with Vv^hich Weil's disease might be for a time confounded are bilious remittent fever, acute yellow atrophy of the liver, phosphorus poisoning, and catarrhal jaundice. The first would be excluded by the absence of the plasmodium of malaria, while the mildness and favorable termination would exclude the second and third. Catarrhal jaundice is distinguished by the absence of fever, and of muscular, joint, and epigastric pain, which characterize Weil's disease. Prognosis. — Recovery is usual, but a few autopsies have been made, with the discovery of no definite morbid anatomy. There is cloudy swell- ing and even fatty degeneration of the cells of the heart, liver, kidney, stomach, and intestines. Treatment. — This is symptomatic. MILIARY FEVER. 301 MILIARY FEVER. Synonyms. — Fehris miliaris; Sudor anglicus; Sweating Sickness; the Siveating Disease of Picardy; the English Szveat. Definition. — An infectious fever of unknown cause, characterized by profuse sweats and an eruption of miliary vesicles. Historical. — The disease first appeared in London in an epidemic of extreme severity in the summer of i486, a year characterized by very wet Aveather. There were other epidemics in 1517, 1518, and 1529. During the latter the disease passed on to the continent of Europe. There was not anotlier epidemic until 1718, when there appeared "the sweating sickness" of Picardy, France, extending thence into Italy, Germany, Austria, and Belgium. Then there followed 194 epidemics up to 1879. Etiology. — As to the specific cause nothing is known. It is not con- tagious nor inoculable, and. not favored by crowding. Most epidemics occur in summer, fewest in the autumn ; second in frequency is the spring ; third, the winter. Moist, warm, and unchanging weather favors the disease. Contaminations of the soil, such as arise from neglected drains and collec- tions of refuse, also contribute to its causation. More women are affected than men, and the vulnerable age seems to be between twenty and fifty years. The healthy and strong are as likely to be attacked as the weak, and the rich as well as the poor. Morbid Anatomy. — No characteristic anatomical changes have been noted in miliary fever. The internal organs are generally hyperemic. The spleen is often enlarged. The most striking feature is the tendency to rapid decomposition, " beginning almost during life," as has been said. The blood is thin and dark colored. Symptoms. — After an incubation of two or three days the patient goes to bed apparently well, and wakes up in the night dripping with sweat. With this is a sense of oppression, and even pain, in the precordial region, ienderness and pain in the epigastrium, palpitation, headache, dizziness, and muscular cramps. The temperature is abnormally high, the pulse and respirations are frequent ; there is even dyspnea, sometimes very violent. The perspiration continues, saturating the bed clothing and diffusing an unpleasant odor throughout the room. On the third or fourth day, as a result of the profuse sweating, miliary -vesicles make their appearance, at first so minute as to be scarcely visible, though they may be felt by passing the hand over the skin. As they become larger they are easily visible by their crystalline contents, which later become turbid and even milky. They appear first on the neck and breast, then over the back and extremities, less frequently on the abdomen and scalp. After two or three days they burst, dry up, and form crusts, which subsequently desquamate. With the appearance of the eruption the other symptoms dis- appear rather suddenly, but there is often noted a burning and prickling sensation of the skin. There is generally loss of appetite, sometimes nausea, seldom vomiting, scanty urine, and especially constipation. The duration of the disease is usually from six to eight days, although it may be prolonged beyond this, the eruption being sometimes delayed to the seventh, tenth, and even fifteenth day. Relapses may occur. Some- times the disease assumes an intermittent character. Diagnosis.— This is not difficult. The prevalence of an epidemic, profuse sweating, and rash scarcely permit an error. Prognosis.— The prognosis has varied greatly in different epidemics. 302 INFECTIOUS DISEASES. the mortality in some of the earUer reaching as much as 50 per cent., while in others none died. The average may be put down at from 8 to 9 per cent. Treatment. — The treatment is mainly expectant and symptomatic. Simple febrifuges and acid drinks are indicated. Warm baths and spong- ing of the skin with warm water are soothing and comforting. The pre- cordial distress and apnea may rec[uire anodynes, preferably subcutaneously administered. The sweating itself, if alarming, may be treated by hypo- dermic injections of atropin, 1-160 to i-ioo grains (0.00041 to 0.00066 gm.), p. r. n., or this drug may be given by the mouth in the same dose. GLANDULAR FEVER. Synonym. — Drilsen-Fieher. Definition. — An acute infectious fever of children, characterized by inflammation of the lymph glands of the neck, especially those back of the sterno-cleido-mastoid muscle. History. — The disease is not a new one, as descriptions corresponding to acute adenitis of the glands affected have appeared from time to time, but the first sys- tematic account seems to have been published by E. Pfeiffer in 1889 under the term Driisen-Fieber. In 1885-87 Filatoff, of Moscow, although less completely, described the same disease. Since then it has been studied by J. Park West, of Ohio, by Samuel McHamill and Albert E. Roussel, of Philadelphia, and by Donkin, Fischer and Dawson Williams, in England. Etiology. — No responsible bacterium has been found. The disease may be epidemic, as was that which occurred in Bellaire, Ohio, described by West. It has been observed to prevail more commonly between the months of October and June in the winter season. The infection, whatever it may be, probably enters through the tonsils or the pharyngeal mucous membrane. Morbid Anatomy. — This includes the enlargement of the glands, which forms so essential a part of the disease. The enlargement may involve not only the cervical glands referred to, but the axillary, inguinal, bronchial, and even the mesenteric. Thus, in West's report of 96 cases occurring between the ages of seven months and thirteen years, in three-fourths of them the post-cervical, inguinal, and axillary glands were involved, with the mesenteric in 37 cases. The liver and spleen were also enlarged, the former in 87 and the latter in 57 cases. Symptoms. — The period^ of incuhation lasts from five to eight days. The disease is characterized by sudden onset of stiiTness with pain on mov- ing the head. Along with this there is fever with a temperature of 101° to 103° F. (56° to 57° C.) with sometimes nausea and vomiting. The enlarge- ment of the glands does not make its appearance until the second or third day, and may attain a size from that of a pea to a hen's e:gg, but rarely goes on to suppuration. The glands are tender to the touch, but there is not usually redness of the skin. There may also be some hyperemia of the tonsils, or pharyngitis. More rarely there is invasion of the tracheal and bronchial glands which may be the occasion of cough. The swelling per- sists from two to three weeks, although the fever does not last nearly so long. Complications. — Among these which may be named as possible are hemorrhagic nephritis, post-pharyngeal abscess, and acute otitis media. GLANDULAR FEVER. 303 Diagnosis.— The disease is to be distinguished from the various forms of infectious sore throat found in scarlet fever and diphtheria which may cause a similar affection of the lymphatic glands. Prognosis. — Favorable. Treatment.— Active treatment is scarcely needed. The patient should be put to rest. Cold or warm applications may be made, whichever form is found more comfortable. An aperient, such as a dose of oil or calomel, may be desirable at the very beginning. West recommended small, doses of the latter drug. SECTION II. DISEASES OF THE DIGESTIVE SYSTEM. DISEASES OF THE MOUTH. THE COATED TONGUE. The natural color of the tongue at its anterior two-thirds is a pale red, on which the fungiform papillse stand out as brighter red points. The epi- theHum covering the fihform papillse, which are much more numerous and uniformly spread over the dorsal surface of the tongue, is thicker, and they are therefore less distinctly seen. As the base is approached, a grayish color is assumed on account of the greater thickness of the epithelium. At the base are seen the circumvallate papillse, arranged in two rows of red circles. In the furred tongue the epithelium is abundant, though it is doubtful whether it is produced in increased quantity or is simply raised by hyperemic swelling of the papillse. The " fur " is also contributed to by various forms of fungi. Too much stress should not be laid on the coated tongue. Some persons have a coated tongue and are perfectly healthy, while others have fair-looking tongues and are ailing seriously with those derangements which are commonly attended with coated tongue, espe- cially gastro-intestinal disturbances. F'ood such as milk, and licorice and tobacco, also contribute to the coating of the tongue. The dry, brown color of the tongue in low fevers is due to a drying of the rapidly exfoliating epithelium, admixed sometimes with mucus or saliva. The tongue may also be coated with dried food and sometimes with dried blood, due to capillary hemorrhage, which imparts to it a black color — the black tongue of certain malignant fevers. The tongue is sometimes pale and anemic in persons whose blood is poor and deficient in red blood-discs. The tongue in these cases is sometimes enlarged and flabby, while its edges are easily indented and marked by the teeth. A bright red or even a raw appearance of the tongue is met with in certain fevers, particularly in the early stages, when it may alsp be dry and glazed. It may be coated at the beginning, but later the epithelium desquamates freely and the whole surface may be red ; or the fungiform papillse may be hyperemic, swollen, and unusu- ally distinct, constituting the " strawberry " tongue so characteristic of scarlet fever. The raw-beef appearance of the tongue is often seen toward the close of exhausting diseases, like tubercular consumption. DERANGEMENT DUE TO DENTITION. The most serious accident of dentition is what is known as the reflex convulsion, which will be considered among nervous affections. Other derangements of gastro-intestinal nature will be discussed under diarrhea. 304 DERANGEMENT DUE TO DENTITION. 305 These are not always reflex. They may be excited by irritation of the swal- lowed saliva, which is not only increased, but also altered in quality. Other anomalous conditions are observed in the natural order of eruption and cer- tain markings on the teeth, ascribed to stomatitis. The order of natural eruption of the milk teeth is well shown in the accompanying diagram. The first to appear are the lower central incisors (i, i), at the age of from four to seven months, then a few weeks later the upper central incisors (2, 2), and next the upper lateral incisors {2a, 2a). Not until the beginning of the second year come the lower lateral incisors (3, 2"), and almost simultaneously the four anterior molars (4, 4, 4, 4). In the second half of the second year come the four canines (5, 5, 5, 5), includ- Fig. 26. —Diagram Showing Eruption of Milk Teeth. I, I. Between the fourth and seventh months, followed by a pause of three to nine weeks. 2, 2, 2 ,a;, 2 a. Between the eighth and tenth months; pause of six to twelve weeks. 3, 3, 4, 4, 4, 4. Between the twelfth and fifteenth months; pause until eighteenth month. 5, 5, 5, 5. Between the eighteenth and twenty-fourth months; pause of two to three months. 6, 6, 6, 6. Between the twentieth and thirtieth months — (from Lota's Starr, slightly modified). ing the two " eye," two " stomach " teeth ; and finally the four posterior molars (6, 6, 6, 6) ; so that by the end of the second or beginning of the third year the first dentition is completed. The milk teeth begin to be replaced by the permanent set in the fifth or sixth year. Before any of the milk teeth are shed the first grinders of the second set are fully developed. Hence they are called the six-year molars. About twelve years are consumed in the cutting of the remaining teeth, but the variations of the date of appearance of each tooth are so great that it is not worth while to attempt to name the dates. In some children (usually the rachitic, the feeble, and badly nourished) the appearance of the milk teeth is greatly delayed — the lower incisors do not appear until the eleventh or twelfth month ; but the completion of dentition is not much delayed thereby, though under these circumstances dentition is sometimes not completed until the end of the third year. In others they appear earlier, — in the third or fourth month,^and occasionally children are born with them. It has always seemed to me that the first appearance of the teeth is more apt to be delayed in blondes and anticipated in brunettes. The diet of children during dentition should be very carefully watched, as the whole gastro-intestinal tract is sensitive and irritable and readily thrown into inflammation. The mouth is tender, the saliva flows freely, and the child is disposed to bite on anything. The term tooth rash 3o6 DISEASES OF THE DIGESTIVE SYSTEM. is applied to certain eczematous eruptions that sometimes appear during teething. Their relation to teething is not certainly established. A'ery rarely a purulent conjunctivitis makes its appearance during the eruption of the upper canines or " eye teeth," which is ascribed to dentition and explained by contiguous extension of inflammation through the antrum of Highmore and the lachrymo-nasal duct. Certain markings are often found on the teeth as a consequence of stomatitis. They include pittings and linear depressions, the result of defects in the development of the enamel. Extreme degrees produce a honey- combed appearance. These, as well as the syphilitic teeth of children, have been studied by Jonathan Hutchinson, and are not to be confounded with the latter. ' See Figs. 27 and 28.) The " honeycomb "" changes are most Fig. 28. — The Permanent Front Teeth of a Boy, aged Fifteen, who had Taken Much Mercury in Infanc3^ The teeth are all of yellow color, some- what pitted in their surfaces, and very thickly coated with tartar. Near the edges of the lower set a horizontal line extends similar to that in Fig. 27 — {after Hutchin- son). Fig. 27. — Thin-edged and Broken Teeth, not Syphilitic, from a Woman, aged Twenty. The notches in the upper teeth differ markedly from those shown in Fig. 19. In these they result not so much from the softness and orig- inal malformation of the teeth as from their preternatural thinness and brittleness. Near the edges of the lower set a horizontal line of notches is seen to extend — {after Hicic/iinson). conspicuous in the permanent teeth, of which the first molars, according to Hutchinson, are the test teeth, though he says the incisors are almost as con- stantly pitted, eroded, and discolored, often showing a transverse line which crosses all the teeth at the same level. These transverse furrows are also ascribed bv !Magitot to infantile convulsions or other severe illness in early life. STOMATITIS. Simple Acute Catarrhal Stomatitis. Definition and Etiology. — A simple erythematous inflammation of the mouth, commonly caused by diffuse chemical or mechanical irritants, such as overheated food (very hot drinks), acids, alkalies, stimulating con- diments (red pepper, horse-radish, and the like), by excessive smoking and use of alcohol. It occurs in adults and children from the action of such causes, independently of the state of health, but is prolonged when its sub- jects are unhealthy and ill-nourished. Dentition is also a cause, while stomatitis may accompany also indigestion and the acute fevers. STOMATITIS. 307 Symptoms. — The mucous membrane is reddened wherever the irrita- tion has reached, but the redness may be greater in certain situations, as on the tongue, gums, lips, and cheeks. There may be at the very beginning dryness, but it is soon followed by increased secretion and slight swelling. There is always discomfort that may amount to pain, which is increased by the introduction of food and its mastication. A corresponding slight febrile movement may be present. Treatment. — The treatment of simple catarrhal stomatitis will be con- sidered in connection with that of the other forms of stomatitis to be described. Aphthous Stomatitis. Synonyms. — Vesicular or Herpetic Stomatitis; Aphtha; Canker; Follicular Stomatitis. Description and Symptoms. — Some confusion attends the use of this term. The term " aphtha " from the Greek means " an eruption." Aph- thous stomatitis is sometimes confounded with thrush, but it is not commonly regarded as a parasitic disease, as is thrush, nor as a follicular disease. Some speak of it as herpetic or vesicular. The Uttle grayish-white spots which char- acterize it consist primarily of an exudate of fibrin and wandered-out leuko- cytes, which pervades the superficial layer of the mucous membrane and is at first covered by epithelium. Hence, an attempt to remove the spots by forceps is futile and follow^ed by bleeding. They are small, round, usually not more than a few millimeters in diameter, and surrounded by a red areola of hyperemia. They are most common on the cheeks and lips, especially in the gingival groove at the base of the latter. They also occur on the tip and edges of the tongue, more rarely on the dorsum. The epithelium dies and desquamates, leaving a superficial ulcer, which under favorable circum- stances heals up rapidly. Under more unfavorable conditions the ulcer grows deeper and becomes more painful, constituting one of the forms of vilcerative stomatitis. Young children are especially subject to it, but it is common also in adults, especially at times of temporary physical depression, as in women during menstruation, pregnancy, and lactation. The aphthse are commonly associated with a variable amount of simple stomatitis, with increased secretion of saliva, a slight " heaviness " of the breath, but without fetor. There is commonly a stinging sensation, espe- cially when brought in contact with food, and even when the tongue and lips are moved in speaking. There is often some constitutional disturbance, including fever. A similar condition is Riga's disease, in which a pearly-colored mem- brane with induration forms on the frenum of the tongue. It occurs in Southern Italy in unhealthy and cachectic children about the time of eruption of the temporary teeth, and may be epidemic. Thrush — Mycotic Stomatitis. Synonyms. — Parasitic Stomatitis; Soor; Miguet. Definition. — Thrush is characterized by grayish-white deposits in the buccal and pharyngeal mucous membranes, due to the development and inter- 3o8 DISEASES OF THE DIGESTIVE SYSTEM. penetration of the epithelium by a fungus variously known as old hi in albicans or saccharoniyccs albicans. It is a variety of yeast fungus made up of branching filaments, at the ends of which oval cells develop. It does not grow on the normal mucous membrane. It forms minute white and yel- lowish spots scattered copiously over the palate, tongue, and cheeks, uniting at times to form larger areas. It may extend into the esophagus and even larynx. In severe cases the entire buccal mucous membrane may be cov- ered. Stenoses of the esophagus have resulted from its accumulation. The little areas are commonly surrounded by an inflammatory areola, and may be scraped off, though with some difficulty, leaving the mucous membrane sometimes intact and sometimes slightly excoriated and bleeding. Thrush is chiefly a disease of nursing children, and is favored by feeble and dyscrasic states and by the w^ant of cleanliness, especially in the care of nursing-bottles and nipples when children are brought up on the bottle. It may be associated with any of the diseases of children or may occur inde- pendent of them. It also occurs in adults after long illness or in dyscrasic diseases like diabetes mellitus and tubercular consumption. Thrush is often vmattended by other symptoms, though the mouth may be sensitive and nurs- ing painful. There should be no difficulty in diagnosis. In thrush the spots are smaller than in aphthous stomatitis, and the microscope at once removes all doubt. The mouth is dry as contrasted with the moist mouth of aphthous sore mouth, where there is free salivation. Other Varieties of Stomatitis Due to Fungi. — The mouth is a favorite seat for the development of fungi, because of the warmth, moisture, and organic matters constantly present. Though ordinarily harmless, in certain states of the system they may play an important role in producing ulcerative stomatitis, as already suggested. Especially worthy of mention are the diplococcus of Frankel and the pneumonia bacillus of Friedlander ; also the delicate, thread-like Icptothrix buccalis, thought to exert a significant part in the production of caries. Ulcerative Stomatitis. Synonyms. — Stoniacace; Fetid Stomatitis; Putrid Sore Mouth. Definition. — This is a much more serious disease of the mucous mem- brane of the mouth, attended with necrosis of the mucous membrane and resulting ulceration. Etiology. — Any one of the above named diseases may become ulcer- ative. It may begin as an aphthous stomatitis, taking on the more serious form in the ill fed and badly cared for. or in those who are indifferent in the care of their mouths. In these, an abrasion or laceration due to any cause, as the tooth-brush or a sharp carious tooth, may be the initial lesion. An ulcer may begin, too, in a herpetic vesicle, which, on rupturing, leaves a raw surface that may remain isolated or unite with others. It is a fre- quent attendant of mercurialization — mercurial stomatitis. The ulcer some- times starts in the mucous follicles of the mouth. In all these cases the stomatitis is probably the result of infection by some organism as yet not isolated ; it may be the omnipresent streptococcus or staphylococcus, to w^hich the sound mucous membrane in health is invulnerable, but which finds a nidus in the abrasions and conditions referred to. STOMATITIS. 309 Symptoms. — The ulcers may occur in any of the situations already named, the lips, cheeks, and, more rarely, the tongue. They vary in size, but are usually of an ashen-gray color, with red areolae, and often exhibit a tendency to bleed. Additional symptoms are profuse secretion, exquisite pain and tender- ness in the ulcers and vicinity, a fetid odor of the breath, which sometimes pervades the apartment. The gttms become spongy and, in extreme cases, the teeth are loosened. There are proportionate constitutional disturbances, fever, and often swelling of the glands at the angle of the jaw. With reference to mercurial stomatitis, or mercurial ptyalism, previously mentioned, this condition is due to mercury administered as a medicine or absorbed in the course of occupations in which mercury is handled. Acquired in the former way, ptyalism, at the present day, is usually acci- dental rather than designed, in persons exhibiting a peculiar susceptibility. In such persons even fractional doses frequently repeated sometimes produce salivation in a day or two. The symptom first observed is usually fetor of the breath, unless the patient be closely watched during the administration of the drug, when tenderness may be ascertained on closing the jaws with some force. Examination will then discover a swelling of the gums about the teeth. Or a metallic taste may make its appearance as the first symp- tom. To these symptoms salivation is soon added, and becomes more or less profuse according to the severity of the poisoning. In severe cases, the entire mucous membrane of the mouth becomes swollen, as does also the tongue. In such cases, also, ulceration and loosening of the teeth take place. This form of stomatitis was not infrequent in the older treatment of syphilis, which used to fill a hospital ward with a sickening fetor at once recognizable. Actual loss of teeth was, perhaps, less common than is sup- posed even in those days, yet necrosis of the jaw has, in rare instances, resulted. Syphilitic stomatitis is also ulcerative, and the ulcers exhibit the same gray color. But the syphilitic ulcers are found in the throat as well as on the gums and cheeks and in the angles of the mouth. They are less disposed to bleed than those of non-specific ulcerative stomatitis, and are really less angry-looking, but penetrate to greater depth. Parrot's ulceration is a form of ulceration occurring in new-born chil- dren, consisting of small, symmetrically placed ulcers on the hard palate on both sides of the median line. Bednar's aphthce, two symmetrically placed ulcers, also occurring on the hard palate on either side of the mesial line near the velum, are similar, though not regarded as identical. This variety is thought to be traumatic in origin, at least in most cases, either the result of pressure of an artificial nipple against the hard palate, or of undue pressure in washing the mouth. Both are described as usually harmless, but in poorly cared for children may be converted Into extensive and deep ulcers. Especially is this the case in the form described by Parrot, which may invade the adjacent bone. Diagnosis. — Scurvy, though a general disease, happily rare of late, is characterized by local symptoms about the mouth, which include ulceration. There are swelling and bleeding of 'the gums, which rise up around the teeth. The latter become loosened and ulceration may extend even to the lips and cheeks. The tongue and fauces are not invaded by ulcers, but are subject to ecchymoses. Salivation and fetor of the breath are also symp- toms, though less decided than in severe ulcerative stomatitis. On the other 310 DISEASES OF THE DIGESTIVE SYSTEM. hand, in extreme cases deep-seated gangrenous processes are met. Along with these are, however, the general symptoms of scurvy, by which it is commonly easily recognized. Treatment of Different Forms of Stomatitis. — Prophylaxis is ex- ceedingly important in averting these various mouth affections. In the case of infants the mouth should be washed out with antiseptics after each nurs- ing. Nothing is better than a saturated solution of chlorate of potash, boric acid, or sulphate of sodium, 15 grains to the ounce (i gm. to 30 c. c.) of water. So, too, the adult should cleanse the teeth after each meal. Listerin, diluted with twice as much water, is an elegant and efficient wash. Equal parts of phenol-sodique and water are also efficient. Compounds similar to listerin and much cheaper may be made up. The following is one known as spiritus thymol comp. in the Dispensary of the University of Pennsyl- vania : i^ Acid, benzoic, Pulv. sodii borat. Acid, borac, Thymol, Eucalyptol, 01. gaultherise, 01. menthee pip., 01. thymi, Spt. vini rect., Aquae destillat., Mix and filter, and color \v gr. 64 gr. 64 gr. 128 gr. 20 m 5 in 5 m 3 in I q. s. ad I xvj ith fluid extract of hydrastis. Any of these substances may be used on the tooth-brush as a simple mouth-wash. The tincture of myrrh, a teaspoonful to four ounces of water, should not be forgotten, and though less agreeable, carbolic acid may be used in the same proportion. Permanganate of potassium in the shape of Condy's fluid, a teaspoonful to a tumbler of water, is an excellent wash. If stomatitis is established, cleanliness is no less important and may be secured by the same antiseptic measures. In addition, the mouths of children may be treated with honey and borax, — ^the mel horacis of the pharmacopoeia, — to which alum may be added. Alum itself is an admirable astringent, too much overlooked of late. A moderately strong solution may be made, 30 grains (2 gm.) to the ounce (30 c. c), or the powdered alum itself may be applied, to the aphthous sore mouth. For the painful aphthous ulcers of adults there is really nothing so efficient as touching with a pointed piece of nitrate of silver. A single appli- cation will often suffice, but when healing does not follow, it may be made daily. A very good application also is a solution of equal parts of tincture of the chlorid of iron and glycerin, applied to the ulcers with a brush. Chlorate of potassium in saturated solution is also a very good mouth-wash, to eight ounces (240 c. c.) of which 1-2 a fluidram to a dram (2 c. c. to 4 c. c.) of tincture of the chlorid of iron may be added. General treatment should not be overlooked. Many persons the sub- ject of stomatitis are much run down, and require iron, quinin, and strych- nin, with nutritious food, to build them up. Attention should also be paid to the bowels. The management of mercurial stomatitis is in no way different from that of other forms. Astringents and disinfectants are especially indicated. It goes without saying that the administration of the drug itself must cease. STOMATITIS. 3U Cancrum Oris. Synonyms. — Gangrenous Stomatitis; Water Cancer; Noma. Definition. — A rare disease, characterized by hard infiltration of the cheek near the angle of the mouth, succeeded by rapid gangrene proceed- ing outward and inward from the central focus until the cheek is perforated, and the gangrenous mass separates. It may start in the gums and produce necrosis of the jaws. It is confined to one side of the face. Etiology. — A parasitic origin seems likely, but has not been proven. It occurs in girls and boys from two to five years old, affecting more of the former than of the latter. Rarely it affects adults. It is usually confined to those badly fed and surrounded by unsanitary conditions, especially when convalescent from infectious fevers, one-half of all cases having arisen during convalescence from measles, scarlet and typhoid fevers. It may, however, be primary. Damp regions seem to favor it. Symptoms. — Its approach is insidious, and it is generally well ad- vanced when discovered. In its extreme severity it may involve the bones of both jaws, the eyelids, and ears ; but in its mildest form its results are limited to perforation of the cheek. The dead tissue comes away in dark, offensive shreds. The constitutional disturbance corresponds to the degree of local involvement, there being high fever, reaching often 104° F. (40° C), with frequent pulse and rapid exhaustion. The adjacent lymphatics are swollen. Inhalation-pneumonia of corresponding virulence often succeeds, while intense irritation of the stomach and bowels follows the swallowing of the ichorous discharge. Diagnosis.— Noma has rarely to be discriminated from anything else. Malignant pustule is less local in its invasion, furnishes the history of con- tagion, is even more severe in its constitutional effects, and exhibits the appropriate bacillus. Very bad cases of 11-lcerative stomatitis sometimes suggest cancrum oris, but the devastation is not so rapid, nor is there such a tendency to invasion of the external integument. Prognosis. — This is almost invariably fatal at the end of three or four days, only the promptest and most energetic treatment occasionally saving life. Treatment. — This consists in the prompt use of the glowing cautery, Paquelin's being sufficient. In its absence cauterization with strong nitric acid may be substituted. Local antiseptic treatment should be carried out in the most thorough manner, syringing with antiseptics being most efficient, while stimulating and nourishing food should be administered. Glossitis. Parenchymatous glossitis, or inflammation of the substance of the tongue, is a rare disease, but occurs as the result of violent injury to the organ, as by accidental biting or poisonous stings. Apparently idiopathic inflammations are probably the result of concealed causes of the kind de- scribed. Symptoms. — The tongue is enormously szvollen and painful, and some- times extruded from the mouth. There is great difficulty in speech, masti- 312 DISEASES OE THE DIGESTIVE SYSTEM. cation, and deglutition, and in extreme degrees these are scarcely possible. The discomfort is almost indescribable, and there may even be obstruction to breathing. If exposed, the tongue becomes dry and fissured. There may be suppuration. There is fcz'cr corresponding to the amount of local dis- turbance. Treatment. — This consists in the constant application of ice, of frequent antiseptic cleansing of the mouth, and sometimes of scarification. Evidence of the presence of pus must be followed by the prompt use of the lancet. Glossitis dcsiccans is a more chronic affection of the tongue, character- ized by deep fissures and indentations, giving it an uneven, ragged appear- ance. Associated therewith are excoriations and occasionally superficial ulcers. Severe pain is caused by contact of acids and even the usual food. Its etiology is not known, but it is sometimes associated with gastro-intes- tinal derangements. Treatment. — This should be directed to the cause, if it can be dis- covered. Washes of chlorate of potash should be employed, and if there are ulcers, they should be touched with solid silver nitrate. Eczema of* the Tongue. Synonym. — Geographical Tongue. Definition and Symptoms. — A localized superficial hyperplasia and desquamation of the epithelium of the tongue, sometimes associated with similar spots in the cheeks and lips. The central parts tend to heal, while the periphery spreads, producing circinate patches. The patches fuse and extensive areas are formed, bounded with sinuous outlines. The appear- ance has been compared to that of a map — lingua geographica. The con- dition is chronic, sometimes lasts years, but does not usually cause incon- venience save by the itching and burning it occasions and the apprehension of more serious disease. It is occasionally mistaken for syphilitic disease. It is best treated by solutions of nitrate of silver, which relieves the itching. Weak solutions of iodin may be useful, applied with a brush. Leukoplakia Buccalis. Synonyms. — Ichthyosis Ungnalis; Buccal Psoriasis; Keratosis mucosa; oris; Smoker's Tongue. Definition and Symptoms. — A condition in which there are intense white spots on the mucous membrane of the mouth and tongue, consisting, in thickened epidermis. They are also sometimes mistaken for syphilitic plaques. The spots on the sides of the tongue are often notched, giving them a scar-like appearance. Those on the inner surface of the cheek are simply flat, tabular swellings. They disappear, to be replaced by others ; they rarely give rise to inconvenience. Sometimes those on the sides of the tongue become ulcerated, when they are painful if brought into contact with irritants. They have been ascribed to smoking, and, though acknowledged to be of non-syphilitic nature, it is said they occur in those who have had syphilis. They occur in adults of both sexes. They sometimes become papil- lomatous, and are said to have been the starting-point of true epithelioma,, as often as once in every three cases. FUNCTIONAL DERANGEMENTS. 313 Treatment. — They are harmless and require no treatment unless ulcerated, when the usual stimulating measures for healing ulcers may be applied. Hot and irritating substances should be kept from the mouth, and smoking interdicted. Should the spots develop into papillomatous or epitheliomatous structures, they should be operated on by the surgeon. Mucous Patches. The true mucous patches or flat condylomata are opaque, white, flat, tabular swellings on the lips, tonsils, tongue, and arches of the palate, and especially at the border-line between skin and mucous membrane. They consist of an irregular imbricated thickening of the superficial layers of the skin ; the cells are swollen and papillae of the mucous corium hypertro- phied. Treatment. — The treatment of the mucous patches of syphilis is that of syphilis constitutionally, and locally by applications of nitrate of silver. DISEASES OF THE SALIVARY GLANDS. FUNCTIONAL DERANGEMENTS. Ptyalism, or excessive secretion of saliva, is a symptom of mercurial poisoning, also of poisoning by gold, copper, and iodin. Some persons are very susceptible to iodin, so that a few grains of iodid of potassium will cause intense salivation, with pain in the saJivary glands. Vegetable substances producing the same effect are jaborandi, muscarin, tobacco. Indeed, almost anything which admits of constant chewing without solution or destruction produces salivation. This is the mechanism of the various agents used in the disgusting practice of chewing gum. Xerostomia, or dry mouth, is the opposite condition of arrest of sali- vary and buccal secretion, not due to fever, — a rare condition, first described by Jonathan Hutchison. As a consequence the tongue and mucous mem- brane are red, dry, and shining. It is more common in women, in whom it follows intense emotion, such as fright, or is associated with hysteria and hypochondriasis. It is probably a neurosis, the result of some cause oper- ating on the center which controls the secretion of saliva and other buccal glands. Treatment. — The treatment of ptyalism and xerostomia is that of the conditions producing them. INFLAMMATION OF THE SALIVARY GLANDS. Acute Parotitis, or Parotid Bubo. — Apart from mumps, or specific parotitis, considered under infectious; diseases, in which any or all of the salivary glands may be involved, the parotid is subject to inflammation from the following causes : I. In the course of infectious diseases, especially typhoid fever, but also scarlet fever, typhus fever, pneumonia, pyemia, and secondary S3-philis. 314 DISEASES OF THE DIGESTIVE SYSTEM. 2. In connection with diseases or injury of organs in the abdomen or pelvis, including the alimentary canal, urinary tract, abdominal wall, perito- neum, pelvic cellular tissue, or genital organs — a very interesting group of cases, which have been especially studied by Stephen Paget. Sometimes simple transient irritation, such as a blow on the testis or the introduction of a pessary, may produce it. 3. In association with facial neuritis. A fatal case, apparently of such origin, has been reported by Gowers. In (i) and (2) septic infection is doubtless the cause of the inflam- mation, which is often intense, going on to suppuration in more than one- half of the cases. Its possible origin through the duct of Steno was con- sidered in treating typhoid fever. In (3) there is probably some vasomotor disturbance which is responsible. Treatment. — This should consist, at first, in attempts to allay the inflammation by leeches and the application of cold, especially ice. Fail- ing in this, fomentations should be applied, while the lancet should be used at the first indication of suppuration. Chronic Parotitis sometimes succeeds on acute inflammation, as that of mumps ; also on mercurialization or lead poisoning, syphilis, and Bright's disease. Sometimes no cause is discoverable. It may be painful or tender or painless. It may be treated by ointments reputed to promote absorption — ointments of iodin and mercury. ANGINA LUDOVICI. Synonyms. — Ludwig's Angina; Cellulitis of the Neck; Cynanche Gangrcenosa. Definition and Symptoms. — An inflammation of the floor of the mouth, beginning in the submaxillary gland ; it occurs first on one side as a secondary inflammation in the specific fevers, including, especially, typhoid, diphtheria, and scarlet fever, but it may also be primary. It is probably a streptococcus infection. It spreads rapidly over the floor of the mouth and the anterior surface of the throat, sometimes invading the glottis by edema, and sometimes terminating in sloughing of the soft parts — cynanche gan- grccnosa. Or it may go on to abscess pointing externally or internally. More rarely, resolution takes place. Further symptoms are sivelling and extreme pain, first in the neighbor- hood of the submaxillary gland, increased by chewing, swallowing, and talk- ing. The swelling may produce compression of the larynx, with resulting dyspnea, which is suffocative if the glottis becomes involved. Constitutional infection may take place, with its grave array of symptoms and fatal termi- nation. There may be remissions and exacerbations. Treatment. — This should consist in energetic measures calculated to combat the inflammation, such as the use of ice and leeching, but very early surgical interference is likely to be called for. QUINSY. 315 DISEASES OF THE TONSILS AND PHARYNX. OUIXSY. Synonyms. — Acute ParencJiyniatons Tonsillitis; Phlegmonous Tonsillitis; Tonsillar Abscess; Cynanche tonsillaris. Definition. — An acute inflammation of the substance of the tonsil. Etiology. — Quinsy is a disease of later youth and adults, being rarelv found in children under ten years of age, and not often in adults over fortv. Some persons are much disposed to tonsillitis, scarcely a season passing for them without an attack, and sometimes more than one attack. In such, almost every cold terminates in acute tonsillitis. Others, after a single attack, never have another, and others still are entirely exempt. Tonsillitis is probably always the result of infection. Exposure to wet and cold cer- tainly often precedes it. Persons predisposed to tonsillitis are often the sub- ject of chronically enlarged tonsils. Overdistention of the follicles with inspissated secretion may also be a cause of inflammation and suppuration. Morbid Anatomy. — The tonsil, more frequently on one side, some- times on both, or on two sides in succession, becomes rapidly enlarged, red, and painful. It is at first hard and resistant and very tender to the touch, but, if suppuration takes place, it gradually softens until rupture happens or the abscess is opened with the knife. The lymphoid parenchyma of the gland becomes more and more distended with leukocytes until the entire gland, or a large part of it, is converted into a pus sac. When both tonsils are involved, the throat is often almost closed by the swelling. Symptoms. — The superadded symptoms are pain and difficultx of deglutition, attended by increased pain, which is often agonizing. The jaws are stiff and the mouth cannot be opened above half an inch without extreme suffering. The difficulty in opening the mouth is increased by the swell- ing of the external glands of the neck. The pain is not confined to the interior, but extends to the neighborhood of the angle of the jaw, the front of the ear, and the floor of the mouth. The voice is greatly altered, having the characteristic nasal draAvl, and the diagnosis can sometimes be made from the altered speech alone. There is increased salivation, and the saliva dribbles from the mouth because of the pain in swallowing it, while it also often becomes fetid. Respiration may be seriously interfered with. There is high fever, the temperature reaching 104° and 105^ F. (40^ to 40.5° C), while the pulse is full, bounding, and frequent, no to 130 a minute. The face is anxious and tells the tale of suffering. From two to six days are occupied in the completion of the process, at the end of which time the abscess begins to point, usually toward the interior of the mouth, when relief is obtained by spontaneous rupture. But more fortunate is the patient who is relieved early by the lancet. Sometimes the abscess points toward the pharynx. The importance of relief at the earliest possible date is emphasized by the fact that death by suffocation has resulted from the discharge of a quinsy passing into the larynx. Prognosis. — Apart from the rare accident just referred to, the prog- nosis is favorable, though it must be mentioned also that death from suffo- 3i6 DISEASES OF THE DIGESTIVE SYSTEM. cation has occurred where the obstruction by double-sided quinsy was so great as to prevent respiration. Treatment. — The physician who suggests a successful plan for " backing " of a quinsy will well deserve the thanks of untold sufferers. As yet such measure remains hidden. Free scarification is sometimes use- ful in shortening an attack, but it is painful, unreliable, and sometimes diffi- cult to do thoroughly. If deferred until about the third day, it will often co-operate with the advancing suppuration and favor an early rupture. Other applications to the tonsils are of doubtful efficacy, though some relief from pain may be secured by painting the surface with a lo per cent, solution of cocain. Painting with a 40-grain (2.6 gm.) solution of nitrate of silver, after thorough cleansing with a cotton swab, is recommended. Parenchymatous injections of carbolic acid are also advised by Kramer,* wath a view to prevent abscess formation. The part is made completely anesthetic by cocain, a sterilized needle attached to a hypodermic syringe gently introduced into the gland, and through this are injected from 7 to 15 minims (0.5 to i c. c.) of a two- to three-per cent, solution of carbolic acid. This may be repeated once or twice a day. Cold, so soothing in other forms of sore throat, often occasions more discomfort than relief. Then poultices and fomentations to the exterior of the throat are apt to be more soothing. And since little can be done to prevent suppuration, these measures are indicated to hasten it. The tonsil should be frequently felt with the finger, and as soon as there is evidence of suppuration, the lancet should be used. A curved bistoury, guarded with adhesive plaster almost to the end, is best. The incision should be made from above downward, parallel to the anterior half-arch. If danger of suffocation is imminent, the tonsil must be shaved off, while extreme cases may even demand tracheotomy. FOLLICULAR TONSILLITIS. Synonyms. — Angina foUicularis; Lacunar Tonsillitis. Definition and Symptoms. — A form of catarrhal inflammation of one or both tonsils, associated with whitish-yellow^ spots corresponding in situation with the lacunae or follicles of the gland. The inflammation may rarely extend to the soft palate^ but the white or yellow spots are the most conspicuous feature. In a day or two they drop out or may be pressed out, when they are found composed of epithelial cells, pus-corpuscles, bac- teria, and debris, to which are sometimes added cholesterin plates and fat- crystals. If let alone, they may disappear rather suddenh% so that if seen one day they may be gone the next, having evidently disintegrated and dropped out spontaneously. IMore rarely the little follicle is converted into a small abscess. The disease occurs in children and young adults, and is one of the affections sometimes mistaken for diphtheria, and is also called diphtheritic sore throat. It is, however, something very different. It is a much less serious disease, of shorter duration, and patients never die of it. It is, how- ever, probably infectious in origin, caused by a germ other than the diph- *'' Anales del Circulo Medico Argentino," October 15, 1897. CHRONIC TONSILLITIS. 317 theritic, perhaps the streptococcus or staphylococcus. There is often very decided fever. Treatment. — The treatment of this form of tonsilhtis is definite and easily carried out. In the first place, cold should be applied to the neck by cloths wrung out in cold water or by ice, which is conveniently applied in little muslin bags made to fit under the angle of the jaw and held in place by a bandage. Then iron and chlorate of potassium are, without doubt, the remedies par excellence, and to these may be added the bichlorid of mercury, if diphtheria is not certainly eliminated from the diagnosis. The antiseptic measures recommended for the throat in diphtheria are not necessary. The disease is an acute one and subsides rapidly without any of these applica- tions. There is, however, a very decided drain on the strength of the pa- tients thus affected, however short the duration of the illness. Hence, qui- nin and iron should be given and continued during convalescence. CHRONIC TONSILLITIS AND HYPERTROPHY OF THE ADE- NOID TISSUE OF THE PHARYNX. Synonyms. — Chronic Enlargement of the Tonsils; Chronic Naso- pharyn- geal Obstni'Ction; Mouth Breathing; Aprosexia. Definition. — A chronic inflammatory enlargement of the tonsils or of the adenoid tissue of the pharynx, of the lingual tonsil, or of two or more of these structures. Etiology, — The most frequent cause is repeated attacks of acute ton- sillitis and of inflammatory processes associated with hyperemia of the ton- sils and vicinity, including scarlet fever and diphtheria, while chronic illness, especially skin affections, bad hygienic surroundings, and insufficient and unsuitable food favor it. It is, therefore, naturally more common in chil- dren, in whom it is also sometimes congenital, but it is found usually at the ages of five to fifteen years, and rather more frequently in boys. Adenoid overgrowths of the pharynx and lingual tonsil are due to the same causes. Morbid Anatomy. — The enlargement of the tonsils is a true lymphoid overgrowth, usually symmetrical. The occasional presence of fibrous stroma produces a harder and smoother tissue. The lumen of the throat is vari- ously encroached upon, sometimes almost closed. The pharyngeal adenoid overgrowths vary in extent from a slight increase in natural unevenness to the formation of actual sessile and pedunculated tumors. The same is true of the tonsillar structures at the base of the tongue, which may encroach upon the glottis. Symptoms. — Simple chronic enlargement of the tonsils may give rise to no symptoms except when the seat of further enlargement due to acute inflammation. Then obstructed breathing is immediate, while it is also a permanent symptom in the more advanced forms. It is proportionally con- tributed to by overgrowth in any of the situations named. The result is month breathing, which is, perhaps, earlier necessitated by pharyngeal than tonsillar overgrowth, while it may be due altogether to the former, the latter being entirely absent. Tonsillar obstruction is, however, more frequent. The effects are usually first apparent at night, when the child is found to be 3i8 DISEASES OF THE DIGESTIVE SYSTEM. breathing, more or less noisily, with its mouth open and head thrown back. Disturbed rest is an inevitable consequence, the patient often waking up with a start, again relapsing into sleep, or continuing permanently aroused because of the dyspnea, which often only gradually passes away. As the conditions persist a changed expression of countenance is gradu- ally acquired. The face becomes apathetic, staring, and vacant, an appear- ance chiefly produced by the constantly open mouth. To this may succeed actual mental failure and even stupidity, with sullenness and general bad temper. Further changes in expression are occasioned by contraction of the nostrils and projection of the upper jaw and lip. If the condition is still unrelieved, deformities of the chest make their appearance, of which the most conspicuous is the well-known chicken breast. In it the upper sternum projects, the manubrio-gladiolar articulation being most prominent, while the lower part is depressed, causing a groove at the gladiolo-xiphoid articu- lation. There is a cup-like depression of the lower costal cartilages and a horizontal circular depression (Harrison's groove) in the thorax correspond- ing to the attachment of the diaphragm. The ribs are separated from each other anteriorly and closely approximate posteriorly, especially in the lower thorax. Posteriorly the lower angle of the scapula projects. This is the result of the act of breathing, a study of which during sleep will recognize the retraction of the lower part of the thorax during inspiration, caused by the action of the diaphragm. Another form of chest is the round or barrel chest, such as is commonly associated with chronic asthma, due to the same cause. Still another said to be caused by mouth breathing is the funnel breast, or Trichterbrust of the Germans, in which there is a deep central depression at the epigastrium. Other symptoms are an altered nasal voice in which the letters m and n are especially badly articulated, the special senses of smell, taste, and hear- ing are deranged, the breath is fetid from decaying secretion, the appetite is impaired, and with it the nutrition of the body. A gradual mental as well as physical deterioration takes place. Among the symptoms ascribed to this condition are habit chorea and stuttering. The former will be considered in a later section. There is an almost constant cough, which is well termed " throat cough," since it is due to irritation of the respiratory passages by the throat outgrowths and the secretion caused by them. This secretion is generally swallowed by chil- dren, but is in part expectorated by adults by the aid of troublesome hawk- ing and coughing, which is stimulated by a sensation as of " something in the throat " or larynx which demands clearing. The absence of discharge from the nose in both children and adults is surprisingly frequent, sometimes misleading the physician as to the trvie cause. Defective hearing is another symptom due to obstruction of the Eusta- chian tube by encroachment of the adenoid growths, or by inflammations, or to retraiction of the drum. Impaired taste and smell are due to involve- ment of the gustatory papillse and the terminal distribution of the olfactor}^ nerve. Extreme fetor of the breath is sometimes present, due to retention of cheesy masses in the crypts of the tonsils. These are often easily visible, are sometimes expectorated, and can usually be expressed. The odor of these masses when compressed between the fingers is indescribably disagree- able. Sometimes they are found in the tonsils of persons not otherwise affected. The very great susceptibility of the subjects of this disease to " cold " is constantly adding aggravation to the symptoms described. CHRONIC TONSILLITIS. 319 Diagnosis. — This is not usually delayed at the present day, siujce the more thorough examination of the throat and nose has become common — thanks to the throat and nose specialists. Most important is it to remember that there may be no tonsillar disease, and all the symptoms may be due to advanced adenoid growths of the pharynx. Digital examination by the finger affords the most ready and accurate means of diagnosis. Especially thorough must be the examination behind the pillars of the fauces. In chil- dren this can only be done with the finger, but in adults the half-arches may be drawn forward, while the laryngeal mirror is availed of. The " chicken breast " of mouth breathing in childhood is different from the " violin " shaped chest of the rickety child. In the latter there are a prominence of the zvhole sternum and a vertical flattening of the sides of the thorax, leaving a large curve behind the costo-chondral articulation and a similar one in front, in addition to the horizontal depression of the lower thorax which is common to both kinds of deformity. Prognosis. — This depends upon the early discovery of the condition, before the secondary effects have established themselves. If the trouble is purely a tonsillar one, it is comparatively easily removed by shaving off the organ. If the overgrowth is pharyngeal, little can be done until children are old enough to submit to the proper treatment. This miay be done by the aid of ether as early as the second year. Hypertrophied tonsils begin to atrophy of themselves after puberty, and they have generally disappeared by thirty. The face and chest deformity may be outgrown if the cause be removed. Treatment. — Most important are local measures to reduce the size of the overgrowth or to remove it and to prevent recurrence of acute attacks. The patient should be discouraged from hawking and clearing his throat. If the tonsils manifestly encroach on the faucial lumen, they should be shaved off by the guillotine or a bistoury or galvano-cautery loop. The same treatment is demanded by the pharyngeal adenoid growths. They may be curetted and sometimes scraped off by the finger-nail. There is sometimes copious hemorrhage, but it is usually easily controlled. If not requiring this, they should receive on alternate days or every third day applications of powdered alum ; solution of iodin of the strength of iodin 8 grains (0.5 gm.) ; iodid of potassium 24 grains (1.5 gm.), glycerin half ounce (30 c. c.) ; of tincture of the chlorid of iron and glycerin equal parts ; glycerole of tannin ; or silver nitrate i to 20. The solid stick of the latter may be used if there be evident lacunar disease, but far better is electrolysis, by which the crypt is obliterated and the gland may be gradually destroyed. Spraying the nose with anti- septic solutions twice daily is helpful in maintaining cleanliness and purity of breath. Dobell's solution may be thus used; also dilute listerin or the spiritus thymol comp. given on page 310. Tablets containing various pro- portions of the ingredients therein named are made for solution in the little cup of the spraying apparatus. Great patience and perseverance are required, for the result is but slowly attained. The general health of the patient should be carefully looked after. Suitable woolen underclothing should be worn, and it should be graduated to temperature and exposure. Cod-l^ver oil, iron, quinin, and strychnin are the best roborants. It is most important that every effort should be made in the direction of so hardening the patient that he may be able to resist the effects of exposure, a task not easy to accomplish. Cold bathing of the neck and throat, indeed, of the whole body is useful, while nourishing food, physi- 320 DISEASES OF THE DIGESTIVE SYSTEM. cal exercise, and outdoor life, with suitable clothing, are means to this end. SIMPLE CIRCULATORY DERANGEMENTS OF THE PHARYNX. Hyperemia of the pharynx is a very common condition in smokers. It is also almost always present when there is chronic nasal catarrh. Under these circumstances the mucous membrane is constantly red, angry looking, often streaked with mucus, and is very easily thrown into a state of active inflammation. In such obstructions to the circulation as are caused by mitral valvular disease, cirrhosis of the liver, or pressure upon the ascending vena cava by aneurysm or tumor, there is venous stasis and the venules may often be seen distended. Occasionally they burst, producing small hemorrhages which stain the mucous secretion. The same causes may produce edema of the mucous membrane of the pharynx, and especially does this occur in Bright's disease. The edema may extend thence to the uvula, which becomes greatly swollen. In aortic regurgitation the capillary pulse may be seen in the pharynx, and the internal carotid also seen to throb strongly. ACUTE CATARRHAL PHARYNGITIS. Synonyms. — Sore Throat ; Simple Angina. Definition.— An acute inflammation of the mucous membrane cover- ing the pharynx and tonsils, sometimes extending upon the palate. Etiology. — Acute pharyngitis occurs at all ages, but is more frequent in children. Exposure to cold and wet is its most frequent exciting cause. The delicate are more predisposed than the robust, and where there is the hyperemia above referred to, a trifling cause lights up an inflammation. Rheumatism and gout are also frequent causes. Pharyngitis and tonsillitis are often associated. Symptoms. — The first symptom is usually pain on swallowing, which is associated at first with a dryness and soreness, producing a desire to " clear the throat." To this is soon added a full feeling, and then pain independent of swallowing. The inflammation may extend into the Eustachian tube, producing partial deafness, or into the larynx, producing hoarseness. There is a varying degree of constitutional disturbance, and sometimes the fever is quite high. On examining the throat it will be found red and congested, sometimes plainly swollen, especially over the tonsils. There is often considerable mucous secretion. The various forms of ulcer of the tonsils described under tonsillitis may be associated with the pharyngitis. Increasing the constitu- tional disturbance and local discomfort. Treatment. — Many simple sore throats pass away without treatment. Astringent washes and gargles are indicated, but the patient should be warmly housed and even in mild cases had better go to bed. Twenty-four hours in bed is by far the best medicine for an ordinary cold. A gargle of alum or tincture of the chlorid of iron in the proportion of a teaspoonful of either to a full tumbler of water may be used, while applications of a mixture CHROXIC CATARRHAL PHARYXGITIS. 321 of equal parts of the iron tincture and glycerin may be applied to the throat two or three times a day. Solution of nitrate of silver, 20 grains (1.3 gm.) to the ounce (30 c. c.j, may be similarly applied, also the glycerole of tannin. In severe cases cold cloths wrung out in ice water and applied to the outside of the throat, the clothing being protected by the interposition of a dry towel, make an excellent measure ; or the little ice bags referred to in the treatment of acute tonsillitis may be applied to the throat, with a dry towel outside of them. Occasionally counterirritation by mustard is more efficient, as every throat does not bear cold equally well. The fever should be met in the usual way by aconite, sweet spirit of niter, and citrate of potash, while chlorate of potash and chlorid of iron should also be administered internally. The bichlorid of mercury may be added under the same circumstances as in diphtheroid tonsillitis. There is no advantage in giving large doses of iron. They are not absorbed and the excess remaining in the alimentary canal locks up the secretions and causes irritation. From two to ten minims (0.12 to 0.6 gm.) every two hours are quite sufficient. The bowels should be kept open, and the treatment may be advantageously commenced with a saline aperient, such as calcined mag- nesia, the solution of the citrate of magnesium, or Hunyadi water. \A'here the disease is traceable to rheumatism or gout, suitable treatment for these diseases should be instituted. The salicylates are the best remedies for both, but guaiacum has some reputation, the tincture or ammoniated tincture being the best preparation, given in doses of 5 to 60 drops (0.35 to 4gm.). CHROXIC CATARRHAL PHARYXGITIS. Synonyms. — Clergyman's Sore Throat; Granular Pharyngitis; Chronic Angina; Chronic FoVicular Pharyngitis. Definition. — Chronic pharyngitis, when not associated with ulceration, presents much the same appearance as chronic hyperemia, plus the addition of a granular appearance due to enlargement of lymphatic glandules, with which the pharynx is studded. Etiology. — The disease is rather one of adults than children. Its causes are repeated attacks of acute pharyngitis and excessive smoking and alcohol drinking. Chronic nasal catarrh with its irritating discharges trickling down the fauces is a frequent cause, as is also nasal obstruction and disease of the third or Luschka's tonsil. It also occurs in those who use their voices largely, as hucksters, public speakers, and singers, while the inhalation of dust and irritating gases is also held responsible. Treatment. — This is very much more unsatisfactory than in the acute type. It is most important to treat the causes or remove them. Post- nasal catarrh is responsible for so many cases that the post-nasal region should at once be investigated and its diseases treated. Smoking and the use of alcohol, if responsible, should 'at once be discontinued. The same local measures useful in the acute disease mav be employed in the chronic, but they are less promising as to results. The little granules, which are apparently a source of irritation as well as a result, can be removed only by the galvano-cauterv needle. Other measures to this end are unsatisfactory 322 DISEASES OF THE DIGESTIVE SYSTEM. and insufficient. The general health of the patient should be carefully looked after, and occupations tending to keep up the irritation should be discontinued. Ulceration of the Pharynx. The ordinary form of chronic pharyngitis rarely produces ulceration. Syphilis, tuberculosis, diphtheria, inflammation, and lowered nutrition, such as is found after the infectious diseases, like typhoid fever and scarlet fever, are frequent causes of sluggish ulcers indisposed to heal. The chief symp- tom of these various varieties of ulceration is pain, increased during deglu- tition, with more or less copious mucous secretion, which often adheres firmly to the pharynx. Diagnosis. — It is not always easy to distinguish the different forms of ulceration. The syphilitic nicer is least painful, in fact often painless, and is commonly situated in the posterior wall of the pharynx. It occurs both as a secondary and tertiary symptom. As a secondary symptom it is super- ficial and associated with mucous patches, while as a tertiary it forms the cavity left by a softened, gummy tumor, and is correspondingly deep. It is associated with the history of syphilis. The tubercular ulcer is more painful — indeed, the most painful of all. It is irregular, not very deep, has a grayish base, and is also seated in the posterior wall of the pharynx, considerable areas of which may be involved, producing an uneven, worm-eaten appearance. It is associated with tuber- culosis elsewhere. The indolent ulcers of lowered nutrition are also often insidious and occasion few active symptoms. After the separation of the membrane in diphtheritic pharyngitis there are sometimes left ulcers more or less extensive, which are slow to heal. Treatment. — This consists locally in the application of stimuli and anti- septics, the former represented by nitrate of silver and the latter by thymol and its class, together with general treatment appropriate to the condition, such as tonics of which iron and quinin are the types. Phlegmonous Pharyngitis. Definition. — This term is applied to any suppurating inflammation involving the pharynx, however induced, except post-pharyngeal abscess, which is a separate condition. It may be a part of the process which con- stitutes suppurating tonsillitis or quinsy, extending to the adjacent pharyn- geal structures. It may include the acute infectious phlegmon of the pharynx described by Senator, in which, along with swelling of the external neck, the pharyngeal mucous membrane is swollen and injected, and becomes rapidly the seat of suppuration. It may include similar conditions induced by injury, the inhalation of scalding liquids, or the swallowing of corrosive poisons. Or it may be the result of pharyngeal erysipelas or of the lodg- ment of foreign bodies. Symptoms. — These are correspondingly intense. There is painful STvelling, interfering not only with deglutition, but also with respiration. There is high fever and rapid exhaustion-. It may terminate in gangrene of the part or gangrenous pharyngitis. EXPLORATION OF THE ESOPHAGUS. 323 Treatment. — The treatment is locally antiphlogistic, including cold by ice or otherwise, scarification and liberation of pus at the earliest possible moment, together with restorative and stimulating internal measures. If gangrene results, cauterization and antiseptic applications must be added. The aid of the surgeon should be early sought. Post-Pharyngeal Abscess. Definition. — A phlegmonous inflammation behind the proper pharyn- geal tissue, subperiosteal in some instances, arising in suppurative inflam- mation of the post-pharyngeal lymphatic glands or caries of the cervical vertebrae. It is a disease of children and adults, more frequently of the for- mer, often a sequel of one of the pharyngeal conditions already considered, favored by bad hygiene and depraved constitutional states, hereditary or acquired. Symptoms. — Its symptoms are intense pain, stvelling, and interference with deglutition and respiration, with more or less early appearance of a tumor in the posterior wall of the pharynx, which can generally be recog- nized by the finger before it can be seen — a fact which emphasizes the impor- tance Oi frequent examination of the throat by the finger in diseases of these parts. There is also stiffness of the neck, sometimes nasal voice or even hoarseness, suggesting croup and edema of the glottis, but there is never absolute loss of the voice, as in the latter, while croup and edema are not associated with painful deglutition. Treatment. — This consists of incision of the abscess as soon as dis- covered. It should be made in the median line and the head should be brought forward to avoid the entrance of pus into the larynx. Anodynes are necessary to overcome the intense pain, but it is to be remembered that they may so mask the symptoms as to permit destructive inroads of the disease before it is discovered. DISEASES OF THE ESOPHAGUS. EXPLORATION OF THE ESOPHAGUS. This is a manipulation so frequently necessary that its description is demanded at the outset. The esophageal bougie is made of flexible whalebone, on the end of which is firmly fixed an olive-shaped piece of ivory. The ivory ends are made of different sizes. The ordinary stomach tube may also be used for the same purpose, and is the safest instrument to use in earlier explo- ration. In introducing the bougie, or tube, the patient should sit on a low chair with his head thrown back. The index-finger of the left hand is then introduced well back into the pharynx, along the median line. The bougie, or tube, is then passed along the side of the finger to the posterior wall of the pharynx and then down into the gullet. Usually a slight resistance is encountered at the level of the cricoid cartilage, but it is easily overcome, 324 DISEASES OF THE DIGESTIVE SYSTEM. and after this the descent is easy. Caution should, however, always be exercised, as the bougie has a few times been pushed through an ulcer of the esophagus into the pleural cavity or lung, while I have also known ulceration to be produced by its repeated use in simple nervous spasmodic obstruction. ESOPHAGITIS. Acute Esophagitis. — An acute inflammation of the esophagus is prac- tically limited to inflammation induced by the swallowing of very hot or corrosive liquids, such as strong acids and alkalies, or by the lodgment of foreign bodies. It is true, diphtheritic inflammation sometimes extends from the pharynx downv^'ard, while the esophagus has also been invaded by a vesicle of smallpox, but these conditions are not likely to be differen- tiated from the primary disease. Mycotic esophagitis, producing stenosis of the esophagus in sucklings, has been alluded to as a possibility on page 308. Morbid Anatomy. — Appearances vary with the cause. In addition to the usual redness, sloughing and disintegration of tissue may result. Milder degrees of inflammation produce less conspicuous alteration. A granular appearance may succeed desquamation of the epithelium. Diph- theritic false membrane presents the same characters here as elsewhere. Symptoms. — These are chiefly pai)i beneath the sternum, increased by swallowing, which in extreme degrees of inflammation becomes agonizing and, indeed, renders swallowing impossible. Copious mucous secretion is sometimes present, which may be raised or regurgitated to the fauces and expectorated or passed into the stomach. Milder grades of inflammation are without symptoms, intermediate grades present corresponding symptoms. If healing results after destructive inflammation, the cicatricial tissue behaves as it does everywhere else, contracting and distorting the parts, oftentimes with resulting stenosis. Treatment. — Little can be done to aid heaUng. For the most part, therefore, it must be given over to nature. If deglutition is possible, demul- cents may be used, while the swallowing of pieces of ice sometimes gives comfort. When deglutition is impossible, the patient must be fed with nutri- tious enemas. The treatment of resulting stenosis is that of stricture of the esophagus, which see. Chronic Catarrhal Esophagitis. — This affection is sometimes fav- ored by valvular heart diseases, cirrhosis of the liver, or other cause of venous obstruction. The resulting affection is a catarrhal inflammation associated with mucus-secretion. A hemorrhoidal state of the veins may be thus caused, which may proceed to rupture, with fatal termination. SPASM OF THE ESOPHAGUS. Synonym. — Esophagismus. This is not an unusual aft'ection in hysterical women, and even in male hypochondriacs. These are generally past middle life. It also occurs in hydrophobia, chorea, and epilepsy. The spasm is commonly excited by an CANCER OF THE ESOPHAGUS. 325 effort to swallow solid food, and rarely even liquids act similarly. A pos- sible result of spasm is a dilatation, as shown in a case of my own, to be again referred to. Diagnosis. — The diagnosis is readily made by the bougie, which, though it may be stayed for a minute at the seat of spasm, ultimately passes it without the application of force. It is also associated with other symp- toms of hypochondriasis, while extreme pain, the gradual emaciation, weak- ness, and ultimate cachexia of cancer are absent. Errors of diagnosis have, however, been made, and death has even occurred when autopsy disclosed no lesion to explain it. Treatment. — This is that of the hypochondriacal state and the frequent use of the bougie, of which the moral effect is also good. One introduction has sometimes been sufficient. On the other hand, I have known the repeated passage of a bougie to have produced ulceration, whence the caution already enjoined in the use of the instrument. CAAXER OF THE ESOPHAGUS. This is usually a hard epithelial tumor, most frequent in the middle third of the esophagus, though it may involve the cardiac orifice of the stomach, and more rarely other portions. E. Rindfleish, especially, describes a softer and more superficial form, which invades larger areas in a diffuse way. It is rather more frequent in men, and appears first as zonular infil- tration of the mucous membrane, which ulcerates. The resulting ulcer may also extend around the tube, acquiring a width of two or three inches (5 to 6 cm.). The primary and usually permanent result, unless ulceration does away with it, is a stenosis of the esophagus, followed by dilatation of the tube, with hypertrophy of the walls above the stenosis. Symptoms. — Diificidt and painful deglutition is usually the first symp- tom of stenosis, though pain, independent of deglutition, may precede. Szvallowing becomes more and more difficult, and ultimately, even liquids may be regurgitated. Regurgitation of food may not be immediate, and the date of its appearance is usually dependent on the seat of the obstruction and extent of dilatation above it. A discharge of hlood and mucus may attend an effort to introduce the bougie. Death commonly takes place from exhaustion or actual starvation. But before this happens there may be a rupture into the larynx or a bronchus, producing death by suffocation, by gangrene, or by an inhalation pneumonia. There may be ulceration into the aorta or one of its large branches, causing fatal hemorrhage ; into the peri- cardium, producing fatal pericarditis. Ulceration into the mediastinum or erosion of the cervical vertebrae sometimes occurs, with more delayed fatal ending. Emphysema is a sign of rupture into the lung. The adjacent lymphatic glands of the neck are sometimes invaded. Rarely the disease is latent throughout its entire course. Diagnosis. — This may have to be delayed a short time, but is soon clear. The continued obstruction, the ^emaciation, and the weakness soon dis- tinguish the case from one of spasmodic stenosis. Compression by adjacent growths should be remembered as a source of obstruction, aneurysm being perhaps the most frequent cause of this kind; but aneurysm may generally be recognized by its other signs. 326 DISEASES OF THE DIGESTIVE SYSTEM. Prognosis. — This is always ultimately fatal. Treatment. — Treatment can only be made to prolong life. The bougie should not be used after the diagnosis of cancer is established, because of the danger of causing perforation. So long as liquid food can pass the obstruction it should be used ; after this, nutritious enemas in the manner recommended under cancer of the stomach. Esophagostomy or gastrostomy may be presented for the patient's consideration. The former promises nothing, but life may be prolonged by the latter. STRICTURE OF THE ESOPHAGUS OTHER THAN CANCEROUS. Etiology. — The most frequent cause after carcinoma is contraction of the scar tissue of a healed ulcer, caused, commonly, by some corrosive agent or syphilis. Next in frequency is pressure by external tumors, such as aneurysm, enlarged lymphatic glands, or mediastinal tumors. Next is con- genital narrowing, and, finally, polypoid tumors projecting from the mucous membrane. If the stenosis be cicatricial, the precise cause is to be determined by the history of the case, and its situation by the esophageal bougie. Symptoms. — These are those of obstruction, described under cancer and spasm, with or without the painful element; to which may be added those of dilatation of the esophagus, to be next considered. Treatment. — This is altogether by the careful use of the bougie. Dilatation of the cicatricial stenosis is often quite successful. The largest bougie should be first introduced very gently, without force, really as a sound, as far as the obstruction only. Then smaller sizes should be tried until one is found which will pass, and from this point, again, larger sizes should be successively employed. At each sitting the bougie originally passed with ease should be started with and followed more rapidly by the larger sizes, as the physician becomes familiar with his patient's case. In congenital cases less is to be expected, while obstruction by external growths, unless they be removable, is practically irremediable, and grows gradually worse. Even cicatricial stenosis may be such that the smallest bougie cannot pass, in which event nourishment by the rectum alone remains, unless gastrostomy be decided on. DILATATION OF THE ESOPHAGUS. Dilatation of the esophagus may involve the whole circumference of tube, when it is known as diffuse or total; or it may afifect only one spot, when it is circumscribed, or constitutes a diverticulum. Diffuse Dilatation. — In every case of stenosis of the esophagus, from whatever cause, there is sooner or later dilatation above it, delayed at first by hypertrophy of the muscular coat, which is thus enabled to force the food through the narrowing. Sooner or later this coat becomes paralyzed, the wall yields to the pressure of accumulated food, and dilatation follows. The resulting sac is usually spindle-shaped, but may be cylindrical, and is naturally larger the lower the seat of obstruction. Rarely dilatation occurs without previous organic stenosis. It would DILATATION OF THE ESOPHAGUS. 327 appear, however, that it must be preceded either by some traumatic cause which weakens the wall of the tube, or by repeated spasmodic stenoses. The fact remains that such dilatations occur. Diverticula.-— D'w eviiculd, or circumscribed pouches in the walls of the esophagus are of two varieties. They have been especially studied by Zenker, who has divided them into pressure diverticula and traction diver- ticula according to their mode of origin. Traction diverticula are the more frequent, yet clinically are of less interest because often not recognized until their subjects are on the necropsy table." They are small, scarcely ever exceeding a centimeter (0.4 in.) in diameter, and relatively frequent in children. They are ascribed to some traction effect exerted on the wall of the esophagus. This may be, as Rokitansky and Zenker suggested, due to the contraction of a tissue which has formed adhesions to the esophagus. Such a tissue is afforded by the bronchial glands, which become inflamed, caseate, and contract, and as they are situated at the bifurcation of the trachea, the more frequent occurrence of traction diverticula at this situation in the anterior wall of the gullet is thus explained. Such diverticula may be multiple. Pressure diverticula are much rarer. They occur almost always in men, rarely in children. They are found most frequently at the junction of the pharynx and esophagus, where the muscular wall, formed chiefly by the inferior constrictor of the pharynx, is weakest, and are caused by pressure from within. This may be exerted by the bolus of food itself, especially if it be habitually large, as in rapid eaters, while its operation may be further facilitated by some traumatic injury to this part of the throat, such as may be caused by the lodgment of a bone. The sac is found to be bounded by mucous membrane and thickened subrn.ucous coat, the muscular coat giving way to let the mucous coat pass through it, as in a hernia. It is found invariably in the posterior wall, and hangs in front of the spinal column. Symptoms. — In cases of diffuse dilatation originating in stenosis, apart from the inference that where there is stenosis there must ultimately be dilatation, the first symptom to attract attention is the feeling on the part of the patient that his food does not enter the stomach, but lodges higher up, though the quantity swallowed is evidently more than would be held by an esophagus of ordinary caliber ; usually, sooner or later, follow^s the regur- gitation, or gulping up of this accumulation. The same symptoms are said to attend dilatation without stenosis. The latter event can only be explained on the supposition that, in consequence of the paralyzed state of the muscular wall of the esophagus, there is no force to push the food down, while the gradual widening of the tube affords support for its lodgment, which is further favored if the enlargement takes the shape of sacculations or a pocket. Traction diverticulum rarely causes symptoms. Those arising from pressure diverticulum are first those of dysphagia, as the diverticulum grows larger, and the food lodges more and more ; regurgitation, though the sac is rarely thoroughly emptied, and the retained food sometimes undergoes decomposition, giving rise to fetid ,breath. The difficulties increase until after a while it is almost impossible to get food into the stomach, though extraordinary efforts are made by the patient to do so,' with greater or less success. Complete closure results when the diverticulum becomes so large as to flex upon the gullet and compress it. 328 DISEASES OF THE DIGESTIVE SYSTEM. The sound should be used in the study of all forms of the disease. By- its means the situation of the stenosis can be ascertained. Should it pass, readily into the stomach, there is no stenosis, but there may still be a divertic- ulum, for at one sitting the sound may pass the opening into the sac, while at another it may enter it and resist further attempts to complete the transit. Zenker and v. Leube have devised a diverticulum-sound bent at an angle, so as to facilitate its entrance into the diverticulum, advantage being taken of the fact that we know about where these diverticula are most frequently found — that is, opposite the cricoid cartilage. With the prolongation of the condition the proper nourishment of the patient becomes more and more difficult ; he emaciates, grows weaker, and ultimately perishes from exhaustion unless carried off by some other disease. The following case, recently under my care, illustrates the symptoms of the condition : C. G. was an actor, thirty-three years old when he came under observation. When only twelve years of age, while eating his supper, his food suddenly regurgitated and he had to leave the table. Returning, another effort was followed by the same result. The next morning his breakfast came up in the same manner. After a time he discovered that by rapidly drinking a large amount of liquid after each meal he could, by a great effort, cause most of the food to enter the stomach. This had to be done at every meal by some indescribable effort, which was painful and exhausting. Furthermore, it was rarely completely successful, some food being always regurgitated, commonly later in the day. Since twelve years of age this regurgitation has continued, and he loses, on the whole, about one-third of the food ingested, while at times his efforts to get it down are totally unsuccessful, in which event the full amount is regurgitated. Fur- ther, the difficulty of successfully getting food into the stomach is gradually increasing. In this case there would appear to be a certain degree of stenosis, for while a part of the food can be forced to enter the stomach, and small sounds can be passed into that organ, larger ones cannot be made to enter. Yet from the suddenness of its occurrence and the early age of the patient, the stenosis, if one is present, has not arisen from the usual causes. Can there be a diverticulum? If so, it is lower than pressure diverticula generally are, and larger than other traction diverticula. Treatment. — The treatment of diffuse dilatation and diverticula is essentially the same. It consists, first, in measures to maintai i the nutrition of the patient. Generally he is able to ingest a certain amount of food by his own eft'orts, of which thosfe detailed in the case of my own patient are an illustration. After this the stomach tube becomes the most ready way. This, too, he should be taught to use himself. Rectal alimentation may help somewhat, but is alone inadequate for any length of time, while the inconvenience of any and all of these procedures renders the patient anxious for more complete relief. This may be accomplished by operation, by which diverticula have been successfully removed. The difficulties in the way of operation are, however, great. The operative treatment of dilatations due to stenoses resolves itself into that of the stenoses themselves. In both forms gas- trostomy may be the ultimate measure that promises relief for a time. DIAGNOSTIC TECHNIQUE. 329 DISEASES OF THE STOMACH AND INTESTINES. DIAGNOSTIC TECHNIQUE. The very great value that modern medicine has discovered in a proper technique for the diagnosis of diseases of the stomach makes its prehminary consideration indispensable to their sufficient and exact study. It is con- veniently divided into the external and internal examinations. External Examination. This embraces inspection, palpation, percussion, and succussion or splashing. Because of the difficulty of separating the external examination of the stomach from that of the intestines they are usually considered jointly. The most important point to be remembered in the medical anatomy of the stomach is that a very small part of it Hes to the right of the median line, not more than one-fourth, the remainder occupying the upper left quarter of the abdominal cavity. The cardiac orifice is fixed behind the sternal attachment of the sixth or seventh cartilage on the left side, while the pylorus, more movable, lies on the right side, between the tip of the sternum and the conjoined seventh and eighth cartilages, and under the left lobe of the liver. The seats of both orifices — the cardiac and pyloric — and the outline of the stomach vary somewhat with the degree of distention, but when the stomach is moderately distended the highest part of the fundus is in the fifth interspace, at the mammillary line, and the lowest part of the organ in the median line, three to five cm. (i to 2 inches) above the umbilicus in men and four to seyen cm. (1.5 to 3 inches) in women. The information given by inspection may be of no value whatever, or may possess considerable import. Commonly, the stomach and bowels are the seat of a moderate distention with gas — just enough to make precise information by this method unattainable. This is especially the case in little children and in men past fifty. In very thin subjects the stomach may be recognized in outline, and exaggerated contractions may even be seen in it and in the intestines. Such contraction does not, however, imply of necessity an effort to overcome obstruction at the pylorus or in the bowel below. It may be purely nervous. Morbid growths in the stomach may sometimes be recognized by inspection. So may many uneven growths of the liver in thin persons, while the end of a distended gall-bladder may, in rare instances, project at the edge of the thorax, near the end of the cartilage of the tenth rib on the right side. Epigastric pulsation is sometimes strik- ingly conspicuous. Enlargement of the superficial epigastric and abdominal veins is always to be looked for. More frequently there is a circumscribed distention recognized in the region of the stomach, or the entire abdomen may be distended, a symptom which may be due to atony, or, among others, points to some obstruction in the lower part of the bowels. In other instances the opposite state of undue flaccidity is observed — the belly flattening out laterally as the patient lies on his back, or falling forward when he stands up. The latter condition occurs especially in persons who have been corpulent and have grown thin, and in women who have borne many chil- dren. The patient may also be examined in the knee-elbow position, which OJ^ DISEASES OF THE DIGESTIVE SYSTEM. will permit movable tumors to fall forward and facilitate their recognition by inspection as well as by palpation. Palpation furnishes at times more definite information than inspection. It should be practiced by laying the hand flat upon the abdomen and depress- ing the ends of the fingers as the hand is moved about, rather than by " poking " with the fingers of the extended hand obliquely placed. The abdominal walls, too, should be relaxed by semi-flexing the thighs on the abdomen and the legs upon the thighs. Thus we learn of the consistency and situation of various organs and abnormal growths, whether they are smooth or uneven, whether there is tenderness or tenseness, softness or hard- ness. In so doing, the degree of pressure must vary. Some pains are relieved by pressure, others aggravated. The former are more apt to be due to neuralgia or colic, the latter to be inflammator\-. Our knowledge of the precise situations of morbid growths is often aided by changing the position of the patient. A tumor of the pyloric orifice of the stomach, which is more apt to be felt toward the median line, above the umbilicus, is also characterized by its greater mobility, as well as change of location with varying degrees of distention of the stomach. Such a tumor may be subject to a peculiar rotary motion. Percussion of the gastro-intestinal region is practiced with the patient on his back in a relaxed position, like that described for palpation. A pleximeter is here conveniently used, and auscultatory percussion may be practiced with advantage. The phonendoscope may also be used to determine the outlines of these organs during scraping or rubbing. The stomach and intestines approach the surface in health in such a way as to make their limitation quite possible by percussion. They require, also, delicacy in discriminating shades of sound, more particularly as to pitch. The quality met with in percussing these organs is, for the most part, tympanitic, and it is chiefly variations in the pitch which are to be discrimi- nated. The same organ may exhibit diflferent degrees of pitch under different conditions. Thus, the stomach, when moderately distended with gas, gives a low-pitched tympanitic sound when percussed ; when more fully distended, it gives a higher pitch ; when distended to a maximum, it may give a dull sound, because all vibration is stopped. Given the stomach and intestine in an equal degree of tension, the stomach will respond to percussion with a lower-pitched tympany than the intestine because it is a larger cavity. This is sometimes spoken of as less tvmpanitic. Sometimes the stomach percussion note is ringing, amphoric, echoing. By means of these differ- ences, when present, we may distinguish one hollow organ from another. Again, the presence of liquids or solids in the stomach influences the per- cussion note. The hollow viscera en masse can be mapped out by determining the boundaries of the solid viscera around them. But we want to do more than this : Ave want to separate one hollow organ from another — the stomach from the small intestine, the small intestine from the large. For this the patient must be recumbent. As stated, the stomach tympany is ordinarily lower pitched than the bowel tympany. Bearing this in mind, we can gen- erally determine the stomach boundaries when the organ is moderately dis- tended with gas. The upper limit of stomach tympany, recognizable by percussion, corresponds with the lower edge of the left lobe of the liver. To the left of the apex of the heart, the stomach tympany is mixed with the resonance of the lung. At this point, about the fifth rib, is the cardiac end DIAGNOSTIC TECHNIQUE. 331 of the stomach. Percussing downward and a Httle backward from this point, we are generally able to find a difference of note — a higher pitch, a purer tympany, belonging to the transverse colon. Keeping close to this line and following it anteriorly, we find it crosses the left edge of the thorax at about the cartilaginous attachment of the tenth rib, the median line just above the umbilicus, and passes thence upward to the junction of the right lobe of the liver with the edge of the thorax. It is the line of the greater curvature of the stomach. Traube's half-moon space is a term applied to the area bounded above by the lower border of the left lung, approximately determined by the upper edge of the sixth rib as far as the axillary line ; on the right by liver dullness, on the left by splenic dullness ; and below by the costal arch, yielding a tympanitic note when the stomach is empty and distended, but a flat note to percussion when the stomach is full or there is pleural effusion on the left side. Leichtenstern has applied the name pulmono-hepatic angle to the point of junction between the lower edge of the left lobe of the liver and the lower border of the left lung. The tip of this angle is behind the sixth, rib, just below the apex seat, and is bisected by the pleural space, which is filled by the lung only during deep inspiration. The stomach fills in this angle, and it is an area pretty constantly maintained. The outline of the stomach may be made more distinct by having the patient drink a glass of water just before the examination ; or, as originally suggested by Frerichs, by taking in rapid succession the two portions of a Seidlitz powder — tartaric acid and sodium bicarbonate — or a glass of soda-water. A better method of outlining the stomach is to inflate it with air, as sug- gested by Runeberg, by means of the double bulb of a spray apparatus. This should be done, if possible, in connection with the use of the tube for some other purpose, as removing the stomach contents after a test meal. The possibility of air passing through the pylorus is to be remembered, but, commonly, if any excess is introduced it passes out alongside of the tube. This is not the case with carbonic acid gas, which excites rather a spasmodic contraction of the cardiac orifice. Both gas and water may distend the stomach beyond the limits described, but the normal limit of the lower curvature may be put above the umbilicus, although it cannot be said to be abnormally low when at the umbilicus, an event not unusual after fifty years of age. As already mentioned, the greater curvature is not quite so low in women as in men, and in working women not so low as in those of leisure. When the lower curvature is below the umbilicus, the stomach may be said to be dilated. It is always desirable, if possible, to examine the stomach with the patient standing as well as lying. As stated, the percussion note of the large intestine is higher pitched and more purely tympanitic than that usual to the stomach. When contain- ing feces it is rendered duller, and in consequence of this fact there is often less resonance in the left iliac fossa than in the right, although feces may also accumulate in the latter, and an impaction in the head of the colon may give positive dullness. The colon may also be artificially distended per rec- tum with air, if desired, for examination. The percussion note of the small intestine is usually still higher pitched than that of the large, and by this it may be distinguished from that bowel, if not filled with solid matter or liquid. The differences in percussion note referred to are not always equally well marked, and it is not always possible in consequence, to demark the organs. Especially difficult is it at times thus 332 DISEASES OF THE DIGESTIVE SYSTEM. to distinguish the transverse colon, when distended with gas, from the stom- ach above it. If the stomach be filled with water, a dull note is brought out on percussion, which contrasts strongly with the tympanitic note of the gas-distended colon. Whether determined by inspection, palpation, or percussion, a stomach the greater curvature of which reaches the umbilicus or below is abnormally dilated, while certain dilated stomachs go far below the umbilicus. The vertical diameter of the normal stomach, from the highest to the lowest points of tympany, as determined by Wagner, was ii to 14 cm. (4.4 to 5.6 inches) in men, and about 10 cm. (4 inches) in women. The width of the zone was 21 cm. (8.4 inches) and 18 cm. {y.2 inches). Other measurements are somewhat different, so that some latitude must be allowed. Auscultation has a less useful application to diagnosis of diseases of the stomach. It is confined to the so-called deglutition murmurs, of which there are two. They are best heard with the stethoscope to the left of the spinal column, behind, in the neighborhood of the ninth or tenth rib; in front, to the left of the xiphoid. One is heard at the beginning of swallow- ing, when the food is transmitted from the pharynx into the esophagus, and is termed by Ewald the prini-ary deglutition sound. It is heard all along the esophagus, and has no significance. It is a hissing sound, as if produced by fluid squirted directly into the stethoscope (Spritzgerausch). Six or seven seconds later, corresponding with the contraction of the lower segment of the esophagus, may be heard the second deglutition sound, con- sisting of a series of tones rapidly following one another, either gurgling, clucking, sprinkling, or splashing (Pressgerausch). It is said to denote a relaxation of the cardia and the direct passage of food into the stomach. It is quite constant, and is usually absent when there is obstruction of the cardiac orifice. It is the absence of the deglutition murmurs rather than their presence on which diagnostic value depends ; that is, they are apt to be wanting in obstructive disease of the cardiac orifice, although too much stress must not be laid upon such absence, since they are not always present in health, and repeated observation is required before conclusions dare be drawn. Gastroscopy and Gastrodiaphany have not as yet been sufficiently per- fected to be available in diagnosis of stomach affections. The investigation of the large intestine by percussion is sometimes aided by distending the bowel with gas or air per rectum in one of the various M^ays suggested for the stomach, the bowel being previously evacuated by an enema. The large bowel may also be explored for a considerable distance from its anal end by specula. IXTERXAL EXAMIXATIOX OR ChE^IICAL EXA:snXATIOX OF CONTENTS. For removing the gastric contents for examination the stomach tube or catheter is used. That usually employed is a thoroughly soft, flexible, red rubber tube, open at the inner end. or, if closed at the end, provided wdth lateral openings, like a Xelaton's soft catheter. (The latter is advised because it has happened with the open-end tube that a portion of sound gastric mucous membrane has been aspirated into it.) The tube should be about 95 cm. (about 3 feet) long. From the fundus of the stomach to the incisor teeth is 60 to 65 cm. (about 2 feet), and the tube is usually marked at this point, thus enabling one to judge whether it has entered the fundus. Suf- DIAGNOSTIC TECHNIQUE. 333 ficient lubrication is secured by moistening it with water. It is carried into the back part of the pharynx in the manner described for the sound (p. 323), when the patient is directed to swallow. At the end of the act of deglutition the tube is pushed gently downward, and the patient again directed to swallow. This is kept up until the tube enters the stomach. A long tube permits the stomach to be emptied by siphonage after a little pressure on the abdomen has been exerted by the hand to start the motion of the contents. This is safer than aspiration by a pump, as sometimes practiced. For analysis of the gastric contents the test meal commonly employed is the test breakfast of Ewald and Boas, consisting of an ordinary roll * w^eighing about 35 gm. (9 drams) and 300 c. c. (10 fl. oz.) of water or weak tea without milk and sugar. At the end of one hour after the meal is in- gested the stomach is emptied by expression and siphonage, as described. There should be 20 to 40 c. c. It has happened to me to fail to secure any- thing after such a test meal from the rapid disappearance of the products of digestion. In such event two rolls may be taken at the next meal and the liquid increased to 400 c. c. (13 fl. oz.). It is first examined by the micro- scope for blood or other abnormal morphological constituents, and then filtered, being previously well shaken. The Leube-Riegel test dinner may be used. It consists of beef-soup, 400 gm. (13.3 oz.) ; beefsteak. 200 gm. (6.6 oz.) ; bread, 50 gm. (1.6 oz.), and water 200 c. c. (6.6 fl. oz.). This should be removed for testing at the end of four hours. Acids of Digestion. — In healthful conditions, in ten or fifteen minutes after food ingestion the gastric contents are acid, the acidity depending on free acids or acid salts, the latter including chiefly acid phosphates of sodium and potassium introduced in various amounts with food. At this stage the free acid recognized is lactic, which is either introduced with food or is formed in the lactic acid fermentation out of carbohydrates, especially sugar. Up to thirty to forty-five minutes the lactic acid predominates, while the tests for hydrochloric acid may be negative. Then comes a stage in which traces of HCl can be demonstrated, coexisting with, it may be, lactic acid. Finally, the lactic acid disappears altogether, and at the end of an hour HCl only should be present. HCl is present from the beginning, but its recog- nition is interfered with, partly because the first secreted immediately com- bines with bases until these are neutralized. Free HCl gradually increases in amount until at the acme of digestion it reaches 0.15 to 0.2 per cent, after a light meal, and 0.2 to 0.33 per cent, after an abundant meal. The reaction of the removed contents may be determined by blue litmus, but Congo-red paper or tropaolin paper f may be used, the former being turned blue and the latter brown. These reactions point also to free acids in general, being uninfluenced by acids when com.bined with bases. Nor can Congo-red or tropseolin be relied upon to dififerentiate between mineral acids and organic acids. ' * Such a roll, containing about 7 per cent, of nitrogen, s per cent, fat and 4 per cent, sugar, 52.5 per cent, of non-nitrogenous extractive substances, and i per cent, of ash, includes, therefore, the usual elements of a mixed diet. t These papers are made by dipping strips of filtering paper into watery or alcoholic solutions of the anilin dyes, Congo-red or tropseolin 00 (I'orange Poirier), allowing to dry, and preserving for use. The paper is, however, less delicate than tl^e solution. The Congo-red strikes a beautifullv skv-blue reaction with a solution containing but 0.02 per 1000 of HCl; a purplish, but not distinctly different, reaction with lactic acid. Acid salts produce no change. The tropseolin solution is dark vellowish-red, and a solution of free acid, 0.025 to 1000, changes it to a deep dark brown. It is slightly less delicate, therefore, than the Congo-red. Acid salts, as acid so- diutn phosphate, make it straiv-vellow. In all of these tests it is necessary to use an excess of the fluid to be tested. This is accomplished by placing five or ten drops of the reagent in a test glass or por- celain capsule and adding one or two c. c. of the filtered contents. 334 DISEASES OF THE DIGESTIVE SYSTEM. To Test Qualitatively for Free Hydrochloric Acid Only. — For this Giinz- biirg's phloroglucin vanillin or Boas's resorcin test is used. Giinzburg's reagent consists of phloroglucin two grams (30 grains), vanillin one gram (15 grains), alcohol 30 c. c. (fSJ)- The solution is pale yellow, and has a decided odor of vanilla. On exposure to light it assumes a dark golden- yellow. It must, therefore, either be kept in dark-hued bottles or freshly made as required. A drop or two of the reagent is placed on a porcelain plate or capsule with an ecjual quantity of the gastric filtrate, and a gentle heat applied, not to boil, but simply to evaporate. If free HCl is present, very soon a beautiful rose-red tinge appears at the edge of the mixture, or red stripes will be observed. Blowing at the edge will favor the appear- ance of the red stripes. This test is unmistakable, and surpasses all others in delicacy, being available when HCl is present in the proportion of I to 20,000 or 0.5 mille. The reaction is not simulated by albuminates nor interfered with by salts present in the normal proportion, nor by organic acids. Boas's test for free HCl is based upon the fact that resorcin strikes a similar reaction with hydrochloric acid. The solution consists of : Resublimed resorcin, 5 parts (gr. Ixxv) White sugar, . . . . ■ . . . .3 parts (gr. xlv) Dilute alcohol, ......... 100 parts (f § iiiss) Three to five drops of the reagent are poured into a porcelain dish and an equa' quantity of stomach contents added. Heat is applied as in Giinz- burg's test, and a piwple-red color appears at the edge of the drop. It is said also to detect 0.05 per mille of HCl. To Estimate the Total Acidity, Including Free and Combined A^cids and Acid Salts. — The total acidity of gastric contents includes free acids, viz., hydrochloric, lactic, and sometimes other organic acids ; combined acids, consisting of acid phosphates ; and loosely combined acids, in the shape of HCl-albumins, HCl-albumoses, and peptones. The reaction of the filtered fluid being determined by litmus paper, the total acidity is then determined by titration. A Mohr's burette is filled with a decinormal solution of caustic soda. Ten c. c. of the filtered solution are placed in a beaker and one or two drops of an alcoholic solution of phenol-phthalein added as an indicator. The solution is then slowly dropped from the burette until the red color pro- duced in the fluid by the action of the alkali on the phenol-phthalein no longer disappears on shaking. As a rule, the acidity of the gastric contents, an hour after such a meal, requires 4 to 6 c. c. of the decinormal solution to neutralize it in normal digestion. Figures above and below this are there- fore abnormal. The acidity may be expressed in percentage according to the amount of decinormal solution used. Thus if 4 c. c. were required to neutralize 10 c. c, there would be 40 per cent., or if 6 c. c, 60 per cent, total acidity. If the acid reaction is due to free HCl alone, — i. e., if there are no organic acids present to contribute to the total acidity, — this titration will represent the total quantity of HCl, and its percentage is easily estimated. One c. c. of the decinormal soda solution is equivalent to 0.00365 gm. HCL'"" If, therefore, the number of cubic centimeters used to neutralize 10 c. c. of the solution be multiplied by 0.00365, and again by 10, the result will be the actual percentage of HCl. Thus, if 6 c. c. of the decinormal solution be used, the percentage will be 6 X 0.00365 X 10 = 0.219, within the normal range, N * Decinormal solution of soda NaHO=4 gm. Na HO dissolved in looo c.c. distilled water. 10 Each cubic centimeter of this solution exactly neutralizes 0.00365 gva. HCl. DIAGNOSTIC TECHNIQUE. 335 which is from 0.15 to 0.24 per cent.; if 4 c. c. be used, the HCl percentage will be 3 X 0.00365 X 10 =: o.io, or less than normal. Total Free HCl. — The quantitative estimation of free hydrochloric acid may be made by Mintz's method, the Krieger-Cohnheim method, or by Topfer's method. The former is as follows : To 10 c. c. of the filtered gastric contents add the decinormal soda solution from a burette until Giinzburg's reagent no longer gives a reaction with a drop of the gastric fluid. Thus, if 2.8 of the decinormal solution are so used, the percentage of free hydro- chloric acid will be 2.8 X 0.00365 X 10 ^ o.i per cent. ^The Krieger-Cohnheim method is regarded by David Edsall as far superior to Topfer's method.* It is based upon the fact that phosphotungstic acid and the salts of this acid precipitate native albumins and the products of their digestion in combination with phosphotungstic acid. The method, as given by Edsall, is as follows : The calcium phosphotungstate is prepared by making a 4 per cent, solution of commercial phosphotungstic acid, heat- ing, and adding calcium carbonate until, after gentle boiling, the reaction becomes neutral ; then filter. The solution may be kept indefinitely. In carrying out the test determine the total acidity ; then to 10 c. c. of gastric con- tents add 30 c. c. of the calcium phosphotungstate solution, filter off the pre- cipitate, wash the filter, collecting the washings with the filtrate, and titrate the filtrate and washings. Subtract the second result from the first, and the figures obtained represent the acidity due to combined HCl. Rosolic acid is used as an indicator in each case. The free HCl is estimated by titration with phloroglucin-vanillin, and the total amount of HCl is obtained by adding the results for the free and the combined HCl. If free HCl is absent decinormal solution is added until a marked reac- tion for free HCl appears, the amount added being known, and the method is then carried out. Any excess over the amount added that may be found is then due to combined HCl. Dr. Edsall suggests a modification of the process that hastens the result, viz., filtering into a graduated cylinder after the precipitation, taking 20 c. c. of the filtrate, titrating this, and doubling the result. This avoids loss of time in filtering and washing. The results in the first titration are better if the stomach contents are diluted about five times, as the color change with rosolic acid is then sharper. For Topfer's method the reader is referred to treatises on diseases of the stomach, and manuals on diagnostic technique. To Determine the Loosely Combined HCl. — It may be that there is no evidence of the presence of free acids, inorganic or organic, and yet the gas- tric contents will redden litmus. Such acidity is due to loosely combined acids. These are decomposed by calcic and sodic carbonate, and are there- fore included in the estimation of total acidity, but do not respond to the test for free acids. The acid thus combined is commonly HCl, forming HCl- albuminates, HCl-albumoses, and peptones. While organic acids may be similarly combined, they are insignificant in amount and may be ignored. These loosely combined acids are also destroyed by combustion. When free HCl is present, the estimation of the loosely combined HCl is an easy matter. We have simply to estimate the total acidity and the HCl, preferabl}^ by Topfer's method, — wh,ich removes also the organic acids and acid salts, — subtract the latter from the former, and the difiference is the loosely combined HCl. * See " A Critique on Certain Methods of Gastric Analysis," by David L. Edsall, " University of Pennsylvania Medical Bulletin, " April, igoi. 336 DISEASES OF THE DIGESTIVE SYSTEM. In cases where there is no free HCl and the contents are still acid, quantitative methods are complicated and only approximate at best. We may, however, by a qualitative test for chlorin by the Ewald-Sjoqvist method, which tests only the chlorin in the organic combination, ascertain whether some of the combined acid is HCl, and thence whether the deranged acid secretion implies a diminution or a total loss of function of the secret- ing cells. Mix lo c. c. of the contents with 0.5 gm. (half a salt-spoonful) of barium carbonate in a platinum capsule. This mixture is evaporated and the residue fused to a red heat only in order to avoid too high a temiperature. The fused mixture is treated with 50 to 75 c. c. boiling water and filtered. To this filtrate, when cooled, 5 to 10 c. c. of a saturated solution of sodium carbonate are added, by which the entire BaCl^ is converted into BaCOj, and thrown down as a flocculent precipitate if chlorin is present. The pres- ence of organic chlorin compounds thus shown indicates that some of the combined acid is HCl. To Determine Acid Salts. — To 15 c. c. of gastric contents in a beaker add enough calcium carbonate to neutralize the free and organically com- bined acids. Stir the mixture thoroughly, expelling the carbonic acid gas generated by passing a current of air through it, using for this purpose a glass tube attached to the bulb of a Davidson's syringe. Avoid blowing air from the lungs, as this contains CO„. Filter, take 10 c. c. of the filtrate and titrate with the decinorm,al soda solution, adding phenolphthalein as an indicator. The number of cubic centimeters used indicates the acid salts, and this, divided by .2, gives the acid phosphates. Determination of Organic Acids. — These include lactic acid, acetic acid, and the true fatty acids, especially butyric. Acetic acid and fatty acids are not formed during normal digestion, and, if present, as they sometimes are, they are either introduced with the food or are produced in a fermentation of the carbohydrates set up by bacteria introduced with the saliva. The physiological presence of lactic acid during what may be termed the first stage of digestion, heretofore regarded as physiological, is now called in question, especially by Boas. Boas, because of his recent discovery that all baker's bread contains lactic acid, substitutes for the ordinary test meal a thin gruel made of a tablespoon ful of oatme.al flour to a quart of water and seasoned with salt. With this meal he maintains that lactic acid is never found in the stomach nnless cancer is present. The matter, however, is still snh pidice, though the following careful data, gathered from the experiments of Ellenburger * and Ewald, on the subject indicate that there is a primary evolution of lactic acid: Time (in Number Number of Minutes) Number i^f Times Times Lac- afterTaking Kinds of Food. of Obser- Lactic tic Acid was Food at Free HCl, vations. Acid was Absent after which Lactic When First Appeared: Found. Taking Food. Acid was Found. Mixed diet. 31 26 5 10-100 After 120 minutes. Bread. 31 13 18 10-30 After 30 minutes. White of egg. 15 I 14 75 Seldom before 6ominutes. Scraped meat. 23 17 6 10-100 Seldom after i2ominutes. * Boas, " Deutsche med. Wochenschrift," 1803, PP- 913-940; Ellenburger and Hoffmeister, " Du Bois Reymond's Archiv f. Physiologie," 1890, p. 280; Ewald and Boas, " Virchow's Archiv," loi, pp. 325. 375- DIAGNOSTIC TECHNIQUE. ^^^-^ Uffelmaiin's Test. — Lactic acid is recognized by its effect upon a very dilute, almost colorless, solution of neutral ferric chlorid, which is converted into a canary-yellow color by its action. This is Uft'elmann's test. It is ren- dered more certain if the solution is made by adding- carbolic acid to the iron solution until it assumes an amethyst-blue color. To lo c. c. (2 1-2 fluid drams) of two to five per cent, solution of carbolic acid the iron solution may be added until the proper tint is attained. A few drops of even a 0.05 per mille solution of lactic acid (i to 20,000) will change the blue to the distinctive yellow color. There are, however, sources of error. The lactates cause the same reac- tion, but this matters not, because we desire to recognize the lactic acid, whether in combination or not. The reaction, however, takes place with alcohol, sugar, and certain salts, especially phosphates, which are often found in gastric contents. The color produced by phosphates is not identical, but if the filtrate operated with has a yellow tinge the resulting color may ap- proximate it very closely. Under these circumstances the lactic acid must be extracted with ether. Two to five c. c. (1-2 to i 1-2 fluid drams) of the stomach contents are thoroughly shaken with three or four times the amount of ether. The ether is allowed to rise to the top, which it does rapidly, and is then poured off into a glass beaker. More ether is added and the washing repeated until in all about one fluid ounce (30 c. c.) of ether has been used, The ether is then evaporated by placing the beaker, with its contents, in a vessel of hot water. The residue is redissolved in a few drops of water and one or tzvo drops of Uffelmann's reagent allowed to fall from a pipette into the solution. Too much of the solution may mask the reaction. The fatty acids, especially butyric, strike a tawny yellow color with a reddish tinge with Uffelmann's chlorid of iron solution, but 0.5 per 1000 or I to 2000 is required before the reaction occurs. Fatty acids may also be detected by heating to the boiling-point a few cubic centimeters of the gastric filtrate in a test-tube over the mouth of which a strip of moistened neutral or blue litmus paper is placed. On this the vaporized acid will produce the usual change. The oily particles of pure fat may be recognized floating in the gastric contents or in the aqueous solution of the residue after evaporating the ethereal extract. Butyric acid may also be separated, in the form of drops by adding small pieces of calcium chlorid. Acetic acid is easily recognized by its odor, but it may also be detected by neutralizing with sodium carbonate the watery residue after the removal of the ethereal extract, and then adding neutral ferric chlorid solution. A striking blood-red color appears, also produced by formic acid, but this is never a constituent of gastric contents. Alcohol, v^hxch. is sometimes formed in the stomach in intense yeast fermentation, may be detected by Lieben's iodoform test applied to the dis- tillate of the stomach contents, as follows : To a portion of the distillate add a small quantity of liquor potassse, then a few drops of a solution of iodin and iodid of potassium (i, 2, 50). If alcohol be present, a yellowish pre- cipitate of iodoform ta'kes place slowly, which may also be recognized by its odor. The same precipitate occurs with acetone, but rapidly. Examination of Products of Albumin Digestion. — The term proteol- ysis is applied to albumin digestion, in which, if complete, all proteid food- stuffs are converted into soluble and diffusible peptone. It takes place partly in the stomach through the agency of pepsin-hydrochloric acid, but probably 338 DISEASES OF THE DIGESTIVE SYSTEM. even to a greater degree in the small intestine, by the action of trypsin, the pancreatic digestive ferment. In this process the first step is the production of certain substances intermediate between albumin and peptone. Those which are of chief importance in the study of gastric digestion are syntonin or acid albumin and the so-called proteoses '•' or albumoses. In the ordinary process of digestion, with a normal gastric juice, some or all of these sub- stances should be at some time present. So far as they are the products of gastric dig'estion, they may be studied by the aid of a test meal and removal of the gastric contents, as already described. The products of pepsin proteolysis may, in a general way, be divided into three groups : 1. Those precipitated by neutralization and represented mainly by syn- tonin or acid albumin. 2. Those precipitated by saturation of the neutralized fluid with am- monium sulphate and represented by the proteoses. 3. Those non-precipitable by ammonium sulphate and represented by what is commonly known as peptone. The relation of these products to each other is shown by the following diagram, proposed by Xeumiester : Native Proteid. Svntonin or acid-albumin Protoproteose Soluble in water onlv Deuteroproteose Heteroproteose 1 (dysproteose) Soluble in salt solution, dilute acids, and alkalies Deuteroproteose Peptone Peptone Non-preciptable by ammonium sulphate. Proto- and hetero-proteoses are primary bodies formed directly from the initial product syntonin by the further action of the ferment. Again, deu- teroproteose is a secondary proteid. being formed by the further hydration of the primary body. Finally, peptone, the ultimate product of pepsinpro- teolysis. is the result of the hydration and possible cleavage of deuteropro- teosis. The two primary proteoses differ from each other more particularly in that protoproteose is readily soluble in water alone, while heteroproteose is soluble only in salt solution, dilute acids, and alkalies. To Separate Proteoses (Propeptone) and Peptone. — Take two or three c. c. of the stomach filtrate and remove any acid albumin or S5-ntonin by neutralization and filtration. The proteoses and peptones remain in solution. '■ The so-called propeptone or hemialbumose is a mixture of proteoses. DIAGNOSTIC TECHNIQUE. 339 To a portion of the filtrate apply the biuret test — viz., one c. c. of liquor potassae and a few drops of a one per cent, solution of cupric sulphate. A purple-red color indicates the presence of proteoses and peptone. Another portion of the neutral filtrate is then treated with an equal quantity of a saturated solution of sodium chlorid and one or two drops of strong acetic acid added. Proteoses, if present, are precipitated, and may be filtered out. To the filtrate again apply the biuret test. A purple-red color indicates the presence of peptone, and its quantity may be approxi- mately estimated by the intensity of the reaction, provided we always use the same proportion of stomach contents, solution of potash, and cupric sulphate. Should it happen that a handsome biuret reaction is struck before removing the proteose, or but a faint one or none at all afterward, the pro- portion of proteose is large and peptone small. Cahn has shown that in dogs, at least, the quantity of peptone remains at a certain percentage, being probably kept at that figure by its removal as formed. Hence, the only index of the rapidity and extent of albumin transformation is the amount of proteose formed or remaining. Finally, Ewald, Gumlich, and R. A. Chittenden conclude that the formation of true peptone in the human stomach is small. It is true, peptone may be found in relatively large amount, but a quantitative estimation of the proteoses and peptone always shows the former to be in excess. Gastric digestion is rather, there- fore, to be considered as a preliminary step in proteolysis, and is preparatory to the more thorough office of pancreatic digestion. To Estimate the Activity of Proteolysis, or Albumin Digestion. — By Ewald's method, coagulated white of tgg is cut into thin slices and out of these small discs are cut by a cork-borer or similar instrument. These may be prepared in quantity and kept for use in glycerin, which should, how- ever, be washed off before using. An equal quantity of the filtered gastric fluid is placed in four small test-tubes and one or two discs of albumin put into each. To the first nothing else is added ; to the second, enough hydro- chloric acid to make a solution of about * 0.3 to 0.5 per cent. This is accom- plished by adding two drops of hydrochloric acid to 90 minims (5 c. c.) of stomach contents. To the third is added a definite quantity of pepsin, about 3 to 7 1-2 grains (0.2 to 0.5 gm.) ; to the fourth, both hydrochloric acid and pepsin. The test-tubes are placed in an incubator at about 100° F. (37.8° C.) and from time to time examined with a view to learning how far the liquefaction of the discs of albumin has proceeded. The rate of this will inform us whether digestion would have occurred without the addition of anything, or whether acid or pepsin or both were necessary. We will learn, also, whether by adding more hydrochloric acid we have made the acidity excessive. It must be remembered, however, that after the peptone has reached a certain percentage its further production is retarded, or even suspended, so that there may be an apparently slow reaction with even a very active gastric juice. Ewald correctly reminds us that all laboratory attempts to imitate digestion are defective in the important respect that with our test- tubes and flasks we can neither imitate absorption on the one hand, nor, on the other, allow for the onward movement to the intestines of the gastric contents, two important functions by which the stomach strives to maintain a fairly uniform degree of concentration of its contents. *The difference between the strength of the acetic acid of the German phamacopoeia (25 per cent, of the anhydrous acid), intended by Ewald, and that of the U. S. P. (32 per cent.) is not suffi- cient to necessitate a change of proportion. 340 DISEASES OF THE DIGESTIVE SYSTEM. The Action of Rennet, or Lab-fcnnent, the Milk-coagnlating Element of the Natural Gastric Juice. — The simplest method of estimating the action of rennet is that of Leo. To lo c. c. (3.6 tiuicl drams) of raztr milk are added two to five drops of stomach contents. Raw milk is used because it coagu- lates ten times more rapidly than boiled milk, while neutralization is unneces- sary because of the relatively small cjuantity of gastric juice used. The mixture is placed in the warm chamber at 100° F. (37.8° C), and coagu- lation should take place in from one minute to several hours. The character- istic coagulating of rennet is a cake of casein floating in clear serum, while acids produce lumpy and flaky masses. The rennet-ferment, or enzyme, does not exist primarily as such, but as a rennet-zymogen or proenzyme, which itself has no action on milk, but is converted into rennet by the action of any acid, as hydrochloric, or of warm chlorid of calcium. This may be shown as follows : If the spon- taneous coagulating action of gastric juice or milk be destroyed by neutral- ization by an alkaline carbonate, this property may be restored by digesting with dilute hydrochloric acid, or by the addition of a five per cent, solution of calcium chlorid. While fasting, and at the beginning of digestion, zymogen only is present in the stomach, but, later, both it and the ferment are found. An acid reaction for the curdling action of rennet is not abso- lutely necessary. As pepsin and rennet usually accompany each other the presence of one may be inferred from the presence of the other. Digestion of Starch and Sugar. — It is well known that during digestion starch is .converted into grape sugar, and cane sugar is converted into invert sugar — a mixture of cane and grape sugar. This action, com- menced in the mouth by the ptyalin of saliva, is continued to a less degree in the stomach so long as the acidity is slight (o.oi per cent, for HCl, o.i or 0.2 per cent, for lactic, 0.4 per cent, for butyric), and is finished in the small intestine by the trypsin (amylolypsin) of the pancreatic juice. As in albu- min digestion, there are intermediate substances between albumin and pep- tone, so between starch and grape sugar there are similar intermediate prod- ucts. The order is as follows : I. Starch. 2. Dextrins (Erythrodextrin, Achroodextrin). 3. Maltose. 4. Dextrose, or grape sugar. Starch is recognized by the deep blue color struck with iodin or Lugol's solution (iodin i, iodid of potassium 2, distilled water 200), and the reaction grows less vivid as the starch is converted. Of the dextrins, erythrodextrin strikes not a blue, but a purple color, while solutions of achroodextrin, maltose, and grape sugar take on only the yellow color of the iodin solution. Where a mixture of these substances occurs, the first few drops of the iodin solution produce no color at all, or only a transitory one, being taken up by the dextrose and maltose, while the addition of more iodin strikes the purple of erythrodextrin or the blue of starch. If, therefore, amylaceous transformation has progressed normally in the mouth and stomach, so much starch should be changed into achroodextrin, maltose, or dextrose that the addition of small quantities of Lugol's solution does not strike the characteristic color. If, however, the blue or purple reactions appear, conversion has not been sufficiently rapid into maltose, the principal product of gastric conversion, the change into dextrose being com- pleted in the small intestine. This may be due either to a deficiency of ptyalin or a too rapid production of acid in the stomach. From such event we might also infer a hyperacidity of the gastric juice. DIAGNOSTIC TECHNIQUE. 341 To Determine the Rate of Absorption from the Stomach. — Penzoldt's and Faber's method is that generally followed. A capsule containing iodid of potassium, o.i gm. (i 1-2 grains), is swallowed, being first carefully wiped to remove any adherent particles. The appearance of the iodid in the saliva indicates that absorption has taken place from the stomach. To determine this, starch paper is first prepared by moistening with starch paste and drying. Then, after the salt is swallowed, a piece of the paper is moist- ened every five minutes with the saliva, and the moistened spot touched with fuming nitric acid. As soon as the iodin appears in the saliva the character- istic blue reaction is struck. When absorption is normal, this reaction usually takes place in ten or fifteen minutes, but when absorption is abnormally delayed, the reaction is also delayed half an hour or more, or it may not occur at all. To Test the Motor Function of the Stomach. — Three methods are practiced. In v. Leube's method the gastric contents are withdrawn six to seven hours after the ingestion of a large meal, or two and a half hours after an Ewald's breakfast. There should be no solid residue. The more suitable meal for this purpose is the larger one given on page 333. In a second method, suggested by Ewald and Sievers, salol is admin- istered, and the products of its lysis are sought for in the urine. This, though not without drawbacks, is preferred. Salol is composed of phenol and salicylic acid, into which it is broken up by the action of the pancreatic juice, but not by the acid gastric contents. Salicyluric acid, a product of decomposition of salicylic acid, appears in the urine forty to sixty, or at most seventy-five, minutes after taking 15 grains (i gm.) of salol when gastric peristalsis is normal. Salicyluric acid is readily detected in the urine by the violet color produced on the addition of neutral ferric chlorid solution. The method employed is to place a drop of urine on a piece of filter-paper and bring in contact with this a drop of a ten per cent, ferric chlorid solution. The edge of the drop will strike a violet color in the presence of a mere trace of salicyluric acid. Decomposition of salol may be delayed by extreme acid- ity of the gastric contents as discharged into the duodenum. Practically this is not a serious drawback, tolerably constant results being obtained. To meet it, however, Huber suggested that the outside limit of excretion of salicyluric acid be determined — that is the point noted when salicyluric acid fails to appear in the urine after the ingestion of 15 grains (i gm.) of salol. This should occur at the end of twenty-four to thirty hours. If, therefore, it continues after this, persistalsis must be slow. A third test of the motor function is Klemperer's oil test, in which 100 c. c. (3 1-2 ounces) of olive oil are introduced into the stomach by the tube after the organ is thoroughlv washed out. Two hours later the stomach is aspirated, and if there is motor sufficiency, there should be a very small residue, not more than 20 to 40 c. c. If any decided quantity above this remain, it is fair to conclude that peristalsis is slow.* *MaxEinhorn (Article "Diseases of the Stomach," in "Twentieth Century Practice of Medi- cine," vol. vii;'.. t8q6) divides motor function of the stomach into two parts— viz., that consisting- in the transportation of the stomach contents into the smaller intestine, which he calls firocIi07-esis (lyi 7rpoxwpr)o-t5, advancing-l, and that consistins: in tyierely mechanical motion to which the ingesta are subjected within the organ, which he calls akinesis (r\ aKiVT/trts, shaking). The former is teste^ m the manner described; the latter, by a mechanical appliance connected with a battery,— the whole too complex for introduction here. 342 DISEASES OF THE DIGESTIVE SYSTEM. ACUTE CATARRHAL GASTRITIS. Synonyms. — Acute Gastric Catarrh; Acute Dyspepsia; Gastric Fever. Definition. — Acute inflammation of the stomach, of moderate intensity, due to simple non-specific irritation or to irritation from the products of decomposing and fermenting foods. Etiology. — This form of inflammation occurs at all ages, and is often due to the irritant efifect of indigestible food or food in a state of incipient decay and fermentation. Simply overloading the stomach, even though the food be wholesome, may be a sufficient cause. The introduction of large quantities of strong alcoholic drinks, as often happens in a debauch, is one of the most common causes of acute gastritis of the simple variety. The susceptibility of different individuals and of different families to the fore- going causes of irritation varies greatly. Morbid Anatomy. — A more or less uniform coating of the stomach with mucus is the most constant feature of simple acute gastritis, and justi- fies for it the name, gastric catarrh. The removal of this mucous coating reveals a hyperemic redness, which in the highest degrees may be associated with punctiform hemorrhages and hemorrhagic erosions. The mucous mem- brane is swollen and edematous, and minute examination recognizes numer- ous mucus-laden cylinder cells, which have been extruded from the mucus- glands everywhere -present, while even the peptic gland cells are cloudy and granular. Symptoms. — These are a natural sequence of the morbid state. A 7vant of appetite and loathing of food, nausea, more rarely pain — these are the more constant subjective symptoms. To them may be added an unpleas- ant taste in the mouth, sometimes bitter, sometimes metallic, a pasty sensa- tion of dryness, and even thirst, a sense of fullness in the head rather than headache, and di::ciness, and often extreme mental depression. Objective symptoms are epigastric distention, more rarely tenderness, a coated tongue, dryness of the lips, rarely herpes, a heavy breath, acid or bitter eructations, sometimes a scanty secretion, at others an excess of saliva, finally retching and vomiting with greater or less relief. The hotvels are, constipated, though sometimes there is diarrhea. Jaundice is occasionally present, and indicates that the inflammiation extends into the duodenum and produces obstruction of the common bile-duct. There may be slight fever, sometimes decided, with a temperature of ioi° F. (38.3° C), or slightly more, and a corresponding pulse. On the other hand, the pulse is not infrequently slowed below the normal, being inhibited by the gastric irritation. The nrine is " feverish," scanty, and high colored, with a corresponding specific gravity and a tendency to deposit urates. Most cases are without febrile symptoms. Indeed, v. Leube says that in a few instances only is fever the result of acute gastric catarrh, and that when the two are associated, the gastric catarrh is rather the result of some acute febrile process, as, for ex- ample, one of the infectious fevers. It has occasionally happened that gas- tritis has been ushered in with a chill. Gastric Contents. — The vomited matter and gastric contents removed after a test meal are deficient in hydrochloric acid, but contain an excess of mucus, lactic and fatty acids, and more than the normal residue of undi- gested food. Digestion is prolonged, the stomach-washings exhibiting a CHRONIC CATARRHAL GASTRITIS. 343 considerable amount of undigested food seven hours after the ingestion of a test meal. Indeed, it often happens that in from, twelve to twenty-four hours after the beginning of such an attack large quantities of undigested food are vomited in much the same condition in which they were swallowed. Diagnosis. — This is not usually difficult, except in the case of the febrile form. In this form, especially when the disease has been ushered in with chill, it is sometimes difficult to decide between it and some one of the infectious fevers, but a few days' waiting will soon remove the doubt by the appearance in the latter of eruptions or other distinctive symptoms. The presence of a cause sufficient to excite gastric inflammation will add to the probability of the presence of acute catarrhal gastritis. Prognosis. — This is invariably favorable in cases of true simple gas- tritis. Treatment. — ^Many mild cases recover spontaneously, if let alone and if all food is withdrawn for twenty-four hours. The symptoms gradually sub- side and the patient recovers. In a few cases where there is evidently retained food, an emetic will give relief; in all, a brisk saline purge is help- ful. A bottle of cold solution of citrate of magnesium in divided doses, say a. fourth every half hour, is one of the most agreeable and efficient aperients to relieve the congestion and the symptom^iS. Or some one of the natural aperient zixiters, such as Hunyadi Janos or Friedrichshalle, Apenta, Ruba- inat, Veronica, or Carlsbad, may be substituted. If there be great sensitive- ness of the stomach, small doses of calomel, frequently repeated, say 1-6 to 1-4 grain (o.oii to 0.016 gm.) every hour, may be substituted, or 7 1-2 to 10 grains (0.5 to 0.666 gm.) may be given in one dose.. In either event a saline should be given sooner or later, as in this way is secured copi- ous depletion of the upper alimentary canal. The alkaline mineral zvaters, represented by the Vichy, Vals, and Contrexville waters in France, but which have unfortunately no equivalent in any of the natural mineral waters of this country, are admirable adjuvants, since they aid in clearing the stomach of mucous secretion and in producing osmosis. The saline mineral waters represented by the well-known Saratoga waters of this country are also effi- cient, more especially by their aperient qualities. CHRONIC CATARRHx\L GASTRITIS. Synonyms. — Chronic Gastric Catarrh; Chronic Catarrhal Dyspepsia. Definition. — A condition of chronic hyperemia, associated wath ex- cessive mucus-secretion and deranged gastric juice formation, with ultimate structural changes in the mucosa. Etiology. — Any cause which will produce continuous moderate irri- tation of the mucous membrane of the stomach is capable of producing chronic catarrhal gastritis. The immoderate use of alcohol is probably the most frequent of these causes, but constant overeating is also a common cause, especially rapid eating. Very frequently, too, chronic gastritis is secondary to primary disease elsewhere, and especially mitral disease of the heart and interstitial hepatitis. Both of these affections cause a passive congestion of the stomach, which ultimately produces the lesions characteristic of chronic gastritis. Throm- bosis of the portal vein acts similarly. Chronic pulmonary disease, and even 344 DISEASES OF THE DIGESTIVE SYSTEM. diseases of the pleura impeding the circulation in the lungs, produce similar effects through stasis. A predisposition exists in certain families to chronic gastric catarrh. Morbid Anatomy. — The fundamental condition is a hjperemic swelling of the gastric mucosa. This is favored by the superficial situation of the venous plexus about the mouths of the gastric glands as contrasted with the deep-seated position of the arterial network around their bases, by the thin- ness and compressibility of the venous walls, and by the sluggishness of cir- culation necessitated by the peculiar secretory function of the stomach. The hyperemic surface is, however, more or less obscured by a tough yellowish- white covering, made up of mucus and emigrant pus-cells. The changes are more marked at the pyloric end. These may constitute the sum of changes, but in more chronic cases minute examination reveals a varying degree of hyperplasia of the connective tissue, and even of the mucous glands, which exhibit in places an atypical branching, like the fingers of a glove. The tubules are distended by secre- tion in some places, and in others stenosed by the contraction of the over- grown connective tissue surrounding them. The hyperplastic process may result in plication of the mucous membrane, such as is natural at the pyloric end, and lead finally to the rnaminillated stomach by atrophy and contraction of certain portions, and to more pronounced swelling of the remaining parts. An ultimate result is sometimes the rare condition known as polyposis ven- triciili. Atrophy of the mucous membrane may be extensive, and even almost total. Symptoms. — These naturally result from the morbid state. The mucous membrane is bathed with mucus. The gastric juice is imperfect in quality and quantity. Especially is the hydrochloric acid deficient. Diges- tion is therefore imperfect, the residue of ingested food undergoes fermen- tation and decomposition, generating lactic, acetic, and butyric acids and alcohol. Peristalsis is delayed because of the absence of its natural stimulus, and thence follows a further retention of food in the stomach. The natural consequence of such morbid changes is loss of appetite and even disgust for food, an unpleasant taste, a pasty sensation in the mouth, a coated tongue, and discomfort after taking food, including nausea, often vomiting, some- times immediately, sometimes an hour or two after taking food. The vom- itus consists of undigested food, usually mixed with a large arnount of mucus. Its reaction may be neutral or acid, sometimes even acridly so, but the acidity is not due to hydrochloric acid, which is diminished, but to the organic acids generated in fermentation. To these symptoms may be added headache, or a dull, unpleasant feeling in the head, vertigo, disturbed sleep, depression of spirits, a sense of v/eaii- ness and disgust with life. Very disagreeable is the distention and sense of fullness in the epigastrium, causing even pain, which adds further to exist- ing discomforts. There may be tenderness, but it is diffuse, and not circum- scribed. There is usually constipation, while the urine may be scanty. Re- flected symptoms are palpitation ; frequent, slozv, or irregular pulse ; shortness of breath. There is no fever. Cough — the so-called " stomach cough " — is sometimes present, but more frequently what is called by the patient stomach cough is the cough of tubercular phthisis, which the sanguine pa- tient easily convinces himself is due to stomach derangement. Gastric Contents. — Analysis of the gastric contents, withdrawn after a test meal, shows a similar deficiency of pepsin as well as of hydrochloric acid, CHROXIC CATARRHAL GASTRITIS. 345 while the other tests described discover retarded peristalsis and delayed ab- sorption. Occasionally there is a little blood present, and frequently fungi, especially yeast-spores and sarcin^ ventriculi. Should the disease progress to total atrophy, the gastric contents, after a test meal, may even be devoid of mucus as well as of free and combined hydrochloric acid, and pepsin, blood, and epithelium, may be made up mainly of undigested food, with bacteria and a few round cells. Repeated examina- tions of stomach contents, after a test meal, may be necessary before a con- fident knowdedge of its features can be arrived at. Diagnosis. — With the symptoms detailed, and the altered state of the secretory, absorptive, and motor functions of the stomach, ascertained as directed, there is usually no difficulty in diagnosing a condition of chronic gastric catarrh. It is to be remembered, however, that chronic gastric catarrh may accompany ulcer and carcinoma of the stomach, in which the otherwise distinctive symptoms of the former are obscured, while with the exception of tumor and occasional coffee-grounds vomit the symptoms of carcinoma may not differ from those of chronic gastric catarrh, hydrochloric acid and pepsin being deficient in both. Dilatation of the stomach is also accom-panied with symptoms of gastric catarrh, including even the clinical characters of the gastric juice, and careful examination must always be made for the physical signs of dilatation. Prognosis. — The prognosis and treatment will depend upon the etiology. If the chronic gastric catarrh is a result of chronic cardiac or hepatic disease, it is curable only so far as these affections are curable, and is relieved as these are relieved. Careful physical examination is always necessary in each case, that obscure cases may be recognized. Chronic gastric catarrh not the result of organic heart or pulmonary or liver disease, and which has not already resulted in atrophy of the mucous membrane, may be cured by careful and persevering treatment. If there be extensive atrophy of the gastric mucous membrane, a proper assimilation of food becomes impossible, and the symptoms of anemia are ultimately added. Their close resemblance to those of pernicious anemia has been pointed out, while an essential cause of pernicious anemia has been held to be gastric atrophy, in evidence of which a case of William Osier and Frederick P. Henry is often quoted. Treatment. — The treatment of chronic gastric catarrh caused by chronic liver or heart disease is largely that of these affections, but the treatment useful in the ordinary primary forms of the disease may be with advantage associated with that of the more chronic affection. A successful treatment of catarrhal dyspepsia requires considerable patience, but if the diagnosis be correctly made and the cause removed, the patient may be promised a cure in time. Of primary importance is the elimi- nation of file cause, whether it be alcohol or injudicious eating. Simple, wholesome, and properly cooked food, thoroughly masticated and slowly taken, should be the rule of every life, and the simple forms of the disease may sometimes be cured by a return to such a habit, especially if a proper action of the bowels is also habitually secured. It is not easy to select a diet which will suit every case, and after the injunction that articles evidently difficult of digestion, such as pastry, oils, and fats, are to be excluded, it is often sufficient, and even necessary, to leave the choice of special articles to the patient, with the direction to discard what his experience teaches is harmful. Often, however, the patient cannot be 346 DISEASES OF THE DIGESTIVE SYSTEM. trusted to do this, while the moral effect of specific directions is good, but even then our bill of fare must often be tentative. The measures by which the regular habit of bozvcl movement is brought about must vary with cir- cumstances, but when it is remembered that we have to deal with a congested mucous membrane, it is plain why the salines which deplete the upper ali- mentary canal are so efficient, especially when associated with mercurials. Among these are the numerous natural aperient waters, such as Friedrichs- halle, Hunyadi Janos, Apenta, Carlsbad waters, and our own Saratoga and Bedford waters, all of which are said, in common parlance, to act upon the liver, though, in fact, they simply deplete the alimentary canal. The use- ful eft'ect of these waters is so often availed of to remove the uncomfortable effect of a debauch in eating that their use is abused. No remedies are, how- ever, so useful when needed, and the fact that almost any of them can be taken before breakfast, :ecuring an effect after that meal, makes them doubly convenient. A fit substitute for the water, especially when traveling, is the Carlsbad Sprudel Salt, obtained by evaporating the Carlsbad water. Carls- bad salt, of which the dose is usually a teaspoonful, is best taken in a glass of hot water. An artificial Carlsbad salt may be made as follows : Sodium sul- phate, 50 parts ; sodium bicarbonate, 6 ; sodium chlorid, 3. The dose is a teaspoonful dissolved in half a glass to a glass of water. The natural waters are, however, to be preferred, if they can be obtained. The occasional associated treatment by mercurials, especially blue mass, in doses of three to ten grains (0.2 to 0.66 gm.) the evening previous, some- times adds to the efficiency of the salines. Calomel may be substituted in doses of five to ten grains (0.33 to 0.66 gm.) , \\\\h as much sodium carbonate. If there be nausea, calomel may be given in smaller doses, say i-io to 1-5 grain (o.ooii to 0.0132 gm.) hourly. Podophyllin may be substituted for the mercurials or added to them in doses of i-io to 1-4 grain (0.006 to 0.06 gm.). Cascara sagrada is one of the most valuable of aperients. The best preparations are the solid and fluid extracts. The former may be given in two-grain doses (0.132 gm.) in a pill after dinner and after supper. The fluid extract, in 15- or 20-minim (i to 1.3 gm.) doses, can be given in the same manner, but the dose of each must be modified to suit the requirements of individual cases. In lieu of the saline aperients before breakfast, a glass of hot water alone, slowly sipped while dressing, is often useful and tends to relieve the morning sickness that sometimes attends chronic gastric catarrh. It probably liquefies the mucus and washes it away into the duodenum. As to medicines intended to aid digestion, the most efficient is hydro- chloric acid, which may sometimes be replaced by nitro-muriatic acid. It seems now definitely settled that hydrochloric is the acid to which the gastric juice owes its efficiency, and as well settled that it is diminished in chronic gastric catarrh. Another very important role is, however, assigned to hydrochloric acid, viz., an antiseptic effect, in checking the multiplication of pathogenic bacteria — bacteria of fermentation and decomposition — which are continually introduced with the food into the stomach. A third role performed by hydrochloric acid is the conversion of the granular pepsinogen in the proto- plasm of the peptic cells into the enzyme, pepsin. Its scantiness, therefore, not only impairs the activity of the gastric juice, but also favors the acetic and lactic acid fermentations, the products of which keep up irritation. On the other hand, pepsin is seldom abnormally scanty, because so little is required for its purpose. As it does no harm, however, it may with pro- priety be administered with hjdrochloric acid. The latter has, heretofore, CHRONIC CATARRHAL GASTRITIS. 347 been administered in too small doses. "^ Not less than 15 minims (i gm.) of the dilute acid should be given, and from 30 to 60 minims (2 to 4 gm.) are sometimes required. It should be given, further diluted, fifteen minutes after a meal, through a glass tube carried back into the fauces, not merely to save the teeth, but also to avoid the unpleasant taste. The pepsin should be given in solution with the hydrochloric acid in doses of five to ten grains (0.33 to 0.66 gm.). The wine of pepsin has always been a favorite preparation with me, notwithstanding the small proportion of pepsin contained in it. I have been in the habit of combining it with nitro-muriatic acid rather than with hydrochloric, and not infrequently adding 1-30 grain (0.002 gm.) of strych- nin to each dose of 1-2 ounce (15 c. c.) or two fluid dram,s (7.5 c. c.) of the wine. Trypsin or pancreafin is also much used. It is commonly prescribed in the tablet form, five grains (0.33 gm.) at a dose, sometimes keratin coated, that it may not be dissolved until it passes into the small intestine, where alone in the presence of an alkali it is capable of acting. It is usual also to employ the bitter tonics in the treatment of this form of dyspepsia, including gentian, quassia, columbo, angostura, cardamom, and nux vomica. They are supposed to stimulate the secretion of gastric juice, and should be taken immediately before meals or with food. A moderate amount of alcohol in the shape of a little whisky with water during meals or a glass of dry sherry is often serviceable, but care should be taken in the use of alcohol lest a habit be contracted. The persons to whom it is advised should be well selected, and it should not be recommended to the young. Stimxilating condiments, such as red pepper and mustard, often give tem- porary relief, but they ultimately aggravate the local congestion and should be forbidden. Common salt, on the other hand, is a rational adjuvant, fur- nishing chlorin for the formation of hydrochloric acid. Nitrate of silver is also a useful drug in pases of chronic gastric catarrh, in doses of 1-4 grain (0.0165 gm.) fifteen minutes to half an hour before meals, dissolved in a quarter of a glass of water. I have never found bismuth of much use in this form of dyspepsia. In fact, its tendency to pro- duce constipation is a contra-indication to its use. Where there is acidity it may be useful, as may also be sodium bicarbonate and mint, but it is better, if possible, to strike at the root of the evil by preventing the fermentations which produce the flatulence and acid. In obstinate cases the milk treatment may be resorted to with advan- tage, and should be carried out with skimmed milk or whole milk diluted with water or Vichy. The efficiency of the milk treatment is largely due to the fact that the quantity of food taken is greatly reduced. Not more than two ounces should be given at first, every two hours, the quantity increased only as the hunger of the patient demands more. There will be at first a loss of weight, but this is again recovered with the increase in quantity. Having secured a tolerance for milk, of which from three to five pints (i 1-2 to 2 1-2 liters) are required in twenty-four hours, the interval may be pro- longed and other articles of food cautiously added — a little bread and butter, an egg, a chop, or a small piece of steak, broiled. Gradually the simpler vegetables, such as rice and potatoes, may be added, then weak tea and cofifee cautiously, the effect of each article being carefully watched. If flatu- * Since 4.5; liters (g pints) of 0.2 per cent, solution of HCl are required to saturate 100 grn. (about 3 oz.) of dry fibrin, and this amount of acid utilized in combining with the albumin leaves none ap- parent as free HCl, it is plain why the small doses often prescribed are insufficient, 348 DISEASES OF THE DIGESTIVE SYSTEM. lence is caused by the farinacea and sugars, they should be withdrawn. Hot bread and fats will rarely ever be permissible to such patients. The; same may be said of ice-cream and iced water with meals, though a moder- ate amount may be permitted between meals, especially of iced water. Ripe fruits, on the other hand, are very desirable foods and should be allowed tentatively. In bad cases of chronic gastric catarrh lavage is one of the most useful measures. Not only does it wash away the coating of mucus which is at once a hindrance to the secretion of the gastric juice and a cause of nauseous discomfort to the patient, but it also stimulates glandular activity. It should be done in the morning before breakfast, with the stomach tube already described, with funnel attachment. Simple water as hot as can be borne, may suffice, or if there be much mucus, a two per cent, solution of sodium bicarbonate or Carlsbad salt, or a one per cent, solution of sodium chlorid may be used. If antiseptic fluids are indicated, a two per cent, solution of resorcin may be substituted, or a one per cent, solution of salicylic acid. The stomach tube having been introduced, as directed on page 333, the tepid water or solution employed is run in slowly and removed by siphonage, 'Fig. 29. — Leube-Rosenthal Arrangement for Auto-lavage. the outer end of the tube being lowered for the latter purpose. This process is repeated until the stomach is thoroughly washed out. x*\uto-lavage is easily practiced by the patient himself by means of the apparatus illus- trated in the text. It is in these cases, too, that a course at Carlsbad is very efificient, and remarkable cures are reported. Here, too, the restricted dietary and deple- tion of the upper alimentary canal by the natural mineral waters are the bene- TRAUMATIC AND TOXIC GASTRITIS. 349 iiting agents. Similar courses are carried out at Kissengen, Wiesbaden, and Ems, but, unfortunately, we have no such places in America. Saratoga fulfills the conditions so far as an aperient water is concerned, but the majority of persons who go to Saratoga continue eating and drinking as at home. Finally, the habitual use between meals of the alkaline mineral waters alluded to — viz., Vichy, Vals, and Contrexville — is undoubtedly use- ful, relieving and averting gastric catarrh. PHLEGMONOUS OR SUPPURATIVE GASTRITIS. Definition. — A rare form of gastritis, in which there is diffuse puru- lent infiltration of the submucosa, but sometimes also circumscribed abscess, causing a possibly detectable tumor in the gastric region, a tumor which dis- appears if the abscess ruptures. Etiology. — Phlegmonous gastritis is a result of infectious processes, among which have been puerperal fever and other forms of pyemia. It has been found associated with peritonitis and trauma. In more cases a cause is not discoverable. It has been met more frequently in men than in women. Symptoms and Diagnosis. — Epigastric pain and tenderness, general abdominal pain and tympany, vomiting, diarrhea, fever, delirium, dry tongue, small, frequent pulse, coma, collapse, and death — symptoms that closely resemble those of peritonitis, with which, as has been said, it is sometimes associated — are those met in phlegmonous gastritis. The vomited matter very rarely contains pus. It is plain, therefore, that these symptoms, asso- ciated with an infectious process, can only give rise to suspicion that the dis- ease is present, since the same symptoms may be caused by peritonitis. Even the vomiting of pus is not diagnostic, because pus may arise from other sources between the mouth and stomach. The presence of a tumor which subsides after vomiting of pus furnishes better ground for suspicion, though vomited pus may also come from an abscess in the vicinity of the stomach which has ruptured into that organ. Treatment. — ^This can only be symptomatic, as nothing can be done to avert a termination which is invariably fatal. TRAUMATIC AND TOXIC GASTRITIS. Definition. — An inflammation of the stomach caused by the ingestion of corrosive poisons, such as the strong mineral or organic acids, caustic alka- lies, phosphorus, arsenic, corrosive sublimate, and the like. Morbid Anatomy. — The appearance differs a good deal, according to the degree of irritation. In extreme degrees, such as are produced by the strongest acids and alkalies, the mucous membrane is disintegated, shredd)'', and may be converted into a black eschar, the borders of which are lighted up with intense inflammation. In milder forms, such as are produced by phosphorus, arsenic, and strong, alcohol, there are cloudy swelling and fatty degeneration of the gastric gland cells and vessel-Avalls, producing ulcer- ation and hemorrhagic extravasation. The fury of the irritation is expended on the fundus, as the part first reached, and its ravages become less exten- sive as the pylorus is approached. 350 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms. — These also vary with the degree of irritation, but there are always intense burning pain, tenderness on pressure, thirst, and vomiting of blood and even of fragments of mucous membrane. To these are added, in severe cases, small, frequent pulse, cold sweat, and collapse. These latter symptoms point to peritonitis, a very frequent complication, the direct result of the deep-seated action of the irritant. If the patient does not perish promptly, symptoms indicating blood dyscrasia supervene, including albu- minuria, hematuria, jaundice, subcutaneous blood extravasations, and the like. When recovery takes place or death is long delayed, varying areas of mucous membrane may be replaced by cicatricial tissue, and there may be subsequent contraction and distortion. Diagnosis. — This is based on a knowledge that the patient has swal- lowed a corrosive poison. In the absence of this knowledge the odor of the breath may suggest the cause, and evidences of corrosive action in the mouth and pharynx often disclose unfailing signs. Prognosis. — This varies with the degree of lesion. The gastritis caused by the powerful corrosive poisons is always fatal. The lesser degrees may be followed by recovery. Treatment. — This consists, first, in the use of chemical opposites, as vinegar and other weak acids for alkalies and alkalies for acids. The anti- dotes called for by special substances are freshly prepared ferric hydrate for arsenic, lime-water for oxalic acid, cold water and ice after the specific action of the poison has been counteracted,^ and ice externally to the abdominal walls. These should be followed by the free use of diluents and demulcents, of w^hich the various mucilages and milk are examples. (See concluding sec- tion of book on the Treatment of Poisons.) Diphtheritic Gastritis. — This occurs sometimes as an extension from faucial or laryngeal diphtheria, but more frequently it is secondary to typhus or typhoid fever, smallpox, scarlet fever, pneumonia, and sometimes pri- marily in weak children. There is no way to recognize such condition dur- ing life. Mycotic Gastritis. — It is very doubtful how far fungi can cause in- flammation of the stomach. The bacteria which flourish in the mouth are destroyed by the acid gastric juice, while the fungi that thrive in acid fluids, such as the yeast fungus, the penicilium, and the sarcina, are probably acci- dental results of the retention of the gastric contents beyond the natural time and are not harmful. The possibility of their producing noxious results can- not, however, be denied. Ulceration has even been ascribed to them. On the other hand, the larvae of certain insects must also be acknowledged as possible causes of inflammation. NERVOUS DYSPEPSIA. Synonym. — Gastric Neurasthenia. Definition. — A form of dyspepsia due to nervous influence, in which, notwithstanding the presence of a train of annoying symptoms, the act of digestion is completely accomplished within the normal time of seven hours, and seven hours after an ordinary dinner the stomach is free from residue. NERVOUS DYSPEPSIA. 351 Etiology. — The nervous temperament and feminine gender predispose to nervous dyspepsia. Any cause that develops an overexcitabihty of the nervous system may become a factor of nervous dyspepsia. It is this form to which the neurasthenic and overworked, and also women with pelvic trouble, are especially prone. Symptoms. — It must be admitted that the only constant feature of nervous dyspepsia is the etiological one, yet we may find symptoms to aid a diagnosis apart from the cause. Pyrosis, accompanied by loud, noisy eructations, is quite characteristic, while noisy rumbling of the bowels is often heard, caused by hyperperistalsis. On the other hand, vomiting is rare. There is also often palpation of the heart, with other nervous symp- toms. Constipation is sometimes present. The nervous dyspeptic is less disposed to be anxious about himself or to dwell on his ills than is he with catarrhal dyspepsia, but may also be restless and sleepless, and depressed in spirits. As in catarrhal dyspepsia there may be loss of appetite, an unpleas- ant taste in his mouth, nausea, di::::;iness, headache — pressure on the head. So, too, a sense of discomfort in contrast to sharp pain ; also distention dur- ing digestion, but in nervous dyspepsia, if the interest of the patient is strongly excited by external matters, as, for example, pleasant society or even business interest, he may for the time forget it. Gastralgia may, how- ever, be associated, especially the form attended by hyperacidity. Wilhelm v. Leube, who has given the subject of nervous dyspepsia much attention, makes three clinical varieties : 1. Those in which the hydrochloric acid is present in normal amounts, which he says may be regarded as a fundamental type. 2. Those in which the HCl is diminished. 3. Those in which the HCl is in excess. In each of these cases the digestion is complete at the end of the normal time, except that sometimes it may be delayed for starches in the third type of hyperacidity. Thus, while nervous dyspepsia is chiefly a sensory neu- rosis, it is to a less degree secretory and also, to a degree, motor, as evidenced by the occasionally associated hyperperistalsis. An annoying symptom that is sometimes associated with nervous dys- pepsia and is at times its chief manifestation is peristaltic unrest. Bor- borygmi and gurgling set up very soon after eating, so loud as to be heard at a distance, and thus to become often a mortification to the patient, while this very emotion reacts to increase it. The movement extends to the lower bowels. The associated discomfort varies greatly and is sometimes extreme. Peristalsis may be reversed, and in extreme cases it is said that enemas and even fecal matter have been discharged per orem. Diagnosis. — The frequent dependence of nervous dyspepsia on other conditions requires a broad etiological study. Thus, as v. Leub)e suggests, we have first to settle the question as to w^hether it is an independent affection or a part of a neurasthenia. The urine should be studied, because the phe- nomena of nervous dyspepsia are sometimes a manifestation of uremic intoxication of a mild degree in contracted kidney. The spleen should also be explored, because the malady is sometimes a result of malaria. In still other cases it is a symptom of chlprosis or hysteria. In all these cases the nervous dyspepsia is the effect of the operation of the disease on the nervous system, and again in other cases it is the result of sympathy with sexual diseases, especially in women wath disease of the uterus and ovaries. 352 DISEASES OF THE DIGESTIVE SYSTEM. Again, we have to distinguish it from ulcc)' of the stomach, which the hyperacid form resembles, but from which it differs in that the pain is reheved by pressure and sometimes by taking food, both of which acts increase the pain in ulcer. The occurrence of hemorrhage from the stomach, of course, under these circumstances points definitely to ulcer. Nervous dyspepsia may, however, continue as a sequel of both healed ulcer and gastric catarrh, since their effect is a neurasthenic one. Finally, it is to be distinguished from the form of catarrhal dyspepsia with similar symptoms by the delayed completion of the digestive act characteristic of the latter, as well as the etio- logical factor, which is the most important criterion. Treatment. — The treatment of nervous dyspepsia varies with the cause, but it is desirable also to determine by chemical examination the state of secretion, whether normal, hyperacid, or of diminished acidity. The treat- ment of all three forms is, however, largely a moral one, since nervous influ- ence may be at once a cause of increased or diminished HCl secretion, but this is especially true of the type attended with normal secretion. The patient must be assured that there is no organic disease and be compelled to desist from self-study. Along with this, his general muscular and nerv- ous tone must be improved. He must be encouraged to take food and not to avoid it, and the moral effect of a systematic arrangement of diet is good. The neuro-tonics, strychnin, gentian, nux vomica, taken with meals are help- ful, but too much medicine is harmful. Occasionally the nervous sedatives, including the bromids and valerian, are of service. When there is scanty secretion of HCl this acid must be given according to the rules already laid down, 15 to 30 minims ( i to 2 gm.) of the dilute hydrochloric acid fifteen minutes to half an hour after a meal. On the other hand, if there is excessive HCl, alkalies must be prescribed as directed in the section on Hyperchlorhydria. Atonic Dyspepsia — Simple Atony of the Stomach of Nervous Origin. — Atonic dyspepsia is a variety of nervous dyspepsia, especially common in neurasthenics, which scarcely deserves separate description; but as the term is frequently employed, some attempt should be made to direct its correct application. If used, it should be applied to cases in which delayed gastro- intestinal activity or muscular atony, with stasis of the gastric contents, is the characteristic feature. As such it may be a variety of catarrhal dys- pepsia or of dilated stomach. In such cases a considerable portion of a test- meal may be withdrawn at the end of seven hours. It is probably associated with more or less deficient secretory activity, though not always. Under these circumstances, too, there is apt to be flatulent distention of the abdomen, whence the terms flatulent dyspepsia and intestinal dyspepsia. A further natural consequence of such delayed mobility is constipation. True gastric atony is also characterized by other symptoms which are not commonly included under those of atonic dyspepsia. Such condition undoubtedly plays a part in dilatation of the stomach, an important morbid state to be separately considered. Such atony, also, involving the cardiac orifice, favors eructation and regurgitation from the stomach, an extreme degree of which is the rare condition of rumination, or merycismns, in which the patient regurgitates the swallowed food, ofttimes voluntarily, and chews it again like ruminants. Such a power of regurgitation had the late Brown- Sequard. It is sometimes hereditary, and may be taught to others. GASTRALGIA. GASTRALGIA. 353 Definition. — A term applied to recurring attacks of gastric pain of great severity without discoverable organic lesion or deranged function. Etiology. — The disease is confined almost exclusively to women, but does occur occasionally in stalwart men. It is more frequent in weak, anemic women, and those subject to menstrual derangement, in brunettes rather than in blondes. It is especially frequent and severe about the meno- pause, but does not cease with it. Excessive secretion of gastric juice, or hyperchlorhydria, is a cause of gastralgia, but the condition is one for sepa- rate consideration. It is usually independent of exciting cause, such as the taking of food, but it may be thus induced. Symptoms. — The attack may come on suddenly or with gradually increasing severity first in the neighborhood of the ensiform cartilage, whence it radiates into the back and around the lower ribs. It is a boring, hurning pain of extreme severity, sometimes causing fainting and collapse, relieved by pressure, such as is produced by boring the fist into the epigastrium or pressing it against some hard substance. On the other hand, it is sometimes excited by pressure. Its most striking feature, after its agonizing severity, is its intermittent paroxysmal character, whence it has been held to be ma- larial in origin. The pain is usually the sole symptom, but it may be asso- ciated with nausea and vomiting or with nervous symptoms, such as globus hystericus and nnnatural hunger. The attack, after a variable duration of from a few minutes to an hour or more, may subside gradually or suddenly without other symptoms, though sometimes with vomiting and eructations, at others with the discharge of a large quantity of pale urine. One case under my care almost always began with a chill, more or less typical, and it is certain that there was no malaria. The interval between the attacks varies greatlv. It may be a week or it may be months. Diagnosis. — Essential gastralgia is to be differentiated from intercostal neuralgia and the so-called symptomatic gastralgia due to ulcer, rarely cancer, from the gastric crises of tabes, and from biliary and intestinal colic. In intercostal neuralgia the pain is not so severe and the paroxysms are of longer duration, while careful examination will discover its focus in an intercostal situation as compared with an epigastric. In nicer of the stomach there is not that total intermission or longer interval of total intermission characteristic of gastralgia, while the general health of the patient with ulcer is commonly more seriously affected. This is, however, not always so, as gastric ulcer may be associated with robustness of appearance. In gastric ulcer pressure increases the pain, while in gastralgia it tends to relieve it. Carcinoma, as contrasted with gastralgia, always visibly affects the general health. Careful examination will generally discover a different seat of the pain in biliary colic, while the almost invariable presence of jaundice settles the question. In a well-established case of tabes there need be no difficulty in diagnosis, but in cases where the diagnosis is not well established there may be much doubt. The history of attacks in comparatively early life and thence throughout life point to gastralgia. Abdominal colic has a different focus and is more apt to be associated with gaseous distention. Prognosis. — True gastralgia never destroys life, but the attacks may continue to recur at intervals throughout it. Treatment. — The severest attacks of gastralgia can only be relieved 23 354 DISEASES OF THE DIGESTIVE SYSTEM. by the use of morphin, which is best given hypodermically in the smallest doses which will suffice. Exceeding care must, however, be exercised to avoid a morphin habit. In milder cases chloroform may answer the purpose, or a combination long prescribed in the clinics of the University of Penn- sylvania and deservedly popular is, eqvial parts of chloroform, compound tincture of cardamom, aromatic spirit of ammonia, and brandy, of which a teaspoonful may be given every half hour or fifteen minutes until relief occurs. If needed, a few drops of deodorized tincture of opium may be added to each dose to increase the anodyne effect. Anemia should be treated with iron and arsenic, and a change of scene is often beneficial, while sea-bathing is a form of hygiene which is sometimes especially useful. The bowels should receive careful attention. If neuras- thenia or hysteria be present, the rest cure, associated with massage, as- described under the appropriate section, is often an efficient cure. HYPERCHLORHYDRIA. Synonyms. — Nervous Hypersecretion of Hydrochloric Acid; Hyperpepsia. Definition. — Hyperchlorhydria, or an excess of hydrochloric acid in the gastric juice, is a symptom of different morbid conditions of the stomach,, notably ulcer and nervous dyspepsia. In a certain number of cases, how- ever, being the chief symptom and apparently independent of any stimulus like the presence of food, it may be studied as an independent neurosis. The term hyperpepsia, suggested by Hayem, is not correct, since this state is not characterized by excess of the digestive ferment, but of the chlorin element, especially hydrochloric acid. In normal digestion the total acidity as represented by free and combined HCl may be put down at 1.8 to 2 parts per looo, while in hyperchlorhydria it may reach 3 and 4 parts in 1000. Eliminating the hyperchlorhydria included under nervous dyspepsia and ulcer of the stomach, there remain two varieties : 1. Simple paroxysmal hyperchlorhydria, lasting for an hour or several days. 2. Continuous chronic hypersecretion, which takes place spontaneously during fasting, or, even though excited by food stimulus, continues after the latter has ceased to act. The latter variety is also called Reichmann's dise2.se, after him who first described it. Etiology. — Both forms "of hyperchlorhydria are most frequent in neurasthenics and emotional persons, but occur also in connection with other neuropathies, such as migraine, chlorosis, and tabes. The simple form occurs also where there is ulcer of the stomach, and more rarely with cancer and gastritis. Symptoms. — In paroxysmal hyperchlorhydria there are pain and epi- gastric discomfort, eructations, heartburn, thirst, nausea, and even vomiting, headache, and constipation. The attacks may last for an hour, or may extend over several days, terminating in vomiting; or by remedial measures, such as drinking large quantities of water, which dilutes the acids, or by satura- tion with albuminous food, with which it enters into combination. The urine, because of much ingestion of albuminous food, is apt to be highly charged with urea. In the continuous form the same symptoms are present, but without HYPERCHLORHYDRIA. 355 intermission. The pain is even more severe, and is especially prone to come on at night; there is a capricious appetite, which is often excessive. Where the appetite remains, pain may occur several hours after taking food. The vomiting is often copious, gaseous, may contain remnants of undigested starchy food, and is of intensely acid reaction. It is likely to take place sev- eral hours after a meal, also at night. The unnc is scanty and there is con- stipation. The patients gradually emaciate and become anemic, even though they may take a good deal of food. A very frequent consequence of continuous hyperchlorhydria is dila- tation of the stomach, as originally pointed out by Riegel, the distinctive symptoms of which may ultimately be added. The dilatation may be caused by spasmodic contraction of the pylorus, due to the irritation of the hyper- acid gastric juice, or to the accumulation of fluid and undigested food in connection with a nervo-motor atony of the muscular coat of the stomach. As the dilatation increases there may ensue atrophy of the glandular struc- ture of the stomach, and while the hypersecretion persists the hyperchlor- hydria gradually diminishes and may disappear. In such event there may be an excess of fixed chlorids in the gastric juice secreted by the mucous membrane, which is, however, incapable of elaborating hydrochloric acid. Gastritis is also a result of hyperchlorhydria and contributes further to the symptoms, especially to pain. Diagnosis. — A positive diagnosis of hyperchlorhydria can only be made through analysis of the gastric contents. This is done in the sixth hour after a test dinner, with a view to discovering the presence of an excess of hydrochloric acid. The same symptoms may, indeed, be caused by organic acids, while the hydrochloric acid is in normal amount. If the stomach is washed out in the evening and the next morning, no food being ingested in the meantime, the contents are expressed and found to be hyper- chlorhydric, the condition is one of continuous hyperchlorhydria. ^vlicro- scopic examination of the gastric contents may also aid in the diagnosis. Such examinations made one to one and a half hours after a test breakfast or three to four hours after a test dinner, will often reveal a large number of unaltered starch-corpuscles, instead of only a few as in normal digestion, while the so-called snail-like cells are often found in this condition, as orig- inally shown by Jaworski. They are also, however, found in patients with normal secretion. Prognosis. — The prognosis of simple hyperchlorhydria is favorable ; that of the continuous form is grave, the disease being incurable after a certain stage has been reached. It becomes, therefore, important to treat the simple form promptly and intelligently before it passes over into the continuous form. Treatment. — The indications for treatment in hyperchlorhydria are evident. Their measure should, however, be based upon the estimation of the acidity of the gastric contents. They are fi) to neutralize the excessive acid secretion, and (2) to restrain its formation. The first indication is met in two ways : (a) By saturating the acid b}' nitrogenous food. (b) By the administration of alkalies. (a) The former is fulfilled by the use of meat and milk diet. It has, however, its limits, because when the tendency to acid secretion exists, it is often maintained even after that present is combined with any albuminous food that may be in the stomach. Hence it is that the pain is felt some hours 356 DISEASES OF THE DIGESTIVE SYSTEM. after a meal when the albumin is digested, (b) Since there is a hmitation to the ingestion of meat its use must be supplemented by antacids, which further neutralize the effect of the acid. The alkali most frequently employed for this purpose is sodium bicarbonate, though calcined magnesia is in some respects better because of its greater saturating power. Prepared chalk was far more efficient than any other alkali in one case under my care. An idea of the amount of hydrochloric acid secreted may be obtained from the fact that probably a half liter (about a pint) of gastric juice is secreted in an hour, four or five liters (8.4 to 10.5 pints) in three hours, and should such gastric juice contain 3 parts of HCl in 1000, a proportion often exceeded in hyper- chlorhydria, there would be some 12 to 15 gm. (180 to 225 grains) of the HCl to neutralize. Since i gm. of hydrochloric acid requires 1.48 gm. sodiimi carbonate, 20 to 25 gm. (300 to 375 grains) would be required to neutralize the whole amount of acid — a large quantity. The sodium car- bonate should be administered some time after meals, just before the time the pains are expected. It should be dissolved in water or milk, or put in capsules or cachets. The doses should be sufficient to counteract the aciditv — /. e., 10 to 20 grains (0.66 to 1.3 gm.) or more. The quantity of carbonic acid evolved sometimes distends the stomach uncomfortably. Smaller doses of calcined magnesia' suffice, and if is surprising that its use is not more general. It has the disadvantage of being insoluble in water, but not only are smaller doses sufficient, but there is also absence of carbonic acid evolution. It is indicated especially where there is constipation. Other alkalies .may be used, such as the potassium salts, and the officinal liquor potasscc in 15 to to 30 drops (0.8 to 1.7 c. c.) in milk may be used with benefit. The benzoate of sodium miay be prescribed in lo-grain (0.66 gm.) doses where antisepsis is required or fermentation is present. Limc-ii'ater is also useful, but large doses are required, as its neutralizing power is small. One-half ounce to an ounce (15 to 30 c. c.) or more should be given. Lime dissolves more largely in saccharine solution than in pure water, and larger doses may thus be given in smaller bulk. Dilute alkaline mineral waters, such as Vichy or A'als or Contrexville, may be used during a meal. (2) Constitutional treatment should be directed to the cause, if it can be ascertained, neurosis by suitable remedies, chlorosis by iron and arsenic. Of course, it is better, if possible, to prevent the excessive secretion of the juice. For this purpose sodium sulphate has been recommended, more par- ticularly in the shape of Carlsbad water. Or the sodium sulphate ma}- be dissolved in Vichy, say 45 to 90 grains (3 to 6 gm.) in a glass. It is given in the morning before breakfast, or, if necessary, may be given before the other meals. Diet. — While the medicinal treatment of hyperchlorhydria is in most cases indispensable, the diet is equally important. It has already been said that theoretically a meat and milk diet is indicated, because meat and milk consume in their digestion the excess of HCl. On the other hand, the starchy foods are but imperfectly digested. Imbibing the acid secretion, they swell up, but do not dissolve, while they favor, on the other hand, irritating acid fermentation. Others object to meat diet because of its overstimulating effect on the acid secretion, and recommend vegetables instead. This is, however, fallacious, and experience sustains the verdict in favor of meat and a minimum of starchy foods. It should be finely cut and well masti- cated, while meat pow^der may be substituted. ]\Iilk should be the drink, HYPERCHLORHYDRIA. 357 though the alkaUne mineral waters may be taken at meals. In extreme cases a pure meat diet, the meat raw or nearly so, finely minced and spread on bread, may be necessary. A meal may consist of about 3 1-2 ounces (100 gm.) of raw meat, a couple of thin slices of stale bread or Zwieback, a little butter, and a glass of plain water or weak alkaline water, such as Vals or Vichy. Or an exclusive milk diet may be tried, in which event the milk should be well alkalized or peptonized. To these are added, as the case im- proves, raw meat or meat powder or meat juice and eggs, and later still starchy foods may be tentatively given, associated with diastasic malt. Where acid secretions and undigested residue of food remain in the stomach long after the ingestion of food, the organ should be washed out. This may be done two or three times a week, or even daily. In these cases overstimulation of the stomach, induced especially by alcohol, or by pepper, mustard, and other condiments, should be avoided. In like manner coarse food of any kind is contra-indicated in these cases. On this account constipation is sometimes best treated by enemas, in order to avoid the administration of irritating medicines by the stomach. Of medicines other than those intended to meet the symptoms, arsenic, in the shape of Fowler's solution, is sometimes efficient. Long courses of it should be practiced, but large doses are not often allowable because of the irritation excited by them. Silver nitrate may also be employed in doses of 1-4 grain (0.0165 gm.), in which dose it is sometimes sedative when given on an empty stomach. Anorexia Nervosa. — This term is applied to a condition in which absolute loss of appetite is the chief and characteristic symptom. Asso- ciated with this are, naturally, great debility, shortness of breath, dizziness, constipation, and sometimes headache ; rarely, also, vomiting ; sooner or later, emaciation. In women, in whom the symptoms usually occur, there is cessation of the catamenia. The name was suggested by Sir William Gull. Prognosis. — This is favorable, cases being rarely, if ever, fatal. Treatment. — The usual tonic measures are likely to fail to excite appetite in these cases, and nourishment must often be given either by the rectum or by forced feeding. The latter is done as follows : A short rubber tube, long enough to reach just below the cricoid cartilage, is introduced as directed on page 323. A bottle or funnel should be attached, and from this liquid nourishment is slowly introduced. This may be milk, plain or pep- tonized, broths or eggs, Murdoch's or Mellin's food. Estimating that 3 1-2 ounces fioo gm.) of albumin, 5 ounces (150 gm.) of fat, and 10 ounces (300 gm.) of carbohydrates are a sufficient amount per diem, Wiessner recommends i quart (i liter) of milk, 2 ounces (60 gm.) of butter, 6 eggs, and 3 1-2 ounces (100 gm.) of sugar to be mixed and warmed while stir- ring. One-third of this amount is introduced three times daily. The food is usually easily digested, for it is not the digestion which is at fault, but the appetite, and the patient, encouraged by the result of forced feeding, is stimulated to eat for herself. Nervous Vomiting. — A form of vomiting resulting from direct or reflex irritation of the centers presicling over vomiting, and independent of anatomical lesion in the stomach. Like nervous dyspepsia, it is probably an expression of a general irritable condition of the gastric nerves — a manifestation of a general neurasthenia. It has been suggested that the exciting cause is some irritating leukomain of unknown nature. 358 DISEASES OF THE DIGESTIVE SYSTEM. Etiology. — Its subjects for the most part are hysterical and neuras- thenic women, more often of dark complexion; but it is also the result of disease of the brain and its membranes and of the medulla and spinal cord, such as tabes dorsalis, when it may take the place of other symptoms of gastric crisis. It is apt to be associated with headache and gnawing sensa- tions in the stomach, with diseases of the kidneys, liver, uterus, and other distant organs. While more usual in adults, it may also occur in children. Pure nervous vomiting is especially seen in neurotic families in which there is a tendency to nervous disease, including insanity and epilepsy. On the other hand, the absence of the hysterical temperament is often conspicuous. It affects rather the upper classes. Symptoms. — Especially characteristic of nervous vomiting are the absence of nausea, the suddenness of the act of vomiting, and the absence of the straining. ]\Iore rarely there is nausea. The appetite is good and the vomiting generally follows a meal, but it may also occur at irregular intervals. In the absence of organic nervous disease the patient may be well nourished. There may also be constipation, headache, dizziness, and epigastric pulsation. Intense acidity of the vomited matter may be present. To this condition Rosenbach has applied the term nervous gastroxynsis. In one of his cases the HCl reached four per cent. In the typical form, however, the vomitus is not abnormally acid, and in this respect it differs from acid dyspepsia and Reichmann's disease. The duration of the vomiting varies. It may be a single act or it may last for twenty-four hours. Diagnosis. — This is based, in the first place, on the exclusion of those organic diseases of the stomach which cause vomiting, and, in the second place, on the presence of any one of the affections named as possible causes. Prognosis. — Except when associated with organic nervous disease, this is ultimately favorable. George M. Garland * reported a fatal case of ap- parently pure nervous vomiting. At autopsy the mucous membrane of the stomach was found thin, and reddened on its inner surface with minute hemorrhagic points. There was slight interstitial nephritis too insignificant to have had any effect, and the gastric changes were probably secondary, so that the case may be regarded as purely neurotic. Treatment. — When vomiting is the result of organic nervous disease, the fundamental treatment must be that of the disease itself. Temporary relief may be afforded such cases by measures which make a profound nervous impression. Such, pre-eminently, is the blister to the epigastrium. The suddenness and irregularity of the vomiting make it almost impossible to provide against a given event. So that ice, internal or external, sinapisms, dry cupping, and similar measures efficient in continuous vomiting or in vomiting preceded by nausea are scarcely available. When, however, cir- cumstances permit their employment, they should be used. Nerve sedatives, including the bromids and valerian, may be used, but hypodermic injections of inorphin are often necessary, and are usually very efficient. When practiced by the physician only, they become a safe measure. Rectal alimentation should be employed when the vomiting is obstinate, and has apparently saved life in many instances. When there is nervous gas- troxynsis, lavage with warm water may be used with advantage, as recom- mended by Rosenbach. The headache, etc., apt to be associated with this form is at once relieved. * Garland, G. M., " Trans, of the Assoc, of Am. Physicians," vol. iv., i88g. GASTRIC AND DUODENAL ULCERS. 359 GASTRIC AND DUODENAL ULCERS. Synonyms. — Ulcus ventriculi pepticum; Peptic Ulcer; Simple or Round Ulcer. Etiology. — There is probably more than one mode of origin of gastric ulcer. It may have its origin in mechanical injury associated with feeble nutrition, which permits the gastric juice to digest out the mucous mem- brane to various depths, resulting in the formation of an ulcer. Such mechanical injury may be due to pressure exerted in the course of one's occupation, such as shoemaking, washing, tailoring, and the like, in which pursuits the costal cartilages are pressed against the stomach. The second of these conditions — for it is likely that neither would be alone sufficient to produce the lesion — is produced by such states as aner/iia, chlorosis, heart disease, Bright's disease, and the like. Over distention of the stomach, it is claimed, may be a predisposing cause by interfering with its proper nutri- tion and thus favoring the action of the gastric juice. Thrombosis and embolism have been held responsible for a certain num- ber of cases of ulcer since Virchow called attention to such causes. Embo- lism of the gastric blood-vessels is extremely rare, but thrombosis is a not infrequent result of obstinate vomiting, as is also punctiform hemorrhage. The stasis of circulation thus resulting affords favorable foci for the sol- vent action of the gastric juice, and certainly no theory explains so satisfac- torily the crater shape of many gastric ulcers. Bottcher ascribes ulcer of the stomach to micrococci, numbers of which have been found by him in the margins of gastric ulcers. The well-known clinical fact that the gastric juice in ulcer of the stomach exhibits intense acidity, while traumatic ulcers of the stomach produced under ordinary circumstances tend to heal promptly, has led to the suggestion that undue acidity plays an important role in the causa- tion of ulcer. The same causes operate to produce the duodenal ulcer. The statements of authors as to the frequency of ulcer of the stomach vary greatly. Thus, Ewald says 5 per cent, of Germans have ulcer. Truly, the disease is not nearly so common in America. Yet the discovery at autopsies of unexpected ulceration goes to show that it may be more frequent than is supposed. Women are much more frequent victims than men. While both the very young and the very old are commonly exempt, the period being between seventeen and twenty-five, gastric ulcer has been found in infants and in adults as old as sixty. In women gastric ulcer usually occurs between the ages of twenty and thirty ; in men, between thirty and forty. Duodenal nicer, on the other hand, is more common in males, in the proportion of 178 to 41, in the combined statistics of Kraus, Chvostek, Lebert, Trier, and William Osier. The last-named observer found it once in a boy of twelve. Its association with extensive superficial burns and tuberculosis should be mentioned. It is commonly situated within i I-2 inches of the pylorus, though Schwartz reports a case where perforation was found on a level with or a little below the ampulla of Vater, permitting a free escape of bile into the peritoneal cavity.* This condition is much more apt to be con- founded with other surgical lesiohs of the abdomen, and especially appendicitis. * Quoted bv Robert F. Weir in an admirable paper on " Perforating Duodenal Ulcers," in " The Medical News," May s, igoo, p. 690. 360 DISEASES OF THE DIGESTIVE SYSTEM. Morbid Anatomy, — Gastric ulcer must be distinguished from post- mortem softening or digestion, which is found after death in stomachs in which gastric juice happens to be present at the moment of death. In this there may be erosion of the superficial mucosa, but nothing comparable to ulcer. The seat of postmortem softening is more commonly the fundus and posterior surface, where the gastric juice naturally collects. The typical gastric ulcer is circular in outline, often with sloping, clean- cut sides, furnishing a crater or truncated cone shape, with the broad end superficially placed, corresponding to that of an infarcted area due to embo- lism or thrombosis. The term " punched out " has long been applied to char- acterize the appearance of a gastric ulcer. The sides are not always, how- ever, smooth, being sometimes uneven or " terraced." Aery rarely ulcer mav be multiple. It is far more frequent on the posterior wall of the stomach near the lesser curvature. W. H. Welch's extensive studies of hos- pital records furnish the total of 783 cases, of w-hich 288 were in the lesser curvature, 225 on the posterior wall. 95 at the pylorus. 69 on the anterior wall, 50 at the cardia, 29 at the fundus, and 27 in the greater curvature. The lesser curvature and posterior wall are, therefore, the miore frequent seats. This is the result also of Langerhans' studies, though Ewald and Nolte, from a very much smaller number of cases, conclude that more ulcers are found at the greater curvature and pylorus. The duodenal ulcer is found just out- side the pylorus, but m.ay occur as low dovrn as the biliary papule. It pre- sents the same appearance as the characteristic gastric ulcer. The floor of the ulcer is usually the muscular coat, but it may be the serous coat, which is sometimes perforated so that the floor may be formed by an adjacent organ to which the stomach has been glued by adhesive inflam- mation. The ulcer is usually small, not larger than a pea, but it may be 10 or even 15 cm. (4 to 6 inches) in diameter, covering the whole lesser curva- ture and part of the anterior and posterior walls. Ulcers may heal, leaving a cicatrix, which, if large, causes contraction and deformity, distorting the organ even to an hour-glass shape and producing stenosis of the pylorus. It is not unusual to find healed ulcers at autopsies. Or tJie ulcer may perforate, causing fatal peritonitis when in the anterior wall ; or, if apposed to neighbor- ing organs, these may be burrowed into. Thus the pericardium and left ven- tricle, the spleen, the head of the pancreas, the left lobe of the liver, the gall- bladder, the omental tissues, the pleura, and even the lungs have been invaded, while fistulous communications have been formed with the duodenum, the colon, and even the external air jn the neighborhood of the umbilicus. Per- foration of the posterior wall opens the lesser peritoneal cavity, and may per- forate the pleura, producing subphrenic pyopneumothorax. It is not unusual to see at the bottom of an ulcer an eroded blood-vessel from which there has been a fatal hemorrhage. The vessels invaded may be the gastric artery of the lesser curvature, or the splenic artery in the pos- terior wall ; or, in the case of a duodenal ulcer, the pancreatico-duodenal artery; or it may be the hepatic artery, and even the portal vein. Small aneurysms have been found in the floor of an ulcer. Gastric ulcer may be multiple, it is said, as often as once in every five cases. Osier records a case in which there were 5 ulcers and refers to a case, reported by Berthold, in which there were 34. Symptoms. — The most prominent symptoms of ulcer of the stomach are pain, tenderness, vomiting, hciuorrhage, and sometimes a tumor, but none of these is invariably present. They require to be separately considered. GASTRIC AND DUODENAL ULCERS. 361 Pain, with tenderness, is the most constant symptom. It is character- istic of the pain of ulcer of the stom^ach that it occurs almost immediately after taking food, especially after cold or hot and indigestible food; but it may also occur in an empty stomach — that is, several hours after a meal, when all food has disappeared. The latter pain is, however, of a different kind, being of a gnawing character, and is even temporarily relieved by tak- ing food. The pain typical of ulcer — a gastralgia, coming on in from ten minutes to half an hour after eating — is perhaps due not so much to the presence of the food as to the irritant effect of the acid gastric juice called out to digest it. It varies greatly in severity, and is further characterized by having a definite center of greatest intensity, commonly in the epigastrium near the xiphoid, less often at a point behind the shoulders, from which it radiates in all directions. A change of position also sometimes increases it, especially turning to the right side, probably due to the irritation of the ulcer by the moving gastric contents. The paroxysms are sometimes of inde- scribable severity, requiring the hypodermic use of morphin to relieve them, though they may also be relieved at times by a full dose of sodium bicarbon- ate, the effect of which also explains their immediate causation. Commonly increased by pressure, it is sometimes relieved by it. and the patient will bend over, pressing his fist into the epigastrium or leaning over the back of a chair to secure relief. Tenderness on pressure is a characteristic symptom, apart from the par- oxysms of pain ; and in order to guard against it, the patient may wear the waistband low. Boas has devised an instrument by which circumscribed pressure may be conveniently induced and diagnosis facilitated. It is, how- ever, necessary to exercise care in such pressure, as perforation mav be pro- duced. The tender point is more frequently an inch or tzuo above the um- hiliciis. In cases of ulcer of long standing palpation may recognize a tumor, the result of inflammatory thickening in the vicinity, and I well remember a case where, in consequence of the distinctness of the tumor, I diagnosed with some confidence a cancer of the pylorus, and a few days later the patient died of a hemorrhage from the stomach. An autopsy revealed extraordinary thickening of the pylorus, penetrated to a great depth by an ulcer, at the bottom of which lay a little perforated artery, whence came the fatal hemorrhage. Vomiting is not so frequent a symptom. When present, it occurs usually soon after the ingestion of food, about the same time as the pain. It often includes acrid acid matters. And this brings us to hemorrhage — hematemesis — a most valuable sign of gastric ulcer. Given a copious hemorrhage of pure red blood from the stomach, with the symptoms described, or even no other symptoms, it can scarcely be due to any other cause ; since although cancer gives rise to hemor- rhage, the blood is mixed with mucus ; it is usually less copious, while a cancer with hemorrhage rarely fails to furnish also the other symptoms of cancer. In a few instances in ulcer the hemorrhage is small, when, of course, the diagnosis becomes more difficult. When the hemorrhage is large, blood quite black is found also in the stools. Indeed, sometimes the presence of blood in the stools is the first intimation of gastric hemorrhage. Especially is this the case when the ulcer is duodenal. A very remarkable case of this kind came under my care in a nurse at the Philadelphia Hospital. When I first saw her, her appearance and condition suggested hemorrhage from somewhere. She was extremely weak, and her lips were bloodless. Her 362 DISEASES OF THE DIGESTIVE SYSTEM. skin was as white as marble. Yet no sign of hemorrhage appeared at the time of examination. Three hours later she had a copious hemorrhage from the stomach, and further examination elicited the fact that Jier stools had contained blood for tz^'o days. Hemorrhages from ulcer are also often recur- rent, and result at times in intense anemia of the subject. They are not rarely fatal, more frequently syncopal, bringing their subjects to the verge of the grave, from which there are often also surprising recoveries. A hema- temesis of 10 pounds (41-2 kilos) is said to have been followed by recovery. Vicarious hemorrhage in menstruating women is to be remembered as a possible event, but the hemorrhage is not usually copious, and its associa- tion with amenorrhea aids in clearing up doubt. Hemorrhage occurs in more than half the cases, at least in hospital practice, since the severest cases come to hospitals. In private practice the proportion is smaller. In this place it may be appropriate to mention what has been called parenchymatous hemorrhage, in which there has been fatal hematemesis in which no ulcer has been found at necropsy. It is more than likely that some of these cases may have been cases in which the ulcer eluded examination, but others are too well authenticated to be thus explained. Perforation is a rare accident in ulcer of the stomach. It is variously stated at from 6 to 18 per cent, of all cases. Its characteristic symptoms are sudden and violent pain, extreme tenderness, rigid contraction of the abdominal muscles, profound shock, shallow breathing, and absence of the normal hepatic dullness — in a word, the symptoms of peritonitis, followed by those of shock. Perforation is much more frequent when the ulcer is in the anterior wall. Thus, in 13 cases reported by A. B. Mitchell to the " British Aledical Journal," March 10, 1890, all were in the anterior wall. The milder symptoms of dyspepsia may also be present in various degrees, including a sense of fullness in the epigastrium, acid eructations, heartburn, and loss of appetite. Patients with gastric ulcer lose in weight and become gradually anemic, quite independent of hemorrhage, a? evidenced by a blood count, which some- times finds the red corpuscles less than a million to the cubic millimeter. This is probably due to the fact that they are afraid to eat enough because of the pain food gives them when taken into the stomach. This anemia is even a characteristic symptom, and should at once suggest a close examination as to a possible cause in ulcer. Chemical examination of the stomach-contents after a test meal almost invariably shows an increase oi HCl. Exception sometimes occurs when chronic catarrhal gastritis is associated. Finally, it is to be remembered of gastric ulcer that it is often latent throughout, quite without symptoms during life, and recognized for the first time at necropsy, when, also, as already stated, healed ulcers are sometimes found. Course and Termination. — The course of ulcer is usually slow, some- times very protracted. One case, which had lasted twenty years, confirmed hy autopsy, came under my treatment. A few cases are acute and rapidly fatal. The symptoms of gastric ulcer quite frequently disappear, and after a time, even considerable time, recur giving rise to the so-called recurrent forms. Diagnosis. — In some cases this is easy ; in others, difificult or impossible. If hemorrhage of the kind described is present in connection with the other symptoms named, it affords conclusive evidence of ulcer, but in its absence GASTRIC AND DUODENAL ULCERS. 363 there must often remain doubt. Aside from hemorrhage the most character- istic symptom is pain, and only in gastralgia and tabes dorsahs do such pains occur. In gastralgia, as in ulcer, hydrochloric acid is increased, and the ques- tion often becomes a m.ost difficult one to settle. In gastralgia, however, the general health of the patient is less severely affected, there is less chlorosis or menstrual derangement, and the pain has a less definite relation to taking food, — indeed, is often relieved by food, — while in ulcer the symptoms of dys- pepsia are more constant. There are longer intervals between the attacks in gastralgia. Above all, in ulcer there is tenderness on pressure between the attacks of pain, a symptom absent from gastralgia, while pressure always relieves the pain of the latter. Indeed, in gastralgia dyspeptic symptoms be- tween the attacks are generally absent. If palpation recognizes a hardening, there is further reason to believe the case is one of ulcer, ^^'e may look for assistance from the standpoint of etiology. Given the causes of ulcer, espe- cially valvular heart disease with possible embolism, the vomiting which pro- duces thrombosis, or the occupations which favor gastric ulcer, their import should be recognized. Gastralgia occurs in neurotic individuals — those sub- ject to hysteria and uterine disease. \'on Leube has called attention to an electrical test between gastralgia and ulcer — viz., if during digestion an elec- trical current, especially with the anode as a testing-pole, be applied, and the pain disappears completely, it is indicative of gastralgia ; if, however, it does not cease, it may be either gastralgia or ulcer. Only the positive effect, the sud- den cessation of pain on the application of the current, is of diagnostic value. In tabes the gastric crises are almost identical with the severe gastralgic attacks of ulcer. But in tabes the appearance of good health is preserved, while it is not long before the distinctive symptoms of the disease show them- selves, if they are not already present — viz., lightning pains, ocular symp- toms, and absence of knee-jerks. In tabes the extreme acidity of the gastric contents characteristic of ulcer is wanting in most instances. In rare cases intercostal neuritis may be mistaken for ulcer, if there be pain in the epigastrium associated with accidental dyspeptic symptoms. But in this aft'ection painful points will also be found in the course of the inter- costal nerves, while, if a large fold of the abdominal wall be raised, tender points will be found in it. From cancer of the stomach ulcer sometimes is distinguished with diffi- culty in the absence of the more distinctive symptoms of the former disease. Heretofore much reliance has been placed on the absence or extreme dimi- nution of free hydrochloric acid in cancer as contrasted with its excess in ulcer. It has, however, been realized also that it occasionally happens that the association of chronic catarrhal gastritis with ulcer may work reduction of HCl. The recent researches of Boas have, if confirmed, added a very much more reliable diagnostic sign in the invariable presence of lactic acid in cancer and its constant absence in ulcer, and, indeed, under all circum- stances in which it has not been introduced from without. Other facts to be weighed in the balance as to the existence of cancer are a palpable tumor, the greater age of the patient (always over thirty), the extreme emaciation and cachectic appearance, and the intermittent vomiting of large quantities of accumulated ingesta, sometimes of blood mixed with mucus, or blood pre- senting the " coft'ee-grounds " character as contrasted with the bright clear blood of ulcer. Rarelv is duodenal ulcer distinguished before death from gastric ulcer, 364 DISEASES OF THE DIGESTIJ^E SYSTEM. though Burwinkel claims that by a careful study of the symptoms he has been able to diagnose five cases of duodenal ulcer in the last five years. The former mav be suspected when pain is in the right hypochondriac region two or four hours after eating : also, if the blood be discharged by the bowel rather than vomited. \'omiting is less frequent than in gastric ulcer, and does not afford relief, as in the former. Jaundice is more frequent in duo- denal ulcer. Jaundice is, however, more constantly, though not invariably, associated with biliary colic, which has also been mistaken for ulcer. In biliary colic the liver may be enlarged and tender and the gall-bladder dis- tended, while the vomiting, which attends it as well as ulcer, is much less acid in reaction. Attempts to locate the ulcer still more precisely have generally proved fruitless. Even when a single painful, unchanging, circumscribed spot has been noted, the apparent seat so rarely coincides with the actual seat that little encouragement is afforded further attempt. When pain immediately suc- ceeds deglutition, especially of solids and hot and cold liquids, there is some reason to believe that the ulcer is in the neighborhood of the cardia, but it is by no means conclusive. Prognosis. — Xot only the disappearance of symptoms, but also the dis- covery of numerous healed ulcers at autopsies of patients dying from other causes, attest the fact that recoveries are not infrequent. Death is caused, as a rule, by hemorrhage or perforation, the latter followed by fatal peritonitis. At least six per cent, of all cases terminate in perforation, which, previous to the institution of operative treatment, was followed by death in the vast majority of cases, in a few hours. The proportion of death in all cases is estimated by \\\ H. Welch and A. B. ]\Iitchell at 15 per cent. ;* by Heyden- reich at from 25 to 30 per cent. ;t by v. Leube at 10 per cent. Treatment. — The indications for treatment are evident, and are, in the main, easily fulfilled. It is plain, in the first place, that food which taxes the secretory or motor functions of the stomach is harmful, and that recovery will be still more likely to occur if the stomach can be placed at total rest, a condition easily met by rectal alimentation. It is clear, too, that absolute rest of body further fulfills such conditions. The greater the stringency with which these measures can be carried out. the greater the chances of a cure, which is always possible. It goes without saying that all solid food should be disallowed. The typical nourishment in my experience is peptonized milk, which should be given at stated intervals, the quantity adapted to the urgency of the symptoms, say 2. ounces (60 c. c.) every two hours, though even this amount may have to be reduced in serious cases, to be increased as danger subsides and the appetite of the patient demands it. Beef peptonoids and egg-albumen may be substituted for milk, or they may be conjoined with it. So, too. when extreme danger of repeated hemorrhages is present, it is a warning that rectal alimentation alone should be relied upon : for which purpose, too. peptonized milk is also the best nutrient. Great care must be exercised in the use of enemas not to exhaust the toleration of the bowel. To this end they should be given at first tentatively and never oftener than once in eight hours, and should not at first, at least, exceed four ounces. This quantity, if borne, may be increased to six ounces. The various meat pep- tones, bouillon, or beef-juice may be substituted for or alternated with the * " British Med. Jour.," March lo, looo. p. 560. t Ibid.s p. 364; quoted by Mayo-Robson from "Semaine Medicale," February 2, 1898. GASTRIC AND DUODENAL ULCERS. 365 peptonized milk, or an egg may be beaten up with the milk, though such addi- tion is not often necessary. A nutrient injection which has given great satis- faction at the Hospital of the University of Pennsylvania consists of four ounces of milk (130 c. c), to which are added tv/o eggs, a pinch of salt and three drops of laudanum, the whole being predigested with pancreatin. The enema should be given through a long rectal tube, the patient having the hips elevated and the position maintained for an hour after the injection. In this way patients may be nourished for weeks with peptonized food, but it is rarely necessary to continue the rectal alimentation for more than a week or ten days. As the hemorrhage and vomiting cease the stomach may be tested, first with small amounts of peptonoids, gradually increased ; and for a time the two methods may be pursued jointly, feeding by the mouth being increased, while that by the rectum is gradually withdrawn. Plain milk and beef- juice may be substituted for peptonized milk, and various thin gruels made with flour may be used as a change is demanded. Lavage, which is of such signal service in chronic gastric catarrh, is hardly safe in ulcer on account of the danger of producing perforation ; but in some cases, when vomiting has been obstinate, lavage has been found bene- ficial. To arrest the vomiting, it is safer to rely on rectal alimentation, though the usual remedies may be tried, including blisters to the epigastrium. Medicines are not to be decried in ulcer of the stomach. Silver nitrate maintains the reputation it has so long enjoyed in the treatment of gastric ulcer. One quarter of a grain (0.016 gm.) three times a day or 1-6 of a grain (o.oii gm.) four times are the usual doses, given on an empty stomach. Of late I have been giving it by preference in solution in about 2 ounces (60 c. c.) of water. If there is pain, the extract of opium should be combined in pill in the same or larger doses, but should be dispensed with as soon as not needed. The extract of belladonna in small doses may be sub- stituted as the opium is withdrawn. Its anodyne effect is perhaps slight, but it has a good effect upon the bowels. Local measures may be employed to relieve the pain, such as warm poultices and other hot fomentations to the epigastrium ; and when more potent measures are needed, morphin may be used hypodermically. The hemorrhage requires also to be met by remedies. For the present all astringent remedies have given place to suprarenal extract or its active principle adrenalin, of which 5 drops of a solution i to 1000 are a dose repeated. Gelatin is a modern remedy of which the value is exaggerated. It may, however, be used, especially as it serves also the purposes of a food. Two to three ounces may be given every six hours. Among the older remedies tannic acid is one of the best — in 15-grain (i gm.) doses, every fifteen minutes, until the bleeding ceases. In the absence of this drug alum may be given, dissolving a teaspoonful in a glass of water, of which one-fourth should be given at short intervals. Pieces of ice may also be swallowed. After the attack is controlled the persulphate of iron, in doses of 1-4 to 1-2 grain (0.0165 to 0.033 gm.), in a pill three or four times a day, may be used to prevent recurrence. Recently Tripier has called at- tention to copious enemas of hot water for gastric hemorrhage, repeated twice daily, at a temperature of 112° tp 120° F. (44.4° to 48.8° C), conjointly with small doses of hot water by the stomach. The acidity which is characteristic of the secretion in gastric ulcer has sometimes to be met, and for this purpose full doses of sodium carbonate or bismuth subnitrate, 15 to 30 grains (i to 2 gm.), may be given. When 366 DISEASES OF THE DIGESTIVE SYSTEM. aperients are needed, as is sometimes the case, the Carlsbad salt becomes suitable, because of its alkalinity and its adaptation to the catarrhal state often associated with ulcer. A teaspoonful may be given in the morning dis- solved in a glass of warm water, or a tablespoonful may be added to a pint of warm water and taken in divided portions during the day. Small doses of magnesium sulphate may be substituted, though, as a rule, the bowels should be regulated by enemas rather than by purgatives. Tlie resulting chlorosis or anemia may be treated with iron and arsenic. Of the former, the neutral preparations are to be preferred ; of the latter^ Fowler's solution, because of the easy regulation of the dose. Large doses of iron should not be given, since the excess of such doses remains unabsorbed, astringing and irritating the alimentary canal. The tincture of the chlorid, so valuable usually, is especially contra-indicated, because it increases the acidity of the gastric juice and thus favors the solution of the gastric wall. Operative Treatment of Gastric Ulcer. — This has become an impor- tant measure of curative treatment, not only after perforation, but also for the cure of non-perforating ulcer causing recurrent hemorrhage. Operation for non-perforating gastric ulcer is recommended by modern surgeons in serious cases, and cases are considered serious where there is either very copious single hemorrhage or recurring hemorrhage. Thus, Dieulafoy advises oper- ation after the first hemorrhage if as much as half a liter (500 c. c.) of blood is lost and if the bleeding is repeated in twenty-four hours. W. L. Rodman * says that " as soon as the bleeding from a second serious hemorrhage ceases and the patient has rallied from the shock and is in good condition," some operation should be performed. Rodman tabulates 63 operations for acute and chronic hemorrhage with 20 deaths, or a mortality of 32.6 per cent. It is scarcely possible for recovery to take place after perforation with- out operation, but after operation at the present day at least 50 per cent, recover. The first successful operation was by Kriege, in Germany, in 1892. Up to 1894 results were far from satisfactory, when, of 85 cases collected by Mikulicz, only one recovered. On the other hand, out of 125 cases collected by Gofife up to the end of 1897, 63, or 50 per cent., recovered. Hence, opera- tion should be borne in mind as a treatment for which w^e should always be in readiness.f CANCER OF THE STOMACH. Synonyms. — Carciiwiua ventriciiU; Gastric Cancer. Etiology. — Little definite is known of the etiology of cancer. Heredity- is an acknowledged factor, though it is less potent than is commonly sup- posed. W. H. Welch i was able to trace cancer, or at least a family history of cancer, in 242 out of 1744 cases. There is some evidence to show that abuse of the stomach by eating and drinking may be influential in causing the disease, though it is not conclusive. The same has been claimed for the depressing emotions. There is better reason to believe that ulcer is a predis- posing cause, since autopsies have disclosed cancer developing in the floor of * Oration on Surgerj- delivered at the Fifty-first Anrmal Meeting of the American Medical Associ- ation. Atlantic Citv. June 5-8, iqoo. t See also Dr. Weir's article, referred to, on "Perforating Duodenal Ulcers," " Medical News," Maj' 5, iqoo. X " System of Medicine by American Authors," vol. ii. Philadelphia, 1886. CANCER OF THE STOMACH. 367 ulcers and in cicatrices. Mention should be made of the fact that a parasitic origin of cancer is claimed by some, but the subject is altogether too unsettled to justify more than reference in a text-book. Gastric cancer is a disease of mature life, three-fourths of all cases occurring between the fortieth and seventieth year. One of my patients was thirty-two when he first consulted me, and died just one year later. Adolf Struempell has seen cases between twenty-two and twenty-five. George Dock * reports three cases occurring in his own practice, where the patients were twenty, twenty-four, and twenty-one years of age, confirmed by autopsy, and Marc Mathieu published in 1884 a monograph, " Du cancer precose de I'estomac." The disease is slightly more frequent in men than in women. Pathology and Morbid Anatomy. — After the uterus, the stomach is the organ most frequently attacked by cancer, a little more than one-fifth of all cases of primary cancer being found in this organ — according to Welch, 21.4 per cent., from an analysis of the very large number of 30,000 cases. It is far more common in the pyloric end and on the lesser curvature, 1300 cases collected by Welch being distributed as follows: pyloric region, 791; lesser curvature, 148 ; cardia, 104 ; posterior wall, 68 ; whole or greater part of the stomach, 61; multiple, 45; greater curvature, 34; anterior wall, 30; fundus, 19. Every variety of cancer is found in the stomach, in the following order of frequency : 1. Cylinder-celled epithelioma, most frequent at the pylorus. 2. Medullary or soft cancer, most frequent in the smaller curva- ture. 3. Scirrhus, at the pylorus and in the smaller curvature, causing, espe- cially, stenosis of the pyloric orifice. 4. Colloid, diffuse infiltration with a tendency to spread to the perito- neum and adjacent organs. 5. Melanotic. 6. Squamous epithelioma, near the cardia. All the forms start from the gland cells of the mucous membrane. The medullary variety is prone to ulcerate and to form extensive fun- goid ulcerated surfaces, from which there may or may not be hemorrhage. It may be associated with scirrhus. While nodular outgrowths are usual, the cancerous tissue may infiltrate the walls, producing diffuse thickening. Secondary cancer of the stomach is an occasional event: in 17 out of 37 cases, according to Welch, secondary to primary cancer of the breast. I have met one case succeeding epithelioma of the lip. Much more frequently primary cancer of the stomach is a cause of secondary cancer elsewhere, most often in the adjacent lymphatic glands, which were the secondary foci in 551 out of 1574 cases collected by Welch; the liver was involved secondarily 475 times ; the peritoneum, omentum, and intestine, 357 ; pancreas, 122 ; pleura and lung, 98 ; spleen, 26 ; brain and meninges, 9 ; other localities, 92 ; among the latter is to be included adjacent integument, especially about the navel. Marked changes in the size, shape, and position of the organ occur as a result. Most common is dilatation, sometimes due to pyloric obstruction. Medullary cancer, on the other hand, is apt to produce a reduction in the size of the stomach and its cavity. A reduction in size may attend obstruc- tion at the cardiac orifice, because of disuse of the organ, while the esophagus * " Transactions of the Association of American Physicians," vol. xii., 1897. 368 DISEASES OF THE DIGESTIVE SYSTEM. itself may be dilated. The same effect may be produced by cancerous infiltra- tion of the stomach walls, by which the capacity of the organ is greatly reduced — in one instance, a case of Livingstone's, to 12 ounces. Further reference will be made to extraordinary dislocation of parts of the organ in treating of symptoms. Adhesions may also form between the stomach and adjacent organs, and between it and the anterior abdominal wall. Peritonitis may occur; also perforation into an adjacent organ, as the transverse colon, and even the small intestine. Symptoms. — The initial symptoms in almost every form of cancer of the stomach are those of indigestion, including anorexia, eructations, vomit- ing, constipation, discomfort, and pain, more rarely acidity. These are present for a variable time before a more serious condition is suspected. Increase in the severity of symptoms despite the use of remedies, progressive debility, emaciation, and cachexia invite closer examination, which may or may not result in the discovery of a tumor. Before a tumor is recognized there is often tenderness, which follows sooner or later, if it does not precede tumor. Cachexia and wasting may also be present a long time before the tumor is discovered. A chemical examinaton of the gastric contents after a test meal may dis- close the absence of free and combined hydrochloric acid or a minimum of it, and Boas' results are confirmatory of the persistent presence of lactic acid in decided quantity, to which, as well as to the absence of hydro- chloric acid, attention was originally called by von der Velden. As to hydro- chloric acid, it must be remembered that it is also diminished in gastric catarrh, in atrophy of the mucous membrane, in amyloid degeneration, and even in nervous dyspepsia at times, while in rare instances it happens that hydrochloric acid is increased in cancer. The motor as well as the secre- tory and absorbing functions will be found impaired, undigested food being found long after the seven hours' limit. Such motor delay characterizes more particularly the pyloric situation of cancer, with its resulting obstruction. The Oppler-Boas bacillus was first described by Oppler in 1895, as an unusually long and thread-like bacillus, non-motile, found in the contents of carcinomatous stomachs.* The bacilli lie either end to end, in long thread- like chains, or at right angles to one another. They stain readily with ani- lin dyes. They prefer a medium containing lactic acid ; indeed, Kauffmann ascribes to the bacillus the power of forming lactic acid from various kinds of sugar. Hydrochloric acid in any large proportion causes it to disappear. Schlesinger and Kauffmann declare the presence of large numbers of the bacilli in association with pyloric stenosis to be an indication of carcinoma, and their absence, associated with the absence of lactic acid, to be evidence against carcinoma. Riegel does not consider the organism pathognomonic of carcinoma, but very important in its diagnosis. Stockton says it is often present in carcinoma, and has not been found in other diseases of the stomach. The Oppler-Boas bacillus and sarcinse do not coexist for any length of time in carcinomatous stomachs. The sarcina thrives in the presence of hydro- chloric acid, and disappears with it, being replaced by the Oppler-Boas bacillus and lactic acid. Even when introduced into the stomach in cases of obstruction due to carcinoma, the sarcinae disappeared in twenty-four hours, the Oppler-Boas bacillus seeming to replace them. * Boas, " Specielle Diagnostik tind Therapie der Magenkrankheiten." Oppler, " Deutsche medi- cinische Wochenschrift,"i8g5, No. 5. CANCER OF THE STOMACH. 369 In evidence of the value of the Oppler-Boas bacillus in diagnosis of gas- tric carcinoma it may be said that Kauffmann * found it in 19 out of 20 cases, and in the one in which it was absent there was no lactic acid. John C. Hemmeter informs me that he found the bacillus in 52 out of 55 cases, that he regards it " an important diagnostic sign in carcinoma of the stomach, within limitations, and though it is by no means pathognomonic." He has found it in a case of benign pyloric stenosis, and also in such cases when HCl was still present. Ullman, of Buffalo, N. Y., found it in all of lo^cases. If this test should prove reliable at an early stage of the disease, the ■chances of success of operative treatment will be greatly enhanced. Fig. 30.— Oppler-Boas Bacillus, from Co-ntents of a Carcinomatous Stomach— {Hefn/neter). At a later stage periodic vomiting of large quantities of fluid containing the ingesta of hours and even days previous is a characteristic symptom, and a dilated stomach may now be easily demonstrated. The vomitus may also contain blood, and that peculiar mixture of blood and gastric juice which is called " coffee-grounds " vomit. If, owing to their disintegration, the microscope does not recognize blood discs, Teichmann's hemin crystals may be easily prepared as directed on page 79, footnote. The vomited matter is sometimes very foul-smelling, as are also at times the eructations. Vomiting is by no means an invariable symptom, though even when there is no vomit- ing, nausea is commonly present. The absence of vomiting generally means that the cancer is not at the pylorus. It may be at the middle belt, at the fundus, or at the cardiac end. When at the latter point, there is almost always difficult and painful deglutition. By this time the patient is emaciated, anemic, cachectic, with a peculiar yellowish, sallow, swollen appearance, and now a tumor is commonly easily recognized by palpation. Very interesting is the varying situation of the tumor, as well as at times its great mobility. Almost never, in my experi- ence, is the tumor of pyloric cancer found in the normal situation of the pylorus, even when the patient is lying on his back, but rather in the neigh- borhood of the umbilicus, a little to the right or left. It is the weight of the tumor which drags it out of the normal position of the pylorus, and it may be found even lower down, toward the symphysis pubis, as in a case * KaufEmann and Schlesinger, " Wiener klinische Rundschau," 1895, No. 5. 24 370 DISEASES OF THE DIGESTIVE SYSTEM. of Struempell's. The tumor itself may be fixed in the position it assumes, or it may be freely movable. Its location is usually uninfluenced by breath- ing, and in this respect it contrasts with tumors of the liver and spleen. It rarelv gives a positive dull note on percussion — rather a muffled note. In a certain number of cases no tumor can be detected throughout the whole course of the disease, it is said in 20 per cent. Especially is this the case when the disease is toward the cardiac end. A rotary motion is sometimes characteristic of the tumor. Toward the end of life edema of the legs and ankles often appears, and an intensity of cachexia, which simulates pernicious anemia, — in fact, even furnishes the blood changes characteristic of this affection, — with extreme weakness and death. The urine is often scanty, and may give a decided reaction for indican. In a few cases a febrile movement makes its appear- ance, with chills and szveating at intervals, probably due to intercurrent in- flammation. To these symptoms are often added those of secondary cancer^ especially of the liver, including enlargement of this organ and jaundice. The signs of secondary cancer elsewhere than in the liver should be sought. The duration of cases of gastric cancer is from one to two years ; it may be less, especially if the cancer is ingrafted pn a pre-existing ulcer. Slow de- velopment is said to be characteristic of cases in younger persons. Diagnosis. — This is generally easy if time and opportunity be allowed for the study of a given case. Ulcer is perhaps the disease which furnishes most difficulty, especially as cancer may succeed it. On the other hand, the earliest symptoms of gastric cancer are also those of gastric catarrh, which in many cases is mistaken for cancer. The pain and the peculiar in- termittent vomiting are the first distinctive signs, and while coffee-grounds vomit may occur whenever moderate quantities of blood are poured into the stomach and mixed with gastric juice, the causes other than cancer are rare. The copious hemorrhage of ulcer gives bright red blood. Bloody vomiting is by no means always present in cancer. To the symptoms de- scribed are soon added the emaciation and cachexia, and the palpable tumor more evident after the stomach has been emptied out by vomiting or washing. In the meantime, however, the gastric contents will have been examined, and furnish their quota of information, not pathognomonic, but contributory. Very rarely does it happen that in the vomitus or washings of the stomach we obtain particles of morbid growth whose examination will disclose the struc- ture of cancer. There is not usually much, difficulty in fixing the location of the tumor supposed to be in the stomach. If there is doubt, it may be eliminated in part or altogether by filling the stomach with liquid and noting the efifect upon the tumor. In one instance I mistook cancer of the gall-bladder for cancer of the stomach, though I scarcely think it would happen again. The chief reason was because the tumor due to cancer of the gall-bladder was in the situation where the tumor of the pylorus might reasonably be expected to have been. There was jaundice with tenderness in the hepatic region, there were no signs of dilatation of the stomach, and the mistake was scarcely excusable. There is usually less interference with digestion in cancer of the gall-bladder, no mobility of the tumor, and often suppuration with incident fever. The distinction of gastric from pancreatic cancer demands some con- sideration. The tumor may be in the same position, but in a large propor- tion of cases of cancer of the pancreas there is jaundice. The tumor of a CAXCER OF THE STOMACH. 371 pancreatic cancer is often inaccessible. In the latter there are also symptoms of indigestion, like those of gastric cancer, but there is often also diarrhea, and frequently the liquid stools contain oil. Such diarrhea may be checked for a time by ordinary remedies, but in a few days the liquid discharges seem to burst through a barrier which held them temporarily in check. The pancreatic tumor, if felt, is also more immovable. Tumors of the liver and spleen are continuous with these organs, while the gastric tumor is generally easily distinguished from them by palpation or by an intervening tympanitic area. A cancer of the transverse colon may occupy much the same position in the abdomen as one of the stomach, and be also quite movable. The filling of the colon and stomach with water or air may also be availed of in diagnosis. As the growth in the intestine in- creases, obstruction may result and the tumor increase by the accumulation of fecal matter behind the stenosed portion. A rare complication, increasing the difficulty in diagnosis, is adhesion between the bowel and stomach, re- stricting motion and possibly causing perforation, through which fecal mat- ter may enter the stomach. Still more difficult, nay, even impossible, in most instances, is the distinction between duodenal and gastric cancer. The absence of hydrochloric acid would point to gastric cancer, though such absence, being due to atrophy of the gastric tubules caused by dilatation, may also occur in obstructive duodenal cancer. The acid might also be neutralized by regurgitated bile, regurgitation being favored by the stenosis of the gut. The presence of jaundice would point to duodenal cancer. Gastric tumors may be confused with omental tumors, which may also cause dyspeptic symptoms. But the omental tumor is usually a more nodular, uneven tumor, and is sooner or later associated with peritoneal effusion. 2\Ioreover, every tumor of the stomach is not a cancerous tumor, although most of them are. I have already mentioned my experience with a thickened pylorus associated with gastric ulcer. Such a circumscribed thickening and induration are always possible. We may have the same pyloric stenosis and secondary dilatation. Similar non-cancerous thickening mav even occur without ulcer. Other forms of morbid growths, such as fibroma, sarcoma, and the like, are too rare to demand notice from the clinical standpoint. Finally, the gastric tumor is not always demonstrable, and may not be throughout the whole course of its existence. It is said to be absent in about 20 per cent, of cases. Then the diagnosis must be made from the symptoms, especially the rapid wasting and cachexia, which are rarely simu- lated, even in ulcer. The age of the patient, generally past forty, the defi- ciency in HCl, and the presence of lactic acid must be allowed due weight. The cachexia of pernicious anemia resembles very closely that of cancer of the stomach, and, in the absence of appreciable tumor in the latter, may occasion difficulty. But a study of the blood will in most cases clear up a doubt. The number of red blood-cells in cancer of the stomach is rarely below 2,000,000, while in pernicious anemia it is often below 1,000,000 per cubic millimeter. This difference exists even while the cancerous sub- ject exhibits more emaciation and weakness than that of pernicious anemia. As F. A. Henry well puts it : " In cancer of the stomach the reduction in the number of red corpuscles does not keep pace with the cachexia; in anemia the cachexia does not keep pace with the destruction of cancer." Cancer of the stomach mav be latent throughout. 372 DISEASES OF THE DIGESTIVE SYSTEM. Prognosis. — This is inevitably fatal, but something may be done toward prolonging life by the proper cleansing out of the stomach, the selection and regulation of food, and measures to aid its digestion. The operation oi gastrotomy should be considered, as it sometimes prolongs life. Treatment. — Since the cure of cancer of the stomach is impossible, treatment must be directed toward prolonging the patient's life. I am quite sure that a great deal more can be done than is commonly thought possible. The limit of life of the victim of established gastric cancer does not exceed two years. The stomach has no use outside of the preparation of the food for absorption. It is not a vital organ in the sense that the heart and the lungs are vital organs. It is important so far as it prepares the food, but if the food can be prepared for absorption outside of the body, its importance is diminished. So it is if we introduce artificially digested food by the rectum. Or we may use both of these methods. We can, by the use of prepared food, diminish the labor of the stomach, and by using the rectum we can, while doing so, relieve the stomach of all labor. This is rendered easier at the present day by the use of peptonized foods of various kinds. The food may be peptonized at home, or the peptonized products of manufacturers may be substituted. First in order of simplicity is peptonized milk. Three to five grains (0.2 to 0.3 gm.) of the extract of pancreas with about 15 grains (i gm.) of sodium carbonate are added to a pint of milk, and the mixture placed at a temperature of 100° F. (37.8° C). In one hour all the casein will be peptonized. A curd is first produced, which subsequently undergoes solution. If peptonizing is complete, the addition of rennet will not produce coagulation. Milk thus prepared makes little demand upon the stomach for digestion, and it can be introduced advantageously by the rec- tum. Peptonized milk has a slightly bitter taste, and unless this bitterness is present, its digestion is unaccomplished. The digestion will take place at a lower temperature than 100° F. (37.8° C), but it takes longer.* Beef may be peptonized for rectal alimentation as follows : Take half a pound of beef with the fat removed and a quarter of a pound of fresh pancreas. The pancreas is finely chopped and afterward bruised in a mortar with tepid water at a temperature of 100° F. (37.8° C). It is then placed in a saucepan, and a raw egg is beaten up and intimately mixed with the meat, previously chopped into small pieces. The product is next allowed to stand at a temperature of 100° F. (37.8° C.) for two hours. It is then strained, after which it^is ready for use. This amount suffices for two daily injections. The preparation decomposes very quickly, so that it has to be made fresh every day. I have been surprised at what I have ac- complished by this method, which is essentially one recommended by Mayer, of Lyons. In a case where nothing could pass the pylorus, under the use of daily nutritious enemas there occurred each morning an evacuation from the bowel as natural as when the patient was living on a mixed diet and digesting it properly. The enterprise of the manufacturing chemists and pharmacists has *The following method, slightly modified from that usually recommended, has been found most satisfactory after numerous trials by patients: Take one pint of skimmed milk, to which add one gill of water. Heat to 140' P. (60° C.)— a temperature at which the finger can be immersed for half a minute. After taking from the fire stir in three grains (0.2 gm.) of powdered pancreatin and 15 grains Ci gm.) of carbonate of sodium. Place in a covered kettle or jug and roll up in a cosey (an ordinary gossamer waterproof coat answers admirably well), near a stove or register to keep warm. Let it remain thus for an hour and a half. It then resembles slightly thickened milk, but there is no curd. Pour it into a covered pitcher, and set aside to cool in the open air. Thus pre- pared, it has the slightest perceptible tinge of bitterness, and is very palatable. DILATATION OF THE STOMACH. 373 resulted in the preparation of a number of beef peptonoids and extracts which may be substituted, but I never feel quite so sure of them as of the product made at home, troublesome as its preparation is, because it seems impossible to learn the nourishment equivalent of the manufacturers' product. However careful the preparation of food, when taken into the stomach in these cases, only a part is used up, and there accumulates gradually a quantity of unabsorbed material which does not pass the pylorus, and to this a copious mucous secretion is added. Hence, occasionally, once a day or every other day, it is desirable to wash out the stomach with water as hot as can be borne, or alkaline waters, as described in the treatment of gastric catarrh. The free use of hydrochloric acid as a medicine also aids not only in the solution of the food ingested, but prevents the fermentations, which contribute irritating acids to the gastric contents and cause further mischief and discomfort. DILATATION OF THE STOMACH. Synonym. — Gastrectasia. Definition. — A permanent increase in the volume and capacity of the stomach, the result (i) of nervo-muscular atony or (2) of pyloric obstruc- tion. It is to be distinguished from temporary distention and simple large stomach. Etiology. — (i) The nervo-muscular atony causing dilatation may be the result of habitual overeating, especially food of defective quality, result- ing in stasis and fermentation ; of excessive drinking, as in beer-drinking employees of breweries ; of chronic gastritis ; of diseases producing general nervo-muscular atony, such as disease of the spinal cord, pulmonary con- sumption, anemia, chlorosis, acute fevers, affections of the heart, liver, and kidneys, and other diseases of' like import. (2) Mechanical or obstructive dilatation is most frequently due to obstruction from cancer at the pylorus or in the duodenum, or to cicatricial contraction, or to hypertrophic thick- ening. Such obstruction may also be due to pressure from without, as by cicatricial adhesion or tumor of an external organ or a floating right kid- ney. It is most frequent in middle-aged persons, but may occur even in children. Tight lacing, by producing dislocation of the stomach and ob- struction to the onward movement of its contents, may also be a cause of dilatation. Acute dilatation of the stomach is a possible, but rare, condition. It may succeed the rapid ingestion of enormous quantities of food and drink. Extreme paralytic dilatation may result, as in two cases described by Hilton Fagge, of which one proved fatal. Morbid Anatomy. — In addition to the increase of volume the coats of the stomach may be thinned and the glandular structure more or less atrophied. The average normal stomach of an adult holds about i 1-2 liters (three pints), while the abnormally dilated organ may attain a capacity of three or four liters (six or eight pints), and even more. Where the dilata- tion is mechanical, there is added the lesion which is responsible for the obstruction. Symptoms. — The symptoms arising from dilatation are a sense of 374 DISEASES OF THE DIGESTIVE SYSTEM. fullness in the epigastrium, eructations, flatulence, and vomiting, often of enormous quantities. The appetite is sometimes poor, at others quite good, and the patient is hungry and thirsty. The vomited matters are largely water, but include also remnants of food and every variety of fungus — viz., bacteria, sarcinse, yeast fungi, etc. Their reaction usually exhibits lessened acidity, because of diminished hydrochloric acid secretion, but it may be normal or even abnormalh- acid. Such abnormal acidity is the result of fermentations producing lactic, butyric, and acetic acids. Various gases are thus produced, including carbonic acid and hydrogen. The latter may also arise from decomposition of albuminoid substances, whence too arises sulphureted hydrogen. These fermentations are favored by the absence of HCl, the importance of which in preventing fermentation has been referred to, and by a stasis of the contents in the stomach ; for not only is absorption delayed, but the transit of gastric contents into the intestine is also hindered. Indeed, in some cases the stomach is never emptied unless by the tube. Nay, more ; it would seem that at times it contains more liquid than was ingested — a possible condition, since the endosmosis of crystalloids (viz., sugar, dextrin, alcohol, and peptones) is attended with the exosmosis of water. From such causes, too, occur torpor of the bozvel, scantiness of urine, and dryness of the skin. Anemia, emaciation, and debility sooner or later succeed, and in fatal cases death is commonly preceded by a drozi'si)iess, which may be due to the absorption of toxic substances arising in the decompositions going on in the stomach. Dilatation of the stomach is also one of the acknowledged causes of tetany, as first pointed out by Kussmaul. The cramps, though often quite severe, are of short duration. They occur chiefly in the muscles of the hands, arms, and legs. Von Leube suggests that this tetany may be due to a " drying out " of the nerves and muscles, but it may also be the result of auto-intoxication. Unconsciousness may precede death. Physical Signs. — These may be elicited by inspection, palpation, and percussion. Inspection does not always afford information, but in emaciated cases the greater curvature of the distended organ may be recognized as low as the navel and below, instead of from 1.2 to 2.8 inches above it (3 to 7 cm.). When the stomach is very low, even the smaller curvature may be recognized about two inches (5 cm.) below the ensiform cartilage, uncovering the pancreas. In obstruction of the pylorus the peristalsis from left to right may even be recognized stopping short at the pylorus, where the tumor-like thickening may sometimes be seen. In rare instances a reverse peristalsis, from right to left, takes place. Palpation may confirm inspection, recognizing the contour of the stomach by its peculiar consistence, which has been compared to that of an air-cushion, but affords little additional information unless there be a tumor at the pylorus which may be felt. Peristalsis, if present, may also be felt, and may be stimulated by filliping the abdominal walls with the fingers, by which also a splashing sound may be produced in the water-laden dilated stomach down as low as the greater curvature. This is to be distinguished from a similar splashing which may be obtained in the normal stomach and adjacent colon, the latter being less constant and less intense. If a stiff sound is used, its end may be felt through the abdominal walls, while the unusual extent to which it may be carried before meeting resist- ance will attract attention. Percussion affords the most valuable evidence as to the presence of a . DILATATION OF THE STOMACH. 375 dilated stomach, and in the majority of instances such evidence is conclusive. Auscultatory percussion is especially satisfactory in determining the outlines of the stomach, and the phonendoscope may be used with advantage. Per- cussion should be made in the standing position, if possible, from above dov^nward, beginning at the edge of the ribs in the neighborhood of the right parasternal line. The note is tympanitic until the upper curvature is reached, when it is substituted by dullness due to the liquid contents, to be succeeded again by tympany of the bowel when the lower border of the stomach is passed. If the patient lies on his back, the dullness disappears and is replaced by tympany. If there is no liquid in the stomach, a change in the pitch of the tympanitic note will indicate the transition from the stomach to the intestine. Further information can be gained by means of the tube, by which the stomach can be emptied and refilled with water and its borders determined by percussion. This is more satisfactory than filling the stomach with carbonic acid gas or air, and even such procedure is not always necessary. If the larger curvature be found by percussion at the navel or below, the stomach is certainly dilated. No reliable evidence of dilatation is furnished by auscultation. Diagnosis. — This is usually readily made by attention to the symptoms and physical signs described. Dilated stomach has, however, been mis- taken for an ovarian cyst, and abdominal section has been made for its relief. The question whether the dilatation is dynamic or mechanical — that is, whether it is the result of nerve-atony or obstruction by a tumor at the pylorus — can generally be decided by recognition of a tumor at this orifice. Vomiting is also more severe and frequent, and the peristaltic unrest is more active. Dilatation differs from falling, or gastroptosis, though descent and dilatation are often present in the same organ. According to Boas, dilata- tion can be distinguished from descent only when the greater curvature is below the umbilicus, and when the greatest vertical diameter of the stomach is from 10 to 14 cm. (4 to 5 1-2 inches). Different also is enteroptosis, or viseroptosis, which will be considered later. Prognosis, — When associated with malignant disease at the pylorus, recovery is, of course, impossible, as, indeed, it is in dynamic dilatation, but in the latter case much relief may be afforded to the symptoms. Treatment. — The most important part of the treatment is zvashing out the stomach, after the method detailed on page 348. This may be done daily, but sometimes it is sufficient to do it on alternate days, occasionally even twice daily. When practiced once a day, it is usually best done on retiring at night, as the stomach is thus freed for the night or irritating material which, if retained, disturbs rest and aggravates the local condition. The patient soon learns the most suitable time for lavage, and when its frequent necessity is determined, he should be taught to perform it. Of drugs, hydrochloric acid is the most likely to be useful, not only because of its importance as a digestive agent, but also as a preventer of fermentation. To this, pepsin becomes a useful adjuvant, because it is scantily formed in the dilated stomach. Nitro-miiriatic acid may some- times be substituted with advantage, especially when a stimulating effect is desired on the liver. It should be freshly prepared, and from three to five drops of a pure acid should be given to an adult at a dose. Strychnin is a drug which has much to recommend it from the theoretical standpoint as 376 DISEASES OF THE DIGESTIVE SYSTEM. a muscular conic, and has the further advantage of easy absorption. It should be administered in full doses from a small beginning, 1-30 grain (0.002 gm.) three times a day, increased to 1-20 grain (0.003 gm.) and even more. Extract of nux vomica may be substituted, but it is less easily absorbed. Tincture of nux vomica is better. It may be given in gradually increasing doses until 30 drops, or 15 minims, are given three times a day. In addition to the hydrochloric acid as an antiferment, other reme- dies for this purpose are charcoal and crcasotc. The power possessed by charcoal of absorbing gases cannot be utilized, because it possesses this prop- erty only in the dry slate. Yet it does relieve flatulence and is antiseptic. Such antisepsis may be extended to the intestine. Doses of charcoal of 5 to 10 grains (0.33 to 0.66 gm.) and even more may be given. Creasote is a useful antiseptic, and may be given alone, in capsule or in pill, in doses of 1-2 grain to a grain (0.03 to 0.06 gm.), or it may be given in sherry wine, whisky or brandy, or tincture of gentian. The fol- lowing one per cent, solution of creasote is a modification, by George Her- schell, of Bouchard's well-known formula: ij Creasoti, ' 10 Tr. gentianse, 20 Vin. xerici, ........... 800 Sp. vini gallici, 170 M. et Sig. One hundred minims contain one minim or one grain of creasote When the condition is part of the morbid anatomy of cancer of the stomach, only palliation may be expected. Dietetic Treatment. — Most important is the selection of food in these cases. Solids should be almost totally prohibited, while the typical nour- ishment is the various kinds of artificially digested food, such as peptonized milk and beef peptonoids. Of the latter, the dry form of beef powder is suitable, because it absorbs some of the excessive liquid sometimes present in the stomach. Beef-juice and rare beef scraped are also easily assimilated, while fatty, and especially starchy, foods are to be used sparingly, if at all. VISCEROPTOSIS. Synonyms. — Splanchnoptosis; Entero ptosis; Gastroptosis; Glenard's Disease. Definition. — A condition in which, as a consequence of the relaxation of the ligaments of the abdominal viscera, especially those of the stomach, intestines, kidneys, spleen, and liver, these organs fall below their normal position. Etiology. — An explanation applicable to all cases of visceroptosis has not as yet been made, although several suggestions are more or less appli- cable. First, Glenard, whose name is so closely identified with the subject that the affection is also called Glenard's disease, holds that a descent of the right or hepatic flexure of the colon, followed by dislocation of the transverse colon, is the primary disturbance in enteroptosis. The hepato- VISCEROPTOSIS. 377 colic ligament, which is the name he applies to the portion of the mesocolon that approaches the right flexure of the colon, he says is naturally very weak, and can be loosened and stretched by the weight of the transverse colon, particularly when this is loaded with feces. He thinks, too, that de- bilitating and emaciating diseases or loss of tonicity of the abdominal muscles by repeated pregnancies, by gastro-intestinal auto-intoxication, by exhausting hemorrhage, or by damage to the abdominal muscles by pres- sure of the clothing, may cause the same condition. The loss of fat in emaciation, however caused, undoubtedly favors its occurrence. When the hepatic flexure of the colon has sunk, the right half of the transverse colon also descends to the point of connection by the tense gastrocolic ligament with the pyloric end of the stomach. At this point the colon becomes kinked, causing stagnation of its contents, followed by dilatation of the colon in front of the constriction. Beyond this it contracts, and, according to Glenard, can be felt as a tense cord. As their ligaments become loosened, the remaining abdominal viscera follow the descent of the transverse colon, the stomach being drawn down by the gastrocolic ligament, the liver and kidneys following. Ewald confirms Glenard except as to the primary fac- tor in the causation of splanchnoptosis. What Glenard regards as the con- tracted- portion of the colon beyond the constriction, and calls " corde colique transverse," Ewald believes to be the pancreas. He denies also that simple kinking of the colon, uncomplicated by peritoneal adhesions or by stenosing neoplasms, can cause stagnation of feces. Without assigning a distinct cause, Ewald emphasizes the fact that long-standing dyspepsias and bodily overexertion may create altered relations of pressure and tension, and thus lead to the condition. Landau especially emphasizes disease of the abdominal walls as the primary cause, though cases are reported in which there is no such relaxation. Recent studies are disposed to call into play a congenital factor the action of which may be intensified by any of the various causes named. In late fetal life and early extra-uterine life the position of the abdominal viscera is quite like that characteristic of the dis- ease. This is especially shown by Joseph Rosengart, although Henle and other earlier anatomists described these positions of the viscera in young children. Kussmaul * and Leichtenstern are among those who regard the vertical position of the stomach and colon in adults as a congenital anomaly. The influence of adhesions in producing displacements of the abdominal viscera must not be overlooked, but these are not included in the condition being described. Enteroptosis is far more frequent in women than in men, 306 out of 404 cases collected by Glenard being women, tight lacing and pregnancy being regarded as the chief causes of this difference in the two sexes. While it is true that the majority of cases met in practice are true visceroptoses, yet it must be admitted that there are instances in which one organ only — as, for example, the stomach, the kidneys, the spleen, or the liver — may be dis- located in the manner referred to. Symptoms. — First of all it must be stated that such a state of affairs as that described may exist without producing any symptoms. The symp- toms which are characteristic are, in 'a word, those of nervous dyspepsia, including derangement of appetite, and especially anorexia, more rarely false sensation of hunger, a sense of fullness in the epigastrium, noisy belching, * " Zeitschrift fur diatetische und physikalische Therapie," Bd. i, 1898, S. 220. 378 DISEASES OF THE DIGESTIVE SYSTEM. various bad tastes, and dryness of the mouth. To the fullness in the epigas- trium may be added various sorts of pain — shooting, burning, etc. — after eating. There may be constipation or an opposite condition of diarrhea. Hard, scybalous masses may be removed by purgatives or enemas, also mucus in varying amounts, including casts like those in membranous ente- ritis. The lower portion of the abdomen is distended, and sometimes, in persons with thin-walled abdomens, the dislocated viscera may be recog- nized by their outlines. Especially is this true if they be dilated with air or gas. By palpation or percussion displacements may be recognized with more or less ease. The transition from stomach to colon can often be recognized by change of note on percussion, while the kidneys, spleen, and liver may be recognized by palpation. Among nervous symptoms may be named general weakness, depression of spirits, headache and fullness of the head, vertigo, and cold feet and hands. There may be palpitation of the heart and disturbed sleep or insomnia. As the result of all this disturbance the patient may become so emaciated as to suggest malignant disease. Chlorosis is often present, and by Meinert is regarded as a constant symp- tom of the disease ; indeed, he holds that gastroptosis is the chief cause of chlorosis in women. Treatment. — When there are no syrhptoms produced by this unusual state of affairs, of course no treatment is indicated. When the symptoms are due to displacement, it is evident that mechanical measures or operation are alone likely to be useful in restoring the organs to their normal situa- tion. The former include trusses, pads, and springs, which must be adapted to each case after a study by the instrument-maker with the aid of the phy- sician. In the absence of more elaborate appliances a simple broad band- age may be of service in relieving the symptom. Various degrees of suc- cess have been attained by these measures. It is reasonable to suppose that permanent relief can alone be obtained by operation. Treves has reported a case of complete cure by laparotomy and stitching the stomach. Lately, in the Hospital of the University of Pennsylvania, a patient of my col- league's, Alfred Stengel, was operated upon by Alfred C. Wood, with ap- parent success. In a stomach thus dislocated there are apt to be atony and sluggish peri- stalsis, which may result in the accumulation of undigested matters, which are better removed by lavage. Other measures useful in dilated stomach may also be expected to be useful as well as those indicated for nervous dyspepsia. DISEASES OF THE INTESTINES. SIMPLE ACUTE CATARRHAL ENTERITIS. Synonyms. — Acute Intestinal Catarrh; Acute Diarrhea; Acute Ileo-coUtis. Definition. — The term employed is applied to a diffuse inflammation which generally pervades more or less of the small intestine and the upper part of the large bowel. More circumscribed inflammations are described, and doubtless sometimes occur, but it is not easy to localize them. Etiology. — The usual causes of simple intestinal catarrh are overeating and excessive drinking, or the swallowing of acid or mineral substances of SIMPLE ACUTE CATARRHAL ENTERITIS. 379 an irritating character. Impurities in drinking-water and, in the summer and autumn, unripe fruit are frequent causes. The toxic products of fermented and decomposed food (leukomains) are also causes. These sometimes arise inexpUcably from substances commonly harmless, such as milk or prepara- tions thereof. Cream-puffs, and even ice-cream, are among these. Irritat- ing minerals are corrosive sublimate and arsenic. Although hot weather favors intestinal catarrhs, especially in infants and older children, they are not so much the direct result of the heat as of its effect in weakening the resist- ing powers of the child and favoring the decompositions and fermentations referred to. The effect of heat on the nervous system of the very young may reasonably be regarded as a factor in increasing irritability of the gastro- intestinal tract or in so diminishing its functional power as to render the ingesta irritating. Cold, or rather a chilling of the body by a fall in tem- perature, is often followed by enteritis. Secretion altered in quantity or quality has already been mentioned as a cause of simple non-infectious intestinal inflammation. Much spoken of, but of inferred, rather than of demonstrated, import, is excessive biliary secretion, producing what is known as bilious diarrhea. When such diar- rhea is associated with a burning sensation at the anus and with the rec- ognized presence of bile in the stools, the term may be justified, but it is to be remembered that an acid reaction of the alvine dejecta produces a similar sensation. A scanty supply of bile to the intestine, by depriving the gut of the important antiseptic property of this secretion, may also favor the fermentations and decompositions mentioned. Hyperemia, however induced, favors catarrhal enteritis. Such is the hyperemia secondary to hepatic and cardiac disease, and to inflammation, whether traumatic or infectious, in adjacent tissues, whence it extends by contiguity. Such is the inflammation occasioned by peritonitis, by intes- tinal obstruction, and the like. Cachectic and anemic states, such as are secondary to cancer, to Addison's disease, and to the last stages of Bright's disease and of tuberculosis, are also favoring causes. Enteritis is also a symptom of certain infectious diseases through their specific poisons, which act directly on the mucous membrane, as in the case of cholera, dysentery, and typhoid fever. Apart from the effect of nervous influence already mentioned, this can- not be said to cause simple enteritis. It is not unusual for fright and other causes of nervous excitement to produce diarrhea ; but this is not the result of an enteritis, but of an increased peristalsis and disturbed vasomotor regulations, and is properly called nervous diarrhea. Morbid Anatomy. — The morbid changes of simple intestinal catarrh are variously distinct. A hyperemia is naturally to be expected, and in the more decided cases may be manifested by a diffuse redness and injection. It is not often, however, that these are demonstrable. A layer of mucus covering the mucous membrane of the bowel more or less interruptedly is mdre frequently present. Nor is swelling often evident. At times the soli- tary follicles are unnaturally distinct, surrounded by a hyperemic circlet. Such enlargements, commonly as distinct as a pin's head, may be as large as a pea, and, becoming filled with pus, 'form little abscesses, which may rupture, leaving an ulcer. They may extend to Fever's patches. More rarely chronic tilceration results. Symptoms. — Diarrhea is the most constant symptom of enteritis, involv- ing the part of the intestinal tract named in the definition. The resulting 38o DISEASES OF THE DIGESTIVE SYSTEM. stools consist of, first, ordinary fecal contents of the small and large intestine, including bile ; but, as they continue, they become more and more watery,, almost colorless. There may be but two or three, or they may equal twenty or more. They contain more or less mucus, and are often frothy and asso- ciated with flatus. With diminished consistence the odor may grow less obnoxious, until totally absent. At other times it is persistently offensive. Minute examination recognizes in these discharges columnar epithelium variously altered, enlarged, granular, and fragmentary, with nuclei obscured or absent, also various non-pathogenic bacilli and cocci, including the bac- terium coli commune, yeast fungus, crystals of triple phosphate, oxalate of lime, cholesterin, and undissolved food matters. The reaction of the dis- charge may be neutral or acid. Next to diarrhea is pain, usually colicky, varying greatly in degree ; often, indeed, in the milder forms, absent. There is rarely tenderness, but palpation may elicit gurgling and the signs of gaseous distention. Thirst and oliguria are natural consequences of the free discharge of water. There is usually little fever, the rise of temperature rarely exceeding one or two degrees, and the higher grades suggest specific inflammation of the bowel. The appetite, at first little altered, ultimately fails. Very rarely do the ordi- nary diarrheas in children and adults terminate in collapse. It is reasonable to expect modifications of the foregoing symptoms as the result of localized inflammation, as contrasted with those of the more diffuse form just described. Thus, the presence of jaundice suggests the probability that the duodenum is especially involved. In such cases the urine may also be jaundiced, and there may be added other symptoms commonly associated with jaundice. In the absence of this symptom there is no sign that points to the duodenum as the special seat of the inflammation. On the other hand, jaundice is by no means always present, even if the duodenum is involved. Duodenitis is often associated with acute gastritis, spreading from the stomach — gastro-duodenitis. An acute catarrhal inflammation of the jejunum and ileum, unassociated with inflammation of the large bowel, would be unattended with diarrhea, the slight acceleration of peristalsis incident to such an event being unlikely to produce this symptom. In this respect, therefore, it will differ. On the other hand, distention of the abdomen, colicky pain, borborygmi, discharge of flatus, and fever continue. Nothnagel has called attention to the presence of little lumps of mucus from the inflamed small intestine in intimate admix- ture with the contents of the large bowel, often, however, requiring the microscope for its recognition. Even if this be true, however, as v. Leube says, it is scarcely available in practice. Whence it is plain that a diagnosis of an inflammation of this part of the intestinal tract is by no means an easy matter. It is probably also a rare condition by itself. Nothing distinctive is added if only the upper part of the large bowel is involved. Quite different is it when there is also involvement of the whole of the large intestine — ileo-colitis. When this is the case, while the lower down the inflammation, the purer the mucus and the more there is of tenesmus, the mucus remains separate and unmixed -with the fecal matter, which may con- tain undigested particles of food, such as muscular fibers, starch, and fat cor- puscles. A diarrhea in which these undigested portions of food are visible to the naked eye is known as lienferic. Gmelin's nitric acid test for the biliary coloring-matters ceases in health at the sigmoid flexure, so that if this reaction is obtainable in the liquid discharges, it implies that the exces- SIMPLE ACUTE CATARRHAL ENTERITIS. 381 sive peristalsis has affected also the large bowel, by which the bile is carried through with abnormal rapidity. The green stools of children, and more rarely of adults, also indicate a large quantity of bile. Simple feverish states, however, may have the effect also of interfering with the proper digestion of food matters, which may appear in the discharges in consequence. Some information — not, however, too much to be relied upon — may be derived from the seat of tenderness and colicky pains. When these are in the middle or inferior part of the abdomen, they point to the small intestine ; when in the upper and lateral parts, to the large. Diagnosis. — The diagnosis of acute intestinal catarrh is ordinarily easy, by attention to the symptoms previously detailed, including those more or less peculiar to the more circumscribed localities referred to. From typhoid fever acute enteritis is usually easily distinguished by its short duration, minor fever, and the absence of the characteristic course the fever takes in the infectious disease, and absence of the spots which so invariably make their appearance on the eighth day in t3^phoid. The Widal test in the latter disease also aids the diagnosis. During cholera epidemics mild cases of this disease are not recognizable symptomatically from the severer colliquative forms of diarrhea. Under these circumstances, bacteriological examination should be made. The importance of a correct diagnosis will be appreciated when it is remembered that indifference in the treatment of simple diarrhea may not seriously affect the result, while such treatment of a case of cholera, however mild, may result disastrously. Prognosis. — This is always favorable with prompt and judicious treat- ment, recovery taking place in from one to three days, as a rule, rarely longer. Treatment. — Many cases of acute catarrhal eriteritis recover under rest and restricted diet, the degree of which necessarily depends on the severity of the case. The simple withdrawal of all food, the substitution of plain milk, or, in severe cases, of boiled milk, for the usual food, generally suffices. A few grains of bismuth subnitrate every two or three hours, fortified with 1-8, 1-4, 1-2 grain (0.0082, 0.015, 0.033 gm.) of opium, or 1-2 ounce (15.5 gm.) of chalk mixture with a fiuid dram (4 c. c.) more or less of pare- goric may be added. No attempt should, however, be made to lock up the bowel until all irritating matters are removed, and it is often desirable to give an aperient, castor oil being the best, though the unpleasantness of the dose often precludes this valuable remedy. In such event the solution of the citrate of magnesium, Rochelle salts, or Hunyadi water may be substituted. When there is much pain, larger doses of opium may be necessary, especially if hot fomentations, mustard plasters, or turpentine stupes fail to produce the desired effect. When there is elevation of temperature, no better means than the local application of ice can be found to relieve pain. Astringents are rarely necessary, but in the absence of other measures may be used. Tannic or gallic acid in five-grain doses (0.33 gm.) may be given separately or com- bined with opium. The various chlorodynes form convenient remedies when there is pain. The dose varies from 20 to 30 minims (i tO' 2 gm.). In severe cases, espe- cially when there is nausea, a hypodermic injection of morphin, 1-8 to 1-4 grain (0.0082 to 0.015 gm.), may be given. For the nausea counterirritation by mustard plasters should be used, pieces of ice swallowed entire, while copious draughts of water should be disallowed. Champagne and cold car- 382 DISEASES OF THE DIGESTIVE SYSTEM. bonated waters may be used for this purpose. The latter may be combined with milk, while the old reliable remedy of equal parts of milk and lime- water should not be forgotten. CHRONIC CATARRHAL ENTERITIS. Synonyms. — Chronic Entcro-coUtis; Ulcerative Colitis; Mucous Colitis; Chronic Diarrhea. Definition. — A chronic inflammation of more or less of the large and small intestine, with or without ulceration. Etiology. — Chronic enteritis may remain after repeated attacks of the acute form, or it may arise de novo, however induced, favored by whatever occasions passive congestion. Such favoring causes are diseases of the liver or heart, feeble and anemic states, and the defective nutrition consequent thereon. Chronic exhausting diseases, such as tuberculosis and Bright's dis- ease, may act in this wa}^ also. Dysentery is a frequent cause of chronic intestinal catarrh, a remnant of the acute process. Morbid Anatomy. — The primary condition is that of acute catarrh, and in many cases the morbid changes do not exceed those of acute catarrh, being simply permanent, or later more pronounced. In others, still more decided changes are found, chiefly in the lower part of the ileum and colon. These are mainly ulcerative, but include also discolorations due to hyperemia, blood extravasation and pigmentation succeeding it, thickening of the coats of the bowel, and contraction of partly healed ulcers. There may be stenosis or the opposite condition of dilatation. Such ulceration is distinct from that of tuberculosis, typhoid fever, and syphilis. It may be follicular, as often seen in the diarrheal affections of children, more rarely in adults, or there may be large ulcers or large areas of ulceration. The remnant of mucous membrane is often pigmented and slate-colored, and a pseudo-polyposis sometimes results from contraction. In the small intestine the pigment is apt to be deposited on the ends of the villi and in rings around the solitary follicles, or in their centers, producing the " shaven-beard appearance." The surface of the bowel is more or less covered with mucus and purulent secretion incident to the inflammation. Still another sort of ulceration, from the etiological standpoint, is found at the bottom of saccules of the large intestine in which scybala or hard fecal masses have lain a long time. Ulceration, too, may result, though rarely, from encroachment from without by various kinds of disease of the peritoneum, including cancer, tuberculosis, and the like. Atrophy of the mucous membrane of the bowel is also one of the results of chronic enteritis, not usually recognizable before death. There may even be atrophy not only of the mucous membrane, with destruction of the glands, but also of all the coats of the small and large intestines. Symptoms. — ^These are not uniform. While there is often more or less diarrhea, this is as often absent, or substituted by constipation, while con- stipation and diarrhea frequently alternate. More characteristic of the stools is the large amount of miucons matter contained in them. This may be present in the shape of " sago "-like masses or " mucous " granules, yellow or brownish-vellow, bile-stained also from the small intestine. Bile-stained CHRONIC CATARRHAL ENTERITIS. 383 mucus is present only when there is abnormally rapid peristalsis of the large bowel, which causes the mucus to be passed out before the bile is decom- posed. Ulceration may be associated with the presence of blood in the stools. A variety of chronic colitis known as mucous colitis or membranous enteritis is characterized by the discharge of large masses of mucus, forming at times complete casts of the bowel. It is more frequent in women, this sex including 80 per cent, of recorded cases, according to W. A. Edwards. It may occur also in children. Its subjects are usually women of the nerv- ous type. It is commonly associated with constipation. At intervals, how- ever, occur attacks of abdominal pain and tenderness, sometimes accompanied by tenesmus and followed by discharges of the mucoid matter referred to. Such attacks may be excited by mental emotion of various kinds. The mucoid material itself seems to be the direct result of an increased activity of the mucous glands, which, with the mucous membrane, are, however, com- monly intact after the separation of the large mucous casts. Minute exami- nation recognizes more or less numerous cells, round and columnar, entangled in the mucus, sometimes also cholesterin plates and triple phosphate crystals. Throughout the numerous attacks nutrition is commonly well main- tained, and the woman subject appears plump and well nourished. At other times there are gradual emaciation and ultimate death. Diagnosis. — This is always easy, except as to the determination of the portion of the bowel involved or the presence of ulceration. Differences in the character of the mucus, as previously noted, will aid in the diagnosis, while the constant or intermittent presence of blood and pus or fragments of tissue in the stools points to the ulcerative condition. Ulceration is sometimes found postmortem where no symptoms were present before death. In the rectum, and, indeed, as high as the sigmoid flexure, ulcer may be recognized by specular examination. Deep-seated ulceration may cause circumscribed peritonitis or may produce abscess. The presence of scybala, surrounded with mucus, points to inflammation of the rectum or colon as far up as its transverse portion. It is not possible to diagnose the presence of atrophy of either bowel. Prognosis. — The prognosis in all forms of chronic intestinal catarrh is grave so far as recovery is concerned, and treatment avails little in many cases. The disease, however, extends over months, and even years, before the patient succumbs, and recovery is sometimes complete, quite independent of treatment. Treatment. — xA-S in the case of acute catarrhal enteritis, rest is an impor- tant condition of success in the treatment of this disease. Next, we must select a diet with a minimum of waste, so that there may be as little irritating residue as possible. Milk and the albuminous foods are the types of these. Still less irritating must they be if partly digested before being taken into the stomach. Thus, milk may be peptonized, and meat also, and the beef peptonoids of the manufacturers may be employed. It is difficult to ascer- tain the ratio of nourishing power of these peptonoids to that of solid meat. This, then, should be a fundamental principle of treatment — to furnish a diet with a minimum of waste. When it is remembered that chronic intestinal catarrh is seated mainly in the large intestine, it is manifest that to reach it with remedies admin- istered in the ordinar}- way is difficult, and that it is more than likely that such 384 DISEASES OF THE DIGESTIVE SYSTEM. remedies are absorbed or decomposed before they arrive at the seat of the dis- ease. It is barely possible that after prolonged administration certain drugs, as nitrate of silver, will ultimately reach the seat of ulceration and stimulate it to heal. Such a course must, therefore, be pursued with any remedies thus administered. Nitrate of silver and the sulphate of copper are the two which possess most reputation. The doses are 1-4 grain (0.0155 gm.) of each three times a day, or a smaller quantity more frequently. The acetate of lead may be substituted in doses of two grains (0.132 gm.). The latter is more astringent, but is less likely to excite healing. All these remedies are commonly combined with opium in suitable doses. Subnitrate of bismuth in large doses, 1-2 dram to one dram (2 to 4 gm.), is strongly recommended by some. It undoubtedly diminishes the discharges, but how far it is curative is uncertain. The natural astringent waters, such as the Rockbridge, and other alum waters in this country, have earned some reputation in the treatment of chronic intestinal catarrh, but improvement under their use is always more marked at the springs themselves, showing that some effect must be ascribed to the change of scene and air and to the salubrious climate of the locality. Should these measures fail, irrigatioii of the bowel may be practiced. This is done by means of a fountain syringe, or a funnel in connection with a tube, which is carried high up into the bowel, the patient being placed on his back with a pillow under his hips. The fluids used are solutions of nitrate of silver, sulphate of zinc, and boric acid. At first tepid water, say at 85° F. (30° C), should be run in very slowly to the amount of two to three pints ( I to I 1-2 liters). Then solutions of any of the foregoing substances, of the strength of 3 to 4 1-2 parts to 1000, or i 1-2 to 2 grains to the oz. (o.i gm. to 0.13 gm. to 30 c. c.) of the more active substances, beginning with the weaker solutions. Salicylic acid may be used in two per cent, solution, boric acid in one per cent, solution, or a one per cent, solution of salicylic and boric acids combined. A one per cent, solution of tannic acid is also recommended, as well as of corrosive sublimate, but the latter is exceedingly irritating and the strength of the solutions should not exceed, at first, i : 15,000, which may be increased, if well borne. The nitrate of silver has, on the whole, the best reputation. A preliminary anodyne enema of 30 minims (i gm.) of lauda- num may be given, if needed, or a suppository of extract of opium, say one grain (0.066 gm.). To be effectual, the treatment must be patiently pro- longed, especially the dietetic part, and not weeks, but months, of patient perseverance insisted upon. I have already said, in treating of dysentery, that a careful trial of this form of treatment in my hands has been disap- pointing in its results. CHOLERA MORBUS. Synonyms. — Cholera nostras; Sporadic Cholera. Definition. — An acute gastro-intestinal catarrh, characterized by pro- fuse vomiting, purging, and painful cramp. Etiology. — The intensity of the symptoms and their similarity to those of true cholera justify a suspicion that a specific organism is responsible for cholera nostras as well as for true cholera. No single bacillus has, however. CHOLERA MORBUS. 385 been settled upon, although the bacillus known as the Finkler and Prior bacillus, which closely resembles the " comma " bacillus of true cholera, is found in the discharges with considerable constancy. The disease may result from toxins generated by a variety of bacilli, but until more definite proof is brought forward, cholera morbus must be regarded as a severe form of catarrhal enteritis associated with gastritis due to some poison generated by the noxious substances causing it. Such are indigestible and decomposed articles of food, unripe fruit, and particularly mixtures of fish, salads and fruit. Especially frequent are these attacks in the hot weather of July and August, though cold and dampness are also regarded as predisposing causes. So are fatigue and a debilitated state of the system. Young adults and per- sons in the prime of life are more frequently victims than either the very old or very young. Morbid Anatomy. — This is in no way different from that of catarrhal enteritis, and visible alterations are not always apparent. The same shrunken, ashen appearance of the skin characteristic of cholera may be found in fatal cases of cholera morbus. Symptoms. — 'The victim of cholera morbus is commonly seized sud- denly, often at night, with sevci'e cramp, vomiting, and purging. The first vomitus is the food last ingested, but this is rapidly succeeded by bilious matter, and still later by almost pure water. The same may be said of the bowel discharges, which follow each other in rapid succession — in fact, become at times almost continuous. They present ultimately all the physical characters of the rice-water discharges of true cholera. The pain is at first confined to the abdomen, the paroxysms succeeding each attack of vomiting. Later it extends to the muscles elsewhere, espe- cially those of the calves of the legs. Corresponding to the loss of water is thirst, often intense. The patient is restless and anxious. Collapse may supervene, and the skin become cold, clammy, and ashen-hued, the eyes deeply sunken, the pulse frequent and feeble. There is not often fever, though the internal temperature is higher than that of the surface. The mind remains clear, even in the event of a fatal termination, almost to the end, when it may become clouded. Diagnosis. — This was fully considered when treating of cholera, to the •section on which the student is referred. The symptoms caused by over- doses of arsenic, antimony, and the poisonous mushroom are similar. Prognosis. — This is usually favorable, the gravest cases recovering, as a rule. A single night commonly measures the duration of an attack. Fatal cases, however, occur, the very old and the very young being most often victims. Prompt treatment is of the utmost importance, as it will usually ■cut short an attack which will otherwise last from twenty-four to thirty-six hours and be succeeded by a slow convalescence. Treatment. — Opium is almost indispensable to the successful treatment of an attack of cholera morbus. The happiest method of exhibition is by the hypodermic needle, more especially because everything given by the mouth is apt to be promptly rejected. For an adult less than 1-4 grain (0.0165 gm.) of morphin is hardly to be thought of. On the other hand, such a dose will often act magically. It should be associated with diffuse counterirritation over the abdomen by mustard, while the hot bath may be added, if the symp- toms do not yield. In the absence of the hypodermic needle, remedies must be given by the mouth. The association with morphin of the hot aromatics, such as 25 386 DISEASES OF THE DIGESTIVE SYSTEM. ginger and cloves, seems to aid its retention. Hence the efficienqy of the various forms of " cholera drops," the formula for some of which are given under cholera. Chlorodyne is an admirable remedy. Unfortunately, the preparations by different pharmacists are not of uniform strengths. On the other hand, the doses are commonly indicated on the labels, and it is safe to say they may be usually doubled without harm to the patient. The nausea may be controlled by ice, by cold carbonated waters, by pieces of ice swallowed whole, or by champagne. The latter is particularly appropriate when stimulants are needed, as constantly happens. When there is a tendency to collapse, whisky and ether may be injected under the skin, while enteroclysis and even hypodermoclysis may be needed for the same reasons as in true cholera — the restoration of the water lost from the system. DIARRHEAS OF CHILDREN. The importance of these, and some specialization in their symptomatol- ogy, demand a separate consideration. Three forms, more or less distinct, are recognizable — viz., acute dyspeptic diarrhea, cholera infantum, and acute entero-colitis. Acute Dyspeptic Enteritis. Definition. — An acute inflammation of the small intestine due to diet unsuited to the infant. Etiology. — The errors in diet referred to do not necessarily consist in unnatural foods substituted for the mother's milk. The latter itself may be altered in quality by emotional causes, by improper food, and by improper hygiene ; or the child may be too liberally supplied by overfrequent nursing. Milk itself may be infectious by the presence of streptococcus and tubercu- losis infection derived from suppurating and tubercular udders. More often, however, acute dyspeptic enteritis is the result of ingestion of unnatural food, either of substances palpably unsuitable, carelessly allowed, or surreptitiously taken, or of substitutes necessarily employed for mother's milk when she is unable to nurse her infant. " Bottle food," the most carefully selected, is unnatural, and is probably the most frequent cause of dys|)eptic diarrhea in children otherwise well cared for. Two factors in this are active : first, the relatively greater indigestibility of the foods thus supplied ; and, second, the bacteria and their toxic products which develop in it before or after ingestion. Normally, the feces of infants contain but few species of bacteria, of which the most important are the ba€- teriuni aerogenes and the bacterium coli commune. The former seems to be an exclusive product of a milk diet, depending upon the milk-sugar for its nourishment, and is found in the upper bowel, where it excites fermentation in milk. The habitat of the bacterium coli commune is the lower part of the small intestine and the colon, where it is probably also an agent of fermenta- tion. In infantile diarrhea the number of species of bacteria is greatly increased, but no one or more species has as yet been shown to possess a Specific causal eiifect. There are also predisposing influences which facilitate the action of the DIARRHEAS OF CHILDREN. 387 essential causes. These are, especially, dentition and the extreme heat of summer. The effect of the former is learned in the experience of every mother, while the extraordinary frequency of infantile diarrhea in summer attests the latter. It is evident, too, that constitutional weakness and bad hygiene must also co-operate to diminish the resisting power of infants to other causes. Hence it is that the children of the delicate, the poor, and the unclean suffer most. Morbid Anatomy. — This seldom exceeds the stage of catarrhal swell- ing, already described when treating of the enteritis of adults. Symptoms. — No symptoms may precede the diarrhea, but usually there is in the beginning restlessness^ wdth slight fever, which seldom becomes high. Such restlessness may be due to nausea or to colicky pain. The nausea may go on to vomiting or not, but purging soon occurs. Sudden onset is characteristic. The stools are at first copious and offensive, often yeasty and sour, and generally contain particles of coagulated milk or other undigested food, such as unripe fruit, if the child is old enough to eat it. At first infrequent, they become more numerous, more scanty, acquire sometimes a green color and sometimes contain mucus, rarely blood. In other words the condition passes over into enterocolitis. There may be but three or four stools or there may be twenty or more in the twenty-four hours. In other cases fever is more decided, and the temperature may rise rap- idly to 104° F. (40° C.) ; there are great thirst and scanty urine. Even when there is no fever emaciation is rapid, and the child falls away amazingly in a few days. Diagnosis. — The sudden onset and the character of the stools are dis- tinctive and scarcely mistakable. The small amount of mucus distinguishes them from those of ileo-colitis, and the absence of serous discharge from those of cholera infantum. Prognosis. — This, among the better classes, is commonly favorable, but among the weak, puny, and half-starved children of the poor large num- bers perish, especially in hot weather. The disease may pass over into the much more serious affection of entero-colitis. Treatment. — The principles of treatment are similar to those of enteritis in adults. A primary purge is commonly indicated. Calcined magnesia is very suitable, though castor oil is here also useful. After the purge, bismuth subnitrate or prepared chalk, in doses of 2 1-2 grains (0.165 gm.) for a child a year old, with 1-2 grain (0.033 S"^-) of salol as an intestinal antiseptic, may be given ever}^ two or three hours. If there is pain, 1-24 to 1-12 grain (0.0027 to 0.0054 gm.) of opium may be added each time or every other dose, as may be demanded by circumstances. An attempt should first be made to relieve pain by gentle counterirritation, as by weak mustard plasters or a plaster of mixed spices, wet in whisky or alcohol, and known as a " spice plaster," and worn continuously. Deodorized tincture of opium or paregoric may be substituted for the whisky. Astringents are seldom necessary in chil- dren's diarrhea, but the compound tincture of kino, which contains a little opium, is an efficient remedy, which probably owes much of its efficacy to the latter. Chalk mixture, to which a few drops of paregoric may be added, is an efficient remedy. The pure antiseptic treatment has never commended itself to me, and I am inclined to think that more harm than good has been done by such remedies as resorcin, napthalin, and the like, which are often irritating. The regulation of diet is of the utmost importance. It is better to give 388 DISEASES OF THE DIGESTIVE SYSTEM. the child nothing except a little cold water or barley-water than unsuitable food, while any food that is given should be very much diluted, and should be scanty rather than overabundant. Too much food is often given. Noth- ing is better than peptonized milk, if the mother's milk or that of a wet- nurse be unobtainable. Plain fresh cow's milk may do as well. All of these should be diluted with Vichy water, lime-water, or plain water, to which a little brandy mav be added. As long as casein appears in the stools the milk requires further dilution, or the casein may be removed altogether and the whey only allowed. Animal broths, however dilute, do not find much favor with me, though occasionally beef -juice is well borne when milk has not been, especially in children two or more years old. Albumen water, made by mixing the albumen of one or two eggs with a pint ( 1-2 liter) of sterilized water, is much more suitable. The hygienic surroundings of the child are important. Frequent bath- ing ; light, cool dressing in warm weather ; and fresh air at all times are indis- pensable. The patient should be removed from city air to the country or sea- side, when possible ; and when this is not possible, frequent excursions should be made to the country or on an adjacent river. It is not desirable to keep the child on the lap any more than is necessary. Acute Extero-colitis. Synoxyms. — Acute Ilco-colitis: Follicular Enteritis; Follicular Dysentery. Definition, — An inflammation more severe than dyspeptic enteritis, chiefly of the ileum and colon, afifecting especially the lymph follicles. Etiology. — Entero-colitis is also a disease of the hot months and of teething. It is met, however, in the cooler seasons. It is produced by the same causes as dyspeptic diarrhea. It is more frequent between the ages of six and eighteen months, — second summer, — and is not infrequent in the third and fourth years. It may be a termination of dyspeptic diarrhea or of cholera infantum. Morbid Anatomy. — The morbid changes are more positive than in acute dyspeptic diarrhea, and are found chiefly in the ileum and colon. In the first stage the mucous membrane is congested and swollen, while the solitary follicles and Peyer's patches are more distinct. The epithelium is exfoliated in places. As the disease continues into the second stage, say after the first week, the enlarged follicles and Peyer's patches become ulcer- ated. The changes may end here or may become more extensive, constitut- ing the third stage, the ulcers enlarging and deepening to the muscular coat, with the separation of a slough. Or there may be a diffuse infiltration of the bowel with small cells, producing a decided thickening of the same, with more or less obliteration of its distinctive structure. The process may be so intense as to cause coagulation-necrosis — false membrane. Symptoms. — The disease may begin as a dyspeptic diarrhea, also as a cholera infantum. It is much more serious than dyspeptic diarrhea, as evi- denced by the higher fever, which rises rapidly to 104° F. (40° C), but still remains lower than in cholera infantum. Vomiting is less common than in dyspeptic diarrhea or cholera infantum. There are decided abdominal pain and a tense, szvollen belly. The fecal discharges, which are at first pain- less, are small in quantity and contain much mucus and even a little blood. DIARRHEAS OF CHILDREN. 389 They vary in frequency from fifteen to thirty in the twenty-four hours, and occur more frequently during the day. The disease may abate at this stage and convalescence be established, though recovery remains slow. Or the symptoms may increase in severity, the fever persist, and the stools he pain- ful and small, consisting mainly of mucus and blood. Commonly odorless, they may also be extremely fetid. The urine is scanty, of high specific grav- ity, and deposits mixed urates. The child wastes almost to a skeleton, the skin becomes loose and flabby, and the " old man " appearance is assumed. Such a case may last five or six weeks, terminating fatally, yet may, on the other hand, get well. A few fatal cases are much more rapid in their course, being ushered in with convulsions and ending in from forty-eight hours to five or six days. Relapses after convalescence are not uncommon, and should be guarded against. Diagnosis. — Acute entero-colitis is characterized by a greater severity than dyspeptic diarrhea, by the high fever, the large amount of mucus in the stools, the greater pain, and the more rapid prostration. From cholera infantum it differs in its lower hyperpyrexia, and in the absence of vomiting, of colliquative diarrhea, and of collapse. Prognosis. — This is more unfavorable than in acute dyspeptic diar- rhea; more favorable than in cholera infantum. Recovery is not infrequent after a lengthy illness of four to six weeks, while the severe dysenteric form is apt to be early fatal. Much depends upon the promptness with which treatment is instituted and the ability of the parents to carry it out, and upon the previous vigor of the child, its hygiene, and its food. Treatment. — The general hygienic and dietetic treatment of acute entero-colitis is similar to that of acute dyspeptic diarrhea ; the medicinal treatment is somewhat different. Anodynes are more imperatively de- manded, because there is greater suffering, and depletion may be needed in the beginning by salines, though good judgment is required, because the child's strength must be husbanded. Otherwise, drugs are not of much use, though bismuth, in full doses, may be given with advantage. The colon may be flushed with a one per cent, cold salt solution, or cold water or pieces of ice may be introduced into the rectum, which may also be used for medication, more particularly by opium. I do not think the large rectal enemas recommended in the chronic colitis of adults are to be advised for children. If used, they should be very weak. Solutions of nitrate of silver, one grain to the ounce (0.066 gm. to 30 c. c), and tannic acid, five grains to the ounce (0.33 gm. to 30 c. c), are suitable. The mouth should be often examined and, when necessary, the coming teeth scarified, not once only, but as often as necessary. Cholera Ixfaxtum. Definition. — A variety of acute catarrhal enteritis of intense severity, corresponding in symptoms and course to cholera morbus in the adult, but much more serious in termination. Etiology. — The same reasons th'at lead us to expect a specific cause of cholera morbus would suggest one also for cholera infantum. None has, however, been found. It may reasonably be ascribed to toxins generated in the decomposition and fermentation of foods, since some error of diet is almost always the apparent exciting cause. There are also predisposing 390 DISEASES OF THE DIGESTIVE SYSTEM. causes, of which hot weather, dentition, or both, bad hygiene, the previous presence of dyspeptic diarrhea or entero-cohtis, are instances. It is less fre- quent than either of the last-named affections, including only a small propor- tion of the summer complaints of children — according to Holt not more than two or three per cent. Morbid Anatomy. — There is little, if any, deviation from the normal appearance in the affected bowel. Symptoms. — These consist in copious serous stools, at first containing some offensive fecal matter, later a few particles of greenish matter ; but ulti- mately they are almost aqueous, being ejected also with great force. They contain numerous bacteria, but no constant organism has been found. There is crampy pain, and the limbs are drawn up or rigidly extended. There is decided fever, more than in either of the two other forms, the temperature reaching 105° F. (40.5° C.) ; the pulse is frequent and feeble, while restless- ness is a characteristic symptom. The temperature should be taken in the rectum, as that of the axilla may be misleading. Indeed, the skin sometimes feels cool when the internal temperature is high. There is intense thirst, and the child eagerly drinks water. The purging may come on suddenly or may succeed dyspeptic diarrhea or ileo-colitis. Simultaneously there is severe and obstinate vomiting, including bile at first ; but later the vomited matter is also serous. The tongue is coated in the beginning, but later becomes dry and red. The child rapidly loses strength and as rapidly emaciates. The restlessness is succeeded by apathy and indifference, and the condition passes into collapse. The eyes become sunken, the fontanels depressed, the skin gray or ashen and closely applied to the frame, producing an appearance which, once seen, is rarely forgotten. Or the more severe symptoms may subside, and a condition of torpor or semicons\cionsness may supervene. The head is retracted, and there may be convulsions; the breath- ing is interrupted and of the Cheyne-Stokes type ; the pupils are irregular ; there is clutching of the fingers — in a word, the " hydrencephaloid " state, so called by Marshall Hall, is present. These " brain symptoms " have often misled the inexperienced, but they are not associated with changes in the brain or in its meninges. They may be due to the toxins developed in the intestine by bacteria. Diagnosis. — This is not difficult. The serous vomiting and purging, rapid emaciation and prostration, and the hyperpyrexia are significant, while the nervous symptoms described as succeeding them confirm the nature of the disease. Prognosis. — Unless the last-described symptoms supervene, the course is rapid to a fatal termination by collapse in from a few to twenty-four or forty-eight hours. If the hydrencephaloid state is added, the disease may be prolonged a few days more. Recovery is not impossible, and begins with abatement of the more serious symptoms within the first twenty-four hours, followed by tedious convalescence. Or there may be a delusive improvement, followed by a return of the choleraic symptoms, or the disease may pass into entero-colitis. Treatment. — All that has been said about food in dyspeptic diarrhea and entero-colitis applies here, but the opportunity for its application cannot, indeed, be availed of unless convalescence sets in. The symptoms must be met with the greatest promptness by the same measures described in the treat- ment of adults, but adapted to the age of the child. Here, too, opiates are in- dispensable. Even morphin may be used hypodermically with great caution. DIARRHEAS OF CHILDREN. 39! One hundredth of a grain (0.00066 gm.) is about the proper dose for a child a year old, and it may be associated with 1-500 grain (0.0001032 gm.) of atropin. This may be repeated in an hour if the symptoms do not subside, at a longer interval if they do. Laudanum or deodorized tincture of opium may be substituted and administered by the rectum in doses of from two to four drops (0.133 to 0.264 gm.) in two drams of starch-water. Minute doses of Dover's powder, say i-io grain (0.006 gm.), may be given in combination with bismuth in doses of two grains (0.12 gm.). For the diarrhea that may continue after abatement of the acute symptoms preparations of silver, prefer- ably the oxid, are sometimes of value. They may be combined with opium, the dose of the silver being 1-12 grain (0.0056 gm.), of the opium 1-24 to 1-12 grain (0.00275 gm. to 0.0056 gm.). The hyperpyrexia must be combated by hydrotherapy — the bath at 80° F., rapidly reduced to 70° F. (26.6° to 21.1° C.) ; or, if this cannot be done, the child should be wrapped in sheets wrung out in cold water. Spong- ing is a feeble substitute. Hyperpyrexia is one of the dangers. Stimulants are indicated, but the difficulty is to secure their retention, Brandy is the best form of stimulant, though iced champagne may be given in small doses often repeated, while the prompt rejection of liquids should not discourage their readministration. Irrigation of the large bowel may be added, using a flexible catheter, which is introduced six or eight inches (2.3 to 2.y cm.). A pint (0.5 liter) will suffice for a child six months old, and a quart (i liter) for one of two years. The water may be tepid, or cold if the temperature is high. The one per cent, salt solution may be admin- istered by enteroclysis, and even by hypodermoclysis in extreme cases of collapse. The hot bath should be substituted for the cold in collapse, and strychnin may be administered hypodermically in doses of i-ioo grain (0.00066 gm.) to a child one year old. Should convalescence set in or entero-colitis supervene, great cau- tion in the giving of food should be observed. Only peptonized milk should be used, substituted occasionally by raw beef -juice, increased, if well borne, a teaspoonful at a time ; or dilute egg-albumen may be tried if these are not retained. The Celiac Affection in Children. Synonyms. — Diarrhcca alba; Diarrhoea chylosa. Definition, — A form of intestinal catarrh of children one to five years old, of insidious onset, and characterized by copious, offensive, loose, frothy stools, resembling oatmeal gruel in color and consistence. It was first described by Gee. Etiology. — This is unknown. Ulceration of the intestine has been found, but there is no distinctive morbid anatomy. Symptoms. — The symptoms, in addition to those named, are progres- sive zvasting and weakness. There is no fever. The abdomen is distended as by flatus, but is inelastic and doughy. Prognosis. — It is commonly fatal. It has been likened to the hill diar- rhea of the tropics, which affects adults. Treatment. — This can only be symptomatic. -392 DISEASES OF THE DIGESTIVE SYSTEM. PSEUDO-MEMBRAXOUS ENTERITIS. Syxoxyms. — Croupous Enteritis; Diphtheritic Enteritis. Definition. — A rare variety of intense inflammation affecting either bowel, and characterized by the formation of false membrane. Etiology. — Pseudo-membranous enteritis occurs in connection with such infectious diseases as pyemia, pneumonia, scarlet fever, and even typhoid fever; also from the toxic effect of mineral poisons, such as lead, mercury, and arsenic, and during the cachexias which develop toward the close of cancer, Bright's disease, cirrhosis of the liver, and the like, as a terminal infection. Morbid Anatomy. — The false membrane present varies in extent and depth. It may be limited so as simply to tip the villi and valvulse conni- ventes or other folds with a grayish-}ellow film, or the coagulation-necrosis may infiltrate a greater depth in flake-like patches, or it may invade the follicles and solitary glands, which may suppurate. To the false membrane is commonly added a hyperemic basis.- The deep-seated diphtheritic in- flammation found in diphtheritic dysentery is elsewhere described. Symptoms. — These may be so slight as to be unnoticeable. At other times there are diarrhea and abdominal pain, but nothing distinctive. Treatment. — This is symptomatic, and that of the attending and caus- ing disease. PHLEGMONOUS ENTERITIS. This is a rare disease, consisting in a dift'use suppurative infiltration of the submucosa, analogous to phlegmonous inflammation of the stomach. It has been found after intussusception and strangulated hernia, and may cause symptoms of peritonitis by invasion of this coat of the bowel, but there are no symptoms by which it can be recognized before death. It has been met in the duodenum. HEMORRHAGIC INFARCT OF THE BOWEL. Definition. — Hemorrhagic extravasation in the wall of the small in- testine, due to embolism or thrombosis of one or other of the mesenteric arteries. Etiology. — A warty vegetation from coexisting valvular heart disease may become the embolus, or the latter may arise from the clot in an aneu- rysm of the aorta. Morbid Anatomy. — There are congestion, infiltration, and swelling of the jejunum and ileum, and the superior mesenteric artery will generally be found plugged with a clot, which may be preceded by an embolus. The mesentery may also be the seat of congestion and infiltration. Symptoms. — There may be sudden nausea, vomitins;, faintness, ab- dominal tympany, and pain. There may be symptoms of obstruction, or diarrhea with blood-stained stools. ULCERATION OF THE BOWEL, 393 Diagnosis. — The condition is so rare that infarction is not apt to be thought of. But should there be valvular heart disease or aneurysm, the sudden occurrence of the symptoms mentioned might suggest this cause. Prognosis and Treatment. — The prognosis is invariably fatal in severe cases, and though the occlusion of a small vessel may be followed by recov- ery, there is no treatment which will avail further than to abate the symp- toms. ULCERATION OF THE BOWEL. What is Meant. — Apart from ulceration symptomatic of typhoid fever, dysentery, tuberculosis, and chronic enteritis, we are not often called upon to recognize this lesion, while its presence is often unattended with any symptoms whatever. The ulceration of typhoid fever, dysentery, and follicu- lar enteritis requires no further reference ; nor the peptic duodenal ulcer which was considered in connection with gastric ulcer ; nor tubercular ulcera- tion secondary to tuberculosis elsewhere, which may be said to be probable whenever such tuberculosis becomes associated with obstinate diarrhea, un- controllable or only partly controllable by medicines. Such probability may be confirmed or not by the finding of bacilli in the fecal discharges, to which end cultures should also be made. At the same time it is to be remembered that bacilli found may have been swallowed with sputum, a source more likely if the patient is known to swallow sputum habitually. Primary Tubercular Ulcer. — Occasionally tubercular ulcers occur primarily or without preceding symptoms of tuberculosis elsewhere, espe- cially in children. They are seldom, if ever, below the ileum and appendix vermiformis, yet they do occur in the rectum. There is no way of discover- ing them during life. In the first place, such ulceration is hardly suggested unless there is some discharge from the rectum of the nature of diarrhea, or pus, with or without hemorrhage. Given, however, such symptoms, with tenderness in the region of the ileum, decided fever, pronounced emaciation, and a tuber- cular history, the feces should be examined for tubercle bacilli, the finding of which would be conclusive in the absence of the possibility of their being swallowed. On the other hand, their absence would not exclude tuberculosis. The sago-like clumps of mucus, formerly considered pathognomonic of tubercular ulceration, are no longer so regarded, since they are found in cases where autopsy has established the absence of any ulceration whatever. The presence of enlarged mesenteric glands palpable through the abdominal walls would be a further confirmation. Especially justified would be the suspicion if to the diarrhea the symptoms of circumscribed peritonitis — viz., tenderness, impaired percussion resonance, and perhaps slight fever — are added, or if there are the symptoms of general peritonitis. A rare, but acknowledged, seat of the tubercular ulcer is the appendix vermiformis, a rupture of which might cause any one of the varieties of perityphlitis and peritonitis due to ' perforation in appendicular disease, including post-peritoneal abscess invading the neighborhood of the kidney and producing one of the forms of perinephric abscess. A similar termi- nation may follow perforation of any form of ulcer of the bowel suitably situated, as in the posterior wall of the ascending and transverse parts of 394 DISEASES OF THE DIGESTIVE SYSTEM. the duodenum, and ascending and descending colon. The presence of tuber- cular ulcer is not incompatible with cicatrization, which may even produce stenosis of the bowel. Tubercular ulcer of the rectum may be recognized by specular examination. Syphilitic Ulcer. — Syphilitic ulceration is confined almost entirely to the rectum, and is not very common here. Its possible presence in the colon and ileum is simply to be remembered, as its diagnosis is out of the question. The suspicion of its occurrence in the rectum is justified under circumstances of rectal discharge of blood and pus not due to carcinoma. Syphilitic ulcers arise as primary sores and papules or from breaking down of gummy tumors. They are characterized by their serpiginous outline, an indisposition to heal, and the presence of condylomata about the anus — usually the broad, but rarely also the pointed variety. Embolic Ulcer is another possible variety of intestinal ulcer, though it is not recognizable before autopsy. Embolism and consequent ulcer may happen when valvular heart disease exists or septic pyemia, and it is possi- ble that a branch of an intestinal artery may become the seat of lodgment of an embolus from the heart or from some septic focus, and be followed by necrosis and solution of the area supplied by it. Treatment. — In addition to the general treatment of tuberculosis, the diarrhea occasioned by the ulceration should be treated by the usual reme- dies, among which should be included nitrate of silver and sulphate of copper with opium. The patient with syphilitic ulceration should receive the specific treat- ment of syphilis, while the ulcer, if accessible, should be treated by local applications of silver nitrate in solid stick. APPENDICITIS. Synonyms. — Typhlitis; Perityphlitis; Paratyphlitis. Definition. — An inflammation of the vermiform appendix, catarrhal, ulcerative, or interstitial, which commonly extends to the structures lying in contact with it, producing: 1. A peritonitis which is plastic and limited — appendicular peritonitis, or peri-appendicitis. 2. Circumscribed suppuration or abscess — para-appendicitis, or peri- typhlitis. 3. Septic and general peritonitis. Perforation and gangrene are often intermediate incidents. The word appendicitis, which is now by almost unanimous consent applied to the disease under consideration, did not secure the appHcation without a struggle. The term typhlitis, so long employed, was adopted because it was thought that the disease began in the cecum, or typhlon. Modern studies go to show that true appendicitis almost never begins in the cecum, but that in essentially all cases the appendix is the root of the evil. Inflammation and perforation of the cecum are, however, possible events, though they are not clinically separable from appendicitis. It also often APPENDICITIS. 395 happens that one of the earHest symptoms by which appendicitis is recog- nized is that of inflammation of the peritoneum covering the appendix and adjacent cecum ; but the existence of very positive disease of the mucous membrane of the appendix has been demonstrated over and over again when the peritoneum has not been invaded. It is, therefore, hkely that the process begins in the appendicular mucous membrane each time. The term appen- dicular peritonitis, or peri-appendicitis, is a good one for the inflammation of the peritoneal covering of the appendix, while para-appendicitis or peri- typhlitis is equally suitable for the more extensive peritonitis about the cecum, and the term perityphlitic abscess indicates well that a similar in- flammation has gone on to pus formation. Historical. — None of the facts bearing on the nature of appendicitis is of very old date, while the correct notion of its nature may be said to have been quite recently established. The first recorded case of perforation of the vermiform appendix ap- pears to have been by Mestivier, in 1759, caused by a large pin in the appendix; another was reported by J. Parkinson, an English phj^sician, in 1812; another by Wegeler, in 1813. In 1S24 Louyer-Villermay reported a case of fatal peritonitis which he ascribed to perforation of the appendix. In 1827 Melier reported four cases — three of perforative appendicitis and one of relapsing appendicitis. Melier even suggested the possibility of curing the patient by operation, providing the diagnosis could be sufficiently established. Other isolated cases of fatal inflammation of the appendix were published from time to time, but the first systematic article was prepared by Husson and Dance in 1827, at the sug- gestion of Dupuytren, and the views promulgated by them were apparently those of the great surgeon himself, since they are the same as those he published six years later (1833) in his " Lectures on Clinical Surgery." He treats of irritation and inflam- mation of the mucous membrane of the cecum, extending thence to the retrocecal tissue and thence rarely to the peritoneum. The appendix is totally ignored. In 1830 Goldbeck, at the suggestion of Puchelt, of Heidelberg, wrote his graduation thesis, " On a Peculiar Inflammatory Tumor of the Right Iliac Region." He adopted the views of the French authors and called the disease peritj'phlitis. He also recorded a case of perforation of the appendix with resulting peritonitis. He says, moreover, that in fatal cases of perityphlitis the appendix has been found intact. In 1831 J. M. Ferrall published a paper, said to have been written several years earlier, on " Phlegmonous Tumors in the Right Iliac Region," in which the cecum is also held to be the primary seat of the phlegmon, which is described as extending thence to the connective tissue behind it, the peritoneum being accorded a minor role. In 1834 James Copland, in his " Dictionary of Practical Medicine," describes what is now known as perityphlitis under the title "Inflammation of the Cecum." He, moreover, recognized the appendix as a possible primary seat of disease excited by foreign bodies in it and terminating in gangrene — a great advance over the views of Dupuytren. John Burne came still nearer the truth in 1837 and again in 1839. Though he wrote on " Inflammation of the Cecum," even in his first paper he speaks of " ulceration of the appendix " set up by foreign bodies, such as raisin seeds, cherry stones, and concretions, of possible perforation resulting in general peritonitis or local peritonitis, with abscess. In his second paper he goes further, and states his belief that all Dupuytren's cases were due to disease of the appendix. He introduced the term tuphlo-enteritis. In 1838 J. F. H. Albers retrograded a little. Publishing a paper on inflammation of the cecum and introducing the term typhlitis, which he divides into acute, chronic, and stercoral typhlitis with perityphlitis, he distinguished the latter aifection from typhlitis, with which he says Puchelt and others confounded it. But while recogniz- ing the possibility of disease starting in the appendix and going on even to perforation he regarded the phlegmon of the right iliac fossa as more frequently due to disease of the cecum. In the next year Grisolle, appreciating correctly the role plaj^ed b}^ per- foration of the appendix in causing the iliac phlegmon and abscess, opposed the teaching of Albers and claimed that inflammation of the cecum would not cause the grave effects ascribed to it, since dysenteric and other well-recognized forms of ulcer- ation of the same structure show no tendency to extend into the neighboring con- nective tissue. Grisolle, however, as thoyigh under the thraldom of Dupuj-tren and the French school, still assigned an important role to the cecum. From this time, however, and, indeed, from the date of Burne's paper m 1837 to the present, appendicitis has been an acknowledged disease; but it has seenied almost impossible, even to this day, to shake off the idea of typhlitis as a responsible factor in the phenomena of appendicitis. Louyer-Villermay in 1840 reported some cases of rapidly fatal inflammation and gangrene of the appendix. In 1843 A. Voltz 396 DISEASES OF THE DIGESTIVE SYSTEM. published a retrospective paper entitled " Ulceration and Perforation of the Ap pendix" occasioned by foreign bodies. He concluded that the appendix was the organ at fault in all cases previously published, and apparently for the first time the cecum and retrocecal tissues were ignored. Simple catarrh of the appendix was first recognized by Rokitansky in 1843 in his classic work on "Pathological Anatomy." He ascribes it to the irritation of fecal matter and to concretions, and contrasts it with the more intense processes of gan- grene and perforation. Sucli inflammation, he says, maj^ become chronic or go on to ulceration. He also refers to the benign effect of inflammatory adhesions in protect- ing against general peritonitis in the event of subsequent perforation. He still ad- mitted the existence of catarrhal inflammation of the cecum, ulceration and perfor- ation of the latter, with inflammation of the postcecal tissue as a consequence. So G. Lewis in 1856 ascribed tlie less serious consequences — including, however, suppu- ration — to typhlitis, while the violent and fatal cases, he said, began with appendicitis, induced always by concretions. In 1858 C. Wister attached further importance to the part of the appendix in producing the symptoms in question. In this year, too, Op- polzer suggested the name paratyphlitis for that form of iliac phlegmon which was extraperitoneal: /. e., between the iliac fascia and bone. Samuel Wilks was one of those who appreciated the role of the appendix. Thus in the treatise of Wilks and Moxon on " Pathological Anatomy " in 1875, he says, referring to the terms cecitis, typhlitis, and perityphlitis: " It is not clear, however, that any one particular form of disease is intended by those who make use of these expressions. The cases to which these names are given frequently occur clinically and recover; but when disease in the same region, with similar characters, proves fatal, we find usually some prior morbid process in the appendix rather than in the cecum itself." Also, "the suddenness of the attack of cecitis and the local peri- tonitis following, even in the large number of cases which recover, all point to the appendix as being the most frequent cause." But he says also: " inflammations of the cecum itself do occur, and apparently are sometimes caused by continuous lodgment of hard feces in this part of the intestines. Such inflammations, by ulcerating the mucous membrane, lead to perforation and local peritonitis, forming fecal abscesses which may discharge inward, but we believe that this is comparativel)^ rare." Dr. Wilks' most recent views are perhaps best expressed by C. Hilton Fagge, who, in his " Practice of Medicine," edition of 1886, says: " Dr. Wilks has repeatedly expressed to me the opinion that in both ' typhlitis and perityphlitis ' the disease begins in the appendix, and that variations in the intensity of the morbid process are the real cause of the supposed distinction between them. And so far as I can learn, all the evidence which morbid anatomy affords points strongly in that direction." C. With, of Copenhagen, was apparently the first to deny pointedly, in 1880, that peritonitis ever originates in typhlitis. In 1883 William Pepper described the " re- lapsing" form of appendicitis. Reginald H. Fitz, in a timely and exhaustive paper read before the Association of American Physicians in 1886, admitted, as an extreme rarity, a primary perforating inflammation of the cecum with which appendicitis vi\a.y be confounded. In a second paper in 1888 he concluded, essentially, that the conditions described as typhlitis, perityphlitis, paratyphlitis, appendicular peritonitis, and perityphlitic abscess are varieties of one and the same affection — appendicitis. The text-books published prior to i8g2 treat very generally of typhlitis as an important factor in producing the ultimate phenomena of what is now known as ap- pendicitis, unless we except that of Dr. Fagge, already quoted, who, while he uses the word typhlitis, evidently means by it disease of the appendix. Ziegler, in his " Pathological Anatomy " (1885), also uses the word typhlitis for appendicitis. William Osier, in his edition of 1892, says that the terms " perityphlitis and para- typhlitis should be altogether discarded, as the cases are, with rare exceptions, due to disease of the vermiform appendix "; and says also of " typhlitis, or inflammation of the cecum," that it is " a doubtful and uncertain malady, the pathology of which is not known, but which, clinically, is still recognized by authors." In his edition of 1898 he says " the ' iliac phlegmon' was thought to be due to disease of the cecum — typhlitis — and of the peritoneum covering xt—pe^'ityphlitis; but we know now that with rare exceptions the cecum itself is not affected, and even the condition formerly'' described as stercoral typhlitis is in reality appendicitis." William Pepper, in the " Text-book of Medicine by American Teachers" (1894), treats of typhlitis as an af- fection very much less common than formerly supposed, because "the majority of cases of acute disease in the right iliac fossa are in reality appendicitis." Five special treatises of great value have been published in English: " The Pathology of the Vermiform Appendix," by T. N. Kelynack, of Manchester, England, in 1893; "Appendicitis and Perityphlitis," by C. Talamon, and translated from the French by Richard J. H, Berry, of Edinburgh, in 1893; "Appendicitis," by George R. Fowler, of New York, in 1894; " Diseases of the Vermiform Appendix," by Herbert P. Hawkins, of London, in 1895; and " A Treatise on Appendicitis," by John B. Deaver, of Philadelphia, in 1896. Hawkins summarizes the situation in the follow- ing proposition, to the confirmation of which American surgery has largely con- tributed: " In fact, it will be generally allowed that a perforating ulcer of the cecum, though it does certainly occur, is of so rare an occurrence that it may be disregarded "; APPENDICITIS. 397 also, " There is ample evidence that appendicular disease is, at any rate, of frequent occurrence; and this frequency, moreover, is sufficiently frequent to justify us in regarding the appendix as the sole cause of all cases of perityphlitis, mild or severe." As historical points in the treatment of appendicitis may be mentioned the sugges- tion of early operation by Willard Parker m 1867. Grisolle had made the same sugges- tion thirty years earlier, and doubtless, as stated by B. Farquhar Curtis,* many such ab- scesses about to point had been incised, but Parker first suggested this as a systematic treatment. In 1881 Kraussold advocated early operation and was apparently thie first in Germany to do so, but made no reference to Parker. In 1882 Noyes reported 100 ■cases treated by Parker's method of which 90 had been done in the United States. In 1887 R. F. Weir, of New York, strongly urged the early operation, without waiting for adhesions between the pus sac about the appendix and the abdominal wall, and even, if necessary, to open the general peritoneal cavity in order to reach the pus. At "the end of 1887 Sands recorded the first successful case of deliberate laparotomy for general peritonitis from ordinary perforation of the appendix, a prior case by Hall in 1886 being rather an accidental one. In 18S8 Treves reported a series of cases of operation for chronic appendicitis of the relapsing type. In 18S9 Charles McBurney advocated even earlier operation and removal of the appendix before perforation. In addition to Parker, Sands, Weir, and McBurney, Bull, of New York. Murphy and Nicholas Senn of Chicago, Maurice H. Richardson, of Boston, and John B. Deaver, W. W. Keen, and Tliomas G. Morton, of Philadelphia, were important coadjutors in placing the operation for appendicitis on its present plane. Pathology and Morbid Anatomy. — The etiology of appendicitis will be more easily understood if its morbid anatomy is first considered. Mod- ern studies establish the existence of three degrees or stages of appendicitis : 1. Catarrhal appendicitis. 2. Ulcerative appendicitis. 3. Interstitial or parietal appendicitis. 1. Catarrhal Appendicitis. — Our knowledge of this is based upon the systematic, minute study of cases which come to autopsy froiti other causes as well as from operation. In the first or acute stage there is a shedding of the epithelium of the mucous membrane, with detachment, partial destruction, and extrusion of the follicles of Lieberkiihn, and some cellular infiltration of the retiform tissue at their base. The lumen of the appendix contains mucus, leukocytes, exfoliated cells, and casts more or less perfect, of the crypts, with granular debris from the same sources. In the second stage the basement membrane is broken and dislocated, the retiform tissue more closely infiltrated with leukocytes, and the internal surface ragged and uneven. In the third or still more advanced degree the mucous membrane is thickened by infiltration with cells. The most important fact as to catarrhal appendicitis is that all three stages offer vulnerable foci for the attacks of pathogenic bacteria, and starting-points of an infectious peritonitis. On the other hand, by the union of the opposing surfaces, obliteration of the lurnen of the tube may take place, by which it is rendered immune against further attacks. A natural cure has, in a word, been effected. The oblit- eration may be partial, producing stricture, beyond which a cystic distention of the tube in the end nearest the cecum is not infrequent. 2. Ulcerative Appendicitis. — In this stage the mucous membrane and submucous tissue are destroyed to various depths, while it may even cul- minate in perforation. It is often associated with a concretion or a foreign body. The latter is now acknowledged to be much more rare than was formerly supposed. The error was a natural one, owing to the close resem- blance of fecal concretions to seeds, grains of wheat, cherry stones, and even date stones, as the result of a gradual molding of shape and loss of water. The concretions are sometimes also the seat of deposit of lime salts. They may be multiple and may be in the appendix a long time without * " Twentieth Century Practice of Medicine, " 1896, vol. viii. p. 434. 398 DISEASES OF THE DIGESTIVE SYSTEM. producing harmful effect, the patient dying of other causes. The same is true of foreign bodies, which do, of course, occur and include the objects already mentioned. Fecal concretions are found in from 35 to 50 per cent. of cases; foreign bodies in a much smaller number — say 7 to 12 per cent. 3. Interstitial or Parietal Appendicitis. — This stage may succeed upon either of the two stages just described, but occasionally it may arise de novo by infection along the lymphatics. In the former event it starts in the abraded or ulcerated surface described ; in the latter, in the substance of the appen- dix wall. It is commonly associated with necrosis or gangrene of the wall, but may prove fatal before the necrosis sets in. The appearances vary greatly. They may be limited to a mere point, scarcely visible, and between this and sphacelation of the entire organ there is every intermediate degree. The gangrenous organ is usually enlarged and distorted. The virulence of the appendicular peritonitis is, however, just as great when there is no necrosis. The peritonitis which ensues on perforation of the appendix is virulent, resulting from the invasion of the peritoneum by myriads of bacteria in the fecal matter set free at the time of rupture of the bowel. The iiiimite changes in interstitial appendicitis are as varied as the mac- roscopic, but Hawkins' summary of three more distinctive stages or degrees may be accepted as nearly correct. The cases which succeed on the catarrhal or ulcerative form are, of course, characterized by the loss of tissue corre- sponding to the extent of the disease. To these succeed destructive necrotic processes in the deeper structures of the wall. In the first stage of the latter the inflammation is characterized by necrosis of the muscular coats ; in the second by suppuration in them ; and in the third by their infiltration with leukocytes and inflammatory exudation. The first is, by far, the most com- mon. In all three bacteria are found in the mucous and muscular coats, and all three are followed alike by virulent peritonitis. The appendix may also be the seat — indeed, is not a very infrequent seat — of tubercular ulceration, followed, too, by perforation. I have lately seen a remarkable specimen of this kind in which no symptoms were present before death. So, too, a typhoid idcer may form in the appendix and perfo- rate, with the formation of a tumor mass in the right iliac region. Follicidar abscess may exist and occasion the usual symptoms of appendicitis. Actino- mycosis has also occurred in the appendix, with the formation of retrocecal abscess and metastatic abscess of the liver. Superadded to these conditions is often a localized or general peritonitis, the development of which, in the majority of cases, constitutes the attack of appendicitis. In lesser degrees of the peritonitis (peri-appendicitis) the adhesions which form are limited to the appendix and adjacent serous tis- sues, limiting the inflammation and acting as a barrier against general peri- toneal infection. In higher degrees the inflammation attacks the tissues in relation to the appendix (para-appendicitis), and forms the iliac phlegmon or tumor. This occupies the right iliac fossa and is variously constituted. It may consist of serous and cellular exudation, which mats together coils of small intestine and the cecum, or there may be a massive accumulation of cells and liquid exudate, constituting abscess. Even the latter, as well as the more solid exudate, may be absorbed. On the other hand, the appendicular or perityphlitic abscess may rupture into the peritoneum, not infrequently producing fatal general peritonitis. The amount of pus varies. There may be a dram or two (4 to 8 c. c), or a pint (a half liter) or more. More com- monly there are from two to four ounces (60 to 120 c. c). The pus is usually APPENDICITIS. 399 thin and very fetid; at times it is thick, yellow, and odorless. It may be mixed with fecal matter. The pus may have escaped into the bowel, bladder, or vagina, or externally at some point in the abdominal wall, — as the navel or groin, as in a case of my own, — or through the obturator foramen into the hip or thigh. The iliac muscle may be destroyed and the ilium bared. The abscess, usually in the iliac region, may be in the lumbar region, or perinephric, in the true pelvis, or under the liver. These very diverse sites are commonly determined by erratic situations of the appendix. There may be secondary abscesses of the liver by pylephlebitis or portal embolism. These may have all the terminations possible to hepatic abscess. If general peritonitis supervene, there are added the usual anatomical appearances incident to this condition — flakes of lymph scattered over the intestines, binding the latter together, with pus-cells in varying numbers in the flakes. Etiology. — Exciting Causes. — All three stages of appendicitis described are probably due to the invasion of micro-organisms, while the foreign bodies, concretions, and other agencies to be mentioned are to be regarded as pre- disposing causes, furnishing the conditions favorable to the operation of the pathogenic bacteria. A word as to the nature of the organisms which are responsible for the virulent forms at least. The bacillus coli communis is a bacterium whose natural habitat is the colon of healthy individuals, cultures of which from the normal colon prove harmless when injected. Yet cultures of this same bacillus taken from cases of virulent appendicitis produce also corresponding virulence ; whence it may be inferred that in some way virulence is engen- dered in an otherwise harmless bacillus. There is good reason to believe that such bacilli may pass from the intestines to the peritoneum through the lymph spaces in an intestinal wall which is simply damaged, as well as through a perforation. Thus, many cases of so-called idiopathic peritonitis, or peritonitis in which macroscopic examination reveals no evident lesion, may still be due to the bacteria of appendicitis from the interior of the tube. This has been actually demonstrated in some cases, and it is not unlikely that it will be found true of all such cases thoroughly studied. While in most instances the bacillus coli communis has been found in pure cultures, pyogenic bacteria have been found associated with it. The most important of these is the streptococcus pyogenes; after this the staphylo- coccus pyogenes aureus and the proteus vulgaris; so that the existence of more than one possibly infecting species may be admitted. The bacilli of typhoid fever and influenza are possible infective agents causing appendicitis. The same is true of the infectious agent of rheumatic fever, and although I have never met a case of appendicitis traceable to rheumatic fever it is quite as reasonable to believe that an infectious appendicitis may be thus caused as an infectious endocarditis and pericarditis. Predisposing Causes. — The most important predisposing cause of appendicitis is the appendix itself. An organ without function, and therefore undeveloped and feebly nourished, is correspondingly feebly resistant to all disease. Its anatomy is such that the entrance of irritating matters is easier than their exit, while inflammatory products are not easily evacuated. As predisposing causes, too, must be considered certain influences which for- merly were regarded as exciting causes, such as overeating, especially of unwholesome and indigestible food, acute indigestion from any cause, in addition to the foreign bodies and concretions already mentioned. It can- 400 DISEASES OF THE DIGESTIVE SYSTEM. not be said that the precise mode of operation of such cause is certainly known. It may be that a hyperemia or deranged circulation thus induced produces a condition favorable to the action of incessantly present bacteria. Similar is the effect of fatigue, cold, and traumatic causes, such as blows and contusions. Appendicitis is a disease of children and young adults. From 50 to 55 per cent, of cases occur under the age of twenty, 30 per cent, between twenty and thirty, 15 per cent, under fifteen. What bearing the fact that the appendix is longer in children and young adults has upon this can only be surmised. Nearly 80 per cent, of all cases occur in males. It has been suggested that this is because the lumen of the appendix is larger in males, and therefore more liable to receive fecal or foreign matters. Attacks have occurred, however, in the first year of life and as late as the seventy-sixth. More cases occur in summer than in winter. Occupation has no effect in exciting it, but after a first attack recurring attacks of appendicitis are more frequent in men who do heavy work, such as porters and carriers, or men who stand on their feet long each day. Symptoms. — Simple catarrhal appendicitis is often unattended by any symptoms whatever. Indeed. I cannot see how it can cause any recog- nizable symptoms excepting pain and tenderness. ^lany cases of ulcerative appendicitis before the peritoneum is reached in the invasion are character- ized by a like absence of distinctive symptoms. Other symptoms more or less mild and vague are on this account overlooked. The interstitial variety, including, as it does, a simultaneous involvement of all the tissues, gives rise promptly to serious symptom.s. In point of fact, as already stated, appendicitis is known to be present, perhaps in a majority of cases, by the symptoms of the resulting peritonitis, local or general. Though in most instances the first attack is a mild one, yet no one knows at the onset whether this is going to be the case or not. Furthermore, it is often im- possible to say when suppuration has taken place. The supervention of general peritonitis is, however, usually attended by unmistakable signs. The first symptom is invariably pain — sudden pain. Its location at first is not constant : it may be anywhere in the abdomen. ]\Iost frequently, perhaps, it is in the neighborhood of the umbilicus. At other times it is m the epigastrium ; at others, dift'use. It is intermittent, or at least remittent. Usually, within the first twenty-four hours, it settles itself in the right iliac region, where it remains. It may then be mild or severe : more frequently it is moderately severe. Even at this stage — end of twenty-four hours — its location is not always in the right iliac fossa. It has even settled in the left iliac fossa, under the liver, or beneath the spleen, anomalous situations for the appendix. This pain is increased by coughing or taking a long breath, or by turning over on the side. As constant as pain is tenderness in the right iliac region, or if the appendix happens to be placed in one of the unusual situations named, it will be in that situation. Rather strong pressure may at times be necessar}' to elicit it, but usually moderate pressure sulBces. Its extent varies. It m.ay occupy the whole lower quadrant of the abdomen, or may extend up to the costal margin and around into the flank, but the seat of maximum tenderness is oftenest a point known as AIcBurney's — a point at the inter- section of a line drawn from the anterior superior spinous process of the ilium to the umbilicus and another along the right edge of the rectus muscle. It is from one and one-half to two inches from the anterior superior spinous APPENDICITIS. 401 process of the ilium. The patient almost invariably assumes the dorsal decubitus, often with the right leg drawn up, because of the relief thus afforded. The third cardinal symptom, if the patient comes under notice suffi- ciently early, is rigidity of the right rectus abdominis muscle and other muscles overlying the focus of inflammation. This may be associated with a slight distention of the entire abdomen. In explanation of the tenseness it may be said that the rectus and other abdominal muscles receive their nerve supply from the seven lower intercostal nerves, while the superior mesenteric plexus gets its splanchnic branches from the same nerves. This primary tenseness, after two or three days, may be substituted by a tumor. The latter varies in size and shape, but is more commonly oval and about as large as a hen's egg, with its longer axis parallel with the upper part of Poupart's ligament. It may be much larger, occupying also the whole lower left quadrant and extending upward and backward into the flank, while its shape may be quadrilateral or triangular. It varies in consistence. Its composi- tion has been described in considering the morbid anatomy of the disease. There is usually impairment of resonance to percussion over such a tumor, though less than might at first be expected. This is because we are really percussing over hollow organs, though matted together by exudation. At times, However, there is a duller note, while at others, it may be natural. In the latter event the tumor is small. Indeed, tumor may be altogether absent, but this can never be said of tenderness. Vomiting is a symptom of more or less frequency. It is commonly regarded as reflex and is variously severe. The matter vomited is first the gastric contents, with the evacuation of which the vomiting usually ceases, though it may recur in the event of perforation or rupture of the abscess. If the symptom is more prolonged, the vomited matter becomes greenish. IMany so-called " bilious attacks " of past times have really been attacks of appendicitis. Constipation is present in a decided majority of cases from the begin- ning of the attack. It is due to paralysis of the bowel, and may be so obsti- nate as to simulate obstruction of the bowel, being even attended at times with stercoraceous vomiting. Indeed, appendicitis has often been con- founded with obstruction. On the other hand, there may be diarrhea, recur- ring with each successive attack. There is loss of appetite. The tongue at first may be natural, but later becomes more or less coated, and in advanced stages dry. There is always fez'er at the outset, the temperature 102°, 103° F. (38.9°, 39.4° C), and even 104° F. (40° C), rarely higher, after which it gradually falls, reaching the normal in from five to seven days in favorable cases, which terminate in resolution. The pulse-rate corresponds with the degree of fever, but its force and volume vary with the patient's strength. Should suppuration take place, the temperature continues with but slight fall, or may even rise higher (see Fig. 31). Suppuration may, hozvever, be unattended with fever. A sudden fall of temperature does not always mean the establishment of convalescence. Not very rarely the^ event has a widely different meaning. It means that, instead of convalescence, perforation has taken place. It is extremely important that this fact should b'e realized. More than once have I known the physician to have been misled by it. The accompanying tem- perature chart illustrates such a case (Fig. 32). Another even more 26 402 DISEASES OF THE DIGESTIVE SYSTEM. unusual explanation of sudden fall of temperature is the rupture of a small abscess into the bowel. Finally, too much stress cannot be laid upon the fact that there may be gangrenous appendicitis in the presence of normal temperature. Leukocytosis is present in a large number of cases, the white cells often amounting to 16,000 to 20,000. It is an unfavorable symptom. On the other hand, the absence of leukocytosis, like the absence of fever, should not inspire over-confidence, as a lowering blood count is sometimes evidence that nature has given up the struggle. I" Details of Treutment i;'=i to CO 4^loi 6.3JQ_0M ^ ^ iO:^M tai^ " fd /9 am,.''^' if.?4^''/5«= = T T T 3 /o\3c /im i ^::::::::::::::::::::::::::]c- \6\an j.aiY,/0 \ to\ef'n 1 )T^/?./^T tjis_o,>^ T T$. ^cW <7!/.y Z9 ^6 iM. .-==:-'■' i 1 1" "^ -^-, IPM T i ^^^ lom _ 1.7 am. V,— ±— - - X^ K iqM^ ^-.^ ^'ta^i /'AY-^i '^y^/bcm '(' \xi'm '" \ dAi.oo? cr/ter c/pknr/iVf ..^i ___1$^3^ ^. ^ -'' / «/'/ /LIY.TX --'>-'' f 17. m cfc ,2'l/J)'KZ'' _ _ "^rC -i.^'-'2J> 7A?r ^^, 5>( rn\ T.5. uijL L7f to T rTj i4 - '2^ X^ i7.MT^ '--4j?/'.Z' __ _L 1 ":>' w/jt/ ^ te' ^k^'.> •?:. oL'iY^^ ^ : 'XiY.iWi ^> \_ ^r-" /<:•«:> r, T T _L__±i[i^ f) "IT" 0) I I I I I I M I 1 I I I I I I I I I I I U I I M M I I I I I I I T O I I I I I I r 4ip Fig. 31. -Temperature Chart Showing Temperature Maintained by Abscess after Partial Decline. The patient was first seen bv Dr. C. F. M. Leidv at 9 a. m. on July 16, the first day of the disease, when the temperature was 104= F. (40" C). It continued the same at I p. M. the same day. It then began to fall, and by 2 p. m. the next day reached 102" F (38.° C). By 4.45 p. M. of the fourth day it had fallen as low as 100° F. (37-7' C.), after which it rose and fluctuated to about 102'' F. (38.9" C), again rose, reaching 103.2° F. (39.5° C.) at 10 a. m. on the seventh day, when the patient was operated on by the late Professor John Ashurst, hi. D., and an abscess evacu- ated, after which the case proceded to convalescence. APPENDICITIS. 403 The urine is scanty, as is usual in fever, and quite frequently contains an abnormal quantity of indican. It is rarely albuminous, unless there be high fever, when there may be the small albuminuria characteristic of fever. There are often irritable bladder and frequent micturition. Details uf Treatment , © , © © 5 1 ij CD - M + o'l'o ° Climcal Memoranda 0,0 , "^ CO *k 01 0) ^ ■ Q 1 ,o 0*0 ^'^.z'^ioWys T — - L-^'-Z 30 W '7. y<^an\ k^6C..m\ li^cm 1 1 • .-1 tir>* /f?,g A /(Gf/.^\ j< za.Yf\' uOLy9 ^,-^^.-55? \ 1 ^r^-^tt/?, \ 1 '<^6.3 7\QM 1 " " 1 T-Hl^>oa.,v. \f-^'u,ak 1 : I /^ fffit n ll. i\Pfr, \. W '^^ap.fn. \ 1 1 ^spm 1 \^^\^\/?.?f- 1 \csam i t _L 1 1 1 i^^.&fi!/'^^ : ' S-U-s?/^ i 1 1 T==i/-^/V"^ '/(T 1 1 \j>rfif&_/^/ yji Y /O \ "X^^fi/n 1 ^^^um ^^'^n/?> T + J^j am '{'vun\ \ > 8\ii,n \ \ J?fVit'(/Ui '/ ~^ r"T "" 1 1 IL I I I I I I [ I I I I I I I [ i I I I I I 09 ^ I I I [ r I I I I I I I I [ I I I I I I I I I I r M I I I I I I I I I r I i I I I T I Q oj t-j 4i -t^ *i CO Fig. 32.— Temperature Chart Showing Misleading Fall to Normal, Incident ° to Perforation. The expression of the patient varies with the severity of the symptoms, but seldom exhibits the anxiousness characteristic of peritonitis, unless the latter actually is present in consequence of perforation or rupture of abscess. Is there any surer information of the event of siippurafion than that fur- nished by the temperature, as discussed? Fluctuation will, of course, be thought of, but this is rarely obtainable on account of the depth and distribution of the pus. The pus may come to the surface and thus be recog- nized, but not often ; and, furthermore, a case that has been allowed to proceed to this degree at the present dav has not been properly handled. The rigor 404 DISEASES OF THE DIGESTIVE SYSTEM. and sweat, such valuable evidences of the occurrence of suppuration under other circumstances, are, as a rule, wanting in appendicitis. Rapid growth of the tumor and the attainment of large size in a short time point to sup- puration, but the most valuable sign is the pi'esejice of exquisite tenderness over the focus of inflauunation. Continued high temperature is significant, though it may be wanting. Fully formed abscess has been found as early as the third day. oNIore commonly six to eight days elapse before a dimin- ished tenderness and 'slight decline of swelling point to this formation. Appendicitis allowed to go on to suppuration — /. e., not relieved by opera- tion — usually terminates by rupture of the abscess into the peritoneum, fol- lowed by general peritonitis and death. The event is variously delayed by the extent and toughness of the protective adhesions which may have formed about the abscess, A few abscesses rupture into the bowel, thus saving the patient's life. Two or three cases in a hundred are thus saved. The fecal fistula incident in this termination usually closes eventually, though not always. In rare instances the abscess, especially if deeply situated in the pelvis, ruptures into the bladder. The termination in these cases is less favorable, 50 per cent, being fatal. A few also break through the groin, and are followed by recovery. Lumbar abscess and perinephric abscess must be mentioned as possible terminations, also" infiltration of the abdominal walls and tissues of the thigh, pylephlebitis, and hepatic abscess. General peritonitis may also ensue after perforation of the appendix. The symptoms of the resulting general peritonitis are those characteristic of this disease when suddenly induced by other causes, viz. : 1. Diffuse pain, as contrasted with pain localized in the right iliac region — pain of extreme severity. 2. Generally distended and tender abdomen. 3. ^Moderate fever, succeeded by normal or subnormal temperature, already alluded to as often misleading the physician. 4. Rapid and feeble pulse. 5. Dry and coated tongue. 6. The phenomena of collapse — i. e., cold, clammy skin, feeble pulse, anxious expression, death. Complications and Sequelae. — The most important complication is obstruction of the bowels, by w^hich is not meant the obstinate constipation so often met as an early symptom of appendicitis, but a true obstruction, the direct consequence of constriction by adhesions developed in the course of the peritonitis. It is one of the causes of death, as determined by autopsy, while operation frequently discloses conditions which could easily have pro- duced obstruction. Other complications are hepatic abscess from pylephlebitis, due to thrombosis and even embolism of branches of the portal vein ; also phlebitis of the right iliac vein. In abscess of the liver the diaphragm has been per- forated, producing empyema and pyopericardium. Pyemic abscesses else- where in the system, including the brain and lungs, have also been found in rare instances. Fecal, vesical, and umbilical fistulse have been referred to. Fatal hemorrhage has also resulted from necrosis of the w^alls of the iliac vessels. Appendicitis may occur in a hernial sac. Recurring and Relapsing Appendicitis. — Chronic Appendicitis. — These terms are applied to cases of appendicitis which recur after a first attack. The terms are sometimes used interchangeably, but, strictly speak- ing, cases are recurring which repeat themselves at considerable intervals, as APPENDICITIS. 405 some months or a year or more ; relapsing, when the attacks are very close — at mtervals, say, of one or two weeks, so as to make them almost continuous. In the former, to which attention was first called by William Pepper in 1883, it is reasonable to believe that the patient has recovered in the interval of the peri-appendicular peritonitis, while the appendicitis, catarrhal or ulcer- ative, has continued, or there exists a cystic appendix as an exciting cause. In the relapsing form it seems likely that there has not been complete recovery in the interval. Certain it is that one attack predisposes to another, so that, in at least 23 per cent, of cases observed, according to Hawkins, and 44 per cent, according to Fitz, it is found that there have been previous attacks. The symptoms of a recurrent attack are the same as those of a primary one. In many cases the interval between the attacks is passed in comparative comfort ; in others, there is no small amount of pain or discom- fort in the situation of the appendix. The term chronic appendicitis may also be applied to such cases. Diagnosis. — The diagnosis of many cases of appendicitis is easy, and becomes more so as experience increases. A certain number of cases must be carefully weighed, and in a few diagnosis is extremely difficult. Sudden pain, becoming localized, tenderness, and rigidity in the right iliac region are three symptoms, which, if present, point almost unmistakably to appendi- citis. A " lump " or tumor in the vicinity of McBurney's point is less fre- quently present, though it is often found in many cases, and greatly aids the diagnosis. The cases difficult of diagnosis are those in which these symp- toms are wanting or are in unusual situations. But, in truth, these symp- toms are less often absent than has been supposed. ]\Iore frequently they are not looked for, because there is very little to draw attention to them. A rule should, therefore, be made to examine carefully for them in any person subject to gastro-intestinal attacks, however induced and however manifested. It is certain that some cases of so-called catarrhal enteritis are really cases of appendicitis. Differential Diagnosis. — Intestinal obstruction is a condition with which appendicitis has sometimes been confounded. The special symptoms of the various causes of obstruction, whether those of fecal impaction, of strangula- tion by bands or twists, by intussusception, or by tumor or foreign body, should be recalled. Especially characteristic of obstruction is the absence of fever, unless the patient lives long enough to permit peritonitis to be set up. The pain in obstruction is more intermittent at first, and though, like that of appendicitis, it may be anywhere in the abdomen, it is not likely to localize itseif in the right iliac region. The constipation is more complete in obstruction, and even the passage of flatus is usually absent. The vomit- ing, also, is more severe and persistent, and is more likely to be stercoraceous. There is more general distention of the abdomen, and limited tenderness is less easily differentiated. Intussusception occurs more frequently in chil- dren younger than those subject to appendicitis, and is often attended with bloody discharges, which seldom occur in appendicitis, while a tumor may often be felt on examination per rectum. Strangulation by bands or twists is more common in adults. Malignant growths causing obstruction are usually in the left iliac region, although cancer of the cecum is to be remem- bered as a disease of the right. Its slower development distinguishes it from appendicitis. (See, also. Obstruction of the Bowels.) Typhoid fever may be confounded wnth appendicitis, and I have more than once been startled in the course of typhoid fever by the thought that 4o6 DISEASES OF THE DIGESTIVE SYSTEM. I might be dealing with an appendicitis, especially when there have been tympany and prolonged tenderness in the right iliac region ; but one has, as a rule, only to recall the mode of beginning of the illness, the gradual devel- epment of the fever, its greater intensity and peculiar diurnal variation, the spots at the eighth day, to say nothing of the Widal test, to be reassured in the majority of instances. I recall one case of typhoid fever terminating in perforation in which was simulated very closely even the iliac tumor of appendicitis. I may add that I do not think the typical spots in typhoid fever are ever closely approached by anything similar in appendicitis, though the event of suppuration is said to be sometimes indicated by an eruption. On the other hand, there is nothing to prevent typhoid fever and appendicitis from accidentally coinciding. A question which one w^ould naturally expect to give rise to difficulty is that differentiating between appendicitis and the pelvic affections of zvonien when on the right side, such as a suppurating ovarian cyst around a Fal- lopian tube, or a pyosalpinx. There can be no doubt that before our present accurate knowledge of appendicitis was acquired, numerous mistakes of diagnosis were made.* Many symptoms are identical, but usually the location of the original pain in the appendicitis is not in the pelvic cavity or in close proximity of the uterus, even though it be not at McBurney's point or the right iliac fossa. The appendicial abscess itself is usually limited to the neighborhood of the normal appendix and cannot be recognized per vaginam, while the pelvic abscess can. Should the appendix rupture, as it rarely does, in the vagina, the pus may be recognized by its st-ercoraceous odor. It should be remembered that appendicitis and pregnancy may be associated. The onset of suppurating ovarian cyst is much more gradual, and the pain more constant and duller. Pyosalpinx is in more intimate relation with the uterus, while the history differs from that of appendicitis. Many cases of acute appendicitis were formerly mistaken for bilious colic and acute indigestion, but these are unaccompanied by tumor or tender- ness, while the vomiting is more persistent and the vomited matter differs. Enterocolitis occasions colicky pains, but there is no hardness or localization, while there is diarrhea with mucous stools. It will be remembered, however, that these symptoms sometimes attend appendicitis, and it should be remem- bered, too, that gastro-enteritis may be a favoring cause of infection of the appendix, indeed may be an actual cause that is the result of an afferent wave of bacterial invasion from an irritated intestinal tract as suggested by Dr. Arthur J. Patek.f Ptomain poisoning or food infection may closely simulate the symp- toms of appendicitis, by abdominal pain, nausea and vomiting. The patient will, however, have taken food of the kind known to produce such illness, namely, lobster, sausage, ham, canned meats, cream puffs, old ice cream and the like. In hepatic colic the pain is higher up. in the region of the gall-bladder, while jaundice is almost invariably present, and sometimes there is pain under the left shoulder ; there is no fever. In nephritic colic the pain extends from the lumbar region into the groin and testicle. A floating kidney with twisted ureter is movable, as contrasted with the iliac tumor of appendicitis ; there is sometimes flattening of the corresponding lumbar region, while sud- * For evidence of this, see an excellent paper bv the late Dr. Paul F. Munde entitled, " Perityph- litis and Appendicitis in their Relations to Obstetrics and Gynecology," published in " Medical News," May 15, iSqy. + " American Medicine," April i, igo2. APPENDICITIS. 407 den relief of symptoms, which characterizes the untwist, is altogether peculiar. The presence of blood in the urine under these circumstances is confirmative of renal origin. In pyonephrosis there is tenderness in the region of the kidney, as well as pus in the urine. Perinephric abscess occasions tenderness in the lumbar region while the pain radiates into the groin, as in nephritic colic. It is to be remembered that perinephric abscess may be occasioned by suppurating perityphlitis, when the position of the appendix is posterior to the cecum. Appendicular colic, or neuralgia of the right iliac fossa, is a vague con- dition of pain in this region, which has been ascribed to peristaltic contraction of the appendix, constituting an effort to expel fecal pellets, but of which no proof is afforded, operation in several cases failing to discover anything abnormal. I think it sufficient for the physician to diagnose the existence of appendi- citis without attempting to point out the particular variety of appendicitis, and while I do not deny the possibiHty of such diagnosis by some, I have known such serious errors to have been made by those claiming such ability that I do not place much confidence in their claims. Mention should be made of carcinoma of the cecum or appendix as presenting identical symptoms with appendicitis. It has occurred to me to make the diagnosis of appendicitis where operation showed the presence of cancer of the cecum.* Prognosis. — It is a difficult matter to consider fairly the prognosis of appendicitis, or rather of the peri-appendicitis growing out of disease of the appendix. For if we separate the cases which do not go on to sup- puration, recovery is apparently the rule. Thus out of 190 cases collected by Hawkins, none died. Again, of cases treated by section and drainage after suppuration has set in, fully 25 per cent, die ; while if general peri- tonitis supervene, 75 per cent. die. Of cases operated on in the interval between attacks, scarcely i per cent. die. On the other hand, it is impossible to say of any case, however mild, that if left alone it will not terminate in suppuration, while a large niimber of cases still perish because of imperfect diagnosis and delayed operation. Again, when the difficulties of an accurate diagnosis in the mildest cases are considered, it is not unreasonable to conclude that many cases of supposed recovery were really not cases of appendicitis. Treatment. — As soon as the diagnosis of appendicitis is established, — indeed, pending its settlement, — a competent surgeon should be associated with the physician, for the reason that in the majority of cases operative treatment is sooner or later demanded, while the hour for such treatment is best settled by daily conference. The course of cases of appendicitis is often very delusive, and the surgeon who operates frequently is likely to have seen more cases than the physician. The diagnosis being thoroughly established, operative treatment should be deferred only long enough to determine whether symptoms will subside under rest. If they do not sub- side, operate at once. If they subside in a degree without disappearing, also operate. If they subside completely in twenty- four to forty-eight hours, and the attack is a first one, operatian may be deferred until recurrence; then operate at once, or after subsidence of acute symptoms, as may seem best. * See also a paper on " Primary Cancer of the Tip of the Appendix," by J. Riddle Goffe, " Medical Tlecord." July 6, igoi. 408 DISEASES OF THE DIGESTIVE SYSTEM. . It must be admitted that it is not always easy to lay down a rule as to when operation is demanded, for it is not only that we must know when to operate to save life, but also that we must know when not to oper- ate in cases so severe that operation will be futile ; it is due the operation that it should be saved the opprobrium of such futility. Certain it is, too, that in cases in which operation is of no avail death will be hastened by it, the depressing effect of etherization co-operating to hasten the fatal end. Much difficulty is, however, removed when we decide to operate zvifhoiit undue haste as soon as the diagnosis is established in all cases, except when operation will evidently be futile. I say without undue haste, for in many cases it is plain that a few days' delay, if the patient is kept at rest, will make no difference in the result ; while, if the inflammation is subsiding, a stage is being reached in which operation is even less dangerous, because the united experience of surgeons goes to show that the mortality of opera- tions between attacks is practically nil, while that immediately succeeding diagnosis in ordinary cases is nearly so. There can be no doubt, moreover, that excision of the appendix after a first attack is a safer procedure than during a first or any attack. Even when suppuration has set in it may be safe to delay operation for a day or two while the patient is held quiescent. When, on the other hand, shall operation be omitted because it must inevitably be followed by a fatal result? In all cases in which there are diffuse septic peritonitis, rapid pulse, leaky skin, constant vomiting, and con- stipation, operation is generally futile. In such cases saline purgatives and stimulants, diffusible and cardiac, are indicated, and rarely, though rarely indeed, recoveries have taken place. Whatever preparation is deemed necessary for operation, when decided on, must be directed by the surgeon. Medicinal Treatment. — Cases must occur, however, in which, from various causes, medicinal treatment is necessary. Operation may be declined even if urgently advised, while rarely a preparative medicinal treatment may be necessary previous to operation. First of all, absolute rest in bed must be insisted upon as the first essen- tial condition of abatement of the inflammation. Many a fatal case would have been saved had this injunction been carried out. Next, relief of pain is demanded. For this purpose opium should be avoided, except in extreme cases. Only when relief cannot be secured by the ice-bag, by hot fomentations, or by mild counterirritants, as . mustard or turpentine, may a minimum dose of morphin, 1-12 or 1-8 of a grain (0.005 or 0.008 gm.), be given hypodermically. The objection to opium is well founded, on the ground that it masks the presence of important S3aTiptoms which should be open to observation. In cases where operation is from any cause out of the question, counterirritation by repeated blistering may be practiced, and excellent results were reported under the older treat- ment before operation became common. Of other remedies for the relief of pain, ice is to be preferred to all others, especially if there is fever. Only- after the temperature has been reduced to the normal does it sometimes be- come abnormally low, and then moist or dry heat may be better borne. The question of the propriety of giving an aperient is a nice one, and must depend, for the most part, on the circumstances and the good judg- ment of those in attendance. The result mav be verv happy or mischievous. Cases may be so advanced or severe that a purgative may cause perforation or rupture of an abscess, but in ordinary cases or in those of moderate- INTESTINAL OBSTRUCTION. 409 severity an aperient may be useful to clear up a diagnosis, while it relieves pressure, depletes the blood-vessels, and diminishes the danger of peritonitis. On the other hand, purgatives should not be aggressive and drastics should not be used. Perhaps a safe rule would be, "If there is doubt, do not purge." The best aperient is castor oil, followed, if necessary, by salines, and of these Rochelle salts or the solution of citrate of magnesium is recom- mended. If the stomach is sensitive, calomel in divided doses, triturated with sugar of milk, is the best drug. When there is reason to believe that suppuration has set in, no purgative should be given, and, as a rule, opera- tion should be prompt toward evacuating the pus and removing the appendix at the same time. In severe cases even enemas should be avoided, as tend- ing to favor perforation and rupture. Nourishment should be purely liquid, and of liquid, milk is the best, though animal broths are not contra-indicated. It should not be an object to force food ; indeed, only the minimum sufficient should be permitted. INTESTINAL OBSTRUCTION.* Definition. — The words intestinal obstruction explain themselves. Obstruction to the descent of fecal matter is the fundamental idea, but the absence of bowel movements is not an essential symptom. For in the course of our studies it will be found that in intussusception, for example, frequent loose bowel movements occur, and that in fecal obstruction they may be present throughout the whole course of the disease, while in other forms of obstruction they are not infrequent at the beginning. Intestinal obstruction is further divided into acute and chronic, according to the rate of development of its symptoms, the same causes at times producing acute, and at others chronic forms. Acute obstruction is produced by strangulation, intussusception, foreign bodies, twists and knots, strictures, and morbid growths. Chronic obstruction is produced also by strictures, morbid growths, and fecal impaction. Intussusception may sometimes cause chronic obstruction. I. Internal Strangulation. Synonyms. — Constriction of the Bozvel; Hernia zvithin the Abdomen. Definition. — By internal strangulation is meant stricture of the bowel by inflammatory bands or adhesions, by vitelline remains, omental or mesen- teric slits, adherent appendix, and the like. Occurrence. — This is probably the most frequent cause of acute intes- tinal obstruction, though intussusception closely approaches it in frequency. Thus, Reginald H. Fitz, in America, found it in 35 per cent, of 295 cases of obstruction, as against 32 per cent, of intussusception ; Duchaussoy, in France, in 54 per cent, of 347 cases, as against 39 per cent, of intussuscep- tion ; while Leichtenstern, in Germany/ found it in 35 per cent, of 1134 cases, as against 39 per cent, of intussusception ; and Brinton, in England, found * Reginald H. Fitz's able paper in the " Transactions of the Con.^ress of American Physicians and Surg-eons," i88g. Leichtenstern's article in Ziemssen's " Cj'clopsedia of Practical jMedicine,'' and Frederick Treves' book on "Intestinal Obstruction," 1884, are'important modern papers to which I am indebted for much of the matter in this section. 4IO DISEASES OF THE DIGESTIVE SYSTEM. it in 33 per cent, of 481 cases, as contrasted with 54 per cent, of intussus- ception. The percentages of Leichtenstern, Brinton, and Fitz are astonish- ingly close, and cannot therefore be far astray. Etiology. — The causes of strangulation have been carefully worked out by Fitz in his loi cases, collected from reports since 1880. Of these in 84 the strangulation was caused by hands and cords, of which 63 were simple inflammatory bands or adhesions and 21 were vitelline remains, repre- sented by Meckel's diverticulum,* or by the persistent remains of vitelline blood-vessels. Meckel's diverticulum is usually attached by these remains to some part of the abdominal wall near the navel or to the mesentery, or it may be adherent because of peritonitis. The persistent vitelline vessels may themselves be the strangulating cord in the absence of Meckel's diver- ticulum. Of the remaining strangulations 6 were due to adherent appendix, 6 to mesenteric and omental slits, 3 to peritoneal pouches and openings, i to adherent Fallopian tube, and i to pedunculated tumor. To these must be added diaphragmatic hernia. This was the cause of strangulation in ten per cent, of Leichtenstern's cases, but Fitz found none reported between 1880 and 1888. I reported two cases of diaphragmatic hernia in i893,f both of some standing, the immediate cause of^ death being acute strangulation. The seat of the strangulation is in the small bowel in a decided majority of cases — nearly 90 per cent. In 83 per cent, the strangulated part lay in the lower abdomen, and in 67 per cent, in the right iliac fossa. Seventy per cent, of cases occur in males, and at least 40 per cent, between the ages of fifteen and twenty, the causes in these being inflammatory adhesions twice as often as vitelline remains. Strangulation in early youth is relatively un- common, and when it does occur, it is usuallv caused bv vitelline remains. II. Intussusception — Invagination. Definition. — In this condition one part of the bowel has slipped into another, always from above downward, and may readily be illustrated by slipping one part of a coat sleeve into another. The external or receiving portion, known as the intussuscipiens, has its mucous surface in contact with the mucous surface of the middle or inter- mediate portion, whose peritoneal surface is in contact with the peritoneal surface of the internal or returning portion, while the two mucous surfaces of the returning portion are apposed. The internal and middle parts are called the intussiisceptnm. The resultant is a cylindrical tumor which varies from half an inch to a foot or more in length. The annexed diagram gives a very good idea of the different parts of the tumor. Intussusceptions may occur in any part of the bowel from the duodenum to the rectum, and are named in accordance with the part of the bowel involved : viz., in the order of frequency, ilea-cecal, of the ileum and cecum into the colon, carrying the ileo-cecal valve with it ; enteric, of the small intestine into itself ; colic, of the colon within itself in any portion of its course, most frequent of the descending colon into the sigmoid flexure; rectal, of the rectum into itself ; colico-rectal, of the colon into the rectum ; * Meckel's diverticulum, a remnant of the omphalo mesenteric duct, throug-h which, in the early embryo, the intestine communicates with the yolk sac, is a fing-er-like projection from the ileum, usually within eighteen inches of the ileo-cecal valve. The length of this tube is on an average three inches, while it has attained at times a length of ten inches. t " Transactions of the Association of .American Physicians," 1893. INTESTINAL OBSTRUCTION. 411 and ileo-colic, of the small intestine into the cecum or colon through the ileo-cecal valve. According to Leichtenstern, 52 per cent, only are ileo- cecal and ileo-colic, 30 per cent, are enteric, and 18 per cent, rectal and colico-rectal. It will be remembered that intussusception is almost, if not quite, as frequent a cause of obstruction as strangulation, under which the percent- ages were given. -■g—cvj Fig. 33. — Vertical and Transverse Sections of an Intussusception, I, the Sheath, or Intussuscipiens; 2, the Entering-, or inner layer; 3, the Returning or middle layer. Etiology. — Diarrhea and habitual constipation are probable exciting causes, having preceded in 13 and 12 cases respectively out of 51. Other possible causes are so infrequent as to be unworthy of mention. Experi- ments with faradism would seem to show, however, that spasm plays a more important role than relaxation. As to distribution, two-thirds are found in males and one-third in females. It is especially an accident of the young, occurring in 34 per cent, under one year and 56 per cent, under ten years. Intussusception of the dying should be mentioned, in passing, as a form of intussusception which often takes place a short time before death, more frequently in children, and is probably caused by certain irregular peristaltic movements toward the end of life. It produces no symptoms during life. III. Twists and Knots — Volvulus. The majority of cases are axial twists, — i. e., the bowel is twisted on its mesenteric axis, — this being the case in 40 out of Fitz's 42 cases, two only being knots. Eighty-seven per cent, of cases occur in the large intestine, the remainder in the small intestine, one-half are in the neighborhood of the sigmoid flexure, and nearly one-third in the ileo-cecal and cecal region. It is more frequent in males in the proportion of two to one. Most cases occur between the ages of thirty and forty. It is a disease of the old rather than the young. ' f IV. Obstruction by Abnormal Contents or Foreign Bodies. The majority of these are gall-stones — 23 cases out of 44 of obstruction by foreign bodies collected by R. H. Fitz ; 19 were fecal impactions and 412 DISEASES OF THE DIGESTIVE SYSTEM. two enteroliths. Obstruction by gall-stones appears to be three times as common in females as in males. They enter the bowel usually by ulcerating through the gall-bladder, commonly into the small intestine, more rarely into the colon. The seat of obstruction by gall-stones is most frequently the ileo- cecal region; after this, lodgments are in the small intestine, with diminish- ing frequency as we ascend. The ages are pretty uniformly distributed from eight to eighty. One of the enteroliths was made up of shellac, found in a man who had been in the habit of drinking alcoholic solution of shellac. Usually, enteroliths are made up of triple phosphate of lime and magnesia, about a nucleus which may be a mass of hair or other foreign body. Cour- voisier collected 131 cases, in 70 of which the stone was spontaneously passed per anum. Some were very large. In six they were found in diverticula or in the appendix. In a few instances obstruction is caused by substances introduced by the mouth, but the objects thus introduced, as pennies, buttons, pins, fruit- stones, and the like, are, as a rule, promptly expelled with the stools. In the George B. Wood Museum of the University of Pennsylvania is a plaster cast showing obstruction of the intestine toward its cecal end by plum- stones, followed by inflammation and abscess. A coil of lumbricoid worms has caused obstruction, as has the accumulation of certain medicines, such as magnesia and bismuth. V. Strictures and Morbid Growths. A comparatively small number of obstructions occur from these causes. They are always found in adults, four-fifths after the age of forty, and are apparently twice as common in women as in men. By far the largest number is met in the large intestine and lower abdomen, the majority being in the left iliac fossa. Strictures may be (i) Congenital, illustrated by imperforate anus or defective union between the pylorus and duodenum. (2) Cicatricial, from healed ulcers. Tubercular ulcers in their healing have produced decided and fatal obstruction, especially in the rectum. Syphi- lis is also thought to produce stricture in the same locality. Of morbid growths, the most frequent is the cylindric-celled epithelioma, which may form a ring in the vicinity of the sigmoid flexure, where colloid cancer is also met. Any of the varieties of benign tumors may produce obstruction, while inflammatory processes external to the bowel, especially in the pelvis, may cause obstruction by pressure from without. VI. Fecal Obstruction. Synonym. — Ileus paralyticus vel nervosus. Occurrence. — Fecal obstruction occurred 19 times in Fitz's 42 cases. It is more frequent in females and in adults, especially in the aged. It occurs more frequently in the large intestine, and in the lower part rather than the upper. The fecal tumors found in appendicitis are now regarded INTESTINAL OBSTRUCTION. 413 as the result of the inflamed appendix, rather than the cause of the cecal inflammation. Ileus paralyticus may affect both the small and large intestines, but is more common in the latter, especially in the cecum, where the pressure is concentrated from above and below. A local peritonitis may also be devel- oped about the paralyzed and distended intestine. Mention is made under Chronic Constipation of the enormous masses of fecal matter thus accu- mulated. The wall of the intestine above the accumulation may also be hypertrophied because of the propulsive efforts of the muscular coat. Etiology,— Fecal impaction is favored by constipation and its causes, although a tendency to fecal obstruction is sometimes congenital. Nervous influence is not to be ignored ; the tendency to constipation is seen in the chronic insane, in the hysterical and hypochondriacal, and in affections of the spinal cord. Chronic enteritis and chronic peritonitis favor it; so may ana- tomical peculiarities of the colon. These causes weaken the muscular coat which moves the contents of the bowel onward, resulting ultimately in an absolute paralysis of a segment of the bowel, arrest of motion of contents, and finally obstruction. The plug of fecal matter grows harder and larger, and compresses and stenoses the adjacent bowel, resisting any further onward movement, and increasing the impediment to the restoration of a natural condition, culminating, finally, in paralysis and stretching of the muscular fibers. The so-called " stercoral ulcer " of the cecum, on which the older writers laid much stress, and which was ascribed partly to gangrene, due to pressure, and partly to the irritating effect of impacted fecal matter, is to-day regarded as extremely rare. Symptoms of Obstruction. — As most of the important symptoms are common to the different causes of obstruction, I will first consider them from the general standpoint, emphasizing any special relation which a given symptom may bear to a special cause. In addition to the usual absence of Trowel movement there is : First, abdominal pain. This is the most constant of all symptoms, Ibeing present in a decided majority of cases of obstruction from whatever cause. The pain is one of the earliest symptoms in every form of acute obstruction. It is usually sudden and very severe, and may be intermittent or constant with exacerbations. It may occur in any part of the abdomen, regardless of cause, though most frequent in the neighborhood of the umbili- cus, so that its location is of no diagnostic value. Nausea and vomiting are almost as frequent. The vomitus at the onset consists of the food last taken, but soon becomes bilious, yellow, and finally fecal. Vomiting is relatively infrequent in strangulation and intussusception, while it is relatively frequent in volvulus, stricture, and tumor. The vom- itus is especially apt to become fecal when caused by strangulation — usually from the third to the fifth day. Tympany is next in frequency. It is a symptom of later occurrence than pain and vomiting, presenting itself usually from the second to the sixth day. It varies greatly in degree, increasing as a rule with the dura- tion of the obstruction and being sometimes enormous. It is of least im- portance in obstruction by intussusception, and most marked in volvulus. Tt is sometimes, but not always, accompanied by tenderness. Inability to pass flatus is as constant as the absence of bowel move- ment. Tenesmus is a frequent symptom when there is obstruction in the large 414 DISEASES OF THE DIGESTIVE SYSTEM. bowel, as in 15 per cent, of cases of volvulus and 55 per cent, of acute intus- susception. Fecal vomiting succeeds in some cases. Tumor, under which are included circumscribed visible intestinal coils as well as swelling characterized by absolute dullness, is a rare symptom except in intussusception, when it is characteristic, having been present in 69 per cent, of Fitz's cases, more particularly when in the large intestine, where it is also sometimes associated with a relaxed sphincter. The tumor of intussusception is more frequently found in the left iliac region in the descending part of the large bowel, because the invagination extends in that direction and often does not form an appreciable tumor till that part of the bowel is reached. Tumor occurs sometimes in obstruction by foreign bodies. In strictures, morbid growths, and invagination it may be recognized by rectal examination. Tumors with dullness on percussion are not seen in twist, though visible coils are sometimes present. Fever is even less frequent than tumor — in fact, its absence is rather characteristic, especially in the beginning. Records of elevated temperature are, however, found in from 22 per cent, to 28 per cent, of all cases, the maximum record being 102° F. (38.9° C). Hiccough is an occasional symptom, and appears to be more frequent in volvulus. Jaundice is often found in obstruction by gall-stones. The urine has been irregularly studied in acute obstruction. It is not infrequently spoken of as scanty and containing an increased amount of in- dican, especially in obstruction in the small intestine, not, it is said, of the large. Albumin is rarely present. It is to be remembered that peritonitis causes an increased indican reaction. Tumultuous peristalsis is not infrequent above the seat of obstruc- tion. Intussusception especially adds bloody stools and tenesmus, which are important in the diagnosis, the former occurring in three-fifths of the cases, the latter in 55 per cent. It may occur early or late. Blood-stained stools also occur in connection with cancer of the lower bowel. Volvulus and obstruction by gall-stones add local peritonitis, caused, in the latter case, rather by the destructive results incident to the passage of the stone into the bowel from the common duct. The same train of symptoms may succeed stricture and tumors, to be followed at times by partial relief, which is again succeeded by similar symptoms leading to ultimate total obstruction and death. Such symptoms will, of course, be associated with the anemic dyscrasia and emaciation which belong to the causing'- diseases, and which more frequently lead to death without obstruction than with it. Meteorism in the right inguinal region is said to be more or less characteristic of obstruction by Meckel's diverticulum. Collapse is the terminal symptom in fatal cases, due to the profound impression on the nervous system, and presents the lowered temperature, leaking skin, and feeble pulse characteristic of collapse from other causes. Cases are reported in which operation during collapse was followed by re- covery. In chronic obstruction due to fecal impaction, more rarely to stricture, cancerous disease, or foreign bodies, these symptoms are less marked and succeed each other more slowly. In fecal impaction, what appears to be simple constipation at first is succeeded by permanent retention, which may last for weeks without causing inconvenience. Examination per rectum will INTESTINAL OBSTRUCTION. 415 often disclose this tube filled with hard fecal matter which may be cleaned out with the finger or a spoon-handle. There may even be diarrhea, due to irritation of the bowel above the impaction, when the catarrhal secretion may channel out the mass and carry a portion with it. Gradually, however, the impaction becomes impregnable to all remedies, natural and artificial, the abdomen swells, there are fullness and weight within, and pain in the genitals or thigh from pressure on the sacrolumbar nerves ; the appetite fails, the tongue is coated, and the breath offensive ; sometimes a condition of lethargy and indifference supervenes along with great weakness, and the patient dies of exhaustion. At any time, on the other hand, may follow with suddenness the train of symptoms already described — pain, tympany, nausea and vom- iting, ultimately of fecal matter, with collapse and death. In many cases of impaction sooner or later, a fecal tumor presents itself — a tumor formed by the mass of retained feces, chiefly in the right iliac fossa, the region of the cecum, corresponding to the outer half of Poupart's ligament. It is sometimes hard, at others soft and yielding, and sometimes tender and painful, probably because of a mild local peritonitis. In the as- cending colon the tumor is soft, and in the hepatic flexure it may give rise to the notion of an enlarged liver. It may move in the more loosely attached parts of the colon, and may drag the transverse colon down toward the pubis. In the descending colon and sigmoid flexure it is usually harder, and may be subdivided into scybala. It is, of course, easier of detection in persons with thin abdominal walls, and may be obscured by flatulent dis- tention. When recognized, it is of great diagnostic value. Such tumors have been mistaken for tumors of the stomach, liver, spleen, and kidneys, and for pregnancy. Diagnosis. — The importance of early and correct diagnosis is intensified at the present day by the fact that operative interference promises by far the best results, while to be effectual it must be early. The diagnosis has three principal objects: first, the existence of obstruction per se ; second, its seat, and third, its cause. The first is by far the most important, as operation is indicated in one variety or situation almost as much as in another. First, as to the presence of obstruction in general, the absence of bowel movements, the presence of abdominal pain and tympany are suggestive symptoms. As to differential diagnosis, it has happened that a case of intense enteritis has presented all the symptoms of obstruction. Fever is commonly present in such enteritis, while it is absent in chronic obstruction, at least at first. Such a cause of error is, however, rare. Acute poisoning associated with vomiting, such as is caused by poisonous mushrooms, biliary, renal, and intestinal colic, the pain caused by twisting of the ureter in a movable kidney, all present symptoms more or less like those of obstruction ; but the combination of signs necessary to the picture of obstruction is still wanting. Much more common is the mistaking of appendicitis for obstruction. In this there are pain, vomiting, and constipation, as well as tumor in the neighborhood of the cecum, but the differentiation between these two con- ditions was considered when treating of acute appendicitis. Peritonitis itself presents symptoms common to it knd obstruction, including abdominal pain, distention, constipation, and collapse, with increase of indican. But the presence of fever, the absence of tumor and of fecal vomiting, point to peritonitis. 41 6 DISEASES OF THE DIGESTIVE SYSTEM. The symptoms of licniia are also those of intestinal obstruction, and in all cases careful search should be made for a concealed hernia. Such hernise have been found in the external ring and in the obturator foramen at autopsy by William Osier, who has also met a case of acute hemorrhagic pancre- atitis presenting the symptoms of acute obstruction. Second, as to the seat of obstruction. This is more difficult to determine. Unfortunately, the situation of the pain gives little information, since it is almost always in the vicinity of the navel, wherever the actual seat of ob- struction may be. In other cases the pain is diffuse. Rarely, it may be at the seat of obstruction. Though fecal vomiting is much more frequent in obstruction of the small intestine than of the large, it still occurs in one-eighth of all cases of the latter. When a tumor is present, it gives valuable information, being com- monly at the seat of obstruction. Active peristalsis limited to one part of the bowels indicates that the obstruction is below it. Having excluded hernia by a careful examination for a seat of strangu- lation, examination per rectum should be made, also per z'aginam. By either method a tumor may sometimes be recognized. Especially is this true of a tumor caused by intussusception. A stricture may also be detected by digital examination of the rectum, as may obstruction by foreign bodies. On the other hand, the rectum may be totally empty of feces and con- tinue so, whence it is probable that the obstruction is in the small intes- tine or high up in the large. The position and size of the uterus and ovaries may also be ascertained by rectal examination. The rectum can be more thoroughly explored by suitable specula in the knee-elbow position, but rectal exploration by the entire hand has not been followed by the results anticipated. The hard rectal tube has produced perforation, while the flexible tube so coils itself up as to be valueless in diagnosis. Some- times, if the distended intestine is filled with hard fecal matter, it can be felt as an uneven mass in the course of the bowel. Moderate distention in the upper part of the abdomen, with flatness below and in the sides, rapid collapse and oliguria, point to obstruction in the duodenum and jejunum. Such distention is temporarily diminished by vomiting, but is uninfluenced by fecal discharges secured by enemas. Nor is the vomiting always fecal in duodenal and jejunal obstruction ; when the obstruction is in the ileum and cecum the distention is more central, the region of the colon being flatter until covered in by the extending tympany, and the vomiting is more likely to be fecal. When obstruction is seated in the colon tympanitic distention is greatest, yet the difiference between it and that of obstruction in the ileum is not so great as to possess much diagnostic value. If in the lower colon, there may be tenesmus and discharge of blood and mucus. Measuring the capacity of the large bowel by air, gas, or water has been recommended as an aid to diagnosis. Reliable observation goes to show that these substances may be made to pass the ileo-cecal valve. Water recommends itself so far above the others that it alone will be considered. Moreover, the difficulty in passing water through the ileo-cecal valve is so great that it is practically applicable only in case of the large intestine. The capacity of the large intestine of adults is about six quarts, or about as many liters. That of infants appears to be widely different in children of the same age. Thus, in measurements by Dr. Muir, the capacity of the colon of a boy five months INTESTINAL OBSTRUCTION. 417 old was found to be but ten ounces (300 c.c), while, in a girl of seven months, it was thirty ounces (900 c. c). If the method is employed at all for diagnosis, it should be early, before the nutrition of the bowel has suffered, since rupture has taken place under light pressure. The patient, etherized, should be inverted or placed on his right side, and precaution taken to keep the fluid from returning. Close pressure of the buttocks generally suffices. The fluid is most conveniently introduced by the fountain syringe, by which pressure can be varied, but the reservoir should not be more than 2 1-2 feet (0.75 m.) above the body of the child. Various diffi- culties, more or less well founded, are suggested, such as resistance by voluntary muscles during life, valve-like obstruction, which permits ascent of fluid, but not descent, and unequal dilatation. However, the method should not be overlooked, and it is more than likely that much will be learned from future opportunity. Thus, since a case of obstruction at the sigmoid flexure, cited by Treves, permitted the injection of three pints of fluid (1.4 liters), it is evident that only in the event of the injection of a larger amount can the gut be considered open at this point. Treves claims, too, that the entrance of fluid in the cecum may be recognized by aus- cultation. Under favorable circumstances — as, for example, with empty colon, a trained ear, and skillful technique — this seems quite possible. Third, the presence of obstruction being recognized, the nature of the obstructing cause may sometimes be determined with a degree of probability. First to be 'considered is the relative frequency of the different morbid states. Adopting Fitz's figures, strangulation and intussusception together make up 70 per cent, of all cases, the two being nearly equal. After that come volvulus with 15 per cent., gall-stones with 8 per cent., and stricture or tumor 6 per cent., — that is, the twists about equal obstruction from gall- stones and tumor and stricture together. Again, if the obstruction be found in the large intestine, it is more likely to be intussusception, twist, or stricture and tumor, since of the obstructions in the large bowel 51 per cent, are intussusception, 30 per cent, twists, and 12 per cent, stricture and tumor. If in the small intestine, it is most likely strangulation or gall-stone obstruction, since 72 per cent, of obstructions in the small intestine are strangulations and 14 per cent, gall-stones, leaving 8 per cent, only for intussusception, 5 per cent, for twists, and i per cent, for stricture and tumor. If the attack has been preceded by one of jaundice or by other liver symptoms, as hepatic colic, it is almost certain to be gall-stone, especially if the patient be over fifty years old. If the patient is under thirty, particularly if a child, it is more likely to be intussusception than twist, while if there are palpable abdominal tumor, bloody stools, and rectal tenesmus, the case is almost sure to be in- tussusception, rendered still more likely if the rectum has a large capacity for water, since the intussusception is found near the cecum in 75 per cent., while twist is found near the sigmoid flexure in 50 per cent. Of all forms, intussusception presents the clearest clinical picture and is most easily rec- ognized. Tzvist, cancer, and stricture are more apt to be below the sigmoid, and the last two may sometimes be felt by the finger. In point of fact, twist in the large bowel is not often recognized. It is a disease of the adult, rarely occurring under forty ; vomiting is less early and less severe than in stran- gulation by bands. Pain is often severe in twist. Some degree of local 27 41 8 DISEASES OF THE DIGESTIVE SYSTEM. peritonitis almost invariably results, causing rigidity of the abdomen, while meteorism appears early and is extreme, the distended intestine often dis- placing the solid viscera. If there is a history of previous peritonitis, strangtdation becomes more likely, since such inflammation precedes in 68 per cent., while there is also a history of previous attacks in 12 per cent. The pain in strangulation is early, sudden, and severe, and the same may be said of vomiting. It be- comes stercoraceous in 60 per cent., while the vomiting affords no relief. There is little or no distention unless peritonitis supervene. There is great prostration, and no tenesmus or discharge of blood. The average duration is about five days. The presence of diaphragmatic hernia as a cause of internal strangulation must not be overlooked ; it is almost always the result of severe injuries. The half of the thorax containing the viscera is distended and tympanitic on percussion, while breathing movement is restricted, the breath-sounds are feeble, the vocal fremitus and vocal resonance diminished or absent — signs shared with pneumothorax. The pitch and intensity of the percussion note vary also with the degree of distention and the position. of the viscera invading the thorax, while there may be metallic tinkling of fluid in the intestine, due to peristalsis. Obstruction by Meckel's divert iciilnm is said to be indicated by meteor- ism in the right inguinal region. Fecal obstruction is recognized by the symptoms already described under chronic obstruction, and such recognition is not very difficult, especially if the fecal tumor is found. Sometimes, however, on account of its insidiousness, fecal obstruction is overlooked when presenting only the more chronic symptoms, and the patient dies of supposedly unknown cause when accurate and careful study would have led to its discovery. Prognosis. — In fecal tumors alone, of all the causes of obstruction con- sidered, is the prognosis favorable if the condition is recognized sufficiently early, while a considerable latitude of duration may also be allowed. Treatment. — In intussusception and fecal impaction alone is it worth while to consider anything but operative treatment. Treatment of Intussusception. — It is usual to attempt to reduce an intus- susception by inflation or irrigation. The latter is preferable in the colic variety, because pressure can be more accurately graduated, but it is con- sidered of little or no value in the enteric form. For the latter Nicholas Senn considers that better results may be obtained by inflation with a gas like hydrogen, which he finds passes through the ileo-cecal valve under a much lower pressure than a ftuid. On the other hand, D'Arcy Power recom- mends that the abdomen be opened at once when this condition is suspected. If irrigation is decided upon, the fluid — salt solution at 100° F. (37.8° C.) — is best allowed to pass into the large intestine slowly by its own weight through a long tube carried high up, the reservoir being raised not more than 2 1-2 feet (0.75 meter) above the etherized patient. A higher level than this for the reservoir may result in rupture of the bowel, while the bowel may also kink if the fluid be allovv^ed to enter too rapidly. Some place the patient head downward over the back of an inverted chair, suitably covered with a bolster and quilts. Others hold that inversion is unnecessary. The nozzle should be closely fitted to the anus, accomplished by simply compressing the buttocks. One hand should be kept flat on the abdomen, while variations of pressure should be avoided. It is said that in this way water may not only be passed from the colon through the ileo-cecal valve into the small intestine, INTESTINAL OBSTRUCTION. 419 but also through the pylorus into the stomach, thence into the esophagus, and out at the mouth. If success is not attained in forty-eight hours, it is not likely to follow, and laparotomy should be done. The extent or size of the intussusception furnishes no reason against the use of the treatment. It has been found effectual in 33 out of 44 cases of suspected or probable intussus- ception collected by Fitz, and therefore merits a trial. Unfortunately, there is always a tendency to recurrence after the reduction of an intussusception by this method. Should the recurrence persist, laparotomy should be done without much delay, especially in view of the fact that the operation is so much better borne early in the disease, before the strength of the patient is exhausted. Rarely should more than forty-eight hours be allowed to elapse without operative interference in cases of acute obstruction from any cause except fecal impaction. What else may be done early and without risk to the patient? Above all, give 7io aperients. To relieve the excessive vomiting after the simpler remedies have been tried, the stomach may be zuaslied out as suggested by Kussmaul and described on page 348. This is at once a harmless measure and may be efficient for the purpose intended. It may be done three or four times a day. It may be expected to be of service in the vomiting of any variety of obstruction. Opium may be administered hypodermically to allay the intense pain, and may also relieve the vomiting. Or it may be given with a view to cure, which there is reason to believe it has accomplished in cases of intus- susception and even strangulation. Opium may, on the other hand, be harm- ful, by obscuring diagnosis and producing an appearance of relief, while the local condition of the bowel is really growing worse. The nourishment of the cases demands careful thought. It is irrational to continue the administration of nutriment by the mouth when it is rapidly rejected. If the obstruction is in the small bowel the rectum should be the only route employed, while ice should be administered freely by the mouth. On the other hand, when the obstruction is in the colon, when tenesmus and diarrhea are symptoms, and v%^hen vomiting is a less prominent symptom, small amounts of liquid nourishment may be introduced by the mouth. Treatment of Fecal Tumor. — The situation is altered when a diagnosis of fecal tumor has been correctly made. Here nothing is so efficient as repeated large injections of warm water, high up and retained for from ten to fifteen minutes if the patient can retain them, as he should be encouraged to do. Good results are sometimes obtained from the coincident use of small doses of calomel, 1-8 to 1-5 grain (0.008 to 0.013 gm.), given hourly. If the fecal impaction is low enough down in the rectum, in most cases the fin- ger or some mechanical appliance, as a spoon-handle, can be used to loosen it. It is in this form, too, that electricity, massage, and metallic mercury, as used by the older practitioners, are sometimes useful. Electricity is vari- ously used, but the most efficient application is the recto-abdominal, in which one electrode of a faradic machine is placed in the rectum, the other over the abdomen. The use of metallic mercury has been revived by M. Matignon in fecal impaction with apparently good results, the dose being 1.5 to 9 ounces (50 to 280 gm.). It probably acts by insinuating itself in a state of minute subdivision through the fecal tumor and between it and the bowel, loosening and breaking up the mass so as to restore the natural passage. It is of no use when there is strangulation, intussusception, or volvulus. In stenosis of the gut, inflammatory or otherwise, the treatment recom- 420 DISEASES OF THE DIGESTIVE SYSTEM. mended for fecal impaction may oftentimes be used, with the eft'ect of remov- ing the obstruction so far as due to the delay of fecal matter at the narrowed point. Sooner or later operative interference becomes necessary. Tix'ist, strangulation by hands and obstruction by gall-stones can only be relieved by operation, and a surgeon should be associated in the treatment from the outset. For treatment of cancer of the bon'cl see section on that affection. COXSTIPATION. Syxoxym. — Costiveness. Definition. — Unnatural retardation or delay in the natural evacuation of the bov.-els. Though there may be some exceptions, an evacuation of the bowels once in twenty-four hours seems to be nature's law in the case of the adult human being, and any prolongation of this interval may be said to constitute costive- ness. A popular application of the term is also, however, to a condition in which, though there may not be infrequency of stools, the dejecta are dryer and harder than natural and are discharged with more or less difficulty and pain. The physician should appreciate this, otherwise misunderstanding may arise as to the exact meaning of the patient. Constipation is also some- thing different from retention due to obstruction by various causes. The in- terval between bowel movements in constipation varies greatly, ranging be- tween a couple of days and weeks. Alany constipated persons have no de- jections unless aperient medicine is taken. Morbid Anatomy. — There are no morbid changes characteristic of constipation. Dilatation of the colon in various degrees is present, some- times enormous, as shown in Fig. 34. and there may be found the remnants of inflammatory or other local lesions which may be responsible for the obstruction. The large accumulations of fecal matter found in these cases are known as coprostasis. Etiology. — The immediate causes of constipation are: 1. Atony of the colon, whence results a slow peristalsis. Perhaps the most common cause of atony is a habit, engendered through indifference or necessity, of disregarding nature's call for relief. Repeated disregard of such call results sooner or later in disappearance of inclination. .Sedentary habits co-operate to produce such disinclination. Atony may also be the result of disease of the bowel and of general disease causing debility, such as anemia, chlorosis, and protracted illness, like typhoid fever. 2. A deficiency of the natural stimuli to peristalsis afforded by various secretions, especially the bile. 3. A loss of muscular power in the abdominal walls from overdisten- tion or obesity. 4. Improper food. The foods which most stimulate peristalsis are vege- tables, especially those with an insoluble residue, such as is afforded by the outer coatings of grain. Foods of an opposite kind are represented by milk and the farinacea. 5. Finally, stricture and displaced organs, — such as the uterus, — tumors. CONSTIPATION. 421 and foreign bodies impinging on the bowel and delaying the descent of the feces, become causes. Among consequences of fecal impaction are hemorrhoids, which result from pressure on the hemorrhoidal veins. Treatment. — Every case of constipation should be carefully studied with a view to determining its cause, and if such cause is found, it should, of course, be removed when possible. If such cause is not found, the first injunction in the management of constipation is the observance of regularity in going to stool at a fixed hour of the day, whether inclination prompts or not. The usual hour for this purpose is immediately after breakfast, though it matters not much when it is, so that it is regularly observed. Especially harmful is it to disregard any inclination which may appear at this time, or, indeed, at any time. Next is the use of food of the kind referred to under the head of etiology, such as fresh green vegetables of all kinds and succulent fruits. Of breads, the so-called " brown " or bran bread, or gluten bread, is to be preferred. With such food should be conjoined massage of the abdomen or compression, either by the patient himself or by another. A very excellent daily practice is to flex the body forward and as far as possible backward, a number of times while in the standing position. This has the efifect of compressing the bowels and stimulating peristalsis, and is one of the most useful aids. It should be practiced once or twice a day : if once, in the morning on rising ; if twice, at bedtime also. Rising to a sitting posture while lying on the back with the feet fixed is another exercise helpful in the correction of constipation ; so is twisting of the body while standing. Daily exercise, including horseback riding, golf, and tennis, has an important influ- ence in correcting constipation. I have known dancing also to be serviceable. The free use of plain water is sometimes sufficient to overcome the milder cases. Thus, a glass of water may be taken before breakfast and another at bedtime. Last of all should aperients be employed. Unfortunately, these are often necessary. The simplest and least irritating should be employed. A simple tonic pill composed of 1-3 to 1-2 grain (0.022 to 0.033 g™-) of the extract of nux vomica and 1-12 to 1-8 grain (0.005 to 0.008 gm.) of the extract of belladonna, three times a day, and kept up for some time in con- nection with the dietetic measures alluded to, is often sufficient. But of atcual aperients, the natural mineral waters are deserving fav- orites, especially Friedrichshalle, Apenta, Hunyadi Janos, and Carlsbad, and, when less active waters are required, the American Saratoga waters. The Saratoga waters are saline waters which present quite a range of pro- portion in their constituents, chiefly sodium chlorid, at the various springs. The waters of the Bedford Springs, of Bedford, Pa., are also very efficient, stimulating, as does the Saratoga water, the secretion of bile. The doses of all of these waters vary so much with circumstances that it is impossible to indicate them with definiteness. The minimum dose of the foreign aperient waters mentioned is two fluid ounces (60 c. c), increased to eight fluid ounces (240 c. c). Less than the latter quantity of the American waters is seldom used at a dose. Of drugs, cascara sagrada has become deservedly popular. The best preparation is the fluid extract, as its dose can be readily regulated. From. 10 to 30 minims (0.6 to 2 c. c.) may be given after the evening meal, and if this should prove insufficient, the same dose after the midday meal is to be 422 DISEASES OF THE DIGESTIVE SYSTEM. preferred before increasing the evening dose. The soHd extract is, however, also efficient, and a grain or two (0.066 to 0.13 gm.) more may be added to the laxative pill already mentioned, or, if a more active aperient is desired, as many grains of extract of colocynth may be substituted. An old favorite, a pill composed of extracts of aloes, nux vomica, and belladonna, in varying proportions, to be taken at bedtime, has been largely substituted of late by another made by the manufacturers and pharmacists, of aloin 1-5 grain (0.013 gm.), strychnin 1-60 grain (o.ooii gm.), and bella- donna 1-8 grain (0.008 gm.), of which one or two are a dose. To such a pill podophyllin, in doses of 1-4 to 1-2 grain (0.0165 to 0.033 gm.), may be added with advantage, or blue mass in doses of 1-2 grain to 2 grains (0.033 to 0.132 gm.), or rhubarb one to two grains (0.066 to 0.013). The bella- donna may be substituted by the extract of hyoscyamus, of which one to two grains (0.066 to 0.132 gm.) may be given. The compound licorice powder in which senna and sulphur are the active ingredients is a favorite aperient with some, but is bulky, and has a tendency to cause griping. The dose is a dram (3.8 gm.) or more. A glycerin suppository or 1-2 dram (2 c. c.) of glycerin injected has become a favorite means of securing an evacuation. It should be remem- bered as a possible remedy, but it acts by irritating the lower bowel and soon loses its effect. The enema of plain water, one to two pints (500 to 1000 c. c), though less convenient, is to be preferred, and some persons use it regularly. None of these measures is curative. They simply empty the bowel at the time, and systematic efifort should be made to reduce them gradually, while the hygienic treatment is kept up. Among the more unusual remedies recommended for chronic constipa- tion is creasote, one drop daily, increasing one drop a day until the result is obtained. It sometimes happens that an impacted fecal mass becomes channeled, and fecal matter may descend from above through it, anl thus lead to the belief that normal passages are being secured. The physician should not be slow to explore the rectum with the finger, and by means of it or the handle of a spoon clear out the mass. This is often absolutely necessary before an evacuation can be secured. Treatment of the Constipation of Infants. — I prefer to overcome this, when possible, by simple small enemas repeated until an effect is produced, and carried out at a fixed hour each day, preferably in the evening. The child is best held on the motli^r's lap, properly protected by a mackintosh and a small quantity, say two ounces (60 c. c), of tepid water is thrown into the rectum. If it returns unchanged, after a few minutes' delay another syringeful is thrown in, and if necessary, another. Ultimately, a fecal discharge is usually thus obtained. I lay stress also on the regularity of this performance. It may be necessary to add a little soap to the hot water. Sometimes slight titillation of the anus by twisted pieces of paper answers every purpose. At the same time, the belly of the child should be massaged by the mother. Small suppositories of soap or of glycerin may be used if the measures mentioned are inefficient. For simple constipation in infants it is preferable to administer nothing by the mouth if it can be dis- pensed with. Dilatation of the Colon. — This is one of the consequences of chronic constipation, though it may also occur as an acute condition, the result of CONSTIPATION. 423 sudden obstmction, as by a twist in the meso-colon. It may '"volve the whole colon, but the vicinity of the sigmoid flexure ,s , s usual seat. Two classes of cases of idiopathic dilatation are met.-first, that of adult males eeneraUy over fifty years of age ; second, that of children in whom abdominal fymptoms have been present more or less since birth. In the former >t .s Fig 34 -Giant Congenital Wlatation of Human Colon. The more distended end is the sigmoid fl^^'^jl'.e narrow part ^^^^tJ^^J'^f' were dried preparations. thought that the overloaded sigmoid dependent into ''■« P'^!™^''"'!,''™^^. itself becomes occluded and responsible for ddatat.on. The form met m ch.l 424 DISEASES OF THE DIGESTIVE SYSTEM. dren is usually congenital and involves the lower portion of the colon, which is also hypertrophied. The congenital form becomes the direct cause of chronic constipation or coprostasis, which in turn increases the dilatation. Such is a remarkable specimen in the museum of the University of Pennsyl- vania, secvired by the late Henry F. Formad * in the course of his work as coroner's physician. Two and a half pailfuls of feces, weighing 40 pounds (20 kilograms), were removed at autopsy. Symptoms. — They are the same as those of obstinate constipation extending over weeks, in addition to enormous distention and tympany of the abdomen. Physical examination in extreme cases recognizes dislocation of the adjacent abdominal and thoracic viscera, especially the liver, spleen, heart,, and lungs. Treatment. — The treatment is that of the resulting constipation, which,, in cases of this kind, is by enemas carried high up into the bowel, together with remedies which stimulate secretion into the upper bowel, of which calo- mel is one of the best. It should be given in doses of not less than 1-4 grain (0.016 gm.) hourly, until an effect is produced in association with that of the enemas. Dilatation probably results, at times, from the gradual accumula- tion of fecal matter, while frequent small discharges are being obtained wdiich do not clear out the bowel. Hence the rectum should unhesitatingly be explored by the finger in doubtful cases. Complete evacuation of the bowels is sometimes extremely difficult, but if the exact state of affairs is appreciated, perseverance will ultimately conquer. Operation with exsection of large portions of the bowel has been done with excellent results. NERVOUS AFFECTIONS OF THE BOWEL. The bowel, like the stomach, is subject to deranged nervous influence, which manifests itself in : I. Increased or diminished contractility of the muscular coat. II. Increased or diminished sensibility of the bowel. III. Increased or diminished secretory function. I. Derangements of Motion. — These are manifested by diarrhea, by constipation, and by cramp. I. Increased motor activity producing nervous diarrhea occurs in adults and children, the result of increased peristalsis due to pure nervous influ- ence. It implies a hyperexcitability of the nerves regulating peristalsis, caus- ing them to respond to stimuli to which they are otherwise indifferent, such stimuli including the simple mechanical and chemical irritation of the natural intestinal contents. Hence we find nervous diarrhea in nervous, hysterical^ and neurasthenic persons. In these persons, too, psychical influences, such as fright, depression, and even joy, cause diarrhea. The attacks of diarrhea which occur in tabetic persons have a similar origin through central nervous influence. Still more does such an excitability of the nervous system respond to unnatural irritation, such as that of teething in infants, producing diarrhea, which may be quite independent of irritating food, though the latter may co-operate. * " Transactions of the Pathological Society of Philadelphia," vol. xvi., 1891-93, p. 23. Dr. Formad gives in his paper a summary of other cases reported. NERVOUS AFFECTIONS OF THE BOWEL. 425 There is no morbid change, and the bowel movements are generally watery and without blood or mucus. They vary greatly in frequency, — from two to twenty or more daily, — occur suddenly, and disappear often as sud- denly as they come. They may last for several days. 2. Decreased motor activity producing constipation, the result of altered nervous influence, is even more common than diarrhea. In this condition, strictly speaking, the muscular coat has lost its impressibility to stimuli ordinarily sufficient to excite the automatic actions which result in bowel movements, and peristalsis is at a standstill. Associa- ated with such condition is often an atony of the muscular coat, which per- mits gaseous overdistention and tympany. It is scarcely possible to separate such phenomena from those of impaired nervous sensibility of the bowel, to the paragraphs on which the reader is referred. 3. Nervous cramp, or excessive contraction of the intestinal muscles, is so intimately associated with pain that it will be considered in connection with deranged sensibility. II. Derangements of Sensibility. — i. Enteralgia. — Sensory neuroses of the bowel are mostly in the direction of increased irritation of sensory nerves derived from the splanchnics, which contain the sensory as well as the inhibitory and vasomotor nerves to the bowel. Such irritation implies increased irritability of these nerves or the presence of unusual irritants. The pain thus induced, unassociated with organic lesion, is known as enteralgia or neuralgia of the bowels. Associated with exaggerated contraction of the muscular coat it is known as colic, though the terms enteralgia and colic are also interchangeably used. Characteristic of enteralgia -are its suddenness of occurrence and, to a less degree, the suddenness of its cessation. It is often associated with crampy contraction of the abdominal walls, when the pain is augmented. Etiology of Enteralgia. — Among the causes which excite pain are such foreign bodies as indigestible articles of food, intestinal worms, fecal masses, overdistention with gases, and the like. The effect of the latter is attested by the relief which attends the discharge of gas. The operation of reflex causes must also be admitted. Such may be the mode of action of cold and of lead intoxication, which produces the well-known lead colic. Such is, possibly, gouty enteralgia, or the enteralgia succeeding an attack of gout. The enteralgia associated with certain nervous diseases, such as occurs in the painful enteric crises of locomotor ataxia, is probably the direct result of alteration in the sensitive nerves themselves. It may be, too, that the action of lead in producing lead colic is thus direct. The hysterical and hypochon- driacal and the anemic are subject to colic through increased sensitiveness of nerves. Diagnosis. — The pain existing in enteralgia is diffuse and throughout the abdomen. Enteralgia is to be distinguished from enteric pain due to organic disease. Most important are the inflammatory and ulcerative states associated with enteritis, typhoid fever, peritonitis, appendicitis, and intesti- nal obstruction. The diagnosis is usually not difficult. There is, first of all, the absence of fever ; second, the history of the ingestion of irritating foods, or some one of the causes named. Very important is the point that colicky pain is relieved by pressure, while pressure increases pain in all of the affec- tions named. Most difficult becomes the diagnosis in those cases in which there is coincident flatulence, as is sometimes the case in typhoid fever, when the question to be answered is. Is this colic, or is it the tenderness which comes 426 DISEASES OF THE DIGESTIVE SYSTEM. of peritonitis? Undoubtedly in some instances both are present, and one condition reacts upon the other. The diagnosis from appendicitis has been considered in treating of the latter. Intestinal obstruction offers further similarity in the absence of fever, but the severity of the symptoms in obstruction is on the whole greater, their duration is longer, while constipation and vomiting are superadded. Rheu- matism of the abdominal muscles sometimes resembles enteralgia very closely. In this, however, there is commonly exquisite tenderness, while the pain is superficial and more continuous. Nervous dermalgia, or hyperesthesia of the abdominal wall, has similar features and is common in hysterical women. Sometimes this is associated with hysterical colic, but even here, while the skin itself is sensitive, deep-seated pressure does not bring out incerased pain. Biliary colic and nephritic colic also resemble enteralgia, and may at first be mistaken for it, but careful examination should soon discover the points peculiar to each, such as localized tenderness and jaundice in the former and the course of the pain into the groin and testicle and thigh in the latter. Uterine colic may also be confounded, but the pain is distinctly local- ized in the region of the uterus and is apt to be associated with menstruation or to precede it. It is important, also, if possible, to discover the form of enteralgia or its special cause, whether due to indigestion, to reflex causes, to constipation, to lead, to hysteria, or to central nervous causes. This is to be arrived at by close attention to .the history and associated symptoms. 2. Neiiralgia of the Rectum. — Some special symptoms characterize the sensory neuroses of the rectum which demand separate allusion. The nerves of the hemorrhoidal plexus are thus concerned. An uncomfortable aching sensation in the lower bowel and lower abdomen, extending at times to the sacrum, perineum, and genitalia, is the principal symptom. With this is associated an irresistible desire to go to stool, which is, however, fruit- less. As a reflex sensory neurosis of the rectal nerves may be considered a peculiar sensation of exhaustion and disposition to faint after a movement of the bowels, complained of by some persons. Wilhelm v. Leube also calls attention to an " intestinal vertigo," excited during the passage of feces through the anus, and capable of being excited, too, by introducing the finger into the rectum. The sensorv neuroses of the rectum are more common in nervous women and in the subjects of hemorrhoids, while tabetic patients are apt to suffer from the same symptoms. 3. Diminished Sensibility. — This is manifested for the most part only in delayed peristalsis. It has been said that constipation is one of its most con- stant results. In the case of the rectum, it is well known how, in health, we are informed of a desire to go to stool. Paralysis of these nerves results in anesthesia, which is followed by the absence of this desire. The effect must be an accumulation of feces in the rectum, which may still be evacuated if volition and the motor nerve route are intact, but which demands artificial removal if these are in abeyance. It is a constant symptom in those affec- tions of the spinal cord associated with paralysis. To higher degrees is added the loss of the limited reflex control, and if there be also loss of the voluntary control over the sphincter ani, an involuntary stillicidium of liquid contents of the bowel results, though the solids go on accumulating unless NERVOUS AFFECTIONS OF THE BOWEL. 427 artificially removed. Thus is explained the constipation of the hysterical and neurasthenic. The constipation associated with the passive congestion of heart and liver disease is the result of a similar lethargy of the nerves distributed to the muscular coat of the bowel. Here, too, we may infer an exhaustion of nervous excitability by overstimulation, if, as is suggested, normal peristalsis is excited by the stimulus of the carbonic acid of the venous blood, as well as by the food present in the intestinal tube. On the other hand, a food may be too- bland and unirritating to excite the normal peristalsis. Hence it is that constipation attends the use of milk and the farinacea. The effect of paralysis of the voluntary muscles controlling the external sphincter ani results in inability to retain the fecal contents, whence involun- tary evacuations take place, a frequent symptom in disease of the brain. Under such circumstances the control of the bowels is given over altogether to the reflex nervous center in the spinal cord, and man is reduced to the con- dition of the infant and the lower animals, in which defecation is a purely reflex act. Oversensitiveness or overstimulation of the sphincter would result in a spasmodic and painful contraction, which is, however, a very rare and anomalous condition. III. Secretion Neuroses. — It is difficult to separate the consideration of the secretion neuroses of the bowel from that of the sensory and motor neuroses. Yet it is well known that secretion into the bowel may be in- fluenced quite independently of peristaltic motion, perhaps through the vaso- motor nerves. Thus, while it is more than likely that the saline aperients produce their effect in response to the physical laws of osmosis, the secretion into the bowel which follows the hypodermic injection of pilocarpin cannot be explained upon any other ground than that of vasomotor nervous influence. Mention has already been made of the responsibility of the nervous system in producing the mucous discharges and casts referred to in discussing chronic enteritis. Treatment of Neuroses of the Bowel. — This follows easily upon a cor- rect diagnosis, which is indispensable. The primary point of attack is that of the nervous condition at fault. The removal of the causes of irritation should be coincident with measures directed to the relief of pain. If irritat- ing ingesta are present, an emetic should be given. In children the gums should often be examined, and lanced when swollen and tender. . If there is constipation, the bowels should be opened. If there is hysteria, a nervous sedative is indicated. In enteralgia the promptest means of relief is a hypo- dermic injection of morphin of 1-4 grain (0.0165 gm.) to an adult. Less may suffice, but if the pain is extreme, it is not worth while to temporize with smaller doses. On the other hand, it is not safe to give more at a single injec- tion. Should this dose be ineffectual, associated with the local measures to be described, it may be repeated in half an hour. The combination of atropin 1-150 grain (0.00044 grn-)» with the morphin will increase its efficiency. Of local measures, massage is probably the most efficient for constipa- tion and enteralgia. It has been mentioned that relief of the pain by pressure is characteristic of enteralgia.' Especially happy results may, there- fore, be expected from massage, an expectation that is realized in practice. Counterirritation to the abdomen by mustard or turpentine stupes may be used as an adjuvant to treatment in lieu of massage. In milder forms of enteralsfia, aromatics and carminatives, alone or in 428 DISEASES OF THE DIGESTIVE SYSTEM. combination with morphin, have always had a justified reputation. Some of these have been mentioned in considering the treatment of cholera and cholera morbus. An especially elegant and efficient preparation is: I^ Spiritus ammon, aromat. "] Tinct. card. comp. ! t •• ca \ Spiritus chloroformi (^^ 3iJ(»c.c.; Spiritus vin. gall. J M. et. Sig. — Teaspoonful every half hour or fifteen minutes, in cracked ice or hot water until relieved. Its efficiency is increased by adding a few drops of deodorized tincture of opium to each dose. CARCINOMA OF THE BOWEL. All parts of the bowel are subject to carcinoma, which occurs in grow- ing frequency as the gut is descended. Thus, of all cases of bowel cancer, barely 5 per cent, are found in the small intestine, 15 per cent, in the cecum and colon, while 80 per cent, are met in the rectum. In the small intestine, in the neighborhood of the orifice of the bile-duct, we meet most frequently the cylinder-celled epithelioma or adeno-carcinoma. In the large intestine there is : 1. Cylinder-celled epithelioma, the most common form of cancer, in the cecum and sigmoid flexure. 2. Colloid cancer 3. Scirrhus 4. Soft cancer ^ in the rectum. 5. Squamous epithelioma just above the anus I 6. Sarcoma, including the melanotic variety j Benign tumors of the bowel, which may present symptoms similar to those of malignant tumors or no symptoms at all, include mucous polypi and fibromata, more rarely lipoma, myoma, angioma, and lymphoma. Symptoms. — There are no symptoms distinctive of cancer of the bowel. The most constant local effect is more or less obstruction of the bowel, and we have already seen in our study of obstruction how far it is contributed to by cancer. There are, howeyer, other symptoms which, added to those of obstruction, aid in the diagnosis. Particularly is this true in the case of the rectum. The symptoms of obstruction met with in cancer of the bowel, already considered in treating of obstruction, include, especially, constipation, pain, tumor, anorexia, nausea, and, more rarely, vomiting. The added symptoms are cachexia and altered fecal discharges, which may include pus, blood, and, in few instances, fragments of cancerous tissue. Of the symptoms of obstruction named tum,or alone demands further consideration, being the most important of all the symptoms of cancer. In fact, without it a certain diagnosis is scarcely possible. On the other hand, given a case of obstruc- tion, the presence of tumor points more to cancer than to any other cause except intussusception and fecal impaction. As contrasted with intussus- ception, the tumor of cancer is of long duration and found in adults ; as with impaction, it is tender and movable, usuallv harder and more irregular. CARCINOMA OF THE BOWEL. 429 While the tumor may give a dull note to light percussion, to a hard stroke it is tympanitic. It may pulsate also if it lie over one of the large blood-vessels. Fecal tumors never do this. The difficulty of distinguishing from a fecal tumor is increased when a fecal mass is added to the cancerous tumor, but some of it may be cleared up by the use of purgatives and injections. Cachexia, added to other signs of chronic obstruction, points to cancer. Change in the shape of the formed feces, especially a band-like flattening, is much spoken of. It may be produced by any cause which protrudes into the lumen of the large bowel, characterizes rather disease of the lower part, and, to be of value in diagnosis, it must be constant. The more or less con- stant presence of sanious pus, particularly of fetid character, is important evidence in favor of cancer. Diagnosis. — Carcinoma of the duodenum is not easily distinguished from tumor of the pylorus; indeed, it is sometimes impossible to separate them. Both are movable tumors. With pyloric tumor are associated symp- toms of obstruction and dilatation of the stomach. More rarely cancer of the duodenum has the same effect. The presence of jaundice points to cancer of the duodenum, as does also the continued natural acidity of the gastric con- tents removed after a test-meal, but neither of these symptoms is pathog- nomonic of duodenal cancer. In cancer of the stomach dyspeptic symptoms occur earlier and are more serious. Carcinoma of the duodenum may ter- minate suddenly by fatal hemorrhage. Cancer of the head of the pancreas also produces jaundice, but the tumor arising from it is fixed and immovable, and much more deep-seated than tumors of any portion of the bowel, being behind the pylorus and the transverse colon, between the left sternal border and parasternal line. With the other abdominal tumors intestinal cancer is not likely to be confounded. The floating kidney is movable, but when sufficiently so to be compared in this respect with a cancerous tumor, is more movable, and may be generally returned to its natural seat. The kidney shape may not infre- quently be recognized. Compression of the kidney often produces a peculiar sickening pain. The presence of nerv^ous symptoms is especially character- istic of floating kidney, but there is no cachexia. A movable spleen is even less likely to be confounded, for similar reasons. It is, moreover, less sensi- tive. A laced-off lobe of the liver, often quite movable, can generally be traced to its normal attachment. An actual tumor of the kidney, being behind the peritoneum, pushes the bowel and the ascending or descending colon before it, and must attain con- siderable size before it shows itself to the usual examination from the front. Such tumor very rarely compresses the bowel so as to produce symptoms of obstruction. The same may be said of tumors of postperitoneal lymphatic glands. An ovarian tumor is characterized by its deep-seated origin, its ascending development, and its relation to the uterus, as determined by joint vaginal and abdominal examination. A circumscribed peritoneal exudate might be mistaken for a cancer of the bowel, but the history of its development, its flat percussion note, and the presence of some temperature, which characterizes it, are wanting in cancer of the bowel. Cancer of the bowel is not likely to be mistaken for appendicitis, the acuteness of symptoms marking the grave form of the latter, while the absence of serious constitutional and cachectic symptoms is characteristic of the more chronic form of appendicitis. 430 DISEASES OF THE DIGESTIVE SYSTEM. Chronic infiauiviatory tlu€kcning of the bowel may, however, be a seri- ous stumbhng-block. Especiahy apt to occur about the sigmoid flexure, it produces also obstructive symptoms, and careful and prolonged study may be necessary to the making of a correct diagnosis. Cachexia remains absent in simple inflammatory stenosis for a longer time at least than cancer. Diagnosis of the Pari of Bowel Involved. — As to the part of the bowel involved, once assured that the tumor is of the bowel, some indication of its more exact location may be obtained by noting its position, which, if in the right abdominal region, suggests the duodenum ; in the vicinity of the um- bilicus, the transverse colon ; in the right iliac fossa, the cecum, and in the left, the sigmoid flexure. It should be remembered, however, that serious dislocation of the tumor from its natural site may occur as the result of in- flammatory adhesions formed w^hile the tumor is temporarily in a position remote from its natural site. Often, too, a cancer of the sigmoid flexure gives no indication of its presence to abdominal examination. Distention of the bowel with water or gas and the application of the principles laid down from this standpoint, when treating of obstruction, may be availed of in settling this cjuestion (see p. 418). Allusion has been made to the presence of jaundice as characteristic of duodenal cancer; also to the retained natural acidity of the gastric contents "removed after a test-meal as com- pared with gastric cancer. Cancer of the rectum exhibits a somewhat special train of symptoms. The rectum is subject to the same forms of cancer as the pylorus, and in somewhat the same order of frequency, the columnar-celled epithelioma being most common. The early symptoms of cancer of the rectum are those of irritation, in- cluding pain, tenesmus, the discharge of mucus and blood, and, probably, most cases of carcinoma of the rectum are mistaken at first for dysentery. In the cases of colloid cancer, the colloid material may be discharged from the bowel and reasonably mistaken for mucus. Fortunate is the clinician if it occurs to him to make an early examination of the rectum by the finger ; for generally the disease can be felt, either as an ulcerated mass infiltrating the wall of the bowel, thus intruding upon the lumen, or as one or more nodular growths under the mucous membrane and adherent to it. If ulceration has occurred, bloody and mucoid matter, characterized by extreme and persistent fetor, is apt to adhere to the finger. Von Leube especially calls attention to hemorrhoids as a symptom of cancer of the rectum, and says they are sel- dom absent, because of the resistance opposed to the return of the venous blood. He claims he has discovered rectal cancer in examination suggested by hemorrhoids when no other symptoms were present. So, too, the pres- ence of secondary cancer of the liver should suggest examination of the rectum, since marked instances of the former have been found associated v^ith cancer of the rectum, otherwise latent. Almost all morbid growths affecting the rectum are cancerous. Polypi, mucous and fibromatous, occasionally found in children, produce dysenteric symptoms, including bloody discharges, while they may project from the rectum during stool. Lipomata and other histioid tumors have been found at autopsy without having caused symptoms. Prognosis and Treatment of Cancer of the Bowel. — The prognosis of cancer of the bowel is always unfavorable. Occasionally operative pro- cedures have prolonged the life of the patient at the expense of an artificial anus in the lumbar or abdominal region, while resection has even been made HEMORRHOIDS. 431 with some degree of success. Especially happy have been the results in some cases of exsection of the rectum. The propriety of operation should, therefore, always be considered. Should it be decided against, the patient must be nourished by easily assimi- lable foods, such as peptonoids and peptonized milk, by the mouth or bowel, as circumstances may determine. A regular and sufficient evacuation of the bowels should be carefully looked after, lest impaction add its inconve- niences to the others present. HEMORRHOIDS. Synonym. — Piles. This troublesome affection lies on the border-line between medicine and surgery, and is, therefore, as appropriately considered from the standpoint of the physician as from that of the surgeon. Definition. — A hemorrhoid is a mass of varicose or dilated and sac- culated veins at the anus and lower rectum, the central situation being almost always the muco-cutaneous surface which joins these two structures. From this edge one or more piles may protrude externally or internally, constitut- ing external or internal piles, the former protruding outside the gut, the latter within the sphincter. Piles are called " open " or " bleeding " as they give rise to hemorrhage, and " blind " when they do not bleed. Morbid Anatomy. — The external pile constitutes a little circum- scribed tumor. Commonly there is more than one of these, whence the common use of the plural, " piles," or " hemiorrhoids." They may be so numerous as to form a more or less complete circle around the anus. Within the sphincter the individual or tumor-like shape is more usually maintained, and the pile may be more elongated. The color varies from dark red to purple, the surface is smooth or lobulated, and the consistence is variously soft, hard, or elastic, corresponding to the degree of vascular turges- cence. On section the pile is found to be a mass of loculi filled with blood and separated by areolar tissue. These cells are produced by the sacculated and dilated veins referred to. After lasting for some time the structure becomes altered. The walls of the veins are thickened, the intervening con- nective tissue becomes firmer, and the whole pile grows harder, and appears more or less shriveled. Etiology. — Piles are favored by the anatomical structure and relations of the seat at which they occur, more particularly the arrangement of the so-called hemorrhoidal plexus of the lower rectum. In health the plexus forms a -.rich, tortuous network lying between the muscular layer and the muco-cutaneous surface, and is subject to pressure by masses of fecal mat- ter accumulated in the rectum and by straining at stool. The blood from the hemorrhoidal veins is discharged partly into the portal system and partly into the general venous system: the :former through the superior hemor- rhoidal and the inferior mesenteric veins, and the latter by the middle hemor- rhoidal and the internal iliac veins. The plexus is therefore between the portal and general venous systems, but more closely connected with the 432 DISEASES OF THE DIGESTIVE SYSTEM. former. Hence obstructions to either the portal circulation or cardiac cir- culation, however induced, tend to engorge these veins, and become a pre- disposing or even sufficient cause of piles. After the predisposing causes described, the most common cause of hemorrhoids is constipation and the accumulation of large quantities of fecal matter in the rectum. Hence it is that persons whose bowels do not act daily are very apt to be troubled with piles, and as women suffer much in this way, it is they who are most frequently victims. On the other hand, women suffer less than they would but for the relief afforded to congestions in this neighborhood by their monthly flow, so that it is not until after the menopause that they become most liable. Hence it is that hemorrhoids are more common in men up to the age of from forty-five to fifty, and that after this age more cases occur among women. The diseases in the abdominal cavity peculiar to women often produce hemorrhoids through the pressure thev exert on, and the resistance they present to, the return of the blood from the hemorrhoidal plexus. Such are uterine enlargements and fibroid tumors of the uterus, ovarian tumors — in a word, any morbid growths which may invade the pelvic organs and become large enough to exert pressure. The pregnant uterus is another frequent cause of hemorrhoids in women, and thus hemorrhoids sometimes become one of the most distressing com- plications of the puerperal state. Symptoms. — External Hemorrhoids. — The first evidence usually afforded of the presence of a hemorrhoid is a tender, painful lump, about as large as a pea, which makes its appearance just outside the sphincter ani, sometimes quite suddenly, more frequently requiring two or three days to attain its full development. This little tumor may pass away in the course of two or three days without treatment, or it may grow to larger size. If it disappears, it may never reappear, but more frequently it recurs — it may be not for months. In other cases the recurrence becomes more frequent, the condition lasts longer, and the inconvenience is correspondingly greater, especially during and succeeding defecation. The size of these tumors also varies, although they begin generally as described. The tendency is to enlargement with each recurrence, until they form a mass which more or less fills the anal region. The degree of hardness and pain also varies. Often the pain is excruciating and throbbing, and the patient will frequently compare the condition to that of a boil. In such cases it is impossible to sit because of the pain, and defecation is torture. If partially relieved, the swelling may diminish, and with it the pain and tenderness, leaving a fleshy mass smaller than the original pile, which may be permanent unless removed by operation. This fleshy mass may at any time become engorged again into a painful swelling, with the characteristics already described. More rarely, instead of the shriveling, suppuration may take place, and the pile is thus cured after weeks of suffering ; or the circulation may be so interfered with that the hemorrhoid becomes sphacelated and ulcerates off. In addition to the local symptoms named, there may be a sense of heat and fullness and itching about the anus. Occasionally, hemorrhoids bleed freely, affording relief to the suffering, and d:> no harm, if the bleed- ing is moderate. At times the bleeding recurs, constituting " bleeding piles." Internal Hemorrhoids. — When the pile is entirely within the sphincter ani, it is called " internal." The sensation produced by piles in this situa- tion varies also with their size, the rectum being sometimes quite filled with HEMORRHOIDS. 433 them, causing a sense of fullness and an inclination to expel the mass, like that excited by the presence of feces in the rectum. Along with this there is often considerable secretion of mucus. The same anal sensations pre- viously described as characteristic of external piles may be present, and, in addition, a dull, aching pain, extending beyond the anal region to that of the sacrum and sacro-iliac juncture. These hemorrhoids are also subject to bleeding, which will sometimes relieve them, and from them especially arise copious hemorrhages, producing at times great prostration. Diagnosis. — The diagnosis of hemorrhoids is usually most easy. It is very common for the lait}:, however, to mistake a variety of conditions, including simple pruritus, eczema with and without pruritus, prolapsus ani, polypus of the rectum, condylomata about the anus, and even fistula: in ano, for hemorrhoids, and absurd mistakes are sometimes made simply be- cause the physician, from unfounded delicacy or other cause, does not make an ocular examination. The distinction from prolapsus ani may be briefly referred to. In prolapsus there is a smooth, symmetrical, complete annular ■proturberance, more prominent than hemorrhoids and, as a rule, less painful. It is also usually more easily reduced. The polypus is recognized by its pedunculated attachment, and the condyloma by its w^art-like appearance and its light color as compared with the red of hemorrhoids. Prognosis. — This is usually favorable, particularly if treatnient be instituted early, and it is most frequently in consequence of neglect of treat- ment that the tumors go on from bad to worse, and that operation is ulti- mately required for their successful cure. Reference has been made to the free hemorrhage which sometimes occurs, even causing the patient to faint from loss of blood ; yet, I never knew death to result. Treatment. — Apart from the prophylaxis furnished by attention to the bowels, this is further secured by absolute cleanliness. Advantage should be taken of the daily bath to wash the anal region thoroughly with water and soap. All irritating particles are thus removed, and any tendency to hyperemia is kept subdued. The first condition necessary to successful treatment is to remove, if possible, the predisposing causes, as constituted by diseases of the heart or liver, or by pelvic tumors, including uterine en- largement, and to favor the return of the blood from these parts. Consti- pation being the immediate cause of the vast majority of cases of hemor- rhoids, it should be corrected, and every efifort should be made to secure free and easy movements of the bowels daily. Fortunately, the same treatment which relieves the constipation tends also to relieve the portal engorgement so often the cause of the hemorrhoids. Hence, mercurial purges are espe- cially indicated, and among these blue mass is the best. It may be combined with compound extract of colocynth, from 2 to 5 grains (0.132 to 0.33 gm.) of each, with 1-4 grain (0.0165 gm.) of extract of belladonna, and may be given nightly in the smaller dose, and two or three times a week, if the larger, followed by a saline in the morning, until the acute stage is passed. Senna, sulphur, and cream of tartar or compound jalap powder have long been favorite remedies. They may be given in various combinations. An excel- lent aperient to be used in this way is equal parts of precipitated sulphur and bitartrate of potassium, made into an electuary with syrup, of which mixture two teaspoonfuls may be taken nigl7tly. Another combination is pow^dered jalap and bitartrate of potassium, each half an ounce : confection of senna an ounce, made into an electuary with simple syrup or syrup of orange, of which half a teaspoonful m.ay be given nightly or two or three times a day, 28 434 DISEASES OF THE DIGESTIVE SYSTEM. as found necessary. The natural aperient waters — Apenta water, Hunyadi water, Rubinat water, Carlsbad water, the Saratoga waters, and others of this class — may be substituted or added in the morning on an empty stomach. After this the medicinal treatment consists largely in the application of astringent ointments, of which equal parts of ointment of galls and ointment of belladonna, the favorite. Simultaneously with the application of this the pile should be patiently reduced and returned within the sphincter, the ointment being used in the manipulation, as well as subsequently applied and properly retained by dressing. In certain cases in which the inflamma- tion is very decided nothing can be acomplisRed until cold applications, such as ice-water or ice itself, are made to the part and retained there. Satisfac- tory results from this treatment are greatly favored by the patient going to bed ; indeed, it is scarcely possible to carry it out otherwise, and some such treatment as this is sometimes necessary to force the patient to bed. The application of cold is often efficiently made by a stream of water played upon the part for fifteen minutes or more, using a bidet or rubber hose at- tachment to a spigot. If the inflammation has been reduced and the astrin- gent ointment is insufficient, I have frequently obtained good results by applications of Monsel's solution of persulphate of iron, applied with a brush, once or twice daily. By this means, used conjointly with the astringent ointment, I have seen large and painful hemorrhoids dwindle away in the course of a few days. In all instances where these applications are made to external hemorrhoids suitable measures should be used to protect the linen from soiling. Too much stress cannot be laid upon the return of the hemor- rhoid within the anus and pressing or " seaming " it down with the finger each time it comes out. D. W. Sam-ways recommends the application of collodion to external hemorrhoids. The hardening of the collodion supports the pile and stimu- lates it to contraction. It is directed to be dropped on a few fibers of cotton wool which are spread over the pile each morning after defecation. The medical treatment of internal hemorrhoids is not essentially differ- ent from that for external hemorrhoids. The suffering in this form is not usually so great, though hemorrhage appears to be more frequent from this kind of pile than from the external form. Failing by the above described efforts to cure, recourse must be had to operation, which will carry us into the field of surgery, to the text-books on which the reader is referred for suitable operative methods. ABNORMALITIES OF THE LIVER. 435 DISEASES OF THE LIVER. ABXORMx\LITIES IX THE SHAPE AND POSITIOX OF THE LIVER. Altered Shape. — The only abnormality in the shape of the liver requiring special mention is the " laced-o£f " or " corset " liver. In this the right lobe is divided by a transverse furrow, more or less deep, into two Tiearly equal parts. In extreme cases the connecting furrow is a mere fibrous band, and the liver can be folded on itself ; in others it contains more or less liver parenchyma. It is usually caused by the pressure of a tight waist- band or corset, and accordingly is more frequent in women, but it is met also in men. It seldom gives rise to any symptoms, but sometimes leads to confusion in diagnosis, being especialh' frequently mistaken for a movable kidney or an abdominal tumor, for the inferior portion may extend as low as the crest of the ilium. This confusion is increased if, as occasionally happens, a loop of intestine lies in the furrow and gives a tympanitic note on percus- sion ; whence the inference that the lower portion is a separate organ. Skill- ful palpation is a valuable means for determining the true nature of such a condition. The edge of the liver should be followed around from the epi- gastrium into the right lumbar and iliac regions. If the continuity with the supposed tumor is uninterrupted, the latter must be a portion of liver laced off. It is not unlikely that such a condition may occasion symptoms of dragging and weight, with the nervous strain frequently incident to them, like that which is so characteristic of floating kidney. The corset-liver is said to be one of the favoring causes of cholelithiasis, by reason of its inter- ference with the natural onward movement of the bile. Abnormality of Position. — The liver in cases of transposed viscera is found on the left side. ^lore frequently it is simply turned downward or upward, anteverted or retroverted as it may be on its transverse axis, chiefly as a consequence of tight lacing in women. It may be pushed upward above its normal site by ascitic fluid or abdominal tumors, and downward by pleu- ritic effusion on the right side or by emphysema of the right lung. The floating Ik'er is by far the most interesting of these conditions. When it occurs, the natural site of the liver is vacant, especially when the patient is in the upright position, occupied usually by hollow viscera, or, in rare instances, by morbid growths. The condition of such movableness is a long suspensory ligament and a coronary ligament so stretched as to form a sort of mesohepar, which permits the liver to fall out of its normal position. It occurs usually in women past middle life, with loose abdominal walls, and is favored by tight lacing. It has been met with in men. It is sometimes responsible for the condition known as the pendent belly. It is a rare condition. The organ itself is usually easily recognized as a large, hard, but movable tumor, below its normal place, and having also the shape and size of the liver, while the normal site is tympanitic on percussion or occupied by organs which do not give the sarrte outline on percussion. The suspen- sory ligament may also be felt. The organ may generally be restored to its normal position when the patient is recumbent. The same dragging symptoms mentioned as characteristic of the con- 436 DISEASES OF THE DIGESTIVE SYSTEM. stricted liver, with the usual contingent of nervous symptoms which succeed upon it and the movable kidney, may be present here. Treatment. — The treatment for both of -these conditions — the con- stricted and the displaced liver — must consist in some instrumental means by which the organ or constricted portion can be held in position. Diseases of the Bile Passages and Gall-bladder. JAUNDICE OR ICTERUS. Definition. — Jaundice is not a disease, but a symptom, consisting in a yellowish discoloration of the skin and other tissues by coloring-matters derived, in some cases, directly from the bile, and in others directly from the blood. The shades of coloring range from a very pale, scarcely ap- preciable, yellow to a brown olive hue. It is a symptom present in so many different diseases of the liver, and so associated with other symptoms more or less constant that its separate consideration is justified. Etiology. — xA.s intimated, its immediate cause is a deposit of pigment in the skin, which, in the majority of cases, is, reabsorbed bile pigment. In other instances the pigment represents the coloring-matter from disinte- grated red blood discs, disintegration so rapid that the liver, spleen, and kidneys, all combined, are unable to eliminate the hematin. It has also been claimed that jaundice may be due to suppressed secretion, the result of extensive destruction of liver cells, but this has been rendered very unlikely by the experiments of Stein, who found that jaundice did not occur when the entire blood supply of the pigeon's liver was cut off. The jaundice due to bile absorption has received the name hepatogenous jaundice, because of its purer hepatic origin ; the second form is called hematogenous, because disintegrated blood is its direct source. Reabsorption of bile takes place when there is obstruction to its onward movement, such as results, for example, from impaction of a gall-stone in the hepatic duct or common bile-duct; from closure of the duodenal end of the common bile-duct by inflamed and swollen intestinal mucous membrane ; from complete or partial obliteration of the duct by adhesive inflammation ; and from pressure from without by morbid growths. These growths may be enlarged glands in the fissure of the liver, or tumor in the gall-bladder, in the liver itself, in the pancreas, and in the stomach, and especially cancer of the pylorus and duodenum. More rarely tumors of the kidney or omen- tum, abdominal aneurysm of the celiac axis or aorta, or enlargement of the uterus may occasion obstruction. So may fecal accumulation. The morbid states in the liver which may produce jaundice are cancer, abscess, hydatid cysts, and cicatrices, all of which will be referred to again. It is reasonable to suppose that the bile is absorbed from the overdistended biliary vessels by the adjacent capillary vessels of either portal or hepatic vein system facilitated by pressure. Reduced pressure in the blood-vessels of the liver, as contrasted with that in the biliary vessels and ducts, also favors reabsorp- tion of bile from the latter. Such explanation is speculative, but thus have been explained those interesting cases of jaundice brought about by emo- tion. Those who have read the charming story of " Put Yourself in His Place," by Charles Reade, will recall the case of Henry Little, whose attack of jaundice is described with the skill of an expert physician. JAUNDICE OR ICTERUS. 437 It should be mentioned, also, that the hematogenous form of jaundice has recently been denied by Stadelmann, who holds that all jaundice is hepa- togenous in origin, and that the needed condition of obstruction is secured in the so-called hematogenous form by a plugging of the smaller bile-ducts by viscid bile or catarrhal secretion, or by compression of these ducts by swollen adjacent liver cells, or by leukocytic infiltration of the interstitial tissue. I do not as yet feel justified in discarding the heretofore accepted classification. Associated Symptoms. — i. Of Hepatogenous or Obstructive Jaun- dice. — This is the usual form of jaundice. All ages are subject to it. In addition to the discoloration described there is often an annoying itching of the skin, due to irritation of the deposited bile pigment. Further evidence of the irritation thus caused is seen in occasional eruptions, such as urticaria, lichen, and even furuncles. A bright yellow discoloration of the sclerotic coat of the eye is as constant as the staining of the skin, while the mucous membranes are often similarly tinged. After the skin, the urine exhibits the most conspicuous alteration, even in mild cases. Indeed, " bilious urine " is sometimes the first symptom. The color may be slightly yellow or deep brown, like that of porter. The presence of bile pigment in the urine is readily shown by Gmelin's nitrous acid test, though ordinary nitric acid answers nearly as well. A few drops of the urine and half as many of the acid are placed on a porcelain plate and gradually allowed to approach and fuse, when a brilliant play of colors appears, in which green, yellow, red, and violet are most easily recognized. The reaction is due to the oxidation of the bilirubin by the acid. The dem- onstration of the biliary acids by Pettenkofifer's test with cane-sugar and sulphuric acid is impossible unless the bile acids be first separated by a tedious process. One of the most reliable ways of recognizing bile in the urine is by the stained cellular elements which it contains. Under no other circumstances are the bright yellow-stained cells found, and they are even met with when the quantity of coloring-matter is insufficient to react by Gmelin's test. In a few cases the bilirubin reaction is not obtainable, when the urine contains in increased amount its normal coloring-matters, urobilin or hydrobilirubin — i. e., reduced bilirubin. Of the remaining secretions, the perspiration is often stained, the milk rarely, the tears, saliva, and mucus not at all. There is sometimes a bitter taste in the mouth, showing an elimination of some constituent of the bile by the buccal glands, probably the salivary. On the other hand, the feces are devoid of biliary coloring-matter, and their pale-gray or pipe-clay color has long been significant of the absence of bile. For the same reason the bowels are usually constipated and the discharges pasty, ill-smelling, and acid. Occasionally there is diarrhea, which may be caused by the irritating effect of the feces disposed to rapid decomposition, because of the absence of their natural antiseptic ingredient. For the same reason, too, the absorption of fats is hindered. There may be other signs of gastro-intestinal derangement, such as loss of appetite, nausea, fetid breath, and fullness in the epigastrium after eating. Gastro- intestinal hemorrhages have been noticed in grave cases. In cases of long standing there may be albumimiria as well, with bile-stained tube- casts. Very characteristic of simple obstructive jaundice is a sloiv pulse, which may be as infrequent as 50, 40, or 30. It must be due to some stimulating 438 DISEASES OF THE DIGESTIVE SYSTEM. effect on the inhibitory action of the pneumogastric nerve. The breathing rate, on the other hand, is normal. The chief subjective symptom of jaundice is depression of spirits, w^hich may even amount to melanchoHa. Irritability is also prominent. Headache and vertigo are frequent. Vision is variously affected : to some, objects appear yellow ; some see better by obscure light — nyctalopia ; to others, the approach of darkness is associated with more than usually difficult vision — hemeralopia. Grave nervous symptoms, rarely manifested, are sudden coma, acute delirium, and convulsions. These usually supervene in cases of long standing, and are attended by fever, rapid pulse, and dry tongue — the symp- toms, in a word, of the typhoid state. The term cholemia is applied to the sum of these symptoms, and the condition is regarded as due to the presence in the blood of the constituents of bile, of which cholesterin is the most important ; whence also the name cholesteremia. The liver is more or less altered, in accordance with the disease which may be present in it and responsible for the jaundice. These changes will be considered in treating of the diseases in which jaundice is a conspicuous symptom. It may also be bile-stained, as are other internal organs, especially the kidneys. The duration of this form of jaundice depends upon the disease which is responsible for it, and it may be a few days or many months. In chronic cases remission and exacerbations occur, but the longer the duration, the more likely is there to be some organic change in the liver. 2. Of Hematogenous Jaundice. — The symptoms of this form are those of the diseases which are responsible for the hemolysis — ^viz., acute yellow atrophy, phosphorus-poisoning, yellow fever, bilious fever, typhoid, typhus, and relapsing fevers, pyemia, pernicious anemia, snake poison, chloroform, and other poisons. In all of these there is some toxic agent working de- struction of the blood. It should be added that in this form of jaundice the stools are not clay-colored. The urine also is less bile-stained, though the true urinary pigments, notably urobilin, are often very much increased. Diagnosis. — One of the most frequent errors of the inexperienced, and a constant one of the laity, is to mistake for jaundice a dirty, yellowish discoloration of the skin, known as sallowness, which is symptomatic of general ill health, especially of uterine disease in women and of malarial poisoning. It is probably an anemia, and may be distinguished from jaun- dice by the fact that it is not associated with staining of the conjunctiva and secretions. It is, moreover, not a yellow, but a dirty brown. One needs only to have his attention aroused to avoid error. Much more closely does the discoloration of the skin in Addison's dis- ease resemble that of some cases of jaundice. In the former there is no discoloration of the sclerotic coat nor of the urine, while the feces remain natural. In Addison's disease the exposed portion of the body and its flexures are more deeply stained. The purpose of diagnosis includes the discovery of the cause and seat of obstruction. In the first place, most cases of acute jaundice are due to catarrhal inflammation of the common bile-duct. If associated with fever, it may be assumed that the smaller ducts are involved. After this, obstruc- tion by gall-stones causes many cases ; then follow hypertrophic cirrhosis and the various malignant diseases of the liver, hydatid disease, abscess, pressure by enlarged glands in the fissure of the liver, and others mentioned on page 436. SIMPLE CATARRHAL JAUNDICE. 439 Prognosis. — This depends on the cause of producing it. Ordinary catarrhal jaundice invariably is recovered from in from two to six weeks, and jaundice from impacted calculus usually sooner or later. When due to other causes, its duration depends on them. In the hematogenous form the duration is brief, because the termination of the disease causing it is usually early and fatal. Treatment. — The treatment of both forms of jaundice must be directed to the conditions causing it, and will be appropriately considered in discuss- ing them. Icterus Neonatorum. Synonym. — Jaundice of the New-horn. Jaundice occurs in new-born children in a simple and harmless form, with symptoms comparable to obstructive jaundice, and in a grave form comparable to hematogenous jaundice. The first is probably a form of obstructive jaundice due to like causes, though it has been assigned a hematogenous origin. It is much the more frequent, and disappears in from a few days to several weeks. The grave form is usually fatal. A patulous ductus venosus has been suggested as an avenue through which the portal blood which contains bile enters the circulation. The grave form has been found associated with absence of the hepatic duct or common duct, with congenital syphilitic hepatitis, and with septic phlebitis of the umbilical vein. Treatment. — The simple form of jaundice of new-born infants demands no treatment. In the graver forms treatment is of no avail unless the condi- tion be traceable to syphilis, when it demands the treatment of that disease in its tertiary form. Simple Catarrhal Jaundice. Synonyms. — Diiodeno-cholangitis ; InHammation of the Common Bile-duct. Definition. — The term catarrhal jaundice is applied to jaundice due to any inflammation of the common duct not the result of impacted gall-stone. Etiology. — The most frequent cause of such inflammation is the ex- tension of a gastro-duodenitis into the common duct. To the same cause is ascribed the jaundice sometimes occurring with passive congestion of the liver due to mitral valvular heart disease, also that found in association with the infectious diseases, especially pneumonia, or with mental emotion. Catarrhal jaundice may also be epidemic. The jaundice in hypertrophic cirrhosis is probably likewise due to cholangitis. Morbid Anatomy. — Opportunities of studying postmortem conditions after catarrhal jaundice are not often afforded, but when they occur, the duodenal end of the duct — the pars intestinalis — has been mostly involved. In it the mucous membrane is swollen, while its orifice and the diverticulum of Vater may be filled with mucus. The inflammation may extend up into the cystic duct, and even higher, into the hepatic duct and branches. Sup- puration does not take place in this form of cholangitis. Symptoms. — Excepting the jaundice, there may be no symptoms. There is no pain, but there may be tenderness, due to gastro-intestinal derangement rather than to the hepatic state, though this may cause it, while such derangement may also lead to general malaise, loss of appe- 440 DISEASES OF THE DIGESTIVE SYSTEM. tite, coated tongue, fetid hrcxith, nausea, z'omiting, a sense of fullness,, constipation, or irregular action of the bowels. There may also be slight fever, particularly if the smaller biliary passages are involved. If the gall-bladder is distended and can be felt at the edge of the liver, there is probably obstruction of the common duct, and if there are pain and tenderness, the obstructive agent is probably a gall-stone. The paler the feces, the more complete must be the obstruction, and the more likely is it to be in the common duct, for, with obstruction of the cystic duct, there may still be a discharge of bile into the intestine; also with obstruction of the hepatic duct until the gall-bladder is empty, which, however, soon happens. Obstruction of the hepatic duct is unas- sociated with distention of the gall-bladder, while there will be jaundice. Obstruction of the cystic duct may still be associated with distention of the gall-bladder, either through transudation or pus-formation, but there may be no jaundice, and the feces may remain colored. If the jaundice is chronic or permanent, we must look for some organic change in the liver or external permanent cause of obstruction outside of its condition. In the hematog- enous form the jaundice is usually so plainly secondary to other symptoms that there is little difficulty in recognizing its cause. Diagnosis. — The presence of jaundice without pain or other symptoms points almost invariably to catarrhal jaundice. The same diagnosis is justi- fied by the presence of the symptoms of gastro-intestinal catarrh, of asso- ciated mitral disease, or of any of the infectious diseases. Prognosis, — Unless associated with infectious diseases or with hyper- trophic cirrhosis, the prognosis of catarrhal jaundice is favorable. In the diseases referred to the danger is not from the jaundice, but from the diseases with which it is associated. Treatment. — The treatment of catarrhal jaundice resolves itself into two parts : first, that for the catarrhal state ; second, that demanded by the absence of bile in the small intestine. For the catarrhal inflammation, either of the duodenum adjacent to the duct or of the duct itself, local depletion is indicated. This is accom- plished by the use of saline aperients and the natural mineral waters which act similarly — i. e., produce watery stools. Of the former, Rochelle salts, Epsom salts, or the solution of the citrate of magnesium are representative; while the Saratoga, Hunyadi Janos, Friedrichshalle, or Rubinat and Carls- bad waters represent the latter. These should be taken daily in aperient doses. In this country the Saratoga mineral waters, particularly those of the Hathorn Spring, are especially valuable, and no better course can be pursued by those who can afford it than to spend some weeks at Saratoga. The Bedford Springs waters, near Bedford, Pa., are also useful, but not nearly so efficient as the Saratoga waters. Of foreign waters, those of Carlsbad are especially valuable, and in Europe these springs may be resorted to. Their use may also be associated between meals with that of the alkaline mineral waters, of \vhich those of Vichy and Vals are the type. These waters are largely employed in this country, and may be availed of at home. There is no indication for the use of calomel, which is so often prescribed, as it is not reasonable to believe the secretion of the bile can be so stimulated by it as to force onward any obstruction, whether by calculus or swollen mucous membrane, until the latter is depleted. After the flow into the intestine is resumed, calomel may be given to stimulate it further. Podophyllin and colocynth may be used for the same purpose. Sodium salicvlate has also a CHOLELITHIASIS. 441 reputation to this end. Irrigation of the large bowel with cold water has been recommended as a means of stimulating the descent of the stone. The second indication should be met by the use of such food as does not require the bile to facilitate its digestion or absorption or to prevent its decom- position. Fats and oils should, therefore, be avoided; hence skimmed milk, animal broths, and egg-albumen, with an abundance of liquids, are indicated. The liquids may be some one or more of the mineral waters previously named, or, in their absence, plain water. Warm bathing is especially indicated, as it causes elimination by the skin and relieves the itching. Lotions of carbolic .acid and glycerin are also useful to this end. CHOLELITHIASIS. Synonyms. — Hepatic calculus ; Biliary calculus. Etiology. — Since the great bulk of the gall-stone is cholesterin, an evi- dent condition of its formation is a precipitation of this substance from the bile, of which it is the chief constituent. The thicker the bile, the more likely it is to throw down sediment. Moreover, recent studies, espe- cially by Naunyn, have shown that micro-organisms play an important part in the production of gall-stones, primarily by exciting a catarrhal inflam- mation which modifies the chemical composition of the bile and favors the precipitation of cholesterin and of lime salts, in combination with epithelial debris and bacteria. Tlie typhoid fever bacillus is an especially frequent cause of inflammation of the gall bladder. Naunyn also showed that choles- terin and lime salts are a secretion of the mucous membrane of the gall- bladder and bile-ducts, and that it is a function which is especially active when the mucosa is in a state of inflammation. If, as is supposed, the cholate salts of sodium hold cholesterin in solution, it is plain that their decomposi- tion or destruction may cause precipitation, which may also be further fav- ored by micro-organisms. Occurrence. — Gall-stones have been met in infants and in the new-born, but practically are found in adults only, while their tendency to form appears to increase from the age of thirty upward. Most patients who consult us for the effects of gall-stones are over forty and under fifty. Cholelithiasis is also very much more frequent in women than in men ; according to Naunyn, four times as frequent, and especially so in women who have borne children or have had abdominal tumors. He says that 90 per cent, of women who have gall-stones have borne children. Naunyn says, too, that 25 per cent, of all women wdio die have calculi in the gall-bladder. Lack of exercise, sedentary habits, and tight lacing are held partly responsible for this, and with some reason, since all of these conditions are calculated to impede the movement of bile. Cholelithiasis has been found associated with the habit of free eating of starchy and saccharine foods and in stout persons ; yet I recall striking cases among the lean also. The movable liver and the movable right kidney are likewise said to pre- dispose to cholelithiasis. Constipation and a tendency to depression of spirits are apt to be associated, probably as effects rather than causes. Morbid Anatomy, — The gall-s1,one itself is a brown object, nearly spherical, oval or faceted, and even polygonal in shape, usually the size of a pea, or as small as a millet-seed, producing in aggregation " gall sand." The faceted shape is produced by close packing of a large number of stones in a 442 DISEASES OF THE DIGESTIVE SYSTEM. gall-bladder, as frequently happens. More rarely the stone is irregular — mulberry-shaped. In addition to cholesterin, which makes up from 70 to 80 per cent, of most stones, they contain in various but still small amounts bile pigment, calcic carbonate, and organic matter. A few are made up almost entirely of bilirubin and lime. On section, the stone exhibits either a con- centric or homogeneous appearance, with or without a nucleus of bile pigment or organic matter, and very rarely of some foreign body. The cholesterin COMMON) BILE DUCT\ Fig. 35. — The Cystic Duct in Section, with Part of the Gall-bladder and Hepatic and Common Bile-duct. — {Testiit). stones are almost completely soluble in etherized alcohol, whence beautiful crystals of cholesterin may be obtained after evaporation. In addition to their enormous accumulation in the gall-bladder, where they may be counted sometimes by hundreds, they are found anywhere in the biliary tract between the duodenal end of the common duct and the ultimate ramification of the bile vessels. Outside of the gall-bladder the cystic duct and the common duct are naturally the situations in which lodgment most frequently occurs. If in the common duct, it is usually at the orifice of the papilla in the diverticulum of Vater, and from the duodenal side the stone feels as though it were directly under the mucous membrane. Two or even more stones may be found in the duct. The common duct under these cir- cumstances may attain a diameter of an inch (2.5 cm.) or more. Permanent obstruction of the cystic duct causes dilatation of the gall-bladder — hydrops veskcE fellece. Such dilatation may be enormous, filling the entire abdominal cavity, and has been mistaken for ovarian tumor ; usually it is more moderate, but the contents frequently amount to a pint (500 c. c.) or more. The con- tents are a colorless, viscid, or watery fluid, more or less albuminous, and neutral or alkaline in reaction ; the greater the dilatation, the more aqueous and unlike bile do its contents become. In any situation the stone may pro- duce ulceration and even suppuration, with perforation into the peritoneal cavity or adjacent organs, the duodenum, stomach, transverse colon, right renal pelvis, ureter, through the diaphragm into a bronchus, and into the abdominal wall. The various situations in which gall-stones are lodged may be easily learned from the accompanying Figure 35. CHOLELITHIASIS. 443 Acute Impaction. Synonym. — Biliary Colic. Symptoms. — The characteristic symptom of impacted gal] stones is biliary colic, but biliary colic is by no means always present in every case of cholelithiasis. The gall-bladder is often found full of calculi without the sug- gestion of a symptom. Small stones even pass into the duodenum without -producing symptoms. Commonly, however, they lodge while in this transit, and give rise to attacks of pain which are known as biliary colic. This pain is usually sudden, very severe, often excruciating, and the patient writhes in agony and sometimes faints in consequence. It is usually referred to the epigastrium, whence it radiates in all directions over the abdomen and at times into the right shoulder and arm. As a rule, however, it is localized on the right side, under the liver. It is a sharp and cutting pain. There is always tenderness in this region, which varies in degree. It is sometimes as- sociated with a more or less rigid state of the abdominal muscles of that side. The duration of the pain is that of the lodgment of the stone, and it may be from a few hours to weeks, ceasing rather suddenly when the stone is dis- charged into the bowel. There may, however, be remissions. Nausea and vomiting are almost invariable symptoms of biliary colic. They often bring temporary relief through the resulting relaxation. Fever is soon added to the pain, while a chill is not infrequent. The temperature is usually 102° F. to 103° F. (38.8° C. to 39.5° C). It may be intermittent, but such intermis- sion is more apt to be associated with prolonged obstruction, constituting with a chill a part of the symptoms of so-called hepatic fever, to be next con- sidered. Gall-stone crepitus may sometimes be detected when the gall- bladder is packed with calculi. If the attack last long enough, jaundice almost always supervenes, whence we infer, too, that the stone is likely to be in the common duct, hav- ing probably started in the cystic duct. Three or four days may elapse between the beginning of obstruction and the supervention of jaundice, the degree of which increases with the completeness and duration of obstruction. The entrance of the stone into the common duct may be attended by one of the remissions alluded to, though the jaundice grows even deeper on account of the more thorough obstruction to the 'descent of the bile. The liver is sometimes slightly enlarged, as determined by percussion. A rare symptom is collapse with fatal syncope, due to perforation at the seat of lodgment, with consequent peritonitis and shock. Diagnosis. — This is commonly easy. While the pain may be more or less diffuse, it is for the most part localized in the right lower thoracic and upper abdominal regions, and the tenderness is always there, while, if jaun- dice and biliary urine are present, all doubt is removed. Nephritic colic and biliary colic are confounded with surprising and unjustified frequency. In the former condition the pain starts in the lumbar region and radiates down- ward into the groin, the testicle, and the inside of the thigh. Such error is fortified by the fact that bilious urine is too often confounded with bloody urine. It should be necessary only to mention this to guard against error. Cholelithiasis has been mistaken for acute pleurisy in the vicinity of the gall-bladder and the reverse mistake has been made. The friction rale of 444 DISEASES OF THE DIGESTIVE SYSTEM. pleurisy should preclude an error, but the friction rale may not be present at the particular stage. Our growing knowledge of appendicitis has led to the discovery that the pain characteristic of this disease is sometimes localized in the right hypo- chondrium, where, indeed, the appendix has been found at operation. Jaun- dice and bile-stained urine do not, however, attend appendicitis. Gastralgia has been confounded with biliary colic, but attention to the symptoms described when treating that afifection should prevent mistake. The term hepatic neuralgia has been applied to an apparently causeless pain, sometimes felt in the neighborhood of the liver, but it is less severe than biliary colic and unaccompanied by any of the other symptoms. This is allied to pseudo- biliary colic which is to be remembered as a possible event in nervous women. Both are characterized by the absence of jaundice. It is very important, immediately after an attack of supposed biliary colic, to search for a stone in the fecal discharges. For this purpose the mass should be placed on a sieve, and water passed over it until all soluble parts are run out. Such examination should be kept up for several days after the attack, for the stone is not always passed immediately. Prognosis. — The termination of an ordinary attack of biliary colic is, in the vast majority of instances, favorable. It is only in the rare cases, where perforation takes place, that a fatal ending follows. Surgery of the gall- bladder has come to be an important division of surgery, and many lives have been saved by operations before and after perforation. The surgeon should, therefore, be promptly sent for. More frequently the escape of the stone is long delayed, producing the symptoms of chronic impaction, to be next described. Chronic Impacted Gall-stone. Symptoms. — These vary somewhat with the seat of the impaction and its duration. From this standpoint they may be divided into certain groups : 1. Syuiptouis Due to Chronic Calculous Obstruction of the Cystic Duct. — In addition to more or less of the symptoms detailed under acute impaction, the immediate result of such obstruction is dilatation of the gall-bladder, or hydrops vesica fellecr, already referred to. Contrary to what might be expected, dilatation is more frequently caused by obstruction of the cystic, than of the common duct. The source of the accumulation is not, however, the bile, which, as might be expected, cannot get into the gall-bladder through the obstructed duct any more than it can get out of it. It is the products of inflammation of the mucosa, added to the bile previously present, which cause the dilatation. The occasional enormous dilatation has more than once been mistaken for ovarian disease, an error the more excusable when we remember that jaundice is often absent. More frequently the dila- tation is moderate, and can be felt below the edge of the liver as a round or ovoid elastic tumor, in which fluctuation may sometimes be obtained. 2. Symptoms Due to Chronic Calculous Obstruction of the Common Dti'Ct. — If the common duct is obstructed, dilatation of the gall-bladder does not necessarily follow, and if it does occur, the dilatation is moderate. Such obstruction is commonly associated with cholangitis, catarrhal or suppura- tive, (a) In simple chronic catarrhal cholangitis the common duct is dilated ; at times also the branches of the hepatic duct extending into the liver. This condition has been especially studied by Charcot and Murchison abroad and William Osier in this country. It may be intermittent or remittent. Very CHOLELITHIASIS. 445 interesting among the causes "of intermittent obstruction is the movable or ball-valve stone in the diverticulum of Vater. Chronic catarrhal cholangitis, in addition to the persistent jaundice and paroxysmal pain, is characterized by ague-like attacks, consisting of chills, fever, and sweats. These occur at surprisingly regular intervals, resembling in this respect the quotidian, tertian, and quartan spells of intermittent fever, with which the condition has been confounded. They may occur for weeks at a time and then remit. Pain is commonly associated with the ague-like spells, but is not always present. The chills may be extremely severe, the sweats also, and the fever correspondingly high, the temperature sometimes reaching 105° F. (40.5° C). The jaundice usually deepens after an attack. There may be nausea and vomiting. The duration may be indefinite from a few months to years, and the patient may yet recover ; or he may perish, although the exhaustion is extremely slow and the effect on the general health barely appreciable from week to week. The fever is probably irritative, although it has been ascribed to the omnipresent organism — hacterium coli commune. There is sometimes slight enlargement of the liver, appreciable to physical examination, and in long-protracted cases some fibroid induration may be expected to take place. The stools are sometimes bile-stained, at others not. There is occasionally enlargement of the spleen. The following are Naunyn's distinguishing signs of stone in the common duct: "(i) The continuous or occasional presence of bile in the feces; (2) distinct varitions in the intensity of the jaundice; (3) normal size or only slight enlargement of the liver; (4) absence of distention of the gall-bladder; ('5) enlargement of the spleen; (6) absence of ascites; (7) presence oi febrile disturbance, and (8) duration of the jaundice for more than a year." Osier * has formulated the following symptom-group for the ball-valve stone commonly found in the diverticulum of Vater, but occasionally also in the common duct itself: " (a) Ague-like paroxysms, chills, fever, and sweat- ing — the hepatic intermittent fever of Charcot; {h) jaundice of varying intensity, which persists for months or even years, and deepens after each paroxysm; (c) at the time of the paroxysm pains in the region of the liver, with gastric disturbance. These symptoms may continue intermittently for three or four years without the development of suppurative cholangitis. An important diagnostic sign of obstruction of the common duct by stone is the absence of dilatation of the gall-bladder — Courvoisier's rule. It would appear somewhat unaccountable that obstruction by other causes is more frequently followed by dilatation of the gall-bladder than obstruction by cal- culus. Thus, Ecklin found that of 172 cases of obstruction of the common duct by calculus, the gall-bladder was contracted in no, normal in 34, and dilated in 28. Of 139 cases of occlusion of the common duct from other causes the gall-bladder was contracted in 9, normal in 9, and dilated in 121. (h) Suppurative cholangitis is marked symptomatically by a fever which is more of the septic type, with remissions rather th?n intermissions. The jaundice is less marked, the liver is tender and enlarged, the duration of the disease shorter, and termination fatal. The inflammation involves more or less the ducts of the liver, whence it may extend into the liver substance or gall-bladder, causing abscess of the liver and empyema of the gall-bladder. Other Remote Results of Gail-stone Impaction. — Rarer terminations of impacted gall-stones are the various forms and situations of biliar>' * See paper by Osier on " Fever of Hepatic Orig-in. Particularly Intermittent Pyrexias Associated ■with Gallstone,"" Johns Hopkins Hospital Reports," vol. ii., No. i, 1890. 446 DISEASES OF THE DIGESTIVE SYSTEM. fistulas, mentioned when treating of the morbid anatomy. Some more detailed reference to these fistulae should be made. Much has been added to our knowledge of the subject by the industry of Prof. L. G. Courvoisier of Basle.* Courvoisier collected 499 cases of ulcerative perfora- tion of the biliary passages of which 70 occurred directly into the peritoneum, while in 49 cases there was encapsulated abscess, and in 3 there was retro- peritoneal perforation. Between the biliary passages themselves were 8 cases: this perforation was found directlyfrom the gall-bladder into the sub- stance of the liver (4 cases) ; into the hepatic duct (2 cases), into a divertic- ulum of the common duct (i case), or between the intestinal and hepatic parts of the common duct ( i case). Perforation between the biliary passages and portal vein was found in 5 cases, if the celebrated case of Ignatius Loyola, about which Courvoisier expresses some doubt, be included. Openings between the biliary passages and gastro-intestinal canal are not uncommon (137 cases) ; most frequently between the bile passages and duodenum, of which there were 83 cases, of which "/t, were between the gall-bladder and the duodenum, while 10 were between the common duct and duodenum. From the biliary passages into the stomach there were 13 perforations; into the jejunum one, ileum one, colon 39. As might be expected, perforation takes place most frequently from the intestinal part of the duct, the stone first lodg- ing in the diverticulum of \'ater. Perforation into the urinary passages was found in 7 cases and into the pleura and lungs in 24 cases. To these last J. E. Graham t added 10 cases of broncho-biliary fistula. Finally, there may be fistulous communication between the biliary passages and the external integ- umient, Courvoisier having collected 196 cases, in 49 of which the communica- tion was in the right hypochondrium, 36 at the border of the ribs, 49 at the navel or in its vicinity, 17 in the right mesogastrium, 10 in the right iliac region, and 6 in the epigastrium. Very interesting in this connection is the fact that out of 169 cases in which the sex was noted, 126 were women and 43 men. Among other remote results are septic cholecystitis, associated with high fever, intense prostration, and death from fatal peritonitis ; empyema of the gall-bladder, already alluded to as a result of suppurative cholangitis ; the latter is commonly associated with gall-stones. Calcification of the gall-bladder is a frequent termination of purulent inflammation. It is present in two forms : first, as a simple incrustation of the mucosa with lime salts, and. second, as a true infiltration of the whole thickness of the wall. Atrophy of the gall-bladder is not infrequent and may succeed on hydrops vesiccs fellecc. I have seen many gall-bladders which did not hold more than a dram (4 c. c.) or two of bil^, and sometimes there is a mere remnant left in the shape of a fibroid mass ; at other times the shrunken bladder closely embraces a gall-stone of large size. Gall-stones are occasionally found in diverticula of the gall-bladder. Suppurative phlebitis and abscess of the liver may also be due to gall-stone, causing a puriform thrombus in an adjacent branch of the portal vein. In other instances the gall-stone is of such size as to obstruct the bowel when discharged into it. although it may have passed through the natural channel, as evidenced by dilatation of the common duct. But for the most part such discharge is by ulceration into the intestinal tract. This subject has been sufficiently considered when treating of obstruction of the bowels. Diagnosis and Prognosis. — There may be some difficulty at first in the * Casuistisch-Statistische Beitrage zur Patholoerieund Chirurgie der Gallenwege, Leipzig, i8qo. t Transactions of the Association of American Phj-sicians, vol. xii., 1897. CHOLELITHIASIS. 447 diagnosis of hepatic fever, but the persistent jaundice, the ague-Hke parox- ysms of chills, fever, sweats, and pain are a combination of symptoms belong- ing to no other condition. A cancer of the gall-bladder, which will form a tumor in the same locality, is much more tender ; it is harder and more uneven, and jaundice is invariably associated with it, while the patient is much more seriously ill and declines more rapidly. There should be no confusion with a movable kidney, which furnishes a different physical condition. An aspira- tor needle may be used to confirm the diagnosis. The suppurative form is characterized by the more continuous fever and the more serious aspect of the septic state, its shorter course, and its ultimate fatal termination. The catarrhal form is less serious and quite often terminates favorably. Treatment of Impacted Gall-stone and its Complications. — The first indication is the relief of pain. This is best accomplished by the hypodermic injection of morphin, the action of which is favored by combination with atropin. Scarcely less than 1-4 grain (0.0165 gm.) with 1-150 grain (0.0005 gm.) of atropin suffices, and this must often be repeated. The use of ano- dynes must be kept up as long as needed. The atropin favors the relaxation needed to release the calculus. The severest cases may require the inhalation of a few drops of chloroform pending the action of the morphin. Whether anything else can be done toward releasing the stone is not established. The nausea and vomiting, which are so often symptoms, sometimes relieve the pain by the relaxation they produce, such relaxation being at times sufficient to favor the onward movement of the stone. Anes- thesia by ether or chloroform may act similarly, and the inhalation above sug- gested while waiting for the morphin to act favors such relaxation. Hot baths or fomentations applied to the region of the liver may also be similarly effective. Some solvent for the stone is constantly inquired after. Ether, turpen- tine, and sweet oil, although lauded for this purpose, have been tried and found wanting. Durande's remedy consists of turpentine one part, ether four parts ; dose, fifteen drops three times a day. It is useless. To relieve the itching caused by the deposit of pigment in the skin, which is sometimes very annoying in chronic cases, the hot pack on alternate days or even every day is serviceable. A very efficient local application for this purpose is a mixture of 7 1-2 minims (0.5 gm.) of carbolic acid, two fluid dramas (8 c. c.) of glycerin, and six fluid drams (24 c. c.) of water. It should be applied with a sponge and allowed to dry on the skin. The free use of alkaline mineral waters does seem to favor the dislodg- ment of the stone, especially if the authorities at Carlsbad are to be relied on, who claim the discharge of immense numbers of biliary calculi under the use of Carlsbad water. Certainly no harm can attend its use, and when within the power of the patient to get it, it may be freely taken. The same is claimed by the physicians at Vichy for the Vichy waters — true alkaline waters. In this country, however, the Saratoga waters may be used instead. These waters are saline and not alkaline waters, but they seem to fulfill much the same indications. Those containing the largest proportion of alkaline carbonate are to be preferred. The waters of Vals — also true alkaline waters — are recommended for the same purpose. Surgical procedures have of late been availed of even with a view to exploration, and if done by competent surgeons with due antiseptic precau- tions, cannot be regarded as more dangerous than most abdominal sections. The curative measure first suggested by Marion Sims consists in removing 448 DISEASES OF THE DIGESTIVE SYSTEM. the impacted stone and emptying the gall-bladder of others. At the present dav the gall-bladder itself is being successfully removed. Under operative procedure is included aspiration of the dilated gall-bladder, which is justified in the event of a positive diagnosis, though it has been followed by a fatal result. A carefully conducted exploratory section is little more dangerous, but, on the other hand, should not be done until the case has assumed some chronicity. Nothing is gained at the present day by exploratory puncture, but it is interesting to know that it was done by the elder William Pepper in 1857, and by Roberts Bartholow in 1878. The preventive treatment is important, and although an attack of biliary colic very commonly does not take place until a number of stones have accumulated in the gall-bladder, so that the descent of one is apt to be fol- lowed bv that of another, prophylaxis should still be availed of. To this end diet is important. The patient should eat sparingly of hydrocarbons and car- bohydrates, omitting every form of fat. alcohol, sugar, and starch. Meat, cheese, and glutens, on the other hand, are allowable. The alkaline and saline mineral waters are more especially indicated between the attacks than during them, and their more or less continued use is advisable, especially in the morning, when their efficiency is also increased by their being taken hot. The sodium salts have considerable reputation for their efficiency in preventing the concentration of bile and formation of gall- stones, having been long ago recommended by Prout. The phosphate is the modern favorite, in dram doses in the morning, or more frequently, but the sulphate is more constant and more potent in its results, and little, if any, m.ore unpleasant. The sodium salicylate has a similar reputation, and may be used when no eiTect on the bowels is desired. By either of the former or by the aperient mineral waters a daily action of the bowels should be secured, while a proper hygiene of the body, in which daily exercise, bathing, and friction play a conspicuous part, is to be constantly maintained. I have been in the habit of placing my patients, between attacks, on the succinate of sodium, in doses of five grains ( 0.32 gm. ) three times a day, and it has so happened that I have seldom met a recurrence in one of these cases, although many of them passed out of my observation and may have had attacks without my knowledge. ACUTE IXFECTIOUS CHOLECYSTITIS. Syxoxym. — Acute inflainination of the gall-bladder. Definition. — Inflammation of the gall-bladder due to infection by patho- genic bacteria. Etiology. — The most frequent predisposing condition which leads to infection of the gall-bladder is probably biliary calculus, the stone being lodged either in the gall-bladder or some one of the biliary ducts, the vulner- ability of the mucous membrane of the gall-bladder being thus increased. But any obstructive cause, such as inflammatory adhesion, or even inflam- mator}- swelling of the mucous membrane of the cystic duct, may be such cause — facilitating bacterial infection. Adhesive inflammation between the gall-bladder and intestines, however induced, is a rare cause, the process extending inwards through the peritoneum. Lithiasis is not. however, necessary to produce infection. Pathogenic bacilli may act independently ACUTE INFECTIOUS CHOLECYSTITIS. 449 of predisposing cause. Indeed, gall-stones themselves are a result of bac- terial invasion. The infecting bacterium may be any one of the pathogenic bacteria infesting the small intestine, but recent observations have shown the bacillus of typhoid fever and the colon bacillus to be probably the most frequent, although the pneumococcus, staphylococcus, and streptococcus have also been found to be the infecting agents. Morbid Anatomy. — This varies with the virulence of the inflammation. In the severer cases there is distention of the gall-bladder with mucus, muco- pus, or pus ; at times its contents may be hemorrhagic. Perforation and ^^angrene have been the first indications of the presence of the disease. There may be adhesion between the gall-bladder and colon or omentum. Symptoms. — The most invariable symptom is pain, which is commonly sudden and sometimes paroxysmal. It is situated to the right of the median line at the border of the thorax ; is attended by fever, sometimes preceded by chills and followed by sweats. So many abdominal conditions, however, cause pain that it alone is not distinctive. Tenderness, less circumscribed than might be expected, is invariably present. Jaundice is not a frequent symptom, never unless the infection involves the hepatic duct or common duct. Vomiting, on the other hand, is very common and often severe. It, too, may be paroxysmal. Certain cases are fulminating, and it may be impossible to get the surgeon soon enough to avert perforation and a fatal termination. On the other hand, many mild cases occur, like one seen with Dr. Thomas Potter, of Germantown, succeeding a relapse of typhoid fever after a normal temperature had been maintained for several days. After recovery from this relapse, there occurred suddenly a chill, sharp pain in the region of the gall-bladder, and rise of temperature. These symptoms sub- sided in four or five days, to be followed by another attack in which, instead of a chill, there was simply chilliness and with pain and fever less marked ; again, after a couple of days, a return of pain with sudden rise of temperature "but no chill, again disappearing in a few days. The distended gall-bladder may sometimes be felt. The pulse is sometimes very slow, as in a case reported by the late Frederick A= Packard, where the rate fell to 48, and another seen with Dr. Markley, of Camden, N. J., in which it fell to 40. It is seldom over 100. In Dr. Packard's case there was no fever, in that of Dr. Markley the temperature rose to 103° F. (39.4° C). Symptoms may arise from adhesions with adjacent organs, chiefly pain, tut sometimes also a dragging sensation. These are commonly part of a chronic condition. Constipation is also a symptom to be expected. In fact, some cases have been treated for obstruction of the bowel, for appendicitis, and more rarely for pancreatitis. Diagnosis. — Since attention has been directed to the subject, the diag- nosis in many cases has become easy. In others it still remains difficult or impossible. Given a case of typhoid fever in which, especially during con- valescence, a chill, fever, and sweat make their appearance and there is pain in the region of the gall-bladder, we may infer reasonably the presence of cholecystitis. The same inference may be made if these symptoms occur in a case of chronic cholelithiasis. The presence of an actual tumor at the seat of the gall-bladder is even more confirmatory, but in my experience it is not often easy to recognize a distended gall-bladder through the abdomi- nal wall unless it be of considerable size. Circumscribed tenderness is more frequent. The severity of the attack cannot always be inferred from the early symptoms, but as there are a good many mild cases, a diagnosis of 29 450 DISEASES OF THE DIGESTIVE SYSTEM. cholecystitis need not necessarily cause alarm. It should be remembered that jaundice is not a frequent symptom, indeed, it is a rare symptom. As to differential diagnosis, the conditions with which it has been con- founded are appendicitis, especially when the appendix happens to be under the liver, as it not very rarely is, pancreatitis, localized peritonitis, pyone- phrosis and inflammatory thickening about the pyloric orifice of the stomach and the duodenum. In the absence of the predisposing conditions referred to, these lesions are sometimes difficult to differentiate. Disease of the head of the pancreas is much more frequently associated with jaundice than is cholec3'stitis. If a tumor is present in pancreatitis, it is fixed and immovable. It is not usually movable in cholecystitis. An exploratory operation should not be long delayed as perforation of the gall-bladder may precipitate a fatal issue. In cases like three narrated by Maurice H. Richardson,* in none of which was there history suggesting gall-stones and where the symptoms, including pain, vomiting, fever, and tenderness over the appendix, were so suggestive that an incision was made in that quarter, a diagnosis of chole- cystitis is impossible. It is difficult to see how anything but appendicitis could be expected in such cases. Prognosis. — This depends, of course, upon the severity of the case and the promptness of operative interference. There appear to be a good many mild cases which seemingly do not go beyond catarrhal inflammation. Treatment. — There is really no medical treatment except the symp- tomatic, and the patient recovers through inherent tendencies, or his life is saved by operation and drainage. In gangrenous cases even operation fails to save some, but all cases demanding operation have the chances of recovery increased by promptness. Richardson says that acute cholecystitis de- mands interference even more strongly than appendicitis. Counter-irritation by mustard or hot fomentations may be applied to the region of the gall- bladder to relieve pain. Nausea and vomiting are among the most difficult symptoms to relieve. It is a reflected nausea like that of appendicitis. Local applications of ice, or at times the opposite treatment by heat, pieces of ice swallowed, champagne, cold effervescing waters may all be tried. The blister applied to relieve pain may also check the nausea and vomiting. Calomel in hourly doses of i-io gr. (.0066 gm.) to 1-5 gr. (.0132 gm.), ap- plied dry on the tongue, should be given in connection with other remedies. CANCER OF THE GALL-BLADDER. Etiology and Morbid Anatomy. — Though rare, this affection has excited much interest and has been thoroughly studied, with widely different results in some points. Thus, John H. Musser, in a study of 100 cases, found it three times as frequent in women as in men, while Courvoisier, in a study of an equal number, found it five times as frequent among men. It is usually primary, when it commonly begins in the fundus. At other times it occurs by contiguous invasion, either from the liver or adja- cent abdominal organs. Cancer may also extend from the gall-bladder to adjacent parts. The primary form is associated in at least 87 per cent, of all cases with biliary calculi, and there has been much discussion as to which * " Acute Inflammation of the Gall-bladder," " Am. Jour. Med. Sci.," June, 1898. AFFECTIOXS OF THE BILE DUCTS. 451 is primary, the gall-stone or the cancer. Zenker and others regard the cancer as secondary, starting in the ulcerative and cicatricial tissue caused by the stones, as is thought to be the case in some instances of cancer of the stomach. This, too, may account for the greater frequency of the disease in women, if such is the case, since women are much more commonly the subjects of gall-stone. It seems reasonable to regard the biliary calculi as secondary to the cancerous disease which may produce changes in the composition of the bile, and I am inclined to agree with ]\Iusser that the gall-stones are only a possible exciting cause of the cancer. A more or less hard, solid, irregular, and fixed mass is the form assumed by the cancer. Symptoms. — Jaundice is absent so long as the disease is limited to the gall-bladder, but as soon as the biliary duct or the common duct is involved it ensues, so that jaundice is present in 69 per cent., gradually increasing in intensity. There is great tenderness, with pai)i; vomiting, sometimes of blood, bloody stools, and dropsy, at times succeeded by the cancerous cachexia. But none of these is distinctive, being found in cancer of the pylorus, duodenum, and transverse colon. The presence of a hard, uneven, and tender tumor in the neighborhood of the gall-bladder, and which moves with the liver in respiration, confirms the suspicion. This has, in fact, been found in about 69 per cent. If the disease is seated in the cystic duct, the enlargement of the gall-bladder is comparable to that due to obstruction in that duct from other causes, and may be marked. Diagnosis. — This is sometimes difficult. Pain and tenderness are more marked than in most other affections of the liver, except cholecystitis. Fever and rigors are exceptional and point rather to infectious disease of the gall- bladder or ducts. Treatment. — The treatment can only be palliative. AFFECTIOXS OF THE BILE DUCTS. Carcinoma of the Biliary Passages. Cancer of the bile-ducts may be primary or secondary. In either event the first symptom is usually jaundice, which grows deeper and deeper until the skin may assume an almost bronze-like hue. A cachexia rapidly de- velops. There are pain and tenderness and moderate enlargement, but noth- ing more destructive than the progressive jaundice, which never grows better. The disease often escapes recognition until an autopsy reveals it. Cancer may invade the bile-ducts from the gall-bladder and possibly from primary or secondary cancers in the parenchyma of the organ. The relation of the morbid growth to gall-stones in its vicinity is governed by the same laws as that between gall-stones and cancer of the bladder. The discussion need not, therefore, to be repeated here. Stenosis of the Biliary Ducts. Stenosis, or more or less incomplete occlusion of the common duct, may be due to inflammatory adhesion or to compression from without. Some- times it follows the ulceration attending the passage of a gall-stone. Exter- 452 DISEASES OF THE DIGESTIVE SYSTEM. nal pressure may be produced by morbid growths and other causes alluded to on p. 436. Notably, cancer of the pancreas is one. Cicatricial contraction the result of perihepatitis, syphilitic disease, per- forating duodenal ulcer, and cholelithiasis should also be mentioned as a cause of external compression of biliary passages, to be recognized, if at all, by aid of the associated symptoms of the disease causing it. In the first there may be a peritoneal friction in the neighborhood of the liver, audible and palpable. Parasites. Parasites may enter the larger biliary passages and produce obstruction. Such are echinococci which may enter the ducts primarily in the larval state and develop there the hydatid cyst with resulting obstruction ; or, as is more frequent, the sac perforates or compresses a duct in the course of its growth. The other symptoms of echinococcus disease are added to those of obstruction thus produced, or the cysts may appear in the stools, vomited matter, or expectoration. Cases are reported in which the distoma hepaticmn has been found lodged in the hepatic duct, and round zvornis in the common and hepatic ducts. A remarkable specimen, containing a number of lumbricoids lodged in these ducts, is in the Wistar and Horner Museum of the University of Pennsylvania. The symptoms of these last conditions would be undistinguishable from hepatic obstruction from other causes. DISEASES OF THE BLOOD-VESSELS OF THE LIVER. Hyperemia. Passive Hyperemia — Red Atrophy. The hyperemia of the liver which is of chief clinical importance is passive hyperemia. Etiology, — It is always due to obstruction to the movement of the blood towards or through the heart. Valvular heart disease is the most frequent cause, though diseases of the lungs, such as emphysema or cirrho- sis, intrathoracic growths, diseases of the pleura, compression of the vena cava, or other cause resisting the movement of the blood through the organ are all competent to produce passive hyperemia of the liver. Morbid Anatomy. — The appearances of the organ after death are deter- mined by the duration of the congestion. If it has been of short duration, the h'ver rapidly assumes its natural size and appearance after death. Even in long-continued passive congestion the liver after death becomes very much smaller than during life, by reason of the emptying of the blood-vessels, which rapidly succeeds death. In other respects, however, after prolonged hyperemia it presents decided changes. It is dark in color, and the vessels still contain an excess of blood, but the /nfralobular vein — i. e.. the central vein of each lobule — and its adjacent capillaries contain most blood, con- trasting stronsrly with the peripheral or z';;f^;'lobular vessel and its adjacent capillaries. There is thus produced in one way that alternation of dark and light tint which constitutes the nutmeg liver and which is particularly con- DISEASES OF BLOOD-VESSELS OF LIVER. 453 spicuous on section. It becomes even more marked at a later stage, when the organ, in its ultimate atrophy, becomes reduced in size, constituting the so-called red or cyanotic atrophy of the liver, — the atrophied nutmeg liver, — the histology of which exhibits a destruction of the cells and capillaries in the center of each lobule and a deposit of dark pigment in their places. In the liver thus atrophied the blood-vessels also share in the destruction, and short cuts are established between the branches of the portal vein and he- patic vein, while the latter may also become dilated. The exterior of the liver is smooth, and the organ dififers in this respect from the cirrhotic liver, though there is sometimes a slight overgrowth of the interlobular connective tissue. Symptoms. — The liver at first is enlarged and tender — sometimes very much enlarged and exquisitely tender. The lower border, as determined by percussion, may be as low as the umbilicus and even lower. It may be the seat of pulsation, due to regurgitation of blood into it from the right heart. This pulsation is to be distinguished from a motion communicated to the liver by the action of the heart. In the true pulsation the whole liver seems to dilate, and does dilate as the blood flows back into it, as con- trasted with the downward movement communicated by the heart. Very characteristic of this enlargement is the changing size of the organ pari passu with the degree of congestion, whether spontaneous or the result of treatment. Ascites is also a symptom. It does not occur, however, until a marked degree of passive hyperemia or secondary contraction is attained. The ascites is partly the result of the general stagnation always present, and partly of the congestion of the portal system due to the backing of the blood of the hepatic vein into it. laundice is another rather rare symptom. It is due to the compression exerted on the fane interlobular gall-ducts by the overdistended interlobular capillaries, thus producing an obstructive jaundice. Scanty urine of high specific gravity is also a symptom, while hyper- emia zvith enlargement of the spleen and hyperemia of the mucous mem- brane of the stomach are constant, as a result of the same cause. Treatment. — The treatment of passive hyperemia is the treatment of the condition causing it. Most frequently the cause is heart disease, and when the latter is amenable to digitalis or other heart tonics, the passive hyperemia disappears with the restoration of compensation. Simultane- ously the urine is increased, and the general dropsy, ascites, and hydro- thorax disappear. Such treatment is aided also by depletion from the por- tal side by purgatives. Blue mass is the type of these, but colocynth, ela- terium, and compound jalap powder, or the simple salts, are also efficient. It sometimes happens that the general dropsy in these cases is dispersed by treatment, but the ascites remains, in which event we must suppose the simple passive congestion to be combined with some degree of atrophy, when the dropsy is more likely to remain. Treatment should now be sup- plemented by hydragogue cathartics, or, still better by tapping, followed by dry diet and the hydragogues. A dram (4 gm.) or more of compound jalap powder may be given each morning fasting, or elaterium, 1-6 grain (o.oi gm.) every three hours, until 'the bowels are moved. It was suggested by George Harley to deplete the liver under these circumstances, and it has been put into practice by East Indian physicians, it is said, with good results. 454 DISEASES OF THE DIGESTIVE SYSTEM. Active Hypcrcniia. Definition. — This is a much less important condition than passive hyperemia, and. indeed, is rarely recognized. A physiological hyperemia of the liver takes place after each meal, which may be exaggerated and even continuous in those who overeat and overdrink habitually. Such hyperemia may lead to structural change, consisting ultimately in intersti- tial growth. Like this, also, is the hyperemia which is associated with diabetes mellitus, and which is the associated condition of many glycosurias, whether experimental or the result of disease affecting the diabetic center. Such is a vicarious hyperemia said to take place during suppressed men- struation and after cutting off a hemorrhoidal flux. Active hyperemia does not, however, present any symptoms referable to it, unless it be that the dull ache and full feeling sometimes felt in the right hypochondrium be caused by such condition. Treatment. — The treatment of fluxion to the liver must consist of measures which tend to diminish this, mainly the substitution of a scanty for an overabundant diet, simple and easily-digested foods, dilute milk, and thin broths, and the avoidance of fats, alcohol, apd sugar. Thrombosis axd Embolism. The portal vein is the seat of thrombosis and of inflammation, consti- tuting pylethrombosis and pylephlebitis. The hepatic artery also becomes rarely the seat of aneurysms. Pylethrombosis. Thrombosis takes place in the smaller branches of the portal vein, which are constantly being obliterated in the course of cirrhosis of the liver. Larger branches are sometimes invaded by cancer, or a gall-stone may be admitted into one of them by ulceration, or the lodgment of a parasite may be the focus about which a coagulum may form, while thrombosis may also be favored by the pressure incident to the encroachment of a neighboring tumor. Symptoms. — These include those to be detailed when treating of cirrhosis — viz., ascites, hyperemia in the parts behind the obstructed vessel, with this dift'erence. that the symptoms appear more or less suddenly and severely. It is mainly by the suddenness and intensity of the symptoms that we are led to suspect thrombosis, especially if it be associated with any of the previously-named conditions capable of producing it. In such an event the symptoms would come about in the course of a few days, instead of weeks and months. A caput mediiscc thus rapidly produced would mean that the thrombus had formed, not in the portal vein itself, but more peripherally, causing the para-iimbilical veins to be filled from the peripheral branches. These come oft' the portal vein in the suspensory ligament, and pass out to the neighborhood of the navel by two branches communicating with the epigastric and internal mammary vein. When pylethrombosis occurs, it sometimes happens that a complete collateral circulation is established, the thrombus undergoing the usual FATTY LIVER. 455 changes, while the portal vein may be ultimately converted into a fibrous cord. Osier reports such a case, in which compensation finally failed, and the usual symptoms, including hematemesis, supervened, and the patient died. Pylephlebitis. Mild grades of pylephlebitis probably succeed the thrombosis referred to, but they are of no consequence unless the thrombus is septic. Hemor- . rhagic infarct does not usually succeed the lodgment of an embolus in a branch of the portal vein, because of the free anastomosis of its branches with those of the hepatic artery, by which the lobular capillaries are supplied. It does, however, sometimes occur. Here again the results are not serious, so long as the embolus is not septic. Much more serious is suppurative phlebitis, the result of septic embolism, or throm- bosis arising from an inflammatory focus somewhere in the portal area, as in the bowel dysentery, or in the territory of the umbilical vein of the new-born child. Pylephlebitis is one of the causes of abscess of the liver. It is associated with the usual signs of septic infection — viz., chills, remittent fever, and sweats, while the symptoms which point to the liver are pain in that neighborhood, jaundice in most cases, and the signs of portal vein obstruction more or less pronounced. Suppurative peritonitis is also sometimes added. Such phlebitis does not always proceed to the degree of abscess formation before death supervenes. The symptoms of abscess will be considered, when treating of that subject, when, too, attention will be called to the diagnosis between it and suppurative phlebitis, so far as it can be made out. Other Changes in the Hepatic Artery and Vein. The artery is sometimes dilated in cirrhosis of the liver ; it may be the seat of endarteritis and sclerosis. Aneurysm of the artery is a rare condi- tion. The symptom is a pulsating tumor, which may be the seat of a mur- mur. In the cases reported there have been hematemesis, bloody stools, jaun- dice from compression of the biliary ducts, and pain in the neighborhood of the liver due to compression of adjacent nerves. The hepatic vein is subject to dilatation, alluded to in treating of passive h}'peremia ; to stenosis, and to thrombosis extending backward from the right auricle. FATTY LIVER. Definition. — The term fatty liver is applied to a condition in which the cells of the liver are more or less completely converted into fat. This is accomplished, however, by two distinct processes. In one there is an infiltration of the liver cells with fat drops, which simply push aside the protoplasm and cause its ultimate disappearance by interfering with its nutrition. In the other there is a disintegration or metamorphosis of the protoplasm of the cell into various products, of which one is oil. In the former, fatty infiltration, the cell maintains its integrity, being simply filled with the fat drops ; in the latter the cell disintegrates and leaves a residue of which fat is the chief representative. It should be mentioned that some use the term " fatty liver " as synonymous with " fatty metamorphosis." 456 DISEASES OF THE DIGESTIVE SYSTEM. Fatty Infiltration. Etiology. — Abnormal fatty infiltration occurs in two ways. 1. In case of overingestion of fat-producing substances, resulting in obesity, of which it is a part, and as the result of which the liver becomes a storehouse for fat. Excessive consumption of alcohol is attended by fatty infiltration, because more carbohydrate is introduced than can be burned up. It is, therefore, stored in the liver cells. 2. In a series of cachectic states, in which oxidation is interfered with and the fat which is ingested is not oxidized, but accumulates in the liver. Such a condition is pulmonary tuberculosis, which is the most common cause of fat-infiltrated liver, except alcoholism. Morbid Anatomy. — The liver of fatty infiltration is uniformly large, soft, and smooth. Its appearance varies somewhat at different stages. Since the infiltration begins at the periphery of the lobule, we have, in the first stage, a simple distinctiveness of the line of demarcation between the adjacent acini. In the second stage this has become more marked, contrast- ing strongly with the darker color of the center of the lobule, and producing one form of nutmeg liver — as contrasted with the liver of red atrophy, already described in treating of passive congestion. In the third stage the entire acinus is infiltrated, and the whole organ assumes a uniform yellow or brownish-yellow appearance, from complete fatty infiltration of the cells. The organ is also anemic. In this last stage it is that we have the macro- scopic changes complete — the softness, the broadened edges, and increase in size, with,' however, a decided reduction in specific gravity, so that the whole organ floats when placed in water. Symptoms. — Outside the physical condition, determined by palpation and percussion, and the causing disease or state, there are no distinctive symptoms. There is no jaundice, and the bile-forming function of the liver seems little interfered with, though the stools are pale. There is no obstruction to the portal circulation, and, therefore, no abdominal dropsy. Percussion recognizes enlargement of the liver, which is, however, moderate compared with that of amyloid liver and cancer, extending, as it does, but a short distance below the normal site, where its edge can be felt even through abdominal walls of some thickness. There is no enlargement of the spleen. Diagnosis. — It becomes necessary to differentiate the enlarged fatty liver from the amyloid liver, which is harder and larger and associated with enlarged spleen and albuminuria. With the hyperemic enlargement of the first stage of cirrhosis it is not likely to be confounded. Such enlargement would be trifling, accompanied by tenderness, and sooner or later succeeded by contraction, while the fatty liver continues to enlarge. From the enlarge- ment due to the cloudy swelling characteristic of the infectious diseases, typhoid and typhus, it is distinguished by the absence of fever and other symptoms of these diseases. Prognosis. — This depends upon that of the causing disease. The liver of fatty infiltration can be completely restored to its natural condition with the removal of the cause. Treatment. — The treatment is that of the disease causing it. THE AMYLOID LIVER. 457 Fatty Metamorphosis. Definition. — This is a much more serious condition, in which the cell protoplasm is directly converted into fat, or rather, perhaps, into a number of products of which fat is one, while the cell undergoes disintegration. It is the effect of some poison, w'hich has its type in phosphorus-poisoning and in the cause, whatever it may be, of acute yellow atrophy of the liver. Morbid Anatomy. — The liver, instead of enlarging, undergoes rapid reduction in size, or at least, if there is enlargement, it is of such short duration that it is never recognized. The appearance and condition of the liver, to be described under acute yellow atrophy, are those of the liver which is the seat of rapidly progressing fatty metamorphosis. Symptoms. — They are those of the diseases causing it, and wall be described under Acute Yellow Atrophy. The prognosis is fatal and treatment is unavailing. THE AMYLOID LIVER. Syxoxyms. — Lardaceous Liver; Waxy Liver; Albuminoid Liver. Definition. — In the amyloid liver there is an infiltration, in various degrees, of all the tissues of the organ by the so-called amyloid substance. The blood-vessel walls are the first affected, and by preference those of the intermediate area of the lobule — i. e., that supplied by the hepatic artery, then the central or hepatic vein zone, and finally the peripheral or portal zone. The infiltration begins in the smaller arteries, then invades the cells and capillaries, and in extreme cases pervades all the liver tissue, including connective tissue. Etiology. — The most usual cause of amyloid liver is prolonged sup- puration, especially in connection with tubercular disease of the bones. Hence it is found in children who have had hip disease. For the same reason it is found associated, though less frequently than might be expected, with prolonged tuberculosis of the lungs. Syphilis is one of the recognized causes, whence it may arise as a tertiary manifestation or as the result of bone disease incident to it. Rickets likewise produces some cases, and it is also associated, though rarely, with leukemia, the cancerous cachexia, and the infectious diseases. Morbid Anatomy. — The liver is much enlarged, reaching sometimes enormous dimensions, scarcely exceeded by the largest cancers. Its appearance is waxy or bacony, especially in thin sections. This appear- ance is partly due to the anemic state of the blood-vessels, whose lumen is encroached upon by the infiltrated walls. The amyloid parts strike a mahogany-red color with weak solutions of iodin. In addition to the change in size and translucency, the amyloid liver is hard and smooth, its border usually, though not always, rounded, and its fissure exaggerated. In certain syphilitic forms its surface is beset with nodules. Instead of being general, the amyloid change is sometimes circumscribed, when it may be associated with red atrophy. ' It is occasionally combined with fatty infiltration. Symptoms. — Bevond the enlaro;c}nent. which is usually manifest, the organ extending sometimes as low as the umbilicus, and, in addition to the 458 DISEASES OF THE DIGESTIVE SYSTEM. symptoms of its causing state, there are none peculiar to the amyloid liver. There is no pain, unless it be the result of an associated syphilitic hepatitis, but there may be a dragging scnsatioji, induced by the weight of the organ. There is no jaundice, though the stools may be light-hued, because the secretion of bile is diminished. There is no ascites, except in extreme cases, when it is a consequence of the general hydremia, and not of obstruction in the portal circulation. It is usually associated with amyloid spleen, which is enlarged, and with the amyloid kidney, which secretes albuminous urine. Diagnosis. — This is usually easy. The large, smooth, hard organ, the history of the presence of the causing disease, the absence of jaundice and of dropsy, the association of enlarged spleen and albuminuria, admit of scarcely any other interpretation. It is to be remembered, however, that amyloid spleen is not invariably present, and, when present, may be over- shadowed and compressed by the large liver. The enlarged liver of leuke- mia, the result of white-cell infiltration, is not likely to be confounded, because the other symptoms of this afifection are so evident. The nodular amyloid liver, due to syphilis, must be remembered as a possibility, and will be referred to again in considering the diagnosis of cancer of the liver. Prognosis and Treatment. — They are those of the causing disease. I have never seen an amyloid liver reduced ,to the normal size, yet the absence of symptoms growing out of moderate degrees of it makes practical recovery not impossible. ■ CIRRHOSIS OF THE LIVER. Synonyms. — Chronic Interstitial Hepatitis; Gin Liver; Granular Liver; Hob-nail Liver. Definition. — Cirrhosis of the liver is a disease characterized by an over- growth of connective tissue with more or less destruction of the paren- chyma of the organ, commonly attended by a harder consistence, sometimes by a reduction of size, at others by enlarg-ement, and at others by no changes in this respect. Too much stress has, perhaps, been laid in the past on shrinking of the organ as a necessary feature of the disease. Etiology and Pathology. — Alcoholism is the commonly recognized cause of cirrhosis of the liver, though by no means all alcoholics, even the most confirmed, have cirrhosis. Indeed, a large number of drunkards, watched to their death and examined with special reference to this subject, have been found to have normal livers at the autopsy. Hence, some expe- rienced observers, notably Francis E. Anstie and, later, Henry F. Formad, were disposed to deny that the abuse of alcohol ever produces cirrhosis. Even W. H. Dickinson's observations, which were made with the definite purpose of settling the question, were not so conclusive as might have been expected. Thus, he noted in 149 autopsies upon persons connected with the liquor traffic, 22. or only 14.75 per cent., had cirrhosis ; while out of 149 otherwise engaged. 8, or 51-2 per cent., were thus affected. On the other hand, the studies of the late R. Palmer Howard,* of Montreal, noted below, seem to reaffirm the long acknowledged dictum. The large fatty liver is probably as frequent a consequence of alcoholism as is cirrhosis. * R. Palmer Howard, "Transactions of the Association of American Physicians," vol. ii., 1887. CIRRHOSIS OF THE LIVER, 459 Long-continued malarial intoxication and congenital syphilis are con- sidered causes of cirrhosis. Syphilis produces, however, quite a special form of interstitial hepatitis. In his able study of that very interesting class of cases, cirrhosis in children, Dr. Howard found 11 per cent, due to syph- ilis, chiefly hereditary, while alcohol was still responsible in 15.8 per cent., even in children. Passive congestion due to heart disease or pulmonary obstruction causes some cases, but red atrophy is the more usual form associated with valvular heart disease. This cause I consider more fre- quent than is commonly supposed. Other causes mentioned are stimulating diet and irritation of the gall-ducts by such agencies as obstructing calculus. Finally, a certain number of cases of cirrhosis are altogether inexplicable. It has heretofore been thought that most of the causes act through the blood of the portal vein, irritating the connective tissue of Glisson's capsule, which accompanies everywhere the branches of that vessel, causing first a hyperemia, and then a hyperplasia of connective-tissue cells. Thus, the first stage of the disease would be one of enlargement, accompanied often by tenderness. Subsequently, it was supposed, this embryonic con- nective tissue undergoes organization and contraction, gradually compressing the cells within its grasp and ultimately destroying immense numbers of them; that the reduction in size so often present goes pari passu with a hardening of the organ, which is also a conspicuous feature of advanced degrees of the disease. But while cases are met with representing both ends, so to speak, of the process, the initial stage of enlargement and tender- ness, and the terminal one of smallness and hardness, few can attest that they have had the opportunity of tracing the one stage into the other in the same patient, though the celebrated Dr. Bright, as far back as 1827, claimed to have traced cirrhosis from the incipient enlargement to the smallness of the later stage. I myself have seen reduction of size succeed on enlargement, but I have never seen the contracted small liver result. ]Much more reasonable appears Weigert's conclusion, based on experi- ment, that the death of the cells is primary and the overgrowth of con- nective tissue secondary. Acknowledging that the majority of causes which produce the disease, such as alcohol, for example, operate through the portal circulation, it is only reasonable that the cells whose business it is to elimi- nate the poison should receive the first sting and perish in consequence, and that their place should be supplied by a reactive overgrowth of connective tissue, as Weigert has shown. We may also admit a reactive contracting effect of the new connective tissue on remaining cells, producing thus the death of a greater number. T. G. Adami's studies " On the Bactericidal Functions of the Liver and the Etiology of Progressive Hepatic Cirrhosis " * tend to support this view. In all the cells of the liver in most instances Dr. Adami finds a few dead bacteria, but in certain cases of cirrhosis, of which he had examined more than twenty livers, he found large numbers of a living bacillus which he regards as one of the many varieties of the colon bacillus. But poisons do not enter the liver by the portal vein alone. Irritants may enter by the systemic circulation (the hepatic artery), and passively by the hepatic vein and bile-ducts when obstruction occurs in either of these sets of vessels. Cirrhosis of the liver may result from any one of these four anatomical sources, and it may be that each one of these may place * Read before the British Med. Assoc, at its meeting in Edinburgh, and published in the " British Medical Jour.," October 22, 1898. 46o DISEASES OF THE DIGESTIVE SYSTEM. a more or less special stamp on the form originating from it, at least at the beginning of the process. Though occurring in children, cirrhosis of the liver is still a com- paratively uncommon disease among them, being rarely met before the age of thirty-five. It is also a disease of men, rather than of women. Morbid Anatomy. — At least two well-defined varieties of interstitial hepatitis are met, known as atrophic and hypertrophic cirrhosis. (a) Of Atrophic Cirrhosis. — In addition to the hardness and reduced size of the liver, which may fall from its normal weight of four or five pounds (1.8 to 2.2 kilograms) to two pounds (0.9 kilogram) or less, the surface of the organ is rough and uneven. In the formation of these inequalities circlets of parenchyma are replaced by connective tissue, within which the parenchyma remains intact and appears raised. According as the elevations vary in size the liver is described as a granular liver, a hoh- nailed liver, or a lobular liver. If the cells are fatty, as is sometimes the case, they are yellow ; at other times they are natural in hue ; at others, paler. It was on the color of these nodules that Laennec based the name of cirrhosis, from the Greek uippo?, reddish-yellow, or tawny. In some in- stances the cirrhotic liver is quite smooth, showing a uniform distribution of the connective tissue through the parenchyma of the organ, appreciable only in thin sections examined by the microscope. As the process extends it involves branches of the portal vein itself in its destruction, and even bile- ducts are obliterated. Amyloid and fatty infiltration may be associated with cirrhosis. Indeed, the atrophic liver is very commonly associated with fatty infiltration, which enlarges the liver to a degree which may overbalance the contraction. The new connective tissue, on the other hand, is richly supplied with blood-vessels from the hepatic artery, and Rindfleisch has suggested that the bile is secreted from this blood, rather than that of the portal vein. (h) Of Hypertrophic Cirrhosis — Elephantiasis of the Liver. — The French clinicians, headed by Charcot and Henoch, have studied this form most thoroughly. The liver is enlarged, and it is not unlikely that what has been characterized as the first stage of atrophic cirrhosis has sometimes been represented by this form of disease. An important difference between the two forms is that, while in both there is an overgrowth of connective tissue, in hypertrophic cirrhosis the newly-formed tissue exhibits little dis- position to contraction. Nor is there any compression of the branches of the portal vein. On the other hand, there is obstruction of the biliar}' channels, producing the jaundice which is so characteristic a symptom, whence the French investigators would have the disease begin as an inflam- mation of these passages — a cholangitis — and call it "cirrhosc hypcrtro- phique avec ictere." It is claimed also by Henoch that there is a new forma- tion of biliary capillaries. Others hold that this absence of contraction in the connective tissue is exaggerated ; that while it is much less marked than in atrophic cirrhosis, it does occur sooner or later if the patient lives long enough. It is said to be further characteristic of the development of con- nective tissue in hypertrophic cirrhosis that it is more active zi'ithiit the lobules. However this may be, the liver, thus enlarged, may weigh from eight to ten pounds (3.6 to 4.5 kilograms). Its color is greenish-yellow or green. Biliary Cirrhosis. — This term is used bv some as synonymous with hypertrophic cirrhosis; but the French clinicians also describe a liver of CIRRHOSIS OF THE LIVER. 461 increased size, in which the enlargement is ascribed to an overgrowth of interstitial connective tissue, an overgrowth which replaces gaps in the parenchyma destroyed through the toxic effect of bile retained in the ducts. This is followed by a deposit of pigment granules in the interlobular con- nective tissue and within the acini themselves. It is, therefore, " secondary " to obstruction of the gall-ducts by any prolonged cause, as a gall-stone, tumor, or the like. In such case the liver is larger and harder. This reasoning seems to be sustained by experiment, since ligation of the common bile-duct in ani- mals has been followed by such cirrhosis. I cannot, however, see any essen- tial difference in the etiology and motive of these two forms. The spleen is found enlarged in most cases of cirrhosis of the liver of any variety which come to autopsy. Symptoms. — (a) Of Atrophic Cirrhosis. — It must be admitted that cirrhosis of the liver sometimes fails to give rise to any symptoms. The early subjective symptoms of this affection are rather the result of secondary conditions caused by it. Among these are, pre-eminently, those of chronic gastric catarrh, anorexia, nausea, sense of distention, and resulting discom- fort. The gastric catarrh is the consequence of chronic passive hyperemia, due to obstructed movement of the portal blood through the liver. As a result of the hyperemia the mucous membrane of the stomach is more or less constantly covered with mucus, which excites nausea and interferes with secretion of gastric juice. A similar condition exists in the small intestine, causing constipation, which is increased by the deficient biliary secretion. This is further shown by the paleness of the stools. The well-known com- forting effect of the early morning " dram " upon the inebriate may be due to some action of the alcohol upon this mucus. The disease is usually afrebile. Occasionally there is slight fever with temperature of 100° to 102° F. (37.7° to 38.8° C). The remaining symptoms are also mainly the result of the ligature-like effect of the connective tissue on the portal vessels. Nasal hemorrhage, often very obstinate, is one of these. So are gastric and intestinal and,' more rarely, esophageal hemorrhages, these hemorrhages being often enormous and alarming, but really beneficial, by removing the gastro-intestinal congestion. I have, however, had two cases of fatal hemorrhage thus caused. Either one of these forms of hemorrhage may be the very first symptom to attract attention. Uterine flooding also sometimes occurs, and even hema- turia. Similarly caused is the abdominal dropsy, which is often enormous. Four gallons (15 liters) and more are not infrequently removed at one tap- ping, and sometimes the fluid, from its weight, bursts through the feeble barrier at the abdominal ring, distending the tunica vaginalis. The navel is ■often pushed out by the enormous distention. The surface of the upper abdomen and lower thorax, anteriorly, is marked by overdistended veins. This is directly due to the backing of the blood into these veins, rendered possible by the anastomotic communication "between the portal and caval circulations. Such anastomosis between the rudimentary veins in the round ligament (branches of the portal vein) and the epigastric and mammary veins leads to enlargement of the superficial branches of the latter, and in extreme cases to the formation of a caput medusce about the navel. Communication between the superior hemorrhoidal vein (a branch of the portal vein) and the middle and inferior hemorrhoidal, and through them with the hypogastric veins and vena cava, produces hemor- rhoids, a characteristic symptom of cirrhosis. Anastomosis between the 462 DISEASES OF THE DIGESTIVE SYSTEM. superior gastric vein (a branch of the portal) and the inferior esophageal, whose blood goes to the cava through the az}gos and hemiazygos, causes a varicose condition of the veins of the lower end of the esophagus which has resulted in fatal hemorrhage. The overfilling of the esophageal and azygos veins also obstructs the movement of the blood through the intercostal and pleural vessels of the right side, causing right-sided hydrothorax. These dilatations, which have been characterized as " attempts at compensation," are to be distinguished from the more diffuse dilatations of the abdominal veins seen in the flanks, which are due to the pressure on the cava of extreme abdominal dropsy, preventing the return of the blood of the lower extremi- ties to these veins. Edema of the legs is, however, much more uncommon than abdominal dropsy, and, when present, depends upon the further pressure exercised by the enormous accumulation of fluid in the abdominal sac upon the returning blood of the lower extremities. Jaundice is a symptom in atrophic cirrhosis, though the constrict- ing effect of the interstitial tissue upon the gall-ducts would lead us to expect it to be more frequent. It may be because comparatively little bile is secreted. Fagge * reports 34 cases of jaundice out of 130 examined in the postmortem room of Guy's Hospital, rather more than might be expected. A sallowness of complexion is also sometimes present, while a ruddiness of face is not uncommon. Physical examination by palpation and percussion discovers a dimin- ished area of hepatic dullness in atrophic cirrhosis. On the other hand, splenic dullness is often enlarged, the latter because of resisted return of its blood through the liver, though the same cause which operates in producing cirrhosis may also co-operate to produce splenic enlargement if it be systemic in origin. According to Frerichs, the spleen is enlarged in about one-half of the cases ; some even say in three-fourths. In alcoholic cirrhosis especially enlarged spleen is considered evidence of an advanced stage of the disease. It is often impossible to outline either liver or spleen because of the extreme abdominal distention, and tapping must first be resorted to before physical exploration is satisfactory. The urine in atrophic cirrhosis of the liver is generally scanty, of high specific gravity, highly colored, and often loaded with urates, which subside on standing, forming a bulky sediment. The proportion of urea is often diminished, a natural result of the deranged function of the liver, to which modern physiology assigns an important role in urea formation. The urine also contains at times bile pigment, but less frequently than in hypertrophic cirrhosis. Blood is also sometimes found in the urine. Drozvsiness and coma and even delirium are sometimes terminal symp- toms, especially in cases where there is jaundice, but also where there is ascites without jaundice. They have been ascribed to cholesteremia. (&) Symptoms of Hypertrophic Cirrhosis. — The symptoms which dis- tinguish this form from the atrophic variety are : 1. The jaundice, which begins with the first vague symptoms of the dis- ease and gradually deepens as the disease progresses. The explanations sug- gested of this feature of the disease, as contrasted v,'ith its absence in atrophic cirrhosis, cannot be said to be altogether satisfactory. It is simply true that in some way there is produced obstruction in the biliary vessels, perhaps by a cholangitis. 2. The absence of hyperemia of the stomach and bowels, of hemor- * "Practice of Medicine," 1886, vol. ii. p. 306. CIRRHOSIS OF THE LIVER. 463 rhoids, enlargement of the spleen, and pre-eminently of ascites ; or the pres- ence at least of only mild degrees of these symptoms. 3. The presence of tenderness in the liver, in addition to its evident enlargement and smoothness. 4. Certain differences in the urine in the two forms. It is a well-recognized fact that when there is jaundice the urine is also jaundiced. In atrophic cirrhosis jaundice is more infrequent, and when present, say in about one-fourth the cases, it is very slight. The same is true to a less degree of the urine, for while the latter is scanty and highly colored, it less frequently contains bile pigment. In hypertrophic cirrhosis, on the other hand, bile-stained urine is more common. Blood is never found in the urine of hypertrophic cirrhosis, while in atrophic cirrhosis it sometimes is in advanced stages, as is also albumin. In atrophic cirrhosis the urea is diminished; in hypertrophic, it is normal in quantity. In hypertrophic cirrhosis the feces are sometimes devoid of bile ; at times, not. Rosenstein has made a study of the blood in hypertrophic cirrhosis, and has found the red corpuscles diminished one-half and the leukocytes relatively increased. He also found it to coincide in certain cases with the hemorrhagic diathesis. Alcohol is said to be even a more important factor in causing hypertrophic than atrophic cirrhosis. The course of hypertrophic cirrhosis is usually more rapid than that of the atrophic. It may be put down at one or two years, yet in some cases it is very short. Osier mentions a case which proved fatal in ten days ; another in three weeks. It may be questioned whether these were not cases of acute yellow atrophy. All cases terminate more or less acutely. Delirium sets in, the tongue becomes dry, the pulse rapid, and the temperature rises from 102° F. to 104° F. (38.9° C. to 40° C). Diagnosis. — (a) Of Atrophic Cirrhosis. — The diagnosis of cirrhosis of the liver is not usually difficult. If one is satisfied that there is a reduction in the size of the organ, and there are associated with this no symptoms of acute disease and no history of starvation, we may infer scarcely anything else but cirrhosis ; and if to this is added ascites, without dropsy elsewhere, the diagnosis is absolute. Tubercular peritonitis, with its liquid effusion, has been mistaken for cirrhosis, and the wasting which attends advanced stages of the former affection closely resembles that in the latter, but the abdominal tenderness in peritonitis is characteristic, there is fever, and the effusion is never very large. The tuberculin test should be applied in all doubtful cases. (b) Of Hypertrophic Cirrhosis. — Hypertrophic cirrhosis is to be distin- guished from cancer of the liver, amyloid liver, multilocular echinococcus disease, and the liver of obstructive jaundice. In cancer there is no splenic enlargement, ascites is more frequent, the liver is more uneven, and the patient is older, while in hypertrophic cirrhosis we have also the history of alcoholism. In amyloid liver there is also splenic enlargement, but there is no pain, no jaundice, and we have the etiological history peculiar to amyloid disease. Multilocular hydatid disease in the liver may present almost identical symptoms, including jaundice and splenic tumor, but in addition there are the nodules on its surface which soften with time. The liver which is associated with chronic biliary obstruction and sec- ondary cirrhosis, while somewhat enlarged, is not nearly so much so as in hypertrophic cirrhosis. Hepatic colic has been present at some time in the course of the disease. It is also hard, and accompanied by marked jaundice 464 DISEASES OF THE DIGESTIVE SYSTEM. and other evidence of hepatic obstruction. Its course, while slow, is more rapid as a rule than that of hypertrophic cirrhosis, while the liver also after a time diminishes in size. Prognosis. — The prognosis of cirrhosis of the liver is unfavorable if restoration of the normal organ be the object. A liver once the seat of inter- stitial hepatitis can probably never resume its normal histologv. Yet the liver has a good deal of elasticity of function, and if the cause of the condition, supposing it to be alcoholism, is removed and the contraction be not too far advanced, the patient may be restored to comparative health. Generally, however, the course of cirrhosis is from bad to worse, although it mav be a slow course, and the patient finally dies of exhaustion and cholemia. It only rarely happens that death, is caused by the copious hemorrhages from the stomach and bowels which sometimes occur. I have already referred to two cases in my practice. On the other hand, thev frequently relieve the portal congestion, thus giving to the patient a new lease of life. He may live many years in comparative comfort. Treatment. — The treatment of cirrhosis of the liver resolves itself into two parts — first, the relief of the symptoms, and, second, the restoration of the organ to its normal state. Toward the first result the removal of the cause is indispensable. The alcoholic must stop drinking. This, after some temporary inconvenience, of itself brings alleviation. But the effect of gastric congestion remains in part, and sufficiently to cause want of appetite, nausea, unpleasant taste in the mouth, and a general disgust of one's self and everyone else. The mucous membrane of the stomach is swollen, and probably bathed with mucus. The latter can be removed by free drinking of alkaline mineral waters before meals, such as those of Vichy, Vals, and Carlsbad, the effect of all of which is increased when hot. Here, too, as in gastric catarrh, — it is really gastric catarrh we are treating, — the hot-water treatment is often highly useful by ridding the stomach of mucus. A tumblerful, as hot as it can be borne, is taken slowly before breakfast, or before each meal. Its effect is often highly beneficial. I know no additional explanation of its action unless it be that it may likewise stimulate the secretion of gastric juice. Lavage also relieves this condition and its consequent symptoms. The congestion which is responsible for this secretion must be removed. This is best done by the saline and mercurial purgatives. Five to ten grains of blue mass at bedtime, followed by a dose of sulphate of magnesium in the morning or of Hunyadi or Friedrichshalle water, will deplete the engorged veins and relieve the symptoms for the time being. The mineral waters of Saratoga in this country, some of which are also purgative, are very useful for the same purpose. A course at Saratoga is greatly appreciated by the confirmed free drinker, and he is always better for some time after it. The hot saline and sulphur waters at Greenwood, Colo., are similar in their effects. Finally, foods which make the least demand upon the stomach are to be used. Fatty matters are especially contra-indicated. In advanced stages milk and \'ichy, peptonized milk, and beef peptonoids may be assimilated when other foods cannot be managed by the feeble digestion, but even these are absorbed with difficulty as long as the mucous membrane of the bowels is much congested. The abdominal effusion is combated by the purgatives alluded to, and diuretics may be added ; of these 'the acetate of potassium seems more effi- cient than the bicarbonates and citrates where dropsy is due to hepatic affec- SUPPURATIVE HEPATITIS. 465 tions. Perhaps this is because in large doses it has also some laxative effect. Theobromin is often an efficient diuretic in these cases, especially when the heart is in good condition. When the abdominal eft'usion becomes large, it must be removed by tapping, although the reaccumulation may be very rapid and it may have to be repeated many times. Recently operation has been suggested for permanent cure of abdominal effusion due to this cause. Can anything be done to remove the growth of the connective tissue and promote the redevelopment of the destroyed parenchyma? Presumably, if the former could be accomplished, the latter may take place, for there is evidence to show that the liver structure may be reproduced. Theoretically, iodid of potassium is a remedy which should melt away the overgrown con- nective tissue. Practically, it is extremely doubtful whether it does. I have never seen such effect, nor can I point to any reliable observations that affirm it. There may be, however, and to such an end it is right to use the drug in small doses, which, to produce any effect, should be long continued. It is also a diuretic. There is reason to believe that the iodid is more efficient when taken freely diluted and on an empty stomach than in larger doses after meals. Thus administered, three to ten grains (0.2 to 0.66 gm.) may be regarded as a sufficient dose. SUPPURATIVE HEPATITIS. Synonym. — Abscess of the Liver. Etiology. — The vast majority of abscesses of the liver, some would say all of them, are traceable to causes which, in one way or another, are associ- ated with microbic origin. Even traumatic abscess, which is of admitted occurrence, is ascribed to an associated infectious agent. The possibility of abscess excited by simple chemical, as contrasted with bacterial cause should at least be mentioned. Most abscesses of the liver arise by infection from the portal area. These are thrombotic, embolic, or amebic. The thrombotic are caused by infectious thrombus, which, starting in the venules of an area drained by the portal vein, extends thence to the branches of the portal vein in the liver, where it gives rise to a suppurative pylephlebitis. Such an area is the colon when the seat of dysentery, the rectum by its hemorrhoidal veins, or the neck of the bladder. More frequently a fragment of such thrombus lodges in a branch of the portal vein and starts an abscess, consti- tuting the embolic origin. Or the oiiieba coli, which is the cause of amebic dysentery, is transferred from its primary seat in the intestine into the liver. A similar mode of origin of abscess is by an umbilical phlebitis in the new- born infant. Abscesses of the liver may also be caused by infectious emboli arising in the left heart, the pulmonic or systemic circulation, reaching the liver via the hepatic artery. These emboli mostly originate in the lungs or left heart, but may arise beyond, the condition being that they are small enough to pass through the capillaries of the pulmonary artery. Such would be the abscesses caused by injuries to the scalp or to bones of the skull, or from seats of osteomyelitis elsewhere, all of whicb are acknowledged to be rare causes of abscess of the liver. Septic emboli, producing abscess of the liver, may arise from the left heart in cases of ulcerative endocarditis. These are among the rare causes of abscess of the liver. Even a non-infectious embolus may 30 466 DISEASES OF THE DIGESTIVE SYSTEM. excite an abscess if brought into association with pyogenic organisms enter- ing the Hver in another way. Such organisms may enter the Hver through the common duct from the ahmentary canal. This is probably the route of the organism causing suppurative cholangitis, and of that causing the abscess often associated with hydatid cyst of the liver. Finally, regurgitant embolism of the hepatic vein is a possible cause of hepatic abscess. In the vast majority of cases, however, abscess of the liver is preceded by dysentery, whence arises an infectious thrombus, an embolus, or an ameba coli. Morbid Anatomy. — The right lobe of the liver in its thickest part is the most frequent seat of abscess — in two-thirds of all cases. The abscess varies in size from that of a mere point to that of a child's head, the whole right lobe being sometimes converted into one abscess cavity. It may be single or multiple. Rarely, the abscesses intercommunicate. The liver is, of course, proportionately enlarged. Notwithstanding ibis, the external appearance of the organ may not be changed. On the other hand, if the abscess is near the surface, there may be a prominence under which fluctuation may be recog- nized, or the liver may become adherent to the abdominal wall or adjacent viscera. The abscess cavity, if of any size, is usually ragged, and not sharply defined from the surrounding hyperemic liver tissue. Such hyperemia may involve two or three rows of acini. In chronic cases, however, there may be a tolerably firm pyogenic membrane. The contents of the abscess may be pus, or a puriform fluid consisting of the granular debris of cells, oil drops, a few leukocytes, cholesterin and other fat crystals, and numerous crystals of bilirubin. The ameba coli has been found among the contents of the abscess, but recognizable liver cells are rarely found. Occasionally the pus may become inspissated, caseous, or even calcified or encysted. Should the abscess accompany hydatid disease, echin- ococcus booklets may be found. The contents of such abscesses is generally a true pus. Any form of abscess may perforate the diaphragm and lung, producing interstitial emphysema; or the pus with echinococcus booklets may be expectorated ; or the abscess may burrow into the peritoneum, setting up fatal peritonitis, or into the pericardium, causing fatal pericarditis ; into any adjacent hollow organs or into the abdominal wall, discharging exter- nally by fistulous openings. The thrombotic and embolic forms of abscess always begin as a phlebitis, which rapidly invades the adjacent tissue. Contrary to what is usual in embolism elsewhere, the lodgment of an embolus in the liver is not followed by hemorrhagic infarct. Symptoms. — There may be latent liver abscess, even when the abscess is of considerable size, though this is a very rare event. Abscess of the liver is generally associated with pain in the hepatic region, with fever, very often with chills, szveats, and sometimes with jaundice. The pain is almost invari- ably accompanied with tenderness. It may be deep or superficial, and in the latter event it may be sharp and cutting, because involving the peritoneum. The characteristic shoulder pain of hepatic disease may also be present. Fever is, perhaps, the most invariable symptom, and in no other affection of the liver does it rise so high. Indeed, except acute yellow atrophy and the so-called hepatic fever, there are no other diseases of the liver associated with fever. In the former it is of comparatively short duration, and in the latter it is moderate. The temperature reached in abscess is very high, — 104° to 105° F. (40° to 40.5° C), — and may be preceded by chills of cor- responding severity, while the fever, in turn, is succeeded by sweats, profuse SUPPURATIVE HEPATITIS. 467 and exhausting. Jaundice is not usually present, but may be, when it varies in intensity. When perforation takes place into the pleural sac, it is likely also to perforate the lung, when there succeeds an anchovy-sauce-like expectoration of purulent matter quite characteristic. In this the ameba coli may be present. Physical examination easily recognizes an enlargement of the organ upward in the mammary and midaxillary regions rather than downward, as is usual with other diseases of the liver. Yet the liver is by no means always enlarged, even if there be multiple abscesses. The enlargement is due not merely to the presence of pus, but is also contributed to by the hyperemia and the swelling of cells. The lung being thus encroached upon, the move- ment of the liver consequent on respiration is less marked than in health. The hepatic region is at first unyielding to palpation, but ultimately fluctuation may be recognized, while a doughy or edematous condition of the abdominal wall is sometimes present and quite characteristic. Diagnosis. — This may be difficult at first, but as time passes doubts clear up. Intermittent fever very naturally is first thought of in many instances, but it will not be long before this disease can be eliminated. There is no enlargement of the spleen, no history of malarial exposure, no malarial organism is found in the blood, and, above all, antiperiodic thera- peutics, so efficient in malarial disease, fails of its purpose. In the absence of malaria and in the presence of the causes usually responsible for abscess of the liver there is little else left to mistake for it. A pleuritic effusion on the right side gives dullness on percussion in the same locality, but along with this are the diminished fremitus and diminished vocal resonance character- istic of fluid in the pleural sac, while there may also be the bronchial breath- ing brought on by compressed lung. A suppurating cchinococcus cyst may give rise to similar symptoms, but in view of its rarity in this country, is scarcely likely to be recognized until aspiration discovers the elements char- acteristic of it. The needle should be tried early if abscess be suspected, yet it is evident that in so large an organ an abscess of moderate size may easily elude it. Hepatic intermittent fever, due to chronically impacted calculus, resembles abscess by its fever, chills, and sweats, and by tenderness over the liver, but the history of hepatic colic is present, jaundice is more marked and obstinate, and the condition is evidently not so serious. Prognosis. — This is generally unfavorable. Even in cases where the abscess happens to point to the surface and is properly opened, death usually superv^enes after long and tedious illness, say in six weeks to three months, and, where surgical interference is not possible, death is even more speedy. Cases do, however, recover, not so much by the aid of the physician as through nature's irresistible tendency. It is said that with surgical inter- ference 30 per cent, recover, and where this is impossible 20 per cent, still survive, but this has not been my experience. The hydatid abscess is more apt to terminate favorably if opened than is the infectious abscess. Treatment. — This is palliative and supporting, except in those cases where surgical interference is possible. The usual measures to relieve pain, nourishing and easily assimilable food, quinin, iron, and stimulants are indicated. 468 DISEASES OF THE DIGESTIVE SYSTEM. PERIHEPATITIS. Definition. — An inflammation of the peritoneal covering of the Uver. Etiology. — Perihepatitis occurs in a circumscribed area — (i) as the resuh of extension by continuity from some one of the various diseases of the Hver, such as abscess or hydatid cyst; (2) as a part of a general peri- tonitis, and (3) rarely by the spread of a pleurisy through the diaphragm; (4) it may also be caused by direct violence, as by a blow, or be the result of a perforation of an ulcer of the stomach or duodenum or gall-bladder. Morbid Anatomy. — In the more acute forms there is a fibrinous or puriform product with more or less adhesion. These adhesions may lace off areas between the liver and the diaphragm which may be filled with pus, sometimes large quantities, constituting subphrenic abscess, or if there be perforation of the diaphragm, subphrenic pyopneumothorax, more common over the right lobe. In the more chronic form the capsule of ihe liver is thickened, especially near the portal fissure, and adhesions may take place with adjacent organs, as the diaphragm, stomach, colon, or abdominal wall. The organ may be shrunken and lobulated, and the portal or hepatic vein and bile-ducts may be stenosed. The capsule of the liver is often found thick- ened at autopsies when no symptoms were present during life to indicate it. Symptoms. — The pain and tenderness which, naturally, are attached to this condition, while often exceedingly severe, like those of peritonitis from other cause, are not distinctive of it. Xor is the jaundice resulting from compression of the bile-ducts ; nor the symptoms of portal engorgement due to compression of the portal vein by the inflammatory products. Physical examination sometimes gives more definite results. Thus, a friction rub may sometimes be heard in the mammillary line from the seventh rib down- w-ard, and in the axillary line from the ninth rib downward ; also sometimes in the epigastrium. It is, however, of short duration. If there is a puru- lent collection, fever is likely to be present, while the right hypochondrium may be distended and the intercostal spaces motionless. The dullness on percussion may extend as high as the angle of the scapula, and all the signs of a pleuritic effusion may be present. On the other hand, the lower border of the liver may be much lowered — as far down as the navel. The course of perihepatitis may be acute, or it may be much prolonged, when all the symptoms of chronic suppurative processes are added — fever, high temperature, sweats, fistulous communications with other organs, including the lungs, intestines, and abdominal wall. Diagnosis. — This lies chiefly between that form of the condition under consideration, attended with pus accumulation between the liver and dia- phragm, and an empyema or pneumothorax. The physical signs and later symptoms are very similar, and it is chiefly in the initial symptoms that the two conditions differ, the one beginning with cough and pleuritic pain asso- ciated with cardiac displacement ; the other with symptoms more abdominal in situation. The liver in pleuritic effusion and empyema is never so much pushed dov.-n as in the hepatic disease. Aspiration may also be availed of in diagnosis. The trocar is to be introduced in the midaxillary line in the seventh or eighth interspace. It was pointed out by Pfuhl that in subphrenic abscess the spurting occurs with inspiration or as the diaphragm moves down- ward, and in empyema with expiration as the diaphragm moves upward. The atrophic results of perihepatitis are rarely recognized before death. ACUTE YELLOW ATROPHY OF THE LIVER. 469 Prognosis.— This is grave in the severer forms terminating in suppura- tion. A protracted illness, with gradual exhaustion of the patient's strength, is prone to occur, which skillful surgical measures may nevertheless turn to recovery. Milder attacks terminate favorably in a few days. Treatment. — Treatment in the early stage must consist of measures to relieve pain, local and general. Counterirritation by cupping operates to check the disease and also shorten the attack. Sinapisms and fomentations contribute in a less degree to the same end. If suppuration occur, the coun- sel and aid of a surgeon should be early sought, as it is by his efforts that a cure becomes possible. Glissonian Cirrhosis. — This is a term applied to a form of peri- hepatitis in which the capsule is thickened, assuming a semicartilaginous appearance. It is associated with reduction in size and some degree of inter- stitial overgrowth and distortion. The capsule may attain a thickness of from 4-10 to 6-10 of an inch (i to 1.5 cm.). ACUTE YELLOW ATROPHY OF THE LIVER. Synonyms. — Icterus gravis; Acute Parenchymatous Hepatitis; Malignant Jaundice. Definition. — A rapidly destructive disease of the liver, resulting in fatty degeneration and atrophy of the organ, associated with toxic symptoms and death. Etiology. — This remarkable and fortunately rare disease is probably due to the action of some virulent poison, autogenetic perhaps, but whose nature is as yet undiscovered. Pregnancy is one of the conditions acknowl- edged to produce it, and more cases occur among women than men. It occurs in the second half of pregnancy. It has occurred in the course of the infectious diseases, and the usual microbic origin has been held responsible for it, as have been alcoholism and mental excitement. Bacteria have been found in the organ after death. Beyond this we know nothing of its cause. Pathology and Morbid Anatomy. — The destructive process in the liver is almost identical with that of phosphorus-poisoning, and consists essen- tially in a very rapid destruction of liver-cells. Opinions are divided as to whether this is the result of an acute inflammatory process, or whether the cells are destroyed by some solvent action. Frerichs and Demme held the view that it is an acute parenchymatous inflammation, of which the chief seat is the peripheral zone of the lobule, whose swelling causes obstruction in the biliary capillaries and the reabsorption of bile. Henoch and von Dusch consider retention of bile the starting-point, and that the liver cells are dissolved by this retained bile. Munk regarded all cases as the result of phosphorus-poisoning. The liver at necropsy is found very much reduced in size, often to half and even quarter its normal volume. This may take place in three or four days, and even less. A stage of primary enlargement is said to be sometimes present, but Is never seen at autopsy. The organ is flattened, flabby, and can be folded over on itself, and the usual lobular markings are either very indis- tinct or altogether absent. The capsule is loose and wrinkled, and the organ is of a dirty yellow color. 470 DISEASES OF THE DIGESTIVE SYSTEM. On section, the surface is either uniformly yellow or it exhibits an alter- nation of yellow and red. The yellow appears, for the most part, in islets, which are surrounded by the red. The yellow represents an earlier stage of the disease. It is soft and spongy, and rises cushion-like above the surface. The red is tougher, more leathery, and sinks below the level of the cut surface. When the organ is uniformly yellow, this later stage, represented by the red, has not been reached before death. Histologically, the ycllozc areas exhibit softening and apparent solution of the cell network, very few liver cells remaining which retain their own con- tour. Instead are found disintegrating cells wath fat drops of all sizes, the cells being in places still united by their connecting substance so as to main- tain the original network. Sometimes crystals of bilirubin, leucin, and tyrosin are met with. The red areas consist of a loose connective tissue whose meshes contain fat drops and biliary coloring-matter, representing the softened liver parenchyma bereft of its cells. In places there may be seen a slight degree of cell infiltration of the interstitial tissue, in others irregular branching bands and apparently blind-ending tubes of cells resembling biliary epithelium. These, Waldeyer says, are the result of an attempt at repair. The atrophy usually takes place more rapidly in the left lobe. The skin and organs are generally intensely bile-stained. There may be small extravasations of blood in various parts. The spleen is enlarged and hyperplastic, the renal epithelium and heart muscle are fatty, while the serous cavities contain more than the normal amount of fluid. Symptoms. — There are no symptoms distinctive of the beginning of acute yellow atrophy. For several days there may be signs of gastro-intes- tinal catarrh, promptly followed by jaundice. The former include headache, malaise, loss of appetite, nausea, vomiting, eructations, and epigastric discom- fort. Then there suddenly supervene serious symptoms — delirium, abdom- inal pain, convulsions, local or general drozvsiness, and coma. Sometimes the symptoms of this stage are delayed — in extreme cases as long as three weeks. The liver rapidly diminishes in sise. Three or four days may see its disappearance to percussion and palpation, favored by further obscuration by distended air-holding viscera. W. von Leube calls attention to a symp- tom elicited by palpation which he thinks may be of diagnostic value — a more or less permanent " pitting " to pressure in the epigastric region. He ascribes this to an impression made upon the relaxed liver, to which the abdominal wall fits itself. The spleen, on the other hand, is enlarged, the jaundice is intense, the vomiting obstinate, while there may be epistaxis, hematemesis, hematuria, nienorrhagia, and hemorrhagic extravasations, while the stools are devoid of bile. The pregnant woman aborts. There is little fever, and in the worst stage there is but moderate rise of tempera- ture — rarely above ioi° F. (38.2° C). The pulse, at first infrequent, in- creases toward the end to 120 or more. The ichanges in the urine are very characteristic and have been thor- oughly studied. It is deeply bile-stained, is concentrated, the specific gravity often reaching 1030. It is slightly albuminous, and may contain the bile acids, bile-stained fatty casts, and bile-stained renal epithelium. The quantity of urea is diminished, even totally absent. The characteristic feature is the presence of leucin spheres and tyrosin needles in most cases. These crystals may appear without treatment of the urine or they may come down after slight concentration. In addition are found also aromatic oxy- MORBID GROWTHS OF THE LIVER. 471 acids, especially oxymandelic acid, all representing products of albumin dis- integration. Diagnosis, — The symptoms of acute yellow atrophy in the first stage do not admit of a diagnosis. This is the more true because there is no symptom, even atrophy, which may not be wanting. Thus, cases have perished from hemorrhage before the disease was recognized or before jaundice appeared in the rapidly terminating cases. In the second stage, on the other hand, the symptoms are so distinctive that it seems almost impossible for one familiar with them to fail to recognize them. It is, however, so rare a disease in this country that the opportunity does not often present itself ; hence it is sometimes overlooked because not sus- pected, the more excusably because grave nervous symptoms may occur even in catarrhal jaundice and in the infectious diseases — as, for example, in pneumonia, where jaundice is sometimes a symptom. Acute phosphorus- poisoning so closely resembles acute yellow atrophy that the diagnosis depends largely upon the possible recognition of the cause. There are, however, some differences. The reduction in size of the liver is not so rapid, the nervous symptoms are not so grave, and leucin and tyrosin are not usually found in the urine of phosphorus-poisoning. Hypertrophic cirrhosis also sometimes resembles acute yellow atrophy clinically, but the enlarged liver is the distinctive feature of the former. Prognosis. — This is so unfavorable that recovery may be said to imply an error of diagnosis. Treatment. — There is no curative treatment. Symptoms should be relieved by the usual palliatives. Headache should be relieved by phenacetin and acetanilid, rather than morphin. An ice-bag may give great relief. MORBID GROWTHS OF THE LIVER. The only morbid growths of the liver which are of clinical importance are cancer and sarcoma. An angioma is an interesting new formation of small size, which presents no recognizable symptoms before death. It is composed of vascular tissue and is distinctly capsulated. The large sizes may be as large as a walnut, more rarely still larger. Some pathologists describe an adenoma, which others class among the cancers as a trabecular variety. Myoma is another form of histioid tumor rarely found in the liver. Cysts, represented by the dilatation cyst and the hydatid cyst, are of occa- sional occurrence. Carcinoma of the Liver. Etiology. — Cancer of the liver is a comparatively common disease ; of internal organs, next in frequency to that of the uterus and stomach. It is, moreover, in the vast majority of cases secondary — in full three-fourths of cases, and of these two-thirds are secondary to primary cancer of the portal area, one-third to primary cancer elsewhere. The stomach Is, naturally, the most frequent primary focus. Cancer of the liver is most common in male adults between the fortieth and sixtieth year, yet it does occur occasionally in children. Morbid Anatomy. — There are two chief forms in which cancer of the liver presents itself — the nodular and the massive. Rare forms are radiating, colloid, and cancer with cirrhosis. 472 DISEASES OF THE DIGESTIVE SYSTEiM. 1. In the nodular form nodules of various sizes are scattered through- out the organ. The nodules vary in diameter from one-fifth of an inch to two inches (0.5 cm. to 5 cm.) or more. They are usually opaque, white, or yellowish-white, and may be very numerous. The superficial nodules project above the surface, and ma}- even be felt through the abdominal wall in the emaciated subject, giving rise to the oft-described '' bosselated " feel. These superficial nodules are often umbilicated, because of the disintegration and absorption of the older central cells, leaving a residue of connective tissue and partially-obliterated blood-vessels. The umbilication is confined to the superficial nodules, which also received the name of Farre's tubercles. This variety of nodular cancer may be both primary and secondary. The nodules usually reach a larger size in the secondary, and are apt to be more numerous. 2. The uiassiz'e form, in w'hich there is one large cancerous mass, greatly increasing the bulk of the organ. It is grayish-white in color, and may reach four or six inches (10 or 15 cm.) in diameter. This form is primary. 3. The radiating form, usually pigmented, in which the nodules may also be multiple, but smaller and less numerous than in ti.e nodular form. It is a form of secondary cancer. 4. A colloid form, rare and only secondary. 5. A rare form is cancer zvith cirrhosis, in which the liver is but slightly enlarged, weighing 4.5 to 6.5 pounds {circa 2 or 3 kilograms), and presents a greenish-yellow appearance, studded over with small white nodules not unlike those of the hob-nail liver, the same appearing in large numbers when the organ is cut. All varieties of cancer are subject to degeneration, but the secondary forms more rapidly. The change is a fatty metamorphosis of the cells, associated sometimes with rupture of blood-vessels and large extravasations of blood, which may even burst into the peritoneum and gall-bladder. There may be occasional suppuration around the nodule. As to the histological origin of cancer, the primary forms start in the liver cells; they are true epitheliomata, the capillary network forming the primary stroma, to which an independent growth of stroma is subsequently added. The secondary forms are embolic in origin, chiefly through the branches of the portal vein, but possibly by the hepatic artery, with or without intermediate involvement of the lung, the first new cancer cell being an infected cell of the capillary wall, whence the parenchymal liver cells are in turn afifected. Tfie stamp of the pigmented radiating cancer is, perhaps, thus derived, and illustrates this mode of invasion. The second- ary forms repeat the type of the primary varieties. The cells are mainly epithelioid, but may be polygonal and even cylindrical. They exhibit va- rious grades of fatty degeneration. The liver is variously enlarged by these dififerent forms of cancer, the maximum product being the largest produced by any disease of the liver (see Fig. 36). Sarcoma. — Of the remaining morbid growths of the liver, sarcoma alone demands a few words. It is almost invariably secondary, very few cases of primary sarcoma of the liver having ever been found. Secondary sarcoma of the liver includes melanosarcoma, lymphosarcoma, and myxo- sarcoma. The melanosarcoma is the most frequent and interesting. It is always secondary and usually multiple, though a diffusely infiltrated variety; MORBID GROWTHS OF THE LIVER. 473 exists, giving the liver on section a granitic appearance. Melanotic sarcoma of the orbit often precedes it, and it is sometimes a part of a general melan- otic distribution over the body, including the skin. Sarcoma of the liver is said to be never associated zvith ascites. Symptoms. — Very rarely cancer of the liver may be latent, except as to a vague ill health explained by the findings of the autopsy. In most instances such ill health grows worse more or less rapidly, and examina- tion of the liver discovers enlargement, to which may or may not be added recognizable nodules. The enlargement may extend beyond the umbilicus. Z', K '^-- • — -^ ---::::;.' "j'_ ""-'^<-'f .-1^^^— Fig. 36. — Showing Approximate Enlargement of the Liver Corresponding to the Dif- ferent Diseases Described in the Text — {after Rindfieisch). I. Position of the diaphragm to the maximum enlargement (carcinoma and in abscess), //, //. Normal situation of the diaphragm. //, ///. Relative dullness. IV. Border of the liver in cirrhosis. V. Border in health. VI. Lower border of the fatty liver. VII. Of the amyloid liver. VIII. Of cancer, leukemia, and adenoma. but it is not usually so great, and in some cases there is none whatever. To inspection the enlargement is first seen in the upper zone of the abdo- men, and produces a change of configuration which involves commonly the whole upper abdomen. Rarely, the nodules may be seen. The supeiUcial veins are enlarged. The other signs of ill health alluded to, apart from those of a primary- cancer elsewhere, are loss of appetite, nausea, a sense of epigastric fullness, pain in the epigastric or hypochondriac region or in both simultaneously. The pain may be lancinating and extend to the right shoulder. To this 474 DISEASES OF THE DIGESTIVE SYSTEM. tenderness is sooner or later added. Indeed, perhaps tenderness precedes. Emaciation may have preceded the more striking degree of these symp- toms and increases rapidly, while the characteristic cachexia develops pari passu. An examination of the blood shows a reduction of hemoglobin and corpuscles, and as the 'blood becomes thin edema develops. In some cases there is fever, especially toward the end, with a temperature of ioo° to 102° F. (37.8° to 38.9° C), more or less intermittent, but rarely associated with rigors. Obstructive jaundice is a frequent symptom in carcinoma hepatis — it may be said in fully half the cases. It is due to compression of the smaller biliary passages, and does not usually reach a high degree. Nor are the feces usually devoid of bile. If the latter event occurs, and the jaundice is intense, it means that some of the larger ducts are obstructed, while involve- ment of the gall-bladder or the portal lymphatics may be suspected. Jaun- diced urine is about as constant as jaundice itself. The presence of melanin is said to point especially to the presence of the pigmented varieties of cancer. Albuminuria is, on the other hand, unusual. Ascites is a rather infrequent symptom, and can only occur when the portal vein or branches become involved either by compression or invasion. Should, however, a bloody fluid be obtained by, tapping, and a tumor of the liver be present, the indications are that the tumor is cancer. Enlargement of the spleen is rarely present in cancer of the liver. The duration of the disease ranges from three to fifteen months. Diagnosis. — This is not always easy, even if there is enlargement. It is simplified if the nodules can be felt, or if there is recognized primary cancer elsewhere. The smooth, enlarged liver of cancer is distinguished from that of the more benignant conditions of fatty liver and amyloid liver by the absence in these two of grave symptoms and of jaundice. The fatty liver is softer than the liver of cancer, the amyloid is harder, more often smoother, while its rounded border can sometimes be felt. It is also accompanied by en- larged spleen. In abscess of the liver the organ may be soft or doughy in consistence, and the same may be true of the abdominal walls over it. There are also the causes of abscess of the liver, and among symptoms the characteristic chills, high fever, and sweats. Multiple echinococcus cysts may furnish similar local signs, even the " bosselated " feel, but hydatid disease is rare in temperate climes ; the nodules are softer, the disease is of longer duration, and is less rapidly fol- lowed by wasting. Enlargement of the spleen is quite common in hydatid disease, present, it is said, in nine-tenths of all cases. Jaundice is even more frequent in this disease than in cancer — in four-fifths, as contrasted with a little more than one-half. Aspiration may aid in the solution. Of other affections attended by uneven surface of the liver the amyloid organ beset zvith gummy nodules offers difficulties, but the lesser gravity, the longer duration, and, especially, the syphilitic history solve the question. Cancer, as a rule, is not associated with enlarged spleen, but the rapid enlargement of the liver in amyloid disease sometimes obscures the enlarged spleen and even interferes with its development. Doubt sometimes arises in the presence of certain stubborn forms of jaundice as to whether cancer may not be the cause, especially as in some of these there is rather rapid loss of weight. If there is enlarge- ment of the liver, the solution is less difficult, because in simple jaundice SYPHILIS OF THE LIVER. 475 there is no enlargement; but in its absence time alone can settle the ques- tion ; for stubborn as these rare cases of jaundice are, they are less so than cancer, while even if they are not followed by ultimate recovery, their course is much longer than that of cancer. Should ascites arise, the ques- tion is settled in favor of cancer. It may sometimes- be difficult to decide between cancer and hypertrophic cirrhosis, which also furnishes an enlarged, hard, more rarely nodular liver, with jaundice. Carcinoma occurs in persons over forty years of age, hypertrophic cirrhosis in those younger. Carcinoma produces cachexia, hypertrophic cirrhosis does not. Carcinoma produces marked tenderness, hypertrophic cirrhosis but slight. A possible cause in either case must be sought, primary cancer elsewhere pointing to cancer, and the alcoholic habit to cirrhosis, to which also the enlarged spleen and the absence of cachexia point. A family history of cancer, if present, adds weight to other signs of cancer of the liver. There is no special reason why cancer of the liver should be distin- guished from sarcoma or adcnom-a, as the clinical significance of the various conditions is about the same. But if, along with a primary sarcoma else- where, as in the orbit, there appears enlargement of the liver, then the inference is reasonable that a secondary sarcoma is there established. Melanosarcoma is more likely to invade other organs, as the lungs, kidneys, spleen, and even the skin. There is no evidence by which secondary cancer can be distinguished from primary, except by the presence of primary cancer elsewhere, notably in the stomach, breast, large intestine, uterus and appendages, and the pre- sumption based on the fact that the majority of all cases of cancer of the liver are secondary. Careful search should, however, be made for cancer in all organs in which primary cancer is likely to occur. The gastric secre- tion should be investigated chemically, the rectum explored by the finger and speculum, the uterus by the finger, speculum, and sound. Such inves- tigation is further useful in the settlement of the diagnosis of cancer of the liver, for a doubtful case becomes confirmed if a primary focus can be found. Prognosis. — This disease is invariably fatal — usually in from three to fifteen months. Treatment. — This must consist in attempts to relieve the discomfort and prolong the life of the patient. SYPHILIS OF THE LIVER. Definition. — Syphilis of the liver includes several morbid conditions i the disease to a recognizable degree. A surgeon should be consulted as soon as the diagnosis is made. A preliminary tapping is justified under strict antiseptic precautions, and, in fact, has been succeeded by permanent recovery. Australian surgeons have had the largest experience, and it appears to justify the bolder course of incision and evacuation of the cysts rather than the more conservative method of first securing adhesion of the sac to the abdominal walls and then laying open the cyst and evacuating the contents. The former practice of injecting the sac with iodin has also been discontinued. Should suppuration take place, the treatment becomes that of abscess of the liver. Other Parasites of the Liver. The remaining parasites of the liver are of pathological rather than of clinical interest. The arthropoda are represented by the peniastomes, of which the pen- tastomum denticulatum — larval form of the pentastomum or linguatuJa tcenioides — has been found in the liver. The adult worm is lancet-shaped and marked with numerous rings. The female is from three to five inches (8 to 13 cm. ) long, the male little less than one inch (1.8 to 2.5 cm.). The adult worm has been found in the nostril of man. The cystercus celhdosce and psorosperma a.re rare parasites. Of the lat- ter, the coccidiuin oviforme, which is very common in the liver of the rabbit, produces whitish nodules, as in other organs, ranging in size from that of a pin to that of a split pea, and even larger. They may produce fever of an intermittent type, diarrhea, nausea, and tenderness over the liver or other organ invaded with enlargement. (See also Parasites at end of volume.) In examining a case of suspected hepatic disease the following questions should be raised with a view to eliciting important facts which bear upon the diagnosis : First, whether there has been or is syphilis ; second, suppu- rative disease or rickets ; third, alcoholism ; fourth, enlargement of the spleen : fifth, elevation of temperature ; sixth, jaundice ; seventh, what has been the duration of the symptoms? DISEASES OF THE PANCREAS. Almost the only disease of the pancreas which possesses much clinical interest is cancer. It is true that Reginald H. Fitz has invested the subject of pancreatitis with increased interest by his masterly ]\Iiddleton Goldsmith lecture, but I note that few cases more are now recognized antemortem than previous to its publication. The remaining diseases are, however, of great pathological interest. 31 482 DISEASES OF THE DIGESTIVE SYSTEM. ACUTE PANCREATITIS. Definition. — Acute pancreatitis is an acute inflammation, affecting primarily the fibrous and fatty interstitial tissue of the organ. It is a rare affection. Fitz divides it into hemorrhagic, suppurative, and gangrenous, but as suppuration and gangrene are rather terminations than initial features, and hemorrhage is at least a very frequent primary etiological feature, I pre- fer to treat the subject under the single heading of acute pancreatitis. Etiology. — It may begin with hemorrhage, which may be traumatic. Most subjects are between twenty-six and seventy years old. The majority are men. A few are alcoholics. James M. Anders "^ collected 40 cases of pancreatic hemorrhage, in 34 of whom the sex was given. Twenty-five of these were males and 9 females. The ages of 30 were stated, of whom 13, or 43.3 per cent., were over forty-five. Many have been previously subject to gastric and gastro-intestinal derangements, often inflammatory. The causative gastroduodenitis extends probably from the bowel to the pan- creatic duct. Morbid Anatomy. — This varies with the stages or varieties, which, as seen at necropsy, are hemorrhagic, gangrenous, and suppurative. In the hemorrhagic stage the pancreas is enlarged throughout or at its head, and is infiltrated with blood, which imparts its color in different shades and may invade the pancreatic duct. The hemorrhagic foci may alternate with white spots of fat-necrosis. The hemorrhage may extend into the peri-pancreatic tissue or the mesentery, mesocolon, omentum, and beyond to the brim of the pelvis. On minute examination round cells and red blood discs are found in the ducts and acini. Many lobules are in a state of coagulation-necrosis, while bacteria are present in large numbers. If the patient survive the first few days, — say the fourth day, — the con- dition passes on either to gangrene or suppuration. If to gangrene, the tip or the entire gland may be converted into an offensive, dark, slate-colored mass, which softens and becomes shreddy. Gangrene may set in almost simultaneously with hemorrhage. The organ may become completely sequestrated in the smaller omental cavity, attached only by a few shreds. The adjacent parts exhibit the appearance of peritonitis, with dirty, purulent extravasate. Disseminated fat-necrosis may be present. The spleen may be enlarged and its veins thrombosed, as may be also the portal vein. In the suppurative termination the organ is enlarged, and contains numerous small abscesses, intervening parts being hyperemic. There may be peritonitis of adjacent areas of the peritoneum. There may be diffuse suppuration or small abscesses disseminated throughout the organ. In the chronic form there may be a solitary abscess as large as a hen's egg, with cheesy contents. The lesser omental cavity and peripancreatic tissue may be invaded ; rarely, also, the liver. Fat-necrosis in this form is a rare con- dition, while thrombosis of the splenic and portal veins may still occur. Symptoms. — The disease begins suddenly with abdominal pain, some- times succeeding attacks of indigestion. It is severe and in the upper left quadrant of the abdomen and in the course of the pancreas, but it may extend throughout the abdomen. It is ascribed to stretching of the celiac plexus of nerves. There is also tenderness. The pain is usually followed by vomit- * "Pancreatic Hemorrhage," "Journal of the American Med. Assoc," December 2, i8gg. CANCER OF THE PANCREAS. 483 ing, rarely by nausea alone. The vomited matter may be bilious or black. The upper abdomen becomes swollen and tympanitic, or the tympany may be general. The temperature is subnormal or slightly elevated. Death occurs usually within three days, but may be delayed a week. If the patient lives longer, the case becomes one of gangrenous pancreatitis. Recovery may occur, though rarely. If the gangrenous termination succeeds, chills, fever, abdominal swell- ing, generally tympanites, tenderness, jaundice, collapse, and death are added. If suppuration ensues, life may be prolonged for three or four wrecks, and there may be added high temperature and irregular chills, with exacer- bations and remissions and signs of deep-seated peritonitis in the epigastric region. Diagnosis. — This is based upon the foregoing symptoms and their sud- denness, especially the circumscribed tympany. The disease is to be differ- entiated from the effects of irritant poison, perforation of the stomach or biliary tract, and acute intestinal obstruction. The history ehminates cor- rosive poison. Perforation of the stomach is preceded by symptoms of ulcer, and of the biliary passages by symptoms of gall-stones. There is no ten- derness localized in the region of the pancreas in intestinal obstruction, which is rare in the upper part of the small intestine. Obstruction in the large intestine must be eliminated by measures calculated to determine the patu- lousness of the bowel. Laparotomy has been done for intestinal obstruction, and pancreatitis was found. Prognosis and Treatment. — The former is almost always unfavorable. If recovery takes place, it is accidental rather than the result of treatment, which, in the main, can only be palliative, and such as is demanded by peri- tonitis. Surgical treatment may be called for, and has been followed by- recovery. Drainage should be practiced. Chronic Pancreatitis. — This consists of an interstitial overgrowth, by which the organ is hardened and slightly enlarged. The secreting struct- ure is compressed and degenerated. It has frequently been found in diabetes. There may be pigmentary deposits, and pancreatic calculi may be found in the ducts. CANCER OF THE PANCREAS. Morbid Anatomy. — Though a rare disease, it is not infrequently cor- rectly diagnosed. It is usually primar\- and situated in the head of the organ. It is commonly scirrhous, but it may also be colloid. It is especially apt to invade adjacent parts by contiguity, and more distant ones by metas- tasis, especially the liver and lymph glands. It may arise by contiguity from cancer of the stomach or intestines. It occurs in those past middle life. Symptoms. — These are not distinctive. The most valuable symptom is jaundice . which occurs when the head of the organ is involved. It is caused by obstruction of the common bile-duct. A -fixed tumor may be felt in the pancreatic region, and if it be associated with jaundice, the pancreas may be justly suspected to be its seat. If we add to these symptoms fatty or greasy stools, the suspicion is fortified. There are symptoms of indigestion and a dull pain in the epigastrium, but these are not distinctive. Emaciation and loss of strength proceed irresistibly. As the former advances the aortic pulse 484 DISEASES OF THE DIGESTIVE SYSTEM. is transmitted with great distinctness through the transverse colon and pan- creas. There may be ascites and diabetes inellitiis. Diagnosis. — Cancer of the pancreas must be differentiated from cancer of the pylorus, of the transverse colon, of the glands in the hilus of the liver, and from aortic aneurysm. In case of cancer of the pylorus there should not be much difficulty, for the pyloric tumor is movable in a decided majority of cases, and the pancreatic is fixed ; the pyloric cancer is rarely associated with jaundice, the pancreatic is almost always so ; pyloric cancer produces dilata- tion of the stomach, pancreatic cancer does not. Cancer of the transverse colon is rare. It is also more movable than pancreatic cancer, and sooner or later obstruction of the bowel results. Cancer in the hepatite fissure is difficult to distinguish, but it is higher up and more superficial. The tumor is also tender. Both are accompanied by jaundice. The pulsation communicated to the pancreas is very different from the expansile dilatation of aneurysin. Fatty stools are of great assistance in diag- nosis, but they are by no means always present. Sarcoma is a possible tumor of the pancreas, but it is not distinguish- able from cancer, tuberculosis, and syphiloma. The prognosis is unfavorable, and the treatment only symptomatic. CYSTS OF THE PANCREAS. Definition. — These are retention cysts, due to closure of Wirsung's duct by concretions or cicatricial contraction. They may become very large, and may even occupy the entire abdominal cavity. They may be slow or rapid in development. Symptoms. — In none of the 53 cases thus far collected — 35 by W. W. Johnston and 18 by N. Senn — was there fatty diarrhea, a condition regarded as symptomatic of suspended function of the pancreas. On the other hand, the stools may be clay-colored and putrescent, probably because there is a simultaneous obstruction to the descent of bile. A resulting tumor presents itself usually in the left part of the epigastrium, between the costal cartilages and the median line. More rarely it is in the neighborhood of the navel. It is globular, resisting, and inelastic, changes its position slightly with the movements of the diaphragm, and possesses some lateral motion. The differentiation of such a tumor, in the absence of more definite symptoms, cannot be said to Se easy, yet the diagnosis was made in seven out of Senn's eighteen cases. Aspiration should be made. The fluid is usually brown or chocolate-colored, but sometimes it is transparent. It presents some of the characteristics of pancreatic fluid, emulsifying fats and converting starch into sugar. Treatment. — After exploratory aspiration the treatment is surgical. CYSTS OF THE PANCREAS. 485 PANCREATIC CALCULI. History. — The first case of pancreatic lithiasis reported, so far as 1 know, was m 1788 by Thomas Cawley. There was diabetes, and at necropsy the pancreas was found stuffed with calculi. In 1882 I made a necropsy on a case of diabetes with diarrhea, in which many calculi were found in the pancreas. In 1883 George W. Johnston reported 35 cases collected from the literature. Minnich reported a case of colic after which calculi composed of calcic carbonate and phosphate were found in the stools; Lichtheim made the diagnosis of pancreatic calculus in a case of severe colic, diabetes, and fatty diarrhea, confirmed by autopsy. Out of 1500 autopsies made at the Johns Hopkins Hospital up to igoi.only two cases of pancreatic calculus were found. Etiology. — Pancreatic calculi can only be regarded as a precipitation from an inspissated pancreatic juice determined by some unknown cause. Morbid Anatomy. — The calculi, commonly about as large as a pea, are contained in the pancreatic duct and its branches. They are usually numerous. They may be smooth, round, faceted, or irregular and rough of surface. They are composed of carbonate and phosphate of lime. Symptoms. — Pancreatic calculi are often unattended by symptoms, but deep-seated colicky pain may be present. The difficulty in distinguishing this from the pain of biliary colic is increased by the fact that jaundice may be associated with either. Theoretically, the pain of pancreatic colic should be more deep-seated, more central, and more to the left. Practically this is not often found to be the case. If fatty diarrhea and diabetes are associated with the colic, pancreatic calculus may be inferred. Rarely stones are passed by the bowel, and if such stones are found to be made up of phosphate and carbonate of lime, they probably come from the pancreas. Treatment is mainly palliative by morphin or other anodynes. Eich- horst has recommended hypodermic injections of pilocarpin to stimulate the pancreatic secretion. DISEASES OF THE SPLEEN. Most of the morbid states of the spleen which possess clinical interest are considered in connection with diseases of the blood and with malaria. Splenitis. — Splenitis occurs rarely as the result of extension of inflam- mation from a neighboring organ, such as the stomach, perinephric tissue, the diaphragm and lungs, or as the consequence of injury. The symptoms are tenderness and enlargement in connection with the inflammatory conditions of adjacent organs referred to, and it is upon the association of such symptoms with those in the spleen itself that the diagnosis depends. Perisplenitis. — This may occur as the result of tfie same causes as produce splenitis, and may be recognized by the presence of palpable fric- tion fremitus. Abscess of the Spleen. — Abscess of the spleen occurs along with pyemic processes elsewhere, in the presence of the usual causes of pyemia. Such abscess may break into the stomach, bowel, or lungs, as well as into the peritoneal cavity. Rupture of the Spleen. — This arises from severe injury, also from extreme and sudden acute hyperemia, due to malignant malaria, and from 486 DISEASES OF THE DIGESTIVE SYSTEM. rapidly growing splenic tumors. The symptoms are sudden pain in the region of the spleen, collapse, pallor, and death, associated with the causes named. The Amyloid Spleen. — This appears as a hard, smooth, and enlarged organ, associated with amyloid disease of other organs, such as the liver and kidneys, especially when there has been long-continued suppuration, as in hip disease, osteomyelitis, tubercular consumption, or syphilis. Atrophy of the Spleen. — On the other hand, the spleen may be reduced in size by fibroid overgrowth and contraction due to syphilis. Hemorrhagic Infarct of the Spleen. — Infectious hemorrhagic infarct results in abscess of the spleen. The non-infectious is the result of embolism by a non-infectious embolus, such as arises from the cardiac valves in acute or chronic endocarditis, from clots in the cavities of the left ven- tricle, or from clots in aneurysms in the large arteries. After the kidney, the spleen is the most frequent seat of such lodgment. Symptoms. — The infarction is sometimes ushered in by chills, vomiting, and painful enlargement, the true nature of which can only be inferred when the causes named are present or the symptoms of embolism elsewhere occur simultaneously. Neoplasms of the Spleen. — These are represented most frequently by gummy tumors, which are almost never recognized before death. Carci- noma, sarcoma, and tuberculosis occur, but are not recognizable by special characters. A nodular and uneven spleen may be regarded as due to cancer when associated wnth cancer elsewhere, sarcomatous when there is general sarcoma, tuberculous if there is tuberculosis elsewhere, and syphilitic if asso- ciated with the history of syphilis, especially the congenital form. EcHiNOCOCCUS OF THE Spleen. — The spleen may present a fluctuating tnmor the nature of which can only be determined by the certain knowledge that a tumor of the same kind exists elsewhere, or by the recognition of booklets in the aspirated fluid. Should the fluctuating tumor be associated with chills and fever, it is more likely to be abscess, which, it is to be remem- bered, may also begin as echinococcus disease which later takes on suppu- ration. Wandering Spleen. — This is a term applied to a condition of the spleen analogous to the movable kidney and liver. It is the direct result of an elon- gation of the gastrosplenic ligament and splenic artery and vein. Under these circumstances the usual splenic dullness in the midaxillary line, between the ninth and eleventh ribs, has disappeared, and the spleen can usually be felt elsewhere in the abdominal cavitv, usuallv, however, on the side below its normal site, whence it may be pushed into the natural situation, to leave it immediately as the upright position is assumed. Rarely, it is found in more distant situations, even in the pelvis. At times it may form attachments by inflammatory adhesion in the new situations, making its restoration difficult or impossible. Symptoms. — The symptoms are not unchanging. The most constant is a dragging sensation, while there may also be the effects of pressure, which ACUTE PERITONITIS. 487 vary with the situation. There may be pressure on the ureter or bladder, causing difficuhy in micturition ; upon the bowel, causing partial obstruction or pain by the compression of sensitive parts. The same train of nervous symptoms which attends floating kidney may also be present. Diagnosis. — Some difficulty of diagnosis may result in consequence of such vagueness of symptoms. There may be a question between the exist- ence of wandering spleen and fecal tumor. With the former, the normal splenic dullness is wanting, though the well-known fact that the dullness is sometimes very small in health may give rise to error. A freely movable ■cancer of the pylorus, a tumor so movable that it may be felt in the left hypo- chondrium, may occasion similar difficulty, which must be settled in the same way. And so with other abdominal tumors of movable nature — the normal splenic dullness remains. The question as to whether a movable organ is the spleen or kidney is not likely to be a knotty one, even if the movable kidney be the left, if the same guide be availed of. The difference in outline of the two organs may be recognized in persons with thin abdominal walls, and, in rare instances, by the splenic notch. The possible coexistence of a movable spleen and a movable kidney is to be remembered. Treatment. — The treatment must consist of mechanical measures to keep the spleen in place — measures which must be determined by the require- ments of each case. They are variously successful. DISEASES OF THE PERITONEUM. ACUTE PERITONITIS. Definition. — An acute inflammation of the peritoneal membrane. Etiology. — Of Primary Peritonitis. — Primary peritonitis, or that iorm which originates independently of inflammation of adjacent structures, is spoken of as idiopathic in origin. It is a disease of such rarity that its existence may reasonably be questioned, and there are those who deny its occurrence in toto. Its reputed cause is exposure to cold. 2. Of Secondary Peritonitis. — By this is meant an inflammation the result of invasion of the peritoneum from a primary focus of disease some- w^here in the vicinity, or traumatic agencies, like blows or punctures involving the peritoneum. Formerly, operations involving the peritoneum were fruit- ful causes of peritonitis, but since aseptic surgery has become general, such operations are done with an immunity previously undreamed of. There are two chief foci whence such inflammation originates. One of these is the digestive tract ; the other, the genito-urinary system, more particularly of women. Inflammation may also invade the peritoneum from the liver, gall-bladder, spleen, or perinephritic region, or from Pott's disease or psoas abscess. Perforation of the stomach in ulcer or cancer, of the intestine in typhoid fever, appendicitis, and dysentery, are the commonest causes originating in the gastro-intestinal tract. The second focus is puru- lent inflammation of the Fallopian tubes and the genito-urinary tract. Endometritis and metritis may be the starting-point of such inflammation, which may extend up the Fallopiafi tube, or there may be parametritis with suppuration, the abscess arising from which may rupture into the peritoneal cavity. All of the diflferent forms of secondary peritonitis are infectious, and caused either by organisms responsible for the primary disease or by 488 DISEASES OF THE DIGESTIVE SYSTEAI. such as are set free with the gastric or intestinal contents by perforation. The organisms found under these circumstances are the streptococcus pyogenes, the staphylococcus pyogenes aureus or albus, and the bacterium coli commune, the latter especially after perforation of the appendix, also the tubercle bacillus. The ameba coli has been found in the peritoneal fluid in amebic dysentery. Peritonitis may also occur from infection from more distant foci of suppuration, when it is also called pyemic peritonitis. Finally, peritonitis not infrecjuently becomes a complication of pleurisy, articular rheumatism, and nephritis by a process not thoroughly determined. The first is probably the result of extension by continuity, since the two cavi- ties communicate by the lymph vessels of the diaphragm. The poison of rheumatism, whatever it is, may.be the cause of the peritonitis, while the retained excreta which accumulate in the blood in Bright's disease may act similarly. Morbid Anatomy. — This varies somewhat with the extent of the peri- tonitis and the duration of the attack. First, there may be a " general " or " diffuse " peritonitis, or it may be " circumscribed." In general peritonitis the peritoneal surface of the intestinal coils is hyperemic and covered more or less continuously with flakes of yellow lymph made up of fibrin and leuko- cytes. This is especially abundant in the sulci between the coils, while it also covers the convexity. In an earlier stage, before the exudate appears, the surface of the peritoneum is dull and rough, owing to a desquamation of the epithelium. In the fl.anks is found a variable amount of fluid, which may be serous, serofibrinous, or purulent, which, increasing, produces an appre- ciable ascites. In prolonged cases organization and vascularization from the capillaries of the peritoneum take place, the solid contingent being formed from the epithelium or wandering cells, resulting in adhesions between the coils of intestine and adjacent organs. These are at first soft and easily ruptured, but later become firm bands. These latter are, however, more common in the circumscribed form. In circumscribed peritonitis limited areas of lymph formation occur and adhesions are more pronounced. Copious fibrinoserous exudate is less fre- quent, though sometimes quite large circumscribed collections of pus occur,, laced off from the remainder of the peritoneal cavity by organized tissue. Such abscesses sometimes rupture into the general peritoneal cavity, produc- ing general inflammation, collapse, and death. Symptoms. — i. Of an Acute General Peritonitis. — The most decided symptom is pain, usually of extreme severity, which is commensurate in extent with that of the inflarpmation. There is also extreme tenderness,. which is similarly limited. So great is this that any tension on the abdom- inal walls excites pain ; hence the legs are drawn up to relieve this, and we have the well-known position almost characteristic of general peritonitis — dorsal decubitus, with the thighs flexed on the abdomen. Any motion such as straining, even the act of breathing and the emptying of the bladder, increases pain. From the nature of the causes this pain is usually sudden in occurrence, succeeding, as it does, on perforation, abscess rupture, and the like. Sometimes, indeed, it is the first intimation of any illness what- ever. Abdominal distention is a third characteristic symptom of peritonitis,, ascribed to a paralysis of the muscular coat of the bowel, and continues throughout the attack. Rarely, however, the abdomen is flat, hard, and board-like. As rarely, too, pain is altogether absent. Among the sym.ptoms which may usher in the attack is vomiting. It ACUTE PERITOXITIS. 489 is regarded as reflex in origin, excited by the inflammation of the peritoneum. The effort is sometimes ineffectual, and sometimes a perforation of the stomach permits the more ready discharge of its contents into the abdominal cavity. The vomitus consists of what happens to be in the stomach at the time, or of mucus and, if the symptom is prolonged, of green, bilious matter. The primary vomiting is followed by abatement and exacerbation. The symptoms which are associated with these or succeed upon them vary with the nature of the cause and extent of the disease. In fulminating cases due to perforation of the bowel, as in typhoid and appendicitis, they are ■the symptoms of collapse — viz., extreme weakness, cold, clammy skin, fre- quent, small, and feeble pulse. The pulse exceeds 120 and often reaches 160 and even more. The breathing-rate is from 30 to 40. The temperature is slightly raised, remains about normal, or may be subnormal. Rarely, it is high, — 104' to 105^ F. (40° to 40.6'' C), — though the skin may feel cool and clammy. The expression is characteristic — Hippocratic. The eyes are sunken, the cheeks and temples are collapsed, and the nose is pinched. The urine is scanty and contains indican. If the patient survive, the physical signs of eft'usion make their appear- ance. There is dullness on percussion, first in the flanks, whence it ascends as the fluid increases. If sufficiently abundant, the dullness becomes general and fluctuation may be recognized. Palpation and percussion both occasion pain. A change of position from the back to the side causes a change in the position of the fluid, and corresponding alterations in the physical signs. In severe cases the diaphragm is raised, the apex of the heart dislocated, and the liver dullness may be obliterated in the mammillary line by combined effusion and extreme tympany. Similar obliteration may happen to the splenic dullness. Both may be restored by turning the patient on his side. Such obliteration is, however, far more characteristic in what is known as pneumoperitonitis, a form of peritonitis caused by perforation from an air- containing organ into the peritoneal cavity, and of intense severity, excited by the pathogenic bacteria thus admitted. Acute pain, rapidly developing col- lapse, scarcely appreciable pulse, icy coldness of the skin, and great distention of the abdomen are the symptoms. The air, of course, occupies the highest part of the abdominal cavity, covering the liver and spleen, causing the obliteration referred to. The distinctive point in the diagnosis between pneu- moperitonitis and the extreme degrees of the ordinary form is the fact that in the former hepatic dullness is absent even in the midaxillary line when the patient is on his left side, whereas, in simple peritonitis, hepatic dullness may be elicited when the patient is in this position, though it may not be if he is on his back. Throughout all, the intellect is clear, and while there is often a total lack of realization of the incA^itable and usually dreaded end, it is as often thor- oughly appreciated by the patient and is viewed with a calmness which in- creases the awe which always attaches to the presence of the shadow of death. Rarely, in the course of his experience, is the physician called upon to witness a more painful scene. Toward the very end, how^ever, a somnolence com- monly supervenes which obscures the expiring moment, or a slight delirium, the visions of which may be interpreted by surrounding friends as the first glimpses into another world. The course of such a case is steadily downward, reaching its end in from two to six days. 2. Of Acute Circumscribed Peritonitis. — The symptoms include those of 490 DISEASES OF THE DIGESTIVE SYSTEM. the general form in a very mtich milder degree. The pain is less severe and more circumscribed, the tenderness proportionate, while the definiteness of neither is very sharp. \'omiting may also usher in the attack, and may be similarly modified. There may likewise be the signs of collapse, and the patient is often very weak. There is, however, more decided and constant fever though remittent, as in septic fever generally, and the cases run a longer course, ending not rarely in recovery, but more frequently in death from exhaustion. As already mentioned, circumscribed abscesses are more frequently recognized by fluctuation, and may even point toward the surface, while they are as liable to rupture into the general peritoneal cavity, producing there the symptoms and more usual fatal termination of general peritonitis. This mischievous termination, at the present day, is often prevented by the timely interference of the surgeon. As varieties of such abscess may be mentioned the perinephric abscess, the pelvic abscess, the subdiaphragmatic abscess, arising from perforation of the stomach or colon or disease of the liver or spleen, and the periappendicial abscess. The results of circumscribed peri- tonitis in children are sometimes seen in the shape of a painful, fluctuating tumor in the groin. Circumscribed peritonitis is also more or less associated with the symptoms of the disease which causes it. Diagnosis. — That of general peritonitis is seldom difficult, especially in the fulminating variety. Some days may, however, elapse before the ques- tion is settled, for sometimes the symptoms are closely simulated by those of other conditions. Particularly is this the case with the extreme tympany and tenderness which are sometimes associated with typhoid fever, especially w^hen there is deep-seated ulceration. It not rarely happens that on these symptoms is based the diagnosis of a peritonitis, which is not found at necropsy. Enterocolitis may give rise to similar symptoms. On the other hand, it has happened that grave and fatal peritonitis has eluded detection, having been found for the first time at autopsy. Hysterical peritonitis is a term applied to a condition met with in women, when every symptom of acute peritonitis is simulated, even collapse itself. It is needless to say that patients do not die of this disease, and that time settles the question ultimately, and when there is recurrence, as is often the case, a second attack is not likely to mislead. Acttte hemorrhagic peritonitis should be mentioned as a variety, the symptoms of which sometimes are the same as those of the ordinary form. Circumscribed peritonitis is more frequently difficult of detection, and its diagnosis often requires a knowledge of the presence of the causative dis- ease to suggest it. Fluctuation 'is only available in diagnosis when there is superficial abscess. The exploring needle may, however, at times be availed of. Prognosis. — This, in general peritonitis, is almost invariably fatal, only the mildest cases ofifering the possibility of recovery. Modern surgery has many times saved life even in peritonitis which succeeds perforation in typhoid fever, gastric ulcer, and perforated gall-bladder. The duration of most cases is from two to six days. Localized peritonitis is a more promising malady. A few cases get well by spontaneous discharge of resulting abscesses, more with the assistance of the surgeon, and some neglected cases doubtless perish when timely aid from this source would have saved life. Treatment. — ^The treatment of general peritonitis succeeding perfora- CHRONIC PERITONITIS. 491 ation consists for the most part of measures calculated to relieve the patient's sufferings while awaiting the end. If the opportune moment can be seized, a laparotomy may be performed, for life has been saved frequently; but no rule can be laid down which will aid in the selection of such a moment. Local measures looking toward cure, such as blisters and other counterirritating agencies, are useless. To relieve pain, the hot poultice or ice-bag may be used in turn. Sometimes one gives more relief, sometimes another. After this, opium may be administered in the minimum degree necessary to relieve pain. I see no advantage in the use of opium for any other purpose, unless "it be also to allay vomiting. It has no effect in limiting the spread of the inflammation. When doubt as to diagnosis exists, — as to whether there is true peritonitis or painful distention of the bowel, — turpentine may be admin- istered with full doses of strychnin, say 1-30 to 1-20 grain (0.002 to 0.003 gm.), while turpentine may be applied locally. Iced turpentine stupes are often exceptionally grateful. Turpentine enemas under these circumstances are of doubtful utility, in fact, may do more harm than good, and should be discouraged. Special symptoms, such as nausea, faintness, and exhaustion, require the treatment usually appropriate to control them. For the first, ice by the mouth or locally, small doses of champagne, and counterirritation are useful. For failing strength, stimulants, local heat, hypodermic injections of ether, digitalis, brandy, and strychnin are available, but I do not approve of the practice, so often pursued by young hospital physicians, of indiscriminately plying these measures when they must evidently be unavailing. The treatment of circumscribed peritonitis permits the use of local measures not admissible in the general form. Counterirritation by blisters, and especially blood-letting by leeches, is sometimes of signal service in relieving symptoms, and may even effect a cure if the primary causing dis- ease is removed. The surgeon and the gynecologist should be early sum- moned, as it is more frequently through their assistance that a cure is accomplished. CHRONIC PERITONITIS. Etiology. — By far the largest majority of cases of chronic peritonitis are tubercular in origin. Some cases are caused by cancer and other morbid growths in the abdomen, while there are also others of simpler origin. Thus originating, we have both a circumscribed and a diffuse adhesive peritonitis. See also Section on Tuberculosis of the Peritoneum, p. 282. Local, Circumscribed, or Chronic Adhesive Peritonitis. This occurs between adjacent organs, such as the spleen and diaphragm, liver and diaphragm, stomach and liver, and organs in similar relation, as the result of chronic disease in one or the other. These adhesive connections are not always close, but sometimes consist of bands of considerable length, such as have already been referred to as occasional causes of obstruction of the bowel. Symptoms. — The symptoms of obstruction of the bowel are often the first evidence of the existence of such adhesive bands. Other symptoms are a sense of restriction in the motion of organs involved, with pain when such motion occurs ; also constipation, colicky pains, and pains resulting from 492 DISEASES OF THE DIGESTIVE SYSTEM. traction exerted in peristalsis. Other vague symptoms occur which go to make the patient uncomfortable, but are not distinctive. Should a peritoneal friction, however, be felt, more conclusive evidence is thus furnished. Should suppuration attend chronic inflammation, more distinctive symptoms also arise. In addition to the pain and tenderness a hectic fever may be present, which may guide to a correct conclusion with or without the aid of the exploring needle or eventual rupture into one of the hollow abdominal organs. Diffuse Chronic Peritonitis. This may succeed upon acute diffuse inflammation of mild degree, which is followed by an abatement in all the symptoms. It may occur in connec- tion with chronic cardiac or hepatic disease where there has been long-con- tinued venous stasis ; or it may succeed the punctures of numerous tappings and, most rarely, chronic intestinal disease. Morbid Anatomy. — The peritoneum is thickened. The intestinal coils may be cemented to one another and to neighboring organs. The liver and spleen are sometimes covered by thick, tough, grisly capsules. The omen- tum and mesentery may be thickened and shrunken. There may be thick- ened nodules, not tubercular. There is in these cases rarely any considerable effusion. A hemorrhagic form, suggesting hemorrhagic pachymeningitis, was described by Virchow. It is more commonly situated in the pelvis and characterized by bloody effusion. Symptoms, — These exhibit for the most part a diminished degree of those characteristics of acute peritonitis, to which may be added tnnwr-like swellings and thickenings and swelling difficult to interpret. Other vague symptoms are engendered by them as the result of contraction and pressure, including pain, edema, albuminuria, irregularity of bozvel action, and some- times feverishness. There is little that is characteristic unless it be the occa- sional presence of recognizable effusion. The very slow forms attended with extensive effusion are not separable from ascites, the result of hepatic disease, although there are differences in the effusion. In peritonitis the effusion is more turbid, contains abundant albumin, and has a specific gravity rather higher than the fluid of an ascites : 1018 as compared with 1012. A chronic peritonitis not unusual in children from two to ten years old is described by Striimpell and others. It is associated with decided ascites, debility, and other symptoms of ill health more or less -marked, while recovery is the usual termination. Such a cause for the ascites should not be assigned without careful search for others, especially disease of the liver. Treatment. — The treatment must be determined by circumstances. It is chiefly palliative, unless operative interference promises more. CANCER OF THE PERITONEUM. Primary cancer of the peritoneum is an event of extreme rarity. Its occurrence as a true epithelial cancer must, however, be admitted. Colloid cancer also occurs as a diffuse and extensive growth, relatively firm, and without fluctuation. More frequently peritoneal cancer is secondary to can- cer of the stomach, bowel, pancreas, uterus, or other organ ; most frequently, perhaps, as an extension by contiguity, though also by metastasis. It occurs in the shape of sniall or larger nodules scattered over the peritoneum. The ASCITES. 493 former constitutes what is known as miliary carcinoma. The larger nodules are found in the omentum, in Douglas' cul-de-sac, around the navel and elsewhere, while the retroperitoneal glands may be simultaneously involved. Symptoms. — These are those of chronic peritonitis, including effusion, with the added cachexia, and a diagnosis must be based on these, the ante- cedent history, and the possible presence of cancer elsewhere. The investi- gation must include the uterus and the rectum. The physical resemblance of the miliary form to tuberculosis is very marked, and in primary car- cinoma the distinction is difficult. Palpation may recognize friction in both. ^In both the effusion may be bloody, but is more apt to be so in cancer than in tuberculosis. The test injection of tuberculin should be availed of. The cancerous patient is past middle life, the tubercular younger, tubercular peritonitis being especially frequent in children. The possible presence of echinococci in the peritoneum is to be remem- bered. The local symptoms may resemble those of cancer very closely. The presence of hydatid tumors elsewhere, as in the liver, of course suggests the true nature of the simulating disease. ASCITES. Synonym. — Hydroperitoneum. Definition. — Any freely movable collection of fluid in the abdominal cavity sufficiently copious to be recognizable by the physical signs furnished. Etiology. — Ascites is a symptom of any one of a number of diseases causing venous engorgement of the vessels draining the peritoneum, but a symptom of such importance as to demand separate consideration. Its causes are local and remote. The most frequent local cause is obstruction to the portal circulation, commonly by some disease of the liver, especially hepatic cirrhosis. Any growth or inflammatory new formation in the gastrohepatic omentum or hepatic fissure exerting pressure on the portal vein may have the same effect. Abdominal tumors outside of the liver large enough to exert the requisite pressure may also produce ascites. Such are enlarged spleen and tumor of the ovary and even of the uterus. Chronic inflammation of the peritoneum, whether tubercular, cancerous, or simple, especially when the cancer and tuberculosis involve the omentum, is also a cause. More rarely cirrhosis and emphysema of the lungs and chronic pleurosy cause it. A rare and peculiar cause is adhesive pericarditis. Ascites thus caused is apt to be erroneously ascribed to cirrhosis of the liver. Remote causes include, first of all, valvular heart disease, the general obstruction due to which causes ascites as a part of a general anasarca, the peritoneal cavity being the last invaded. Rarely, it is the only dropsical symptom of heart disease, in which event there must be associated some intermediate obstructing state of the liver. Bright's disease is also a cause of abdominal dropsy, in which disease, too, the peritoneum is, as a rule, last invaded. More rarely it occurs as a consequence of intense cachectic states, such as the gravest forms of anemia. Symptoms. — Some fourteen tq. twenty pints (7 to 10 liters) are re- quired before the physical signs to be described are developed. The ab- dominal cavity thus occupied is more or less distended, pendent when the patient is upright and widened when the patient is on his back, the flanks 494 DISEASES OF THE DIGESTIVE SYSTEM. dropping down and outward. The fluid also flows from one side to the other when the patient turns on his side. If the distention is excessive, "silver lines," such as extend across the abdomen in pregnancy, make their appearance, and the umbiHcus is obhterated or protuberant. The super- ficial veins — branches of the epigastric — are distended and distinctly visible from pressure by the fluid on the vena cava, by which the return of blood from the lower extremities is interfered with. Sometimes these superficial veins from below are seen to join those of the mammary from above. Such distention, however, is often contributed to by coincident portal ob- struction (see p. 461). There may also be edema of the lower extremi- ties. There is no caput medusse about the navel unless the portal circulation is also obstructed. As intimated in the definition, the physical examination affords the most reliable evidence. To palpation there is the succussion wave, which is elicited by placing the palm of one hand on the side of the abdomen and tapping with the fingers on the opposite side. A false succussion wave is sometimes produced by this procedure in persons with fat, flabby belly walls, but error may be avoided by having an assistant place the edge of his hand vertically on the median line while the tapping is done, as in this way the false wave, which travels around through the abdominal wall, is obliterated. It is always difficult, and sometimes impossible, to palpate solid organs when the abdomen is distended with fluid. Such palpation is, however, facilitated by a modification of the ordinary method — viz., first applying lightly only the ends of the fingers, then suddenly depressing them, and so displacing the fluid that the solid organ can be felt. Percussion elicits absolute dullness over the fluid, while over the bowels, which are floated upward, a tympanitic note is produced, which changes with the position of the patient. If there is considerable effusion and the patient lies on his back, there is a small oval area of tympany in the middle of the abdomen. If a small amount of fluid is present, the flanks only are filled in this position, and there is a large superficial area of tympany in front, which will be substituted by dullness if he be placed in the knee-elbow position. The statement that in ascites there is dullness in the flanks must be taken with some allowance, for it sometimes happens that a tympanitic note may be produced by percussion far back in the flank behind the mid- axillary line, because in this situation lie the ascending and the descending colon, with the posterior aspect uncovered by peritoneum and therefore inac- cessible to the fluid. Differential Diagnosis.— The morbid condition which the physician is most frequently called upon to distinguish from ascites is probably the ovarian cyst. The ovarian cyst, especially when large, furnishes some points of resemblance, yet there are striking differences. It begins in one side and rises up from the pelvis toward the center of the abdomen, which soon becomes the most prominent portion, w^hile the dropsical eft'usion spreads out into both flanks. The ovarian cyst distends one side more than the other at first, and continues to do this even when large and fully developed. It produces no obliteration or projection of the navel, as does abdominal dropsy. Palpation also recognizes fluctuation in the ovarian cyst, but it is usually less distinct and more circumscribed, while in ascites the wave passes all the way across the abdomen. To percussion, the latter condition aft'ords a central tympany and dullness in the flanks, while in ASCITES. 495 ovarian cyst the flanks are resonant because the bowels are pushed into them. This is at least true of one flank, even if the other is completely occupied by a large tumor. If there is tympany in the upper abdomen, with an ovarian tumor, it is bounded below by a convex line, while in ascites its lower border is concave. A change of position has less influence on the dullness in ovarian tumor than in ascites. Vaginal examination affords some information. In ascites the vaginal vault is obliterated, the uterus prolapsed, but freely movable, while in ovarian tumor the vagina is less encroached upon, the .uterus being sometimes drawn up and less movable. The characters of the contained fluid are, as a rule, widely different. The fluid of a simple ascites is usually transparent, has a low specific gravity, commonly below 1012, and contains a small quantity only of albumin and a few leukocytes. The ovarian fluid is usually dark and grumous in appear- ance, highly albuminous, with a specific gravity of 1020 or more, and reveals to microscopic examination numerous granular fatty cells (compound gran- Fig- 39- — So-called " Ovarian Cells." ule cells), cholesterin plates, and small, pale granular cells. These last are round or slightly oval, about the size of a white blood-corpuscle, and are by some regarded as pathognomonic of ovarian cyst contents, and there- fore called "ovarian cells." They are found in pleuritic fluids, pus, and even ascitic fluids, but they are much less numerous in these. The cell is probably a degenerated endothelial cell from the peritoneum. The presence of these cells in large numbers is certainly a help to the identification of ovarian fluids. In rare instances the fluid of ascites is milk-white. This occurs when from any cause there is leaking of chyle into the peritoneal cavity — ascites chylosus. In the effusion associated with morbid growths, such as cancer and tuberculosis, the fluid is also sometimes white in color, from the pres- ence of an unusual number of fattily degenerated cells from these sources or from the peritoneal endothelium. The over distended bladder has been more than once punctured by mis- take for ascitic fluid, but this accident can never occur if the patient is directed to empty his bladder or the patheter is used before tapping. Hydronephrosis has been confounded with ascites, and this is less ex- cusable than the confounding of hydronephrosis and ovarian cyst. In ad- vanced hydronephrosis the fluid may be almost identical with that of ascites. 496 DISEASES OF THE DIGESTIVE SYSTEM. but its mode of development is from one side and exceedingly slow, while there are pain and tenderness in the region of the kidney. W. von Leube relates a case in which he mistook an enormously dilated stomach filled with fluid for ascites, and points out how easily the mistake could have been avoided by the previous use of a stomach-tube. A cyst of the omentum is a rare condition, but should be remembered as a possible one to be distinguished from ascites. Chronic peritonitis is also attended by effusion, which is, however, more limited than in ascites, and the change in the area of dullness on change of position is less complete because of the peritoneal adhesions, which inter- fere with the ready movement of the fluid. In tubercular peritonitis, where there is less limitation by adhesions, there is also tenderness. The with- drawn fluid is more highly albuminous and of higher specific gravity than the ascitic fluid. Treatment. — The treatment of ascites is that of the causing disease. Paracentesis is often necessary to relieve the discomfort of the patient. The fluid may accumulate with rapidity and the tapping require to be repeated quite frequently, but it is not true, as commonly supposed by the laity, that a first tapping necessitates a second per se. When frequent tapping is necessary, it is sometimes better to keep the orifice open and allow the fluid to drain away continuously, rigid antiseptic precautions being taken. Under these circumstances the patient sometimes improves rapidly, as he is re- lieved from the exhausting effect of the pressure and weight of the large amount of liquid and of the constant dread of repeated tappings. SECTION III. DISEASES OF THE RESPIRATORY SYSTEM. DISEASES OF THE NOSE. The first in the natural order of this system are the nasal passages. These are subject to but few medical diseases. They are explored from the front by nasal specula or dilators. The nares are investigated poste- riorly by the rhinoscope, which is another name for a very small laryngeal mirror. The mirror is, however, introduced differently. The position of the patient in relation to the observer and source of illumination is much the same, but the head of the former is not raised, and the tongue is best held down by the tongue depressor or the forefinger. The warmed mirror is introduced with the reflecting surface upward, and is passed backward over the tongue behind the uvula until it lies against the posterior wall of the pharynx. It is then directed upward and forward, and upon it will be found the nasal image and that of the vault of the phar}mx (see Fig. 40). ACUTE RHINITIS. Synonym. — Coryza. Definition and Symptoms. — Simple acute inflammation of the nasal passages, giving rise to the well-known uncomfortable full feeling which all have experienced under the name of " cold in the head," is a frequent event. There may be previous sneezing. The fullness is due to swelling of the mucous membrane, the result of inflammation, and is sooner or later followed by a discharge which, at first watery, may or may not become mucopurulent. With it comes relief of the most uncomfortable symptom, the nasal obstruction. This is most serious in nursing children, in whom it renders sucking often very difficult. There may be slight fever, but the constitutional disturbance is seldom decided, and the elevation of tempera- ture is correspondingly trifling, rarely exceeding a degree. The nasal mucous membrane may be involved in diphtheria, constituting diphtheritic rhinitis. Etiology. — Cold is the most frequent cause of simple acute rhinitis. The exudative forms, including simple fibrinous rhinitis and nasal diph- theria, are, of course, of an infectious nature. Treatment. — When this condition is associated with inflammation of the adjacent mucous membrane of the respiratory passages and of the throat, its treatment is that of the concurrent affection. An ordinary cold in the head may sometimes be cut short by a full dose of quinin. if given early enough. When the discomfort is sufficient to require treatment, I have had excellent results from the inhalation of a solution of iodin in 32 497 498 DISEASES OF THE RESPIRATORY SYSTEM. ether, one or two grains to the ounce. The discomfort is partially due to the dryness, and this is overcome by the application of any simple ointment^ as cold cream or vaselin, applied by means of a brush or the end of the finger. The same result is better accomplished by the oil spray, for which liquid paraffin may be used. Such applications to the adjacent parts are also useful when the discharge is irritating. In infants it is not unusual to apply the grease to the exterior of the nose, and it may be that some good effect is thus produced. Dobell's solution may also be spraved into the nose, and when dry discharges accumulate, they should be washed out b\- gentle injections of tepid salt water. Dobell's solution is composed of ^pip'Totii^' -ZofyerJofv^ Fig. 40.— Illustrating Technique of Rhinoscopic Examination— (a//^r Sahh). sodium borate one dram (4 gm.), sodium bicarbonate one dram (4 gm.), glycerite of carbolic acid (U. S. P.) two drams (8 gm.), and water one pint (0.5 liter). V* CHRONIC NASAL CATARRH. Synonyms. — Chronic Rhinitis: Ozena. Definition. — Chronic inflammation of the nasal mucous membrane,, associated with increased secretion and loss of the sense of smell. Etiology. — Chronic catarrh of the nasal passages may be the result of acute inflammation frequently recurring, but more commonly it arises from Special causes. Only a small number of the cases of rhinitis so common in the so-called scrofulous are the result of tuberculosis of the mucous mem- brane of the nose, but tuberculosis of the nasal passages does occur, and CHRONIC NASAL CATARRH. 499 must be recognized as a cause of chronic nasal catarrh. A more frequent cause is syphilis. It must be admitted, however, that these very persons known as " scrofulous " — that is, persons with fair, soft, and translucent skin, in whom inflammations run a slow course — are more subject to the disease, and that it arises in them either spontaneously or is excited by the more ordinary causes, such as recurring " colds." In consequence of the offensive odor frequently associated with one form of chronic nasal catarrh — the atrophic — it has been termed ozena. Morbid Anatomy. — Two broad divisions of chronic nasal catarrh are jnade from the anatomical standpoint — the hypertrophic and the atrophic. In the hypertrophic there is a thickening of the mucous membrane, while in the atrophic, a thinning or atrophy is present. In the hypertrophic ca- tarrh, the membrane is red, swollen, and spongy. The cavernous tissue over the turbinated bones shares in the process, and the nasal cavities may be encroached upon from all sides. The protrusion becomes more promi- nent as the disease progresses, and to it is added a greater or less hypersecre- tion of mucus. In the atrophic or fetid form, the nasal mucous membrane is thinned, the cavities are enlarged, and within them are found the thick, yellowish- green crusts which, in decomposing, give rise to the characteristic offensive odor of this form of rhinitis. The atrophic process involves all the tissues, from the epithelium down to and including the underlying bone. The accessory sinuses connected with the nose — the frontal, ethmoidal, and maxillary — may all become implicated in this disease by extension from the nasal chambers, and may become the seats of chronic purulent inflammation. Symptoms. — The two principal forms of nasal catarrh have certain symptoms in common. In both there is more or less marked obstruction to nasal respiration. In the hypertrophic form, however, this is due to actual narrowing of the nasal chambers by the overgrowth of the con- tained structures, while in the atrophic form it is due to the choking of the passages by the large masses of inspissated mucus and muco-pus. There is generally some slight impairment of the sense of smell in the hypertrophic form, while in the atrophic it is more often completely abolished. Both forms are usually accompanied by disturbances of secre- tion in the nasopharynx, and these lead to those noisy efforts at clearing the throat termed " hawking." The ozena, or fetid odor, is symptomatic only of the atrophic variety. No odor is attached to simple hypertrophic catarrh. Hypertrophic nasal catarrh is apparently much more common in the United States of America than in Europe — indeed, the observations of the specialists go to show that almost every person is more or less the subject of these hypertrophic processes, of which, in many instances, he is quite ignorant until examination has shown their presence. Treatment. — The proper local treatment of chronic nasal catarrh, Avhich is by far the most important, demands such special measures as in the main can only be carried out by accomplished specialists. This treat- ment, therefore, so far as can be taken up in this book, can only be palliative, or, if curative, limited to the early stage of the disease. In all forms of chronic catarrh the most important pleasures to be employed by the physi- cian, as distinguished from the specialist, are those which have for their purpose the attaining of the greatest amount of cleanliness of the affected regions. The simplest means for accomplishing this purpose is sniffing 500 DISEASES OF THE RESPIRATORY SYSTEM. from the palm of the hand simple salt solution of the strength of a teaspoon- ful of sodium chlorid to a pint (0.5 liter) of water, or some one of the substitutes named below. This method, however, accomplishes the purpose but feebly, and the same solution can be more effectually introduced by the irrigator or nasal douche. There is much dift'erence of opinion among specialists as to the efficiency and safety of the douche. Doubtless, harmful results have suc- ceeded its careless use, among which are said to have been inflammation of the middle ear and meningitis. Carl Seller claims, as did the late Dr. Elsberg, of Xew York, that these may be avoided by the observance of proper precautions. According to Seller, the best irrigator is a tin vessel holding a pint (0.5 liter) and provided v/ith an opening in its bottom, to which a rubber tube may be attached, furnished at the end by a nozzle made of glass, rubber, or wood which fits into the nostril. The vessel is filled with fluid, warmed to a temperature slightly above blood-heat, and the douche should be so placed upon a table or mantel that it does not stand more than an inch above the eyebrows of the patient. If higher, too great pressure may result, and the fluid be forced into the frontal sinuses, causing the frontal headache, or into the Eustachian tube, causing otitis media. The nozzle is introduced into one nostril, and the head being inclined forward, the water runs up in that side of the nose 'until it reaches the velum palati. when it passes around into the other side and through it, bathing the mucous membrane and washing out the mucus or loosening it so that it may be forced out by gentle blowing. It is important that the liquid used should be of the same temperature as the blood, and of the strength which is secured by the proportion named. The plain salt solution may be substituted by alkaline solutions, such as solutions of sodium bicarbonate and borate, of the strength of one dram (4 gm.) of either to the pint (0.5 liter), or of a half dram (2 gm.) of each combined. The dDuche sometimes fails of its purpose when the nasal passages are obstructed by deviation of the septum or bony hypertrophies. It should first be used carefully, therefore, under the direction of the physician, who will desist when he finds obstruction. It remains then to use the hand, as directed, or the nasal spray apparatus. Whatever the dangers of the douche, they do not extend to the spray. As ordinarily used, it is, however, much less efficient. A\ e may use with it varying proportions of " listerine " * and water, say from one to four up to equal parts ; also an alkaline solution composed of listerine one part, water four parts, and a half dram (2 gm.) each of sodium bicarbonate and sodium borate. When large quantities are required to wash out the nasal cavities, the postnasal syringe may be used instead of the nasal douche. Listerine is disinfectant and deodorizing, but salicylic acid and carbolic acid may be added to solutions for these purposes. A plug of borated or salicylated cotton may be used for a like purpose. Recently, Dr. J. Aluller, of A^ienna and Carlsbad, has availed himself of the pressure of condensed carbonic acid for producing the spray. He finds that a pressure equivalent to one and a half atmospheres is quite suf- ficient where a pressure of seven atmospheres by atmospheric air is neces- sary. Dr. Miiller, when at Carlsbad, uses the water of the Sprudel Spring at blood-heat, and when at Vienna, an artificial Sprudel water. These sprays are played into each nostril ten to fifteen minutes at a time, and for * For a formula for a solution similar to listerine, spts. th3-mol comp., see p. 310. HAY FEVER. 501 a like period into the fauces. This treatment is most searching, and yet harmless, as I can attest from a thorough personal examination. General treatment, although not so important as the local, is still of great value, and the general health of the patient should be carefully looked after. In view of the fact that atrophic rhinitis is very apt to occur in scrofulous persons, cod-liver oil is a tonic always indicated, and should be given for a long time, intermitting occasionally to avoid derangement of the stomach. It should be associated with iron, and even with arsenic. Other tonics should be given as indicated, and the best of food should be prescribed, including an abundance of meat, eggs, and cream. Wholesome ventilation should be secured for the indoor life, while as much time should be spent in the open air as possible. The air indoors is especially apt to be contaminated by the breathing of the patient with atrophic rhinitis, and on this account good ventilation is imperative. If syphihs is present, it should receive appropriate treatment at once. HAY FEVER. Synonyms. — Catarrhus ccstk'us: Hay Asthma; Autumnal Catarrh; Rose Cold; Pollen Catarrh; J^asoinotor Coryza. Definition. — A catarrhal affection of the upper air-passages, associated with asthmatic dyspnea and occurring in the late summer or autumn and spring of the year. Historical. — Hay fever v:a.s first described by Bostock, an English phj'sician, in 1819, the description being based upon his own experience. He ascribed i't to heat. Elliotson, in 1839, appears to have been the first to suggest pollen as its exciting cause. Blakely's observations in his own case (1873) confirmed this view, which is now generally held. Phoebus' classic work was published in German}^ in 1862. The first elaborate work by an American was that of \Yyman, of Cambridge. George M. Beard, of New York, in 1S76 called attention to the neurotic factor. In 1877 Elias Marsh, of New Jerse}-, read a paper in which he added further evidence to the pollen theory. Voltolini, of Breslau, was the first to point out an anatomical cause — a nasal polyp, the removal of which was followed by the cure of the case. Since then numer- ous observers have added evidence in this direction, including Hack, in Germany, and Harrison Allen, Charles E. Sajous, AVilliam H. Daly, John O. Roe, and John N. Mackenzie in this country. Etiology.— In -a large proportion of cases, hay fever has as its funda- mental condition an anatomical change in the nasal passages, such as hvper- trophy of the mucous membrane, a polypoid growth, a deflection of the septum, or a lowered position of the inferior turbinated bones so that thev rest upon the floor of the nose. These conditions are not always demon- strable, but they, or some allied source of reflex irritation, produce an irrita- bility. This may be increased by a neurotic constitution, though the latter may not manifest itself until after the attacks have become habitual, so that at times, at least, it is more likely that the neurosis is a result, rather than a cause, of the disease. A third necessary etiological factor is an irritant. This irritant, whatever it is, originates usually in the spring or the late summer. In the spring, it has been regarded as coexistent with the fra- grance of roses ; hence the term, " rose cold." In the autumn, the pollen of flowering plants is commonly regarded as the exciting cause, and in certain instances this seems to have been conclusively demonstrated, as by Blakely in his own case. Other substances are, however, capable of acting similarly, and it is not unlikely that they are numerous. Changes of temperature 502 DISEASES OF THE RESPIRATORY SYSTEM. may excite attacks ; also emotional causes, imaginary odors, and the like. Heredity is an important factor in its causation, successive generations being attacked with astonishing regularity. Localities variously favor it. Generally, cities furnish more cases than the country, and low countries more than elevated ones, yet certain seaside places are absolute cures for many cases. Such a place is Long Beach, N. J., where is located Beach Haven, a seaside resort, fifty miles from Phila- delphia, which has long been a resort for the victims of hay fever. The disease is more common in the United States than in Europe, and in the United States than elsewhere in America. It is more common in men than in women, there being three cases of the former to every two of the latter. Morbid Anatomy. — There is no morbid anatomy other than that re- ferred to in the remarks on the etiology of the disease. Symptoms. — The onset of hay fever may be quite sudden, coming on with remarkable regularity often on the same day of the month each year. At other times it is more gradual in its onset. It frequently begins with sneezing, and, indeed, may consist entirely of inveterate sneezing. At other times there are asthmatic attacks of great severity, closely resembling those of bronchial asthma, constituting the " asthmatic type " of the disease. Again, there may be obstinate cough, with or without expectoration; or there may be an alternation of the two symptoms, but generally there is more or less persistent shortness of breath. There is also often great de- pression of spirits, and victims have even been impelled to suicide. The eyes are sufifused with redness, and there may be conjunctivitis. Diagnosis. — The diagnosis furnishes no difficulty. The season of the year and the periodical recurrence of the cough and asthma combine to make the recognition easy. Prognosis. — Patients seldom die of hay asthma, yet I have known cases which seemed to be almost dying when they reached the haven which afforded them relief. Treatment. — ^The cure of an individual attack is seldom accomplished except by removal from the district in which the patient resides. The White Mountains and the Adirondack Mountains are favorite resorts in the eastern part of the United States, and Bethlehem, N. H., is the Mecca of American hay-fever victims, though other places in the same neighborhood- are equally exempt. The Catskills and Alleghanies are less celebrated. Certain seaside resorts have also a deserved reputation : Beach Haven, N. J., has already been mentioned ; Fire Island, on the Atlantic Coast outside of New York Bay; the Isles of Shoals, Nantucket, and Mount Desert, on the New England coast, are others. Sometimes a sea voyage will abort a threatened attack, and some persons are quite exempt while at sea. A few cases have been totally cured by operations on the nasal cavi- ties, such as correcting deviations, and the removal of hypertrophic proc- esses by the knife or actual cautery. Home treatment, at best, is uncertain and but partially successful, and. as is always the case with a malady so difficult to cure, the number of remedies is legion. Of late, irrigation of the nasal passages by the nasal douche or spray with simple salt solution or weak solutions of quinin, one grain (0.065 gm.) to the ounce (15 c. c), has been used, with varying re- sults. Helmholtz was the first to suggest quinin solution, and thought it efficient. The oil spray is probably the most efficient measure of this kind. Cod-liver oil is preferred by some. A strong solution of cocain — 4 to 10 HAY FEVER. 503 per cent. — applied with a brush affords temporary rehef, but the effect soon wears away, and there is danger of forming the cocain habit. Sub- nitrate of bismuth and boric acid, 1-2 dram (2 gm.) to the ounce (15 gm.) of vasehn or simple ointment, will sometimes allay the itching. Solution of suprarenal extract will be considered later. Boric acid, ten grains (0.65 gm.) to the ounce (30 c. c.) of water, may be used for the conjunctivitis. It is usual to give quinin internally also, in doses of 10 to 15 grains (0.65 to I gm.) a day. lodid of potassium and belladonna, so efficient in bronchial asthma, are of little use in hay asthma, but I have known them to be of service. The iodid is better given in small doses, frequently repeated, as 3 grains (0.2 gm.) every two hours. Fowler's solution has some reputation. Morphin is undoubtedly a useful palliative, but its employment is to be deferred until other measures fail. From 1-8 to 1-2 grain (0.008 to 0.03 gm.) may be required, and the smaller doses should he tried first. Chloral is also of undoubted use as a palliative, and is much safer than morphin, with which it may be combined. It renders smaller doses of the anodyne more efficient, and may be given in combination with 1-24 to 1-12 grain (0.0027 to 0.0055 gni-) of morphin at short intervals. Suprarenal extract has acquired considerable reputation in the treatment of hay fever. S. Solis Cohen and Beamon Douglass were among the first to report favorably on its effect. It acts by reducing turgescence of th^ turbinated tissue. It is used' externally and internally. For local appli- cations a fresh solution is made by shaking the dried extract with water, and after allowing it to stand for an hour or two the clear solution is re- inoved from the top and the precipitate discarded. In the shape of a spray the solution may be used every two hours until the symptoms have subsided, repeating the treatment on the appearance of obstruction, coryza, and sneez- ing. Internally it may be given in the tablet form or in a capsule. Five to ten grains are administered, day and night, every two hours until an exami- nation of the nasal membrane shows that the vasomotor paralysis is under control, or until giddiness or palpitation is noticed. After this improvement the same dose may be given every three hours, then every six hours, and finally, only twice daily, which is continued during the hay-fever season. If the dose is too rapidly diminished and the symptoms reappear, one tablet should again be given every two hours until the symptoms are controlled. Mild cases may be comparatively comfortable during the season when the €xtract is used in this way. If the pure dried extract is used one to three grains may be given in a capsule. DISEASES OF THE LARYNX. Examination of the Larynx. — For the proper investigation of the morbid states of the larynx the laryngoscopic mirror has become almost as indispensable as the stethoscope in the study of diseases of the chest. Only under the most favorable circumstances, when direct sunlight is avail- able, may it be used with natural light. In such event, the head-mirror, intended to direct the light upon the throat and laryngoscope, should be plane. Artificial light is far more convenient, and for its management a concave mirror is required. The light may be directed upon the throat by means of a condensing lens, but the mirror is not only more convenient, but also less costly. The patient should sit in front of the examiner, whose 504 DISEASES OF THE RESPIRATORY SYSTEM. eyes should be on a level with the mouth of the former, at a distance of about one foot. The convenience of a head-rest and a stool which can be raised or lowered to suit the stature of the patient is at once apparent. The light should be placed on the right of the patient's head, and a little behind it, at about the level of the ear. The head-mirror is then adjusted upon the middle of the examiner's forehead, no attention being paid to the central perforation. The patient's head should be slightly raised and the light reflected into the open mouth, of which a general sur- vey should first be made. The patient's tongue is held down by a tongue depressor, or drawn out with the aid of a napkin, and may be held by the lotrerK^x^Y!' Fig. 41. — Illustrating Technique of Laryngoecopic Examination — {after Sahli). patient himself. The larynx is thus drawn up at the same time. The mirror, slightly warmed and tested upon the back of the hand, is then carried carefully over the tongue, between it and the palate, without touch- ing either, or gagging will inevitably result, especially at the first exami- nation. The uvula is gently pushed up by the mirror, and the handle carried to one side, and raised or lowered until the larynx comes into view. Practice is, of course, necessary to secure success. The patient is requested to say " Ah," in order that the epiglottis may be made to rise and the vocal cords approach each other. As stated, much practice is required on the part of both patient and ACUTE CATARRHAL LARYNGITIS. 505 physician to enable the latter to avail himself of the mirror in the most satisfactory manner. Some persons can barely allow the mouth to be approached, while others are not at all sensitive. The mirror should be at once withdrawn on the occurrence of gagging-, and gradually its presence will be sufficiently endured. Various devices have been suggested for the Fig, 42. — Natural Size of Image of the Vocal Apparatus. 1,1,1. Rings of the windpipe. 2. Cricoid cartilage, 3,3,3,3. Thyroid cartilage. . 4,4,4. Epiglottis. 5,5. Vocal cords. 7,7. Ventricular bands or false vocal cords. 8,8. Back part of the tongue. M. Cricothyroid membrane. improvement of the illumination in the use of the laryngoscope, and they include the electric light, but for these the reader is referred to books especially devoted to the subject. The best shape for the laryngeal mirror is, on the whole, circular, but special conditions may demand the oval form. Figure 42 shows the image at rest and during phonation. ACUTE CATARRHAL LARYNGITIS. Etiology. — The most common cause of catarrhal laryngitis is cold, but predisposition plays a most important part. Such predisposition may be the result of previous attacks of laryngitis, or it may be brought about by con- stant use of the organ in speaking and singing; whence it is common with persons thus engaged. In these occupations the larynx is hyperemic from overuse, and this hyperemia is ever ready to be fanned into active inflamma- tion. Exposure to cold is constantly at hand to furnish the exciting cause. Laryngitis is also brought about by the inhalation of irritating vapors or gases, while intemperate smoking and the use of strong alcoholic drinks are also causes of the hyperemia so readily converted into an inflammation. Catarrhal laryngitis is frequently associated with catarrh of the adjacent parts, as of the nose and pharynx, trachea, and bronchi. Morbid Anatomy. — It is characteristic of the mucous membrane of the larynx, and, indeed, of the trachea and larger bronchi below it, that it loses, postmortem, the anatomical characters of the inflammatory process as they appear during life. It is only by the image in the laryngeal mirror, there- fore, that we can obtain an idea of these appearances as they present them- selves during active inflammation. The picture thus obtained by the laryn- geal mirror is one of intense redness, with swelling. These changes involve the true and false vocal cords and the trachea below, as well as the epiglottis 5o6 DISEASES OF THE RESPIRATORY SYSTEM. above. The latter appears in strong contrast to the yellowish-pink of health. Even greater is the contrast between the appearance of the vocal cords and the pearly white of health. If secretion has set in, streaks of mucus may be seen in places. Excessive swelling of these parts is known as edema of the glottis, but it is not frequent in simple acute laryngitis and will be described separately. Symptoms. — The most constant symptoms of acute laryngitis are hoarseness and cough, which vary with the degree of the swelling and hyperemia, and which also give rise to a sense as of something present in the larynx and a constant desire to clear the throat. In high degrees of inflamma- tion there may be aphonia. To these there is sometimes added pain in deglu- tition; with higher degree of inflammation there is a feeling of constriction or oppression. The cough is more or less husky and often stridulous. It is further characterized by its dryness and som.etimes the act is painful. Both these features disappear with the establishment of secretion. There is gen- erally a slight febrile movement, seldom very high. All of these symp- toms are aggravated as the disease becomes more severe, culminating in the intense distress and impending suffocation accompanying edema of the glottis. Treatment. — The patient should be kept in a uniformly warm, moist air, while special inhalations of such air are extremely useful both in giving him comfort and in abating the inflammation. They require no complicated apparatus. A piece of rubber tubing may be attached to the spout of a tea- pot or kettle, or the steam may be collected by an ordinary funnel and carried thence to the mouth. For obvious reasons, care should be taken that the funnel be not allowed to become too hot. Special appliances in the shape of a steam atomizer, more costly and scarcely more useful, may be used instead of the simple measures. Cold applications may be made to the outside of the throat. More rarely counterirritation by mustard may answer better. The irritative cough may require to be relieved by anodynes, which may consist of small doses of opium or some one of its preparations or derivatives. Expectorants are of doubtful value, and certainly are not nearly so useful as the simple measures which have been mentioned. SPASMODIC CATARRHAL, OR FALSE CROUP. Definition and Symptoms. — What is known as spasmodic croup in children of from one to five years is acute catarrhal laryngitis, to which is added a spasm of the glottis, producing the hard, stridulous breathing, with croupy cough characteristic of this affection, which, once heard, is never forgotten. It is produced by the same causes. To the croupy cough are added extreme restlessness and an anxious expression. The attacks gener- ally come on suddenly at night, the child waking from a sound sleep, although warning is often given by some disturbance of respiration while the child still sleeps. There is little fever. The next day the child may appear almost or quite well, or there may be a slight croupy cough, yet there may occur another attack on the following night and even the third, while in very severe cases the recurrences continue for a week. Diagnosis. — The only condition with which spasmodic croup can be confounded is diphtheritic croup, and then only if no membrane is visible. SPASMODIC CATARRHAL OR FALSE CROUP. 507 The throat should always be examined. In diphtheria, suddenness of onset seldom occurs, and the child is much sicker previous to the croup. There is high fever and the anxiety of expression is much greater. Prognosis. — The prognosis in all forms of acute laryngitis is generally favorable, and death is very rare from spasmodic croup. Carelessness may, however, prolong an attack. Treatment. — The favorite measure to break the paroxysm of croup in children is an emetic. The simplest of emetics is ipecacuanha, which may be given in the shape of the wine or syrup in the dose of 1-2 dram -to a dram (2 to 4 c. c.) every few minutes until vomiting is produced. The mineral emetics are more prompt, but more depressing in their action. An excellent remedy for the purpose is powdered alum with molasses or honey, which may be given in teaspoonful doses, repeated every ten or fifteen minutes until vomiting is produced, but it is not often necessary to give a second dose. While waiting for the action of the emetic the little patient may be put into a hot bath, — temperature 98^ to 112° F. (36.7° to 44.4° C), — and some mustard may be added. The tem- perature is kept up by the addition of hot water, as required. The majority of attacks of spasmodic croup may be broken up in this way without further treatment. Between the paroxysms the child should receive small doses of syrup or wine of ipecac, say five to ten minims (0.33 to 0.66 c c), until nausea is produced, or small doses of powder of ipecac conveniently in the shape of triturates containing 1-20 grain (0.003 g^n-) fo^" ^^i infant a year old. An opiate is particularly useful at bedtime, and by means of it a child may often be tided through a night without an attack. Just as early as possible in the treatment an aperient should be given, than which none is better than castor oil, but calomel is also an admirable remedy for children, given in doses of from one to three grains (0.06 to 0.2 gm.). When there is fever, aconite and sweet spirits of niter in appropriate doses should be given. Special pains should be taken to maintain a uniform temperature and avoid drafts, especially when the child is perspiring freely, and it is on this account that bed is the safest place. Counterirritation by weak mustard plasters is an adjunct to treatment which should never be omitted, while gentle permanent irritation is very useful. It may be secured by any of the rubber-spread plasters now sold, Icnown as porous plasters or capcine plasters. In severe cases, ice to the exterior of the throat, or cloths wrung out of iced water should be used, especially when there is much fever. Parents are naturally anxious to secure some treatment by which the recurrence of attacks is prevented. It is to be remembered that a gradually increasing immunity comes with added years. Certainly no medicine can accomplish anything. It is possible, however, to do something by care and judicious outdoor life, by which is secured a " hardening " or protection against the more usual causes of larv'ngitis. As an instance of neglect of ordinary care may be mentioned the practice so common, especially among the poorer classes, of allowing children with their heads uncovered to be at an open doorway or open window in the cooler seasons of the y^ear. Often a mother will be seen standing with her infant thus exposed in her arms. Such exposure is very apt to be followed by an attack of croup the same night. Children are also often too warmly clad while in the house, so that their bodies are constantly moist with perspiration. In this 5o8 DISEASES OF THE RESPIRATORY SYSTEM. condition a current of air, even when not very cold, will often produce spasmodic laryngitis. Children who are housed are much more susceptible to croup than those who spend a portion of each day in the open air. SIMPLE CHRONIC CATARRHAL LARYNGITIS. Etiology. — The causes of non-specific chronic catarrhal laryngitis are chiefly those which have been already mentioned as producing the predispo- sition to acute laryngitis — that is. the constant use of the voice in speaking and singing, excessive smoking, and the use of strong alcoholic drinks. Laryngitis occasioned by smoking and whisky-drinking is often accom- panied by chronic granular pharyngitis. So, too, frequently recurring attacks of acute catarrhal laryngitis independent of predisposing cause, and the long-continued inhalation of slightly irritating substances are to be included among the causes of chronic inflammation. Morbid Anatomy. — The morbid anatomy of simple chronic catarrhal laryngitis is commonly not widely different from that of the acute form. There are the same redness and swelling, but the former is less vivid. The chronic hoarseness which is so constantly associated with it is due to a per- manent thickening of the parts concerned in the production of the voice. Ulceration is not com^mon, although there may be superficial erosions. The follicular glands are often distended, and, if the inflammation is long kept up, a hyperplasia of the squamous epithelium may result in a moderate villous outgrowth on the cords. Nodular swellings on the vocal cords are also recognized, but rare, condition, known as choriditis tiiberosa or pachy- dermia laryngis. Relaxation of one or both cords is often present, and maintains the voice symptoms as long as it continues. Symptoms. — The most prominent symptom of chronic laryngitis is hoarseness, which is found in every degree from a simple roughness of the voice to almost entire loss of it. There are also more or less pain and discomfort, but these are not ordinarily conspicuous symptoms, except when an attempt is made to use the voice. There is a decided disposition to cough, with a view to getting rid of some foreign, substance which seems to be in the larynx. The cough also varies in degree. It may be a mere hack, or it may be scraping or ringing. It is also variously effectual in bringing up a secretion of mucus and muco-pus, scanty for the most part. Prognosis. — The prognosis of chronic catarrhal laryngitis is not en- couraging for total recovery, largely, perhaps, because it is so difficult to induce the patient to comply with the conditions essential to his cure. Could this entire co-operation be secured, sometimes withheld through no fault of his own, it is not unlikely that better results would follow treat- ment. Treatment. — The treatment of chronic catarrhal laryngitis requires, first, the removal of its causes, whatever they may be. The public speaker cannot expect to be cured of his malady v/hile he continues the use of his voice, nor can the singer, or he who works among irritating vapors, nor the ban vivant who will not give up his alcohol. Next to the removal of the cause comes the use of local measures, for internal medication with a view to local effect is not promising. Of course, the patient's general condition must be looked after and his strength maintained, but local treatment is TUBERCULAR LARYNGITIS. 509 mainly to be relied upon. Applications to the larynx may be made in four different ways : 1. By inhalation. 2. By lozenge or troche. 3. By insufflation. 4. Direct application. The general practitioner must, in the main, confine himself to the first three, and much may be accomplished by them, particularly by the judicious use of the atomizer. Cases are rare in which the direct application of medi- cated substance to the larynx is necessary, and requiring as they do the simultaneous skillful use of the laryngeal mirror, they are for the most part relegated to the specialist. Inhalations are further divided into three : (a) Nebulae, or atomized fluid — sprays. (b) Steam or vapor. (c) Volatile substances. 1. A great variety of apparatus is employed for spraying medicated solutions into the larynx, and undoubtedly the most efficient is the com- pressed-air machine with spraying tubes, but the cheaper forms of atomizers are also useful. Many excellent machines are to be had, but rubber tubes are to be preferred where chemically active solutions are to be used. A double hand-ball secures a more continuous stream of spray than a single one. The spray should be thrown into the wide-open mouth, and advan- tage taken of inspiration to draw it into the larynx, and a very little practice will teach the patient how to accomplish this. Astringents are the favorite medicaments, of which alum and tannin are the most usual — of alum a 3 per cent, solution, 15 grains (i gm.) to the ounce (30 c. c.) of water; of tannin, a i to 2 per cent, solution, 5 to 10 grains (0.32 to 0.65 gm.) to the ounce (30 c. c). Other substances are sulphate of zinc, 15 grains (i gm.) to the ounce (30 c.c.) ; chlorate of potash, 15 grains (i gm.) to the ounce (30 c. c.) ; sulphate of iron and ammonia, 1-2 to i dram (2 to 4 gm.) to the ounce (30 c.c). Before any of these solutions are used, however, the larynx should be cleansed from mucus by an alkaline spray, say Dobell's solution, or dilute listerine alkalized. Steam inhalation may consist of hot steam alone, or the vapor may be charged with a volatile substance. The efficiency of the former in acute laryngitis has already been referred to, and it is in acute disease that it is chiefly used. Benzoin, benzoic acid, and, for chronic conditions, cubebs and benzonate of ammonia are among the substances added. A teaspoonful of the compound tincture of benzoin may be added to a pint of water at 140° F. (60" C), and placed in any one of the numerous inhalers, of which, how- ever, none is better than an ordinary teapot. Volatile substances like nitrite of amyl are commonly inhaled for spasmodic bronchial disorders, to the treatment of which further allusion will be made. 2. The lozenge or troche is a favorite medium for medicating the larynx, and is often useful. Few have failed to realize the effect of a stimulating lozenge in clearing the throat, or the soothing effect of one of the anodyne or demulcent kind. An infinite variety is made, and the properties sought are stimulating, astringent, or anodyne, or a combination of two or more of these. Among the first is the lozenge of benzoic acid, the strength of 1-2 grain (0.03 gm.) to each lozenge; the cubeb lozenge contains from one to two grains (0.065 to 0.13 gm.) each; the ammonium chlorid 5IO DISEASES OF THE RESPIRATORY SYSTEM. lozenge contains three to five grains (0.2 to 0.32 gm.) ; the potassium chlorate lozenge contains five grains (0.32 gm.). The astringent lozenge is made up of tannic acid one grain (0.065 gm.), catechu two grains (0.13 gm.), kino two grains (0.13 gm.), gallic acid two grains (0.13 gm.). Seda- tive lozenges contain opium in very small quantities, say 1-20 to i-io grain (0.002 to 0.006 gm.) in each, or of morphin 1-30 to 1-15 grain (0.002 to 0.004 gin-)) lactucarium extract one grain (0.065 grii-)j althea one grain (0.065 gm.). The selection of a suitable adjuvant in the preparation of lozenges is best left to the apothecary. Three to five lozenges a day at various intervals are allowed to dissolve in the mouth. 3. The treatment of the larynx by insiMation is sometimes very useful. The difficulty in the preparation of the powder is such that it' may be irri- tating from a failure to secure sufBcient subdivision of its constituents. The powder is applied by means of an instrument known as the insufflator. Starch is the basis of most of this class of remedies. Among the astringent powders are tannic acid and powdered starch, equal parts ; alum and pow- dered starch, equal parts. Sedative powders contain of acetate of morphin two, five, eight, and ten grains (0.13, 0.32, 0.52, 0.65 gm.) to 1-2 ounce (15 gm.) of iodoform. Pure iodoform is also used; three drams each (12 gm.) of iodoform and subnitrate of bismuth with 1-2 ounce (15 gm.) powdered starch; also borate of sodium three drams (12 gm.), powdered starch 1-2 ounce (15 gm.). 4. The direct application is usually made by means of a brush, sponge, or cotton wad. The favorite remedy is the solution of nitrate of silver of the strength of from ten to fifteen grains (0.65 to i gm.) to the ounce (30 c. c), the weaker solutions being first used, as they are often quite effectual. The application should only be made after considerable experience, and always with the aid of the laryngeal mirror, which, indeed, should be used whenever possible in making applications of any kind. Local treatment with nitrate of silver should be used every three or four days, the larynx being previously cleansed with a weak alkaline spray. Ten per cent, solution of resorcin in glycerin is a good application. The selection of these various forms of medication in chronic laryngitis must be based on the requirements of the case, but the order in which they generally prove most useful seems to be about as follows, subject, however, to frequent variation : 1. Inhalation of medicated spray. 2. Inhalation of stimulating vapor, especially when there is much se- cretion. 3. Topical applications by "the cotton wad. 4. Insufflation of powders. Topical applications with the brush are likely to be made much earlier by the specialist than by the general practitioner. The frequent association of chronic laryngitis with nose and throat conditions renders associated treatment necessary in these cases. In such, the method of spraying devised by J. Miiller and described on p. 500 is an efficient aid. TUBERCULAR LARYNGITIS. 511 TUBERCULAR LARYNGITIS. Etiology. — The occurrence of primary tubercular laryngitis, long de- nied, has come to be generally conceded as possible, though rare. With the accepted view of the etiology of tubercular phthisis, tubercular laryngitis of the primary kind ought to be of frequent occurrence, for if the tubercle bacillus reaches the respiratory passages from without, the first point of attack would naturally be the larynx. The fact that such is not the case -can only be explained on the ground that the bacillus fails to find in the mucous membrane of the larynx conditions as favorable for its growth and multiplication as it finds in the deeper portions of the lung. Since tuberculosis of the larynx is commonly secondary to the same affection of the lungs, the bacillus probably invades the larynx from the expectoration, inoculation being favored by the greater or less friction between the vocal cords. Tubercular laryngitis occurs as a complication of 20 to 25 per cent, of all cases of pulmonary tuberculosis. Morbid Anatomy. — To the essential morbid anatomy of tubercular laryngitis is always added that of simple catarrhal laryngitis. The latter has been described. The first stage of miliary tuberculosis without ulcera- tion is sometimes recognized by the laryngoscope, appearing sometimes as pearly granulations in the mucous membrane, more frequently as a less dis- tinctive, close, small-celled infiltrate. The tubercular ulcer is more easily discovered, yet it possesses no one anatomical character by which it can be infallibly recognized. Nor are all the ulcers in the larynx associated with tuberculosis of the lungs necessarily tubercular. The larynx is more vulnerable to the ordinary causes of simple Mryngitis under these circum- stances, while the constant coughing and gagging in consumption may of themselves cause laryngitis. The true tubercular ulcer results from the caseation and disintegration of the miliary tubercle. The ulcer thus pro- duced by the fusion of adjacent miliary tubercles is at one stage more or less characteristic by its racemose or sinuous edge, resembling in this re- spect the conglomerate tubercular ulcer elsewhere. Its favorite seat is the posterior part of the larynx, viz., the posterior part of the vocal cords, the interarytenoid fold and the laryngeal surface of the arytenoid cartilages. The epiglottis is less commonly invaded, and the ventricular bands more seldom. In the case of the epiglottis there is swelling, succeeded by ulcera- tions. Symptoms. — ^The early symptoms of tubercular laryngitis differ in no way from those of simple catarrhal laryngitis, and it is the intractability of the disease which often gives the first intimation of its tubercular nature. The stage of simple hoarseness with which it is always ushered in varies also in duration, but sooner or later it is succeeded by the aphonia and the painful whispering voice which are so characteristic of ulceration of the vocal cords or the other parts intimately concerned in the production of the voice. Sooner or later, too, painful deglutition sets in as a result of the extension of the ulcerative process to the more exposed portions of the larynx. The pain on deglutition is often agonizing, and is due to the fact that during the act the constrictor mpscles of the pharynx squeeze the sensi- tive epiglottis and arytenoids. Inanition and emaciation characteristic of the latter stages of the disease now rapidly increase, and death is often a welcome relief to the sufferer. 512 DISEASES OF THE RESPIRATORY SYSTEM. Diagnosis. — Just suspicion attaches to an obstinate laryngitis associ- ated with acknowledged tuberculosis of the lung. With obstruction of the larynx the auscultatory signs of tuberculosis are sometimes wanting, so that we must depend on the percussion sounds entirely. As has been intimated, the distinctive features of the ulceration are scarcely sufficiently w^ell marked to enable us to recognize the tubercular ulcer by the laryngoscope, and to distinguish it either from the ulceration of sypliilis or that of certain stages of malignant disease. To distinguish it from the former, tuberculosis else- Avhere and the history of the case may help to a conclusion, while in case of further doubt, the tuberculin test or the therapeutic test by iodids and mercurials may be used. Syphilitic laryngitis, even when it is ulcerative, quickly yields to these remedies, as a rule, while the tubercular condition is quite unaffected by them. \\{\h the healing of the former comes also the tendency to contraction so characteristic of all cicatrization, and especially of that of syphilitic ulcers. It is also to be remembered that syphilitic ulceration and tubercular ulceration are sometimes associated. The in- volvement of the tongue in the infiltrating and ulcerating process is more characteristic of tuberculosis. Prognosis. — The prognosis of tubercular laryngitis is unfavorable at best. It is true that of late years the reported cures of laryngeal tubercu- losis have become much more numerous, but these still bear a verv small proportion to the cases that progress from bad to worse, in spite of the most skilled treatment. It is to be expected that primary tubercular laryngitis is much more easily curable than the form secondary to consumption of the lungs. Severe pain and signs of stenosis of the larynx are unfavorable symptoms. Treatment. — All measures which have been mentioned as useful in the treatment of chronic catarrhal laryngitis are also more or less so in tubercular disease, with, however, less complete and less permanent results. IMar^'elous effects have been reported as following the use of lactic acid, while iodoform and even alkaline inhalations are also said to have healed tubercular ulcers. We hear much less of lactic acid of late. Two note- worthy cases illustrative of its efficiency are reported by Dr. Percy Kidd in " The Clinical Journal " (London), July 31, 1895. It requires the skill of the specialist for its application. All local treatment must be, of course, asso- ciated with that of general tuberculosis of the lungs. The painful deglutition, which is at once so characteristic and so distressing, has been relieved by the use of cocain applied directly to the larynx by the brush or by the spraying apparatus. The latter is the^ more convenient, because it can be used by the patient himself. For this purpose a 2 per cent, solution is suitable. A stronger — 10 or 20 per cent. — may be necessary, but this must be applied with a brush by a second person. They should be used some minutes before the taking of food, as deglutition is rendered less painful for the time being by their successful application. Solutions of morphin may be sprayed for the same purpose, or the morphin, either pure or mixed with powder or starch, may be insufflated upon the painful larynx. When the pain is persistent and frequent applications are necessary, I have found none more satisfactor}' than the official solution of morphin sprayed into the larynx. EDEMA OF THE GLOTTIS. 513 SYPHILITIC LARYNGITIS. Etiology and Morbid Anatomy. — It is not necessary to dwell on the etiology of syphilitic laryngitis, as there is but one cause — the virus of syphilis. Syphilitic laryngitis may be either secondary or tertiary, and may occur at any time in the course of the disease subsequent to the second or third month following infection. Like tubercular laryngitis, the morbid anatomy of the syphilitic form is associated with that of simple catarrhal laryngitis of the chronic kind. Excessive mucous and muco-purulent secretions cover the surface of the epiglottis and the vocal cords, while the ulcer of syphilitic laryngitis is usually more distinctive in its characters than is that of tubercu- lar laryngitis. The milder forms of syphilitic laryngitis are not accom- panied by ulceration and are in no way peculiar, from the anatomical standpoint. The most distinctive anatomical manifestation of syphilis in the larynx is the mucous patch, like that on mucous membranes elsewhere. It is found on the epiglottis, in the laryngeal wall, and on the epiglottidean folds ; rarely, on the vocal cords. The patches are rarely replaced by ulceration. The breaking down of the syphilitic gumma gives rise to an- other form of syphilitic ulcer, often of greater depth. The ulcer may come to a standstill at any stage, and cicatrization take place with deformity and permanent change of voice. In addition, necrosis of the laryngeal cartilages is not infrequent; portions of these being at times expectorated. Among the results of cicatrization are stenosis, resulting sometimes in complete obstruc- tion, necessitating even tracheotomy for their relief. Symptoms. — These are essentially the same as in tubercular laryngitis, hoarseness, cough, aphonia, pain in deglutition. Diagnosis. — The diagnosis of S3'philitic laryngitis is justified in the ab- sence of tuberculosis elsewhere, especially when the history of primary syphilis is present. Prognosis. — The prognosis of this form of laryngitis is rather more favorable than that of tubercular disease, especially if the diagnosis be made early. The effect of contraction after healing is, however, often serious in producing stenosis, or, at least, a permanent impairment of the voice. Treatment. — The treatment of syphilitic laryngitis is the treatment for the general affection plus the topical treatment. The latter includes the use of measures to free the larynx of mucus and muco-pus, these being followed by applications of strong solutions of nitrate of silver to the ulcers, or even the solid stick. An insufflation of iodoform, in combination with bismuth and a little morphin, is an excellent addition to the treatment. EDEMA OF THE GLOTTIS. Definition. — By edema of the glottis is meant edema of those parts which immediately surround that opening. Symptoms. — Its consideration has been deferred to this place because it so commonly results from the other conditions which have just been described, or accompanies them. Tljus, it may occur in connection with acute laryngitis, though rarely, and occasionally with the tubercular and syphilitic form. It not infrequently, also, is a complication of general dis- eases attended with dropsy, especially Bright's disease, more rarely typhoid 33 514 DISEASES OF THE RESPIRATORY SYSTEM. fever, smallpox, and even diseases of the heart. In any of the latter condi- tions it may come on quite suddenly. The more precise situation is the sub- mucous tissue of the aryteno-epiglottic folds or of the ventricular bands. The edema may also involve the epig*lottis. It occurs most frequently in middle life, but it also happens in the young. An additional symptom of this condition is a feeling of intense oppres- sion or suffocation. The breathing is stridulous, and the efforts of the pa- tient to obtain air may bring into play all the extraordinary muscles of respi- ration, the whole expression being in extreme cases one of great anguish. Treatment. — For the mild degrees of edema of the glottis the prompt application of a blister to the larynx is often sufficient to relieve the symp- toms. Another remedy of some value in the milder cases is a direct spray, frequently repeated, of a solution of alum, 20 grains (1.3 gm.) to the fluid ounce (30 c. c). In the treatment of the severer cases, cold plays an im- portant role. Ice should be constantly kept in the mouth, as well as applied externally by means of ice-bags. If obtainable, the Leiter coil may be used. When danger is imminent, and time is too limited to wait for the tardy action of blisters, a half dozen or more leeches may be applied over the region of the larynx. These failing to afford relief, scarification of the edematous tissues is to be promptly performed, and, as dernier ressorts, either intubation or tracheotomy. The hypodermic administration of pilocarpin has been remarkably successful in some cases, and particularly when the symptoms are of a sthenic nature this should never be omitted. One-quarter of a grain (0.0165 gm.) is the proper dose thus administered. PARALYSIS OF THE LARYNGEAL MUSCLES. To understand these clearly it is necessary to remember — 1. That there are eight intrinsic muscles of the larynx, five of which are muscles of the vocal cords and rima glottidis, and three connected with the epiglottis. The former are the crico-thyroid, the posterior, and lateral crico- arytenoid, the arytenoid and the thyro-arytenoid. The muscles of the epi- glottis are the thyro-epiglottideus and the superior and inferior aryteno- epiglottideus. 2. That the epiglottis is depressed by the thyro-epiglottidean and the aryteno-epiglottidean muscles. The aryteno-epiglottideus superior constricts the superior aperture of the larynx when it is drawn upward during degluti- tion and the opening closed "by the epiglottis. The aryteno-epiglottideus inferior, together with fibers of the thyro-arytenoidei, compress the sacculus laryngis. The epiglottis is raised by the genio-hyo-glossus, the genio-hyoid, and the mylo-hyoid muscles. 3. That the separation of the vocal cords or opening of the glottis is accomplished by the posterior crico-arytenoid muscles alone, while its closure is effected by the lateral crico-arytenoids, the arytenoid muscle, and the thyro- arytenoids. The crico-thyroids, acting in conjunction with the arytenoid, become tensors of the vocal cords, producing the different degrees of tension tiecessary to delicate modulations of the voice in speaking or singing, while, at the same time, narrowing the opening of the glottis. The right and left inferior or recurrent laryngeal nerves supply all the intrinsic muscles of the larynx on their respective sides except the crico- PARALYSIS OF THE LARYNGEAL MUSCLES. 515 thyroid, which derives its motor innervation from the superior laryngeal nerve. This is the generally accepted view of the motor nerve supply to the larynx, although it has been shown to be subject to occasional variations. It is to be remembered that the motor fibers of these nerves are originally derived from the spinal accessory nerve by branches to the vagus before the latter leaves the cranial cavity. Consequently, motor paralysis may be due to : ( I ) Degenerative changes in the spinal accessory nuclei in the floor of the fourth ventricle ; or (2) pressure on or destruction of the spinal accessory fibers before they join the vagus; or (3) degeneration, injury, or pressure suffered by the vagus trunk or its superior and inferior or recurrent branches; or (4) the paralysis may be myopathic. As effects of one or more of these causes we may find the following con- ditions : 1. Paralysis of the thyro-epiglottidean and aryteno-epiglottidean mus- cles, resulting in a rigidly upright position of the epiglottis, and the opening of the superior aperture of the larynx. 2. Paralysis of the crico-thyroid, enfeebling the voice and lessening the ability to produce the higher tones. Examination by the laryngoscope dis- closes imperfect approximation of the cords, a lack of visible vibration in them, and, at times, if the paralysis be unilateral, a higher position of the unaffected cord. 3. Laryngoplegia or total paralysis of a vocal cord. This is usually the result of pressure upon the recurrent nerve trunk. If the paralysis is uni- lateral, the symptoms are not at all striking. Respiration is not affected ; the voice, perhaps, is slightly modified and easily fatigued, but it is far from being wholly stippressed. Inspection by the mirror shows the affected cord in Fig 43. — Cadaveric Position of the Left Vocal Cord, Midway between Ad- duction and Abduction in Paralysis of the Crico-arytenoid Muscle due to lesion of the left Recurrent Laryngeal Nerve at the moment of Inspiration — (after von Zie?n5sen). Fig. 44. — Complete Both-sided Ab- ductor Paralysis of the Posterior Crico-arytenoid Muscles (the Open- ers of the Larynx) at the Moment of Inspiration — (after von Ziemssen). what is called the " cadaveric " position, one that is midway between abduc- tion and adduction. On phonation, the sound cord is seen to pass beyond the median line and approximate itself more or less closely to the other. The corresponding arytenoid cartilage is also drawn in front of that of the affected side, and the glottis is thus given an oblique position (see Fig. 43). In bilateral recurrent laryngeal paralysis both cords are in the cadaveric position, and remain so both during respiration and upon attempted phonation. 4. Paralysis of the abductors of the glottis, the posterior crico-arytenoid muscles. Unilateral abductor paralysis due to pressure upon the recurrent nerve is not uncommon. The affected cord remains in the middle line in 5i6 DISEASES OF THE RESPIRATORY SYSTEM. consequence of the unopposed action of the adductor muscle. Phonation is not interfered with, and dyspnea occurs only in case of severe exertion, so that this aflfection is, doubtless, often overlooked. Bilateral abductor paralysis is rare, and is generally dependent upon central degenerative change. The cords are found in the middle line with but a very narrow chink between them, and respiration is consequently noisy and much embarrassed. Slight exertion or emotional disturbance may pro- voke alarming dyspnea, and at times prompt tracheotomy becomes necessary (see Fig. 44). 5. Paralysis of the thyro-arytenoid muscles, whose office is to relax and approximate the vocal cords. This is usually bilateral and is quite common. It may be caused by voice strain, by exposure to cold, or it may accompany catarrhal laryngitis. Approximation of the cords is incomplete, an elliptical Fig. 45. — Paralysis of the Internal Thyro-arytenoid Muscles (Tensors of the Vocal Cords) in Acute Laryn- gitis. Position of the vocal- cords during pho- nation. Fig. 46. — Paralysis of the Transverse and Oblique Arytenoid Muscles (the Respiratory Closers of the Glottis) — (after von Ziemsseti). Position in laryngitis of the vocal cords during phonation, the respiratory glottis remaining open. space remaining between them which leads to hoarseness and feebleness of the voice. The laryngoscopic appearance is seen in Figure 45. 6. Paralysis of the arytenoid muscles. This may occur alone, the usual causes being cold, catarrhal laryngitis, or hysteria. A triangular gap is found between the vocal processes in attempted phonation, and the voice is very feeble or wholly extinct (see Fig. 46). Fig. 47. — Bilateral Paralysis of the Thyro-arytenoids Combined with Paresis of the Arytenoid. 7. Combined paralysis of the arytenoid and thyro-arytenoid muscles. In this condition the mirror discovers a narrow, hour-glass opening between the cords, caused by the suspended activity of these muscles, while the lateral crico-arytenoids bring the tips of the vocal processes together (Fig. 46). Etiology. — The causes producing paralysis of these muscles are largely ACUTE BROXCHITIS. 517 pressure by morbid growths within and without the larynx, among the latter being conspicuously aneurysm of the arch of the aorta and mediastinal tumors. Laryngitis and hysteria are also frequent causes. Treatment. — The first effort of treatment in all these conditions should be directed to the removal of their causes. Unless this be possible, the prog- nosis is necessarily unfavorable. Catarrhal processes must be cured. The asthenia following diphtheria is to be overcome by general tonics and nerve invigorants. Electricity is frequently of great value, the galvanic or faradic currents being selected as each case may require. Hysterical paralvses are best treated by electricity, chiefly for the moral effect. Brilliant results often succeed this treatment, but relapses frequently occur. DISEASES OF THE TRACHEA AND BRONCHIAL TUBES. ACUTE BROXCHITIS. Syxonyms. — Acute Bronchial Catarrh; Acute Tracheobronchitis. Definition. — An acute intiammation of the tracheal and bronchial mucous membrane. It is essentially a symmetrical disease, the bronchial tree in both lungs being more or less uniformly invaded. Etiology. — The most frequent cause of acute bronchitis is the action of cold in chilling the body. It often succeeds an ordinary coryza or cold in the head or a laryngitis, the inflammation extending from the upper air- passages downward. It is naturally more prevalent in the winter than in the summer. It is usually a symptom of influenza, whether epidemic or sporadic. Invariably, too, it accompanies m.easles. of which it is the most annoying symptom. ]\Iore rarely it is caused by irritating fumes. A microbic origin of acute bronchitis is possible in certain cases, but such origin cannot supplant the more usual causes described. Morbid Anatomy. — The mucous membrane of the trachea and large bronchi is congested and more or less covered with a tough mucus, rich in cells, the hyperemia being especially marked about the glands whence comes the secretion. Decided cellular infiltration of the mucosa does not occur in ordinary cases, because of the almost tendinous basement membrane which intervenes between the blood-vessels and the mucosa. Symptoms. — Cough is the most constant and conspicuous symptom. At the beginning it is hard and dry, wdthout expectoration : sometimes it is painful. As the disease advances it gradually becomes looser. In the milder degrees there is no shortness of breath, but in the severe there is a var}-ing degree of dyspnea with a sense of oppression or constriction in the front of the chest, caused by stenosis of the bronchial lumina, due to the swelling of the mucous membrane and the presence of secretion. Fezrr in mild degree is commonly present, but the temperature rarely exceeds loi^ F. (38.3° C). If it does, there is reason to suspect a more deep-seated involvement of the smallest or capillary tubules, whence the name capillarv bronchitis, referred to in considering bronchopneumonia. This extension is particularly apt to take place in children and old person,s, in whom the physician should always be on the lookout for it. With the access of fever the pulse is correspond- ingly accelerated. Rarely, a cliill may usher in the disease. The scanty expectoration of acute bronchitis is at first glairy or mucoid, 5i8 DISEASES OF THE RESPIRATORY SYSTEM. and later muco-purulent. With the appearance of the latter the cellular ele- ment, composed of pus-cells and desquamated epithelium, becomes more abundant. With the abatement of the disease the pus-cells become again less numerous and finally disappear. Physical Signs. — There may be absolutely no physical signs — inspection, palpation, percussion, and auscultation being alike negative. In other cases inspection may recognize increased frequency of breathing, and possibly increased rate of the cardiac apex-beat if there be fever. Palpation may appreciate a rhonchal fremitus if there be sufficient narrowing of the breath- ing tubes. It may be found anywhere on either side, and is usually tran- sient. Percussion continues invariably clear so long as the bronchitis is uncomplicated. Auscultation furnishes the most distinctive and constant physical sign, the presence of dry rales, the sonorous and sibilant, which may invade either or both lungs, and may also be transient, coming and going. To these may be added harshness of breathing sounds. When resolution sets in, bubbling rales may take the place of the sonorous and sibilant, in conse- quence of the presence of liquid secretion. For physical signs of capillary bronchitis see Bronchopneumonia. Diagnosis. — This is generally easy. The presence of the dry rales and a clear percussion note belong to no other condition than acute bronchitis and bronchial asthma, but to the latter are added the' signs of spasmodic contrac- tion of the bronchi, notably the panting breathing. The same clearness of percussion note continues with the appearance of moist rales, unless there be the complication of capillary bronchitis or pneumonia. Prognosis, — Very often the symptoms subside without treatment in the course of two or three days. The cough becomes loose, expectoration is easy, fever and other unpleasant symptoms disappear, and in a week the patient is well. Suitable treatment may hasten such an issue. In other instances, especially in persons who are weak and debilitated, no such speedy termina- tion takes place, but even in many of these after a long interval the patient recovers. More rarely, particularly in the very young and old, the inflamma- tion travels down into the smallest tubes, producing the capillary bronchitis alluded to. In other instances still, especially after several attacks, and in the old particularly, chronic bronchitis may supervene with the symptoms and physical signs which will be described when considering it. Treatment. — The best treatment for a case of ordinary acute bronchitis is " the bed." Twenty-four to forty-eight hours in a warm bed will go farther to cure such a case promptly than all the cough medicines ever pre- scribed. Such a course is not, however, always possible, and the physician is often expected to cure acute'bronchitis while the patient is on his feet and even attending to business. The patient should, however, be put to bed if possible. Next to rest in bed is counterirritation. Turpentine and mus- tard are the best agents. A turpentine stupe or weak mustard-plaster applied to the front of the chest will aid greatly in allaying cough and reliev- ing the sense of oppression. Cough medicines are, of course, expected, and are useful. In the ordi- nary simple bronchitis, especially when there is moderate fever, there are few rem.edies more efficient than the simple solution of citrate of potash of the United States Pharmacopeia, in doses of 1-2 ounce (15 c. c.) every two hours. It may be desirable to add a few drops of wine of ipecac or wine of antimony to each dose to increase the relaxing effect, while, if the fever is decided, one minim (0.055 c. c.) of the tincture of aconite will aid in breaking it. A CHROXIC BROXCHITIS. 519 diaphoretic effect is further encouraged by adding thirty minims (2 c. c.) of the spirit of nitrous ether. By such measures the cough is usually loosened in twenty-four hours, the dry rales are substituted by moist ones, and con- valescence progresses. If there is decided oppression, it may be relieved by inhaling the steam from a hot saturated solution of chlorid of ammonium, or the compound tincture of benzoin floated on hot water, while in children an emetic dose of ipecac may produce the desired relaxation. The cough may, however, be so constant as to harass the patient and keep him awake in spite of the measures suggested. In this event an opiate is ^necessary, and a small quantity of morphin, say 1-16 to 1-12 grain (0.004 to 0.0055 gm.) for an adult, may be added to the combination previously recom- mended. It is, perhaps, on the whole better to administer the opium sepa- ately, and of all the preparations, Dover's powder is probably the best. Indeed, Dover's powder alone is one of the best medicines in acute cough in ■doses of 2 1-2 grains (0.16 gm.) every two hours, preferably in a pill or capsule; or if it be at night and a prompt eft'ect be desired, five grains (0.32 gm.) or even ten grains (0.65 gm.) in one dose will often act like a charm. Codein is a good preparation of opium, and has the advantage of disturbing the system less than some others. It may be given in doses of 1-4 to 1-2 grain (0.016 to 0.032 gm.) as often as necessar}- to quiet cough. Heroin is a popular modern remedy of this class, given in doses of 1-20 to 1-12 of a grain (0.003 to 0.0055 g™-)- Should convalescence be slow and expectoration prolonged, the ammo- nium chlorid in five- to ten-grain (0.32 to 0.65 gm.) doses with syrup or tincture of squills may be substituted for the sedative mixture, and quinin and restorative measures added to the treatment. If the cough is parox- ysmal, the preparations of belladonna may be given, and are often efficient in controlling the paroxysms where opium is contra-indicated or deemed un- necessary. So, too, when secretion is copious and cannot be expectorated, belladonna tends to diminish it, and may be given with expectation of relief. Copious secretion in children is somewhat removed by an emetic. To this end alum and honey may be given or syrup of ipecacuanha in teaspoonful doses. All such measures are, however, depressing and may be succeeded by recurrence of secretion, and should be used onlv when necessary. CHROXIC BROXCHITIS. Synonym. — Chronic Bronchial Catarrh. Definition. — A chronic inflammation of the mucous lining of the large •and medium-sized bronchial tubes, commonly symmetrical. Etiology. — Uncomplicated and primary chronic bronchitis usually develops gradually, representing the accumulating remnants of frequently recurring " colds," each of which leaves something behind it until the chronic condition is established. A bronchitis that is associated with or consequent itpon another disease may continue and become chronic after the disease has disappeared. This may happen with measles or influenza, or even, rarely, pneumonia. Chronic bronchitis constantly attends other affections as a consequence. The most common of these causes is tubercular consumption, but it is also the result of diseases which favor congestion of the air-tubes bv reason of 520 DISEASES OF THE RESPIRATORY SYSTEM. the obstruction to the circulation which they cause, such as cardiac valvular disease. Especially is this true of mitral disease and Bright's disease. Morbid Anatomy. — The bronchial mucous membrane is bathed with a dirty gray secretion derived from the mucous glands, which are sometimes hypertrophied. The darker color is due to inhaled " blacks," exfoliated degenerate cells, and sometimes to decomposed blood. On scraping this mucus away, there may be little or no change of appearance ; at other times there may be a decided hyperemia. In places the mucous membrane may be thickened by cellular infiltration ; at others it may be thinned, producing some- times a lattice-like appearance, because of the prominence of the bands of elastic tissue which resist the atrophic process. In old cases there is often dilatation, which may be saccular, fusiform, or cylindrical, and sometimes cavernous dilatations are present, usually about the center of the lung. It is in the latter more particularly that the mucous membrane is found thinned and the mucous glands atrophied ; at others, ulcerated. In other old cases there are ulceration and necrosis of the cartilaginous rings. Symptoms and Course. — The chief symptom of chronic bronchitis is cough, which is troublesome in various degrees, and is apt to be worse at night or in the morning. Frequently it is paroxysmal, the spells terminat- ing in free expectoration of the secretion which has excited the coughing. Chronic bronchitis is commonly attended with free expectoration, either in the manner just described or more uniformly distributed through the day. The expectorated matter is usually muco-purulent or purulent, the color deepening to yellow as the proportion of pus corpuscles increases, and becom- ing darker in hue with the admixture of dead epithelium and decomposed blood. The quantity is sometimes very large, amounting to 1-2 liter (a pint) or more in the twenty-four hours. As the quantity increases, however, the consistence diminishes, and it may be thin and watery. To such copious expectoration the name of brojichorrhea is applied. IMore com- monly it is purulent, containing greenish-yellow^ masses which are coughed up easily. The bronchi are usually more or less dilated in these cases. The more copious secretion of bronchorrhea or bronchial blennorrhea usually separates, on standing, into two portions — a superficial sero-mucous portion, which may be frothy, and a lower thick portion made up more largely of pus- cells. In addition to such pus-cells the microscope discovers squamous epi- thelium from the mouth, columnar cells from the deeper air-passages, bacteria, and sometimes a few blood-corpuscles, as well as the delicate whetstone- shaped cn-stals known as Charcot's crystals. Respiration is accelerated in various degrees, but except in the rare forms to be described and on exertion, dyspnea is never so marked as even in mild cases of tubercular consumption. The absence of fever is character- istic as contrasted with tubercular consumption, which chronic bronchitis so often resembles in other respects. Sometimes there is slight elevation of temperature, rarely exceding 100° F. ('37.8° C). After chronic bronchitis has existed for a long time in the old. especially when secretion continues copious w^hile expectoration becomes difficult, there sometimes superv^enes a condition of lozv fever, probably septic, from absorp- tion of putrid matters, and unless expectoration can be re-established, the patient sinks and the fatal end is not very remote. The appetite commonly remains quite good, and the patient maintains his weight for a long time. After a while, however, the appetite and diges- tion are apt to fail, especially if there is much expectoration, and then the CHRONIC BRONCHITIS. 521 patient loses weight. Some subjects of chronic bronchial catarrh remain quite corpulent and well nourished throughout a long illness, and except for the cough, the amount of disturbance is often remarkably slight. There is no pain, except sometimes about the attachment of the diaphragm in the lower thorax in consequence of the harassing cough. A variety of chronic bronchitis is the asthma humidum of the older authors, called by Laennec catarrhe pituiteux. It is characterized by still more copious serous expectoration, amounting sometimes to two liters (quarts) in the twenty-four hours of thin, frothy sputum, and by severe paroxysms of coughing. Rarely, the cough is " dry," without expectoration except small, tough, tenacious masses of mucoid matter. These are brought up after paroxysms of coughing, often of great severity. This dry variety — the catarrhe sec of Laennec — is commonly associated with emphysema, and is a very troublesome form. Still another variety of chronic bronchitis is well called putrid or fetid bronchitis, in which the secretions decompose in the air-passages and acquire a sweetish, sickening, and disgusting odor, which may pervade an entire apartment and make the patient a nuisance to himself and others. The decomposition is due to the bacteria of decomposition, the action of which is doubtless favored by retention of secretion in dilated bronchi and phthisical cavities, and in a decided majority of cases it succeeds an ordinary chronic bronchitis. It also sometimes follows an empyema which perforates into the lung. At times it is said to be primary. The expectoration is copious and correspondingly thin. It also separates into layers : an upper one of frothy, muco-purulent matter in which occur separate masses, and an inferior of thicker, greasy, purulent matter. In the latter the naked eye often recog- nizes dirty gray masses about as large as a pea, known as Dittrich's plugs, which on microscopic examination are found to contain pus, bacteria, and detritus of uncertain origin, together with delicate acicular fat crystals. Among other fungi are found also leptothrix filaments, which must not be mistaken for elastic tissue. The chief additional symptoms are fever — it may be septic — with increase of cough and pain in the side. There is also sometimes a chill. These symptoms may again abate and those of the more usual form of chronic bronchitis prevail, subject to exacerbation and improvement. The effect of the fetid form, as might be expected, is more severe on the constitu- tion, and there are loss of appetite, indigestion, and failing health. The fingers may be clubbed, as in phthisis. Secondary purulent meningitis and abscess have appeared from the transfer of pus germs. The physical signs do not differ from those of chronic bronchitis and bronchiectasis, to be described. Physical Signs. — Physical signs of a decided character more constantly attend chronic bronchitis than acute. They present, however, no unchanging picture. There may be nothing apparent to inspection, or the frequently asso- ciated complication of emphysema of the lungs may be the cause of a dimin- ished excursion of respiratory motion, and the roundness or barrel shape of the chest characteristic of that disease may be seen. Such emphysema may give dimunition of the normal tactile fremitus and to percussion a hyper- resonance. In the vicinity of a superficial dilated bronchus filled with secre- tion there may be impairment of resonance. The resonance is, however, restored after copious expectoration, or the percussion signs of a cavity may 522 DISEASES OF THE RESPIRATORY SYSTEM. be substituted, though in the middle or lower part of a lung instead of the apex, as in consumption. Vesiculo-tympanitic or even tympanitic resonance may be present from relaxation of lung tissue, especially in the lower pos- terior part of the lungs. Auscultation may also be negative, but much more frequently recog- nizes an alteration or combination of harsh and feeble breathing, sonorous and sibilant rales, with moist rales of all sizes, variously modified by differ- ent distances from the ear and varying consistence of the secretion. The moist rale is the most characteristic sign of chronic bronchitis. Diagnosis. — This is not usually difficult, for while the symptoms, in- cluding coarser appearance of the sputum, sometimes closely resemble those of tubercular consumption, the physical signs do not, except when a dilated bronchus presents the same signs as a cavity. Such a dilatation is, however, found in the middle of the lung, and furnishes its signs in the neighborhood of the angle of the scapula, rather than at the apex. The absence of fever and especially of tubercle bacilli from the sputum after careful examination is confirmatory evidence of the absence of tubercular consumption, but above all, the tuberculin test will settle the question. Prognosis. — This is unfavorable as to recovery, but favorable as to termination. The patient rarely dies of the direct effect of the disease, being generally carried off by some intercurrent affection, often croupous pneumonia. In the old, however, a condition described on page 521 may intervene, or a bronchopneumonia may supervene and terminate fatally. On the other hand, many patients the subject of chronic bronchitis live for years in comparative comfort, getting almost well in the summer and re- lapsing in the winter. Treatment. — If it were possible to remove every person with simple chronic bronchitis uncomplicated by heart or kidney disease to a warm climate, they would probably get well. Certainly is this true of the earlier stages. Aluch may, however, be done at home to prevent the exacerbations due to cold, each of which adds a little to the previous chronic condition, by care in avoiding exposure. This consists mainly in dressing warmly and remaining indoors in bad weather. Heretical as it may seem, my experi- ence teaches me that old persons can better bear a little " bad air " than " cold air," and it is wiser to submit to a little " closeness " than to encoun- ter very cold air for the sake of " ventilation " ; it is, of course, better to have both, if possible. It is especially important that the old should be warmly clad with wool next the skin, and precautions against cold feet should be especially secured. When bronchitis complicates other diseases, as heart disease and kidney disease, the treatment of these is important. In the way of medicine, much can be done by the stimulating expec- torants. The terebinthinates are the best, and of these one of the best is terebene. Five to ten minims (0.3 to 0.6 c. c.) in a capsule every three hours is a proper dose. Terpene, another derivative of turpentine, may be given in doses of i 1-2 grains (o.i gm.) in pill as often, or it may be given in mixture with enough alcohol to dissolve it. Turpentine itself is a good remedy, in doses of from ten to twenty minims (0.6 to 1.3 c. c). Creasote is an admirable remedy in chronic bronchitis : one grain or minim (0.06 c. c.) or two minims (0.12 c. c) three times a day, increased gradually to five grains (0.3 c. c), or even more than three times a day, will after a while diminish the secretion and the cough. Creasotol, or the carbonate of creasote, is a much more pleasant remedy, and may be given in doses of ten minims CHRONIC BRONCHITIS. 523 (0.6 c. c), which may be increased. Sandalwood oil or balsam of tolu or Peru may be substituted. The compound tincture of benzoin is another old but good remedy. Other stimulating expectorants, like the carbonate of ammonium or the aromatic spirit of ammonium, are often useful, but they lose their effect after a time. The carbonate of ammonium, to be useful, must be given often — five to ten grains (0.32 to 0.65 gm.) every two hours. The ammonium chlorid is indicated where less of a stimulating effect is necessary — 5 to 15 grains (0.32 to i gm.) four times a day in combi- nation with the syrup of squill in 15-minim (i c. c.) doses, both in the •compound licorice mixture. In some cases the iodid of potassium is very useful, especially when secretion is scanty. It should be kept up for some time. Among the more recent drugs recommended for chronic bronchitis is hydrastis canadensis in doses of 20 to 30 minims (1.25 to 1.85 c. c.) of the fluid extract four times daily. It is advised when there is muco-purulent expectoration, of which it changes the character and reduces the consistency with diminution of cough. Inhalations of medicated vapors are sometimes useful. Th^ com- pound tincture of benzoin may be thus used, also turpentine. They may be placed on the surface of boiling-hot water, the vapor from which will carry the medicated preparation with it, and may be conducted to the air- passages through a cone of paper placed over the vessel containing the medicament. These vapors are more efficient than atomized fluids. Simple steam or vapor from a two per cent, solution of common salt or of sodium bicarbonate may be used. If there is fetor, carbolic acid may be used in the atomizer, a two per cent, solution, or thymol one part in 1000. Alkalinity is an essential condition of easy secretion from the air passages, so that both inhalations and internal remedies should fulfill this condition. Hence, simple liquor potassse, U. S. P., in fifteen- to twenty- minim (i c. c. to 1.25 c. c.) doses in milk is a good remedy. To this end the free use of alkaline mineral waters, as those of Vals, Vich}^, and Ems, is useful. Digitalis and strychnin are excellent medicines, especially the latter. Both stimulate the cardiac action and aid in pumping the blood through the lungs with increased force, thus causing relief to the congested mucous surfaces. Strychnin in ascending doses may be given with advantage. As to health resorts suitable for cases of chronic bronchitis, those with a dry climate, not too cold, should be selected for cases with copious secre- tion, such as southern Georgia and the Carolinas or New Mexico in this country, or for stronger persons the cooler climate of Colorado. For cases of dry bronchitis the warmer moist climates of Florida are very suitable. In this, as in all other diseases, the factor of complete bodily and mental rest enters largely into the cure. Chronic bronchial catarrhs always improve in summer, and it is gen- erally sufficient if the patient be directed to leave the hot and noisome city and spend his summers either in the mountains or at the seaside, where the air is pure and bracing. Of foreign resorts, those of southern Europe, especially Italy, the "western Riviera, San Remo. Mentone, and Cannes, are suitable, while still better, if they can be availed of,, are Egypt, Algiers, and the island of Madeira. 524 DISEASES OF THE RESPIRATORY SYSTEM. BRONCHIECTASIS, OR BRONCHIAL DILATATION. Historical. — Laennec (1S19) was the first to describe anatomically bronchial dila- tation, and his admirable account remains at the present day the standard description of the condition. It should be mentioned, however, that Laennec himself tells how his attention was first called to it by Cayol, at that time a student, but afterward a professor of medicine, who was "astonished at finding a diseased state of the lung which up to that time had remained undescribed." This, according to Laennec, was in iSoS. Laennec attributes the formation of bronchiectatic cavities to mechanical cause — viz., the pressure of bronchial secretion. Andral (1823) called into play dis- turbances of nutrition, and Reynaud (1835) the respiratory act. Etiology. — The most common cause of bronchiectasis is chronic bron- chitis, either simple or tubercular, the effect of the inflammation being to weaken the bronchial walls so that they yield to the inspiratory and expira- tory strain to which they are subjected in the act of coughing. It is, there- fore, often associated with emphysema. The same cause contributes to the bronchial dilatation following bronchopneumonia, measles, and whooping- cough in children. Accumulated secretion is also a factor, as seen in the dilated bronchi which succeed obstruction of a bronchial tube by a foreign body, or compression by aneurysm or mediastinal tumor. The traction associated with fibroid induration is also a cause of bronchial dilatation ; hence we find it in association with interstitial pneumonia and sometimes in chronic pleurisy. Finally, bronchial dilatation is-rarely a congenital defect, in which event it is also commonly unilateral and general — bronchiectasis universalis of Grawitz. Morbid Anatomy. — Bronchial dilatation is cylindrical and sacculated. The terms explain themselves. Both forms may occur in the same lung. In the cylindrical form, which is the more common, dilated tubes of nearly equal caliber may run through the substance of the lung, from the root to the pleural surface, producing an appearance not unlike the fingers of a glove. More frequently the smaller tubes only are affected, dilatation being recognized at autopsy by the inequality of lumen, rather than by ante- mortem physical signs. It may, however, be suspected in any case of chronic bronchitis with copious expectoration. The saccular bronchiectases are spherical or oval dilatations, into which the tube merges gradually or suddenly. They may attain a diameter of from two to three inches (5 to 8 cm.), more or less. The lung tissue about a saccular dilatation is rarely normal. Commonly, the dilatations, single or multiple, are surrounded by indurated and contracted lung tissue, the trac- tion of which on the bronchial wall produces the dilatation. Adhesion of the lung to the costal pleura also contributes, and large subpleural cysts are at times thus formed by the contracting tissue. The cavities thus produced are commonly at the base of the lung, while in chronic phthisis they are found at the apex. Cylindrical and saccular dilatation may also be associ- ated under these circumstances. In universal bronchiectasis the entire bronchial tree is converted into a series of sacs communicating one with the other. Alany cavities in pulmonary consumption are primarily bronchiec- tatic cavities. In all forms there is decided change in the bronchial wall, the prin- cipal feature of which is atrophy. This atrophy not only attacks the mucous coat, but also the muscular, and sometimes the elastic tissue and cartilage, reducing the wall to a thin, smooth membrane, lined with pave- ment epithelium, instead of the usual cylindrical form. At times over- growth, involving particularly the connective tissue, takes place, forming BRONCHIECTASIS. 525 lattice-like projections on the inner surface of the tube already referred to in treating of chronic bronchitis. At other times ulcerative processes de- velop, perforating the bronchus and invading the lung parenchyma, con- verting the bronchiectasis into an ulcerating cavity. Symptoms. — These, in addition to those of the disease with which the bronchiectasis is associated, are the peculiar sputum and paroxysmal cough. The sputum furnishes the most distinctive feature, from which alone the diagnosis can sometimes be made. It is muco-purulent, of a dirty yellowish-green color and unpleasant, stale, and sweetish odor, though not .exactly fetid, as in fetid bronchitis. It is often raised in mouthfuls — another characteristic. It also separates into layers, usually three, of which the upper is frothy and thin, the middle mucoid, and the lowest made up of pus and epithelium in various stages of fatty degeneration, acicular fat crystals, and sometimes red blood discs and hematoidin crystals sufficient to color it. Elastic tissue of the lung is not usually present ; nor are tubercle bacilli, unless there is associated tuberculosis with ulceration of the bronchial walls. The cough is paroxysmal, because it is not usually excited until the sac, which is often insensitive, becomes full enough to irritate the healthy mucous membrane, when cough is at once excited and continues until the cavity is empty. The paroxysms are usually in the morning, when they may be excited by a change in position. After their termination there is com- monly a long period of rest until the sac — or a sac — is again filled. The more paroxysmal the cough and copious the expectoration in chronic bron- chitis, the more likely is there to be a dilated bronchus. Very characteristic is the absence of fever. Physical Signs. — When distinctively present, they are those of a cavity in the lung, readily recognizable when near enough to the surface. They include tympanitic percussion note, bronchial and even amphoric breathing, bronchophony or pectoriloquy if the cavity is empty. If it contains liquid, gurgling may be heard and the percussion note is dull. To palpation there is usually increased vocal fremitus, caused by surrounding consolidation. All signs vary according as the cavity is filled or emptied of secretion. A restricted breathing excursion may also be present, uninfluenced by the state of the cavity, whether full or empty. Diagnosis. — A bronchiectatic cavity is usually distinguished from a phthisical cavity by the absence of tubercle bacilli and elastic tissue from the sputum of the former, the situation of the cavity in the center instead of at the apex of the Ivmg, the history of its development, the absence of cachexia and fever. Hypertrophy of the right ventricle is more frequent in bron- chiectasis, but may also be present in fibroid phthisis with or without bronchiectasis. A circumscribed empyema which has ruptured into the lung is much more sudden in its development than bronchiectasis, while the history of a previous pleurisy is superadded. A coincident external perforation of an empyema would clear up all doubt. A true abscess of the lung which has found its way into a bronchus has also a different history of origin, suc- ceeding, as it usually does, a pneumonia, a massive hemorrhage, or trau- matic cause. The same is true of gangrene of the lung, which is, however, disclosed by the extreme fetor of thp breath and expectoration. Treatment. — This includes that of chronic and fetid bronchitis, to which may be added, under favorable circumstances, the injection of sacs and their drainage. It is to he remembered, however, that physical signs 526 DISEASES OF THE RESPIRATORY SYSTEM. are sometimes misleading, and that what seems to be the clearest evidence as to the exact site of a sac is not always to be relied upon. I well remember a case of my own in which there seemed to be the most conclusive evi- dence of the presence of a dilated bronchus below the angle of the left scap- ula — evidence satisfactory not merely to myself, but also to my colleagues, William Pepper and J. William \M'iite. At my request. Dr. White opened the thorax by exsecting parts of two ribs, when, to our astonishment, no cavity could be found by the cautious use of exploring needles. Prompt closure of the wound was followed by healing, and the patient lived for eight months. The cure of well-established bronchiectasis is impossible, except, per- haps, in young persons. Something may be done to prolong life and make the patient more comfortable and less disagreeable to others. To this end we must aim at the evacuation and disinfection of the offensive purulent secretion, and as far as possible the obliteration of cavities. For the first of these, the inhalation of crude creasote vapor was recommended, first by Arnold Chaplin, and indorsed by Theodore Dyke Acland in an exhaustive paper on this subject. Intralaryngeal injections of oily and antiseptic sub- stances have been employed, with doubtful results. The difficulties in the way of operation are shown in the first paragraph on treatment. BROXCHIAL ASTHMA. Definition. — Bronchial or spasmodic asthma is a paroxysmal asthma or a panting for breath, which is the direct result of a contraction of bron- chial tubes. Etiology. — There is some diversity of opinion as to the etiology^ of bronchial asthma. This much, however, is admitted, that in some way there is produced a narrowing of the smaller bronchi. Various explanations of the narrowing are suggested. Some allege a simple swelling of the mucous membrane to be a cause. Such swelling is variously spoken of as " fluctionary " (Traube), "vasomotor turgescence " (Weber), "diffuse hyperemic swelling," or "exudative" inflammatory swelling (Curschmann). On the whole, the older view of Trousseau, that the narrowing is due to a spasmodic contraction of the muscular coat, seems the most likely one, and has recently received the support of Biermer. Mention should be made of the theory of "Wintrich and Bamberger that asthma consists in a tonic spasm of the diaphragm, a theory which Riegel has further developed by ascribing the spasm to a superexcitation of the phrenic nerve, resulting in a partially inhibited excursion of the diaphragm. Accepting Trousseau's view of a primary spasmodic contraction of the bronchi, it becomes necessarily a reflex act, the causes of which are various. It implies, first, a hyperexcitability of the reflex center. Hence bronchial asthma is not infrequent in neurotic persons, and has even been classed as a functional nervous disease with neuralgia and epilepsy, with which it is said to alternate at times. Such hyperexcitability is sometim.es inherited, so that bronchial asthma often runs in families. Presupposing such excitability, numerous peripheral causes may supervene, the most fre- quent of which is bronchitis. It very often happens that an asthmatic sub- ject has an attack of asthma, brought on by " taking cold," the incident bronchitis being the exciting event. BRONCHIAL ASTHMA. 527 Comparatively modern studies have demonstrated the association of some affections of the throat and nasal passages with bronchial asthma, and that their removal has resulted in its cure. Among these have been en- larged tonsils, chronic catarrh, nasal polypi, and the like. Other causes in susceptible persons are impressions of certain odors, pleasant and un- pleasant, notably that of flowers or plants in early summer, whence the term " rose " asthma and hay asthma, both of which are allied affections. A change of air, as from town to country, or the reverse, or from mountain to lowland, acts similarly. Causes more remote than those of the nasal ^passages, such as gastric derangement, intestinal worms, uterine disease, may be admitted. Purely emotional causes, as fright and emotion, may also act. The frequency of bronchial asthma in children has already been mentioned. It is more common in the male sex. Morbid Anatomy. — Whatever may be the morbid state of the tubular structure of the lung during an attack of asthma, there are no post- mortem appearances which are distinctive of it. In the first place, the chance is seldom offered at the opportune moment, and I know of no report of a necropsy made on a person dying during an attack of asthma. In the case of the asthmatic dying at other times, there may be found the morbid states peculiar to chronic bronchitis and emphysema, but nothing more. Symptoms, — The symptoms of an attack of spasmodic asthma are unmistakable. The typical asthmatic is apparently in good health between the attacks, and often is so up to the time of the attack, which then comes on suddenly, often at night. At other times there is a prodromal stage, a feeling of thoracic discomfort or " tightness " in the chest, or an anxious, nervous, restless feeling, the import of which is well understood by the victim. The attack consists of a long-drawn-out inspiratory act, in which it is evident the air cannot get into the lung fast enough to meet the demands of the besoin de respirer. The auxiliary muscles of respiration, the sterno- cleidomastoid, and the scaleni, do their best to enlarge the thorax, but that is not the difficulty. It is the contracted tubes which resist the entrance of the air. Even more marked are the effort and the duration of expiration ; hence the dyspnea is spoken of as an expiratory dyspnea. The abdom- inal muscles are the auxiliaries here, and they contract strongly and assume a board-like hardness. The air is heard to whistle as it enters and passes out of the chest. The patient sits in an upright position, or leans slightly forward, and often astride of a chair grasps the back with his hands, for it is by fixing the shoulders that he can bring the extraordinary muscles of respiration into play. His face is anxious, pale, or it may be cyanotic, and few more distressing pictures are seen. Notwithstanding his efforts, they fail of their purpose and comparatively little air enters the lungs. With all these efforts, the breathing is not accelerated, — at least accelerated to any marked degree, — while in a few instances the breathing-rate is diminished. The temperature is normal or subnormal, and the pulse is accelerated and small. The attacks last for a variable period, rarely less than an hour, and unless broken up, sometimes several hours. They may terminate as suddenly as they began, sometimes with a spell of coughing. On the other hand, cough is not a fmirked symptom, and in brief paroxysms of asthma may be altogether wanting. In the severe ones, however, it is present, accompanied by a tough and scanty expectoration, containing rounded masses of matter, either yellowish or grayish translucent — the " perles " of Laennec. On q28 DISEASES OF THE RESPIRATORY SYSTEM. minute examination, these are found to be made up of the so-called Cursch- mann's spirals, together with numerous swollen and fatty degenerated pus- cells and cells shed by the bronchial mucous membrane and alveoli. The spirals have long been recognized, but were first studied bv Ungar and Curschmann. They appear to be made up of mucin spirally arranged, en- tangling pus-cells and alveolar epithelium. A second form of Curschmann's spirals contains, in the inside of a tightly-wound spiral of mucin fibrils, another bright, clear filament. The spirals are believed by Curschmann to be formed in the finer bronchioles, and to be a product of bronchiolitis. Their spiral form is unexplained. The sputum also sometimes contains crystals of calciiun- oxalate and calcium phosphate. The yellow masses contain, in addition to the cells named, various numbers of acicular crystals, which were first found by Leyden in the sputum of asthmatic patients, and therefore called Leyden's crystals. They are identical with the so-called Charcot's crystals, found in leukemic spleen, bone-marrow, and semen. In addition to the cases of typical asthma in patients perfectly comfort- able between attacks, and for which the foregoing description is intended, — while arsenic is an admirable tonic either in the shape of Fowler's solution, five drops at a dose for an adult, or of arsenious acid, 1-30 grain (0.0022 gm.). While the bronchitis is treated by the usual remedies, it is of the utmost importance that the stomach should be kept in good condition, and that diges- tion should not be interfered with, while more than ordinary care is required in the selection of remedies for the bronchitis. A very useful measure in these cases is counterirritation, which in no way interferes with digestion. This may be applied in various ways ; blisters, iodin, and mustard may be used. A mustard plaster can be so prepared that it may be worn continuously without discomfort — taking mustard and flour in the proportion of one to five, and using equal parts of the white of an egg and glycerin with which to mix it instead of water. Strychnin is an admirable remedy, not only as a tonic, but it may also be regarded as an expectorant, and secretions in the lungs are often disposed of by its use. It has also the effect of improving the nutrition of the muscular tissue of the walls of the bronchi, as it has of improving the muscular tissue in general. Full doses should be given — not less than 1-30 grain (0.002 gm.) three times a day, increased gradually to 1-12 grain (0.0055 gn^-)- This is to be kept up for a long time. Bronchial asthma is one of the most serious and frequent complications, and often overshadows all else. There is no more eiBcient means of breaking up such an attack than the hypodermic injection of 1-4 grain (0.0165 gm.) of morphin with 1-120 grain (0.00055 g^n-) of atropin. This will usually relieve the paroxysm almost immediately. If relief is not complete, the TUMORS OF THE LUNG. 537 injection may be repeated and renewed every six hours. The various inhala- tions employed for asthma may be used, such as the smoke of burning stra- monium or tobacco, ether, chloroform, and amyl nitrite. Of course, in con- nection with the attacks of asthma the other remedies of service in relaxing spasm, such as belladonna and iodid of potassium, may be given. Tincture of belladonna in doses of five to ten minims (0.31 to 0.62 c. c.) combined with ten grains (0.66 gm.) of iodid of potassium will break up so much of this condition as is due to spasmodic contraction of the tubules. To relieve the constant dyspnea, the treatment suggested some years ago bv Waldenburg is one the usefulness of which is only limited by its rela- tive difficulty in application and the costliness of the necessary apparatus. It consists in the inspiration of compressed air and the expiration into rarefied air. It is evident that if compressed air can be introduced into the vesicles, the aeration of the blood will be more perfect, and that if the patient breathe into rarefied air, the residual air, which it is so difficult to get rid of, will be more effectually sucked out. The compressed-air chamber has a similar purpose. Expiration may also be aided by compression of the chest, intermittently applied so as to coincide with natural breathing. This must usually be prac- ticed by a nurse or an attendant, but Striimpell describes in his text-book a simple contrivance devised by a patient of his own for self-treatment. It consists of two boards fastened behind and allowed to project forward on each side in front, so that the patient himself, taking hold of the projecting ends, can compress his own chest with each act of expiration. TUMORS OF THE LUNG. The lungs are subject to morbid growths classified as tumors, though, owing to their situation, they rarely present the macroscopic, tumor-like qualities. They include carcinoma, and many of the histioid tumors. Etiology and Morbid Anatomy. — Carcinoma occurs rarely as a primary growth, but is not infrequent as a secondary new formation. Primary can- cer presents itself usually in the shape of a white or yellowish nodule two to four inches (5 to 10 cm.) in diameter. It is found in the upper lobe of one lung, posteriorly and externally ; more seldom in other parts. It probably originates in the alveolar epithelium, and causes secondary infiltration of the bronchial glands and pleura. It may be represented by any of the three prin- cipal forms, scirrhous, encephaloid, or epitheliomatous, also by colloid and melanotic. It occasions a reactive pneumonia in the lung tissue about it, and often furnishes the physical signs of this affection. There also occurs in the lung a primary peribronchial cancer, dissemi- nated in nodules throughout the lung along the bronchi, smaller nodules on the smaller bronchi, and larger, irregular masses on the larger, varAdng in size from that of a pea to a walnut. It produces also infiltration of the lymph glands at the root of the lung. Sarcoma is also a rare form of pri- mary tumor of the lung. jMore frequently both carcinoma and sarcoma are found in the shape of secondary nodules invading both lungs.' From three to twenty opaque W'hite nodules, 1-2 inch (1.25 cm.), more or less, in diameter, are found 538 DISEASES OF THE RESPIRATORY SYSTEM. irregularly scattered through each lung. Every variety of primary cancer may be thus represented secondarily in the lung. Its origin is probably embolic, and it may be secondary to cancer elsewhere, most frequently in the breast. As elsewhere, these growths generally present themselves after middle life, primary cancer affecting either sex about equally, while secondary is more common in women, consistently with the more frequent occurrence of cancer elsewhere in women. The histioid tumors are represented by a subpleural enchondroma, occur- ring, rarely, primarily as large as a walnut ; more frequently, secondary to occurence elsewhere, when it may attain a large size. Other histioid tumors are myxoma, adenosarcoma, dermoid cysts, hydatid cysts, fibromata, osteo- mata, and gummy tumors. Symptoms. — Carcinoma and sarcoma may both be latent, or at most produce such vague symptoms that it does not occur to physician or patient to locate them. There may, however, be pain, oppression, cough, expecto- ration, and superficial signs of vascular obstruction, such as lividity of the face and swelling of the upper extremities. The encroachment of the larger cancerous masses upon the pleural cavity may be marked. Pressure on the trachea and bronchi may occur and occasion great dyspnea, while the heart may be dislocated. The pneumogastric and recurrent laryngeal nerves are sometimes involved, occasioning the various forms of paralysis of the vocal cords and aphonia. The reactive pneumonia referred to may present the physical signs distinctive of this disease, and it is probably thus that the prune- juice expectoration, thought to be quite characteristic of cancer of the lung — ten times oiit of eighteen, as elaborated by Stokes many years ago, — originates. This complication, too, may occasion the fever which is some- times present. The external lymphatic glands, as those in the neighborhood of the clavicle, may be involved and exhibit enlargement. Sooner or later, if the patient lives long enough, — that is, if his life is not destroyed by some encroachment on the breathing or vascular function, — he emaciates, and becomes cachectic and debilitated. The more usual dura- tion of the disease is from six. to eight months, but death is liable to occur suddenly from the causes named. Physical Signs. — These, of course, are indefinite, and it is probably their indefinite and irregular manifestation, with the symptoms named, which will suggest the nature of their cause. Physical signs of pneumonia and pleurisy, either alone or combined, may be present, the voice and breathing sounds and percussion note being affected" accordingly. Diagnosis. — This, in the case of primary cancer elsewhere, is suggested whenever any of the symptoms named occur in a pronounced degree and are sufficiently long continued. In the case of primary growths, the diagnosis must longer remain doubtful, and we must study and await the development of the more distinctive symptoms. The non-malignant tumors present no signs by which they can be dis- tinguished from the malignant, except that their course is less rapid and they develop no cachexia. Treatment. — This consists only in measures calculated to relieve symp- toms and to make the patient comfortable. ACUTE PLEURISY. 539 DISEASES OF THE PLEURA. ACUTE PLEURISY. Definition. — Acute inflammation- of the serous investment of the lung or of its reflection on the ribs and diaphragm. Etiology. — I still believe that pleurisy may be caused by simple chilling of the body during exposure to cold, in other words, that not every pleurisy is a tubercular pleurisy. Doubtless more cases are tubercular than was for- merly supposed, but it does not seem likely that the large number, exhibiting the physical signs of pleurisy, from which recovery is apparently complete, can originate in this way. At the same time it must be admitted that the proportion of cases which are tubercular in origin is very much larger than was at one time supposed, and, moreover, that many cases of tuberculosis supposed to have succeeded upon pleurisy have really been primary tuber- cular pleurisy. The conclusions of a very important paper read by Richard C. Cabot before the Association of American Physicians in May, 1902 * may be said to be the most recent expression of our knowledge : 1. Eighty per cent, of the cases of uncomplicated serous pleurisy are in good health after five years or more (more than half of these have been fol- lowed for ten years or more). 2. Ninety per cent, are apparently in full health at the end of from two to five years — that is, the pleurisy had no immediate connection with any other affection. 3. Fifteen per cent, of the cases have sooner or later developed demon- strable tuberculosis of lung or bone, but in only three per cent, has this tuber- culosis manifested itself within two years of the date of pleural efifusion. 4. The type of tuberculosis which occurred in these cases was, as a rule, mild and of slow course. Death did not occur until five years or more after the pleurisy in one-half of the 23 cases which developed obvious tuberculosis. Six of the 23 are still alive, despite the tuberculosis, after periods of ten, nine, six, four, two, and one year. 5. Nevertheless, a very rapid form of tuberculosis may develop many years after the pleurisy — nine years and sixteen years, respectively, in two cases of this series — so that the patient is never safe from the possibility of death from tuberculosis merely because his pleurisy lies ten or fifteen years Ibehind him. 6. A study of the clinical records of the whole group of patients under consideration shows that among those who have remained in perfect health for five years or more only 25 per cent, had any family history or past history of tuberculosis, while of those who have become tuberculous 67 per cent, had tuberculosis in their immediate family or in their own past history. A care- ful history, therefore, is of great importance in the prognosis of pleural effu- sion. On the other hand, the physical signs during the course and convales- cence of the pleurisy were not markedly different in the group of cases in which tuberculosis later developed from the signs in those who have remained well. 7. Recurrence of the pleurisy itself in patients who have recovered from the original attack occurred in only five cases, or 3 per cent, of this series. * " Transactions of the Association of American Physicians," vol. xvii., igo2, p. 156. 540 DISEASES OF THE RESPIRATORY SYSTEM. Reaccumulation of the fluid immediately after tapping is rare, occurring in only two cases, or 1.3 per cent. 8. Among the 14 patients who, after recovering from the pleurisy, died of some other disease not one developed any disease which could reasonably be considered a result of the pleurisy — the causes of death were alcoholism, hepatic cancer, dysentery, pulmonary embolism, mitral stenosis, aortic regurgitation, chronic nephritis (3), cerebral hemorrhage, measles, pneu- monia (3). 9. Finally, no attempt was made to discover what percentage of this whole group of cases is due to tuberculosis. So far as the statistics go the cases may be all of tuberculous origin. What his figures do tend to prove is that whether pleurisy means tuber- culosis or not, the outlook is bright, provided no family history of tubercu- losis clouds it. If pleurisy means tuberculosis, it is a very mild form of tuber- culosis and one from which recovery is usually complete under proper treatment. In addition to tuberculosis as a primary cause of pleurisy we must mention rheumatism and chronic Bright's disease as predisposing causes, at least. It should be said, also, of the latter that a certain proportion of them have been relegated to the tubercular pleurisies. The pleurisies which go to make up the sum of the phenomena of pyemia are of undoubted microbic origin. If rheumatism be microbic, then, too, the pleurisies which occur secondary to it must, of course, be referred to the same category. In addition to these instances of primary and secondary pleurisy must be mentioned those which are the result of extension of inflammation by continuity and contiguity, as from the adjacent lung to the pleura over it or from the diaphragm to the pleura above it ; also pleurisies of traumatic origin. Morbid Anatomy. — The morbid anatomy of pleurisy will be best understood by supposing every pleurisy to begin, as it probably does, with a dry stage, a plenritis sicca, whatever may be its subsequent course. Thus considered, the earliest stage of all pleurisies has a hyperemic basis, suc- ceeded immediately by a roughness of surface due to loosening and detach- ment of the epithelium, a roughness increased by the addition of fresh inflammatory lymph composed of transuded fibrin and wandered-out leuko- cytes from the subpleural blood-vessels. Further progress of such pleurisy is — First, toward resolution, in the course of which the product described liquefies and is reabsorbed. Second, toward organization and adhesion, in which vascularization and fibrillation take place and the two surfaces of the pleura are more or less permanently glued together over an area corresponding to that of inflamma- tion. This is the probable explanation of the little patches of adhesion so frequently found at autopsies, some of which may have formed without the consciousness or discomfort of the patient, while others have succeeded upon a " stitch " in the side which has been passed by as of little conse- quence. Other instances of this primary adhesive inflammation are found between the opposed surfaces of pleural membrane covering tubercular deposits in the lung, or limited pneumonic areas, or morbid growths, such as gummy tumors, cancers, and sarcomata. Third, toward serous accumulation constituting exudative pleurisy, in which varying quantities of fluid are transuded into the pleural cavity. In ACUTE PLEURISY. 541 this usually clear, straw-colored exudate may be suspended shreds of the yellowish plastic lymph already described, which accumulates also most abundantly where the movement of the pleural surfaces is least, as in the chinks and corners of the pleural cavity. This effusion also, in a large number of cases, is absorbed, allowing the pleural surfaces to approach each other and again unite by what is known as secondary adhesive inflam- mation, organization taking place as before, producing either continuous fusion or bands of new tissue attaching different parts of the pleural surface. The question as to how the process of exudation is stopped is an interesting -one, which cannot be satisfactorily answered, though it is probable that pressure of accumulated fluid and contraction incident to organization, as well as cessation of the cause, may be a part. The ordinary serous fluid which commonly fills the sac in sero- fibrinous pleurisy is a highly albuminous liquid, sometimes coagulating spontaneously, in which may be found a few leukocytes, exfoliated endo- thelial cells, shreds of fibrin, and sometimes a few red blood discs, ^lodifications are those in which the red blood-corpuscles are much in- creased, producing a bloody fluid, or in which leukocytes are variously numerous, short of a number sufficient to justify the term pus. Urea, uric acid, and sugar are sometimes found in pleural exudates. The quantity of fluid ranges from half a liter to four liters ( i pint to 4 quarts). Fourth, toward pus-formation, in which either primarily, from the outset, or secondarily, — that is, some time after the process has com- menced, — the microbes of suppuration become active, and produce a puru- lent product or an empyema. The onset of this wandering out of number- less colorless cells is often announced by a chill. Even such an accumulation of pus may in rare instances disappear without active interference, per- miitting the approximation and union of the two pleural surfaces. The pleural surfaces thus apposed are, however, comparable to an ulcer, and the union and repair take place by formation of cicatricial tissue. This is subject to the contraction usual to such tissue, dragging not only the heart and lungs out of place, but also in extreme cases the ribs and vertebrae, pro- ducing slight lateral curvature of the spine. Various displacements of adjacent organs are caused by the liquid effusion, in right-sided pleurisies the liver is depressed. A very strik- ing case came under my notice, in which the liver was pushed so far forward and downward as to produce the appearance of an abdominal tumor to the left of the epigastrium. In left-sided pleurisies the heart may be displaced so far that the apex will be to the right of the sternum. The displacements from traction after organization are difiicult to describe, but the heart may be dragged so that its apex is much higher than is normal or further to the right, while the parts of lung adherent are drawn in various directions, with the production, at times, of bronchiectatic cavities. If the patient die while large liquid effusions are present, the lung is also found compressed into the back part of the pleural sac. Symptoms. — The initial symptom of pleurisy is usually pain — at first in the side. It may, however, be preceded by a chill, and at times there may be a short prodrome of discomfort in no way peculiar. The pain in bad cases is of the severest kind, and among the pains most difficult to relieve. It is sharp and cutting in character, aggravated by breathing, so that the patient takes the shortest breath possible, and the breathing is made up of short, hurried gasps. Cough likewise causes agonizing pain, and it is 542 DISEASES OF THE RESPIRATORY SYSTEM. accordingly restrained. Xor is the pain in these cases always confined to the chest, but may shoot down into the abdomen and back. The latter probably implies that the diaphragmatic pleura is involved. Fever is also a constant symptom, but is not, as a rule, so high as in pneumonia. At the beginning the temperature may be 102° or 103° F. (38.9° or 39.4° C), but it subsides early, even though the other symptoms abate but partially, and under any circumstances it falls much lower after a week or ten days unless there is purulent exudate, when the fever assumes a hectic type. The cougli is peculiar enough to require special mention. It is a short cough, attended with little expectoration, and is a much less conspicuous feature than in pneumonia. Its characteristic shortness is due to the pain caused by the act of coughing, on account of which the act is cut short. The decubitus of pleurisy is quite constantly on the affected side, in order that the unaf- fected side may be free to expand. The patient also has less pain when he lies on the affected side, because the range of its motion is restricted. This pertains to pleurisies associated with copious effusions, as well as dry pleurisies. While the majority of pleurisies begin in this way, a certain number also begin insidiously. For days and even weeks the patient, while feel- ing uncomfortable and doubtless feverish and slightly dyspneic, continues his occupation, and even when the physician is called, scarcely mentions symptoms which suggest an examination of the thorax. Such pleurisies are known as latent pleurisies. They are latent only to superficial observa- tion. Closer investigation promptly reveals the physical signs of a pleural effusion. It has already been mentioned that purulent pleurisies may be primary or secondary. In any event, they are most frequently tubercular, and an examination of the pus from such a pleurisy not infrequently discovers the tubercle bacillus in it. Physical Signs. — Acute pleurisy is also resolvable clinically into three stages, each of which is characterized by physical signs more or less dis- tinctive. They include a dry stage, a stage of effusion, and a stage of reso- lution or absorption. The Urst or dry stage is characterized anatomically by the presence of the so-called lymph or exudate on the pleural surfaces. During this is re- vealed to inspection a restrained expansion of the affected side, often thrown into jerks or catches because of the pain suffered in a continuous inspira- tion. The expansion on the opposite side is full and unhampered. The patient lies on the affected side. Palpation may recognize a fremitus corre- sponding to the friction of the two pleural surfaces. Percussion in this stage is negative, except that it may cause pain, but auscultation recognizes the friction sound, which will be further characterized in treating diagnosis. It may be at a single spot in the inframammary or infra-axillary space, and hence be overlooked. At other times it may be noted over a considerable area. According as the inflammatory process stops here with resolution or continues into the second or stage of effusion, there may or may not be other signs. The signs of the second stage vary with the amount of liquid in the sac; with a small amount the lungs are slightly floated up, and there may be no signs, unless it be a vesiculotympany above the line of the fluid, a Skodaic resonance by mediate relaxation of the air vesicles. The effusion, however, rarely remains so trifling, but commonlv rises to the midchest. In the ACUTE PLEURISY, 543 upright position of the patient inspection recognizes in a spare person shal- lowness and perhaps obliteration of the lower intercostal spaces. The motion of the chest-wall is lessened both in the vertical and transverse directions. To' palpation vocal fremitus is diminished over the area of effusion, but may be increased in the lung above it. To percussion there is absolute flatness over the area of effusion, but the line of demarcation is not every- where at the same level, being higher behind than in front. The late Cal- vin Ellis first called attention to an S-like curve in the line of demarcation which is said to be diagnostic. Very important in the diagnosis is the fact that the fluid changes its level when the position of the patient is changed, and correspondingly the line of dullness is altered. There is also an abnormal sense of resistance to the finger in percussing over the area of effusion. Above the effusion, especially anteriorly, there is again Skodaic resonance by mediate relaxation, and even rarely a " cracked-pot " sound. Tympany may also be due to the proximity of a distended stomach. Meas- urement discovers that the circumference of the affected side is a centimeter (0.4 in.) or more greater than that of the other side. To auscultation the breathing sounds are inaudible or very feeble, as compared to the corresponding portion of the opposite side, but vocal reso- nance, though diminished, is still distinctly heard where the collection of fluid is moderate. Above the line of dullness there is occasionally a friction sound, and close to the root of the lung bronchial breathing may be heard. This is, however, more apt to be the case when the effusion is larger and the lung is further compressed. Egophony is also sometimes heard. When the effusion is larger, filling up two-thirds or three-fourths of the pleural sac, the effects described are increased, while new ones are added. Inspection notes that respiratory movement is still more hampered, that the intercostal spaces are widened and even bulging, while fluctuation may sometimes be recognized through them. The heart is displaced by the accumulated fluid, and if the fluid be in the left sac, the apex is often found far over to the right of the median line, and if in the right, the apex may be pushed further to the left. The heart-sounds are not, however, altered. On the opposite side the breathing movements are supplementally increased. There is complete absence of vocal fremitus on the affected side. Percussion is absolutely flat all over the effusion, and Skodaic reso- nance is not now obtainable, because the lung is too thoroughly compressed up into the apex of the sac. Resistance to pressure is marked. On auscul- tation bronchial breathing may be heard at the upper posterior portion of the lung, because the large tubes are still pervious to air, and the compressed lung intensifies the sound. Sometimes bronchial breathing is heard in more peripheral parts of the chest, probably conducted hither along a band of ad- hesion or along a rib. Elsewhere there is absence of breath-sounds. Vocal resonance and whispering voice are alike absent, or the former is very feeble. In certain situations, too, high up, where there is but a thin film between the chest-wall and the lung, there may be egophony, but this is more likely to be present as the fluid is being absorbed. In the third stage, if resolution takes place with a gradual retrocession of the fluid and the re-expansion of the lung, we have a return to normal physical signs. There may be, too, a friction rediix. A considerable time is, however, required for absorption, and it is often many days before the normal breathing sounds are heard with their usual intensity or the natural fremitus is felt. Often, on the other hand, resolution is not complete, and 544 DISEASES OF THE RESPIRATORY SYSTEM. the two surfaces become glued together, constituting a plastic pleurisy, and the feebly-heard breathing sounds and diminished fremitus and vocal reso- nance remain more or less permanent (chronic pleurisy). There then re- main the symptoms and sequelae of a chronic pleurisy. In cases of purulent pleurisies, if recovery takes place it is always by adhesion of the apposed surfaces. (See Chronic Pleurisy.) In connection with the heart, pleuropericardial friction may be heard if the pleura covering the portion of the lung adjacent to the pericardium is involved. The apex-beat may not be discoverable if it is so dislocated as to be covered by the sternum, and it often happens that the heart must be located by its signs. Varieties of Acute Pleurisy. — Tubercular pleurisy is a pleurisy due to the invasion of the pleura by the tubercle bacillus, and has been con- sidered when treating of tuberculosis. Diaphragmatic pleurisy is a painful form of pleurisy, in which the pleural covering of the diaphragm is involved, either alone or along with the re- maining pleura. It is usually dry, plastic, but may also be exudative, with a serofibrinous or purulent product. The pain is low down in the thorax in the zone of the diaphragm, and is often aggravated by deglutition as well as by breathing. Because of the pain in breathing, the diaphragm is fixed and the patient breathes by the upper thorax. Of diagnostic value is the fact that the pain may be increased by pressure at the insertion of the diaphragm at the tenth rib. Hemorrhagic pleurisy, characterized by bloody effusion, is found in asthenic states, however induced, in tubercular pleurisy, in which event the hemorrhage occurs from the young blood-vessels, and in cancerous pleurisy ; also sometimes in persons otherwise healthy. It is, of course, not to be confounded with blood-stained serum, caused by wounding a blood-vessel in the act of tapping or with a hematothorax from rupture of an aneurysm. Encysted or circumscribed pleurisy is a form of purulent pleurisy in which adhesions form so as to produce loculi, or spaces which are filled with pus. They are quite difficult to recognize during life — in fact, they are commonly found when exploring the chest with the needle. More rarely they are revealed to physical examination, dull percussion areas being found in alternation with clear areas. Such physical signs should suggest the use of the needle to clear up the diagnosis. These collections some- times pulsate and become pulsating pleurisies. Pulsating pleurisies are al- most invariably on the left si4e and receive in some way the impulse of the heart, which in turn is communicated to the eye or hand of the observer. The possible confounding of these with aneurysm will be again referred to. In interlobular pleurisy the apposed surfaces of two lobes of the lung are agglutinated, and sometimes a sac of pus is pent up between them, forming a variety of encysted pleurisy. Such an abscess may break into a bronchus. It is not usually recognized before autopsy. Diagnosis. — The certain diagnosis of pleurisy depends almost entirely upon the physical signs, for, however severe the other symptoms, there is nothing in them by w^hich the disease can be surely recognized. In the majority of cases of pl-eurisy the diagnosis is made easy by the aid of these signs. It is true there is a certain resemblance between pleurisy and pneu- monia in the first stage of each, and in that stage a diagnosis is often difficult, especially when the physical signs are not distinct. The resemblance of the ACUTE PLEURISY. 545 friction sound to the crepitant rale is well recognized. The usual distinctive features are the superficial situation and the intermittent character of the friction sound, its presence during expiration as well as inspiration, and if confined to one of these acts, rather to expiration, while the crepitant rale is heard only during inspiration. The friction sound is also usually rougher and more circumscribed, while it may sometimes be heard better with the stethoscope. Pain is very apt to be elicited in pleurisy if the stethoscope is pressed hard upon the chest. As the pleurisy becomes dry and adhesions form, the friction sound resembles more closely that of creaking leather. In the second stage of pleurisy, too, furnishing as it does a dullness on percussion like that of the same stage of pneumonia, and frequently bron- chial breathing, we have also a resemblance in the physical signs. But it is true of the bronchial breathing of pleurisy that it is comimonly best heard at the upper border of the dullness and least where the dullness is most marked ; whereas, in pneumonia the bronchial breathing is most intense where the consolidation is greatest. Above all, in pleurisy zcith effusion there are diminished vocal fremitus and diminished vocal rcsoiance ; in pneumonia, increased vocal fremitus and increased vo'cal resonance. There is commonly, further, in pleurisy with effusion, a change of level of the dullness with a change of the position of the patient, which is not the case in pneumonia. The egophonic voice is also often here present in pleurisy; whereas we have only bronchophony in pneumonia. Finally, in the differential diagnosis be- tween acute pleurisy and pneumonia, the trifling cough and absence of ex- pectoration in the former are valuable signs, though it must not be forgotten that in old persons there is sometimes very little cough in pneumonia. As to further differential diagnosis, pleurisy in the dry stage has been mistaken for muscular rheumatism, intercostal neuralgia, periostitis, and caries of the ribs, and even gastralgia and ulcer of the stomach. The ab- sence of fever in the first two, the circumscribed situation of disease of the ribs, and the associated history of gastralgia and ulcer of the stomach, serve to differentiate them. The confusion of mediastinal tutnors arising from the pleura itself with pleurisy is a natural error, especially since such tumors in their turn pro- duce pleurisy. In pleurisy, the physical signs are commonly limited to one side, while in mediastinal tumor the fremitus is less diminished, the dullness extends upward, is more irregular, and more circumscribed ; while symp- toms of compression of nerves and vessels, and of encroachment on the esophagus sooner or later make their appearance. Repeated exploratory punctures may be necessary to settle the diagnosis, which, after all, may require some time. The impulse of a pulsating empyema sometimes very strongly suggests an aneurysm, but the empyema furnishes no murmurs or pressure symptoms, while the location is usually different from that of aneurysm. Prognosis. — The prognosis of acute pleurisy depends largely upon its cause. The simple pleurisies which are the result of cold always get well, and recovery is the termination in most cases even when there is large effu- sion, if the exudate remains serous. It has already been said that a purulent pleurisy is, in the vast majority of instances, tubercular. We have learned, however, that a tubercular pleurisy is, not necessarily fatal, and it is more than likely that some of the cases of healed empyema with which we are familiar are instances of such recovery. Others are cured by the introduc- tion of drainage-tubes and exsection of ribs, but often the patient slowly 35 546 DISEASES OF THE RESPIRATORY SYSTEM. succumbs to the exhausting effect of the ihness or to tuberculosis of the lungs. Not a very rare event is the spontaneous rupture of such a pleurisy outward, an event better anticipated by paracentesis. Very stubborn, too, are the somewhat rarer cases in which perforation takes place from the pleural sac into the lungs, adding the symptoms of a pneumothorax to those of the pleurisy. Yet even these sometimes heal spontaneously. Though not a frequent event, sudden death, when least expected, is sufificiently so to make it important that one should be on his guard for it. It is not alone when the chest is full, or during a tapping, that it occurs, but it may happen several days after a large part of an effusion has been removed. Pulmonary thrombosis is probably the most frequent cause. A case of my own terminated thus, when convalescence was thought to be estab- lished, and the patient expressed himself better than on any day during his illness. At the necropsy, a white " chicken-fat " clot was found in the right ventricle, extending as a red clot into the pulmonary artery. The chest was partly filled with serofibrinous fluid. Edema of the opposite lung and degeneration of the heart muscle are probable causes, suggested by WeiL Obstruction to the circulation by dislocation of the heart or twisting of the great vessels has also been suggested as a cause. Treatment. — Many simple pleurisies doubtless get well of themselves, with, perhaps, more or less adhesion of the lung, which may be the cause of certain unexplained restrictions in expanding the chest. For very severe cases of pleurisy, local blood-letting is the promptest measure of relief, and there is no condition in which so delightful an effect comes to the suffering patient gasping for breath and racked with pain. I am confident, too, that the duration of many pleurisies would be shortened by such a treatment. In its absence, the next best measure is the application of a blister, which seems- to suspend the process, as well also as to relieve the pain in the less severe- cases. Succeeding the blister, a cotton jacket or a poultice should be ap- plied, for a time at least. Anodynes — morphin hypodermically is the best — are often necessary to relieve the pain, and must sometimes be repeated,, while I have even known repetition to be inefficient and unsatisfactory, when a blood-letting produced prompt relief. Even where the effusion is considerable, it often passes away without any very active measures. The blister aids in its absorption, however, and. the iodid of potassium may be used in co-operation — ^five to ten grains (0.32 to 0.65 gm.) every six hours. If there is much delay, however, in. the absorption of fluid, paracentesis thoracis should be practiced as soon as the fever has subsided. It is an operation every physician should be ready to do without calling on the surgeon. I prefer for it the line of the angle of the scapula between the eighth and ninth ribs, and, while it is true that the chest-wall is a little thicker here, and sometimes perforation is not immedi- ately easy, it is a point freer from danger to adjacent organs than the side where the chest-walls are really thinner. The point for tapping preferred by others is the seventh interspace in the midaxillary line. The interspaces are made wider and the operation easier if the arm of the side to be operated is carried over to grasp the opposite shoulder. The needle should be introduced close to the upper margin of the rib, so as to avoid wounding the intercostal artery. Local anesthesia should be obtained by the applica- tion of ice and salt, or by chlorid of ethyl. It is particularly in the insidious forms of pleurisy that the tapping of the chest becomes necessary, because they seem to be as slow to disappear as they are slow to make their presence CHRONIC PLEURISY. 547 known. A further indication for paracentesis is aggravated dyspnea. The operation is usually well borne, though sometimes faintness results. It is, therefore, well to fortify the patient in advance with an ounce of whisky, and if faintness results, to desist. Sudden death during the operation has hap- pened in rare instances. On the other hand, sudden death has occurred more frequently in cases of full pleura without operation. When this accident occurs, it is more than likely that the heart was previously damaged. Empyemas almost never get well after a simple tapping. The pus reaccumulates, and the symptoms and physical signs are renewed. Free -opening should be made without delay, and a good large drainage-tube passed into the chest through an upper and out through a lower opening in the chest-wall. The drainage-tube is often very much too small. In the event of failure of the drainage-tube to effect a cure, which at best requires weeks, with daily washing out of the chest cavity, exsection of a part of one or two ribs is sometimes practiced with better results. A cure means thor- ough union of the pulmonary and costal pleurae, and complete obliteration of the pleural sac. CHRONIC PLEURISY. Definition and Pathogeny. — Under the term chronic pleurisy are included several morbid states, the result of inflammatory processes of longer duration than a few weeks. These include both exudative and dry or plastic pleurisies. 1. Exudative pleurisies, characterized by liquid product, include — (a) The condition already spoken of as latent pleurisy associated with effusion. (&) Suppurative pleurisies, all of which, though they may originate acutely, are always of long duration, and may therefore be appropriately classified as chronic. 2. Plastic pleurisies, characterized by a dry product. These originate in two ways : First, they are plastic from the beginning — that is, the so- called lymph first deposited becomes permanently organized as a more or less thick layer uniting the pleural surfaces. Such primary adhesions are more usual in circumscribed areas of pleural surface. Second, the same result follows when the surfaces separated by the more copious sero- purulent transudate reapproach each other as the latter is absorbed, pro- ducing secondary adhesions. Third, we have a most distinctive product of chronic pleurisy in the cicatricial tissue, which succeeds the healing of the extensive suppurative surfaces forming the walls of an empyema and which also closely cements the lung to the costal pleura. Mention should also be made of the form of chronic pleurisy resulting in a thick interpleural deposit of slow formation, also tubercular in origin, which extends its new formation from the pleura into the interlobular tissue of the lung, dividing it or dissecting it in extreme cases into distinct areas, well shown upon section, which has given rise to the name pneumonia dissecans, or pleurogenous pneumonia. This form of pneumonia has its type in the pleuropneumonia of cattle. I have met one striking instance of this form of chronic pleurisy of tubercular origin in man. Any one of these varieties of chronic pleurisy may originate as a tubercular pleurisy, and probably most of them are of this kind. 548 DISEASES OF THE RESPIRATORY SYSTEM. The morbid product of chronic pleurisy requires no further description than has just been given, and in the description of the morbid anatom}^ of acute pleurisy, which necessarily included to some extent that of its frequent termination in the chronic form. The adhesion between the lungs and the ribs is variously close and the product variously thick, insomuch that while usually the two surfaces are easily dragged apart, sometimes it is impossible to do this without lacerating the lung. Attention may again, however, be called to the displacement of viscera, the retraction of the chest-wall, and curvature of the spinal column, which sometimes take place as a consequence of the extreme contraction of the plastic product of chronic pleurisy in its most aggravated form — that with empyema. Treatment. — It need only be added to what has already been said in the treatment of acute pleurisy that, in chronic pleurisy especially, chest gymnastics, consisting in systematic inspiratory efforts and massage of the thoracic walls, must be availed of. Operative procedures must be consid- ered in conjunction with the surgeon. Mild local measures, such as counter- irritation by iodin and counter-irritating ointments, may be useful to relieve pain, which sometimes annoys the subjects of chronic pleurisy. Nothing more can be accomplished by active counter-irritation by blisters. HYDROTHORAX AND HE^vIATOTHORAX. Definition. — The term hydrothorax is applied to any accumulation of clear serum in the pleural sacs. Etiology. — It is the result mainly of resistance to the free circulation of the blood through the vascular basis of the pleural membrane. It occurs as a part of general dropsy, however caused, but Bright's disease or valvular heart disease are the most frequent causes. Hence the chest should be frequently examined in these diseases, as hydrothorax may be the first symptom of dropsy. Hydrothorax is usually bilateral in both renal and heart affections. In a careful study of this subject by J. Dutton Steele,* based upon a large number of autopsies with cardiac hydrothorax, in about 83 per cent, of cases the eff'usion was bilateral, and in 17 per cent, unilateral. Of the bilateral, 70 per cent, were unequal in distribution, and of these, three- fourths were greater on the right side. Of the 13 unilateral cases, 10 were right-sided and 3 left-sided. The usual explanation of this preference of pleural effusion to the right side in cardiac hydrothorax is that more fre- quently pressure is exerted by a dilated right auricle upon the root of the right lung, interfering with the return circulation from the pleural sacs. Left unilateral eff'usion occurs as the result of pressure upon the root of the left lung and left superior intercostal vein. Unequal bilateral pleural eff'u- sions must, therefore, be due to unequal pressure on the roots of the two lungs. The serous fluid in hydrothorax is characterized by the small amount of albumin as compared with that exuded in pleurisy. Symptoms. — The symptoms are those of pleuritic eff'usion, both as to subjective symptoms and physical signs. Crepitant rales are sometimes heard in the lung above the eff'usion, due to its retraction and to partial atelectasis. Treatment. — This is considered under that of the diseases causing the hydrothorax. * "Distribution and Etiology of Cardiac Hydrothorax." "University Medical Jilagazine," vol. ix., iiSq-, p. 56:5. PNEUMOTHORAX. 549 Hematothorax is a term applied to any accumulation of blood in the thorax, however caused. It may be due to the wounding of vessels, maUg • nant disease, or aneurysmal rupture. The symptoms and physical signs and treatment are those of pleural effusion. PNEUMOTHORAX. Synonyms. — Hydro pneumothorax ; Pyopneumothorax. Definition. — Pneumothorax means air in the thorax, but the term is limited to the condition in which there is air in a pleural sac. It is almost always accompanied by a liquid inflammatory exudate, usually purulent or seropurulent, whence the terms pyopneumothorax and seropneumothorax. The effects of pneumothorax are compression of the lung, almost always dislocation of the heart toward the opposite side, and in some instances dis- placement of the liver and spleen. Pneumothorax is almost without excep- tion one-sided, though it is not impossible for it to be double. Etiology. — The most frequent cause is perforation of the pleura over a phthisical cavity or a hemorrhagic infarct, or over a septic bronchopneu- monic focus, or gangrene of the lung. Other causes are perforating wounds of the lung, perforation of the diaphragm due to malignant disease in the abdomen, especially cancer of the stomach or colon, or of the esophagus. Perforation into the lung from the pleural side may occur in empyema. Rupture of the lung due to straining has caused it. The opening may be valvular, so as to admit air intermittently. Symptoms. — Sudden pain and increased dyspnea usually usher in a perforation causing pneumothorax, though the effect may be more gradual. Sometimes the symptoms are more severe, constituting those of collapse — faintness, frequent pulse, and loivered temperature. Later, at least slight fever, corresponding acceleration of pulse and breathing rate, continue while the condition lasts. Pneumothoraces have also been found postmortem when unsuspected before death, having occurred without producing symp- toms. The patient may be orthopneic, or may lie upon the affected side, for the same reason as in pleurisy. Pleurisy is a frequent, but not invariable, consequence, and superadds its own symptoms, most palpably effusion. Physical Signs. — These are the most distinctive symptoms. Inspection recognizes commonly a bulging half-chest, with the intercostal spaces oblit- erated or prominent, as compared with the opposite side. The breathing is frequent and short. Palpation recognizes absent or very indistinct vocal fremitus, the lungs being no longer in contact with the chest-wall, which is also in a state of tension interfering with vibration. The percussion note is resonant, often ringing and amphoric over the upper part of the side, — that containing air, — while over the area below, containing the fluid, there is absolute dullness. On the other hand, there may be dullness over the air-containing space, instead of tympany, on account of the extreme high tension checking all vibration. We may also meet here that interesting modification of tympany known as Biemer's change of note, based upon the fact that with a given tension the larger an air-containing cavity, the lower the pitch of the percussion note. If the patient with pyopneu- mothorax sits, or especially stands, in the upright position, the pleural air- containing space is enlarged, because the weight of the fluid pushes the dia- 550 DISEASES OF THE RESPIRATORY SYSTEM. phragm downward, whereas in the horizontal position the fluid flows into the gutter between the ribs and spinal column, the diaphragm rises, the cavity becomes smaller, and the pitch of the percussion note is raised. There is also the usual change of level of the dullness corresponding with change of position, as in pleurisy with effusion. Auscultation recognizes feeble or absent vesicular murmur in the situa- tions where it is present in health, while amphoric breathing may be sub- stituted — bronchial breathing of a metallic character. Ringing amphoric bronchophony is also heard when the patient speaks. An interesting aus- cultation sign is the so-called " metallic tinkling," a sound ascribed to the dropping of liquid from the seat of perforation into the fluid below. Here also is produced in its typical expression the " coin-clinking " sound con- veyed to the ear of the auscultator listening at the back of the chest, while a coin placed against the chest in front is tapped by another coin. This is a sign usually limited to pneumothorax, though it may also be produced over bronchiectatic cavities. Here, too, may be produced the well-known Hippocratic succussion sound by shaking the body of the patient, the splashing being intensified in the air-distended cavity. Diagnosis. — Almost the only condition with which pneumothorax may be confounded is diaphragmatic hernia, the physical signs of which very closely resemble those of pneumothorax. The' causes of diaphragmatic hernia are usually severe traumatic agencies, such as compression between cars or under masses of earth, yet occasionally more trifling causes produce it, as in the case referred to on page 535. If such a condition be suspected, all doubt may be settled by passing a stomach-tube or sound, which will disclose the exact position of the viscera. A distended stomach itself is named as a source of confusion with pneumothorax, and it is true that succussion and metallic tinkling can be elicited in it in great perfection. The absence of distention of the thorax itself, the limitation of the physical signs to the neighborhood of the stomach, their association with movements of the stomach quite independently of breathing, point to the proper source. Pneumothorax is scarcely likely to be confounded with large tubercular cavities, for while the latter furnish amphoric signs over them, vocal fremitus is increased, or at least remains distinct, while with pneumothorax vocal fremitus is diminished or absent. Further, there is at least no prominence over cavities, while there is often depression, and succussion signs cannot be elicited. Finally, cavities are circumscribed. Bronchiectatic cavities furnish signs behind and below the scapula, and therefore more in the situation of those of pneumothorax, but there is dullness instead of tympany, no bulging, and vocal fremitus probably remains distinct, while there is often pec- toriloquy, never present in pneumothorax. Treatment. — This is mainly symptomatic. Sudden pain and extreme dyspnea must be treated by morphin, preferably subcutaneously ; em- barrassing accumulation of fluid by thoracentesis and draining of the sac, and in extreme cases the air may be liberated in a similar manner. Often pneumothorax gives surprisingly little inconvenience, and it is by no means impossible for spontaneous healing to take place. Potain suggested re- placing the air and fluid by sterilized air, but such air would soon be sub- stituted by impure air. Operative interference has been carried out with more or less success.* * See a paper on the " Operative Treatment of Pneumothorax," by Samuel West, " British Medical Journal," Novejiber27, 1897, p. 7568. MEDIASTINAL DISEASE. 551 MORBID GROWTHS OF THE PLEURA. These are rare and will be considered to some extent in treating medi- astinal disease. The pleura is subject to carcinoma and to sarcoma, the clinical phenomena of which are identical. Most cases of carcinoma of the pleura arise by contiguous growth from primary cancer of the lung. Secondary cancer of the pleura occasionally arises by metastasis from the mammary gland or lungs. Sarcoma occurs as a primary growth in the shape of the so-called endothelial carcinoma of Wagner, which starts from the endothelial cells of the lymphatics and connective tissue. It also gives rise to secondary ■deposits in the lungs, lymphatic glands, the liver, and muscles. The symptoms of any one of these forms of growth are those of chronic pleurisy, varying in intensity with the extent of the growth, single secondary nodules often giving rise to no symptoms, while the diffuse forms, spreading from the lungs, cause all the symptoms described as belonging to chronic pleurisy, the lung symptoms being relatively insignifi- cant. In the meantime the true nature of the disease may long remain unknown, its real nature being determined with the development of cachexia toward the end, the decline of strength, and probably secondary deposits in discoverable localities. The bloody character of the effusion is a sign point- ing to malignant disease of the sarcomatous or carcinomatous type. The prognosis is altogether unfavorable, and treatment is palliative ■only. There are also sometimes found in connection with the pleura chon- droma and lipoma, while calcification sometimes takes place in chronic in- flammatory products. Echinococcns or hydatid disease is occasionally found in the pleural cavity. Of this, the first clinical symptom is hydrothorax, the fluid from which is non-albuminous, differing in this respect from that of pleurisy and to a less degree from that of ordinary hydrothorax. The only unmistakable evidence of hydatid disease is the presence of booklets and fragments of the hydatid cysts in the aspirated fluid. Here, also, the product may be purulent. MEDIASTINAL DISEASE. Definition. — Under mediastinal disease are included all anatomically morbid conditions situated in the mediastinal space, except diseases of the heart, aorta, trachea, and esophagus. By far the greater number of these are tumors, but simple lymphadenitis, abscess, and hemorrhage are also included. Anatomical. — In consequence of the difficulty attending the concep- tion of the mediastinum and its contents. I precede the consideration of mediastinal disease by a brief anatomical description of the mediastinum and its spaces. The mediastinum is bounded in front by the sternum, posteriorly by the vertebral column from the lower edge of the fourth dorsal vertebra down- ward, and laterally by the two pleurse. Clinicians are in the habit of subdi- viding this space into the anterior, middle, and posterior mediastinum or 552 DISEASES OF THE RESPIRATORY SYSTEM. mediastinal spaces. The portion above this is called by anatomists (notably Struthers and Gray), whom I follow, the upper or superior mediastinum: The superior mediastinum is that portion of the interpleural space above the upper level of the pericardium, between the manubrium sterni in front and the upper dorsal vertebrae behind, and bounded below by a plane passing" Pulmonary artery. Pulmonarv iry J veins. ( Left bronchus Descending aorta. Dorsal vertebra. Ascending aorta. Superior cava. Right bronchus. E-opihagus. Fig. 49. — Section through Frozen Thorax at Second Interspace in Front, Looking" from above down-^-ard, Showing Mediastinal Spaces. from the junction of the manubrium with the body of the sternum backward to the lower border of the fourth dorsal vertebra. It contains the origins of the sternohyoid and sternothyroid muscles, and the lower end of the longus colli ; the transverse portion of the arch of the aorta ; the innominate, the left Ascending aorta Sternum. Pulmonary artery. Superior cava. Right bronchus. Esophagus Pulmonarv vein- Left bronchus. Dorsal vertebra. Descending aorta. Fig. 50.— Section through Frozen Thorax at Second Interspace in Front, Looking from below upward, Showing Mediastinal Spaces. carotid, and left subclavian arteries ; the superior vena cava and the innomi- nate veins, and the left superior intercostal vein ; the pneumogastric, cardiac, phrenic, and left recurrent laryngeal nerves: the trachea, esophagus, and thoracic duct, and the remains of the thymus gland with lymphatics. The anterior space of the lower or clinical mediastinum is bounded in MEDIASTINAL TUMORS. 553. front by the sternum, posteriorly by the pericardium, and laterally by the pleura. It is wider below than above, and is narrowest in the middle, since at this point the two pleural edges approach each other, while in some instances they are actually in contact. The anterior mediastinum contains the origins of the triangularis sterni muscles ; the internal mammary vessels of the left side ; a quantity of loose areolar tissue ; a few lymphatic glands, with lymphatics from the upper surface of the liver and two or three lymphatic glands called anterior mediastinal glands. The middle space contains the heart in its pericardial sac, the ascending aorta, the superior vena cava, the pulmonary artery and veins, the phrenic nerves, the bifurcation of the trachea, and the roots of the lungs, with numerous lymphatic glands. It is broader than the anterior or posterior mediastinal space. The posterior space is triangular in form, and is bounded behind by the vertebral column. Its anterior boundary is the pericardial sac and the roots of the lungs ; its lateral walls, the pleurae. It contains the descending portiort of the arch and the descending thoracic aorta; the greater and less azygos veins, the thoracic duct, the pneumogastric and splanchnic nerves, the. esophagus, and some lymphatics. • MEDIASTINAL TUMORS. Historical. — The celebrated English physician and acute observer, Thomas Willis (1621-75), seems to have been the first to have made an observation on mediastinal disease. H. Boerhaave recorded a steatoma of the anterior mediastinum in 1742. Joseph Lieutaud (1703.80) described several cases. Boole published others in 1812, and J. G. C. F. M. Lobstein gave the first text-book description in 1835, after which cases multiplied, although the number which came under the notice of any single observer was always few. F. Strauscheed analyzed 112 cases in 1887, and Hobart A. Hare collected 520 cases in his Fothergillian Essay in 1889. Out of 7566 autopsies at the Marine Hospital at Cronstadt, 158 subjects were found to have tumors of the mediastinum said to be malignant. A study of mediastinal disease by the late William Pepper and Alfred Stengel, published in the Transactions of the Association of American Physicians in 1895, is noteworthy. Pathology and Morbid Anatomy. — The varieties of growth consist mainly of sarcoma, including lymphosarcoma, carcinoma, simple lymphad- enoid tumors ; more rarely cysts, dermoid and hydatid, fibroma, lipoma, gumma, and chondroma ; also the teratoma myomatoids of Virchow. Sar- coma and carcinoma and lymphadenoid tumors make up the larger number. Most observers have found more carcinomata than sarcomata, but in the light of the fact that many tumors formerly described as cancerous are at the present day acknowledged to be sarcomata, it is more than likely that the latter have always predominated. Hilton Fagge and Douglas Powell were the first to announce this, and William Pepper and Alfred Stengel, in their monograph published in 1895, came to the same conclusion. The majority of tumors in the anterior mediastinum start from the remnant of the thymus gland and are lymphosarcomata. The lymphatic structures in the anterior mediastinum furnish a few. In the middle medias- tinum the lymphatic glands are the principal starting-points of the relatively frequent lymphosarcomata. The carcinomata are usually primary, but sec- ondary carcinoma is not infrequent.^ The breasts, lungs, and stomach are among the primary seats named. The secondary cancers do not usually attain a large size. Cancer may extend from the abdomen to the lymphatic glands of the chest by vascular embolism, by direct spread of the disease to 554 DISEASES OF THE RESPIRATORY SYSTEM. the under surface of the diaphragm, through which it may penetrate along the lymphatics into the chest and glands, or by embolism through the thoracic duct to the chest and then by retrograde embolism to the mediastinal glands. The pleura is also a frequent starting-point of mediastinal growths. Among these are the so-called endotheliomata of Wagner and Schulz, start- ing in the endothelium of lymphatic vessels and sometimes the surface endo- thelium. They are sarcomata or carcinomata according as the endothelium is counted mesoblastic or endodermic in origin. The cases of primary can- cer of the pleura are probably endothelioma. Fibrous, fatty, and calcareous tumors of the pleura are of rare occurrence. The lungs also contribute tumors to this locality — carcinoma, primary and secondary, and sarcoma, primary and secondary. Of the primary tumors, carcinoma is the more com- mon, but primary sarcoma of the lymphatic glands surrounding the bronchi and within the lungs near the root is not very rare. The clinical symptoms are the same as when the glands around the bronchi outside of the medias- tinum are affected. The cancers may start from the surface epithelium of the bronchi, from the mucous glands, or from the alveolar epithelium of the lung. Finally, from the esophagus, also, start cancerous tumors invading the mediastinum, usually small, though not always. From these the pos- terior mediastinum and lungs may also be invaded. Symptoms. — ^Mediastinal tumors may be latent. Their symptoms when present are, in a word, those of pressure. Such pressure may involve the lungs, the trachea, the bronchi, the esophagus, the heart, the vessels, and the nerves of this locality. They include symptoms, subjective and objective, of the usual kind, and also physical signs. It will be remembered that the symp- toms of aneurysm are also largely those of pressure, and it is chiefly from aneurysm that mediastinal tumor is to be distinguished, often a matter of some difficulty. The division by Pepper and Stengel into three groups affords the most convenient mode of studying these symptoms. These groups are : 1. Those in which the anterior mediastinum is the seat of the growth. 2. Those involving the middle and posterior spaces. 3. Those in which the pleura or superficial portion of the lung is involved. I. Intrathoracic Tumors Situated in the Anterior Mediastinum. — The symptoms are mainly those arising from pressure exerted on the venous trunks, the superior vena cava, and the right and left innominate veins. The yielding walls of these vessels as contrasted with the firmer adjacent arteries easily suffer compression, and may even be penetrated by the growths which may proliferate within them, sometimes causing occlusion by thrombosis. The consequence is distention of the -veins of the upper part of the body — the head, neck, and upper chest, sometimes the arms. Coldness, lividity, edema, and clubbing of the ends of the fingers resvilt, while the superficial venous channels may be dilated and tortuous. From pressure on the arteries may result inequality of the radial pulses. Of the nerves, the inferior laryngeal is especially liable to compression, with resulting hoarseness and aphonia. The sympathetic is also sometimes compressed, with consequent inequality of pupils, the pneumogastric being less frequently involved than when the tumor occupies a more posterior situation. As the tumor enlarges and the air-passages are intruded upon, dyspnea makes its appearance. Dyspnea is usually of the inspiratory kind. Pericarditis and pleurisy, with pain, hydro- pericardium, and pleural effusion may be present. With the prolongation of the disease the patient wastes, but it is said that cachexia is less apt to MEDIASTINAL TUMORS. 555 develop than in malignant growths of the posterior mediastinum. Pain is not always present — indeed, it is said to be less marked than in aneurysm. Physical Signs of Groivths in the Anterior Mediastinum. — To inspec- tion the sternum is frequently pushed forward, and in a few instances eroded. Vocal fremitus may be either increased or diminished. Percussion elicits abnormal dullness, characterized by more or less irregular shape. Pulsation may occur, but is rare, while the sharp diastolic shock of aneurysm is want- ing. If the tumor extends upward sufficiently, it may be felt in the supra- sternal fossa. Auscultation over the area of dullness may be negative, but sometimes the breath-sounds and heart-sounds are well transmitted, while a distinct systolic bruit may be produced by pressure on the aorta or the pul- monary artery. Secondary enlargement in the cervical lymphatic glands sometimes makes its appearance. 2. Intrathoracic Tumors in the Middle and Posterior Portions of the ■Spaces around the Bronchi, Esophagus, Aorta,: and Nerves, and in which the symptoms predominate over the physical signs. — The first effect is likely to be pressure on the trachea and bronchi. Hence dyspnea is an important and early symptom of tumors in this situation, and the inspiratory effort is ■extreme. Pressure here is also exerted upon the vena cava ascendens, whence results edema of the abdominal walls and lozver extremities. The effect of pressure on the arteries is not serious. From pressure on the vagus nerve arises pecidiar cough, paroxysmal and whooping. Sometimes it is loud and ringing, at other times constant and hacking. This is said to be due to the joint involvement of one vagus and the pulmonary plexus ; whereas experimentally two pneumogastrics are required to be cut to produce this symptom. The explanation is in the involvement of the pulmonary plexus. Mucopurulent and even blood-stained sputa may attend the cough. The latter is sometimes a sign of perforation of the bronchial wall. Dsyphagia from pressure on the esophagus is a symptom in this group, sometimes, indeed, the only one. It is not, however, invariably present. Vomiting, cardiac palpitation, with irregularity, and syncope, when present, are also ascribed to the pneumogastric involvement. Pressure upon the asygos veins may cause edema of the upper part of the abdomen and serous effusion in the chest, while pleural effusions are also due to complicating inflammations or neoplasms of the pleura. Fever may be a symptom of tumor of the posterior inediastinum. It is usually moderate, but is sometimes high and irregular, followed by sweating. On the other hand, there may be lowered tem- perature, as in tumor of the anterior mediastinum from impeded circu- lation. Cachexia is much more frequent in this group of symptoms, as might be expected from the greater severity and disturbing effect of the disease, including, as it does, destructive process involving bone and lung structure, as well as severe and deep-seated pain. Physical Signs. — It is evident that in this group the physical signs play a secondary role, and except as the result of modified breathing by pressure and impairment of resonance to percussion, have little significance. 3. Tumors Originating in the Pleura and Lung, and in which the symptoms and physical signs are of equal prominence. The former is the more frequent starting-point, but the ivnderlying lung is usually soon invaded and may be more frequently the actual starting-point than is commonly sup- posed. Naturally, the symptoms -first produced arc those of pleurisy, and the disease is generally so regarded at first, being characterized by the com- 556 DISEASES OF THE RESPIRATORY SYSTEM. paratively sudden onset, sharp pain, cough, embarrassed breathing, and pleuritic effusion. Instead of abating ultimately, as is the course in pleurisy, these symptoms grow worse, especially the pain, which extends along the intercostal nerves and their distribution and to the neck and arms. The cough also persists, while the expectoration may become bloody and include sometimes cells from the morbid growth. Paracentesis, too, is successful, and often furnishes in the peculiarity of its product valuable aid in the diagnosis, because, instead of being clear or nearly so, it is apt to be bloody or slightly chyliform from the presence of fatty matter. This fatty character has been found where there were cancer and sarcoma. The diagnostic importance of certain large, swollen cells of endothelial nature, which seem to become detached and transformed only in case of pleuritic disease of malignant character, is insisted upon by Fraenkel. To the information gained from the fluid obtained by tapping are added also unusual resistance to the trocar and imperfect relief to the dyspnea. Rapid emaciation, anemia, and cachexia complete the picture, while all doubt is removed if secondary growths make their appearance in the lungs, as not infrequently happens. Diagnosis. — In view of the similarity of symptoms to aneurysm, the history of the case in mediastinal disease becomes of the utmost importance, but shortness of breath, the bulging of the thorax, irregular outline of per- cussion dullness, the feebleness of breathing sounds, the dislocation of the heart and sometimes of the abdominal organs, the symptoms of venous engorgement, which are usually more marked in mediastinal disease, the more rapid course, and secondary metastatic deposits are strong points in favor of the latter as contrasted with aneurysm. Laryngoscopic examination with a view to discovering any constriction of the trachea from pressure by the tumor may be availed of. The subjects of mediastinal disease are usually younger than those of aneurysm. Bony erosion and pain are less frequent. Constitutional disturbance and emaciation are more marked. Diastolic shock is never present in mediastinal disease, while pulsation, if present, is not expansile. Confusion with pleurisy and pericarditis is a natural error when the symptoms involving the pleura and pericardium are recalled, and here the slower development of the symptoms associated with those of compression of the various mediastinal tissues and absence of tendency to improve should lead to suspicion of the true nature of the disease. The nature of the tumor may even be suspected from certain features. Thus, rapid growth, metastatic deposits in the glands of the neck and apices of the lungs, cachexia, and tumors in other situations point to malignancy. Especially may sarcoma be suspected if the subject be a youthful one. Abscess may be suspected if there is a history of injury, caries, or pyemia, or if there is abscess of the lung or empyema attended by the supervention of pressure symptoms. Hemorrhage may be suspected also when there is trauma and the symptoms develop very rapidly. Treatment. — There is no treatment for mediastinal disease, except such as may suggest itself for the palliation of symptoms. Mediastinal Abscess. — Separate mention should be made of mediastinal abscess, since it is relatively not a very rare disease. Out of Hare's 520 cases of disease of the mediastinum 115 were abscesses, as contrasted with 134 cases of cancer and 98 of sarcoma, 21 cases of lymphoma, 7 of fibroma. MEDIASTIXAL TUMORS. 557 II of dermoid cyst, 8 of hydatid cyst, with isolated cases of gumma, chon- droma, and Hpoma. The abscesses were found in the majority of instances in males, most often in the anterior mediastinum, and most could be traced to traumatic causes. Other causes were tuberculosis, the eruptive fevers, and erysipelas. A few cases of mediastinal abscess also originate in the bronchial and tracheal lymphatic glands, as tubercular lymphadenitis. In fifty-four cases the abscess was acute. Of symptoms, substernal pain, sometimes throbbing, was the most con- -spicuous. To this was added fez'er in acute cases; sometimes chills and szueats. Erosion of the sternum and burrowing along a rib into the abdomen were noted, also rupture into the trachea and esophagus. In chronic abscess the pus may become inspissated — cheesy. Suppurative lymphadenitis has been known to terminate thus, previous symptoms having been masked by the lung afifection. Rarely are we able to detect fluctuation at the edge of the sternum and in the suprasternal notch, where there may be pulsation. Only as the abscess becomes large enough to encroach upon the air-passages does it cause dyspnea. The physical sigjis are not distinctive. They are essentially those described in the general description of mediastinal disease. Fever, throbbing pain, fluctuation, and the history of trauma are symptoms which, if added, aid the diagnosis. As to treatment, given a correct diagnosis, operative interference is justified, and likely to afford relief if the pus is reached. Simple Lymphadenitis. — This probably occurs to a degree, in all inflam- matory^ affections of the bronchi and of the lungs, but is rarely recognizable. The glands are mostly in the posterior mediastinum, and their enlargement may be appreciable to percussion in the upper interscapular region behind, though lymphatic enlargement may contribute also to dullness in the region of the manubrium. Tuberculosis may aft"ect these glands. SECTION IV. DISEASES OF THE HEART AND BLOOD-VESSELS. GENERAL SYMPTOMATOLOGY OF CARDIAC DISEASE. I. Shortness of Breath, Cardiac Asthma. — Shortness of breath is com- monly the first symptom of cardiac disease. At first it is very shght, being felt only on exertion. As the disease advances it is induced by slighter efifort, and finally it is more or less permanent. The higher degrees are commonly characterized as cardiac asthma. It differs essentially from bronchial or spasmodic asthma : 1. In that there is no spasmodic contraction of the bronchial tubes. 2. In that the essential morbid change is an overfilling of the pulmonary capillaries which, intruding on the lumen of the air vesicles, interferes with the access of air to the blood, causing diWaffOfxa^or panting, an effort by fre- quent and deep breathing to accomplish aeration.. The overfilling of the pul- monary capillaries is commonly caused by a backing of blood from the left heart into the lungs, because of valvular insufficiency, or it may be caused by a weak right heart. The same results follow in the so-called paretic cardiac asthma due to dilatation of the left ventricle. This is a common condition of the senile heart in consequence of its imperfect nourishment, and is especially prone to occur when a feeble heart is forced to overcome an unusual resistance. Such is the increased arterial tension due to arteriosclerosis and chronically contracted kidney, both of which are often associated with shortness of breath. In both the blood does not pass from the arteries into the veins so freely as it ought. So long as the heart is well nourished it hypertrophies in these dis- eases and overcomes the resistance, but as soon as its nutrition fails, it slowly undergoes dilatation, the blood is backed into the lungs, and the asthma occurs. In cardiac asthma as contrasted with bronchial asthma there is an absence of the wheezing rales which characterize the latter and obscure the vesicular element of the breathing sound, at first unaltered in cardiac asthma. Later, if edema of the lungs occur, there may be small, m,oist rales, crepitant or subcrepitant, and still later,Mf the air vesicles fill up, bronchial breathing" with an impairment of resonance. In bronchial asthma if there happen to be, as indeed there often is, associated emphysema, there is hyperresonance. Under these circumstances the normal areas of cardiac and hepatic dullness are diminished. Bronchial asthma is an asthma of expiration, as spasm of the larynx furnishes an asthma of inspiration. In the former the lungs are overdistended and the difficulty lies in getting them emptied. Hence expira- tion is four or five times longer than inspiration. Yet it is ineffectual. In cardiac asthma there is no obstruction to inspiration or expiration and both share in the overeffort to accomplish the perfect aeration of the blood. The air vesicles do not receive enough air to aerate the blood because the latter is in excess. Cardiac asthma and bronchial asthma are sometimes associated. 2. Palpitation. — The second symptom characteristic of heart disease 558 ACUTE PERICARDITIS. 559 and next in order of frequency after shortness of breath is palpitation. By palpitation is meant undue frequency of the heart's action, with or without irregularity. It succeeds very early upon shortness of breath, or is coincident with it, and is more common in mitral disease than in aortic disease. It varies greatly in degree, being at times scarcely noticeable by the patient, and at others exceedingly distressing. The rate attained by the heart under these circumstances is sometimes as great as 200 in a minute, more frequently 120 to 150. 3. Slow-pulse. — Unnaturally slow action of the heart as a symptom of organic heart disease is not infrequent. The number of heart-beats. is reduced to forty, twenty, or even less. It is more frequently associated with muscular disease of the heart and disease of the coronary arteries, and is distinct from nervous bradycardia, to be separately considered. The immediate cause, as in the case of palpitation, is deranged innervation of the heart, the inhibitory nerves, with their ganglia situated in the heart muscle, being the usual medium by which it is brought about. 4. Pain. — Pain is not so frequent in heart disease as is palpitation or dyspnea. It is of two kinds — a dull, aching pain and a sharp pain of great severity, radiating through the heart and down the arms, especially the left arm. Sometimes the patient complains of a sensation as if the heart was being compressed, or even as if grasped in a vise. The pain is associated with an anxious expression and feeling, including a sense of impending death,, which is characteristic of the severer forms of angina pectoris. Pain of this kind is apt to be associated with disease of the muscular substances of the heart, of its blood-vessels, and of the aortic valves. Pain is less common in mitral disease, and when present is more likely to be of a dull, aching character. 5. Dropsy. — Dropsy is the last of the symptoms characteristic of heart disease. It does not occur with every form of heart disease, being for the most part absent in disease of the aortic valves and most common in mitral disease. Not every case of mitral disease is associated with dropsy, but it occurs sooner or later in the vast majority of cases. Very rarely it is the first symptom noticed, and first makes its appearance almost invariably in the lower extremities. It is the direct consequence of backing of the blood into the venous side of the circulation, and is due to the transudation or filtration of its watery elements. The serum is, as it were, strained out. When unchecked, the swelling extends from the feet to the legs, thighs, the trunk, abdominal walls, and, last of all, serous cavities and especially the peritoneal cavity, producing ascites. The pleural sacs may, in rare instances, be the first seats of transudation in heart disease. (See remarks on Hydrothorax, page 548.) These simple transudates are usually free of albumin, as con- trasted with inflammatorv exudates. DISEASES OF THE PERICARDIUM. ACUTE PERICARDITIS. Definition. — An inflammation of the serous covering of the heart and of its reflection on the inner surface of'the pericardial sac. Etiology. — By far the larger number of cases of pericarditis are due to some toxic substance in the blood, such as is developed in the infectious dis- eases, or to some excrementitious matters which accumulate in the blood 56o DISEASES OF HEART AND BLOOD-VESSELS because of deficient elimination. Other cases arise per contiguum, a few cases are traumatic, and those that cannot be accounted for are called idiopathic. Acute articular rheumatism or its cause is by far the most frequent etiological factor, from 30 to 70 per cent, of all cases being ascribed to it. The greater the severity of the primary disease, the more likely is it that the complication, pericarditis, will occur ; yet it arises also in the mildest cases, and has some- times even preceded the rheumatic attack. It may be that certain seeming idiopathic cases are due to the toxin of rheumatism spending itself on the pericardium instead of on the joints. Other infectious diseases causing it are pyemia, scarlet fever, typhoid fever, diphtheria, and even measles. Bright's disease is one of the best recognized causes of pericarditis, and it is probably the excrementitious matters which accumulate in the blood in this disease which are responsible for it. Such dyscrasic states of the blood as are repre- sented by scurvy and pupura hsemorrhagica play an important part in its pro- duction. Tuberculosis of the pericardium is a common cause of pericarditis. Tubercular pericarditis may be part of a general tuberculosis or a secondary infection from the lungs. Diseases of adjacent organs which cause pericarditis are chronic valvular disease, pleuropneumonia, pleurisy, especially tubercular pleurisy, morbid growths in the vicinity, ulcerative disease of the esophagus, disease of the bronchial glands and bronchi, disease of the vertebrae, ruptured aneurysm, abscess of the heart, or invasion of the pericardium by suppuration through the diaphragm. Morbid Anatomy, — The appearances vary with the stage of the dis- ease. Ordinary acute pericarditis is met with in one of three stages. The Urst stage is represented by hyperemia and its consequences. The initial events are hyperemic redness, followed by roughness caused first by loosen- ing and detachment of the epithelium, and further increased by deposits of fresh inflammatory lymph. This lymph is spread at first in yellow flakes over the surface of the pericardium. From this point onward morbid appearances vary with the mode of ter- mination. This may be by resolution, when the products described undergo fatty degeneration and are absorbed, restoring the normal state. More fre- quently there supervenes the second stage, in which the liquid transudate increases, separating the two surfaces of the pericardium and distending the sac. This transudate is a clear, straw-colored fluid in which may be found floating flakes of lymph above described. The quantity of fluid varies greatly, amounting sometimes to a liter (2 pints) or more. In favorable cases it, too, is reabsorbed, and the two pericardial surfaces are reapposed with or without tmion of the apposing surfaces. Sometimes this union is complete, so that the two surfaces are separated, with difficulty, or it may be partial, by bands of varying length. At other times the second stage is represented by imme- diate organization without intervening transudation — primary adhesive inflammation. The term third stage is usually applied to the phenomena succeeding the transudation described. They include organization or suppuration. The former may be adhesive in various degrees or villous. The latter occurs when, union being apparently prevented by the constant motion to which the two surfaces are subjected, organization takes place without attachment of the opposing surfaces, and a peculiar villous product results, characterized by numerous projections, uniform in size and shape, resembling closely the papillae on a sheep's tongue. These papillae, composed of vascular connective ACUTE PERICARDITIS. 561 tissue, originate in the usual way by an outgrowth and vascularization of the connective tissue of the serous membrane, and not by organization of the €xuded lymph, as was formerly supposed. This lymph undergoes fatty ■degeneration and absorption. The more unfavorable cases terminate in suppuration, which may also be primary or secondary. In the former instances there is at once a rapid outwandering of leukocytes and the formation of a purulent fluid in the peri- cardium — pyopericardium. In the secondary form the clear, serous transu- date is substituted by pus, an event which is usually ushered in by a chill .and is followed by hectic fever. The cause of the suppuration in either case is the access of the usual pus organisms, the streptococcus and the staphy- lococcus. The contents of the pericardium may become cheesy, especially if the inflammation is tubercular. Symptoms. — Clinically, as well as anatomically, we seek to separate the stages, first of roughening, second of effusion, and third of absorption or organization, chiefly by aid of the physical signs. Pericarditis is sometimes ushered in by a chill. More frequently a sharp pain in the region of the heart initiates the attack, previous to which there may, however, have been a sense of discomfort or distress about the organ, which may, indeed, be the only subjective symptom. The pain and discom- fort may be referred to the epigastrium. To these symptoms may be added dyspnea or orthopnea. There is also fever, which is not very high — tempera- ture 102° F. (39.9° C.) — unless there be previous disease with fever, when the pericardial complication adds an increment. The pulse is frequent and the patient restless and uncomfortable. There is often tenderness over the region of the heart, which may be brought out by percussion or pressure with the stethoscope. The position assumed by the patient varies : sometimes he may prefer to lie on the affected side, at other times on his back or on the right side, or he may prefer to sit up. Finally, there may be no subjective symp- toms added to those of the primary disease, in which case the pericarditis must be discovered only by the physical examination, or it may escape detec- tion altogether until the necropsy reveals it. As the effusion distends the pericardium and encroaches on the lung, the difficulty in breathing increases, dyspnea becomes more marked, the action of the heart more disturbed, frequent, and irregular. When very large, it may press upon the left lung. It may even influence the percussion note in the tipper lobe below the clavicle, causing there a tympanitic note — Skodaic resonance — by indirect relaxation. Much more frequently the lower lobe is compressed, sometimes completely emptied of air, whence the percussion note in the lower axilla and about the angle of the scapula may be Skodaic or impaired in resonance or even absolutely dull. The breathing sounds may b)e feeble, broncho-vesicular, more rarely bronchial, and there may be egophony. These signs are not to be confounded with those due to pleuritic effusion, which are characterized by diminished or absent tactile fremitus, T/hich is not the case in compression by a distended pericardial sac, where it is rather increased. Attention was called to these symptoms as far back as 1857 "by H. Bamberger, whence they are known as Bamberger's sign.* The nor- mal state -of the lung may be in part restored by changing the position of the patient, causing him to lean forward, jie on his right side, or assume the knee- elbow position. * "Lehrbuch der Krankheiten des Herzens von H. Bamberger," Wien, 1857. 36- 562 DISEASES OF HEART A\D BLOOD-VESSELS. William Ewart has called attention to signs similar to those described by Bamberger below the right mamma ; also to an area of dullness below the ninth rib between the spine and a line drawn through the angle of the scapula and to a less degree to the right of the spine. In this area, known as Ewart's posterior pericardial patch of dullness," the respiratory sounds are also absent and the voice sounds are feeble. He ascribes this sign to an altered dorsal relation of the liver due to pressure of the pericardial effusion. Ewart has also called attention to what he calls the " first rib sign,"' also recognized by palpation. The upper edge of the first rib may be followed round by the finger tip, because the clavicle is apparently raised above its normal position, by the efifusion. which must of course be large. Still larger effusions produce dysphagia in consequence of encroachment on the esophagus. Aphonia may occur from pressure on the recurrent laryngeal nerve. The pressure of the full sac on the aorta may produce the pulsus paradoxus of Griesinger and Kussmaul, in which the pulse beat is weakened and accelerated during inspirations. A certain degree of prominence of the epigastrium may result from the encroachment of distended pericardium, while the excursion of breathing movement mav be noticeablv greater on the rigrht side. Fig. 51. — Pulsus Paradoxus. Influence of Respiration upon the sphygmogram (after Riegel); I, During inspiration; E, During expiration. Physical Signs. — In the first stage there may be pain in response to pressure, but the physical sign characteristic of this stage is the friction sound. It may be associated with an impulse stronger than natural. The friction sound is of the greatest importance in diagnosis. It is a superficial to-and-fro sound heard directly under the ear, commonly loud and rasping, never blowing, sometimes creaking. It is loudest over the middle of the heart. It is not conducted as are the murmurs at the valves in the direction of the blood current. It is often influenced by changes of position or by breathing. The rub may sometimes be felt by the hand placed over the heart. In the first stage, at least, it lasts a short time. — a day or two at most and sometimes only a few hours, — and disappears with the filling of the peri- cardium by effusion. It may sometimes be brought out or intensified by hav- ing the patient lean over on the stethoscope. The second stage, or that of eft'usion, exhibits usually, but not always, signs discoverable to inspection or palpation, or to both. They depend on the amount of effusion. If large, the precordium may be bulging, the interspaces obliterated, and the impulse undulating, tumultuous, and indistinct. As the effusion increases the heart is pushed further and further away from the chest-wall and assumes a more horizontal position, while the impulse, feebler and feebler to vision and touch, may disappear altogether. Percussion fur- nishes the most striking change. The area of dullness is enlarged — peculiarly enlarged. It becomes rudely triangular or truncated pyramidal with the apex toward the inner end of the left clavicle and the base as low as the ACUTE PERICARDITIS. 563 seventh rib, and extending in extreme cases from nipple to nipple, even pushing the diaphragm and liver dow^nward. The absence of resonance in the fifth intercostal space, to the right of the stefntim, is known as Rotch's sign in pericarditis, and has been assigned considerable diagnostic value. It is not impossible, however, that a similar dullness may be caused by a circum- scribed pleuritic eif usion or even great enlargement of the heart. The cardio- hepatic angle as determined by percussion, normally an acute or a right angle, may become obtuse. Auscultation confirms palpation. The conditions of friction sound are removed more or less by separation of the opposed peri- rardial surfaces. Yet the sound does not always disappear. The heart- sounds are indistinct and best heard at the top of the sternum. Sometimes there is a basic systolic murmur. The third stage represents a return to the normal state of affairs, which may come about with the intermediation of a friction rednx or not; or adhe- sions may form between the heart and the sac, embarrassing its movements permanently, and producing retraction of the chest-wall with systole. On the other hand, necropsy has often revealed close adhesions between the heart and the pericardium which were not suspected during life. Permanent roughening, represented by the " sheep's tongue " surface or other roughen- ing or adhesions, may produce permanent friction sound, and the pericarditis is chronic. Physical Signs of Chronic Adhesive Pericarditis or Adherent Pericar- dium. — These differ materially. They are most easily studied in children, in whom the condition is especially apt to occur after rheumatism. Their study is further facilitated by dividing the condition into two groups : 1. Simple adhesion of the pericardial and epicardial layers. These are the cases more frequently overlooked, sometimes giving rise to no symptoms and first found at necropsy. 2. Adherent pericardium, with chronic mediastinitis and fusion of the outer layer of the pericardium zvith the pleura and to the chest-ivalls, a serious form, leading to marked hypertrophy and dilatation, especially in children. To inspection and palpation the precordium is bulging, the impulse is more diffuse, extending sometimes from the third to the sixth interspace, and from the right parasternal line to outside the left nipple. The apex may be dis- placed in various degrees from its natural site ; it may be to the right of its normal position and above it or down toward the epigastrium. It is some- times multiple, or spreads in a wave-like manner over the area named. At other times the systole is associated with a tugging retraction of the chest- zvall, which is especially evident in thin persons and is regarded by some as the most valuable sign of adhesion of the pericardium. It is most frequently noted between the seventh and eighth ribs in the left parasternal line. This may be followed by a rapid rebound of the chest-wall, known as the diastolic shock. It may be associated with a coincident collapse — the diastolic col- lapse of the cervical veins, due to a sudden emptying of these vessels con- sequent on the expansion of the chest-wall, a sign first described by Fried- reich. Broadbent's diaphragm sign has recently attracted much attention — a systolic tug which is communicated through the adherent diaphragm to its points of attachment, especially on the left side behind, between the eleventh and twelfth ribs. It is distinct and apart from the tugging in the left para- sternal line, between the seventh and eighth ribs, to which attention had been previously called. Furthermore, owing to the attachment of the pericard- ium to the central tendon of the diaphragm this muscle does not descend with 564 DISEASES OF HEART AND BLOOD-VESSELS. inspiration, and consequently the usually visible movement of the epigas- trium during this act does not take place. It is in adhesive pericarditis, too, that we sometimes have the pulsus paradoxus, referred to on page 562. First, Griesinger, and later Kuss- maul, called attention to it as a constant symptom of cicatricial mediastinitis, due to the dragging of the cicatricial tissue on the great vessels during inspi- ration. It happens, too, when the great vessels, already compressed by the exudate, are further encroached upon by the expanding lung, making the pulse smaller and more frequent. This is more frequently demonstrable by the sphygmograph, but in extreme cases may be appreciated by the finger. It is not a pathognomonic sign of either event, but if associated with an inspiratory distention of the cervical veins, it points strongly to adhesive pericarditis. To percussion there is usually a large increase in the normal area of car- diac dullness, commonly upward and to the left, sometimes as high as the first interspace. Often the pericardium is adherent to the adjacent pleura, in which event the area of cardiac dullness is not influenced by deep breath- ing, a sign pointed out by C. J. B. Williams as of great value in diagnosis. Auscultation may be entirely negative, or there may be a modification of the usual friction sound which closely resembles the creaking of leather. A galloping or fetal rhythm may be present, or there may be a loud systolic murmur at the apex, which has often given rise to the erroneous diagnosis of mitral valve disease, being due to relative insufficiency. Endocardial dis- ease may, however, coexist, especially in children. A presystolic murmur is sometimes heard. The possible association of chronic adhesive pericarditis and medias- tinitis with proliferating peritonitis, perihepatitis, and splenitis should be remembered. Diagnosis. — In all cases of acute articular rheumatism the heart should be frequently examined, because pericarditis often supervenes with feebly pronounced subjective symptoms. At the outset the distinction is to be made between pericarditis and acute endocarditis, which even more frequently suc- ceeds on rheumatism with subjective symptoms no more distinctive. There is usually not much difficulty in acute cases. The to-and-fro rhythm, heard directly under the ear, usually most distinct over the center of the heart, and the absence of sounds transmitted in accordance with the laws of transmission of the valvular abnormal sounds, are distinctive features of the cardiac fric- tion. If, however, one of the to-and-fro elements is wanting, the difficulty is greater and errors do occur. Close study must be made as to transmission. It is further characteristic of the friction sound that it is increased in loudness by pressing the chest-wall with the stethoscope, while this is not the case in endocardial murmurs. Such pressure is, however, often painful to the patient. In chronic valvular defects there are changes in the size and posi- tion of the heart which are not present in the first stage of acute pericarditis. When both acute endocarditis and pericarditis are present, the difficulty is greatly increased and one or the other condition is likely to be overlooked. The " pleuropericardial " friction sound or " extra-pericardial " friction sound is to be distinguished from pericardial friction sound. It is a sound similar in rhythm to the pericardial sound, but the primar}' conditions of its causation are in a pleuritis involving the opposed surface of the mediastino- costal sinus of the left side. It is more commonl}- heard, therefore, over the left border of the heart. It is the combined product of the respiratory and ACUTE PERICARDITIS. 565 cardiac action, being usually louder during expiration. It generally ceases during a deep inspiration, because at this time the cardiac action cannot pro- duce the required rubbing. On the other hand, this is sometimes the very condition under which the friction sound is loudest. Simply holding the breath may also stop it, though not necessarily, because the heart motion pro- duces it. This influence of the breathing one way or the other is, however, of importance in diagnosis, while other symptoms must also be taken into consideration. Thus, if it be a pleurisy, the pleural friction sound is probably heard elsew^here, and there are the other symptoms of a pleurisy present, -.while those of a pericarditis are absent. Unlike the true" pericardial friction sound the pleuropericardial friction sound is uninfluenced by bending the body forward, but is heard with equal distinctness with the body in any posi- tion. Difficulties again increase when it is associated, as it sometimes is in a pleuro-pneumonia, with endocarditis. It also occurs in tubercular phthisis, where it is sometimes associated with a systolic click due to the simultaneous expulsion of a bubble of air from a portion of softened lung. For diagnosis between pericarditis with effusion and dilatation of the heart see page 605, It is in this differential diagnosis particularly that Rotch's sign and the diff'erence as determined by percussion of the cardio- hepatic angle become valuable. It must be remembered, however, that Rotch's sign is not always present, even when there is considerable effusion. The possibility of a circumscribed pleuritic effusion must also not be over- looked. Bamberger's sign — dullness in the region of the angle of the le'ft scapula — should be sought ; also Ewart's posterior pericardial patch. Prognosis. — The course of pericarditis varies with dift'erent cases. In an ordinary uncomplicated case passing to recovery, the duration is one to three weeks, even when there is considerable eff'usion, which is often absorbed with surprising rapidity. In other cases, especially in cachectic subjects, the duration is longer. Relapses occur. When adhesion results, convalescence is greatly prolonged, and in many cases the heart is perma- nently crippled. On the other hand, extensive adhesions are sometimes found at necropsy where no lesion was suspected. The pyopericardial cases are usually fatal. Treatment. — Prompt treatment is of the greatest importance in peri- carditis. Rest is an absolutely essential condition. As soon as the diagno- sis is made, a blister is of the greatest value. There is no other disease in which I am so satisfied of the efficiency of a blister. It should be at least three inches (7.5 cm.) square. I am confident that it helps to prevent effusion and also to promote the absorption of effusion. Along with this, measures to relieve pain are indicated. Nothing is so satisfactory as mod- erate doses of morphin administered hypodermically, associated wdth atropin in the proportion of 1-150 grain (0.00044 g™-) of the latter to 1-4 grain (0.0165 gm.) of the former. Cold applications to the pericardium by Lei- ter's coil or the ice-bag are sometimes useful. At other times hot applica- tions are more comforting. Digitalis in moderate doses is usually indicated to steady the heart at its work, without, however, stimulating it too forcibly. For the same reason alcohol and ammonia, especially the aromatic spirit of ammonia, are indi- cated. Strychnin is a valuable heart tonic. Liquid food, including milk and broths, should be adhered to until convalescence is established. Eggs may, however, be early allowed. If the effusion is very large, tapping the pericardium may be necessary 566 DISEASES OF HEART AND BLOOD-VESSELS. to relieve the patient, although practically the relief which first follows a successful operation is rarely followed by complete recovery. The aid of the surgeon should be secured if possible, but if not, puncture may be made in the fourth interspace, an inch (2.5 cm.) to the left of the edge of the sternum. If made in the fifth interspace, the puncture should be made a little further out — say i 1-2 inches (3.5 cm.). A safe point which may be used in large effusions is the left xiphocostal angle, at which the needle should be pushed upward and backward. When the pericardial fluid is pus, a simple tapping is insufficient. Free incision should be made, and free drainage should be established with aseptic precautions. John B. Roberts* collected thirty-five cases of suppurative pericarditis treated by incision, of which fifteen recovered and twenty died. It is not impossible that if oper- ation were done earlier, better results would follow. The treatment of chronic adhesive pericarditis is mainly symptomatic, and directed to building up the strength of the patient. OTHER PERICARDIAL AFFECTIONS. Other affections of the pericardium are hydropericardium, hemoperi- cardium, pneumopericardium, and tuberculous pericarditis, rarely morbid growths. Hydropericardium. — This term is applied to a large accumulation of serous fluid in the pericardium. In health the pericardium is simply lubri- cated by this fluid-. It occurs som.etimes as a part of a general dropsy, most frequently cardiac dropsy, more rarely in renal dropsy. The accumu- lation is seldom large in these cases. It is not common, but is sufficiently so to demand frequent examination of the heart, as it is often overlooked. Its signs are the same as those of the inflammatory effusion. Heinopericardiwn, or blood in the pericardium, occurs only as a result of rupture of an aneurysm in the first part of the aorta into the pericardial sac, from rupture of the heart itself or a wound of the heart. It is rapidh' followed by shock and death. Its physical signs are those of effusion. Cancer of the pericardium may be associated with blood effusion. It may also be caused by tuberculosis of the pericardium. Pneiwiopericardimn, or gas in the pericardial sac, is a rare condition, analagous to the much more common one of pneumothorax. As in pneumo- thorax, the presence of air implies also the presence of liquid, and that, usually, pus. It is produced Uy similar causes, such as perforation into an air-containing space like the lungs or esophagus. Such perforation is usually traumatic. Decomposition of pericardial exudate or morbid growth, it is said, may also produce it. Symptoms. — Its symptoms are pain and pericardial embarrassment, but the physical signs are most distinctive, especially those of auscultation. To inspection there is prominence of the precordium, with indistinctness or obliteration of apex-beat, restored by the patient's bending forward. Per- cussion furnishes dullness over the lower portion of the cardiac area and tympanv above it, the position of both being altered by change in position of the bodv. To auscultation the heart-sounds assume a striking metallic character, being audible even at a distance from the body. A similar * "American Journal of the Medical Sciences," December, 1897. ACUTE ENDOCARDITIS. 567 metallic character is given even to a friction sound, if it is present, as it ■often is. Diagnosis. — The diagnosis of this condition requires differentiation from the effect of an air-dilated stomach on the heart-sounds, or rarely of a phthisical cavity or pneuinothorax. All doubt in the case of the stomach is removed by filling it with water. The associated symptoms of the other conditions make a mistake unlikely. Treatment is scarcely available, except in case of external injury, when operation may be of service. Tuberculous Pericarditis presents nothing peculiar in its symptoms or signs as already described. Morbid Growths of the Pericardium are rarely diagnosticated before •death. DISEASES OF THE ENDOCARDIUM. ACUTE ENDOCARDITIS. Synonym. — Valvulitis. Definition. — Endocarditis in both its acute and chronic forms is an inflammation for the most part confined to the valves; for such inflammation, therefore, valvulitis is a more correct term. The lining of the cavity of the heart is, however, sometimes affected in acute endocarditis, especially in the more severe cases, when it is known as mural endocarditis. It is usually in the apex of the left ventricle that such inflammation occurs. Etiology. — All cases of acute endocarditis in the light of modern studies must be regarded as infectious — that is, as due to a specific poison commonly associated with some disease which is regarded as the cause of the endocarditis. Acute rheumatism is the best recognized and most fre- quent of these. Upon this follow closely the infectious fevers, with their various specific organisms or their toxic products. In the disease which is acknowledged to be the most common cause — acute articular rheumatism — no causing organism has as yet been found. There is, however, a great difference in the severity of different cases of acute endocarditis, and the disease is easily separable into two classes, from one of which recovery almost always takes place up to a certain point, leaving often a degree of valvular defect known as chronic endo- carditis, while the other is invariably fatal. The first, or milder, of these classes was for a time ascribed to some specific non-organized agency, even after the more severe and fatal form was recognized as infectious, whence arose the terms simple endocarditis on the one hand, and infectious, ulcer- tive, malignant, or mycotic on the other. In attempting to explain why at one time the simple form and at another the virulent form of endocarditis arises, it may be stated that the toxins generated by the less virulent bacteria pave the way for the operation of the virulent streptococcus and staphylococcus pyogenes, the pneumococcus, the gonococcus, and other organisms which are found in the morbid products of malignant endocarditis. It is not unreasonable to suppose that the former produce the simple form of endocarditis, while the co-operation 568 DISEASES OF HEART AND BLOOD-VESSELS. of the septic bacteria named is necessary to produce the mahgnant variety. On the other hand, it may be not so much the specific organism as the con- stitutional or local peculiarities of the individual on whom the disease is en- grafted — the natv:re of the soil, as it were. The Mild or Simple Form of Acute Endocarditis. Synonym. — Warty or Vcrrucosc Endocarditis. Etiology. — zA.lmost any one of the recognized infectious diseases may become a cause of simple endocarditis. Acute articular rheumatism is, how- ever, the most frequent cause, 20 per cent, of all cases being ascribed to it. After this comes chorea. Indeed, William Osier, who has made the sub- ject a special study, says : " There is no disease in which, postmortem, acute endocarditis has been so frequently found." Vegetations were found on the valves in sixty-two out of seventy-three fatal cases of chorea col- lected by him. This fact has suggested even a microbic origin of chorea, which is sustained by other features in the history of the disease, but not by actual demonstration. In the absence of such demonstration, chorea must be regarded in the light of a predisposing cause. Scarlet fever, pneumonia, tuberculosis, and peliosis rheumatica are not infrequent predisposing causes ; less frequently are tonsillitis, diphtheria, erysipelas, smallpox, and typhoid fever. Endocarditis also super^^enes as a complication of Bright's disease. Even in these cases bacteria are found in the vegetations. Cachectic states, such as are caused by tuberculosis and cancer, also seem to favor the develop- ment of acute endocarditis. Finally, chronic valvulitis is a predisposing condition to simple acute endocarditis as well as to the malignant form, being often complicated by acute attacks, whence the term " recurring " en- docarditis. Morbid Anatomy. — The left side of the heart is more frequently in- volved, and in this the mitral leaflets first, in at least half of all cases ; next the aortic cusps ; then, in the right heart, the tricuspid valve, and finally the pulmonary valve. In embryonic life, in which acute endocarditis also occurs, the right side of the heart and the tricuspid valve are most frequently affected, accounting thus for certain congenital valvular defects. The type of the morbid change on the valves in simple endocarditis is so constantly a product warty or fungous in appearance that the term warty or verrucose endocarditis is often applied to this form. On the auricular surface of the mitral, and the ventricular surface of the aortic valves, at the line of their contact during closure, — ?'. c, 1-25 to 1-12 inch (i to 2 mm.) back of the valve edge, — granular and warty excrescences make their ap- pearance. These rise 1-12 to 1-8 inch (2 to 3 mm.) above the surface and extend a variable extent along the valve. They soon become capped with fibrin, often abundantly, and thus a vegetation is formed. The vegetation begins in a proliferation of the cells of the adventitia and of the connective tissue of the external laminae of the endocardium. Thus formed, it is a friable product, liable to be broken off at any time and carried into the gen- eral circulation to a point of lodgment, where it plays the role of an embolus. In point of fact, this accident does not often happen in the simple acute endocarditis succeeding febrile diseases. It occurs more frequently in the acute endocarditis engrafted on chronic valvular disease, and in the malignant form. More frequently the vegetation undergoes organization ACUTE ENDOCARDITIS. 569 and contraction, and the valve is restored partially to its natural condition, leaving a simple sclerotic thickening, which is especially prone to become the starting-point of new processes. But not every aortic murmur in the course of rheumatism implies endocarditis, as the condition of the blood predisposes to a hemic murmur ; nor every murmur at the apex, because the state of the muscle predisposes to imperfect closure of the auriculo- veritricular orifice. Unless there has been previous valvular disease, there is no enlargement of the heart in acute endocarditis. Symptoms. — These are often masked by those of the previous disease, and sometimes overlooked, the autopsy first disclosing the lesion. There is frequently noticed, however, greater or less embarrassment of breathing, orthopnea being not infrequent ; the pulse is much more rapid and may be irregular, the patient is restless, the countenance dusky, while the tempera- ture is a degree or two higher than normal. Altogether, it is plain that he is sicker. Yet there is rarely acutal pain, as in pericarditis. Physical Signs. — In the first attacks of endocarditis there is no notable enlargement of the cardiac area as determined by percussion or mspection of seat of apex-beat. Auscultation may recognize a murmer, of which the situation varies with the valve involved. If the mitral, a murmur is heard in this area, usually systolic, soft, and blowing, at times quite harsh. Very rarely is there a presystolic murmur, though its more frequent occurrence might be expected from the nature and situation of the lesions described. When the lesion is at the aortic orifice, the murmur is heard in the aortic area at the second interspace at the right edge of the sternum. It is usually also systolic, but may be diastolic. But not every murmur heard in acute endocarditis is due to a valvular lesion. Basic murmurs also occur in the pulmonary area to the left of the sternum, which are functional in nature — the bellows murmur. A systolic murmur in the mitral area is not always due to regurgita- tion. The same excrescences which grow on the valve leaflets may also attach to the papillary muscles and chordae tendinese as well. Alitral re- gurgitation may also occur in rheumatism and in other acute febrile diseases from myocardial changes, as the result of which the basal part of the cardiac muscle is enfeebled and unable to do its part of the work of closing the mitral orifice, and the valve leaflets are insufficient to complete it. Some of the cases of murmur which disappear with recovery may belong to this category. It is characteristic of endocardial murmurs to come and go. Diagnosis. — This is based almost entirely on the physical signs, as no one of the symptoms is pathognomonic. Nor are the murmurs always to be relied upon, for the reasons assigned. The distinction of the endocardial from the pericardial murmur was considered in treating of pericarditis. The more superficial situation of the latter over the body of the heart, its to-and-fro rhythm, not connected with the heart-sounds, its failure to follow the usual law^s of conduction, and the fact that it is made more pronounced by pressure — all serve to distin- guish it. A. E. Sansom calls attention to a possible source of error in a pericardial roughening at or about the apex, especially in children, which causes a systolic apical murmur. This should be remembered as a possible, but rare, occurrence. Prognosis. — The subject of the simple form of acute endocarditis rarely dies, but he is likely to recover with a damaged heart — in other words, chronic valvular disease results. This is not, however, always the case. 570 DISEASES OF HEART AND BLOOD-VESSELS. for complete recovery is not impossible. On the other hand, some of the instances of complete recovery after mitral regurgitant murmur belong- doubtless to the category described of insufficiency due to myocardial defect without mitral lesion. It should not be concluded, however, that because a murmur has disappeared the patient has certainly recovered, since a murmur due to myocarditis may be succeeded by another true valvular murmur. Finally, one acute attack from which recovery has taken place is liable to be succeeded by another and another, so that, sooner or later, chronic valvular defects are produced. Treatment. — The keynote of the proper treatment of simple acute endocarditis is absolute quiet. It is not often that much else is required. A blister is not of the signal service here that it is in pericarditis, while digi- talis is not indicated unless there is irregularity, when the dose should be moderate — only enough to steady the heart. Dyspnea is best treated by sufficient doses of opium or morphin, which should not be put off too long. The diet should be easily assimilable and liquid until convalescence is established. The Severe or Malignant Form of Acute Endocarditis. Synonyms. — Ulcerative, Infections, Mycotic, or Diphtheritic Endocarditis. Definition. — Malignant endocarditis is an acute infectious fever due to inoculation of the blood by a bacillus or its toxic products, and characterized locally by a specific valvulitis. It is called primary when not engrafted on some other infectious disease. Historical. — It was recognized as a separate form of disease in 1851 by Senhouse Kirkes, and further studied by Charcot and Velpeau, in France, Virchow in Germany, and recently in this country by William Osier, who made it the subject of his Gul- stonian Lectures before the Royal College of Physicians, England, in 1885. Its mycotic nature was not suspected until after Koch discovered the bacillus of tuber- coJosis, in 1882. Etiology. — Malignant endocarditis shares with the simple form an infectious origin. No satisfactory explanation has, however, been furnished of its more malignant nature. Mention was made when treating of the simple variety of the suggestion sustained by the experiments of Wyssoko- witch, Ribbert, Orth, and others, that a state of the blood due to the toxic effect of bacteria may be the cause of the simple form, and that it may afford conditions favorable for the Operation of the more virulent bacteria found associated with the malignant form. It is extrem.ely doubtful whether there can be a primary malignant endocarditis without the intervention of some one of the diseases which usually precede it. The presence of chronic val- vular defects affords the most important predisposing cause favoring the action of the causes of the acute malignant form. Goodhart found it in 61 out of 69 cases, and Osier in 54 out of 209. The latter also found it II times at 100 autopsies of fatal cases of pneumonia. Of the infectious diseases associated with the malignant form of endocarditis, pneumonia is the most frequent. The disease occurs also in association with gonorrhea, rheumatism, peliosis rheumatica, pleurisy, puerperal fever, bone necrosis, and septicemia from any cause. More rarely it has been found in connection with meningitis, smallpox, diphtheria, scarlet fever, tuberculosis, and dysen- MALIGNANT ENDOCARDITIS. 571 tery. Most frequently, perhaps, the micro-organism is the lancet-shaped bacillus of pneumonia; after this, pus organisms, the streptococcus and staphylococcus. Morbid Anatomy. — As to the acute cardiac lesions associated, we find, either alone or in addition to the old sclerosis, three sets — vegetative, ulcerative, and suppurative. The vegetative are for the most part made up of closely-packed spherical micrococci, more or less commingled with small fibrin masses. The vegetations vary in size from that of a pin's head to that of a pea, and are reddish-yellow in color. The seat of this vegetation be- -comes rapidly necrotic, and breaks down into an ulcer which may perforate the valve, with or without previous protrusion — the so-called valvular aneu- rysm. More rarely minute foci of pus are found in the deeper tissues of the valve leaflets. The invasion is, however, not always confined to the valves, but may extend to the mural endocardium. Of the valves, the mitral is most frequently involved; next, the aortic; next, mitral and aortic jointly; next, the lining of the heart-wall ; next, the tricuspid ; and last, the pulmonary valve. In a few instances the right heart alone is invaded. Other morbid changes include the lesions of the concurrent affection and the phenomena of embolism due to lodgment of fragments of the vegetation. The result of the latter when complete is a metastatic abscess, though the earlier stages of red infarction may also be present. The spleen, kidney, skin, and even the cerebral cortex may be seats of embolism. In addition to these, we may also have embolism and hemor- rhagic infarct occurring in the lungs from emboli starting in the right heart, as contrasted with those originating in the left heart which lodge in the systemic circulation. The number of em.bolisms varies greatly in these cases. They may be altogether absent, while they may be counted by hundreds, in which event they are, of course, very small. The spleen is enlarged even when not the seat of embolism, as in other infectious diseases. Symptoms. — Given a pneumonia, pleurisy, the puerperal process, or any one of the diseases named, with the supervention of chills, followed by fever and szveats, this form of heart disease should be immediately thought of and the organ carefully examined for the auscultatory signs of endocarditis. In the primary form, however, should this exist, we have not even the presence of one of the diseases named to suggest the occurrence of ulcerative endocarditis. In this form, particularly, the resemblance to intermittent fever seems at first close, but a careful study of the temperature chart from day to day, and, above all, utter failure of the antiperiodic remedy to produce any effect, will in a short time show that the malarial disease is not present. Doubtless, often the malady under consideration has been mistaken for intermittent fever, and not without reason, for many a case of irregular quotidian and tertian fever presents similar symptoms ; but the regular, almost rhythmical, rise and fall of temperature, as exhibited in the chart of an intermittent fever, is wanting. Indeed, I think there is no disease in which the extreme irregularity in temperature reaches that of the one under consideration, as a careful study of the appended temperature chart from a ease of my own in the University Hospital will show. Note that the maxi- mum is reached at any time of day or night. Yet the temperature is not always so high, nor is the extreme range always so great as here indicated. The absence of the plasinodiiim malar ice serves only to distinguish it from malarial disease. It always greatly aids the diagnosis when to chills and fever are added 572 DISEASES OF HEART AXD BLOOD-VESSELS. other symptoms suggesting ciiibolisiii, which so frequently occurs. The occurrence of a hemiplegia, pain in the region of the spleen, with increased dullness on percussion, pain in the region of the kidney with hematuria, or a sudden blotch in the skin, of the kind described, is of inestimable value. Rarer symptoms of similar origin are impaired vision, from retinal hemor- rhage, parotitis, and 'abscess of the parotid gland. The symptoms are not always so pointed as detailed, while they may include others not mentioned. The fever may not be so high, but it is always present ; again, it may not 105' 1 1 1 \" 1 i 1 104? , 1 t A \ '■ 1 1 1 103" \ \ 1 \ \ \ 1 j \ \ 1 i ^ 1 \ \ ' i ~ 1 1 ■ro'2° 1 1 1 1 101° i [ > \ 100° 1 1 i 1 1 I [ • 1 ' / 1 i 99° fi 1 / j 1 1 'l 1 1 1 i/ 1 ! f \ 1 1 ■ 1 1 / ' "~1^ 1 ' j \ / • 1 j \ ! ■ \ / i i \ 1 \ / 1 / 1 s i \ \ / > / 1 '^ \ ^~\ ^ i f 1 ' ; 98" ^^ i J - ll i i 97° \ ' 1 / 1 ll — — -7— 1 1 1 1 ii 1 y ' 1 , 1 1 f 1 ^i_ \' 1 j 1 1 -4— ( V i 1 K 1 96° \l ; 1 ^7 1 u V 1 l\ I 1 1 w 1 "It ] 1 u 1 1 ' i^ 1 1 i 1 I "^^ ! 1 SI 1 i V, Nt 1 95 1 1 Fig. 52. — Temperature Chart, Malignant Endocarditis. be remittent, but continuous. There may be jaundice, precordial oppres- sion, shortness of breath, while heart symptoms may be altogether absent, when it is almost impossible to distinguish the disease from a septic fever of the ordinary kind. The pulse and respirations are invariably accelerated. Extreme embarrassment of breathing is very characteristic. Albuminuria and casts occur in all forms, either as the result of acute nephritis or of renal embolism. A further study of the symptoms of malignant endocarditis permits MALIGNANT ENDOCARDITIS. 573 their classification into three groups, known as the septic or pyemic, the typhoid, and the cerebral. The septic type occurs in connection with such septic processes as ex- ternal wounds, the puerperal process, or acute bone disease with necrosis. The symptoms added are rigor, irregular fever, sweats, and exhaustion. Yet these are only the symptoms characteristic of pyemia. In fact, it is a pyemia ; and the term arterial pyemia, suggested by Wilkes, is a good one, because the pyemic abscesses result from emboli, starting in the left heart and lodging in arteries. The endocarditis constitutes the distinctive feature of the disease. The resemblance to intermittent fever here exists also, and a quotidian or double tertian type may be simulated. It is in this form especially that leukocytosis occurs, determined by a blood count. The symptoms of the typhoid type are even more characteristic. We tneet here, too, the same prostration, irregular temperature, and sweating; rigor is less frequent, and the onset is more gradual. There are delirium, drowsiness, often diarrhea, with distention of the abdomen and tenderness in the right iliac region, to which a rash may also be added, which, though not identical with that of typhoid fever, is, nevertheless, similar to it. The tongue is dry and brown, and sordes collects about the teeth. The tem- perature is remittent, like that of typhoid, reaching 103° F. to 104° F. (39.4° C. to 40° C.) and even higher. Here again the heart symptoms may be overlooked. Still another group is the cerebral, in which the symptoms simulate meningitis, basilar or cerebrospinal, with acute delirium as the distinctive feature. Physical Signs. — If there is anything peculiar about the physical signs, it is their want of definiteness. When murmurs are present, it is often difficult to locate or time them precisely. They often vary from day to day. They may occur at both base and apex, and with reason, for both sets of valves may be and often are involved. The superaddition of pericarditis adds a further source of confusion in the friction sound superadded. If chrowic valvular disease exists, its signs are also present, including those of hypertrophy. Complications. — As to complications, these are mainly the original car- diac disease or the diseases the specific organisms of which most frequently cause the virulent inflammation. Pericarditis and pleurisy are frequent complications in the strict sense of the term ; there may also be meningitis. Acute nephritis, the result of sepsis and quite independent of embolism, may be present, with its characteristic symptoms, albuminuria, blood casts, and free blood-corpuscles. Gastro-intestinal derangements not of embolic origin are sometimes conspicuous. Diarrhea may be especially troublesome. Diagnosis. — This is not always easy at first. A few days' study of the temperature, with its extreme fluctuations, the rigors, and the super- vening sweats, should at once lead to suspicion, and these, if continued, point only to this disease. If one would always remember the possibility of the occurrence of malignant endocarditis in connection with the diseases named, it would be less frequently overlooked. The fever is a septic one in all cases, the heart symptoms adding the peculiarity. In true typhoid fever there is always splenic enlargement and often parotitis, so that the presence of these symptoms naturally suggests that disease, and an erroneous diag- nosis is not inexcusable. It is said that splenic enlargement is not so marked as in typhoid fever, and that there is commonly more tenderness in 574 DISEASES OF HEART AND BLOOD-VESSELS. ulcerative endocarditis. This may be true in some cases, and not in others. So far as I know the Widal test has not been made in a case of ulcerative endocarditis. Rheumatic fever often more closely resembles malignant endocarditis, with its high, irregular fever, and copious sweats, while confusion is further contributed to by the fact that endocarditis is one of the most frequent complications of rheumatism, the malignant form being, however, more in- frequent than the simple. But recurring rigors are not usual in rheumatism. The joint symptoms of rheumatism are conspicuous at an early stage of the disease ; there is no enlargement of the spleen, nor symptom ascribable to embolism, unless secondary to endocarditis. The essential identity of ordinary pyemia and malignant endocarditis has been mentioned, and only the endocarditis and its consequences distinguish the disease from ordinary septic fever. It must not be forgotten that the simple and severe forms are not separated by any sharp line. The crucial diagnostic test is a bacteriological examination of the blood. Prognosis. — The prognosis is always unfavorable, though ulcerative endocarditis may be prolonged for many weeks and even months. Usually, however, five or six weeks measure its course, while some cases are of shorter duration. Eberth reports a case fatal in two days. Treatment. — Treatment heretofore has availed little. There seems reason to believe antistreptococcus serum may be of service, and several cases of cure are reported. Twenty c. c. may be injected daily. It seems quite harmless. The patient should be kept at rest. Remedies should be restorative and supporting — quinin, stimulants, digitalis. Nourishing food is indicated. The high temperature may be treated by sponging or by an ice-cap, or by Leiter's coils applied to the thorax or abdomen ; but high tem- perature is seldom of so long duration as to require special treatment. CHRONIC VALVULAR DEFECTS. Synonyms. — Chronic Endocarditis ; Chronic Valvular Disease. Definition, — Permanent alterations in the structures about the cardiac orifices, producing incompetency, narrowing, or other deviations from the normal. Etiology. — The majority of chronic valvular defects are the consequence of endocarditis, acute or chronic. It may be that the very first attack of acute inflammation has left the valve leaflets in so sclerotic a condition that they readily become the seat of the subsequent changes which constitute the chronic disease, or that several attacks may be necessary before a permanent effect is produced. On the other hand, we must acknowledge, too, a chronic valvulitis, in which valvular defect is brought about gradually without the intervention of acute inflammation. This process is analogous to chronic endarteritis, consisting in hyperplasia with fatty (atheromatous) and cal- careous degeneration of the new tissue. In fact, a chronic endarteritis may spread from the aorta to the aortic valves. These slowly induced inflamma- tions are variously caused. The rheumatic poison may cause them, as it does the acute forms. Alcoholic indulgence and intemperate eating, whether by the direct irritation of the substances taken into the blood o' through the CHRONIC VALVULAR DEFECTS. 575, poison of gout engendered by their use, are frequent causes. Another cause is prolonged muscular strain, producing overtension of the valve leaflets. This operates in laborers who do much heavy lifting, and sometimes in athletes. Especially potent is it when, as is often the case, hard muscular work is associated with overeating and drinking. To these, syphilis also often contributes a factor in some unknown way. Under all of these latter circumstances it is the aortic cusps which suffer most. Morbid Anatomy. — The anatomical condition of the defective valves is made up of five separate factors, each of which may enter more or less into the lesion. This is true both of the auriculo-ventricular and semilunar valves. These conditions are : (i) Thickening. (2) Retraction. (3) Adhesion. (4) Calcification. (5) Atheroma, either alone or associated with calcification. 1. Thickening is the immediate result of an overgrowth of connective tissue. The slighter degrees are seen along the bases of the aortic cusps and at the line of contact in closure of the mitral leaflets. Such degrees do not necessarily impair the function of the valves. More advanced stages produce a distinct thickening and sclerosis of the whole of each aortic cusp and mitral leaflet. 2. Retraction or curling is the result of shrinkage of this hyperplastic tissue. The three aortic cusps are often reefed back and fixed, although the very edge of the valve may still remam movable. In the case of the mitral valve, the tendinous attachments of the papillary muscles often contract and draw the valves into the left ventricle, producing a permanent funnel-like extension analogous to that which takes place in physiological closure of the mitral orifice. 3. Adhesions unite the valve leaflets, increasing their fixedness and rigidity, interfering with complete opening and closure. The right and pos- terior aortic cusps are most frequently united. Most serious is the effect of union of the mitral leaflets, which sometimes results in a reduction of the orifice to a mere slit or buttonhole-like opening — the buttonhole mitral orifice. 4. Calcification or limy infiltration of the valves thus united may succeed in various degrees, producing in extreme cases firm, bony rings which further diminish the mobility of the valves. In mild degrees there are formed splinter-like projections into the substance of the valve which also interfere with complete closure and opening ; at other times there may be simple mar- ginal deposits which impede the function of the valves only slightly or not at all. 5. Atheroma, or fattty degeneration, is also often found in the shape of 3'ellow spots on the surface of the valves and at the marginal attachments of the aortic cusp, without producing insufficiency. Still another form of lesion found at necropsy is rupture of a leaflet, the result of strain. This is perhaps not possible with a sound valve, while one weakened by the morbid states described may give way. The physiological result is insufficiency, while the lumen of the orifice during systole is not encroached upon. Such an accident is not infrequent in acute ulcerative endo- carditis in consequence of erosion and partial destruction of the valve. Insufficiency of the aortic orifice at the time of life at which it is most common — say middle age — is favore(^ by a gradual widening of this orifice from 4-5 inch (20 mm.) at birth to a possible 2 4-5 inches (70 mm.) at eighty years. Congenital defects are relatively common to the right side of the heart. 576 DISEASES OF HEART AND BLOOD-VESSELS. which is the subject also of inflammations during intra-uterine life. The changes resulting from the latter are of the nature of fusions. Such defects .also occur rarely on the left side ; most rarely in the mitral valve. Mitral Insufficiency or Incompetency. Occurrence and Mechanism. — This is the most frequent of the uncom- bined forms of valvular disease. The valve leaks. The blood flows back- Avard during systole from the left ventricle to the left auricle. The distended auricle, first attempting to resist the backward flow, hypertrophies but eventu- ally dilates, and the blood is crowded backward into the lungs, which become ■engorged. The right ventricle, in its efforts to push the blood through the engorged lungs, hypertrophies, and the pulmonary factor of the second sound becomes louder and sharply accentuated. The compensating effect of the hypertrophied right ventricle for a time arrests the mischief. At this stage, perhaps, begins the hypertrophy of the left ventricle, which in all cases of mitral insufficiency presents itself sooner or later, although at first the double •outlet for the blood from the ventricle would seem to demand less strength of the left ventricle. The right ventricle, however, in its hypertrophied state, delivers more blood through the lungs to the left ventricle, which demands more power to drive it on, hypertrophy results, and thus compensation is for a time longer maintained. Sooner or later the right ventricle dilates, the tricuspid valve becomes insufficient, the blood regurgitates into the right auricle and thence into the great veins of the neck. The valves of these ulti- mately yield, the jugular pulse appears, and the general venous system is engorged. Incompetency of the cardiac valves is often brought about by dilatation of the ventricles and the great vessels leading from the heart, the valve leaflets themselves remaining intact. Such relative insufficiency affects most frequently the auriculo-ventricular valves, and, as a consequence, the latter are not " sufficient " to stretch across their respective orifices and close them. Less commonly the semilunar valves are similarly deficient ; more frequently the aortic in dilatation of the aorta ; and more rarely also the pulmonary valve when that vessel is dilated. It should be said of auriculo-ventricular insuffi- ciency of this kind that it is found more frequently in the autopsy-room than recognized clinically, for it does not always cause a murmur. Etiology. — Endocarditis, acute or chronic, is the most frequent initial cause of mitral insufficiency. Symptoms. — Often there are no symptoms, because for a considerable length of time compensation kfeeps pace wath the development of the disease unless the latter be sudden, as by rupture of a valve leaflet. The first thing noticeable is usually shortness of breath on exertion, the so-called cardiac asthma. With this is soon associated palpitation, or " beating " of the heart, which increases and abates pari passu with the dyspnea. Next is irregularity of the heart's action^ This is the beginning of waning compensanuii, of which the immediate result is congestion of the lungs. Dyspnea is now per- manent. Thence the engorgement extends to the right ventricle and venous side of the circulation, the pressure in the arteries being proportionately less. The lung engorgement invites frequent attacks of bronchitis, excites cough and increases dyspnea. Orthopnea is frequent at this stage, and the patient can only rest sitting in a chair. There is sometimes blood-stained expectora- tion, in which may be found alveolar epithelium dotted with pigment granules. CHRONIC VALVULAR DEFECTS. 577 Along with this, or before it, the liver becomes congested, enlarged, and tender; the mucous membrane of the stomach also becomes congested, caus- ing nausea and indigestion. The hepatic enlargement is sometimes very great, and I have known it to be mistaken for cancer of the organ. The liver is often the seat of pulsation, and as often a jugular pulse is seen. Both signs are pathognomonic of mitral regurgitation. Later, this enlarged liver may return to its normal state or contract still further, constituting the so-called red atrophy. In advanced stages the kidneys also become passively con- gested, the urine is scanty and its specific gravity high, while there are copious .deposits of urates. It contains a small quantity of albumin and there may be hyaline tube-casts, rarely even a few blood discs. As a secondary result of hepatic engorgement only there may also be enlargement of the spleen. Concurrent, or succeeding on failing compensation, comes edema or dropsy, the direct result of venous engorgement and the filtration of the liquid elements of the blood into the subcutaneous connective tissue of the body — first of the feet and legs, then of the trunk, face, and upper extremities, and, finally, into the pleural and peritoneal cavities, causing various degrees of inconvenience. Effusion into the pleural sacs may occur before there is any tendency to dropsy elsewhere. Allusion has been made to the studies of J. Dutton Steele on this subject on page 548. Dr. Steele does not, of course, deny the eflfect of concurrent conditions, such as diaphragmatic pleurisy, hepatitis, and the like. Nose-bleed is a symptom sometimes seen in this disease. It is a natural result of the venous congestion. Physical Signs. — Inspection discovers the apex-beat to the left of its normal position in the fifth interspace, or perhaps a little lower down. It may be in the line of the nipple or even beyond it, more forcible and diffuse than in health. The outward dislocation of the apex-beat is due to the enlargement of the two ventricles. In thin persons an auricular impulse may be seen to the left of the pulmonic area in the second interspace, and may "be presystolic and active for the auricle — that is, produced when the auricle contracts ; or systolic and passive for the auricle — that is, caused by a filling ■of the auricle by regurgitation from the ventricle during the latter's systole. In young persons a bulging precordium may be looked for in the second and third interspaces to the left of the sternum ; also to the left of the lower part of the sternum from hypertrophy of the right ventricle. In advanced stages there is a jugular pulse, which is also pathognomonic of tricuspid regurgi- tation. On palpation the apex-beat is found more forcible than normal, at least while compensation is maintained, and there may be a pulsation near the ensiform cartilage, caused by the systole of the enlarged right ventricle. As compensation wanes the apex-beat becomes weaker and irregular. Some- times an intermittent systolic thrill is felt in the fourth interspace in the left mammillary line. Very rarely is there a systolic thrill at the apex. The radial pulse in the early stage is comparatively unaltered. Later, it becomes frequent and irregular in volume. Appended (Fig. 53) is a sphygmogram of the pulse in advanced mitral insufficiency. It is of the type of the pulsus parvus irregularis. Percussion finds enlargement of, both the relative and absolute areas of dullness, upward in the direction of the left auricle, downward to the left and also to the right, the right border of the heart extending at times beyond the right border of the sternum. 37 5/8 DISEASES OF HEART AND BLOOD-VESSELS. Auscultation recognizes a systolic murmur in the mitral area, conducted with various degrees of loudness into the left axilla and under the angle of the scapula. This direction of its conduction is the distinctive feature of this murmur. It is usually soft, but occasionally rough, more rarely musical. Richard C. Cabot says that musical murmurs are heard more frequently at the Fig- 53- — Tracing of Pulse of Mitral Insufficiency. mitral valve in regurgitation than at any other valve. A fading mitral systolic murmur generally means failing compensation, and when compensation is completely gone it is substituted by incomplete valvular sounds, great irregu- larity, gallop rhythm, labored breathing, and all the signs of pulmonary con- gestion. It is also sometimes heard distinctly to the left of the pulmonic cartilage, and rarely over the entire precordium. Not always loud enough to be easily heard, it may be brought out by exertion on the part of the patient. The second sound of the heart is heard sharply accentuated at the pul- monary area until the tricuspid valve fails, when the accentuation fades away. The aortic second sound is less strong, corresponding with the smaller degree of hypertrophy of the left ventricle. Differential Diagnosis. — The mitral regurgitation murmur is not usually difficult of recognition through the features which have been described. A functional murmur is rarely heard at the apex. Should it happen that it is, it will not be conducted as is the organic mitral systolic murmur, and it is not heard behind and below the angle of the scapula. Aortic roughening pro- duces a murmur heard at the same time as the mitral systolic, and may also be propagated to the apex, but the position of greatest intensity is the second interspace to the right of the sternum and the murmur is transmitted loudly into the great vessels of the neck, which is never the case with the mitral systolic murmur. The tricuspid systolic murmur occurs at the same time, but its point of greatest intensity is at the ensiform cartilage ; it is not commonly a loud murmur and is more apt to be observed by the mitral regurgitant murmur than it is likely to obscure the latter. Mitral Stenosis. Occurrence and Mechanism. — This lesion occurs as an uncombined or simple form of valvular disease in young persons, especially women, but is more commonly combined with mitral insufficiency. Seventy-six per cent, of all cases are said to occur in the female sex. In the simple fonn the orifice is stenosed, and the blood is restrained from passing freely into the left ven- tricle. It is backed into the left auricle, the lungs, right ventricle, and gen- eral venous circulation, but the left ventricle is not hypertrophied in simple mitral obstruction because no extra muscular demand is made on it, while hypertrophy of the left auricle is one of its most characteristic signs. Theo- retically, the left ventricle should even atrophy from diminished function. Practically this does not occur, but the absence of the enlargement is of great diagnostic value. Excellent compensation is often maintained in mitral stenosis for many years. CHRONIC VALVULAR DEFECTS. 579 Pure stenosis without regurgitation is possible if the mitral valve leaflets are fused without retraction, so as to form the funnel-shaped opening already described. In these cases a postmortem demonstration of insufficiency by means of the hydrostatic test is scarcely possible. Less frequently the mitral orifice viewed from above is a mere slit, — Corrigan's buttonhole contraction, — straight or slightly crescentic, in a smooth septum formed by fusion and contraction of the valve leaflets and tendinous cords. In some cases cal- careous infiltration is added, and in a few rare instances uratic deposits are found. The ratio of buttonhole mitral stenosis to the funnel-shaped orifice ~ varies with different observers — i to 10 by A. E. Sansom, i to 13 by Hayden, I to 46 by Hilton Fagge. Etiology. — Most frequently mitral stenosis is the result of endocarditis, acute or chronic, but it may in rare cases be congenital. In these cases, of which a number have been collected by Bedford Fenwick, the stenosis is sec- ondary to narrowing of the tricuspid orifice, thus explained : A small quan- tity only of blood being allowed to pass into the right ventricle and lungs, a diminished supply is sent to the left heart, whence both its cavities and orifices are reduced in size. No functional disorder can cause mitral stenosis. Symptoms. — These, often delayed by compensation, as in mitral insuffi- ciency, are the same as in that lesion. In consequence of this commonness of symptoms the diagnosis of mitral stenosis is based largely on the physical signs. Physical Signs. — Mitral stenosis may exist for many years without giv- ing rise to physical signs. Inspection consistently with what would be expected in absence of hypertrophy of the left ventricle, recognizes little or no displacement of the apex in pure stenosis. If there is any, it is due to the hypertrophy of the right ventricle, which pushes the apex toward the left rather than downward and to the left. Nor is the true apex-beat increased in force, though there may be strong epigastric pulsation because of hyper- trophy of the right ventricle, and in persons with thin chest-walls there may be an impulse in the third and fourth interspaces to the left of the sternum while compensation is maintained. A left auricular impulse, presystolic, may be noted in the second interspace to the left of the sternum, for the same rea- son as in mitral regurgitation. A jugular pulse may also be present if there is tricuspid regurgitation. A bulging precordium is possible only from great enlargement of the right ventricle and is not often seen. In children the lower sternum and fifth and sixth left costal cartilages may be prominent from this cause. Palpation discerns that the apex-beat is without undue force, but it may be diffuse, and an impulse may be felt in the epigastrium, the situation of the apex of the right ventricle. The most marked feature recognized by palpa- tion is the presy^stolic thrill at the apex, differing in this respect from the rare systolic thrill of mitral insufficiency. It is usually best felt in the fourth or fifth interspace, within the nipple-line. It is similar in rhythm to the pre- systolic murmur, but may be present without it. It is often absent. It is pathognomonic of mitral stenosis. In moderate degrees of stenosis the pulse is not altered ; in high degrees it is small, from want of blood and left ventricular power. Irregularity, like that of mitral regurgitation, is charaoteristic of advanced stages. Two trac- ings from cases of mitral stenosis are introduced in the text. Percussion recognizes cardiac enlargement in the direction of the left auricle and right ventricle, but not of the left ventricle in pure mitral stenosis. 58o DISEASES OF HEART AND BLOOD-VESSELS. Auscultation may not recognize a murmur in every case of mitral stenosis because of the feebleness of the auricular contraction, especially toward the end of life, when compensation has failed and there is not the force of contraction sufificient to throw the blood stream into audible vibration. Most characteristic is the abruptly terminating presystolic murmur, confined for the most part to the mitral area to the inner side of the apex-beat, though it may be conveyed upward, and it is even heard posteriorly, though rarely. It is true that the presytolic murmur is heard in atypical situations, espe- cially in the axilla and below the angle of the scapula, more frequently than has commonly been supposed.* The presystolic murnutr of mitral stenosis is a diastolic murmur occur- ring at the end of diastole of the ventricle, because it is at this time that the auricular systole takes place, giving the propulsive force necessary to produce the audible vibration. It is a loud, rough, vibratory murmur terminating suddenly with the first sound, sharp and ringing and coincident with the pre- systolic thrill. The murmur terminates with the impulse, and as the two are not always easily separable, the former is commonly more readily distin- guished by its qualities than by its time. It is often followed by a " thump- ing " first sound, which, in consequence of this character, is sometimes mis- taken for a second sound. As the disease advances it may occupy the entire period of diastole. In such cases there is sometiines a short pause between the beginning or diastolic part and the terminal or presystolic part of the murmur. In the last stage the murmur may disappear altogether, leaving only the snapping first sound. Differential Diagnosis. — The murmur of mitral stenosis ought not to be confounded with the murmur of aortic regurgitation, for the latter is heard loudest in a different situation, but moreover there is enormous hypertrophy of the left ventricle, which is wanting in mitral stenosis. The time of tri- cuspid stenosis is identical with that of mitral stenosis, but it is heard in a different part of the precordium — in the epigastrium. Tricuspid stenosis is, however, a very rare lesion. Much more reasonably might the murmur of mitral stenosis be confounded with the so-called Flijit inurnuir. This mur- Fig. 54. — Tracing of Pulse in Mitral Stenosis. mur is heard at the apex, at the same site as the presystolic, and may be similar in quality. It occurs in high degrees of dilatation of the ventricle, and is due to the fact, according to the late Austin Flint, Sr., that in such dilatation the mitral leaflets cannot, during diastole, be kept back against the ventricular wall, but remain in the blood current, throwing the latter into audible vibration. It may be said of the Flint murmur that it is never as intense as the mitral presystolic murmur. Otherwise the acoustic qualities are similar. The snapping first sound and systolic shock are also apt to be * See an excellent, well-illustrated paper on this subject bj' J. P. C. Griffith in the "Transactions of the Association of American Physicians," 1895. CHRONIC VALVULAR DEFECTS. 581 modified or absent. But the other signs of aortic regurgitation most heip us to a diagnosis. A rumbHng sound succeeding a pericarditis in children, referred to espe- cially by Broadbent and Rosenbach, has occasioned error, but this, too, is said to be unaccompanied by accentuation of the first sound at the apex. It is a transient murmur often succeeded by recover}-. These sources of error are well illustrated by the observations of Phear,* who investigated 46 cases of presystolic murmur in which no mitral lesion was found at autopsy. In 17 of these there was aortic regurgitation; in 20 ■of these there was adherent pericardium ; in 9 nothing more than dilatation of the left ventricle was found. In none was the snapping first sound, so com- mon in mitral stenosis, recorded during life. Not infrequently the presystolic murmur is associated with a mitral sys- tolic or regurgitant murmur, usually soft and not very loud, though some- times it is distinct and is well transmitted into the axilla. The pulse is small, as would be expected from the small volume of blood ejected from the ventricle, but may be quite regular, as seen in the sphymograms. Alore frequently it is irregular. Sometimes there is a rhythmical failure of an alternate heart-beat to reach the wrist, while the sphygmogram will show a small rise between two higher ones constituting the pulsus higeminus. On account of the difficulties mentioned, while the presystolic murmur is a valuable sign of mitral stenosis, it should not be alone relied upon for diagnosis, but should be taken in connection with other signs. Tricuspid stenosis may be associated with mitral stenosis or insufficiency, or both. With the loss of compensation the presystolic murmur disappears together with the thrill, and there remains only the sharp, ringing normal first sound. Accentuation of the second sound is marked, but confined to the pul- monary area, because there is no hypertrophy of the left ventricle. The second sound may also be duplicated, because of the want of synchronousness in the closure of the aortic and the pulmonary valves. Dr. Sansom regards this reduplication as only a seeming one of the second sound. He regards it rather as the normal second sound followed by another sound due to a sudden tension of the mitral valve itself. He also says it occurs in at least one-third of all cases of mitral stenosis, and is rare in other cardiac conditions. The accentuation of the pulmonary second sound also disappears with the enfeeb- ling of the contraction of the right ventricle. In slight degrees of mitral stenosis the second sound is heard at the apex, but as the lesion becomes more serious the second sound becomes fainter and eventually inaudible, though markedly accentuated in the pulmonic area. The physical signs of mitral stenosis are more changeable and fleeting than those of any other valvular disease of the heart. Dr. Sansom lays great stress on the evidence of the cardiograph in the diagnosis of mitral stenosis, which enables one to judge of the relative length of systole and diastole. In stenosis the diastole may be greatly prolonged, or the diastolic intervals vary greatly in duration. In mitral regurgitation, on the other hand, a short interval only separates the systoles. Patients with mitral stenosis are subject to attacks of recurring valvu- litis, with consequent embolism in different parts of the body. Embolism is a frequent complication of mitral stenosis. Pulmonary tuberculosis, quite * "Lancet," September 21, 1895. 582 DISEASES OE HEART AXD BLOOD-VESSELS. infrequently associated with valvular heart disease, is found more often in association with mitral stenosis than anv other form. Mitral Insufficiency and Stenosis. Occurrence. — More common than mitral stenosis as an uncombined lesion is stenosis associated with insufficiency, in which case we have the double mitral murmur, sometimes with difficulty divisible into its two parts. Extreme irregularity of rhythm and pulse, with frequency and smallness of the latter, conspicuous thrill, marked right-sided hypertrophy, and sharply accentuated pulmonic sound are characteristic of advanced stages. The presence of hypertrophy of the left ventricle points to associated mitral insufficiency and stenosis. Whence this combined lesion exists, mitral insuffi- ciency is said to usually precede. Aortic Insufficiency or Incompetency. Occurrence and Mechanism. — By aortic insufficiency is meant an abnormal dilatation of the aortic orifice. This is the most serious and irremediable of the valvular diseases of the heart commonly met. Next in frequency to mitral incompetency, much more frequent than aortic stenosis, with which it more often coexists, it is a disease of men rather than women, commonly adults at or before middle life. The w-idth of the aortic orifice increases from birthi to old age, while the valve cusps tend to shrivel, so that conditions favorable to incompetency coexist. It includes 30 to 50 per cent, of all cases of chronic valvular disease. It is more frequently associated wath arterial sclerosis and less frequently the result of rheumatic endocarditis, though it may be thus caused. It is the lesion most frequently followed by sudden death. When it exists, the aortic valves are incompetent to close the aortic orifice, either on account of the large size of the latter or of disease of the valve segments themselves, and the blood flows backward into the left ventricle during diastole. The ventricle, seeking to restore the balance, redoubles its energy and hypertrophies. The blood is thus driven into the aorta with great force, swelling the arteries to an extreme fullness, which, however, falls promptly away, because of the backward flow into the ven- tricle at the same time with the forward movement into arteries and capil- laries. This sudden falling away of the pulse, from extreme distention to collapse, is very characteristic of this form of valvular disease, and is called the " trip-hammer " or " water-hammer " pulse, also Corrigan pulse. To the casual observer it may even be visible in the exposed arteries, such as the carotid, temporal, and radial, while the aortic beat, ordinarily beyond reach in the suprasternal notch, may be felt in this situation. The abrupt jerking impulse with sudden recoil is easily recognized by the finger on the pulse, which, however, fails to find the pulse as strong and hard as would be expected from its appearance. On the other hand, it is soft and receding. It is commonly regular. A tracing of this pulse is seen in Figure 55. It is the typical pulsus celer ef alius. A frequent and irregular pulse is much more serious in aortic valve disease than in mitral disease. Sclerotic changes in the arterial zivlls are not uncommon in aortic incompetency. CHRONIC VALVULAR DEFECTS. 583 The product of this defect is the largest heart met in morbid anatomy, the left auricle and right ventricle often sharing in the enlargement. From its size the heart is called the bovine heart. It may weigh as much as thirty- five ounces (1050 gm.), and has attained a weight of fifty ounces (1500 gm.) or more. The cavities are enlarged and the walls are thickened, so that it furnishes an instance of eccentric hypertrophy. There may be ultimate dilatation of the arch of the aorta from the constant pounding of the blood against it in systole, while the carotids may be seen throbbing in the throat. The gradual enlargement of the ventricle may ultimately cause the mitral valve to yield. Compensation is still maintained for a time by hypertrophy of the left auricle, which -also yields after a time, becoming dilated and allow- ing the blood to engorge the lung. Hypertrophy of the right ventricle then comes to the rescue for a time. Sooner or later it, too, yields, dilates, the Fig- 55- — Tracings of Pulse of Aortic Regurgitation. tricuspid valve weakens, and finally gives way, allowing the blood to flow back into the venous side of the circulation, producing engorgement of the liver, stomach, kidneys, general dropsy — the train of symptoms described under mitral regurgitation. Etiology. — Causes of insufficiency in addition to those considered under the general etiology of valvular disease are congenital malformations, includ- ing fusion of two leaflets, commonly those behind which the coronary arteries come off. Such fused leaflets are especially prone to valvulitis and its conse- quences. Aortic insufficiency is quite often caused by dilatation and aneurysm of the ascending aorta, giving rise to relative insufficiency. Symptoms. — Like all other forms of valvular heart disease, aortic incompetency may be compensated for a long time, and elude detection for a corresponding time. Indeed, full compensation is said by some to be most usual in this form of valvular disease. Both dropsy and dyspnea are char- acteristically absent until compensation ceases, which is never the case until the mitral valve begins to yield. Then, however, both appear and may be very distressing. An especially frequent symptom is dissiness with faint- ness, particularly on rising quickly. Palpitation ensues on slight exertion, and this effect is in marked contrast to the comfort of the patient when quiet, when the pulse may be slow and breathing regular. In advanced cases, on the other hand, the patient complains of a constant " beating " or pulsation all over the body, especially in the head, which is exceedingly unpleasant. 584 DISEASES OF HEART AND BLOOD-VESSELS. The patient is very apt to be troubled in ]iis sleep and to dream, probably because of disturbed circulation in the brain. Even permanent mental symp- toms may result from this cause, including insanity and suicidal tendency. Lesser degrees are irritability and peevishness, though these are not confined to this form of heart disease. Precordial pain, present also in stenosis, is frequent in this form of valvular disease. It may be a dull ache with a sense of constriction of the chest, or sharp and radiating down the arms, particularly the left, as in angina pectoris, which condition itself is also common. With the yielding of the mitral valve and loss of compensation come the symptoms of mitral disease already described. As previously stated, this is the form of valvular disease in v,-hich sudden death is most frequent. It has overtaken many a victim in the course of his daily vocation and without warning, though it is most apt to be induced by some slight overexertion or mental excitement. The cause of such sudden death is probably interruption of the circulation in the coronary arteries. This may be brought about in one of two ways. These arteries, in common with others, are especially disposed to endarteritis and resulting sclerosis and atheroma, a condition which constantly invites thrombosis and obstruction to the circulation ; or it may be due to embarrassed circulation in these vessels,,, caused by the aortic regurgitation, for even if the blood enters the coronary arteries during systole, it must still receive in health some further supply in the recoil of the blood on the closed semilunar valves, which cannot take place when the valves are incompetent. On this variety, too, supervenes not infre- quently acute infectious endocarditis of the grave type, with the train of symptoms and the sequelae described. Embolism in various organs is also a complication independent of the acute involvement. Physical Signs. — Inspection often discerns the prominent left precor- dium, with the apex-beat lowered and to the left, and the visible pulsation far beyond the normal situation of the apex, all confirmed by palpation. Palpa- tion also recognizes at times a diastolic thrill over the base, in the carotids and subclavians, and sometimes in the aorta at the suprasternal notch. This is, however, much rarer in aortic regurgitation than the systolic thrill in stenosis. The Corrigan pulse may also be felt, but is much more strikingly manifested in the sphygmogram. A capillary pulse is also sometimes demon- strable in the skin and mucous membrane. This may be observed by draw- ing a pencil lightly across the skin of the cheek or forehead ; and on the muc®us membrane of the everted lower lip by pressing a glass microscope slide against it. It may often be w^ell studied around the lunula of the finger- nail. Pulsation in the retinal arteries may be recognized by the ophthalmo- scope. Pulsation may even be ^en in the uvula as originally pointed out by F. Miiller in 1889, by Schlesinger * the next year and recently by David Riesman.f Percussion discloses increased dullness to the left and downward, and also, sometimes in advanced cases, upward to the left of the sternum, owing to hypertrophy of the left auricle, as w^ell as -to the enlargement of the ventricle upward. Auscultation recognizes a diastolic murmur, long, loud, and blowing in quality, usually harsher than the aortic obstructive murmur. It may or may not replace the second sound of the heart. It is well heard in the aortic area, but its seat of maximum intensity is commonly to the left of the second inter- * " Wiener klin, Wochenschrift," October 4, 1900. t "American jMedicine," June 15, igoi. CHRONIC VALVULAR DEFECTS. 585 space, near the midsternum, sometimes as low as the fourth left costal car- tilage, and even at the ensiform cartilage. The murmur is naturally trans- mitted downward toward the ensiform cartilage or along the left edge of the sternum. Hence it may be mistaken for the murmur of tricuspid disease, but this, be it remembered, is unaccompanied by hypertrophy of the left ven- tricle. It is sometimes also well conducted toward the apex which is in the direction of the regurgitating column, but it is not conducted in the direc- tion of the great vessels of the neck, at least with any loudness. In this con- dition also occurs the Flint murmur, described under mitral stenosis. This rnurmur is additional to the distinctive diastolic murmur (see p. 580). The aortic regurgitant murmur is probably the most widely conducted of all car- diac murmurs. Auscultation of the vessels furnishes interesting information in aortic insufficiency. It is well known that if the stethoscope be placed as lightly as possible over the carotid artery of a healthy person, two sounds are usually audible, corresponding to the expansion and contraction of the artery. Of these the latter is simply the second aortic sound conducted into the carotid. It is probable also that the first sound corresponding with the arterial expan- sion is produced by vibrations of the arterial wall induced by the blood driven into it from the ventricle. The second arterial sound is greatly diminished in intensity or even absent in aortic incompetency, since the valve remains open. The aortic diastolic murmur is sometimes faintly transmitted into the carotid, while a short, rough, systolic murmur is sometimes heard in the same vessel. A valvular sound may also be heard in smaller arteries, such as the femoral, the brachial, and often the radial, the ulnar, and even the palmar arch and dorsalis pedis, by pressing lightly with the stethoscope, rendered more intense by strong pressure. Then there is Traube's double sound, in the femoral and popliteal arteries quite often heard. The sounds are such that the two follow each other closely, so that the first seems preparatory to the second, or they are separated by a longer interval, like the two sounds of the hesrt. No indisputable explanation of these sounds has been suggested. The first femoral sound is ascribed to a sudden filling of the unusually empty artery, and Traube explained the first of his sounds in this way, while he explained the second by sudden relaxation of this tension. Friedreich pointed out that a similar double sound could be heard in the femoral vein in tricuspid insufficiency, which he ascribed to tension of the valves of the vein. It is claimed that the double sound is heard in other diseases of the heart, especially mitral stenosis, and even in aneurysm, but it is acknowl- edged to be most frequent in aortic incompetency. Finally, there is Durosies's sign, a. murmur produced by pressure with the stethoscope upon the femoral artery, sometimes heard in aortic insufficiency. Duroziez's sign will be more easily understood when it is remembered that a murmur may be produced by pressure with the stethoscope on any artery of the caliber of the carotid. The murmur occurs during the expansion or diastole. During the collapse or systole of the artery, on the other hand, nO' murmur can be thus produced in health. In aortic regurgitation, however, this is possible, and it is the second murmur thus produced which is Duroziez's sign. It is said that this sign dies out as compensation fails. T. Clifford Allbutt does not consider Duroziez's sign peculiar to aortic regurgitation, though Vierordt says it is. A right degree of pressure, tO' be determined by prac- tice, is necessary, and the artery on which it is obtained is usually the femoral. 586 DISEASE OF HEART AXD BLOOD-VESSELS. Aortic Stenosis. Occurrence and Mechanism. — By aortic stenosis is meant a narrow- ing of the aortic orifice. Pure and uncompHcated aortic stenosis is probably the rarest of the valvular lesions. Writers have been led into error because the presence of an aortic systolic murmur has been interpreted as meaning stenosis, where it has been produced by simple roughening of the valves or beyond them. Richard C. Cabot says that out of 250 autopsies made at the ^Massachusetts General Hospital, there was not one of uncomplicated aortic stenosis. Stenosis is said to be relative when there is a normal orifice while the aorta is dilated beyond it. It occurs in older persons, and the older the person, the more likely are there to be calcareous deposits causing it. It may be congenital. When uncombined with insufficiency, it is the least dangerous of the various forms of valvular disease. The narrowed orifice prevents the free discharge of blood from the left ventricle into the aorta. The ventricle attempts to overcome this, and its walls hypertrophy in propor- tion to the degree of resistance, and often for a long time compensate for the obstruction — until dilatation occurs, when the danger really begins. The hypertrophy thus induced, usually of the simple form, is only second in degree to that produced by incompetency. Symptoms. — The symptoms of aortic stenosis may be long deferred, so long as compensation is maintained, and when they do occur, they are usually those of a deficient supply of blood to the brain and heart itself — viz., dizziness and fainting. Succeeding exertion there is apt to be a sense of constriction or oppression and even pain in the precordium, which may develop into the severe pain of a true angina pectoris. Physical Signs. — Inspection and palpation recognize usually a forcible apex-beat outside of its normal site, and at varying distances, in accordance with the degree of hypertrophy. Some describe the apex-beat as without force and indistinct. Broadbent savs it is " a well-defined and deliberate Fig. 56. — Pulse-tracing of Aortic Stenosis. — Anacrotic Curve. push of no great violence." Palpation often perceives a thrill of great intensity with each beat of the heart, more marked when dilated hypertrophy is established. A bulging of the precordium may also be present, though less often than in incompetency. The pulse is the pulsus parvus et tardus, slow in reaching its maximum volume, which is small. It is frequent, but regular, contrasting in the latter respect with the pulse of mitral disease. It is sometimes infrequent, pidsus rams. Figure 56 is a sphygmogram. Percussion elicits dullness downward and laterally toward the left, since, as a rule, the enlargement is confined to the left ventricle. There may, however, be slight enlargement upward to the left of the sternum if hyper- trophy of the left auricle is added. Auscultation discloses a systolic basic murmur, loudest at the aortic area, — second interspace at the right of the sternum, — conducted distinctly into the carotids, and even sometimes along the course of the aorta, behmd and to the left of the vertebral column, into the popliteals and dorsal arteries CHRONIC VALVULAR DEFECTS. 587 of the feet. It is not, however, confined to the aortic area, but may be heard over the entire precordium. It is usually rough, at least until com- pensation fails, but may be soft and musical. It may be heard even at a distance from the chest. It is late systolic, as a rule, following the apex- impulse, often at an appreciable interval. It is made louder by exercise. The aortk factor of the second sound is very feeble, or not at all heard, if the constriction be quite marked, because of the feeble recoil, the necessary result of the small amount of blood in the aorta. The first sound is normal, somewhat louder and more prolonged than natural, because of the powerful contraction of the left ventricle. Roughness of the aorta, dilatation, and narrowing of the vessel, how- ever caused, may also produce a systolic murmur; so may roughness within the ventricle in the course of the outgoing column of blood. But these causes have a less positive efifect upon the substance of the heart — that is, do not produce as marked hypertrophy of the left ventricle. Nor do these causes interfere with the production of a normal second sound, except, perhaps, dilatation, which in that event is accompanied by an aortic regurgitant murmur. From this it follows that the important point to re- member in diagnosis is that an aortic systolic murmur by no means always indicates aortic stenosis. So, also, anemic or hemic murmurs, which are always systolic and for the most part basic, may simulate aortic systolic murmurs but these occur in young, delicate persons of both sexes, are often intermittent and without other efifect on the muscular heart, while they are also unaccompanied by thrill. There may be roughness, too, in. the pulmonary artery, which can be localized to the left of the sternum. Stenosis of the aortic orifice is very apt to be associated with insuffi- ciency, the same rigidity and adhesion which prevent complete patulousness of the orifice preventing also complete closure. Differential Diagnosis. — The signs which distinguish aortic stenosis from aortic roughening are not many. In aortic stenosis the pulse would naturally be small as contrasted with that of simple roughening or dilatation of the aorta. A systolic thrill is more characteristic of aortic stenosis. It may be felt at the base and apex, and rarely at the apex alone. From the last may be inferred that the cusp nearest the mitral leaflets is involved. Aortic Stenosis and Insufficiency. Occurrence. — This double lesion is a comparatively frequent one; in- deed, it is commonly- reg'arded as- the- next- in -frequency after mitral insuffi- ciency, and therefore more frequent than either aortic insufficiency or aortic stenosis alone. It occasions a double basic murmur, systolic and diastolic, and is also a grave condition, giving rise to the same dangers as aortic regurgitation, and the same enormous hypertrophy of the left ventricle. Diagnosis. — The diagnosis of this condition requires special mention, "because it not infrequently happens that it is mistaken for aneurysm of the arch of the aorta, which is associated with a similar double murmur of which the systolic element is due to the roughness of the aorta and aneurysmal walls, and of which the diastolic is a sign of relative insufficiency due to dilatation of the aorta. The distinctive differences between the two condi- tions will be given in treating aneurysm of the arch of the aorta. 588 DISEASES OF HEART AND BLOOD-VESSELS. Tricuspid Insufficiency or Incompetency. Occurrence and Mechanism. — Tricuspid regurgitation as a primary condition is extremely rare, and, when present, is probably the result of an endocarditis during fetal life, endocarditis at this period being more prone to attack the right than the left side. Endocarditis involving the tricuspid valve may, however, also occur in children — according to Byrom Bramwell,''' more commonly than has been supposed. Infectious or ulcerative endocarditis, also affects the tricuspid valve — according to Osier, in 19 out of 238 cases. More frequently tricuspid regurgitation is the result of a relative insuf- ficiency, one of the terminal events of mitral disease, the tricuspid orifice yielding with the dilatation of the right ventricle, which takes place sooner or later, consequent upon the resistance to the movement of the blood through the engorged lungs. It is also one of the possible sequelae of emphysema of the lungs and long-standing fibroid phthisis or chronic bron- chitis, succeeding, too, a primary hypertrophy of the right ventricle, due to these causes. Thus, out of 405 autopsies at Guy's Hospital in which evidence of tricuspid regurgitation was found, 271, or two-thirds, resulted from mitral disease, 68 from myocardial degeneration, 55 ,from pulmonary disease, bronchitis, emphysema, and cirrhosis of the lung. The effects of tricuspid insufficiency growing out of the venous obstruction have been detailed on page 576. Tricuspid insufficiency succeeding upon mitral insufficiency is not al- ways accompanied by an audible murmur. It is evident that every case of mitral regurgitation associated with dropsy must be attended with tricuspid regurgitation. Very few of the cases above referred to had been diagnosed during life, and in all of them the valve was itself healthy, but insufficient to close the dilated orifice. Symptoms. — These are those described when treating of mitral disease after the stage of tricuspid regurgitation has been reached, dropsy more or less general, engorgement of the stomach, liver, and kidneys, an enlarged,, tender, pulsating liver, and a jugular pulse. The last two symptoms are re- garded as pathognomonic. Jugular pulse is often more forcible in the right than in the left jugular. There is also cyanosis, dyspnea, and pulmonary edema. The jugular pulse is systolic in time, and does not appear until the valves situated at the open- ing of the internal jugulars into the innominate veins yield. These give way first on the right side, because the course of the right innominate is straighter and communication is more direct. So long as the valve above the bulbus jugularis is closed, the pulse is confined to the bulb, but with the yielding of this valve the pulse becomes general throughout the vein.- It is sometimes difficult to distinguish a true jugular pulse from the " physiological " or " false " jugular pulse, which may sometimes be seen in health and whenever the venous system is overfull. Pressure on the vein above the valves will cause the false pulse to disappear, while the true pulse, coming from the right ventricle, will remain. The physiological or false jugular pulse alter- nates with the ventricular systole and corresponds with the auricular systole, while the true jugular coincides with the systole of the ventricles. Physical Signs. — In primary tricuspid disease with regurgitation, in- * " Amer. Jour. Med. Sci.," April, 1886, p. 419. CHRONIC VALVULAR DEFECTS. 589 spection and palpation reveal an apex-beat diffused toward the ensiform cartilage and the epigastrium. Percussion detects enlargement toward the right edge of the sternum, due to hypertrophy of the right ventricle, which occurs for the same reason as hypertrophy of the left ventricle in mitral insufficiency. To auscultation the systolic murmur thus engendered is invariably feeble, and is heard almost solely in the tricuspid area, just above and to the left of the ensiform cartilage. Occasionally only is the second pul- monic sound accentuated. There should be no confounding of this mur- mur with that of aortic regurgitation conducted toward the same situation, but different in time, nor with that of mitral regurgitation heard at no great distance, for the reasons already given. To these must be added a dift'er- ence in quality and pitch between the tricuspid and the mitral murmur, not always, however, manifest. Tricuspid Stenosis. Occurrence. — Tricuspid stenosis is a rarer condition, but it may be an acquired one in association with left-sided heart disease as the result of rheumatic endocarditis, and of unknown causes. Ninety per cent, of cases are associated with mitral stenosis. It is much more frequent in women, fully 80 per cent, of all cases being in women. As in endocarditis of the left side, there are thickening, adhesion, narrowing. A presystolic tricuspid murmur pointing to stenosis, in a case obsen^ed by Gardner, w-as found due to a growth from the endocardium of the right auricle, so placed as to fall over the tricuspid orifice in the manner of a ball valve. Fred. C. Shattuck has met one instance of tricuspid stenosis with mitral stenosis and regurgitation, along with adherent pericardium, hepatic cirrhosis, and slightly granular kidney, as determined by autopsy. In this case there was a presystolic tricuspid murmur observed for three years be- fore death. Physical Signs. — Simple uncomplicated tricuspid stenosis would be recognized from the presence of a presystolic murmur and thrill, best heard in the tricuspid area, unaccompanied by hypertrophy of the right A-entricle. When associated with left-sided heart disease, the diagnosis is seldom made, because the murmur is masked by the coincident mitral presystolic nuiruinr. In a very few cases only is it confined to this valve. Frequently there is no murmur. Percussion shows dullness to the right of the sternum. Congenital stenosis of the tricuspid orifice occurs, but is usually asso- ciated with defects of other valves, which early cause death. Other symptoms are cyanosis of the face and lips and, in the later stages, extreme and obstinate dropsy. PULMOXARY IXSUFFICIEXCY OR IXCOMPETEXCY. Occurrence. — Simple pulmonary regurgitation is rarely seen. It may, however, exist as a congenital defect (fusion of two segments), and the pulmonary valve has been found involved in ulcerative valvulitis. Physical Signs. — It is easy from what has gone before to deduce the physical signs which are to be expected — a diastolic murmur heard in the pulmonic area, hypertrophy of the right ventricle, later jugular pulse, venous congestion, and cyanosis. The diastolic mmrmur may be confounded wath 590 DISEASES OF HEART AXD BLOOD-VESSELS. that of aortic insufficiency, but the latter is accompanied with hypertrophy of the left ventricle, with Corrigan pulse and capillary pulse. A few cases are related in which a diastolic murmur has been found associated with defects in the pulmonar}- valves — in one, warty, which might have been the result of infectious endocarditis. All others are congenital. Among them is aneurysmal dilatation. Such was a case reported to the Pathological Society of Philadelphia by Edw^ard T. Bruen (see " Transactions " for 1883). Pulmonary Stenosis. Occurrence. — The great majority of systolic murmurs heard at the pul- monary orifice are functional. Pulmonary stenosis, though very rare, may, however, exist, in which case it is far more likely to be congenital from arrested development, although intra-uterine endocarditis may also cause it. So, also, may infectious endocarditis, and in rare instances, atheroma. I well remember a case of malignant endocarditis with a pulmonary systolic mur- mur in which I was led from a correct diagnosis, because I thought that such murmurs are so invariably functional that it w^as scarcely worth while to consider the probability of an organic lesion. The autopsy disclosed a val- vulitis of the pulmonar}' valve. Since then I have met other cases. The valve leaflets are apt to be fused. When the lesion is congenital, it is com- monly associated with patency of the foramen of Botal or foramen ovale, together wnth imperfect ventricular septum and tricuspid stenosis. Physical Signs. — Pulmonary stenosis should furnish a systolic munnur in the pulmonary area, to the left of the sternum. The murmur may even be heard behind, between the shoulders, and it may be rough. It is accom- panied by hypertrophy of the right ventricle. There may be a basic thrill, as in aortic obstruction, but the pulse is uninfluenced. Compensation may be set up by means of a patulous foramen ovale, an open ductus arteriosus, or interventricular communication. The invariable presence of cyanosis due to venous obstruction and of attacks of dyspnea complete the picture and aid greatly in the diagnosis. Anemic murmurs at the same time and place are unaccompanied by cyanosis. Walshe has described a case of death from thrombosis of the pulmonary artery in which he heard a pulmonary systolic murmur before the end came. Congenital Defects. Congenital defects in the cardiac valves and orifices deserve a passing notice. They may be the result of endocarditis during fetal life or of arrest of development. Their most frequent seat is the right heart, and the most frequent form is stenosis of the puhnonary orifice, the effects and signs of which have already been considered. Another is a permanently patulous foramen ovale ; or there may be a defect of the septum of the ventricles, or a communication between the aorta and pulmonary artery, — a persistent ductus arteriosus, — or between the aorta and the vena cava or aorta and right auricle. All of these intercommunications produce murmurs difficult to separate, and it is, after all, by attention to the general condition that the defect is recognized. The patient is a child of arrested development, more or less permanently cyanosed, with continued embarrassed breathing — all of these are conditions which point to the congenital defect. If there be CHRONIC VALVULAR DEFECTS. 591 added to these a persistent loud murmur at the base of the heart without other signs or symptoms of valvular disease, this may be due to congenital defect. In addition to these, there are a large number of defects of develop- ment which are rather pathological curiosities than of clinical interest. Among these may be mentioned acardia, or absence of heart, met in the monstrosity thus named ; double heart, sometimes present in high degrees of fetal defect ; dextrocardia, in which the heart is on the right side, alone or with other viscera. In ectopia cordis, or dislocation, which is associated with fission of the chest-wall and of the abdomen, the heart may be in the cervical, pectoral, or abdominal regions. Then there are anomalies of the cardiac septa, of which the patulous foramen ovale is the most frequent, various in degree. Next is a small defect in the upper part of the septum, between the ventricles, in what is known as the " undefended " space, or just anterior to it. A 6fcuspid state of the semilunar valves, from fusion of cusps, is often met — most frequently of the aorta. The combined valve is more liable to sclerotic change. Finally, there is fenestration of the semi- lunar cusps. Relative Frequency of Valvular Defects. — The order of frequency of the various valvular defects is not entirely agreed upon. As to one, however, there seems to be universal concurrence, and that is that mitral regurgitation is the most frequent. After this, however, statistics differ. Thus, of the older authors, W. H. Walshe presents the following order of frequency for the single or simple murmurs : I. Mitral incompetency. 2. Aortic stenosis. 3. Aortic incompetency. 4. Mitral stenosis. 5. Tricuspid incompetency. 6. Pulmonary stenosis. 7. Tricuspid stenosis. 8. Pulmonary incompetency. Presumably, this list is based upon necropsy records. This order, in the light of modern studies, must be corrected, except as to mitral incompetency. Frederick J. Smith, analyzing the registers and postmortem records of the London hospitals for eleven years, — 1877-87, — and taking the fatal cases only, arrived at the following order : 1. Mitral incompetency. 2. Mitral stenosis. ) r\s: ^- u 1 r ... ^ )■ Ui practically equal frequency. 3. Aortic incompetency, j ^ -1 -1 ./ 4. Aortic stenosis. 5. Tricuspid stenosis. To these we may add : 6. Tricuspid incompetency. 7. Pulmonary stenosis. 8. Pulmonary incompetency. It is evident that the older observers mistook the aortic systolic murmur to mean aortic stenosis, when roughening only of some kind was present. Out of 705 cases, Smith found 26, or 3.38 per cent., of mitral stenosis, and 25, or 3.25 per cent., of aortic regurgitation ; so it cannot be said there is any practical difference in the relative frequency of these two lesions. Von Leube says that, after mitral incompetency, aortic incompetency is the most frequent, and this is my experience. Smith's statistics, being recent and based, as they are, upon the examination of registers and autopsy records, are probably nearly correct, but these two lesions approxi- mate in frequency. Such are to be distinguished from those based on 592 DISEASES OF HEART AND BLOOD-VESSELS. observation at the bedside, regardless of autopsy. Such observation cer- tainly fails to detect all cases of mitral stenosis. Of " double " initnnurs heard at one orifice, those of mitral stenosis and insufficiency are more numerous than aortic stenosis and insufficiency, wom^n being the most frequent subjects. It should be mentioned, however, that George S. Middleton, in a clinical study of 150 cases of chronic valvular disease at the out-patient department of the Royal Glasgow Infirmary, found a much larger number — 22 per cent. — of the double aortic lesions, as against Dr. Smith's 4 per cent. ; also, that Walshe makes the double aortic lesion the second in frequency of all valvular diseases. I am inclined to agree with the latter statement. Associated or Combined Valvular Lesions. — These terms are applied when two valves are diseased at the same time — a very frequent occurrence.* The valves which are most frequently jointly affected are, of course, the aortic and mitral, then the mitral and tricuspid, then the aortic, mitral, and tricuspid. Aortic disease of either kind is more frequently associated with mitral incompetency than mitral stenosis, because the former is, sooner or later, a result of the aortic disease, while mitral stenosis arises by a sepa- rate process. The very careful analysis by Frederick J. Smith referred to furnishes the following order, which is not far from correct : 1. Aortic incompetency and stenosis; mitral incompetency. 2. Aortic stenosis and mitral incompetency. 3. Aortic incompetency and mitral incompetency. There is less than one per cent, difference in the frequency of 2 and 3. 4. Aortic incompetency and stenosis, with mitral stenosis and incom- petency. 5. Mitral incompetency and tricuspid incompetency. 6. Aortic incompetency and stenosis, with mitral incompetency, tri- cuspid incompetency. Too much reliance must not be placed on the order of combined mur- murs, as after i the arrangement is not altogether what would be expected from a consideration of the natural sequence. In children, it is said, the most frequent combination is aortic incompetency and mitral incompetency. One would expect this to be the case with adults also. The diagnosis of these combinations is based upon the quality and situation of the murmurs and their conduction. Prognosis of Chronic Valvular Disease. — Possible positive statements as to the prognosis in chron[c valvular disease are few, so uncertain is it and so many circumstances influence it. Undoubtedly, valvular disease often exists where the subject is totally free from symptoms, and therefore quite unconscious of it. Yet such subject is not free from danger. On the other hand, fifteen, twenty, thirty, and even forty years pass over such cases without inconvenience, compensation being easily maintained. Such cases are usually of mitral incompetency or stenosis, or both. Much de- pends upon the life led by the patient — whether one of ease and quiet, associ- ated with proper food and clothing and without dissipation. Even when such disease occasions symptoms, the same measures may hold them in abeyance for a long time, and occasional judicious medication may raise _ * Dr. Sansom has sug-Rested that the term "combined" be retained for two murmurs at one orifice, commonly known as " double " murmurs— an unfortunate suggestion, as it will be sure to give rise to confusion, while the term double is easily understood. CHRONIC VALVULAR DEFECTS. 593 the patient from a serious condition to one of comfort. It is astonishing with what Httle disturbance women with these affections sometimes bear children. Of the lesions at the mitral orifice, incompetency is usually most easily compensated, then combined stenosis and incompetency, and finally stenosis only; but even the last exists at times without subjective symptoms in persons who have worked hard. After all, the prospect of life must be judged from the symptoms in each case. The compensation which is ob- tained by extreme hypertrophy and apex displacement is tottering. An ad- ditional danger in mitral disease, especially mitral stenosis, is that of em- Ijolism. Recurring attacks of rheumatism not only increase the latter dan- ger, but augment the valvular defect. The supervention of dropsy and dyspnea indicate failing compensation, and though they may be overcome, it is with increasing difficulty at each recurrence. Aortic incompetency is a much graver condition. It is this valvular disease in which sudden death overtakes the patient. Yet it, too, may be compensated for years. Much here depends upon the state of the arteries, the danger being increased when associated with sclerosis or atheroma, for these conditions are likely to affect the root of the aorta and the valves, and especially the coronary arteries. Any obstruction in these, as already stated, may be the cause of sudden death. Angina pectoris indicates a diseased condition of the coronary arteries, which may at any time be fol- lowed by complete obstruction and sudden death. Overdistention, such as takes place during exertion, may be too much for a fatty heart already dilated, and becomes also a cause of sudden death. The most unfavorable of all forms of cardiac valvular disease is tri- cuspid regurgitation, which occasions obstinate dropsy and dyspnea. Chronic valvular disease is regarded as much more serious in young children, say those under ten years of age ; this, in spite of the fact that many conditions favorable to compensation are present, such as integrity of heart muscle and vascular supply. Notwithstanding this, the valve lesion is apt to increase. On the other hand, there is a popular notion, which physicians are disposed to encourage, that a child may outgrow a heart disease under favorable circumstances, such as abundance of good food and protection against exposure and overwork. This may be true, but it is more likely that compensation is established with the growth and de- velopment of the organ. That the apparent event does sometimes occur, I can attest. Congenital defects in the heart are apt to destroy the lives of children the first few years of their existence. Finally, almost any serious illness, especially when involving the lung, increases the danger to the life of the subject of cardiac disease, while mitral disease, and especially mitral stenosis, invites pulmonary congestion and inflammations. Treatment of Chronic Valvular Diseases of the Heart. — i. Prophy- laxis. There can be no doubt that the number of cases of chronic valvular disease may be decreased by a careful treatment of the diseases which ex- cite them or favor their occurrence, especially acute rheumatism. The stu- dent is referred to a valuable monograph by R. Caton, M. D., on " The Prevention of Valvular Disease of the Heart." * This author emphasizes especially ( i ) the importance of rest awd a minimum of exertion of all kinds for the rheumatic patient; (2) stimulation of the trophic centers by small * London, C. J. Clay & Sons, igoo. 38 594 DISEASES OE HEART AND BLOOD-VESSELS. blisters in the neighborhood of the affected joints and in front and in the axilla, preferably in front between the clavicle of the nipple on both sides, with a view to stimulating vasomotor nerves; (3) treatment by absorbents, including the iodid of sodium and mercury. The rest and quiet should be prolonged long after the symptoms of pain and fever have subsided, and a second attack of rheumatism should especially be guarded against, as an apparently cured endocarditis is sure to be followed by another attack. 2. Remedial Measures. — Since there are certain points in the treatment of disease of the cardiac valves which are the same for the different orifices, I shall consider first such measures as are thus common, referring more especially to mitral and aortic disease. In the first place, it is well known that there exist chronic valvular defects at either of these orifices which give rise to no symptoms whatever and are often accidentally discovered. From the standpoint generally con- ceded, that such defects themselves are irremediable, it is clear that, in the absence of symptoms, medicinal treatment is quite unnecessary. On the other hand, it is a happy circumstance when the subjects of such lesions are made aware of their presence, because they are enabled so to regulate their mode of life as to prevent harmful consequences, either symptomatic- ally or organically. Such persons should avoid overexercise and excite- ment. Running or even walking rapidly, hurriedly ascending stairs, ex- tremes of passion of all kinds, and especially of anger, should be avoided, as should also exposure and irregular living. In a higher grade of involve- ment of either orifice, the same treatment is demanded in a more imperative manner, since its omission results in a loss of compensation, manifested by dyspnea, palpitation, and precordial distress. In a still more advanced degree of interference with normal functions the treatment becomes different with the seat of the lesion. Let us first consider lesions of the mitral valve, and first the most common of all forms — mitral regurgitation. We have seen that the blood flows back into the left auricle during systole of the ventricle, at a time when all communication between these cavities should be cut off and the movement of the blood should be forward only. Averted for a time by hypertrophy of the left auricle, engorgement of the lungs ultimately results, with defective aeration of blood, and consequent shortness of breath. This effect is at first counter- acted by the increased effort of the right ventricle, whence its hypertrophy, with sharp accentuation of the pulmonary second sound. So long as compensation is thus maintained there is probably no sign of embarrassed breathing, iri^^egularity, precordial oppression, or digestive derangement ; but as soon as compensation begins to fail, in consequence of a suspension of the conditions which co-operate to help it, or of a slight yielding of the heart muscle, assistance is demanded. The heart tonics, of which digitalis is the type, are the agents pre-eminent for this purpose. That they operate by directly increasing the force of the right ventricle and left auricle, and thus contribute to the compensation, can scarcely be doubted; but that they help also to make the closure of the mitral orifice more complete by forcibly increasing the contraction of the left ventricle seems also reasonably sure, since the experiments of Ludwig and Hesse have made it so plain that this can occur. They have shown that the mechanism for closing the mitral orifice does not reside in the valve alone, but that the surrounding muscles of the ventricle have an active share, not only in floating up the valve curtains, but in reducing also the size of the CHROXIC VALVULAR DEFECTS. 595 opening which these valve curtains have to close. This is, of course, less applicable in chronic valvular conditions where there is stiffness from cal- careous change, than where regurgitation results from simple feebleness of muscle in anemia and after the infectious fevers. The effect required of this class of drugs varies with the degree of obstruction to be overcome, and the doses var)^ accordingly. Very often the heart requires but little steadying to enable it to accomplish the desired end, and moderate doses — such as five minims (0.3 c. c.) of the tincture of digitalis once in six or eight hours — suffice. On the other hand, it is a mis- take to give too small a dose, and too great timidity often results in failure. Doses of from ten to fifteen minims (0.6 to i c. c.) of the tincture of digi- talis every four hours, and corresponding doses of the other preparations, are often necessary and sometimes produce magical effects. The irregular and halting pulse becomes regular, the dropped beat is again taken up, the dusky lips become pink, the scanty urine is increased, the shortness of breath disappears, and calmness and quiet succeed distress and restlessness. As soon, however, as the desired effect is produced, the dose should be lowered. Digitalis is a remedy always better intermitted to obtain its best effects, and a remedy, too, which, having once excited nausea, is thereafter badly borne. The same principles apply to the management of the still more serious engorgements of the venous system which succeed upon tricuspid insuffi- ciency, and produce dropsies and serous effusions. This engorgement is also relieved by the use of purgatives, and as the portal area, including the liver itself and the stomach, is especially involved, mercurial purgatives are especially indicated. From five to ten grains (0.32 to 0.65 gm.) of blue mass at bedtime, followed by a saline in the morning, relieve the congestion, and with it the nausea and indisposition to take food which attend it. Such remedies may be resorted to occasionally. Sometimes the continued use of small doses for a long time — say 1-2 to one grain (0.03 to 0.065 gm.) of blue mass three times a day — is more efficient. It is generally recog- nized that digitalis produces also contraction of the arterioles, and that through this, in connection with the forcible systole, the arterial pressure is increased. This effect is desirable and useful in the early stages of mitral regurgitation, before tricuspid regurgitation and dropsy have set in. Later in the disease, however, when dropsy has set in, this effect militates against the diuretic action which is so much needed. The manner in which this may be overcome will be described later. As to the relative value of the different preparations of digitalis : While testimony is generally favorable to the infusion as the most efficient remedy, yet, on account of convenience and accessibility, the tincture is most fre- quently used. I am inclined to believe that the greater apparent efficiency of the infusion is partly due to the fact that it is generally given in larger doses. Thus, a tablespoonful, or 1-2 ounce (15 c. c), is not an infrequent dose of the infusion, while ten minims (0.6 c. c. ), or twenty drops, of the tincture and one grain (0.066 gm.) of the powder are not often exceeded. When it is remembered that 1-2 ounce (15 c. c.) of the infusion, as made by the United States Pharmacopeia, represents nearly three grains (0.19 gm.) of the powder, or twenty minims (1.2 c. c.) of the tincture, one may under- stand why it is more efficient. It is true, however, that the infusion is some- times better borne by the stomach than equivalent doses of the tincture. It mav be that the cinnamon water with which it is made has this effect. All 596 DISEASES OF HEART AND BLOOD-VESSELS. preparations of digitalis thus far mentioned are more or less uncertain, and I purpose to use hereafter more of the so-called " normal liquid," which, if correctly represented, must be a constant preparation. Each minim repre- sents one grain of the drug, and hence the proper dose is easily determined. Of remedies which may be substituted for digitalis, strophanthus should be first mentioned, not that it is always the best. It was at one time thought that strophanthus might have all the effects of digitalis on the left ventricle without the contracting effect on the arterioles. This expectation was not, however, realized by clinicians, but it is a fair substitute for digitalis in about the same dose. It is better borne by the stomach, as a rule, than digitalis. Caffein is an admirable heart tonic in mitral regurgitation. I do not give less than three grains (0.2 gm.) at a dose, but seldom give more, every four to six hours. When caffein has been given in full doses for some time, it may produce mental symptoms quite characteristic, consisting in hallucinations not unlike those of delirium tremens, the patient imagining there are persons, animals, and other objects about him, and he is some- times difficult to control. These symptoms, however, cease immediately when the drug is discontinued. Another effect of caffein which sometimes interferes with its usefulness is insomnia. Spartein sulphate is another heart tonic which I have come to value very highly, especially when a diuretic effect is desired. The dose should never be less than 1-4 grain (0.016 gm.), increased to 1-2 grain (0.032 gm.), four, five, and six times a day. I am sure many have been disappointed in spartein because they have given too small a dose. Broom itself, in the shape of an infusion or " tea," is a popular and efficient remedy, less well borne by the stomach than its active principle, spartein. Spartein and broom are more commonly used as diuretics, and will be again referred to in the treatment of the dropsy of Bright's disease. In the much rarer disease of simple mitral stenosis, compensation is even easier and longer maintained by nature's own resources than in mitral regurgitation. Here, for evident reasons, there is no tendency to dilatation or hypertrophy of the left ventricle. On the other hand, hypertrophy of the left auricle becomes a conspicuous condition, succeeded by hypertrophy of the right ventricle, for the same reason as in mitral regurgitation. Espe- cially easy is it to maintain compensation if the narrowing is not too great and if there is a well-preserved left auricle and a strong right ventricle. If, however, the mitral narrowing is extreme, it is plain that the pulmonary engorgement will become greater if we increase the force of the right ven- tricle. Much more cautious must we be, therefore, in the use of digitalis. Much more important under these circumstances is relief to the pulmonary congestion, which in turn will relieve the right heart tension. Blood-letting is the most direct method of accomplishing this, and in severe cases associated with great dyspnea and cyanosis it may be practiced. For the same pur- pose, aconite is sometimes of advantage in these cases, in small doses, say one minim or i 1-2 minims (0.06 to 0.09 c. c.) every two hours or every hour, watching its effect. It is possible that it is through a somewhat similar action that convallaria majalis — a remedy in which most observers have been disappointed — has been found useful by Dr. Sansom * in mitral stenosis, and also by French physicians. By these observers it has been found diuretic, * " The Treatment of Some of the Forms of Valvular Disease of the Heart," Lettsomian Lectures, second edition, with corrections, London, 1886. CHRONIC VALVULAR DEFECTS. 597 increasing the twenty-four hours' urine to 85 and even to 115 ounces (2550 to 3450 c. c), reducing the pulse rate, regulating irregularity, and improving the breathing, even when accompanied by tricuspid regurgitation. The doses given are from ten to twenty minims (0.6 to 1.2 c. c.) of the tincture three times a day, and it may with advantage be associated wdth caffein. The French physicians give the extract in doses of from one gram to i 1-2 grams a dav — /. c, fifteen to twenty grains (i to 1.3 gm.). Veratria may be used under the same circumstances. More effectual than either of these remedies to relieve pulmonary congestion is purging, sometimes blood-letting, and repeated small bleedings are often of great advantage in this form of chronic valvular disease. The principles governing the treatment of combined mitral regurgitation and stenosis are rather those of mitral regurgitation than of mitral stenosis. And what shall be the treatment of pure aortic disease? It wdll be remembered that both aortic obstruction and regurgitation give rise to hyper- trophy of the left ventricle, and that this is compensatory in purpose. For a time this is quite sufficient to ward off any unpleasant symptoms, and for a still longer time when associated with a quiet life., the absence of excitement, of exposure, and privation. High degrees of h3'pertrophy are accompanied with a powerful systolic impulse, a symptom which is of itself often a source of great discomfort. Shall we, then, give heart tonics which increase the force of this thumping blow? Certainly not. Shall w^e give aconite or veratrum viride, which slow the heart and diminish the force of its stroke? Yes, at times these remedies are very useful. W^henever, as the result of overexertion or undue excitement or gastric derangement, the heart is turbu- lently overactive, and even irregular in its rhythm, then I have often seen aconite in small doses — say one minim (0.06 c. c), or two drops, repeated every half hour or hour under close observation — act happily, especially when combined with bromid of potassium, say fifteen grains (i gm.). The tincture of veratrum viride may be given in slightly larger doses. As soon, however, as this period is past, the aconite should be omitted. Even in mitral regurgitation I have seen aconite act most happily under these circumstances. We want also in this condition remedies which will help to maintain the integrity of the heart muscle. Such are strychnin, iron in small doses, arsenic, and nutritious, easily assimilable food. Especially useful are well- ventilated living- and sleeping-rooms, wholesome outdoor life, with moderate, deliberate muscular exercise. Like all other muscles, the heart is strength- ened by judicious exercise. In the light of this fact even the mountain- climbing advocated by Oertel is not so irrational and dangerous as it seems at first thought. Very cautious and gradually increased exercise is doubtless intended. On the other hand, so much judgment is required in the applica- tion of this treatment that it is perhaps better honored in the breach than in the observance. Such measures as those described tend to ward off the next stage, for sooner or later the integrity of the muscle of the ventricle yields, dilatation is added to hypertrophy, the auriculo-ventricular orifice enlarges, and w^e have mitral regurgitation. Then the treatment becomes that for mitral disease. The treatment for aortic regurgitation and of aortic stenosis with regurgitation is similar to that of aortic stenosis. Treatment of Dyspnea. — As the dyspnea is primarily the result of defi- cient blood aeration in the congested lungs, the same remedies which force the blood through these organs, and thus relieve the congestion, tend also to 598 DISEASES OF HEART AXD BLOOD-VESSELS. relieve the dyspnea, and often do so. When the dyspnea persists, it is fre- quently caused by efifusions into the pleural cavity, which are most promptly and successfully removed by tapping, although a blister may also answer the purpose. Repeated tapping may be necessary. Dyspnea not thus relieved demands an opiate, and of opiates under these circumstances, morphin is the best. One-fourth of a grain (0.0165 gm. ) at bedtime, by the mouth or hypo- dermically, gives unspeakable comfort. Hoffmann's anodyne, given in fluid dram doses (3. 5 c c), will sometimes relieve the milder degrees, and should perhaps be tried first, as it is always desirable to put ofif the use of morphin as long as possible. Paraldehyd may be substituted for Hoffmann's anodyne in the same doses. Chloralamid is even a better remedy in thirty-grain (2 gm.) doses. Sulphonal may be tried in full doses of fifteen to thirty grains (i to 2 gm.). Trional in the same doses is a similar drug. So is- thermol. None of these is an anodyne. They are simple hypnotics, and cannot be expected to take the place of morphin. though they may be tried at first. All the coal-tar products are more soluble in hot liquids, of which milk is a typical form. Inhalations of oxygen should not be forgotten as sometimes giving signal relief in dyspnea. Treatment of Dropsy. — In like manner the measures that relieve the con- gestion and dyspnea tend also to relieve the dropsy, but special means are also necessary. Here it is that full doses of digitalis are especially indicated, and at closer intervals — every three hours. But these measures are often insufficient. They may be materially aided by restricting the ingestion of liquids. With the tissues water-logged and secretion insufficient, it is plain that copious liquid ingestion only in- creases the difficulty. I am speaking now of cases in which there is general dropsy which resists the ordinary treatment. The principle of the ^Matthew Hay method is correct, but in practice it is limited, because, with an already congested stomach, solids cannot be digested without an admixture of liquid, and further embarrassment results from the effort to dissolve them and from the presence of undigested residue. Therefore it is better to omit solid food altogether and reduce the liquid to a minimum that will sustain life — not more than three ounces every two hours, and that only during the wakirg hours. To this may be added the use of purgatives. While diuretics some- times fail us, we can always secure an effect from purgatives. A daily morn- ing dose of Epsom salts or Rochelle salts or compound jalap powder is given. Then, when action of the bowels begins, full doses of digitalis, caffein, or spartein, associated with nitro-glycerin, are almost sure to be followed by copious diuresis : and when diuresis starts in in these cases, it is astonishing what quantities of urine are passed. The association of nitroglycerin with digitalis at this stage may be helpful. The object of nitroglycerin is to dilate the renal artery and allow more blood to pass through the kidney: i-ioo to 1-50 grain (0.00065 to 0.0013 gm.) may be given as often as the digitalis and simultaneously. One need not be afraid of this drug. I have given this dose every two hours for twenty-four hours or more at a time. Elimination by the bowels and kidneys being simultaneously stimulated, the sucking up of the interstitial fluid is greatly favored and often rapidly brought about. If these measures be associated with paracentesis of the chest, which may be required, the diuresis set up is often enorm.ous, while the swelling rapidly declines. As diuresis is established or hunger sets in the quantity of milk allowed may be increased, and when the dropsy has entirely disappeared, a cautious return to solid food mav be permitted. HYPERTROPHY AND DILATATION. 599 A time-honored remedy in the treatment of cardiac dropsy which should not be overlooked is the combination of calomel, squills, and digitalis, in doses of 1-2 grain (0.03 gm.) of the first and one grain (0.065 grn-) of the second and third every three or four hours ; this is most happy in its results. Still another remedy sometimes very efficient in this form of dropsy is theo- bromin. It is obtained from cacao, and is chemically closely allied to caffein, the latter being trimethyl-xanthin, while theobromin is dimethyl' xanthin. Like cafifein, theobromin is a renal diuretic as well as a heart tonic. The dose I have found most satisfactory is forty-five grains (3 gms.) in the twenty-four hours, coiiveniently divided into doses of 7 1-2 grains (.5 gm.) every three hours, which, allowing for necessary interruptions, results in the administration of at least forty-five grains in this period. On the other hand, diuretin, which is supposed to contain 50 per cent, of soluble theo- bromin in combination with salicylate of sodium, I have found of little or no use in any form of dropsy. Treatment of Irregularity of Heart Action and Palpitation. — For these symptoms, in addition to the cardiac tonics mentioned, belladonna is also a useful remedy. It may be combined with digitalis. A good belladonna plaster placed over the palpitating heart is one of the most efficient agents in subduing it. Nitroglycerin is often very useful to the same end; i-ioo grain (0.00065 gi^i-)) rapidly increased to 1-50 grain (0.0013 gm.). every four hours or oftener, is the proper dose. It may also be combined with digi- talis, as previously directed. Cardiac pain is also sometimes relieved by the same remedy. For further treatment of dropsy see section on Bright's disease. Sec also treatment of cardiac dilatation by the Schott treatment and Nauheim baths. DISEASES OF THE MYOCARDIUM. The heart is subject to alterations in its muscular substance independent of valvular defect. Simple hypertrophy, dilatation, fatty infiltration, and fatty metamorphosis or true fatty degeneration, and atrophy are the most important. Myositis, abscess, and aneurysm of the walls of the heart are such rare conditions that they need only be mentioned in passing, especially as there is no way to recognize them before death. HYPERTROPHY AND DILATATION— ATROPHY. Definition. — Some vagueness exists in the application of these terms. The word enlargement may be applied with its literal meaning to any increase of size, whether hypertrophy or dilatation. Hypertrophy should be limited to indicate such enlargement as is associated with increased thickness of the v^alls, with or without increase in the size of the cardiac cavities. When such increased thickness is associated with a cavity of normal size, it is known as simple hypertrophy. More frequently the cavity is also enlarged, producing eccentric hypertrophy, also known as jjypertrophy with dilatation, but I pre- fer to retain the term dilatation for pathological states. Hypertrophy is physiological. The term concentric hypertrophy was applied to a condition in which thickening is associated with reduction in the size of the cavity, but 6oo DISEASES OF HEART AND BLOOD-VESSELS. it is now conceded that such condition is a postmortem product and does not exist antemortem. Even simple hypertrophy is more infrequent in the post- mortem room than is supposed. When the left or right ventricle alone is affected, the hypertrophy may be simple or eccentric ; when there is general hypertrophy, it is always eccentric. All true hypertrophies are numerical — that is, there is an actual increase in the number of muscular fasciculi, due partly to a fission of previously existing fibers and partly to a new formation of fibers. The word dilatation is applied to conditions in which the cavities are enlarged without corresponding thickening of the walls. Usually there is attenuation of the walls. The latter is the typical condition. Dilatation implies fatty degeneration, for it is through intermediate degeneration that the muscular fasciculi waste and ultimately disappear, producing thinning. Hypertrophy more frequently affects the left ventricle, dilatation the left auricle and right ventricle, but the whole heart may be involved by one or the other condition. Hypertrophy of the Heart. Etiology. — Hypertrophy implies an overgrowth of muscular tissue, and is naturally the result of extra work, increased effort to overcome increased resistance, whatever its cause. The term idiopathic hypertrophy is applied to such hypertrophy associated with no abnormality in the valves and no cause external to the heart exciting it to overaction. Hypertrophy without valvular disease involves the left ventricle more frequently, but may involve both cavities, and even the right ventricle alone. The resistance needed to excite increased action may be from within or from without, or due to nervous influence. Resistance from within is occa- sioned by obstruction to the outflow of blood from the heart, or to increased intravascular pressure. Such obstruction is offered in the case of the left ventricle by aortic stenosis, congenital narrowing, aortic insufficiency, and mitral insufficiency. Increased intravascular pressure is caused by endarteritis and resulting sclerotic changes in the vessel-walls and by aneurysm ; by contraction stimu- lated by the irritation of toxic substances in the blood, such as accumulate in Bright's disease, or as the result of overeating or excessive drinking, espe- cially of large quantities of beer ; finally, by excessive physical exertion. All these are, therefore, causes of hypertrophy of the left ventricle. External obstruction to the contraction of the left ventricle is found in pericardial adhesions and myoc'&rditis. Such hypertrophy is always eccen- tric. Hypertrophy of the left ventricle from nervous influence is seen in exophthalmic goiter and allied conditions, and in long-continued palpitation. Constant mental excitement is a possible cause. In the case of the right ventricle, internal resistance is produced by pul- monary congestion due to mitral regurgitation or to mitral stenosis, to nar- rowing of the same vessel or branches, such as occurs in pulmonary emphy- sema. Valvular lesions of the right side of the heart produce hypertrophy of the right ventricle, just as those of the left cause it to hypertrophy. The greater infrequency of these lesions and their frequent development in ntero are to be remembered. Pericardial adhesions also constitute a cause of external resistance to contraction of the right ventricle. Auricular hypertrophy is always eccentric — that is, while the walls are HYPERTROPHY AND DILATATION. 6oi thickened, the cavities are also dilated. Hypertrophy of the left auricle is usually caused by stenosis of the mitral orifice, and to a less degree is a result also of regurgitation of the blood in incompetency of the mitral valve. Hyper- trophy of the right auricle might also be expected as a consequence of regurgitation of blood from the right ventricle to the right auricle, but the resistance to the further backward flow into the veins is so much less than on the left side of the heart that hypertrophy is correspondingly less frequent. In like manner, even if stenosis of the tricuspid orifice is present, the same conditions prevent any marked degree of hypertrophy of the right auricle. In all cases of hypertrophy due to disease of the valves it is likely that a certain amount of distention of the heart cavity by blood precedes the mus- cular growth. Morbid Anatomy. — The hypertrophied heart is altered in its weight, dimensions, and shape. The adult heart weighs in health, in the male fifty to sixty years old, about 335 grams (11.8 ounces) ; in the female, 295 grams (10.44 ounces). The average thickness of the wall of the lefc ventricle in health is from 5-8 to 2-3 inch (1.6 to 1.7 cm.) ; of the right ventricle, 1-6 to 1-4 inch (0.4 to 0.6 cm.) ; of the left auricle, 1-8 inch (3 mm.) ; the right auricle, 1-12 inch (2 mm.). Hearts exceeding these weights and measurements are, therefore, hyper- trophied. Measurements should be made before rigor mortis sets in or after it has passed away. The latter may be favored by soaking the heart in water. Commonly, the hypertrophied heart does not exceed 25 ounces (750 grn.), though hearts weighing 48 and 53 ounces (1440 to 1590 gm.) have been noticed. The shape of the heart varies : in left ventricular hypertrophy it is elon- gated to the left and lies more horizontally, while the conical shape is less marked ; when both ventricles are hypertrophied, the heart is round. In mitral stenosis with hypertrophy of the left auricle and right ventricle it is also quadrate, the right ventricle occupying the chief bulk of the organ, while the left ventricle recedes behind it. Symptoms. — Hypertrophy, being a process of compensation, is not at first attended by any symptoms. It is the result of a generous conservative efifort of nature, by means of which symptoms are averted. But unlike the hypertrophy of the muscles of the blacksmith's arm, it tends ultimately to degeneration, and thus becomes the initial link in a chain of evil which is well stated by J. G. Adami : * " In the first place, it leads to an increased nutri- tion of the walls of the arteries; increased nutrition leads to increased con- nective-tissue growth of the walls ; increased fibrous tissue of the walls leads tO' contraction and increased rigidity of those walls ; the increased rigidity leads tO' increased resistance to the passage of the blood current. The increased resistance requires increased propulsive power on the part of the ventricular muscle — that is to say, increased work ; the increased work of the heart leads to overgrowth and hypertrophy (myocarditis), and with this, heightened blood pressure and further increased nutrition of the walls, and now, at last, the stage is reached, this vicious circle continuing, in which either the vessel walls give way or the heart." From this standpoint increased blood pressure alone is sufficient to explain the anatomical changes — i. e., the arterial sclerosis, atheroma, and fibroid thickening so constantly seen in valves and heart-walls without calling in chronic inflammation or * "Notes upon Cardiac Hypertrophy," "Montreal Medical Journal," May, 1895. 6o2 DISEASES OF HEART AND BLOOD-VESSELS. specific agency. Certain it is that the two conditions react on each other, and it is more than likely that the former (increased blood pressure) may produce the latter (chronic inflammation) de novo, and many otherwise unexplained facts are rendered clear. When reactive effect sets in, we begin to have symptoms which are at first intermittent, brought about only by some temporary cause which excites the heart, such as exercise, mental emotion, fatigue, mental or physical, tobacco, or alcohol. There is a feeling of vague discomfort about the heart, seldom amounting to pain, sometimes increased when the patient lies on the left side. To this may be added palpitation, a consciousness of the beating of the arteries in the head, dizziness, headache, ringing in the ears, flushes or flashes of light, and a tendency to hemorrhage of the nose. Physical Signs. — While symptoms other than physical signs may be wanting, the latter are present from the beginning, increasing with the dura- tion of the hypertrophy. In hypertrophy of the left ventricle inspection and palpation furnish much the same information as in hypertrophy of the left ventricle from val- vular disease — an apex-beat lower and to the left, strong and diffuse. The radial pulse is strong and tense, the carotids pulsate visibly, and the auscul- tated vessel sounds are loud and distinct. Percussion shows enlargement to the left and downward. To auscultation there is nd murmur, but a distinctive intensification of the aortic second sound is noticed, sometimes ringing, quite characteristic, and itself of great diagnostic value. It may be reduplicated. The first sound, while louder, is also duller, more prolonged and diffuse, some- times suggesting a systolic murmur not present. It may also be reduplicated. In hypertrophy of the right ventricle the signs of enlargement are toward the right edge of the sternum and beyond, also without murmur, but with sharp accentuation of the second sound in the pulmonary area to the left of the sternum. The apex-beat is also displaced outward, but not downward ; pulsation may be distinct in the lower sternal or epigastric region or between the ensiform cartilage and the seventh rib. In persons with thin chest-walls an impulse may be seen in the third and fourth right interspaces. The pulse at the wrist is small, unless there be associated hypertrophy of the left ventricle. Diagnosis. — In view of the fact that hypertrophy is a part of the mor- bid anatomy of chronic valvular defect, we need concern ourselves only with the so-called idiopathic hypertrophy. The resemblance to hypertrophy may arise from pericardial effusion, circumscribed pleuritic effusion, aneurysm, or mediastinal tumor in the neighborhood of a normal heart, the latter espe- cially if it push the heart forward. A normal heart may appear enlarged to percussion when it is uncovered by a lung retracted from any cause, as cir- rhosis of that organ. Simple palpitation of the heart may be mistaken for hypertrophy. In all cases the situation of the apex-beat is a valuable criterion, because, although its position may be changed in pleuritic effusion and pericardial effusion, it is in the opposite direction from that in hypertrophy, while the impulse is feeble instead of being strong. Aneurysm and mediastinal tumor will certainly furnish some of the signs peculiar to them, and thus permit a distinction. Simple palpitation is without the percussion signs of enlarge- ment of the heart. Under none of the circumstances named will its situation be altered. Hypertrophy may be obscured if the heart is overlapped by an emphy- HYPERTROPHY AND DILATATION. 603 sematous lung. This is partly the case in hypertrophy of the right ventricle, which is often associated with emphysema of the lungs. In such cases the pulse does not help, but rather tends to mislead, because it is small in hyper- trophy of the right ventricle. Prognosis. — When associated with valvular disease, the prognosis is that of the disease itself, against which hypertrophy is, for a time, a pro- tection, counterbalancing the growing defect of the valve until the nutrition of the heart begins to be impaired and dilatation replaces hypertrophy with loss of compensation. The latter may be sudden, though it may be delayed for a time by treatment. While such malnutrition may be of local origin, — that is, resident in the heart muscle itself, — it may be due to general causes also, as general illness, hardship and exposure, overexertion, fatiguing occu- pation, insufficient food, and the like. When it is the result of endarteritis and aneurysm, the termination comes with the rupture of the vessel or of the aneurysm. In the so-called idiopathic forms due to toxic substances in the blood d^.nger does not threaten until sclerotic changes are established in the blood- vessel walls. Treatment. — ^This embraces that of the causal condition and of measures to reduce overaction. Dilatation of the Heart. Synonym. — Fatty Degeneration of the Heart. Definition, — This has already been defined on page 600, so far as the state of the chambers is concerned. Dilated heart is of two kinds : first, acute dilatation ; and, second, chronic dilatation, or dilatation accompanied by fatty degeneration. Of the latter, two varieties exist : ( i ) Those succeed- ing valvular disease; (2) those succeeding hypertrophy due to muscular effort, especially when associated with alcoholic intemperance and other forms of dissipation. Acute dilatation may be unassociated with structural change, except as to mechanical arrangement of the muscular elements. Cloudy swelling may be present. The latter is associated with fatty change. Etiology. — Chronic dilatation is the last stage in a valvular disease the result of failing nutrition. The conditions under which this manifests itself have been described. Acute dilatation is the result of prolonged muscular effort, such as occurs in rowing, running, and mountain-climbing. Moderate degrees of distention occur with any decided muscular effort. The more marked degrees capable of mischievous consequences are the result of pro- longed severe muscular exertion. The effect of moderate, well-regulated exercise on the heart, known as training, by which endurance is developed, is to produce eccentric hypertrophy, or hypertrophy with dilatation, which is not dilatation in the sense under consideration — enlargement of the cavity with thinning of the walls. The right heart is the seat of such dilatation. In overexertion the harmful effect of excessive acute strain is averted for a time by the safety-valve action of the tricuspid valve, permitting a regurgita- tion of blood into the right auricle. Dilatation has exceeded its physiological limit when the cavity is no longer able to empty itself of blood, ^^l^ile moderate degrees of acute dilatation may be recovered from, either rapidly or slowly, dilatation may be carried to degrees at which recovery is impos- sible and death results. Such results have followed rowing and mountain- climbinsf. 6o4 DISEASES OF HEART AND BLOOD-VESSELS. The so-called irritable heart, to which attention was first called by J. M. Da Costa in a graphic description based on a study of the cases of soldiers in the American War of the Rebellion, is an example of an abnormally dilated heart, a heart in which compensation has failed. Another example of the idiopathic hypertrophy already referred to is seen in those persons w'ho, through hard work, acquire muscular strength and at the same time, through alcoholic indulgence, become obese. Such are the drivers of beer-wagons and workers in breweries where an unlimited amount of beer is allowed — as much as twenty liters (as many quarts) a day. After a while, in these hearts compensation is lost and the symptoms of dilated heart follow. Sud- den dilatation may happen to hearts whose muscular substance is degener- ated, though seemingly hypertrophied, as in chronic Bright's disease, where overexertion often brings on dilatation. In a few instances in malignant forms of the infectious diseases, such as scarlet fever and diphtheria, the nutrition of the heart may be so rapidly impaired by the toxic agency which causes the disease that dilatation occurs with very little or no undue intravascular pressure. All these belong to the second category, that of chronic or slow dilatation. Symptoms. — The symptoms of " heart strain '' are sudden pain in the region of the heart or epigastrium, shortness of breath, and rapid, feeble action of the heart. If it be not immediately fatal, the symptoms may pass ofif, but are renewed on the slightest exertion. In the acute cases described as due to the toxic causes of infectious disease, sudden death may be the only s)'mptom. In some cases it may be preceded or not by very brief precordial distress. Less serious degrees may be associated with faintness or palpita- tion on exertion, extreme feebleness of the heart's action, and dyspnea. It is rather characteristic for these symptoms to pass away wdien the patient is at rest, to be renewed on the slightest exertion. Symptoms growing out of dilatation of the heart, going also to make up the sum of those constituting chronic valvular disease with failure of compensation, are general venoits congestion, dropsy, feeble, frequent, and irregular radial pulse — rarely, on the other hand, a sloiv pulse. The former may be due to impaired pneumogastric inhibition the result of anemia of the brain, the latter to scanty nutrition and a loss of irritability of heart muscle. To anemia especially affecting the medulla oblongata may be ascribed Cheyne- Stokes breathing, also a symptom of the terminal stage of the disease. To it may be ascribed, too, S3-mptoms simulating apoplexy, vs^hich characterize the slower dying in some of these cases. Palpitation, angina pectoris, and dyspnea — cardiac asthma, with syncopal attacks, coldness, and slow pulse (thirty to forty) — are all symptoms more or less associated with dilatation of the heart. It is further characteristic of these symptoms of dilatation that they are often not transient or amenable to treatment by the usual heart tonics, of which digitalis is the type. In some instances, especially in the dilated heart of pernicious anemia, there may be a full, strong, and regular pulse. High-colored, scanty urine of high specific gravity, sometimes contain- ing hyaline casts and blood discs, also result from cardiac dilatation. Physical Signs. — When the termination is not immediate, physical signs may be recognized. To inspection the impulse, if visible, may be diffused over a wide area, but is feeble and fluttering, a point of greatest intensity or an apex-beat being often wanting. At times it is found higher up and to the left of its normal position. If the right heart is chiefly involved, the beat. HYPERTROPHY AND DILATATION. 605 as far as caused by the left apex, is completely wanting, while an impulse may be felt below or to the right of the ensiform cartilage, as well as a wavy impulse in the fourth, fifth, and sixth interspaces to the left of the sternum. A pulsation may be seen in the second left interspace, which, while sometimes presystolic, is commonly systolic. In the latter event it may be a further expansion of an already dilated auricle by blood regurgitating during systole of the left ventricle ; or if presystolic, it may be the pulse of auricular systole. Such at least are possible explanations. The fact that at autopsies, even in extreme dilatation, the left auricle is found so far back from the thoracic wall ■as to be scarcely able to beat against the second interspace, does not preclude the possibility of this during life. In dilatation of the right auricle, on the other hand, there is sometimes seen an impulse in the third interspace on the right side which is clearly systolic and due to regurgitation from the right ventricle during its systole. The pulsating symptoms described in this para- graph are commonly seen only in persons with thin chest-walls. To percussion there should be increased dullness to the right and down- ward toward the epigastrium or to the left beyond the normal line, though these boundaries may be obscured by an emphysematous lung. The results •of aiiscultation are greatly influenced by complications. If cardiac murmurs are present, they may obscure all else. On the other hand, previous murmurs may disappear. The typical sounds are found in the dilatation following idiopathic hypertrophy. The impulse is feebly heard as well as felt ; the first sound is feeble but pure — that is, shorter and more like the second, lacking, as it does, the muscular element. It may be scarcely audible, even in the absence of murmurs. It is sometimes reduplicated because of asynchrony in the action in the two halves of the heart. Sometimes there is a loud systolic murmur at the apex, due to relative insufficiency of the mitral valve, the true nature of which becomes apparent only in the event of its disappearance. The second pulmonic sound may remain sharp if there is dilatation only of the left ventricle and there is compensatory hypertrophy of the right ; feeble if the right ventricle is involved. Finally, there is intermittent and irregular action ; at times the characteristic gallop rhythm/^ which is almost pathognomonic of dilatation, is present. The pulse is very rapid and feeble. Diagnosis. — An acknowledged difficult matter at times is the dis- tinction of pericarditis zvith effusion from the dilated heart. Whether in- spection furnishes any information, depends mainly upon the stoutness or leanness of the patient. In the stout person nothing is recognizable in either condition. In the thin-chested the impulse is visible and wave-like in dilatation ; it is not visible, or barely so, in pericardial effusion. The same is true of palpation, except that, if the patient leans forward, the impulse may be felt in pericarditis. Percussion affords the miost valuable information. If it brings out the well-known triangular shape of dullness, with the apex toward the inner €nd of the left clavicle, and the base in the fifth or sixth interspace, espe- cially in the absence of a cardiac impulse, there must be pericardial effusion. To auscultation, while the heart-sounds have lost their characteristic sharp- ness, they still contrast with the distant and muffled sounds in pericardial effusion. Especially if there is left any of the original hypertrophy, the second sound will retain some of its sharpness, while, if there happens to have been valvular disease, the murmurs remain to help us. *For explanation of gallop rhythm see Barth and Roger, "Traite Pratique d' Auscultation." "Thirteenth Edition, Paris, i8g8, p. 352. 6o6 DISEASES OF HEART AND BLOOD-VESSELS. Bamberger's sign, described on p. 561, must be sought for in evidence of pericardial effusion. There may be encroachment on the lung in dila- tation, but it is very much less in dilatation than in pericarditis with effusion. This encroachment in the case of dilatation does not give rise to Skodaic resonance in the axilla. While there is shortness of breath in both, it is less pronounced in dilatation and more influenced by exertion, being less while the patient is quiet. Prognosis. — This is ultimately fatal; in fact, the stage of dilatation is the stage in which remedies become unavailing. At the same time, marvel- ous results sometimes follow treatment. I, have seen general anasarca with effusions in the serous cavities disappear when least expected, so that one is never justified in giving an unqualifiedly unfavorable prognosis. Treatment. — This is essentially that of valvular heart disease. Rest is even more important, while the heart tonics are, of course, indicated. Strychnin is an important remedy, and in dangerous stages may be given hypodermically in 1-30 grain (0.0022 gm.) doses every three or four hours or oftener for a short time. Digitalis in 7.5 minims (0.5 c. c.) or Merck's German digitalin, in doses of i-io to 1-2 grain (1.0066 to 0.033 g"^-)» ^^^y ^^ given under like circumstances. Suitable nutritious food and, if the patient survives the primary danger, well-regulated exercise, are indicated. A timely blood-letting may save life if the signs of engorgement of the right ven- tricle are present — intense dyspnea, lividity. It is in this condition that the Schott or Nauheim treatment is especially useful. It consists in the use of the carbonated saline baths at Bad Nauheim, associated with special exercises called " resistance " movements, originated by the brothers Schott. Fortunately, artificial baths may be substituted for the natural baths, or the treatment would have limited application. Ignoring for the present the rationale of the action of these baths, their therapeutic efficacy is undoubted. The waters at Nauheim have a tempera- ture ranging from 82° F. (27° C.) to 95° F. (35° C). Their important constituents are chlorid of sodium and chlorid of calcium. The baths may be imitated at home by dissolving chlorid of sodium and chlorid of calcium in water, to which carbonic acid is added by decomposing" bicarbonate of potassium by hydrochloric acid. Dr. K. N. B. Camac has calculated the required quantities of salt to each forty gallons of water for six different strengths of the baths. In the baths I recommend I have adopted the proportions of sodium chlorid and calcium chlorid calculated by Camac, but have slightly modified the proportions of carbonic-acid-form- ing constituents, making three^ strengths of the latter, after the method recommended by Bezley Thorne, of London : Bath No. I : Sodium chlorid, 4 pounds ; calcium chlorid, 6 ounces. Bath No. 2 : Sodium chlorid, 5 pounds : calcium chlorid, 8 ounces. Bath No. 3 : Sodium chlorid, 6 pounds ; calcium chlorid, 10 ounces. Bath No. 4 : Sodium chlorid, 7 pounds ; calcium chlorid, 10 ounces ; sodium bicarbonate, 1-2 pound ; HCl (25 per cent.), 12 ounces. Bath No. 5 : Sodium chlorid, 9 pounds; calcium chlorid, 11 ounces; sodium bicarbonate, i pound ; HCl, i 1-2 pounds. Bath No. 6 : Sodium chlorid, 10 pounds ; calcium chlorid, 12 ounces ; sodium bicarbonate, 2 pounds ; HCl, 3 pounds. I rarely use anything beyond No. 4 bath. The alkali should always be slightly in excess, unless a porcelain or paper tub is used. In preparing the bath, the salts, including the right proportion of bi- HYPERTROPHY AND DILATATION. 607 carbonate of sodium, are dissolved in the water. The bottle containing the hydrochloric acid is inverted and lowered until its mouth is below the surface, when the stopper is withdrawn and the bottle moved about so as to diffuse the acid as uniformly as possible through the water. In this way the bath is made ready in a few minutes. The carbonic acid is the most unsatisfactory feature of the artificial bath, since it is rapidly dissipated, and produces only feebly the effect of the acid in the natural baths. Hence the patient should be promptly put into the bath after the HCl is added, lest the CO, is lost before he can get the effect of it. My plan has been to give -^the baths on alternate days, using the weaker until its effects are exhausted, then passing on to Nos. 3 and 4 in the same manner. Nos. 5 and 6 are not often called for.* As already stated, the baths are most efficient in cardiac disease, but they are also useful in renal affections. Their immediate effect is a dimin- ished pulse-rate, intensified heart-sounds, diminished breathing-rate, while the dilated heart is reduced in size — under favorable circumstances to almost its natural limits. The effect is also to increase the action of the kidneys and that of the skin. These effects are apparent in a free flow of urine, which may continue for days and weeks. Metabolic changes are accelerated and improved ; the deep-seated organs, especially the liver and pelvic viscera, are relieved of congestion ; while the heart, relieved of its burden, and contracting strongly, derives from its improved coronary circu- lation material for the repair of weakened and damaged tissue. I find in my experience that it is more satisfactory to give the baths on alternate days until about fifteen or twenty baths are taken, gradually passing from the weaker to the greater strengths, and gradually reducing the temperature from 95° F. (35° C.) to 82° F. {2y° C). The exercises are not so easily described as shown by actual practice, but briefly they may be said to include every reasonable movement of the arms and legs, gently resisted by opposite pressure exerted by the phy- sician or attendant. Thus, there is flexion of the arms on the forearm, carrying the arms forward until the palms are apposed, then backward from this position until they are in a line, and raising them from the sides upward until they touch the sides of the head. There are also radial move- ments of the arms alongside of the head, etc. — in all, nineteen movements. Similar movements are made with the legs, including flexion and extension at the knee-, ankle-, and hip-joints. They include also lateral and twisting movements of the trunk. The exercises are not commenced until some very positive effect of the baths is secured, when they are associated with the baths or substituted after the latter are discontinued. The effects of these gymnastics are described as identical with those of the baths. The extremities become warm, the breathing is deepened, the sense of oppression is relieved, the pulse becomes slower, the dilated heart area reduced. Even the liver, which is so often enlarged in heart disease as a result of passive congestion, is said to be reduced in size. * I have had constructed for use at the Hospital of the Universitj' of Pennsylvania an apparatus for introducing carbonic acid into the water of the bath, after a device suggested by Dr. Smitheman, when a student of medicine. ' 6o8 DISEASES OF HEART AND BLOOD-VESSELS. Atrophy of the Heart — Brown Atrophy. Definition. — Atrophy of the heart is the opposite state to hypertroph}' — viz., a reduction in the muscular substance, with a corresponding reduc- tion in the size of the cavities. It is associated with pigmentation, hence the term brown atrophy. It is Hmited cHnically, being confined to the sub- jects of wasting diseases, Hke phthisis puhiionahs and carcinoma. It is the special result of senile marasmus. It is occasionally associated with chronic valvular disease. The muscular fasciculi undergo molecular death, the organ wastes, and is symmetrically reduced. It is dark red-brown in color and firm in consistence. By the microscope is recognized a peculiar ar- rangement of pigment granules about the nuclei and between the primitive fibrillse. The source of the pigment is not precisely known. It may be the coloring matter of the muscle, or directly derived from the blood. The diagnosis of such condition can only be based on a diminution in the normal area of cardiac percussion dullness associated with feeble pulse, and the long-continued presence of the causal disease. Reduced area of cardiac dullness must be unassociated with emphysema of the lungs or other causes which may diminish cardiac dullness by covering up the heart. The treatment is that of the causal disease. DEGENERATIONS OF THE CARDIAC MUSCLE. The heart muscle is subject to parenchymatous degeneration, to fatty degeneration, to fatty infiltration, to amyloid degeneration, to the hyaline transformation of Zenker, to calcareous degeneration, and to the changes known as brown atrophy and yellow atrophy. Parenchymatous or Albuminoid Degeneration (Cloudy Swell- ing). — This is a change in which the sarcous substance is converted into granular matter of albuminoid composition, which produces also more or less indistinctness in the striated appearance of the fasciculi. The albu- minoid composition of the product is attested by its solubility in acetic acid, and its insolubility in ether. The general effect is one of softening and flaccidity. It is ascribed to some toxic agency, and occurs most frequently in the infectious fevers — typhoid fever, typhus fever, scarlet fever, diphtheria, and the like. It was at one time considered a consequence of high tempera- ture, but this view is no longer held. It is believed also to be, at times, at least, the first stage of fatty degeneration, or to precede fatty degeneration. It is certainly at times associated with it. Cloudy swelling may disappear and the muscle resume its natural histology. Fatty Degeneration or Fatty Metamorphosis. — In this change, also sometimes known as yellozv atrophy, the sarcous substance of the mus- cular fasciculi is directly converted into globular fat, as contrasted with the condition of fatty infiltration, in which the fat is deposited between the fasciculi. The little fat drops — and they are very minute, as a rule — are seen in rows parallel to the fibrillse of the fasciculus, and all transverse DEGENERATIONS OF THE MYOCARDIUM. 609 striation has disappeared. As intimated, the cause of such degeneration is an interference with the proper nutrition of the heart-muscle. It may be general, when it has its most frequent expression in the dilated heart which succeeds upon hypertrophy, involving the walls of one or more cavities. It is also a result of the impaired nutrition of old age, of the grave infectious diseases, and of cachectic states generally — such, for ex- ample, as pernicious anemia. In the infective diseases and cachexias it may be associated with parenchymatous degeneration or succeed upon it. It is also a result of the action of certain poisons, as phosphorus and arsenic, .the effects of which may extend to other muscular organs. Under these circumstances, the heart is generally enlarged (dilated), flabby, and relaxed, of a light yellow or yellowish-brown color, and very friable, permitting the finger to be easily poked through it. The papillary muscles and the tra- beculae in the left ventricle may be the seat of circumscribed fatty degen- eration, and be dotted and streaked with yellow, fatty matter. Unlike parenchymatous degeneration, fatty degeneration, when once established, is considered irremediable. Fatty degeneration of the heart may also be circiimscrihed in small foci variously distributed. Thus, it may be confined to the superficial or sub- pericardial layers, when it is especially the result of pericarditis. Or there may be numerous pinhead-sized foci in the subendocardial layer in cases of extreme dilatation. Finally, there may be a single focus in the substance of the left ven- tricle or the septum, due to total obstruction of one of the branches of the coronary artery, usually the anterior, by a thrombus or embolus. The product is an area of fatty degeneration known also as anemic necrosis, or white infarct. In the early stage the infarction is brownish-yellow or hemorrhagic. Minutely examined, the muscular fasciculi are without nuclei, and later they break up into a cheesy detritus. The infarct is not always thus made of fatty debris, but may present a hyaline appearance. It may be the seat of rupture, and thus cause hemorrhage into the pericardium, and immediate death. Diagnosis. — The diagnosis of fatty degeneration, so far as recogniz- able, is that of dilatation, slight degrees and circumscribed fatty degeneration being unrecognizable, while considerable areas of partial degeneration may also exist without exhibiting symptoms. In fact, the presence of some dilatation of the cardiac cavities seems to be necessary to the production of symptoms — the feeble pulse, palpitation, and dyspnea being symptoms of the dilatation, rather than the fatty degeneration. Prognosis. — This is grave. It is impossible to restore the degener- ated muscular substance to its natural structure. With degeneration estab- lished death is liable to occur suddenly, and remedies which avail with an integral organ are useless here. Treatment. — This embraces that of cardiac dilatation. Acute attacks should be met by stimulants, of which alcohol, aromatic spirit of ammonia, and digitalis are the type. Strychnin is also indicated, and may be used hypodermically. Fatty Infiltration or Fatty Overgrowth. — Strictly speaking, this con- dition is not a degeneration of the heart muscle, though it leads ulti- mately to fatty metamorphosis. It is the cor adiposum of the older authors, and differs from fatty metamorphosis in that the fat is infiltrated between the muscular fasciculi. In the true cor adiposum, the fat extends deep into the 39 6io DISEASES OF HEART AND BLOOD-VESSELS. substance of the muscle, sometimes as far as the endocardium. It covers also the outside of the heart, at times so completely that the true muscular structure is invisible. This infiltration sooner or later interferes with the proper nutrition of the muscular substance, a true fatty degeneration results, with its symptoms, so far as any are manifested, and becomes ultimately also a cause of death. The fatty infiltrated heart is commonly a part of general obesity, and occurs, therefore, at a time of life when this is usual, — that is, between the ages of forty and seventy years, — and is more than twice as frequent in men as in women. The condition is inferred from the presence of extreme obesity asso- ciated with signs of cardiac weakness. The treatment is that of obesity. Amyloid infiltration invades the heart as it does other organs, at- tacking the blood-vessels and intermuscular connective tissue. Zenker's hyaline transformation attacks, on the other hand, the muscular fasciculi, causing them to appear swollen and transparent, and the striae to be indis- tinct or absent. Calcareous infiltration is a rare condition, in which the muscular fas- ciculi are infiltrated with lime salts. MYOCARDITIS. Chronic Myocarditis or Fibromyocarditis. Synonyms. — Fibroid Degeneration of the Myocardium; Fibroid Heart; Fibrous Myocarditis; Interstitial Myocarditis; Indurated Degeneration; Myodegeneration ; Sclerosis of the Coronary Arteries. Definition. — A condition of the cardiac muscle in which there is more or less substitution of the normal substance by fibroid tissue, either localized in patches or diffused throughout the organ. It is analagous to fatty infil- tration. Etiology and Pathology. — The condition is not, strictly speaking, in- flammatory, the patches representing transformed areas of anemic necrosis, due to obstructive disease of the coronary arteries and branches. The dis- ease in the coronary arteries is endarteritis, resulting in arteriosclerosis. It not only diminishes the blood supply, but it causes degeneration of the mus- cular fasciculi, and their substitution by fibrous tissue. Only in the event of such diminished supply do the changes occur. Hence it is that arterio- sclerosis of the coronary arteries is not always followed by fibroid change. The causes of arteriosclerosis of the coronary arteries, which in its turn gives rise to the fibroid change, are those of endarteritis elsewhere. They include all the causes which produce idiopathic hypertrophy (p. 603). The tendency to arteriosclerosis is often hereditary. It is a disease also which seldom occurs prior to middle life, though sometimes seen surprisingly early. It might be said that it is natural to old age — one of its evolutional terminations. In pure, uncomplicated cases the valves are normal, while the muscle, on examination, is found dotted with white, shining areas present in varying numbers. Minutely examined, these are found made up of pure or partly fibroid tissue, the muscular fasciculi being correspondingly destroyed. MYOCARDITIS. 6ii They are seated for the most part in the left ventricle toward the apex and in the anterior zvall, though they may be found elsewhere. They may often be seen from the endocardial or pericardial surface as cicatricial-like depressions. Sometimes there is a single large patch known as a Hbroid patch. The papillary muscles may exhibit the same fibroid change. The fibroid change may also be associated with valvular disease, the mechanical impediment to the movement of blood in these conditions being the cause of a chronic venous congestion, which results in a fibroid infiltra- tion ; or the valvulitis may give rise to embolism of the coronary arteries or branches, thus cutting off nutrition. From the cardiac thrombosis which sometimes results there may arise cerebral, renal, and pulmonary embolism. Long-standing emphysema of the lungs results in similar congestion ; so does obstruction of the pulmonary artery from any cause. A further result of the fibroid change is dilatation of a part or of the whole of one of the heart cavities, producing in the former instance what is known as cardiac aneurysm. Fibrosis may also be associated with hyper- trophy without valvular disease, though the recognition of such combination before death must be a matter of inference, based on the presence of arterio- sclerosis elsewhere and of the causes of such hypertrophy. Symptoms. — Slight degrees of fibroid change occasion no symptoms, while autopsies even disclose advanced stages of indurative myocarditis which were not suspected. In consequence of the frequent association, too, of endocarditis and pericarditis, the symptoms of these diseases are often combined and mask the distinctive symptoms of the fibroid change. Un- masked, the symptoms are, in a word, those of dilatation of the heart, in- cluding dyspnea, often so severe that the patient cannot lie down. With this may be associated Cheyne-Stokes breathing, commonly occurring during sleep. There may be palpitation, with small, frequent, and irregular pulse, or the pulse may be unnaturally slow. There is precordial oppression, with attacks of faint ness, and, finally, venous stasis with cyanosis, general edema, congestion of the liver, stomach, and kidneys, feeble digestion, scanty urine, and albuminuria. These symptoms may set in gradually or suddenly. On such a heart, digitalis and other heart tonics are often without effect. A persistently slow pulse should be mentioned as an occasional symptom. Angina pectoris is also a symptom of indurative myocarditis, though it also occurs in other cardiac diseases, especially aortic stenosis. It will be de- scribed when treating of neuroses of the heart. The same symptoms may aris^ from fatty heart. A very interesting train of nervous symptoms may arise, due to changed local distribution of blood in the brain, partly due to feeble cardiac action and partly to stenosis of the basilar vessels. They may include brief un- consciousness and various degrees of paralysis, and anesthesia resembling the symptoms of cerebral embolism. Physical Signs. — Physical examination recognizes a feeble impulse, often scarcely appreciable, and, on percussion, either enlargement of the heart — dilatation — or the reverse. The first sound lacks its muscular element, and is more like the second — more purely valvular, and therefore short. Both sounds maintain for a time considerable distinctness, but ultimately grow feeble. Occasionally there maA- be a mitral murmur, which may be functional and transitory or permanent. Such murmur is explained by the experiments of Ludwig and Hesse, already alluded to, and more recentiv confirmed bv Krehl. These go to show that a certain integrity of the 6i2 DISEASES OF HEART AND BLOOD-VESSELS. muscles about the mitral orifice or of the papillary muscles is necessary to a complete closure of the latter. Such integrity is impaired by myocarditis, and the resulting murmur increases the difficulty of diagnosis. There is, however, usually absence of accentuation of the pulmonic second sound characteristic of mitral regurgitation, though this may also be relatively present if the right ventricle happens to be less severely involved than the left. The second sound is also sometimes reduplicated. The mitral mur- mur in the fibroid heart is more variable and more subject to intermissions than that of mitral regurgitation. The sudden addition of a mitral systolic murmur in a fibroid heart previously without murmur may also indicate a lacerated valve. Diagnosis. — This is often difficult, requiring the opportunity of pro- longed study of the case for an accurate diagnosis. For the most part, we are compelled to rely on the absence of the symptom.s and signs of valvular disease, and the presence of the symptoms of dilatation, the evidences of arteriosclerosis elsewhere, a persistently slow pulse, angina pectoris, the history of syphilis and of other causes, together with the age of the patient. When the fibroid condition is associated with murmurs, the diagnosis is still more difficult, and must, indeed, be a matter of probability, if even suggested, so much more likely are the signs to be interpreted as those of valvular disease, with which, however, the fibrosis may be associated. The presence of radial sclerosis is strongly confirmatory, but not essential. Prognosis. — This is grave, or, to say the least, uncertain. Associated as it is with sclerosis and narrowing of the coronary arteries or branches, complete obstruction is liable to occur at any time, producing sudden death. On the other hand, the patient may live for many years with the heart the seat of considerable fibroid change. Treatment. — ^This must mainly consist in treating the causes, and in a proper hygienic management. Habits of overeating and excessive drink- ing should be overcome. The avoidance of overexertion, associated with just sufficient exercise to develop the heart healthfully, should be observed. Outdoor life and a proper hygiene of the skin and body by bathing and massage are important. Drugs which will remove the diseased condition of the coronary arteries and fibroid overgrowth probably do not exist. Still, the reputation of iodid of potassium as a remover of fibroid overgrowth and for the cure of svphilitic disease should be availed of. The iodid is also serviceable in pro- ducing vascular dilatation and facilitating the movement of the blood. For the symptoms of stasis and hgart weakness, of dyspnea and of angina pec- toris, the treatment is the same as that for these conditions under other circumstances. The judicious use of digitalis is indicated, and may accom- plish much. Nitroglycerin may be associated with advantage or used alone. Acute Suppurative Myocarditis. Synonym. — Abscess of the Heart. This is a rare condition. It is always metastatic or pyemic in origin, in association with puerperal fever, malignant endocarditis, or other septic processes. It may occur in the septum, as well as the outer ventricular walls. As such it is not recognizable before death, and is commonly discovered MYOCARDITIS. 613 at autopsies. It may, however, rupture into the heart cavities, causing other metastatic abscesses, or into the pericardium, causing septic pericarditis and early fatal termination. Aneurysm of the Heart. This is a term given to two conditions : 1. A saccular projection from the ventricular surface of a sigmoid or cuspid leaflet, where the valve is weakened by ulceration through one of the lamellse, the intravascular or intracardiac pressure furnishing the dis- tending force. It is much more common in the aortic segments. The sac- cule may ultimately perforate, causing laceration of the valve. 2. Projection outward of a circumscribed portion of the muscular wall, which has been weakened by the fibroid patch or by an injury to the wall. Here, naturally, the left ventricle, too, suffers, and near the apex in more than half the cases. The resulting pullulation varies in size from 2-5 inch ( i cm.) or less to dimensions equal to those of the heart itself. The aneurysm may be sacculated or partitioned and even multiple. There are no symptoms by which the condition may be recognized with any degree of probability. It may also terminate fatally by rupture into the pericardium. Rupture of the Heart. Rupture of the normally integral heart muscle does not occur. It is only when weakened by disease that such an event is possible. Fatty meta- morphosis furnishes the most frequent predisposing condition. The soften- ing due to obstruction of a branch of the coronary arter}^, as already described on page 610, and known as massive softening, is the most frequent cause of heart rupture, but the fibroid change, abscess, or ulceration are all conditions which at times precede rupture. Morbid growths in the heart- wall, such as gummy tumor and carcinoma, are also possible causes. These preliminary conditions presupposed, any unusual strain is suf- ficient to produce rupture, though this is not always necessary, especially in the case of the white infarct, where the degeneration is so great as to admit rupture with the ordinary pressure. It is naturally an event of the second and third half-centuries of life. The anterior portion of the left ventricular-wall near the septum is the favorite seat. Rupture is rarely recognized before death, which usually follows in the course of a few hours. The symptoms are precordial pain, a sense of oppression, dyspnea, pulselessness, and collapse. There may be enlargement of the cardiac area of dullness, owing to filling up of the peri- cardial sac. 6i4 DISEASES OF HEART AND BLOOD-VESSELS. NEUROSES OF THE HEART. NERVOUS PALPITATION. Definition. — By this is meant an unnaturally frequent, regular, or irregular beating of the heart, of which the patient is uncomfortably con- scious, but which is unattended by any physical evidence of organic disease of the organ. This does not mean that there may not be functional or acci- dental murmurs, because these are especially prone to be present in the different varieties of anemia which are commonly associated with palpita- tion. Such murmurs are always, however, systolic, a diastolic murmur always indicating organic disease. Palpitation, or uncomfortable heart- beating, also occurs in connection with organic disease of the heart, but this is not nervous palpitation. Etiology, — There are numerous causes of palpitation. In the first place, it is much more frequent in women than in men. Again, it is prone to occur at the time of puberty in girls, and at the menstrual period and climacteric in women. Anemia is at once a predisposing and an exciting cause ; indigestion is a very frequent causal agent. Mental emotion, in- cluding fright, anxiety, and grief, diseases of the uterus and stomach, the exhaustion of protracted illness, sexual excesses, overwork, the abuse of alcohol, tobacco, tea, and coffee, are all active etiological elements. The " irritable heart " described by Da Costa, based on observations made on soldiers in the late War of the Rebellion in America, has for its most strik- ing symptom palpitation ; yet this dare not be called nervous palpitation, as dilatation of the heart was probably here present. Overwork and excite- ment were its chief causes, abetted by exhaustion from illness. Symptoms. — The " beating " referred to is, of course, the chief symp- tom. It varies greatly, however, in degree and duration. At times there is a mere fluttering, lasting for a few minutes. At other times the pulse- rate may reach i6o or more and be scarcely countable. When the character last described is attained, and continues for a variable time of hours to days, but finally ceasing, the term paroxysmal tachycardia is applied. The rapid heart-action is sometimes associated with a sense of weakness or " gone- ness " in the epigastrium, and sometimes with natisea. The face is usually pale, but is sometimes flushed. The physical signs usually add nothing to the undue beating noted on auscultation, though, as already mentioned, there may be functional murmurs systolic in time at the base of the heart, more rarely at the apex. The normal heart-sounds may be somewhat sharper and clearer, or they may be more blurred. Diagnosis. — The only two conditions with which nervous palpitation may be confounded are myocarditis and fatty degeneration of the heart and dilatation, the symptoms of which, it will be remembered, are similar. The nervous affection is, however, a less serious affection, characterized by intermissions during which the heart is quiet. Its subjects are also of the anemic nervous type, whose history greatly aids the diagnosis, and they are commonly younger, . Treatment, — This is by rest, nerve sedatives, and a suitable moral treatment of encouraging words and a confident manner. A few drops of TACHYCARDIA AND BRADYCARDIA. 615 tincture of digitalis, with a few more grains of sodium bromid, repeated every hour, may be useful. When the patient is weak and anemic, he should be built up and strengthened by iron, quinin, and strychnin. TACHYCARDIA AND BRADYCARDIA. Paroxysmal Tachycardia. — This term is applied to conditions of the heart in which, without evident cause, there appears paroxysmally an inordinate increase in the number of heart-beats a minute, of which also the patient is conscious. The number of beats may reach 200 or more. The paroxysm may last for a few minutes only, or for hours. The inter- vals between two attacks vary greatly, and their recurrence may extend over many years. Bradycardia; Brachycardia ; Sloiv Heart. — The term bradycardia is applied to urmatural slowness of pulse. It is to be remembered, how- ever, that some healthy persons naturally have a slow pulse, as others have one whose rate is more rapid than the typical y2. A rate of from 50 to 5o is not unusual. It may even be slower, as in the case of a patient of mine whose habitual pulse for many years of my observation was from 36 to 40. I do not know, however, what it was in youth. Of abnormally infrequent rates, cases with 20 beats are reported, some even at 12, 9, and 7. These instances of extremely slow rate are apt to be associated with fibroid heart, and there can be no doubt that the nervous condition is often confounded with the organic one. In the study of an apparently slow pulse, care must be taken that the actual count is based on a corresponding heart-rate, for it sometimes hap- pens that in^ consequence of the weakness of an alternate systole the heart- beat does not reach the wrist. Bradycardia occurs under a variety of conditions, which have been carefully collected by Riegel. They include the following : 1. Convalescence from acute fevers, such as typhoid, pneumonia, diph- theria, acute rheumatism, and the like. 2. Diseases of the digestive apparatus, especially dyspepsia, but also ulcer and cancer of the stomach. 3. Rarely in diseases of the respiratory system. 4. Diseases of the circulatory system, more frequently those involving the muscular structure of the heart, and associated with deficient nutritive supply, especially conditions succeeding obstruction to the coronary artery. 5. In nephritis. 6. From the action of toxic agents, including the uremic poison, lead, alcohol, coffee, and digitalis. 7. Certain diseases of the nervous S3'stem, including apoplexy, brain tumors, especially those involving the medulla and cervical cord. (To these may be added epilepsy and catalepsy. — Author.) 8. Finally, affections of the skin and sexual organs. Explanation of Tachycardia and Bradycardia. — The rationale of the production of tachycardia and bradycardia has excited much discussion and cannot be said to be settled. The heart's action is accelerated by stimulating the accelerator branch of the sympathetic or by paralysis of the inhibitory root of the pneumogastric, and slowed by stimulation of the latter, directly or reflexly. Direct stimulation of the latter is caused by pressure on its root. 6i6 DISEASES OF HEART AND BLOOD-VESSELS. which may be exerted through the cerebrospinal fluid, which in turn may be excited by brain tumor, hemorrhage, and meningitis of the dura or pia.. Such irritation may be caused by toxic constituents of the blood, as in uremia. Increased arterial pressure — such, for example, as occurs in acute nephritis — is said also to produce cerebral vagus irritation. On the other hand, such slowing is not maintained if the arterial tension is kept up, as in chronic Bright's disease and arterial sclerosis. Under such circumstances the excitability of the penumogastric center may be said to be exhausted. Deficient nourishment to the heart substance, such as is caused by atheroma and obstruction of the coronary artery, leads also to a slow pulse. Refiexly, the pneumogastric may be stimulated by diseases of the abdominal organs — as, for example, the stomach, bowels, and peritoneum. The effect of disease of the muscular substance of the heart in reducing its rate has often been mentioned in the foregoing section. On the other hand, poisons and high temperature increase the pulse-rate. In this way the infectious diseases may produce acceleration. Other poisons slow the pulse, possibly by acting on the nerve endings in the heart. Such are the salts of the biliary acids and the uremic poison, whatever it may be. It is well known that in the course of acute infectious diseases, especially typhoid fever, slowing of the pulse occurs at times very strikingly. This is not uncommon in the beginning of convalescence. It has been observed also in typhus fever, in croupous pneumonia, erj'sipelas, diphtheria, and measles. I have met it as slow as i8 in typhoid fever. In explanation of this phe- nomenon one may suppose a lesion of the cardiac ganglia by the toxic sub- stances circulating with the blood, or a consequent weakness of the heart muscle due to the long continued fever.* His and Romberg, in their studies on the innervation of the heart, were led to believe that the cardiac ganglia are sensory in function and that they share the increased sensitiveness of the entire nervous system, variously caused, and thence reflexly may excite the violent cardiac action of tachy cardia. Not unlike this is the explanation of H. C. Wood, who suggests that the paroxysms of tachycardia are due to " discharging lesions " affecting the centers of the accelerator nerves. In some one of these views, perhaps, must be sought the required explanation. On the other hand, anesthesia of the cardiac ganglia, however induced, would be expected to have the opposite effect of a bradycardia. By recalling these facts many of the cases of brady- cardia may be explained. IRREGULAR PULSE. Synonym. — Arrhythmia. Description of the Different Varieties, Peculiarities, and Explana- tion. — The simplest form of irregular heart is that in which there is an occa- sional drop or intermission in the beat, while the pulse in the intervals is per- fectlv regular. This may occur once only in twenty or more beats, and from this rate mav increase until it happens once in six or four beats, or it may be every second or third beat ; or the pulse may be altogether irregular — arrhyth- mical. A striking feature of even the simplest form of intermittent pulse or * See a very full paper " Ueber Bradycardia," by Dr. F. Grob, " Deutsches Archiv fur klinische Medicin," vol. xxii., 1888, p. 574. IRREGULAR PULSE. 617 heart is that the omitted beat is commonly recognized by the patient himself, and often it becomes a matter of intense annoyance to him. Here, again, it is quite important to decide whether the dropped beat at the wrist is the con- sequence of an omitted systole recognized by absence of the first sound in the auscultated heart, or whether it is a simple weak systole which does not send the pulse to the radial artery at the wrist. It is more apt to be the former, if the patient recognizes it. It may be constant or occur at regular intervals or only occasionally. In the latter event it may be associated with some such disturbing cause as dyspepsia and, especially, flatulence. It follows the use of tea, coffee, or tobacco, and is in rather frequent association with chronic gout. It follows also mental shock, and is especially prone to occur in nervous, hysterical per- sons. The intermittent pulse thus occurring is vaguely ascribed to nervous influences, and nothing more definite can at present be confidently suggested for its causation. It may be due to some influences of the causes named on the cardiac ganglia of the sympathetic nerve. It is probably at times directly due to organic changes in the heart muscle, especially in fatty degeneration, in which event it is a more serious symptom. It is characteristic of the more purely functional variety of intermittent pulse that it may be removed by exercise or excitement, while it often dis- appears during pyrexia. On the other hand, the effect of exertion on the intermittent pulse of fatty heart is to increase the intermission or convert it into an irregularity. The irregular pulse is indicated by its name. It is associated with a corresponding degree of irregularity of the heart's action, the highest degree of which is known as delirium cordis. This irregularity varies also, may be habitual or occasional, and produced by the same causes as intermission. It may also be induced by temporary or permanent derangements of the respira- tory organs through changes in pressure on the large arteries in the chest. This, be it noted, is not an influence on the heart. Irregularity of the pulse and heart is a distinctive symptom of mitral insufficiency. This is very rea- sonably ascribed by W. H. Broadbent not to nervous influence, but to varia- tions in pressure due to traction of the lungs during the inspiratory act on the cavities of the heart. This is favored by the thin, flabby, and feebly resisting walls of a dilated auricle, incapable of resisting variations of external pressure. In mitral stenosis, though the auricle is dilated, the narrow auriculo-ven- tricular orifice prevents the disturbing efifect of the varying pressure of the respiratory movements. In like manner may be explained the pulsus bigeminus and trigeminus, also common in mitral disease, more especially mitral stenosis. In these two and three beats follow each other in rapid succession, separated by a longer interval. The pulsus paradoxus of Kussmaul, in which the beats during inspiration are more frequent, but less full than during expiration, may also be explained in this way, occurring as it does in weak heart, chronic peri- carditis, and other conditions in which the normal relation of respiration to the heart's dilatation and contraction is interfered with. Other modifications of the cardiac rhythm are the gallop rhythm and embryocardia. The former consists of three sounds, and is so called because it resembles the footfall of a horsre in canter. It occurs especially in the hypertrophy which accompanies interstitial nephritis with arteriosclerosis, and in fatty dilated heart. It is variously ascribed to an ( i) abnormal " clacking," produced by the contraction of a hypertrophied auricle, preceding the ven- 6i8 DISEASES OF HEART AND BLOOD-VESSELS. tricular shock (Charcelay) ; (2) to a presystolic impulse which immediately precedes the precordial shock; (3) to the contraction of a hypertrophied auricle and powerful tension of the ventricular wall produced by the rushing of the column of blood into the ventricles in connection with the elastic resist- ance due to the muscular tonicity of the hypertrophied wall (Potain) ; (4.) Cuffer and Barbillion suggest, in explanation of the variety occurring in the feeble myocardium of ataxic fevers and dilatation, that the ventricular con- traction and consequently the first sound is broken into two parts succeeding the precordial shock.* Emhryocardia, first described by Stokes, is a condi- tion in which the first sound is shortened, and therefore more like the second, the resultant being a sound similar to that of the fetal heart. It occurs espe- cially in the latter stages of dilated heart, in which the muscular element of the first sound has become lost because of weakness and the sound is purely valvular. The dicrotic pulse is a double beat, and is foand in every normal sphyg- mogram. It is the effect of the elastic recoil of the overdistended aorta on the contained blood immediately succeeding the closure of the aortic valve, and is shown at / in the catacrotic or descending portion of the normal sphyg- Fig. 57- — Showing Normal Pulse-tracing. mogram appended. It is preceded by the aortic notch e; this by the tidal wave d and the percussion wave b, the apex of the curve. Only when exag- gerated is it felt by the fingers. It may occur abnormally wherever there are a forcible systole and unobstructed arterioles, especially in aortic regurgita- tion, and although here the incompetent aortic valves do not furnish the requi- site resistance, this is furnished by the full ventricle behind them, so that while the dicrotic factor may be delayed, it is marked when it occurs. This is seen in the sphygmogram on page 583. It occurs also in anemia after venesection, the necessary atony of the arterial system being thus produced; after the administration of amyl nitrite and nitroglycerin ; also in uncompen- sated mitral regurgitation, when the emptiness of the arterial system is pro- duced in a dififerent way — that is, by diminishing the amount of blood which enters the aorta with each systole. Another variety of double beat is the ptilus bisferiens, most frequently noticed in aortic stenosis, but also in senile degeneration of the arteries. This resembles the dicrotic pulse, though quite different in its etiology. In it the second beat is a reinforcement near its close of a prolonged systole. Under these circumstances the dicrotic wave will be absent. Mention should be made in passing of the anacrotic pulse, though this is * For an elaboration of these and further explanations see Barth and Roger, " Traite Pratique ■d'Ausctiltation," thirteenth edition, Paris, 1898. IRREGULAR PULSE. 619 not appreciable to the finger. It is similar to the pulsus bisferiens. An ana- crotic pulse-wave is one in which a more or less marked notch occurs in the ascending limb, as in Figure 59. It is the pulse of high arterial tension, and occurs when the arteries are rigid and do not expand promptly to receive the contents of the ventricle during systole. The walls yield slowly, the pressure is prolonged, broadens the top of the sphygmogram, and throws the highest part of the tracing toward the end of the systole and nearer the dicrotic Fig. 58. — Pulsus Bisferiens (Broadbent). wave, which is usually ill developed. So, too, the percussion wave is prac- tically abolished and the tidal wave forms the apex of the curve. The pulse of prolonged arterial tension is produced by anything which resists the motion of the blood through the capillaries and arterioles, and such causes are numer- ous. Chronic renal disease, especially interstitial nephritis, is one of them ; so are gout, lead poisoning, constipation, atheroma, or calcification of the arterial walls. The anacrotic pulse is also produced in aortic stenosis, where it is of diagnostic value. Treatment of Palpitation, Tachycardia, and Arrhythmia. — It is of the greatest importance that the cause of nervous palpitation should be Fig- 59- — Anacrotic Pulse-Curves — Pulse of High Arterial Tension. {Landois and Sterling) ascertained, for with its removal recovery may be expected. Indigestion, distant causes of reflex irritation, such as uterine and ovarian disease in women, anemia, chlorosis, and the like should be carefully sought and elimi- nated by a proper treatment. During an attack the strictest quiet should be enjoined, and the patient should be kept in the recumbent posture. It is much more important that this should be done than that heart tonics or heart sedatives should be administered. Yet at this time it may be helpful to give small doses of digitalis, frequently repeated, say three to five minims (0.18 to 620 DISEASES OF HEART AND BLOOD-VESSELS. 0.3 c. c), or five to ten drops, every hour, combined with the bromids in ten- to fifteen-grain (0.66 to i gm.) doses, or aconite and veratrum viride in one- minim (0.06 c. c.) doses as often. When the palpitation is prolonged, a bella- donna plaster may be applied to the heart, or cold may be applied over the cardiac region. The treatment of an attack of tachycardia is similar. Every conceivable remedy has been tried by those subject to these attacks and their advisers, with results apparently satisfactory at one time and totally disappointing at another. In one remarkable case, a dear medical friend of my own, a glass of ice-water rapidly drunk almost always stopped a paroxysm. I have seen this eflfect in his case follow in a few minutes. This remedy he arrived at after fifty years' trial of everything he could think of. Bradycardia is perhaps best left alone, unless some evident, easily removable cause be found. As to treatment between attacks, the continuous use of strychnin may be expected to be useful. It should be combined with iron and quinin in moderate doses. A very elegant and convenient preparation is the elixir of iron, quinin, and strychnin of the U. S. P. On the other hand, strychnin sometimes causes nervousness. The dose must be regulated to avoid this. The tincture of nux vomica has been commended as especially suitable in these cases, given in ascending doses until thirty minims (2 c. c.)or more are reached. Outdoor life and exercise, walk- ing, riding, cycling if not too violent, and mountain-climbing, all con- tribute to improve the general health and strengthen the heart at the same time. Cold bathing is one of the best measures for the same purpose, either at home or at the seaside. The same principles of treatment apply to intermittent heart and arrhythmia. When these are the result of organic cardiac disease, their treat- ment is that of the disease. In the treatment of the simple slow pulse any cause of pneumogastric irritation should be sought for and removed, such as dyspeptic states, torpor of the liver, poisoning with retained bile salts, and the like. In the absence, however, of certain knowledge of the presence of such cause, the condition is best left alone, as treatment under such circumstances may do more harm than good. ANGINA PECTORIS, OR STENOCARDIA. Definition. — An affection of the heart characterized by intense par- oxysmal pain, at first usually substernal, extending thence down the arms^ especially the left, and up into the neck. It is a symptom rather than a dis- ease, as it is commonly associated with some recognizable organic change in the heart or great vessels, though not always the same change. Often, how- ever, such change cannot be found, and it may be that in rare instances it is a purely functional state. Etiology. — The immediate cause of angina pectoris is deficient cardiac nutrition, however induced. It may be on account of obstructive disease of the coronary arteries, aortic stenosis or insufficiency, pressure by a tumor or other cause, dilatation or enlargement of the heart beyond the capacity of the coronary arteries to nourish, or any cause which produces cardiac ischemia. Adhesive pericarditis may act in this way. It may be that the excessive use of tobacco, which has been accredited with the direct effect of causing angina, may operate in this way. The exciting cause of the attack is usually some ANGIXA PECTORIS, OR STEXOCARDIA. 621 overexertion or mental emotion calling for some additional effort from an already crippled ischemic heart. These events after a meal are more apt to produce this effect because a full stomach encroaches on the heart. Thus, the taking of food alone, even in moderate amount, may excite an attack. Still more, excessive eating and indigestion, however caused, become excit- ing causes. It must be admitted that all explanations of the pain are purely specu- lative, for though total obstruction of the coronary arteries experimentally produced is followed by death, pain has not been found an associated symp- tom. On the other hand, the pain which succeeds the obstruction of an artery, leading to gangrene of a part, as the leg, is precisely analogous to the anginose pain which succeeds obstruction of the coronary arteries, while the results of experimental closure of these arteries have their parallel in recog- nized cases of angina sine dolorc. Again, neuralgic pain of the ordinary kind occurs in a nerve which is badly nourished. ]May one not explain the pain of angina in the same way, since a defective nutrition is the one acknowl- edged condition of angina? ^Mention should be made of the view recently announced by Clifford Allbutt* that the agonizing pain and dread char- acteristic of angina pectoris may be produced by an acute aortitis. Angina pectoris is a disease of adults, and of men rather than women, and though it may happen in early life, 80 per cent, of all cases occur after the fortieth year. Morbid Anatomy. — Atheroma of the coronary arteries is the most con- stant anatomical change found associated with angina pectoris. It is well known, also, that obstruction of these arteries experimentally produced results fatally, though such death is not attended by the pain of angina. On the other hand, many cases of advanced sclerosis of the coronary arteries occur without angina. In these it must be concluded that the nutrition of the heart has not seriously suffered. The other associated conditions named in con- sidering the etiology must also be regarded as a part of the morbid anatomy. A fair estimate of the frequency of such associations may be obtained from W. H. Walshe's statement that in every one of twenty-four cases he exam- ined during life distinct signs of changes in the heart, the aorta, or in both coexisted; The testimony of G. W. Balfour and P. W. Latham is similar. Acute aortitis has been found. (See Clifford Allbutt's paper previously mentioned.) Symptoms. — The cardinal symptom is agonizing pain — pain beginning beneath the sternum in the region of the heart, extending up into the neck, sometimes the jaws, and down the arms, especially the left, following the dis- tribution of the ulnar nerve. Associated with this are shortness of breath, precordial oppression, and a sense of impending dissolution. The pulse is often strikingly natural, though it is also at times unnaturally small, frequent, and irregular. The pain is often associated with a numbness or tingling in the fingers or over the cardiac region. There are usually extreme pallor and an agony of expression which are not soon forgotten. The skin is pale or ashen gray, and often the perspiration stands out in huge beads. This ashen- gray color of the skin is not confined to the period of the paroxysm. It is. in my experience, quite a characteristic symptom, and when associated with atheromatous arteries, is of diagnostic value. The duration of the paroxysm varies from a few seconds to a half hour. At the end of this time, or earlier, *"Ang-ina Pectoris," by Clifford Allbutt, M. D., "Philadelphia :Med. Jour.." vol. v., June 30, :i89o, p. 1464. 622 DISEASES OF HEART AXD BLOOD-J'ESSELS. the patient either passes out of the attack or dies in it. The paroxysms occur at widely different intervals, sometimes once in a few months, sometimes oftener, and sometimes at intervals of a year or more. Xeither are they always so painful as described, and it is more than likely that the slighter attacks of cardiac pain associated with aortic stenosis and sometimes with aneurysm are of the same nature. Diagnosis. — The only condition with which true angina pectoris is liable to be confounded is the hysterical form known as psciido-aiigiiia. It is not often, however, that practical difficulty occurs in separating the two condi- tions. The hysterical form is more common in younger women, in nervous and hysterical persons, than the true form, and is associated with other ner- vous symptoms. In all instances careful examination should be made of the vascular system with a view to detecting alterations in it, such as arterial sclerosis and enlargement of the heart. These will generally be found in some one of their modes of manifestation in true angina. In false angina, as in other manifestations of hysteria, there is something indescribable which will guide the experienced physician aright. In cases of doubt the patient should have the benefit of it. Intercostal neuralgia in the neighborhood of the heart resembles the pain of angina somewhat. It is, however, more circumscribed. It does not radiate into the neck and arms, and the heart and blood-vessels are normal. The pain is not so severe, and the anxious expression of the face is wanting. The Adams-Stokes Syndrome may be here alluded to. It is a condition allied to true angina which may or may not, however, be associated with it. It was first described. by Robert Adams of Dublin in 1827* and later more fully by Stokes in i846.t The syndrome consists of vertigo with repeated apoplectic or syncopal seizures with unconsciousness, usually preceded for a few days by hebetude and a loss of memory; slow pulse — permanently slow, but slower at the time of the attacks. These were the symptoms in Adams' case. Stokes suggested the name false or pseudo-apoplexy, laid stress on the syncopal character of the attacks, their frequency, the absence of paralysis, and the good effect of a stimulating rather than a depleting plan of treatment. Both Adams and Stokes' patients were sixty-eight years of age. There is myocardial change, fatty or fibroid, and the visible arteries, espe- cially the radials and temporals, are sclerotic. Slowness of heart-rate and vertigo are distinctive symptoms. The former may fall to 40. 30, 20, or even 10 and 5. The slowness must be of the heart's action and not of the pulse. The latter may be only 20, while the heart-rate may be 40, because the intermediate pulse does not reach the radial, producing in sphymogram the so-called bigeminal pulse. Prognosis. — True angina is a very grave condition because, although fully three-fourths of all persons attacked recover from the first paroxysm, sooner or later a fatal ending may be expected, and no one knows what attack is going to be the last. In some instances paroxysms recur at inten-als of considerable length throughout a lifetime, while in others the first proves fatal. G. W. Balfour mentions the case of an old gentleman who had a final fatal attack after an interval of ten years, in which he had enjoyed excellent health. ]\Iany instnces of death in the first paroxysms are reported. * "Dublin Hospital Reports," vol. iv.. 1827. + " Observations on Some Cases of Permanently Slow Pulse." "Dublin Quarterly Jour- nal," 1846. ANGINA PECTORIS, OR STENOCARDIA. 623 Treatment. — Treatment naturally resolves itself into that of the par- oxysm and that for prevention or cure. For the first, morphin is the most efficient remedy, and if at hand, should be used hypodermically in not less than 1-4-grain (0.016 gm.) doses for an adult, combined with atropin. Nitrite of amyl has come to be an acknowledged remedy, first suggested by Lauder Brunton. A few drops may be placed upon a handkerchief or on cotton and inhaled, or, more conveniently, pearls of glass filled with the nitrite are crushed in a handkerchief. The pearls recommend themselves further because they can be conveniently carried, and it is desirable that per- sons subject to angina pectoris should always have the drug at hand. Chloro- form may also be used instead of nitrite of amyl, if more convenient. Nitro- glycerin is used for the same purpose in doses of i- 100 to 1-50 grain (0.00065 to 0.0013 gm.) at short intervals, say 15 minutes. Counterirritation should be simultaneously applied. The ordinary mustard plaster is a most convenient and efficient measure for the purpose. Prophylaxis is exceedingly important, and is best accomplished by avoid- ing the exciting causes commonly responsible for the paroxysms — overexer- tion, overeating, and mental excitement. The patient subject to angina should never hurry or get into a passion or become excited in any way. The use of all indigestible articles of food should be carefully avoided. Nitro- glycerin is sometimes efficient as a prophylactic as well as for the paroxysm in the same doses once in four hours or oftener. The alcoholic solution, of such strength that one minim represents i-ioo grain (0.0006 gm.), is the best preparation. Nitrite of sodium may be used in from three to five-grain (0.1944 to 0.32 gm.) doses. Other remedies recommended with a view to averting the attack are arsenic, nitrate of silver, the bromids, and especially iodid of potassium, the long-continued use of full doses of which has appar- ently sufficed to prevent the recurrence of attacks previously present. Its efifect in this disease is comparable to that produced by it in aneurysm. As heart tonics, arsenic and strychnin in doses of 1-50 to 1-25 grain (0.0012 to 0.024 gm.) should be given. While sudden exertion and overexertion are to be avoided, carefully graduated exercise is to be recommended, for like all organs, the heart is strengthened and invigorated by exercise properly regu- lated. When moderate exertion, if borne at all, brings on an attack, even this should be avoided. Could we correct the faulty nutrition of the heart we could hope for a cure, and though this may be impossible, we may do that which promotes it. Angina pectoris is one of the conditions in which the Nauheim hot bath may be expected to be beneficial. So it might, so far as the hot baths are used, but the cold bath in any form is harmful. Iodid of potassium should be used with the same end in view as in arteriosclerosis. The treatment of hysterical or pseudo-angina is that of hysteria under other circumstances. 624 DISEASES OF HEART AXD BLOOD-VESSELS DISEASES OF THE BLOOD-VESSELS. ARTERIOSCLEROSIS. Syxoxyms. — Endarteritis chronica deformans: Atheroma of the Blood- vessels; Artcriocapillary Fibrosis. Definition. — A disease chiefly of arteries, consisting of inflammation first of the intinia, but extending also to the media and adventitia. Etiology. — There is a tendency to atheronia in the arteries of the old, as an evolution process quite independent of exciting causes. This tendency also varies greatly in different families, being very strong in some and absent in others. 'Men are decidedly more liable than women. There are, how- ever, many exciting causes, among which are overeating and drinking, with consequent accumulation of irritating matters in the blood, syphilis, the gouty poison, and lead. Chronic Bright"s disease is especially frequently suc- ceeded by it ; more rarely acute articular rheumatism.. In the latter the rheu- matic poison is probably the responsible agent; and in Bright's disease it may be retained excrementitious matter. Two classes of cases may, however, be associated with Bright's disease, in one of which the arteriosclerosis is general and primary, causing interstitial nephritis, and in the other it is secondary, the result of the Bright's disease. One set of observers regard all cases of interstitial nephritis as secondary. Among these the late Sir William Gull and Henry D. Sutton, of England, and Arthur \'. ^leigs, of Philadelphia, have been conspicuous by their v.-ritings. Still another cause of arteriosclerosis is increased arterial tension due to prolonged muscular exertion. Morbid Anatomy, — The aorta is the most frequent and conspicuous seat of the changes ascribed to chronic endarteritis, but the carotids, sub- clavians, brachials, radials, and ulnars, the iliacs, femorals, and especially the arteries of the brain and coronary arteries of the heart, are frequentl> involved. The arteries to viscera, like the stomach and liver, are rarely affected, while the pulmonary arteries take an intermediate place. On the other hand, the latter are sometimes invaded to the exclusion of the aorta. Whatever invites high tension in the lesser circulation tends to produce sclerosis in these vessels. The portal vein may also be invaded. The super- ficial arteries thus affected are easily recognized. They are tortuous, stand out conspicuously, and feel hard to the finger, under which they may be made to roll. These features are often recognizable in the temporals and less plainly in the radials. The smaller arteries and veins with transparent walls, especially in the brain, exhibit to the naked eye white patches which are the seat of the atheroma. On slitting them open, the inner surface of these and other arteries will be found to have lost its natural smoothness, to be rough and uneven, while the lumen is more or less encroached upon. ^Minutely examined, the appearances vary with the stage. The first stage is that of cellular infiltration, represented by the translucent yellowish areas of intima thickened to three or four times its natural thickness. Later these young cells are in part converted into connective tissue, causing the primary hardness of the vessel-walls. In the second stage the cells of the connective tissue and the surface cells of the intima undergo fatty degenera- tion, and the intercellular substance liquefies. In the third stage, which is ARTERIOSCLEROSIS. 625 not reached in the smaller arteries, or, indeed, usually in those below the aorta, there occurs a further liquefaction with the formation of the so-called athero- matous abscess, whose contents are not pus, but the well-known atherom- pulp, representing the debris of fattily degenerated cells, including fat drops and cholesterin crystals. Alongside of the atheromatous patches appear also plates or scales of calcareous infiltration of the intima, produced by a deposit of lime salts in the intercellular substance of the deeper layers. The athero- matous abscess sometimes undermines the intima, forming sinuous cavities, and after evacuation there results the atheromatous ulcer. Both the limy ^ plates and ulcers furnish inequalities which favor thrombosis. In the later stages of the more diffuse form of arteriosclerosis, especially studied by Coun- cilman, the media or muscular coat and the adventitia are also invaded, the former mainly by atrophic changes, alongside of which, at times, is a homo- geneous hyaline infiltration. In this form the capillary walls are also thick- ened, especially those of the glomeruli of the kidneys, in some of which the vessels become obliterated. A calcareous infiltration of the muscular coat without previous inflam- mation may be found in old age in arteries like the radial, crural, and tem- poral. Still another primary degeneration is the fatty erosin of Virchow, extending through the intima and media as a transverse fissure thought to be the starting-point at times of dissecting aneurysm. The effect of these changes is to produce rigidity and narrowing of the vessel, a loss of the propulsive power residing in the elastic coat, a slowing of the current, and increased intravascular pressure. These events tax the compensating power of the left ventricle, which therefore hypertrophies. This hypertrophy keeps up so long as its nutrition is maintained. But another effect of obstructed circulation is defective local nutrition, some of the consequences of which have already been considered in the study of the fibroid heart. Similar interstitial overgrowth and contraction may be met in the kidney and have been referred to. Localized softening of the brain also succeeds upon atheroma, though this event is usually preceded by throm- botic obstruction favored by the sclerosis. A more frequent accident to the brain is rupture of one of these atheromatous vessels, succeeded by the symp- toms of apoplexy and hemiplegia. Such rupture may be preceded by an aneurysmal dilatation. Finally, aneurysm of the larger vessels has for its almost indispensable condition, except in traumatic cases, atheroma of the dilated vessel. Both events — the primary atheroma and the subsequent dila- tation — are favored by the increased intravascular pressure. Symptoms. — Superficial vessels in a state of atheroma are easily de- . tected by their dilated, tortuous, pulsating appearance in the temples, while in other situations, as at the wrist, antebrachial and popliteal spaces, they may be recognized more or less by the touch. Distinction should be made between simple increase of tension and thickening of vessel-walls, though the two are constantly associated. The vessel in both instances is hard and requires some force to compress it, and between beats it is still full and can be rolled under the finger, but the artery with the thickened wall, if firmly enough compressed to obliterate the blood current, can still be felt beyond the seat of compression. In many instances, on the other hand, the changes escape detection until a fatal apoplexy gives notice of their presence. In most of these cases, however, if attention had been directed to the patient, the previously described condition of the arteries would probably have been recognized, while a certain degree of hypertrophy of the left ventricle would also, perhaps, have been detected. It 40 626 DISEASES OF HEART AND BLOOD-VESSELS. does not follow, however, that the absence of atheroma in one place implies its absence in another, since fatal rupture of an artery in the brain has occurred when there has been no sign cd sclerosis in the radials. Prolonged h3'per- trophy and the increased tension incident to it may produce atheroma, or the two may be the result of the same cause — as, for example, contracted kidney. Cardiac hypertrophy is not always demonstrable to percussion, as the enlarged heart may be covered by an emphysematous lung, also often present in the aged, in whom atheroma is most prone to occur. On the other hand, the usual sharp accentuation of the a(irtic second sound is present if the hyper- trophy has not given way to dilatation or fibroid induration. Cardiac mur- murs do not occur unless the atheroma invades the valves to produce insuffi- ciency, stenosis, or roughening of the aortic orifice or aotta near the orifice. This is not so very rare in old persons, apart from the relative insufficiency due to aortic dilatation. For the reasons mentioned, the pulse is prolonged, hard, and tense, — the pulsus tardus, — while its sphygmogram is very characteristic : a slow, oblique ascent, a broad top ; a slow descent and absence of the dicrotic rise, which in the normal state depends on an elasticity absent in the diseased vessel. Owing to the same slow transmission of the pulse-wave the pulse is some- Fig. 60. — Sphygmogram of an Atheromatous Vessel — The Pulsus Tardus. times retarded at the wrist, while the rate is also slow. At other times it is frequent and irregular, especially toward the end of life when the heart begins to fail. The arcus senilis is often an associate of arteriosclerosis, and strongly confirmatory of its presence. One of the most annoying consequences of atheroma of the blood-vessels of the brain is dizziness or vertigo,. and this symptom, when present in the aged, is very apt to be caused by it. The consequences of atheroma of vessels of the lower extremities include muscidar zveakness, stiffness, and a tottering gait. In extreme cases gan- grene of the lower extremities may result from obstruction to their arteries due to thrombosis' invited by the atheroma. Such termination is not very rare in contracted kidney. With the supervention hi cardiac dilatation and heart failure there appear paralysis, precordial oppression on slight exertion, dyspnea, edema, pulmonary congestion, scanty urine, aggravated vertigo, angina pectoris — in a word, all the symptoms of chronic heart disease. Finally, other symptoms are those of the morbid states it causes — /. e., apoplexy, contracted or senile kidney, atheroma of the coronary artery and its consequences. Treatment.— Treatment is mainly the removal of conditions causing it, such as too free living, gout, lead poisoning, and syphilis ; together with rest and quiet, the avoidance of ^excitement, also the free use of diluent drinks and aperients to lower the arterial tension, a slight increase of which is often the last straw required to produce an apoplexy. The iodid of potassium is highly recommended by G. W. Balfour as a vascular stimulant in the sense that it promotes the flow of blood through the vessels and lowers the blood ANEURYSM. 627 pressure. As such, it ought to be useful in arterial sclerosis and probably is. Moderate doses should be continued a long time. In conjunction with this the usual cardiac tonics should be employed with a view to promoting a proper circulation of the blood. ANEURYSM. !' Definition. — An aneurysm is a more or less circumscribed dilatation of a blood-vessel. Aneurysm is known as true or false. A true aneurysm is one in which, at the outset, all three coats of the blood-vessel share in the dilata- tion, though one or two may disappear later in the course of its growth. A false aneurysm, on the other hand, starts at the outset with a laceration of one of the coats. 1. True aneurysm may be saccular, fusiform or spindle-shaped, cylin- drical and cirsoid. The " cirsoid " or varicose aneurysm is one in which a blood-vessel — one of medium size — and its branches are irregularly dilated and contorted like a varicose vein, whence the name " variax," a dilated vein. The " invaginating " aneurysm is a rare form of cylindrical aneurysm, in which the cylindrical sac overlaps at either or both ends the main trunk of the artery involved. Saccular and fusiform aneurysms are for the most part fre- quent. The " neck " of an aneurysm is a constricted portion by which a sac- cular aneurysm is attached to the main trunk. 2. False aneurysm includes two varieties, traumatic and dissecting. (a) Traumatic aneurysm. In traumatic aneurysm the initial event is some injury from without to one or more of the coats of the vessels, as the result of which the resistance to intravascular pressure is diminished and a protrusion of the intima through the yielding media takes place, the latter being the most passive of all the coats. The simplest illustration of this form of aneurysm is the antebrachial aneurysm caused by accidental wounding of the brachial artery in venesection of the median vein. The blood pushes out the intima and antebrachial fascia and forms a sac communicating with the artery through the wound. A second form is the aneurysmal varix or anastomotic aneurysm, in which the blood from the wounded artery passes directly into the adjacent vein through the wound made at the same time, causing a dilatation of the vein. This is resisted by the valves, which, however, give way to the extent of two, three, and even more pairs before the current is successfully resisted. (b) Dissecting aneurysm. This involves the aorta, in which, in conse- quence of a perforation through the intima and media, the blood dissects between them and the adventitia. The initial slit is found most frequently in the inner and posterior portion, about one inch (2.5 cm.) above the semi- lunar valves. The blood may dissect from this point around the arch of the aorta, even as low as the diaphragm, before it returns to the lumen of the vessel. Even the visceral pericardium has been thus separated by an aneurysm which projects into the pericardium, rupturing finally into the peri- cardial sac. Etiology. — The aneurysm most frequently encountered by the physi- cian is the saccular and fusiform form. Its most frequent essential cause is endarteritis and its consequences, including the more acute stage of cellular infiltration, as well as atheroma. The coats thus weakened yield to the intravascular pressure. The intima is capable of a considerable degree of expansion without rupture, while the media is entirely passive 628 DISEASES OF HEART AND BLOOD-VESSELS. and yields very soon to the distending force. The adventitia alone seeks to guard the sac against rupture by reactive overgrowth. The causes of endarteritis, already discussed, such as syphilis, alcohol, and other toxic substances variously introduced into the blood, are responsible for the more usual forms of arteriosclerosis which furnish the initial lesion of aneurysm. But weakening of the coats is caused also in the smaller vessels by emboli, after the lodgment of which the proximal part of the vessel often becomes dilated. Such embolus may excite an endarteritis, or may occasion direct violence to the vessel-walls if it be hard or sharp, as is often the case with a fragment of a calcified valve. Muscular compression exerted by muscles in certain situations may also produce it. Such may be the origin of pop- liteal aneurysms so frequent in footmen, who maintain a rigidly erect posi- tion. Finally, disturbances of innervation are considered capable of causing dilatation, and to such influence are ascribed the varicose aneurysms of the arteries of the scalp, of the temporal, and of the popliteal. Aneurysm of the Thoracic Aorta. ThoracicT aneurysm occurs in the arch of the aorta, in its ascending transverse and descending portions, and in the .thoracic aorta below the arch. Such aneurysm may but slightly exceed the normal caliber of the vessel, or it may be six inches (12 cm.) or more in diameter. The greater frequency of aneurysm in the male sex and during early middle life is recognized. To the pre-existing conditions of atheroma there may be added the effect of extreme exertion in lifting, or muscular strain of any kind, the effect of which is always to increase intravascular pressure. Partly because they are points of least resistance, and partly because they are in the line of successive impingement of the whirling blood stream, there are certain points of selection in the aorta which are quite constantly seats for beginning aneurysm. These are shown in the appended illustra- tion. The first point (i) of election is the beginning of the aorta directly behind the trunk of the pulmonary artery. Aneurysm originating there may produce early hypertrophy of the right ventricle because of the resist- ance to the outward flow of the blood through this vessel, a basic murmur in the pulmonary area, relative insufficiency of the tricuspid valve and venous pulse, with a possible ultimate perforation into the pericardium or pulmonary artery. The second point (2) is the favorite seat of aneurysm of the ascend- ing limb of the arch, behind^the sternum, at the manubrio-gladiolar junc- tion, at which place it often bores its way through the sternum as a saccu- lated aneurysm, which may finally burst through the external integument. The third seat (3) is at the convexity of the arch toward the apex of the right lung. The pleural cavity at this point is soon obliterated by adhesive inflammation, through which the aneurysm bores its way, rupturing into the bronchioles of the apex of the lung, producing fatal hemoptysis. The fourth (4) is between the innominate and left carotid at the apex of the arch behind the trachea. It may perforate into the trachea before attaining very large size. The fifth position (5) is posterior in the descending limb of the arch, between the left subclavian and the isthmus of the aorta to the left of the vertebral column. The aneurysm here is more commonly a cylindrical dilatation. It may also rupture into the larynx. The remaining aneurysms of the aorta all point more or less toward the vertebrae, but the greater resist- ANEURYSM. 629 ance to their formation in that direction favors lateral development. Ulti- mately they rupture, with hemorrhage into the pleural or abdominal cavity. As much as seven pounds (3.17 kilos.) of blood have been found in the pleural cavity after a fatal hemorrhage. Aneurysms of the thoracic aorta lying close upon the diaphragm may bore their way between the trunk mus- cles behind, attaining often large size without perforation. Symptoms of Thoracic Aneurysm. — Apart from the physical signs, the most important of the symptoms due to thoracic aneurysm are the result of pressure of the growing aneurysm, hence they are called pressure symptoms. The first of these is pain, which may be sharp and acute when nerves are directly involved, or dull and boring when the result of pressure on bone. In the latter case, too, it is localized; in the former it may extend all over Fig. 61. — Showing Sites of Election for Aneurysms in the Aorta — {after Rindfieisch). a, b. Line of impingement of the whirling blood current — the continuous line is sup- posed to be on the anterior surface of the aorta, the dotted line on the posterior. the chest and down the arms, simulating angina pectoris. It may be uni- lateral. It may occur in aneurysm of any part of the arch, but is more frequent in that of the ascending limb. Shortness of breath, especially on exertion, is a frequent S3'mptom. It may be due to pressure of the aneurysm on the trachea, or on a bronchus, especially the left. Dyspnea may be increased on changing position. Dysphagia from pressure of the tumor on the esophagus is a frequent symptom, especially in aneurysm of the descending aorta, anywhere in the thorax. Such pressure may be strikingly demonstrated by Schnell's* method of introducing into the esophagus a stomach-tube, of which the lower end is closed, attaching to the outer end a glass tube, and filling the * " Miinch. med. Woch.," xxxvi., " Der Diagnose des Aneurysma der Aorta descendens." 630 DISEASES OF HEART AND BLOOD-VESSELS. whole with water, and watching the rise and fall of the water in the glass tube, corresponding to the pulsation. Cough and alicrations in the voice are important symptoms. The latter include hoarseness, aphonia, and stridor. Some of these symptoms may be produced by direct pressure on the trachea itself, others by pressure upon the left recurrent laryngeal nerve. A stridulous voice, unaccompanied by dysphagia or aphonia, was early pointed out by Thomas Jolliffe Tufnell as indicating that the pressure is on the right side of the trachea and does not affect the esophagus or recurrent laryngeal nerve. Cough may be caused by tracheal pressure or by a resulting tracheo-bronchitis with copious thin or mucous expectoration, sometimes bloody. It is often brassy in character. On the other hand, hoarseness, aphonia and various degrees of paralysis of the vocal cord are due to paralysis of the recurrent laryngeal nerve, com- monly the left, which passes around the arch of the aorta and is, therefore, more likely to be involved than the right. The paralytic phenomena may be present without other laryngeal symptoms, hence any alteration of voice in a person exhibiting palpitation or dyspnea calls for a laryngoscopic exami- nation. When paralysis is total, such examination may show little alteration in the position of the vocal cords in ordinary breathing, or the left may be a little nearer the median line. On deep inspiration the right vocal cord is well abducted, the left remaining quiescent in the so-called cadaveric po- sition, midway between that of inspiration and phonation. The attempt at pJwjiation is more or less abortive. During it, the right vocal cord may go to the median line, leaving a small opening between it and the motion- less left cord, or it may even cross the line to its paralyzed neighbor. Partial recurrent paralysis results if only the twigs distributed to the abductor muscle — /. e., the posterior crico-thyroid — are involved in the pressure. There ensues gradually a permanent shortening or " paralytic contracture " of the antagonistic orfductors of the same side, and the affected cord is drawn by this into a position of constant phonation — that is, to the median line. The result is that the voice may be entirely natural, the paralyzed cord being in the position of adduction, while its tension is mainly regulated by the external branch of the superior laryngeal nerve, which is uninfluenced in aortic aneurysm.* In these cases quiet breathing is also unimpeded. These phenomena imply, of course, a destructive lesion, a wasting of the nerve, the result of pressure, which may be preceded by a primary neuritis. Such neuritis and resulting irritation of the entire pneumogastric may ac- count for certain attacks of extreme dyspnea sometimes experienced by sub- jects of aortic aneurysm. Associated with the neural degeneration is also found atrophy of the left abductor muscle, the crico-arytenoid, while the adductors remain nearly intact. Constant dyspnea is more likely to be due to direct compression of the trachea. Other nerves may also be compressed, especially the intercostal, vagus, and sympathetic. By compression of the intercostal nerves, pain may be caused : of the vagus, vomiting : and of the sympathetic, inequality of the pupils and unilateral sweating. I remember well a very stubborn case of intercostal neuralgia in my own practice which turned out to be caused by aneurysm of the descending aorta, confirmed by autopsy. * For the muscles involved see Diseases of the Larynx. ANEURYSM. 631 Then, there is the tracheal tugging of aneurysm first described by Sur- geon-Major OHver, and further studied by Ross and McDonnell, in Canada.* It is generally indorsed by English clinicians as a valuable sign. Recently Frankel, from the German side, confirms the importance of this symptom. f This is a dragging downward of the larynx with each systole of the heart. In Ewart's method the patient sits with his mouth closed, his head well bent backward, steadied against the chest of the examiner, standing behind him. The trachea is drawn up gently by inserting the ends of the fingers under the edge of the cricoid cartilage, when with each impulse the larynx is felt to be pulled downward. Oliver directs, with the patient in the upright position, the mouth closed, and chin elevated, grasping the cricoid cartilage between the fingers and the thuriib and pressing it steadily upward, when, if aneurysm exists, the pulsation of the aorta will be distinctly felt. It is said that it may be the sole sign of aneurysm, and a sign, also, that the position of the aneurysm is such as to involve the posterior aspect of the arch — 4 in Fig. 61. It should be a distinct tug downward, as light degrees of tracheal tugging are found in healthy persons. Cardarelli's sign of lateral movement of the larynx is similar, with an obvious difference. It is said never to be present in aneurysm of the innominate. J. N. Hall called attention | to a sign of aneurysm not previously de- scribed, which he calls tracheal shock, consisting in a distinct sharp impulse, diastolic in time, transmitted through the aneurysm to the trachea just after the tracheal tug, when the latter is present. Alteration in the pulse in distal arteries is also a sign of considerable diagnostic value. It is chiefly when the aneurysm involves the origin of blood-vessels leading to those arteries, as the innominate on the right and the carotid or subclavian on the left. If the right radial pulse is enfeebled or delayed, the aneurysm will be on the right, involving the origin of the innominate ; if the left radial is influenced, the aneurysm is probably in the neighborhood of the left subclavian. Great care should be taken in the examination, and it should be made from the center to the periphery — that is, the carotids, the subclavians, the brachials, and the radials should be suc- cessively examined, as recommended by Sansom. These effects are variously produced. Thus, the aneurysm may narrow or distort the orifice of the blood-vessel by traction on it ; or there may be atheromatous change in the branch vessel analogous to that in the aorta itself, which may cause narrowing of the orifice, while the possibility of this, in the absence of aneurysm, is also to be remembered ; or the aneurysmal sac may act as the elastic air-chamber in a pump, diminishing thus the pulsatile force in the vessel and branches beyond. It is particularly in the arteries of the lower extremities, by aneurysm of the descending thoracic and abdominal aorta, that this air-chamber effect is seen, and the pulse, even in the abdominal aorta and its branches, has been thus obliterated by a large thoracic aneu- rysm. Capillary pulse is occasionally present, and is probably favored by the recoil of the blood into the aneurysmal sac. Pressure of the aneurysm on a bronchus may lead to retention of secre- tion and fetid bronchitis and bronchiectasis, and favor the inoculation of tubercular phthisis, thus accounting for the frequent association of tubercu- losis of the lungs and aneurysm. ^ * " London Lancet," i8qi. t " Centralbl. f. innere'Med.," August 5, iSqq. $ " Amer. Jour, of the Med. Sci.," January, 1901. 632 DISEASES OF HEART AND BLOOD-VESSELS. Spitting of blood is an occasional symptom, which may be the fore- runner of larger and more dangerous hemorrhage. Still rarer is pressure on the thoracic duct, causing emaciation. Though this symptom is more frequently due to mediastinal tumor. Physical Signs. — Inspection does not always discover changes, but if the sac grows outwardly, sooner or later a swelling makes its appearance, to the right of the sternum if in the ascending limb, possibly raising a rib or the end of the clavicle ; above and behind the sternum if in the transverse portion, raising the manubrium or boring its way through it; and to the left of the sternum if in the descending limb of the arch. As the tumor pro- trudes, the skin becomes smooth, shining, and tense over it, and may be- come gangrenous previous to rupture. Such a tumor may pulsate or not. The aneurysm is, as it were, a rudimental heart, dilating in all direc- tions with every jet of blood that is shot into it, and contracting on the with- drawal of the intravascular pressure so long as any elasticity remains. Should this property be lost, either as the result of calcification or the lining of the sac with successive layers of coagulum, such dilatation becomes impossible, and pulsation does not occur. The pulsation is, however, of great importance in the diagnosis. When present, it is synchronous with the systole of the ventricles. The heart itself is sometimes displaced down- ward, as seen from the lowering of the apex sometimes as low as the sixth interspace and outside the mammillary line. Less frequent is hypertrophy of the left ventricle, and when present, not so extreme as in aortic valve disease. If the aneurysmal tumor press upon the great veins of the neck, there may be venous engorgement and edema on one side of the neck or both, according as the innominate of one side only is compressed or the descend- ing cava itself. The aneurysm may rarely rupture into the descending cava, resulting in a form of varicose aneurysm, producing, in addition to the ordi- nary signs of aneurysm, sudden distention of the veins in the upper half of the body, edema of the face, hands, and arms, cyanosis, systolic venous pulse, and purring thrill. Palpation also appreciates the impulse of the aneurysm if it is visible, and sometimes when it is not visible. This beating is peculiar, being expan- sile, and differs thus from the rising of a tumor over a pulsating blood- vessel. Sometimes there is a double beat, the second and weaker being the usual recoil following closure of the aortic valves. A thrill is also often felt, a vibration in the walls of the sac caused by the whirl of the blood in it. It is by no means, however, invariable, and it may come and go. Very great tenderness is sometimes present over the seat of the protruding aneurysm. Palpation may also recognize the " diastolic shock," or recoil blow of the aneurysm on the closed aortic valve, if this be competent — to be again referred to. Percussion over the swelling of an aneurysm invariably elicits impaired resonance, varying greatly in degree and extent. On the other hand, the adjacent lung may be compressed, producing an area of dullness beyond the tumor itself. The dullness is usually in the right upper intercostal spaces, especially if the aneurysm is in the ascending limb of the arch. Aneurysms in the transverse portion produce dullness in the middle line under the manubrium and toward the left of the sternum, while aneurysms of the descending part may produce dullness in the left interscapular and scapular regions posteriorly. Sometimes the impairment of resonance ANEURYSM. 633 precedes the pulsation, though such dullness is of uncertain signifi- cance. Auscultation is no exception, as compared with the other modes of physical investigation, as to the inconstancy of its information, sometimes furnishing the most distinctive signs, while at other times it is totally negative. The murmur of bruit heard over an aneurysm varies. Sometimes but one murmur is produced — systolic, corresponding with the first sound over the ventricles, but more intense ; more rarely it is diastolic only. Not infre- quently there is a combined or double murmur, both systolic and diastolic, the first intense and prolonged, the second fainter and shorter. It varies greatly, being sometimes rough, sometimes soft, and sometimes musical. The murmur is not infrequently absent. The mechanism of these sounds is not settled. The systolic is most easily explained. There can be little doubt that it is produced by the inequalities which meet the entrance of the blood into the sac. When the aneurysm is at the beginning of the aorta, the diastolic murmur will probably be an aortic regurgitant murmur, due to relative insufficiency of the aortic valves. When the aneurysm is distant from the aortic orifice, the diastolic murmur may be due to the recoil of the distended sac, propelling the blood through the outlet with additional force, or the whirling of the blood through the sac. Rarely in these distant situations there is a diastolic murmur only, probably thus caused. A much more constant symptom is an accentuated aortic second sound, which is, in fact, rarely absent in aneurysm of the arch where the aortic valves are intact and which constitutes the so-called diastolic shock. It is an exaggeration of the second sound, recognizable by the ear and due to the elastic recoil of the aneurysmal sac. " It is the shock of the second sound that is heard and the recoil that is felt." It is not always present, and requires a sound aortic valve to produce it in its most marked degree. Sir Douglas Powell holds that it is best studied with the wooden stethoscope, and that the binaural fails to observe it. Ernest Sansom considers it best investigated by the ear direct, with only a slight intervening chest covering. It may be accompanied by or replaced by the diastolic murmur referred to. It is rarely, if ever, present with mediastinal growths, even when they perforate the sternum and produce pulsation. J. N. Hall * calls attention to what he names tracheal shock in aneurysm — a communication of the diastolic shock to the trachea. Occasionally a peculiar zvhiifiiig interruption of the breath-sounds may be heard bv the stethoscope or ear placed near the open mouth, due to the expansile pulsation of the aneurysm. Similarly caused is Dnimniond's sign, produced by having the patient take a full inspiration and allowing the air to pass out slowly through one nostril, the other being compressed by the finger, while the clinician listens with the stethoscope over the manu- brium. Perez's sign is a creaking sound heard when auscultating over the sternum when the patient raises and lowers the arm. It is caused by traction on adhesions, which may have formed in the anterior mediastinum in cases of aneurvsm of the first and second parts of the aorta. Glasgow's sign is a systolic thud audible by the stethoscope in the brachial or similar large artery like that heard in aortic regurgitation. S cheek's sign is a momentary' disappearance of the systolic murmur, accompanied by severe pain, pro- duced by pressing over the crural arteries of the two sides. It is an experi- ment not altogether without danger, as death occurred in one instance on^ * "Tracheal Diastolic Shock in the Diagnosis of Aortic Aneurj-sm," " Amer. Jour, of the Med. Sci.," vol. cxix., 1900, p. 10. 634 DISEASES OF HEART AND BLOOD-VESSELS. practicing it. Enlargement of the tumor mass may also arise by the pressure on the crurals.* But any one or all of these signs may be wanting. Particularly is this the case where the aneurysm occurs just after the aorta has left the heart. The most valuable is the pulsation distinct and separate from that of the heart, or, as grapliically put by Da Costa, " what is more essential is to find two points of pulsation in the chest — two hearts, apparently each with its own distinct beat, its own distinct sounds." f The X-ray has been brought to bear on the diagnosis of aneurysm, and commonly a distinct demonstration of the tumor can be made, both by the fluoroscope and skiagraphy, but it is scarcely available to the practicing physician, because of the costliness of the apparatus. Is it possible to determine the portion of the aorta involved by aneurysm ? Yes, with a certain degree of probability : In aneurysm of the Ascending Aorta there is more apt to be pain like that of angina pectoris, dyspnea, dullness to the right of the manubrium sterni from the second intercostal space upward, pulsation in the same region, displacement of the heart downward and to the left, delayed pulse in the peripheral arteries as contrasted with the heart's impulse, compression svmptoms involving the sympathetic and the area of the superior cava, pres- sure upon the pulmonary artery producing a pulmonic systolic murmur, with hypertrophy and dilatation of the right ventricle if the aneurysm com- press the pulmonary artery. Aneurysm of the Transverse Part of the Arch furnishes more par- ticularly pulsation in the fossa jiignlaris, dullness on percussion over the manubrium and to its left in the first intercostal space, with possible narrow- ing of the orifices of the innominate, the left carotid, or left subclavian, and resulting inequality of the pulse in the. head and arm, pressure on the left innominate vein, with resulting congestion and edema of the left half of the neck and head. It is when in this situation that aneurysm compresses the left recurrent laryngeal nerve and causes paralysis of the left vocal cord, presses on the trachea, with resulting stridor and cough, and on the left bronchus, producing inspiratory dyspnea. In aneurysm of the Descending Limb of the Arch of the x\orta J we look for the pulsation posteriorly to the left of the vertebral column opposite the angle of the scapula or below. The bruit is faint or absent. In the thoracic aorta below the arc, in consequence of the air-chamber effect, we may find smallness of the crural pulse as contrasted with the radial, and symptoms of pressure upon the left lower azygos or hemiazygos vein — i. e., edema of the upper part of the abdomen and pleuritic effusion: also pressure on the esophagus and left bronchus. The intercostal nerves may be compressed, producing intense pain in the course of their distribution, the vertebral column may also be eroded, the spinal canal opened, and the cord compressed, with resulting paraplegia. If the aneurysm project forward, which is rarely the case, it may press upon and displace the heart, causing palpitation, or it may also compress the esophagus, causing painful degluti- tion. It sometimes ulcerates and breaks into the esophagus. Obscure symp- * " Reitraar zur Casuistik und Symptomatologie des Aorten Aneurismen," " Berl. klin. Wochen- schr." XV 1878. t Da Costa, " Medical Diagnosis," eighth ed., 1835. P- 5o7- J The descending part of the arch of the aorta is somewhat arbitrarily terminated by anatomists at the lower end of the fifth dorsal vertebra, below which it is called the descending thoracic aorta, ■which terminates at the opening of the diaphragm in front of the last dorsal vertebra, below which it is the abdominal aorta. The symptoms of aneurysm of the descending part of the arch and the descending thoracic aorta do not'differ wideU-. ANEURYSM. 635 toms of this variety of aneurysm may exist for a long time before a tumor shows itself posteriorly between the shoulders, which is unmistakable at this late stage. Aneurysm of the Abdominal Aorta furnishes a pulsating tumor to the left of the vertebral column, to the left and above the umbilicus. The bifurcation of the aorta takes place on the fourth lumbar vertebra, which point corresponds to the umbilicus. Sometimes a thrill may be felt and a systolic murmur heard, rarely a double murmur. Here, too, the smallness of the crural pulses, as contrasted with the heart's impulse and the radial pulse, may be observed, while in some, cases the crural pulses disappear altogether. The symptoms vary somewhat, according as the aneurysm grows backward or toward the front. In the former case pain is also a striking symptom, and may be of two kinds, a fixed and constant pain in the back, caused by the pressure of the tumor on the solar plexus and splanchnic nerves, or a sharp lancinating pain radiating along the branches of the compressed lumbar nerves, whence pain in the loins, testes, hypo- gastrium, and in the lower limb, usually of the left side. If the sac grows anteriorly, gastro-intestinal symptoms may be present, such as vomiting, gastralgia, diarrhea, and even symptoms of obstruction. Paui is also present, but is more likely to be fixed in the loins, epigastrium, or some part of the abdomen. Erosion of the spine is much rarer in ab- dominal aneurysm than in thoracic. In emaciated persons the abdominal aorta sometimes pulsates so plainly that one is strongly reminded of aneurysm, and I have myself been misled by such pulsation, but under these circum- stances there is absence of the systolic murmur and of the alterations in the pulse of the arteries of the lower extremity, and none of the pain described. Indeed, evident abdominal, pulsation occurs far more frequently without aneurysm than with it. Aneurysm of the Branches of the Abdominal Aorta. — Of these, aneurysm of the celiac axis is most often mentioned and diagnosed, though not always confirmed by the necropsy. The symptoms may be said to be a pulsating epigastric tumor, associated with pain in the same neighborhood, and often vomiting. The pain and vomiting may precede the pulsation and tumor by some months. These aneurysms are sometimes traumatic, and have been referred to railroad accidents in which sudden and powerful com- pression has been exerted upon the abdomen. As intimated, their diagno- sis is not always easy. Two illustrative cases have come to my knowledge. In one, an aneurysm diagnosed as being of the celiac axis was at the autopsy proved to be in the abdominal aorta. In another case of supposed aneurysm the celiac axis was excluded, and the necropsy disclosed an aneurysm of that axis. Aneurysm of the Splenic Artery is sometimes met. Ten cases have been collected by Lebert out of thirty-nine involving various branches of the abdominal aorta. Osier reports, in his book, one in a patient aged thirty. The aneurysm was as large as a cocoanut, and was found at autopsy between the stomach above and the transverse colon below, and extended to the left as far as the level of the navel. The sac contained densely laminated fibrin and had perforated the colon. The symptoms were a deep-seated tumor in the left hypochondriac region, with fullness, which merged into that of the spleen. There was no pulsation, but a bruit was thought once to have been heard. The symotoms were vomiting, epigastric pain, occasional hemate- mesis, and, finallv, hemorrhage from the bowels. 636 DISEASES OF HEART AND BLOOD-VESSELS. Aneurysm of the Hepatic Artery is a rare lesion, some ten or twelve cases having been recorded. These aneurysms are not usually large, while the liver has been found greatly enlarged. Aneurysms of the Superior Mesenteric Artery have been found at necropsies. Aneurysms of the Renal Artery are more numerous. They are gen- erally small, but may terminate in rupture and retroperitoneal hemorrhage. Aneurysm of the Innominate is especially indicated by its murmur, thrill, and impulse in the vicinity of the inner end of the right clavicle, which is sometimes raised by the resulting tumor; also by the comparative absence of signs of pressure on the larynx or esophagus. The differences in the right radial pulse alluded to are especially present here. Compres- sion of the right subclavian and right carotid diminishes the force beat of the innominate aneurysm, but is without effect in aortic aneurysm. Nor are there percussion signs of enlargement of the aorta. If the Subclavian is involved, the signs are further outward, on the outer side of the sternocleidomastoid, while in aneurysm of the innominate they are found on the inner or tracheal side. To those named may be added pressure symptoms upon the subclavian vein, producing swelling of the arm and neck ; upon the right recurrent laryngeal, producing defective speech and dyspnea ; on the sympathetic, producing contraction of the pupil, and on the brachial plexus of nerves, pain. Especially would these signs point to aneurysm of the subclavian if the pulse of the carotids is unin- fluenced while the right or left radial pulse is influenced. The very rare .condition of aneurysm of the Pulmonary Artery may produce a swelling, with the other local symptoms described, to the left of the sternum, in the second interspace. A murmur is less constant and is not conducted into the vessels of the neck, while the superficial pressure signs are more conspicuous. There is lividity of the face, with dropsy, and the dyspnea is naturally very great. There is no cough or voice alter- tion. It is to be remembered, however, that the swelling of an aneurysm of the arch of the aorta may extend to the left of the sternum. Such an aneurysm may break into the pulmonary artery. An aneurysm of the Heart is not recognizable, though it may be sus- pected if there is bulging succeeding the signs of fibroid disease of the organ. Differential Diagnosis of Aneurysm of the Arch. — Further diagnosis distinguishes aneurysm of the aorta mainly from mediastinal tumors. There may be the same percussion signs, and there is often similar pain ; there is also pulsation, but instead of the expansile pulsation extending in all directions, there is in mediastinal tumor more upheaving. Percussion dull- ness is more irregular in mediastinal tumor. Murmurs are not usual in the latter. The ringing, or accentuated second sound — diastolic shock — which may be present in aneurysm when the aortic valves are intact, or substituted by the diastolic murmur when the valves are incompetent, is absent in mediastinal tumor. Tracheal tugging does not occur in medias- tinal tumor, nor do differences in the pulse or changes in the voice. The state of the blood-vessels usually associated with aneurysm must be ascer- tained. Fever is often present in mediastinal tumor ; very rarely in aneu- rysm. A differential diagnosis is often impossible, and experts have held opposite opinions on the same case. Should the patient develop a cachectic state and secondary glandular enlargements appear, presumption is in favor of mediastinal disease. ANEURYSM. 637 The resemblance of some of the symptoms of aneurysm of the ascend- ing aorta to some of those of aortic incompetency is very close. The same pulsating aorta, the same double basic murmur with impaired resonance at the right of the sternum, may be present. I have seen a case diagnosed as aortic regurgitation, with stenosis, in which the autopsy disclosed perfect semilunar valves with, however, aneurysm and relative insufficiency, which caused the diastolic murmur. In aneurysm there is less hypertrophy of the heart than in aortic valvular disease. The age of the patient, if tinder forty, especially the history of heart disease in early life, the history of rheumatism, and the absence of the causes of atheromatous vessels, point to valvular disease. Though there may be pulsation at the root of the neck in both, in aortic incompetency the same strong pulse-beat ex- tends to the wrists. Traube's double sound in the femorals and popliteals, though possibly otherwise caused, is still more frequently associated with aortic incompetency than any other lesion. Simple dilatation may, indeed, be present in aortic incompetency, but the pressure signs are wanting. A pulsating empyema on either side of the upper sternum sometimes closely resembles a pulsating aneurysm, and the illusion is more complete because the pulsation is expansile. I well remember a case of my own in which the pulsation to the left of the sternum was so like that of an aneurysm that I hesitated to use the exploring needle. Pulsating empyemas are generally further to the left of the sternum than aneurysmal pulsation. Other signs of aneurysm are also wanting, unless it be tenderness, which may be present. A rare condition is a narroiving of the aorta below the remains of the ductus arteriosus at the junction of the arch with the thoracic aorta, which produces small delayed pulse in the femorals, a thrill and murmur over the upper part of the sternum, but the extraordinary enlargement of the collateral vessels, especially the mammary and epigastric arteries, should set the question at rest. How shall the symptoms, which also so much resemble those of a laryngitis, be recognized as due to aneurysm instead of the latter affection in the absence of the physical signs of aneurysm ? In acute laryngitis we have often the cause — exposure to cold — to help tis, though in the chronic form we have not. In laryngitis there is usually m.ore huskiness and less stridor in the voice, nor is the cough so brassy, or the voice so uniformly changed ; it is more likely to alternate with normal voice. In aneurysm the voice grows progressively weak until aphonia re- sults. The dyspnea in aneurysm is more often attended with wheezing, and is sometimes relieved for a time by coughing. Stokes called attention to the fact that in aneurysm the stridor of the voice seem.s to come from the notch of the sternum, rather than from the larynx itself. In aneurysm the breathing sounds are more likely to differ in the two lungs. Then we have the laryngoscopic picture. There is no swelling of the cords in aneu- rysm, while there may be the paralytic phenomena detailed. Finally, in laryngitis there may be fever. Prognosis. — Aneurysm is not infrequently found at necropsy with- out having been suspected. In other cases the fatal termination is' the first notification of its presence. When an aneurysm of the aorta is so de- veloped as to exhibit its usual signs plainly, it is sooner or later fatal in some one of the modes already described. To foretell in which of the directions pointed out perforation will occur depends upon the accuracy v/ith which diagnosis of its position can be made, and such diagnosis is at 63S DISEASES OF HEART AND BLOOD-VESSELS. best a matter of probability. Only in cases in which aneurysm slowly erodes the anterior wall of the chest is there a gradual termination. Then there are sometimes repeated small hemorrhages, which gradually reduce the strength of the patient, who finally dies of exhaustion or of an ultimately fatal large hemorrhage. Perforation into the vena cava, pulmonary artery, and right side of the heart is a rare termination. The course of the disease may, however, be prolonged many months, and if treatment is instituted early, it may contribute to such prolongation.' When death does not occur from sudden hemorrhage, the symptoms may assume the type of chronic heart disease, for which, indeed, the condition is. sometimes mistaken bv. the untrained observer. With failing heart, come dyspnea, palpitation, dropsy, and death. Treatment. — W^e seek in the treatment of aneurysm to diminish intra- vascular pressure and restore the integrity of the vessel. The former mav be accomplished in a degree by placing the patient under conditions which will avert the causes of such increased intravascular pressure, which is constantly co-operating with the disease of the artery to produce further dilatation and ultimate rupture of the blood-vessel. This is, of course, best accomplished by absolute rest. It is plain the less frequently the heart beats and throws the weight of its blood against the weak blood-vessel, the longer will that blood-vessel last, while it is known to every student that the heart beats less frequently in the sitting than in the standing posture, and less in the recumbent than in the sitting position. On the other hand, it is evident that absolute rest is an impossibility. Yet it may be approximated in various degrees. It is Ir.ipossible also to restore the integrity of the vessel, but to this end also measures are suggested which have for their immediate pur- pose coagulation of the blood in the vessel and obliteration of the sac. That this sometimes occurs numerous autopsies also attest. The method which has met most favor is that now known as Tufnell's treatment, though Valsalva originally suggested a restricted diet and prac- ticed frequent venesections. Bellingham advised starvation without bleed- ing. It was, however, revived by the late T. Jolliffe Tufnell and modified by W. G. Balfour. Tufnell's treatment consists in absolute mental and physical rest in the recumbent position, together with a moderate dry diet. The object of this is to diminish the blood pressure and volume of blood, to increase the proportion of fibrin in the latter, and to promote its coagulation. The diet is as follows : For breakfast, two ounces of bread and butter and two ounces of milk ; for dinner, two or three ounces jof meat and three or four ounces of milk or claret ; for supper, two ounces of bread and two ounces of milk. Thus it is hoped to diminish the blood volume and reduce the pressure within the sac, to render the blood more fibrinous and to favor coagulation. The addition of iodid of potassium is Balfour's modification. The proper maximum dose is from five to twenty grains (0.33 to 1.3 gm.) three times a day. An additional effect of the iodid of potassium is the relief it affords to pain. To its efficacy in this direction I think I may add my testimony. It is supposed also to act by increasing secretions, thus thickening the blood. Dr. Balfour also claims that it lowers the blood pressure by promoting the flow of blood through the arterioles. It may be expected, also, that cases of syphilitic origin will be those especially benefited, but it is said that experience does not confirm such expectation. Occasional small bleedings are said to contribute to a favorable result. Evidences of improvement are reduction in the size of the tumor. AXEURYSM. 639 diminished force of pulsation, and relief of pain. It should be kept up for several months, or as long as the patient will submit to it. It is said to be useful more particularly in saccular aneurysm communicating- by a small orifice with the aorta. It is doubtful whether it is worth while to subject a patient with large aneurysm communicating with the aorta by a large orifice to the inconvenience of such a treatment, and whether it may not be better to advise him to live a life as quiet as possible and to await the inevitable, while we relieve symptoms as they arise, and remember especially that iodid of potassium is often one of the best remedies for pain. Small venesections — to the amount of a few ounces — are also recom- mended for the relief of pain in aneurysm. Acupuncture as a means of secur- ing coagulation and contraction of the clot was suggested by Velpeau. It consists in placing an iron wire or needle into the aneurysm with the hope that the bl'ood will coagulate on it. Filling the aneurysm with horsehair or fine zvire has been suggested for the same purpose. The wire is introduced through a hypodermic needle. Galvanopuncture, suggested by Loretta, fur- nishes perhaps the most satisfactory results. Two needles are introduced into the sac, and a mild current of electricity is passed through them. In this W'ay a combined electrolytic and mechanical effect is obtained. The intro- duction of astringent substances, as solution of acetate of lead or persulphate of iron, into the ar.eurysm may be mentioned only to be discouraged, since the danger of producing embolism far exceeds the chance of benefit. Liga- tion of the carotid or subclavian, or both, has also been done for aneurysm of the aorta with satisfactory results. It is, however, a formidable opera- tion. The latest method of inducing coagulation for the cure of aneurysm is by the subcutaneous injection of gelatin, suggested by Lancereaux."^' Two hundred and fifty cubic centimeters of a solution of two grams of gelatin in 100 grams of saline solution are injected under the skin of the thigh. This is renewed at varying intervals from every two to fifteen days. It has been claimed that, as a rule, ten, fifteen, or twenty injections produce complete cure. They act by increasing the coagulability of the blood. Recently, Pro- fessor Shoicesco of Bucharest reported f six cases treated in this way with good results in five cases. On the other hand. Osier treated ten cases at Johns Hopkins Hospital without a single cure. Xo other internal treatment for aneurysm other than that suggested — by iodid of potassium — has ever be^en of any use. As a part of the medicinal treatment of thoracic aneurysm it should be added that where there is violent action of the heart, cardiac sedatives are sometimes indicated to allay this, in addition, of course, to the enjoined rest. Among these sedatives we include aconite and veratrum viride in extreme cases, also cold to the seat of the swelling and to the cardiac region. The treatment of peripheral aneurysm, as of the popliteal and femoral, is usually relegated to the surgeon, who will treat it by ligation or compression. The injection of ergotin in the vicinity of the aneurysm, as suggested by Langenbeck, may be tried. From two to five grains (0.132 to 0.33 gm.) of the aqueous extract dissolved in water or glycerin are injected every two days. TufnelFs method is also applied to peripheral aneurysm, for which indeed, it was originally recommended. The treatment of peripheral aneurysm by compression has long been an * "The Lancet." October 22, i8or. + "Journal de Medicine Interne," July i, iSgg. 640 DISEASES OF HEART AND BLOOD-VESSELS. acknowledged method for the purpose, and though looked upon as a surgical procedure, is as medical as surgical. The method adopted which has been most successful is digital compression, which is exerted by relays of students or others available for the purpose. The effect is that in the course of forty- eight hours coagulation has taken place and the aneurysm is cured. Failing in these measures, ligation is practiced in case of the smaller arteries, but all details of this operation belong to the province of surgery. SECTION V. DISEASES OF THE BLOOD AND BLOOD-MAKING ORGANS. DISEASES OF THE BLOOD. THE MIXUTE STRUCTURE OF THE BLOOD. An accurate knowledge of the histology of the blood has become so important to an intelligent study of its diseases that a brief statement of its minute constitution seems justified. It is more especially since the practice of staining blood preparations has come into use that our present more inti- mate knowledge has been acquired. The red blood disc needed these aids least, but it is nevertheless a more interesting object thus studied. Thus, when stained with a solution of orange G, contained in the Ehrlich triple stain, it assumes a beautiful yellow or pale-orange color. By means of this stain the expert observer may even measure a diminution in the amount of hemoglobin, indicated by a diminished intensity of the central coloring. Only in high degrees of loss of hemoglobin do the edges of the cell become paler. Eosin solutions stain the red disc a brilliant red.* (See F in plate opposite p. 662.) The average number of red discs in a cubic millimeter in the male is 5,000,000, in the adult female 4,500,000 ; previous to menstruation, the number is somewhat larger. The blood plaques, though a constituent of normal blood, are not ren- dered visible by staining They are most readily demonstrated by placing a drop of fresh blood at the edge of a thin cover previously placed on the slide, whence the blood is drawn in by capillary attraction. The plaques may be recognized as dotted bodies of irregular outline Jialf the diameter of a red blood disc and often coherent. Fibrin is not stainable, but its delicate threads may be seen after a time in specimens prepared as previously directed. * The student is referred to works on diagnosis for technical methods, but it may not be amiss to add directions for making and using Ehrlich's triple stain. The formula is as follows : Saturated aqueous solution orange G, 120-135 c. c. Saturated aqueous solution acid fuchsin, 80-165 c. c. Saturated aqueous solution methyl-green, 125 c. c. Add— Water 300 c. c. Absolute alcohol, 200 c. c. Glycerin 100 c. c. Or the colors previously mixed, constituting the Ehrlich-Biondi or Ehrlich-Biondi-Heidenheim pow- der, may be used as follows : Ehrlich-Biondi powder, 1-70 Sm. Acid fuchsin o-o5 S^- Absolute alcohol, . 2.00 c. c. Distilled water 18.00 c. c. To Sfai'n.— After cleansing the finger thoroughly with soap and water and alcohol, it is pricked with a clean needle and a clean cover-slip touched to the blood as it flows from the puncture. Drop this cover-slip on another, draw the two apart and drv in the air. At any time within a few days fix by heating at 2^" F. (no" C.) for ten minutes, or bv p'lacing in absolute alcohol or alcohol and ether. Then place for four minutes in the Ehrlich tricolor mixture. Drv and mount. Better success in the differential staining is obtained, according to Henry F. Hewe's, if the specimen is washed after treatment with the Ehrlich tricolor mixture and treated for from one-half a second to ten seconds m Loffler's solution of methvlene-blue rsaturated alcoholic solution of methylene-blue 30 c.c, potas- sium hydrate— i : 10.000 solution— 100 c. CI. Wash, dry, and mount in balsam. The second alkalme basic stain is recommended because it completes the conditions necessary for acid, neutral and basic staining, the last being furnished imperfectly by Ehrlich's stain, which does furnish perfectly acid and neutral staining. 41 641 642 DISEASES OF THE BLOOD. It is the study of the colorless corpuscle which is most facihtated by the staining process. By it are differentiated first the different varieties of white cells. They include the following: 1. The Small Lymphocyte (C, plate opposite p. 662). — This consists of a greenish blue nucleus as stained by the acid fuchsin of Ehrlich's triple solution. It is about as large as a red disc, surrounded by a thin, slightly stained, scarcely visible or even invisible ring of protoplasm. The small lymphocyte is from 5 to 10 /^in diameter. 2. The Large Lymphocyte or Large Mononuclear Cell. — This presents the same characters as the small lymphocyte, but is larger and paler. Both nucleus and protoplasm have increased in size, but the former more than the latter. The protoplasm continues free of granules, as a rule, but fine and pale granules may be brought out by intense basic stain like methylene-blue. Between the small and large lymphocyte are intermediate forms. These cells have a common origin and represent different stages of development. It was formerly erroneously supposed that the large mononuclear cell arose from the spleen and the small one from the lymph glands. The large lymphocyte may have a diameter of 13 to 15 //. Both large and small cells sometimes show a disposition to division of the nucleus. 3. Transiiional Leukocytes. — These differ from the large mononuclear cells only in the fact that the nucleus is indented or horseshoe shaped, and are a still more mature cell than the large lymphocyte. Its protoplasm is like that of the large mononuclear leukocyte, but neutrophilic. The proto- plasm of the three varieties described is therefore quite similar. 4. P olymor phomuclear or Polynuclear Cells.— Thtst include three sub- divisions : (a) Polymorphonuclear Neutrophiles (B, plate opposite p. 662). — These are regarded as matured leukocytes. They make up the majority of the white cells of the blood and of pus. They are large, possessed of an irregular nucleus, often bent or twisted into fantastic shapes, which stain a green or greenish-blue in Ehrlich's tricolor fluid. Different parts of the nucleus are variously distinct, according to the distance of such parts from the surface, and thus the impression of a polynuclear cell is often produced, though a multiple nucleus is not present. Two or more nuclei are, however, sometimes found. The cell is further characterized by the presence within the nucleus and the protoplasm surrounding it of minute granules which stain well only in neutral solutions like Ehrlich's, whence the name neu- trophilic or £ granules. In this fluid they stain violet or purple. Between the granules may be seen a pinkish matrix. Occasionally the nucleus of a neutrophile appears to have a round or oval nucleolus, but this is said to be an optical effect caused by the arrangement of the nucleus or point of view" whence it is seen. The presence of these neutrophilic granules constitutes the chief difference between this variety and the three forms previously described. (&) The Eosinophiles (A, plate opposite p. 662). — These are also large polymorphonuclear cells, slightly smaller than the neutrophiles, with granules much larger, which stain in acid stains such as eosin and the acid fuchsin of Ehrlich's triple stain : hence they are called oxyphiles or « granules. With- eosin they assume a brilliant pink color, with acid fuchsin in the Ehrlich- Biondi a copper red. The nucleus stains bluish, and there may be more than one. The eosinophiles are actively ameboid, and are regarded as overmature cells, as contrasted with the adult or mature neutrophile. THE MINUTE STRUCTURE OF THE BLOOD. 643 (c) The Basophilic or "Mast'' Cell. — Occasionally is found in normal blood a polymorphonuclear cell whose granules either do not come out with Ehrlich's fluid or appear as white spots. They stain, however, in a basic solutioTi of the anilin dyes, — as, for example, dahlia in glacial acetic acid and water, — and are hence called basophilic. The large basophilic granules are called y granules ; the fine, 6 granules. The relation of the " mast " cells to the other leukocytes is not known. The proportion of the different varieties of colorless cells in normal blood is approximately as follows : Small lymphocytes (young) 20 to 30 per cent. Large lymphocytes (young), 4 to 8 Polymorphonuclear neutrophiles (adult), . . 62 to 70 " Eosinophiles (old), 0.5 to 4 " Coarsely Granular Basophilic or " Mast " cells 0.25 to 0.5 " These proportions are not absolute in health. Thus, in infancy the per- centage of young cells represented by small and large leukocytes may be from 40 to 60 per cent., while the adult cells, or polymorphonuclear cells, may be as low as from 18 to 40 per cent. A similar ratio is at times found in conditions of debility without actual disease. The eosinophiles are more abundant in various parts of the body, as in the marrow of bones and in the thymus gland, while their number often varies in an unexplainable way in the blood. The total mean number of leukocytes in health is 6000 per cubic millimeter. Cell Forms Rarely or not at all Found in Normal Blood. — (a) The myelocyte of Ehrlich, or marrow cell; Cornil's "cellules medullaires" (A, plate opposite p. 662). — Certain large leukocytes twice or three times as large as a red blood disc and corresponding in all respects to the large granular cells of the bone-marrow are thus named. They are the variety of leukocyte most numerous in the bone-marrow, in which lymphocytes, polymorphonuclear cells, as well as eosinophiles, are also found. Their proto- plasmic granules are commonly neutrophilic, but occasionally eosinophilic. They are recognizable only by the Ehrlich staining methods. The nucleus stains pale in the Ehrlich-Biondi stain, is large, single, at times smooth, at others irregular, and sometimes showing a tendency to degeneration. Smaller cells exhibiting all the characteristic features of true myelocytes are sometimes met associated with the large variety. Myelocytes resemble the large lymphocytes, dififering, however, in the presence of granules. They differ also from the polymorphonuclear cells in the shape of the nucleus. They may be an intermediate stage between these last mentioned cells. Rarely if at all found in normal blood, these cells are numerous in certain varieties of leukemia and occur also in pernicious anemia and in some infectious diseases. There is every reason to believe they are the cells originally described by Cornil as " cellules medullaires." (b) Nucleated Red Corpuscles (D, plate opposite p. 662). — These are red cells possessed of a nucleus. They are usually divided into three classes : (a) Normoblasts, about the size of a normal red corpuscle; (b) megaloblasts, large and irregular cells; (c) microblasts, very small cells, smaller than a normal corpuscle. These cells are regarded as pointing to regenerative change. The normoblast, representing an immature red corpuscle, is found normally in the bone-marrow, whence it may be prematurely ejected before it has expelled its nucleus. Its nucleus stains deep blue, almost black with the 644 DISEASES OF THE BLOOD. Ehrlich-Biondi fluid. It is found in severe anemias, occasionally in large numbers. The megaloblast is very large, with a large nucleus, staining pale green or a robin's-egg blue with Ehrlich-Biondi fluid. It is found nowhere in the normal adult body, but it does occur in fetal marrow and in grave forms of anemia along with the normoblast. Ehrlich regarded it as degen- erate, while the normoblast is regenerate. The mkroblast is still smaller than the normoblast. It is variously regarded as degenerate and as a younger normoblast. It is found in the blood in anemias. Irregular or atypical forms are also met. The smaller forms of nucleated cells appear in the earlier stages of anemia, the megaloblasts and irregular forms in the more advanced stages. Muller's * "blood dust" (hemoconien) is the latest discovered constit- uent of normal and pathological blood. It consists of small, round colorless granules resembling the smallest fat drops, about 1-4 to i /x in diameter, highly refracting and characterized by molecular movement. According to Stokes and Weyforth f they may be the extruded granules of neutrophilic and eosinophilic leukocytes. THE ANEMIAS. Broadly defined, anemia means " bad blood." It is further subdivided into local and general. The former is known also as ischemia. Its special consideration requires but brief treatment in a text-book of medicine. It is illustrated by the pallor of the fainting person, and by that interesting dis- ease known as Raynaud's disease, which will be considered with diseases of the nervous system. By general anemia is meant any state of the blood in which there is a diminution of its total bulk, its red corpuscles, its hemoglobin — any one or all of these. The first is the condition which ensues from a large hemor- rhage of any kind, as from the rupturing of an aneurysm, erosion of a blood- vessel, such as sometimes happens in ulcer of the stomach or in tubercu- losis of the lung, or from a blood-vessel wounded in any way. In all instances, however, where the hemorrhage is not fatal the original bulk of the blood is rapidly restored by the absorption of water and salts from the tissues, while the hemoglobin and albumin remain deficient until they can be restored by suitable nourishment. Practically, therefore, anemias resolve themselves for study into conditions in which there is a reduction in the amount of hemoglobin through a diminution in the total number of red corpuscles or in the proportion of coloring-matter in each corpuscle, or both. Anemias are further divided into primary or essential, and secondary anemias. The former, strictly speaking, should include only those which are the direct result of a defect in the blood-making apparatus, while sec- ondary anemias are those due to loss of blood, or some one of its important constituents, or from a defective supply of blood-making material. Richard C. Cabot defines primary anemia as an anemia " in which the causal factors are entirely unknown or are insufficient to cause so severe a disease." That such a definition has some foundation will appear from the facts to be adduced as our study proceeds. *"Centralblatt f. allg. Path.," viii., i8g6. t "Johns Hopkins Hospital Bulletin," December, 1897. SECONDARY OR SYMPTOMATIC ANEMIA. 645 Among primary anemias are commonly included chlorosis, pernicious anemia, leukocythemia, lymphatic anemia or Hodgkin's disease, and splenic anemia. It is not conceded by all observers that pernicious anemia is the result of a defect in blood-making. In fact, each year adds more evidence to show that the conclusion of Quincke and William Hunter that it is a hemolysis, or disintegration of the red blood-corpuscles in the circu- lation or certain parts of it, especially in the liver, is the correct one. Par- ticularly noteworthy are the studies of J. P. C. Griffith and C. W. Burr,* favoring such view. As the chain of evidence is not, however, complete, I shall for the present consider it among the essential anemias. The secondar}^ anemias are numerous, including those due to hemor- rhage and other drains of various kinds on the economy, inadequate food, and defects in the digestive apparatus ; also those due to^ the action of poisons on the blood — the toxanemias, including lead-poisoning and uremia. SECONDARY OR SYMPTOMATIC ANEMIA. This form of anemia is the direct result of trauma, accidental hemor- rhage, chronic disease, or toxic agents. I may again refer to the fact men- tioned in the preliminary remarks on the anemias, that reasons are being found to show that some, at least, of the so-called essential anemias may be due to agencies tending to destroy the corpuscles, rather than to diseases of the blood-making apparatus. The secondary anemias include : 1. Anemias Due to Hemorrhage, hozvever caused. — Traumatic hemor- rhage, postpartum hemorrhage, lung hemorrhage, and gastric and intestinal hemorrhages comprise most of these ; ruptured aneurysms, purpura, and the bleeding habit furnish others. Parasites invading the intestinal canal may be causes of hemorrhage and consequent anemia. So may parasites else- where, as the distoma hcematohium in the kidney. In non-fatal hemorrhages from these causes the immediate loss of blood in bulk is rapidly made up by the absorption of water from the gastro- intestinal tract, but a long time is required, even under favorable circum- stances, before the corpuscles and hemoglobin are restored. At other times regeneration is quite rapid, restoration being complete in ten days. The hemoglobin is always rather more reduced than the corpuscles, but both increase for a time pari passu, as shown in the appended chart. The albu- minous constituents are more rapidly restored. 2. Anemias Due to the Drain of Chronic Disease. — Such are chronic Bright's disease, suppurative processes, cancer, or prolonged lactation, or chronic diarrhea. In this group belong the anemias of malaria, in which the corpuscle is directly consumed by the plasmodium. 3. Anemia from Inanition. — This results from starvation, which may be the practical consequence of diseases which interfere with the successful ingestion and assimilation of food, such as obstruction of the esophagus by cancer or otherwise, or chronic and prolonged dyspepsia. Carcinoma of the stomacii may also be included in this group. The last two groups (2 and 3) overlap. Under these circumstances, the tlood mass is greatly reduced, but it is by a reduction in the blood plasma, rather than in the corpuscles, for the * " Pathology of Pernicious Anemia," "Transactions of the Association of American Physicians," vol. vi., i8qi. 646 DISEASES OF THE BLOOD. latter, though reduced, are not markedly so, and may even be relatively increased. 4. Toxic Anemias. — Finally, there remain the toxic anemias. These are the result of the presence in the blood of such substances as lead, acquired by painters or workers in lead-paint factories, type-setters, and type-founders ; also arsenic from dress fabrics, wallpaper, and furniture coverings ; mer- cury, and certain disease poisons, among which that of chronic malaria is the most conspicuous. Syphilis is also one of these, producing what is some- times known as syphilitic chlorosis. The blood-chart (Fig. 62) is from a case of syphilis. RED ■CEilLS 5500000 5000000 iSOOOOO 4000000 S5GOO0O 3000000 2500000 2000000 1500000 1000000 500000 100000 ". " •= - » => s s 2 ;2: 15 s 2 2 s Si S5 Z ^ C» 55 s M " 0, » ' •« ■^ - » = n S 3 ■* — — "# ,„^ -^ / t / ■ / ,.-' ,/ ^ / f / / / / / 4 f{ A / l¥ \, /. f s, •\ Jf V ■"^ V / — — '^ .^ - ~7 '/- — - — — ^ — ^— — P*' - -^ — — - ~ — - — — — y ■^ ^ — — — - ^ ^ "V ^- ^ — — ~ - — - -^ - - V \ A ^ / / \ \ \ V '/ \)^f s 1 ^, 9 V Fig. 62. — The Blood in Simple Anemia. Hemoglobin Red, Corpuscles Black. From a Case of Syphilis. In the true toxic anemias the poisonous substance acts directly upon the red corpuscles, destroying them, or perhaps also by increasing their consumption in the ordinary way. Among the toxic anemias must, perhaps, be included those due to unsanitary surroundings ; also those due to infectious diseases, the organisms causing which generate toxins. Among these is the anemia of tuberculosis. Similar products, generated by intestinal and other parasites, are responsible for the anemias associated with them. Such intestinal parasites are the anchylostoma duodenale, bothriocephalus latus, and angiiiluUa intestinalis. The latter also contributes to anemia by causing hemorrhage. Symptoms. — The most commonly recognized symptom of anemia is a paleness of the skin, and this is undoubtedly present in the vast majority of cases. Yet a total reliance dare not be placed on it, for it sometimes hap- pens that the skin and even the lips are pale, and yet no anemia is found SECOXDARY OR SYMPTOMATIC AXEMIA. 647 when the blood is examined. On the other hand, the skin and hps may have a good color, and yet anemia be actually present. Weakness, faint- ness, and palpitation are also symptoms. In addition to these are the blood changes, which vary with the degree of anemia. Both corpuscles and hemoglobin are reduced, the latter in somewhat larger proportion. The disproportionate lowering of the hemoglobin is explained by a more than natural paleness of the red corpuscles. Their average size is reduced, while there is algo a moderate poikilocytosis. Nucleated red corpuscles also make their appearance soon after a hemorrhage. The normoblasts and micro- blasts are the prevailing forms. They exhibit, after staining with hema- toxylon, a deep-blue nucleus, while free nuclei are occasionally found. Microcytes, megalocytes, and poikilocytes are present in advanced cases. The colorless corpuscles are moderately increased, such increase being represented by the multinuclear neutiophiles, while the small mononuclear lymphocytes are diminished. The leukocytosis gradually disappears with •the return of the blood to its normal state. The presence of leukocytes as well as of the nucleated corpuscles is evidence of regenerative activity. The proportion of the different varieties is nearly normal. In severe cases the lymphocytes miay be in excess and the polymorphous leukocytes be reduced. Myelocytes are exceptionally present. Diagnosis. — In addition to the blood changes more or less common to all of these causes of anemia, the same general symptoms of pallor, lassi- tude, debility, and faintness which characterize the essential anemias are also present in less degree. The distinctive feature of simple anemia is the nearly coequal reduction of the hemoglobin and corpuscles. The history of the case in the presence of one of the causes named is of itself sufficient to determine the diagnosis in many cases. The simple anemias are not always, however, sudden or rapid in their occurrence, and a study of the blood is often necessary to clear up a doubtful case. Treatment. — The treatment of simple anemia is eminently satisfac- tory. The administration of nourishing food with rest is followed by a very rapid coequal rise in the hemoglobin and corpuscles, as is beautifully shown in the foregoing chart (Fig. 62) made from one of my cases in the Philadel- phia Hospital. And when to the treatment by nourishing food we add the use of iron, there is nothing more to be desired. Full doses of iron are well borne in these cases, and we have the choice of almost any of the prep- arations, including Blaud's pills of the carbonate, reduced iron, tincture of the chlorid, Basham's mixture, and the vegetable salts. Though full doses are here indicated, it is still unnecessar}- to give the massive doses recom- mended by some, as they are not absorbed and produce constipation. The rapidity of the cure in some of these is surprising. 648 DISEASES OF THE BLOOD. THE PRIMARY OR ESSENTIAL ANEMIAS. These include chlorosis, for the present pernicious anemia, leukocy- themia, lymphatic anemia, or Hodgkin's disease, or pseudoleukemia, and splenic anemia. I. CHLOROSIS. Synonyms. — Morbus Tirgineus; Green Sickness: Chloreniia; Chloranemia. Definition. — An essential anemia most frequently met in young women, characterized by a very marked relative reduction in the hemoglobin of the blood. Etiology, — As stated in the definition, it is a disease of women, and especially of young women. Yet its occurrence is not impossible in men having the habits and occupations of women, among whom Hermann Eich- horst especially instances tailors. ^Moreover, while it is especially a disease of young women from about the age of puberty to twenty-four years, it is also possible in those who are older, as well as those who are younger. In the former it is known as chlcrosis tarda, and as siich is met in women be- tween thirty and forty. Rather more frequent is its occurrence in children who have not reached the age of puberty. Niemeyer held that girls who menstruated at thirteen or fourteen, in whom there was, as yet, no develop- ment of pubis or breasts, most invariably become chlorotic. The disease occurs the world over, and is apt to be recurrent in the same individual. It is more common in blondes than in brunettes, in the weak and delicate,, rather than the strong and vigorous. Yet this general truth is not without exception. Among predisposing causes are overwork, especially in closely confined and ill-ventilated rooms, insufficient nourishment, exhausting drains, such as prolonged lactation and profuse menstruation. ^Menstrual derangement is, however, also a consequence as well as a cause. Sustained or repeated emotion, especially such as arises from sexual excitement and masturbation,, is a cause. Homesickness and grief are included among causes. The frequent association of constipation with chlorosis led Sir Andrew Clark to suggest that it might really be a copremia. or poisoned blood due to absorption from the large bowel of poisons of the nature of ptomains and leukomains. Such poisons may readily interfere with the proper de- velopment of the hemoglobin df the blood disc, without in a great degree causing its destruction. Similar is the hypothesis of Bunge that intestinal putrefaction due to imperfect stomach digestion is the cause of chlorosis. These views explain what seems to me a closer relation between chlorosis and pernicious anemia than has commonly been admitted, a relation con- sistent with the newer etiology of pernicious anemia, as well as with features in its clinical course, and with the results of treatment, to which attention will be called when considering the latter aft'ection. Morbid Anatomy. — Other than the changes in the blood, to be con- sidered under symptoms, there is no essential miorbid anatomy in chlorosis. Many years ago Mrchow pointed out an imperfect development of the circulatory apparatus as more or less characteristic — that the heart was small, the right ventricle sometimes dilated, the aorta and its larger branches CHLOROSIS. 649 were poorly developed and thin-walled. Such a condition, when present,, is probably an accidental coincidence. There is no enlargement of the spleen or lymphatic glands. Imperfect development of the uterus and Other genitalia has been noticed. The rarity of fatal termination in chlorosis may limit our knowledge of the morbid anatomy, uncertain at best. Symptoms. — Of these, the blood changes may be regarded as funda- mental, though not absolutely constant. They consist in a decided reduc- tion in the hemoglobin, with a moderate oligocythemia, or reduction in the number of red corpuscles. Thus, the hemoglobin value of each red disc is diminished. The usual range may be put at from 3,500,000 to little less than normal. Thus, Thayer, in 63 consecutive cases in Osier's clinic, found the average 4,096,544, or over 80 per cent., and Lembeck found the maximum in one of 15 cases to be but 3,600,000. In a few instances, how- ever, in cases of acknowledged chlorosis, there has been found a more decided reduction in the erythrocytes. One has been reported in which they were reduced as low as 1,190,000 in a cubic millimeter. The hemoglobin, on the other hand, is much reduced, the average of Thayer's cases referred to being 42.3 per cent., which may be regarded as a fair average. This disproportionate fall in the hemoglobin, while not invariable, remains, however, a tolerably constant feature, producing some- times a recognizable diminished intensity of color when the blood is seen en masse. Along with the lowering of hemoglobin, as would be expected,, since it is a constituent of the hemoglobin, the iron of the blood falls. An increase of alkalescence, announced by Graeber * as a constant symptom,, has not been found by Kraus f in his more exact methods of testing. In- creased coagulability of the blood has been observed. As to remaining changes, the red corpuscles may be altered in shape to a moderate extent, constituting a small degree of poikilocytosis, a term suggested by Quincke, or they may be larger than in health, when they are known as megalocytes. More frequent is an undue reduction in size of the corpuscles — a microcytosis. The red discs are sometimes appreciably paler than in health. A very slight degree of leukocytosis may be rarely present, an average of 8467 in Thayer's counts, as contrasted with a mean normal of 6000 in cubic millimeter, while the blood plaques in severe cases, may also be increased. Nucleated red corpuscles are sometimes met, espe- cially in the later stages, represented by the smaller forms (microblasts) which sometimes appear in crops. In this stage the corpuscles may assume irregular shapes. Myelocytes have rarely been met. While the blood alterations in chlorosis are scarcely distinctive enough to be considered diagnostic, the other symptoms help greatly to the forma- tion of a correct conclusion. The patient is almost invariably a girl, gen- erally between sixteen and twenty, who, although she may have been over- worked, does not seem badly nourished ; certainly she is not emaciated. There is often derangement of menstruation, and sometimes the girl is hysterical. Most striking, though not invariable, is a peculiar pallor, often exhibit- ing a yellowish-green tinge, extending to the lips, and especially the mucous membranes, and which is responsible for one of the names of the affection — green sickness. The patient is extr^iely weak, especially on exertion, and short of breath. She is subject to vertigo, palpitation of the heart, and even * "Zur klin. Diag-nostik d. Blutkrankheiten," Leipsic, 1888. t "Zeitschrift f. Heilkunde," Bd. ii. 650 DISEASES OF THE BLOOD. irregularity of the heart's action. Physical examination will sometimes dis- cover functional cardiac murmurs ; also a systolic murmur at the apex, ascribed by Balfour to a relative insufficiency of the mitral value due to dila- tation of the left ventricle. Rarely, a compensatory hypertrophy of the left ventricle has been noticed, but never actual valvular disease. Sometimes a bruit dc diable, or humming-top murmur, may be heard over the right 130% vm 40^ 6.000.000 2,000,000 200.000 120JS lOOS NORMAL NO. CORPUSCLES. Red Corpuscles — Black. Hemoglobin — Red. Colorless Corpuscles— Blue. Fig. 63. — Blood in Chlorosis. jugular. Epigastric pain is also a symptom at times. It must not be for- gotten that a chlorosis late in life, or chlorosis tarda, does sometimes occur. Fever is not rarely present. On the other hand, the hands and feet are often cold. Diagnosis. — The diagnosis is based chiefly upon the age and sex of the patient, the peculiar greenish-yellow color, the paleness of the lips, and the decidedly diminished hemoglobin, unaccompanied, as a rule, with a CHLOROSIS. 651 proportionate reduction in the number of erythrocytes. The same lost nor- mal ratio between the hemoglobin and the corpuscles is also a characteristic of lead-poisoning, which has, however, superadded its own characteristic symptoms, and is almost restricted to adult males. The epigastric pain mentioned as occurring in chlorosis resembles that more common in nicer of the stomach. The anemia which so constantly attends ulcer of the stomach, often in a high degree, is, however, different from that of chlorosis, there being a proportionate decline in the number of the erythrocytes and their coloring-matter. At least, the reduction is .not so widely disproportionate as in chlorosis. It dare not be said, as it once was, that there is subacidity, as a rule, in the gastric fluid in chlorosis, nor is there motor deficiency. A not infrequent error of diagnosis in connection with chlorosis is the mistaking of it for a " decline," a pulmonary consumption, which it resembles in the pallor, the feebleness, and shortness of breath of the patient. The absence of emaciation, of cough, and of the physical signs of consumption exclude that disease. On the other hand, evidences of tuberculosis should always be sought where the symptoms of chlorosis prevail. Latent cancer is also sometimes responsible for similar symptoms. Most frequently chlorosis is confounded with secondary anemia, and with reason. Close observation will recognize in chlorosis the yellowish tinge of the skin and mucous membranes, while the sclerotic remains white or bluish. The most constant dift'erence is in the reduction of hemoglobin, which is disproportionately large in chlorosis. Leukocytosis is less frequent in chlorosis ; so are nucleated red cells. In advanced degrees of chlorosis the blood approaches nearer that of pernicious anemia, in which, however, the blood coagulates more slowly. The question whether a chlorosis will be transformed into that more serious variety of anemia known as pernicious anemia has been raised. This seems not impossible. If the view of Sir Andrew Clark be accepted, that chlorosis may result from the absorption of poisonous substances from the larger bowel, and if pernicious anemia be due to the absorption of more intense poisons from the small intestine, the difference is only one of degree. Both are characterized by defects in the cellular constituents of the blood. In the one, chlorosis, the coloring- matter is chiefly wanting, although associated with this is usually found a small degree of morphological defect. In pernicious anemia both cell- shapes and coloring-matter are defective. In both diseases the oxygen- carrying office of the blood is interfered with, and thus important vital processes are embarrassed, the total suspension of which must be fatal. Prognosis. — The prognosis is nearly always favorable when the disease is recognized and the proper treatment instituted. There are few results more satisfactory in therapeutics than those of a properly treated case of chlorosis. Time is, however, required, and too rapid a cure must not be promised, several months and even longer being sometimes required. Treatment. — The treatment is pre-eminently by iron, and it matters not very much what preparation is used. The tincture of the chlorid well diluted is probably the most easily assimilable, but the carbonate, in the shape of Blaud's pill, made by a double decomposition between the carbonate of potassium and the sulphate of iron, maintains its popularity, one to five grains (0.06 to 0.2 gm.) being given at a dose three times a day. Reduced iron or one of the vegetable salts may be given. Much larger doses are sometimes given, as much as 45 grains (3 gms.) a day. I have 652 ■ DISEASES OF THE BLOOD. many times said that iron is given in too large doses in the majority of cases for which it is prescribed. Most of it is unabsorbed, and therefore wasted. Nay, worse, that which is unabsorbed locks up the intestinal secretions by its astringency, produces headache, and makes the patient otherwise uncom- fortable. But chlorosis is one of the few diseases in which large doses of iron are well borne. The reason is plain. It is the iron-holding constituent of the blood which is wanting, and the iron is needed to replace it. The blood is, as it were, hungry for it. Next to iron comes arsenic. The effi- ciency of iron is greatly aided by union with arsenic, which should be given in increasing doses, bvit short of toxic effect. Hydrochloric acid in full doses, originally suggested by Zander on the ground of supposed deficiency of this acid in the digestive fluid in chlorosis, is useful also in promoting the solubility of iron, as well as for its tonic and antiseptic properties. But to give these drugs is not alone sufficient. Rest in bed, at first continuous, is imperative to secure a rapid result, and this must be associated with an abundance of good food. Daily massage, except during menstru- ation, is also a useful adjuvant. There is no condition in which the so-called " rest cure " is more efficient than in chlorosis. With a return of color to the lips, or, better, with the growing increase in the hemoglobin as meas- ured by the hemoglobinometer, the patient should be permitted to be out of bed at first from a half-hour to an hour only, but this should be gradually increased until she is up most of the day. For a long time, however, fatigue should be avoided. To those who can afford it, a residence at the seaside materially aids convalescence. Indeed, I know of no condition so rapidly improved at the proper time by sea air as chlorosis. To the poor, a well-regulated hospital treatment is a boon for which there is scarcely a substitute. 11. PROGRESSIVE PERNICIOUS ANEMIA. Synonyms. — Idiopathic Anemia; Pernicious Anemia. A second variety of essential anemia is pernicious or idiopathic anemia,, originally described by Addison in 1855 in his celebrated paper on " Dis- eases of the Suprarenal Capsules." Interest in the subject was revived by Biermer in 1868, and since then it has been thoroughly studied anatomically and clinically. It is, however, still the least understood of all the anemias. Fortunately, it is an infrequent^disease. Definition. — Pernicious anemia is an anemia in which the red cor- puscles have been destroyed and reduced in number, along with a reduction of the hemoglobin, while the ratio of the latter to the remaining corpuscles is one of excess. Etiology. — The etiology of pernicious anemia is very obscure. Preg- nancy seems to be in some way responsible for a certain number of cases. Such a condition, associated with the puerperal state and with functional dis- ease of the uterus, was first described by Walter Channing * in 1842. The symptoms described by him are evidently those of pernicious anemia, though he called the condition simply " anhemia." A. Gusserow f published, in * "New England Quarterly Jour, of Medicine and Surgery," Boston, 1842-43. + "Ueber hochgradigste Anamie bei Schwangerer," "Archiv fiir Gynakologie," Berlin, 1871. PROGRESSIVE PERNICIOUS ANEMIA. 653 1871, a number of cases in pregnant women. It has also followed lactation. Other causes are cited, such as atrophy of the stomach, early noted by Flint and Fenwick, profound and long-continued gastro-intestinal disease, and intestinal parasites, especially the anchylostomum duodenale and bothrio- cephalus latus, which undoubtedly produce symptoms clinically indistin- guishable from the general anemia which Addison characterized as " oc- curring without anv discoverable cause whatever — cases in which there had been no previous loss of blood, no exhausting diarrhea, no chlorosis, no purpura, no renal, splenic, miasmatic, glandular, strumous, or malignant disease." I have already expressed my partiality toward the view of Quincke and others, who ascribe the state of the blood to a hemolysis, in proof of which they point to the enormous accumulation of iron in the liver noted "by Quincke in 1876 and confirmed by Rosenstein in 1877. To these, Wil- liam Hunter added a pathological increase of the urobilin in the urine. In a noteworthy paper, Griffith and Burr take the same view.* Figs. 64 and 65 are from Griffith and Burr's paper, and show the deposit of iron in Fig. 64 — Liver Lobules in a Case of Pernicious Anemia, Showing Distribution of Iron Pigment — {after Griffith and Burr). the liver cells demonstrated by ferro-cyanid of potassium. Such a hemol- ysis is most satisfactorily explained on the supposition of absorption from the intestine or elsewhere of poisonous products engendered under any of the circumstances named. Among these may be included the products of imperfect digestion, such as may be expected to arise when there is atrophy of the gastric tubules. The disease is widespread, being quite common in this country. It affects mostly those past middle age, but children also have it, and Griffith mentions ten cases occurring under twelve. It is more frequent in males. Symptoms. — The approach of the symptoms of pernicious anemia is most insidious, beginning with a gradual progressive zveakness. What is first interpreted as a causeless weariness or languor grows slowly into an extreme debility, with faintness on the slightest exertion, and thence into a state of thorough muscular weakness, which ultimately prostrates the pa- tient, and he is too weak to rise from bed. To this succeeds a state of * Loc. cit. 654 DISEASES OF THE BLOOD. mental hebetude and bodily torpor. Yet there is no euiaciation. The body bulk is well preserved. The skin acquires gradually a lemon-yellow hue, and sometimes an actual jaundice, whence the disease has been mistaken for the slower form of yellow atrophy of the liver, a mistake not altogether unsus- tained bv other symptoms. In fact, the jaundice is similarly caused. It is probably a hematogenous jaundice, a matter of blood disintegration, al- though it has also been ascribed to defective cell action on the part of the liver. The mucous membranes, on the other hand, are blanched, as may be noticed in the lips, gums, and mouth. Cardiovascular symptoms are especially conspicuous in progressive per- nicious anemia. Hemic murmurs, visibly pulsating and throbbing arteries, even pulsating veins, have been noticed. The large, but soft, jerky pulse. Fig. 65. — Cells from Liver in Pernicious Anemia, More Highly Magnified, Showing Position of the Iron Pigment within them — {after Griffith and Burr). resembling that of aortic regurgitation, w^as mentioned by Addison. The capillary pulse is also frequently seen, and hemorrhages, cutaneous and retinal, occur. Digestive derangements form an important part of the symptomatology of pernicious anemia. Indisposition to take food, or, rather, a disgust for food, nausea, vomiting, and diarrhea are often troublesome symptoms. Hydrochloric acid is constantly deficient in gastric digestion. Moderate elevation of temperature, irregular and intermittent, is also noticed, while nervous syjuptoms, including numbness, languor, and even paralysis, are sometimes present. The urine exhibits no constant changes, being sometimes pale and sometimes dark-hued. The dark color is ascribed by Mott and Hunter t© an excess of urobilin. Blood Changes. — The changes in the blood are more distinctive than in chlorosis, although it is true also that there is no single constant character- PROGRESSIVE PERNICIOUS ANEMIA. 655 istic feature. It may be pale and watery. The most constant feature is a very decided oligocythemia, without a corresponding reduction in the hemoglobin, although the hemoglobin, m toto, is much reduced. Rarely it has been found increased. Quincke found as few as 143,000 corpuscles in a cubic millimeter of blood, while it is not uncommon to find less than half a million. Frederick P. Henry found 315,000 a few hours before death, and Laache 360,000. In a case under my own care at the Phila- delphia Hospital, in 1898, the red discs fell to 437,000, and the hemoglobin to 9 per cent., death taking place two days after the count was made. The inevitable conclusion from the average of cases observed is that either the hemoglobin value of each corpuscle must be increased, or there is a hemo- globinemia, which has its seat in the plasma. This latter view Silbermann. n — 1 IW 6,000,000 g ^ S § s -< 110? B >. 5 60 -5 < in(W 5,000,000 v» . ftor 4,000,000 1(K m 3,000,000 ^ — _ ^ x" ■*■ MiH \— (ifK . .-< ^ / J - ~\ ~i — -« — < " J 1/ ~- L_ ,^ m 2,000,000 1 — ~~ y ^ L-< ^ - " 1 L_ S(K _ _^ — '-^ i ' "" ?m 1,000,000 1(K 500,000 250,000 200,000 '■" 3^ 150,000 2? 100,000 90,000 80,000 70,000 60,000 ¥ 50,000 _ _ 120^ 110^ 100# eoif 1055- 5« H Red Corpuscles — Black. Fig. 66.— P Hemoglobin Red. ernicious Anemia. has adopted, because he has been able to produce, by the administration of blood-corpuscle-dissolving substances, as pyrogallol, to animals, a complex of symptoms like those of pernicious anemia. If pernicious anemia be a hemolysis, as seems likely, rather than a defective hematogenesis, we would expect such a hemoglobinemia to result. A further striking peculiarity in the blood of pernicious anemia is an increase in the size of the red corpuscles. They become megalocytes, from ten to fifteen micromillimeters in diameter, as compared with a normal of from 6.5 to 9.4. The majority may be so enlarged. They are often also ovoid in form. On the other hand, there are also microcytes — cells smaller than normal — and poikilocytes — corpuscles characterized by great irregu- larity in shape. While these irregular shapes were first demonstrated in connection with pernicious anemia, and although they are more or less characteristic, cases of the disease have been described by Grainger Stewart, Lepine, Hermann Miiller, and others, in which poikilocytosis was altogether 656 DISEASES OF THE BLOOD. absent. Neither megalocytosis, micr'ocytosis, nor poikilocytosis is therefore a pathognomonic feature. Nucleated red corpuscles are a constant constituent of the blood of per- nicious anemia, and have also been regarded by their discoverer, Ehrlich, as almost pathognomonic. Two kinds are found — first, the small, normal- sized corpuscle, with its deeply stained nucleus (normoblasts), and certain large forms w4th pale nuclei (megaloblasts). They are not confined to this disease. Blood plaques are either absent or very scanty. Leukocytes are usually slightly diminished in number, while there is a tendency to an increase of the mononuclear white cells, as compared wdth health. F. P. Henry * has called attention to a fact which condenses the peculiarities of the blood changes, by saying that in this disease the red corpuscles " ap- proach those of the lower animals in many, if not all, of their chief charac- teristics — namely, in their number, their size, their shape, and the amount of hemoglobin they carry." There are also sometimes found in the blood numerous minute highly colored spherical bodies, called Eichhorst's corpuscles. Eichhorst regarded them as pathognomonic, but they, too, are sometimes absent. When present they contribute to the hemoglobin in the blood, but as they are not included in the blood-count, they get no credit for their effect. The relative excess of the hemoglobin may, in a measure, be thus accounted for. Morbid Anatomy, — X'arious tissues have been studied in the eft'ort to find a morbid anatomy for pernicious anemia. In the absence of lym- phatic involvement or enlargement of the spleen, except sometimes in small degree, the marrow of hones has claimed close study. H. C. Wood de- scribed the red condition of the marrow of long bones in 1871. It was further studied in this country by William Pepper f and myself ,t and abroad especially by Cohnheim.§ Although the appearances described by these observ^ers are not identical, they are sufficiently constant to justify their association as more than accidental. Summed up, they amount to this: ]\Iarrow dark red; consist- ence less soft ; fat vesicles absent ; specific lymphoid cells increased, including marrow cells of various sizes, containing one or more nuclei ; numerous nucleated red corpuscles present, especially the larger forms, the giganto- b)lasts of Ehrlich. These studies were made before the days of differential staining and counting. ]\Iore recent studies add neutrophiles and eosino- philes. These appearances are now commonly interpreted as due to an eflfort of the blood-making apparatus to reproduce the disintegrated erythro- cytes. They are not, however, constant, as the marrow is sometimes pale or yellow. The deposition of iron in the liver cells has already been alluded to. It is found in the outer and middle zones of the lobules, and may be so distributed as to outline the bile capillaries. It is regarded by Hunter as characteristic. I have myself examined the preparations of Griffith and Burr, and they are striking and seem unmistakable. The liver itself is often fatty and is sometimes enlarged. The iron is, in like manner, sometimes increased in the kidney, but not in the spleen, and these organs are not * "Anemia," Philadelphia. 1887. t "Progressive Pernicious Anemia," "American Journal of the Medical Sciences," October, 1895. X "Die Betheiligung des Knochenmarkes bei pernicioser Anaemie," " Virchow's Archiv," 1877, Ixxi. 118-126. § "Virchow's Archiv," October, 1876. PROGRESSIVE PERNICIOUS ANEMIA. 6^7 otherwise essentially changed. The spleen also has its iron pigment in- creased, and has been found reduced in size. The heart muscle is fatty, while the other muscles are unusually red. Other morbid .changes are described, but they cannot be regarded as essen- tial. Such are changes in the ganglion cells of the sympathetic, and scle- rosis of the posterior columns of the cord, first studied by Lichtheim.* Softening of the upper part of the lumbar cord has also been reported by Sir Dyce Duckworth. f While the association of the changes in the pos- terior columns are so constant that they cannot be regarded as accidental, .experimental studies by Burr and Griffith intended to determine this relation to pernicious anemia resulted in nothing definite. Complete atrophy of the secreting tubules of the stomach has been described by Fenwick, and by William Osier and F. P. Henry in one case studied jointly by them. Diagnosis. — The diagnosis of pernicious anemia may be uncertain at first, but the true nature of the disease soon declares itself. The intense anemia, extreme weakness, digestive derangements, and cardiovascular symptoms, in connection with a blood-count of 1,000,000 or below, with a relative increase, or at least no proportionate diminution, in the hemoglobin, and an admixture of megalocytes, microcytes, and poikilocytes, point to a condition scarcely mistakable. It may be said, moreover, that almost never in the case of a pernicious anemia do the number of corpuscles fail to fall below 1,000,000. The large forms of nucleated red corpuscles have been regarded as characteristic, but are also found in leukemia (see also diagnosis of Cancer of the Stomach, p. 371). Prognosis. — The prognosis is to-day regarded as less unfavorable than it was a few years ago, since recent experience has developed the fact that temporary improvement is not uncommon, and it is said that recovery some- times takes place. Still, Addison's original prognosis, of a termination sooner or later fatal, is seldom astray. Treatment. — Treatment of this form of anemia is, moreover, not fruitless. The same measures which are almost a specific for chlorosis are not without effect in pernicious anemia. Accordingly, arsenic, to a less degree iron, good food, and favorable hygienic surroundings, are to be adopted. The arsenic treatment has been followed by results which justify the words " temporary cure," and it is said that permanent cure has fol- lowed. Such temporary cures have covered a period of three years. The best preparation appears to be Fowler's solution, in gradually increasing doses, until twenty and even thirty minims (1.3 to 2 c. c.) are reached, and this three times a day. It should be continued for a long time, for weeks or months, with intermissions of a few days if unpleasant results appear, to be again resumed. Arsenic is not a specific for pernicious anemia, but the results of its use are often surprisingly gratifying. Cakodylate of sodium has been recommended for other preparations of arsenic. It is said to be less irritating and suitable for hypodermic use. The dose is half a grain (0.033 g"^-)- three times a day. Inhalation of oxygen has also been recommended, as advised in leukemia. The relation between chlorosis and pernicious anemia, already referred to. is sustained by therapeutic results. Certain cases of chlorosis very closely resemble pernicious anemia, especially when not arrested by treatment. Tjie arsenic, administered as directed, is wonderfully well borne, nausea and vomiting being rare. Rest in bed is * " Congress fiir innere Medicin," 1887. t " British Medical Journal," November 10, igoo. 42 658 DISEASES OF THE BLOOD. indispensable, but sbould be supplemented with massage, if possible. Food should be in easily assimilable shape, such as beef-juice, beef-peptonoids, and peptonized milk. Pernicious anemia is one of the diseases in which much was expected from the use of bouc-iiiarrozv, originally suggested by Thomas R. Fraser."^ Fraser used three ounces (90 gm.) daily of beef- marrow, in addition to iron and arsenic, with apparent cure. At the pres- ent day the glycerids are used in doses of half an ounce (15 c. c. ), three times a day. I have had some experience with it, but my results have not been very encouraging. Salol has been suggested as an intestinal antiseptic, from the standpoint that the disease may be due to toxins absorbed from that canal. Recently, too, Dr. William Hunter has suggested the use of antistreptococcus serum to counteract possible general infection. Transfusion of blood and of milk, which seemed at one time to give promise of favorable results, has been discontinued. At the present day, hypodermoclysis would probably answer the same purpose, and is much easier done. III. LEUKEMIA. Definition. — A disease characterized by an enormous increase in the colorless corpuscles of the blood, by hyperplastic changes in the spleen, in the lymphatic glands, or bone-marrow, any one or more of these. It has been called leukocythemia as well as leukemia, the former of these words meaning white-cell blood, the latter simply white blood. From the etymological and histological standpoint, leukocythemia, suggested by Hughes-Bennett, is the more accurate term, but Virchow's term, leukemia, has become the one in common use. Historical. — The history of the development of our knowledge of leukemia pos- sesses unusual interest. The older observers spoke of a purulent blood, ascribed to an inflammation of this tissue, while Piorry and Rokitansky spoke of a hematitis as the cause of a literal pyemia. Craigie undoubtedly saw a case of the disease in Edinburgh in 1841. He did not, however, publish the case until John Hughes-Bennett published his on October i, 1S45, in the " Edinburgh Monthly Journal of Medicine." Both Craigie and Bennett noted enlargement of the spleen. Rudolph Virchow pub- lished his case in Froriep's "A^otiseii " in the second or third week of November, 1845. The matter of priority between Bennett and Virchow has given rise to much discus- sion. There can be no doubt that Bennett's case was published first ; also that he declared it unconnected with inflammation of any of the tissues, and especiall^^ uncon- nected wnth phlebitis, and that he attributed the condition to the development of white corpuscles in the blood. Craigie, on the other hand, ascribed it to the absorp- tion of pus from an inflammatory lesion either in the mesenteric veins or the spleen. Virchow confirmed all the observations made by Bennett and published new cases, especially one of great importance, in which there was enla7-ge7}ient of the lymphatic glands iiiithout enlargeineyit of the spleen. Virchow also said the blood changes consisted essentially in an increase of the colorless cells of the blood, and that these cells originated in the lymphatic glands. He also suggested the name leuketnia, while Bennett did not suggest that of leiicocytJiemia until 185 1 in a series of papers, and again in 1852 in a separate work. It appears to me that Bennett is clearly entitled to priority, and was the first to interpret the condition as an increase in the colorless corpuscles of the blood, though he speaks of it ^.s pus. Virchow's added point w^as ascribing the formation of the cells to the lymphatic glands. Vogel first recognized a case during life in 1849. Virchow described two forms of the disease in his "Cellular Pathology," in one of which the smaller forms of leukocytes predominated and in which there was marked involvement of the lymph glands. In the second the larger white blood cells predominated, and there was marked enlargement of the spleen ; hence he inferred that the Ij'mphatic glands were at fault when the smaller cells predominated, and the spleen when larger cells pre- vailed. Varieties thus characterized do exist, but we dare not draw conclusions as to the organs involved as sharply as Virchow did. Large cells predominate in the ♦ " British Medical Journal," June 2, 1894. LEUKEMIA. 659 lienomedullary form, while small cells characterize the lymphatic variety. Interme- diate forms, however, interfere with sharp distinctions. It was many years later that Neumann described a case in which the dofie-Diarrow was markedly altered. Pure splenic and pure medullar}^ forms scarcely exi^t, though a case or two of the latter is described. The pure lymphatic form does occur, but even this is rare. Most common is the mixed lieiioinednllary or lietiomyelogenoiis. The extremely rapid course of certain cases of leukemia justifies its division into an acute and chronic form. An instance of the former was a fatal case reported by Ebstein, in which the w^hole duration of the disease, including a prodromal stage, w-as but six weeks. Similar cases are reported -by others, eleven by Fraenkel.* M. H. Fussel and A. E. Taylor collected fifty-six cases. The duration of the chronic form may extend over years. Leukemic women have been repeatedly pregnant and have borne children at term. Etiology. — Xothing definite is known of the cause of leukemia. It occurs in all countries, in both sexes, and at all ages, although it is more common in middle life and in males. Cases have occurred in the eighth week and seventieth year. It is sometimes hereditary, but leukemic women have borne non-leukemic children. ]\Ialaria has been assigned as a cause, and certainly its association with this disease has been seemingly more than accidentally frequent. To a less degree this is true of syphilis. Pregnancy is said to favor it. It is said to have followed a blow or injury, and to have been found in the lower animals. The idea of the infectious origin of leukemia, advanced by Klebs and supported by observations of Osterwold, Roux, Byrom Bramwell, Pawlow- sky, Kelsch, Vaillard, and others, seems well founded, but no single micro- organism has been found associated. A case has, however, been reported where an attendant on a case of leukemia contracted the disease and died. The frequent association of leukemia with stomatitis and intestinal ulceration was pointed out by Hunterberger. Morbid Anatomy. — Leukemia has a definite morbid anatomy, con- sisting in alterations in the blood and in the hemogenic apparatus, including the spleen, the lymphatic glands, and the marrow of bones, and it is called, accordingly, splenic, lymphatic, myelogenic, while combined or mixed forms are indicated by suitable compound terms, such as lieno-myelogenous. Most leukemias are mixed. In the first place, the spleen is almost always enlarged. It may be adherent to the abdominal walls, the diaphragm, stomach, or other viscera. The splenic changes exhibit three stages in their development. In the first, the spleen is simply hyperemic, soft, and swollen, sometimes even ruptured. The Malpighian bodies share in the hyperemia, and may be slightly en- larged, but are overshadowed by the swollen pulp. In the second stage, hyperplastic changes make their appearance in the Malpighian bodies, and as these grow the pulp is intruded upon. They may reach such size as to be recognized by the naked eye as spherical gray nodules one to three lines in diameter, or they may be elongated or forked, following the course of the blood-vessels. The third stage furnishes the granitic spleen, in which white dots are separated by dark streaks representing the destroyed pulp, pigmented by the disintegrated blood. The spleen is now hard, and is cut with resistance. Its size may be enormous, and the organ may weigh from two to eighteen pounds ( i to 9 kilos.). * "Wiener klin. W'ochenschrift," i8 66o DISEASES OF THE BLOOD. The lymphatic enlargement is a true hyperplasia. Xot only do the glands enlarge, but new foci of lymphatic tissue appear in various organs, as the liver and kidneys. These arfe regarded by some as simple extravasa- tions of leukemic blood from the capillaries. All the more prominent groups may share in the enlargement — the cervical, axillary, inguinal, and perineal glands. The individual glands remain, however, soft. The lymphatic folli- cles in the tonsils and in the tongue, pharynx, and mouth may' enlarge. This is also occasionally the case with the solitary glands of the intestine and the agminated glands of Peyer. The uiarrozv changes may be described, in a word, as reversion to the embryonal type of medullary tissue. The fat of the adult marrow has dis- appeared, and a mass of lymph cells mingled with nucleated red corpuscles in all stages of development takes its place. The marrow is often pyoid. The lymph cells include numerous large mononuclear cells, many in the act of division, also miultinuclear leukocytes. There are also numerous marrow- cells or myelocytes and eosinophiles, like those found in the blood. The liver is often enlarged, and, according to von Jaksch,* pari passu with the spleen, and it has this further peculiarity, that its edges are rounded, while in what he describes as pseudoleukemia infantum the edges are sharp, and the enlargement does not go hand in hand with that of the spleen. The liver is also at times infiltrated with leukemic patches and nodules, not unlike miliary tubercles. The same is occasionally true of the kidney. The thymus gland has been found enlarged in some cases of acute lymphatic leukemia, and even the skin, stomach, and gastrosplenic omentum have been the seat of growths, presumably lymphatic. In fact, there is no situation in which such growths may not make their appearance. The pos- sibility of their being blood extravasations, white in consequence of the large proportion of white cells, is always to be remembered. The lungs and heart alone seem free from encroachment by the lymphatic tissue. The heart may, however, be dislocated by a large spleen. The alterations in the hlood constitute really a part of the morbid anatomy of leukemia, but are commonly treated under the head of symp- tomatology, where I, too, will consider them. An increase in the mass of the blood may, however, here be mentioned. The heart and vessels are commonly found gorged with blood, usually coagulated, sometimes whitish or yellow in color. Symptoms. — The early symptoms of leukemia are precisely those of the other anemias, viz. : Insidious onset, pallor, rapid breathing amounting to dyspnea on exertion, iveakness and faintness, headache, indigestion, and loss of appetite. The last two symptoms may precede all others. Emacia- tion is ultimately added. Moderate fever, with rapid pulse, is also present in the majority of cases, the temperature sometimes reaching 103° F. (39.4° C). Headache, more or less continuous, is a symptom noticed. Lymphatic gland enlargements are evident. In a case recently under my care the first intimation of the presence of a large spleen was an attack of circumscribed peritonitis, favored, doubtless, by the presence of the splenic tumor and ascribed to exposure to cool air while perspiring. Hemorrhages from the nose and stomach are common, and dropsical swelling appears toward the close. Nasal hemorrhages are sometimes fatal. Thomas Oliver reported a case terminating fatally by sudden post-peritoneal hemorrhage. f * See cases reported by J. Chalmers Cameron and Saenger, Sajous' "Annual " for 1S151, E. t Sajous' " Annual " for 1890, vol. i., E, p. 12. LEUKEMIA. 66 1 Hematemesis may be an early and almost initiatory fatal symptom. Purpura hcsmorrhagica sometimes presents itself as a manifestation of the same tend- ency, as may also cerebral hemorrhage, producing coma. Priapism is an occasional symptom ; it is sometimes persistent, and in a case of Edes was the first symptom noticed. 1SJ0? 6.000.000 g s ^ IS ? j= g ? s s 1 130!5 1^ n(H S i t iin«? ^ fe ^\\w■ 5,000,000 100^ 9(V? 90% ^ m 4,000,000 •' 80^ 1 -i i— — — ^ -' 1W. _ V' '~ " /■ 10% r ~~ -■ /\ y m, 3,000,000 y 60 Arteriosclerosis is almost always present, and must now be ascribed to the xanthin bases, which are toxic while uric acid is not. The heart is hyper- trophied in its left ventricle. There may be deposits of urate of sodium on its valves. Changes in the lungs are mainly confined to emphysema, which is found in many cases of long standing. Symptoms. — Of Typical Acute Gout. — Persons subject to attacks of gout sometimes have premonitory symptoms suggesting the approach of an attack. These vary with the individual and are significant only in each case. They may be headache, neuralgia, any one of the numerous manifestations of deranged digestion, irregularity of the heart's action, palpitation, high tension of the pulse, depression of spirits, drowsiness, a disposition to yawn, a tired feeling — in fact, any symptom which the patient learns to associate wdth the attack. Attacks are apparently also invited or determined by anything which lowers the vitality of the patient. On the other hand, a supper with wine or a single glass of champagne will often produce an attack. The first actual symptom of the typical attack is articular pain, commonly in. the great toe, at the metacarpo-phalangeal joint, and with its appearance the premonitory symptoms usually pass away. The pain is extremely severe, sharp, shooting, and sudden, often arousing in the middle of the night a patient who has gone to bed apparently well and least expecting an attack. With this pain are the szcelling, heat, and discoloration already described under morbid anatomy. Rarely, the attack begins with a slight chill. On the other hand, there may be pain without heat, redness, or swelling, and all the typical local anatomical features of an attack without pain. In some instances the attack develops more slowdy. At times the first attack is so little distinctive that it is assumed to be something much more trifling, such as rheumatism or some slight injury, while the personal peculiarities, natural or acquired, always more or less influence the symptoms. After the outburst at night the extreme pain diminishes as morning advances, but it may recur the next night, and this goes on for four, five, or six days, when the attack terminates. Some fe-'ccr usually accompanies the onset of acute gout. The tem- perature promptly rises to ioo° F. (37.8' C), but does not far exceed it, 102° F. (38.9° C.) being the usual maximum attained. As in other acute diseases, the temperature is higher in the evening. The local temperature, notwith- standing the sensation of heat, is five or six degrees below that of the axilla at the same time. The attack terminates with desquamation of the epidermis over the inflamed joint. Changes in the urine are almost distinctive. It is scanty, acid, highly colored, and of high specific gravity. It deposits uric acid and urates on standing, and often contains a small quantity of albumin. It sometimes contains sugar in small or even decided quantity, but I am certain that at other times the reaction of uric acid on copper oxid is mistaken for that of glucose. During or preceding an attack the uric acid excreted may be diminished; later it may be increased, but, as elsewhere stated, a relative increase in uric acid is often mistaken for an absolute increase in the twenty- four-hours' amount. The probabilities are that these changes are inconstant. A recognized symptom of acute gout, and sometimes the only one, is pharyngitis, and now the term " gotvty sore throat " is one in common use, though it is doubtless also often used carelessly. There seems no way oi distinguishing it locallv from other forms of sore throat in which there is no decided swelling. 786 COXSTITUTIOXAL DISEASES. Gout is said to be rctroccdcnt or metastatic when it disappears suddenly from its external site and there are substituted for the outward symptoms derangements of some internal organ, especially the heart or stomach or brain or urinary bladder. In the first there appear cardiac symptoms of vary- ing severitv. including pain, shortness of breath, and irregularity in the heart's action ; in the second, gastro-intestinal pain, a sinking sensation, vomiting or diarrhea, often associated with intense mental excitement or depression ; in the third, meningeal symptoms ; and in the fourth, cystitis and prostatitis. ]More rare events are gouty orchitis, parotitis, and urticaria, or other fugitive skin affections. ^letastasis is more prone to occur in atonic cases. Sudden death has supervened in some instances, but postmortem lesions of a definite kind seem to be wanting, at least lesions which can be held responsible for the symptoms. Of Irregular or Atypical Gout. — This includes a set of symptoms not so distinctive in themselves as peculiar in this, that they occur only in persons Fig. So. — Tophaceous Gout. Both hands were symmetrical!}^ affected, man aged sixty (after Duckworth.) who have had gout or who have a decided hereditary tendency thereto. These conditions being fulfilled, there is scarcely any superficial or visceral symptom which may not be of gouty origin, but among them may be named cutaneous eruptions, gastro-infestinal disorders, various forms of headache and neuralgia, hot and itching palms and soles, especially at night, a similar condition of the eyeballs, lumbago and other muscular pains, arteriocapillary fibrosis and its consequences, iritis, bronchitis, pericarditis, cystitis with hemorrhage into the bladder, and others. Some affections of the teeth occurring under the same conditions may be regarded as gouty. Such are the so-called pyorrhcea alveolaris and " dental erosion." All that was said of the general physical and chemical characteristics of urine in acute and chronic gout may be true of it in irregular gout. Among other orgns the eye in its blood-vessels, retina and optic ner^^e falls heir to changes w^hich are ascribable to gout, but the same law as to their necessarv relation holds, bv which I mean that identical conditions occur GOUT. ;87 which are not due to gout, and the conclusion that they are thus related depends upon a definite knowledge of the previous existence of gout in the patient. An exception to this exists in the rare cases of actual uratic deposits in certain situations, as the cornea, the crystalline lens, vitreous humor, and even the retina. Many conditions are called gority on insufficient foundation. Of Chronic Gout. — As repeated attacks of gout occur and the patient grows older, there gradually accumulate the morbid changes described under morbid anatomy as more or less characteristic — the joints deformed by toph- aceous and other deposits, the lipping, the seal-fin hand, the renal and arterio- vascular changes, interstitial nephritis, etc. The urine now is in- creased, lighter hued, and contains albumin and a few hyaline and granular casts. Some further allusion should be made to the deformities thus resulting as symptoms of chronic gout. They appear especially in connection with the toes and fingers, causing swellings, deflections, and torsions which pro- duce the most fantastic shapes. Among these are deflected and abducted toes. Heberden's nodosities, the seal-fin hand, and the deformities caused by tophaceous deposits. It is important to remember that any of these except the tophaceous deposits may be due to rheumatoid arthritis as well as gout. Bursal cysts or crabs' eyes on Heberden's nodosities are said to point to iheir gouty origin. The appended cut from Duckworth illustrates the ai)pearance of enormous tophaceous deposits undoubtedly of gouty origin as contrasted with Heberden's nodosities. Treatment. — The treatment of gout easily divides itself into two parts : iirst, that of the gouty diathesis ; second, treatment of the paroxysm or of the acute attack. I. Treatment of the gouty diathesis. — It is plain that we may diminish the quantity of uric acid in two ways : first, by confining the gouty per- son to such food as produces a minimum of uric acid ; second, by admin- istering such medicines as will promote its solution and elimination. The first of these constitutes, in the main, the dietetic treatment, the second the medicinal. I. The Dietetic Treatment. — This is by far the most efficient of the treat- ments of gout, without which all else is only palliation. It consists essentially in the elimination, from the dietary, as far as possible, of all nitrogenous or albuminous principles, the complete combustion of which results in urea, and the incomplete, in uric acid. I say as far as possible, for it is prac- tically impossible to eliminate them altogether. The foods which are the type of this class should, however, be altogether omitted. Such are the meats of the butcher-shops, the albumen of eggs, and the cheeses. The first include beef, veal, mutton, lamb, and pork, whether salt or fresh, and for the most part fish. As to cheese, as one-half pound of this contains almosc as much nitrogenous matter as a pound of beef, — 27 per cent, when made of the whole milk, and 28 per cent, when made of skimmed milk, — it is plainly contra-indicated. If we consider only the edible parts of beef, — i. e., meat deprived of the refuse represented by bones, skin, etc., — it contains according to its source, from 17 to 23fper cent, of proteids ; mutton, from 15 to 18 per cent. Of fish, flounder contains 13.8 per cent.; mackerel, 18 per cent.; halibut, 15 per cent.; and salmon, 21 per cent., or quite as much as beef and more than mutton. Salt codfish contains 15 per cent. ; smoked her- 788 COXSTITUTIOXAL DISEASES. ring, 20 per cent. ; and canned sardines, 24 per cent. Poultry contains from 14 to 15 per cent, of albuminates, and game 22 per cent. The hen's egg, including albumen and yolk, contains 13.7 per cent, of proteid, whence it is plain that it is a less objectionable food than meat. On the other hand, milk contains but from 3 per cent, to 4 per cent, of protein ; butter, i per cent. ; and oleomargarine, 0.6 per cent. The fat oyster contains 8 per cent., the lean, 4.2 per cent., and the lobster, 5.5 per cent. ; fish other than those previously mentioned, from 5 to 10 per cent. Of vegetable foods, wheat bread contains 8.9 per cent, of protein ; wheat flour, II per cent., and Graham flour, 11.7 per cent. ; rye bread, 6.7 per cent. ; buckwheat flour, the same; corn (maize), 9 per cent.; rice, 7.4 per cent.; sugar. 0.3 per cent. ; potatoes, 2 per cent. ; sweet potatoes, 1.5 per cent. ; tur- nips and carrots, i per cent.; cabbage, 1.9 per cent.; melons, i per cent.; apples and pears, 0.4 per cent. ; and bananas, 2 per cent. Again, beans con- tain 23.2 per cent, and oatmeal from 12 to 15 per cent., large proportions of proteids. Thus, the typical foods permissible from the standpoint of composition are milk, butter, fruits, and succulent vegetables, except beans, and oat- meal. To these oysters and lobster may be added, moderately; fish, except that containing a large amount of protein, and, when extreme rigidity is not required, poultry in moderate amount; but all "butcher's meat should be strictly forbidden. It is usual, also, to inderdict the use of carbohydrates, — /. e. starches and sugars, — as well as the hydrocarbons, — fats and oils, — but I have never been able to see any reason for this. There is absolutely none from the standpoint of chemical composition, since they are totally without nitrogen, and, so far as my own experience goes, none from the clinical standpoint. Only in the event of their producing indigestion and fermentation, with the generation of acids, can they become a cause of gout, and then only, I should say, an exciting cause. I am in the habit, therefore, of permitting the use of rice, potatoes, and other farinacea, and, to a reasonable extent, sugar. I am glad to be able to say that I am sustained in this view by Sir William Roberts, who, in the brochure quoted on page 771, says also: " The most trustworthy experiments indicate that fat, starch, and sugar have not the least direct influ- ence on the production of uric acid, but as the free consumption of these articles naturally operates to restrict the intake of nitrogenous food, their use has indirectly the effect of diminishing the average production of uric acid." Basing his conclusions upon experiments with solutions of blood-serum impregnated with common salt (o.i per cent.), in which he found the precipi- tation of crystalline biurate always appreciably hastened, Sir William Roberts for some years past has directed the gouty to restrict, as far as possible, the use of common salt at meals. On the other hand, he recommends that the subjects of uric acid gravel should be advised to take habitually with their meals as much culinary salt as their palates will tolerate. There are, however, other sorts of ingesta, also entirely or almost free from nitrogen, acknowledged to be both a predisposing and an exciting cause of gout — namely, malt liquors and zcincs. These are composed of water, alcohol, carbohydrates, and a trace of miner'al matters, but no nitrogen. It is not easy at first to understand why these substances should be harmful. Experience, however, shows that the stronger wines, such as port, ]\Iadeira, and sherry, by their continued use, are very likely to produce gout, while the lighter wines, — the clarets, hocks, and Moselle wnnes, — if taken in modera- GOUT. 789 tion, rarely produce it. After these, stout, porter, and the strong ales induce gout. Even lager beer, which contains but 3 per cent, of alcohol, is capable of acting similarly, and I know many men who have been forced to give up this beverage because of this effect. Cider and perry least of all beverages predispose to gout. On the other hand, distilled spirits, especially whisky, are almost entirely without effect in producing gout. Why is this? Appar- ently, the amount of alcohol is not the measure of the effect, for whisky, gin, brandy, and rum all contain more alcohol than any of the wines named. If reference is made to the wines most likely to produce gout, it will be found that they are those which contain a considerable quantity of both sugar and alcohol. Such are port, sherry, and Madeir'a, all of which contain more than. 15 per cent, of alcohol and much sugar ; also sweet champagnes containing 11 per cent, of alcohol. On the other hand, some very sweet wines, as Tokay,. Malaga, and the higher Sauternes, which contain much sugar, are said to produce gout less rapidly. It would seem that those Uquors which contain alcohol in combination with other substances, especially sugar, are potent in producing gout, particularly when they excite indigestion, probably by restricting elimination rather than producing more uric acid. As to the acidity of alcoholic drinks, their influence is pretty clear as exciting causes. In this way act the beers, in which both alcohol and sugar are present in small amount, but which are highly acid. An explanation of this fact is less ready from the standpoint that the acute attack of gout is due to a reabsorption of the deposited uric acid by alkaline blood, than on the supposition that the attack is due to the irritative effect of uric acid deposited in the joints, because of the diminished alkalinity of the blood induced by the absorbed acid. Whatever be the explanation, few facts in the clinical history of gout are better established than that the ingestion of acid may be an excit- ing cause of attacks. In the same way act acid fruits, such as strawberries, acid oranges, and lemons. On the other hand, to such influence I have known the most diver- gent response. Thus, a gouty patient of my own could bring on an attack by drinking a single glass of lemonade, while a gouty friend would drink a pitcher of lemonade at dinner without any ill effect whatever. It is to be remembered that the otherwise harmful effects of the strong distilled spirits, such as are well borne in gout, are no less serious in gouty subjects than in others, and are often induced by the careless prescription of whisky because less harmful than wines in gout. A most valuable adjuvant to the dietetic treatment are the natural mineral waters. The waters which have heretofore received almost universal approval are the alkaline and alkaline-saline water's, although those possess- ing purgative properties also enjoy a good reputation. In America, however, few alkaline waters are native, while those which are, are so far inferior to the foreign waters that they do not serve the purpose. On the other hand the costliness of the foreign w^aters constitutes a very serious obstacle to their general use. Most of the native waters which have been employed and highly vaunted by their owners are of the kind known as negative waters — that is, they have no mineral ingredients in any quantity to justify their classification in any of the five principal varieties of mineral waters — viz., the alkaline, the saline, alkaline-saline, the purgative and sulphurous — or on which to base any therapeutic results except by their diluent effect. At the same time it has been noticed that these waters are not without effect in relieving gouty symptoms. Reasoning from these facts, we may prescribe such native nega- 790 CONSTITUTIONAL DISEASES. tive waters as are accessible to the patient, or distilled water, with this end in view — the simple diluent and solvent effect which comes from an increased proportion of water ingested. The further propriety of such a course is found in the fact that gouty and lithemic patients are often moderate water- drinkers, never drinking water between meals and very little at meals. To such, eight ounces of water ordered on rising, between meals, and at bedtime, will often clear off a dark-hued urine of high specific gravity and substitute a light-hued, clear urine, without any sediment. The mineral waters which have actually acquired the greatest reputation in the treatment of gout are those of which sodium bicarbonate is the chief ingredient, to which the calcium bicarbonate is regarded a valuable adju- vant. Such are the alkaline waters of Vals and Vichy in France, Evian-les- Bains in Switzerland, Neuenahr and Fachingen in Prussia, Contrexville and Vittel in the Vosges (France), and Dax in France. Other waters possessed of reputation in the treatment of gout, in which the quantity of alkaline bi- carbonate is smaller, owe it to their combined alkaline and aperient properties, chiefly due to sodium sulphate and magnesium sulphate, and belong in the second category of remedies for the treatment of gout. Such are the alkaline and saline waters of Carlsbad and Marienbad in Bohemia, Kronthal in Nassau, and Brides-les-Bains in Savoy. Then there are the saline waters represented by Baden Baden, Ems, Homburg, Kissingen, Wiesbaden, and our own Saratoga waters. In saline waters we are much more fortunate in this country, the Saratoga waters furnishing all that can be desired. Finally, there are the bitter acidulated and bitter purgative waters — Hunyadi Janos, Friedrichshalle and Rakoczy in Hungary, Piilna in Bohemia, and Rubinat in Spain — rarely resorted to for gout, but useful as eliminating agents. Among the weaker aperient waters are those of Bedford Springs, Pa., in this country. The use of these mineral waters is especially indicated in a continuous manner between the attacks, with a view to averting them. Especially useful are the thermal waters in the chronic arthritic complications, in which their internal use is combined with bathing. In this connection may be mentioned Calrsbad and Marienbad (at both of which the mud-baths are employed). Baden Baden, Ems, Wiesbaden, Hammon RTrha in Algeria, available in winter, Plombieres in the Vosges, and Dax in France. Homburg and Kis- singen are also resorted to for their baths, although the waters are cold. Sulphurous waters also have some reputation in gout. Especially is this the case with the waters of Aix-la-Chapelle in Rhenish Prussia and Aix- les-Bains in Savoy, Harrogate in England, Richfield Springs, Sharon, and St. Catherine's in Canada and Mt. Clemens in Michigan, U. S. A. In all these places the bath treatrrrent is an important adjuvant. America is also more fortunate in sulphur waters. The remedies in the second category — the aperients — are decidedly useful in gout, both as eliminators of toxic substances, and to prepare the way for the absorption and prompt action of the alkaline bicarbonates. They are not, however, used at the present day so freely as they were a century ago, and they are commonly reserved for the acute attack. Hygienic measures are also of importance in the treatment of gout. The patient should bathe daily, using the cool bath in the morning or the warm in the evening on retiring, as experience may determine to be the best. The skin should be thoroughly groomed, and daily exercise should be practiced, an open-air, outdoor life being desirable whenever possible. II. The Medicinal Treatment and the Treatment of the Acute Attack. — GOUT. 791 As a rule, the use of medicines is reserved for' the acute attack. From the earliest history of the disease practice has recognized two classes of remedies in the treatment of gout, — alkalies and purgatives.— the object of both being to eliminate the offender, the first by producing soluble combinations which pass off readily by the kidneys, and the second to carry it off by the bowels. It is plain that a combination of the two principles might be expected to be more efficient than either one alone. First, as to alkalies and alkaline combinations. ]\Iy experience places the salicylate of sodium easily at the top. and while it is not so rapid in its effect in relieving the pain of an acute attack of gout as it is in rheumatism, it is nevertheless an invaluable remedy, excelling all others. During an attack it should be given in doses as large as can be borne. As a fule, adult men easily bear fifteen grains (i gm.) four times a day, or ten grains (0.65 gm.) may be administered every two hours. Even larger doses may be given with advantage, if borne by the stomach. With relief to the acute symptoms the dose should be reduced : but, as in rheumatism, the remedy should not be discontinued, and between attacks smaller doses should be kept up for some time. These, however, may be substituted by the natural mineral waters to be presently alluded to. The efticiency of the salicylates is explained by the fact that their prolonged internal use is attended with an .increased elimination of uric acid. After the salicylates, the alkaine carbonates have alwys held a high position in the treatment of gout. Half an ounce ( 15 gm.) a day in divided doses should be the initial treatment, continued, but in smaller doses, when relief comes to the acute symptoms. It may be combined with a little lemon- juice to improve the flavor, or the citrate of potassium may be given in the same doses. Among the eliminating remedies is the time-honored colchicum, a drug which is of undoubted value in gout, but which, in my experience, must yield the palm to salicylic acid. For a long time its action was inexplicable, and it came to be known as a specific in gout as quinin is in chills and mercury in syphilis. ^Modern studies have, apparently, solved this problem. Pro- fessor Rutherford has shown that it is one of the most powerful cholagogues known. This, taken in connection with what we now know of the office of the liver in urea formation, simplifies very much the solution of the problem. It explains, too, why colchicum produces its sedative and anesthetic effect without necessarily causing purgation. Indeed, some, as Sir Alfred Garrod. considef that its eifects are best attained without purgation, and Garrod says that if cathartic action is required, it is better to combine some aperient with the colchicum, as when much purging and vomiting results from col- chicum, nervous and vascular depression follows. I confess I like to see a mild action on the bowels by increasing the dose gradually, and it is not necessary to produce either violent purging or vomiting. \Miatever its mode of action, it sometimes operates in the most magical manner in relieving pain. The preparation commonly used is the wine. In this country the wine of the seeds is no longer official, so that if the wine is ordered, that of the root is dispensed. This is more powerful than the wine of the seeds. The dose of the latter is from 1-2 to i 1-2 drams (2 to 6 c. c.) ever}- three hours dur- ing the attack, but of the root from fifteen to thirty minims (i to 2 c. c), reducing the dose when nausea or purgation ensues. The acetic extract of colchicum was a favorite preparation of the older physicians, especially Scudamore, who introduced it, and who considered its action milder than 792 CONSTITUTIONAL DISEASES. that of anv other form. It is still sometimes used, and has the advantage that it may be put into pill form. Its dose is from one to two grains (0.065 to 0.13 gni-)- Scudamore's gout remedy consisted of magnesium sulphate, four drams (15 gm.) ; magnesia, eighty grains (5 gm.) ; vinegar of col- chicum, four fluid drams (15 c. c.) ; syrup of crocus, four fluid drams (15 c. c.) ; mint watef, five fluid ounces (150 c. c). From one to three table- spoonfuls are given every two hours until from four to six evacuations are produced in twenty-four hours. The fluid extract of colchicum may be administered in doses of from two to six minims (0.12 to 0.30 c. c). Colchicin, the active principle of colchicum, is also employed. Its dose is 1-50 grain (0.0013 gm.j. The same dose may be employed hypoder- micallv. A favorite modern remedy is the salicylate of colchicin in doses of 5 minims (0.31 c c), given in pearls or capsules. The other aperients commonly used in gout are the sulphates, of which magnesium sulphate is the favorite. Sodium sulphate is also used, and it is the constituent of the most actively purgative mineral waters already mentioned, viz., the Hunyadi Janos. Rakoczy, and Friedrichshalle, now largely used instead of the pure salt. It is also the largest constituent of the Carlsbad waters. A favorite combination of the older physicians was magnesium sulphate two drams, magnesium carbonate a scruple suspended in an ounce of cinnamon water, given two or three times a day until active purgation resulted. These two substances may be combined with colchicum. and with it make one of the forms of Scudamore's mixture, alluded to. Another of the older remedies, also purgative should not be lost sight of. It is Warner's gout cordial, essen- tially the tincture of rhubarb and senna of the pharmacopeia of the present day. Colocynth is also employed as an aperient in gout, and advantage has been taken of this fact in the preparation of the secret remedy known as Laville's tincture, which is very largely used by the laity, and which undoubt- edly has a very prompt efifect in many cases of acute gout. The following has been published * as the composition of Laville's remedy, as determined by analysis : Quinin, 5 parts. Cinchonin 5. Colocynthin, . ' 2.5 Lime salts, 5. Water, 82.5 Alcohol, ......... 100 Port wine, ......... 800 The lithium compounds — the carbonate and citrate — have not proved so ■jseful as to cause me to prefer them to salicylic acid. Indeed, the early results of Garrod with them cannot be said to have been realized in modem therapeutics. Sir Dyce Duckworth says of lithia that it is a remedy better adapted to the chronic than to the acute phases of gout, and so I have been using it. Five grains (0.3 gm.) four times a day, freely diluted, is the dose usually administered, and with this the potassium salts are sometimes combined. Another modern remedy asserted to be efficient in the treatment of gout is piperazin. I regret to say that I have been disappointed in it. In my early trials I thought it useful, but soon learned that it was less efficient than the salicylates and colchicum. While an acknowledged solvent for uric acid * "Druggist's Circular," October, 1889. LIT HEM I A. 793 when dissolved in water, it seems to be incapable of dissolving uric acid in the system. It still has some stanch adherents, and may be tried. From fifteen to thirty grains ( i to 2 gm. ) daily are advised, dissolved in water or in some one of the numerous mineral waters. Local Applications. — For the relief of the acute attack of gout, leeches, blisters, and cold have all been discontinued of late years, not only because they are useless, but also because their use has been followed by fatal at- tacks of the so-called internal gout. Warmth and moisture do, however, have a mollifying effect, which is increased if the liquid preparations of opium be associated. Cocain, which might be expected to be useful, operates only through surfaces whence the epiderm is removed. Should such be pres- ent, a five per cent, solution may be applied on lint. It often happens that the pain in a paroxysm of gout is so severe that it is impossible to wait until the effect of the foregoing remedies is secured, and a hypodermic injection of morphin is absolutely necessary to relieve the sufferings of the patient. I must remind the reader, however, that as many old subjects of gout have contracted kidneys, the use of morphin under these circumstances is attended with some danger, and the drug should be used with great caution. All pressure by boots on joints disposed to gout should be carefully avoided, as well as injuries, as such influences undoubtedly act as predis- posing causes. Muscular and mental fatigue are exciting causes of acute attacks, and should be avoided by the gouty. Treatment of Retrocedent Gout. — The true nature of a metastatic attack having been determined, it must be relieved symptomatically, while efforts to stimulate a true external attack may be made by the hot mustard foot- baths, sinapisms, and the like. It has even been suggested that a pint of champagne may be advised, this being the wine most frequently responsible for acute attacks. LITHEMIA. Synonyms. — Uricacidemia; Uricemia; American Gout. Definition. — A condition of imperfectly determined anatomical and chemical nature, but probably the result of an accumulation in the blood of partly oxidized products of food metamorphosis, of which uric acid is the type. It differs from gout chiefly in the absence of joint deposits and joint inflammation. In England the name of Murchison is inseparably associated with lithemia, and in this country that of J. M. Da Costa. The former ascribed the accumulation to inactivity of the liver. It has been called Amer- ican gout, because it has been thought to take in this country the place that gout occupies in England. Etiology. — The accumulation referred to is the result of intemperate eating and drinking, especially if associated with the lack of exercise suffi- cient to oxidize the food ingested. In either event the income is greater than the output, accumulation results, and morbid phenomena follow. Heredity also plays a part at times. Symptoms. — Among symptoms^ tolerably constant are manifestations of indigestion, including fullness and discomfort after meals, an unpleasant taste, at times nausea, and at others acidity : a tendency to constipation and absence of bile from the discharges; also a tendency to aphthous ulcers in 794 COXSTITUTIOXAL DISEASES. the cheeks and hps, with punctiform ulcers on the end and sides of the tongue. Extreme nervous irritability is also often associated or may be the most striking symptom, while vertigo and headaehe are among the most con- spicuous and annoying. While vertigo is often associated with a fullness and throbbing, the vertigo and severe headache are rarely associated. A further characteristic is the slozv pulse, which may beat at the rate of but iiftv or sixtv times a minute and even less, and exhibits a correspondingly increased tension, with sharp accentuation of the aortic second sound. On the other hand, if the patient be an alcoholic or addicted to tobacco, the lirst sound of the heart may be feeble. Curious paresthesias are also often present, of which tingling and a sense of numbness are conspicuous. There may be anesthesia. In contrast to this muscular pain, shooting or aching may occur anywhere in the body. Last, but by no means least, is depression of spirits, most inveterate and unpleasant, the patient imagining he is the subject of every known disease, while suicide is sometimes sought for relief. There is almost invariably alteration in the quality and quantity of the urine. It is scanty, Jiighly colored, of high specific gravity, depositing on standing, especially at a slightly lower temperature, a large bulky sedi- ment composed of mixed urates or uric acid or both. In this sediment also are sometimes included oxalate of lime crystals. Yet though almost invari- ably present, this state of the urine cannot be regarded as essential, and cases occur with the tout ensemble of symptoms while the urine is in a natural condition. Diagnosis. — This hinges very largely upon the condition of the urine, as described, and upon the habits of the patient. It has already been stated that lithemia differs from gout in the absence of joint symptoms, but it cannot be denied that the two conditions often occur conjointly. Less frequently, if at all, is lithemia the result of heredity, and it demands as an essential condition the overeating and drinking with defective oxidation referred to, which, while exciting causes of gout, are by no means always necessary to its production, especially when there is a decided hereditary tendency to the same. As intimated in the definition, uricacidemia is rather a condition in- ferred than actually demonstrated — inferred from the disproportionate amount of uric acid excreted as compared with urea. Prognosis. — It may be said, too, of lithemia, as distinguished from irregular gout and from gout, that the prognosis is, on the whole, more favor- able, and a cure may be generally promised the patient if he comply with the physician's instructions. Treatment. — The indications are evident. The overeating and over- drinking must be feduced, and" active outdoor exercise must be practiced in order to burn up the remnant of unoxidized food. The restriction which Avould be required depends somewhat upon the severity of the case, but in all instances may be covered by the injunction to the patient to become a vegetarian rather than carnivor. The juicy green vegetables, such as peas, beans, spinach, asparagus, cauliflower, celery, onions, cabbage, lettuce, and an abundance of milk, are allowed. The free use of water, preferably the alkaline mineral waters referred to in treating of gout, and the omission of all alcoholic drinks should be enjoined. A quart (a liter) of Vichy or Vals daily, or in their absence any one of the indifferent mineral waters, with the addi- tion of lithium or sodium carbonate, should be drunk. When urgency is re- quired, a diet of diluted milk or of milk and \'ichy may be insisted upon until such symptoms pass away. DIABETES MELLITUS. 795 Of meats which may be permitted in moderate quantity along with vegetable food are oysters, fish, the white meat of chicken, and game. The question of the carbohydrates is a mooted one. I have never seen such food as rice and potatoes do harm, nor bread — if of good quality and not too freshly baked. Sugar is best restricted, because of its tendency to produce acid fermentations and acidity. There is no chemical contra-indication. H)^dro- carbons, on the other hand, are not well borne, and all fats should be for- bidden, including butter, as well as the fat of meat. As to medicines, the most important are the alkalies, which may be added to the negative mineral waters if they are used instead of the more truly alkaline waters. Aperients, and of these again the salines, are espe- cially indicated, and above all the natural mineral purgative waters, such as Saratoga waters in this country, Hunyadi, Friedrichshalle, and the like. Phosphate of sodium is a favorite aperient in these conditions on account of its supposed action upon the liver. The usual dose is one dram (4 gm.) in the morning, on rising, dissolved in hot water. The lithium salts may be used, and while I have not been able to trace any very direct results to their action, they serve as an excuse for the administration of liquids, since they are usually given dissolved in water— say five grains (0.3 gm.) of the carbonate or citrate in a glass of water before meals. Pleasant effervescing tablets containing these doses are now made by many manufacturing chemists. The stomachics and bitter tonics, of which nux vomica and strychnin are the types, may form useful adjuvants, and pepsin with hydrochloric acid after meals is often useful. The salicylates, if well borne, are useful remedies to hold in solution the uric acid and favor its elimination. Extremely painful attacks may require the use of opiates, but the doses should be as small as possible, and their use should be discouraged under all circumstances excepting in extreme urgency. DIABETES MELLITUS. Definition. — A condition characterized by copious secretion of a urine charged with glucose and due to some as yet imperfectly understood de- rangement of the glycogenic and glyco-destructive functions of the organism. Historical. — Diabetes is one of the oldest diseases known, being referred to by the Roman Celsus and the Greek Aretaeus, both of whom lived in the first century of the Christian era; also by the early East Indian physicians as a condition character- ized by copious secretion of urine, extreme thirst, and emaciation. Little, if any- thing, was, however, added to the subject until the latter part of the seventeenth century, when Thomas Willis (1622-75) in England first inferred from its sweetness the presence of sugar in the urine. Moreover, it was not until a century later, 1775, that Matthew Dobson, also an Englishman, actually obtained sugar from urine. Among other early students of this subject were Cowley (1788), Frank (1704), John Rollo (i7q7), W. Prout (1825) in England, and Bouchardat and Mialhe in France. Inseparably associated with the subject is Claude Bernard, who first discovered that glycosuria could be produced by puncturing the floor of the fourth ventricle. Since that time there is perhaps no subject in medicine to which has been contributed so much knowledge from an experimental side as this one, and yet no subject as to the true pathology and etiology of which we possess proportionately less accurate infor- mation. Other names associated with the clinical and experimental investigation of diabetes are Briicke, Cantani, Dickinson, Pavy, Ebstein, Frerichs, Kiilz, Lecorche, von Mehring, Minkowski, Naunyn, Seegen, C. C. von Voiht, Senator, F. Voit, and Carl von Noorden. ' Geographical and Racial Distribution. — Diabetes is not a common dis- ease anywhere, and it is variously frequent in different countries and races. 796 CONSTITUTIONAL DISEASES. Thus it is less common in the United States than in Europe, where there are said to be from five to nine cases among 100,000 inhabitants, while according to the last United States Census there are but 2.8 in 100,000. According to Dickinson, the disease is more widely prevalent in the agricultural counties of England than in the cities. It is common in Sweden, on the one hand, and in southern Italy and India, especially in Ceylon, on the other, while espe- cially rare statistically in Holland. Russia, and Brazil. It is much more frequent among Hebrews than among Christians in the experience of almost everyone, yet for what reason I have been unable to discover. One of my Hebrew friends suggested that it is due to the in- tensification of hereditation by intermarriage. It is rare in the negro race, though I have met several cases. It is a disease especially frequent among the rich and well-to-do, though the poor are not exempt. It is also a disease of adults, yet it has occurred in infants at the breast. In the reports of the Registrar-General of England for the years 1851-60, ten deaths are regis- tered under the age of one year and thirty-two under the age of three. The youngest patient I ever had was a little girl aged twenty-two months, who was delivered prematurely because of nephritis in the mother, though the child was healthy up to one year. Albuminuria was associated with the dia- betes. The disease is most frequent between the ages of thirty and sixty. It is more serious in the young, recovery in very young subjects being almost unknown. It is much more frequent in males than in females, in the pro- portion of nearly three to one, though Senator's* statistics show that under the age of twenty more females are affected than males. This has been my own experience. Little is known of the effect of occupation, though it is thought that occupations taxing the mind favor it. It has happened to me to treat a number of physicians and farmers. Heredity has in my experience been less conspicuous than European writers find it. From 10 to 25 per cent, are thus traced by different Continental observers. On the other hand, it may occur in several members of a family. It is not unusual to find dia- betes mellitus in some members of a family and gout in others. Pathology and Pathogenesis, — The etiology of diabetes is so inti- mately united with its patholog}' that it is scarcely possible to separate their consideration. What is known, therefore, of its immediate causation will be developed in connection with the pathology, while its more remote causes will be briefly considered in the ensuing paragraph. Inseparably connected, also, with the pathology of diabetes are the phenomena of sugar formation in the economy. A brief statement of the latter seems, therefore, justifiable. During life there is constantly being produced and stored in the liver of man and the lower animals an amyloid substance, which was named by its discoverer, Claude Bernard, glycogen.j Its formula is C^, H,„, O 5, that of starch, and the term ^oaiiiyliir, or animal starch, was at one time suggested for it. The glycogen formation takes place whether animal or vegetable food be taken, but it is much larger upon a vegetable diet. It is commonly held that it does not occur at all with a diet of pure fats, but Salomoni: claims that it is produced in the livers of rabbits fed on olive oil. C. von Noorden also considers that fat is converted into sugar in the liver. § All physiologists agree that this amyloid substance is derived mainly from the * See Senator's article on "Diabetes ^Mellitus " in " Ziemssen's Cyclopagdia of Medicine." vol. xvi. p. 866, ad fin. + Bernard, " Xov. Fonc. du Foie," Paris. 1S53. X " Yirchow's Archiv," vol. Ixi., part 3. 1874. 18. ^ Article "Diabetes Mellitus," in "Twentieth Century Practice of Medicine," New York, iSgs^ vol. ii. p. 42. DIABETES MELLITUS. 797 starchy and saccharine principles of food, but partly also by a splitting up and rearrangement of the elements of nitrogenous food. This possibly takes place in the liver, resulting in the production of urea and glycogen, the latter being stored in the liver-cells. The muscles are also favorite reservoirs for glycogen storage. The most important property of glycogen is its ready convertibility at the temperature of the body into glucose, or grape-sugar ; for this a glycolytic ferment is probably required. By means of these storage reservoirs the blood is kept supplied with 0.12 to 0.18 per cent, of grape- sugar in health, the oxidation of which contributes to the forces of the economy. In diabetes mellitus some derangement of this balance takes place, as the result of which more or less of the glucose delivered to the blood is not utilized, in a word, is wasted. This may be brought about in several ways : (i) It may be that the glucose arising by a reconversion of the glycogen stored in the liver is contributed to the blood too rapidly to be oxidized; (2) It may be that, although the glucose is delivered in normal quantity, it is still not consumed because of some defect in the oxidizing mechanism, some deficiency in the glycolytic ferment; (3) It may be that the glucose arising from sugar and starch digestion in the intestine is not first con- verted into glycogen as in health, but passes directly through that organ to the vena cava too rapidly or in too large quantity to be utilized, or lacking some molecular quality which permits its oxidation. One or the other of these alternates will explain all cases of glycosuria when the non-utilized glucose is derived only from the carbohydrates of the food. These are the milder cases and include also those cases of glycosuria clearly traceable to overingestion of sugars and starches. Those bad cases of diabetes, however, which Dr. Pavy calls " composite diabetes," in which the glucose arising from proteid foods, and finally even from proteid tissues, is not utilized, are less easy of explanation. For it would seem that not only is the glucose normally arising unconsumed, but that there is also an increased formation of glucose from these sources, and it may be even from the " fixed proteids " of the body. Whichever of these it is, the excess of sugar thus resulting in the blood is eliminated by the kidneys, and thus glycosuria becomes an essen- tial symptom of diabetes mellitus. Etiology. — What causes this deranged mechanism? I have already said that there is no disease concerning which so much accurate knowledge has been arrived at and of the true pathology of which we are so thoroughly in the dark. It is not a kidney disease, as was once supposed in its early his- tory, although this impression still prevails among the laity, and naturally so, because the essential evidence of its existence is found in the urine. We know, further, that diabetes occurs under very different circumstances. We can produce diabetes in an animal by irritating the floor of the fourth ven- tricle, as was originally done by Claude Bernard in his celebrated piqiire experiment. There are, however, also other parts of the nervous system, the irritation of which will produce diabetes, from the cerebellum down to the point of emergence of the sympathetic nerves to the viscera. It is commonly admitted that this experimental glycosuria is caused by a centrifugal stimulus from the nervous centers to the liver, through the vasomotor system. We know, also, that tumors impinging on the floor of the fourth ventricle, and lesions of this part of the brain, including abscesses, are attended by diabetes mellitus ; also injuries to the spinal cord. Relatively remote from the nervous centers is an organ, the pancreas, 798 CONSTITUTIONAL DISEASES. - the diseases of which are often associated with diabetes melHttis, and whose extirpation is followed by glycosuria. On the other hand, we know that in a large number of the gravest forms of diabetes autopsies have failed to disclose any lesion whatever ; in fact, the most unmanageable and serious cases are those in which we find no lesion. Therefore, while we must admit that both the nervous system and the pancreas have something to do with the causation of diabetes, we are not able to trace a nervous or pancreatic lesion in every case. It is further likely that the sympathetic nerve is an important channel for nervous influence, regulating as it does the opening and the closing of the blood-vessels. A word more as to the relation of the pancreas to diabetes. I have said such relation is proved from the experimental as well as from the clinical side, and I myself, in a few cases at autopsies, have found a pancreatic lesion. Hanseman claim pancreatic lesions in 50 per cent, of cases. From the experi- mental side it is found by von Mehring and Minkowski that extirpation of the pancreas is immediately followed by diabetes ; and, although there are some differences in results, it is one of the best determined facts that glyco- suria follows such extirpation. Sometimes such a diabetes has been tran- sient, but then it has been found also that a fragment of the pancreas was left behind. I repeat that while we must admit that the pancreas has some- thing to do with a large number of cases of diabetes, we cannot say so of all, as there are some in which no lesion is found. The rationale of this relation of the pancreas is not settled. It has been alleged that the absence of the pancreatic secretion is responsible, but it has been shown that simply cutting off the secretion from the intestine does not cause diabetes. It has been suggested that extirpation of the pancreas really operates by disturbing the sympathetic nerves in the vicinity ; but this has also been experimentally refuted, and, with this, the view of Klebs, accepted by Senator, that the coexistence of diabetes mellitus and disease of the pan- creas is primarily or secondarily due to lesions of the celiac plexus. The researches of Lepine, which have been confirmed, ascribe the glycosuria to the absence of a glycolytic ferment furnished in health by the pancreas to the blood. This explanation certainly accounts for the facts. It is evident that it is impossible to explain all cases of diabetes from any one standpoint to the exclusion of another. An important relation has recently been established between the supra- renal gland and glycosuria, by the studies of Blum,* Herter, and Croftan. The first showed that glycosuria ensued upon the subcutaneous injections of animals with freshly prepared^ suprarenal extract, even when the diet was free of carbohydrates. This was confinned by G. Suelzer f and A. C. Crof- tan. $ Reasoning thence Croftan announced that the suprarenal capsules contain a substance which either causes the formations of sugar or inhibits the normal destruction of sugar. Herter § does not accept Croftan's conclusion, but concludes rather that many and perhaps most forms of glycosuria and diabetes are due to the action of substances or conditions which interfere with normal oxidation in the cells of the pancreas. He adduces in proof, the fact shown by himself that * " Ueber Nebennieren Diabetes." " Archiv f. klin. Med ," iqoi, Bd. Ixxi., Heft 2 u. 3, S. 146. t" Zur Frag-e der Nebennieren Diabetes," " Berlin, klin. Wochenschrift," iqoi, No. 48. S. i2oq. t" Concerning a Sugar-forming Ferment in Suprarenal Extract," " American Medicine," Janu- ary 18, iqo2. § With A. N. liichards, " Preliminary Communication," " Med. News." February i, iqo2. Also " Experimental Glycosuria from Adrenalin Chlorid and its Relations to other Forms of Glycosuria, Dependent on the Action of Reducing Substances on the Cells of the Pancreas," "Trans. Assoc. Amer. Physicians," igoz. DIABETES MELLITUS. 799 glycosuria results from subcutaneous injection of adrenalin chlorid, and moreover that painting the pancreas with the same solution is followed by a transitory glycosuria with corresponding glycemia, while no such effect fol- lows a similar application to the liver or spleen; while after adienalin chlorid undergoes oxidation it loses its ability, when thus applied, to cause glycosuria. Thus is laid at the door of the suprarenal capsule interference with the cell activities in the pancreas which are concerned with the production of an oxidizing enzyme whose function it is to oxidize glucose. Closer than this we have been unable to come. Deranged suprarenal function is of course not the only cause which interferes with the normal function of the pancreas. Any agency, direct or reflected, which is capable of influencing normal cell activity of the pancreas may becoine a cause of diabetes. Hence a variety of causes, some of which seem but rem.otely connected with the dis- ease, may operate to cause diabetes. In illustrations of traumatic agency by which the pancreas is indirectly affected I may refer to cases of movable kidney causing pancreatic diabetes, cured by nephropexie reported by Sher- man Thompson Brown.* As instances of such influence may be mentioned the rare instances of diabetes associated with pregnancy. Operating through the nervous system, in addition to nervous lesions already named, may be worry, gastro-intestinal derangements, disorders of the liver, sexual excesses, and the like. Among more remote causes recently suggested are toxic agencies introduced from without or originating in the alimentary canal, such, as instanced by Williamson, f may be the explanation of many cases otherwise unaccountable. Morbid Anatomy. — Diabetes can hardly be said to have an essential morbid anatomy, for, except in the instances mentioned, the morbid lesions which are found after postmortem examination to have been associated with diabetes are, in the main, such as are the consequence of the continued pres- ence of the condition, rather than such as cause the symptoms. Sometimes there are absolutely no alterations discoverable, either by the unaided eye or with the microscope. To begin with the organ which has so much to do with the glycogenic function of the body, — the liver, — it frequently presents the appearances of a hyperemic organ — that is, it is darker and harder than the normal organ, while it is also enlarged, sometimes considerably, at other times only slightly. Corresponding to this, the microscope, by very moderate amplification, shows enlarged and distinct acini, with capillaries dilated and distended in various degree with blood. Higher magnifying powers — 300 to 400 diameters — show the liver-cells to be enlarged, distinctly nucleated, rounded, and disposed to fuse. If a weak solution of iodin is added, they may strike a wine-red color, which, according to Rindfleisch, is confined to the nucleus ; but, according to Senator, may extend to the whole of the cell. Klebs ascribes this reaction to postmortem changes in the glycogenic substance. The minute changes described are said by Rindfleisch to be mote striking in the peripheral zone of the lobule than in that of the portal vein, while the intermediate zone, or that of the hepatic artery, is fatty, and the central part, including the rootlets of the hepatic vein, is nearly normal. Incidental morbid states are hyper- trophic cirrhosis and atrophic cirrhosis. An interesting fact in this connec- tion is that the most serious organicf disease of the liver appears never to cause glycosuria. * "Philadelphia Medical Journal," April 4, 1902. t "The Practitioner," July, igoo. 8oo CONSTITUTIONAL DISEASES. As to the pancreas, about which so much has already been said, it may be well to mention the changes found at different times. They include calculi found in the pancreas of a diabetic as early as 1778 by T. Cowley, cancer by Bright at a comparatively early date and atrophy by Griesinger, who had found the pancreas atrophied in one of the five diabetics whose bodies he examined after death, yet believed that this lesion was of no significance whatever. But the observations which have been published in great numbers (Hartsen, Fles, von Recklinghausen, Frerichs, Klebs, Harnock, Kiilz, Schaper, Lancereaux, Senator, and others) allow us to assume that diseases of the pancreas are present in about one-half of all the cases of diabetes. The statement of Senator * that this organ " is found diseased with surprising frequency, in particular either atrophied or, in addition, degenerated," is in the main correct. Among nine cases Frerichs saw atrophy or fatty degeneration of the gland five times, and in the Vienna dead-house the pancreas was found strikingly small, soft, and anemic in thirteen out of thirty diabetics (Seegen). Other coincident diseases of the pancreas already mentioned are cancer and impacted calculus. Reference should not be omitted to the important work of Eugene L. Opie, who has shown minute changes in the island of Langerhaus in certain cases of diabetes mellitus.t The kidneys, primarily unaffected, are in many cases sooner or later influenced by the constant hyperemia to which they are subjected in eliminat- ing the sugar. The appearances commonly met are those of hyperemia and overgrowth of epithelium — in a word, those of catarrhal nephritis. Occa- sionally the changes are more advanced, and the epithelium is fatty. More rarely granular contracted kidney is present, contributing a more serious significance to the albuminuria. These changes are not necessarily attended by albuminuria previous to death. In most other cases I believe nephritis to be an accidental coincidence. There occurs also sometimes a vesicular swell- ing of the epithelium in the straight tubes, hyaline changes in the descending limb of Henle's loop, as well as a hyaline change in the vessels of the Mal- pighian tubes. As to the proportion of cases in which the kidneys reveal morbid alterations, it is a decided majority. The hings are often the seat of tubercular deposits and cavities resulting from their softening ; also of bronchopneumonia and croupous pneumonia, which may terminate in gangrene. The heart is sometimes hypertrophied. Symptoms. — Almost invariably the earliest symptoms noticed by the diabetic are thirst and polyuria. One or the other of the two may be noticed first, or the patient's attention may be called to both simultaneously. It occa- sionally happens that a dryness of the fauces and a glutinous viscid character of the saliva attract attention before any other symptom. Sometimes it is observed that a drop of urine falling upon the boots or clothing and evaporat- ing there, leaves a persistent white or yellowish spot due to sugar. Dryness and harshness of the skin, due to absence of perspiration, soon make their appearance and early attract the attention of those who ordinarily perspire freely, and occasion varying amounts of discomfort. Itching of the skin is also sometimes present. The temperature of the body is not increased, at this stage scarcely altered, although later in the disease it may be decidedly lowered. If the further progress of the disease is not arrested, a voracious * Senator, loc. cit.. p. 8S7. f'On the Relations of Chronic Insterstitial Pancreatitis to the Islands of Langerhaus anc Diabetes Mellitus," "Jour, of Experimental Medicine," vol. v., 1900-1901, p. 396. DIABETES MELLITUS. ■ 8oi appetite becomes the next symptom, notwithstanding which the patient observes that he slowly loses in zueight and grows daily tveaker. Extreme languor and zveakness are characteristic. The rapidity with which these symptoms succeed one another varies. Sometimes the course is very rapid, constituting an acute form ; at other times the successive stages are exceed- ingly slow in developing chronic diabetes. Boils and carbuncles in the skin are also of frequent occurrence, favored \)y the malnutrition growing out of diabetes, and the former are occasionally the first symptoms recognized. The latter never occur early, but, when present, are frequently the immediate cause of death. Gangrene of various parts of the body is another of this class of symp- toms. It is sometimes spontaneous, but more frequently is immediately caused by some trifling injury which, under other circumstances, would be without result. It has been known to start from a blister and from the cut- ting of a corn. Beginning most frequently in those parts of the body most remote from the center of the circulation, as the toes, its progress and appear- ances are like those of senile gangrene. Sometimes, however, the gangrene is moist. Eczema, with itching and burning of the labia and vicinity, is a frequent and troublesome symptom in women incident to the extremely frequent mictu- rition. In the male the meatus urinarius is sometimes the seat of a similar irri- tation. Eczema elsewhere, as on the palms of the hands, is also a symptom. The early loss of sexual desire is characteristic. Dyspeptic symptoms may appear at various stages, seldom very early. Acid eructations, flatulence, and epigastric pain, or an indescribable sensation described as " sinking " of the epigastrium, are among them. Constipation is sometimes a very troublesome symptom, and adds, in my experience, to the seriousness of the case ; on the other hand, diarrhea is occasionally present. The foregoing category includes all the symptoms which present them- selves in the milder form of the disease. But unless averted, all these symp- toms become intensified. The patient complains of constant burning thirst, is continually urinating, and as constantly drinking w^ater to quench his thirst, and, while often eating enormously, grows emaciated, although at the onset of the disease he may have been a robust, vigorous man. As the disease advances there is a peculiar vinous or acetous odor of the breath, which has been compared to that of stale beer, and by Sir Thomas Watson to the odor of a place in which apples ar'e kept. This is believed to be due to acetone and diacetic acid, both of which exist in the blood of severe cases of diabetes. Later, cough often sets in, owing to bronchitis and tubercular phthisis, and, with the copious expectoration incident to them, adds to the debilitating agencies already at work. Roberts thinks phthisis occurs in one-half the ■cases. I am sure not so many die of it in this country. C. von Noorden says one-fourth of all diabetic subjects in Germany have the disease, and Lancereaux, that victims of pancreatic diabetes are especially prone to tuber- culosis. The consumption thus induced sometimes rapidly hastens the fatal termination, while at other times it appears to have but a trifling influence in this respect. The other symptoms characteristic of pulmonary consumption are also present, not excepting hectic sweats. The perspiration thus arising may contain sugar. Diabetic coma, first described by Kussmaul in 1874, is a form of coma which often comes on in advanced stages of diabetes and almost as often ter- 51 8o2 ■ COXSTITUTIOXAL DISEASES. minates in death. The condition is one of suddenly or gradually superven- ing unconsciousness, with or without previous irritability or uneasiness, anxiety, vertigo, or symptoms resembling alcoholic intoxication. Sometimes it is preceded by obstinate constipation or intestinal catarrh or severe colicky and muscular pain. Convulsions do not occur, but the eyes are half open, the pupils dilated, and the eyeballs wandering. In addition to coma there are frequent and feeble pulse, deep inspiration, with short expiration, more or less frequent than in health, and gradually invading cyanosis. The tem- perature, at first slightly elevated, is subsequently subnormal. The condition lasts for from twenty-four to forty-eight hours, when death usually super- venes. Over one-half of all deaths in diabetes are ascribed to diabetic coma by Frerichs, but others assign a much smaller number to it. The odor of ace- tone may issue with the breath. The coma has been variously ascribed to acetone and diacetic acid, to oxybutyric acid, and by Professor Saunders and D. J. Hamilton * to slow carbonic acid poisoning due to fat embolism of the pulmonary vessels, the result of lipemia. All views are speculative. Acetone and diacetic acid are very often present for a long time, and yet no diabetic coma supervenes. There would seem to be better reason for ascrib- ing the condition to " acid intoxication," as held by Stadelmann and ]SIin- kowski, since the continued presence of oxybutyric acid is always followed, sooner or later, by coma unless the patient dies from some other cause. Diabetic coma must not be confounded with other forms of coma which may occur in diabetes, as true apoplexy and uremia. Alore Unusual Symptoms. — The previously recorded symptoms occur sooner or later in most cases, the thirst and saccharine polyuria being essen- tial. There are many others which occur more or less frequently, but not constantly. Among the rarer symptoms is cataract, the association of which with diabetes was long ago noticed by Prout. It develops rapidly and is nearly always symmetrical, involving both eyes simultaneously, but not to the same degree. It is sometimes a very nice point to determine whether cata- ract is due to diabetes or to the usual causes. The earlier the age at which it occurs, the more probably is it due to diabetes. Other visual defects may occur. Among these are myopia, amblyopia, presbyopia, and loss of accommodating power from defect of the cilian,' muscle. George E. de Schweinitz informs me that a sudden development of myopia between the fortieth and sixtieth years without apparent lesion is characteristic of diabetes. It may be due to a fine edema of the choroid, or a choroiditis which in turn determines an elongation of the axis of the eyeball and thus produces myopia. The ophthalmoscope may "reveal dilatation of the retinal vessels. The late Albert G. Heyl f described a condition which he called intra-ocular lipemia, in which the light salmon color of the blood contained in the branches of the retinal vein and artery contrasted with the cinnabar-red of the vein and yellow-red of the artery, also by the greater width of these vessels and the lighter yellow of the fundus. Finally, atrophy of the retina and hemorrhagic and inflammatory affections of the eye have been described, and total blind- ness has been ascribed to the first named. i Derangements of other special senses said to attend diabetes are impairment of hearing, roaring in the ears, and derangement of smell and taste. A spongy state of the gums, with recession and excavation, is an occa- * "Edin. Med. Jour.," July, 1879. t "Lipemia and Fat Embolism in Diabetes MelHtus," " N. Y. Med. Rec," vol. xvii.,i88o, p. 477. X Dufresne, " De 1' Amblyopic Diabetique," " Gaz. Heb.," November, 1861. DIABETES MELEITUS. 803 sional symptom, resulting in extreme cases in absorption of the alveolar processes and falling-out of the teeth. Severe neuritis in the brachial and crural nerves is not infrequent. In grave cases the tendon reflexes are diminished or absent. Unilateral szveat- ing has been observed. Senator refers to three cases — two of the left half of the face and one of the right. Edema sometimes appears late in the dis- ease, and is not necessarily the result of renal complication. Alterations in the Blood. — It has already been mentioned that in diabetes the blood becomes highly charged with glucose, which increases from a normal of 0.05 to 0.15 per cent, to 0.2, and in extreme cases to 0.57, per cent, and from this abnormal glycemia comes glycosuria. From the presence of the first we should naturally expect a higher specific gr'avity of the blood- serum, which has been found as high as 1033, as contrasted with the normal 1028. On the other hand, the serum has been found thinner than normal, containing, according to different analyses, from 80.2 to 84.8 of water instead of the normal 78 to 79 per cent. The red blood discs are often diminished, and the alkalinity of the blood is also lowered. As such diminution is at a maximum when oxybutyric acid is being excreted, it has been ascribed to this substance. An abnormal amount of fat in the blood, producing the technical lipemia, was observed by the earliest students of diabetes, and is attested by many analyses, as well as by the milky appearance of the serum and the intra- ocular appearances described by Albert G. Heyl. The analyses of Simon show from 2 to 2.4 per cent, instead of the normal 1.6 to 1.9 per cent. Changes in the Urine. — The peculiarity of diabetic urine most noticeable to the patient is its enormous quantity, which has been known to exceed seventy pounds (31.78 kilos) in twenty-four hours, while apocryhal accounts of larger amounts are extant. Frank records 52 pounds (23.6 kilos) ; Bardsley * 36 pints (20.4 liters) and 32 pints (18.6 liters) ; Bence Jones found 56 pints (31.78 liters) ; Sir Thomas Watson and Dr. Dickinson 26 pints (14.77 hters), and Dr. Pavy 32 pints (18.16 liters). From 70 to 100 ounces (2100 to 3000 c. c.) are frequent quantities. The quantity of urine passed is limited by the amount of fluid ingested, for while it is pos- sible that the amount of the former secreted may exceed for a very short period the quantity of the latter ingested, it is evident that this cannot con- tinue for any length of time, and, in point of fact, it is found to be almost invariably a little less, the remainder being removed by the lungs, skin, and bowels. It is said that in health the lungs exhale fully one-fourth as much water as the kidneys secrete. Should it be proven that cases do occur in which the amount of water secreted exceeds that ingested by the mouth for any considerable period, it must then be admitted that absorption of water from the air by the skin is possible. On the other hand, it was early observed by Th. Cowley t (1788) that the quantity of water occasionally is not at all or but slightly increased. To this condition Frank,! another old author, gave the name of diabetes decipiens. It is well known, also, that intercur- rent diseases, especially febrile affections, sometimes diminish the quantity of urine as well as the amount of sugar excreted ; while the same diminution of urine and sugar also occasionally occurs toward the fatal termination of the disease. ' * Bardsley, article on "Diabetes " in the "Cyclopedia of Prac. Med.," Philadelphia, 1845, P- ^°7- tTh. Cowley, "London Medical Journal," 1788. . .. t J. P.Frank, " De Curandis Horn. Morbis Epitome," lib. v., " De Profluviis," Pars i, Manheimn, 1794. 804 CONSTITUTIONAL DISEASES. But the most important change is, of course, the presence of glucose. Of this, the quantity varies greatly in different cases and at different times in the same case. Every case of trifling and temporary glycosuria should not, however, be considered a case of diabetes. The sugar should be easily recognizable by the ordinary tests and should be constant. From what may be indicated as " evident traces " the proportion of sugar may reach, it is said, as much as 15 per cent. I have never found more than 10 per cent., though I often hear reports of the finding of larger quantities which I can scarcely credit. The twenty-four-hours' quantity varies similarly. The maximum quantity secreted in this time appears to be that reported by Dickinson, wherein a man twenty-five years of age voided 50 ounces (1500 gm.) of glucose in twenty-four hours. But the more usual quantity is from 10 to 80 milligrams to the cubic centimeter, or from 20 to 25 gm. in twenty-four hours ; this corresponds nearly to from 5 to 30 grains to the fluid ounce of the Eng- lish system, or from 300 to 3800 grains in the twenty-four hours. The effect of muscular exercise in diminishing the quantity of sugar in the urine of diabetics was early confirmed by Kiilz and others, while it is scarcely necessary to say that accidental as well as intentional changes in diet are followed by consequent variations. So, too, urine passed after fasting, as on rising in the morning, contains generally less sugar than that passed after a meal, and in the clinical study of cases of diabetes, where a part of the twenty-four hours' urine is not obtainable, it is important to bear this in mind. As the difficulties in obtaining a part of the twenty-four hours' urine regularly are very great, it is often preferable, in my experience, to take for examination two samples, one passed in the morning on rising, and represent- ing the fasting urine, and another on going to bed, representing the day urine. Consistently with the increased solid matter thus added, the specific gravity of diabetic urine is, as a rule, high, 1040 being very common, while Bouchardat found it as high as 1074 in one instance. The well-known dis- position of diabetic urine to become frothy on shaking, and to maintain this frothy condition, is a natural physical result of its increased density. Urine may, however, have a low specific gravity and yet contain sugar. I have found it as low as loio and lower. Such low specific gravities of glucose, if present in any decided degree, must depend on the low proportion of other normal ingredients. Sugar sometimes disappears very rapidly from urine by fermentation, thus reducing also the specific gravity. Concurrent with the increase in quantity of urine is an absence of color, which in extreme degrees is almost total, so that the urine may be as clear as spring-water. Almost all diabetic urine, sooner or later after exposure at a moderate temperature, becomes cloudy from the development of fungi coincident with fermentation. The odor of the urine is usually normal when first passed, but sooner or later, in consequence of fermentation setting up, it may acquire an acetous odor. The latter change also increases the degree of the normal acid reaction and maintains it much longer after exposure to the air than is the case with normal urine. This acetous odor is ascribed to acetone and diacetic acid. The urine may have a sweetish odor when passed, which has been compared to " sweet brier." Diabetic urine is sometimes quite free from sediment. At other times there is a copious sediment of uric acid. In the sediment may also be included the pencilinm fungus, common to acid urine, as well as the more characteristic yeast or sugar fungus, or the torula cerivisia;. This also sometimes appears as a mold on the surface of the urine. Of the normal chemical constituents of the urine, iirea is almost invari- DIABETES MELLITUS. 805 ably increased. This is contributed to by two causes. The first is the inges- tion of large amounts of nitrogenous food, whether to appease the appetite or by the physician's advice. The second cause is the destruction of the tissues themselves which characterizes the severest cases in the last stages in spite of the enormous food consumption. In such event the nitrogenous tissues are split up into urea and sugar. As regards uric acid, it is either normal or slightly increased. Of the other constituents of the urine, creatinin is increased ; sulphuric acid is sub- ject to its normal variations; chlorin, phosphoric acid, lime, and magnesia are said to be increased; phosphoric acid and lime especially so. Ammonia is sometimes largely increased. Of abnonnal constituents, albumin is often present — perhaps m one- third of all cases ; some make it a larger proportion, some less. The albu- minuria is not generally larger and, in my experience, is not often a serious symptom. Albuminuria does not necessarily imply renal change. It is scarcely necessary to say that the urine may become albuminous from any of the causes of albuminuria independent of diabetes, as pus from pyelitis, cystitis, etc. Inosit, or muscle-sugar, occasionally replaces the grape-sugar in dia- betes, but more frequently accompanies it. Gallois '■' found it in five out of thirty-five diabetics. Finally, acetone, diacetic acid, and beta-oxybntyric acid are all fre- quently met in diabetic urine. It is now conceded that the source of these substances is albumin either of the food or body tissues, diacetic or aceto- acetic acid being probably first formed and rapidly transformed into acetone. \Mien but little diacetic acid is produced, it is all converted into acetone ; when much is formed, both substances appear in the urine. The conversion takes place mainly in the urine, but doubtless also in the tissues or the blood, since acetone may be present in the expired air. To acetone is ascribed the vinous odor sometimes present in the urine. Acetone is produced in health in a slight amount in the normal decomposition of albumin, freely in certain diseases other than diabetes. According to von Xoorden, these substances are formed in the disintegration of the albumin of the body and not of the food — in a word, when the patient is " consuming his own proteids." Beta-oxybutyric acid is believed by many to be the first stage in the for- mation of diacetic acid. Von Noorden also thinks this possible, but he claims for it a certain " clinical independence," and considers it probable that oxybutyric acid, on the one hand, and aceto-acetic acid, on the other, arise from qualitatively different disintegration processes. While acetone in the urine does not add to the seriousness of diabetes, the presence of oxybutyric acid is of the gravest prognostic significance. It is said never to disappear permanently after being once present, and to be almost always followed in a few^ days or weeks by diabetic coma and death. Diacetic acid has an inter- mediate significance between acetone and beta-oxybutyric acid. Of the other secretions, the perspiration, when present, frequently con- tains sugar, at times a notable amount, as much as 6 1-2 grains (0.42 gm.) having been extracted by Fletcher from a piece of flannel, three inches square, which had lain upon the skin of a diabetic patient for forty-eight hours. The salizv has rarely been found to contain sugar independently of that which it acquires from the food. That the gastric juice ever contains it * Gallois, " Comptes Rendues," i, p. 533; also " De I'Inosurie," Paris, 1864. 8o6 COXSTITUTIOXAL DISEASES. under similar conditions is disputed, but it has been found in effusions and exudations, as might be expected. Duration. — Though the course of a few cases of diabetes is so rapid as to justify the name acute, the number of these cases is not sufficient to justify a classification into acute and chronic. In such rapid cases death has taken place at periods ranging from two days to six weeks, yet in no instance can it be averred that the disease was of as short duration as it seemed, since it may have existed some time before it was discovered, while in several it was evidently of longer duration. It is true, therefore, that diabetes mellitus is a disease almost invariably of long duration. Cases of fifteen, eighteen, and twenty years' duration are reported. I have had a number of cases under my care for more than ten years. The younger the subject, the shorter the duration and the more promptly fatal the result, while after middle age, under treatment, the duration may be indefinite. Diabetes mellitus is sometimes distinctly intermittent for a time, re- gardless of treatment. I was for a long time incredulous on this subject, but recent experience has taught me that such a form of diabetes occurs, in which both polyuria and glycosuria may disappear without treatment, to recur again. Such cases are, however, easily controlled by treatment when discovered, while they are as certain to pass over -into the permanent form if neglected. Complications. — The diabetic is characteristically subject to compli- cations, which may be accounted for in a word by his diminished power of resistance to all disease-causing agencies and to the toxic influences inci- dent to the disease itself. ]\Iost of these have already been considered among symptoms. Such are the num.erous skin aft'ections, gastro-intestinal dis- turbances, pancreatic and renal affections, functional cardiac and nervous symptoms, including neuritis and diabetic coma. Tuberculosis has also been mentioned. It is especially apt to attack young subjects and to cause their death. Arteriosclerosis is prone to occur in diabetics, with its full train of consequences, and to appear earlier in life among them. Jaundice sometimes occurs, and having presented itself twice in the history of a case under my observation, can hardly be considered accidental. Senator says that, when not an accidental complication due to a catarrh of the duodenum, it may re- sult from compression of the biliary capillaries by the overloaded blood- vessels or enlarged gland-cells of the liver.* Gout and diabetes are sometimes associated, and an interesting and im- portant fact has been learned from this association, viz. : that cases of diabetes complicated with gout are always mild cases and easily controlled. Some- times the symptoms of gout and diabetes alternate. That is, when the gly- cosuria appears the gouty symptoms subside and vice versa. These cases are apt to be associated with arteriosclerosis and death from apoplexy may ensue. Diagnosis. — The diagnosis of diabetes mellitus is very easy, yet I have known it to be long overlooked by the practitionsr. Unnatural thirst and copious diuresis should always suggest a chemical examination of the urine, and although there are sources of error in testing for small quantities of sugar, the quantities thus overlooked are not usually of clinical significance. In fact, in my observation, glucose is more frequently declared present by inexpert examiners when absent than the reverse. Almost any one of the * Senator, loc. cit.. p. 912. DIABETES MELLITUS. 807 tests, therefore, which are found in the various manuals for the examination of urine, apphed with ordinary care, will respond readily to quantities which are of clinical significance. Tests for Sugar. — For provisional purposes Trommer's method of using the copper test answers very well. Its ingredients are easily attainable, and there is no risk of error from changes during keeping, to which Fehling's and Pavy's solutions are subject. ( 1 ) Trommer's test is used as follows : To a small quantity of urine, say five c. c. (80 minims), add half as much liquor potassse or sodse, then drop by drop a 5 or 10 per cent, solution of cupric sulphate. On first adding the copper, a blue precipitate of hydrated cupric protoxid takes place, which, if sugar is present, is redissolved on shaking, producing a clear blue liquid. The copper solution should be thus added until the precipitate is no longer dissolved on shaking. Then heat the mixture to boiling, and if sugar is present, a copious yellow precipitate of hydrated cuprous oxid or of red cuprous oxid occurs. Either is con- clusive evidence. Occasionally the precipitate of earthy phosphates is so copious as decidedly to obscure the reaction, and by beginners is sometimes mistaken for the suboxid. In this event the earthy phosphates may be re- moved by filtration after slightly warming" the mixture. The reaction should take place as soon as the boiling-point is reached — indeed, it sometimes occurs before this point is reached. Prolonged boiling should be avoided. (2) In Fehling's solution * the constituents of Trommer's test are united in definite proportions in order that a quantitative estimation may be made. It is also used for qualitative testing, while a rough quantitative estimation may be made at the same time by what is known as the clinical method at the University of Pennsylvania Clinic. A given quantity, say one c. c, of Fehling's solution is placed in a test- tube, diluted with about four times its bulk of water, and boiled for a few seconds. If the solution remains clear, add immediately the suspected urine, drop by drop. If sugar is abundant, the first few drops will usually cause the red or yellow precipitate, but if the reaction does not occur, the dropping may be continued, followed each time by heating until an equal volume has been added. If no red or yellow precipitate occurs, sugar is absent. Now, Fehling's solution is so composed that if an equal volume is exactly reduced by an equal volume of urine, that urine contains 1-2 of i per cent, of glu- cose; if by half bulk, i per cent. ; if twice the bulk, 1-4 per" cent., and so on, whence one can easily estimate roughly the percentage. Should the urine contain more than i per cent, of sugar, it should be diluted one to ten and the result multiplied by ten. If a reduction takes place on boiling the test fluid alone, a new supply may be obtained, or a little more soda or potash may be added, the fluid filtered, and it is again ready for use. Such spontaneous reduction of the cuprous oxid often occurs when Fehling's solution is kept for some time. In judging the progress of a case of diabetes under treatment it is not sufficient to test the urine qualitatively, but a quantitative determination of * Fehling's solution. — Dissolve 34.652 %m. of pure crystallized sulphate of copper in 200 gm. of dis- tilled water; 175 gm. of chemically pure crystallized neutral sodic tartrate in 480 gm. solution of caustic soda of specific gravity 1.14, and into thisfbasic solution the copper solution is poured, a little at a time. The clear mixed fluid is diluted to one liter, or 1000 c. c. Ten c. c. of this solution will be reduced by 0.05 gm., or 50 milligrams, of diabetic sugar. If Fehling's sohition is to be kept some time, it is absolutely essential that it should be placed in smaller bottles holding from 40 to 80 gm., sealed, and kept in a cellar. Still greater security may be obtained by dissolving the cupric sulphate in 500 c. c. and the tartrate salt and potash in 500 c. c, keeping the two solutions separate in rubber-stoppered bottles. Equal volumes of the two solutions are united when needed for use. 8o8 CONSTITUTIONAL DISEASES. sugar must be made. This may be done by the cHnical method just de- scribed or by volumetric processes described in the manuals for the exami- nation of urine, but the simplest process is the (3) fermentation method of Dr. Roberts. In this the specific gravity of the urine is taken before and after fermentation, and the difference in the two results indicates the number of grains of sugar in each fluid ounce of urine. Suppose, then, the specific gravity before fermentation to be 1045, S'^d after fermentation 1035 : the quantity of sugar is ten grains to the fluid ounce, or 0.65 gm. in thirty c c. These figures can be reduced to percentage by multiplying by 0.23. Mention should be made of those rare instances in which the sugar does not reduce cupric oxid. I have had a case under my care. The urine had a specific gravity of 1050 when the patient came under observation, but there was no response whatever to the copper or bismuth test; yet by the fer- mentation test a large amount of sugar was shown to be present. (4) Polarimetry is a very convenient method of analysis if an instru- ment is at hand, though the costliness of a good instrument will probably always be in the way of its general use. Tests for Acetone, Diacetic Acid, and Oxybutyric Acid. — Of the numerous tests for acetone, most of which require the distillate for their suc- cessful application, Legal's nitroprussid of sodium test is the most satis- factory for the practitioner, because it does not require the distillate. LegaTs Test for Acetone. — A fresh, rather strong solution of sodium nitroprussid is made by dissolving a few fragments in a little water in a test- tube. To three or four c. c. of the suspected urine add enough liquor sodas or potassse to secure a distinct alkaline reaction. To the mixture then add a few drops of the nitroprussid solution, when the whole quickly assumes a red color, whether acetone is present or not, said to be produced by creatinin even more rapidly than by acetone. In any event the red color disappears ; but if acetone is present, the addition of a few drops of concentrated acetic acid causes a purple or violet- red color. If there is no acetone, this final change does not occur, while the purple color also fades in a little while, even if caused by acetone. To test for diacetic acid add a few drops of a solution of ferric chlorid to a small quantity of the urine, when a beautiful Burgundy-red reaction occurs. A precipitate of phosphates succeeds the adding of the first few drops, but this is redissolved by a further addition of the chlorid. The test is confirmed if, after heating the original fluid, there is no response on appli- cation of the chlorid of iron — the effect of heat being to dissipate the diacetic acid. A more brilliant reaction is obtained if the urine be first treated with a solution of acetate of lead, filtering out the white precipitate and testing the filtrate. Urine passed after the administration of salicylic acid, antipyrin, carbolic acid, salol, phenocol, kairin, and other drugs furnishes a similar reaction. The reaction for diacetic acid being obtained, it is scarcely necessary ta test for beta-oxyhutyric acid, as the significance is the same. The test is a complicated one, but beta-oxybutyric acid is presumably present when a quantitative estimation indicates a larger quantity of glucose than does polarization, since beta-oxybutyric acid rotates polarized light to the left, as contrasted with the dextrorotatory power of grape-sugar. Again, if after complete fermentation with yeast or precipitation with basic acetate of lead and ammonia the urine is found Isevorotatory, beta-oxybutyric acid is pre- sumably present. DIABETES MELLITUS. 809 Prognosis. — The prognosis of diabetes varies with the age at which the disease makes its appearance, the time which has been allowed to elapse before treatment is instituted, and the treatment itself. Once thoroughly established early in life, or before twenty-five years of age, recovery is rarely possible, but even at this age, if treatment is instituted sufficiently early, much may often be done to avert the end. Diabetes is a disease in which the expectant plan of treatment is disastrous. It is a disease which never gets well of itself, and always gets worse if not properly treated. At the same time the mild cases amenable to treatment are in a decided majority. When the disease appears after middle life in fat persons or those disposed to gout, and is early recognized and promptly treated, it is usually easily controlled ; and although it is almost never safe to declare a case of diabetes absolutely cured, it does occasionally happen that recovery is so complete that the patient may be left to his own mode of living. As a rule, however, even those who have appar- ently recovered must keep a watch upon their diet, and should at intervals have their urine examined with a view to sounding, as it were, their condi- tion. We are entirely justified in saying to a diabetic patient, " As long as your urine remains free of sugar you are practically as well as if you had no tendency to diabetes." On the other hand, for spare, nervous, and hard- worked persons, especially mentally overworked, under forty, there is a much more unfavorable outlook. Even here, if the co-operation of the patient can be secured, much may be done. Every intermediate degree of seriousness may occur. When diabetes depends upon recognized nervous lesions, the prognosis is altogether that of the lesion itself. The cause of death is very frequently some intercurrent or consequent disease, as phthisis or diabetic coma. The syphilitic origin of the disease and obesity are favorable prog- nostic factors ; a spare habit and habitual constipation are unfavorable. Treatment. — This resolves itself easily into the dietetic, the hygienic, and the medicinal. I. Dietetic Treatment. — This is by far the most efficient, and no per- manent results have ever been obtained without it. It consists essentially in the elimination from the diet of such articles as are readily convertible into glucose — viz., the carbohydrates. It is acknowledged that in the early stage of the disease only the saccharine and amylaceous foods fail to be consumed in the economy in the usual way and appear in the urine as glucose. Hence, if these be excluded from the diet and their place supplied by other assimilable articles, the symptom disappears, and the disappearance of this symptom seems to be, for the time being at least, the cure of the disease. If it were necessary to select a diet absolutely free from sugar and starch, it would indeed be restricted, as there are comparatively few articles of food thus constituted. Such are, however, meats of every kind, fresh or salted, including tripe, tongue, ham, bacon, and sausage ; soups made from meat and without flour ; game, poultry, fish, oysters, lobsters, crabs, eggs in every form ; butter and new cheese, oils and fats. Happily, however, it is not necessary to use articles absolutely free from the two baneful principles, and in this man- ner quite a variety of palatable articles may be added to the dietary. Among these are cream, curds, milk, and buttermilk, and all green vegetables, includ- ing spinach, endive, lettuce, dandelion, cabbage in various forms including coleslaw, Brussels sprouts, cauliflower, broccoli, string-beans, tomato, water- cress, celery tops, asparagus tops, turnip tops, young onions, cucumbers, pickles, and olives. To these may be added unsweetened jellies (prepara- tions of gelatin) and especially a variety of nuts, including almonds, walnuts. 8 10 CONSTITUTIONAL DISEASES. butternuts, filberts, pecan nuts, Brazil nuts, but not chestnuts ; also, all acid fruits, as apples, lemons, strawberries, etc. Tea and coffee, with cream and without sugar, cocoa-nibs, but not chocolate, are permitted ; also all wines which contain little or no sugar, including claret. Burgundy, Rhine, and still Moselle wines, together with very dry sherry, unsweetened brandy, whisky, and gin when required. The carbonated waters, natural or artificial (the so-called soda-water of the shops), are pre-eminently suitable. Water is to be allowed ad libitum, for water is the medium by which the sugar is carried out of the blood and tissues. Its supply should therefore be liberal, and with the diminished sugar formation comes diminished thirst. Better still are the alkaline mineral waters, especially those of Vals, Vichy, Carlsbad, and the Saratoga Vichy. Beer, ale, porter, cider, and the fermented liquors generally are not allowable because of the sugar and carbohydrates they contain. They are less objectionable when fermentation is carried to a high degree, resulting in a more complete destruction of the sugar. This is the case with certain bottled lager beers and English ales. It is not simply the small quantity of sugar and starch contained in them which renders the vegetable substances named admissible, for many of them contain a great deal of sugar ; but these sugars, unlike grape-sugar, are more easily assimilable. Such are pre-eminently mannite, the sugar of manna ; lactin, or sugar of milk ; levulose, or fruit-sugar, and probably, also, inosit, or the sugar of muscle. Such is also inulin, a hydrocarbon and starchy prin- ciple found in the inula hcleniuin, or elecampane, but especially in Iceland moss. Hence, too, • the impunity with which milk can often be taken by diabetics, although it contains from 3 to 6 per cent of lactin. On this ac- count, too, levulose may be cautiously used for sweetening tea and coffee in mild cases. Glycerin is also sometimes substituted for sugar, but though less objectionable, both theory and experience go to show that it is not a safe substitute. Levulose and even mannite are much to be preferred to glycerin, both for sweetening and as a substitute for sugar in force produc- tion. But none of these sugars can be used with safety for sweetening pur- poses, and if sweetening is indispensable for the patient, it should be done with saccharin. It will be noticed that not only all saccharine substances of animal or vegetable origin and all vegetables largely composed of starch, as potatoes, rice, and corn, are omitted from the category of admissible articles, but that bread, and all preparations made of wheat, rye, rice, or corn-flour, are con- spicuous by their absence. This is found to be a very important omission from the dietary of most persons, and numerous, indeed, have been the attempts to devise substitutes for it, with varying success. The best known and most popular of these is gluten bread, made of the so-called gluten flour, whence the starch is partially removed by washing. Unfortunately, the gluten flour made in this country contains nearly as much starch as the white flours, with perhaps a single exception — a meal made by the Battle Creek Sanitarium Co., of Battle Creek, Mich.* In England and France diabetic patients are much more fortunate, gluten flours of sufficient purity being there obtainable. Flour of the soya bean [soya hispida), containing only 4 per cent, of starch and a large amount of nitrogenous matter and oil, is also used for making griddle-cakes and biscuit. These, if freshly made, are very * This is known as gluten meal No. i. A biscuit is made of this known as No. i gluten biscuit. No. 2 meal and biscuit contain more starch. DIABETES MELLITUS. Sii palatable ; but biscuits made for some time become rapidly rancid from decomposition of the oil. Another substitute is bran flour or unbolted wheat flour, which contains relatively less starch. The pure bran itself is not wholly innutritions. Dr. Prout very early recommended, as a substitute for bread, a compound of bran, milk, and eggs, which he declared not unpalatable.* Still another substitute for wheaten bread is the almond food suggested by Dr. Pavy. The almond is composed of 54 per cent, of oil, 24 per cent, of nitrogenized matter known as emulsin. 6 per cent, of sugar, 3 per cent, of gum, and no starch. Chemically speaking, it is therefore admirably adapted for diabetic food, and when the sugar and gum have been extracted, it leaves nothing to be desired. The sugar and gum are removed by treating the powered almonds with boiling water slightly acidulated with tartaric acid, or by soaking the almonds in a boiling acidulated liquid, which may form part of the process for blanching. The boiling and the acid fluid are necessary in order to precipitate the emulsin , which would otherwise emulsify the oil of the almond. Biscuits made of almond-flour f and eggs are palatable, and may be eaten with a little dry sherry or whisky and water. Biscuits made of imiUn, the starchy principle already referred to on page 810, were suggested by Kiilz.i Lichenin, or moss-starch, abundant in Ice- land moss, is a variety of inulin, and would be the material used for the pur- pose. Being very cheap, it is suitable on this account. Though a starch, it is, according to Kiilz, one of the assimilable starches already mentioned, of which small quantities, at least, do not increase the excretion of sugar. The biscuits are mxade with the addition of milk, eggs, and salt. The best of these substitutes is unsatisfacton,-, as patients soon tire of them and want the real bread. Aleuronat § bread is regarded by von Noor- den as the only one at all satisfacton,-, since it retains the bread taste. Although containing some carbohydrate, I have lately commenced to use it for my patients, and it promises to be fairly satisfactory. The following classified summary of articles of food admissible for diabetics will be found convenient for reference : Shell-fish. — Oysters, mussels, and clams, raw or cooked in any way. without the addition of flour. Fish of all kinds, fresh or salted, including lobsters, crabs, sardines, and other fish in oil : fish roe, caviare. * The folio-wing are Dr. Catnplin's directions for making biscuit of the bran flour: To one- quarter of a pound of flour add three or four fresh eggs, one and a half ounces of butter, and half a pint of milk; mix the eggs with a little of the milk, and warm the butter with the other portion; then stir the whole ^vell together; add a little nutmeg or ginger or other agreeable flavoring, and bake in small forms or patty-pans. The cake, when baked, should be about the thickness of an ordinary captain's biscuit. The pans must be well buttered. Bake in rather a quick oven for half an hour. These cakes or biscuits may be eaten by the diabetic with meat or cheese for breakfast, dinner, or supper; at tea they require rather a free allowance of butter, or they ma3- be eaten with curd or anyof the soft cheeses. ' + Seegen recommends an almond food made as follows : Beat a quarter of a pound of blanched s-weet almonds in a stone mortar for about three-quarters of an hour, as fine as possible; put the flour thus produced into a linen bag, which is then immersed for an hour and a quarter in boiling water acidulated with a few drops of vinegar. The mass is then thoroughly mixed with three ounces of butter and two eggs; the j-olks of three eggs and a little salt are added, and the whole is to be stirred briskly for a long time'. A fine froth made by beating the whites of the three eggs is then added. The whole paste is now put into a form, smeared with melted butter, and baked by a gentle fire. t Kiilz, " Beitrage zur Path, und Therapie des Diabetes Mellitus," Marburg. 1874, Bd. i, p. i45- § Aleuronat bread is made by R. Williamson as follows: Mix two ounces C62 gm.) of desiccated cocoanut powder with a little w'ater containing a small quantity of German \-east. Make the mass into a sort of paste, and put in a warm place fo5 half an hour or longer. The small amount of sugar contained in the cocoanut is almost entirelv decomposed bv the fermentation produced by the yeast, and the cocoanut paste becomes spongv. Add two ounces'(62 gm.) of aleuronat. one beaten egg, and a small quantitv of water in which a little saccharin has been dissolved, and mix well until a dough is formed'. Divide into cakes and bake in a moderate oven for twenty or thirty minutes. Aleuronat is a vellowish powder containing from 80 to go per cent, of vegetable albumin and only 7 per cent of carbohydrates. I have found much difficulty in securing properly desiccated cocoanut powder. 8i2 CONSTITUTIONAL DISEASES. Meats of every variety except livers, including beef, mutton, chipped dried beef, tripe, ham, tongue, bacon, and sausages. Also poultry and game of all kinds, with which, however, sweetened jellies and sauces should not be used. Soups. — Clear bouillon and other soups, beef-tea and broth made with- out flour, rice, vermicelli, or other starchy substances ; and without the vege- tables named below as inadmissible. Vegetables. — Cabbage, cauliflower, Brussels sprouts, broccoli, green string-beans, the green ends of asparagus, spinach, dandelion, mushrooms, tomatoes, lettuce, endive, coleslaw, olives, cucumber (fresh or pickled), radishes, sorrel, young onions, watercresses, mustard and cress, turnip tops, celery tops, artichokes, gherkins, okra, parsley, or any other green vegetables. Bread and \cakes made of pure gluten, bran, aleuronat, soya, peanut- or almond flour, inulin, with or without eggs and butter. Griddle-cakes, pan-cakes, biscuit, porridges, etc., made of these flours. Oatmeal porridge with cream. Where especial stringency is required, the last should be alto- gether omitted. Eggs in any quantity and prepared in all possible ways, without sugar or ordinary flours. Butter and Cheese. Nuts. — All except chestnuts, including almonds, walnuts, Brazil nuts, hazelnuts, filberts, pecan nuts, butternuts, cocoanuts. Condiments. — Salt, vinegar, and pepper in moderate quantities. Fruits. — Cranberries, plums, cherries, gooseberries, red currants, straw- berries, acid apples,' lemons, oranges sparingl}' — all without sugar. Acid fruits may be stewed, with the addition of bicarbonate of sodium instead of sugar. Jellies. — None except those not sweetened with sugar. Saccharin may be used for sweetening instead of sugar. Jellies may be made of calf's foot or gelatin and flavored with wine. Drinks. — Coffee, tea, and cocoa-nibs, with milk or cream, but without sugar. Also, milk, cream, soda- (carbonated) water, and all mineral w^aters freely; lemonade without sugar, acid wines, including clarets, Bordeaux, Rhine, and still Moselle wines, and very dry sherry. Unsweetened brandy, whisky, and gin. No malt liquors except those ales and beers which have been long bottled and in which the sugar has all been converted into carbonic acid and alcohol. Saccharin may be used for sweetening tea and coffee. To be Especially Avoided. — Cantaloupes, watermelons, peaches, grapes, and all other sweet melons and fruits ; potatoes (white and sweet), rice," beets, carrots, turnips, parsnips, peas, and beans ; all vegetables containing starch or sugar in any quantity ; sweet wines, including sherry, Madeira, port, and champagne. In mild cases the dietetic measures previously indicated are usually fol- lowed by the most prompt and decided results, in some instances by the per- manent removal of all symptoms, in others by a continued absence of them so long as a watchfulness over diet is maintained. In a more advanced stage of the disease, in which more rapid emaciation and loss of strength show themselves, such a regimen is followed by a decided dimunition in the amount of sugar excreted, but it fails to disappear altogether, and a more rigid elimi- nation of saccharin and amylaceous articles must be attempted. Sooner or later, however, a stage is reached when not only albuminous food breaks up into urea and sugar and urea and water, but the albumin of the tissues under- DIABETES MEELITUS. 813 goes the same metabolism and excretion, while emaciation, starting first with the disappearance of fats, invades even the muscular tissue. Fatty foods longest resist this breaking up, but. ultimately, in progressive cases, even they increase the elimination of sugar. Each case should be thoroughly studied as to its own peculiarities and demands. I do not pursue the same plan in every case. Sometimes I place the patient at the onset on a strict nitrogenous diet of broths, meat, and eggs, Avith a view to determining what can be accomplished. This done, successive articles of food are added and their effect upon the urine is watched. In other cases, especially when the quantity of sugar is not large, I first take away from the diet all sweets, and the purest starch foods, including bread. Too great stringency must not be insisted upon, and the presence of one per cent, or a maximum of two per cent, of glucose in urine may be per- mitted for a time; but semi-occasionally, say once a month, a return should be made to the strict diet, with a view to taking soundings, and if it is found that all the glucose disappears, we may be encouraged to permit for a time a more liberal diet. In many cases of diabetes of long standing there comes a time when it becomes necessary for the welfare of the patient that a rigid diet must be suspended for a time. So settled is this truth that some physicians erred on the other side and have been led to decry altogether the dietetic treatment. A question of great practical importance asks what shall guide us to such a change of diet? It has occurred to me that it is the continued presence of diacetic acid in the urine. For this informs us that not only the proteid ele- ments of food, but even the fixed proteids of the body, are splitting up to supply the demand for glucose which is still wasted because it cannot be oxidized. The carbohydrate at least meets this demand and thus conserves the fixed proteids for other uses. 2. Hygienic Treatment. — Xext in importance to the dietetic is the hygienic treatment of diabetes. This consists in bathing, and attention to the skin, together with outdoor muscular exercise and perfect ventilation within doors. The diabetic should breathe the freshest and purest air. While the cases are not numerous in which embarrassed respiration results in glycosuria. there are undoubted instances in which this has occurred, as in croup and whooping-cough ; and it is well known that asphyxiated lower animals are likely to have glycosuria. Although the glycosuria thus resulting is prob- ably reflex, it can hardly be expected that the diabetic should improve under unfavorable respiratory conditions. He should not, therefore, live, work, or sleep in a confined atmosphere, but secure the most perfect ventilation, spending much of his time out of doors, and sleeping in large, well-ventilated chambers, with windows open, etc. Especially should he avoid inhalation of irrespirable gases. Attention to the skin, or skin culture, is most impor- tant to the diabetic. He should bathe at least twice a week in tepid or hot w^ater on going to bed in winter, and on rising take a cool sponge-bath daily. In summer he may take a cool bath on rising and on retiring. He should groom his skin thoroughly daily, either after the bath or independent of it on the days on which he does not bathe. Two tablespoonfuls of sodium car- bonate to an ordinary bath is a suitat)le addition to the latter, softening the skin and facilitating its action by removing the effete epithelium. ^Muscular exercise should be taken daily by the diabetic, both by walking and ofvmnastics. Glvcosren is undoubtedlv consumed in the muscles during 8 14 CONSTITUTIONAL DISEASES. their action, and it is quite certain that in diabetes there is an undue accumu- lation of sugar in the muscles. Exercise should be sustained regularly day by day, even in wet weather, care being taken to keep the feet dry, while it should never be carried to the point of fatigue. Attention to other secretions, particularly to that of the bowels, is of the greatest importance. Diabetics who are constipated are always more difficult to relieve. It is probably partly on account of their action in this respect that the alkaline and alkaline-saline aperient waters, as those of Vichy, \'als. and Carlsbad, are so useful. To those who visit these springs, a part of the benefit is ascribable to the other favorable hygienic influences, such as rest, fresh air, and exercise, by which they are surrounded. Independently of these in- fluences, however, there is reason to believe that the alkaline waters are of service to diabetics, and when their cost is not a consideration, a quart of Vichy or Vals and half as much Carlsbad may be taken during the day, begin- ning before breakfast. The Vichy is a more alkaline water, containing thirty- five grains (2.3 gm.) of carbonates to a pint (0.5 liter), while Carlsbad con- tains but eleven grains (0.51 gm.), but twice the proportion of chlorids, eight grains (0.7 gm.) to a pint (0.5 liter), and nearly ten times as much sodium sulphate, or nineteen grains (1.25 gm.) ; hence its more purgative quality. Since Carlsbad has the highest reputation, it is more likely that it is through the action of the sulphates and chlorids on the liver rather than that of the alkalines they contain that these waters are efficient. This is the more likely, as other alkaline waters nearly as rich as those of Vichy and richer than Carls- bad waters in sodium carbonate, but without sulphate of sodium, are without reputation. The alkalies may, however, increase the effect, and are especially of service when there is acidity. The waters of the celebrated Saratoga Springs in this country have an undoubted action on the liver, probably through the chlorids they contain, which are in very large proportion, reaching in the Geyser Spring seventy grains (4.6 gm.) to the pint (0.5 liter), and in the Empire and Hathorn, sixty-three grains (4.19 gm.) to the pint (0.5 liter). They contain no sul- phates, but the carbonates are present in considerable proportion, though much less than in the Vichy waters. Saratoga Vichy, which, of the Saratoga waters, contains most sodium carbonate, has ten grains (0.6 gm.) to the pint; the Geyser, nine grains (0.58 gm.). In the absence of the Carlsbad and Vichy waters I would use the purgative Saratoga waters, especially the Vichy and Geyser. 3. The Medicinal Treatment. — Like all diseases in which treatment by drugs is relatively inefficient, diabetes has its full share of reputed remedies, most of which are useless. This dare not, however, be said of all. The only drug that can be relied upon to produce an effect in diminish- ing glycosuria is opium. It seems that it was used for diabetes as early as the second century by Archigenes. It was also used by ^^tius the physician, in the fourth century, and in the latter part of the eighteenth century and beginning of the nineteenth by Rollo, Frank, Tommasson, and especially the English physician, Pelham Warren, in 1812. It is certainly a useful agent in diabetes, but its use is united with disadvantages in the locking-up of the secretions which attends it. On account of its comparative freedom from these effects, codein has come to be the favorite alkaloid of opium in dia- betes. It may be given in 1-4-grain (0.016 gm.) doses three times a day, or 1-2 grain (0.032 gm.) twice a day, increasing 1-4 grain (0.016 gm.) daily until the desired effect is produced or it proves useless. If the sugar dis- DIABETES MELLITUS. 815 appears, the drugs should be gradually withdrawn. If constipation is caused by it, aperient remedies should be associated, and very suitable are the natural aperient waters, including the bitter waters, Friedrichshalle, Hunyadi Janos, Racokzy, Piillna, etc. I have seen a patient entirely relieved under its use, and it alone, with no return of the sugar after its omission. I rarely give as much as ten grains (0.65 gm.) a day, and usually defer its use until I find other measures insufficient. After opium, arsenic has longest maintained its reputation as a remedy in diabetes, and I use it in all mild cases, preferring Fowler's solution. It seems to me there is something more than a simple tonic action in it. Pos- sibly it acts partly on the gastro-intestinal tract and partly on the red blood discs, increasing their oxidizing power over glucose. The plan I have adopted, after many years' experience, is to give small doses long continued rather than to attempt to bring about its physiological action. Hence three drops twice a day, continued indefinitely, is now my favorite method. The bromid of potassium is sometimes efficient in diabetes accompanying functional nervous disorders due to mental overwork or psychic disturbance. Bromin and arsenic are combined in the shape of Clemens' solution of •bromid of arsenic, of which the dose is from three to five minims (0.184 to 0.3 c. c). Substances which possess the power of oxidizing sugar in the blood have long been sought. The alkalies, and especially the alkaline carbonates, at one time enjoyed considerable reputation in the treatment of diabetes, after Mialhe claimed for them the power of destroying the sugar in the blood, and of neutralizing the volatile acids retained within the organism in consequence of the defective action of the skin. Whatever their mode of action, the car- bonates continue to be used by many physicians, both in Germany and in Eng- land, with results which justify the practice. Potassium or sodium bicar- bonate, in ten-, fifteen-, or twenty-grain doses (0.6, i, or 1.3 gm.), may be administered. The efficiency of the alkaline mineral waters is thus explained. Much was hoped of pancreas preparations, especially since the brilliant results that followed the use of thyroid extract in myxedema. They have proved disappointing. The glycolytic ferment isolated by Lepine from the pancreas and from malt diastase has not been any more satisfactory. Supra- renal extract has also been employed. The coal-tar derivatives, antipyrin, antifebrin, and phenacetin have been highly recommended by the French physicians, and I have found them of service in mild cases, giving from ten to fifteen grains (0.6 to i gm.) three times a day on an empty stomach, beginning with the smaller dose in the case of the first two. Their efficacy is said to be increased when combined with an equal bulk of sodium bicarbonate. Salicylate of sodium has warm advo- cates, and in gouty cases it may be useful. According to von Noorden, it is especially in neurogenous diabetes that the last of the remedies just named is useful, quieting the irritability of the central nervous system. Jambul is a remedy with some reputation. I have been so much dis- appointed in its effects that I rarely use it. It is given in the shape of powder or fluid extract, in doses of 5 to 30 grains (0.3 to 2 gm.) of the former and a half to 2 drams ( 1.8 to 7 c. c.) of the latter. lodid of potassium has produce'd some striking results in the case of diabetes due to syphilitic lesions of the brain. Lactic acid was strongly advocated by the Italian physicians. Cantani recommends that from 75 to 150 grains (5 to 10 gm.) of the acid should be 8i6 CONSTITUTIONAL DISEASES. taken daily in from eight to ten fluid ounces (240 to 300 c. c.) of water. Whence buttermilk or Zoolak (a fermented milk in which the sugar of milk is converted into lactic acid by a ferment) becomes a suitable food at least. Cod-liver oil becomes a useful remedy in cases in which the carbo- hydrates are totally converted into sugar and excreted, the albuminoids for the most part, while the body albumin is being encroached upon as a source of energy. Especially useful does it become when associated with alcohol in the shape of whisky or brandy, which always helps the assimilation of fat. In the same category as cod-liver oil must be placed butter, cream, bacon, and the like as foods. Treatment of Complications. Eczema and Pruritus. — These sometimes intensely annoying symptoms commonly abate with the reduction of the glycosuria, but require also other mieasures. In the first place scrupulous cleanliness is necessary, accom- plished by warm, tepid bathing. In addition, we may use solutions of boric acid 2 drams (8 gms.) to the quart (i liter) or sodium hypophosphite, one ounce (30 gm.) to a quart (i liter) of water; also zinc ointment, ointment of acetate of lead ; solutions of corrosive sublimate, very weak, — i to 3000, — and tumenol-sulphonic acid in 10 per cent, alcohol solutions. Carbolic acid 5 to 10 minims (.3 to .6 gm.) glycerin ^ss (8 c. c.) and water an ounce (30 c. c.) make a soothing preparation. As a last resort in pruritis nitrate of silver may be used in the strength of twenty grains (1.3 gm.) to the ounce (30 c. c), making daily applications, which though sometimes painful, are ulti- mately effectual. Diabetic Coma. — Treatment is usually futile here. The alkalies and' alkaline mineral waters should be pushed. Intravenous injections of alka- line solutions have been disappointing. More hopeful is the intravenous injection of a 0.8 per cent, salt solution, as recommended by von Noorden, using a liter in four doses at intervals of four hours. A teaspoonful of com- mon salt to a gallon of sterilized water aflfords a strength sufficiently near the percentage named. Hypodermoclysis. which is much easier, will accomplish the same result, as I can attest from personal experience. Copious diuresis follows, and may be expected to carry out noxious substances. More hopeful is a prophylactic treatment of diabetic coma, called for when diacetic acid or oxybutyric acid and large amounts of acetone are found in the urine. Under these circumstances it seems certain that whatever be the form of diet in use at the time, it must be changed, and if it be remem- bered that these substances are now conceded to arise from the disintegration of body albumin and not from food, as formerly supposed, diet would at least seem a matter of indifference under the circumstances, while a change alone seems desirable. The patient should be immediately placed upon alkaline treatment, associated with the free use of alkaline mineral waters. Thus, twenty grains (1.3 gm.) of sodium bicarbonate may be given every three hours, dissolved in eight ounces (250 c. c.) of Vals or Vichy water. The bowels should be kept open, and alcohol in the shape of whisky or brandy freely given. DIABETES INSIPIDUS. 817 DIABETES INSIPIDUS. Definition. — Any excessive secretion of non-saccharine and non- albuminous urine which has continued for a long time. Etiology. — The condition, unlike diabetes mellitus, affects more fre- quently younger persons, being rare in those over fifty years of age, relatively frequent in infancy, and most common between the ages of twenty and thirty. As to sex, it is said to be much more frequent in males than in females, two to three times as many of the former as of the latter. In my own experi- ence I have found the disease nearly equally frequent in both sexes. As to causes, the same uncertainty prevails as with diabetes mellitus. An examination of cases shows an association with a certain number of con- ditions, such as cerebral disease, including tumor of the brain, meningitis, paralysis of the sixth nerve, sunstroke, cerebrospinal fever, falls and blows on the head, exposure to cold and the drinking of cold fluids, drunkenness, pregnancy, hysteria, emotion, especially fright, hereditary influence, syphilis, and previous disease, etc., but this does not show causation. The propor- tion, however, of cases in which the condition is associated with brain diseases and injuries to the head, taken in connection with the fact of Bernard's dis' covery that puncture of the floor of the fourth ventricle above the diabetic center produces polyuria without glycosuria, makes it very likely that central nervous irritation, however induced, is at the bottom of the symptom. It is reasonable to suppose, too, that diabetes insipidus may be the result of some irritation, direct or reflex, of this center in the medulla oblongata, or of the sympathetic ganglia in the abdomen. The latter explanation also applies to cases of polyuria attending the presence of abdominal diseases, such as tumor, aneurysm, or peritonitis, though it is doubtful whether these should be regarded as cases of diabetes insipidus. Morbid Anatomy, — The essential morbid anatomy of diabetes insipidus would be the lesions of the nerve centers or sympathetic ganglia which may underlie the symptoms. But as these are often undiscoverable, or at least indefinite, it is impossible to describe them. Notably is this the case with lesions of the third and sixth nerves. Associated central nervous lesions, when present, are found more frequently in the vicinity of the base of the "brain. Symptoms. — ^The enornwus secretion of urine of almost spring- water- hke clearness, and of specific gravity often as low as 1003. is the most con- spicuous symptom, but more annoying, probably, is the extreme thirst which always attends it. These may be said to be the essential symptoms, others which may or may not be present being rather their consequence. Very con- stant among the latter are dryness of the skin and absence of perspiration. The health may be otherwise perfect, though emaciation and weakness are often present. The debility is sometimes extreme. Occasionally there are derangements of digestion, and sometimics also the appetite is ravenous, as in diabetes mellitus, though less frequently so. These symptoms may occur suddenly in the midst of apparent health, or they may supervene upon others or be substituted for them, chiefly those of a nervous character, which may be the result of the nervous lesion caus- ing the polyuria. Such symptoms are headache, restless, irritability, 8i8 CONSTITUTIONAL DISEASES. sleeplessness, what is commonly called nervousness, more rarely convulsions,, delirium, paralyses — indeed, any one or more of the great variety of symp- toms which result from organic or functional nervous disease. Sometimes these symptoms succeed upon the polyuria or are increased by it. It is cer- tain that the milder nervous symptoms are sometimes the result simply of the inconvenience and annoyance caused by the two cardinal symptoms, polyuria and thirst. The patient is kept busy, as it were, night and day, in passing water. It is not surprising that such a patient should be fretful and irritable,, and that sooner or later his health should be broken if the symptoms are not relieved. In addition to the symptoms detailed, there are said to occur at times dryness of the tongue, epigastric and lumbar pains, diarrhea, and impairment of mental faculties and of the sexual function. In some instances there is the most extraordinary tolerance of alcoholic drinks, while in others there is an exaggerated susceptibility to their influence. A very slight lowering of the ho&y-temperature has been observed, amounting, however, to but a few tenths of a degree, and it is never below 97° F. (36.1° C). In advanced stages of the disease edema of the lower extremities sometimes occurs. The duration of the condition varies greatly. Sometimes it continues through life with no inconvenience except that from the constant diuresis and thirst. Dr. Willis records a case lasting fifty years. On the other hand, it is seldom of brief duration ; indeed, there is needed a certain chronicity in order to admit it in the category of diseases. One case is reported as termi- nating fatally in seven weeks. Under prognosis will be found some further information as to duration, but it may be said, in general, that most cases which terminate unfavorably and most which recover completely do so within a year. I have now under my care a lad of seventeen who has been under treatment for eleven years. He is able to work quite hard much of the time. No complications arise except such as cause the disease or results from it. Among the latter is occasionally dilatation of the pelvis of the kidney, and atrophy of this organ is mentioned, due to pressure of the accumulated urine and resulting in a sacculated condition. The symptoms of the malady are almost always influenced, and sometimes even cut short, by inter- current disease, especially of a febrile character, or even by a profound physical impression, as long-continued suppuration after a blister. The boy referred to was an aggravated choreic before he became diabetic. Physical and Chemical Characters of the Urine. — As to the quantity of urine passed, it is enormous, exceeding often the amount passed in saccha- rine diabetes. As many as forty-three liters (90 pints) are recorded by Trousseau, and one-fourth this quantity is common. It has been said, even, that the quantity secreted sometimes exceeds the amount of fluid ingested, but this is impossible for any length of time, unless water is absorbed from the atmosphere, which is not impossible. In point of fact, the water excreted is always a little less than that ingested, either as drink or in the solid food. As the quantity of urine excreted increases or its normal acidity diminishes, its color disappears and its specific gravity declines. In one case under my care the specific gravity w^as scarcely looi, while the urine in moderate bulk was absolutely colorless. Again, a faint greenish tinge is exhibited b}' the urine in bulk. As to the other constituents of the urine, it may be said in general that they are all increased, except possibly uric acid. Thus, the urea is increased DIABETES INSIPIDUS. 819 to three and even four times its normal amount. In a case reported by J. AI. Da Costa * the urea was diminished. Sulphuric and phosphoric acids are both increased, and especially, according to Dickinson, the combination of phosphoric acid with the earths, lime, and magnesia. The same is true of the chlorids. Of abnormal constituents, inosit has been found, and alhiiinin very rarely, but care should be taken not to confound the polyuria with the slight albuminuria of a contracted kidney or with an albuminous polyuria in which there is no organic disease of the kidney. Some of the accounts published as to the quantity of water consumed and excreted are almost incredible, yet they seem well authenticated. In illustration may be mentioned the following instances from Dr. Willis' work on " Urinary Diseases " : f An artisan, fifty-five years old, had had constant thirst with commensurate diuresis since he was five years of age. From the age of sixteen he had drunk, on an average, no less than two pailfuls daily. While in the Hotel Dieu, to which he was admitted for an injury of the knee, he drank on an average thirty-three pints of water every day, often swallow- ing two liters, or about two quarts, at a draught. He passed daily about thirty-four pounds of urine and one pound of feces. He otherwise enjoyed good health, and was the father of several children. The long duration of this case and the otherwise excellent health enjoyed by him are by no means exceptional. X&vy little serious disturbance seems to result so long as water is supplied to quench the resulting thirst. In extreme cases patients have been known to drink their own urine. An extraordinary flow of saliva was observed in one instance by Kiilz,:|: along with polyuria, in a hysterical girl of eighteen years, from whom as much as 18.72 ounces (525 c. c.) were collected in twenty-four hours, while the quantity ranged during four months from 360 c c to the former amount. The quantity of urine passed during this time ranged from 200 to 260 ounces (6000 to 7800 c. c). The increased flow of saliva may be explained by the fact that in some of the experiments of Eckhard,§ Loeb,|| and Gruetzner ^ puncture of the medulla oblongata was followed by ptyalism. Diagnosis. — The diagnosis of diabetes insipidus is very easy. The per- sistent thirst, polyuria, and absence of sugar from the urine are pathog- nomonic. The only possible error is mistaking the polyuria of chronically contracted kidney of interstitial nephritis for that of diabetes insipidus. In addition, however, to the fact that a careful examination for albumin will dis- close it in the urine of contracted kidney, the quantity is never so large, nor is the thirst so extreme ; so that it would seem only necessary to mention the possibility of such an error in order to avoid it. Prognosis. — It is extremely unusual for a case of diabetes insipidus to terminate unfavorably unless there have been also present symptoms point- ing to serious nen^ous lesion. Recovery is not infrequent. According to Roberts, of 67 cases collected, 16 are reported as complete recoveries and 14 ended fatally, nearly an equal proportion. The remaining ■^'j were still in progress. In cases of recovery or death the duration is comparatively short. Of the 16 recoveries, in 9 the duration was less than a year; in i, four years; in 2, eighteen and nineteen years, and in the remainder, some years. Of the ' f * " Transactions of the College of Physicians of Philadelphia," third series, vol. i., 1873, p. 139. + American edition, Philadelphia, zB%q, p. 2:;. X " Diabetes Alellitus and Insipidus," Marburg:, 1873. § Eckhard, " Beitrage zur Anat. und Phj'siol.," iv, p. iqi. P Loeb, Eckhard's " Beitrage," v., p. i; and " Dissertation," Giessen, 1869. IT Gruetzner, " Pfliiger's Archiv," vii. p. 552. 820 CONSTITUTIONAL DISEASES. 14 fatal cases, 9 terminated in less than a year, i in seven weeks, and 2 in two months ; the other two survived eighteen months and twenty years respectively. Of the ■t,? cases in progress, only 5 continued for a year or less. The remainder had continued for periods ranging from something over a year to fifty-nine years. These results seem to be tolerably independent of treatment. It may be said, therefore, that, as a rule, cases that last more than a year are apt to con- tinue, but ordinarily only require to be furnished with an abundance of water to keep them tolerably comfortable. According to Dickinson, cases due to drunkenness are more likely to run a severe and rapid course, usually termi- nating fatally within a few months, and one terminated thus in two months. The disease appears to me altogether less serious than diabetes mellitus, and I quite concur with Senator, who says " it is rather a troublesome than a dangerous complaint." But Trousseau and Da Costa were inclined to con- sider it more serious than diabetes mellitus. Treatment. — ^The treatment of diabetes insipidus would naturally resolve itself into the treatment for the disease of which it is the symptom rather than of the symptom itself ; but as the former is very frequently undiscoverable, it must consist mainly of efforts to diminish the secretion of urine, and with it the thirst. First, it is generally conceded that there should be no restriction in the drinking of water or other harmless fluids, for the diuresis is not so much caused by the great ingestion of water as the thirst is caused by the diuresis. It should be mentioned, however, that one or two instances are reported wherein improvement seems to have resulted from such restriction ; and if, as in some cases, a habit of drinking has been the initial event, moderate restriction may be reasonable. Caution should be used in the administration of drugs, though my experience is not that of Dickinson, who says that " remedies designed to restrain the urinary secretion seldom fail to do harm." The older remedies are ergot, opium, gallic acid, and valerian ; of all, the doses ultimately used are usually large. In one of my patients the symptoms subsided under the use of gallic acid after I had failed with full doses of ergot. In another, probably due to syphilis, the effect of the iodid of potas- sium was shown in an aggravation of the symptom whenever it was discon- tinued and an amelioration when it was resumed. Of all drugs, I have found the iodid of potassium most frequently followed by improvement. Trousseau and Rayer claimed extraordinary results from the use of valerian, the former using the fluid extract in enormous doses — 2 1-2 drams (6 c. c.) a day, which was increased to one ounce (30 c. c.) daily in one instance. Rayer used the powdered valerian and the valerianate of zinc, giv- ing the latter in pills in gradually increasing doses until twenty grains (1.25 gm.) a day were given. At the present day the more palatable elixir of valerianate of ammonia, combined with bromid of potassium, is to be preferred. Reasoning from the effect of intercurrent disease and powerful physical and nervous impressions, Roberts suggests a large blister at the nape of the neck or epigastrium, according as the associated symptoms and the anamnesis point to the nervous or the digestive system, a suggestion which may be acted upon with advantage. The constant galvanic current has been recommended, and in cases of spinal lesion may be expected to be of advantage. Both Seidel and Kiilz have used it with good results. The former applied one pole of a " strong OBESITY. 821 battery " over the loins near the spine, and the other as deeply as possible over the hypochondrium, upon each side daily for five minutes. In eight days the urine fell from 195.9 ounces (5957 c. c.) to 153.3 ounces (4600 c. c.) per diem, in three weeks to 76.6 ounces (2300 c c), and the next month 63.5 ounces (1904 c. c), while the weight of the body increased nine pounds. Kiilz applied one pole of a battery of from thirty to forty cells as high as pos- sible in the nape of the neck, and the other to the loins or epigastrium, the best results being apparently obtained with the positive pole to the nape of the neck, and the negative first to the loins for four minutes and then to the pit of the stomach for four minutes. Tonics and nervines, such as strychnin, iron, arsenic, salts of quinin, cod-liver oil, etc., are appropriately added to the treatment with a view to sus- taining the strength of the patient, which is apt to fail. To these are to be added fresh air, sea air, exercise, and all possible favorable hygienic influences. Hygiene is even more important than in diabetes mellitus, and should include a careful attention to the skin, warm clothing, warm baths, frictions, etc., in order to divert a portion of the circulation from the kidneys to the skin. The thirst should also be quenched when possible by bits of ice and acidulous fluids. OBESITY. Synonyms. — Adipositas universalis; Polysarcia adiposa; Corpulence. Definition. — Obesity may be defined as an inconvenient accumulation of adipose tissue in the body. Etiology. — The most usual cause of an excessive accumulation of fat doubtless is overeating associated with an inactive life ; and though it may be true of some fat persons that they are really moderate eaters, careful exami- nation will generally prove that they are not. Heredity exerts an undoubted influence, and we find corpulence running in families. Commonly it does not make its appearance until after thirty-five years of age, but in this country particularly it is often seen earlier, in boys and girls of ten years and upward. Of foods, each one of the representative varieties, albuminoids, carbo- hydrates, and fats, is capable of contributing fat, deposited in fat vesicles in the body, and it has even been said that albuminoids furnish more of the fatty tissues of the body than the carbohydrates. Certain it is that a person may become corpulent who eats very little fat. In most cases, however, corpulent persons are found to be liberal consumers of all three of the food elements. While the carbohydrates are direct sources of fat production, it is generally conceded that they act largely by sparing the fats derived from other sources. They decompose and oxidize so rapidly, and thus give themselves up so readily to force production, that the stored fats are not called upon. Thus it is that sugars and starches indirectly favor corpulence. To this class belong also alcohol, and especially beer, which contains over five per cent, of carbo- hydrates, in addition to from 3 to 4 per cent, of alcohol, and it is well known that liberal beer-drinkers furnish a large quota of fat men. A second method in which large quantities of alcohol contribute to adiposis is by hastening albuminous metamorphosis, setting free non-nitrogenous substances readily 822 CONSTITUTIONAL DISEASES. converted into fat, which are deposited, among other situations, in the Uver, giving rise to the fatty Hver so constantly found in drunkards. Another cause of corpulency is muscular inactivity. Fat is consumed by muscular contraction, and its absence must contribute to fat accumulation, and one need not go far to see its evidence in many who lead lives of idleness. Oertel has especially called attention to the fact that a simple diminished in- gestion of fluids, without other changes in the diet, will reduce the amount of fat. The effect may be brought about in two ways ; first, by diminishing the work of the heart and thereby favoring oxidation ; second, by an effect which is not so much the diminution of fat as a withdrawal of water — a sort of " desiccation," it is called by Striimpell. The subjects of anemia and chlorosis often become fat, probably because of defective oxidation, growing out of a diminished supply of oxygen, which the crippled corpuscles are unable to carry in sufficient quantity. Sexual continence probably contributes to corpulence, since eunuchs are well known to grow fat, and both w'omen and men are disposed to grow fat when the sexual function begins to abate. Finally, corpulence itself favors the further accumulation of fat, first by interfering with the muscular activity of its subject, and therefore with the oxidation of fat, and, again, diminishing combustion by reason of a reduced demand for heat, the fat itself conserving heat by preventing its radiation. Symptoms. — A description is scarcely needed of the anatomical condi- tion which constitutes obesity. The round, plump face, the double chin and hanging cheeks, the enormous girth of body, the pendulous belly and elephan- tine arms, legs, and thighs need no further description. The labored, wad- dling gait is often conspicuous. The first evident indication of harmfulness due to corpulence is an increased frequency in the breathing-rate, at first on slight exertion and later independently of it. This is in part a true cardiac asthma — due, first, to the fact that the heart cannot push the blood through the lungs rapidly enough to permit its aeration at the ordinary breathing- rate ; and, second, to the fact that the motion of the lungs is also restricted. The latter is due to the accumulation of fat over the thorax and in the medias- tinum, and to the accumulated intra-abdominal fat and probably enlarged liver, which interfere with the proper descent of the diaphragm. This leads at first to cardiac hypertrophy, further stimulated by the extra work demanded of the heart in propelling the increased bulk of the blood ; further augmented by resulting arteriosclerosis, and impeded venous circulation. Later the fatty infiltration of the muscular walls of the heart leads to further embar- rassment in its action and to impairment of its nutrition, whence come cardiac weakness and ultimate failure, with edema, pericardial and pleuritic effusion, and sometimes sudden death. The pulse, hard to find, is usually frequent, but may be slow and irregu- lar. The heart can be examined only wdth difficulty, on account of the large accumulation of fat, and the normal sounds are feeble and distant. The situation of the apex can be found only by the aid of the stethoscope. Inter- trigo is often an annoying symptom, and great care is required to avert it. Interstitial nephritis may be superadded. By no means all corpulent per- sons run this course. Many lead lives of considerable comfort. Treatment. — This consists in acting upon two principles : first, furnish- ing less food to oxidize, and, second, increasing the oxidation of the fat in the body. The first is accomplished by cutting down the quantity of all kinds of OBESITY. 823 food, but especially carbohydrates. Sugar should be prohibited altogether, and saccharin substituted, if sweetening is desired. Bread may be taken in small amounts, say two ounces, well toasted and with it a thin layer of butter ; or hard biscuit may be substituted. A cup of tea or coffee with a little milk may be allowed ; also a single egg at breakfast or luncheon ; meat once a day. The latter may be of any kind, and with it may be taken green vegetables, such as peas, string-beans, tomatoes, cabbage, spinach, Brussels sprouts, lettuce, celery, and the like, omitting altogether rice, potatoes, and the fari- nacea in general. A little cheese may be allowed. Only small quantities of fluid should be permitted at meals — just enough to aid in the solution and digestion of food. This may be tea, coffee, water, or skimmed milk, the first two without sugar or cream. Beer, porter, and sweet wines should be prohibited, but a glass or two of hock or claret with an alkaline mineral water may be allowed. A diet of skimmed milk only is a sure way of reducing fat, and a start may be made with it, commencing with two ounces every two hours and increasing until from six to eight ounces are attained. Unfortunately, very- few persons will bear this treament for any length of time, but, as stated, a beginning may be made with it, and when the patient tires, the other treat- ment just described may be instituted. The second indication to promote oxidation is accomplished by exercise, gymnastics, walking, mountain-climbing, or cycling. The last has been effective in reducing the weight of the corpulent, and if combined with a proper diet, may be expected to do more. Massage is also useful, especially in co-operation with the Turkish bath and steam bath. These last help in the " desiccation " of the body, which in turn facilitates oxidation. Great diffi- culty is experienced in getting the patient to carry out the dietary and to exer- cise assiduously. Certain health resorts have much reputation for their efficiency in reduc- ing corpulence. Homburg, Marienbad, and Carlsbad are among the most celebrated of these, and I have seen many patients return thence after a cure of four to six weeks markedly improved in all the symptoms which come from obesity. The effect is probably altogether due to the strict diet, the systematic exercise, and the bathing, the massage, and the laxative effect of the waters, although the physicians at the various spas which have a repu- tation for reducing obesity claim also that the effect of the sulphate of soda, which is a constituent of most of these waters, is to stimulate oxidation in the direction of the fatty structures, while limiting the metamorphosis of the nitrogenous substances. This intermittent method of treating obesity, by recourse to baths and springs once a year while the intervening period is spent in free eating, is not to be recommended. It is much better to adopt a continuous method which may not be as rapid, but is persistent. Thyroid extract has been administered with reputed advantage in obesity in doses of from three to five grains (0.2 to 0.35 gm.) three times daily, which may be gradually increased to twenty grains (1.3 gm.), with the same precau- tions as advised in the treatment of myxedema. Under this treatment the loss of weight is sometimes quite rapid, going to show that defective thyroid secretion may be a factor in causing obesity. Mention should perhaps be made of the so-called systems of diet for reducing corpulency, a number of which have been suggested. Those espe- cially deserving of notice are the Banting system, Ebstein's method, the method of Dancel-Oertel, in addition to the mineral water cures. It is, of 824 CONSTITUTIONAL DISEASES. course, impossible in the limited space of a text-book to give these methods in full. The principles of their application will alone be considered and the student is referred to special sources for their detailed description/'' ( I ) The Banting system consists in the administration of a large amount of albuminous food, especially lean meat to the exclusion of fats and carbo- hydrates ; green vegetables being allowed ad libitum; (2) Ebstein's method demands moderation and restriction in the quantity of foods generally, and for the fat-forming carbohydrates substitutes the albumin-saving, but not fat- forming fats 1(3) the Dancel-Oertel method reduces especially the quantity of water and other liquids, only a minimum of 800 grams (about i 1-2 pints) of water mixed with wine, and twice a day a cup of coffee or tea ; of solid foods, nitrogenous alimentary substances and vegetables, especially such as contain little water, with fat only in such quantity as to render the dishes palatable. Oertel emphasizes the mechanical advantages of restric- tion in the use of water upon derangements of the vascular system; (4) the mineral water cures, as might be expected, are based chiefly upon the use of such waters, especially those containing sulphate of sodium and chlorid of sodium, the cold springs being preferred. The springs are thus classified: (a) cold waters containing sulphate of soda — Marienbad, Tarasp, Schulz, Frazensbad, Elster, Cudowa. and Rolitsch — carbonic acid waters; (h) hot springs containing sulphate of sodium — Carlsbad, Bertrich ; (c) cold waters containing chlorid of sodium — Homburg, Kissengen, Nauheim, Neuhaus and Oeynhausen ; in America the Saratoga springs; (rf) springs containing iodin — Hall, Krankenheil, Salzschlirf, Kreuznach, Miinster am Stein. The drink- ing of waters at these places is combined with the use of saline, carbonated, mud, and steam baths. RICKETS. Synonym. — Rachitis. Definition. — "There is a disease of infants called the rickets, wherein the head waxeth too great, while the legs and lower parts wane too little " (Thomas Fuller, 1608-61). This quaint description of the celebrated Eng- lish chaplain, written over two hundred and fifty years ago, remains so nearly correct at the present day that I cannot forbear adopting it. It is further defined as a constitutional disease characterized by deformity in bones, due to cell overgrowth and deficiency in lime salts. " The rickets " was evidently known for some time by the laity before it received its description by F. Glisson in 1650, who suggested the change of name to rachitis from the Greek pocxi^, the spine. The term rickets is derived from the old English word wrickken, to twist. Etiology. — Rickets rarely begins before the child is six months old or after it has attained the age of eighteen months, though a form is described by Sir William Jenner coming on as late as the ninth or even the twelfth year ; on the other hand, it may begin earlier, and the child may even be rickety in the womb. Yet it cannot be admitted that rickets is hereditary, in the usual sense of the term. The child may become rickety in the womb if the mother is feeble, underfed, and overworked, and if the father is weak at its concep- tion, but not because the father and mother were rickety when children. * " Dietetic and Therapeutic Hints to the Visitors of Bad Homburg." By Heinrich Will, M. D., 1893. RICKETS. 825 Again, certain races tend to be rickety, especially the negro and the Italian- Foul air and bad food, absence of sunlight and exposure to dampness and cold, are more potent factors, and it is likely that a defective composition of the iDreast milk, including a deficiency in the phosphates, is the strongest. Prolonged lactation may contribute to such deficiency. It is a disease of the city rather than of the country, and of the Continent of Europe rather than of America. Vienna, London, and Paris are prolific fields. In the first- Fig. 81.— Deformed Skeleton from a Case of Rachitis— (/r^w Atlas du Musee Dupnytren). named cities from 50 to 70 per cent, of all children brought to the clinics are said to be rickety. Parrot held that congenital rickets was a form of syphilis, basing this view on studies in the French capital. On the other hand, there is reason to believe that the changes in prenatal rickets are not identical with those of the postnatal form. The subjects of the former are usually still- born, are short of limb, and though the curves of the bones are exaggerated, there is no proliferating zone of cartilage between the epiphysis and apophysis, v;hence the term achondroplasy, suggested by Parrot, and chondro dystrophia^ 826 CONSTITUTIONAL DISEASES. foetalis, by Kaufmann. Boys and girls are equally liable to rickets. The syphilitic origin of congenital rickets is not, however, conceded by others. Minute examination recognizes numerous cells in the spongy spaces in the bone. The studies of Kassowitz lead him to believe that a hyperemia of the periosteum, the marrow^, the cartilage, and the bone itself is the funda- mental condition responsible for the abnormal development. His views may be regarded as a refinement and development of those originally suggested in 1650 by F. Glisson, who held that an excessive vascularity was at the bot- tom of the changes. Morbid Anatomy. — This shades somewhat into symptomatology, and the two can scarcely be separated. The changes are mainly in the bones of the skull, the long bones, and the ribs. The first may escape if the disease sets in after the middle or end of the second year. The frontal and parietal eminences are exaggerated, while the top of the head and the occiput are flattened, the whole effect being toward making the head square or " box- shaped." The fontanels remain open some time, — until the second or third year of life, — while the edges of the bones where they come together to form the sutures are thickened, though soft and yielding. In addition to these changes, or instead of them, there may be large areas of delayed ossification Fio. 82. — Rickety Chest— {after Gee). Dotted line indicates the shape of the chest of a healthy infant about the same age. in the parieto-occipital regions, producing yielding spots, constituting the so-called craniotabes- of Elsasser ; but as craniotabes occurs in connection with syphilis and other wasting diseases of young infants exhibiting no other sign of rickets, and even in new-born infants, it cannot be regarded as pathognomonic. In the long bones, such as the radius and ulna, swelling of the cartilage between the epiphysis and shaft is apparent. Owing to the rapid prolifera- tion of cartilage cells, resultingSn a broad band of jelly-like material between the cartilage and the bone, a spongy structure is rapidly built up, deficient in strength and stiffness. Beneath the periosteum the same gelatinous material is deposited, and a spongy tissue is formed instead of normal bone. The process of bone formation does not proceed further. There is no deposit of lime salts. The periosteum is loosely attached. The long bones bend easily, especially the tibia, producing the characteristic bow-leg, which may occur even before the child walks, when it is caused by sitting cross-legged. The thighs may also become bowed, the inner ends of the condyles prolonged downward and the tibia set outward, producing the " knock-knee." This does not, however, appear until the child begins to walk. In extreme cases the long bones may fracture. Sometimes both the femora and tibiae are bowed forward. RICKETS. 827 Quite as characteristic are the changes in the chondral ends of the ribs and in the shape of the chest. The former are enlarged and nodular at the junction with the bone, producing the well-known beaded appearance, which may often be recognized at a glance. The altered shape of the chest-walls, most marked in children who have had much cough, is due to the yielding of the soft costal ends of the cartilages and to a falling-in of the ribs at these points, while the sternum and cartilages are pushed forward, as seen in Figure 82. This is especially the case in the region between the fourth and eighth ribs, which may be so bent in as to form a vertical groove, increased during inspiration. Associated with this is sometimes a transverse groove, known as Harrison's groove, starting at the ensifomi cartilage and passing trans- versely outward toward the axilla. At the same time the arch of the ribs below may be widened and the belly thrown forward by the arching inward of the vertebrae. Extreme degrees of this chest deformity produce the proi-jii- nent sternum constituting the " chicken-breast " or '' keel-shaped " thorax. Other changes in the bones are an exaggeration of the normal double curve in the clavicle ; a bending of the humerus, usually at the insertion of the deltoid, sometimes produced by lifting the child by the arms ; the radius and ulna may be curved and twisted, the articulations knotted and bulbous, loose and mobile, because of relaxed ligaments. The spine is also often altered, the change being for the most part an increase in the normal curve outward in the cervico-thoracic portion and inward at the lumbo-sacral. In other cases there is a lateral curvature. The scapula is often thickened. The pelvis is distorted and twisted, and the antero-posterior diameter is markedly lessened. The rickety pelvis is one of the well-recognized causes of dys- tocia. These changes are all the result of mechanical causes, such as the weight of the body or muscular traction. Chemical analysis of rickety bones approximately reverses the normal proportion of organic and mineral constituents (calcium salts), reducing the latter to 35 per cent., while the gelatinous or organic matters amount to 65 per cent. An enlarged liver and spleen are usually present, and sometimes also the mesenteric glands are enlarged. Symptoms. — (See also Morbid Anatomy.) The earliest symptoms noticed are not invariably the same. There is usually profuse szveating. especially about the head and neck, and a mild degree of fever, as the result of which the child is inclined to throw off the bed-clothing. There is evi- dent discomfort in being handled. The last symptom is apparently due to a tenderness of the skeleton, causing pain when the child is raised or danced up and down after the manner of amusing children. Along with these are the less distinctive symptoms of indigestion, indicated by nausea and vomiting, offensive stools containing partly digested milk, and flatulent distention, causing the belly to be prominent. Among other less essential symptoms may be mentioned nervousness, restlessness, peevishness, and infantile con- vulsions, the relationship of which to rickets is not accidental and was pointed out by Jenner. Tetany and laryngismus stridulus are also often symptoms. Concurrently it is noticed that teething is delayed, and we have the authority of Sir William Jenner that if there are no teeth at nine months there is something rickety about the child. But I am confident that I have seen dentition delayed after this time in children who were not and who did not become ricketv- In ricketv children the teeth which are cut soon decay. 828 CONSTITUTIOXAL DISEASES. Muscular n'cakiicss is characteristic, so that the child cannot sit up and makes but a feeble or no efifort to walk. Such muscular weakness has been mistaken for paralysis, whence it has been called the pseudoparesis of rickets. Close upon these symptoms, or at least within two or three weeks of the first symptom, follow the skeletal changes described under morbid anatomy, page 826. The head is large in comparison with the face, the skin is pale and thin, and the child has often an old and a wise look quite beyond its years. The appearance of the beaded ribs, the bowed legs or " knock-knees," promi- nent belly, and curved spine often serve to make the diagnosis easy at a glance. The prominent belly requires some further description, as it varies somewhat at different periods. Before the child walks the normal cervical anterior curve may be increased and a posterior curve present from the first dorsal to the last lumbar vertebra, which may be recognized by holding the child up. After it begins to walk, however, the dorsal spine continues curved backward while the lumbar projects forward. The latter, therefore, contributes also to the prominent belly produced in part by flatulent distention, and partly at times by an enlarged liver and spleen. Complications. — These include especially bronchial catarrh and broncho- pneumonia, the eft'ects of which are aggravated by the conformity of the chest, the weakness of the ribs, and the feebleness of the respiratory muscles. Collapse of the lung is often a consequence of lung affections. Chronic hydrocephalus is a complication, while many of the conditions mentioned under symptomatology — viz., diarrhea, convulsions, laryngismus stridulus, and the like — may also be so regarded. The rickety child is weak and is vul- nerable to all the illnesses of childhood. Diagnosis, — This is usually easy, although, of course, all the symptoms detailed are not always present in their typical expression. The various spinal curvatures may be somewhat confusing. Thus, the question of caries may arise. But the rickety spine differs from that of caries by the wide curve, the absence of angularity, the flexibility of the spine, and the fact that by laying the child flat on its face the curs^e disappears. The other symptoms of rickets are also present. The lordosis of rickets produces a deformity resembling that of congenital dislocation of the hip and of hip disease, but here again other signs of rickets are present, while the distinctive signs of the disease in question are absent. Prognosis. — Rickets is never in itself fatal, and the course is toward recovery. But the child is always in danger from the complications. Such are bronchitis, bronchopneumonia, laryngeal spasm, and convulsions. Walk- ing is always delayed, and the child may be still unable to walk at the end of the second or third year. [Mention has been made of the fact that the rickety pelvis in women is one of the most frequent causes of difficult labor. Treatment. — We should seek to avert rickets by a judicious prophylaxis, which consists in keeping the health of the mother at the highest point at all times ; this, not by organic food only, but by a judicious admixture of salts such as are contained in the whole cereal grain, especially in wheat and barley. Frequent pregnancies and prolonged nursing, being acknowledged causes, should be interdicted. The treatment of the child should be dietetic, medicinal, hvgienic, and operative or mechanical. As the condition depends often upon the lack of ordinary good food, the simple addition of such food in lieu of the mother's milk, if this be found defective, may be all that is required, especially if it be possible to secure that rarely attainable article, a healthy wet-nurse. In the OSTEOMALACIA. 829 absence of this beef- juice, the yolk of eggs, peptonized milk, and beef pep- tonoids may be substituted. Due consideration must, however, be paid to digestion in the selection of food, the stools should be examined daily, and if undigested residue is found, the food should be changed. Pepsin and hydro- chloric acid in doses adapted to the age of the child should be given, while the predigested foods are often highly useful. Cod-liver oil inunctions are invaluable, and though in some respects unpleasant, I have seen so many chil- dren seemingly wrested from death by their use that I value nothing more highly. Saccharine and starchy foods should not be allowed, except in very moderate quantities. The flours of the whole cereals, well baked and cooked as thin gruels and strained, make a suitable addition to the food, while the fruit-juices of orange and lemon may be given in small quantities. Medi- cines should bC' cautiously given. Among them are lime salts, as the hypo- phosphite of calcium or lactophosphate of calcium, ten grains (0.65 gm.) of either three times a day, or lime-water, or the official syrups containing the salts mentioned. Doses should be carefully regulated, as digestion is feeble. Minute doses of iron, preferably the citrate or malate, may be given. Phos- phorus was recommended by Kassowitz, and is indorsed by Wegener, Jacobi, and Striimpell, in doses of from 1-200 to i-ioo grain (0.00033 to 0.00066 gm.) two or three times a day dissolved in olive oil or cod-liver oil. The principle of the administration of these two drugs is different. The salts previously mentioned are convenient modes of administering calcium, while phosphorus is supposed to stimulate bone grozvth. The hygienic treatment is more important than the medicinal. Fresh air and outdoor life are indispensable. If the child is warmly clothed and well protected, it may be taken out even in cold weather. If should not he aUoived to zvalk or even tx) sit up unless properly supported — in fact, should be handled as little as possible. Mechanical appliances ma}' be employed with advantage, especially in lateral bowing, before the bone is hardened. Forcible manual straightening may also be employed in moderate grades of deformity, but should be rele- gated to the experienced orthopedic surgeon. After ossification is complete, deformities may be corrected by the orthopedic surgeon, by osteotomy, chiefly of the bones of the lower extremities, though the radius and ulna are some- times operated on. Osteotomy of the pelvis has been suggested by Macewen in parturient women in whom delivery is impossible, but a recently revived operation, symphysiotomy, has made it unnecessary. OSTEO^IALACIA. Definition. — A softening which takes place in the bones by a solution of lime salts subsequent to their complete development. Etiology. — The precise cause is unknown. A geographical distribu- tion, however, exists, in accordance with which it is common on the Rhine, in Westphalia, in Eastern Belgium, and in Xorthern Italy. In this respect it is similar to goiter, which prevails in special localities, and it has been sug- gested on this account that it may be due to some local cause. It is for the most part a disease of adults between thirty and forty years old, and of women more than of men. It is favored by unhygienic surroundings, such as damp and badly ventilated dwellings. Frequent pregnancy is supposed to be an exciting cause. 830 CONSTITUTIONAL DISEASES. Pathogeny. — There is, primarily, increased vascularity. To this suc- ceed a solution and disappearance of the lime salts of the bone. These take place from within outward, from the marrow cavity, dissolving out first the lime salts and then melting away the matrix, enlarging the central cavity until the cortical portion acquires a paper-like thinness. The whole bone has been compared to an " inflated and dried intestine." The product of the solution at first is a mucoid matter that mixes with the marrow. The latter soon loses its vascularity and gradually acquires a thinner but still viscid character and a yellow color. The periosteum is likewise hyperemic and at first thick- ened. The process is compared to the artificial solution of the earthy salts from bone by hydrochloric acid, and it is supposed that the solvent agent exerts its effect from the medullary spaces and Haversian canals. It has been suggested that lactic acid is the solvent, as it has been found in the medul- lary canal and in the urine of subjects of osteomalacia. The process extends unevenly. It differs from rickets in being a degeneration of fully formed hone, while the latter is a degeneration of developing bone. Morbid Anatomy. — The favorite seats of the process are the vertebrae and the bones of the pelvis and thorax. The result in the former is an S-like curve of the spinal column, due to a kyphosocoliosis or backward curvature of the dorsal and a lordoscoliosis or forward curvature of the lumbar part, while the cervical portion in connection with the upper dorsal portion protrudes anteriorly. The thorax is distorted and compressed laterally, while the sternum is prominent and bent. The pelvis is also compressed laterally, the symphysis projects like the prow of a ship, and the sacrum pro- jects forward producing a deformity of the pelvis often discoverable only by internal examination. Symptoms. — The first symptom is usually pain, deep seated and severe, oftenest in the sacral region, nape of the neck, back, and thighs, and this pain is persistent and increased by motion, giving rise to a hobbling gait. There is also tenderness. Walking, therefore, becomes more and more difficult and finally impossible, and the patient takes to bed. But this affords no relief, the pain being kept up by the pressure of the bed-clothing and the weight of the body. In the meantime the deformities described under morbid anatomy take place, though those of the pelvis are less obvious exter- nally. Diificiilt labor is an inevitable consequence should the patient conceive, just as it is in rickets. Dyspnea is a frequent consequence of compression of the lung by the distorted thorax. Fractures, complete and incomplete, are frequent events, even of the ribs as well as of the extremities. In this respect osteomalacia differs from rickets, in which the bones bend but do not break. Such fractures repair imperfectly. Sometimes, on the other hand, the limbs are soft and yielding, and may be bent like lead pipe. The bones of the head and face are for the most part exempt, though the head is much bent toward the chest, making the stature lower. The general condition of the patient often remains for a long time unal- tered. There is little or n6 fever. The organic functions are normally main- tained. The presence of lactic acid in the urine has been mentioned. It is said that phosphoric acid is diminished. Albumin is also sometimes present. Calcareous concretions have been found in the kidneys and bladder. Diagnosis. — At first there may be doubt as to the nature of the disease, but as the characteristic symptoms present themselves, its real nature becomes evident. Disease of the vertebrce and cord has been confounded with it, but the hobbling gait peculiar to it does not usually resemble any of the gaits of PURPURA. 831 spinal disease. Being a disease of adults, it is not likely to be mistaken for rickets. Moreover, it is a disease which afifects the shafts of bones rather than the epiphyses. Prognosis. — The disease is usually ultimately fatal, although death is often long deferred and the course is chronic — from two to ten years. Arrest sometimes occurs, but is only temporary. The disease again starts, and its course is generally irresistible. Death commonly takes place from exhaus- tion or from some compHcation like pneumonia. Recovery is not impossible. The so-called cystic degeneration of bone is said to be a consequence. Treatment. — Theoretically, the indications are the same as for rickets — viz., to supply the blood with lime salts. Practically, they have not proved of much value. They may, however, 'be prescribed in the shape of the syrup of the lactophosphate of lime in the dose of from one to two fluid drams (4 to 8 c. c.) or the syrup of the hypophosphites in the same dose or the latter in combination with iron or with cod-liver oil. Proper hygiene and good food are of the utmost importance. Phosphorus itself is a drug highly com- mended. (See Rickets.) Striimpell gives the following prescription for it: i^ Phosphori, o.oi gm ( 3-20 grain Olei amyg. express, ...... 10.00 (150 grains) Misce, deinde adde, Pulv. acaciffi . I aa . . . . 5.00 gm. ( 75 " Syrupi, simplicis, f . 3 & v /j Aqusedest. , 80.00 gm. (1200 " M. Sig. — Two to four teaspoonfuls a day. Women who are subjects of osteomalacia should be warned against marriage. PURPURA. Synonyms. — Morbus macitlosus ; Peliosis. Definition. — A name given to several dyscrasic states, all attended by subcutaneous or submucous extravasations of blood. Such extravasations do not disappear on pressure, and vary in size from that of a pin-point to areas a centimeter or more in extent. When minute or punctiform, they are called petechiae ; when larger than this, ecchymoses. An indisposition on the part of the blood to coagulate is commensurate with the tendency to extrava- sation. Purpura is always a symptom rather than a disease, but in certain conditions it forms the most conspicuous symptom of a group which scarcely admits of any other classification. In this event an adjective term derived from some more conspicuous one of these symptoms, or from the name of some investigator who has described the condition, is added to give precision. In other instances it is so purely a symptom and plays so minor a role in the disease that it is called symptomatic. Under any circumstances it is not always easy to keep the varieties distinct. Symptomatic Purpura. This includes the forms of purpi5ra in which the petechise and ecchy- moses are usually of minor importance. In a few instances in which the dyscrasia is very great they become by their number and extent indices of the degree of such dyscrasia. Such are: §32 CONSTITUTIONAL DISEASES. 1. The purpura which often invades the extremities of the old (senile purpura). 2. The purpura of the infectious diseases (infectious symptomatic pur- pura), especially typhus fever, smallpox, scarlet fever, measles, pyemia, mycotic endocarditis. 3. The purpura of poisons (toxic symptomatic purpura) — as, for example, that which occurs in connection with venomous snake-bites, or with overdoses of' certain medicines, such as ergot, mercury, copaiba, quinin, iodid of potassium, and others. Certain persons possessed of idiosyncrasies acquire purpura on the administration of much smaller doses. In these the extrava- sations may occur anywhere on the body. 4. The purpura attending certain diseases which, though not infectious, induce cachectic states — viz. (cachectic symptomatic purpura), cancer, tuber- culosis, Bright's disease. 5. Certain nervous diseases (neurotic symptomatic purpura), including locomotor ataxia, myelitis, rarely neuralgia, and hysterical states associated with the bleeding points known as stigmata. 6. Mechanical symptomatic purpura, when induced by some cause resist- ing the onward movement of the blood, as a paroxysm of whooping-cough, croup, or an epileptoid fit. The diagnosis of these conditions is a purely etiological one, and the prognosis and treatment are those of the diseases causing them. SCURVY. Synonym. — Scorbutic Purpura. Definition. — A disease characterized by a dyscrasic state of the blood, which favors subcutaneous or submucous hemorrhage, by a peculiar spongy state of the gums, and extreme general weakness. Etiology. — Less than half a century ago the idea of scurvy was always associated with the seafaring life, since sailors were its chief victims, though almshouses and prisons also held their complement. In the food of these persons fresh vegetables and vegetable juices and organic salts were want- ing. So it came to be acknowledged that such privation was responsible for scurvy, and proof of this belief was thought to exist in the fact that with the quicker voyages of ships and a supply of suitable food, scurvy had almost vanished from the nosology. It appears, however, that, after all, the effect of such causes is predisposing and the disease may be really infectious, being due to some as yet undetected^^organism. Especially firm in this belief are those who' have, by reason of its distribution, had the best opportunities for its study — as, for example, in Russia, where the disease is endemic, some- times epidemic. Finally, it turns out that not only sporadic cases, but even epidemics, occur quite independently of the dietetic causes named. At the present day scurvy has become a rare disease, but is still met in camps, prisons, almshouses, and situations where the food causes named exist along with dampness, foul air, and depressing influences generally, among which nostalgia is supposed to be especially potent. The efifect of the food causes has been held by Garrod and by Ralfe to be the deficiency of the potas- sium salts, more especially of the alkaline carbonates derived from the con- version of the organic salts of the vegetable and fruit juices — viz., the malates, tartrates, citrates, and lactates. Experimental proof of the latter is adduced PURPURA. 833 by feeding animals upon acid salts, the effect of which is to impair their nutri- tion and to produce dyscrasic states of the blood similar to those of scurvy and followed by like extravasations. The disease attacks the old and young of either sex, though the old are more susceptible, and it happens, probably from accidental circumstances, that more males are affected than females. Reference should be made to the observations of my colleague J. P. C. Griffith,* who has shown that scurvy has appeared in children who have been too long fed on certain artificial infant foods. Morbid Anatomy. — This consists in (i) alterations of the blood; (2) the extravasations of blood, which may be anywhere, — subcutaneous, sub- mucous, intermuscular, and interstitial. The blood changes are not dis- tinctive. The blood is dark and fluid, the blood-corpuscles and hemoglobin are concurrently reduced, and there is no leukocytosis. Rarely there is even sloughing of the skin and mucous membrane, leaving ulcerated patches in the skin and bowels. The spleen is soft and enlarged, and there may be degenerative changes as well as hemorrhages in the kidneys, liver, and muscles. Symptoms. — The more evident symptoms are the changes in the gums, and the deep-seated and superficial hemorrhages. The gums are swollen, soft, and spongy, with disposition to bleed easily. In the more severe cases there is ulceration, with loosening and falling out of the teeth, the tongue is swollen, and the breath excessively foul. The gums of young children and of the aged are more often uninvaded. In rare cases only is there necrosis of the jaw\ The hemorrhages, always petechial, appear usually first in the lower extremities, then on the arms and trunk, but they occur anywhere as roundish, dark-red spots which may assume larger size. They are rare in the face and scalp, and are less common under the mucous membranes and in deep-seated tissues. Subperiosteal hemorrhages may occur. Nasal hemorrhages may be frequent, melena and hematuria rare, hematemesis and hemoptysis still rarer. The extravasations are slow to disappear, even when recovery takes place. The occasional sloughing has been referred to. A residual, slowly healing ulcer results. Other symptoms are debility, extreme in severe cases, and anemia. The pulse is small, feeble, and frequent, and corresponds to the heart's action, which is sometimes irregular; more rarely is it slower than in health. The temperature is normal, rarely somewhat elevated. Sore throat is mentioned as a premonitory symptom. In bad cases nephritis and endocarditis occur. Articular swelling is an occasional symptom ; it is one of the results of the dyscrasia ; so are wheals and vesicles. Diagnosis. — This depends, as stated, on the etiology, the gingival changes, and the hemorrhages. It is these which chiefly distinguish it from the other forms of purpura. Prognosis. — Sporadic cases always get well, and epidemic cases usually, unless too far advanced before coming under treatment. Treatment. — This is usually most satisfactory when the necessary con- ditions are fulfilled — a restored wholesome hygiene and suitable food. Good ventilation and outdoor life in health <- localities, with plentv of fresh vege- tables, fruits, and fresh meats, ordinarily suffice to accomplish a prompt cure. It is usual to give lemon and orange- juice as the types of the fruit- juices. Tonics and roborants, of which iron, quinin, and strychnin are the * " The Relation of Scurvy to Recent Methods of Artificial Feeding," " N. Y. Med. Jour.," Feb. 23, igoi; Scurvy, Not Rheumatism." "Phila. Med. Jour.," Feb. 2, iqoi; "American Pediatric Society's Collective Investigation on Infantile Scurvy," " Arch, of Fed.," July, iSg8. 53 834 CONSTITUTIONAL DISEASES. type, are the medicines needed. Calcium chlorid may be used in doses of from 5 to 15 grains (0.3 to i gm.). Antiseptic and astringent mouth- washes should be used, and ulcers should be stimulated by local applications,, of which nitrate of silver in solution is the best. Infantile Scurvy. Synonyms. — Barloiv's Disease; Periosteal Cachexia. Definition. — A cachectic condition of infants, associated with sub- periosteal hemorrhagic extravasations. Historical. — In 1878 and again in 1S82 Cheadle published in the " Lancet," and about the same time Gee published as occurring in England, cases of a cachexia in very young children, associated with hemorrhage, and due to imperfect food-supply. About the same time Barlow made an exhaustive study of the subject and gave his results in the " Medico-Chirurgical Transactions," volume xlvi., 1883, and in the Brad- shaw Lecture for 1894. W. P. Northrup published a paper on " Scorbutus in Infants," describing cases in this country, in the " New York Medical Journal," December 12, 1891, and another with Crandall in the same journal, volume i., 1894. Symptoms. — Barlow's account is graphic, almost sensational, but I gather that the condition exists essentially in a hemorrhagic subperiosteal extravasation, causing thickening and tenderness in the shafts of the bones beginning in the lower extremities, but invading also the forearm and arm, more rarely the scapula, vault of the cranium, and face. Rarely there is intermuscular extravasation. The resulting tenderness and pain on motion cause the child to keep quiet, with the legs drawn up, and to cry out when handled. The lesions are symmetrical. The joints remain free. The sternum and adjacent cartilages and a small portion of the contiguous ribs may be sunk bodily back as though subjected to violence. There may be a sudden prolapse of an eyeball. Along with these symptoms are profound am,emia and erratic teuiperature, which may be subnormal, normal, or as high as 102° F. (38.9° C). The disease occurs at any period after four months, but it is most com- mon from the ninth to the eighteenth month, and is of rapid development. Treatment. — It has been ascribed to the use of the proprietary forms of condensed milk and preserved foods for infants. These should therefore be omitted, and fresh cow's milk substituted, with beef -juice and strained gruel made from whole-grain cereals only. Orange- juice or lemon- juice in water may also be given in moderate doses. Under this treatment the prognosis is favorable and recovery prompt^^ Arthritic Purpura. Synonym. — Rheumatic Purpura. Definition. — The characteristic feature of arthritic purpura is a joint involvement. Hence it is also called rheumatic purpura, though its rheu- matic nature cannot be said to be absolutelv settled. Symptoms. — Three varieties are distinguished : I. Simple Arthritic Purpura. — This is a mild form, most frequent in children. The articular pain is very mild and attended with but slight fever. The spots are found for the most part on the legs, more rarely on the trunk and arms. There may be digestive derangement, manifested by loss of appe- PURPURA. 835 tite and diarrhea. The condition terminates favorably in a week or ten days. It may be associated with a mild degree of anemia. 2. Peliosis Rheuinatica. — Schonlein's disease. This is a much more serious affection from every standpoint, occurring usually in young persons from fourteen to thirty. The joint symptoms are pronounced and multiple, and there are decided swelling, pain, and fever, with a temperature of 101" to 103° F. (38.3° to 39.4" C). The eruption first appears on the legs near the affected joint, but I have seen it present extensively on the arm, distant from the joint, followed by sloughing; in the same case were retinal hemor- rhages. Sloughing and necrosis of the skin even have occurred. It may be simply purpuric, or may be associated with urticarial wheals — exudative — or vesicles (pemphigoid purpura). When severe, it is often associated with hematuria and hemorrhagic nephritis with edema. I saw, with Agnew and Osier, a remarkable case in which the latter condition hastened a fatal termi- nation by uremia. Endocarditis is also a complication. 3. Henoch's Purpura. — This is a variety occurring most often in chil- dren, but also in adults, characterized by severe gastro-intestinal disturbance in addition to the previously named symptoms. There are pain, vomiting, and diarrhea, rarely intestinal ulceration, and perforation with fatal peri- tonitis. Acute enlargement of the spleen has been observed. Here, also, recovery is the rule. Diagnosis. — The diagnosis is easy by reason of the associated joint symptoms, but the same doubt exists as to a true rheumatic nature in all forms. Prognosis. — This is regarded as favorable, but fatal terminations do occur, especially in peliosis rheumatica in which there is nephritis. Relapses in this form may occur at the same time of year for several years in succession. Purpura Hemorrhagica. Synonym. — Morbus maculosus WerlhoH. Symptoms. — This form of purpura is characterized by hemorrhage from the mucous membranes, including nose, mouth, palate, stomach, and intes- tinal canal, in addition to extensive subcutaneous ecchymosis. The brain and kidneys and serous membranes may also be seats of hemorrhage — apoplectic symptoms indicating the first. A prodrome of languor and weak- ness may precede for a couple of days, to be succeeded by a rapid succession of ecchymoses and hemorrhages. More decided constitutional disturbances follow, including typhoid symptoms and fever, though the latter is mild and may be altogether absent, even in severe cases. In the purpura fuhninans the hemorrhages are mainly confined to the skin, producing confluent ecchymoses and dense infiltrations covering large areas, with sanguineous blisters. The internal organs, on the other hand, remain free, while the urine and the bowel evacuations are natural. At times there is fever ; at others, not. Hemorrhagic purpura has occurred after pneu- monia and scarlet fever, and again in children apparently healthy. Diagnosis. — As to diagnosis, sc^irvy is almost the only condition liable to be mistaken for purpura hsemorrhagica. In the latter the gums are intact, and there is an absence of the conditions favoring scurvy. Prognosis. — The termination is usually favorable in from ten days to two weeks, although there may be fulminating cases, usually in children, ter- minating fatally in twenty-four hours. Severe cases recover more slowly. 836 CONSTITUTIONAL DISEASES. Treatment of Arthritic Purpura and Purpura Haemorrhagica.— Treatment is best directed to improving the quaHty of the blood and to build- ing up the general tone rather than to the control of the hemorrhage, though the latter must not be entirely ignored. Almost all that has been said of the treatment of scurvy is applicable to these forms of purpura. Iron and arsenic are the typical roborants and blood-builders, to which nutritious food, includ- ing vegetable juices, is to be added. Arsenic should be given in full doses, beginning with small ones and ascending rapidly. In the articular forms the salicylates and salicin should be used in such doses as the stomach will tolerate. Of the astringent remedies found serviceable may be mentioned ergot, in doses of from five to thirty minims (0.3 to 2 c c.) of the fluid extract ; per- sulphate of iron, in doses of from 1-4 to 1-2 grain (0.016 to 0.032 gm.) ; acetate of lead, one to three grains (0.0648 to 0.2 gm.) ; dilute or aromatic sulphuric acid, five to fifteen minims (0.33 to i c. c). Hemorrhagic Diseases of the New-born. Hemorrhagic Syphilis of the New-born. — Usually about from the third to the fifth day after birth hemorrhage is observed at the navel of the child, or it may occur earlier. Blood also flows from the mucous membranes of the mouth, the bowels, and the kidneys. The skin becomes jaundiced. The stomach rejects food, and though it may appear well nourished at birth, the child rapidly wastes, and dies at the end of a zveek or ten days. The autopsy discloses syphilitic lesions in the liver, lungs, nasal passages, and elsewhere. Epidemic Hemoglobinuria of Infants, or Winckel's Disease. — As de- scribed by Winckel in 1879, in an epidemic at the Foundlings' Hospital, at Dresden, the first symptoms, noticed usually on the fourth day after birth, are a bluish tinge on the skin of the face, trunk, and limbs, with a more or less icteroid hue. There are fever, rapid breathing, and sometimes cyanosis. Occasionally there are vomiting and diarrhea. The nrine is light brown, albuminous, contains methemoglobin, and deposits a sediment consisting of epithelium and tube-casts. The blood contains an excess of leukocytes and numerous granular bodies. The child lives, on an average, two days, though in one case death supervened in nine hours. The autopsy in this case dis- closed yellow staining of the skin and internal organs ; the spleen was large, hard, and darkened ; the kidneys were dark brown in color, their tubules being filled with granular pigment ; the liver and heart were fatty. There may be punctiform hemorrhages on the surface of the internal organs. There is no septic condition of the umbilicarvessels. An infectious origin is not unlikely. Acute Degeneration of the Internal Organs of the Nezv-born, or Buhl's Disease. — How far this disease, described by Buhl in 1861, differs from Winckel's disease, or the latter from the former, remains to be settled, for, in the first place, fatty degeneration of the heart and liver is found in many cases of Winckel's disease, while in others there is found the general fatty degeneration of kidneys, liver, heart, etc., described by Buhl. In the second place, infants surviving the first few hours after birth in Buhl's disease have the "same symptoms as those described under Winckel's disease, while the other symptoms, such as minute hemorrhages and bile staining of various internal organs, are not essentially different. Morbus Macidosus Neonatoriun. — Still another form of hemorrhage froiTi one or more of the surfaces, and especially of the alimentary canal, in HEMOPHILIA. 837 the new-born is described under this title. The bleeding generally beghis within the first u'eek, but may be as late as the second or third week. Hemorrhage from the bowels (melsena neonatorum) is the most frequent form, but it may be from the stomach, mouth, nose and navel, or from the navel alone. It may be accompanied by hematogenous jaundice, — indeed, by any or all the symptoms described under Winckel's disease, — ^but differs in the occasional presence of fever and apparent absence of postmortem lesions, though ulcers of the esophagus, stomach, and duodenum have been found. It is generally fatal in from one to seven days. All these con- ditions can be appropriatel}^ considered as forms of purpura. Treatment. — The treatment of hemorrhagic affections of the new-born often avails little, though recoveries sometimes take place, especially in the last-described form, in which C. W. Townsend reports nineteen recoveries out of fifty cases collected. The treatment demands absolute rest with the head low. Even the exertion necessary in nursing at the breast should be interdicted, and the infant should be fed, vvhile recumbent, with a teaspoon, using also the mother's milk if this be not condemned as worthless. The utmost care in providing uniform warmth should be taken. This can best be accom- plished by means of an incubator. One may be improvised, as suggested by F. A. Hoffman, out of a box in the bottom of which hot bricks are placed. Over them is swung the infant's bed. A thermometer is so inserted as to be readily observable, and the temperature is kept at 90° F. (32° C). To control the hemorrhage ergotin may be used hypodermically, one grain or minim (0.06 gm.) every six hours. Gallic acid may be given by the mouth in one grain (0.06 gm.) doses, but extreme care should be taken in using remedies by the mouth. HEMOPHILIA. Definition. — A hereditary vice of constitution, manifested by a tend- ency to uncontrollable hemorrhage, occurring either spontaneously or as the result of trifling injury. Etiology. — No explanation has as yet been offered of hemophilia other than that it is usually hereditary, though rarely also sometimes acquired. While individual instances of fatal hemorrhage were observed centuries ago, " families of bleeders " were first described in this country. Of great importance because of its bearing on the marriage of these hemo- philic subjects is the fact that the tendency is transmitted through the female line rather than through the male. Thus, if a man belonging to a bleeding family who is himself not a bleeder marries a woman who is healthy and not a bleeder, his offspring are usually exempt from the afflic- tion. On the other hand, a woman a member of a bleeding family marries, and even if she be exempt herself, she m^ay have offspring who are bleeders. These facts were pointed out by Grandidier. Not all the children of such persons are afflicted, while the male members are more frequently sub- ject than females. The families of bleeders are apt to be large, and their appearance is that of health, as a rule. It is said that blondes predominate, with delicate, soft skin and distinct, distended veins. Morbid Anatomy. — Two facts of importance have been recognized ■ — viz., that in some instances the walls of the blood-vessels have been 838 COXSTITUTIONAL DISEASES. found thin with a fatty degeneration of the intima, and in many there is deficient coagulabihty of the blood. A third fact, which adds nothing in explanation of the hemorrhagic tendency, is a superficial situation of the arteries. A striking case of this kind in a blonde woman, formerly a bleeder, was for a time under my observation. Beyond this w^e know nothing, notwithstanding the exhaustive studies of Wickham Legg, Gran- didier, and Hossli. Symptoms. — Attention is commonly called to a bleeder by the occur- rence of a hemorrhage difficult to control, though induced by some trifling cause. The extraction of a tooth is one of the most frequent of these events. It may be the prick of a pin, or a scratch, or a slight cut, as in vaccination, or no cause may be discoverable. The tendency may manifest itself at the cutting of the umbilical cord at birth, or in Jewish children at the circum- cision. On the other hand, the same accidents which are without result early in life may induce the hemorrhage later. Uncontrollable epistaxis is one of the most frequent manifestations, occurring in 169 out of 334 cases collected by Grandidier. It may be induced by simply blowing the nose. Other situations are the mouth, stomach, ear, and eyelids. On the other hand, hemorrhages rarely occur in the interstices of organs, and though inter- stitial hemorrhages do occur, they are usually the result of trifling blows, when the well-known " black-and-blue " appearance is produced. The absence of interstitial hemorrhages, except as the result of some cause, however trifling, may be said to distinguish hemophilia from the acquired hemorrhagic tendency. Menstruation may be very copious in w'omen, but not fatal, while the natural loss of blood in child-bearing is rarely augmented. In the case re- ferred to on page 837 the hemophilia disappeared with the appearance of the menopause, soon after which it w^as substituted by a chronic nephritis. The external hemorrhages, including those of the mouth and nose, may be profuse and even fatal. They often last twenty-four hours or longer. When checked, reaction from them is rapid, and the victims quickly resume their natural appearance, though repeated hemorrhages may engender a permanent anemia. Joint affections may be associated w^ith this as with the acquired hem- orrhagic tendency. They involve usually the larger joints, and may include swelling and pain, with fever, producing a close resemblance to rheumatism, or there may only be pain. Diagnosis. — This is apparent if the family tendency is known, and any alarming hemorrhage without sufficient cause should excite inquiry. Prognosis. — Sooner or later hemophilia is apt to be fatal, though there may be many severe hemorrhages before the last one comes. The younger the subject, the more serious the outlook. It does, however, happen that the tendency is outgrown, subsequent attacks becoming milder and milder. In the majority of cases death takes place between the first and the eighth year, and adolescence once survived, the chances of outgrowing it are greatly increased. Treatment. — ^This may be prophylatic. The children of bleeding families should be carefully guarded against traumatic causes, however slight, while they should be carefully looked after from the hygienic and nutritive standpoints. Fresh air, daily bathing, outdoor exercise, and judi- cious measures intended to harden the threatened subject should be prac- ticed. Plain, wholesome, and nourishing food should be given, and due HEMOPHILIA. 839 attention should be paid to digestion. As a part of the prophylatic treat- ment, too, is discouragement from marriage, especially in the case of women. During an attack absolute quiet must be enjoined. Styptics are to be •employed locally, rather than internal medicines. Of styptics, the solution of the perchlorid or persulphate of iron is the best, beginning at first with dilute solutions and increasing to the full strength of the official solution if necessary. Tannic acid is another good styptic, and if at hand, may be dusted well upon the part or applied on cotton to cavities. In epistaxis the nose must 'be plugged if the ordinary methods of applying these agents fail. Though little is to be expected from internal remedies, they may be tried. Wickham Legg recommends the tincture of the perchloiid of iron in half-dram (2 c. c.) doses every two hours. Ergotin and acetate of lead may also be used. Suprarenal extract and its active principle, adrenalin chlorid, have also been employed for hemophilia, the former in doses of five grains every three hours. Adrenalin chlorid is used in the shape of a one per cent, solution, of which a fluid dram (4 c. c.) may be added to a half-pint or pint (250 to 500 c. c.) of normal salt solution by hypo- dermoclysis, or intravenous injection. If urgent 15 minims (i c. c.) may be used undiluted and the remainder in the diluted form. The usual treatment for consequent anemia should be employed. SECTION IX. DISEASES OF THE NERVOUS SYSTEM. ' GENERAL INTRODUCTION. HISTOLOGY OF THE NERVOUS SYSTEM. The difficulties in the diagnosis of diseases of the nervous system are gradually diminishing as the thread of its histology is being unraveled. The studies of Golgi, His, Forel, "VValdeyer, Ramo y Cajal, Dejerine, Lenhosse, van Gehuchten, and others have considerably altered previously accepted views. A brief statement of the fundamental features of the newer histology seems, therefore, necessary. The studies of these and other observers resolve the nervous system into an immense number of units, to which Waldeyer has given the name neurons — whence the name neuron theory. It is necessary to state that the neuron theory is now being vigorously attacked, but as it is of service in explain- ing nervous diseases, it may be employed until the evidence against it be- comes so convincing that we are free to abandon it. Each neuron is made up of: 1. A nerve cell. 2. Protoplasmic processes, or dendrites. 3. An axis-cylinder or axon continuous with the nerve-fiber. 4. Terminal ramifications of the axis-cylinder. The axis-cylinder of a motor spinal cell gives off at different intervals lateral branches known as collaterals. These collaterals or paragons, and finally the axis-cylinder itself, break up intO' many fine fibers, known as ter- minal ramifications, or end brushes, or branch tufts. Each neuron has been believed to be independent of every other — that is, no protoplasmic process of one neuron is continuous with that of another, nervous communication being through simple contact or proximity. More recent investigations, however, throw some doubt on this. The protoplasmic processes conduct impulses to the cell, are cellulipetal, as named by Cajal ; the axis-cylinders conduct im- pulses away from it and are cellulifugal. The nutrition of the neuron depends largely on the cell body. If the latter is intact, the processes are preserved. If it is injured they waste, or if they are cut off they degenerate; on the other hand, the cell body suffers when its processes become diseased. The motor neurons, having their cell bodies in the gray matter of the brain, are called central neurons ; those neurons having their cell bodies in the spinal cord and in the ganglia on the peripheral nerves, are called peri- pheral neurons. The end brushes or terminal ramifications of a central motor neuron surround the body and protoplasmic processes of a peripheral motor neuron, while those of the peripheral neuron are in connection with a motor plate. The axis-cylinders of the central and peripheral neurons traverse chiefly the white tracts of the brain and spinal cord and the per- 840 HISTOLOGY OF THE NERVOUS SYSTEM. 841 ipheral nerves. The cells of the anterior roots of the spinal nerves lie in the anterior cornua of the gray matter, and have the protoplasmic processes short and the axis-cylinders long. (See Fig. 83.) The cells of the posterior roots are situated in the ganglia on those roots ; the axis-cylinders of these cell bodies divide soon after leaving the cell body, one process passing to the periphery, the other to the spinal cord. Communication between different parts of the nervous system and with the rest of the body is thus rendered possible. The processes extending to the periphery receive impressions from the exterior and carry them cellulipetal to the ganglion cells on the posterior root of the spinal nerves, whence they are conveyed by the axis-cylinders cellulifugal to the cord. This impres-^ |1 Skin Fig. 83. — Diagram of an Element of the Motor Path — {after Strumpell, modified). C. Motor ganglion cell in the cerebral cortex. Py S. Lateral pyramidal tract, central or upper motor neuron. V. Ganglion cell of anterior horn. in. Motor- nerve, peripheral neuron. M. Muscular fiber. sion may result in a reflex act without the co-operation or knowledge of the brain, or it may proceed to the brain and give rise to a volitional act through the motor tract. A motor impulse starting from the brain cortex must pass through at least two sets of neurons before it can reach the muscles. In this course it is cellulifugal from the cell in the cortex, cellulipetal to the cells in the gray matter at different levels in the anterior coruna, and thence cellulifugal from the latter cells to the various muscles of the body, ending in the end-plates. Hence we speak of the motor tract as being composed of two segments, an upper end and a lower. The neurons of the upper motor segment have their cell bodies and protoplasmic processes in the cortex about the fissure of Ro- 842 DISEASES OF THE NERVOUS SYSTEM. lando. The axis-c}"linder processes run through the internal capsule and the cerebral peduncles, through the pons, medulla oblongata, and cord, ending in terminal ramifications around the protoplasmic processes and cell bodies of the lower segment. The neurons of the lower segment are those having their cell bodies and protoplasmic processes in the anterior cornua of the gray matter, while their axis-cylinders leave the spinal cord by the anterior roots of the spinal nerves, to be distributed as described. The upper seg- ment, in large at least, is a crossed tract — that is, the neurons com- posing it have their cell bodies and protoplasmic processes in the cortex, while their axis-cylinders cross the middle line to end about the cell bodies in the opposite half of the spinal cord ; so that motor impulses starting in the left half of the brain produce contraction in the muscles of the right half of the body, and vice versa, although both sides of the brain probably innervate unequally each side of the body. (See Fig. 83.) The lozver motor segment is a direct tract — that is, its neurons, and the muscles to which they are distributed, are all on the same side of the body. The path for sensory conduction is also composed of segments, but the direct route of sensory conduction is more complicated and our knowledge is much less exact. The cell bodies of the lower neurons are in the gan- glia of the posterior roots of the spinal nerves and in^the ganglia of the sen- sory cranial nerves. These ganglion cells have a single process, which, after leaving the cell, divides in a T-shaped manner, one branch running into the central nervous system and the other toward the periphery. The process which connects with the periphery is regarded by some as a protoplasmic process, while that which passes to the center is known as the axis-cylinder. The former runs in the sensory nerves, starting from the various specialized sensory apparatus of the periphery. The axis-cylinder enters the cord by the posterior roots. After entering the cord it divides into an ascending and a descending limb, which traverse the posterior columns. The descend- ing branch runs a short distance and ends in the gray matter of the same side of the cord, giving off a number of collaterals, which also end in the gray matter. The ascending branch may end in the gray matter soon after entering the cord, or it may run in the posterior columns as high as the medulla oblongata, ending in the nuclei of the posterior columns. Thus the Iciver segment is also a direct tract terminating in the gray matter of the pos- terior cornua at different levels, and in the gray matter of the medulla oblon- gata. (See also section on Spinal Cord.) The upper segment starting from these is a crossed tract, crossing at different levels, so that sensory impressions are ultimately lodged in the brain on the side opposite that whence they start in the periphery. The so-called muscular sense, perhaps better called the sense of position, is probably conducted upward on the same side in the columns of Burdach and Goll on each side of the posterior median fissure. The exact termination of the sensory processes in the cerebral hemisphere is not known, but they pass up in the tegmentum of the pons and possibly in the internal capsule. It is believed by many that these processes terminate in the optic thalamus, and that from here the impulses are conducted to the cortex by means of another set of neurons. The motor cortex is probably also sensory, although the sensory area may be more extensive than the motor. Both motor and sensory spinal nerve roots come from definite segments of the spinal cord. They descend a short distance within the spinal canal, unite within the intervertebral foramen, but external to the point where the roots perforate the dura mater and pass through the foramina as spinal GENERAL SYMPTOMATOLOGY. 843 nerves. But in their distribution they do not retain the same definiteness, the same sensory and motor areas being suppHed with nerve fibers from different segments of the cord, and there is an overlapping, as it v^ere, of parts supplied by different nerve fibers. At the same time, by the combined aid of experi- ment and morbid physiology, we have learned that movements in certain muscles are accomplished by motor nerves which emanate from corresponding segments of the spinal cord, and that from certain sensitive areas are gath- ered up impressions which are carried to corresponding sections of the spinal cord. Nay, more. By the same means we have learned that there are areas in the cortex of the brain that preside over certain motions, and areas which have to do with sensation ; though with respect to the latter our knowledge is much less definite. We know more of the cortical localization of the special senses than of general sensibility and pain. These facts are the foundation of what is known as topical diagnosis, in the case of the brain as cerebral lo'cali- sation, by which is meant the inference, from the study of local derange- ments of sensation and motion, of the more or less exact site of lesions in the nervous centers. These will be considered with appropriate detail in our study of the diseases of different parts of the nervous system. GENERAL SYMPTOMATOLOGY. (Investigation of a Case of Nervous Disease.) The advantages of a careful method in the study of disease are per- haps more apparent in the case of the nervous system than in that of any other of the anatomical divisions of the human body. This is partly because of the number and variety of the affections to which the nervous system is subject, and partly because of the association of certain identical symptoms with widely different lesions. The primary steps of family and personal history are the same as for other diseases, including age, sex, occupation, and whether married or single. We may therefore pass at once to the study of such symptoms as are special. L Phenomena of Motion. — It is immaterial whether we set out with sensory or motor phenomena, but it appears somewhat easier to begin with derangements of motion, and of these ( i ) voluntary motion is natu- rally first investigated. To this end, the patient is asked to move his iimbs, while the strength of whatever motion he is capable is easiest measured by resisting it, and by testing the power of his hand-grasp. For more accurate measurement the dynamometer is used, an instrument devised to measure both compression and traction, although it is more com- monly restricted to the former. Advantage may be taken of the fact, too, that the same motion requires different degrees of strength in different posi- tions of the body. Thus it is easier to draw up the thigh when lying on the back than when on the side, and it may be possible in the former posi- tion when it is not in the latter. Both extensor and flexor muscles must be thus tested. By such an investigation we discover the presence of a complete paralysis or total loss of Voluntary motion, and paresis or simple weakening of such power. By a monoplegia is meant an isolated paralysis of one part of the body, as of an arm or a leg. By a lieniiplegia is meant a paralysis of the entire 544 DISEASES OE THE NERVOUS SYSTEM. half of the body, inchiding half of the face, one arm, and one leg, also known as unilateral paralysis. By a paraplegia is meant a simultaneous paralysis of corresponding halves of the body. Paralysis of the two arms is known as a superior, or hrachial, paraplegia, of the two legs as an inferior, or crural paraplegia, while the word paraplegia alone is often used for the latter condition. A diplegia is a paralysis in which upper and lower limbs are affected on both sides of the body, usually attended with spasm of all the extremities, although the term is also employed for bilateral facial paralysis. Though commonly congenital, diplegia may also be acquired. Impairment of voluntary muscular power, as thus tested, must be the result of structural change in the motor area of the cortex, in the great motor tract of the brain or cord, or impairment in the integrity of the efferent nerves, or it may be more rarely in the muscle itself, " myopathic palsy " ; or the power of the will may be abrogated. In diseases of the peripheral nerves, when the paralysis is called peripheral, it is limited to the region of distribu- JixiTi pxce -pyjc. "iExrireTm^i^ Fig. 84. — Illustrating Crossed Paralysis— (rt//^r Hirf). O. Medulla oblongata, pyx. Decussation of anterior pyramids, going to extremities. F. Nerve-fiber to face. E. Nerve-fiber tion of the affected nerves, whether one or many. It may be said in general that hemiplegia is the usual form of cerebral paralysis, while paraplegia is the expression of spinal paralvsis. Monoplegias are usually either due to lesions of the cortex, or are peripheral palsies ; cortical monoplegia, however, is rare. In all hemiplegias caused by lesions above the pons the palsy, including that of the face and extremities, is on the side opposite the lesion, but in most lesions in the middle or lower part of the pons there is crossed paralysis — that is, there is paralysis of the extremities on one side, and of the face on the other side, provided the central fibers of the extremities and the facial nerve are involved in the lesion. The reason of this is that the central fibers of the facial nerve cross much higher than do the fibers to the extremities, and in such a lesion the intra-medullary portion of the facial nerve, and not the cen- tral fibers connecting its nucleus with the brain cortex, are injured. The result is a paralysis of the face on the same side as the lesion and of the extremities on the other. This would be the case with a lesion at h, Figure GENERAL SYMPTOMATOLOGY. 845 84. If, on the other hand, the lesion is higher up, above the decussation of both the facial and pyramidal tracts, as at a, the paralysis is on the side oppo- site the lesion in both face and extremities. Other nerves may substitute the facial in this crossed paralysis as the oculomotorius (third nerve) or hvpoglossal (twelfth nerve) or abducens (sixth nerve). In rarer instances it is possible that a lesion at the very decussation of the pyramids, by cutting the motor fibers of one extremity before they cross, and those of another after crossing, may produce the very rare event of paralysis of an arm on one side and of a leg on the other. That this is theoretically possible may be seen from Fig. 85, in which the black lines represent fibers to the upper extremities and red lines fibers to the lower, and the red circle the seat of a small hemorrhage. (2) Having determined this question of muscular strength, and the corollaries which grow out of it, we have next to ascertain to what extent the power of co-ordination is influenced. Every muscular act requires the duly proportioned co-operation of a number of muscles ; and as the com- plexity of the act increases, the number of muscles required to co-operate also increases. Such co-operation is termed co-ordination, and its absence is recognized in the staggering gait of the drunkard, and the condition is known as ataxia. There are certain parts of the nervous system which Fig. 85. — Illustrating the possibility of paralysis of arm on one side and of leg on the other. preside over co-ordination — such as the cerebellum, and the posterior columns, and probably the direct cerebellar tract, of the spinal cord. Disease of any of these may, therefore, produce ataxia. The ataxia or tabetic gait is described under tabes dorsalis, p. 926. A corollary, growing out of the investigation of the co-ordinating power, is the study of station, or the steadiness with which one stands with the eyes closed or open, and it is measured by sway of the head and body, laterally and anteroposteriorly. In health a lateral sway of the head exists to the extent of half an inch (1.25 cm.), and an anteroposterior sway of an inch (2.5 cm.). A sway much beyond these limits is abnormal. (3) After ascertaining the condition of voluntary motion, co-ordination, and station, we must inquire into the question of possible motor irritation or excessive muscular action or spasm. Spasm may be continuous, — i. e. lasting for minutes, hours, or days, — when it is known as tonic or tetanic; it may be intermittent or clonic; or it may be an admixture of both, when it is termed tonic-clonic. Tonic spasm is well illustrated by trismus or lock- jaw, while tetanic contraction of' the muscles of the back produces opisthotonos, in which the vertebral column is arched and the body rests uoon the back of the head and upon the heels. Tonic spasms are often attended with pain, probably due to pressure on intramuscular nerves, 846 DISEASES OF THE NERVOUS SYSTEM. when they are called " cramps." Spasm occurs also in uivoluntary non- striated muscular tissue. The presence of spasm implies irritation of motor centers, motor tract, or motor nerves, but motor irritation may also be excited secondarily by some reflex route, the result being a reflex spasm. Spasm and paralysis are often associated. Thus, a limb may be par- alyzed in a state of contraction, exhibiting a peculiar rigidity, and to such a condition the name spastic paralysis is applied. This condition may also exist as a state of persistent contraction of the antagonists of the paralyzed muscles, constituting the so-called contractures. Paralyses in which there is no such resistance to passive motion are known as Uaccid paralyses. Through the combination of tonic and clonic spasm result different varieties of morbid involuntary movements more or less complex. Some of these are the following : 1. The Epileptiform Convulsion. — This consists in a succession of clonic and tonic-clonic spasms extending over the whole or a part of the body, throwing the part involved into violent motion. The masseter and the temporal muscles share in the contraction, whence the tongue is often bitten. The convulsion of epilepsy is the type of this form, but the con- vulsions of uremia, or hysteria, and of organic disease of the brain may be epileptoid. 2. Rhythmical Contractions. — These occur in single groups of muscles, and are sometimes seen in apoplexy and cerebral sclerosis. They may usher in the epileptiform convulsion, or the convulsion may terminate by a gradual substitution of the rhythmical contractions for the more violent spasms. 3. Tremors or Trembling Motions. — These are limited movements — /. e., movements of short excursion which rapidly succeed each other. " Shak- ing " is a more pronounced degree of tremor. Tremor is characteristic of paralysis agitans and of some other nervous affections. It occurs in old persons as senile tremor, and in abusers of alchohol and tobacco. When it occurs or increases during voluntary motion, it is known as intention tremor, and is characteristic of multiple sclerosis. The immediate ana- tomical changes on which tremors depend are not known. 4. Single Contractions. — These are either sudden twitchings or slow contractions of muscles, seen especially in diseases of the nerves, — as, for example, in old facial palsy. They may be single or multiple and persistent. They may be the result of direct motor irritation or reflex in origin. 5. Fibrillary Contractions. — These are contractions of separate small bundles of muscular fibrillae, comparable to the " quivering " of raw flesh. They are independent of voluntary or passive motion. They may be pro- nounced and wave-like over the muscular substance. They are seen espe- cially when the motor nerve cells are degenerating, as in progressive spinal muscular atrophy or bulbar paralysis. The " quivering "of the eyelid and of the orbicularis muscle below the eye, the so-called " jumper," often an annoying symptom, is an instance of this condition. 6. Choreic Movements. — These are inco-ordinated movements, usually separated by short intervals of time, often first seen in the face, later in one limb or over the whole body. They may be very complex and general. They are characteristic of chorea, but also accompany other nervous affec- tions, such as posthemiplegic chorea. Under the term posthemiplegic chorea, however, a variety of movements are included. 7. Athetosis. — This is a peculiar slow, involuntary rhythmical move- GEXERAL SYMPTOMATOLOGY. 847 ment, usually of the fingers and hands, but also of the head and trunk, or of the toes. The fingers make slow movements of the nature of extension, and flexion, spreading and approximating each other in a striking way. Thev are a symptom of certain central nervous diseases, especially of the cerebral palsies of children. 8. Constant or Co-ordinate Spasms. — These consist in irresistible com- plicated movements, like moving forward or moving in a circle or rotating on the axis of the body; also complicated forms of spasm resembling jumping, laughing, screaming, all involuntary and forced. The first group of these is especially seen in disease of the cerebellum and cerebellar pe- duncles, the latter in severe forms of hysteria. 9. Xystaguius is a clonic rhythmical oscillatory and involuntary move- ment of the eyeball, usually horizontal, sometimes rotatory, more rarely vertical, the result of spasm of muscles supplied by the third nerve, espe- cially the internal rectus and levator palpebrcc. It is noticed in congenital and acquired afifections of the brain, including Friedreich's ataxia and insu- lar sclerosis ; also in albinism and in miners who work in dimly lighted mines, using the pick while reclining and directing the eyes laterally. 10. Cataleptic Rigidity. — In this there is also a tonic contraction of muscles whereby a limb remains for a considerable time in any position in which it may be passively placed, the will being abrogated. If the position of the limb be changed, it remains again in this situation, and from a resemblance to the behavior of wax under like circumstances it has received the name of " waxy flexibility."' It is characteristic of certain forms of hyst-eria, and may be produced at times in hypnotism. In hysteria it is commonly associated with anesthesia and loss of consciousness. It is also associated with psychoses, especiallv grave forms of melancholia known as melancholia attonita and w4th katatonia. 11. Associated Movements. — These are unintentional and uncontrollable movements which take place in muscles coincident with other motions actually intended — as, for instance, a motion in the arm when the patient wills to move only the leg. (4) Bladder control and rectum control are next to be looked into. Full control over the acts of these organs im.piies, first, an integrity of the sacral portion of the cord, in which reside the reflex centers regulating these acts; second, the integrity of volition, which, to a certain extent, fortifies such reg- ulation ; and thirdly, integrity of the afferent and efferent nerv^e fibers con- stituting the reflex arcs. Through the operation of the reflex center, bladder and rectum both empty themselves when a certain degree of distention is at- tained. Through the operation of the will such evacuation is put off to a convenient time. Through an undue irritability of the reflex center such evacuation is imperative, and does not bide the will, or it may take place while the will is in abeyance, as in sleep. Thus may be explained some of the cases of incontinence of urine in children. Again, if will-power is lost from disease of the cerebral cortex, evacuations of the bowels and bladder take place involuntarily so long as the sacral cord is intact, but not in a nor- mal manner. On the other hand, if the integrity of the sacral cord is lost, there will be no response to the sensory impressions conveyed from a full bladder or rectum, because the reflex arc is interrupted, and the organ remains un- emptied; whence torpor or complete paralysis of the bowels and bladder are common sym.ptoms of spinal disease ; and while the repletion of the 848 DISEASES OF THE XERJ'OUS SYSTEM. latter may finally overcome the resistance of its sphincter and lead to drib- bling, the rectum may go on filling up until it is emptied by the finger or the handle of a spoon. A lesion situated higher in the central nervous system than the sacral portion of the cord may also cause similar disturbance of de- fecation and urination, probably because of a spastic condition of the sphinc- ters, so that the laiter do not relax until the bladder or rectum becomes dis- tended, and finally they lose all function. Again, if it should happen that the sphincter center is destroyed while the detrusor center is intact, there would be dribbling of urine from the outset, but this is not likely to occur. (5) The state of the reflexes, as they are called, is next ascertained. As here used, the term " reflex " is applied to a muscular contraction stimu- Fig. 86.— Diagram Showing Probable Plan of tne Center for 'Slictmition—[Gou'£rs). MT. Motor tract. ST. Sensory tract in the spinal cord. MS. Center, and ms motor nerve for sphincter. MD. Center, and w^ motor nerve for detrusor, s Afferent nerve from mucous membrane to S, sensory portion of center. B. Blad- der. At r the position during rest is indicated, the sphincter center in action, the detrusor center not acting. At a the condition during action is indicated, the sphincter center inhibited, the detrusor center acting. lated by a sensory impression, the simplest illustration of which is the re- traction of the leg of the sleeper when the sole of the foot is tickled. For diagnostic purposes the reflexes are divided into the " cutaneous reflexes " and the " tendon reflexes." The cutaneous or superficial reflexes are muscular contractions which take place in different parts of the body in response to irritation of sensory nerves of the skin, as by tapping the skin lightly or drawing the finger or a pointed instrument lightly over it. The sudden application of heat or cold or the prick of a pin or pinching are modes of excitation. The contractions are generally confirmed to the neighborhood of the locality irritated. The skin reflexes are much more easily excited in children than in adults, and in the lower extremities rather than in the upper; also with varying facility in different persons. They receive various names, according to the situations where they are readily excited. Thus we have the " plantar reflex," where contraction is excited by tickling the sole of the feet, resulting in a movement of the toes or foot, or even in a drawing up of GENERAL SYMPTOMATOLOGY. 849 the leg; the " cremaster reflex," contraction of the cremaster muscle and consequent drawing up of the scrotum on stroking or scratching the inside •of the thigh. The retraction may take place on the one side of the scrotum only or on both. Then thrre is the "abdominal reflex," or a contraction of the abdominal muscles when the skin of the abdomen is stroked or scratched. A subdivision of the latter is the " epigastric reflex," produced iDy an irritation on the side of the thorax in the fourth, fifth, and sixth inter- spaces. The result is a dimplmg of the epigastrium on the side stimulated. Cutaneous reflexes may be brought out in other portions of the body, as in the gluteal region by irritating the skin of the buttock. A contraction of the muscles about the scapula, the " scapular reflex," is produced by an irri- tation between the scapulae. To test for the cutaneous reflexes is more important in the lower extremity than in the upper. The tendon reflexes, or deep reflexes, are so called because they are -generally elicited by striking upon tendons, while the corresponding muscles are placed slightly on the stretch, care being taken, however, to avoid all active tension in the muscle by the person examined. The blow is made either with the edge of the hand or with a hammer adapted to the purpose, commonly made of rubber. A sharp, sudden contraction of the muscle usu- ally takes place. A similar, though less decided, contraction may be elicited by the mechanical irritation of parts analogous to tendons, as peri- osteum and fasciae, and by striking the muscle itself. When the reflexes are in excess, sudden tension alone will excite them. The most commonly tried of the tendon reflexes is the knee-jerk, or patellar tendon reflex, produced by striking the tendon of the quadriceps femoris between its insertion and the patella, while the leg is crossed upon its neighbor. The weight of the pendent leg gives a sufficient degree of tenseness. When the knee-jerk is normal, there is a decided rise of the foot with each blow of the hand hammer. This motion may become abnor- mally increased or diminished. A more limited movement may also be produced by striking the patella itself or the quadriceps tendon above the patella, and, when the reflex is exaggerated, by a very light tap in these situations or even on the tibia. When thus exaggerated, the reflex may also be brought out in bed, as follows : the quadriceps tendon being put on the stretch by pressing the patella downward in the direction of the leg with the finger, the patella is percussed in the same direction. With each stroke there is a contraction, and the finger and patella are drawn upward. A ■" clonus," or repeated contraction, may even be produced thus. Similar is the ankle reflex, produced by tapping I'-e tendo Achillis when the calf muscles are placed slightly on the stretch by a slight dorsal flexion of the foot. In health the ankle reflex is not always producible, but in disease in connection with this contraction is shown the most remark- able of the exaggerated reflexes, the "ankle clonus " or " foot clonus." It consists in contractions rapidly repeated so long as the tension of the calf muscle is kept up by pressing the foot toward dorsal flexion. From six to nine such contractions ma}- occur in a second, and sometimes the whole leg is thrown into vigorous contractions. One of the best ways to obtain the tendo Achillis jerk is to have the patient kneel on a chair with the feet projecting over the edge of the chair ; the muscles are thus relaxed, and a tap over the tendo xA.chillis produces a movement of the foot. The Babinski reflex or phenomenon is the extension or turning up- ward of the toes, and especially of the great toe, obtained by stroking 850 DISEASES OF THE NERVOUS SYSTEM. the sole of the foot. In the normal individual, stroking the sole, if it pro- duces any response, causes plantar flexion or turning downward of the toes, especially of the four outer toes. The reflex usually indicates a lesion, or compression of the motor tracts in the cord and brain, and probably also of the motor centers in the brain. The response is usually best brought out by stroking the inner surface of the sole from the heel toward the toe, al- though in marked cases it may be elicited by applying the stimulus to the sole in various positions and directions. In infancy some observations have shown that the toes tend to turn upward normally when the sole is stimu- lated. The reflex is obtainable in about 70 per cent, of cases of hemiplegia and diplegia, and ni about the same proportion of diseases involving the motor tract in the spinal cord. It is found only exceptionally in cases of another class, viz., meningitis, hydrocephalus, poisoning, as for example alcohol or uremia. Reflexes are also elicited in the upper extremities, but they are much less striking, and often cannot be shown in health. The most important of these are the arm-jerks^ produced by striking the biceps tendon at the elbow- joint in front, or by striking the triceps tendon above the olecranon. So-called periosteal reflexes — reflexes excited by striking the periosteum — may in exaggerated states be produced in the supinator longus and biceps of the upper extremity by striking the lower end of the radius and ulna ; also in the adductors of the thigh by striking the internal condyle of the femur. A w^ist clonus, resembling the ankle clonus of the lower limbs, may sometimes be obtained when the tendon reflexes of the upper limbs are much exaggerated. It is produced by pushing the hand of the patient forcibly back- ward and holding it dorsally flexed ; involuntary antero-posterior move- ments of the hand may then occur. The jaw-jerk is produced by tapping on the front of the jaw, while the closing muscles of the jaw — viz., the ptery- goids, masseters, and temporals — are placed on the stretch by partially open- ing the mouth. The ophthalnik (supraorbital) reflex is a pure sensori-motor reflex, elicited by mechanical irritation (tapping lightly with the percussion ham- mer), or by the application of heat, cold, or pain-stimuli over the distribu- tion of the ophthalmic nerve, especially in the distribution of the supraorbital branch on the forehead. It is manifested by a fibrillary contraction of the individual fibers in the inferior half of the orbicularis palpebrarum. The sensory impulse travels through the supraorbital nerv^e (purely sensory) to the pons and thence through the facial fibers (purely motor) to the orbicu- laris palpebrarum. The value of the reflex depends upon the loss of the contractions from a lesion cutting the arc either in the ophthalmic branch of the trifacial, in the nucleus of the trifacial or facial in the pons, or in the fibers of the facial going to the orbicularis palpebrarum.. It is therefore of value in localizing lesions of the pons in which it may be lost, and differentiating a facial paralysis due to a lesion of the nucleus or its peripheral fibers, where it is likewise lost, from a supranuclear or cortical lesion in which case the reflex is present and increased. It has the same significance as the reflex closure of the eyelids from irritation of the conjunctiva, as this also is a reflex in the distribution of the facial and trigeminal nerves. Physiology of Tendon Reflexes. — The tendon reflexes were first studied by Erb and Westphal, and later by Tschirjew, Gowers, Jendrassik, Weir GENERAL SYMPTOMATOLOGY. 851 Mitchell, Lombard, and others. Erb explained the phenomena as purely reflex in their character, requiring the offices of a centripetal and a centri- fugal nerve, an intermediate center, and an excitant. Westphal, on the other hand, regarded them as simple muscular contractions, stimulated as are the bared, quivering muscles of the recently killed animal, the tendon being simplv the intermediary substance through which the irritation is conveyed. It was early objected to the purely reflex nature of these phenomena that a shorter time is usually required to produce them than to produce an ordinary reflex action, being but from 1-40 to 1-30 of a second, as compared with 1-15 of a second. But the strongest objection is found in the results of the experi- ment of Tschirjew, who cut all the nerves to the patellar tendon and found that the reflex still remained excitable. Nevertheless, the tendon reflexes are arrested by any lesion which arrests reflex action. Hence reflex action must somewhere come into play. Accordingly, Gowers suggests that " the irritability is developed by the passive tension. If the muscle is relaxed, the fibers may contract, if they are struck directly, as do the fibers of a separated frog's muscle, but no con- traction ensues on striking the tendon. Hence we must assume that the tension excites, by a reflex influence, a state of irritability to local mechanical stimulation, such as a tap on the muscle, its tendon, or even the vibration from a tap on adjacent parts. But only that form of mechanical stimulation is effective which suddenly increases the previous tension. It is only because the tap on the tendon does this so readily that the tendon is the means by which the contractions are most easily produced, and through which they have been chiefly studied and prematurely named. If the tension put on a muscle is gentle and gradual, it may only develop the irritability, and an, additional local stimulation is necessary to produce a visible contraction. If, however, the tension is sudden and forcible, it not only develops the irritability, but produces visible contraction in the muscle thus rendered irritable, as in setting up foot-clonus." Hence, too, according to Gowers, the term " tendon reflex " is altogether too inaccurate, and he suggests the word myotatic, from /xvgjv, muscle, and ratiHO?, extended, because tension is necessary for the production of the contractions. Weir Mitchell describes it well in these words : " A muscle moves when struck because of its innate capacity to twitch when irritated, but it does not move when excited by a blow on its tendon unless it has, besides its own excitability, a constant influx of tone-weaves from spinal centers." * Hence in a com.plete examination the " muscle jerk," or idiomuscular contraction, also known as mechanical muscular irritability, should be tested as well. It is done by a sharp, sudden tap on the muscle with the hammer. The response is of two kinds, first as a sudden contraction, and second as a hump-like rise which subsides slowly. The pectoral muscles are favorite sites for eliciting the pure muscle reflexes. It is, of course, impossible to deny that there is nerve as well as muscle irritation in such a blow. Both the tendon jerk and muscle jerk are capable of re-enforcement by coincident muscular exertion, as in lifting weights or clinching fists, originally discovered by Jendrassik y m 1883 in the case of the tendon jerk. Mitchell and Lewis | also discovered in the course of their study of ataxic cases that the pure muscle jerk or hump could be produced after the tendon * Mitchell and Lewis, " Tendon and :Muscle Jerk," " Trans. Assoc, of Amer. Physicians," vol. i. p. 1886. t " Beitra xxxiii. p. 175. 13, 1886. , J. ■ f'Beitrage zur Lehre von den Sehnenflechsen," " Deutsches Archiv f. khn. Medicm, i88^, vol. t Loc. at. 852 DISEASES OF THE NERVOUS SYSTEM. reflex could no longer be elicited, and that both could be produced by the re-enforcement referred to after the}' had disappeared to ordinary conditions. Significance of Abnormal Reflexes. — What are the conclusions to be drawn from modifications in the reflexes? In the first place, it is to be re- membered that they vary somewhat within the limits of health. Especially is this true of the cutaneous reflexes, which are also less easily elicited than those of the tendons. In general terms, diniinution or absence of a reflex norinally present in health implies either, first, a breach of integrity somewhere in the reflex arc as formed by the centripetal nerve, the motor nerve cells in the spinal cord situated in the anterior cornua of the gray matter, and the motor nerve ; or, second, an increase in the reflex cerebral inhibitory influence. The latter would be irritative. Thus, it is well known that disease of one cerebral hemisphere may lessen or abolish the superficial reflexes on the oppo- site or paralyzed side of the body soon after the onset of a hemiplegia. Breach of integrity may lie in the spinal cord or in the centrifugal or the centripetal nerve; more commonly, of course, in the former. If it is in the centripetal nerve, it may be accompanied by impaired sensation ; if in the centrifugal, there will be defective motion. Disease of the centrifugal nerve and of the motor center in the cord may also cause degeneration and wasting of muscle with loss of its irritability. Increase of the reflexes, on the other hand, implies increased irritability of the motor areas of the cord — when the reflexes are spinal (anterior cornua and possibly of the pyramidal fibers) or a withdrawal of cerebral inhibition, as in certain cases of destructive brain disease or disease of the cord high up. In the case of a cortical lesion the increase in the reflexes is greater on the side opposite that of the brain lesion, but the reflexes on the same side as the lesion may also be somewhat increased. In certain diseases of the cord there is a delay in the manifestation of the cutaneous reflexes after the irritation has been applied to the skin, an interval of from ten to fifteen seconds being often recorded before the response ensues. Increase of cutaneous reflexes is manifested by an unusual readiness of response in the normal areas, or an extension of these areas beyond their normal boundaries. In general it may be said that absence of the tendon reflexes is espe- cially characteristic of poliomyelitis and tabes dorsalis, and of all peripheral paralyses and neuritis ; also of advanced diabetes melHtus. Abnormal increase is present in spastic spinal paralysis and in cerebral paralyses, being due in the latter instance to withdrawal of the normal inhibitory influences. Appended is a table showing the conditions under which the tendon reflexes as represented by the knee-jerk are increased or diminished: TENDON REFLEXES. Increased. Decreased. Spastic spinal paralysis. Poliomyelitis, acute and chronic. Amyotrophic lateral sclerosis. Tabes dorsalis. Cerebral paralysis in which the inhibitory Progressive spinal muscular atrophy. center is impaired. Muscular dystrophy. Lesions of the cord above the reflex arcs. Peripheral paralysis. Disseminated cerebrospinal sclerosis. Neuritis. Irritability of cord, as in maniacal hys- Degenerated muscle. teria. Exhausted spinal centers. Strychnin poisoning. Poisoning from drugs (?) Cerebral palsies of children. Advanced diabetes mellitus. Increased or Diminished. Paretic dementia: Diminished as a tabetic symptom; increased in beginning spastic paralysis of the leg. Cerebellar tumor, not infrequently diminished. GENERAL SYMPTOMATOLOGY. 853 Se Tensor fasciae femoris. Sartorius. Quadriceps femoris. Rectus femoris. \ Vastus externus. Fig. go.— Motor Points on Thigh, Anterior Surface— (a//^r Erb and de Wattevilley CIC, AnClC, AnOc, KaO—; with strongest currents, KaClTe, AnClC, AnOC, KaOc. In pathological states two sets of deviations from the normal reaction to electrical stimulus are observed — viz., quantitatwe and qualitative. In the quantitative deviations there is simply an increase or a diminution of the normal irritability of both nerve and muscle to either faradism or gal- vanism. These differences are, of course, most easily measured when the alteration exists only on one side of the body, which may then be compared with the other. When both sides are affected, estimates can be made only by comparison with a healthy body or by the galvanometer. For this purpose superficial nerves, such as the frontal, ulnar, and peroneal, are usually selected. Instances: Increased quantitative changes are found in tetanus and in the early stage of certain peripheral palsies, while diminished electrical. GEXERAL SYMPTOMATOLOGY. 857 excitability is found when the lower motor segments ( motor spinal cells, motor nerA^es, including the muscles ) are involved — as, for example, in pro- gressive spinal muscular atrophy, bulbar paralysis, and muscular dystrophy. ]\Iore important from, a diagnostic point of view, at least, are the so-called qualitatiz-e deviations from the normal law of contraction knoivn as the reaction of degeneration. These are produced by the gahanic current only, and may. in general terms, be regarded as a reversal of the usual order of response to interruption of currents and in the substitution of a slow and vermicular contraction for the usual sudden and jerking contraction. The entire group of events is best illustrated by describing the electrical phe- nomena which present themselves in an ordinary case of peripheral paralysis. In two or three days to a week after its appearance there begins a gradually diminishing response in the nerve to both faradic and galvanic currents. This goes on for one or two weeks, at the end of which time it disappears to both currents, even the strongest. The nerve is now dead. During this same time the muscle is also losing its responsiveness to the faradic current, but not to the galvanic. There may be also at first a slight diminution to the galvanic current, lasting, say. one week, and constituting the " first degree " or " first stage " of degeneration. But during the second week this is substi- tuted by an increased excitability, so that there is now marked response to weak currents — increased quantitative deviation. But there is also qualita- tive change. The anodic closure contractions become now as strong as or stronger than the cathodic closure contractions. Xay, more: the cathodal opening contractions, which in health were exceedingly weak and could be brought about onlv by the strongest currents, are now often stronger than the cathodal closure. This state of affairs for muscle may be represented thus : ( Diminished quantitative response to gal- First stage of reaction of degenera- - vanism. tion — one week : ( No qualitative deviation. f Increased quantitative response to gal- j vanism. Second stage of reaction of degen- J Qualitative deviation as follows: eration — four to eight weeks: 1 AnCl=or > KaClc. ^ I KaOC > KaClc. 1^ Contraction prolonged and A-ermicular. The phenomena of qualitative change are purely muscular, and it should be mentioned that they are not always typically present. Even more con- stant and equally distinctive and more reliable as a sign of reaction of degen- eration is the second qualitative change in the muscular contractions excited by galvanism in this stage. Instead of being quick or sudden, they become slow, prolonged, and vermicular. The second stage lasts from four to eight weeks, increasing during the third and fourth. In cases of recover}- the abnormal muscle irritability to galvanism often persists after return of voluntary power, but it diminishes as the faradic irritability returns. In severe cases, when recovery does not take place and the nerve is not restored to its natural state, all nerve irrita- bility and faradic muscular irritability remaining permanently absent, the increased galvanic muscular irritability mav continue for months, but ulti- mately also decreases, disappearing finally with the muscular substance. Certain exceptions to these laws must be mentioned. Thus, when the nerve lesion is slight, the fall in quantitative nerve irritability is sometimes preceded by a corresponding rise, or the rise may persist throughout, and 858 DISEASES OF THE NERVOUS SYSTEM. such rise may be considered as evidence of a slight lesion. Further, the change is not always the same to faradism and galvanism, and is often brought out much better by the slow interruptions in the faradic battery than by the rapid interruptions in the same or by the galvanic current. Gowers noticed in one instance moderate but prolonged diminution of faradic irrita- bility when no change could be found with galvanism, and Bernhardt has noticed lessened irritability to faradism with distinct increase to galvanism in an ulnar nerve the seat of traumatic paralysis. Again, faradic irritability may not diminish to the same degree in the muscle as in the nerve in mild Sciatic. Biceps (long head). Biceps (short head). Peroneal. Gastrocnemius (outer head). Soleus. Plexor longus hallucis. Gluteus maximus. Adductor magnus. Semitendinosus. Semimembranosus. - Posterior tibial. Gastrocnemius (inner head). Soleus. Flexor longus digitorum. Posterior tibial. Fig. 91. — Motor Points on Lower Limb, Posterior ^uxid^QQ— {after Erb and de Watteville^. cases, and conduction of voluntary impulses from the brain may be possible when there is no response to electrical currents, and there may be response to electrical currents when there is no conduction of voluntary impulses from the brain. In still milder peripheral paralyses there is no reaction of degeneration at all, whence a favorable prognosis may always be made. It is to be especially observed in recovery from nerve lesions that voluntary motion often returns decidedly earlier than the electrical excitabilitv of peri- pheral nerv'es. What do reactions of degeneration teach usf Simply that the disease GENERAL SYMPTOMATOLOGY. 859 is seated in the anterior cornua of the gray matter of the cord, or in the peripheral nerves. They teach us nothing as to the nature of the lesion. Upon the integrity of the cells in the anterior cornua and their " trophic influence " depends the nutrition of the nerve and the muscle over v^hich the cells preside. Hence with disease of the cornua result degeneration of the nerve and wasting of the muscle. The muscular fasciculi become reduced in size and ultimately totally disappear. This is associated with a certain amount of interstitial overgrowth. In the transition referred to, certain fas- ciculi assume the yellow, glassy appearance known as waxy degeneration. The sensibility of the muscle, if the sensory nerve is intact, becomes increased, and there may be pain, partly due to compression of the nerves by morbid contraction, and partly to a morbid sensitiveness of the nerve-endings and to Tibialis anticus. _, Extensor longus digitorum Peroneus brevis. Extensor longus hallucis. Interossei. \ Peroneal. Gastrocnemius. Peroneus longus. -Soleus. Flexor longus hallucis. Extensor brevis digitorum. Abductor minimi digiti. Fig. 92. — Motor Points on Leg, External Surface— («//i?r Erb and de Watteville). the interstitial inflammation. The recovery of the nerve is followed not only by gradual restoration of its power over the muscle, but also by restoration of the nutrition and redevelopment of the muscle. For this, however, much time is required, and it often remains permanently smaller than normal. The atrophy of muscle can be prevented to some extent by massage. Lesions of motor nerves, whether inflammatory or traumatic, are fol- lowed by similar results — degenerative atrophy of nerve and muscle because of interference with the conduction of the atrophic influence. Occasionally in cerebral palsies and in spinal paralyses in which the lesion is above these ganglion cells there is some wasting, but no reaction of degeneration is devel- oped, because the nutrition is maintained by the intact cell body of the lower neuron. 86o DISEASES OF THE NERVOUS SYSTEM. From the foregoing the diagnostic and prognostic value of the reaction of degeneration is at once apparent. The seat of the lesion, whatever its nature, is easily determined, in so far as it is within the cerebral or peripheral motor segments, but we may not be able to say whether the nerve-cells or their peripheral processes (the peripheral nerves) are diseased. We are also informed that recovery, though not impossible, must be delayed in proportion to the degree of degenerative reaction, because of the extensive repair necessi- tated in muscle and nerve. Much experience with the use of electricity should, however, be had before the physician permits himself to draw conclusions. II. Sensory Phenomena. — Under this head naturally fall first the sub- jective sensations of the patient. They include, strictly speaking, only the various modifications of sensibility appreciable to him alone and independent of external impression, — pre-eminently, pain. They also include those peculiar modifications due to internal irritation as contrasted with external impression, and known as paresthesias — viz., numbness, tingling, prickling^ formication, or a feeling as of ants crawling over the skin ; also a sensation like that of the contact of wool or fur, — a furry feeling, — vertigo, tinnitus aurium, or ringing in the ears, and a sense of unpleasant odors or tastes. After these come modifications of the different varieties of cutaneous sensibility as excited by external impressions — objective sensations. They are of the nature of increase or decrease, the former being known as hyper- esthesias and the latter as anesthesias, the latter "being further characterized as partial or complete. To the latter the term paralysis of sensation, partial or complete, is also applied. I. Tactile sensibility, the sense of touch or pure contact, is usually first investigated. The simplest method is by the touch of a finger or other blunt object of about the same temperature as the body, for both heat and cold must be eliminated in this test. The patient should be directed to close his eyes or avert his head. More refined measures are the application of rough, smooth, or coarsely uneven surfaces. More delicate still is the esthesiometer, essentially a pair of compasses with blunt and sharp points and graduated quadrant attached, by which the distance between the two points is accu- rately measured. By this instrument, in connection with a normal standard of relative sensibility worked out by E. H. Weber, the degree of impairment in delicacy of touch may be measured. Closer approximation may be recog- nized if the two points of the compasses are put down one after the other and varying the test by touching th^ same place twice or a different place each time. Weber's table is as follows : Minimum distance at zvhich the two points of a pair of compasses in con- tact with the skin may be recognized as two points: Cheek, ii to 15 millimeters. Backs of the hands, 31 millimeters. Tip of the nose. 6 millimeters. Backs of the finishers, 11 to 16 millimeters. Forehead, 22 millimeters. Tips of the fingers, 2 or 3 millimeters. Tip of the tongue, 1.2 millimeter. Back, 55 to 77 millimeters. Back of tongue and on the lips, 4 or Chest, 45 millimeters. 5 millimeters. Thigh, 77 millimeters. Neck, 34 millimeters. ' Leg, 40 millimeters. Upper arm, 77 millimeters. Instep, 40 millimeters. Forearm, 40 millimeters. These figures can, however, only be used within limits, as they are by no means constant for ditTerent individuals, or, indeed, for the same indi- GEXERAL SYMPTOMATOLOGY. 86i vidual at different times. ^Marked deviations from them may, however, be accepted as indicating derangements of tactile sense. 2. The sense of pain is of equal importance to that of pure touch, because these two not infrequently fail to diminish or increase pari passu in morbid states. Parts insensible to touch may respond decidedly to painful impressions. Pain is most easily investigated by pricking with a pin or pinching a fold of skin, by painful electrical currents or painfully hot metals. The special term analgesia is applied to loss of sense of pain while the tactile sense is preserved. Analgesia exists in peripheral and central nervous disease and may be observed especially in syringomyelia. Tenderness or pain on pressure in the course of nerves should be studied in connection with the sense of pain. It is found in nerves which are the seat of inflammation, especially in sciatic neuritis and multiple neuritis. 3. The sense of temperature may be roughly tested by ascertaining the power of the patient to discriminate between the warm breath close to the skin and the cooler current produced by blowing from a distance. More precisely, the sense of temperature is studied by testing the ability to recog- nize dift'erences in the temperature of flat-bottomed test-tubes filled with water of different temperatures and brought into contact with the skin. The therm-esthesiometer has been devised by Eulenburg for the same purpose, but the student is referred to works on nervous diseases for its descrip- tion. In health dift'erences of 1-2'' to i"" F. (0.27' to 0.55^ C.) may be recog- nized on the fingers and face at temperatures from 80" to 100'' F. (26° to 37° C). while on the back differences to be recognized must amount to 2" F. (1° C.J. In disease we sometimes notice complete loss of sense of temperature, while the skin appreciates other forms of irritation, and, again, this state of affairs is precisely reversed; or the temperature and pain sense may be lost or impaired, while tactile sense is preserved, as in syringomyelia. This is known as dissociation of sensation. It occurs most commonly in syrin- gomyelia, but has been seen in other diseases. Striimpell has called atten- tion to a peculiar reversal of the sense of temperature, as the result of which cold objects appear warm. This has been noticed in various diseases. 4. Sense of Locality. — By this sense we know, without looking, w^hat part of the body is being touched. \\'hile cutaneous sensibility may remain intact, the sense of locality may be seriously deranged. Thus, a patient may think he is being touched on the leg when the contact is with the foot. 5. Delayed conduction of sensory impressions represents a form of modified sensibility of which after-sensations are a further subdivision. In delayed conduction an irritation, more particularly a painful one, like the prick of a pin, is noticed by a patient after an appreciable interval, whereas in health the recognition is instantaneous so far as the unaided perception is able to judge. Touch and pain may even be thus separated, the immediate contact of the pin being promptly recognized, while the sense of pain presents itself a few seconds later. It is likely, also, that the sense of touch ma}- be delayed. 6. An after-sensation is a prolonged sense of pain which succeeds a momentary impression. Such is the prolonged burning on the sole of the foot which sometimes succeeds the prick of a pin. or which may occur once or oftener after a short interval, as if additional pricks had been made. Occa- sionally an isolated prick of a pin is not perceived, and repeated pricks are 862 DISEASES OF THE NERVOUS SYSTEM. necessary, the whole producing a painful sensation ; this is known as summa- tion of sensation. These abnormal sensations occur particularly in diseases of the spinal cord or of the nerves, and especially in tabes dorsalis. 7. TJie muscular sense, it were better named the sense of position, is that sense by which we become aware of the position of any of our limbs without the aid of vision, as well as of any degree of motion by them. It is probable, however, that the sensibility of the articular surfaces, ligaments, tendons, and skin aids the sensibility of the muscles in furnishing this infor- mation, and it is better to call this sense the seiise of position when we speak of it in reference to the position of the limbs, or deep sensation. This power is diminished in nervous diseases, and may be tested by having the patient first touch a certain object with his eyes open and asking him to repeat the act with the eyes closed ; or by moving the fingers or toes of a patient and request- ing him to give their positions when his eyes are closed and voluntary move- ments of the parts are restrained. The " muscular sense " is not only thus estimated, but the strength required to lift a leg or an arm, more plainly evident when one is tired, is also measured through it. It is the muscular sense which causes the paretic to say that his leg feels heavy. By the m.uscular sense, too, or by the " sense of power," we estimate the amount of strength demanded by any muscular contraction, and thus measure the difference in weight of objects, eliminat- ing, however, the sense of pressure, which may be done by suspending the object in a towel. In tabes dorsalis, as well as in paralysis of cerebral origin and in cortical lesions, the muscular sense may be defective ; also in hysterical affections. It is also found defective in diseases of the peripheral nerves and in diseases of the lemniscus, or of the internal capsule, or of the nerve fibers passing to the cortex around the fissure of Rolando. It is disputed whether the muscular sense has a center separate from that of motion in the cortex or from the pain or tactile or temperature senses, but a recent observation by Allen Starr * would go to show that it has a sepa- rate center two inches behind the fissure of Rolando and about an inch and a half to the left of the median line. It seems probable that the posterior columns of the spinal cord and the parietal lobes are especially concerned with the muscular sense. The muscular sense is estimated by the amount required to be added to an existing weight on the skin before the addition is appreciated. Thus it has been ascertained that in health an addition of 1-20 or 1-30 to an existing weight can be appreciated. Thus, if a weight of ninety-five gm. be placed on the skin, an addition of a single gram will not be recognized, but nearly five gm. must be added before the increase is appreciated, while if consider- ably more than this is necessary, it means that the sense of pressure is less delicate. Sufficiently accurate measures are coins of different weights. Temperature must be eliminated by placing non-conducting substances be- tween the weight and the skin, while the part to be tested must also be sup- ported. It is not unusual to find, in paralysis of the muscular sense, failure to recognize a doubling and even tripling of weights. It is more especially in. tabes dorsalis that such paralyses are found while the tactile sense proper is * " Psychological Review," January, 1895. GENERAL SYMPTOMATOLOGY. 863, intact, a light touch of the skin being felt, while a considerable pressure is not appreciated. Stereo gnosis — the faculty of recognizing the nature and uses of objects by contact in handling them. Astereognosis, or, as some prefer to call it, stereoagnosis, is the inability to so recognize objects. The ability to recognize objects by handling them depends upon the integrity of the afferent nerves, the cortical sensory area, and the cortical perceptive area. Disease of either of these will make it impossible for the patient to recognize objects by handling them.* , 8. Anesthesia is said to be peripheral, spinal, or cerebral, in accordance with the seat of the broken conduction between the terminal apparatus and the cerebral cortex. Peripheral anesthesia occurs after chilling of the skin through the action of ether, from cocain, aconite, veratrum, as w^ell as cor- rosive agents like acids, alkalies, and carbolic acid. Spasm of the small ves- sels, forming the so-called spastic anemias, is also attended by anesthesia. The anesthesias of washerwomen, who have their hands in water all day long, may belong to this class. Lesions of nerve trunks by pressure, inflam- mation, and degeneration may cause anesthesia. The paresthesias referred to — numbness, formication, and tingling — are among the eft'ects of such lesions. Spinal anesthesias are found, especially in connection with disease of the posterior roots, posterior columns, and posterior cornua of the cord. Such a disease is tabes dorsalis especially. Anesthesia is found, however, also in myelitis, acute and chronic, and when there is pressure on the cord from hemorrhage into the spinal canal or pressure by diseased or broken vertebrae or from tumors. Such anesthesia is usually bilateral and is known as para- anesthesia. Cerebral anesthesia occurs as the result of hemorrhages, soften- ing, or tumors, whicli impinge on the posterior limb of the internal capsule^ through which the sensory fibers, probably after interruption in the thalamus, pass upward to the cerebral cortex. If the cerebral anesthesia affects half of the body, it is known as hemianesthesia, and the half of the body affected is opposite the hemisphere of the brain in which the lesion lies, since the sen- sory libers also decussate in their course from the periphery, and most of them throughout the cord very soon after their entrance into the posterior roots. The hysterical anesthesias, and anesthesias due to the action of narcotics and anesthetics, are regarded as cerebral in their origin. Those succeeding such acute infectious diseases as typhoid fever have been ascribed to both peripheral and spinal origin. The hysterical hemianesthesia is much com- moner than the organic cerebral hemianesthesia. III. Sensory ]\Iotor Phexomexa. — These words explain themselves,- but in addition to the general application they include such special conditions as akinesia algera in which all sorts of muscular action are attended with pain in the active muscles — even the act of speaking is attended with pain. It is a symptom of several neuroses, among which hysteria and neurasthenia are conspicuous. Atreniia. which resembles akinesia, differs from it in the absence of tenderness of the muscles affected. IV. Vasomotor and Trophic Phexomexa. — We pass next to the study of vasomotor and trophic alterations. Two sets of vasomotor nerves * See Burr, " American Journal of the IMedical Sciences," March, igoi. 864 DISEASES OF THE NERVOUS SYSTEM. have been demonstrated by physiologists, — the vasoconstrictors and vaso- dilators — the former contracting the arteries when stimulated and permitting their dilatation when paralyzed. The vasodilators are influenced in an oppo- site manner by the same agencies, but their number, so far as proved, is not great, as thev include up to the present time only fibers in the chorda tympani, nervi erigentes, and sciatic nerve. Blushing may be the result of stimula- tion of vasodilators. Moreover, pathology has as yet failed to separate lesions of the two sets of ner\^es and their consequences, and the latter are generally looked upon as results of paralysis or of irritation of vasocon- strictors. Instances of the former are redness, a feeling of warmth, and sometimes an actual elevation of temperature, sweating, all in circumscribed areas or half the body. They may persist or intermit. Instances of vaso- motor irritation are pallor, coldness, accompanied by stiffness, formication, and even pain. These are the phenomena of vasomotor spasm. A more or less permanent condition of the hands sometimes results, characterized by a blueness or mottled appearance accompanied by a lowered temperature fur- ther augmented by external cold. Still higher degrees are said to have pro- duced circumscribed gangrene (Raynaud's disease). Symptoms of vasomotor paralysis occur in connection with cerebral and :spinal lesions and with injuries of the sympathetic system and nerve trunks which include vasomotor fibers. The essential causes of vasomotor spasm are less easy to locate. It is found associated with prolonged convulsive seizures, and in angina pectoris at the beginning of the attack, as if caused by irritation of the sympathetic ganglia in the heart. That trophic or nutritive phenomena are closely allied to vasomotor phe- nomena is commonly admitted. That they are under the control of the same nerves is doubtful, although the proof of the existence of separate trophic nerves is still wanting. \'esicular eruptions in the area of distribution of nerves, such as herpes zoster, certain atrophic skin diseases, pigmentations and depigmentations, such as morphea, Addison's disease and vitiligo, sclero- derma, and the glassy skin which succeeds certain injuries to nerve trunks are illustrations of trophic influences. Similar are the changes in the skin, hair, and nails, as the result of which the first becomes dry, the second is lost or becomes rapidly gray, and the last grow brittle, thicken, or drop off. The latter events are the result of spinal and even cerebral lesions. The circum- scribed edema known as acute angioneurotic edema and the more permanent condition of myxedema are also probably trophic. So, also, are the atrophies which result from disease of the cells of the anterior horns of the gray matter of the cord, or from injuries to nerves by which they are essentially cut ofif from the trophic cells ; also unilateral facial atrophy, including even atrophy of bone, and the still more remarkable spinal arthropathies of Charcot, as the result of which the joints enlarge or become the seat of efifusions. Finally, there is the acute bed-sore or eschar, so well described by Charcot,* beginning in an erythematous patch on which bullae and blebs are rapidly developed, quickly succeeded by gangrene. While pressure or irrita- tion may be necessar>^ to the production of these sores as exciting causes, they are more easily invited in spinal paralyses than in non-paralytic condi- tions. Such results follow cerebral lesions and lesions in the medulla oblongata, spinal cord, and sympathetic nerve. It is well known that the vasomotor nerves surrounding the various * " Lectures on Diseases of the Nervous System," Philadelphia. 1879. GENERAL SYMPTOMATOLOGY. 865 blood-vessels are derived from the sympathetic trunks, which, in turn, receive their vasomotor filaments from the roots of the spinal nerves. V. Mental Phenomena. — Under this head come the phenomena of consciousness or unconsciousness, coma, the state of the will, the various per- versions of mental process, including delirium, hallucinations, delusions, illusions, and insane acts. Hallucinations are states of the mind in which the subject conceives that he perceives external objects which do not exist. The victim of delirium tremens who conceives that he is pursued by monsters of various sorts is the subject of hallucinations. Hallucinations may exist through any of the special senses. A delusion is a false idea unassociated with sensory conceptions. The deluded person imagines that he is the happy possessor of millions when he is actually a pauper, or complains of poverty although affluent. An illusion is based upon an actual perception, but an erroneous impression arises therefrom. In a hallucination no object is actually seen; there is no sensory impression. The idea of relief obtained on looking at a picture in the stereoscope is an illusion ; and Gowers adds that if used in connection with morbid mental states, the term illusion should be confined to false ideas and images the erroneousness of which the patient recognizes. Delirium is the more or less acute manifestation of one or all these per- versions of mental process, associated with muttering or active speech sug- gested by them or with action growing out of them. Thus constituted, delirium may be the result of toxic states or acute disease other than of the brain. The same perversions of mental process continued and unaccompanied by fever constitute insanity, which is probably always associated with struc- tural change in the brain or its membranes, although such may not always be demonstrable. Other symptoms are added, however, in iwsanity, such as extreme depression of spirits, while hallucination, delusion, and illusion may l>e present in various degrees. Special insane acts should be specified and modifications of normal sleep noticed. VI. Alterations in Vision and Hearing. — In addition to the ordi- nary defects of vision, the response of the pupil to light should be noticed ; also its accommodating power. The former is absent in three-fourths of all cases of locomotor ataxia, while the latter remains. The pupil thus failing to respond to light, but retaining its accommodation to change of distance, is known as the Argyll Robertson pupil. Each eye should be tested separately, the other being covered. Finally, the eye-ground should be examined in every exhaustive study of a nervous case. Modifications in hearing are of the nature of increased and diminished intensity, and there is that very common symptom known as tinnitus aurium, or ringing in the ears, already alluded to as a good instance of a subjective symptom. Hyperacusis occurs in association with augmented acuteness of the other senses in acute affections of the brain or when there is hyperemia of the brain from any cause. It is also often complained of in hysteria. Deaf- ness, on the other hand, is more frequently the consequence of diseases of the ear itself. Ringing in the ears occurs in many conditions, known and unknown. While some more than usual impression on the nerve is a condi- tion of tinnitus, it by no means follows that the cause resides in the nervous system. In addition to the numerous forms of irritation due to ear disease, 55 866 DISEASES OF THE NERVOUS SYSTEM. the blood in an adjacent vessel may be thrown into vibration and produce an audible murmur. On the other hand, tinnitus is sometimes due to intra- cranial irritation either of the nerve or of the auditory centers. VII. Alterations in Breathing and Pulse. — Alterations of breath- ing are very common in nervous diseases. Respiration may be rapid or slow, and labored and sighing', or irregular, but especially peculiar is the Cheyiie- Stokes breathing, in which, succeeding a long pause, so long sometimes that it seems as though the patient would never breathe again, follows gentle and shallow respiration, which gradually grows deeper and more frequent until an acme of dyspnea breathing is reached, when it again gradually diminishes in depth and frequency until the pause again occurs. It is an arrythmical breathing of a periodic type. During the pause the pupil often contracts and the heart's action becomes less frequent. Cheyne-Stokes breathing may occur in tubercular meningitis, cerebral hemorrhage, embolism, thrombosis,. and aneurysms of the basilar artery ; also in uremia, heart disease, and more rarely in other conditions, including the infectious fevers, in which the respi- ratory center is influenced. The period of arrest varies from five to forty seconds, and the duration of each cycle may be from fifteen to seventy-five seconds, and may vary. A modification of Cheyne-Stokes breathing is a form in which there are periods of deep and energetic breathing which begin suddenly, and in which the respirations gradually become shallower until they cease, and after a pause energetically recommence. Cheyne-Stokes "breathing was ascribed by Walsh and later by Traube and Rosenbach to lessened excitability of the respiratory center in the medulla oblongata. Filehne suggested that the rhythmogenic purpose of the respira- tory center is modified by a periodical vasomotor spasm caused by stimula- tion of the I'asomotor center by the asphyxiated blood. The arterial spasm in the medulla oblongata thus caused prolongs the stimulation of the respira- tory center as well as that of the vasomotor center by hindering the access of oxygenated blood. The respiratory center being less excitable, the re- spiratory movements, therefore, continue energetic — run riot as it were — after the blood has become oxygenated. The gradual onset of the breathing may be due to the fact that the reactive vasomotor dilatation exceeds the nor- mal, and thus the quantity of blood reaching the respiratory center lessens the stimulating influence of its quality ; but these are merely theories. The pulse is influenced chiefly by diseases of the cranial contents, espe- cially of the medulla oblongata^, the cerebrum, and the meninges. It is at times very slow, as in meningitis and apoplexy, or when there is intracranial pressure from any cause or when there is pneumogastric irritation. It may be accelerated when there is inflammatory pyrexia or irritation of the cardiac center. Again, it may be irregular, acting through the nervous system, of which opium poisoning is among the familiar causes ; uremia is another cause, rarelv also is influenza. Changes in the order of investigation proposed in this section will, of course, be demanded by circumstances, while at times certain steps may be omitted altogether. NEURITIS. 867 AFFECTIONS OF THE PERIPHERAL NERVES. NEURITIS. Definition. — Neuritis, or inflammation of a nerve, may be confined to a single trunk, whence it is called localised; or it may involve a large number of nerves, when it is known as nuiltiple neuritis or polyneiiritis. In peri- neuritis the connective tissue surrounding a nerve is the seat of the inflamma- tion; in interstitial neuritis the tissue between the bundles of nerve-fibers is involved, and in parenchymatous or degenerative neuritis the substance of the nerve-fibers themselves is affected. Localized Neuritis. Etiology. — Exposure to cold is the most frequent cause of neuritis, and the nerve most frequently thus afifected is the facial. Trauma is another cause, including compression, contusions, or cuts, as with glass, or stretching and laceration such as occur when there are dislocation, fracture, and other violent injuries. Neuritis may also occur as the result of extension of inflam- mation from contiguous parts, as from caries in a bone through which the nerve passes, adjacent joint inflammation, pleurisy, and meningitis. Finally, neuritis may be caused by toxins and morbid states of the blood, such as pro- duce the infectious and constitutional diseases, as diphtheria, syphilis, and gout. The mineral poisons, especially lead and arsenic, are frequent causes. Alcohol is also a cause of this kind of neuritis, although it more frequently produces multiple neuritis. Morbid Anatomy. — An inflamed nerve is reddish, from hyperemia of the vasa nervorum, though the stage of demonstrable hyperemia may have passed away when the nerve comes under observation. In perineuritis and interstitial neuritis the primary change is in the connective tissue — in the former, an infiltration of the nerve sheath with leukocytes, and in the latter, of the interstitial tissue with the same cells. There may even be minute extravasations of blood. These changes are more apt to occur in places along the course of the nerve where it is exposed to special irritation, as in passing through foramina or over bone. The lymphoid cells gradually become fusiform cells, resulting in the formation of true connective tissue. The pressure of this new tissue gradually destroys the nerve itself, the medullary sheath being gradually broken up into drops, which subsequently disappear, while the nuclei of the sheath of Schwann increase; finally, the axis-cylinder also becomes granular and disappears — all this in varying de- grees. The nerve-fiber may be substituted by a fiber of connective tissue, in which there may be a deposit of fat, a condition seen in the lipomatous neuritis of Leyden. In parenchymatous neuritis the primary change is in the nerve-fiber itself. Here the medullary sheath and the axis-cylinder are the first involved, the former breaking up into drops, as flescribed, and the latter into granules, both ultimately disappearing, while the interstitial connective tissue remains comparatively unchanged ; but the nuclei of the sheath of Schwann proliferate and become a part of the interstitial connective tissue. The muscles con- nected with the inflamed nerve also atrophy, — in the case of the motor 868 DISEASES OF THE NERVOUS SYSTEM. nerves, at least, — being practically cut off from their center of nutrition. The change in the nerve is essentially the W'allerian change noticed in the nerve-fiber of a cut nerve. In some instances the changes noticed in the sheath of Schwann extend over into the interstitial tissue of the muscle. Symptoms, — There is not much constitutional disturbance in localized neuritis, though the thermometer may show some rise of temperature. Pai)i, especially pain on motion, and tenderness, are the salient symptoms. The pain may be confined to the seat of the inflammation or may involve the distribution of the nerve, or the whole limb may be involved. It varies in degree and also in character, being sometimes burning and at other times aching, boring, or shooting. It is apt to be worse at night, and when in situations involving pressure on the nerve itself. The nerve may be swollen appreciably, and rarely the skin over it is reddened. The pain in the trunk of an inflamed nerve is probably due to pressure on the }ierf-i nervornin. Weir ^Mitchell has especially called attention to this. An interesting fact is that the nerves composed almost purely of motor fibers are less tender than sensory nerves. This would imply that fewer sensory nerves are distributed to the motor nerve trunks than to sensory nerves. Mitchell also describes elevation of surface temperature and trophic disturbances, such as sweating, herpes, and eft'usion into neighboring joints. Other motor disturbances, including twitchings and contractions, are noticed. Trophic derangements, including muscle wasting, associated with peculiar " glossy skin '' or slight edema, may be present. Vesicles, bullae, and herpetic eruptions may occur. The nails become brittle, rough, and marked with transverse ridges. The bones in the fingers may even become atrophied. There may be thickening of the skin and a condition resembling ichthyosis may be present. Ultimately the hyperesthesia and paresthesia may become anesthesia, though usually limited to small areas. The electrical condition of the nen^es and muscles must be studied. It may be normal in slight cases. In more severe cases there may be the reaction of degeneration, with the slow, lazy contraction of the muscles, and the reversed reaction to opening and closing currents, described on page 856. The course of the disease is variously prolonged. Alany acute cases terminate favorably in a few weeks. More cases become chronic, extending over months and even years, after which they may gradually subside. A rare variety is " ascending neuritis," in which the inflammation extends from smaller to larger branches, until finally most of the nerves of a limb may be involved, 01^ possibly even the spinal cord, producing myelitis, with or without spinal meningitis. Paralysis may result from such a condition. This is possibly the rare form of paralysis that succeeds visceral disease, as that of the bladder. Even the corresponding ner^^es of the other side ma)^ be involved. It is the opinion of some of the best neuropatholo- gists that this ascending neuritis occurs only from a suppurating wound. The theory of an ascending neuritis is not universally accepted. Additional Sympto:sis Due to Nerves Involved. — In inflammation of the facial nerve there is complete paralysis of all the muscles supplied by the nerve. In inflammation of the niedhini nerve there is disturbance on the palmar surface of the thumb, forefinger, and middle finger on its radial side, and there is often intense pain in these same situations. In inflammation of the ulnar nerve, there are pain and loss of sensation in the outer half of the fhird finger and in the fourth finger, with wasting of the flexor carpi radialis, NEURITIS. 869 the intrinsic muscles of the Httle finger, the interossei, lumbricales, and the adductor of the thumb. Here, in case of long standing, we have the " claw hand," the result of overextension of the first phalanges and flexion of the last two. In inflammation of the ninsculospiral there are great pain and tenderness of the upper arm and forearm, the region of the brachial anticus and triceps extensor, the extensors of the wrist and fingers, the two supinators — the back of the hand, thumb, and index finger. In extreme degrees we have the characteristic wrist drop and inability to extend the first phalanges of the fingers and thumb, with partial anesthesia of the base of the thumb and forefinger. The circumflex nerve supplies the deltoid and teres minor. There may be pain or impaired sensation in the muscles and the skin over them, to which may succeed loss of power and atrophy of the deltoid and the arm cannot be raised. In inflammation of the brachial plexus, which is prone to occur in gouty subjects over fifty years old, there may be a combination of the symptoms belonging to the last-named four nerves. A subvariety of brachial neuritis is radicular neuritis, in which the pain suggests the involvement of the roots of the nerves. Diagnosis. — The disease is chiefly to be differentiated from neuralgia. This depends upon pain and tenderness in the course of the nerve and upon the limitation of the symptoms to its distribution. Neuralgia is more inter- mittent, and is relieved rather than aggravated by pressure. The presence of the paresthesia points to neuritis and the diagnosis is confirmed if there is ultimately lessened sensibility. In neuralgia, nerve and muscle reactions remain normal. It is possible, however, that neuralgia may result in neuritis. The distal pain of central spinal disease must be separated. In brachial neuritis the pain may radiate to the left side, suggesting angina pectoris, and there may even be a tendency to cardiac distress, but there is no tenderness in the course of the nerve in angina. Prognosis. — The prognosis varies greatly, being favorable in mild and in most traumatic cases. Those consequent upon local suppuration are the gravest. In ordinary cases from cold or contusion recovery ensues sooner or later, although some last a long time and recurrences are not unusual, espe- cially in neuropathic dispositions, in which, too, recovery is slower. Treatment. — Here, as elsewhere, if a cause is discoverable, it should be removed. Exposure to cold and dampness should be avoided, pressure by cicatricial tissue or dislocated bones should be relieved, and constitutional states favoring neuritis, such as gout and syphilis, should be corrected. Of curative measures, rest is the most important. When a limb can be splinted, this should be done, pressure by muscular contraction being thus prevented. Cold may be a useful application, as by an ice-bag. In other instances heat, now dry and again moist, subserves a useful purpose. A blister or blisters may be applied over the tender nerve. Especially con- venient is the Paquelin cautery, which should be used earlier than it com- monly is; its application takes but a second, and may be rendered painless bv previously applying, for a few minutes, a mixture of ice and salt to the spot to be burned, although this has'been largely superseded of late by the more convenient ethyl chlorid. Morphin is sometimes indispensable, and the hypodermic method of application is best — 1-6 to 1-4 grain (o.oii to 0.0165 gm.) for an adult. But the m_orphin habit is easily acquired, and the patient 3;o DISEASES OF THE XERVOUS SYSTEM. should not be allowed to use the syringe himself. Cocain may be similarly- used — i-io to 1-3 grain (0.0066 to 0.022 gm.) — and Gowers recommends it highly, more particularly for its power in arresting local transmission of the impulses that cause pain. Eucain is even better. Here, too, the injection should be made at the seat of the pain by the physician or a trusted attendant. Gowers, whose large experience always bespeaks respect, considers mercury also a most efficient agent, in the shape of a blue pill, one grain (0.066 gm.) once or twice a day, associated, if necessary, with morphin, the constipating effect of which it counteracts. Salicylate of sodium is undoubtedly some- times viseful, as is also more rarely iodid of potassium. Strychnin is also of service. In the chronic form also Paquelin's cautery should be repeatedly used, or if not at hand, blistering may be substituted. Electricity here comes into play, and galvanism is the form to be used, the positive electrode being placed over the nerve or seat of pain, and the negative indififerentiy placed. A weak current should be used, but its strength may be increased if such current be inefficient. The application should continue for about ten minutes. The wasted muscles usually recover as the inflammation subsides, but massage and galvanic electricity help them. Faradism is less favorably regarded, especially in the active stage. Special Variety of Localized Neuritis — Sciatica. Definition. — This term is applied to all painful affections in the dis- tribution of the sciatic nerve, some of which may be neuralgic, but the vast majority are inflammatory and perineuritic, as it is the sheath of the nerve that is usually involved. Etiology. — Sciatica is far more common in men than in women, in the ratio of about four to one. Brachial neuritis affects both sexes about equally. It is also a disease of adults, being unknowm in children and very rare in the second decade. It is most frequent between forty and fifty, next between fifty and sixty, and next between thirty and forty. Gout and rheumatism are favoring causes, especially fibrous rheuma- tism. Very rarely syphilis may be a predisposing cause. Exposure to cold is the most frequent exciting cause, especially after severe muscular exertion, while standing in water, sitting or lying on the cold ground, and the like are frequent causes. Exposure to drafts, though less frequently so than in neuritis of the upper extremity, is still a cause. A sciatica may also arise by exten- sion from a rheumatic focus, especially that form of lumbago involving the fibrous attachments of muscles at the back of the sacrum, whence the inflam- mation extends to the sheath of the sciatic nerve. Pressure by mechanical agents and possibly muscular contraction may be a cause ; also pressure by tumors and other new^ formations within the pelvis. Even fecal accumula- tions may cause it by pressure. In bilateral sciatica the possibility of intra- pelvic tumor should be carefully considered. In addition to the intrapelvic causes referred to, secondary sciaticas may be caused by bone disease and other foci of suppuration external to the pelvis. Morbid Anatomy. — The morbid changes are those already described under neuritis. Symptoms. — The leading symptom, is, of course, pain in the course of the nerve. Felt first in the back of the thigh, it also travels above the hip- joint, into the sciatic notch, behind the knee, below the head of the fibula. NEURITIS. 871 behind the internal malleolus, and on the dorsum of the foot. It may be more diffuse, but the course of the main trunk of the nerve is often indicated bv it. and the points previously named, especially the back of the middle of the thigh and the sciatic notch, will often be pointed out h\ the patient as seats of special tenderness. It usually begins gradually, but it may start suddenly, especially in cases of rheumatic origin. ^Motion, particularly in walking, and positions in which the nerve is put in a state of tension or is compressed, aggravate it. A valuable sign of sciatica is pain produced by passive flexion of the thigh upon the pelvis with the knee extended (Lasegues sign) ; by this means the sciatic nerv^e is stretched, and pain is readily produced if the nerve is inflamed. The characteristics of the pain are those already described under neuritis. The other more unusual symp- toms of neuritis may also be present, as herpes, edema, and wasting, but the reaction of degeneration is almost never present. The loss of the tendo Achillis jerk is an important sign. Diagnosis. — This is not difficult, although a careful study should be made of each case with a view to determining its primary or secondary origin. Pekic tumors, especially in women, and rectal accumulations should be sought for. Lumbago, hip disease, and sacro-iliac diseases are all to be recalled, but in none of these is there pain on pressure in the course of the nerv^e. In the last only is there sometimes pain in the posterior part of the thigh. Pain felt only in the outer side of the thigh is not sciatica. The rare cases of sciatic neuralgia are not characterized by tenderness. They occur in persons subject to neuralgia, and the pain is not influenced by position and motion. It is purely spontaneous. Disease of the vertebra:, of the cauda equina, and even of the spinal cord may produce sciatic pain ; but here, again, there is no tenderness in the course of the nerve, the pain is peripheral and is more apt to be bilateral. Inflammation of the roots of the sciatic nerve, however, may extend downward. Bilateral pain is indicative of disease of the nerve -roots, although bilateral sciatica does occasionally occur. The shooting pains of tabes dorsalis are like those of sciatica, but the other symp- toms of the former disease are present. Prognosis. — Cases of sciatica, however obstinate, usually sooner or later get well, although they may persist for months. A case came under my observation which lasted seven years. Treatment. — Every case of sciatica should be at once ordered to rest, and the more complete the rest, the sooner the recovery. Splinting of the limb as recommended by \\q\t ^^litchell, is necessary in some cases, and would probably hasten cure if used earlier, but it is so inconvenient that the temptation to temporize is very strong. Rest being secured, I am confident that recoveries would be prompter if Paquelin's cautery were oftener used at the onset. Counterirritation by blisters, mustard, and iodin is relatively inefficient. Treatment by cold along the course of the nerve certainly relieves the pain for a time, but in my experience the relief thus obtained is not permanent. First, attention should be paid to the local causes, if these are discov- erable, and to constitutional causes as well. If of rheumatic or gouty origin, the salicylates will be found useful : in other cases they are useless. Here, as in neuritis from other causes. Cowers commends the pill of blue mass, one grain (0.06 gm.) twice daily, when there is active inflammation. For the relief of mild degrees of pain phenacetin and antifebrin, and especially a combination of phenacetin and caft'ein citrate, say ten grains 8/2 DISEASES OE THE NERVOUS SYSTEM. (0.66 gm.) of the former and three grains (0.2 gm.) of the latter every two hours are often efficient. For severe degrees morphin is necessary, and is best given hypodermically in doses of from 1-8 to 1-4 grain (0.008 to 0.0165 gm.). The danger of establishing the morphin habit must always be kept in mind, and cocain should be tried first as a deep-seated injection in doses of from 1-8 to 1-4 grain (0.008 to 0.0165 gm.). Acupuncture over the course of the nerve is of service for the same purpose — relief of pain rather than cure. Anodyne liniments may be used, and although not curative, do give some comfort and meet the wishes of the patient that something should be done. Recently the internal administration of ichthyol in small doses has been highly recommended by Grocq. Ichthyol locally is sometimes serviceable. In chronic cases change of scene is often of advantage, and if associated with thermal bath treatment may accomplish a cure in otherwise obstinate cases. The mud-bath is a measure of treatment applied in Europe with some success. In the chronic stage electricity also meets the demands of patients and friends and may do some good. The galvanic current should be employed. Massage is less efficient than in muscular rheumatism, though it should be tried. Nerve-stretching may be resorted to. I have had it done in cases with uncertain result. Multiple Neuritis. Synonyms. — Polyneuritis; Peripheral Neuritis. Definition. — An inflammatory condition involving many peripheral nerves, either simultaneously or in rapid succession. Historical. — Multiple neuritis is a disease of modern recognition. The symptoms peculiar to the condition were described first, probably, by James Jackson, Sr, ,of Boston, Mass., as early as 1S22. In 1854 Robert Bentley Todd, of London, wrote of lead palsy ; " The nervous system is thus first affected at its periphery, in the nerves, and, the poisoning influence continuing, the contamination gradually advances toward the center." Duchenne described the symptoms fully in 1858. Samuel Wilks described alcoholic paraplegia, but the existence of multiple neuritis as an actual disease was first demonstrated by Dumenil, at Rouen, in 1864, and the literature was further con- tributed to by Joffroy in 1879, Leyden in 1880, Grainger Stewart in 1881, Buzzard in 1886, James Ross, Henry Hun, and Charles K. Mills in 1892. W. R. Gowers' article in the second edition of '' Diseases of the Nervous System," 1891, is a ver}^ complete one. Etiology. — The causes of multiple neuritis are numerous, and by no means easy of classification. They include : 1. The commonly acknowledged poisons introduced from without: (a) Organic, including alcohol, by far the most frequent cause, ergot, morphin, ether, carbon monoxid, carbon bisulphid, benzine and its products, and anilin ; (b) inorganic, including lead, arsenic, phosphorus, and mercury. 2. Endogenous toxins generated in the organism by chemical changes. Such is the cause of the neuritis of diabetes mellitus, whether oxybutyric acid, diacetic acid, or acetone, all of which are found in the blood in that disease. 3. Toxins inherent to the infectious diseases, whether an organism or its product. Instances of the former are malarial neuritis, leprous neuritis, beri-beri or so-called endemic neuritis, also, probably, the neuritis of acute infectious jaundice (Weil's disease). In these instances the cause is an organism. Of the latter, diphtheritic neuritis, septicemic neuritis, the . MULTIPLE NEURITIS. 873 neuritis of smallpox, typhoid fever, tuberculosis, and possibly syphilis are instances. The cause is here a toxin generated by an organism. 4. Intrinsic states of the blood of undetermined nature, with which cold may or may not co-operate as an exciting cause — viz., rheuiTiatism, gout; also the puerperal state, and chorea. Advanced microbic doctrines would place rheumatic neuritis in 3, while a greater conservatism might place septi- cemic neuritis in 4. Malnutrition such as characterizes cachectic and senile states, cancer, tuberculosis, and wasting diseases generally are also causes. It is not impossible that cold alone may, by its operation, generate a poison capable of producing a polyneuritis, but more probably it acts by lowering the vitality of the nerves and rendering them liable to attacks from other agents. Age and Sex. — Multiple neuritis is a disease of adults. Aside from rare cases of diphtheritic neuritis, the most common form met in children is a compHcation of acute poliomyehtis. Gowers says " it may, perhaps, now and then be met with apart from the spinal malady as an infantile variety of multiple adventitial neuritis irregular in distribution." It is not improb- able that in some of the cases of poliomyelitis the changes in the ner^^es are secondary to alterations of the nerve cells in the anterior horns of the spinal cord. The remaining chief forms occur usually between the ages of tw,enty and fifty, the alcoholic between thirty and forty or later, and senile neuritis at a still later age. The alcoholic form is more frequent than all others put together, and of this form 70 per cent, occur among women. This pre- ponderance of the disease in women has been especially noticed in England, where alcoholism among females is more common than in this country. More than one cause may co-operate, when one may be the predisposing and the other the exciting. Cold probably most frequently plays the latter role, but there may be others, such as depressing emotions, anemia, and the like. Morbid Anatomy. — The special characteristic of multiple neuritis is that it is parenchymatous, as contrasted with interstitial and perineural — that is, the changes begin in the nerv^e-fibers themselves, as described on page 867, rather than in the connective tissue between and around them. Yet this is not invariable. Indeed, it is improbable that either form of neuritis exists without the other for any length of time. It is further characteristic of multiple neuritis that the involvement is symmetrical — that is, the cor- responding nerves on the opposite side of the body are affected. The more this is the case, the more likely is it that the change is parenchymatous. The changes are also more marked in the peripheral distribution of the nerve than in the trunk of nerves. Macroscopic changes are very rarely appreciable. In acute changes the nerve may be swollen, reddened, hemorrhagic, or in old cases hardened from overgrowth of connective tissue. Symptoms, — The symptoms vary greatly in different varieties of neu- ritis, but there are some more or less common to all varieties, particularly illustrated by the alcoholic and rheumatic. These common symptoms will be considered first, and aftervvard some special features of varieties due to specific causes, particularly the metallic poisons, the acute infectious diseases. and the poison of beri-beri. The symptoms are easily dividend into three classes: Motor weakness, sensory derangement, and inco-ordination. The first is the result of the in- volvement of motor nerves, and manifests itself usually first in the extensors of the wrist and fingers, flexors of the ankle, and extensors of the toes. The 874 DISEASES OF THE NERVOUS SYSTEM. sensor}' disturbances are tingling, numbness, and pain, while the inco-ordina- tion resembles that of the mildest degree of tabes. According as one or the other of these sets of symptoms predominates we have a motor form, a sen- sory form, and an ataxic form. The onset may be rapid or slozi.'. In the rheumatic form, or that due to cold, it is usually sudden, with chill and fever and a temperature of 103° or 104° F. (39.5° to 40° C), headache, and backache. The slow onset is characteristic of alcoholic neuritis, though it may be precipitated by some exciting cause, as cold, exposure, fatigue, or some toxic state. It is rarely febrile. In the initial stage sensory symptoms are numbness and tingling of the fingers and toes, palms of the hands and soles of the feet, and other parts of the lower arms and legs ; then hyperesthesia, tenderness, and pain, more marked in the legs, including cramps in the calves. These may in mild degree precede the onset as premonitory symptoms for weeks and for months, especially in the alcoholic form. The motor symptoms, seldom absent, soon follow the sensory phenomena previously mentioned. They include palsy or inco-ordination or both in upper and lower limbs, but with this characteristic — that the involvement of the limbs is symmetrical and the distal extremities, as the feet and hands are affected, the former more frequently. Motor symptoms may exist in the feet and sensory symptoms in the hands, the latter commonly preceding. The muscles commonly involved are those supplied by the peroneal nerve in the lower, and by the posterior interosseous branch of the musculospiral in the upper extremity. With weakness in the legs comes loss of knee-jerk and ankle-jerk, quite constant, but not invariable, depending, of course, on the involvement of the nerves forming these reflex arcs. The muscles above the knee are less frequently affected, and still less frequently those which move the hip-joint. The paralysis of the muscles innervated by the peroneal nerve gives rise to a peculiar and distinctive walk known as the steppage gait, and occasion- ally it is unilateral, when only one peroneal nerve is affected. It is the gait of polyneuritis in which the foot drops, and in order to raise it from the ground and thereby to " shorten " the limb, the thigh is drawn up unneces- sarily high and the knee is flexed excessively so that the gait resembles that of the " high-stepping " horse. The extremity of the foot strikes the ground first, followed by the heel, so that there is often a recognized interval of time between the two events. Closing of the eyes does not affect this gait. As contrasted with the diminished tendon reilexes, the reflex action from the skin may be increased, especially when there is hyperesthesia, even when there is considerable motor paralysis, the movement being caused by the muscles which escape involvement. In severe cases, on the other hand, when there is much loss of sensation and motion, the skin reflex is absent; exceptionally, it may be absent when sensation is perfect. Myotatic irrita- bility is almost always lost, although some rare cases are reported in which it was said to be present. Very characteristic is the tenderness qf the muscles themselves, devel- oped as they become weaker, and elicited by grasping them, the slightest pressure often causing the patient to cry out with pain. This is regarded as evidence, that all the nerves of the muscles are involved, the sensory as well as the motor. The nerve-trunks are also tender, although this tenderness is less marked than in simple neuritis, because the contrast with the hyper- esthesia of the surrounding skin is less conspicuous. MULTIPLE NEURITIS. 875 In the arms it is the extensors of the wrist and fingers which are first affected, and these symmetrically, illustrated by one of the best recognized toxic forms of neuritis, lead palsy. In the latter there is paralysis of the extensors, though the extensor of the metacarpal bone of the thumb and the supinator longus usually escape, although in some cases of lead palsy these muscles are affected. After the extensors, the flexors of the wrists and fingers are involved, then the interosseous muscles, and, finally, the thenar and hypothenar muscles are attacked, always to a less degree than the exten- sors. The muscles above the elbow suffer less. Occasionally the fibers of the pneumo gastric are involved, causing fre- quent pulse-rate and paralysis of the vocal cords, cardiac failure, and death. Still more rarely the diaphragm and muscles of the thorax and abdomen are involved. The facial and motor oculi nerves are possible seats. Neuritis confined to the cranial nerves has been described. The sphincters are also rarely affected. The muscles exhibit the reaction of degeneration, faradic irritability being lost, while galvanic irritability is increased, but not always altered in quality. In the nerves, irritability to both currents diminishes and ultimately disappears, although in the very first stage there may be increased galvanic irritability, as described under the reaction of degeneration. In severe cases total loss of excitability may occur at once because of a corresponding de- struction of muscular substance, instead of being preceded by an intermediate state of increased excitability. Wasting of the muscles is sooner or later inevitable, unless the dis- ease is of short duration, although it may be obscured by a temporary edema or a condition of fatty infiltration, in which the fat accumulates between the wasting fasciculi, keeping up for a time the bulk of the muscle. The less affected muscles are apt to undergo shortening and contracture because of maintaining so' long a fixed position, either from being given over to gravi- tation or as a result of an effort to relieve pain. This alteration occurs most frequently in the lower extremity, contributing to intensify the " foot-drop " at the ankle, and more rarely to produce flexure at the knee-joint and to a less degree even at the hip, both of the latter being the result of posture. The foot-drop may possibly be increased by the pressure of the bedclothes upon the foot. The sensory and motor phenomena are commonly associated pari passu, the latter extending from the hands and feet up the outside of the arm and leg. Very rarely either set of symptoms may occur alone. Tremor is a marked symptom in some alcoholic cases and may precede loss of power. Ataxic phenomena are usually associated with the sensory and motor symptoms. They are manifested by difficulty in balancing while standing, or by inability to execute finer movements with the fingers. Indeed these may be the first symptoms, and may lead when studied to the knowledge of some defect in extending the wrist and fingers, or in raising the toes, or foot, from the ground while walking. The ataxia is more marked in the lower extremi- ties, and is believed to depend chiefly upon the afferent nerve involvement, since these are supposed to have most to do with co-ordination. Involve- ment of the motor nerves may possibly also cause ataxia. Because of the associated absence of the knee-jerk, the term peripheral pseudotabes has been applied to the ataxic stage. The neuritis may in some cases not progress beycnd this stage. The symptoms may closely resemble those of tabes, but 8/6 DISEASES OF THE NERVOUS SYSTEM. the phenomena always fall short of those of true tabes. It may be said, too, of the ataxic form that the sensory disturbances are sometimes less severe than in other typical cases. Absence of the Argyll Robertson pupil and of vesical disturbance, rapid development of the disease, a history of the case suggesting a cause for neuritis, and, finally, recovery, are diagnostic points in favor of the ataxic form of neuritis. Trophic changes may occur in prolonged cases, including mainly glossy skin, arthritic adhesions, and thickening ; also vasomotor derangement, shown by edema, especially about the ankles and the dorsum of the foot ; also pallor of the fingers, and changes in the nails and hair. Mental symptoms are found more particularly in connection with the alcoholic form of neuritis. Besides irritability and general ill temper, more active symptoms are at times present. A childish jocularity in women, hysteria, and skillful duplicity in obtaining alcohol are characteristic. The phenomena may be those of delirium tremens or simple hallucination with extravagant ideas. Especially peculiar is the condition described by Wilks, in which there is a loss of appreciation of time and place, the patient describ- ing with minute detail impossible journeys recently taken and persons whom he imagines he has seen. Convulsions and optic neuritis are rarely present; if present, they are probably due to meningeal inflammation. A simple mild delirium ma}^ occur in toxemic cases from the actioii of the poisons on the brain-cells. Mental symptoms are not usually present in multiple neuritis from other causes. The number and variety of the symptoms vary greatly in different forms, being most widespread in those cases due to alcoholism, to cold, or to com- bined causes, and limited in the cases due to metallic poisons, as lead. The more acute the case, the more widespread are the symptoms. Complications. — These are the other diseases to which alcoholics are subject — cirrhotic and fatty livers, gastric catarrh, and diseased kidneys and their consequences. The chief one in the toxic form is gout the result of mineral poisons, almost exclusively of lead. Pulmonary tuberculosis is com- mon, and pneumonia, invading especially the middle portion of the lung, and sometimes bilateral, is a frequent cause of death. Diagnosis. — The diagnosis of alcoholic cases is usually easy from the history, although sometimes skillful deception, especially in women, deprives the physician of this assistance. The distinctive features of the disease are the symmetrical localization of the sensory and motor symptoms, first and mainly in the extremities, and the tenderness of the skin, nerve trunks and muscles. There are, however, great variations in different cases, even in those dependent on the same cause, some being very acute and general and even rapidly fatal, others slow and limited to groups of muscles ; some mainly motor, others sensory and ataxic (pseudotabes). The possible sources of confusion are rheumatism, acute and chronic; neuralgia, tabes dorsalis, poliomyelitis, acute and subacute ; pachymeningitis, damaging the nerve-roots, aaite ascending paralysis, and hysterical palsy. In rheumatism the tingling characteristic of neuritis is not present, and although the tenderness of a nerve passing in the neighborhood of a joint, especially apt to be aggravated in motion, may be mistaken for joint pain, careful examination will elicit its true nature. Neuritis differs from neu- ralgia in the bilateral symmetry of the pain, and in the persiitence of tender- ness and hyperesthesia as contrasted with the spontaneous pain of neuralgia. The ataxic form of the disease, especially the form called neurotabes MULTIPLE NEURITIS. 877 (peripheral pseudotabes), sometimes resembles tabes dorsalis very closely. In neurotabes the lesion consists only in the nerve degeneration, while the spinal cord is free, its claim to the title being the fact that the loss of motor power may be slight in neurotabes, as in most cases of true tabes. The diag- nosis from tabes may generally be easily made. The association of absolute paralysis or distinct weakness of extensors with inco-ordination would in- dicate neuritis. The " lightning pains " of tabes are seldom found in neu- ritis, nor are waist constriction nor pupillary symptoms, while the muscular tenderness is not found in tabes. Rapid onset of the disease and ultimate recovery occur in pseudotabes. The extreme hyperesthesia, so distinctive a symptom of neuritis, is less valuable in diagnosis, because it is often absent in the ataxic form. Girdle pains, paralysis of the sphincters of bladder and rectum, all point to cord involvement, even in alcoholic cases. Poliomyelitis — inflammation, acute or subacute, of the gray matter of the cord — resembles the rheumatic and toxemic forms of neuritis, which have, like it, a febrile onset, initial rheumatic pains, and muscular wasting with the reaction of degeneration. But, again, we contrast the symmetrical dis- tribution of the palsy of neuritis and its limitation to nerve distribution with the random distribution of poliomyelitis. Pain on pressure and subjective sensory disturbances are not prominent in poliomyelitis. In pachymeningitis which involves the nerve-roots, producing paralysis, wasting, and anesthesia, the legs do not suffer early in the disease, as a rule ; and while the upper parts of the arms and trunk may be anesthetic, there is no tenderness of the nerve trunks, unless these are also inflamed. Acute ascending paralysis (Landry's) resembles the most rapid form of multiple neuritis in some of its symptoms, but the paralysis usually ascends the trunk from the legs to the arms, and does not begin in the hands and feet at the same time, nor does it affect the trunk last, as in neuritis. There is, moreover, no anesthesia in typical ascending paralysis. There are, however, transitional cases between multiple neuritis and Landry's paralysis, and the term Landy's paralysis is somewhat in disfavor. Some assistance m diagnosis may be had from the etiological standpoint ; the history of metallic poisoning, of alcoholic excesses, or of exposure to infectious diseases, or the presence of diabetes being suggestive. Prognosis. — A very large number of cases of multiple neuritis get well, though slowly, especially if the cause be discovered and removed. Especially is this true of the alcoholic cases, although improvement does not always begin immediately on withdrawing the cause — indeed, the disease may even progress for a time, and improvement may not be observed for several months. Hence the prognosis should be guarded. The acute and wide- spread cases are the most dangerous to life, and in such the prognosis should always be guarded. The involvement of the muscles of respiration, includ- ing the diaphragm, is most to be feared. Pain in the tnmk muscles is a grave symptom if the motor power of the limbs has diminished much. Paralysis of the diaphragm may be insidious and unnoticed until that of the intercostals is added, when there may be accumulation of mucus, bronchitis, and death by suffocation. Involvement of the cardiac nerves is also serious, and is manifested by frequency of pulse. Superadded involvement of the spinal cord increases the danger. At best, months are required for recovery, and even years may be necessan'. Involvement of the spinal cord precludes total recovery. The return of faradic irritability in nerve and muscle is fav- orable. To sum up with Gowers : " The prognosis is better in the sensory 8/8 DISEASES OE THE NERVOUS SYSTEM. than in the motor form, better when the arm escapes than when all the limbs are involved, better in cases of chronic than acute onset, and better if a case of apparently acute onset is really such than if it succeeds slight symptoms of longer duration." Treatment. — The removal of the cause, if possible, is a primary step in treatment. Along with this, rest is most important, and the rest should be complete — in bed, and this should be enforced in the earlier stages ; later the pain and loss of motor power make rest obligatory. Care should be taken to avoid any pressure of the bed-clothes upon the feet, which might aid. in the contracture of the muscles in the position of foot-drop. There should be no compromise with alcohol, although in some cases of great debility, when the cardiac action is feeble, gradual withdrawal may be justifiable. The patient should, on the other hand, be fed on the most nutritious food. Local anodyne applications may be resorted to to relieve the pain, and may be varied according to effect. Dry heat, moist heat, applications of lead-water and laudanum, and ointments of aconite and veratrum are some of those which may be employed. Wrapping in cotton or wool is sometimes beneficial. Warm baths are soothing ; sometimes very hot ones give relief. Postures assumed because of the relief they give to pain should not be too long permitted lest deformity result by contraction and adhesion, difficult or impossible to overcome. Dropping of the feet should be prevented by splints or by support with sand-bags. The same is true of flexion at the knee and hip. As to drugs, they are of little use ; the salicylates, phenacetin, antifebrin, and antipyrin may be useful in mild cases, and should be tried in doses of from five to fifteen grains (0.3 to i gm.). They are more particularly use- ful in cases due to cold. Extreme pain may demand the cautious use of morphin hypodermically in doses of from 1-6 to 1-3 grain (o.oii to 0.022 gm.) combined with 1-150 grain (0.00044 gm.) of atropin, which modifies and improves the action of morphin most happily. For the mental symp- toms the hydrobromate of hyoscin in doses of from 1-200 to i-ioo grain (0.00033 to 0.00066 gm.) hypodermically, or hyoscin in doses of from 1-400 to 1-150 grain (0.00016 to 0.00044 gii^-) may be tried. Mercurials, so highly approved by Cowers in simple neuritis, are useless here. The iodids are sometimes beneficial in chronic cases and in cases due to lead absorption. Roborant medicines, such as iron and cod-liver oil, are indicated to build up the patient, who is generally broken down. Electricity and massage are very useful after convalescence has set in. Endemic Neuritis. Definition. — This term is applied to certain forms of multiple neuritis, supposed to be due to vegetable organisms, limited, or endemic to certain localities. Three separate varieties have been recognized, but others prob- ably exist. The three referred to are malarial neuritis, beri-beri, and leprous neuritis. I. Malarial Neuritis. — This corresponds in its clinical features to the simpler forms of multiple neuritis, and requires no detailed description. Its malarial nature is based on its prevalence in malarial districts and its curability by quinin. A\'hile it is believed to be caused by the plasmodium of MULTIPLE NEURITIS. 879 malaria, I am not aware that this organism has as yet been discovered in the blood of patients suffering from it ; the plasmodium, however, has been found in the central nervous system of persons who have manifested various symp- toms of nen/ous disease. 2. Beri-beri, the Kakke of Japan. — Beri-beri is a disease prevalent in Japan, the Eastern Archipelago, India, New Zealand, Ceylon, the South Pacific Islands, and the coast of Brazil. It is especially prevalent in the Dutch East Indies among soldiers and in prisons, and has been thoroughly investigated under the Xetherlands Government. In this countr}^ J. J. Put- man has described a similar disorder among New England fishermen who frequent the Grand Banks of Newfoundland, and Bondurant has observed it among sailors in the Gulf ports of Alabama. It is also not uncommon among Norwegian sailors. Seguin, of New York, has described cases origi- nating in the West Indies and coming to this country. Etiology. — Sheube and Baelz first determined its true nature, but our knowledge has been greatly increased of late by the studies of Pekelharing and Winkler.* It is believed to be due to a special organism, of which rods and cocci have been described, and of which cultures have been made. These, when inoculated, produced peripheral neuritis of the same distribu- tion as beri-beri. Repeated inoculations having, however, been required to produce the disease, it has been reasonably concluded that repeated exposures are necessary before infection results. It is transmissible from individual to individual. The disease is also acquired by residence in certain houses, and patients recover after removal to a district which is free, relapsing on return- ing. It has been thought that a nitrogenous and especially an exclusive fish diet predisposes to the disease, and, again, a rice diet. Roll "j" has shown that in all probability the disease is transmitted through drinking-water, since he traced two epidemics on board ship to this cause. In both cases the sailors were free so long as they had a supply of European water; but in one instance, after laying in fresh water at Batavia, and again in Alauritius, where the disease prevailed endemically, it appeared among the crew at the end of five wrecks. Symptoms. — There are several types of cases. Among the earliest symptoms is a change in the electrical excitability of the peroneal nerves and the flexors of the ankles, consisting in a slight degree of reaction of degenera- tion, quantitative and often qualitative, this even before there are any sub- jective symptoms. Sometimes, indeed, the disease goes no further. Gener- ally, however, the subjective symptoms begin as a sense of heaviness of the legs, a tendency to tire easily, perverted sensation, diminished tactile sense in the lozver part of the legs, and irritability of the heart. ■ In an acute per- nicious formi the nervous phenomena are less marked. There are fever, cmemia, and general anasarca. The edema is quite constant, beginning in the legs. The urine is scanty, but not otherwise altered, and contains no albumin. A critical increase in the quantity of urine indicates an improvement. In the second group the neuritic symptoms are more marked, there being numb- ness, anesthesia, loss of tendon reflexes, nnisciilar atrophy, and anasarca. In the third group, the atrophy and paralysis are most conspicuous, and the clinical picture is that of a rapidly progressing multiple neuritis with sen- sory and motor symptoms. The mortality varies from 3 to 60 and even to * Pekelharing and Winkler, " Centralblatt f. Xervenkrankheiten." iSoq, and " Deutsche med. Wochenschr.,'' 1888 No. 30. + " Norsk Magazin for Laegevidenskaben," November, 1895, and May; 1896. 88o DISEASES OF THE NERVOUS SYSTEM. 70 per cent. The diaphragm and larynx may become paralyzed, and the cardiac branches of the vagus involved, producing cardiac failure and death. Treatment. — The treatment calls for the removal of the cause by dis- infection or removal of the patient from the infected house or district and by the withdrawal of suspected food or drinking-water. The symptoms are treated as in other forms of neuritis. In conse- quence of the tendency to cardiac weakness heart tonics may be needed, such as digitalis, strychnin, strophanthus, and caffein. 3. Leprous Neuritis. — Similar to beri-beri is leprous neuritis, already considered as to its etiology, symptomatology, and treatment. (See Infectious Diseases.) It differs from beri-beri in being transmitted from parent to offspring and in its extreme slowness of development after ex- posure, as much as ten years intervening. It differs also from beri-beri in that the neuritis is not an essential part of the disease. The neuritis is a symptom of the so-called " anesthetic leprosy." Leprous neuritis differs, further, from the usual forms of multiple neuritis in not being perfectly sym- metrical and in being a perineuritis and an interstitial neuritis instead of parenchymatous. The bacillus is also found in the tissue, by its presence causing the inflammation, while in beri-beri the virus circulates in the blood. Hence the irregular distribution of the neuritis in tlie leprous form, resem- bling in this respect the more isolated neuritis of syphilis. Symptoms. — ^The special symptoms are muscular wasting and anes- thesia, more marked toward the extremities of the limbs, but not confined to them, being found elsewhere, as in the face, involving the fifth and seventh pairs of nerves. Sometimes tenderness and pain are present ; the latter is, however, not severe. There may be tingling, also anesthesia, and dimin- ished electrical excitability, with reaction of degeneration. The irregular areas of anesthesia are generally associated with irregular patches of pig- mentation and pallor. The diagnosis, prognosis, and treatment are the same as those of leprosy. NEURALGIA. Definition. — Strictly speaking, the term neuralgia should be restricted to such varieties of nerve pain as are unattended with structural changes in the nerve. Formerly, many cases now regarded as cases of neuritis were called neuralgias, and it is probable that, as our knowledge grows, other so-called neuralgias will be eHminated. Finally, the border-line existing between neuralgia and neuritis cannot be drawn sharply, but as far as pos- sible, the term neuralgia should be restricted to nerve pain without organic change. Etiology. — Neuralgia is a disease of adults. It rarely occurs before puberty, and is relatively rare in old age. It is more common in women than in men, although not so very rare in old men. Heredity is responsible for a tendency to neuralgia. It is frequent in so-called neurotic families. According to Anstie, fully one-fourth of all cases are the result of heredity. Neuralgia is prone to occur in the so-called " nervous " person — i. e., one who is excitable, anxious, and worrisome in disposition. In this category, too, come the hysterical neuralgias. The debilitated, anemic, and poorly fed are liable to it. So are they who are overworked and Avorried. The most frequent exciting cause is cold. Malaria is one of the most NEURALGIA. 88 1 common causes, producing, especially, hemicrania, while the malarial cachexia also predisposes to neuralgia. The pain of carious teeth is not re- garded as neuralgic, but when such pain causes irritation of the peripheral branches of the fifth nerve, a neuralgia may be produced in the distal dis- tribution. Symptoms. — Pain is, of course, the leading symptom. " Spontaneous pain," by which is meant pain independent of neuritis or irritation of the nerve, and the modifications to which it is subject in severity and distribution, constitute, in fact, the disease. This pain is irregularly paroxysmal, shoot- ing, darting, or burning in character, not usually increased by motion, and if not relieved by pressure, may be by gentle friction. The more the pain is increased by motion and the more there is pain over the nerve-trunks on pressure, the more is it a neuritis and the less a neuralgia. Yet we cannot literally adhere to this, as evidenced by the " tender points " of Valleix, which will be further referred to under the different varieties of neuralgia. Multiple dartings and shootings, separated by seconds or minutes of free- dom from pain, are characteristic. The absence of primary tenderness is also characteristic; but after the pain has continued for some time there often succeed tenderness of the skin and even a redness and swelling, the absence of any unnatural degree of which at the beginning is considered distinctive. These phenomena, includ- ing edematous swellings, are regarded as vasomotor in origin. Other vaso- motor symptoms are hyperidrosis, increased secretion of saliva and tears, and elevation of temperature. Trophic effects are seen in shedding of the hair and its rapid blanching, and other symptoms to be referred to. Muscu- lar twitchings are also not uncommon at the seat of the pain, and sometimes even muscular spasm. The duration of an attack of neuralgia varies from an hour or even less to many hours. Sooner or later, if not relieved, it subsides spontane- ously, though with a greater tendency to recur than when relieved by treatment. Varieties Depending upon Nerves Involved. Neuralgias are variously named in accordance with the nerves affected, whence we have the following varieties : I. Trifacial Neuralgia (Neuralgia of the Fifth Pair; Tic douloureux ; Prosopalgia). — This form involves one or more of the branches of the fifth pair, rarely all. It is more common than all other varieties of neuralgia com- bined. Here, doubtless, we have sometimes to do wdth a neuritis not always easily separable. One or more numerous tender points are usually demon- strable, of which those at the supra-orbital and infra-orbital foramen are the most conspicuous. Of the branches of the fifth, the ophthalmic, or the first division, is that most frequently affected, giving rise to the well-known supra-orbital neu- ralgia. The pain radiates from the " tender point " at the supra-orbital notch over the anterior half of the head sometimes to the eye itself, the eye- lid, and half of the nose. There may be injection of the eye and suffusion. There is sometimes pain in the occipital protuberance and cervical spines. This supra-orbital form must most frequently be distinguished from catarrh of the frontal sinuses, but the latter is more likely to be symmetrical, and while the pain is severe, it is duller, less shooting, and is accompanied by 56 882 DISEASES OF THE NERVOUS SYSTEM. coryza; it terminates suddenly with a free discharge of purulent matter, sometimes offensive. When the distribution of the infra-orbital, or second branch is involved, the pain occupies the area between the orbit and the mouth, over the cheek to the ala of the nose. The " tender points " are at the emergence of the nerve below the orbit, at the side of the nose, over the most prominent part of the malar bone, and along the gingival line in the upper jaw, rarely in the upper lip. When there is involvement of the third, or inferior maxillary, division, less common as an isolated form, — except as to its inferior dental branch, — there is a much more extensive area of pain, including the parietal eminence, the temple, the ear, the lower jaw, and the tongue. The " tender point " is in front of the ear where the auriculotemporal crosses the zygomatic arch, where there is often burning pain. The movements of mastication and speaking may be painful, and there may be salivation. A herpetic eruption about the eyes or lips is occasionally present and is then distinctive. Atrophy and induration of the skin have been included in the symptoms, but these are ascribable only to a neuritis. There is a pure ocular neuralgia involving the eyeball only. It may or may not be due to errors of refraction. Of these, hypermetropia, or far- sightedness, is the most common cause. Either one or both eyes may be affected. It may be accompanied by dimness of vision. A form of trigeminal neuralgia, called by Trousseau " epileptiform," consists in sudden, severe, and frequent attacks of pain, lasting from a few seconds to a few minutes, many times repeated during the .day. 2. Cervico-occipital Neuralgia. — This affects the area of the neck sup- plied by the posterior branches of the first four cervical nerves, and the pos- terior part of the head supplied by the great occipital branch of the posterior division of the second cervical nerve, at the exit of which there is a tender point about half way between the mastoid process and the first cervical ver- tebra. Two other tender points are just above the parietal eminence, and between the sternomastoid and trapezius muscles. The pain may extend over the greater part of the neck and head, as far forward as the parietal eminence and the ear. Exposure to cold or a draft of air is the most common cause of this form. Nephritis has been believed to be a cause. 3. Cervico-brachial and Brachial Neuralgia. — This involves the area supplied by the four lower cervical and the first thoracic nerves, the area of sensory distribution of the brachial plexus. The tender points are the axillary, the circumflex at the posterior part of the deltoid, the superior ulnar behind the elbow, and the inferior ulnar in front of the wrist. This form is often confounded with neuritis due to rheu- matic affections of the joints or injury. 4. Neuralgia of the Phrenic Nerve. — This is rare, the pain in its area during pleurisy and pericarditis being rather a neuritis. The pain is at the lower part of the thorax, at the attachment of the diaphragm. Breathing is shallow, because pain is caused by the breathing movements. Coughing and even deglutition cause pain. 5. Trunk Neuralgia. — This naturally divides itself into two subvarie- ties: dorso-intercostal and lumbo-abdominal. (a) Dorso-intercostal neuralgia covers the area supplied by the inter- costal nerves from the third to the ninth, and is characterized by pain along NEURALGIA. 883 the intercostal spaces or in parts of them. It is sometimes bilateral. There is usually a constant dull pain with or without acute stabbing exacerbations, or the latter may be excited by deep breathing or motion. There may be special tenderness at the points of emergence of the three branches of the intercostal nen,'e — viz., near the vertebrae, anteriorly near the median line, and midway between these two points in the midaxillary line. The term pleurodynia has been used with a good deal of vagueness. Strictly speaking, it should be limited, as it is by Gowers, to neuralgia of the pleural nerves. Consistently with this it should not be applied to pain local- ized in the course or point of exit of an intercostal nerve. It is very acute in character and excited by expansion of the thorax rather than by lateral movements of the trunk. The pain of herpes zoster is not a neuralgia, but a neuritis. Another variety in this locality is the inframammary neuralgia of anemic women. (b) Lumho-ahdominal neuralgia involves the posterior branches of the lumbar nerves, especially the ilioscrotal branch. The area of the pain is the region of the iliac crest, along the inguinal canal and the spermatic cord in the scrotum, or round ligament in the labium majus. The pain is often bilateral, sometimes resembling the constricting girdle pains of spinal cord disease, from which it differs, however, by its changing place. It is espe- cially frequent in connection with diseases of the pelvic organs, particularly in women. The testes and penis are the seat of neuralgic pains. 6. Neuralgia of the spinal column is the more modern term for the " spinal tenderness " of the older authors. It is common in feeble and hys- terical women, and a sequel of the modern railway accident under the name of " spinal congestion." The pain in most cases is felt along a considerable vertical extent of the spine, but is more intense in certain spots. The thoracic region is the most common seat, next the lower cervical, and least frequently the lumbar region. 7. Sacral neuralgia and coccygodynia are defined by their names. These affections reside in the nerves between the bone and the skin, and are often exceedingly difficult to cure. The pain really may be due to organic lesions in the part. 8. Neuralgia of the feet includes painful heel, plantar neuralgia, and erythromelalgia. In the latter, first described by Weir Mitchell, vascular changes, including either acute hyperemia or cyanosis, — probably of vaso- motor origin, — are associated with severe pain in the heel or sole of the foot. It is probably a neuritis in some cases. 9. Visceral neuralgia means neuralgia affecting the gastro-intestinal tract, the kidneys, ovaries, and other pelvic organs. Idiopathic nephralgia, or neuralgia of the kidney, I regard as a rare event. It and testicular neu- ralgia are more frequently secondarv- to inflammation of adjacent urinary passages, but idiopathic testicular neuralgia is less rare than nephralgia. Neuralgias are further classified according to character and cause. Thus, in addition to the epileptiform variety alluded to. there are reflex or symptomatic neuralgias, traumatic neuralgias, herpetic neuralgias accom- panying herpes, hysterical, rheumatic^, gouty, diabetic, anemic, malarial, syph- ilitic, and degenerative neuralgias. i\Iany of these terms are loosely applied. The term rheumatic neuralgia is often erroneously applied to muscular rheu- matism. It should not be used. Very interesting and important is the subject of reflex neuralgias and 884 DISEASES OF THE NERVOUS SYSTEM. referred pains which have been especially studied by the late Dr. Anstie in England and Charles L. Dana in this country. Reflex neuralgias are due to disease in organs distant from the actual seat of the neuralgia. The fifth nerve is a favorite seat of such neuralgias. Thus, an iritation of the distri- bution of one branch of this nerve by a carious tooth may excite a neuralgia in another distribution of the same nerve. Illustrations of referred pain are the " pain in the back " or spinal pain in ulcer of the stomach, the left scapular pain in diseases of the liver, the sacral pain in uterine disease, and the testicular pain in renal colic. Diagnosis. — Neuralgia is chiefly to be distinguished from neuritis and the effects of pressure on nerves; and also rheumatism. From neuritis it is separated by its unilateral distribution as contrasted with the more frequent symmetrical distribution of neuritis, although neuritis is not infrequently unilateral ; also by its numerous remissions and intermissions, and the shift- ing of the pain from one spot to another. The fixed neuralgias are more difficult of separation from neuritis, especially mild cases. The severe forms of neuritis are soon recognized by the anesthesia which succeeds upon the hyperesthesia in the case of sensory nerves, and muscular wasting with changes in the electrical irritability in mixed nerves. In the case of com- pression of nerves the pain is continuous, while the symptoms and conse- quences of neuritis will, sooner or later, show themselves. Nevertheless, doubt and error must not infrequently occur. Muscular rheumatism differs in its localization in muscles or groups of muscles such as the lumbar or shoulder muscles, its continuousness and pain increased by motion. Prognosis. — The prognosis in neuralgia is usually ultimately favorable, although some forms and cases are very stubborn. Especially true is this of neuralgia of the fifth pair. The more frequent the recurrence and the wider the distribution, the more difficult is the cure. On the other hand, the severity of the pain is not, in my experience, a measure of obstinacy to cure, some of the severest cases being easiest relieved. Hereditary cases are the most obstinate. The same is true of cases occurring in the decline of life. Epileptiform neuralgia is said to be incurable. Treatment. — The treatment of neuralgia is divided into that of the condition predisposing to it and of the paroxysm. The anemias, — especially chlorosis, — malaria, and other predisposing causes should be corrected by quinin, iron, and arsenic. Good nourishing food is important. Change of scene and residence is often necessary. Reflex causes should be carefully sought for and removed. Until 4hese predisposing causes are removed, the treatment of the paroxysm affords but temporary relief. For the paroxysm quinin is by far the most efficient remedy, and will cure many cases. Two or three grains (0.12 to 0.194 gm.) should be given hourly until the paroxysm is relieved or decided cinchonism is produced. The salicylate of cinchonidia is a valuable preparation. Some cases are relieved by phenacetin or antifebrin (acetanilid) in from ten to fifteen- grain (0.66 to I gm.) doses. A combination of phenacetin and caffein, three grains (0.33 gm.) of the former and one (o.ii gm.) of the latter each, in hourly doses, is often efficient. Some cases can only be relieved by sulphate of morphin. The hypodermic injection is the promptest and surest remedy, in doses of from 1-8 to 1-4 grain (0.008 to 0.016 gm.), but morphin is a drug to be avoided in neuralgia, if possible, as the danger of acquiring the mor- phin habit is extremely great. The patient should never be allowed to use NEURALGIA. 885 the hypodermic syringe himself. The use of anodynes is sometimes more than palliative, the repeated removal of the pain tending to prevent its recur- lence. The combination of atropin with morphin undoubtedly modifies the unpleasant effect of the latter drug and increases its efficiency. Belladonna, and its active principle, atropin, are remedies vv^hich have long enjoyed reputation in the treatment of neuralgia, when uncombined with other drugs, but in my hands they have been feeble remedies. The doses recommended are from 1-6 to 1-2 grain (o.oii to 0.03 gm.) of the extract and from 1-120 to 1-60 grain (0.0005 to o.ooii gm.) of atropin. Aconite and gelsemium have also some reputation, especially in neuralgia of the fifth nerve. Gelsemium may be given in doses of fifteen minims (0.92 c. c.) of the tincture, frequently repeated. Gelsemia may be given hypoder- mically in doses of from 1-60 to 1-30 grain (o.ooii to 0.0022 gm.), and aconitin in doses of from 1-250 to i-ioo grain (0.00027 to 0.00066 gm.), but the latter is a remedy so dangerous that I rarely employ it. Cannabis indica is also sometimes useful in doses of 1-4 grain (0.016 gm.) three times a day, but the drug varies so much in strength that it cannot be relied upon. Local applications are sometimes very useful. Pressure relieves many mild cases, especially when associated with gentle friction. Local anes- thetics, such as menthol, the ointments of veratria and aconitia, are similarly useful ; so is the tincture of aconite painted over the involved area. The local use of opiates, at least without first removing the epidermis, and of atropin (5 per cent, strength), is, however, commended. The extract of belladonna, diluted with glycerin so as to admit its being smeared on, is sometimes useful. Frequent renewals of all these local applications should be made in the course of the day. Counterirritation by blisters or sinapisms, by chloroform either pure or variously diluted, and by camphor may be used. The last two may be applied on lint and covered with oiled silk. Both will blister if left on too long. Cocain might be reasonably expected to be useful, but to act through the skin the ointments and solutions containing it should be strong — from 10 to 15 per cent. For mucous surfaces this strength should be used with caution. A cocain habit is as easily established as morphinism, and is about as unpleasant in its results. The hypodermic injection of cocain is much more efficient. The usual dose is 1-4 grain (0.016 gm.), but smaller doses may be commenced with. The Paquelin cautery is often a prompt and effi- cient agent. Acupuncture and aquapuncture are employed, the latter consisting of injecting water under the skin. For their local effect, also, chloroform, car- hoik acid, and osmic acid have been injected hypodcrmicaUy. From fifteen to twenty minims (0.92 c. c. to 1.23 c. c.) of the first may be used, from five to ten minims (0.31 c. c. to 0.62 c. c.) of the second, and one or two drops of a I per cent solution of osmic acid in water and glycerin. Chloroform should be cautiously used in this manner, as it may occasion ugly sloughing. It is more especially in sciatica that these measures have been employed. Local applications of heat and cold have been found useful — cold by freezing or by the ether spray ; heat by the hot-water bag, or in the case of a supra- . orbital neuralgia, by the nasal douche. Heat is usually more efficient than cold; indeed, the latter sometimes aggravates neuralgia. Electricity is of uncertain value in neuralgia, but is sometimes very use- ful. The constant current is the form most frequently used, but faradism may also be employed. It is used in two ways : a strong current is applied at 886 DISEASES OF THE NERVOUS SYSTEM. once with a view to removing the neuralgia promptly (this is scarcely to be recommended) ; in the second method a sedative effect is sought by a weak current, preferably of galvanism, just sufficient to produce a tingling or burning sensation. Experience goes to show that the direction of the cur- rent may be ignored, but it is commonly recommended to apply the positive pole to the painful part, the sponge being well wet with warm water, and if faradism is used, it should be with rapid interruptions. The surgical treatment of neuralgia has been followed by brilliant results, and has met signal failures. The most common procedure is divi- sion of a nerve, or, better, the exsection of a portion of the nerve. It has been most frequently done in the case of the fifth nerve, and is almost always followed by temporary relief, but, sooner or later, an operation on the Gas- serian ganglion usually becomes necessary. Operation is to be recom- mended in intractable cases, and should be done at a point as near the origin of the nerve as possible, as second operations are not infrequently necessary on account of the recurrence of the pain. Nerve stretching is also performed with a measure of relief less thor- ough than exsection, but in view of the fact that its disadvantages are less lasting, it is the better operation to do first in the case of certain nerves. It IS important to remember that relief does not always immediately follow the operation. The sciatic is the nerve most frequently stretched, but the inter- costals and branches of the fifth, including the lingual, have been similarly treated with satisfactory results. The removal of the Gasserian ganglion affords relief in tic douloureux, but is a serious operation. TUMORS OF NERVES. Definitions and Morbid Anatomy. — Strictly speaking, the term neuroma should be restricted to tumors composed purely of nervous tissue, which are to be distinguished from flhroiis tumors or fibromata, often seated on nerves and known as false neuromata. Some, however, dispute the existence of true neuromata, and they are certainly very uncommon. Another form of false neuroma is a variety of the small, subcutaneous, pain- ful tumor — tubercula dolorosa — occurring in nerves of the skin in the neighborhood of the joints on the face, and on the breast. Myxomata, sarcomata, and even carcinomata are found in connection with nerves. The latter are commonly the result of extension by contiguity, infiltrating the connective tissue between the fibers. The nervous tissue represented in the true neuroma is usually fibrous, but very rarely ganglionic nerve- cells are found, and in such event the tumor may be regarded either as dislo- cated nerve tissue or as a glioma the cells of which closely resemble true nerve-cells. The nervous tissue may be of the medullated or non-medullated variety — i e., myelinic or non-myelinic. Connective tissue varying in quan- tity is associated with both, producing various degrees of hardness, which is most striking in the multiple fibroneuroma. An interesting variety is the plexiform neuroma, nodular and tortuous in appearance to the naked eye, tha internal structure of which is composed also of interlacing nodular and tortuous nervous cords made up of con- nective tissue and nerve-fibers. It is most frequently found in connection with the fifth pair of nerves in the orbit, on the upper eyelid, or on the TUMORS OF NERVES. 887 temporal bone, but is seen also in connection with any of the spinal and even sympathetic nerves. It grows slowly, and probably begins in fetal life. True neuromata are usually small, but may be three or four inches (7.5 to 10 cm.) in diameter and even larger. They are usually found seated in nerve-trunks, or at their ends, are often multiple, and their number is sometimes large. Etiology. — Nerve tumors which are not congenital may be traumatic. More than one member of a family has been found affected. Their growth seems stimulated by perversion in the healing process, since they are found on the ends of nerves in cicatrices after amputation. Symptoms. — Neuromata may be totally without symptoms. At other times they are very painful, the pain being aggravated by pressure. There may be nu-mbness and formication and even loss of sensation on the one hand, muscular ttvitching and paralysis on the other, the latter especially when the tumor is in the course of the nerve. Neuromata of the cauda equina may cause paraplegia. Reflex spasm in adjacent or distant muscles, and even epileptiform convulsions, are occa- sionally present. A neuroma may give rise to visible swelling, or it may be beneath the surface out of sight and touch. Diagnosis. — Except in the case of plexiform neuroma, which has a characteristic form described, the exact diagnosis of the variety of nerve tumor can for the most part be made only by microscopic examination after removal, since all the symptoms occasioned by true neuroma may be caused by pressure on nerves by any form of morbid growth. Multiple neuromata are usually false neuromata. Prognosis. — Nerve tumors rarely cause death, though they sometimes undergo malignant change, and in this way cause a fatal termination. The extreme pain which is so characteristic may in time exhaust a patient, but the course of the disease is always prolonged. Treatment. — Excision is the proper treatment for neuromata and all other forms of tumors connected with nerves, if they can be reached, and if the symptoms demand active treatment. Often such treatment is not de- manded. If syphilitic origin be suspected, syphilitic treatment should be adopted. In operations involving section of a nerve trunk the possibility of loss of function is to be remembered. Local anodyne applications may be used to palliate in mild cases, but they are useless in severe ones. Cocain in doses of from 1-6 to 1-2 grain (o.oii to 0.033 grn-) "^3-y be injected hypodermically, but morphin should not be used, as the conditions are especially favorable to the production of morphinism. 888 DISEASES OF THE NERVOUS SYSTEM. AFFECTIONS OF THE SPINAL CORD. Anatomical. — The spinal cord, covered by its membranes, the dura and pia arachnoid, hangs loosely in the spinal canal from the atlas to the second lumbar vertebra. It is, therefore, much shorter than the spinal canal itself. The remainder of the canal is occupied by the cauda equina. Each pair of spinal nerve-roots arises above the foramen of exit, and descends to the latter within the canal. The part of the cord whence each pair arises is known as the segment of that particular pair of nerves. The following from Deaver's " Surgical Anatomy " locates with sufficient accuracy the origin of these nerves : " The eight cervical nerves arise above the sixth cervical spine, the upper six thoracic nerves between the sixth cervical and fourth thoracic spines, the lower six thoracic nerves between the fourth and eleventh thoracic spines, the five lumbar nerves between the eleventh and twelfth thoracic spines, and the five sacral nerves between the last thoracic and first lumbar spines." See Fig. 93. In transverse section the cord is easily seen by the naked eye to be made up of central gray matter and external white substance. The former is composed largely of cells, the latter of fibers. The gray matter, roughly comparable to two crescents placed back to back, reaches the surface only b}' its posterior horns at the two points, whence enter the posterior roots of the spinal nerves. The broad, blunt anterior cornua do not reach the surface,, but the white fibers , of the anterior roots are seen perforating the white matter to enter the gray. The cord is separated into halves by the anterior median fissure, and by the posterior median septum, which is not a fissure. At the bottom of the anterior median fissure is the transverse commis- sure of white matter, in front of the central spinal canal. A short distance to the outside of the posterior median septum is another less distinct sep- tum, the posterior intermediate septum, which bounds the posterior median column or column of Goll, which does not extend as a distinct column below the cervical and thoracic portions of the cord. Outside of this, bounded by the posterior horn, is the posterior external column, or column of Burdach, limited in like manner to the cervical and thoracic parts of the cord. The antero-lateral column is divided artificially by a line coinciding with the outermost of the anterior nerve roots, and thus is made an anterior and lateral column, which, with the posterior column, makes three columns for each half cord. The white matter is composed of the usual medullated nerve- fibers unprovided with neurilemma and of neuroglia supporting the nerve fibers. The further divisions of the cord in transverse section are clearly indicated in Fig. 95, representing a transverse section of the cord in the cervical region, with description. Of these parts, the anterior (or direct) pyramidal tract, the lateral (or crossed) pyramidal tract (adjacent to the posterior cornua), and anterior cornua may be characterized, generally speaking, as motor, while the pos- terior columns, the direct cerebellar tract, the antero-lateral ascending tract of Gowers, part of the antero-lateral ground bundles, and the posterior cornua, may be described as sensory. The white matter gradually diminishes as the cord is descended. The gray matter also varies in extent and shape at different levels, which, will be appreciated by the examination of Fig. 94, which explains itself. It should AFFECTIGXS OF THE SPIXAL CORD. 8S9 F^g- 93- — Diagram from an Ori- iginal Investigation by "W. R. GoAvers, Showing Relation of Vertebral Spines to their Bodies and to the Xerve-roots. Only in the lumbar region are the ends of the vertebral spines opposite the middle of their bodies. They correspond to the lower edge of their bodies in the cervical and at the last two dorsal; and to the upper part of the body below them in the rest of the dorsal region. (See also text.) Fig. 94- — Diagram Showing Re- lative Size and Shape of the Cord and Gray matter at Dif- ferent Levels— ( o.fterGo'wei-s). 890 DISEASES OE THE NERVOUS SVSTEAL be added that certain tracts recently described, and at present chiefly of interest to the anatomist, are not included in this diagram. Mention should be made of Clarke's column, a group of nerve-cells in the inner part of the neck of the posterior horn, from the upper dorsal to the second lumbar, also known as the lateral fascicular column. Above this, in the upper dorsal and lower cervical regions, a group of cells projects outward from the gray matter into the lateral column, called by Lockhart Clarke the intennedio- lateral process, but well named also the lateral horn. The lateral or crossed pyramidal tracts, representing about three-fourths of the motor fibers, pass- ing down from the cortex decussate at the lower part of the anterior pyramids, and pass over into the lateral columns. The remaining fibers, which do not decussate, pass down the same side of the cord in the inner part of the antero-lateral column, constituting the anterior or direct pyramidal tract, also known as Tiirck's column. At every level of the spinal cord axis- Fig. 95- — Section of Spinal Cord in the Cervical Region — [after Cowers). c. Anterior commissure, p. c. Posterior commissure, i. g. s. Intermediary gray- substance, the gray matter between the two horn. p. cor. Posterior cornu. c. c. p. Caput cornu posterioris. l. l. l. Lateral limiting layer, a. l. a. t. Antero- lateral ascending tract of Gowers, which extends along the periphery of the cord. cylinders leave the crossed pyramidal tract to enter the anterior horns and end about the cell bodies of the lower motor neurons. This tract extends down to the end of the cord, but becomes smaller and smaller. The fibers of the direct anterior or pyramidal tract possibly cross at different levels in the anterior white commissure, to end about the nerve-cells in the anterior horn on the opposite side of the cord. If primarily small, this tract may not extend beyond the middle of the cervical enlargement. If originally large, it may be traced as far as the lumbar enlargement, or even into the sacral part of the cord. Throughout the greater part of the cervical and dorsal regions the lateral pyramidal tract is separated from the surface by a narrow layer of fibers, the direct cerebellar tract, which in the upper cervical region lies further forward, so that the pyramidal tract comes up to the surface close to the posterior horn. AFFECTIONS OF THE SPINAL CORD. 891 The axis-cylinder processes forming the anterior roots of the spinal nerves start from the nerve-cells in the segments where these roots arise, and pass out as a part of the anterior roots to be distributed to the muscles they supply. The relation of the axis-cylinders of the posterior roots after they enter the cord is not, however, so simple. It has already been said (p. 841) that ^■"'"- ■P^''4-iiVu' Med. oblong Muscle Fig. 96.— Sensory and Motor Paths in the Spinal Cord— {a/Ur Barker). the single process which leaves the cell'in the ganglion on the posterior roots of the spinal nerves divides in a T-shaped manner, one limb traversing the spinal nerve to the periphery of the body, the other passing toward the spinal cord as an axis-cylinder. After entering the cord each axis-cylinder process 892 DISEASES OF THE NERVOUS SYSTEM. again divides into an ascending and a descending limb, which run in the pos- terior cohnnns. The descending branch runs a short distance and ends in the gray matter of the same side of the cord. The ascending branch may end in the gray matter soon after entering it or may run upward in the posterior cokimns to the medulla oblongata, ending probably in the nuclei situated in the posterior columns of the medulla oblongata (nucleus gracilis and nucleus cuneatus), remaining up to this point on the same side of the middle line. From the nuclei of the posterior columns of the medulla oblongata the axis- cylinder processes, after crossing, run toward the brain, form the fillet, into which possibly enter also the ascending fibers of the lateral column contain- ing the crossed fibers of the upper sensory neurons. The exact termina- tion of sensory processes in the cerebral hemispheres is not known. The position of the tract in the crus is posterior. The lower sensory neurons also have endings in the cells or about the cells in Clarke's column, from which cells the axis-cylinders run in the direct cerebellar tract of the same side ; also about cells the axis-cylinder processes of which run but a short distance in the cord to end in the gray matter on a different level. Thus the possible paths of sensory conduction, probably many, are not definitely determined, whence disturbances of sensation do not give us so much help in topical diagnosis as those of motion. It may, however, be said in sum- mary that cutaneous sensory impulses in man are conducted toward the brain chiefly on the opposite side of the cord. The crossing of sensory impulses takes place partly in the central gray matter soon after the path enters the cord, and partly after the fibers leave the higher nuclei in the posterior columns of the medulla oblongata. The muscular sense " or sense of posi- tion " is probably conducted on the same side of the cord in the posterior columns, to cross in the medulla oblongata, and we have some evidence that the tactile fibers ascend in the posterior columns. Thermal and pain impulses probably cross to the antero-lateral columns of the other side very soon after entering the cord. Spinal Cord Localization. — It has already been said that the areas of distribution of spinal nerves, sensory and motor, are not sharply defined for each nerve as it emanates from the spinal cord, and that the regions thus sup- plied overlap. At the same time physiologists and clinicians have been able to map out with approximate accuracy the motor and sensory areas corre- sponding to the distribution of each pair of nerves emanating from different segments of the cord. Among those who have especially devoted themselves to this subject are M. Allen Starr, Charles K. Mills, and Charles L. Dana in America, and William Thorburn and Henry Head in England. The results of various observers differ in detail, but agree in essentials. The appended table is that originally devised by Starr, further modified by C. L. Dana and C. K. Mills. It must not be forgotten that these areas of distribution correspond to a nerve constituted as it is when it emanates from a corresponding segment of the cord, and not to a nerve as it is constituted immediately before it begins to spread. AFFECTIONS OF THE SPINAL CORD. 893 LOCALIZATION OF THE FUNCTIONS OF SPINAL CORD. THE SEGMENTS OF THE Segment. Muscles. Reflex and Centers. Sensation. IC. S.ectus lateralis, tiectus capitis. Anticus and posticus, sterno-hyoid. Sterno-thyroid; II and III Sterno-mastoid. Hypochondriiim {?'). Sud- Back of head to vertex and C. Trapezius. den inspiration produced neck. (Occipitalis major, Scaleni and neck. by sudden pressure be- occipitalis minor, auricu- 3mo-hyoid. neath the lower border of laris magnus, superficialis Diaphragm. ribs. colli, and supraclavicular.) IV c. Diaphragm. Pupillary C4th cervical to Neck. Deltoid. 2d dorsal). Dilatation of Shoulder, anterior surface. Biceps. the pupil produced by ir- Outer arm. (Supraclavicu- Coraco-brachialis. ritation of neck. lar, circumflex, external Supinator longus. musculo-cutaneous, cuta- Rhomboid. neous.) Supra- and infra-spinatus. vc. Deltoid. Scapular (5th cervical to Back of shoulder and arm. Biceps. ist dorsal). Irritation of Outer side of arm and fore- Coraco-brachialis. skin over the scapular arm to the wrist. (Su- Brachialis anticus. produces contraction of praclavicular, circumflex. Supinator longus. scapular muscles. external cutaneous, inter- Supinator brevis. Supi7iator longus. Tapping nal cutaneous, posterior Deep muscles of shoulder- the tendon of the supina- spinal branches.) blade. tor longus produces flexion Rhomboid. of forearm. Teres minor. Pectoralis (clavicular part) Serratus magnus. VIC. Deltoid. Triceps (5th to 6th cervical). Outer side and front of fore- Biceps. Tapping elbo-w tendon arm. Brachialis anticus. produces extension of Back of hand, radial dis- Subscapular. forearm. tribution. Pectoralis (clavicular Posterior ivrist (6th to 8th (Chiefly external cuta- part). cervical). Tapping ten- neous, internal cutaneous, Serratus magnus. dons causes extension of radial.) Triceps. hand. Pronators. Rhomboid. Latissimus dorsi. VII c. Triceps (long head). Anterior wrist (7th to 8th Radial distribution in the Extensors of wrist and cervical). Tapping an- hand. fingers. terior tendons causes Median distribution in the Pronators of wrist. flexion of wrist. palm, thumb, index, and Flexors of wrist. Palmar (7th cervical to ist one-half middle finger. Subscapular. dorsal)^ Stroking palm (External cutaneous, in- Pectoralis (costal part). causes closure of fingers. ternal cutaneous, radial, Serratus magnus. median, posterior, spinal Latissimus dorsi. branches.) Teres major. Till C. Triceps (long head). Ulnar area of hand, back. Flexors of wrist and fin- and palm, inner border of gers. forearm. (Internal cuta- Intrinsic hand muscles. neous, ulnar.) I D. Extensors of thumb. Chiefly inner side of fore- Intrinsic hand muscles. arm and arm to near the Thenar and hypothenar axilla. muscles. (Chiefly internal cuta- ueous and nerve of Wris- berg or lesser internal cu- taneous.) II D. Inner side of arm near and in axilla. (Inter costo- humeral.) II to XII Muscles of back and ab- Epigastric C4th to 7th dor- Skin of chest and abdomen. D. domen. sal). Tickling mammary in bands running around Erectores spins. region f causes retraction and downward, corre- of the epigastrium. sponding to spinal nerves. Abdominal (7th to nth dor- Upper gluteal region. (In- sal). Stroking side _ of tercostals and dorsal pos- abdomen causes retraction terior nerves.) of belly. Vasomotor centers. Second dorsal to 2d lumbar. 894 DISEASES OF THE NERVOUS SYSTEM. LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF THE SPINAL CORD— {ConitMued). Segment. I L. II L. Ill L. IV L. V L. I and II S. Ill to V S Muscles. None. Vastus internus. adductors of Sartorius ; thigh. Flexors of thigh. Extensors of knee. Abductors of thigh. Outward rotators. Flexors of knee. Flexors of ankle. Peronei. Extensors of toes. Calf muscles. Glutei. Peronei. Extensors of ankle. Small muscles of foot. Perineal. Muscles of bladder, rec- tum, and external geni- tals. Reflex and Centers. Cremasteric (ist to 3d lum- bar). Stroking inner thigh causes retraction of scrotum. Patellar, .Striking patellar tendon causes extension of leg. Gluteal (4th to 5th lumbar). Stroking buttock causes dimpling in fold of but- tock. Achilles iettdon. Over-ex tension causes rapid flex- ion of ankle, called ankle clonus. Plantar (5th lumbar to 2d sacral). Tickling sole of foot causes flexion of "toes and retraction of leg. Genital center. Vesical centre. Anal centre. Sensation. Skin over groin and front of scrotum. (Ilio-hypo- gastric, ilio-inguinal.) Outer side and upper front of thigh. Lumbar region. (Genito-cr ur a 1 , external cutaneous.) Front and outer side of thigh. Inner side of leg and foot. Inner side of thigh, leg, and '^oot. (Internal cutaneous, long saphenous, obtura- tor.) Back of thigh and outer side of leg and ankle ; sole ; dorsum of foot. (External popliteal, ex- ternal saphenous, muscu- lo-cutaneous, plantar.) Back of buttock and thigh, side of leg and ankle ; sole ; dorsum of foot. Circum-anal region, anus> rectum, penis, urethra, vagina, perineum. (Small sciatic, pudic, inferior hemorrhoidal, in- ferior pudendal.) The preceding table includes only the distribution of spinal nerves. The following table includes the distribution of nerves starting from the nuclei in the pons and medulla oblongata, so far as these are concerned with motion : Nuclei. Muscles. {. Sphincter iris. Ciliary muscles. Ill Cranial. \ Levator palpebrae superioris. Rectus internus in convergence. IV VI V VII XII IX X XI Superior rectus. Inferior rectus. Obliquus inferioris. Obliquus superioris. (Upper facial group .^ Rectus externus. Rectus internus of opposite side in lateral movements. Associate(J movement of levator palpebrae. Muscles of the lower jaw. Facial muscles. Lower facial group. Muscles of tongue. Muscles of pharynx. Muscles of esophagus. Muscles of larynx. The study of the sensory areas is facilitated by the use of diagrams in which the areas are mapped out and indicated by color or a shading which will permit one to separate them easily one from another, like those annexed, in which, too, the areas corresponding to each spinal segment are indicated by suitable lettering. Interpreting by the data contained in tables and diagrams such motor AFFECTIONS OF THE SPINAL CORD. 895 or sensory derangements as may be present, one may deduce with more or less accuracy the seat of the lesions in the cord producing them. It has been mentioned that motor localization, being more definite, its arrangement permits more exact inference than sensory derangements. The union of both adds further facility. Results vary also according as a lesion involves only one half or a complete section of the cord. Recalling the distribution of the two tracts, as given on page 890, it is evident that an injury involving the entire transverse section of the cord must produce, first, motor paralysis in all parts supplied with ^1 ^1 1^ XIID Fig. 97. — Diagram of Lesion Showing Brown- Sequard's Paralysis — {after Starr). L. Lesion in left half of cord cuts off motor impulses to left leg, sensory impulses from right leg, and sensory impulses from elev- enth dorsal nerve. Fig. 98.— Schema Sho^ Chief Symptoms in Left unilateral Lesion of the Dorsal Cord — {after Erb). Oblique shading at a signifies mo- tor and vasomotor paralysis ; vertical shading cutaneous anesthesia at b and d ; dots on a cutaneous hypereesthesia. b. Small anesthetic zone. c. Small hyperesthetic zone. nerves emanating from segments below it. In less complete lesions correspondingly limited degree and extent of motor paralysis succeed. Such paralysis may extend to the bladder and rectum. After com- plete or nearly complete section, the muscles are usually flaccid and the deep reflexes absent. There is no rapidity developing atrophy, and the muscles respond normally to ele'ctricity. No satisfactory explanation has as yet been offered of the abolition of the deep reflexes in complete or nearly complete transverse lesion of the cord ; even above the level of the reflex arcs, although neuritis is supposed by some to be the cause of this 896 DISEASES OF THE NERVOUS SYSTEM. c/v CM Pig. 99._Diagram of Skin Areas Corresponding to Different Spinal Segments— (^/^z>/?/ after Starr. Trun/e areas from Head). Roman numerals refer to nerves. AFFECTIOXS OF THE SPIXAL CORD. 897 CP7 cf.# Fig. 100.— Diagram of Skin Areas Corresponding to Different Spinal Segments— (ic in the affected limb is delayed, and even arrested, and a stunted development results. After a time there also ensue relaxation of the joints and deformity from secondary muscular contraction. In the lower extremities the paralytic club-foot {talipes varo-equinus) develops, resulting from the paralysis of peroneal muscles and the tibalis anticus, permitting the point of the foot to drop, while a contracture develops in the antagonistic muscles of the calf. In paralysis of muscles of the calf there results, on the other hand, a moderate degreee of talipes calcaneus, from contraction of the antagonistic muscles. In the arms and vertebral column numerous contractures and deformities arise, mainly due to the contracture of unparalyzed antagonistic muscles and to external mechanical conditions,, such as weight and pressure. Sensation remains intact, as also does, fortunately, bladder and rectum control. At the onset micturition is sometimes slightly deranged, but sub- sequently this disappears. The tendon retlexes, and almost always the skin reflexes, are lost in parts affected by the atrophy. The skin sometimes exhibits trophic disturbances, being cool and cyanotic. Diagnosis. — This is usually easy. There are few diseases in which one can reason so soundly from characteristic symptoms to morbid states causing- them. The paralysis of one or more limbs, the flaccidity, the rapid wasting, the reaction of degeneration, and the absence of reflexes, with integrity of sensibility and undisturbed mental state, point only to disease of the anterior cornua. The pseudoparesis of rickets presents some similarity in paretic and muscle phenomena. There is not, however, in rickets true paralysis— simply pain on motion, to which are added the peculiar head-sweating and hyperesthesia, together with rachitic symptoms elsewhere. Prognosis. — This is always unfavorable so far as recovery is concerned, but improvement, at first general, and afterward in groups of muscles, is often decided, so much so, indeed, as to be somewhat delusive. In pro- tracted cases we must expect the superaddition of contractures, while deformities must be mentioned to parents as possible. The initial period passed, there is no danger to life, and subjects may live to old age. Treatment. — Notwithstanding the unfavorable prognosis, treatment should not be ignored. Paralysis is established, of course, before the diag- nosis is made, and atrophy nearly as soon. The early symptoms can, there- fore, only be treated symptomatically. An aperient should be given and febrifuges ordered. Should an opportime circumstance favor an early diag- nosis, cold applications may be made to the spine ; it is doubtful whether they will accomplish much. Paralysis supen-ening, the little patient must imme- diately be put at rest in bed and w-rapped in cotton. No active measures should be taken at this stage. The acute stage passed, electricity is the most important therapeutic measure to be employed. It is used both for curative purposes and to keep up the nutrition of the muscles. In attaining the former, galvanism is pre- ferred, a broad electrode being placed on the vertebral column over the spot supposed to be diseased, — on the cervical region, if the upper extremity is paral3-zed, and over the lumbar if the lower, — while the other pole is placed over the paralyzed muscles and nerves. The latter is moved about, the current being at times reversed. Interruptions may also be made. While- the galvanic current is commonly employed, faradization may be used. ACUTE POLIOMYELITIS IN ADULTS. 921 The second purpose of the electrical treatment, keeping up the nutrition of the muscles, is more likely to be effectual. For this purpose massage and baths, after the method laid down under treatment of myelitis, are also useful. The electrical treatment must be persisted in for months and even years in order that the muscles may be in a condition to resume their function should the integrity of the cord be restored. Both massage and electrical treatment may be carried out by members of the family after a little instruction. Tonics are employed for the usual purposes, and orthopedic appliances may be necessary to overcome the effect of muscular relaxation on the one hand and of contractures on the other. ACUTE POLIO^IYELITIS IN ADULTS. Synonym. — Acute Atrophic Spinal Paralysis of Adults. The existence in adults under thirty of a disease with all the clinical manifestations of the one just described as comparatively frequent in chil- dren must be admitted, since an undoubted anatomical lesion of the same kind, associated with such manifestations, has been found by investigators. On the other hand, it must be conceded that the disease is very rare and that many of the cases so diagnosticated were really cases of multiple neuritis. Landry's paralysis in some cases may be the clinical manifestation of polio- myelitis. In view of the fact that the symptomatology is almost the same as that of the infantile form, no separate description is necessary. Among pecuharities may be mentioned the possible involvement of all four extremi- ties, as contrasted wdth a monoplegia or a paraplegia at other times. Again, there may be the involvement of groups of muscles. Thus, in paralysis of the crural region the sartorius muscle often remains free. In the leg the tibialis anticus may be separately involved or the extensor digitorum. In the forearm the supinator longus supplied by the musculospiral nerve may remain free w^hile all the other muscles on the extensor side of the forearm are paral3-zed, furnishing " the forearm type " of E. Remak ; or the supinators may be paralyzed alone or together with the biceps, brachialis anticus, and deltoid, furnishing " the upper arm type " of Remak. The latter form is said to correspond to a lesion at the level of the fifth and sixth cervical roots, and the former to a lesion of the eighth cervical and first thoracic roots. Diagnosis. — This is mainly from multiple neuritis, in which the palsy is symmetrical instead of irregular in distribution, pain is more character- istic and persistent, while the nerve trunks are inflamed and painful. Prognosis and treatment are similar to those of the same affection in children, except that the prognosis is rather more favorable, recovery being" reported, though such cases may have been multiple neuritis. Subacute and Chronic Poliomyelitis. Synonyms. — Subacute and Atrophic Spinal Paralysis; General Anterior Spinal Paralysis, Subacute of Duchenne. All that w^as said of the probable 'confounding of acute poliomyelitis of adults with acute" multiple neuritis may be said of the subacute and chronic form. Yet it would seem that undoubted cases have been studied. Oppen- heim especially studied a case — in which the anterior cornua of the cord 922 DISEASES OF THE NERVOUS SYSTEM. were found markedly diseased at necropsy. There were, clinically, paralysis and atrophy of all four extremities without sensory disturbance. The cases differ from the acute form in the absence of the severe initial symptoms, fever, headache, somnolence, delirium, and vomiting. ACUTE ASCENDING SPINAL PARALYSIS. Synonym. — Landry's Paralysis. Definition. — A disease first described by Landry, in 1859, character- ized by an advancing paralysis beginning in the lower extremities, passing upward to the trunk and arms, and finally to muscles supplied from the medulla oblongata, including those of respiration, sensibility and bladder and rectum control remaining intact. Etiology and Pathology. — It is most common in men between 20 and 30, and usually those who are strong and healthy. Cases have, however, been seen in children and old persons. No anatomical lesions pathognomonic of the disease have been shown to be associated with it. Hence attempts have been made to classify it elsewhere, and H. Oppenheim, James Ross, Neuwerk, Barth, and others regard it as a form of peripheral neuritis, Ross having found an interstitial form confined to nerve roots, while Neuwerk and Barth described a case confined to peripheral nerves. Other carefully studied cases failed to disclose such lesion. In some cases myelitis, espe- cially poliomyelitis, is the cause. A toxic cause seems not unlikely. It is quite consistent with such cause that it should leave no local lesion, as well as that it should always seek the same spot. Gowers is especially disposed to ascribe the disease to such a cause. Some cases have, however, followed trauma. Symptoms. — The characteristic symptoms are commonly preceded by a prodrome, in which loss of appetite, general malaise, moderate fever, head- ache, backache, and tingling in the extremities are conspicuous. These symptoms vary in severity and last from a few days to several weeks, when a paresis suddenly sets in, first of one leg and then of another, increasing rapidly, so that in a few days, sometimes in a few hours, an almost total motor paraplegia is developed. The paresis next extends to the trunk ; in a few days or even less the arms are paralyzed. The muscles of the neck are next involved, and ultimately those of respiration, deglutition, and articu- lation, producing bulbar symptoms. Finally, facial paralysis and other dis- turbance of facial muscles may ensue. The paralysis is a flaccid one, and there is no tendency to spasm or resistance to passive motion. There is not usually a change in electrical reaction, although there is sometimes a rapid loss of faradic muscular excitability. The reflexes are diminished or absent, but the muscles do not zvaste, because death usually occurs before atrophy has had time to develop. There is no definite loss of sensation, but in addition to the primary tin- gling referred to there is sometimes hyperesthesia and musctilar tenderness. In other characteristic cases sensation is intact. More rarely there is a blunted and delayed sensation. The special senses are not affected, nor are the bladder and rectum. Sometimes there are vasomotor edema- and sweat- ing. The spleen has been found enlarged and slight albuminuria has been observed. ACUTE ASCEXDIXG SPIXAL PARALYSIS. 923 Diagnosis. — This is not always easy, the disease being simulated by multiple neuritis, acute auterior poliomyelitis, and ascending myelitis. All these mav cause difficulty, and sometimes a distinction clinically and patho- logically is impossible. The rapid motor paralysis, advancing from below, in the feet and hands, instead of from above, the absence of anesthesia, of wasting, and of electrical changes, are characteristic of Landry's paralysis. Prognosis. — This is grave, and the possibility of a rapidly fatal termi- nation, even in a few days, is to be remembered, the danger being from inter- ference with the cardiac and respiratory functions of the medulla oblongata. Other cases terminate similarly in three or four weeks. If, on the other hand, the acute stage passes off, the symptoms of paralysis may cease to extend, and recover}^ is possible and has occurred in some cases. Treatment.— The patient should be put to bed immediately, and coun- terirritation should be applied to the back by dry cups, and maintained by gentler means, as by a mustard plaster. The thermocautery has been recommended, but is of doubtful value. Paquelin's cautery is, at least, harmless. Of internal remedies the apparent results from ergotin and mercury justifv their further use. Cowers relates a remarkable case of recovery under the use of the former drug, twenty grains (1.32 gm.) having been given in the course of a night in divided hourly doses. Likewise cases of syphilitic origin have been reported, in which the iodid of mercury has seeminglv proved of service. The biniodid may be given in doses of from 1-50 to 1-30 grain (0.003 to 0.006 gm.). The salicylates have been advised. Both remedies are indicated if its toxic origin be admitted. Perchlorid of iron is recommended in traumatic cases, especially when there is evidence of septic poisoning. If swallowing is difficult the patient must be nourished by the rectum or through the nasal tube, and if symptoms of respiratory failure come on, electrical stimulation of the phrenic ner^-e and respiraton,^ muscles may be used. If the acute symptoms pass away and paralysis persists, the usual application of galvanism and faradization may be made for restoring mus- cular and nervous power. 924 DISEASES OF THE NERVOUS SYSTEM. Chronic Affections of the Spinal Cord. SPASTIC SPINAL PARALYSIS. Synonyms. — Primary Lateral Sclerosis; Spasmodic Tabes Dorsalis. Definition. — A chronic disease of the spinal cord, characterized by stiff- ness and weakness of limbs with greatly exaggerated tendon reflexes, but without atrophy or sensory or vesical derangement. History. — In 1875 Erb, and independently Charcot, called attention to a form of paralysis characterized by "a gradualh' increasing paresis and paralj-sis, usually advancing from below upward, with muscular tension, reflex contractions and con- tractures, with marked increase of the tendon reflexes and complete absence of sensory and trophic dtsturbaiices of vesical and sexual weakness, and of any cerebral dis- tjtrbance." Both observers agreed on a " primary symmetrical sclerosis of the lateral columns " as the anatomical condition of the disease. Since then numerous cases have been observed corresponding in clinical features, but while the anatomical features described as essential have been found, they have, with one or two excep- tions, been accompanied b}^ other lesions, which are not alike in different cases. A few cases have been described, which seem to show the possibility of the occurrence of primary lateral sclerosis, without complications, but most foreign writers discard the name of lateral sclerosis, and some speak of it by its most prominent symptom, spastic paraplegia. Etiology. — The etiology is not always apparent, although the causes are probably many. The cases mostly begin between the 20th and 40th years. It may occur in children. It has been traced to syphilis, several times to trauma, after acute infectious fevers, lead poisoning, and to the puerperium ; the diagnosis in such cases usually has been without anatomical confirmation. Striimpell has called attention to hereditary family type, found in male mem- bers, between the 20th and 30th years, and in some families the symptoms are first manifested in early childhood. A form closely related, but resulting from arrested development rather than from atrophy of the central motor tracts, is the spastic paraplegia occurring in children born prematurely, and sometimes classed as one type of Little's disease. Morbid Anatomy. — The lesion which would be expected in spastic spinal paralysis is degeneration of the pyramidal tracts. In point of fact this condition is found, but it is apt to be part of a mixed lesion which may include that of myelitis, meningomyelitis, multiple sclerosis, compression of the cord by tumors or by caries of the vertebrae. In a few cases, however, the lesion almost uncomplicated has been found by INIunkowski, Striimpell, Dejerine, and Sottas. Symptoms. — The conditions may begin with a sense of fatigue and weariness in the legs, but the two essential and predominating symptoms are increase of the tendon reilexes and motor paresis. The first is the more unmistakable, constant, and characteristic. In decided degrees of this in- crease the contractions come on even with that amount of tension on the tendons which is produced by the weight of the limbs or any active or passive movem.ents, while the reflex muscular tension or rigidity opposes any attempt at motion. The muscles feel rigid and firm, and the legs are found in almost permanent extension, while the feet are in plantar flexion. Any attempt, especially if sudden, to flex the leg at the knee or the foot dorsally meets with resistance. Yet if slow eft'ort is made, flexion may generally be accomplished, the leg. while undisturbed, remaining in the position assumed, SPASTIC SPINAL PARALYSIS. 925 whence the graphic term of Weir ^Mitchell — " lead-pipe contraction." If the thigh be placed over the edge of the bed, the traction of the leg on the quadriceps extensor may be sufficient to excite vigorous extensor tetanus and a convulsive tremor of the whole leg, like that of ankle clonus. If the patient is examined in a bath, the spasms are less violent because the effect of the weight of the legs is diminished. The superficial reflexes are also increased. Walking is interfered with in two ways, first by the stiffness in the legs, and second by the paresis. The legs are only partially, if at all, flexed at the knee, and the foot is not raised, but is pushed along the floor in short, difficult steps. Owing to the contraction of the calf muscles the toes are brought to the ground, and thus the patient walks on his toes ; sometimes an ankle clonus is developed by contact of the toes with the ground. The legs are kept close together, the knees touch, and in certain cases adductor spasm may cause cross-legged progression. Stiffness is not always so marked. The effect is the so-called spastic gait. In some cases there is no paresis, and the peculiarity of the gait depends purely on the muscular spasm. The effect is what Striimpell calls pseudoparesis, or spastic pseudoparesis. The absence of actual paresis is shown by the fact that, notwithstanding the stifif- ness in the gait, the patient can still walk some distance, even miles. With all this, the patient is zcell nourished and there is no wasting of muscles, which may even be hypertrophied, and outside of these symptoms he may enjoy excellent health. Nor is there vesical disturbance. There is no sensory disturbance. Ocular symptoms are rare. The tendency is to grow gradually worse, but very gradually ; finally the patient cannot walk at all, nor can he stand. Rarely the muscles of the trunk and arms become involved, presenting also a paresis with decided increase in the tendon reflexes without disturbance of sensibility or muscular atrophy. Such is the picture of spastic palsy, rarely, perhaps, seen in an uncompli- cated form. Diagnosis. — As stated at the outset, there is absence of sensory and trophic disturbance. The onset may be sudden, but is never so in typical cases, with numbness in the extremities, progressive loss of strength, but no emaciation. Spastic symptoms, with increased knee-jerk, appear, followed by gradually developing paresis. The arms are often affected, but less so than the legs, and may escape. The course of the disease is slow, and mental symptoms similar to those of dementia paralytica may be present at the close ; also amyotrophic lateral sclerosis in some of its symptoms, but it differs in the absence of muscular atrophy. Hysterical spastic paraplegia ma.y furnish in the most striking manner the symptoms detailed. Every symptom to be mentioned may repeat itself more or less identically. It is, therefore, not necessary to name them. Moderate wasting is sometimes added. It occurs more commonly in women, and usually careful examination will reveal some distinct stigmata of hysteria. Prognosis. — Spastic paraplegia of all forms except the hysterical is of long duration with little prospect of recover\\ The upper extremities are tolerably free from derangement, and the mind is usually clear. Hysterical spastic paraplegia may end in recover}^, if properly managed. \"\''hen the cause is transient, also, recovery may be expected with removal of pressure, as in caries. Treatment. — If caries is present, mechanical measures should be used to remove pressure. If syphilis is suspected, treatment by iodids and mer- 926 DISEASES OE THE XERVOUS SYSTEM. curials should be persevered in. ^Mercurial inunction is the most ready way of bringing about mercuriaHsm. Galvanism and faradization are less useful in spastic conditions of the muscle than in those in which nutritional changes are more decided, but in hysterical spastic disease they are of signal use for their moral effect. The electrical brush is here the most useful instrument. It should be associated with massage and passive motion, and early attempt at locomotion should be encouraged and a positively favorable prognosis made. These, at least, tend to defer the immovable stage. In any case friction, massage, and forcible flexion may be of benefit, but should be used cautiously, as the irritation produced in this way may pos- sibly hasten premature contracture. Hydrotherapy is commended. The effect of the prolonged warm bath at 90° to 95° F. (32.2° to 35° C.) is often an amelioration of the spastic symptoms. The bath should be kept up for half an hour and manipulation practiced during it. TABES DORSALIS. Syxoxyms. — Posterior Spinal Sclerosis; Duchenne's Disease; Locomotor Ataxia. Definition. — A disease especially characterized clinically by loss of co-ordinating power, and by sensory and trophic symptoms ; anatomically it is pre-eminently a disease of the posterior spinal roots and posterior columns of the cord, although the cerebrum does not always escape, and the optic nerves are commonly affected. Historical. — Inco-ordination of movement in cases of spinal cord disease was noticed in the first third of the last century, but the cases in which it was present were not separated from those with loss of power. The association of this distinctive symptom with disease of the posterior columns was first announced hy Stanley in 1840. and the first accurate account of the disease was published by R, Bentle}- Todd in 1847. He distinguished inco-ordination without weakness from paraplegia, inferred involvement of the posterior columns, and confirmed his inference bv autops}-. In 1851 Romberg described the disease and the lesion in the posterior columns, but failed to eliminate loss of power from the symptoms. In 1855 Russel Revnolds accurately described the symptoms and ascribed ataxia to muscular anesthesia, giving thus the first correct explanation of this symptom. Tiirck first recognized with the microscope the wasting of the fibers in the posterior columns of the cord. In 185S-59 Duchenne, without adding anything essential to the s^-mptomatologj" or pathology of the disease, published a monograph which so attracted attention that the disease has come to be called by his name, although, as Gowers correctlv savs. if the name of anv man should be associated with tabes dor5alis,it is that of Todd. Etiology. — The etiology of tabes dorsalis is not a satisfactory chapter. The disease is more common in cities, affects ten men to one woman, is rare in the negro, and is pre-eminently a disease of middle life, about one-half the cases beginning between thirty and fort}-, one-fourth between forty and fifty. and less than one-fourth between twenty and thirty. It has been met as late as sixty-six, and occasionally before the age of twenty. Direct inheritance, independent of inherited syphilis, is almost unknown, but a slight tendency is found in neurotic families. Of the direct causes, syphilis is believed to be the most frequent. From 50 to 90 per cent, of cases have been ascribed to it by different authors, Erb and Striim.pell leading with the latter figure. Mobius even believes that all cases of tabes are due to syphilis. Yet there are difficulties in tracing the relation growing out of the facts, first, that the pathological product is not TABES DORSALIS. 927 anatomically a syphilitic one, and, second, that it does not respond to the treatment of syphilis. A reasonable explanation ascribes it to a toxic cause analogous to that of the paralysis which follows diphtheria, acting especially on the centripetal sensory fibers. Prolonged exposure to cold and wet, such as belongs to certain occu- pations, as lumbering, is a commonly admitted cause, but simple overexer- tion, physical and mental, especially sexual excesses, formerly held respon- sible, are probably not causes. Alcoholism is also held responsible less commonly than formerly. On the other hand, Tuczek has shown that in ^t-i^f-L^f-^^^' h rife Fig, 105. — Lumbar Region. £' ^, degenerated posterior roots, A h, normal anterior roots, f f, degenerated posterior columns, e e, ventral fields of the posterior columns intact — {after Spiller). chronic ergot poisoning symptoms like those of tabes develop, and with them a lesion appears in the posterior columns of the cord. Traumatism affecting the spine has been believed to be a cause in a few instances, but this relation has not been established. Morbid Anatomy. — Tabes dorsalis is pre-eminently a disease of the posterior spinal roots and posterior columns, although the cerebrum does not always escape, and the optic nerves are usually affected. Directing our attention to the spinal cord, in which are found the most manifest changes, we find that, at times, even when inclosed in the mem- branes, its smallness and thinness are noticeable, while through the pia we may see the posterior columns distinctly as a gray band throughout the length of the cord. The pia is, howe^ver, commonly thickened and opaque, especially on the posterior surface, sometimes more firmly adherent than is natural, while the blood-vessels also show signs of arterial sclerosis. The contraction of the posterior columns is more conspicuous on section. They are flattened instead of convex, while the gray translucent appearance of 928 DISEASES OF THE NERVOUS SYSTEM. the posterior column is also evident, being due to the fact that the nerve- fibers have been substituted by neuroglia tissue. Hence, also, the name " gray degeneration." In the cord hardened in Miiller's fluid the difference in hue is even more striking than in the fresh state. The posterior cornua and the posterior nerve-roots are small and gray. On minute examination, in transverse sections stained by carmine or other staining fluid, the affected areas are more conspicuous, because of the deeper staining of the sclerosed tissue, while all parts of the posterior col- umns are not equally affected. In the lumbar cord, which, with the lower thoracic region, is usually the most frequently and seriously involved, the change affects chiefly the middle and posterior parts of the columns, while _ c b c Fig. io6. — Thoracic Region, ii d, degenerated posterior roots, c c, degenerated pos- terior columns, d b, degenerated columns of Clarke, a, small group of normal fibers from one or more posterior roots, lower in the cord, which were not entirely- degenerated, e, normal anterior root — {after Spiller). the extreme anterior portion, the so-called ventral fields, remains intact. The sclerosis is commonly most intense in the part adjacent to the posterior cornua, into which the posterior roots enter, also near the surface of the cord. Ascending into the thoracic cord, the intensity of the disease gradually diminishes in the external parts of the posterior columns, and increases in their median portions. It presents also the distribution of an ascending degeneration, which in fact it is, receding from the commissure in the upper cervical region. In the cervical cord the columns of Goll are chiefly affected, sometimes with the fibers in the root zones — that is, those portions of the columns of Burdach in which fibers enter directly from the posterior nerve-roots, and from which fibers may be traced further into the gray matter of the posterior TABES DORSALIS. 929 cornua; but two anterolateral areas in the columns of Burdach remain free from disease, at least for a long time. Figure 108 shows how the beginnings of the disease are localized in the posterior columns. It is in consequence of involvement of the posterior roots that the corresponding posterior cornua into which they enter are also affected. The same is true of the meduUated Hhers of Clarke's columns (Fig. 106), which are also direct processes of the posterior roots, while the cells of the columns remain normal. Lissauer's tract, a narrow strip at the periphery of the posterior cornu, is early involved. In advanced cases, in the larger peripheral nerve trunks, such as the sciatic, and in the finer branches of the sensory nerves, many degenerated fibers can be recognized. Some of these atrophies may be secondary, but modern clinicians are disposed to regard the peripheral degenerations of tabes as independent and primary, especially since, in addition to these, decided degenerative processes sometimes occur in the trunks of certain Fig. 107. — Cervical Region. The degeneration of the posterior columns is now nearly limited to the columns of GoU, e e. b, normal fibers from roots lower in the cord which were not entirely degenerated — {after Spill er'). Figures 105, 106 and 107, from an advanced case of tabes. cranial nerves, such as the optic and oculomotor, and more rarely the vagus and auditory. They will be referred to in treating the diseases of special nerves. Finally, there are even cerebral changes of various kinds. While the spinal ganglia on the posterior roots have been found invaded in a few cases only, it is the disposition of some observers to place the initial changes of the morbid process constituting tabes dorsalis in these ganglia, and thence the fibers ascending into the posterior columns. Thus considered, tabes dorsalis would be a general disorder of the central and peripheral nervous system, but limited mainly to sensory tracts though motor ganglia and nerves do not altogether escape. Symptoms. — The characteristic symptoms of tabes are easily divisible into three sets : motor, sensory, and reflex. In addition to these there are 59 930 DISEASES OF THE NERVOUS SYSTEAI. others not essential, but striking, including modifications of special sense and certain visceral symptoms characterized by pain and known as " crises."' The special sense modifications include especially that of vision, while of " crises " the gastric is most striking. The motor phenomena are usually the most prominent, whence the dis- ease takes the name of locomotor ataxia, but this symptom may be absent Fig. io8. — Lumbar Region. ^ h, posteromedian root zones (Flechsig) only slightly- degenerated, i j , middle root zones (Flechsig) degenerated, g, normal ventral fields. This section represents the earlier lesions of tabes. Figure 108 should be compared with Figure 105 — {after Spiller). for years, and hence the inappropriateness of the term. The dis- tinctive symptom is a loss of co-ordinating pozver in the legs, having its simplest illustration in the unsteady gait of a drunken man. It is intensi- fied when the patient attempts to walk with his eyes closed — that is, when the guiding sense is removed, and, indeed, in its early development does not appear except when the eyes are closed. It is usually unacco'>npanied by a loss of pozver or muscular zmsting, but the latter may be extreme. On the other hand, inco-ordination is by no means alzvays the earliest symptom and it may, indeed, never be developed, while there is usually a preataxic stage in most cases of tabes. The inco-ordination may be shown sometimes, before otherwise evident, by directing the patient to place the heels and toes together and then to close the eyes, when a swaying appears, as though the patient were going to fall — Romberg's symptom, or " tabetic TABES DORSALIS. 931 swaying."* In health a sHght unsteadiness under these circumstances is present, which varies in different persons. Higher degrees develop the " sway " even when the eyes are open. The symptom often exists for a long time before being recognized by the patient, but is sometimes discovered quite early through an accidental production of the favoring conditions. Soon the peculiar gait is noticeable. The foot is thrust forward too far, and brought down suddenly, with the heel first on the ground, with a stamp. This is the typical tabetic or " heel " gait. The patient cannot walk in a straight line, and the staggering becomes worse when the eyes are closed, because the power of orientation through vision is lost. The movements of the lower limbs are excessive and unnecessary. Ultimately, he can walk only with the aid of a cane or by keeping the eyes fixed upon the floor. He rises from the sitting posture with difficulty, often after three or four efforts. The loss of co-ordinating power may also be shown in the recum- bent posture when the patient attempts to touch the knee with his heel, when he will carry it around and in front and behind without accomplishing his purpose. The tabetic gait is not confined to tabes, but may occur in disseminated sclerosis and cerebellar disease. In the latter closure of the eyes may not increase the ataxia of the gait. Iiico-ordinaiion also develops in the hands, but much more rarely, and late in the disease, though it may appear in them first. It is shown in connection with more delicate acts, such as picking up a pin, buttoning, and writing. It may be demonstrated also by asking the patient to bring the ends of two of his fingers together with his eyes closed, or to touch the end of his nose with one, which he may not be able to do. With all this ataxia the muscular potver remains intact. The patient lying in bed can kick out with great force, and resist successfully any effort to flex the extended leg, while the grip of the hand is strong. The sensory symptoms are less distinctive, especially at first. The most frequent of these — indeed, among the most frequent of all symptoms — are pains of a darting, shooting, or stabbing character, whence they are called lightning-pains. They are said to occur in nine-tenths of all cases. They resemble closely those of neuralgia, lasting but a second or two. They are most common in the legs, and are often accompanied by burning or tingling, especially in the feet. They may be felt in the trunk, arms, and even in the head. Commonly they do not correspond with nerves or affect joints. They are often considered by the patient as rheumatic pains. A sensation of cold is felt, also a feeling as though the limb were immersed in cold water. The pains are induced by fatigue or excesses or by temporary ill health from other causes, and are apt to come on at night. They may last hours or a day or two. There may be areas of hyperesthesia and anes- thesia. A very curious sensation is felt in the soles of the feet when walk- ing, a feeling as though soft carpet or cotton were interposed between them and the floor. A painful sense of constriction about the limb or waist or around the entire trunk — girdle pains — is regarded as char- acteristic. There are other disturbances of sensation, such as retardation of tactile sensation, wher'ein the prick of a pin,, instead of being instantaneously felt, is delayed for several seconds. Another sensory symptom is difficulty in * This symptom is classed bv Striimpell among those of impaired sensibility in the soles of the feet and the muscles, whence follows defective control of muscular movements necessary to equili- brium. 932 DISEASES OF THE NERVOUS SYSTEM. locilization, manifested, for example, in referring a pin-prick to the right foot when it is made in the left, — allochiria, — or it may be felt in both feet — polyesthesia. In advanced stages the muscular sense is also impaired, and the patient is unable to indicate correctly the position of a limb. There may be other perversions of sensibility. The sense of pain may be lost or perverted; also the temperature sense — that, too, without derangement of the pain-sense or common sensibility. All varieties of sensation may be lost in the most diverse parts of the body and most irregularly. Visceral pains, known as tabetic crises, among which the gastric is the most common, are also among the sensory phenomena. They may be laryngeal, rectal, nephritic, urethral, and are sometimes exceedingly severe. The gastric crises are sometimes accompanied by vomiting of strongly acid gastric secretion. On the other hand, the vomited matters may be alkaline, the result of a reflux of the intestinal contents into the stomach. Xor are gastric crises limited to tabes. They may occur in other cerebrospinal disease, including general paralysis, sclerose en plaques, and subacute or chronic central myelitis. The laryngeal crises may be associated wuth spasm and dyspnea, with noisy breathing. Death is a possible termination from this cause. Rectal crises consist in paroxysmal pain and tenesmus, with a sensation as of a foreign body in the rectum. - The reflex symptoms consist in impairment in reflexes, both tendon and cutaneous. The loss of the knee-jerk is one of the most frequent and early of these, occurring sometimes years before ataxia appears. Of itself it is not diagnostic, as it may be absent in healthy persons, but in association with lightning pains and ocular symptoms it is almost conclusive evidence of the disease. In by far the greater number of tabetics — at least 70 per cent. — the patellar reflex is wanting, with or without the Argyll Robertson pupil. The skin reflexes fail pari passu with the loss of tactile sensibility. and it is doubtful whether they are ever present without this. The plantar skin reflex is that most frequently impaired, and after this are successively involved the gluteal, cremasteric, and abdominal. It happens rarely that in the early stages of the disease the skin reflex is increased, sometimes considerably, but even then the knee-jerk is absent or diminished. Of the remaining symptoms the ocular are the most important. They include ptosis of one or both eyelids, producing a very striking appearance. It may be unaccompanied or associated with external strabismus and double vision. Rarely there may be paralysis of all the external muscles of the eye, producing ophthalmoplegia externa. The most remarkable eye symptom is. however, the Argyll Robertson pupil, in which ther'e is loss of reflex con- traction of the iris in response to light, while the contraction in accommo- dation remains. According to Gowers, the loss of this reflex occurs in five- sixths of all cases. The contraction in accommodation is, however, not always maintained. \^ery rarely the reverse of the Argyll Robertson pupil exists. Wendell Reber has made a clinical study of the correlation between the iris and patellar tendon reflexes, and finds that in non-specific cases of tabes they are both involved in 70 per cent., and in the specific cases in yy per cent. He holds that the co-involvement of these distant reflexes is evidence in favor of the view held by Sachs. Trevelyan. and Hirt. that tabes is a sec- ondan,- degenerative process in which the entire nervous system takes part, and of Nageotte that the three separate clinical pictures of general paresis. tabes, and cerebrospinal syphilis are only the result of the preponderance of the inflammatory process in different localities, the nature of the process TABES DORSALIS. 933 being essentially the same, the initial change being vascular starvation." Often the dilatation of the pupil which takes place in health when the skin of the neck is pinched cannot be produced and coincident with this is often unnatural smallness of the pupil — spinal miosis. Finally, there is sometimes atrophy of the optic nerve, producing the amaurotic form. When it occurs, it is often an early symptom, usually com- mencing before inco-ordination ; and, what is more singular, the ataxia often does not supervene — that is, there seems to be a tendency for the spinal malady to become stationary when the optic nerve is affected early. The failure of vision usually begins with peripheral limitation and progresses slowly to total blindness, sometimes to a considerable extent before the patient notices it. Occasionally it ceases, and there may even be slight impairment. Hemianopsia may occur from disease at the optic chiasm. Deafness may be present from disease of the auditory nerve; also, more rarely, anosmia, from atrophy of the olfactory nerve. Attacks of vertigo are common in these cases. Abnormalities in function of other cranial nerves may be due to similar involvement. Among these may be mentioned pain at one time and anesthesia at another in the area of the fifth nerve ; also unilateral atrophy of the tongue. There may be delayed micturition from weakness of the detrusor muscle of the bladder, or incontinence from paralysis of its sphincter, with partial evacuation of the bladder, and resulting cystitis. The anal sphincter is less frequently affected. Vasomotor and trophic phenomena also occur, and may be predominat- ing symptoms. They include local sweating of the palms and soles, or of half the head, edema, skin ecchymoses, herpes, and modified haif growth, loss of pigment from hair and skin, thickening of the epidermis of the sole, succeeded by blisters under it. Alteration in the nails, and onychia with ulceration, may be present ; also decay of the teeth and the so-called per- forating ulcer of the foot, which is almost peculiar to this disease. Only late in the disease may atrophy of muscles, sometimes associated with neuritis or involvement of the anterior cornua, occur. Paroxymai diarrhea occurs, and has been regarded as vasomotor in origin. The so-called arthropathies are an interesting trophic symptom and are directly the result of the disease. The most common is that known as Charcot's joint, anatomically similar to chronic affections in which the dis- ease begins in the bone as contrasted with the synovial membrane, resulting in atrophy and in the destruction of bone and cartilage, while brittleness of bones, attended with spontaneous fracture or luxation, may occur. If union takes place, there is a superabundance of callus, with ossification or calcifi- cation of adjacent structures and of any newly for'med inflammatory tissue. The large joints are those commonly affected and are painless when the seat of arthropathy. There may be effusion and even pus in the joints. The arthropathies may even occur in the preataxic stage. They may be excited by injury. The joints may also become greatly relaxed, while changes in the tarsal bones and articulations may cause the foot to become flat, with pro- jection backward or inward of the tarsometatarsal articulations and of the tarsal bones, producing the " tabetic club-foot." Cerebral symptoms also occur, but are rare, and may resemble those of * Reber's paper, published in the " Annals of Ophthalmoloary and Otolog-y," vol. v. No. 3, July, i8g6, showed also that in non-specific cases the patellar reflex alone was involved in 23_p_er cent., the iris alone in 77 per cent.; in specific cases, the patellar reflex alone in 7 per cent., and iris alone in 16 per cent. 934 DISEASES OF THE NERVOUS SYSTEM. dementia paralytica. It is not always easy to decide whether the dementia or the tabes is primary. The final stage of the disease, in which the patient is bed-ridden, is known as the paralytic stage. Diagnosis. — The diagnosis, commonly easy when the characteristic symptoms are developed, may demand critical judgment in the early stage. The combined presence of lightning pains, absence of knee-jerk, early ocular palsies, including the Argyll Robertson pupil, ptosis or squint, and ataxia are conclusive. Lightning pains and ocular palsies should always stimulate to thorough examination. The same is true of severe attacks of gastralgia in middle-aged men. Differential Diagnosis. — Disease of the vertebral column with resulting compression of the spinal nerves is also associated with lancinating pain and absence of the patellar reflex, but the later symptoms ar'e widely different. The same is true of deep-seated tumors impinging on the spmal cord. Peripheral alcoholic neuritis and arsenical neuritis also may be asso- ciated with diminished knee-jerk, a pseudotabetic gait, and sharp pains, but the gait differs from the true tabetic gait, the leg being lifted high in order that the toes may clear the floor. The pain also follows the course of the nerves, which are tender on pressure, and there is none of the shooting character. Nor is there reflex immobility of the pupils, and seldom bladder disturbance, while atrophic paralysis, always absent in tabes, also develops. Multiple sclerosis in rare instances presents similar symptoms, but defective speech, nystagmus, mental weakness, and ultimate apoplectiform seizures serve to distinguish it. In diphtheritic palsy and ocular palsies there is absence of knee-jerk, but the history of the case, the throat palsy, and all absence of pain are distinctive. Ataxic paraplegia also displays ataxia, but here again eye symptoms and pain are absent. In cerebellar disease there is also loss of co-ordination, and the knee-jerk may be absent, there may be headache, optic neuritis, and vomiting, but no lightning pains or sensory disturbance. Occasionally neuritis may present a clinical picture closely resembling tabes, known as peripheral pseudotabes. The rapidity of development, the absence of the Argyll Robertson sign, and of implication of the bladder, and in some cases recovery, are the most important dif- ferential features. General paresis and tabes sometimes merge, the latter developing on the former, and the former on the latter toward the end. Rapidly devel- oped ataxia with mental symptoms often resolves itself into general paresi^;. Yet acute involvement of the posterior columns may be possible, producing ataxia. v Finally, there is the nicotin tabes of Striimpell, w^ho has twice met, in men long working in tobacco factories, a set of symptoms consisting in pain- ful sensation, absence of patellar reflex, contracted pupil, wuth reflex immo- bility and uncertain gait, differing, however, from tabes in the presence of tremor and marked increase in the skin reflexes, especially in the lower extremities. Course and Prognosis. — It is generally conceded that no case of thoroughly developed tabes has ever recovered. The disease may, however, be arrested. This happens especially if optic nerve atrophy has set in early, after which ataxia rarely develops further, while the other svmptoms sub- side. In most cases of the disease, however, the advance is slow but irre- sistible. The duration of the first stage, characterized by absence of knee- jerk, and by the presence of the Arg}^ll Robertson pupil and of lancinating TABES DORSALIS. 935 pains, lasts from a few months to twenty years. The second stage, — that of ataxia, — from which, indeed, the patient often dates the disease if the initial .symptoms were slight, may then supervene gradually or suddenly. Finally, the paralytic stage supervenes, to be soon followed by death. Tabes is believed by some to assume a mild type more commonly now than was the case twenty or twenty-five years ago. Treatment. — While recovery from tabes dorsalis probably never occurs, much may be accomplished by treatment in arresting progress and relieving symptoms. There is no specific treatment, although this effect has been claimed for more than one remedy. Nitrate of silver, first recommended by Wunderlich, has probably had most reputation, but has latterly fallen into comparative disuse, and coincidently the number of cases of chronic argyria has diminished. The dose administered is from 1-6 to 1-4 grain (o.oii to 0.0165 gm.) three times a day. A proper question is as to the length of time the remedy may be used without danger of producing this unfortu- nate result. Professor E. Harnock asserts that in no recorded case of argyria were less than 450 grains (30 gm.) of the salt taken before the dis- coloration appeared. To consume this much in 1-4-grain doses three times a day would take six hundred days. If, therefore, it is given in the usual doses for a month and then suspended for one week, as commonly directed, it does not seem possible that unpleasant effect can result. In this manner, then, it may be kept up indefinitely ; or it may be alternated with arsenic, of which last Gowers at least says that it does distinct good more frequently than any other remedy. The favorite preparation in this country is Fowler's solution, of which five minims (0.3 c. c.) are given three times a day for an adult. The edema beneath the eyes, which results from its accumulated effect, is a sign that the dose should be reduced or the drug temporarily sus- pended. Arsenious acid in doses of from 1-30 to 1-20 grain (0.0022 to 0-0033 gm.) or sodium arsenite in doses of from 1-30 to i-io grain (0.002 to 0.006 gm.) may be substituted. Sometimes a smaller dose only is borne. Gowers has also found the chlorid of aluminium useful in doses of from two to four grains (0.132 to 0.264 gm.) three or four times a day. More recently it has been recommended in doses of five to ten grains three or four times a day. The supposed frequent causal relation between syphilis and tabes renders the antisyphilitic treatment appropriate in all cases in which such relation can be traced. To this end mercurials are to be administered until the specific effect is produced. This is best accomplished by inunction, a dram to a dram and a half being rubbed into the armpit or inner surface of the thigh daily, to be discontinued when the gums are affected. After this the hichlorid may be given in doses of 1-24 grain (0.0027 ^^•) three times a day, in association with the iodid of potassium in ascending doses if well borne, or the biniodid of mercury may be given in doses of 1-24 grain (0.027 gm.) three times a day. If this treatment is found effectual, the iodid should be continued in the minimum doses, which will keep up the effect. Calabar bean in doses of from i-io to 1-5 grain (0.0064 to 0.0128 gm.) three times a day and the fluid extract of ergot in doses of from five to thirty minims (0.3 to 1.6 c. c.) or more, are recommended, but the results have not been such as to give them a permanent reputation. Iodid of potassium may be tried apart from the indications of syphilis. The rest treatment, originally suggested by Weir Mitchell, has been found useful in arresting the disease, but I do not know that it has been followed by permanent 536 DISEASES OF THE NERVOUS SYSTEM. results. Extension of the spina! column and presumably of the cord by suspension of the body for from one to three minutes daily was used for a time, among others by Mitchell, but it has been discontinued, perhaps too soon, for instances of undoubted improvement have been reported under its use : vide one reported by Charles S. Potts in the " University Aledical Alaga- zine " for September, 1891, and several by De Forest Willard and Guy Hins- dale in the " :\Iedical News," November 24. 1894. In Germany electricity is still a popular remedy, and failure with it in this country may be due to imperfect and too brief trial. Erb's directions for galvanism are to place a moderate-sized anode in the vicinity of the sym- pathetic in the neck, and a large kathode on the side of the vertebral column for four or five minutes, moving it at intervals from above downward. Severe pain and vesical weakness are treated by galvanization and the faradic brush. The latter, as recommended by Rumpf, should be brushed over the skin of the back and extremities for five or ten minutes, using a strong current. Counterirritation by blisters is of no use, although simple rubefacients may relieve slight degrees of pain. Hydrotherapy likewise maintains its popularity in Germany, although claimed by some authorities to be sometimes harmful, especially in the shape of hot baths and vapor baths and wet packs. The tepid hath is entirely safe and often symptomatically useful. Its temperature should be from 80° to 90° F. (26.6° to 32.1° C.), accompanied by gentle rubbing. Wet compresses upon the abdomen or legs at night sometimes relieve the pains. In Germany, too, there are numerous water-cure establishments in the hands of experi- enced directors, to which patients may be advantageously sent, but, unfor- tunately, there is nothing of the kind in this country which can be recom- mended. Oeynhausen-Rehme in ]\Iinden has the best reputation for its carbonic acid thermal salt baths, but the baths at Nauheim in Hess are shnilar. Mud and iron baths are found at Pyrmont, near Brunswick ; Dri- burg, in Westphalia, Prussia ; Elster, pleasantly situated in Saxony ; Karls- bad, Marienbad, and Frazenbad, in Bohemia. The painful attacks are often not relieved by the measures thus far sug- gested, and require more powerful treatment. The first to be used should be phenacetin, ocetanilid, exalgin, salophin, aspirin, and antipyriii, while mor- phin should be deferred as long as possible. It may, however, be necessary, when it should be used hypodermically. Cocain used in the same manner in doses of from 1-6 to 1-4 grain (o.oii to 0.165 gm.) is also sometimes effi- cient, while cannabis indica in doses of 1-4 to 1-2 grain (0.0165 to 0.033 g^'^'^-) of the extract may also be tried. Bandaging with a broad flannel bandage from toes to thighs has been recommended for the sciatic pain and pressure for the relief of painful spots. Massive doses of strychnin have been sug- gested for the same purpose. Fatigue of all kinds as well as anxiety of mind should be avoided, while moderate exercise may be encouraged. Excesses in smoking, and espe- cially in the use of alcohol, are harmful, as is also sexual indulgence. Over- eating and the use of indigestible articles of food should be avoided, as gas- tric crises are invited by them. Great benefit has been claimed for the so-called Frankel movements. They are " based upon the education of the central nervous system by means of repeated exercises, whereby it is enabled to receive sufficiently distant stimuli from the limbs as to their position and so on, although the available quantity of sensation is rather small. It is necessary, of course, that the HEREDITARY ATAXIA. 937 movements be attempted and carried out repeatedly and with great atten- tion." They are too complex to be repeated here, and the student is referred to Frankel's book.* HEREDITARY ATAXIA. Synonyms. — Hereditary Ataxic Paraplegia; Friedreich's Disease. DefinitiotL — A disease whose clinical features are especially ataxia and paraplegia, occurring in families and at an age much earlier than ordinary tabes, from which it differs also in the addition of peculiar symptoms asso- ciated anatomically with lesions in the posterior and lateral columns. Historical. — Friedreich reported in 1861 six cases of this disease and a further number in 1870, whence the association of his name with it, but as the name Fried- reich's disease is also applied to paramyoclonus multiplex, confusion results. On the other hand, the term hereditary ataxia is scarcely correct, because while some- times it is hereditary and even congenital, it is not always so. It usually occurs in families, several brothers and sisters being, as a rule, affected. Yet isolated cases occur. In one case of William Osier's three generations were involved. A neurotic tendency is sometimes noticed. Alcoholism and syphilis were present in parents in a few instances, consanguinity of parents in a very few only. Etiology. — Its etiology is unknown. It is more common in males than in females, affecting 86 males and 57 females out of 143 cases collected by J. P. C. Griffith. Striimpell makes the opposite statement as to sexes, but other observers agree with Griffith. Of Griffith's cases, 15 occurred before the age of two, 39 before the age of six, 45 between six and ten, 20 between eleven and fifteen, 18 between sixteen and twenty, and 6 between twenty and twenty-four. Morbid Anatomy. — There is decided degeneration of the posterior and lateral columns, and the degeneration in the posterior columns may extend throughout the cord, leaving a narrow band of normal tissue near the pos- terior cornua. Different opinions are held in regard to the condition of the posterior roots. The degeneration of the lateral columns involves the area of the pyramidal tracts, but it is disputed whether the pyramidal fibers are actually diseased. The degeneration is found also in the direct cerebellar and Gowers' tracts as well as in the column of Clarke. As yet no changes have been found in the cells of the posterior horns. The pia mater over the posterior columns is sometimes thickened. The disease seemis to consist of a double morbid process, consisting in early degeneration of nerve elements, associated with a tendency to over- growth of interstitial or neuroglia tissue. According to Dejerine and Letulle, it is a gliosis of the posterior and lateral columns, due possibly to defect in development. Symptoms. — The essential symptoms are ataxia ivith paraplegia. Initial pains are rare. The ataxia is, however, peculiar. As in tabes, it be- gins in the legs, but it is swaying and irregular, more like that of drunken- ness. The feet are not often raised too high, and while there is stamping, as in true tabes, it is less marked. Tabetic swaying — Romberg's symptom — may or may not be present. The ataxia of the arms occurs early and is striking, the movements being choreiform, jerky, irregular, and swaying. The hand first moves an object in its efforts to secure it and then pounces *" The Treatment of Tabetic Ataxia by means of Systematic Exercise," Freyberger's Trans- lation, Philadelphia, 1902. 938 DISEASES OF THE NERVOUS SYSTEM. upon it. There seems to be a superabundance of effort in voluntary move- ments, action is overdone, and prehension is claw-Hke. Again, the fingers may be spread out or overextended. The first manifestation of the disease in children is often a tendency to fall. As the disease advances, irregular, jerky movements aft'ect the head and shoulders, sometimes tremor-like. In most cases there is nystagmus when the eyes are moved laterally or upward, usually a late, sometimes an early, symptom. Atrophy of the optic nerve is rare, and the pupils are normal. Speech is sometimes impaired, generally as a late symptom — three, five, or ten years after the initial symptoms. Syllables are elided, — the speech is scanning, — with occasional movements of the tongue, but no twitching of the lips. The paresis is at first slight, — indeed, the power of the muscles is at first unimpaired, — while there is rarely ever total paralysis. Some patients, however, never walk. The nutrition of the muscles is good. The knee-jerk generally disappears early, or is at least absent when the cases come under observation. In a few this symptom appears late, while in some atypical cases this reflex has been reported increased. Sensory symptoms are not usually conspicuous. There may be none, even in bad cases. At times there is delayed sensation or impaired sensibility to pain and temperature. Increased sensitiveness may be present. No visceral crises occur. While trophic lesions of the usual kind are rare, there occur peculiar deformities, especially of the feet. There is talipes equinus or equinovarus, and the patient walks on the outer edge of the foot. The great toe is over- extended or dorsally flexed, and occasionally this is the first sign of the dis- ease. There may be lateral curvature of the spine. Diagnosis. — This is not difiicult, although sometimes the disease is con- founded with chorea, with the hereditary form of which it has certain points in common. The ataxia in early life, the club-foot, overextended great toe, spinal curvature, lost knee-jerks, nystagmus, and scanning speech form a complex of symptoms not found in any other disease. It resembles ataxic paraplegia in more than its symptomatology, but the increased knee-jerk, foot clonus, and spasm of the latter disease are want- ing. In cases of combined lateral sclerosis and posterior sclerosis in which the knee-jerk is absent the family history and youth of the subject can alone settle the question. The loss of iris reflex in children points to tabes, the result of inherited syphilis. Disseminated sclerosis presents inco-ordination, nystagmus, and defective articulation, but the knee-jerks are almost always exaggerated, and intention tremor is characteristic. Prognosis. — This is invariably bad, so far as recovery is concerned, although the disease lasts many years. Treatment. — There is no treatment except such as will overcome tend- ency to deformity. The remedies used in locomotor ataxia may be tried. Cerebellar Hereditary Ataxia has been described by Marie, Sanger- Brown, Klippel, and Durante. It starts after twenty years of age. There are ataxia, disordered speech, nystagmus, and heredity, but the knee-jerks are normal or exaggerated, there is Argyll Robertson pupil, optic nerve atrophy with limitation of the field of vision, while there is no scoliosis or club-foot. The opposite is true of hereditary ataxia. Many do not recog- nize the cerebellar hereditary ataxia as a distinct symptom-complex. Progressive Interstitial Hypertrophic Neuritis of Childhood is also a family disease. The symptoms are a combination of those of tabes ATAXIC PARAPLEGIA. 939 ■dorsalis with those of neurotic muscular atrophy (peroneal type of pro- gressive atrophy). There are hypertrophy and hardening of peripheral nerves. It was first described by Dejerine and Sotas. Toxic Sclerosis, especially of the posterior and lateral columns, results from such diseases as pellagra, ergotism, and pernicious anemia ATAXIC PARAPLEGIA. Synonyms. — Combined Sclerosis; Progressive Spastic Paraplegia; Com- bined Lateral and Posterior Sclerosis. Definition. — A chronic disease of the spinal cord, characterized by symptoms which point tO' lesions of both lateral and posterior sclerosis, including, therefore, both spastic and ataxic features, the symptoms of one lesion being more or less modified by the other. Etiology. — This is obscure. It is more common in males, is a disease of adult life in which overexertion, exposure, spinal traumatism, and sexual excess each have been antecedent events. Less frequently than tabes does it follow in the wake of the syphilitic taint. It is always associated with general paralysis of the insane. Hereditation has been observed in one- tenth of the cases, and the neurotic constitution seems to favor it. It is probably most frequently associated with anemia. Morbid Anatomy. — As the name suggests, lesions are found in both posterior and lateral columns. In the posterior columns they resemble those of uncomplicated tabes dorsalis, and are most intense in the cervical and thoracic portions of the cord, variously distributed, sometimes equally, at others preponderating in one or the other. The changes in the posterior root zones are less pronounced than in true tabes. In the lateral columns the crossed pyramidal tracts and in the anterior columns the direct pyramidal tracts are chiefly involved, though the mixed zones of the lateral columns, the lateral limiting layers, and the direct cerebellar tracts may also be invaded. The gr'ay matter and membranes remain intact. In most cases the lesions are diffuse and the apparent systemic degeneration is usually the result of secondary degeneration. Symptoms. — The symptoms are slow in their development, though occa- sionally a more rapid course is pursued, the only modification in this being that occasionally months instead of years are sufficient to develop the distinctive features. Those of either lesion may predominate at first. More usually those of ataxia are the first to appear, including fatigue and even pain after comparatively slight exertion, unsteadiness of gait, increased with the eyes closed, though an associated stiffness, may prevent the typical gait of tabes. There is also more or less paresis. There may be dull pain or numbness in the lower extremities and in the back or sacral region, but the lightning pains of tabes are rarely present ; nor is the girdle sensation, while visceral crises very rarely occur. The Argyll Robertson pupil is, also, com- monly absent, but nystagmus is not infrequent. The most striking dift'erence in the symptomatology of ataxic paraplegia, as contrasted with true tabes, is the presence of exaggerated reflex,es in the former, including knee-jerk and ankle clonus. Simple tapping of the patella or the belly of the quadri- ceps extensor brings out the former. The upper extremities are also often involved, and the chief symptoms here are weakness, inco-ordination with exaggerated wrist- and elbow- jerks. 940 DISEASES OF THE NERVOUS SYSTEM. Sensibility is also diminished in combined sclerosis, but less so than in pure tabes. Electrical reactions are unaltered, at least in the early stages of the disease. With advance of the disease the features of a purely lateral sclerosis become very pronounced ; those of tabes less so. Muscular paresis and rigidity become marked, and the patient is unable to leave his bed. There is no localized atrophy of the muscles, although general wasting is not uncommon in the late stages of the disease. Very rarely there may be atrophy of the optic nerve, the ocular muscles remaining intact. The sphincters of the bladder and rectum are sometimes involved ; at others not, those of the bladder more frequently, producing difficult micturition. On the other hand, by rest and tonic treatment the spastic symptoms may be diminished, while ataxia remains unchanged and the symptoms of this con- dition become more pronounced. The mind remains normal. Diagnosis. — This is usually easy, enough of the symptoms of each lesion being present to show the existence of a combined disorder. The absence of co-ordination on the one hand and increase of knee-jerk on the other are the two antipodal symptoms around which others of each lesion cluster. Then, as to differential diagnosis, myelitis may present similar symptoms. On the other hand, myelitis is usually a disease of sudden devel- opment, characterized by a rapid increase of symptoms as contrasted with the slower course of the disease under consideration. Friedreich's ataxia resembles ataxic paraplegia closely in its pathology, but the exaggeration of the tendon reflexes and the spasticity are absent in the former. Cerebellar tumor may be mentioned with better reason as a disease which may be con- founded, but in this disease headache, optic neuritis, and vomiting are peculiar, and while there is ataxic gait, it is the reel of a drunken man, and not the inco-ordination of tabes. So, too, there may be spastic symptoms in cerebellar disease, but they are less decided than in combined sclerosis. Dis- seminated sclerosis is a disease with which combined sclerosis may be con- founded, and although it is the less pronounced forms of each which give rise to doubt, it is important to remember that the former has been found postmortem in cases which presented the clinical symptoms of spastic para- plegia during life. Whence it is not impossible that it may also present in its earlier stages symptoms of ataxic paraplegia. Prognosis. — This is unfavorable as to recovery, but the disease is so slow in its development that death commonly results from intercurrent dis- ease or from complications favored by the disease itself, such as diseases of the urinary organs, bed-sores, and septic complications. It does happen also that the disease is arrested for^ time. Treatment. — The treatment is mainly symptomatic : warm baths and a warm climate for the spastic symptoms ; massage and exercise for the ataxic symptoms. Electricity and spinal stimulants like strychnin are con- tra-indicated as calculated to increase the spastic symptoms, while bromids and belladonna may be of service in controlling these. If a specific history can be traced, the disease should be appropriately treated by iodids or mer- curials, and when anemia is present the treatment should be directed to the improvement of this condition. SYRINGOMYELIA. 941 SYRINGOMYELIA. Definition. — A term applied to all cavities in the spinal cord, most of which are surrounded by an overgrowth of neuroglia. Etiology and Morbid Anatomy. — The cavities are formed by defective closure of the central spinal canal or by the breaking down of residual embryonal tissue or of gliomatous tissue. The cavity of a syringomeylia is usually in the posterior part of the cord, extending toward the posterior cornua. It may prevail throughout the entire extent of the cord, but in most cases involves only the cervical or thoracic regions or more limited areas. The transverse section is oval or circular, but it may be fissure-like or quadrilateral, even irregular. On the other hand, a primary hemorrhage of traumatic origin, or even without trauma, may be the starting-point of a syringomyelia, and it has been supposed that such a hemorrhage into the spinal cord, occurring at birth from difficult labor, may later in life cause the symptoms of syringomyelia. So, also, compression of the cord due to fracture or dislocation may furnish the condition which will result in dilata- tion of the cervical canal of the cord. The cavities may be multiple. The term hydromyelia, applied to the forms in which the cavity is merely the dilated central canal, is falling into disuse, and there is no real difference between this and the other varieties. It is probable that hydromyelia may change into syringomyelia. Symptoms. — The milder degrees are without symptoms and are often overlooked. Symptoms usually make their appearance about the period of adolescence. They are mostly gradual in development, and are partly the result of the secondary processes of distention which derange natural function. The symptoms are influenced also by the situation of the cavity, which is found most frequently in the cervico-thoracic region, whence the arms and neck are correspondingly affected. They depend also on the greater involvement of the gray matter of the cord. The essential symptoms are modified sensibility; chiefly to pain, tem- terature, and to a less degree simple touch ; also muscular atrophy, the latter progressive in development; and trophic disturb an^ces. The sensory symptoms are the earlier and more constant. The sense of tactile im- pression is lost by involvement of its path, which, as has been said, is not precisely known after it enters the posterior roots, though it is possibly, partly in the posterior columns. The comparative rarity of this involve- ment may be said to be due to the difficulty in destroying this path com- pletely. Derangement of the sense of pain and thermal sense is probably due to implication of the central gray matter, since it is through it that these impressions probably radiate to the white conducting tracts of the opposite side. The extension of the process to the lateral columns probably explains the derangement of these senses in portions of the body below the level of the cavity in the spinal cord. There may not only be a loss of thermal sense, but it may be reversed in that heat is felt as cold, and vice versa. So, also, subjective sensations are felt, including heat and cold, or, in their absence, pain, which mav be neuralgic in character and irregular. The muscular atrophy is the result of injury to the motor cells of the anterior cornua from compression or destruction of these cells. This causes degeneration of the nerves and wasting of the muscles, and along with it is a lowered electrical irritability. There is also muscular weak- 942 DISEASES OF THE NERVOUS SYSTEM. ness, involving the trunk muscles, and possibly to this is due the lateral cur- vature. If the legs are affected, it is generally from simple spastic paralysis from pressure on the pyramidal tracts, but sensory changes in the lower limbs occur. Great wasting of the legs indicates lumbar involvement, and the presence of ataxic symptoms points to involvement oi the posterior columns. The remaining symptoms are not essential, but may be incidentally present from the action of the causes which usually produce them. The reiiexes may or may not be increased, and myotatic irritability may in rare cases be lost, while tremor of the limbs has been noticed in some cases. Trophic symptoms are not rare in the parts affected by sensory loss. The skin may be glossy and thin, or thick and horny, while there may be eczema, herpes, bullae, and even ulceration and gangrene. The nails may become fissured and drop off. There may be deformity and absence of the end phalanges and lingual hematrophy. Vasomotor disturbances are more common, including coldness, lividity, or redness with swelling and heat. There may be sweating, brittleness of bone, and joint changes like those of tabes. The area of the cranial nerves may be invaded when there is involve- ment of the medulla oblongata. The phenomena may include paralysis of one vocal cord, the tongue and face, difficulty in swallowing, of breathing, and embarrassed heart's action. The eyes may be disordered, and the pupils unequal, but the other special senses escape. Diagnosis. — This is based upon the sensory S3aiiptoms, and of these thermo-anesthesia and analgesia rather than tactile insensibility, together with muscular atrophy succeeding after some interval. Cervical pachymen- ingitis causes like symptoms similarly distributed. J. Hendrie Lloyd, in an important paper,* has also called attention to certain traumatic affections of the cervical region of the cord simulating syringomyelia. Cervical pachy- meningitis runs a more rapid course; the anesthesia includes all varieties of sensation and corresponds more nearly in its distribution to that of the muscular atrophy, pain is more conspicuous, and the reaction of degeneration is commonly present in the wasting muscles, and later, signs of compression of the cord are observed. The symptoms of syringomyelia are sometimes simulated by the anes- thesia and wasting of anesthetic leprosy, but in the latter disease the trophic changes are more marked, the phalanges often drop off, while the sensory symptoms include all varieties of sensation. Progressive muscular atrophy differs in the absence of altered sensation. An intramedullary spinal tumour in the same situation as a syringomyelia furnishes almost identical symptoms, and may have an identical origin if it starts from the neuroglia, but the symptoms may be more rapid in their development. The diagnosis of syringomyelia is sometimes exceedingly difficult to make, as the characteristic disturbances of sensation may be absent. Prognosis. — This is ultimately fatal, although the course is slow, extending over a period from fifteen to twenty years. Toward the end the course is more rapid, death resulting from exhaustion or interference with the functions of the medulla oblongata. Treatment. — This can only consist in measures to combat symptoms and tendencies to them, such as cystitis, bed-sores, and the like. * Read before the Philadelphia Neurological Society, March 26, 1894. COMPRESSION OF THE SPINAL CORD. 943 Morvan's Disease. Synonyms. — Analgia Panaritium; Analgesic Paresis with Panaritium; Painless Whitlows. Definition. — This term is applied to a chronic affection described in 1883 by a Breton physician named Morvan, which is characterized by neu- ralgic pains, tactile and thermal anesthesia, analgesia, and painless destructive felons (paronychia). The disease is probably in most cases the same as syringomyelia; in some instances it is leprosy. Twenty cases were recognized in a population of 50,000 in Brittany. One or two cases have been reported in America. Zambuco, of Constantinople, found in the broken-down matter of the syringomyelic cavity of what seemed a typical case, Hansen's lepra bacillus. In two well-studied cases reported by Marinesco and Jeanselme to the Societe Medicale des Hopitaux de Paris, February 12, 1897, the typical lesions were found, but no bacilli. COMPRESSION OF THE SPINAL CORD. Synonyms. — Compression Myelitis; Pressure Paralysis of the Spinal Cord. Definition. — Under this head are included all forms of paralysis due to gradual compression of the cord from whatever cause. Etiology. — A large number of causes may operate in the way indi- cated, among which are tumors or inflammatory new formations, including syphilitic products either in the membranes or outside of them, caries of the vertebrae, especially the form known as Pott's disease or tuberculosis of the vertebrae, cancer of the vertebrae, echinococci and cysticerci in the ver- tebral canal. Extraspinal causes may also produce erosion of the vertebrae and compression of the cord ; among these are aneurysm of the aorta,, retroperitoneal sarcoma, lymphadenoid growths, and suppurating kidney; also retropharyngeal abscess. Pott's disease is by far the most frequent cause. Morbid Anatomy. — The changes in the cord as the result of com- pression are best studied in the compressions due to dislocation of the ver- tebrae in the breaking down of the bodies of one or more from tubercular infiltration, or as the result of intrusion into the spinal canal of foci of cheesy pus from the posterior surface of the bodies of the vertebrae. Macro- scopically, the cord is often smaller, softer, and sometimes bent. In old cases it may be harder. The term myelitis has been applied to the changes thus produced in the cord, but careful examination fails in some cases to find any of the usual histological products of inflammation. In the early stages the axis-cylinders are swollen, and fatty granular cells may be present. The nerve-cells suffer more or less alteration depending on the degree of pressure. At a later stage may be seen a secondar}^ overgrowth of neu- roglia, replacing the destroyed nervous tissue, first loose, later firm and fibrillated. After a certain duration there may be ascending and descending secondary degeneration of certain systems of fibers in the spinal cord. Symptoms. — When tubercular disease of the spine is the cause, the resulting deformity — kyphosis — is usually seen long before the symptoms 944 DISEASES OF THE NERVOUS SYSTEM. of compression of the cord are present. On the other hand, when the erosion is due to aneurysm or growths within the thorax or abdomen, the subjective symptoms appear before the deformity, or more frequently with- out external deformity. The first of these symptoms is usually pain at the seat of the compression, which often does not amount to more than a dull ache, w^hile at another time it is extremely severe. It is also aggravated by bending or straightening the body. Again, the pain is distributed along the course of the nerves, when the compression is exerted on the nerve- roots. Previous to such pain and associated with it are paresthesias of various kinds, such as numbness, tingling, and formication. More rarely there is impaired sensibility, the same degree of pressure which deranges the function of motor fibers having often no effect on the sensory. Marked anesthesia is rare, and then only in the last stages. With the foregoing soon become associated motor symptoms, which may consist in stiffness, giving rise to difficulty in moving arms or legs, with peculiarity of gait, or there may be simple w^eakness or paresis, increasing to complete motor paralysis. These symptoms rarely affect both arms or legs at once, but rather first one and then the other. The seat of the more pronounced sensory and motor symptoms varies with the segment compressed. Thus, when the caries is in the upper cer- vical region, between the axis and the atlas, or between the latter and the occipital bone, there may be spasm of the cervical muscles, the head may be fixed, and movements may either be impossible or extremely painful. Retropharyngeal abscess may be the cause of such a symptom, as in a case in the Montreal General Hospital mentioned by Osier, where movement was liable to be followed by transient instantaneous paralysis of all four extremities from the compression of the cord, the patient dying in one of the attacks. If in the lozver cervical region, there may be dilatation of the pupils from interference with the ciliospinal center or nerve-fibers arising in this center. There may be flushing of the face and ear on one side or nnilateral szveating, rigidity of the muscles of the neck, while the sensory and motor symptoms described, if present, will be found in the arms. The deformity of tuberculous caries is not always marked in this locality, but after recovery evidence of its presence may be found in a conspicuous callus, which may cause permanent rigidity of the neck. The cortical inhibitory influence "being suspended, both tendon and cutaneous reflexes are increased, some- times so markedly as to produce in the lower extremities a pronounced type of the spastic paralysis, with^ increased patellar reflex and ankle clonus. The increase of the skin reflexes is less marked than that of the tendons. When the thoracic and lumbar segments are involved, only the lozver extremities suffer from the effect of compression ; commonly the paresis is late, though rarely it may appear before the deformity of Pott's disease. When the lesion is confined to the thoracic region, there may be girdle sen- sation and pain in the course of the intercostal nerves. Here, as elsewhere, motion is affected before sensation. As to the reflexes, since the reflex arc for the lower tendon reflexes is in the lumbar region, compression of the thoracic cord should produce an increase in them, and this is usually the case. On the other hand, they are diminished when the lumbar cord is compressed. If the lower thoracic and lumbo-sacral region is aft'ected, the sphincters are apt to be involved, and there is, first, difficulty in micturition, then retention, and finally incontinence with cystitis, but the sphincters may COMPRESSION OF THE SPINAL CORD. 945 also be involved from lesions higher in the cord. Yet all these symptoms may disappear, and recovery take place after many months' duration of the disease. Trophic symptoms may be present in the paralyzed parts. These may include herpetic eruptions in the course of the nerves, at other times derange- ment of nutrition, manifested by bed-sores forming on slight irritative provocation, rapid shedding of the epidermis, and brittleness of the nails. With the involvement of their trophic center the muscles may waste. Diagnosis. — This is easy when there are evident signs of caries of the spine, manifested by prominence of spinous processes of the vertebrse and by tenderness on pressure. Repeated examination of the spine should be made. Nerve-root symptoms, or symptoms resulting from pressure of nerve- roots, as they pass out between the vertebrse, are always significant. They include radiating pains, girdle sensation, and hyperesthesia or anesthesia, spasm and wasting. Stiffness on motion in separate parts of the spinal column is also significant. Root symptoms are said to be more common in cancer than in caries, but any of the symptoms named have increased diagnostic value if there has been cancer elsewhere, especially of the breast, and if the age exceeds forty. There is much more pain attending the paraplegia of cancer — whence the term paraplegia, dolorosa, and when the pain is referred to areas anesthetic to tactile and painful im^pressions, ancesthesia dolorosa. Such is the case whenever erosion is wrought from the abdomen outward, as by retroperitoneal growths or aneurysm. Prognosis, — This is unfavorable in all cases except tuberculous spon- dylitis, which often terminates in cure, for, sooner or later, especially with suitable treatment, the tuberculous process may cease and the symptoms of paralysis disappear, although, of course, the kyphosis remains. Some cases perish from miliary tuberculosis, others from the exhaustion incident to bed- sores, cystitis^ and pyelonephritis. Treatment. — Only when tuberculous spondylitis is responsible is there hope of cure. The treatment is general, by the usual measures found useful in tuberculosis, such as cod-liver oil and creasote or creasotol, with such tonics as iron and iodin, good food, fresh air, and mechanical appliances suggested by the orthopedic surgeon. These should be so adjusted as not to produce pain. Their object is to produce extension and thus relieve com- pression, and if this is not accomplished, they are useless. The method of extension by suspension, originally suggested by the late Dr. J. K. Mit- chell, and more recently revived by Weir ]\Iitchell and extensively prac- ticed of late years, has again fallen into comparative disuse, partly because of the difficulties in carrying it out, and perhaps because there have been some unfortunate accidents. Good results have, however, followed its use. Especiallv may such results be hoped for if the extension is used early, although they have followed even after paralysis had supervened. Along with the extension, rest in bed is a most important measure, and many cases are arrested by such rest. Local measures, like counter- irritation and the hot iron, are of no use — rather harmful than otherwise. The same may be said of electrical treatment and massage, except so far as they are useful to keep up the nutrition in the paralyzed muscles. On the other hand, warm bathing is useful in relieving pain and allaying dis- comfort. Operative treatment — laminectomy — has lately been practiced with a good showing of result, and it should be considered, at least, after other 60 946 DISEASES OF THE NERVOUS SYSTEM. measures have failed. Treatment should be persevered in, as recovery takes place sometimes after paralysis has long persisted, and in no form of tuberculosis has the general treatment previously recommended been so useful. In the incurable forms anodynes must be resorted to to relieve pain, including even the hypodermic use of morphin, which should never be used without bearing in mind the possibility of the patient acquiring the morphin habit. TUMORS OF THE SPIXAL CORD AXD ^lEMBRAXES. Both the memibranes and the substance of the cord may be seats of tumors, while the cord may also be invaded from the spinal column by enchondroma or sarcoma. Varieties. — From the spinal column, enchondroma, sarcoma, and can- cer may intrude into the canal. External to the dura mater in the extra- dural space occur fatty and malignant tumors, while parasites are also found in this region. The extradural tumors, all rare, may spring from the dura or from the tissue between it and the bone, or may arise outside and pass Fig. 109. — Sarcoma of the Lower Cervical Fig. no. — Sarcoma Compressing the Cordi—{Ada}nkze2uzcs). Cervical Cord— (£". Long Fox). through the intervertebral foramina. Within the dura are found myxomata, fibromata, lipomata, and neuromata on the nerve-roots. Subdural tumors may arise from the inner surface of the dura, the arachnoid, or from the pia, and may include sarcomata, syphilitic, tuberculous, and parasitic growths. The last two are rare, but both echinococci and cysticerci have been met, developing in the meshes of the arachnoid. Schlesinger collected forty-four cases of ecchinococcus disease. When the parasite is intradural it is round or oval and compresses the cord. The dura is not usually impli- cated, merely distended. Of the forty-four cases onlv five were intradural. TUMORS OF THE SPINAL CORD. 947 so that the extradural location is seven times more frequent than the intra- dural. They are usually on the posterior surface of the cord and in the thoracic portion of the vertebral canal, at least in the extradural variety. They may be the size of a pea, of a walnut, or even larger. Their contents are clear and they often contain daughter cysts. Their growth is usually slow. It is said that the hydatids are sometimes found in the substance of the bone. Fatty tumors are also rare, but have been found and are probably con- genital, because they were usually found associated with spina bifida. In the cord itself and attached to the pia occur tuberculous, syphilitic, and glio- matous tumors ; sarcomata and myxomata have been found. Syphiloma and sarcoma are the most common. Most of these tumors spring from the pia mater, but tuberculous growths also develop in the gray matter. Some tumors are compound, as myxosarcoma, etc. The size attained by tumors of the spinal cord and membranes is neces- sarily limited by the surrounding space. The largest do not exceed two inches (5 cm.) in diameter, and many are very small, not larger than a pea. They are usually single, rarely multiple, as seen in the instance oi neuromata, and occasionally sarcomata. Tumors developing within the cord may lead to syringomyelia. Symptoms. — These vary with the seat of the tumor and the degree of pressure exerted. When the latter increases slowly, the growth . may reach quite a large size before serious mischief is done. Pain is a frequent and conspicuous symptom, and is apt to be maintained by pressure on nerve- roots which are in the way of the growth. The seat of pain varies with the course of the nerves impinged upon, and may be of every variety, such as " burning," " tearing," '* stabbing," " aching," " girdle sensations." and the like. It may be unilateral or bilateral, and is worse, according to Horsley, when the tumor presses forward. Sometimes the pain is in the spine itself, which may also in rare instances be tender to pressure. When the growth is in the lower lumbar region, the pain may be referred to the soles of the feet, and may ascend from this seat. In other cases there is hyperesthesia of the skin, which may be associated with pain felt at the level of the tumor, or pain may be felt in anesthetic areas. Very rarely pain is absent, chiefly in extradural lipoma. Muscular spasm is also frequent, especially when the tumor springs from the membranes, when it may be very decided. There may be rigidity at the seat of the growth, most marked when the disease is at the more mobile parts of the spine, as the cervical region. Then there is apt to be pain in the vicinity, increased by motion. Spasm in the abdominal muscles may also be associated with girdle pains. Contractures may arise in the limbs, both those supplied by nerves directly irritated by the tumor and by those gi,ven off lower down. It is important to note the seat of the rigidity and its character, which may aid us in diagnosing the seat of the tumor, whether it is on the nerve-roots or conducting tract of the cord. Thus, a tumor in one-half of the cord, in the cervical region, may cause persistent contraction of the arm and leg on the side of the growth, and in the early stage of thoracic tumors one leg only, may be rigid at a time or one may be more so than the other. In the dorsal region the level of the pain is apt to correspond accurately with the level of the growth, and the reflexes centering at this level may be lost, but retained in the legs. Paralysis occurs sooner or later as constantly as pain, increasing grad- 948 DISEASES OF THE NERVOUS SYSTEM. ually with the pressure. Paraplegia is more common, but all four limbs may be paralyzed by a tumor in the cervical region, one limb being usually affected before the other, though when the tumor is exactly central, both sides are affected simultaneously. Loss of sensation follows paralysis sooner or later. It corresponds in distribution to the motor palsy when the tumor is below the middle of the dorsal region, but if higher and on one side, the sensory loss may be greater on the opposite side; especially is this the case when the tumor is within the cord, when the symptoms may be those already described under the head of Brown-Sequard's paralysis. Atrophy follows involvement of the anterior cornua, and vasomotor dis- turbances may be marked. In cases of prolonged interruption ascending and descending degenerations may occur. Tumors not infrequently cause subacute or acute myelitis, whose symptoms may mask the clinical picture. Diagnosis. — The characteristic symptoms are slow development of severe and constant unilateral root symptoms, later bilateral, at the level of the growth, and a progressive paralysis, motor and sensory. The radiating pain is usually at the level of the tumor or below. Pain in the spine itself is an important sign. Rigidity of the muscles of the spine, muscular contrac- tions in the limbs, early and marked exaggeration of reflex action when the cord itself is involved, are also important signs, especially when associated with the history of syphilis or tuberculous disease. Caries of the spine may produce the same symptoms, but the radiating pains are less severe and the effects of compression of the cord are more likely to be bilateral, either from the first or soon after their commencement. Tenderness of the spine may generally be elicited by careful examination, while irregularity of surface, from the breaking down of the bone, sooner or later makes its appearance. When the tumor is in the bone itself, the symptoms at first scarcely dift'er from those of caries, though the pain on motion is usually worse in the former. The symptoms of cervical meningitis also closely resemble those of tumor. They are, however, usually bilateral from the first and have con- siderable vertical extent. Central tumors covering a like area may produce identical symptoms. Pain and muscular atrophy in the arms without wast- ing occur in both, but are usually less severe in tumor, while the early and localized impairment of all forms of sensation is less. Chronic transverse myelitis also closely simulates tumor in its radiating pain, sense of constriction, progressive paralysis, and a differential diag- nosis is sometimes impossible. The symptoms here, too, are from the first bilateral, while the radiating pain is commonly not severe in myelitis, which invades also larger areas of the cord. As to the exact seat of the tumor, in general terms it may be said that when ivithin the cord, the symptoms are those of a gradually increasing para- plegia or of a Brown-Sequard's paralysis, while vasomotor disturbances are marked, and reflexes are bilaterally influenced, according to the law explained. Atrophy means involvement of the ventral cornua. Acute or subacute myelitis may be associated and complicate the clinical picture. Tumors in the membranes are characterized by early " root symptoms," including radiating pains, girdle sensation, and hyperesthesia or anesthesia. Irritation of motor nerves may cause spasm or wasting, with paralysis late in the disease. The nature of the tumor may be inferred only from the history of the case, syphilis and tuberculosis giving the most valuable assistance. Its seat LESIONS OF THE CAUDA EQUINA. 949 is suggested by the level of the transverse symptoms. It is never below these, while it may be a distance of three or four vertebrae above the nerves corresponding to the highest level of anesthesia or pain. The diagnosis of tumor from other transverse lesions of the cord may be at times impossible. Prognosis. — Only when the tumor is syphilitic may any relief be ex- pected from medical treatment. In all other forms the symptoms gradually increase until paralysis results, unless operative interference produces a more favorable termination — a practice which modern methods are rendering more frequent and justifiable. Treatment. — When there is reason to believe syphilis is present, the antisyphilitic treatment may be used with reasonable expectation of success.. Beyond this, symptoms must be met as they arise. Attempts made of late years to formulate the laws governing surgical operations in these cases have been more or less successful, but wider experience is necessary before they can be thoroughly relied upon. I may, however, close this subject wnth the advice of Victor Horsley, whose studies on surgery of the nervous system entitle his opinion to the highest respect : " If it is clear that the growth is not syphilitic, and that no good can be done by other treatment, delay in an operation can only cause harm — can only result in a less favorable state for the proceeding, less chance of recoverv', longer and greater suffering, and should, on every ground, be avoided." LESIONS OF THE CAUDA EQUINA AND CONUS MEDULLARIS. The Cauda equina is the bundle of nerves coming oiif from the lower cord and occup3"ing the spinal canal from the second lumbar vertebra down- ward. At this vertebra the cord itself terminates in the conns medullaris, prolonged into the thread-like iilujn terminale. Fractures and dislocations in the lumbosacral region may impinge on these parts, while the filaments of the nerves of the cauda equina may be invaded by tumors or compressed by cicatrices. Symptoms. — Compression of the conus and of the IcDst sacral nerves given off from it, such as may be caused by a dislocation of the first lumba^- vertebra, produces paralysis of the bladder and rectum and loss of sexual power, whence it has been inferred that the anovesical center and the center for the sexual function are seated in this part of the cord. This paralysis may be the only symptom or it may be associated with disturbance of sensa- tion about the anus and in the perineum and external genital organs except the testicle, the latter being supplied with sensation from a higher segment d the cord. When the lumbar nerve-roots'^^ are involved, from the second to the fourth inclusive, there is paralysis embracing all the muscles of the thigh and leg except the outer rotators of the thigh the flexors of the knee and of the ankles, the peroneal muscles, the long flexors of the toes, and the small foot muscles. There is also loss of sensation in the front, inner, and outer parts of the thighs and the inner side of the I'eg and foot. Involvement of the fifth lumbar and first and second sacral produces * Of the lumbar nerves, the first root appears between the first and second lumbar vertebra, the fifth between the last lumbar and the base of the sacrum. The four upper sacral nerves pass from the spinal canal through the sacral foramina, the fifth between the sacrum and coccyx. 950 DISEASES OF THE NERVOUS SYSTEM. paralysis of the muscles just excepted, and loss of sensation in the outer and posterior part of the leg, foot, and sole of the foot. Lesion of the third, fourth, and fifth sacral and coccygeal nerves causes paralysis of the perineal muscles, the bladder, rectum, and of the external genitals, the cocc}geus, with loss of sensation in the back of the thigh, anus, perineum, genital organs, and skin about the anus and coccyx. SPINA BIFIDA. Synonyms. — Split Spine ; Hydrorrachis; Myelocele; Meningocele. Definition. — A name applied to a congenital defect in the closure of the spinal canal, through which protrudes a sac-like portion of the dura contain- ing cerebrospinal fluid, at times a part of the cord, either normal or altered, and forming also, as a rule, an external prominence of tumor covered by skin. Description. — The tumor is found commonly in the lumbar and sacral portions of the spine, rarely in more than one place, very rarely throughout the whole column. Its size ranges from that of a small nut to that of an orange, and occasionally it is so large as to interfere with the birth of a child afflicted with it. On section of the skin the protruding sac of the dura is seen and beneath this the arachnoid. Barely is the dura cleft so that the sac is formed by the arachnoid only. There may be a dilatation of the central canal, — hydromyelia, — when the substance of the cord is found more or less atrophied, while the central canal communicates directly with the cavity of the spina bifida. At other times the cord is normal, while its lower end may be adherent to the sac. A tumor of similar character is occasionally seen protruding through the skull. Symptoms. — At first there are usually no clinical symptoms. By pres- sure the contents of the tumor can often be forced into the spinal canal, caus- ing expansion of the fontanels and increase of cerebral pressure with its con- sequences — viz., somnolence, with changes in the pulse and breathing, which may be fatal if the pressure is continued. The absence of such symptoms goes to show that communication of the tumor with the spinal cord is cut ofif. With the lapse of time the tumor usually grows slowly, and the effects of pressure on the spinal cord or cauda equina appear. These are paralysis, atrophy, anesthesia, bed-sore^, vesical derangements, talipes varus, and trophic phenomena, of w^hich perforating ulcer of the foot is one. The sac may burst, or the walls become inflamed, converting the contents into pus. Prognosis and Treatment. — Unless removed by surgical interference, the child dies sooner or later of exhaustion. The tumor has been rarely obliterated by gradually increasing pressure or by injecting the cavity, after evacuation of the fluid, with iodin, producing obliteration through an inflam- matory process. Other surgical measures m^y be found in text-books on surgery. PROGRESSIVE BULBAR PALSY, 951 PROGRESSIVE BULBAR PALSY. Synonyms. — Polioencephalitis inferior chronica; Glossolahiolaryngeal Par- alysis; Paralysis of the Tongue, the Soft Palate, and the Lips; Du- chenne's Disease; Atrophic Bulbar Paralysis. Definition. — Bulbar palsy is a progressive paralysis invading the lips, the tongue, the palate, the pharynx and larynx, and in more advanced cases the low^er face muscles, due to lesion of the motor nuclei in the medulla oblongata (or bulb), whence arise the nerves distributed to those parts. Historical. — Bulbar palsy was first completely described in its clinical aspects by Duchenne in i860, but the exact seat of the disease was not determined until 1870, when Charcot in France and E. Leyden in Germany confirmed the earlier suggestion that it was a progressive degeneration and atrophy of the nuclei in the medulla oblongata. Etiology. — Primary progressive bulbar palsy is difficult to account for. It is more frequent in men, and sometimes heredity or family tendency is noted. It has been ascribed to the overuse of the muscles of the mouth, as Fig. III. — Situation of the Cranial Nerves — {after Editiger). Cranial nerve nuclei, oblongata, and pons represented as transparent. Motor nuclei, black; sensitive nuclei, red. in the blowing of wind-instruments ; to a tumor in the medulla oblongata or vicinity ; while syphilis, to which so many of the unaccountable lesions of the nervous system are ascribed, is less commonly held responsible for this affection than for some others. Q>ld, emotional excitement, and extreme fatigue have all been named as causes. Most frequently, however, no cause is traceable. Morbid Anatomy. — Most writers concede that the lesion starts in the nuclei of the medulla oblongata. It may be that the entire motor apparatus from the muscular fiber to the gangHonic cell is invaded simultaneously. Certain it is that bulbar paralysis is often associated both with progressive spinal muscular atrophy and amyotrophic lateral sclerosis, the symptoms now o£ one and now of the other preceding. There can be no doubt that these three conditions are closelv allied. The nature of the lesion is the same in 952 DISEASES OF THE NERVOUS SYSTEM. each, the motor cells in each are involved, the muscles are wasted in each, though the particular ones involved vary as the situation of the motor cells is different. The anatomical lesion is an atrophy of the motor cells of the medulla oblongata. The nucleus of the hypoglossus, the nucleus of the pneumogas- tric, to a less degree, that of the facial and that of the glossopharyngeal are all involved, while the sensory nuclei are intact. Very rarely the nuclei of the ocular nerves, third, fourth, and sixth, are involved. From these nuclei the degeneration extends to the nerves which have their origin in them, and thence to the muscles to which they are distributed. The nature of the degeneration is a more or less complete destruction of the motor cells. In addition, there is an overgrowth of neuroglia tissue and a thickening of the walls of the blood-vessels. The nerve-fibers of the pyramidal tract may undergo degeneration. Symptoms. — The symptoms of progressive bulbar paralysis are exceed- ingly gradual in their development. The first symptom noticeable is usually a diMculty in the pronunciation of zvords containing letters which require the use of the tongue in their formation, such as E, R, L, S, G (hard), K, D, T, and N. Still later there is difficulty in pronunciation of words requir- ing the aid of the lips, as P, B, F, V, O, A (long), and the sound of O in tool, while whispering becomes impossible. Concurrently with these symptoms the tongue and lips are observed to waste, the tongue becomes thinner and narrower, the lips thin and com- pressed in appearance, the loss of power being commensurate with the degree of wasting. Fibrillar tremors are usually seen in the tongue, and the mucous membrane may be thrown into transverse folds. Finally, the tongue cannot be protruded, or can be brought only to the edge of the teeth, while the mouth cannot be closed because of complete paralysis of the orbicu- laris oris muscle. In more advanced stages other muscles of the face become' involved, the labionasal fold is less distinct, and the face becomes expres- sionless. Before this degree has been attained, however, the muscles of the palate have commenced to fail in their action, and thus a further difficulty in the articulation of words is added, while the z'oice is nasal. Fluid begins to pass through the nose when swallowing is attempted. The difficulty in swallowing is increased by growing paralysis of the pharyngeal muscles, and is further aggravated by the inability of the tongue to carry the bolus of food backward. Feeding the patient is a troublesome and disgusting proc- ess, the food being scattered all about and sometimes thrown to a consid- erable distance, by the act of coughing facilitated by absence of power in the lips to retain substances in the mouth. By this time, too, the larnygeal muscles are involved, and the patient's efforts to speak result in mere grunts. Thus he cannot talk, he cannot swallow, he cannot close his mouth r he cannot expectorate, yet the saliva flows from his mouth because he can neither swallow nor close his lips, and the term " driveling idiot " well covers the impression caused by his appearance. Yet his mental powers are unim- paired, and may remain so until the last. The motor electrical phenomena in the muscles involved may be altered, and the reaction of degeneration may be present. To these symptoms are to be added complications due to the paralysis. From the difficulty in swallowing, particles of food may enter the larynx, be PROGRESSIVE BULBAR PALSY. 953 insufflated to the deeper parts of the lungs, and there cause a pneumonia which may be fatal, or the fragment which enters the larynx may be so large as to cause death by suft'ocation. In rare cases the lower distribution of both facial nerves is involved, producing diplegia facialis; but the upper distribution usually escapes. Or there mav be paralysis of the ocular nerves to which it may be confined ( an- terior bulbar paralysis or progressive ophthalmoplegia of von Graefej. Even the muscles supplied by the spinal accessory and the motor branch of the trifacial may be invaded. In all these instances the nuclei of the cor- responding nerves are afifected. Diagnosis. — The diagnosis is generally easy, the symptoms are so characteristic and so evident. For a typical case they must be purely motor; they must be disassociated from other nmscular involvements which would go to make them a part oi progressive spinal muscular paralysis or amxotrophic lateral sclerosis. If there are disturbances of sensation, invasion of the upper division of the facial, of nerves of special sense, the disease is not true bulbar paralysis. There must be some general involve- ment of the medulla, thrombosis, or embolism, a tumor developing near it or diffuse sclerosis through it. There is a glossolabiopharyngeal paralysis of cerebral origin known as " pseudobulbar paralysis," in which there is complete paralysis of the tongue and lips, due to bilateral and possibly even unilateral cerebral lesions. Close examination will, however, detect, sooner or later, deviations from the typical course, which include absence of fibrillary tremor, and of atrophy, and of reaction of degeneration. The symptoms tend, too, to occur first on one side and later on the other. ^Mentality is much affected, and the reflexes may be exaggerated. Bulbar tumors run a like chronic course, but almost always presents unilateral symptoms. Prognosis. — This is invariably sooner or later fatal, although it is said that the progress of the disease may be delayed by treatment. Treatment. — If there be any suspicion that syphilis is the cause, iodid of potassium should be used, but the treatment which has been found most effectual is electrical. Galvanism is recommended, electrodes being applied to the tw^o mastoid processes daily for two or three minutes, the current often reversed. The sympathetic nerve and the affected muscles of the lips and the tongue may be similarly treated, faradization being also substituted for galvanism in the case of the muscles. Deglutition may even be excited by galvanism when it begins to be impaired. This is accomplished by placing the anode on the nape of the neck and the cathode on one side of the lar3"nx. At everv cathodal closure, or every time that the cathode is carried across the side of the larynx, there is a reflex act of deglutition. When deglutition becomes very difficult, the stomach-tube should be used and nutrient substances thus introduced. Great care should be exercised in feeding the patient without the tube, lest the food pass into the trachea and cause suffocation. Hence, too, the use of the tube should not be too long deferred. In addition to iodid of potassium, nitrate of silver and ergot are also recommended. The first should be given in such doses as the stomach will tolerate, while salivation may be controlled by atropin — i-ioo to 1-60 grain ro.ooo66 to o.ooii gm.). Silver should be given in the usual doses of 1-6 to 1-4 gr. (0.0106 to 0.016 gm.) ; ergot in usual doses. 954 DISEASES OF THE NERVOUS SYSTEM. Acute Bulbar Palsy. Etiology. — Besides the chronic or progressive form of bulbar palsy, there is an acute variety which is caused by hemorrhage into the pons and medulla, or possibly by thrombosis or embolism of the vessels supplying these centers — viz., the anterior spinal, vertebral, and basilar. Inflamma- tion of the medulla oblongata is also a cause. Thrombosis mav occur in any of the vessels, and is commonly due to atheromatous or syphilitic en- darteritis. Inflammation is a rare affection, but does occasionallv occur. Hemorrhage, thrombosis, and embolism are subject to the same causes here as elsewhere in the brain, but the cause of the inflammatory form of acute bulbar palsy is unknown. It is probably infection or intoxication. Symptoms. — In any event the symptoms are sudden. They are those already detailed in connection with progressive bulbar paralysis, but others are added. There is usually no loss of consciousness, though there may be. There may also be deranged cardiac action and respiration, including irregular and frequent pulse, vasomotor derangements, and Cheyne-Stokes breathing. The temperature, normal at first, may rise to 105° to 107° F. (40.5° to 40.71° C.) and higher as a fatal termination is approached. Sen- sation is rarely aft'ected. ]\Iost characteristic of all is the so-called crossed paralysis, described on page 844, which attends most hemorrhages into the pons, in which there is paralysis of the face on one side and of the extremities on the other; but the motor tract may not be involved, and in that case paralysis is not obsen'ed. Diagnosis. — Suddenness of occurrence of the symptoms named indi- cates one of the accidents previously mentioned, while a crossed hemiplegia is conclusive. \Mien inflammation of the medulla oblongata is present, the phenomena of bulbar paralysis do not occur quite so suddenly. They may "be several days or even a few weeks in developing, and may be preceded by prodromal symptoms such as vertigo and painful sensations in the back of the neck. Treatment. — The treatment is the same as for similar lesions else- where in the brain. PSEUDOPARALYTIC MYASTHENIA. Synonyms. — Bulbar Palsy zvifhoiif Discernible Anatomical Changes; As- thenic Bulbar Paralysis: General Profound Myasthenia ; Erb's Disease; Hoope-Goldflam Symptom Complex; Myasthenia Gravis. Definition. — A disease beginning usually with weakness of the muscles of the tongue, lips, lar\-nx. and eyes, followed by rapid exhaustion and tem- porary paralysis of the muscles of the extremities ; by temporary recoverv' of power after rest ; occasionally terminating in persistent paralysis. It is more common than the true bulbar palsy. History. — The disease was first described by Wilkes in 1877 as " an tinusual form of glosso-labio-]arynp;-eal paralysis." In 1879 Erb reported three cases which he described as a new SA-ndrone, probably of bulbar ori.sfin. It, however, attracted little attention until the publication of Goldflam's paper in 1891. In 1891 and 1892 Jolly, PSEUDOPARALYTIC MYASTHENIA. 955 and in 1892 Hoope published reports of cases; also in 1892 Goldflam published his paper in which were collected all cases published up to that date with four new cases. In 1S96 Striimpell collected twenty cases. In 1900 Harry Campbell and Edwin Bramwell made the most complete study of the cases so far as published — in all about seventy. They give the details of sixty. In a later paper* Edwin B'-amwell says up to the present time only some eighty or possiblj^ ninety cases have been reported. Etiology and Pathology. — The disease occurs usually in those from twenty to forty years of age, and in both sexes alike. It is believed to be due to an autogenetic toxin. Congenital defect or abnormality either in the construction or mode of functionating of the neuro-motor apparatus rather than in the muscles, has been suggested by E. Bramwell, and especially the lower motor-neuron. It has followed the infectious diseases, and in about one-fourth of the cases neuropathic heredity has been noted. At necropsy no lesion has been found which would account for the symp- toms. Symptoms. — These include ptosis, paresis of the facial muscles, difficult mastication, and difficulty in swallowing and talking. They are due to fatigue of the muscles involved, and the patient can talk a few sentences quite glibly, but his speech soon grows indistinct and ultimately incom- prehensible. So with chewing and swallowing so far as the first mouthfuls are concerned, but these acts soon become impossible. The muscles of the extremities and trunk, as well as those innervated by the cranial nerves are involved, the same rapid fatigue supervening on effort. Thus one of Striim- pell's patients could ascend a flight of stairs very well once, but in making a second effort had to invoke the aid of a bannister, while the third and fourth efforts were ineffectual. Such a condition is known as the myas- thenic state. At times the abnormal fatigue and consequent symptoms are limited to the lower extremities. A similar effect succeeds on continued faradization of the muscles, first detected by Jolly, and is called the myas- thenic reaction. Almost equally characteristic is the disappearance of fatigue after the muscles have been put at rest for a time. Diagnosis. — In well-marked cases this is easy, but when the symptom? are less pronounced, there may be difficulty. Cases are often met, especially in hysterical women, who complain of inability to hold up the head, which clearly do not belong to this class. But it is to be remembered that true myasthenia gravis is something very different from hysteria. An ability to use the muscles at first, followed rapidly by an opposite state, must always be looked for, and these conditions must be applicable to the muscles of the lower extremities, as well as to those of the bulbar nerves. The absence of muscular atrophy is essential to myasthenia gravis ; there is more apt to be ocular and upper face paralysis as contrasted with bulbar palsy. The myasthenic reaction should be sought. The muscles respond normally to galvanism. Prognosis. — This is not always unfavorable, but one must not be mis- led by the apparent improvement succeeding rest, which is often temporary. Treatment. — It is evident from what has been said that rest is most important. Prolonged rest and the avoidance of mental excitement, and the use of massage and mild galvanization of muscles are recommended, and even central galvanization of the spiral cord and medulla oblongata. Since faradization excites the myasthenic state, it should not be used. The nourishment, or mode of nourishment, is most important, in view * " Scottish Med. and Sur. Journal," May, igoi. 956 DISEASES OF THE NERVOUS SYSTEM. of the fact that the muscles of mastication and degkitition are at fault. The food, therefore, should either be liquid, or very finely minced, and unless deglutition is natural and easy, the stomach tube should be used. The drugs recomm'ended are the usual ones : strychin, arsenic, phos- phorus, and other tonics, but no direct results have been traced to them. AMYOTROPHIC LATERAL SCLEROSIS. Synonym. — Charcot's Disease. Notwithstanding the similarity of the clinical phenomena, and, to a certain extent, of the morbid anatomy of amyotrophic lateral sclerosis to those of the so-called progressive spinal muscular atrophy, to be next con- sidered, there appears to me sufficient difference to justify a separate con- sideration. Definition. — Amyotrophic lateral sclerosis is a systemic degeneration of the pyramidal tracts of the spinal cord, with atrophy of motor cells in the anterior cornua and medulla oblongata, and consequent wasting of muscles, depending upon these cells for their trophic influence. History. — The confusion which has long existed between this disease and pro- gressive spinal muscular atrophy was first cleared up by Charcot and his pupil, Joffroy, who published a fairly accurate account of the disease in T869 and a complete description in 1874. Such description became possible, however, only after Flechsig's studies of the pattas of motor conduction in the spinal cord. That there are, however, certain common features in the two affections appears not only from the clinical history, but also from the morbid anatomy. Etiology. — The causes of this condition are still essentially unknown. Severe muscular exertion has been assigned as a cause, as it has also of the allied affection, progressive spinal muscular atrophy. As in it, too, the male sex suffers most. It is a disease of young adult life and middle age, from twenty-five to forty-five. It is probably due to the degeneration of an imperfectly formed central motor system. Morbid Anatomy. — A sclerosis of the crossed pyramidal tracts in the two lateral columns and the direct pyramidal tracts in the anterior columns is essential to the morbid anatomy in a typical case. As important is atrophy of the corresponding large ganglion cells in the anterior cornua and medulla. The degeneration has been traced in the pyramidal tracts from the sacral cord upward to the pyramids in the medulla oblongata, sometimes even through the pons and crura into the internal capsule and central convolutions, in which, too, the large ganglion cells have been found atrophied. The nerve nuclei which are affected in the medulla oblongata are especially those of the vagus and hypoglossal nerves. The motor cranial nerves are sometimes degenerated. The changes in the motor ganglion cells of the cord and the nerve nuclei in the medulla oblongata are analogous and produce corresponding results in the muscles supplied by the motor nerves originating from them. These results are an atrophy present in various degrees, some fibers disap- pearing almost entirely, others partially. The process is by fatty meta- morphosis and absorption of resulting fat, leaving a residue of connective tissue. Symptoms. — The clinical phenomena are in strict accord with what would be expected from the pathological lesions, consisting in muscular AMYOTROPHIC LATERAL SCLEROSIS. 957 ■wasting and corresponding paresis. Before the muscular wasting appears, a sense of fatigue succeeding slight effort may be manifested, followed by a positive weakness, primarily almost always in the upper extremity, first one and finally both. This is followed by zcasting of the muscles of the same extremity, usually first seen in the thenar and hypothenar eminences, the interossei and the muscles of the extensor side of the forearm, while the flexors of the hand and fingers remain longer uninvaded. The atrophy is particularly well seen in the deltoid, and to a less degree in the triceps, still less in the biceps and shoulder muscles. Usually symptoms do not appear in the lower extremities until some time after they have appeared in the upper, but occasionally the disease begins in the lower limbs. When the lower limbs are affected, the patient tires easily in walking, the gait becomes unsteady and stiff', and rising from the chair becomes difficult. Tremor may appear in the legs. The paresis in both extremities is proportionate to the destruction of muscle, though first, at least, it is independent of the atrophy. Associated with muscular atrophy, sooner or later, is a diminished electrical excitability. Some excitability, however, remains as long as the muscles are intact, diminishing as their destruction spreads. A reaction of degeneration may also develop in the muscular fibers still intact. The excitability remains for the most part intact in the nerve-trunk because in any event a large number of fibers are preserved in their normal state. A distinctive feature of amyotrophic lateral sclerosis is found in the reflexes, which, in strong contrast to progressive muscular atrophy, are markedly increased. Even in the early stages of the disease vigorous con- tractions are obtained by gently tapping the tendons of almost any of the muscles in the extremities. Always most conspicuous is the patellar reflex, while more rarely ankle clonus may be obtained. The same is true of the masseter reflex. In the arms the biceps and triceps and the flexors of the hands may be excited to strong contraction. Contractures may take place in the later stages of the disease in ihe arms and hands, but not always. In the lower extremities, where the atro- phic symptoms develop some months later and are less marked, spastic symptoms are a more prominent feature. The legs become rigid and some strength is required to flex them, though the muscles themselves are paretic. A typical spastic paraplegia may be produced, which is due mainly to the increase of the tendom reflexes, and a spastic paretic gait is common — that is, at first. Later on in the disease bulbar symptoms may present themselves, mani- fested first by defects of speech, difficulty in retaining the saliva and in swallowing ; and later still the lips and tongue may be seen to be atrophied, and ultimately there is difficulty in taking food, whence nutrition is im- paired, and the patient gradually sinks. In some cases the disease may begin without bulbar symptoms. Throughout, sensibility remains normal in the upper and lower extrem- ities, and the superficial reflexes are not much altered. The sphincters are, as a rule, unaffected. ^Micturition is natural. Only in the event of involve- ment of the reflex center in the lumbar cord may there be incontinence at night when the inhibitory power is in 'abeyance. There may be constipation, but no actual paralysis of the bowel. Sexual power may be lost. The successive involvement of the upper extremities, the lower extrem- ities, and the bulbar centers marks quite vrell-defined stages of the disease. 958 DISEASES OF THE NERVOUS SYSTEM. Death comes ultimately from exhaustion, or more frequently through an inspiration pneumonia, caused by entrance of foreign matter into the air-passages as a result of defective deglutition. Diagnosis. — The disease is distinguished from progressive spinal mus- cular atrophy by the invariable increase in the tendon reflexes, even in the early stages, as contrasted with their absence in the latter disease. Prognosis and Treatment. — The prognosis is very unfavorable and the disease cannot be arrested. By rest in bed, massage, electricity, and hot bathing we may be able to defer the end somewhat. (See, also, Treat- ment of Progressive Spinal ^luscular Atrophy.) PROGRESSIVE SPIXAL MUSCULAR ATROPHY. Syxoxyms. — Wasting Palsy; Progressive Mitseular Atrophy, Type Duch- enne-Aran; Diichcnnc-Aran's Disease; Cruveilhiefs Atrophy; Chronic Anterior Polioinxelitis; Chronic Degeneration of the Motor Nuclei. Definition. — Progressive spinal muscular atrophy is a progressive zvcsting of more or less limited groups of voluntary muscles, associated with degenerative atrophy of the corresponding portion of the motor nerve tract, including the ganglion cells of the anterior cornua, but unaccompanied by disease of the pyr ami-da! tracts. The existence of this condition has been disputed, but degeneration of the cells of the anterior horns without degen- eration of the pyramidal tracts has been seen by most reliable investigators. It is well to include the word spinal in the description of this disease, as thereby the disease is distinguished from progressive muscular atrophy from other causes. Historical.— The history of the development of our knowledge of this disease is very interesting. A few facts only can be given here. Although a number of isolated cases were described at an earlier date, Duchenne's memoir on -'Atrophic Micscu- laire avec Transformation Graisseitse," Y>^h\\'t,\i&A in 1849, and Aran's '• Recherches sur line Maladie non encore decidce dii Systemc Musculaire" published in the next year, contained the first accurate descrip'tion of this malady. Cruveilhier's studies were commenced in 1832. but were not given out until 1S53. All of these observers believed at first— Cruveilhier reluctantly— that the disease w-as purely muscular. In his third case, however, Cruveilhier found atrophy of the anterior roots of the spinal nerves, and in his fourth, lesion of the grav matter of the cord, whence the anterior roots take their origin, and first asserted the belief that the disease of the gray matter in the spinal cord was the special anatomical lesion of the disease. The researches of Lockhart Clarke in 1S66 and 1867 and of Charcot in 1S69 mav be said to have established the spinal nature of tl^e disease ; while Friedreich in 1873 still maintained its muscular nature, and Gowers and Leyden regard it as identical with amyotrophic lateral sclerosis. Striimpell also separates the' two diseases of progressive spinal muscular paralysis and amyotrophic lateral sclerosis, and it appears to me there is quite enough reason for doing so. The close relation of these two diseases cannot be disputed, but most unquestionable proof has been furnished by Dejerine and others that they are not identical. Etiology. — In the majority of instances we fail to find a sufficient cause. Heredity has been regarded as playing an important role in its causation, but Striimpell considers the cases thus originating as instances of the juvenile myopathic variety of atrophy — that in which no nervous lesion is traceable. On the other hand, e.vcessive muscular exertion seems to be more than an accidental coincidence. Exposure to cold, especially to very cold water, and the infections diseases — typhoid fever, influenza, diphtheria, and syphilis — have all been held accountable, but it is likely that some of PROGRESSIVE SPINAL MUSCULAR ATROPHY. 959 the atrophies thus resuUing include other forms than the true progressive spinal muscular atrophy. It is a disease commonly of adult males, most supposed cases among those who are younger being probably, as held by Erb, instances of the juvenile form of muscular dystrophy, although a very rare family form of progressive spinal muscular atrophy has been observed in children. Morbid Anatomy. — The anterior horns of the gray matter are Vv^asted and reduced in size ; their ganglion cells wholly or partially destroyed ; the neuroglia is proliferated and is intercalated in places with spider cells. The ante}iGr nerve-roots passing from the horns are atrophied, as are also the motor nerve filaments in the peripheral nerves. But the crossed pyramidal tracts in the lateral columns containing the crossed motor fibers descending from the brain to the cells in the anterior cornua are intact. A slight degen- Fig. 112. — Position of Hands and Fingers in Ulnar Paralysis of Long Standing; Bird-claw Hand, " Main en Griffe" — {after Duckeniie). A, A. Wound of the ulnar nerve. B, B, B, B, B. Ends of the metacarpal bones. D. Tendons of the flexor sublimis digitorum. C. Muscles of the ball of the thumb. eration may be seen in some cases in the anterolateral columns about the anterior horns. The muscles see^n to be wasted before death are found con- verted into fat and connective tissue, a remnant of true muscular tissue remaining. At times also they are the seat of waxy change, at others still, narrowed but retaining their transverse striation. As to the relation of the nervous changes to the muscular atrophy, the conspicuous symptom of the disease, there is more than one possible explana- tion. As in bulbar palsy, according to one view, the atrophy of the anterior cornua is primary, the result of chronic poliomyelitis anterior, the degeneration of the peripheral nerves and muscles being secondary to it. According to another view, the muscular atrophy is primary, possibly due, as Friedreich sought to prove, to a myositis, followed by fatty metamor- phosis of the sarcous substance and subsequent absorption of fat, or to a simple primary fatty metamorphosis. In such event it m.ay be inferred that 960 DISEASES OF THE NERVOUS SYSTEM. the nerves atrophy from want of use. According to a third, the degen- eration begins in the last terminal branches of the motor nerves and extends upward along them to the spinal cord. Finally, it is held that there may be a simultaneous degeneration of the whole motor system involved, includ- ing muscle and nerve, and nerve cell. It is more in accord with the office of the spinal cord as a nutritive center, as well as with its morbid anatomy, to suppose the disease is a chronic poliomyelitis anterior, the essential infan- tile paralysis of Relliet and Barthez being an acute form of the same disease. Very important is the anatomical fact that the pyramidal tracts are quite normal. Symptoms. — One of the most striking features of the disease is its slow dcTclopuieiit. Like its congener, amyotrophic lateral sclerosis, it begins most frequently in the upper extremities, 7 out of 9 times in Aran's cases. Of the upper extremities, the right was first invaded in 37 out of 62 of Sandahl's cases, the left 14 times, while the involvement was simul- taneous in II. The disease may begin in the lozver extremities, as shown by Friedreich's statistics, according to which these were first invaded 2y times out of 146, the upper extremities iii, the lumbar muscles in 8. The atrophy usually begins with the short muscles of the thumb, the abductor policis brevis first, then the opponens .and the abductor. The consequent flattening of the ball of the thumb and its persistent approxi- mation to the second metacarpal bone produces the so-called " ape-hand." Simultaneously, or almost simultaneously, the interossei begin to waste, pro- ducing conspicuous depressions between the metacarpal bones, associated V. ith loss of power to extend completely the terminal phalanges of the fingers. Atrophy of the lumbricales follows, producing a flattening of the hollow of the hand. The ultimate result is the characteristic iiiain en griff e of Duchenne, in which the extensor tendons on the dorsum of the hand, and the flexors in the palm, become as distinct as if dissected out. From the hand the wasting creeps up. the forearm and thence to the arm, or it may skip the forearm and pass into the arm, sparing usually the triceps extensor. In the forearm the muscles on the extensor (external) side are usually first aft'ected, then the abductor pollicis and extensor longus pollicis, and later the supinators and flexors. It may come to a standstill at either of these stages, or may involve the muscles of the shoulder, espe- cially the deltoid, in which, indeed, it may begin, preferably in the right, passing thence to the scapular and trapezius muscles, the pectorals, the rhom- boidei and latissimus dorsi, while a grotesqueness of efifect is often produced by reason of certain adjacent muscles retaining their natural size or being even seemingly hypertrophied. This is particularly the case with the in- ferior part of the trapezius and platysma myoides, which are almost never involved. The disease may be arrested at almost any of these stages. The lower extremities may escape altogether, and the atrophy always develops late. The small m.uscles of the foot would naturally be the first affected. Very rarely there may be exceptions to this rule. The muscles of the face are invaded late or not at all. but ultimately even the intercostal and abdominal muscles may be involved. The result, then, is a veritable living skeleton, instances of which are sometimes exhibited. Deformities, including" lordosis or anterior curvature of the spine may result. With all this, sensibility is unaffected in the vast majority of cases, but the patient may complain of a numbness and coldness of the affected limbs. Very rarely pains precede the wasting in the muscles, when they are some- PROGRESSIVE SPINAL MUSCULAR ATROPHY. 961 times regarded as rheumatic. The galvanic and faradic irritability of the muscles progressively diminishes and disappears with the complete destruc- tion of the muscle, the galvanic persisting longer. The reaction of degen- eration may, however, be elicited late in the disease in certain muscles, more especially in the modified form known as " partial reaction " of degenera- tion. If the disease runs a rapid course, it may occur earlier and be more typical. Fibrillary muscular contractions may be present, and idiopathic muscular contractions, or myoid tumors brought out by a blow, may be thus produced. The bladder and rectum remain intact, but suxual functions may be lost. Sweating and other vasomotor disturbances may occur in the affected muscles, such as pemphigoid bullous eruptions, thickening and fissuring of the skin, and curving and grooving of the nails. In certain places there is an overaccumulation of fat, producing an appearance of hypertrophy when there is actual atrophy. Along with wasting there is a corresponding paresis, the result of the atrophy and not its cause. The arms are flaccid and toneless and hang loosely at the sides. The patient can no longer dress himself, and various devices are resorted to in order to accomplish certain acts. Especially char- acteristic is one of these — when the shoulders, being first afifected, the arm and forearm retain their usefulness. Under these circumstances the power of lifting the arm from the side, and especially of raising it above the head, is lost, while that of the forearm remains. Hence, if the patient wishes to lay hold of anything, he swings the arm forward with a jerk until the ob- ject is brought within reach of his fingers, when it may often be caught by the pathologically hooked terminations of these. So long as the neck muscles remain effective, objects may be grasped by the mouth. In true progressive spinal muscular atrophy the reflexes are entirely absent, at least in the wasted extremities, a natural result of the atrophy of the ganglion cells in the anterior cornua and of the centrifugal motor fibers of the reflex arc. The special senses and the sphincters remain normal. Toward the close of the disease sometimes, and then only after it has existed for a long time, the phenomena of bulbar paralysis may present themselves after invasion of the ganglia of the medulla oblongata. These have been detailed in the section on that subject. They are by no means always present, even in advanced cases. Diagnosis. — Muscular atrophy is not confined to the disease under consideration. It occurs in diffuse myelitis, in tumors of the cord and when cavities are formed in its interior, in multiple neuritis, and especially in amyotrophic lateral sclerosis. From all these named, except the last, it is easily distinguished by strict attention to the conditions and order of devel- opment of the symptoms — viz., insidious and progressive atrophy of groups of muscles to the exclusion of others, beginning usually in the hand or more rarely in the shoulder and upper arm ; accompanied by a correspond- ing loss of power in the affected muscles and partial or complete reaction of degeneration in the same, hy diminished reflexes and fibrillar twitchings. Differential Diagnosis — From amyotrophic lateral sclerosis it is to be distinguished by its greatly slower co'drse and absence of the reflexes and of spastic symptoms. It is also to be distinguished, from muscular dystrophy in its various forms — the ■ myopathic juvenile muscular atrophy of Erb, pseudohypertrophic mAiscular paralysis, and Duchenne's infantile hereditary palsy, in the juvenile progressive muscular atrophy of Erb there is also 6i 962 DISEASES OF THE NERVOUS SYSTEM. slow symmetricai, and intermittent wasting, with weakness in certain groups of muscles, especially those of the shoulder girdle and upper arm, and later possibly the pelvis, upper thigh, and back, associated at times with true or false muscular hypertrophy, but usually unassociated with fibrillar contrac- tion or reaction of degeneration. The average age, also, in the juvenile form is much less, Erb's cases ranging from seven to forty-six and one-half, or an average of twenty-six and one-half, while in the spinal form or true pro- gressive spinal muscular atrophy the average age is much greater. Of Roberts' cases, all of which seem to be true cases of progressive spinal mus- cular atrophy, the youngest was twenty, while the ages of the remaining four were thirty-eight, thirty-nine, forty-seven, and sixty-seven. While in the pseudohypertrophic form there are also great weakness and wasting of muscles, though the latter may be obscured by the fatty deposit, there are no alterations in the spinal cord. It is a disease of childhood, and strikingly liercditary, beginning in the lower extremities, while progressive muscular atrophy is a disease of adults, is not hereditary, and begins usually in the upper extremities. Duchenne's hereditary infantile atrophy is characterized by onset at an early age, infancy or adolescence, and by beginning in the facial muscles. It is often hereditary. The distribution of the atrophy is very similar to that of Erb's form, when the disease has involved the muscles of the shoulders, but it begins in the face and may fie confined to the face. The muscles of the hands and fingers are spared in Ducherme's form ; fibrillar tremors are not present, and there is no reaction of degeneration. Prognosis. — Alany years are required to develop these symptoms in their entirety, and there may be spontaneous arrest, during which the patient may die of other causes. Sooner or later, if the patient lives, they recur, and their march is irresistible. Treatment. — It has already been said that cure is impossible, although well-authenticated cases of arrest are reported. Mercurials and iodid of potassium should be used in cases of suspected syphilitic origin. Cooke reports a case of arrest under a course of mercury, after the disease had progressed for five years, during which many remedies were tried. In the main the treatment must consist of measures intended to maintain the health and strength of the patient and to counteract the muscular wasting. To the former end an abundance of nutritious food, fresh air, and outdoor life should be supplied, while tonics, including, especially, cod-liver oil, iron, arsenic, and strychnin, are indicated. The muscular wasting may be com- bated by electricity and judicious massage. Both kinds of electricity may be used, the faradic with rapid interruption to stimulate the circulation, or with slow interruption to excite individual muscles to contraction. The current should be of moderate strength, not too frequently interrupted, and con- tinued for a few minutes only. Duchenne recommended, particularly, treat- ment of important muscles, like the diaphragm through the phrenic nerve, or the intercostal muscles and the deltoids before they are actually invaded by the disease. In evidence of its usefulness he relates the case of a man who had lost many of his trunk muscles, and who was beginning to suffer from dyspnea, on whom faradization of the phrenic nerves, repeated three or four times a week, was of great sendee, enabling him to walk considerable dis- tances and to go upstairs without fatigue. Another patient, whose arms were much wasted, was again able to support his family. The direct cur- rent — galvanism — is useful in advanced stages of the disease, when the LOCALIZATION OF CEREBRAL DISEASE. 963 strongest faradic currents fail to produce response. When galvanic currents fail to excite contractions, the treatment ought to be persevered in for a long time, using very strong currents at the onset, gradually reducing them as contractiUty returns. Remak, who especially advocated the use of the con- tinuous current, advised placing the positive pole in the front of one mastoid process and the negative pole on the opposite side of the neck, near the spinous process of the vertebrae, not higher than the fifth cervical, by which he produced the contractions already described as diplegic in the fingers and other paralyzed parts. Galvanization of the sympathetic has been apparently useful in the hands of some, Erb reporting a case of complete cure. Massage is especially important, and should be used in connection with electricity, but at a different time of day. Eulenberg refers to a case said to have been brought to a standstill by it. Hypodermic injections of strychnin, from i-ioo to 1-40 grain (0.0005 to 0.002 gm.), are said to have arrested the disease 011 the authority of Gowers. In families in which a hereditary tendency exists prophylactic treatment should be used. It should include hygienic measures of the kind already referred to and the avoidance of undue fatigue and exposure, and in the selection of an occupation these matters should be kept in view. On the supposition that the disease is a purely local one, gymnastics involving the exercise of the groups of muscles prone to attack are indicated, but assume less importance from the standpoint that it is a spinal cord disease. At the same time the patient should have the benefit of any doubt in the pathogeny, and as gymnastics are eminently calculated to improve the general health and thus indirectly to avert disease, their use is indicated on these grounds. DISEASES OF THE BRAIN LOCALIZATION OF CEREBRAL DISEASE. Synonyms. — Cerebral Localisation; Relation of Locality to Symptoms; Topical Diagnosis of Cerebral Lesions. Physiology. — The brain is the organ of consciousness and of percep- tion of impressions and sensations — o£ memory, of thought, of origination of voluntary motion, and of speech. It is also the seat of the instinctive acts. It has been learned from clinical observation in connection with studies at the autopsy table and from experiment that certain parts of the cortex are concerned with corresponding offices, especially motion, speech, vision, and hearing, so that from the presence of given symptoms the involve- ment of corresponding localities may be inferred. Allusion has already been made to the subject of topical diagnosis, on page 842. Such diagnosis, it is important to remember, gives no information as to the nature of the lesion, the result being the same whether it be abscess, hemorrhage, or softening. We are simply informed that such and such area is involved. Historical. — As early as 1825 Botiillaud asserted that derangements of speech are produced only by disease of the anterior lobes of the brain. In 1836 Marc Dax, also a French physician, pointed out that aphasia was caused only by lesions in the left half of the^brain. In 1861 Broca announced that aphasia results from a lesion of the third left frontal convolution, which was accordingly called the convolution of Broca. 964 DISEASES OF THE NERVOUS SYSTEM. More recent observations show that it is the posterior part, or the pars opercitlaris — the part of the frontal lobe covering the island of Reil, which is the speech center, and, further, that lesions here are the cause of motor aphasia only. In 1S70 Fritsch and Hitzig published the results of their experiments in irritating the surface of the brain in animals, such irritation being followed by muscular contractions in definite portions of the opposite side of the body. These observations were rapidly confirmed and extended in further experiments by Meynert and Flechsig among anatomists Ferrier, Munk, Goltz, and others among physiologists, and Charcot, Nothnagel, Hughlings Jackson, and Horsley among clinicians. Our knowledge in this depart- ment is, however, still inexact, and is likely to be altered as well as increased by further studies. I. The Motor Areas of the Cortex. An examination of the following illustrations (Figs. 113 and 114) from Ecker will furnish a sufficient knowledge of the gyri and sulci of the sur- face of the brain, which, therefore, need no further description in the text. Functional Assignments. — The motor region is made up of the two central convolutions, anterior central and posterior central, also known as ascending frontal and ascending parietal, the posterior part of the three frontal convolutions, the upper part of the parietal lobe adjoining the ascend- ing parietal convolution and the paracentral lobule (Fig. 114) on the median MINOBLINONESS., MEMOKV OP 'p ■^ii-etg. "SigJi^ Optic Tierre ihi OpUc track .Ihnrr- Occ^ai&Hcorieso. Fig. 126.— Diagram of Course of Optic Nerve-fibers from the Cortex to the Retina —(after Sahli, Modified and Extended). monly natural, are sometimes contracted. This is usually due to an inflam- matory affection of the peripheral fibers of the optic nerves in front of the chiasm. There are other differences in the dividing-line, such as obliquity, want of sharpness, etc.. due to the same cause, but minute description of these belongs to special works on nervous diseases. Since vision remains intact 63 994 DISEASES OF THE NERVOUS SYSTEM. in the central region, equally in right and left-sided hemianopsia, it follows that there must be a passage of fibers from the macular region to the optic tract of each hemisphere, else this region would be blinded by disease of one or the other tract. There is usually the same loss of vision for color in the half field, but half vision for color may be lost in central disease without any change in the field for white. This is known as hemmchro- matopsia. 4. Lesion of the Tract and Centers. The optic tract on each side crosses the crus cerebri backward and passes to the external geniculate body to the pulvinar of the optic thalamus, and to the anterior coUiculus of the quadrigeminal body. From these so- called primary optic centers fibers pass backward through the posterior part of the internal capsule, forming the fibers of the optic radiation in the white substance of the occipital lobe, into the visual area of the cortex, of which the area about the calcarine fissure is the chief cortical center, though other parts of the occiptal cortex possibly also receive and store up visual impressions. Whence it is plain that vision may be influenced by lesions in any of the following situations : 1. In the tract itself. 2. In the external geniculate body. 3. In the pulvinar of the optic thalamus and in the anterior colliculus of the corpora quadrigemina. 4. In the fibers passing from the primary optic centers to the occipital lobe, as at c (Fig. 126), in the hinder part of the optic radiation. 5. In the area about the calcarine fissure. The effect of lesion in any one of these situations is to produce anes- thesia of that half of the retina corresponding to the afifected side and a homonymous hemianopsia of the opposite half of the visual field. Morbid States Affecting the Optic Nerve, Chiasm, Tract, and Centers. — Outside of the affections of the retina, which concern the oph- thalmologist chiefly, and outside of optic neuritis or papillitis as a result of intracranial disease, already considered, the affections of the optic nerve which concern the physician are tumors springing from the pituitary body or the bone, aneurysm of the ophthalmic artery within the orbit or of the carotid within the skull, and interstitial inflammation from an adjacent focus, or rarely from rheumatism and injury. The optic chiasm is encroached upon by tumors in the neighborhood, especially of the pituitary body ; by tubercular or syphilitic growths in its substance, or by inflammation invading it from the adjacent dura mater or from carious bone; by internal hydrocephalus, the distended infundibulum of the third ventricle pressing on the middle of the chiasm ; by intersti- tial inflammation of a possible gouty origin or associated with tabes dor- salis ; and, finally, by interstitial hemorrhage. The optic tract may be invaded or compressed by tumors springing from the inner part of the temporosphenoidal lobe, by softening after throm- bosis of the internal carotid, or by disseminated sclerosis. Primary soften- ing in the tract is rare, as is also hemorrhage. The cortical visual centers may be invaded by hemorrhage, softening, tumors, pressure by depressed bone in fracture, and other traumatic causes.. OPTIC NERVE AND TRACT. 995 Symptoms of Lesions of the Optic Nerve, Chiasm, Tract, and Cortex. — 1. Visual Effects. — (a) Lesions of the optic nerve cause defects of vision on the same side, with lessening of the reflex action of the pupil proportionate to interference with vision. The impairment of vision in- cludes extent of field of vision as well as degree. There may be concen- tric limitation of the visual field because the peripheral layer of nerve-fibers near the opfic foramen is damaged by processes external to it. In other .cases there is irregular defect, and in others still the loss of sight is total and lasting. To the ophthalmoscope there may be at first no change, but if the lesion is considerable, the atrophic condition soon makes its appearance " secondary " to changes in the nerves, as distinguished from " consecu- tive " atrophy, which succeeds papillitis. There may be slowly super- vening atrophy without recognizable papillitis. Central loss of vision,, due to axial neuritis, is less common, but occurs sometimes in tobacco amblyopia. {b) In lesions of the chiasm the characteristic symptom is bitemporal hemianopsia, or loss of the outer half of each field of vision ; this is because the lesions mainly afifect the chiasm at its central portion, where the fibers, after decussating, pass to the nasal half of each retina. Usually, however,. the process, be it tumor or inflammation, which causes temporal hemianopsia extends laterally, involving the non-decussating fibers of one side of the chiasm, causing total blindness of the corresponding eye; or, if extending to both sides, blindness of both eyes. These different stages may often be traced in a single case as the disease progresses. The term " oscillating bitemporal hemianopsia " is applied to a rapid and frequent variation of the dark fields, and is regarded as more or less clearly diagnostic of basal syphilis, such as gumma or syphilitic meningitis. More rarely we have the binasal hemianopsia already described. Slight variations in the extent of the dark fields have been referred to as the result of peculiarities in decus- sation rather than of lesion or seat of lesion. (c) In lesions of the optic tract between the chiasm and the external geniculate body there is bilateral hemianopsia. (d) Bilateral hemianopsia is also a result of lesion of the central fibers of the nerve between the primary visual centers and the cerebral cortex. (e) Lesions of the cuneus cause bilateral hemianopsia. A lesion in each hemisphere, affecting the visual paths back of the chiasm, will cause a double hemianopsia, with total loss of vision in both eyes. Such a result has followed successive lesions in the two occipital lobes. (f) Hemianopsia may be due to functional disease. Transient hemian- opsia is sometimes a symptom of migraine, either as an isolated symptom apart from headache and gastric disturbances or associated with them. It may affect now one half of the field and now another. Hemianopsia is also rarely a symptom of hysteria. 2. Other Symptoms Associated with Hemianopsia. — In about one-half the cases of hemianopsia there is transient or permanent hemiplegia, the result of the same lesion, the hemiplegia being on the side of the loss of vision, so that the patient cannot see 'the paralyzed side. Hemianesthesia may also be associated, and defects in speech are sometimes found when the paralysis is on the right side. Hemiachromatopsia has been mentioned. (See p. 994.) In this con- 996 DISEASES OF THE NERVOUS SYSTEM. dition there is no change in the field for ordinary objects, but all colors appear gray as soon as ihe vertical line is passed. The symptom, accord- ing to Gowers, probably depends on disease of one part of the occipital lobe, and is proof of a separate center for color not yet precisely located, perhaps in some part of the occipital cortex in front of the apical region. The limitation of the remaining functionally active half field and the isolated loss for colors are the only known differences in the features of hemianopsia due to variations in the seat of the lesion in the optic path behind the chiasm, the limitation of the active half field indicating a lesion in the optic radiation near the thalamus, the isolated loss for colors pointing to a lesion in the occipital lobe. 3. Amblyopia. — Amblyopia is another form of sight defect due to brain disease. The term is used to indicate a partial loss or blurring of vision. There is concentric limitation of the visual field, varying in different cases, and along with it the color fields are also reduced. Similar eye defects, associated with hemianesthesia, occur sometimes in hysteria, with which it may be confounded. Since a simple functional loss of vision may rarely result as a reflex from irritation of the fifth nerve or from hysteria, so a functional amblyopia, afifecjing both eyes, may also result from such causes — indeed, is more common than the organic form. A carious tooth may act in this way. Amblyopia from errors of refraction must not be confounded with the amblyopia due to brain disease. Diagnosis. — How shall we interpret these phenomena of vision con- cerned with the optic nerve and tract? Some conclusions are easy; others are difficult, by reason of the limitations of our knowledge. Accurate inves- tigation of fields of vision, with a view to the study of hemianopsia and other defects in the visual fields variously caused, is made by means of the perim- eter, for directions concerning the use of which instrument the student is referred to works on ophthalmology. Herman Sahli suggests an easy, rough method, quite sufficient for recognizing marked difference in the field of vision, performed as follows: The physician seats himself opposite the patient, whose right eye — supposing this to be the one to be tested — is opposite the physician's left, the other eye of each being closed. The two open eyes being thus fixedly opposed, the physician passes his finger to and fro across the field of vision exactly midway between the two eyes. In this way he can compare his own field of vision with that of the patient, noting at what moment the finger is seen approaching from the periphery of each. Care must be taken that the, finger is kept exactly midway between the physician and patient, and in order to do this, the examiner must from time to time open his closed eye. Defective sight in one eye with diminished reflex action of pupil proportionate to the defect, the function of the remaining eye being intact, usually means disease of one optic nerve. In some rare cases of functional disease in which the sight of one eye only is involved, the perfect responsiveness of the pupil distinguishes it from organic disease of the nerve. Total loss of sight in both eyes may mean chronic atrophy, damage to the chiasm, or disease of both tracts or in both hemi- spheres. In these cases the symptoms are at first partial, and in this way the diagnosis is aided. Central scotoma means damage to nerve-fibers in the center of the trunk of the optic nerve, either inflammatory or the result of hemorrhage. Periph- eral limitation of vision means damage to fibers running in the periphery of OPTIC NERVE AND TRACT. 997 the nerve. Sectorial blindness in one eye means disease of the nerve, decided in degree but limited in extent. Bitemporal hemianopsia means disease of the chiasm, while the combina- tion of complete blindness of one eye with temporal hemianopsia in the other means disease of the chiasm which has extended to the outer fibers, and even to the optic tract or optic nerve, on the side on which blindness is complete. Bilateral hemianopsia is due to disease back of the chiasm, and the determination of the spot involved in the tract between the chiasm and the occipital area which is the cortical center of vision, stimulates diagnostic acumen. The most that can be attempted is the setthng of the question as to whether the disease is in the tract between the chiasm and the external geniculate body or in the fibers beyond bounded by the visual centers. To this end the hemianospk pupillary reaction of Wernicke is sought. A perfect pupil reflex requires the integrity of the retina, of the fibers of the optic nerve and tract, of the center and fibers of the third nerve, and of the iris. When the light is thrown on the blind half of the retina the pupil contracts as much as if it is thrown on the seeing half, if the disease is in the hemispheres ; but if the disease is in the tract, it does not contract because the path to the third nucleus below the corpora quad- rigemina is interrupted. The employment of the test requires much care and experience. Seguin directs that the patient, being in a darkened room with a light behind his head in the usual position, be directed to look to the other side of the room, so as to eliminate accommodation movements. Then a faint light is thrown upon the eye from a plane or large concave mir- ror, held well out of focus, and the size of the pupil is noted. With the other hand a beam of light, focused by an ophthalmoscopic mirror, is then thrown directly into the optical center of the eye, then laterally in various positions and from above and below the equator of the eye, noting the reaction at all angles of incidence. According or not as a response is obtained in the pupil the inference is drawn. Amblyopia with concentric reduction of the field, decided in one eye and slight in the other, may be due to atrophy of the nerve, to disease of the higher visual center in one hemisphere, or to hysteria. If atrophy, the ophthalmoscope recognizes the lesion and the responsiveness of the pupil is diminished. If disease of one hemisphere, the nerve is normal to the ophthalmoscope, the pupil contracts perfectly under the action of light, and the onset is sudden or accompanied with other signs of organic brain disease. Mind-blindness, described on page 975, may also be a result of lesion in this locality. In hysteria the symptoms are the same as in dis- ease of the higher visual center, and the diagnosis depends on the presence or absence of signs of organic or functional disease. In hysterical blind- ness the loss of sight is rarely complete. In hysterical and neurotic defects of vision there may be a derangement of the natural relation in color fields. Thus, while normally the blue field is most conspicuous in the last-named conditions, it is often overshadowed by other colors. 998 DISEASES OF THE NERVOUS SYSTEM. LESIONS OF THE MOTOR NERVES OF THE EYEBALL. Anatomical. — The third cranial nerve (oculomotor) supplies the leva- tor palpebrse superioris, the superior and inferior recti, the rectus internus, the obliquus inferior, the sphincter of the iris, and the ciliary muscle. The fourth cranial nerve (the trochlear) supplies the superior oblique; the sixth cranial nerve (the abducens), the rectus externus. The functions of the muscles to which these nerves are distributed are sufficiently indicated by their names. Third Nerve. — Lesions may involve the nerve at it,s nuclear origin or in its course. Lesion of the third nerve at its origin involves also usually the origin of the other motor nerves of the eye, producing general ophthal- moplegia, as a result of which the eyeball is motionless, and an object moved about in front of it can be followed only by moving the entire head. The nerve may be invaded in its course by traumatic causes, meningitis, gummata, aneurysm, or neuritis, frequently rheumatic, and may also be affected in diphtheria, tabes dorsalis, and diabetes mellitus. The effect may be spasm or paralysis. The results of spasm of the muscles supplied by the third nerve are manifested in nystagmus. This consists in an involuntary, clonic, rhyth- mical, oscillatory movement of the eyeball, usually horizontal, but some- times rotary, more rarely vertical. It is seen in congenital or acquired brain lesions, and is often a striking feature in albinism. In meningitis and hysteria there is also sometimes spasm of the muscles supplied by the third nerve, especially the internal rectus and the levator palpebrse, the antagonist of the orbicularis.* Paralysis of those muscles supplied by the third nerve, which include all the eye muscles except the external rectus and the superior oblique, results in outward squint ; ptosis, or drooping of the upper eyelid ; the absence of contracting power in the pupil, which remains of medium size; loss of accommodation ; the double vision, or diplopia. Such paralysis, involving all the branches of the nerve, may be recurrent, especially in women, often at the menstrual period, or at wider intervals. It is sometimes associated with pain in the head and at other times with migraine. The individual attack lasts a few days, or as many weeks. Partial involvement of the third nerve may include the levator palpebrse, the superior rectus, the ciliary muscle, and the iris, while the external muscles — that is, the internal ^nd inferior recti and the inferior oblique — may escape. Ptosis only, due to paralysis of the levator palpebrse, complete or partial, may occur under various conditions. It may be congenital and incurable, or due to cerebral lesion ; or it may be hysterical, when it is apt to affect both eyes and is associated with other symptoms of hysteria. It may be caused by disease of the sympathetic nerve (pseudoptosis), and may be associated with symptoms of vasomotor palsy — viz., elevation of tempera- ture on the affected side, redness or edema of the skin, and contraction of the pupil on the same side. Finally, it is seen in weak, delicate women as a transient event, especially in the morning. When the result of a definite * Blepharospasm is a spasm of the orbicularis muscle, which is supplied by the facial nerve. It amounts usually only to twitching: of the eyelids, but may be so severe as to close them completely, so that it is not in the power of the patient to open them. LESIONS OF MOTOR NERVES OF EYEBALL. 999 .lesion of the third nerve, at its nucleus or in its course, it may also be asso- ciated with a paralysis of the superior rectus alone, or of the internal and inferior recti in addition. Condition of the Pupil. — The condition of the pupil should be studied with light of moderate intensity, and in doubtful states the pupil under examination should be compared with that of the eye of a healt.hy indi- vidual about the same age. Miosis, or contraction of the pupil, is found physiologically during sleep, especially in elderly persons ; pathologically, as an early symptom in tabes dorsalis, in progressive paralysis of the insane, and as an effect of eserin, pilocarpin, morphin, and in complete chloroform narcosis. Mydriasis, or dilatation of the pupil, occurs in deep unconsciousness, during extreme pain, in dyspnea, in peripheral blindness, especially from optic atrophy, in oculomotor paralysis, rarely in tabes dorsalis and pro- gressive paralysis of the insane. It is also an effect of atropin, duboisin, and cocain, and of the early stage of chloroform narcosis. The pupil may be unduly large from palsy of the sphincter (third pair) fibers or from spasm of the radiating (sympathetic) fibers; or the pupil may be abnormally small from the opposite conditions. Other limited paralyses due to third nerve disease are cycloplegia and iridoplegia. Cycloplegiu is paralysis of the ciliary muscle, producing loss of the power of accommodation. In this state of affairs distant vision is good, but near objects cannot be seen distinctly. It may occur in one or t)oth eyes, being in the latter event more usually due to disease of the nuclear origin of the third nerve. It is one of the earliest manifestations of •diphtheritic paralysis, and is a symptom also of tabes dorsalis. It may be corrected by the use of eye-glasses. Iridoplegia is paralysis of the iris, and its three forms are thus classified l>y Gowers, one associated and twO' reflex : 1. Accommodative iridoplegia is a form in which the pupil does not diminish in size during accommodation. It is tested by having the patient look at a distant object and then at a near one in the same line of vision, so as to avoid any change in the amount of light entering the eye. It is usually associated with paralysis of accommodation, but the ciliary muscle may be efficient and yet the associated action of the iris be lost, or the reverse. This loss is less common than that of reflex action. It is the result of the same cause as cycloplegia. 2. Re-flex Iridoplegia, or Argyll Robertson Pupil. — The path for the optic reflex is along the optic nerve and tract to the nuclei of the third nerve ; thence to the ciliary ganglion, and through the ciliary nerves to the eye. In testing for this condition each eye should be tried separately, the other being covered, but not closed. The patient is asked to look toward a dark part of the room, when a bright light is thrown suddenly in front of the eye at a dis- tance of three or four feet, so as to avoid the effect of accommodation. If the patient looks at a nearer light, he will accommodate for it, and the pupil may contract when there is no action to light. Such absence of light reflex without loss of the accommodation contraction was first pointed out by Argyll Robertson. 3. Skin Iridoplegia. — Loss of skin reflex. If the skin of the neck is pinched or pricked, or stimulated by an electric shock, the pupil dilates reflexly. Since active dilatation of the pupil is through the sympathetic nerve, the motor path for this action must be along the cervical sympathetic, lOOO DISEASES OF THE XERVOUS SYSTEM. and along the fibers connecting this with the cord, at the lowest part of the cerv^ical region. These reactions are lost when the path is interrupted or the center is damaged. Thus, the light reflex is lost or impaired in disease of the optic nerve including the retina, or in disease of the third nerve. Disease of one optic tract does not lessen the action imless the light falls on the blind half of the retina, because, as already stated, the fibers from the central and most sensitive region of each retina pass through both optic tracts, whence dis- ease of one does not abolish the reflex. The skin reflex is lost in disease of the cervical sympathetic and sometimes of the cervical spinal cord, especially when there is associated loss of sensibility. Thus, tumor of the cord some- times produces this symptom. When the eye reflexes are lost without disease of the sympathetic or cervical cord, it is generally due to degenerate disease of the centers. Tabes dorsalis, in which it is a common and an early symptom, is a conspicuous instance. Less frequent is general paralysis of the insane, and other degen- Fig. 127. — Situation of the Cranial Nerves — {after Edinger), Cranial nerve nuclei, oblongata, and pons represented as transparent. Motor nuclei, black; sensitive nuclei, red. erative processes less definite. It may occur also without other nerve symp- toms. In most of the cases in which it has come under Gowers' observation thus isolated, the patient had suffered from constitutional syphilis for years. The two palsies, that of the skirT reflex and that of the light reflex, are com- m.only associated, but not always. The pupils are often small, reduced to two millimeters, or even one millimeter, in diameter. Inequality of pupils, or anisocoria, is also a symptom of progressive paresis and tabes dorsalis, but occurs also in healthy persons. Fourth Nerve. — The fourth cranial nerve (trochlear), as it passes around the outer surface of the crus into the orbit, is liable to be compressed by tumors, by aneurysm, or by the exudation of basal meningitis. Its nucleus below the aqueduct of Sylvius may be involved in tumors, or may undergo degeneration with other ocular nuclei. As the superior oblique muscle, supplied by it, acts in such a way as to direct the eyeball downward and rotate it slightly, paralysis causes retardation of downward and inward LESIONS OF MOTOR NERVES OF EYEBALL. loor movement, often so slight as not to be noticeable. The head is inclined somewhat forward and toward the sound side, and there is double vision when the patient looks down, as in descending- stairs. Paralysis of this nerve is seldom met with alone, except in nuclear disease. Sixth Nerve. — The sixth nerve (abducens), emerging at the junction of the pons and medulla oblongata, passing forward and entering the orbit, is liable to be affected by meningitis at the base, or by tumors, especially gum- mata, or by cold. The external rectus being alone supplied by it, the effect of its paralysis is to produce internal squint, and the eye cannot be turned outward. There is diplopia when looking toward the paralyzed side. It is a frequent ocular palsy, because the nerve has so long and exposed a course. If the nucleus of the sixth nerve is affected, a very interesting condition results, which was first studied by Beevor. In consequence of paralysis of the external rectus the eye of that side is turned inward, while at the same time the internal rectus of the eye of the opposite side has lost the power to turn its eye inward. Consequently, both eyes are turned to the side oppo- site and away from that of the injury. Thus, if the nucleus of the right sixth nerve is involved, both the right and the left eye are turned toward the left. Such opposite deviation away from the side of lesion is known as " conjugate deviation." It is due to the fact that the nucleus of the third nerve, supply- ing the internal rectus, is connected by fibers with the nucleus of the sixth ; whence in lesion of the nucleus of the sixth nerve there is paralysis of the internal rectus, supplied by the third nerve, in associated movements, though the nucleus of the third nerve is not involved, the power of convergence is not affected. In consequence of the proximity of the nucleus of the sixth nerve to that of the seventh or facial, disease of the former is apt to involve the latter. Whence, say if there is lesion of the left nerve, there follows con- jugate deviation of both eyes to the right, with a complete paralysis of the left half of the face. Diabetes insipidus is sometimes associated wnth paralysis of the sixth nerve. Such a case I saw at the Philadelphia Hospital with J. Hendrie Lloyd. The paralysis of the sixth nerve was subsequently substituted by paralysis of the third, the polyuria remaining. A case of this character may be caused by syphilitic meningitis. Basal meningitis, involving the vas- cular supply to the floor of the fourth ventricle, was suspected. Other cases of polyuria associated with paralysis of the sixth nerve are reported, notably Maguire's. Phenomena in General of Paralysis of Motor Nerves of the Eye. — These include, first, limitation of movement and strabismus, referred to. In addition to these certain derangements of vision, known "as secondary devia- tion, erroneous projection, double vision, occur. Secondary deviations are thus demonstrated : After covering the sound eye, let the paretic eye fix itself upon a point which it cannot reach at all, or can reach only after extreme exertion. Then remove the covering hand from the sound eye, and it will be found that the latter has been moved much too far in the same direction, the abnormal attempt at innervation of the affected eye passing over to the associated muscle of the healthy eye and caus- ing in it too great a contraction. Erroneous projection furnishes the idea that an object at which we are 1002 DISEASES OF THE NERVOUS SYSTEM. looking is further on one side than it really is, or that the movement of the eye in following it, when moving, is greater than it is. Under these circum- stances, in an attempt to touch the object with the fingers the latter may go beyond it. This grows out of the fact that when the eyes are at rest, in the mid position, an object at which we are looking appears directly opposite the face. Turning the eye to one side, the object appears to the side of its former position; and if the object moves, we estimate the extent of its motion by the amount of movement of the eyeball following it. Now, when one muscle is weak, the increased innervation required to contr'act it gives the impression of a degree of movement greater than actually takes place. This is erroneous projection. Now, as the equilibrium of the body is largely maintained by a knowledge of the relation of external objects to it, obtained by the action of the eye muscles, the erroneous projection due to paralysis disturbs the harmony of visual impressions and may produce dizziness, known as ocular vertigo. Double z'ision results from the fact that if one eye is paralyzed the axes of the two eyes do not coincide, nor do the images in the two retinae. The image produced in the sound eye is called the true image ; that in the affected eye, the false image. In simple or homonymous diplopia the false image is on the same side as the paralyzed eye ; in crossed diplopia it is on the other side. It is one of the most annoying symptoms 'of paralysis of the eye muscles. Ophthalmoplegia. — Ophthalmoplegia, or nuclear palsy, is a term applied to a chronic progressive paralysis of the ocular muscles, due to dis- ease of the ocular nuclei. It is called internal when the internal muscles only are involved — /'. c, the iris and ciliary muscles ; external, when the external muscles are affected more or less completely. When both internal and ex- ternal muscles are involved, it is known as total ophthalmoplegia. Historical. — The term was first used bj' Brunner, in 1850. The nature of the cases was pointed out by v. Graefe in 1856, and in 1S68 compared b}- liim with bulbar palsy. Forster localized the lesion in 1878 for external palsy, including all the mus- cles except the iris and ciliary muscles. Internal ophthalmoplegia was described by Hutchinson in the same year, and the external form, with postmortem proof of its nature, in 1879. Symptoms, — These vary according to the position and character of the lesion, which may be degenerative, hemorrhagic, or the result of pressure by tumors or the product of basilar meningitis. They are bilateral, except in the instance of the sixth nerve, with resulting conjugate paralysis. Gowers describes three modes of onset-^chronic, sudden, and acute. The chronic form is the most common, due to nuclear degeneration, or more rarely to tumor and embolic obstruction, and still more rarely to hemor- rhage. In this form there is a great variety of combination and degree. Thus, there may be internal ophthalmoplegia only, or external, or both. In the internal form there may be loss of the iris-reflex only or of the ciliary muscle action only. In the external variety the levator and superior recti are commonly first involved, the other muscles gradually. There may be loss of the upward and downward movement of the eye, ptosis, and conjugate lateral palsy. There may be double vision, generally of short duration. In the total form the eye is fixed and immovable. Each variety may be asso- ciated with tabes dorsalis, general paralysis of the insane, progressive mus- cular atrophy, and bulbar palsy, often with syphilis. It is more common in LESIONS OF MOTOR NERVES OF EYEBALL. 1003 jnales, and occurs occasionally in the young. There is a form occurring in children, known as infantile oculo-facial palsy, which may be congenital or acquired ; rarely, it occurs as a sequel of diphtheria, late and permanent. The disease may be very slow in developing, and may require years. Sometimes one eye is more affected than the other. If the internal muscles are unaffected, the disease is quite certain to be nuclear disease, because these muscles can scarcely escape bilateral disease of the nerve trunks. Indeed, V. Graefe thought this absence of involvement of the internal muscles char- acteristic. Palsy of the external ocular muscles is likely to be accompanied by facial palsy. In sudden nuclear palsy, the second in frequency, the onset may take but a few minutes or an hour or two. The causes in such cases are com- monly obstruction to the basilar arterial branches, rarely embolic obstruction, and still more rarely hemorrhage. The obstruction is usually bilateral. The lesions are irregular, and the symptoms are correspondingly irregular and unsymmetrical ; the tendency is to recover. In these respects it differs from the chronic form also in that hemiplegia is a frequent accompaniment, gen- erally on the side opposite the greater eye palsy. When hemorrhage is a cause, the resulting ocular palsy lasts usually but a few hours, provided the hemorrhage acts on the ocular centers only by pressure, while the other phe- nomena of presure by effused blood, which is apt to spread, make their appearance. Acute nuclear palsy is rare. It develops in a few days or weeks, and is possibly of inflammatory or toxic origin, whence called by Wernicke poliomyelitis superior; but toxic cases may occur without inflammation. This form, according to Gowers, may be due to peripheral neuritis and not to nuclear disease. Alcohol may be a toxic cause. The eye muscles are invaded irregularly, and it is common for the internal muscles to escape. In fatal cases the causal influence extends to the centers of other nerves and possibly to the cortex. In cases that survive there is improvement, various in degree. Treatment of Ocular Palsies. — The cause should be sought and, if found, treated. Although syphilis is thought to be one cause of this disease and of tabes dorsalis, with which it is so frequently associated, disappoint- ment follows the syphilitic treatment in the majority of cases. Yet mercury perhaps accomplishes more than any other single remedy. Arsenic, strych- nin, and iron are sometimes used, strychnin hypodermically. In acute cases, when there is pain, hot fomentations, leeches, and coun- terirritation may be used. In chronic forms electricity has been extensively used, galvanism being preferred. Benedikt recommended placing the anode, or positive pole, on the forehead, and the cathode, or negative pole, on the margin of the orbit near the affected muscle. If the faradic current is used, the orbital pole is held still ; if the voltaic, it is kept moving over the skin, or the current is broken by the commutator. To overcome the ptosis, electric stimulus is applied to the third nerve, as the muscle is not accessible. The diplopia is removed by a prism not strong enough to fuse the two images completely, but of sufficient force to approximate them, so that the fusion may be completed by muscular action. Such action may be practiced for an hour each day. The dizziness due to erroneous projection can be removed only by throwing the eye out of use by an opaque glass. Opera- tive treatment is not recommended. Periodical Oculomotor Paralysis. — Up to June, 1890, according to A. I004 DISEASES OF THE XERVOUS SYSTEM. Nieden,* 21 cases of periodical oculomotor paralysis had been published. The organic lesion at the bottom of these paralyses is not yet settled upon. Mobius.f who was one of those who has contributed largely to the subject, claimed a nuclear degeneration as the cause, while Mauthner t another con- tributor, considers that the majority of cases have a basal cause, by which it is presumed he means a basal meningitis or other cause compressing the trunk of the nerve at the base of the cranium. In the paper referred to, Nieden reports a case of periodical combined facial and abducens paralysis occurring in a woman thirty-six years of age, who had seven attacks involving the sixth and seventh nerves, separately or jointly, at intervals of from a few days to several months. Between these attacks she was free from symptoms. At other times there was derange- ment of other cranial nerves, especially of the auditory on the same side, manifested by tinnitus, which considerably interfered with the sense of hear- ing for the time. Again, in the fourth attack there was a paralysis of the left half of the tongue, which made speech stammering and unintelligible. All the attacks were accompanied by severe headache, which is more or less characteristic of oculomotor paralysis. Morbid Anatomy. — From these conditions Nieden infers an involve- ment of the muscular region of the sixth and seventh cranial nerves affect- ing first the nucleus of the latter on the left side, ^ and after a short inter- val the former of the same side and a part also of the nucleus of the hypo- glossal. He thinks that there may have been an exudation in the region of the floor of the fourth ventricle deep enough to involve the nuclei of these nerves as well as the trunks of some of them. Treatment. — Because of syphilitic origin, in many of these cases mer- curial treatment proved promptly efficient, while at times the symptoms sub- sided spontaneously. LESIONS OF THE TRIFACIAL OR FIFTH NERVE (TRIGEMINUS). Anatomical. — This important mixed nerve of the face supplies by its motor trunk the muscles of mastication ; by its sensory portion, the skin of the face, the mucous membrane of the mouth and nasal cavity, the conjunc- tiva, and the cornua : also, according to some physiologists, the anterior part of the tongue with gustatory fibers. The gustatory fibers are supposed to reach the lingual fibers of the fifth nerve by the chorda tympani nerve. Recent studies of Harvey Gushing make this doubtful. Lesions. — i. There may be lesions of the pons, especially hemorrhage^ or areas of sclerosis invading the trigeminus nucleus. 2. Injury or disease at the base of the skull, especially acute and chronic meningitis and caries of the bone, tumors, syphilis, new formations com- pressing the trunk or the Gasserian ganglion. Fracture of the base rarely afTects this nerve. 3. Tumors or aneurysms pressing on the first division (ophthalmic) of * " Centralblatt fiir praktische Aug-enheilkunde.' 1800, p. 164. t Mobius, " Ueber periodische wiederkehrende Oculomotoriuslahmungr," "Berliner klin. Wochenschr.," 1884, Nr. ^o u. ^8, S. 604 ; and "Arch. f. Psych. 11. Nervenkrankh.," xiv., S. 844. t Mauthner, "Die ursachlichen Momente der Augenmuskellahmungen," "Vortrage," S. 415, Wiesbaden. 1885, Bergmann. LESIONS OF THE TRIFACIAL OR FIFTH NERVE. 1005 the nerve through the cavernous sinus, on the second division (superior maxillary) and on the third division (inferior maxillary) by invasion of the sphenomaxillary fossa. 4. There may be inflammation of the nerve, which is rare. The sensory division may also be affected in hysteria. The gustatory fibers of the trigeminus may be influenced by peripheral lesions of the facial, whence the chorda tympani is derived. Symptoms. — Paralysis of the Sensory Portion. — The distribution of the anesthesia varies according as the whole trigeminus or only a part is involved. In total anesthesia there is loss of sensation in half the corre- sponding side of the head, including the conjunctiva and cornea, mucosa of the lips, tongue, hard palate, and nose of the same side. Hence on the tongue or mucous membrane there are often ulcers which come from uncom- scious lacerations by the teeth. There is, according to the views of many, loss of the senses of taste and smell. The loss of the sense of smell is prob- ably due to drying of the mucous membrane, as it is not probable that the fifth nerve contains olfactory fibers. The so-called trophic phenomena are also observed, and among them the much-discussed neuroparalytic oph- thalmia^ an ulcerative keratitis, beginning, also, always in the lower segment of the cornea, and passing over into purulent inflammation of the whole eye- ball. It seems, on the whole, more likely that the inflammation is primarily due to the action of irritants which in health are excluded by the proper closure of the eyelids, though the inflammatory process itself may be trophic- ally influenced. The salivary, lacrymal, and buccal secretions may be diminished and the teeth may become loose. Herpes is a trophic result which may develop in the course of the nerve, is painful, and may last a long time. So, too, the anesthesia may be preceded by tingling. The skin of the face is sometimes swollen. Paralysis of the motor portion, which supplies especially the muscles of mastication, the masseters, temporals, and pterygoids, is not common. It is most frequent in diseases of the base of the skull, compressing this branch. Difficulty in chewing is the result. If on one side, the patient can chew only on the other; if on both sides, he cannot chew at all. The lower jaw hangs dow^n, and cannot be moved from side to side because of the paralysis of the pterygoids. If on one side, the external pterygoid cannot push the jaw toward the sound side, and when depressed, the jaw is pushed by the muscle of the sound side toward the paralyzed side. Cases have occurred associated with cortical lesion : from one such Hirt inferred that the motor center for the trigeminus is in the neighborhood of the lower third of the ascending frontal convolution. Spasm of muscles of mastication is found in connection with muscular cramp, the muscular contraction of tetanus (trismus), sometimes in tetany and meningitis, and reflexly through painful affections of the jaw or teeth, or from irritation near the motor nucleus. It is also sometimes hysterical. Clonic spasm occurs in muscles supplied by the fifth nerve, constituting " chattering teeth." It occurs generally in connection with general condi- tions, such as chorea, but it may happen as a local symptom in women late in life. Diagnosis. — This is not difficult. Sensibility is tested in the ordinan- way. The preliminary pain must not be mistaken for neuralgia. Gustatory sense is tested in the anterior end of the tongue by applying weak acid or salt solutions and comparing the eft'ect on the two halves. The motor power ioo6 DISEASES OF THE XERVOUS SYSTEM. is tested by biting on a piece of wood or cork or by moving the jaws against resistance. Treatment. — This must depend upon the cause, which should be care- fully sought. Syphilitic new formations are the lesions most commonly amenable to treatment. In the absence of such causes the treatment must be symptomatic. Stimulating liniments and faradization through the elec- tric brush are often useful. Galvanism may also be used, brushing the part with the cathode. The anesthetic part should be carefully protected against irritants. In the absence of tangible cause, systemic treatment is not indicated, except to build up the general health of the patient. LESIONS OF THE FACIAL XERVE, OR SEVENTH PAIR. The seventh pair ( portio dura of the seventh, old classification) is the motor nerve of the face, and is subject to paralysis of motion and to spasm. Paralysis of the Facial Nerve. Synonyms. — Mimetic Facial Paralysis; Bell's Palsy; Monoplegia facialis. Monoplegia facialis may be caused by lesions in the cortical center of the nerve, in the brain between the cortex and the nucleus, in the nucleus itself, and in the nenr trunk. Supranuclear Paralysis. — The cortical center resides in the foot of the central convolution, probably the anterior central, from which pass out fibers along with the pyramidal fibers through the internal capsule to the facial nucleus in the tegmentum of the pons on the opposite side. Accordingly, the nen-e is commonly involved in hemiplegias — in fact, facial paralysis forms a part of most hemiplegias. Such a paralysis, due to lesion above the facial nucleus, is known as supranuclear. In such a palsy the voluntar}- muscles of the lower half of the face are paralyzed, while the secretory and gustatory functions of the facial are not affected : nor are the orbicularis and forehead muscles, except in some cases in the beginning of the hemiplegia, these being innervated by the upper branch of the facial. These features, together with the normal elec- trical excitability of both nerve and muscle, the intact reflexes and taste sense, all point to a central facial paralysis as distinguished from a per- ipheral. The limitation of the ^paralysis to the lower half of the face is due to the fact that the lower portion only of the face receives more ex- clusively crossed innervation, while the upper part, like the ocular muscles and the motor trigeminus, is innervated more from both hemispheres, so that a lesion in one be overbalanced by the other. This will be understood by an examination of the schematic drawing (Fig. 128), from which it is plain that a one-sided brain lesion at a paralyzes only the inferior and not the upper facial. Recent investigations show that the upper and lower branches of the facial nerve have not separate nuclei. That they are func- iionally distinct is further shown by the fact that in bulbar paralysis, also a disease of the nerve nuclei of the medulla oblongata, only the inferior facial is involved. That the upper face muscles are totally uninvolved in central facial paralysis is not quite true, for careful examination will show LESIONS OF THE FACIAL NERVE. 1007 that the function is not quite so perfect as in health; the patient cannot close the eye of the paralyzed side by itself, as in the normal state ; whence it follows that the upper half of the face is innervated from both hemi- sphers, as is also shown in Figure 128. The crossed influence is, however,, the larger. Cortical facial paralysis, monoplegia facialis, has been found associated with lesions in the center for face muscles in the lower Rolandic region, but isolated facial paralysis due to involvement of the nerve-fibers in their path from the cortex to the nucleus is extremely rare. Cortical or capsular facial paralysis, as already explained, is on the same side as that of the arm and leg. Nuclear Paralysis. — Paralysis may also be caused by lesions of the nucleus, but is not common. There may be tumors, chronic softening, and Portion of the facial Nucleus for the Upper Facial Distribution !Pe?'^?iercd'J'hu:ictZ' Portion of the Facial Nu- cleus for the Upper Faciar Distribution . Portion of the Nucleus for the Lower Facial Distribution. Fig. 128. — Schema for Central Innervation of the Facial Nerve — {after Sahlt). The nucleus of the upper branch is innervated from both hemispheres, though mostly- from the opposite side, while the nucleus of the lower branch is innervated almost totally from the opposite side. hemorrhage, while rarely anterior poliomyelitis may involve the facial nucleus or it may be attacked by the diphtheritic poison. The symptoms are essentially the same as those of paralysis of the trunk of the nerve, or peripheral facial palsy. Intranuclear Paralysis, or Peripheral Facial Paralysis. — This includes all cases due to involvement of the nerve trunk. The distinctive features of this, as compared with cortical paralysis, have already been stated. It still remains, however, to determine the precise segment of the nerve involved, to be again referred to when treating of diagnosis. Etiology. — Cortical paralyses are usually due to compression or de- ioo8 DISEASES OF THE NERVOUS SYSTEM. struclion of the cortical center, as by traumatism, hemorrhage, tumor, men- ingitis, or emboHsm. Nuclear paralysis may be caused by tumors, chronic softening, hemorrhage, or the diphtheritic toxin, while rarely anterior polio- myelitis may involve the facial nucleus. The most frequent cause of peripheral paralysis is exposure to cold, as to a cold wind or draft from an open window. Such cases include so-called rheumatic paralysis, and may be due to neuritis. Disease of the middle ear and caries of the petrous portion of the temporal bone are relatively fre- quent causes, which have evident explanation in the course of the facial through the Fallopian canal adjacent to the tympanic cavity, whence it may be invaded. At the base of the brain, tumors, syphilitic new formations and inflammatory processes also involve the facial. Rarely swelling of the par- otid gland is a cause of pressure. Finally, the facial is frequently impli- cated in disease of the brain and medulla oblongata. Symptoms. — The symptoms vary with the exact seat at which the nerve is invaded. Paralysis of the facial muscles of expression produces the most striking change of physiognomy. The homely description, under- stood by everyone, is that the face is drawn to one side ; and so it is — to the sound side, except in old cases after contracture has occurred. Exami- nation discloses that on the opposite and paralyzed side there is a remark- able smoothness of face, the wrinkles have disappeared from the forehead, the labionasal fold is gone, and this half of the face is quite expressionless. The corner of the mouth is lowered, while saliva frequently flows from it ; the eye is wider open than natural, and can be only partly closed, even dur- ing sleep, — lagophthahnos, — and the eye waters. These symptoms are ren- dered still more striking on effort at smiling, talking, or whistling, at turn- ing up the nose, wrinkling the forehead, inflating the cheeks, or closing the eyes. On attempting the latter the upper lid drops as though heavy, the eye is turned upward, the pupil covered, but quite a space remains " un- covered. The so-called " corneal " and " optical " reflexes, by which, through closure of the lid, the eye protects itself from the entrance of foreign bodies seen approaching, are lost, and a tendency to conjunctivitis results. In complete facial paralysis winking is impossible. Whistling is also impossible, and speech may be interfered with, ov/ing to the difficulty in forming labial sounds. The proper muscles of manifestation are not para- lyzed, but, owing to paralysis of the buccinator muscle, food collects between the teeth and cheek on the paralyzed side, and an attempt to snifT reveals j>aralysis of the nasal muscles. The upper teeth cannot be uncovered, and an attempt to drink is only partly successful, because the lips cannot be kept close to the glass. The tongue is sometimes described as protruding toward the paralyzed side, but this appears to have been an error. The organ is really central, when examined in its relation to the incisors, and the erroneous impression arises from the fact that the lips are drawn to the sound side. Many authorities speak of a paralysis of the soft palate on the affected side, since facial fibers pass through the superficial petrosal nerve to the sphenopalatine ganglion. It is described as drooping, while effort at pho- nation raises the soft palate obliquely to the sound side. Both Gowers and Hughlings Jackson, however, deny this symptom in most cases, and are sustained by the discovery of Horsley, and Beevor, that the soft palate is innervated by the spinal accessory nerve. The innervation of the soft palate is not definitely known. LESIONS OF THE FACIAL NERVE. 1009 Derangement of taste also" occurs in the anterior two-thirds of the tongue on the paralyzed side in cases where the facial is involved in that part ■of its course in which it contains the chorda tympani nerve — that is, in the Fallopian canal between the genu and the union of the chorda tympani with the facial. When the nerve is affected outside of the skull, the sense of taste is intact. Tactile sense in the tongue is also sometimes lessened; salivary secretion is diminished, producing dryness of the mouth. Hearing may be more acute, especially for low notes, because of paralysis of the stapedius jnuscle, antagonized by the tensor tympani, which is innervated from the ,^ ^ ^ vi) ,to fji r^P Fig, 129. — Simplified Drawing of the Peripheral Distribution of the Facial Nerve — {a/fe?- Sahli). trigeminus. Hence results a greater sensitiveness of the membrana tympani. Other disturbances of hearing are also present, but they are generallv due to associated aural trouble. Herpes is also an occasional symptom, and is ascribed to the presence of trigeminal filaments among those of the facial. Facial paralysis usually sets in suddenly, rarely gradually. Sometimes there are prodromata, consisting in abnormal sensations of taste, pain in the ear and face, and ringing in the former, all from inflammation of the nerve. With this exception, pain is not common. 64 10 lo DISEASES OF THE NERVOUS SYSTEM. Diagnosis. — The recognition of the presence of paralyses of the facial is for the most part easy. More difificuh, and proportionately important, is it to ascertain in what part of its course the function of the nerve is cut off. This is rendered easy by the appended schematic drawing of the distribution of the facial nerve, after Sahli. (See Fig. 129.) The phenomena vary in accordance with the following: (a) Lesion at A, trunk of the facial, affecting only the mimetic branches. Paralysis of all the facial muscles; taste, secretion of saliva, hearing, and palate normal. (b) Lesion at 5, within the styloid foramen. Paralysis of facial mus- cles, and occipital muscles innervated by the posterior auricular nerve.* Taste, secretion of saliva, hearing, and soft palate normal. (c) Lesion at C. Paralysis of the facial muscles, derangement of taste, diminished secretion of saliva ; hearing and soft palate normal. (d) Lesion at D. Paralysis of the facial muscles, derangement of taste, diminished secretion of saliva, abnormal acuteness of hearing, and paresis of soft palate. (e) Lesion at E, above geniculate ganglion. Paralysis of the facial muscles, diminished secretion of saliva, abnormal acuteness of hearing, paresis of soft palate, but no disturbance of taste. (/) Lesions at F, in Fallopian canal, often associated with a lesion of the auditory nerve in consequence of its proximity to it. Paralysis of facial, diminished secretion of saliva ; hearing may be influenced by common lesions to auditory ; palate normal, taste normal. The student is referred to what has previously been said as to the modification rendered necessary by the observations of Gowers and others on the non-involvement of the soft palate in facial palsy. We are aided also in recognizing precise forms by the causes, if known, like the presence of ear disease, or a history of exposure to cold or of trau- matism. Coexisting symptoms of brain or bulbar disease must also be considered. Reaction of degeneration cannot occur in true cerebral facial palsy, only in peripheral palsy or in such bulbar paralysis as affects the facial below the nucleus itself. In cortical facial paralysis the frontal dis- tribution of the facial nerve and the ocular muscles are not seriously affected except in the early stages ; in the peripheral paralysis they are. The existence of bilateral facial paralysis — diplegia facialis — points almost invariably to a central lesion, and more especially to a bulbar affec- tion, since it must be a rare event to have a simultaneous involvement of both nerves in their peripheral distribution, though its possibility cannot be denied. Prognosis and Course. — The prognosis varies with the etiology and with the degree of severity. Some cases get well rapidly; others partly recover ; many are permanent. The following division of forms with their probabilities, according to Erb, will be helpful : 1. The Mild Form of Facial Paralysis. — To this many rheumatic cases belong. The affection is usually one of facial muscles only. Electrical ex- citability in the paralyzed muscles remains normal, and there are no severe and deep-seated changes in nerves or muscles. Recovery is rapid, usually taking place in two or three weeks. 2. Middle Form. There is partial reaction of degeneration, the ex- * Since the occipital muscle is in most men not under control of the will, its paralysis can be ascer- tained only by the electrical test (.reaction of degeneration). LESIONS OF THE FACIAL NERVE. loii citability of nerve being diminished but not lost ; in the muscles, however, in two or three weeks, there is decided increase of galvanic excitability to direct excitement, the anodal closure contraction being greater than the cathodal while contractions are slow. Recovery may still be quite rapid, usually in from four to six weeks. 3. Severe Form. — Complete reaction of degeneration in nerve and muscles — i. e., loss of faradic and galvanic excitability of nerve, loss of faradic excitability of muscle, and quantitative and qualitative changes in galvanic excitability of muscle. In this form there is always degeneration of nerve and muscle, so that, if recovery takes place at all, it is only after two or six months, or longer. In these cases there often intervene symptoms of motor irritation, consisting : 1. In a marked tonic contraction of the paralyzed muscles, sometimes very striking. 2. Single spasmodic contraction of muscles. 3. Special associated movements. Thus, if the patient closes his eyes or winks, there always follows a marked distortion of the corner of the mouth, which cannot be restrained. 4. An increased reflex irritability, as the result of which, on pricking or blowing on the skin, vigorous muscular contractions follow. These symptoms last for a long time — for years in incurable or imper- fectly cured cases. Further points bearing on prognosis have reference to the nature of the primary disease. Paralysis caused by tumors of the base of the brain and caries of the petrous bone is almost always incurable. If the paralysis is due to middle-ear disease, the prognosis depends on the curability of the ear disease. The electrical examination affords helpful data. If at the end of one or two weeks electrical excitability still remains normal, a rapidly favorable termination may be predicted. If, on the other hand, the reaction of degeneration is present, a much longer course and delayed recovery, if any, may be expected. Relapses may occur. Treatment. — The treatment, is, of course, that of the lesion which Hes at the bottom of the paralysis. If it is a syphilitic, inflammatory prod- uct, the iodids should be administered in the usual ascending doses. Middle- ear disease should receive the promptest and closest attention, as some of the most unfortunate cases are thus caused. Any possible cause of pressure should be sought and removed. When cold is the cause, and the case comes early under observation, warmth, either dry or moist, should be applied to the distribution of the nerve in the face, while mild counterirritation at the pes anserinus is useful. Decided blistering is of questionable utility, but it is harmless and may do good. For the paralysis remaining after the removal of the cause electricity is indicated, and more especially the constant current. A weak current should be used for from three to five minutes at a time, interrrupting from four to six times a minute, placing first the anode and then the cathode in the auriculo-mastoid fossa, the other pole in front of the ear. Galvanism and faradization may be applied to^the muscles themselves, including the orbicularis, the direct effect of the electricity on which is shown by an increased power to close the eye immediately after the application of the current. Massasre of the muscles mav be used. IOI2 DISEASES OF THE XERFOUS SYSTEM. Sulphate of strychnin is a drug which has some reputation in facial paralysis, although it is difficult to trace the results of its use. Its admin- istration by subcutaneous injection, daily or on alternate days, is recom- mended. The salicylates may be used with advantage in some cases. Facial Spasm. Syonyms. — Mimetic Facial Spasm; Convulsive Tic. Facial spasm is manifested in a variety of w"ays. Mimetic facial spasm, or convulsive tic, consists in a clonic contraction of the muscles supplied by the facial nerve, a lew or all. usually unilateral, sometimes bilateral. A similar condition, especially frequent in children, as the result of imitation or of habit of grimacing, is known as habit spasm. Etiology. — Xo cause can be found for most cases. Possible causes are exposure to cold, lesions at the base of the skull, or irritation of the facial center in the cerebral cortex. Other cases may be explained by reflex causes, such as irritation by carious teeth, intestinal worms, or disease of the sexual organs. Others have been ascribed to violent mental excite- ment. Predisposition to the disease is heightened by a hereditary neuro- pathic habit. Symptoms. — These consist in short contractions in the muscles affected. Sometimes the contractions are of longer duration. The face is the seat of constantly changing grimaces during waking hours. Sometimes, how- ever, there are mtervals of complete rest. The contractions are commonly without exciting cause. Sometimes they invade adjacent muscles, as those of mastication, the tongue, or the muscles of the neck. \'oluntary motion is unimpaired, and there is no pain or anesthesia. Blepharospasm. — A variety of the partial form is blepharospasm, a tonic or clonic spasm of the orbicularis muscle. In the clonic form it is apt to be associated with spasm of the lateral facial muscles, and there is constant twitching of the side of the face, with partial closure of the eye. In another clonic variety there is constant contraction of the eyelids and consequent winking. The tonic form is usually reflex in origin, bilateral, and may last for days or weeks, with occasional interruptions. The reflex cause is commonly some affection of the eye, producing photophobia, or it may reside in some other point in the distribution of the trigeminus. The clonic form may also sometim^es be traced to a reflex cause. \*ery interesting in connection with blepharospasm is the discovery by V. Graefe of certain so-called "-^pressure points." These are points at which pressure causes the spasm to cease, so that the eyelids " fly up as if by a spring." These are commonly found at points of exit of the trigeminus, but have also been found on the vertebral column and elsewhere. For other forms of spasm of the facial nerve see Choreiform Aft"ections, page 1097. Prognosis, — This in all forms is, as a rule, unfavorable. There are intervals of suspension, somethnes of considerable length, but the spasm recurs, and the disease generally remains incurable. Treatment. — The treatment is correspondingly unsatisfactory, but a number of things may be done. Causes of reflex irritation should be sought and removed, such as carious teeth and ophthalmia. Paquelin's cautery may be applied to the trunk of the nerve, or to pressure points, if LESIOXS OF THE AUDITORY OR EIGHTH NERVE. 1013 they exist. Nerve section of the supra-orbital nerve has been practiced in blepharospasm. Xerve stretching has been followed by relief, at least as long as the paralysis continues, which is commonly a welcome substitute for the twitching. The constant current may be used, seeking also for pressure points, to which the anode is to be applied. If there are none, this pole should be applied to the trunk of the nerve and to the different branches of the pes anserinus. In cases of reflex origin Berger reports that satisfactory results were obtained by applying the anode to the occiput just under the protuberance, while the cathode was held in the hand — an attempt at galvanization of the medulla oblongata. The single sitting should last from five to ten minutes. Weir Mitchell recommends the freezing of the cheek every day or every other day with the rhigolene spray; at least transient relief follows. As to medicines, those usual in nervous affections should be tried — bromid of potassium, strychnin by hypodermic injection, arsenic, iron, oxid of zine, atropin, curare. The treatment of convulsive tic is that of hysteria. LESIONS OF THE AUDITORY OR EIGHTH NERVE. The eighth pair (portio mollis of the seventh in the older classification of Willis) may be affected anywhere in its course from its cortical center in the upper part of the first temporo-sphenoidal convolution, thence in the internal capsule across to its nucleus at the junction of the pons with the medulla oblongata, or at the base of the brain after it passes out of the pons into the internal auditory meatus to its distribution in the cochlea and vestibule. The proximity of this nerve to the facial at the base of the brain and in the internal auditory meatus is to be remembered. As indi- cated by its name, it is softer and more vulnerable than the facial, so that equally acting causes may affect it and leave the facial intact. The auditory nerv^e should be regarded as two nerves — the cochlear and the vestibular ; the former having to do with hearing and the latter with co-ordination. Symptoms. — Directly due to disease of the auditory nerve are limited to some derangement of hearing, and it is their association with others which widens their significance in the study of nervous diseases. The derange- ments of hearing resulting from such lesion are six: 1. Loss of hearing, or deafness. 2. Increased sensitiveness, auditory hyperesthesia, or hyperacusis. 3. S3'mptoms of irritation, causing subjective aural sensations — tinnitus aurium and allied symptoms. 4. Disturbances of equilibrum or sensation of such, due to irritation of the fibers in teh semicircular canals — ^Meniere's disease. 5. Certain rare instances of involuntary movements, due to disease of the nerve within the ear, as oscillaton.- motions of the head. 6. Purely functional derangements of hearing, occurring especially in connection with hysteria and with anemia following large hemorrhage. I. Loss OF FuxcTidx ; Nervous Deafxess. Etiology. — Deafness may be congenital when it is due to labyrinthine defect. According to Cowers, 80 per cent, of deaf mutes are congenitally 10I4 DISEASES OF THE XERVOUS SYSTEM. deaf. The remaining 20 per cent, become so from disease in early life. Of congenital cases it is said that the intermarriage of relations having similar defects is responsible for some, while such intermarriage, even where there is no such defect, is held responsible for a smaller number. Partial as well as total deafness may be congenital. Of the cases of acquired nervous deafness, disease of the labyrinth, either primary or secondary to that of the middle ear, causes most. The labyrinth is subject to inflammation, acute or chronic, to syphilitic disease, to degeneration, and to hemorrhage. It may be invaded b}' meningitis, cere- brospinal or tuberculous. Its membrane may undergo degeneration, due to gout or simply to old age. The product of all these may be fibrous or cal- careous new formation. The deafness caused by certain drugs, as quinin, has been ascribed to congestion of the internal ear, and that by loud noise, as the explosion of artillery, to hemorrhage. Lesions of the nerv-e trunks are less common causes. They may be of the same character as those of the labyrinth, except primary inflanmiation, although even this is said to be a cause. Primar}- degeneration may occur in tabes dorsalis. The nerve may be compressed by thickening of the cranial bones, calcareous nodules, tumors, or extravasated blood. The nuclei within the pons may be damaged by hemorrhagic extrava- sations and tumors. Above the nuclei there may be a lesion encroaching on the superficial layer of the tegmentum, a lesion in the internal capsule, or in the cortical center. Symptoms. — Since, as already stated, derangement of hearing consti- tutes the only essential symptom of nervous deafness, any enlargement of the subject can be made only by considering the miodifications and conditions of this symptom, and by reviewing such methods of determining the precise seat of the lesion as exist. The ability to hear through the bone while the air conduction is impaired implies that the function of the labyrinth is intact, and that deafness is due to obstruction of the meatus or to disease of the middle ear and not to nerve deafness. This is further confirmed if the bone conduction is intensified by closing the meatus, since in this way the vibrations, which ordinarily pass out by the meatus, are retained. On the other hand, if there is diminished bone conduction, it does not necessarily follow that the labyrinth is diseased, because there may be ankylosis of the stapes, which will diminish bone con- duction, although no amount of disease of the middle ear will extinguish it if the labyrinth be intact. Further, in health air conduction is heard after bone conduction ceases. This is the basis of Rinne's test, in which the vibrating tuning-fork is first placed upon the mastoid process and allowed to remain until the sound dies away to the patient, when the fork is suddenly trans- ferred to the external auditory meatus of the same ear. If the air-conducting apparatus is normal, the vibration of the fork should again be heard. Again, there may be a moderate impairment of hearing and maintenance of the rela- tive delicacy of the air conduction. Absence of bone conduction is, however, the characteristic symptom of nervous deafness. So, to a less degree, is deafness to short and high-pitched sounds, whence the high-pitched, short sounds of the ticking of a w^atch is a delicate test of the ability to hear through the bone. Simple senile labyrinthine degeneration may be respons- ible for inability to hear the ticking through bone in persons sixty years old or more. Can we distino-uish between labvrinthine disease and disease of the LESIOXS OF THE AUDITORY OR EIGHTH XERJ'E. 1015 nerve before its terminal distribution? Given the absence of bone conduc- tion, if the facial nerve is paralyzed, and there is no disease of the middle ear or of the bone, we may conclude that the ner^^es (facial and auditory) are affected at the base of the brain or in the internal meatus. 1+ there is dis- ease of the middle ear along with deafness and paralysis of the facial, it is probable that the facial nerve and labyrinth are affected by extension of the disease from the tympanum, but this is not certain. An involvement of the trunk of the nerve at the base is also probable if some other nerve near it, as the sixth, is involved. The fact that the auditory nerve is more sensi- tive to pressure than the facial has already been mentioned, whence an agency, such as an inflammatory product, pressing on both nerves may affect the auditory and leave the facial intact. No distinctive symptoms have been found associated with lesion of the auditory nuclei in the medulla oblongata. Such lesion is very rare, but has been found associated with deafness on the same side, while it has also been found when the hearing has been unaffected. Sudden deafness, associated with other symptoms of a lesion of the pons or medulla oblongata, should excite suspicion of nuclear lesion, especially if paresis of limbs on the opposite side be one of those symptoms. The auditor}- . fibers between the cortex and the auditory nucleus in the pons, in their passage through the tegmentum, may also be affected and may produce deafness. Such a lesion is a tumor of the corpora quadrigemina. Lesions of the cortical center are very rare, though they have been suffi- ciently frequent to confirm the results of experiment on the monkey, which go to show that the first temporo-sphenoidal gyrus represents the center for liearing, since the destruction of this gyrus on the left side in man has been attended by word-deafness. It is possible that the first temporal gyrus in each hemisphere in man must be damaged in order to produce cortical deaf- ness for sound. Hemorrhages, softening, and pressure by fractures or tumors may be causative lesions in this situation. Treatment. — This is for the most part unsatisfactory, at least from the physician's standpoint. Careful otoscopic examination should be made with a view to discovering the existence of disease of the external and middle ear, and the aural surgeon should invariably be consulted in derangements of hearing of more than brief duration, with a view to obtaining certainty of diagnosis between nerve deafness and disease of the middle or external ear. Suspected syphilitic tumors should be treated by iodids. A blister in front of or behind the ear may be useful, especially in acute cases ; but deep blister- ing should be avoided in front lest it cause facial neuritis. Electricity has been employed with partly satisfactory results. 2. Auditory Hyperesthesia. True hyperesthesia, or hyperacusis, is a condition in which ordinary sounds are heard with more than normal acuteness, and in which sounds inaudible become audible. In dysesthesia, or dvsacusis, ordinar}- sounds, although not intensified, produce discomfort. There is generally present some pre-existing symptom, as a headache, during which sounds usually without effect intensify the headache. Both these conditions occur in func- tional as well as in organic brain disease. 0£ the former, hysteria is an instance ; of the latter, meningitis. Treatment. — The treatm.ent, outside of the removal of the cause, is by nerve sedatives, as the bromids, preparations of valerian, and asafetida. ioi6 DISEASES OF THE XERVOUS SYSTEM. 3. Irritation of the Auditory Xerve — Tinnitus Aurium. The term tinnitus includes almost every conceivable form of auditory subjective sensation, of which the most common is ringing, roaring, or hiss- ing. The tinnitus may include humming, ticking, the sound of rushing steam, the roaring of machiner\- and the like, the sound of a bell, and even articulate speech, music, or the sound of voices. It may be persistent or intermittent, with rhythmical intermissions — these commonly correspond- ing with the beating of the pulse. The sounds may be so slight as to be for- gotten when the attention is directed to something else, or they may be heard through everything, causing the sorest distress and misery. In fact, their victims have even been impelled to self-destruction. The clicking symp- tom, sometimes audible to those standing near, is often very annoying, and may be due to clonic spasm of the muscles connected with the Eustachian tube or levator palati. The so-called premonitory " aura " of epileptic seizures may be a variety of tinnitus. Etiology. — Beyond what is conveyed by the word " irritation," it is exceedingly difficult to discover the cause of tinnitus. Changes in the labyrinth appear to be the most common, and Cowers tells us that " evi- dence of nervous deafness, mostly due to changes in the internal ear, is dis- tinct in four-fifths of the cases which come under the physician's notice. Disease of the middle and external ear, including inflammation and wax accumulation, is also a fruitful cause, while in a few cases the process may be wholly in the auditory centers, in the nucleus of the nerve, or in the cor- tical area. Blood movement, not usually audible, may become so. Internal aneurysm is a possible cause. Tinnitus is a very frequent symptom in gouty cases, in my experience, especially when associated with the nen'ous tempera- ment. So it is in anemia and neurasthenia. An epileptic aura is often a tinnitus. A systolic brain murmur is sometimes heard over the ear in chil- dren, and even in adults. Treatment. — This is generally most unsatisfactory. The ear should be explored and its surgical diseases treated. The gouty diathesis must be treated by the administration of the salicy- lates, colchicum, and purgatives, and by regulation of the diet; anemia and neurasthenia by iron, arsenic, nutritious food, and rest. Large doses of salicylic acid and quinin, it is known, produce ringing in the ears — a fact to be remembered always. The bromids are sometimes beneficial, and a few drops of tincture of bel- ladonna are sometimes added. ^ Xitro-glycerin has been highly commended. Beginning with doses of i-ioo grain ( 0.00066 gm.), they should be rapidly increased until the physiological effect is produced. ]\Iy experience with nitro-glycerin is that the physiological eft'ect is often not attained in adults even by doses of i-ioo grain (0.00066 gm.). Counterirritation is undoubtedly useful at times. It should be applied behind the ear, and actual vesication is the most efficient form. The tempo- rary effect is sometimes striking, while permanent results may be produced by repeated blistering. LESIONS OF THE AUDITORY OR EIGHTH NERVE. 1017 4. Disturbance of Equilibrium Associated with Defect of Hear- ing — Labyrinthine Vertigo. Meniere's Disease. Definition. — The term Meniere's disease is applied to a vertigo, usually sudden, associated with deafness and noises in the ear. Pathology and Etiology. — In 1861 Meniere described some cases in which vertigo was produced by a sudden lesion of the labyrinth. Since then the term Meniere's disease has come to be applied to all cases of sudden ver- tigo associated with labyrinthine disease. Gowers says that " in nine cases out of ten in which there is definite giddiness, not epileptic in nature or obviously due to organic brain disease, it is due to a morbid state of the laby- rinth or auditory nerve endings." Thus the vertigo becomes the result of the irritation of the nerve. In addition to clinical sources for the confirmation of this view there is the fact that experimentally induced lesions in the semicircular canals of animals result in vertiginous movements. In point of fact, aural vertigo results from almost any one of the morbid processes possible to the labyrinth and the nerve endings it contains, but not from disease of the middle ear. The precise nature of the morbid change can only be conjectured. It is twice as frequent in men as in women, and four-fifths of all cases occur between the ages of thirty and sixty. Cold, gout, and syphilis have been followed by it, probably through inflammation, and possibly resulting hemorrhage. The slower forms may be due to degenerative processes, like those of tabes or such as are due to age. Vasomotor neuroses of the vessels of the labyrinth have been held responsible. Symptoms. — The vertigo is usually sudden and paroxysmal, though there may be slight continuous dizziness between paroxysms, which occur at intervals of from a few days to as many weeks. Occasionally they occur daily. They may be spontaneous or an exciting cause of trifling character may bring them on, such as turning, coughing, or sneezing. Gastric dis- turbances may excite them — a fact to be remembered in the differential diag- nosis from gastric vertigo. There may be brief unconsciousness. The attacks generally pass off in a few minutes, leaving the patient pale, faint, and nauseated, often in a cold, clam.my sweat. Vertigo may or may not be accompanied by a tendency to fall forward, backward, or to one side, and the victim may have to grasp something to save himself from falling. External objects may appear to circle about him. The seeming movements of person and external objects are usually in the same direction. The auditory symptoms — deafness and tinnitus — may be in one or both ears, and more marked in one side than in the other. In the latter case the sense of movement may be toward or from the ear most affected ; but when the subjective and objective movements coincide in direction, they are more often toward the affected side. The deafness is nervous and always partial. The tinnitus is usually roaring or throbbing. There may be ocular symptoms ; these are secondary, and include nystagmus and diplopia. Pressure on the drum or on the meatus may bring on the nystagmus, and sometimes an apparent jerky move- ment of objects. Diplopia, nystagmus, and jerky movements may occur together. Diagnosis. — The essential symptoms of Meniere's disease are dizziness, tinnitus, and deafness. Gastric disturbance is not peculiar to it. The deaf- 1018 DISEASES OF THE NERVOUS SYSTEM. -ness must be proved to be nervous and not the result of defective air con- duction. True gastric vertigo is not associated with deafness, while other symptoms of dyspepsia are present with it. While the aura of epilepsy is sometimes accompanied by giddiness, there is no impairment of hearing. Moreover, in Meniere's disease slight vertigo is more or less constant, the tinnitus is persistent, and loss of consciousness, if present, is very brief. It is the petit mal, with its brief unconsciousness, with which the confusion may occur. The vertigo of cardiuc valvular disease, especially aortic insufficiency, ■of arteriocapillary fibrosis, and of chronic interstitial nephritis is unaccom- panied by any of the other distinctive signs of Aleniere's disease. Gelicr's vertigo, characterized by attacks of paretic weakness of the extremities, ptosis, and profound depression, but without loss of consciousness, occur- ring especially among laborers in the canton of Geneva, should be mentioned as a source of possible error. Prognosis. — This depends upon the durability of the lesion causing the malady. In cases resulting from remedial causes — such as gout and even syphilis — recovery is possible, while palliation is not infrequently attained. Other cases are obstinate and incurable. Relief, however, comes to the dizziness when the deafness becomes total. Treatment. — When traceable to gout and syphilis, the remedies appro- priate to these diseases should be prescribed. The salicylates and iodids are most frequently useful, but the lithium salts and colchicum are to be remem- bered. The salicylates should be given in moderate doses rather than large ones, which produce, the ringing in the ears. In the absence of knowledge of a definite cause the bromids are the remedies to be most relied upon. From twenty to thirty grains (1.3 to 2 gm.) should be given at a dose, and Gowers recommends the addition of a few minims of the tincture of bella- donna. Nitro-glycerin has been recommended. The general health should be looked after. Counterirritation by blistering behind the ear is som.etimes promptly followed by favorable results. LESIONS OF THE NINTH OR GLOSSOPHARYNGEAL NERVE. Anatomical. — This triply mixed nerve supplies sensibility to the soft palate, the tonsils, the upper part of the pharynx, the Eustachian tube, and the tympanic cavity ; motor impulses to the stylopharyngeus and to the middle constrictor of the pharynx : and the sense of taste to the posterior third of the tongue and to the palate. The study of the precise pathology of this nerve is rendered difTficult by its numerous communications with other nerves, notably with the fifth, the facial, and the pneumogastric, and by the fact that it is rarely involved alone. Experimental inquiry with it is also difficult. The nerve may be invaded by meningitis, tumors, or degenerations. Symptoms. — Symptoms of such lesion would be diiUcult deglutition and perversion of the sense of taste — parageusia — or complete gustatory anesthesia. Modifications of the sense of taste are tested bv means of sapid sub- stances in solution, applied to the anterior and posterior parts of the tongue LESIONS OF THE PNEUMOGASTRIC NERVE. 1019 by a glass rod or a brush, suitable substances being used for each taste. Thus, for bitter a solution of quinin may be used ; for sweet, a solution of sugar ; dilute acetic acid or vinegar for acid, and common salt for the saline taste. Ageusia may result not only from lesions of the glossopharyngeal nerve, but also from those of the gustatory or lingual branch of the fifth, and of the fifth itself within the cranial cavity ; from affections of the chorda tympani in disease of the middle ear, of the facial between the entrance of the chorda tympani and the geniculate ganglion, and in lesions of the peripheral organs of the nerves of taste. Disturbance of taste may possibly result from cere- bral lesions, but the cortical area for taste is not known. Perversion of the sense of taste is known as " parageusia." It is a rare phenomenon, found in patients with facial palsy, in the hysterical, and in the insane, in whom, also, subjective sensations of taste may be present. The latter also occurs as an aura in epilepsy. Hyperesthesia of taste is even more rare, and is purely a hysterical symptom. LESIONS OF THE PNEUMOGASTRIC OR VAGUS NERVE— THE TENTH PAIR. Anatomical. — This nerve has by far the widest distribution of any of the cranial set, supplying the pharynx, larynx, lungs, heart, esophagus, and stomach, and in part also the intestines and spleen. The symptoms of its involvement are, therefore, numerous and varied. It is a mixed nerve of motion and sensation, some of its most important motor functions being derived from the spinal accessory nerve. It is the chief sensory nerve for the respiratory center in the medulla oblongata, but contains, also, accelerating and inhibitory fibers for this center. The former office preponderates, so that section of the nerve renders respirations less fre- quent, 'though deeper, while stimulation of the divided central end accelerates them, and acceleration may proceed to tetanic arrest. The inhibitory fibers are contained chiefly in the superior laryngeal nerve, stimulation of which arrests breathing with the muscles in a state of relaxation. It is also the inhibitory nerve of the heart, slight stimulation increasing the length of diastole, while stronger stimulation arrests its action. On dividing the nerve cardiac contractions become more frequent. It is also inhibitory for the vasomotor center, and its stimulation produces relaxation of the arteries throughout the body. It is the motor and sensory nerve for the esophagus, sensory nerve for the stomach, and partly the motor nerve for the stomach and intestines. Lesions Involving the Nucleus and Trunk of the Pneumogastric AND Branches. The nucleus in the medulla oblongata may be involved in softening, bemorrhage, or slow degeneration, but adjacent nuclei are also afifected at the same time, whence resulting effects are associated and are especially seen in bulbar palsy. , The trunk of the nerve near its origin may be compressed by thick- ened meninges, tumors, or aneurysm of the vertebral artery. In its course it has been implicated in incised wounds, and tied in ligation of the carotid. I020 DISEASES OF THE NERVOUS SYSTEM. Neuritis and neuromata are possible. The results of such lesion are com- monly paralytic, rarely irritative. The former, if total, are diminished breathing-rate, " suffocation," frequent pulse-rate, and death. According to Traumann and others unilateral division of the vagus in experiments on animals caused few pulmonary symptoms. One vagus seems to be sufficient for the function of both lungs. The results of partial paralysis are better considered in connection with lesions of the separate branches of the pneu- mogastric, some of which are also invaded separately. Lesions of the Pharyngeal Branches. — These branches of the pneu- mogastric, together with branches of the glossopharyngeal, form the pharyngeal plexus, from which the muscles and mucous membrane of the pharynx are innervated. Etiology. — Nuclear disease is a most common cause of paralysis of the pharynx. It shares with disease involving adjacent nuclei, constituting bulbar palsy, already considered ; but it may also be caused by meningitis or bone disease at the base of the skull, or it may form part of the lesion of diphtheritic paralysis. Symptoms. — The results are mainly paralytic, occasionally irritative, producing spasm. The symptoms of paralysis are difficulty in swallowing, food lodging in instead of descending into the esophagus. A most frequent consequence is the entrance of food into the larynx, causing spasm and even choking. Pulpy food is better swallowed than liquids, the latter passing easily into the posterior nares when there is paralysis of the soft palate, and even when the paralysis is limited to the superior constrictor of the pharynx owing to contraction of the middle constrictor. When the nerves on one side only are involved, the difficulty is much diminished. Should there be a doubt in diagnosis between paralysis of the pharynx and obstruction or morbid growth, the passage of a bougie will clear it up. Spasm of the pharynx is always functional in origin, chiefly hysterical. The so-called " globus hystericus," or sensation as of a ball in the throat which has to be swallowed but immediately rises again, is one of its mani- festations ; so is eminently the spasm in hydrophobia. Extreme degrees are those in which persons cannot swallow their food in the presence of others. Lesions of the Laryngeal Branches. — The laryngeal branches are two, the superior and inferior, or recurrent laryngeal. The former supplies the mucous membrane above the vocal cords, the cricothyroid, and the depressors of the epiglottis. The inferior or recurrent laryngeal on the left side winds around the arch ol the aorta; on the right, around the subcla- vian. The nerves then pass up to the larynx between the trachea and the esophagus, supplying all the laryngeal muscles except the cricothyroid and epiglottic, and the mucous membrane below the cords ; also that of the trachea. It has been supposed that the motor fibers in these nerves come from the spinal accessory nerve, but this is now doubted. The sensory filaments of the laryngeal branches pass to the medulla oblongata in the roots of the pneumogastric. In order to appreciate the phenomena of paralysis of the larynx it should be remembered that the glottis is opened or closed only by the movement of the posterior extremity of the cords, the anterior remaining fixed, and that this movement is effected chiefly by the arytenoid cartilages attached to the cricoid cartilage by an articulation which permits free move- LESIONS OF THE PNEUMOGASTRIC NERVE. 1021 ment. Each arytenoid is shaped like an irregular pyramid prolonged at the base into two processes — an anterior or vocal, from which the cord passes to the thyroid cartilage, and an external or muscular, to which the muscles are attached. When the latter, which is at right angles to the vocal process, is moved back, this process moves outward from its fellow, the cord is abducted, and the glottis opened. If the muscular process is moved forward, the vocal process is moved inward toward its fellow, the cord adducted, and the glottis closed. These movements are further aided by movements of the arytenoids away from or toward each other. Symptoms. — These are phonic and respirators, together with altered position of the cords, as recognized by the laryngeal mirror. The voice may be changed or lost, the entrance of air in breathing impeded, while the closure of the glottis, necessary to coughing, is usually imperfect. The voice and respiratory functions of the larynx are regulated by the same muscles and nerves, but by centers that differ in anatomical connection, if not in position. In breathing the cords are abducted or separated during inspiration, the extent being proportionate to the force of inspiration. During expira- tion they are a little nearer than in inspiration. In phonation they are made tense and brought together, the degree of adduction and tension varying with the note produced. After death the vocal cords assume a position of slight abduction from the middle line, a little nearer than during ordinary breathing, known as the cadaveric position. The position is one of partial relaxation, complete relaxation being never fully attained during life. The symptoms of deranged function of the laryngeal nerves admit of classification into those of paralysis and spasm. 1. Total Paralysis of Both Cords or of One. — In what is known as complete paralysis of the lar}'ngeal muscles — which does not, however, usually include the cricothyroid — the vocal cords assume the cadaveric posi- tion previously mentioned, from which they cannot be moved. Hence vocal sounds cannot be produced. In deep inspiration the current of air may bring them a little closer, and there may slight stridor, and instead of the natural explosive cough, there is only a sudden rush of air through the glottis. If one cord is paralyzed, it alone is motionless in the cadaveric position. Phonation may still be possible, because the unaffected cord may be overadducted beyond the middle line, but the voice is low-pitched and often hoarse. During inspiration the abduction of the healthy cord pre- vents stridor, while an explosive cough is impossible because the glottis is not closed w'ith sufficient firmness to produce it, unless the paralysis is very slight. The causes of complete paralysis are central disease and disease of the trunk of the vagus or of the recurrent laryngeal. 2. Bilateral Abductor Paralysis. — In abductor paralysis involving the posterior crico-arytenoids the cords are near together — in the position of phonation — and cannot be abducted even as far as the cadaveric position. They can, however, be brought together in phonation and in coughing, at the cessation of which they recede a little, but the normal wide abduction of inspiration does not take place. This slight recession is due to the elas- ticity of the attachment of the cords.. The adductors, unopposed, undergo secondary contracture, so that if the paralysis is of long duration, the chink of the glottis becomes permanently narrower. The tensors are still active, as well as the adductors, hence the voice is little affected. The chief diffi- I022 DISEASES OF THE NERVOUS SYSTEM. culty is in breathing, since the normal recession of the cords essential to inspiration does not take place, while they are even brought closer together by the pressure of the entering air. Hence inspiration is accomplished with stridor, and the obstruction to the entrance of air brings into play the extra- ordinary muscles of respiration, the effect of which is to prolong the inspi- ratory act. Expiration is unimpeded, the current of outward air tending to open the cords. The absence of voice involvement and of cough may cause the obstruction to be referred to the trachea, but the absence of expiratory stridor excludes this, while the movement of the larynx up and down during breathing is greater than in tracheal stenosis. The added urgent dyspnea, the loud inspiratory stridor, livid features, and cold ex- tremities finish an unmistakable picture ; so that a laryngoscopic examination is therefore not necessary to complete the diagnosis. In bilateral palsy there is even great danger, as a slight catarrhal swelling may close the larynx and tracheotomy may be necessary to save life. The causes of abductor paralysis are central disease and local influence such as laryngeal catarrh and degeneration of the posterior cricothyroids, possibly of toxic origin. Disease of the recurrent laryngeal has produced such paralysis, although this nerve supplies fibers to the adductors as well as abductors. On the other hand, the abductors have been found degen- erated when the other muscles were found normal". Paralysis of both cords is generally due to disease of both nerves, and may be produced by pressure on both vagi and both recurrent laryngeal nerves. Central causes are tabes dorsalis and bulbar palsy. Abductor paralysis is also a rare symptom in hysteria, when it is bilateral, with characteristic symptoms, and has caused death. 3. Unilateral Abductor Paralysis. — In this the afifected cord is near the middle line, and it does not move in inspiration. There are hoarseness and roughness of voice and sometimes dyspnea, but the mobility of the other cord permits the function of the larynx to be carried on with tolerable comfort. If the adductors become involved, as is sometimes the case, phonation is still more impaired. The most frequent cause is aneurysm, and the left icord is most fre- quently involved, — though other tumors may cause it, — and on the right side the nerve may be involved in a thickened pleura. 4. Adductor Paralysis {Phonic Paralysis; Hysterical Paralysis). — In adductor paralysis due to involvement of the lateral crico-arytenoid and the arytenoid muscles the cords are apart and cannot be approximated. In true adductor paralysis there is still the power of separating the cords on deep inspiration, but no power to"" bring the cords nearer than in the cadaveric position. The causes of adductor paralysis are rarely organic diseases of the nerves or centers. It is the condition causing the oft-quoted hysterical aphonia, and may be brought on by overuse of the voice and catarrhal laryn- gitis. The patient with hysterical aphonia can sometimes sing, though she can talk only in a whisper. It is most common as a partial paralysis. While the cords cannot be approximated for phonation, they can be in coughing. Hence it was called by Tiirck " phonic paralysis." Another partial adductor paralysis is due to the loss of power in the arytenoid muscle, resulting in defective closure of the posterior part of the glottis and hoarseness or loss of voice. 5. Tensor Paralysis. — Little is known of this except that palsy of the LESIOXS OF THE PNEUMOGASTRIC NERVE. 1023, internal fibers of the thyro-arytencideus causes the edge of the cord to be concave. Diagnosis. — The laryngoscope is necessary to a proper diagnosis of laryngeal palsies, but symptoms are also useful. The inability to produce explosive cough is of great value in pointing to palsy of organic origin, if there is no local lesion to prevent it. (a) Absence of cough with entire loss of voice points to bilateral palsy of organic origin. (&) No cough, voice low-pitched and hoarse, paralysis of one cord. (c) Loud inspiratory stridor without loss of voice, total abductor paralysis. (rf) Little change of voice or cough, unilateral abductor paralysis. {e) Perfect cough, no voice, no stridor, unimportant adductor palsy. The following table from Gowers contains in separate columns the symptoms, laryngoscopic picture, and lesions : Symptoms. Signs. Lesion. Total bilateral palsy. (a) No voice ; no coiig-h ; stridor Both cords moderately abducted and only on deep inspiration. j motionless. (d) Voice low-pitched and hoarse ; One cord moderately abducted and Total unilateral palsy. no cough ; stridor absent or slighti motionless, the other moving freely on breathing. and even beyond the middle line in phonation. ic) Voice little changed ; cough Both cords near together, and during normal ; inspiration difficult and inspiration not separated, but even long, with loud stridor. j drawn nearer together. (d) Symptoms inconclusive ; little One cord near the middle line, not ~ affection of the voice or cough. , moving during inspiration; the other 1 normal. \e) No voice ; perfect cough Stridor or dyspnea. no Cord normal in position and moving normally in respiration, but not brought together on an a..cempt at phonation. Total abductor pals}'. Unilateral abductor palsy. Adductor palsy. Spasm of the Larynx. — In spasm of the larynx the adductors are alone concerned. The closers of the glottis are stronger than the openers, while reflex mechanism is connected chiefly with those muscles because of the im- portance in guarding against the entrance of foreign bodies into the larynx. Spasm is quite common in children, especially in the rickety, and is not rare in adults under the name of laryngismus stridulus. It is generally reflex, although the reflex cause is not always discoverable. The patient commonly wakes up at night in an attack of intense dyspnea ; but it may occur at any time. The symptoms are like those of ordinary croup. The paroxysm differs from that of abductor paralysis in that the stridor accompanies expiration as well as inspiration. The attacks occur in the so-called laryngeal crises of tabes dorsalis, in tetany, in the paroxysms of hydrophobia, sometimes in alternation with attacks of migraine, and in hysteria. Spasm is also sometimes excited by attempts to speak, when aphonia results. The condition is the reverse of phonic paralysis, in which the cords cannot be brought together in speaking, while in spastic aphonia they come together too forcibh'. Disturbances of the sensory innervation of the larynx are chiefly con- fined to the irritation which causes cough and spasm. I024 DISEASES OF THE NERVOUS SYSTEM. Lesions of Cardiac Branches. — The cardiac plexus is made up of fibers derived in part from the pneumogastric and in part from the sympa- thetic. The vagus fibers are motor, sensory, and probably trophic. The motor fibers include those which inhibit, control, and regulate the cardiac action. Their irritation inhibits the heart's action and causes slow- ness oi the pulse, or bradycardia. In complete paralysis of the vagi the inhibitory action is abolished and the accelerator influence is unhampered, producing rapid pulse, or tachycardia. Yet it sometimes happens that com- plete paralysis of the vagus is followed by no cardiac symptoms. The causes of these effects are, unfortunately, not always discoverable. Pressure of a tumor, accidental ligation of one vagus, irritation of its nuclei, anginal attacks, in one instance associated with a small tumor of the vagus, have all been followed by bradycardia. Toxic blood states are also held responsible for it. Some persons are able to control the action of their own hearts, notably a Colonel Townsend, who could control the action of his heart at will. The heart may sometimes be slowed by pressure against the pneumogastric in the neck. The opposite condition, tachycardia, has been produced by diphtheritic neuritis, tumors of the vagus, or accidental removal of the vagus. Sensory phenomena in connection with parts supplied by the cardiac branches of the pneumogastric are unusual, but a^ny uncomfortable sensa- tions arising from palpitation or irregularity are conveyed by branches of the pneumogastric. Trophic influence in the pneumogastric is inferred from the fact that the heart has been found in a state of fatty degeneration after injury to the nerve. Lesions of Gastric and Esophageal Branches. — Among phenomena ascribed to effect on these branches are spasm of the esophagus and diffi- culty in swallowing. The vagus is also the sensory nerve of the stomach, and pain in this organ is felt through this nerve. The severe gastric crises which occur in tabes dorsalis are due to central irritation of the vagus nuclei. The senses of hunger and thirst are also believed to be conveyed through it, and have been lost in disease involving the root, but appetite is not always lost after section of the nerve, while in some cases of disease of the nerve there has been excessive appetite. On the other hand, loss of appetite is due to so many causes that it cannot be ascribed to pneumogastric lesion without careful investigation. The pneumogastric is also the motor nerve of the stomach, though motion of the organ is not entirely arrested after its section. Vomiting is probably produced through its agency, and is excited by central and reflex irritation. Meningitis, which so frequently excites vomiting, does so through it ; the pressure of a tumor on the nerve has had a similar effect, also direct pressure on an exposed nerve. Lesions of Pulmonary Branches. — While the vagus sends branches to the lungs, little is known of their office. They are supposed to go to the bronchial muscles, and it is held that asthma is a neurosis of these fibers. Irritation of the afferent pulmonary fibers certainly produces spasm. Stimu- lation of the respiratory center also causes energetic respiratory movements, while rapid congestion and even hemorrhage have been noticed after section, LESIOXS OF THE PXEUMOGASTRIC XERVE. 1025 though these effects may possibly be of reflex origin excited through the sympathetic, since the vasomotor fibers in the vessels of the lungs are derived from the sympathetic. After section of the vagus animals die of broncho- pneumonia. This has not been considered the result of trophic influence, but because of the entrance of foreign particles into the bronchi in conse- quence of paralysis of the larynx and esophagus ; this was shown by Traube as far back as 1871, and confirmed by Frey by numerous experiments in 1877. Such broncho-pneumonia has also been ascribed to paralysis of the bronchial musculature and of the vaso-constrictor fibers which causes neuroparalytic hyperemia of the pulmonary tissue. Spiller's case, recently reported,* has some bearing on the subject. This patient suffered an injury of the left glossophar\-ngeus and vagus by a fracture of the base of the skull. He died 46 days after the accident and at necropsy numerous areas of bronchopneumonia were found. It seemed improbable that the pulmonary condition was caused by the entrance of foreign bodies into the lungs in this case, because the patient was unable to swallow. Saliva, however, doubtless passed into the trachea and carried with it muco-organisms. The patient was tested with a glass of water and his choking was so alarming that the attempt was not repeated. He was nourished by rectal enemas and the stomach tube was passed only on the day before his death. The choking was probably the result of impaired function of the epiglottis. Spiller thinks it reasonable to attribute the pulmonary condition to the paralysis of the vagus nerve, although the pulmonary lesions were not recognized until the necropsy was made. The phenomena of hiccough may be the result of disease of this nerve, as they are also the result of disease of the respiratory center. Prognosis in Pneumogastric Lesions. — This varies greatly. In cen- tral and nuclear disease it is unfavorable : it is unfavorable also when it is the result of pressure from intrathoracic tumors, especially aneurysm. In hysterical and purely local aft'ections the prognosis is more favorable. Treatment. — This is, of course, that of the causal lesion, if it can be discovered. Syphilis is the more curable of the central causes. Other causes of central disease are not removable. Of diseases of the trunk, neuritis of the vagus is as amenable to treat- ment as the polyneuritis of which it is a part. The laryngeal symptoms due to involvement of the recurrent laryngeal are as remediable as the causes which produce them. If they are caused by aneurysm of the aorta or cancer, treatment is useless : if caused by syphilitic and scrofulous growths, the prog- nosis is more hopeful. In the paralyses of more purely local origin, especially the hj^sterical, phonic, and diphtheritic forms, electricity oft"ers the most promising results. The method of its employment will be found detailed under diseases of the larynx. Either form of electricity may be used. Strychnin is a useful remedy, used locally as mentioned. The method preferred is by hypoder- mic injection, the nitrate being employed in doses of from 1-60 to 1-30 grain (o.ooii to 0.0022 gm.) daily. In addition to stn-chnin, other tonics should be used to restore the general health of the patient. Lar}-ngeal gymnastics have been recom- mended and used with some success. ,They consist in pressing firmly with the thumb and forefinger on each side of the upper and hinder part of the * "Univ. of Fenn. !Med. Bull," March, 1903 65 I026 DISEASES OF THE NERVOUS SYSTEM. thyroid cartilage, the patient being requested to make a simple sound dur- ing the compression. The treatment of laryngeal spasm demands also the removal of the cause if possible, in addition to which sedatives, local and general, especially the bromids and cocain, may be used. Chloral, chloroform, and nitrite of amyl by inhalation may be necessary to break up the spasm. LESIONS OF THE ELEVENTH PAIR OR SPINAL ACCESSORY NERVE. Anatomical. — This nerve, purely motor in its function, has two por- tions — an internal, which passes to the pneumogastric and innervates the laryngeal muscles, and an external or spinal portion. The former has been considered. It should be regarded as probably a part of the vagus, and the eleventh nerve is called by some the vago-accessory nerve. The latter, i. e., the spinal portion, is essentially a set of motor fibers from the cervical spinal cord, which ascends into the cranial cavity and passes out again with one of the cranial nerves to be distributed to the sternocleidomastoid and trapezius muscles, whose innervation they share with the spinal nerves. The purpose of the trapezius is chiefly to raise the shoulder ; that of the sternocleido- mastoid is to assist in turning the head to the opposite side, the chin being at the same time raised. This is accomplished by drawing the occiput toward the side of the muscle acting. Lesions. — The nuclear origin of the nerve may be involved and con- tribute to the phenomena of bulbar palsy, or it may shafe in progressive central degeneration, causing wasting in the muscles supplied, which may be a part of a more general muscular atrophy. The trunks of the nerve or both nerves may be compressed in the foramen magnum by meningitis or tumor'. Outside the skull there may be wounds, tumors, caries of the ver- tebrae, and resulting abscesses, and sometimes abscesses springing from the cervical glands. Rarely the spina! accessory may be invaded by rheu- matic neuritis. The resulting conditions are paralysis and spaswk Those of the in- ternal or accessory portion have been described under lesions of the pneumo- gastric. It remains to consider only those of the external branch. Symptoms of Paralysis o£ the External Branch of the Spinal Acces- sory Nerve. — The seats of the paralysis are the sternomastoid and trapezius muscles. When one sternomastoid is involved, the head may still be moved to the opposite side, and there is no wry-neck, or' torticollis, though in some cases the head is held obliquely. The trapezius is not so much involved because it is well supplied with cervical and thoracic nerves, but the portion which passes from the acromion to the occipital bone is motionless. The middle portion of the muscle is also weakened, the shoulder droops down- ward and forward, and the inferior angle of the scapula is rotated inward bv the action of the rhomboids and the levator anguli scapulae. Elevation of the arm is also partial, because the trapezius does not fix the scapula at a point whence the deltoid can work. The paralysis is well seen when the patient takes a deep breath or tries to shrug his shoulders. Wasting almost always accompanies the loss of power, and there is usually reaction of degeneration. LESIOXS OF THE SPIXAL ACCESSORY NERVE. 1027 In bilateral paralysis the power of holding the head in the upright posi- tion is impaired. If both sternocleidomastoids are affected, the head tends to fall backward ; if both trapezii, it falls forward so that the chin rests on the sternum. The latter is the characteristic position of the head in pro- gressive spinal muscular atrophy, and in children who have chronic menin- gitis about the foramen magnum, pressing on both nerve-trunks, and in cer- vical meningitis the result of caries. A peculiar ' drooping of the head is sometimes seen during the first year of life in children, which Gowers says may be due to injury to the spinal accessory nerves in difficult labor. In recent cases the nerves may give characteristic reaction of degeneration. In central disease the reaction varies, as it does in progressive spinal muscular atrophy. Treatment.— This must have for its object, first, the removal of the cause, or the morbid process which produces it. After this the weak muscles are to be treated by massage and electricity. Faradization is, per- haps, most efficient for this purpose, and either form of current will answer. Symptoms of Accessory Spasm (Torticollis; Wry-neck). — Though the muscles supplied by the spinal accessory are not the sole ones responsible for these conditions, they are the ones chiefly concerned. The terms are applied to unnatural positions of the head resulting from contraction of these muscles. There are two principal varieties : 1. Fixed wry-neck, or congenital torticolhs. 2. Spasmodic wry-neck. These two may be regarded as true torticollis, and are to be distin- guished from two somewhat similar states which may be called false torti- collis. The first of these is the ordinary " stiff-neck," which is really a rheu- matic condition due to exposure to cold, and characterized by pain and ten- derness, for the relief of which the position is assumed, and should not be called wry-neck. The second is a twist-neck, not due to muscles, but to some other cause, most frequently disease of the cervical vertebrae. This deviation puts the sternocleidomastoid muscle on the stretch, and thus may give rise to the impression that it is responsible. I. CoxGEXiTAL Torticollis, or Fixed Wry-xeck. — This depends on the shortening of some muscle, commonly the sternocleidomastoid, which is also often atrophied, hard, and firm. It is met most frequently in children, and is thought to be due, in some cases at least, to injury of the muscle pro- duced by traction during birth. In others it is ascribed to developmental shortening of the muscle, due to the inclined position of the child's head in the pelvis. It is not always noticed immediately after birth because of the natural shortness of the child's neck. A similar condition may result from injur}- to the muscle during life, producing inflammation and cicatricial con- traction. It aft'ects the right side almost exclusively. It is more or less constantly associated with facial asymmetry, first noticed by George Wilks and further studied by Golding Bird, who suggested that the two conditions are parts of one affection which has a central origin. In fixed wn--neck the head is turned toward the side opposite to that of the contracted muscle, which stands out conspicuously, and cannot be turned toward the latter. While the sternocleidomastoid is the , muscle almost invariably responsible in these cases, the trapezius is occasionally the seat of similar atrophy. Treatm.ent. — The treatment is by section of the contracted muscle. Somie appliance may be necessary for a time to keep the head in proper 1028 DISEASES OF THE NERVOUS SYSTEM. position, especially when secondary changes in the articulation have taken place. In simple rheumatic wry-neck I have used an appliance consisting of webbing or " saddle girth " about three inches wide, stretched from side to side of the bed and raised a few inches above the mattress, — the distance to be regulated by circumstances, — on which the patient lay at night, instead of on a pillow on the side to which the head is drawn. This expedient may be used after operation. The facial asymmetry is apt to remain after the wry-neck is cured, and may even become more conspicuous. 2. Spasmodic Wry-neck. — This is a condition analogous to the facial spasm, occurring as a symptom of disease of the facial nerve. There are two forms, the tonic and the clonic, which may alternate in the same case or, as is most usual, occur separately and remain so. Etiology. — It is for the most part an affection of adults, and, accord- ing to Gowers, is more common in females — that is, in twenty-two out of thirty-two cases. While this must be true of England, the opposite seems to be the case in this country, since of eight or ten cases observed by Osier in Philadelphia and Montreal, all were men. It is more common in middle life, two-thirds of all cases occur'ring between the ages of thirty and fifty. In women under thirty it is apt to be of a hysterical origin ; rarely it is ascribable to the same cause in boys. It is prone to occur in neurotic fami- lies. Very rarely it occurs in the first year of infantile life, ceasing after a few months. Cold has been assigned as a cause ; also traumatism. In the tonic form, when the sternocleidomastoid is responsible, the head is continually turned to the opposite side, the chin is raised, and the occiput is drawn down toward the afifected side — the caput obstipuin spasticuiiK When the trapezius is involved, the head is still more depressed toward the same side. In combined and bilateral spasm of these muscles the head is drawn backward, producing the retrocoUic spasm. In prolonged cases the muscles involved are prominent and rigid, and there may be spinal curvature with the convexity toward the sound side. In the clonic for'm there are paroxysmal twitchings of the head, which may be very severe and correspondingly distressing. When there is pre- dominating unilateral spasm of the sternocleidomastoid, the head is turned to the opposite side and the chin is raised with every contraction of the muscle. In unilateral spasm of the trapezius the head is drawn more back- ward with each contraction and toward the shoulder of the affected side. In bilateral and combined spasm there is clonic retrocollic spasm, with shaking and nodding movements — the so-called " salaam convulsions " sometimes seen in children. They may^be produced also by contractions of the other muscles of the neck. Tonic and clonic spasm of the splenius may occur either alone or in combination with that of the trapezius and sternocleido- mastoid. In splenius spasm the head is also drawn backward and toward the afifected side, and ther'e will be noticed muscular swelling to the outside of the cervical portion of the trapezius. The splenius is, according to Gowers, associated with the sternomastoid about half as often as the trape- zius. The retrocollic spasm is commonly associated with a wrinkling of the forehead in both the tonic and clonic form. In the clonic form the contractions may come on suddenly or be pre- ceded by stififness and irregular pain. The movements occur every few minutes, and the head cannot be kept still, although the movements cease during sleep. They are increased by emotion, excitement, or fatigue. LESIONS OF THE SPINAL ACCESSORY NERVE. 1029 Sometimes there is pain, but at other times there is merely a sense of fatigue. The muscles in time may become hypertrophied, but never waste. Pathology. — This is very obscure. Reasoning, rather than demonstra- tion, leads to the conclusion that the muscular contractions probably depend on the overaction of nerve-cells, and not on irritation of nerve-fibers ; the movement usually involves the deep rotators on one side of the neck and the sternocleidomastoid muscle on the opposite side. It is therefore a movement of associated muscles, and this suggests a cortical origin, at least in many cases. Diagnosis. — The distinction lies between true and false torticollis, in which there is deviation of the head from some other cause than muscular contraction, and it is only the form of tr'ue torticollis due to shortening of one sternocleidomastoid which is likely to be confounded with the false. In the spurious form the sternomastoid is tense on the side toward which the face is turned, and in the true form the tension is on the side opposite. In retrocollic spasm the invariable association of contraction of the frontalis muscles, producing the peculiar wrinkling of the forehead, distinguishes it from simple tremor. The hysterical form occurs in women under thirty, and this fact is presumptive evidence of its presence, while hysterical spasm is also apt to spread from the neck to the trunk ; in the true form of torticollis it is limited to the neck. Prognosis. — The prognosis is always grave, and the more severe and extensive the spasm, the more unfavorable. Relief is more possible in the first half of life than in the second. Cases do, however, occasionally get well, and temporary relief is more frequent. Treatment. — If the cause can be found v/hich is responsible, it ought to be removed. If discovered in an acute stage, absolute rest in bed and fomen- tations or dry heat are indicated. Electricity has, perhaps, more reputation than any other remedy. The far'adic brush may be applied over the skin of the affected muscles and to the swelling. Gradually increasing faradic cur- rents may be used. If the galvanic current is used, a weak one is preferred, and the anode, or positive pole, is placed below the occiput or highest acces- sible part of the nerve, and the negative on each contracting muscle, for ten minutes at a time. Sedatives and narcotics have also some reputation. Among these the bromids and cannabis indica are included in large doses. Five-minim (0.3 c. c.) doses of the fluid extract of cannabis indica may be given, rapidly increased. The drug is proverbially unreliable. The hypodermic use of morphin is of tmdoubted value in r'elaxing the spasm, but the dangers of its protracted use almost preclude it. It would be unfair to the drug, however, to omit the statement of Gowers that, " continued for several months in doses increased gradually to half a grain or a grain a day, it has entirely removed the spasm." Naturally such persons are weaned from the drug with dififi- culty. The hypodermic use of atropin in the affected muscles has also been recommended. -Mechanical supports for fixing the head are recommended, but are not well borne. Surgical measures have been employed — such as section, exsec- tion, stretching of the nerve, and section of the muscle — with, at best, but temporary results. Mention should be made, however, of the deep-seated operation of W. W. Keen and Noble Smith, which consists in dividing the spinal accessory nerve and the posterior branches of two or three cervical nerves which also supply the splenius and complexus. This reduces the I030 DISEASES OF THE XERVOUS SYSTEM. spasms that reside in these muscles to a slight degree, while the otherwise paralyzing effect of the division cf branches of the spinal nerves is compara- tively unimportant. LESIONS OF THE TWELFTH PAIR OR HYPOGLOSSAL XERVE. Anatomical. — This is the motor nerve of the tongue, ana supplies also the depressors of the hyoid bone and the hyoglossus and geniohyoid of the elevators. It arises from the medulla oblongata beside the olivary body. Its cortical center is probably the lower part of the ascending frontal gyrus or the posterior part of the third frontal convolution. It is subject to paralysis and spasm. Etiology. — I. Cortical disease is frequently responsible for paralysis of the tongue on the opposite side, as is seen in the numerous cases of hemi- plegia associated with this condition. The same accident occurs when the fibers between the cortex and the nucleus in the medulla oblongata are in- vaded, and probably this is the most frequent cause of paralysis of the tongue. Apoplexies and other causes of compression, softening, throm- bosis, and embolism, are agencies operating to this "end. 2. Nuclear disease is another cause. It is usually degeneration, rarely sudden softening: the former as a part of bulbar palsy and tabes dorsalis, and the latter from vascular obstruction. The effect is almost always bilateral, the nuclei being so close together that it is scarcely possible to in- volve one only, although such isolated result has occurred in sudden cases and, rarely, in slow ones, as in tabes dorsalis and general paralysis. 3. Infrannclear disease may operate at various sites — (a) Within the medulla oblongata the root fibers may be invaded by a tumor or by softening. (&) Outside the medulla oblongata the fibers may be damaged by the products of meningitis, simple or syphilitic, and by new fortnations. The nerve may be compressed in its foramen by outgrowth of bone. Outside the skull the nerve is compressed by tumors, by inflammatory products, or in- jured by disease communicated from caries of the upper cervical vertebrae and by penetrating wounds. Hence the spinal accessory and vagus nerves are often implicated coincidently and there is paralysis of the palate, occa- sionally of the vocal cords, with or without wasting of the trapezius and ster- nomastoid. The hypoglossal may be the seat of neuritis. Symptoms. — i. Of Hypoglossal Paralysis. — These are motor only. When there is supranuclear disease in addition to the palsy of the tongue, there is hemiplegia, but no wasting of the tongue, which is protruded toward the affected side, nor change in electrical reaction. In nuclear disease the lesion is apt to be bilateral palsy. The tongue lies motionless in the floor of the mouth, and speech and deglutition are seriously impaired. ^Mastication is interfered with mainly because the tongue cannot regulate the position of the food, the proper muscles of mastication being intact. There are atrophy and reaction of degeneration. The mucous membrane is thrown into folds. The condition is likely to be a part of a bulbar palsy. In infranuclear disease only one nerve is aft'ected, there is wasting with reaction of degeneration and fibrillary twitching. Speech is not much impaired, nor is swallowing. 2. Of Spasm. — Spasm of the tongue as an isolated event is very rare= CERVICAL PLEXUS. 103 1 It may be unilateral or bilateral. It commonly occurs as a part of some other convulsive affection, as epilepsy or chorea, or spasm of the facial muscles. It may also occur in hysteria. In the biting of the tongue in epilepsy the organ is thrust between the teeth by spasmodic contraction of the genio- glossus and caught by the jaws through ^ spasm of the masseters. Spasm of the tongue occurs in some forms of stuttering, the spasm often preceding the explosive utterance of words. In other cases there are various protru- sions and deviations of the tongue, produced in some instances by irritation of the fifth nerve, variously induced, as by a carious tooth. The spasm may be clonic, the tongue being thrust in and out many times in a minute, at others more slowly. It may be associated with facial spasm. It may occur during sleep. Diagnosis. — This is generally easy. If there are hemiplegia and palsy, t)ut no wasting of the muscles of the tongue, no reaction of degeneration, the lesion is supranuclear. If there is paralysis of the tongue on the one side and of the limbs on the opposite, there is probably a unilateral lesion in the medulla oblongata, involving the nucleus or the fibers arising from it. When the disease is on the surface of the medulla oblongata, the paralysis is commonly unilateral, and is associated with paralysis of the correspondmg half of the palate and vocal cord, because of the involvement of the spinal accessory nerve. Spiller believes it is because of involvement of the vagus. Prognosis. — The prognosis is usually unfavorable because the lesion is incurable. Treatment. — The treatment embraces that of the disease producing it. The symptom of lingual paralysis may be treated with electricity — with an electrode in the shape of a tongue depressor. The treatment of spasm has been by sedatives, including bromids, by iodid, and by electricity. DISEASES OF THE SPINAL NERVES AND BRANCHES. CERVICAL PLEXUS. Affections of the Phrenic Nerve. — Paralysis of this nerve may be the result of a lesion in the anterior horn of the gray matter of the cord, at the level of the third and fourth cervical nerves ; of a lesion to these nerve-roots in disease of the membranes of the cord or of the vertebrae; or by compression by aneurysms or other tumors. Exposure to cold, pro- ducing neuritis, may cause it, and it may be a part of a diphtheritic palsy. Symptoms. — The result is paralysis of the diaphragin, which is com- plete if both nerves are involved, as is the case in disease of the cord or its membranes ; partial when a tumor or other cause affects one nerve. Res- piration is still carried on by the intercostals, and when the victim is quiet, there is little or no embarrassment, but examination shows the abdomen to be retracted in inspiration and protruded in expiration. In other cases, in consequence of increased movement^ of the thorax, the upper abdominal walls are drawn outward with inspiration — a movement not to be mistaken for movement of the diaphragm. On exertion, however, there is dyspnea, which is also observed if the paralysis is sudden. The effect of paralysis 1032 DISEASES OF THE NERVOUS SYSTEM. of a single phrenic, involving one-half of the diaphragm, is scarcely notice- able. A further effect is to aggravate any lung affection, as bronchitis or pneumonia. There is difficulty in coughing effectually, and, therefore, of emptying the lungs of mucus, accumulation of which may result in impair- ment of resonance at the base of the lungs in bronchitis, and in the physical signs of edema. Diagnosis. — Xervous breathing resembles the breathing of paralysis of the diaphragm in that this muscle is used very little, while the upper thorax is freely used. If, however, the attention of persons thus breathing is distracted, or they are watched when not conscious of observation, the diaphragmatic breathing will at once become apparent. The diaphragm does not move when it is inflamed or in diaphragmatic pleurisy, but it is because of the extreme pain which its motion causes under these circumstances. The diaphragmatic palsy from diphtheritic neuritis is only a part of the symptoms due to such neuritis. In diaphragmatic paralysis due to spinal disease there is usually atrophy of other muscles, together with other symptoms of that disease. Prognosis. — This depends upon that of the disease of which it is a part, except in diphtheritic neuritis, in which it is'the direct result of the disease, and where the prognosis is unfavorable. Treatment. — The treatment is that of the disease of which it is the result. If there is neuritis, effort should be made to galvanize the nerve by pressing one pole outside the clavicular portion of the sternomastoid, and the other pole over the epigastrium or the corresponding half of the diaphragm. Counterirritation may also be applied in the triangle of the neck outside the clavicular portion of the sternomastoid. BRACHIAL PLEXUS. Of the Combined Plexus. — This may be affected above the clavicle by causes producing pressure on the nerve-trunks — the five lower cervical and first thoracic — after they leave the spine and before they unite to form the plexus. Such causes are tumors and other morbid processes in the neck. IMore frequently, causes operate below the clavicle, of which the most frequent is prolonged luxation of the humerus, especially under the coracoid process. One or more branches may be thus involved, producing a corre- sponding degree of paralysis, to which is added wasting of muscles, with reaction of degeneration and trophic changes in the skin. Fracture of the humerus is another cause. Blows or falls on the shoulder and injuries in the neck may produce the same results, as may also compression during birth. The muscles involved may be the deltoid, supraspinatus, infraspina- tus, biceps, and brachialis anticus. X^euritis of the brachial plexus also occurs rarely as a primary inflam- mation. The result ultimately may be complete loss of power in the arm. A still rarer disease is neuroma of the plexus. Lesions of Individual X^erves. — D/ the Long Thoracic or Posterior Thoracic (Serratus Palsy). This nerve is particularly subject to pressure through its long course and position, especially in the posterior triangle of BRACHIAL PLEXUS. 1033 the neck. Such pressure may be direct, as by carrying heavy burdens on the shoulder, or as the result of severe muscular effort in carrying or wield- ing a hammer, or long exertion with the arm raised, as in whitewashing a ceiling. The result may be a neuritis. Neuritis may also be caused by cold. The same nerve may be involved in progressive spinal muscular atrophy or poliomyelitis anterior. From natural causes it is more common in men. The result is a dislocation of the scapula of the corresponding side, which presents a winged appearance in consequence of projection of its angle and posterior border, rendered especially distinct when the arm is moved forward, since the scapula is no longer held to the thorax by the serratus. In severe cases faradic irritability is lost, though voltaic excita- bility may remain. Severe neuralgic pain may precede the paralysis. The course of serratus palsy is slow, and the paralysis is sometimes permanent. Treatment. — The treatment consists in maintaining the nutrition of the muscles by electrical stimulation. Counterirritation may be applied over the scalenus muscle, because it is in it that the nerve is most frequently injured. The arm should be kept at rest, and to this end should be carried in a sling, embracing the elbow in such a way as to raise the shoulder. Nerves of the Arm. — i. Of the Circumiiex Nerve. — This rises from the posterior cord of the plexus and supplies the deltoid and teres minor, and the skin over the deltoid. It may be injured by dislocations, blows, bruises, pressure by a crutch, or position long maintained, as during illness. Neuritis may result from these causes and from cold, or by extension of inflammation from the joint. There is loss of power in the deltoid and the arm cannot be raised, also a loss of sensation in the skin over the lower part of the muscle. The muscle wastes and the shoulder becomes flattened. The joint may relax and a space arise between the head of the humerus and the acromion. On the other hand, adhesions may form, partly trophic, since the articulation is supplied by the sam^e nerve. Movement may be further impaired by thickening of the ligaments. Paralvsis of the deltoid is to be distinguished from ankylosis, in which the scapula moves with the arm, which it does not do in palsy. 2. Suprascapular Nerve. — This nerve rises from the trunk formed by the union of the sixth, fifth, and a branch of the fourth cervical, but its own fibers are derived from the fifth and partly from the fourth cervical. It is occasionally injured alone or with the circumflex in dislocation of the humerus, and by falls on the shoulder, or by carrying heavy weights. The result is palsy of the supraspinatus and infraspinatus muscles. The first is of little significance, but the latter causes a defect of rotation outward of the humerus, interfering with many movements, of which one is carrying the hand along in writing. The scapula is rotated so that the lower angle is rotated upward and inward. 3. Mnsciilospiral Paralysis. — The musculospiral nerve arises from the posterior cord of the brachial plexus, and apparently derives its motor fibers from the nerve-roots forming the plexus except the first thoracic. With the branches it supplies the triceps,, all the muscles of the back of the forearm, the extensors of the wrist and fingers, both the supinators, as well as the skin on the radial side of the back of the hand, back of the thumb, index-finger, and half of the middle finger. As the musculospiral nerve is 1034 DISEASES OF THE NERVOUS SYSTEM. called the radial by the Germans, its paralysis is described in German literature as radial palsy. It is more frequently paralyzed than any single nerve, because of its position — winding around the head of the humerus after it leaves the plexus. It is often bruised by crutches, producing the so-called " crutch palsy," by blows and fractures, and especially by pressure when sleeping with the arm over the back of a chair or with the arm under the body. Even a sudden and violent contraction of the triceps, as in pulling on a tight boot, or forcible extension of the forearm as in throwing a ball, may bruise it. More rarely it is the subject of a neuritis from cold. In a lesion of the nerve high up all the muscles previously named are involved ; when near the middle of the humerus, the triceps generally escapes. The supinator longus and exterior carpi radialis longior usually are involved, but escape if the lesion is below the origin of the branches supplying them, and sometimes in partial injury of the nerve higher up. A Fig. 130. — Wrist-drop in Musculospiral Paralysis — {Leube). characteristic symptom of extensor palsy is the " wrist-drop," while the inabilit} to supinate is also striking. Sensation is rarely lost, though there may be tingling without loss of sensibility. Paralysis of the musculospiral is to be distinguished from the wrist- drop of lead palsy, which is, however, bilateral, while the supinators are unaffected and the onset is gradual. However, in lead palsy the supinator longus may be affected, and in wrist-drop from pressure this muscle may escape. Bilateral wrist-drop is common in other forms of neuritis, especially the alcoholic, but the gradual mode of onset, the involvement of the legs, and the sensory symptoms are their characteristics. The prognosis is usually favorable, the pressure palsv disappearing in a short time, while recovery is the rule even when delayed. Erb's rules as to prognosis apply as follows : If both faradic and galvanic irritability are maintained, recovery may be expected in from four- teen to twenty days ; if these are lessened for the nerve and increased for the muscle, while An C > Ca C, with contraction sluggish, recovery may take BRACHIAL PLEXUS. 1035 place in from four to six weeks, sometimes in from eight to ten weeks. When there is evidence of degeneration of the nerve, the prognosis is more unfavorable, so that recovery may be delayed for from two to fifteen months. 4. Ulnar Nerve. — This comes through the inner cord of the plexus from the last cervical and first thoracic. It is the first of all the brachial nerves to be affected by disease ascending from the thoracic to the cervical part of the cord. It supplies the ulnar flexor of the wrist, the ulnar half of the deep flexor of the fingers, the muscles of the little finger, the interossei, two of the lumbricales, the adductor, and the inner head of the short flexor of the thumb. Its sensory portion supplies the ulnar side of the hand, back and front, — more on the back, — two fingers and a half, with one finger and a half on the front, although the distribution is not in- variable. The course of the nerve, superficial behind the elbow and at the wrist, makes it vulnerable. It may be injured in wounds of the forearm and about the elbow, in dislocations and fractures about the shoulder and elbow, and Fig. 131. — Position of Wrist, Hand, and Fingers in Ulnar Paralysis — {Leube). continued flexion of the elbow. Neuritis is a possible cause. The most common cause is probably a blow upon the arm. The hand moves toward the radial side because of paralysis of the ulnar flexor, and adduction of the thumb is impossible, the first phalanges can- not be extended, and in long-standing cases the " claw-hand " may be produced, consisting in overextension of the first phalanges and flexion of the others. There may be wasting of the muscles supplied by the nerve. There is loss of sensation in the sensory distribution. A similar condition of the ulnar nerve may be produced by lesion of the lower cervical portion of the cord. 5. Median Nerve.— Its motor fibers arise from all the cervical roots that enter the brachial plexus. They supply the pronators, the radial flexor of the wrist, flexors of the fingers, — except the ulnar half of the deep flexor, — the muscles that abduct and flex the thumb, and two radial lumbri- cales. The sensory fibers supply thQ radial side of the palm and the front of the thumb, the first two fingers, half of the third finger, and the dorsal surface of the same fingers. Isolated palsy of this nerve is not frequent, but it may be caused by 1036 DISEASES OF THE NERVOUS SYSTEM. wounds or fractures of the forearm, rarely from injuries of the upper arm. There may be neuritis from compression. The wrist can only be flexed toward the ulnar side, and the thumb is in a state of persistent extension and cannot be opposed to the tips of the fingers. Pronation is impossible beyond the midposition to which the supinator can bring the forearm ; an attempt is made to supplement this by rotating the humerus inward and separating the elbow from the side. The second phalanges cannot be flexed on the first, nor the distal phalanges of the first and second fingers, while in the third and fourth fingers this action can be performed by the ulnar half of the deep flexor. There is conspicuous wasting of the thumb muscles, which gives a characteristic appearance. There may be complete or partial loss of sensibility. If there is anes- thesia, it is more marked on the palmar surface. Treatment of Lesions of Nerves of the Arm. — The first principle of treatment is the removal of the cause, whatever it may be, as determined from the etiology. If neuritis is present, it must be treated. Rest by sup- ports or splints may be necessary, on the one hand, and electrical stimula- tion and massage on the other. LUMBAR AND SACRAL PLEXUSES. The Lumbar Plexus. — This is sometimes damaged by growths in the abdomen, especially of the lymph glands, by inflammatory process, by psoas abscess, and by diseases of the bones and vertebrse affecting the nerve-roots. The obturator nerve may be injured during parturition; the anterior crural nerve by the same cause, by wounds of the groin or thigh, by dislocation of the hip, and sometimes by growths about the spine. Symptoms. — In paralysis of the obturator, adduction of the thigh and crossing of the legs are impossible, while outward rotation is also deranged. In paralysis of the anterior crural extension of the knee is impossible ; there is wasting of muscles, with anesthesia of the anterolateral part of the thigh and of the inner side of the leg and big toe. There may be pain in the area of distribution. Paralysis of the superior gluteal nerve, which is rare in the isolated form, causes loss of the power of abduction and circumduction of the thigh from paralysis of the gluteus medius and minimus. The Sacral Plexus. — This suffers from compression by growths in the pelvis, pelvic inflammations, and compression during labor. In addi- tion to spontaneous neuritis, there may also be a neuritis ascending to it from the sciatic nerve. The sciatic may be affected by wounds, dislocation of the hip, disease of the bone, and morbid growths. It is also occasion- ally the seat of neuroma. The result of lesions of the sciatic varies with its seat. If near the sciatic notch, there is paralysis of the flexors of the leg and all the muscles below the knee, while injury below the middle of the thigh involves only the latter muscles, the flexors of the legs escaping. There is anesthesia of the outer half of the leg, of the sole and greater portion of the dorsum of the foot, but the leg may escape, perhaps through the intermediation of other nerves. Frequently there is wasting of the muscles, with other trophic symptoms. In lesion of one sciatic the leg is fixed in extension by LUMBAR AND SACRAL PLEXUSES. 1037 the action of the quadriceps extensor, and the patient can walk, even when all the muscles below the knee are paralyzed, the foot being raised by over- flexion of the hip. The stnall sciatic is implicated only when the pelvic plexus is impinged upon, and it rarely suffers alone. The effect is palsy of the gluteus maximus, with difficulty in rising from the sitting poisture, and a strip of anesthesia along the back of the middle third of the thigh and upper half of the calf. Injury to the external popliteal or peroneal nerve results in paralysis of the tibialis anticus, long extensor of the toes, peronei, and extensor brevis digitorum. There results inability to flex the ankles or extend the first phalanx of the toes, or to raise the foot from the ground in walking — there is foot-drop. Talipes equinus ultimately results, and may be attended with persistent flexion of the first or proximate phalanges from contraction of the unopposed interossei. In walking the whole leg must be lifted, and there is the steppage-gait of neuritis. In old cases there may also be wasting of the anterior tibial and peroneal muscles. There is also anesthesia in the outer half of the front of the leg and on the dorsum of the foot. Lesion of the internal popliteal produces paralysis of the popliteus, calf muscles, tibialis posticus, long flexors of the toes, and muscles of the sole. The symptoms are loss of plantar flexion, inability to extend the ankle-joint, and, if the disease is high enough to involve the branch to the popliteus, loss of power to rotate the flexed leg internally ; the foot cannot be adducted, nor can the patient rise on tiptoe. Talipes calcaneus results, and the toes may assume a claw-like position from secondary contraction, due to over- extension of the proximal and flexion of the second and third phalanges. There is also loss of sensation on the outer lov/er part of the back of the leg and on the sole of the foot. Treatment. — The treatment of lesions of the nerves of the legs is similar to that of lesions of nerves of the arms. Secondary contractures are to be guarded against, being favored by position. Fatigue and exposure to cold should be avoided, as they favor fresh attacks of neuritis. I038 DISEASES OF THE NERVOUS SYSTEM. DISEASES OF THE MEMBRANES OF THE BRAIN. Although, anatomically considered, the brain is enveloped by three membranes, — ^the tough dura mater, the delicate arachnoid, and the highly vascular pia mater, — the diseases of the membranes are practically confined to the dura on the one hand, and the arachnoid and pia conjointly on the Other, the last two being always affected together. The dura is, however, separable into two layers — a thin internal layer with its endothelial covering, and a looser external layer which serves as a periosteum to the bones; these two layers may be affected separately. The term pachymeningitis is applied to inflammation of the dura mater, and leptomeningitis to that of the pia and arachnoid ; the latter is commonly meant when the word meningitis is used alone. PACHYMEXIXGITIS. Synonym. — Inflainination of the Dura Mater. External Pachymeningitis. Etiology. — External pachymeningitis is akuays acute and is commonly circumscribed. It usually results from injuries to the head, especially fractures; from caries of the petrous portion of the temporal bone itself, the result of middle-ear disease; or from syphilitic disease of the bone with pus formation. Sometimes no cause is discoverable. Rarely pus infiltrates between the two layers of the dura mater. j\Iore frequently there is pus between the dura and the bone. This may occur in syphilis, which, too, may cause thickening of the bone. Symptoms. — These are indefinite and are often obscured by those of its causal disease. They are pain, delirium ; sometimes, but not always, fever ; sometimes convulsions, and signs of pressure. Such pressure may or may not be sufficient to cause paralysis of the opposite side. Treatm.ent. — The treatment is that of the causing disease, with sur- gical interference to remove pressure and give vent to pus. Internal Pachymeningitis. This is usually chronic. Three forms are commonly noticed — purulent, pseudomembranous, and hemorrhagic. Purulent and pseudomembranous internal pachymeningitis are not recognized before death. The former may follow an injury primarilv, but commonly it is an extension from inflammation of the pia. Pus between the dura and arachnoid is rare. Pseudomembranous internal pachymenin- gitis may occur as a secondary process in infectious diseases. Internal Hemorrhagic Pachymeningitis. — Hemorrhagic pachv- meningitis, or hematoma of the dura mater, is a rare, but well-recognized condition ; it is much more common in infirmaries and hospitals connected with almshouses and asylums. It occasionallv occurs in children. PACHYMENINGITIS. 1039 Etiology. — It is probably most frequently a result of chronic alcoholism, though it has been found in chronic insanity without association with alco- holism, especially in general paralysis of the insane ; also in acute fevers, when it is associated with profound anemia. Syphilis is a possible cause ; in like manner, tuberculosis. It occurs chiefly in males over fifty, but also in those between thirty and forty. In mild degree it is sometimes found in chronic cardiac, renal, or pulmonary diseases, when it is commonly first recognized at necropsy. Pathology and Morbid Anatomy. — The original dictum of Virchow continues for the most part to be held — viz., that it begins as a hyperemia in the area of the middle meningeal artery, extending thence forward, back- ward, and downward. The arteries become tortuous, dilated, and sur- rounded by thickened adventitia, while the capillaries, being overfilled, pro- duce a rose-colored flush on the under surface of the membrane. To this succeeds a delicate weblike tissue containing wnde, thin-walled capillaries three or four times the natural width, between which is a delicate reticulum of spindle cells extending over the greater part of one or both hemispheres. This becomes afterward paler and firmer. Upon this succeeds another deli- cate vascular layer, succeeded by another and even another. From three to seven la^yers are thus superposed until a product of from 1-8 to 1-5 inch (3 to 5 mm.) in thickness results. The delicately walled capillaries, however, easily give way, causing hemorrhages which vary in extent from, mere points to large collections of blood — the smaller being interstitial and the larger be- tween the youngest vascular layer and the next older. The proportion of blood and organized membrane varies greatly, now one predominating and now another. At times there seems to be blood only. The hemorrhage is believed by some to be the initial event. Both products are subject to degenerative changes, the effused blood being disintegrated and partially absorbed, while the blood-vessels become obliterated and substituted by lines of pigment deposit along their course. There may also be serous infiltration, cystic degeneration, and even diffuse suppuration. Symptoms. — The symptoms are indefinite. There may be apoplecti- form seizures coincident with fresh hemorrhages, drozvsiness, or coma. Muscular zveakness was very marked in a case under my own observation. Headache in the region involved, vomiting, nystagmus, convulsions, gener- ally unilateral, and even hemiplegia may be present, and, toward the close, optic neuritis; extensive disease may, on the other hand, exist without any symptoms whatever. Diagnosis. — In the absence of distinctive symptoms the possibility of the presence of hematoma should be remembered when there are other signs of general paralysis or chronic alcoholism. If to such symptoms great mus- cular weakness is added, further suspicion is justified. Treatment. — With a prognosis absolutely unfavorable as to recovery, it remains only to treat symptoms as they arise. Indications of hemorrhage should be treated by rest In bed, elevation of the head, and an ice-cap. 1040 DISEASES OF THE NERVOUS SYSTEM. LEPTOMENINGITIS. Synonym. — Inflammation of the Pia Mater. Of leptomeningitis there may be an acute and a chronic variety. In addition, other adjective terms are used to indicate its seat and the nature of its cause ; such as basilar meningitis, meningitis of the convexity, tuberculous meningitis, etc. Epidemic meningitis has received separate consideration. Acute Leptomeningitis. Definition. — An acute inflammation of the pia and arachnoid mem- branes, attended by exudation between the two membranes. Etiology. — All ages are subject to meningitis, that of the convexity being possibly more frequent in adults because they are more subject to trau- matic agencies which cause it, while the basilar form is more common in children. It is rather more frequent in males, and there is a hereditary tendency to one form — tuberculous meningitis. Of the direct causes — 1. An eruption of miliary tubercles is the mast frequent. This cause may operate at all ages, but is most active in children. In adults it gener- ally starts from a recognized tuberculosis elsewhere ; in children the process is almost always part of a general tuberculosis. Tuberculous meningitis takes place generally at the base of the brain, constituting the chief form of basilar meningitis. • 2. Adjacent disease, which may be outside of the dura mater, such as caries, especially in the petrous portion of the temporal bone. Even disease outside the skull, like erysipelas or suppurative disease of the scalp, may be a primary focus. In these cases it is usually unilateral, and may be accom- panied by thrombosis of the sinuses and abscess ; or the disease may result in abscess within the brain. 3. The bacterium or toxin of the acute infections diseases — pneumonia, ulcerative endocarditis, measles, scarlet fever, smallpox, typhoid fever, acute rheumatism, and septicemia. Care must, however, be taken not to confound the simple intense delirium in some of these affections with meningitis, remembering, too, that the latter complication is, under any circumstances, a rare one. The toxin of pneumonia is the most common cause, and perhaps after this that of smallpox. The inflammation thus caused is chiefly of the convexity, except in septicemia?> when it is general. 4. Chronic Bright's disease and other cachectic conditions. In these the inflammation* is commonly basilar. 5. Sunstroke. 6. Mental excitement and brain work — doubtful cause. 7. Rarely in acute inflammation, syphilis, whose product is also basal. 8. Finally, unknown causes may produce meningitis of the convexity or of the base. Possibly, as Gowers suggests, organisms otherwise power- less may become sufficient causes during ill health. Thus may be caused some undoubted though rare cases of non-tuberculous basilar meningitis of children — leptomeningitis infantum. In tuberculous meningitis, which is chiefly basilar, the eruption of tubercles precedes the inflammation. There may even be tuberculosis of the LEPTOMEXIXGITIS. 1041 pia without inflammation. In tubercular meningitis the inflammation is never actually purulent, though the lymph has often the appearance of pus. The tubercles are most abundant about the optic chiasm, over the pons, and in the fissure of Sylvius, but the cortex is often affected. xA.ccording to Dr. Spiller's experience the brain cortex has contained more tubercles than were found at the base. Morbid Anatomy. — The early results of leptomeningitis are the same in all varieties. They consist, first, in a hyperemia of the capillaries produc- ing a diffuse pinkish tinge. The next visible changes are a turbidity and an opacity of the arachnoid which extend to the pia, where opacity is especially distinct along the blood-vessels, consisting, in fact, in an infiltration of the lymph spaces and h-mphatic sheaths with leukocytes. As the cellular accumulation increases the exudate beneath the arachnoid assumes a yel- lowish-white, creamy appearance. The subarachnoid fluid increases, consti- tuting hydrocephalus extenius. In suppurative cases it becomes pus, which forms a greenish-yellow layer at the convexity or base, or both. Ventricular effusion is present in the majority of instances, — about four out of five, — constituting hydrocephalus interuus, generally associated with closure of the opening of the fourth ventricle. The effusion is usually limited to a few ounces, but it may be large in quantity, distending the ven- tricles and compressing the cortex. The walls of the ventricles and the choroid plexuses may be inflamed, and the ventricular eft'usion may be the result of such inflammation. In all varieties of meningitis, and especially in the tuberculous, the super- ficial layer of the cortex is also involved, being at least hyperemic, and some- times softened ; it may also be the seat of punctiform hemorrhages, consti- tuting red softening. This is especially prone to occur in tuberculous menin- gitis, because of the extension of the tuberculosis along the blood-vessels which dip into the cortex. In pulling off the pia these blood-vessels are dragged with it, leaving a ragged appearance of the cortex. Leptomeningitis infantum presents an appearance similar to that of tuberculous m.eningitis. It involves chiefly the posterior part of the m.en- inges and cerebellum, closing sometimes the foramen of ]\Iagendie, whence the term occlusive meningitis. It may also cause an acute, sometimes puru- lent, hydrocephalus. Symptoms. — These are varied and not always distinctive of the dift'er- ent forms. First, it is important to remember that all except those which are peculiar to inflammation of the base may be present in any of the serious infectious fevers without meningitis, especially pneumonia, typhoid fever, and smallpox ; but in some cases of typhoid fever the typhoid bacillus has been found in the cerebral membranes. "When secondar}- to these affections, they are accompanied by the symptoms of the disease to which they succeed. Meningitis is usually ushered in by premonitory symptoms, which, again, are not distinctive, being those usual to acute disease. Perhaps irri- tabilitx is more constant than in other acute diseases. In case of children, vomiting with a slight cause, or without discoverable cause, is a symptom of more suspicious nature. It is especially frequent in basilar meningitis, of w^hich it is more or less characteristic. It has this peculiarity, that it is not usually accompanied by nausea and retching. Generally there are high fever, coated tongue, and constipation, although fever is not invariable. The usual temperature is from 103° to 104° F. (39.5° to 40° C), but it may reach from 105° to 106° F. (40=5° to 41.1° C), and toward the close of fatal cases, 108*- 66 I042 DISEASES OF THE NERVOUS SYSTEM. F. (42.2° C.)- It is especially apt to be mild or absent in the meningitis of Bright's disease or of debilitated children. The pulse is increased in fre- quency at first, but later may be slow and irregular. Of the symptoms the direct result of the disease, pain in the head is the most constant. Commonly frontal, it may be general. Its constancy and severity are characteristic. Yet it is subject to such exacerbations as may cause the patient to cry out, constituting the hydroecphalic cry of children. The headache is invariable, followed sooner or later by unconsciousness. Delirium is an early symptom and soon follows the headache ; at first wander- ing, it soon becomes active, and may alternate with drowsiness or stupor. General convulsions are also another symptom, occurring in all forms and at all ages, but more frequently in the tuberculous meningitis of children. When the inflammation is at the base, rigidity of the neck with retraction of the head is very marked, especially when the inflammation extends down the membranes of the spinal cord. Optic neuritis is another symptom, iisually late in occurrence, — at the end of the first week, — and possibly due to involve- ment of the sheath of the optic nerve within the skull. Strabismus is also common. There may be weakness of the eye muscles and slight ptosis. The pupils are usually contracted in the early disease from intolerance of light; later, they are dilated. Inequality of the pupil is even a more characteristic symptom, though transient and variable. It occurs in connection with in- flammation of the convexity as well as of the base. The facial nerve may be involved in basilar cases, producing slight paralysis, as may also be the iifth nerve, producing anesthesia and trophic changes in the cornea. On the other hand, hyperesthesic skin is often present ; also hyperesthesia of the special senses, especially hearing and sight. S}"mptoms in the limbs may present themselves, such as muscular rigidity, unilateral convulsions, and even hemiplegia, but the last is rare. When they occur, they are late symptoms. Diagnosis. — The diagnosis is not always easy, because so many symp- toms may be simulated by simple congestion due to the poison of the infec- tious diseases. The basilar symptoms are the most distinctive, and it is a real help to know that a possible cause is present, either predisposing or exciting ; such, for example, as the tuberculous taint, or tuberculous disease, or middle-ear disease. Retraction of the head, so characteristic of this form,, may result from rheumatism of the muscles of the back of the neck. Sir \\'illiam Jenner pointed out a difference between the relation of headache and delirium in general disease and meningitis : In general disease the head- ache ceases when the delirium begins ; in meningitis the headache continues and coexists with the disease. ^Convulsions, too, when present, occur at the beginning of a general disease, particularly in scarlet fever, while they occur late in meningitis. Optic neuritis and other eye symptoms are common in meningitis. A rapidly growing intracranial tumor often gives rise to difficulty in the diagnosis between it and meningitis. In tumors which may be tuberculous or gliomatous, symptoms in the extremities, such as weakness, hemiplegia, and convulsions, are manifested only after the tumor once begins to interfere with function, which it may not do at first ; the loss of power, moreover, comes on gradually, while in meningitis all these symptoms are rapidly devel- oped. Higher degrees of optic neuritis, as observed by the ophthalmoscope, are found in connection with tumor rather than with meningitis. The dura- tion of the disease will settle the question ultimately, as meningitis is of short LEPTOMENINGITIS. 1043 duration — from two or three days to as many weeks — while tumors last for months. Meningitis, especially tuberculous, is sometimes mistaken for hysteria, but the almost invariable presence of fever in meningitis and its total absence in most cases of hysteria should prevent error. In children the symptoms even of tuberculous meningitis are sometimes closely simulated in bad cachectic states, in which there is no meningitis whatever. What is re- garded as meningitis after sunstroke is a prolonged state of mental hebe- tude with symptoms usually aggravated on slight exposure to the sun. Prognosis. — The prognosis in leptomeningitis is unfavorable, although not necessarily hopeless. In meningitis of the convexity recovery is pos- sible ; in undoubted tuberculous meningitis it is very rare, and yet it may occur. But I have so often known an erroneous diagnosis of tuberculous meningitis with corresponding prognosis followed by complete recovery in children, that I have grown very cautious in making a prognosis. Espe- cially in general tuberculosis should we avoid too unfavorable a prognosis, because mistakes here are quite frequent. In meningitis from adjacent bone disease much depends on the accessibility of the bone lesion, but as this is generally difficult of access, the prognosis is correspondingly serious. This is especially the case in ear disease. In syphilitic meningitis if the diagnosis is made early, chances of recovery or improvement are better. Treatment. — ^The treatment of adjacent disease which may cause the meningitis is of the first importance. Surgical interference should be promptly resorted to in middle-ear disease. In the absence of such disease the treatment is mainly symptomatic. The utmost quiet and the avoidance of all causes of excitement are paramount. It is the one disease, outside of ophthalmia, in which the darkening of the room may be justified. The head should be raised. Leeching is a most valuable measure toward cure, when possible, and temporary relief when cure is impossible. Leeches should be applied to the back of the ear and to the temple. Ice should be kept applied to the head. C ounterirritation by blisters to the back of the neck is also very useful, and not so painful or annoying as its appear- ance suggests. It has even been applied to the whole scalp after shaving the head, but I have never felt justified in doing this, especially when the diagnosis of tuberculous disease is quite clear. The bowels should be kept free. The diet should be liquid — milk and animal broths of a light kind are the best food. Such drugs as meet the symptoms should be given. Phen- acetin to relieve pain in the head if the ice and abstraction of blood do not do it. The temperature is kept down by sponging and even by cool bathing. Mercury is still an acknowledged drug in meningitis not tuber- culous ; and as chances of error of diagnosis always exist, it may be em- ployed in any case. It should be administered to the production of slight salivation, preferably by inunction because the effect is more rapidly pro- duced. The mercurial ointment should be used. Chronic Leptomeningitis. Etiology and Morbid Anatomy. — This comparatively rare disease affects chiefly the convexity of the brain, and is the result of alcoholism, syphilis, or tuberculosis. In milder degrees, seen in alcoholics, the pia arachnoid is opaque, as 1044 DISEASES OF THE NERVOUS SYSTEM. seen over the sulci, the opacity and thickening being more marked along the borders of the blood-vessels. In syphilis there are often foci or thick- ened patches, thickest in the center and receding toward the edges. These may reach dimensions to justify the term gummy outgrov^^th or tumor. The blood-vessels are the seat of endarteritis. In the tuberculous forms in children the base of the brain is affected, as in acute tuberculous menin- gitis. Internal hydrocephalus may be a consequence when there is obstruc- tion to the orifice of the fourth ventricle. Symptoms. — These are those of the acute form in a milder and more prolonged manner — headache, vomiting, mental symptoms, sonjetimes con- vulsions, rigidity, retraction of the head, optic neuritis, more rarely strabis- mus, and nystagmus. They may last from a month to a year or more. Fever is more frequently absent in chronic meningitis, but careful observa- tion will generally find some elevation of temperature. Diagnosis. — It is, in fact, the chronic variety of leptomeningitis which is separated from tumor with the greatest difficulty. Loss of motor power is more characteristic of tumor. Optic neuritis is also a more decided symptom in tumor, and goes on increasing, while it seldom reaches an ad- vanced stage in chronic meningitis. Other eye symptoms — strabismus, irregularity of pupil — are more distinctive of meningitis. Strabismus occurs in hysteria, but it is always convergent and there is total absence of fever, as shown by the absence of elevation of temperature. Prognosis.— This is not so unfavorable as in the acute variety. The syphilitic form is quite amenable to treatment, the alcoholic less so ; the tuberculous is almost always sooner or later fatal. Caution in prognosis is demanded by occasional error in diagnosis. Treatment. — ^The cause must be carefully sought. If syphilitic, iodids and mercurials must be used, as for this disease. In alcoholism and tuber- culosis the symptoms must be treated by measures already indicated. HYPEREMIA. 1045 AFFECTIONS OF THE BLOOD-VESSELS OF THE BRAIN. HYPEREMIA. Synonyms. — Cerebral Hyperemia; Congestion of the Brain. Definition. — A condition of tlie brain in which the blood-vessels are surcharged with blood. The congestion is active as the result of increased flow of blood to the brain, as in alcoholic hyperemia ; passive when there is obstruction to its outward movement, as in constriction of the vessels in the neck. Etiology. — The causes of active hyperemia are prolonged mental activity, excitement, and overw^ork, pre-eminently alcohol and the causes of the acute fevers ; the hypertrophy and overaction of the heart which attend aortic regurgitation m.ay be causes. The causes of passive congestion are mainly mechanical, including mitral valvular heart disease, emphysema, straining, or other cause obstructing the return of blood from the brain, — such as tumors pressing on the vessels of the neck, or tight clothing. Morbid Anatomy. — While, from the standpoint of morbid anatomy, our ideas may be very definite as to what should constitute active and passive hyperemia, it cannot be said that a definite set of symptoms is associated with either in the case of the brain. In the first place, the amount of blood in the brain varies greatly within the limits of health, and while it might be said that physiological hyperemia ends where abnormal mental phenomena present themselves, it is undoubtedly true also that an overfullness of the vessels of the brain may exist for some time without the symptomatic expres- sion which finally appears. With the appearance of such symptoms we com- monly date the clinical beginning of the pathological state known as chronic hyperemia. The dii^culties are increased by the fact that in acute active and passive hyperemia, at least, no postmortem evidences of it remain, the congestion having disappeared with death, although an unusual distinctness of the puncta vasculosa has long been regarded as postmortem evidence. The difficulty of recognizing such condition makes this sign an unreliable one. In chronic hyperemia there result, sometimes at least, a turbidity and even an opacity of the pia mater, wuth slight thickening, together with elongation and tortuosity of the vessels, which are regarded as characteristic. Symptoms. — These are not very distinctive. Tlie symptoms of active h3^peremia, so far as recognizable, are a sense of fullness or pressure, head- ache, mental excitement, irritability, confusion of ideas, insomnia, vertigo, ringing in the ears, and. in extreme cases, hallucinations, delirium, and mania. These symptoms are increased when the head is held downward or there is straining. The phenomena of so-called " rush of blood to the head " are probably the result of active hyperemia. They include a suffu- sion of the skin of the face and head and a feeling of warmth in these situations, strong beating of the carotids, headache, tinnitus aurium, spots b-efore the eyes, vertigo, and sometimes actual falling. It is not easy to separate the phenomena of passive hyperemia from those of active congestion. They are, however, less pronounced and slower in their development. I046 DISEASES OF THE NERVOUS SYSTEM. Treatment. — The indications for treatment are, nevertheless, plain. The head is to be kept raised. Purgation is the first measure to be thought of. The saline and hydragogue cathartics are especially indicated, because of their depleting effect. The ice-cap should be used. In extreme cases even blood-letting may be necessary, the efficiency of which is sometimes seen in the relief afforded by bleeding of the nose. Leeches applied behind the ears often afford magical relief to the symptoms commonly ascribed to congestion of the brain. Wet cups may be placed upon the back of the neck for the same purpose. The diet should be spare and easily assimilable, in acute cases liquid only. Of medicines, the hromid of potassium theoretically fulfills the indica- tions, and in full doses of from fifteen to thirty grains (i to 2 gm.) every three hours to adults is often useful, though it should not be allowed to sub- stitute the other measures mentioned. Phenacetin- and phcnalgin are ad- mirable remedies for the headache, a single dose of ten grains (0.66 gm.) being often sufficient. It may be repeated if necessary, or smaller doses may be given more frequently. ANEMIA OF THE BRAIN. Definition. — The more usual application of the term anemia of the brain is to conditions in which the quantity of blood in the organ is dimin- ished, although depraved states of the vital fluid without loss of bulk may also produce the same symptoms. Etiology. — The causes leading to this condition are for the most part those which withdraw blood from the brain, but they include also such as prevent its access. Among the former are hemorrhages, profuse and rapid ; bowel fluxes, such as those of cholera in adults and cholera infantum in chil- dren ; and the opening of vascular areas b}^ the removal of pressure caused by large tumors or ascitic fluid. Thus is explained the fainting which some- times succeeds the removal of a large abdominal dropsy. In the second set of causes are feeble action of the heart, ligation of the carotid artery, or other obstruction in vessels carrying blood to the brain. Such obstructions are thrombi and emboli. The brain substance adjacent to the dilated ventricles in hydrocephalus interna is anemic from compression. The fainting due to sudden emotion, such as fright, is ascribed to a withdrawal of blood from the brain. Morbid Anatomy. — This is more distinctive than in hyperemia. The membranes are pale, the bloctd in their vessels, except the larger ones, is scanty, and over the convolutions the vessels are quite empty. The gray and the white matter are both pale on section, and the puncta vasculosa are less distinct and less numerous. The cerebrospinal fluid is increased. Symptoms. — Some of these are definite and the direct result of loss of blood to the brain. Such are the dizziness, confusion of ideas, flashings of light, roaring in the ears, nausea, and ultimate loss of consciousness and even death which succeed hemorrhages or emotion. In other cases the skin is cold and clammy, and a cold perspiration starts to the surface. Other symptoms are less distinctive. They are ascribed to chronic anemia, but may result also from other causes. Such are mental apathy, disinclination to work, a sleepy feeling during the day, and insomnia at night. Nausea, headache, tinnitus, vertigo, hallucinations, and delirium are also conse- Anterior communicating a Antero-median ganglionic arteries Ophthalmic a Internal carotid a Vertebral a Posterior spinal a Anteriorspinal a. Anterior cerebral a. Postero-median ganglionic arteries tero-lateral ganglionic arteries Middle cerebral a. Superior cerebellar a. nor inferior cerebellar a. Posterior-inferior cerebellar a. Posterior meningeal a. Circle of Willis and Arteries of Brain. — (Deaver. EDEMA OF THE BRAIN. 1047 quences more particularly of lowered composition of the blood, of anemia, in fact, the result of prolonged illness, like pulmonary consumption and Bright's disease. The convulsions characteristic of the latter disease have been ascribed to anemia and also to edema of the brain. The hydrocephaloid symptoms, described by Marshall Hall as the direct result of prolonged diarrhea and of cholera infantum in children, are re- garded as results of anemia. They include semistupor with eyes unclosed, later, dilated pupils, strabismus, convulsions, rigidity, and death. Treatment. — The immediate consequences of the acute form of anemia are diminished or averted by placing the patient on the flat of the back with the head low ; by diffusible stimulants, of which alcohol and ammonia are the types ; also cardiac stimulants, and nourishing and easily assimilable foods. The chronic forms of brain anemia are treated by nutritious, easily assimila- ble foods, and tonics, especially iron and arsenic. In the hydrocephaloid con- dition in infants alcohol is the pre-eminent remedy, associated with warm baths and general restorative measures. . EDEMA OF THE BRAIN. Definition. — • The term includes two conditions, the most definite and easily recognizable of which is an abnormal accumulation of cerebrospinal fluid within the pia arachnoid. In the second condition there is added to the first an abnormal moistness of the substance of the brain. Etiology. — The most common cause is mitral stenosis, although any cause obstructing the return of blood from the brain as well as recurring irritative hyperemias, such as are produced by alcoholism and the psychoses, are also causes. Bright's disease is a cause of edema of the brain, local or general. Local edemas of the brain are also caused by obstruction of single minuses of the dura mater, or compression by tubercular or other tumors of the veins of the velum interpositum, known as the vence Galeni. Morbid Anatomy. — The membranes are turbid, their vessels are dis- tended and serpentine in their course, and the subarachnoid space is filled with clear fluid. The substance of the brain is anemic, moist, and glisten- ing. In extreme cases there is compression of the cortex, with resulting flattening of the convolutions and widening of the sulci. The fluid in the lateral ventricles may also be increased. Symptoms. — Tbese are ill defined. There may be hallucinations and •even mania, very similar, in fact, to those of anemia. Traube and Rosen- stein ascribed the convulsions of Bright's disease to edema of the brain, while certain unilateral convulsions and paralysis in connection with this disease bave been assigned to the same cause. Even death has been ascribed to sudden serous effusions of this kind, constituting acute edema of the pia mater, or apoplexia serosa. In recent years much has been written on cere- bral edema under the name of meningitis serosa. Treatment. — 'The treatment is that of the conditions to which the symp- toms are secondary. The effects of cardiac stenosis must be overcome by cardiac stimulants; Bright's disease ^ must receive appropriate treatment. Thrombosis of the sinuses admits of no treatment, though its effects may diminish by gradual contraction and possible liquefaction and removal of the thrombus. The psychoses should receive treatment appropriate to them. I04& DISEASES OF THE XERVOUS SYSTEM. APOPLEXY. Definition. — The temi apoplexy is applied to a sr.dden loss of con- sciousness and motor power due to cerebral hemorrhage, or the sudden plug- ging of a blood-vessel. Laceration of the brain without hemorrhage pro- duces a like effect. In point of fact, when the term apoplexy is used, cere- bral hemorrhage is commonly intended. Unconsciousness mav also be produced by simple congestion, and it was formerly thought that a simple serous transudate could produce similar symptoms in a milder form and of shorter duration; w'hence the term '■ serous apoplexy." Concussion of the brain, however, causes similar symptoms. I. Cerebral Hemorrhage. Arterial Distribution. — In the first place hemorrhage is meningeal or central . ^Meningeal hemorrhage may be outside of the dura mater, be- tween it and the bone, or between the dura and the arachnoid, or within the pia arachnoid. The extradural and subdural meningeal hemorrhages are both traumatic, one variety of which is produced during birth, but those in the pia arachnoid are due to the causes to be considered below. Central hemorrhages may also burst into the membranes as well as into the ventricles of the brain and in some instances the hemorrhage is almost entirely intra ventricular. ^leningeal hemorrhage may occur in the infectious fevers, in leukemia, and in anemia. It is a rare event to find a rupture in any of the large arteries of the circle of Willis, although white patches of atheroma are often seen upon them at autopsy. But the free anastomosis of this circle scarcely allows of increase of intravascular pressure sufficient to cause rupture. Further, it is the " central " rather than the " cortical "' branches of this circle which rup- ture, and especially the central branches of the middle cerebral, which, enter- ing the brain at the anterior perforated space, pass to the corpus striatum and internal capsule. One of these is the so-called artery of " cerebral hemorrhage,"' thus named by Charcot because of the frequency of its in- volvement. It passes to the internal capsule and lenticular nucleus, where the majority of the massive hemorrhages of the brain occur. Etiology. — Disease of the artery involved is responsible for the vast majority of cerebral hemorrhages. Indeed, except in the case of traumatic hemorrhages either with or without fracture of the skull, it is very doubtful whether hemorrhage ever occurs without such disease. The simplest form is the fatty degeneration and " erosion " of the intima, characteristic of ad- vanced age. Endarteritis, however produced, is perhaps the most frequent cause. Its ultimate result, as shown by Charcot and Bouchard as far back as 1868, is the miliary ancnrysm which in almost every instance precedes the rupture. It is a spindle-shaped, rarely lateral, dilatation, from 1-25 to 1-5 inch f I to 5 mm.) in diameter. The inflammatory process preceding it con- sists in a proliferation and degeneration of the intima cells, followed by atrophy, which extends also to the muscular layer and the scanty adventitia. These, yielding to the intravascular pressure at the weak points, dilate to form the little aneurysm, which is later ruptured by some further increment APOPLEXY. 1049 of pressure. Embolism is also a cause of endarteritis which may result in aneurysm. The " fatty erosion " of the intima which is the next most frequent cause of vulnerability is favored by age, by chronic interstitial nephritis, and the overstrain of the vessels due to hypertrophy of the left ventricle, so often associated with that disease as well as with valvular heart disease. While by far the larger majority of hemorrhages are preceded by miliary aneurysm or fatty erosion, — fully nine out of ten, — there still remain a num- ber of instances in which careful search fails to find anything but diffuse degeneration; whence the miliary aneurysm and fatty erosion cannot be re- garded as indispensable conditions. The infectious fevers, leukemia, and anemia are also causes of hemorrhage which is independent of miliary aneurysm. Age is also a predisposing factor, most ruptures occurring after fifty,, although apoplexy has occurred under ten ; while the occupations and dis- sipations of men furnish an additional predisposing elements which accounts for its greater frequency in the male sex. Other predisposing causes are those usually responsible for endarteritis — viz., gout, alcohol, syphilis, Bright's disease, the apoplectic habit, as seen in the stout, short-necked, full- blooded individual ; and, finally, heredity, Vv^hich is, strictly speaking, a hereditary tendency to the favoring diseases. The exciting causes are such as temporarily increase intravascular pressure, as violent exertion, straining, debauch in eating and drinking, and mental emotion. Morbid Anatomy. — The large central ganglia in the neighborhood of the lateral ventricles — /'. e., the optic thalami, the caudate and lenticular nuclei, and the adjacent white matter of the internal capsule and centrum ovale — are the favorite seats of miliary aneurysm and consequent hemor- rhage. These aneurysms are found also, but much more rarely, in the smaller branches of the cortical vessels, in the pons, cerehellum, crura cerebri, or medulla oblongata. On section of the large ganglia these may be seen as small dark points, as large as a pin's head, and are often very distinct in arteries drawn out of the substance of the brain, especially the anterior per- forated space. Coarser aneurysms are also found on the branches of the circle of Willis. Given a massive hemorrhage, what is its effect on the brain substance, and what are the changes in the extravasated blood? The former varies somewhat with its situation. If extradural, the dura mater is torn away from the bone to a varying extent. If subdural or beneath the pia arach- noid, it separates these membranes from the brain substance, but in either event the convolutions are more or less flattened and the sulci more or less obliterated. As already stated, central hemorrhage most frequently occurs in the neighborhood of the corpus striatum, through which, if large, the blood finds its way toward the outer section of the lenticular nucleus, pushing inward the optic thalamus and bursting into the lateral ventricle or into the white matter of the centrum ovale. The pressure exerted is often such as to flatten the convolutions, empty the parietal veins, and press the falx aside, sometimes even to produce a sense of fliuctuation over the membranes. Hem.- orrhages may occur in the crura or pons or fourth ventricle, and also in the cerebellum, not infrequently from the superior cerebellar artery. Osier mentions two cases of death in women of twenty-five from cerebellar hem- I050 DISEASES OF THE NERVOUS SYSTEM orrhage. Very rarely hemorrhages into the ventricle may start in the cho- roid plexus or the ventricular walls. Blood in large quantities may be poured out at the base of the brain, and it may flow down into the cord from a rup- ture of any of the arteries going to or from the circle of Willis. If the patient survives, changes take place in the extravasated blood, which promptly coagulates into a dark-red mass. This almost immedi- ately begins to contract, permitting often the return of a certain degree of function by removing pressure. As time elapses the dark-red mass passes into a chocolate-brown pulp, composed of liquefying blood-clot and disinte- grated nervous matter. The microscope, at this stage, recognizes numer- ous hematoidin crystals and granular fat-cells which are probably fatty by imbibition of fat-granules. The adjacent nervous tissue is stained yellow by the imbibed hematoidin. The clot itself becomes encapsulated by fibrin and gradually absorbed, being often substituted by a semitransparent or completely transparent fluid, forming the apoplectic cyst. If smaller, the walls approach and unite, leaving only a linear pigmented scar. Especially is this the case with small clots on the surface of the convolutions, which may leave only a staining of the membranes. In other cases of abundant cortical effusion, especially in infants, there may be circumscribed wasting of the convolutions and a cyst of the meninges or brain. The position and extent of the permanent lesion determine the presence of secondary descending degeneration. If the motor cortex or motor tract is involved, there may be found, in persons dying some years after a stroke of apoplexy with hemiplegia, degeneration in the pyramidal fibers of the pons and medulla oblongata, in the direct pyramidal fibers of the cord of the same side, and in the crossed pyramidal fibers of the opposite side, and to some extent in the crossed pyramidal fibers of the same side. Symptoms. — Premonitory signs are occasionally present. There may be a feeling of fullness in the head, headache, tinnitus, vertigo, or numb- ness, tingling, pains in the limbs on one side, loss of memory of words or choreiform movements, — prehemiplegic chorea, — possibly due to miliary aneurysm or otherwise diseased vessels. With the bursting of a vessel of sufficient size there occurs the apoplec- tic " stroke," or apoplectic shock. Its most striking feature is sudden loss of consciousness. If complete, the patient falls heavily to the ground, and there may be slight convulsive movement, but it soon ceases. More rarely a true convulsion ushers in the attack. The patient cannot be aroused, the face is sufifused, cyanotic — sometimes, however, pale; the breathing is slow, noisy, stertorous, often attended with a puffing sound during expiration, corresponding with a blowings out of the relaxed cheek on the paralyzed side ; it may also be of the Cheyne-Stokes type. In contrast with the foregoing, the development of unconsciousness is sometimes much more gradual, requiring several hours or a day, corresponding to which it is pre- sumed that the hemorrhage is slow, constituting the " ingravescent form." The second major symptom of apoplexy is motor paralysis, of which bemiplegia is the most conspicuous form. In most cases the motor pyr- amidal tract, as it descends in the internal capsule, is either directly destroyed or indirectly affected. Hence most patients who survive the primary shock present a hemiplegia — paralysis of half the body opposite that of the hem- orrhage, and most frequent on the right side. It is most noticeable in the arms and legs. These are thoroughly relaxed, falling limp when allowed to drop, as the limb of one thoroughly etherized. More rarely there is early APOPLEXY. 1051 rigidity, especially on the paralyzed side. This symptom is possibly more frequently associated with hemorrhage into a lateral ventricle. Reflex ca- tion is early either totally suspended or only brought out in response to a deep pin thrust or severe pinching. The signs of hemiplegia are not always easily elicited at first, because a certain degree of consciousness is necessary to stimulate attempt at motion, but it may be that the angle of the mouth hangs down lower on one side, — the paralyzed side, — while the puffing of the cheek alluded to may be present on the same side, or the limbs of one side may be appreciably more flaccid than those of the other, or a small amount of reflex response may be elicited on the sound side. The pulse is usually slow, full, strong, and tense. The temperature may be subnormal at first, rising to normal and even above, and in basal hemorrhage may be higher. In a rapidly fatal case it remains subnormal to the end. The pupils are irregular — /. e., sometimes contracted, at others dilated, unequal. They respond to light either slowly or not at all. If the hem.orrhage is where it can irritate the nucleus of the third nerve, the pupils are contracted. This may occur with hemorrhage into the pons or ventricles. In cortical lesions quite often one of the early symptoms in hemiplegia is conjugate deviation from the paralyzed side and toward the side of lesion, from which we have the expression that " the patient looks at the lesion " ; that is, in right hemiplegia the head and eyes look toward the left side. This symptom usually passes away, but sometimes continues for weeks, and, as Gowers suggests, is perhaps occasionally represented by nystagmus or movement in the direction concerned. Should, however, convulsion, or spasm, or early rigidity develop, the head and eyes are rotated toward the paralyzed side — l e., away from the side of lesion. This is true only of cortical lesions. In lesions of the pons, on the other hand, where the conjugate deviation may also occur, the phenomena are reversed, — the patient looks away from the lesion, in the absence of spasm, — but if the convulsion or spasm or rigidity occur, the eyes and head look toward the lesion. These facts are a little confusing at first and may be expressed in the following . In lesion of the cortex — Without spasm, conjugate deviation is toivard the side of lesion. With spasm or convulsions or early rigidity, from the side of lesion. In lesion of the pons — Without spasm, etc., from lesion. With spasm, etc., toivard lesion. This may be due to the fact that these movements in health are inner- vated from both sides, and when a lesion occurs on one side of the cere- brum, the innervation is given over to the other side until the injured one resumes its function, or until irritation in it causes it to assert or exceed its function. In pontile lesions the destruction occurs possibly below the decussation of the fibers innervating the parts affected in the conjugate deviation and the symptoms are reversed. The feces and urine are passed involuntarily, and the latter is some- times slightly albuminous. , As to further progress in a few cases there is no reaction from the pre- viously described condition. The symptoms all deepen, the breathing be- comes rapid and rattling, the skin cool, the pulse weak and rapid, and the 1052 DISEASES OF THE NERVOUS SYSTEM. patient dies. In most cases, however, there is a certain abatement of the symptoms, even if the patient does not recover more fully. Consciousness returns partially or completely, the patient can be aroused by a loud voice, and one can recognize which side is paralyzed. There may, at this time, be a febrile movement, due to cerebral inflammation, during which the patient ma}- die, or there may be another hemorrhage which carries him off. On the other hand, improvement may continue to a further degree. The consciousness and intelligence may return completely, and the signs of paralysis may gradually grow less, more rapidly in the legs than in the arms. They, however, almost never disappear completely, the patient continuing lame and requiring the use of a cane for the rest of his life. In severe cases a remnant of paralysis of the face can almost always be recognized, while articulate speech may also continue defective. Such marked improvement is. for the most part, reserved for the milder attacks, in which there is great variety as to degree. In such the loss of consciousness is of short duration, or it may not occur at all. Such attacks are not infrequently ushered in by nausea, vomiting, vertigo, or sudden headache. The paralytic symptoms may still be marked, and permit a study rather more satisfactory than the fulminating cases. In such study it will be found that all muscles are by no means equally para- lyzed. Thus it will be seen that the lower division of the facial nerve, which supplies the muscles of the cheek, nose, and mouth, is plainly para- lyzed ; while the upper division, distributed to the muscles of the eyes and forehead, is almost, if not entirely, intact. The forehead may be wrinkled with equal ease on the two sides, but an attempt to draw up the nose or purse the mouth fails, while one labionasal fold may be obliterated and one angle of the mouth lower than the other. The natural wrinkles of the forehead are commonly less distinct on the paralyzed side than on the other. This event — the comparative freedom from paralysis in the upper part of the fall — may be explained by the fact that while both sides of the face receive fibers from each cerebral hemisphere, this is especially true of the muscles of the upper part of the face, which are always exercised bilaterally. The tongue may not be paralyzed, but when it is, if protruded, it goes toward the paralyzed side, being pushed out by the geniohyoglossal muscle of the other side, the innervation being by the hypoglossal nerve. Occa- sionally paralysis of the tongue contributes to difficulty in articulation. The motor branch of the fifth nerve is sometimes involved on the hemiplegia side, and there is paralysis of the pterygoid, temporal, and masseter muscles. Of the trunk muscles, the^^trapezius is almost solely involved, and that but slightly, permitting the shoulder to drop a little, and the paralyzed side of the chest may expand more than the normal side in ordinary breathing, while in voluntary deep breathing this is not the case. The reason of this possibly may be found in the exaggeration of the reflexes on the paralyzed side; ordinary breathing being a reflex action. Sensation is but slightly impaired in most cases of hemiplegia due to cerebral hemorrhage, and such impairment usually grows rapidly less as time elapses. It is hemianesthesia when anesthesia exists, and it is on the side opposite that of the lesion. There may also be trifling paresthesia at first. Any marked disturbance of sensation means that the posterior extremity of the internal capsule is involved, or, according to some authors, it indicates that the optic thalamus is invaded. Distinct impairment of the deep sensi- APOPLEXY. 1053 bility — the so-called muscular sense or sense of position — may indicate a lesion of the parietal lobe. There is sometimes temporary and even per- manent heniiaiiopsia, which implies some lesion of the fibers of the optic radiation posterior to the internal capsule or the posterior tubercle of the optic thalamus — the pulvinar. The tendon reflexes are increased in nearly all cases on the paralyzed side, though at the ver\- beginning of a severe shock they may be abolished, and if this abolition of the reflexes persists, it is regarded as a serious sign. In cases of any duration even the periosteal reflexes are increased, and to a less degree the reflexes of the sound side are increased, because each side of the body is innervated from both sides of the brain, although the num- ber of fibers passing to the same side of the body is considerably less than those passing to the opposite side. There is even, at times, ankle clonus, and, more rarely, wrist clonus. These events are explained by supposing a suspension of the inhibitory reflex cortical centers, due to the cerebral lesion. The skin reflexes, on the other hand, are diminished on the paralyzed side, remaining normal on the sound side. The rapid improvement mentioned as occurring in some cases is usually confined to a few weeks or days, after which improvement goes on more slowly, the lower extremities recovering more completely than the upper. The gait resulting from partial recovery is peculiar. Short steps are taken by the affected leg, and the toe is dragged more or less, while locomotion is sometimes accomplished by sweeping the leg around in a semicircle by the iliacus and psoas and the vastus externus, while it is held stilt, as in a splint, by the quadriceps extensor muscle. In the upper limb the hand mus- cles are the last to recover. Later in the history of the case contractures may come on in the para- lyzed muscles, shown especially in flexures of the fingers, contracture of the forearm in a position of pronation, and partial flexion, with the upper arm adducted. The lower extremity is usually in the position of extension. This contracture is explained by some, and notably by Striimpell. as a " passive contracture," the position assumed being the natural one in a state of rest. On the other hand. Charcot and his pupils hold that the contrac- tures are due to secondary degeneration of the pyramidal tract, a view that is probably incorrect. There are also sometimes associated movements of the paralyzed muscles, to which Hitzig has called attention. In these, move- ments of the sound side excite associated movements in the corresponding muscles of the other side, and attempts to move the aft'ected side result in motion of corresponding muscles of the sound side. Sometimes, also, in- voluntary movements of the lower extremity occur when the patient at- tempts to move the corresponding arm. A posthemiplegic chorea, first described by Weir ]\Iitchell, should also be mentioned. It is seen not so much in the hemiplegia resulting from cerebral hemorrhage as from focal disease of the posterior end of the internal capsule and optic thalamus. A form of hypertonia has recently been described in which the muscles are in a state of exaggerated tonicity without much paralysis. In this condition the position of the spastic lim.bs varies from time to time. It is seen in some cases in which a cerebral lesion has occurred early in life. TropJiic symptoms may appear latcin the disease, seen at first in elevation of temperature, increase of color on the paralyzed side of the face, swelling of the eyelids, and contraction of the pupil ; also swelling of the hands. It is to be remembered, however, that slight swelling may result from 1054 DISEASES OF THE XERVOUS SYSTEM. sluggish circulation of blood and lymph, contributed to by diminished muscular contraction and absence of use. In a more advanced stage the extremities become cooler and are often constantly moist. Among these vasomotor events Charcot has placed what he calls acute malignant decubitus — a disposition to rapid gangrene of the tissues over the sacrum. It may appear in a few days after the shock, beginning with a circumscribed redness and formation of vesicles, succeeded by deep-reaching necrosis. While this is probably, as Charcot regards it, a vasomotor phenomenon, it is also invited by the usual causes of gangrene in dorsal decubitus, such as irritation by urine, feces, and even inequalities in the bed-clothing. Charcot also considers an occasional arthritis, acute or chronic, a neuropathic event. General nutrition is well maintained, the patient even gaining in flesh at times. ]\Iore rarely there is rapid wasting. The mental condition of patients who recover partially from the eftects of hemorrhage is, for the most part, good, but it not infrequently happens that after a time mental weakness manifests itself in loss of memory and defective intellection, while imbecility sometimes ultimately supervenes. Diagnosis. — The greatest difficulty lies in the differential diagnosis between cerebral hemorrhage, embolism, and thrombosis. I will, however, defer its consideration until cerebral embolism and thrombosis are treated. In fulminating cases the coma is sometimes so profound that it is diffi- cult or impossible to ascertain the presence of hemiplegia. The symptoms which aid in deterniining this have been mentioned on page 1050. To these may be added the increase of reflexes on the affected side, not present in an early stage of the paralysis, conjugate deviation of the head and eyes, and rigidity of limbs on one side. It is these cases that are sometimes con- founded with epilepsy, opium poisoning, acute alcoholism, or uremia. In epilepsy there is the historv of previous convulsions, and it is only when this has been overlooked that mistakes occur. In opium poisoning the coma is slow in its onset, the pupils are uniformly contracted, and the odor of laudanum is often on the breath. But here, too, the victim is often only discovered after coma has thoroughly developed. In alcoholism there is the odor of whisky, but many an innocent person has been treated as a drunkard on whose brain lay a clot pressing him to death. The young ambulance or police surgeon is wise who defers his opinion. Sometimes alcoholism and apoplexy are combined, when a conservative course will be no less astute. The coma of uremia in Bright's disease very strongly simulates that of apoplexy, especially in the rare cases of the latter in which there are convulsions. ^The presence of dropsy, or, in its absence, of the peculiar anemia of Bright's disease, and the finding of albuminuria and casts should suggest this disease, but albumin may be found in hemi- plegia not of uremic origin. It is to be remembered, too, that uremic con- vulsion may terminate in hemorrhage, while Bright's disease is also associated with a state of the arteries which disposes them to rupture. Coma in a puerperal woman, associated with dropsy and albuminuria, means uremia. Prognosis. — To have had a stroke of paralysis is justly regarded as having received a blow which marks the beginning of inevitable decline in health and usefulness, though cases are constantly occurring in which a " slight stroke " is followed by complete recovery. Some of these are probablv errors of diagnosis, yet all are not. The cortical hemorrhages are those most frequently followed by recovery. After these come a large number of cases of first attack, from which the patient recovers quite a APOPLEXY. loss considerable degree of health. Second attacks are prone to occur, which are more severe, and few survive a third attack. The unfavorable cases are those in which the coma is profound and lasting. Such are hemorrhages into the ventricles and co'-ona radiata, which are rapidly fatal. Meningeal hemorrhages are serious, but less so when traumatic than when due to diseases of the vessel. Cases attended by early and persistent fever and delirium are unfavorable, as are also cases complicating renal disease and alcoholism. Hemorrhages into the corpus striatum and internal capsule produce persistent hemiplegia, followed by contracture. When cases survive the primary stroke and improvement sets in, this is much more rapid in the first few weeks than later. In ex- planation of this it has been held that the symptoms thus rapidly removed are indirect focal symptoms, due to pressure of the clot on adjacent nervous tissue, while those more slow to yield are the result of destructive lesion. Treatment. — The patient should be promptly placed in a horizontal position luith the head raised. This is of the greatest importance, as it con- stantly happens that a patient in whom consciousness is returning imme- diately becomes comatose when the head is lowered. He should then he hied, unless the pulse be small and feeble. The bleeding should be accom- panied by a laxative, which should be given alone if there be any reason why phlebotomy should not be practiced. In view of the unconscious state of the patient the best laxatives are croton oil and elaterium. Two drops of the former should be mixed in a little glycerin or oil and carried to the back part of the throat, or 1-4 grain (0.0165 gm.) of elaterium, dissolved in a small quantity of water, may be given in the same way. The rectum should be at once cleaned out by an enemia of warm water. An ice-bag should be placed on the top of the head, hot water and mustard to the feet, while counterirritation may also be applied to the back of the neck, but it is doubtful whether any of these measures will accomplish much. Conipression of the carotid artery, formerly recommended and practiced on empirical grounds, has recently received the indorsement of Horsley and Spencer, these experimenters having found that bleeding from the lenticulo- striate artery ceases when the carotid is compressed. It is especially in the ingravescent form that it has been recommended. F. X. Dercum and W. W. Keen* report two cases of ingravescent hemorrhage treated by ligation of the common carotid, of which one recovered. If, after bleeding and purgation, the pulse continues bounding, the tincture of aconite or zeratrum viride may be given in doses of a- minim g every half-hour tintiHhe pulse is influenced. lodid of potassium can hardly be expected to promote absorption of the clot, but may be given if syphilis is suspected. It may, however, facilitate circulation by dilating the blood- vessels. The foregoing treatment is for the period immediately succeeding hem- orrhage. The remainder of treatment consists in measures to protect the patient against the effect of decubitus if this is prolonged, and in main- taining the nutrition of muscles and protecting against contractures. The former is accomplished by attending to the secretions, preventing the irri- tation of the body by putrid urine and feces or foreign substances like bread-crumbs, by bathing and drying? the body thoroughly, by frequent changes of posture. The latter will also guard against pneumonia, which * "Jour, of Nervous and Mental Disease," September, 1894. r-. /(p 1056 DISEASES OF THE NERVOUS SYSTEM. is rather prone to occur on the paralyzed side. This last disease may also be caused by the inspiration of particles cf food, liable to happen if there is paralysis of the muscles of deglutition. The second indication is met by massage, faradization, and gymnastics^ but they should be deferred for two ■or three weeks. Warm salt baths three or four times a week are useful to the same end. Tonics in the form of iron in small doses, quinin, aiid strychnin may be given, but alcohol in more than very moderate amounts is contra-indicated. Operative treatment has been suggested to relieve the pressure of a clot in cerebral hemorrhage, and when it is certain that the clot is menin- geal, especially after fracture, satisfactory results show that it is justified. Careful attention should be paid to the facts mentioned under topical diag- nosis with a view to determining the seat of hemorrhage and the place to trephine. Deep hemorrhage is, however, beyond reach. 11. Embolism and Thrombosis of the Cerebral Vessels. A. — Of Cerebral Arteries. Synonyms. — Cerebral Softening; Acute Softening. Definition, — By embolism is meant the plugging of an artery by a for- eign body carried into the circulation from some point in the vascular sys- tem and taken by the blood current to a point beyond which it cannot pass. By thrombosis is meant plugging of an artery or vein by a clot formed in situ. Etiology. — Nature and Source of Embolism. — The embolus is most frequently a vegetation from a diseased valve in the left ventricle. Less commonly it is a fragment of a clot in the same ventricle or in the auricular appendage or in an aneurysm, or it may be a calcareous particle from an atheromatous vessel or a piece of thrombus from the same. Even the terri- tory of the pulmonary veins may contribute an embolus. Embolism is very much more frequent in chronic valvular disease than in primary acute endo- carditis. It is prone to occur in recurring valvulitis, and especially in mycotic endocarditis. Pregnancy with or without heart disease, the infec- tious fevers, and blood dyscrasise may be predisposing causes. The embolus commonly enters the brain by the carotid, especially the left, — which furnishes the most direct course, — thence through the internal carotid to the left middle cerebral in the fissure of Sylvius ; more rarely by the vertebral and its posterior" cerebral branch. Thrombosis. — In thrombosis there is also plugging of a living vessel, but by a clot formed in situ, which is either primary at the point plugged or secondary about a previous embolus. Some favoring cause commonly exists. This is most frequently roughening due to endarteritis, with or without atheroma. Weak heart and blood dyscrasise are also predisposing causes. Ligation of the carotid artery is sometimes followed by thrombosis of cerebral vessels. The vessels most frequently afTected in thrombosis are the middle cere- bral and the basilar, but the vertebral, the posterior cerebral, and the branches of the circle of Willis may be plugged, and the basilar at its bifurcation. Relative Frequency of Thrombosis and Embolism. — Embolism has been thought to be more frequent in women, but of 79 cases collected by Newton APOPLEXY. 1057 Pitt at Guy's Hospital, 44 were in men and 35 in women. Thrombosis is con- sidered more common in men. Embolism is rare in children, being more frequent at from twenty to fifty ; thrombosis in older persons, at from fifty to seventy. Morbid Changes Due to Thrombosis and Embolism. — Degeneration and softening of the brain are the direct result of obstruction of its arteries, and occur sooner or later when the shutting off of the blood supply is suffi- ciently complete. The process generally begins within twenty-four hours, and the minimum time required to complete it is from one to two days. The local anatomical product of embolism is much less distinctive in the brain than in the lungs or spleen. Thus, there is almost never a dis- tinct hemorrhagic infarct, though there is often a condition resembling it, the area cut off being infiltrated with blood. At other times the region is paler than in health and slightly softer. In either event the area becomes gradually infiltrated with serum and a more or less complete liquefaction results, presenting a reddish, yellow, or white color, whence, the terms red softening, yellozu softening, or zvhite softening. These variations are not the result of any essential difference in the nature of the process, as was for- merly thought, but are rather accidental. In red softening the softened focus happens to contain an unusual amount of extravasated blood, due to punc- tiform hemorrhage or capillary apoplexy. This blood melts away and stains the softened mass. In yellow softening the proportion of fatty degener- ated cells is larger, and it is found, therefore, chiefly in the cortex, where cells prevail. In white softening there are few or no cellular elements, hence the white softening is found in the white or fibrous nervous matter. It is most characteristically seen about tumors and abscesses. As the gray matter of the cortex is also the most vascular part of the brain, it is here also that we find red softening. Certain superficial yellow spots known as plaques jaunes are found at times on the surface of the cortex in old per- sons. They are sharply circumscribed, measure from 2 to 4 centimeters (.8 to 1.6 inches), are niade up of a yellow, turbid material sometimes crossed by trabeculae, and represent fatty degeneration of peripheral corti- cal arteries. Minutelv examined, the softened areas consist of fatty granules and oil drops, myelin drops, fragments of swollen nerve-fibers, fatty granular cells representing fatty neuroglia and nen-e-cells, or leukocytes and neuroglia cells, and perhaps endothelial cells which have imbibed the oil drops, arising probablv from disintegrated nervous matter. In the yellow softening these constitute the sum of altered materials. In red softening there are added in the early stages blood-discs, later pigment granules or hematoidin crys- tals, or there is general staining by dissolved hemoglobin. In the white sof- tening the fragments of nerve-fibers together with myelin drops make up the chief bulk, as already stated. If collateral compensatory circulation is set up within two days, the destruction may not go so far, and the nervous elements may resume their function ; or if this does not occur and the patient lives, the dead and disintegrated tissue may be gradually absorbed and eventually be replaced by a cyst, while a minute focus of softening may be replaced by indurated cicatricial tissue. If the embolus is derived from an infective focus, as ulcerative endocarditis, an abscess may result. Symptoms. — Xeither thrombosis nor embolism of the cerebral arteries is always followed by recognizable symptoms. All the large arteries of the base and the smaller arteries of the surfac-e anastomose so freely 67 I058 DISEASES OF THE NERVOUS SYSTEM. that the effects of obstruction are promptly equaUzed. Nay, more ; it ia not unusual to find at the necropsies of elderly persons yellow spots of fattv degeneration, the plaques jauncs referred to, scattered over the convo- lutions where nothing was suspected before death. ^Moreover, softening may take place in the " silent regions " without exciting suspicion. Very different is it with obstruction of the middle cerebral artery — the artery of the fissure of Sylvius. The clinical aspect dift'ers, however, according as this vessel is plugged at its origin or a little further on in its course. Allusion has already been made (p. 1049) to the two separate systems wnrh which the brain is supplied — the "cortical arteries'' (Duret), passing to the cortex, and the "central" arteries, passing to the central ganglia. The central arteries are the first given off bv the cerebral branches of the circle of Willis, and are terminal arteries, unprovided with anastomoses. The cortical arteries spring from a network of branches of the cerebral arteries in the pia mater, in which tolerably free communication exists between the tertiary branches of the same trunk, and even between the branches of different trunks. These two^ systems of cortex and center are, however, altogether independent of each other, and no anastomosis takes place between them, the zone at which they meet within the cerebral substance being situated about an inch and a half below the cerebral convolutions. In the case of the middle cerebral artery, when it is obliterated beyond the point at which its " central " branches come off, the superficial parts of the brain are alone affected, and since its branches in the pia mater anastomose with those of the anterior and posterior cerebrals, there may be no softening at all, and but a temporary loss of function. At other times softening does occur, the exact situation and extent of which vary with the arteries plugged. The blood supply of the two central, the three frontal, and the three parietal convolutions being more or less cut off, there is motor paralysis of the opposite side of the body, and as the lesion is most frequent on the left side, there are right- sided hemiplegia and aphasia ; the same phenomena, in fact, as follow hem- orrhage, and which may be peniianent or transient ; or the lesion may be still more limited. The embolus may lodge in the artery, passing to the third frontal convolution, or in that of the ascending frontal or ascending parietal. It may lodge in" the branch passing to the supramarginal or angular gyrus, or to the lo^\est branch, which is distributed to the upper convolution of the temporosphenoidal lobe. If, on the other hand, the seat of the lesion is at the point where the Sylvian artery arises from the internal carotid, the cen- tral ganglia are involved, and there is almost certain to be softening of the corpus striatum and optic thalamus, because the arteries have no anasto- moses, while the cortex escapes entirely because its vessels are distinct. Summary of the Effects of Pluggitig of the Cerebral Vessels : Internal Carotid. — There may be no SA^mptoms or there may be transient hemi- plegia, or permanent hemiplegia and coma ending in death in a week or ten daj'^s. In the first alternative the circulation is maintained by the communicating vessels of the circle of Willis, which ordinarily dilate rapidly. If these vessels are small or absent, permanent hemiplegia and death must result, as a small part of the hemi- sphere only receives blood by the posterior cerebral. Thrombosis is verj- apt to extend from an initial focus in the internal carotid to its branches, and maj^ extend to the ophthalmic artery. Aiiterior Cerebral — Because of the right-angled direction at which this vessel is given off from the internal carotid, it is rarely obstructed b}^ embolus unless the parent trunk is plugged before this branch is given off, and then the mischief is trifling" or }iil. since branches of the middle cerebral may supply much of the same territory. Middle Cerebral. — This is the most frequently plugged of all cerebral vessels.. APOPLEXY. 1059 The result is hemiplegia, permanent if the embolus lodges before the central arteries are given off, since softening of the internal capsule ensues ; if beyond this point, the hemiplegia involving the arm and face is more apt to be transient. If on the left side, there is aphasia, and there may also be impairment of sensibility for a time. The symptoms vary somewhat, according as one or more of the cortical branches are obstructed by a plug at the point of division of the vessel in the island of Reil. Oc- clusion of the first branch may produce softening of the third frontal convolution and aphasia if on the left side ; occlusion of the second and third branches, softening of the ascending frontal or ascending parietal convolution and hemiplegia, partial when the softening is incomplete ; of the fourth branch, softening about the posterior limb of the fissure of Sylvius, and if on the left side, sensory aphasia — defective perception of words — with corresponding impairment of speech. Posterior Cerebral. — Plugging of this branch distributed to the occipital and temporosphenoidal lobes is a rare cause of softening. So far as ascertainable the phenomena are mostly sensory, including hemianesthesia from softening of the teg- mentum of the crus, or of the internal capsule, or hemianopsia from softening of the 'cuneus, though the same symptoms may result from interruption of the optic tract when the cortex is intact. Complete but temporary less of sight has resulted from plugging of one posterior cerebral artery. Basilar A rler_}'.— Total occlusion of this vessel may produce bilateral paralysis- from involvement of both motor paths in the pons, with other symptoms of apoplex}'- of this center — viz., bulbar palsies, irregularity of heart and breathing, spasm, and. rarely convulsions ; the temperature may rise rapidly to log^ F. (42.6° C.) or there- abouts after an initial fall. Vertebral Artery. — The left is more frequently plugged, rarely alone, commonly along with the basilar. The nuclei of the medulla oblongata are affected, and we have symptoms of acute bulbar pais}'. Cerebellar Arteries. — Obstruction of the isolated cerebellar arteries is rare as compared with plugging of the parent trunk in the basilar. Even then the area of cerebral softening is limited, by reason of collateral anastomoses, and the symptoms are obscured by those due to damage to the pons and medulla oblongata. Inco-ordi- nation of movement has been reported in one or two cases in which the region sup- plied by the posterior cerebellar was cut off. Diagnosis. — It has already been said that the chief difficulty lies in the differential diagnosis between cerebral hemorrhage, on the one hand^ and embolism and thrombosis on the other. Sometimes, indeed, at first it is impossible. Both are sudden. In embolism the patient is commonly younger, but not always so, and we look for valvular heart disease. Accord- ing to Charles L. Dana, even in patients say between the ages of thirty and fifty, when there is no heart disease, the chances are six to one in favor of hemorrhage. An apoplectic seizure after parturition is apt to be embolic. In embolism, too, there is less disturbance of temperature, the paralysis is more apt to precede the coma and convulsions if the lattter are present ; the turgid face, hard pulse, loud breathing, and greater general disturbance of a serious stroke of apoplexy from hemorrhage are wanting. In thrombosis the difficulty in diagnosis may be even greater. The symptoms of thrombosis are slower in their development, but in the " ingravescent " form of apoplexy, in which the hemorrhage is gradual, requiring sometimes a day or two, the development of symptoms is corre- spondingly slow. In thrombosis there are more frequently prodromata in the shape of slight seizures, quickly recovered from. Such events occurring in the aged, when there is evident atheroma of the blood-vessels and weak heart, point to thrombosis, in which, too, there is absence of stertorous breathing, of variations in temperature, and of pupillary disturbance. Lesions in the pons and cerebellum are more likely to be hemorrhages. It is also important to be able to decide whether the obstruction is embolic or thrombotic. In the former the onset is sudden, without pre- monitory symptoms ; in the latter it is gradual, and there are often premon- itory symptoms. In the former there may be convulsive twitchings. but hemiplegia quickly follows, with or without temporar}- loss of consciousness. In the latter the patient has previously complained of headache, vertigo, or io6o DISEASES OF THE NERVOUS SYSTEM. tingling in the fingers ; then paralysis may begin in one hand or foot and extend slowly, the hemiplegia often remaining partial. Speech may have been embarrassed for some days previous, and the memory defective. In thrombosis due to syphilis, especially, the hemiplegia may come on gradually without loss of consciousness. The same is true of the so-called senile softening, which is generally due to thrombosis after atheroma of the cere- bral arteries. In a few cases the onset is more sudden, and may happen during sleep. The temperature usually has a slight initial fall, followed by rise, as in hemorrhage. In embolism aphasia is quite a characteristic symptom, as it seems to occur more frequently on the left side than on the right. In both embolism and thrombosis the hemiplegia tends to improve- rapidly unless the vessel obstructed be a large one or there be rupture of a collateral branch. It is true that acute softening may terminate fatally within twenty-four hours, but usually the patient survives the onset, and at the worst dies after several weeks, the phenomena of the chronic stage being almost identical with those of hemorrhage. Spastic symptoms are also likely to occur, and there is a tendency to the characteristic mobile spasm. Prognosis. — A patient rarely dies of a first attack of cerebral embolism, unless a very large vessel is obstructed, such as the internal carotid or basilar, whose occlusion is fatal ; next in seriousness after these is plugging of the middle cerebral and vertebral, while obstruction of the two verte- brals is always fatal. Every succeeding attack increases the danger. Em- bolism is less serious than thrombosis ; and thrombosis due to syphilitic disease is more hopeful than senile softening. Sudden severity in thrombosis is serious, and deranged breathing is an unfavorable symptom. Convulsions may be a result of- syphilitic thrombosis. When the embolism is due to valvular heart disease, it is apt to recur ; when due to other causes, not. Throimbosis is prone to occur, especially when due to atheroma. Treatment. — Neither thrombosis nor embolism demands blood-let- ting, as does hemorrhage. Indeed, it is strongly contra-indicated. Rest in bed, with head raised, is important. If syphilis is the cause of throm- bosis, it should receive the usual treatment — the idodid of potassium in ascending doses until doses of a dram or more are reached. There is no treatment for atheroma. Attention should be paid to the heart, kid- neys, and bowels. The heart is commonly feeble, and digitalis and stro- phanthus are needed to keep its action uniform and strong, by which one condition of thrombosis is removed. The urine is scanty and highly colored, but the treatment for the heart is also the treatment for the scanty secretion, which calls also for diluents. The bowels should be kept freely open to aid in promoting the circulation. The latter is aided by nitroglycerin, which may be given in doses of i-ioo grain (0.0066 gm.) every two hours. The iodid of potassium is useful also for this purpose. Its effects are more permanent than those of nitroglycerin. From five to fifteen grains (0.33 to 0.99 gm.) three times a day should be given. Moderate stimulation is beneficial. The aromatic spirit of ammonia and alcohol are the most useful for this purpose. Mental excitement is to be especially avoided after a return to consciousness, and physical rest should be continued. Stimulants are then best discontinued, or continued in great moderation. Care should be taken to protect against the effects of decubitus. APOPLEXY. y 1061 Unfortunately there is no treatment which will restore softened brain matter, although a certain amount of function may be vicariously assumed. The same measures calculated to maintain nutrition and muscular integrity as are recommended in the treatment of hemorrhage should be taken. B. Of the Cerebral Sinuses and Veins. Description. — Thrombosis chiefly attacks the sinuses, and is primary or secondary. Primary thrombosis is the result of a state of the blood and circulation ; secondary, a consequence of disease adjacent to the sinuses. The former is much the rarer, occurring half as often. Primary thrombosis is met in the longitudinal sinus, more rarely in the lateral, sometimes in the cavernous. It is found associated with general malnutrition and prostration, more frequently in children during the first six months of life as the result of exhausting maladies, especially diarrhea. It is met also in older children. Brayton Ball and others have shown its association in young girls with chlorosis and anemia. It occurs in the aged also as the result of exhausting disease, like pulmonary tuberculosis and cancer. Coagulation is favored by the trabeculce which cross the cavity of the sinus, and by irregularities in the shape and lining of the latter. It may or may not be associated with phlebitis. Very little is known of thrombosis of the cerebral veins, except that it may occur in veins of the convexity as the result of meningitis, and from the same causes that produce thrombosis of sinuses. Secondary thrombosis occurs at any age, and is the result of disease adjacent to a sinus, commonly caries of bone, and is especially frequent as the result of disease of the internal ear. It spreads more frequently from the posterior wall of the middle ear, but also from the mastoid sinuses. Frac- ture, suppurative disease outside of the skull, especially erysipelas, and tumor compressing the sinus may produce it. Symptoms. — There may be no symptoms in prim.ary thrombosis, or there may be nausea and vomiting, headache, and hebetude increasing to coma. Dilatation of the pupils, choked discs, and paresis have been re- ported. Secondary thrombosis is a septic process. It is commonly announced by a chill, followed by fever and occipital pain, succeeding on earache with suppurative otitis. The sinuses occluded are those near the ear, but the blood escapes by other channels, and the brain substance is not seriously invaded. The symptoms of meningitis are soon added. They are head- ache, somnolence, and stupor, or there may be active delirium and convul- sions, rigidity, or optic neuritis, all the results of meningitis. Death is most frequently due to suppurative pulmonary pyemia, as was the case in 70 per cent, of Newton Pitt's cases, and the appearance of the latter disease under the circumstances is almost conclusive evidence of previous sinus thrombosis. Prognosis. — This is always grave. The average duration of the sec- ondary' disease is about three weeks, and its termination is almost always fatal. Pitt reports a case of recovery' in a boy of ten who had otorrhea for years, after removal of a foul clot from the lateral sinus by opera- tion. Treatment.— For primar}' thrombosis there is no treatment except io62 DISEASES OF THE NERVOUS SYSTEM. that for its cause. For secondary, operative treatment is indicated by tre- phining or other measures to give exit to pus. Quinin and restorative measures are indicated. Gowers lays particular stress on the use of the tincture of the chlorid of iron. INTRACRANIAL ANEURYSM. Definition. — Intracranial aneurysms are of two kinds, miliary and those of larger size. The former have been considered when treating of hemor- rhage. Distribution. — Larger aneurysms affect the larger arteries at the base of the brain in the following order: 1. Middle cerebral. 2. Basilar. 3. Internal carotid. 4. Anterior cerebral. The anterior or posterior communicating and vertebral arteries are also occasional seats ; the posterior cerebral and inferior cerebellar rarely. Wil- liam Osier found 12 of these aneurysms in 800 autopsies, and Newton Pitt 19 in 1900. The aneurysm varies in size from that of a pea to that of a walnut. Etiology. — Intracranial aneurysms are found rather more frequently in the male sex, and most frequently between the ages of from ten to sixty. Osier and Pitt each found one at the age of six. Heredity exercises some influence. Endarteritis and embolism, both of which weaken the vessels, are the chief causes. The former may be syphilitic or simple. The pres- ence of endocarditis should especially invite examination for them at au- topsies. Symptoms. — Death from, apoplexy, owing to rupture of the aneurysm, may be the first intimation. Not only are there often no symptoms, but when present they are vague. They may be those of tumor at the base of the brain, including optic neuritis and paralysis of the third and other cra- nial nerves. There are rarely convulsions. There may be headache, vertigo, nausea, hebetude, and even coma, hemiplegia, and hemianopsia. A murmur may be heard on auscultating the skull, while occasionally the patient himself is conscious of a murmur or recognizes the pulsations in his head. Diagnosis.— This is usually impossible, but the foregoing symptoms, associated with endocarditis, may excite suspicion. Syphilitic disease being as likely to produce tumor, the history of its presence gives no assistance in diagnosis. Treatment. — None exists which can be specifically directed to the dis- ease. THE CEREBRAL PALSIES OF CHILDREN. Definition. — Referring to the division already made of the motor path into an upper cortico-spinal segment, extending from the cells of the cortex to the gray matter of the cord, and a lower spino-muscular, extend- ing from the ganglia of the anterior horns to the motorial end-plates, the diseases now to be considered have their anatomical seat in the former, and THE CEREBRAL PALSIES OF CHILDREN. 1063 are characterized by paralysis, with spasm or disordered movements, exag- g-erated reflexes, normal electrical reactions, without rapid or extreme wast- ing. They result from a destructive lesion of the motor centers, or of the pyramidal tract in the hemisphere, internal capsule, crus, or pons. They are hemiplegic, diplegic, or paraplegic. Spastic Infantile Hemiplegia. Synonyms. — Hemiplegia spastica cerebralis (Heine) ; Hemiplegia spastica infantilis (Bernhardt) ; Acute Encephalitis der Kinder (Striimpell) ; Die atrophische Cerehrallahmung (Henoch) ; Agcnese cerebrale (Cazau- vieilh) ; Sclerose cerebrale atrophic partielle cerebrale (other French writers). Historical. — In 1884 Striimpell, in a paper, " Ueber die acute Encephalitis der Kinder," called attention to the possibility of encephalitis in children. Numerous papers on infantile hemiplegia have appeared in Germany, France, and America, among which may be especially mentioned those of Gaudard, Wallenberg, Jules Simon, Morse, Ross, Gowers, Sarah J. McNutt, Weir Mitchell, B. Sachs, Wharton ■Sinkler, H. C. Wood, J. Lewis Smith, and William Osier. Etiology. — The disease is somewhat more common in girls than in boys, 63 out of 120 cases studied by Osier at the Nervous Infirmary in Philadelphia being of this sex. Of these cases 15 were congenital, 45 arose in the first year, 22 in the second, 14 in the third, i in the fourth, 3 in the fifty, sixth, and seventh, i in the eighth, ninth, tenth, and older. In 10 the age of onset was not given. The hemiplegia' was right-sided in 68 and left-sided in 52 cases. Among the causes may be mentioned abnormal conditions of the mother during pregnancy, including accidents, possibly disease, especially syphilis, in a few cases fright or distress, the effect of the last two being doubtful. Especially frequent causes are difficult or abnormal labor, in- jury with forceps producing flexures and fractures of the cranial bones dur- ing delivery. After birth are penetrating wounds of the head, ligation of the common carotid, and infectious diseases, including whooping-cough, diphtheria, scarlet-fever, measles, meningitis, typhoid fever, vaccinia, and mumps. Previous convulsions may cause the lesion on which the paralysis depends, and in a few cases embolism may be responsible. Morbid Anatomy. — The morbid states of the brain found at autopsy are mainly sclerosis and porencephalia — defect consisting in arrest of devel- opment of the brain resulting in the absence of convolutions or even lobes, causing irregular subpial cavities. Em^bolism and thrombosis of vessels, especially of the Sylvian artery, and hemorrhage into the ventricle and sub- stance of the brain, are found in a few cases. The sclerosis involves either groups of convolutions, an entire lobe, or even an entire hemisphere. The skitrll may be flattened on the affected side, broad and prominent above the mastoid processes, sometimes thickened. The dura may be thickened and adherent, and in one case contained extensive osseous plates. The arach- noid is turbid and thickened and the amount of cerebrospinal fluid is increased. The pia mater may be thickened and adherent, and drag portions of the cortex away on being remove^, leaving a roughened surface, while there may be nodular projections of sclerosed tissue. The reduction of weight of the sclerosed hemisphere may be very considerable ; in one case, referred to by Osier in his monograph, the atrophied hemisphere weighed io64 DISEASES OF THE NERVOUS SYSTEM. 5 1-2 ounces ( 169 gm.)> the normal being 20 ounces (653 gm.). The lateral ventricle may be greatly dilated, and the brain tissue over it very thin, while cysts have been found in the sclerosed areas — the remnants of old hemor- rhages. The Rolandic area is that most frequently involved. In 90 cases studied by Osier the lesions in 50 were atrophy and sclerosis, in 24 porcencephalia, and in 16 embolism, thrombosis, or hemor- rhage. Symptoms. — The symptoms are complex and varied, but may be divided into three classes : those of the onset, those pertaining to the par- alysis, and the residual symptoms. The hemiplegia is usually preceded or accompanied by convulsions and coma, although the disease may come on suddenly, without spasms or loss of consciousness, in children apparently healthy. In the majority of cases, however, the disease begins with convulsions, partial or general. Loss of consciousness almost always accompanies the convulsions, and may last from a few hours to many days. Rarely coma occurs without convulsions. Among other symptoms may be mentioned fever, transient or persistent ; according to Striimpell and Gaudard, it is an invariable accompaniment of the convulsions. Delirium is a common symptom, as is also soreness of the general surface. Vomiting and screaming spells are also noticed. The hemiplegia, which is noticed as soon as^the child recovers con- sciousness, is usually complete. Less commonly there is first, paresis, which gradually extends to complete loss of power; and in some instances a total paralysis is established after repeated convulsions. The face is not always involved, and, as a rule, in facial paralysis of cerebral origin the superior muscles are intact, and the child can close the eyes and elevate the brows. The facial palsy usually disappears rapidly and completely. As to residual symptoms in adults, also, the residual paralysis is most marked in the arm, which is subject to slow wasting, and is commonly use- less for the ordinary purposes of life. The atrophy is moderate, but there may be arrested development, leaving a wasted and withered member. In extreme cases the arm is held close to the side, the forearm strongly flexed at right angles and in a semiprone position, the hand flexed and the fingers contracted, the palm usually embracing the thumb. Motion may be almost lost in the arm and completely in the fingers, though in most cases there is considerable power of movement, the patient being able to lift the arm above the head, while flexion and extension can be made at the elbow and wrist. The finer and more delicate movements of the hand are rarely recovered. The leg, as a rule, recovers more rapidly and completely than the arm, and the palsy may disappear entirely in'^it, while it rarely does in the upper extrem- ity. In the leg the wasting is also less pronounced, while arrested develop- ment is also less frequent. A persistent halt is apt to remain — indeed, al- most always does — as evidence of impaired power ; this may consist in simply favoring the affected side, noticeable only on rapid walking. A decided dragging of the limb is, however, more usual, and there may be tremor of the leg while moving. The frequency with which rigidity is present has given rise to one of the names of the disease, spastic infantile hemiplegia. It is not, however, an invariable symptom, and the paralyzed limbs may be relaxed a long time after paralysis sets in. When rigidity is present, it is lessened during sleep, and is increased by emotion and forcible attempts to overcome the spasm. Contracture may ultimately result, after which relaxation is no longer THE CEREBRAL PALSIES OF CHILDREN. 1065 possible. A form of rigidity without much paralysis is known as postapo- plectic hemi-hypcrtonia, and has been previously referred to. The reflexes are almost always increased in the affected limbs, ankle clonus being often obtainable in addition to exaggerated knee-jerk. The reflexes may even be increased on the sound side. Rectus clonus and clonus of the flexors of the Angers are rarely present, while in a very few cases the reflexes are absent. Sensation is rarely affected, but vasomotor derangements are sometimes present. Electrical reactions are normal^ as a rule. Posthemiplegic chorea — hemiataxia — is not infrequent. More uncom- nion are mobile spasm and athetosis and posthemiplegic tremor. These interesting symptoms were first described by S. Weir Mitchell and Hammond in a study of cases of cerebral palsy. Aphasia is present in a majority of cases almost invariably transitory^ associated most commonly with right hemiplegia, very rarely with left. Defects of intelligence are very common, the degree of feeble-minded- ness ranging from low-grade imbecility to total idiocy. Psychoses may occur late in life, even when there have been no defects in childhood. Epilepsy is very frequent, and is sometimes confined to the paralyzed side, but also tends to become general. The attacks usually begin within two or three years, sometimes within a few weeks, after the onset of the hemiplegia, but may be delayed from eight to ten years, or even longer. The seizures may present three zvell-dcfined degrees — the first, in which the child is simply dazed for a moment or two, or longer, without any motor in- volvement ; second, Jacksonian epilepsy, without loss of consciousness, in which the spasms are confined to the affected side,* and third, general con- vulsions, beginning in the paralyzed limbs, and usually accompanied by loss of consciousness. The Jacksonian epilepsy is most common, but all forms may occur in any one case. Diagnosis. — Infantile spinal paralysis, anterior poliomyelitis, most fre- quently must be excluded, usually without difficulty. The history of the case, including the presence of some of the causes named, the frequent onset with convulsions, the hemiplegia, the absence of rapid wasting of the affected muscles, the retained electrical reactions, are characteristic of in- fantile cerebral hemiplegia in its early stage ; while rigidity of muscles, in- creased reflexes, the peculiar gait, and residual palsy, with mental imbecility and epileptic seizures, distinguish the latter stage. Tumor of the brain sometimes produces similar symptoms. Tubercu- losis and glioma are the forms most common in children. Pressure paral- ysis by obstetrical forceps affects the face and upper extremities, but other symptoms are wanting, and it is scarcely likely to be confounded with infan- tile hemiplegia. Prognosis and Treatment. — The prognosis is favorable so far as life and the recovery of considerable locomotive power are concerned; unfavor- able as to recovery from mental defect and epilepsy. An institution for feeble-minded children, in which the subjects have the benefit of training and watching, is the safest permanent home for them. * Jacksonian epilepsy is usually without loss «if consciousness, unless the convulsions are very severe or involve a large portion of the body. io66 DISEASES OF THE NERVOUS SYSTEM. Bilateral Infantile Spastic Hemiplegia. Synonyms. — Spastic Rigidity of the Nciv-born (Little) ; Tonic Contraction of Extremities; Essential Contractions; Permanentes Kinder-Tetanus (Stromeyer) ; Spastic Paralysis of Children (Adams) ; Spastic Dip- legia (Gee) ; Spasme Muscnlaire Idiopathique (Delpech) ; Birth Palsies (Gowers) ; Little's Disease. Historical. — Delpech was probablj- the first to describe the disease fairly cor- rectl}'. To the German orthopedic surgeon, Heine, belongs the credit of first appre- ciating these conditions and their cerebral origin and separating them. from common infantile paralysis. His paper was written in iS6o. Little's paper, published two years later in England, so attracted attention that his name became applied to the disease. Stromeyer, Adams, and Rupprecht have furnished careful accounts. Etiology. — 'Slost cases of bilateral hemiplegia in children date from birth, and are the result of injury during birth. The infectious fevers are responsible for a certain number, and a few are direct results of convulsions. In a word, the causes are those of infantile hemiplegia. Morbid Anatomy. — As may be inferred from the name, the lesions are bilateral and involve motor areas of the cortex almost solely. They consist in sclerosis or porencephalous defect, of which the most frequent pri- mary cause is compression by a blood-clot due to meningeal hemorrhage from the veins or longitudinal sinus. A meningo-encephalitis may, how- ever, be responsible for the sclerosis. Descending degeneration of the pyramidal tracts or imperfect develop- ment of these tracts has been found in a few cases. Symptoms. — These are to be distinguished from those of the next form, cerebral spastic paraplegia, which the disease closely resembles when the arms are so slightly affected that the palsy is scarcely appreciable. The cerebral spastic paraplegia of childhood is due to lesions similar to those of the bilateral spastic hemiplegia. In the diplegic state all the e.vtreuiitics must be more or less spastic, although the legs almost always are more so than the arms. These cases are further characterized, as are those of spastic paraplegia, by their occurrence at or very sooji after birth. There may be convulsions or a prolonged succession of convulsions immediately after birth. After this or without it there may be noticed a linip)iess or flaccidity of uuiscles, an expression of paresis, often overlooked, because present at a time when the muscular development of the child is so slight that little is expected of it. Soon, however, the inability to hold up its head may be observed, and when the time comes for it to walk, it is noticed that the limbs are chimsily used, and when examined, thev are found to be stiff. As the child grows older it slowly acquires some power so as to be able to sit, but the legs are crossed and the head is not well sup- ported by the neck muscles. If it is held up, the legs are extended and strongly adducted, and crossed with the feet in the pes equinus or equino- varus position. Occasionally the legs are partially fle.ved. while stiffness varies greatly, involving, in extreme cases, the whole body, sometimes one side more than the other. It is sometim.es constant, at other times not. It may be greater on one side than another. The arms are usually stiff in flexion. To the spastic symptoms described are added, in certain cases, spasm and certain movements known as athefoid. In the former, in an attempt at voluntarv movement, as taking hold of an obiect. the fingers are thrown THE CEREBRAL PALSIES OF CHILDREN. 1067 out in a stiff, spasmodic, or irregular manner, or there may be constant irregular movements of arms and shoulders, movements which are usually characterized as choreic. In fact, such cases have been named chorea spastica, being differentiated from the congenital choreas by the spastic feature. Spasm rarely affects the muscles of the face, though it does occa- sionally, causing a continual grimacing, which does not always disappear during sleep. The athetosis is double or bilateral, resulting in the most grotesque and distorted movements. They consist in a constant flexion and extension of muscles, more particularly of those of the fingers of one hand and fore- arm. Flexion of the fingers of one hand may take place, while those of the other may be extending, and the same may be true of different fingers of the same hand. The shoulder and trunk m.uscles may be also affected, producing a rhythmical and orderly twisting and bending of the body; or those of the neck, producing a turning of the head from side to side. These movements are all increased under excitement or with the effort to do any- thing. Mental defect, consisting in imbecility and various grades of idiocy, is more or less characteristic of these cases, but is commonly less than in in- fantile hemiplegia. The form resulting from premature birth should be distinguished from that caused by injuries at birth, or by lesions acquired later, as in the former convulsions and athetoid movements do not usually occur, mentality may not be affected, and improvement may be slowly progressive even after many years. Infantile Spastic Paraplegia. Synonyms. — Paraplegia cercbralis spastica (Heine) ; Tetanoid Pseudopara- plegia (Seguin) ; Spastic Spinal Paralysis (Erb) ; Tabes dorsalis spas- modique ( Charcot ) . Definition. — Spastic paralysis of the legs in children. Historical. — A common affection of children, though only recently understood, was fully described and correctly named by Heine in 1849. Delpech and Stromeyer in Germany and Adams and Little in England described it. Erb and Seeligmiiller in Germany and Gee in England brought the subject to the notice of physicians, and Erb contrasted it with the spastic paraplegia of adults. Ross, Hadden, Gowers, d'Heilly, Gilbert, and Osier have more recently treated the subject as one of the cere- bral palsies of children. It must be distinguished from the spastic paralysis occurring in adults and found in a very few cases to be due to primary degeneration of the pyramidal tracts. Etiology. — The causes are those of spastic diplegia and infantile hemi- plegia, and also premature birth, the child being born at a period when the central motor tracts are very imperfectly developed ; premature birth causes an arrest in the development of these tracts. Morbid Anatomy. — This is less known than the morbid anatomy of the other forms of cerebral palsy. It may be due to cerebral lesion involv- ing especially the centers for the lower limbs, to imperfect development of the motor tracts, or to other causes. A few cases with necropsy are re- corded, r Symptoms. — These are almost identical with those already described as belonging to the spastic paraplegia of adults, with which the earlier writer classed it. Spastic paralysis of the lower extremities, dating from io68 DISEASES OF THE NERVOUS SYSTEM. birth or appearing within the first few years of life, with tahpes equinus or equinovarus, adductor spasm, rigid stiff gait, the patient walking on his toes or by crossed-legged progression, — all without wasting, — these are, in a word, the symptoms. The order of sequence of events is very similar to that described under spastic diplegia. In attempting to walk the heels are everted and knees approximated, because of spasm of the adductors, which may be so strong as to make it impossible to separate the thighs. The spastically extended legs may, however, be gradually forced into flexion after the manner of the " lead-pipe " contraction. If, however, the attempt be made to extend the leg, the spasm returns. If the extension be gradually insisted upon, it often happens that when the extension is nearly complete, the spasm suddenly completes it, as the spring acts on the blade of a pocket-knife, whence the name " clasp-knife " rigidity. Mental imhecility is not so serious as in spastic diplegia or even as in infantile hemiplegia, and may be entirely absent, especially in those cases resulting from premature birth. Diagnosis. — The distinction between spastic diplegia and paraplegia is not a very important one. The two conditions are probably the results of different degrees of similar lesions having different locations. There is an affection of children known as pseudoparalytic rigidity, idiopathic contrac- tion with rigidity, or tonic contraction of the extremities, with which it is sometimes confounded, but the following table of differences from Osier's monograph will aid in separating the two conditions. PSEUDOPARALYTJC RiGIDITY. Spastic Paralysis ; Diplegia and Para- plegia. Follows a prolonged illness. Is often as- Usually exists from birth. Histor}^ of sociated with rickets, laryngismus difficult labor [or of premature labor], stridulus, and the so-called hydro- of asphyxia neonatorum, or of con- cephaloid state. vulsions. Begins in hands and feet as carpopedal Arms rarely involved without legs and spasm ; often confined to hands and not in so marked a degree, arms. Spasms painful and attempts at extension Usually painless, cause pain. Intermittent and of transient duration. Variable in intensit5^ but continuous. The spasm in the pseudo cases is altogether more severe and difficult to overcome. The disease is associated with rickets and other constitutional diseases. Tetany is characterized by a different history and causation. Bilateral rigidity may also be produced by tumors of the pons and cerebellum. Treatment. — The treatment varies with the stage existing at the time the physician is called. If in the stage of initial convulsion, there is no remedy like chloral, which should be given in doses sufficient to control the fits. In the mild degrees, or with a view to keeping up an effect first obtained by chloral, the bromids may be used. If chloral fails, chloroform may be inhaled. In established paralysis medicines do not avail much and recoveries are rare. Hygiene and good food, gymnastics, manipulation, massage, passive motion, and surgical appliances may be used. Baths and electricity should not be forgotten. The epileptic convulsions should be treated as when occurring under other conditions, though the cortical lesions occasioning the disease preclude any expectation of permanent relief. Operative procedure has been sug- SCLEROSIS OF THE BRAIN AND SPINAL CORD. 1069 gested in certain selected cases and carried out, but with results which have been disappointing. The mental deficiencies are best treated in an institution for feeble- minded children, where all such cases should be taken, whatever the circum- stances of the parents. SCLEROSIS OF THE BRAIN AND SPINAL CORD. IMuLTiPLE Sclerosis of the Brain and Spinal Cord. Synonyms. — Insular Sclerosis; Disseminated Nodular Sclerosis; Sclerose en plaques. Definition. — A chronic affection of the brain and spinal cord, consisting in the presence of numerous sclerotic patches scattered through the nerve centers, characterized especially by intention tremor, scanning speech, and nystagmus. Etiology. — Its precise cause is unknown. The infectious diseases, especially scarlet fever, are alleged causes ; so are cold, exposure, mental emotion, and syphilis, but without definite foundation. Hereditars' predis- position has been noticed. The disease is more common between the ages of eighteen and thirty-five, though Striimpell met a case which came to autopsy at sixty. Both sexes are equally subject. Prichard states that more than fifty cases have been reported in children, but it is doubtful whether the diagnosis was invariably correct. It has been thought that the disease depends on anomalies of the vessels, but this view is not held by all. Morbid Anatomy. — The sclerosed patches are widely scattered through the brain and cord, rarely in the cord alone. They may generally be recognized by their gray color and unnatural firmness. On section, they appear as grayish-red areas. Histologically they consist of thickened neu- rogHa traversed by a few healthy nerve-fibers. In the vessels there is an increase of the nuclei and, later, a thickening of the walls. Fatty granular cells are present in fresh cases. Many of the axis-cylinders are preserved in the sclerotic patches for quite a long timie after destruction of the medullar}- sheaths. The favorite seats of the plaques in the brain are the centrum ovale, the walls of the lateral ventricles, the corpus callosum, and the cerebellum ; while they are quite numerous in the pons, less so in the medulla oblongata, but numerous in the cord, especially the white substance. The cortex is not often invaded. Symptoms. — By no means every case of multiple sclerosis can be recog- nized, so often are the symptoms united with those of other lesions whose effects predominate, while the slowness of the onset necessitates delay in the recognition of even typical cases. Typical cases do, however, occur, and they present a set of symptoms whence their recognition is more or less easy. One of the most important of these symptoms is tremor, known as " intention tremor," because associated w'ith any voluntary effort to perform an act, as picking up an object, raising a glass of water to the lips, or appos- ing the ends of the fingers of the two^hands. This does not prevent the ulti- mate attainment of purpose. When the patient is quiet, the tremor ceases, and in this respect it can be differentiated from the trembling of paralysis agitans. It is not confined to the arms, but occurs also in the head and trunk, I070 DISEASES OF THE NERVOUS SYSTEM. so that the head trembles when it is raised from the pillow. It is increased by excitement. Another characteristic symptom is what is known as scanning speech, a slow, measured, yet indistinct and obscure utterance, depending upon dis- turbances in the innervation of the tongue and larynx, probably due to the presence of sclerotic patches in the pons and medulla oblongata. There may be tremor in the tongue and lips when speaking. The third symptom is nystagmus — oscillatory or lateral movements of the eyeball when the eyes are directed to an object. In addition there may be spastic symptoms mani- fested chiefly in the presence of increased reflexes — including periosteal as well as tendon reflexes — in both upper and lower extremities, but the skin reflexes remain normal. There is ankle clonus, and the gait is often spastic. Paresis, at first absent, ultimately appears, amounting at times to complete paralysis. Indeed, spastic rigidity and paresis may be among the earliest signs of the disease. The sphincters remain intact, at least until toward the close. There are no disturbances of sensibility in the majority of cases. Optic atrophy is sometimes present, less commonly than in tabes dorsalis, and associated with such derangements of vision as amblyopia, achroma- topsia, and even blindness. Optic neuritis may occur with subsequent atrophy, especially in the temporal halves of the optic nerve. There may be also derangements of innervation with diplopia. Mental iveakness and imbecility are sometimes present, more rarely melancholia or exaltation. Apoplectiform attacks also occur, following pro- dromal symptoms, such as vertigo and headache, and succeeded by hemi- plegia, which, howev.er, subsequently disappears. Diagnosis. — This is not difficult in typical cases. The intention tremor, the scanning speech, and nystagmus are characteristic, and when associated with spastic weakness, the diagnosis of multiple sclerosis is probably correct. The apoplectiform seizures and mental weakness are also valuable signs. When the symptoms are mixed with those of other nervous lesions, diagnosis is not so easy. In paralysis agitans tremor occurs during rest as well as motion ; in multiple sclerosis only when motion is attempted. Striimpell says : " The circumstance, indeed, that the anomalous cases will not properly fit the molds of any other form of disease should make us think of the pos- sibility of multiple sclerosis." The disease known as pseiido sclerose en plaques, described by Westphal, seems to have most of the symptoms of multiple sclerosis except nystagmus. The tremor movements are said to be more violent. Striimpell has found slight degneration of the pyramidal tracts in a few cases of this kind. Prognosis. — This is unfavorable after a long and tedious course, termi- nating in the bedridden state. Treatment. — This is unavailing. The end may be delayed by galvanism and tepid bathing. DEMENTIA PARALYTICA. Synonyms. — Chronic Diffuse Meningo-encephalitis ; Paretic Dementia; General Paresis; Progressive General Paralysis of the Insane. Definition. — A chronic progressive meningo-encephalitis, or meningo- rachitis, with resulting mental and motor derangements, terminating in dementia and paralysis. DEMENTIA PARALYTICA. 1071 Historical. — Boyle in 1822 and Calmeil in 1826, by their descriptions, first sepa- rated paralytic dementia from other diseases which run a like course. The minute anatomical changes lying at the bottom of the symptoms are a matter of compara- tively modern study, and have received valuable contributions from Bevan Lewis and others. Etiology. — At least 75 per cent, of all cases are caused by syphilitic infection, and observations reported by Krafft-Ebing seem to indicate that the proportion is much greater. Starting out with this assumption, we have at once an explanation of its greater frequency in the male sex, though many women have it ; while it is rather a sad commentary on the fidelity of man that it is much more frequent among married men. The fact that it occurs most frequently between the thirtieth and fiftieth years, that it is a disease of the better classes, — especially anny officers and artists, — and that it is pre-eminently a disease of the cities, should be added. Although other factors apparently enter into the causation of general paresis, those who have most closely studied the subject are disposed to assign to them a predispos- ing role. Such influences are heredity and exhausting mental work, such as comes of public political life and ambitious financial ventures. Intem- perance, chronic lead poisoning, and traumatism are included among causes. Morbid Anatomy. — An atrophy of the brain, and especially of the frontal lobes, may be set down as the m.ost important morbid change. The convolutions are wasted and pale in color, the fissures are wider, and the weight of this portion is reduced to one-fourth or one-third the normal, while the consistence is finricr and more resisting to section. Other macroscopic changes are a thickening of the dura mater, pachymeningitis interna, edema of the pia with thickening, opacity, and adhesion to the cortex. Minute examination of the cortex recognizes thickening of the vessel-zvalls and cel- lular infiltration of the adventitia of the arterioles and lymphatic sheaths — in other words, the effects of mild inflammation. To these are added demon- strable destruction of nerve elements, especially of the fine medullary nerve fibrils known as " tangential fibers " in the frontal convolutions, island of Reil, and elsewhere ; also atrophy of the ganglion cells. Associated with this are neuroglia or proliferation and numerous Deiters' spider cells. Here enters a contested question as to whether these nerve changes are primary or secondary to an interstitial encephalitis. Tuczek, Wernicke, and Striim- pell hold to the former view ; while Rindfleisch and Mendel adopt the latter, making the destruction of nervous tissue secondary to the overgrowth of neuroglia. The white matter is also involved, the central ganglia as well. Coin- cident changes in the spinal cord, — first described by Westphal, — consisting in fascicular systemic degeneration of the lateral columns and posterior columns, either alone or jointly, are quite constantly present. To these is ascribed a large part of the ataxic and spastoparalytic S)-mptoms. From this brief statement of the character and situation of the morbid changes it will be seen that they are widespread in their distribution through the nervous system, while they are also degenerative. Symptoms. — So widely scattered a distribution of morbid phenomena naturally brings about corresponding differences in the variety and degree of the symptoms. As further characteristic, no absolute constancv is ob- served in the order of their development. As a rule, however, the first stage is characterized by abnormal mental processes, and these are at first what may be comprehended under the single expression peculiarity or " queer- I072 DISEASES OF THE NERVOUS SYSTEM. ncss " of conduct. The patient will perform acts wholly unnatural to him, and will surprise his friends and family by breaches of decorum and morality. An apathy and loss of memory, causing the omission of obligations, are also constant. At first these may pass unnoticed as temporary, but their per- manence is gradually established. In lieu of this may be present an irri- tability and intense restlessness, so that the patient cannot remain in one spot, but walks constantly to and fro. Not often in this stage is there much volubility, but rather a morose silence is observed. In this stage, too, the patient may make rash and ruinous financial ventures, and lose his own money and that of his friends, or he may become very generous, ^giving away freely all he possesses, and more, too. The power of arithmetical calculation is defective or gone. He may be self-satisfied and intensely egotistical. On the other hand, he may be conscious of these ills and be anxious about them, as well as experience a discomfort or malaise, for which he may consult the physician. Nor are motor disturbances wholly wanting in the first stage. They arc chiefly derangements of speech and handwriting, and are of no small diag- nostic value. The speech is slow and hesitating, yet the patient stumbles over syllables, especially when the word is complex or rather difficult to enunciate. As to the handwriting, it is tremulous, characterized by the omission of letters and substitution of wrong ones, as well as erroneous spell- ing — all motor defects. Other symptoms of the first stage are inequality of the pupils, ocular paralysis, and absence of patellar reflex, in tabetic cases often reflex immo- bility of the pupils, and in spastic cases increase of reflexes. There may be neuralgic pain and attacks of migraine. The second stage is characterized by more exalted mental symptoms and excitement, with a higher degree of motor disturbance. The former consist in exaggeration of all previously maintained mental symptoms, amounting to noisy, boisterous, and maniacal excitement, and even uncontrollable violence. In this stage belong, too, those extraordinary delusions of grandeur — expan- sive delirium — in which the patient imagines himself or herself to be a per- son of great consequence and unlimited wealth. This is not, however, in- variable, and there may be an exaggerated degree of the opposite condition of melancholy sometimes present in the first stage, or the two conditions of delirium and depression may alternate or may be absent. Sleeplessness may be added to restlessness and mental excitement, causing rapid decline of strength. Motor disturbances are greatly increased in this stage, but a uniform order of invasion is by no means always observed, while remissions and tem- porary improvement are often noticed. Speech becomes almost impossible and incomprehensible. There is paraphasia — persistent repetition of words — and reading and writing are impossible. The voice can no longer be modulated, and is weak and rough from imperfect innervation of the vocal cords. The gait becomes defective, and. the patient often trips in walking. There may be ataxia and other tabetic symptoms ; apoplectic seizures with paralysis; or epilepsy with grand or petit mal and aura, sometimes one-sided and followed by monoplegia or hemiplegia. There may be loss of sensihility, with bladder and rectum paralysis. The tendon reflexes may be lost and the pupil be immobile, or the opposite condition of spasm with increased tendon reflexes prevails. The paralytic attacks may occur in the earlier stages. DEMENTIA PARALYTICA. 1073 though in mild degree, manifested by vertigo or obscuration and loss of consciousness, lasting for a short time and then passing away. There may be local twitching in the face and extremities and even typical Jacksonian epilepsy. Finally, biilbar symptoms may appear with invasion of the medulla oblongata. Ultimately, the patient becomes helpless, bedridden, and completely demented, dying from exhaustion or intercurrent disease. In a few cases none of the mental symptoms described are present, but a gradual decline of mental power takes place until complete dementia super- venes. An acute variety is also sometimes met, properly termed " gallop- ing," in which the disease runs its whole course in a few months, and is especially characterized by emaciation and rapid loss of strength due to restlessness, sleeplessness, and insufficient food. The pulse and temper- ature are essentially normal, or at least there are not characteristic varia- tions. Diagnosis. — To recognize paretic dementia ab initio is perhaps impos- sible, but to watchful observation the disease commonly reveals itself after the symptoms have existed for a short time. The early symptoms resemble those of neurasthenia, but dififer from those of the latter disease in their steady progression. Other affections possibly mistaken for it are cerebral syphilis, tumors of the brain, and multiple sclerosis. In cerebral syphilis the onset is usually more sudden, and paralytic symptoms appear earlier. Headache is more frequent and severe, and there may be convulsive seizures, but affections of the tongue and speech are wanting, while the train of men- tal symptoms is less complete and characteristic, and expansive delirium, as a rule, does not occur. The epilepsy is more commonly Jacksonian. It is to be remembered that the syphilitic virus produces both, and it is not unnatural that the two should sometimes merge. Tumors of the brain frequently, but not always, produce symptoms more localized, and often also optic symptoms, including choked disc. The symptoms of insular sclerosis, which include dementia, are often identical with those of paralytic dementia, and the two diseases cannot then be differentiated. Intention tremor is more character- istic of sclerosis. The cerebral symptoms of some forms of plumbism, it is said, also sometimes closely resemble those of paralytic dementia. Prognosis. — The prognosis is almost always unfavorable, although the course of the disease varies somewhat. The most rapid cases of the gallop- ing form may terminate in a few months, but two or three years is the more usual duration ; sometimes much longer, it may be ten years or more. Death ensues from exhaustion, hastened by the complications and secondary condi- tions which naturally supervene on an illness so prolonged and in which nutrition is so interfered with ; or it may be due to intercurrent disease. Treatment.— In view of the general acknowledgment of the syphilitic origin of chronic diffuse meningo-encephalitis and the acknowledged effi- ciency of antisyphilitic treatment over tertiary manifestations of the disease, it is rather surprising that attempts at curative treatment are so futile. The treatment is confined mainly to iodids and mercurials. Mercurials are best used by inunction, and the iodids in ascending doses. These, however, do not arrest the disease. As to the rest, treatment m.ust be symptomatic. The bromids and chloral, with quiet, hygienic svirroundings, and sometimes enforced retire- ment, are measures demanded for the relief of the nervous excitement. For the opposite condition of depression and melancholia change of scene by travel and residence in different localities should be enjoined. 68 10/4 DISEASES OF THE NERVOUS SYSTEM. Further than this the use of a proper hygiene, with bathing, frictions, whole- some outdoor hfe, and an abundance of nourishing and easily assimilable food constitute about the sum of the means we can bring to bear against the disease. TUMORS OF THE BRAIN. Synonyms. — Ncoplasniafa cerebri; Intracranial Tumors. Definition. — Cerebral tumors, clinically considered, include not only tumors of the meninges and substances of the brain, but also all intracranial and even such extracranial tumors as ultimately invade the brain. Among the latter are tumors of the orbit or nasal cavity, of the antrum, and of the sphenopalatine fossa. Varieties. — The principal varieties of cerebral tumor, approximately in the order of frequency, are : I. Tyroma, or tubercular tumor. 2. Glioma. 3. Sarcoma. 4. Car- cinoma. 5. Cystic, including parasitic cysts and cysts arising in sarcomata and gliomata. 6. Gumma. 7. Histioid tumors. After these occur in irregular order, cholesteatoma, lipoma, myxoma, angioma, fibroma, psam- moma. Even dermoid cysts, as well as parasitic cysts — including the echinococcus or hydatid cyst — and the cysticercus cellulosse, are met. Of these tumors, psammoma and glioma are peculiar to the brain. According to M. Allen Starr's tables, gliomata and gliosarcomata practically equal in number the sarcomata, but the term gliosarcoma is regarded by many unfavorably. Etiology. — Except sarcoma, tumors are found in males more frequently than in females. Tubercle is more common in childhood ; parasites, glioma, sarcoma, and gumma in early and middle life, and cancer in middle and late life, but is rare even then. Brain tumors of any kind are rare after sixty. Heredity appears to have slight, if any, influence. A few brain tumors are metastatic, especially carcinoma, and to a less degree sarcoma. Eichhorst relates several remarkable cases in which trauma seemed to be the exciting cause. Certain tumors seek by preference special localities. Thus, tuberculous tumors are most numerous in the cerebellum and about the base of the brain. Glioma starts from the neuroglia in any part of the brain, but more frequently the cerebrum, and may also attain a large size — larger than any other brain tumor ; it is further characterized at times by its great vascularity, leading sometimes to rupture ^and apoplectic symptoms. Glioma may also occur in the eye. Sarcoma develops also most frequently in the membranes of the brain and sheaths of the vessels ; it may be primary or secondary ; it is often encapsulated. Myxoma and fibroma occur in the same localities. Carcinoma is usually secondary, but may be primary ; it arises more fre- quently in the membranes, but may be found in the substance of the hemi- spheres ; it is especially secondary to primary cancer of the breast, lungs, or pleura. Syphilorda elects the hemispheres or the pons and vicinity ; it is generally superficial, grows from the meninges, or is attached to arteries, attaining sometimes a large size. It may be multiple. Parasitic tumors are found in the membranes, the substance of the brain, and the ventricles. The hydatid cysts developed by the echinococcus are usually on the surface of the brain; the cysticercus, usually multiple, on the surface or in the ventricles. TUMORS OF THE BRAIN. 1075 Psammonia, or sand tumor, is found commonly in the neighborhood of the pineal gland. Symptoms. — The symptoms of cerebral tumor are in no way special- ized by the kind of tumor present, and depend entirely upo'H the effect exerted on the surrounding brain substance, chiefly by pressure. They do, however, vary somewhat with the part of the brain involved. It occasion- ally happens that a brain tumor may produce no symptoms whatever, being thoroughly latent, and disclosed only by the autopsy. On the other hand, apparently insignificant tumors cause very decided symptoms. Such differ- tnces may depend in part on the location of the tumor, and in part on the rapidity of its development. As in all local diseases of the brain, two sets of symptoms usually present themselves: (i) Diffuse and (2) Focal symptoms. I. Diifuse or General Symptoms. — These are symptoms which may be associated with various forms of nervous disease. The most constant of these is perhaps headache, which varies in intensity and constancy. Prob- ably the severest headaches it is given human beings to suffer are caused by brain tumors, exhibiting every variety of pain — sharp, cutting, shooting, boring, or dull and pressing. At times it is moderate, producing a sense of discomfort only. It may be intermittent or constant. It may be over the entire head, or half of it, or be still more localized in the forehead or back of the head, extending also from the former over the face and the latter down the neck. It may be increased by mental excitement of any kind, by noise, or by alcoholic drink or strong light. There may be tenderness on pressure, or pain in percussing the head. The seat of pain is, however, for the most part, no indication of the seat of the tumor, though the presence of pain limited to the occiput and back of the neck suggests a tumor in the posterior fossa of the skull, the occiput, or the cerebellum. Localized pain on tapping the skull is a more reliable index. Vomiting is another characteristic symptom of brain tumor. It may occur independent of headache, but is often associated with it. It is further characterized by being independent of food ingestion, may be without nausea, and is apt to be worse in tumors of the cerebellum and pons. Dizziness is also a very frequent symptom, and often an early one. It is at times intermittent, at others constant, and it may be so severe as to make it impossible for the patient to walk. It is most serious in tumors of the posterior fossa and of the cerebellum. Along with vertigo may be slozv- ing of the pulse. Mental symptoms may be present. They may be intermittent, and vari- ously manifested in peculiarities of temper, such as sullenness, indifference, absent-mindedness, and loss of memory; or the opposite condition of maniacal excitement or delirium ; or there may be drowsiness and even coma. Such mental states may, indeed, be the only manifestations of tumor. Speech. — The patient may talk slozdy, and the facial expression is some- times altered. Apoplectic seizures and epileptiform attacks, especially of the Jacksonian variety, are distinctive symptoms. The former may be due to hemorrhages in the tumor or around it, and may be followed by transitory paralysis and paresis. Epileptic convulsions, especiaUy if unilateral, point, though not unmistakably, to tumors in the hemispheres impinging on the cortex. Choreiform, movements are sometimes present. Choked disc or papillitis and optic neuritis are the most constant and io;6 DISEASES OF THE NERVOUS SYSTEM, most valuable diagnostic symptoms of brain tumor. Choked disc consists, in brief, in a swelling of the optic nerve, with overdistention and congestion of the retinal veins, and narrowing of the retinal arteries. It is usually bilateral, rarely unilateral. There is still much difference of opinion as to the mechanism of choked disc, but it is thought by many to be the result of intracranial pressure forcing the cerebrospinal fluid from the subarachnoid space into the lymph sheath of the optic nerve, causing compression of the nerve and the vessels within it. The vision is not necessarily deranged in choked disc, and its defects are not uniform, varying from slight amblyopia to total blindness. The swelling may diminish and improvement in vision ensue, but retinitis or neuroretinitis may set in with consequent nerve atrophy, producing permanent impairment of vision. The choked disc is sometimes the only symptom, of brain tumor, and its subject first consults the oculist for relief. On the other hand, it is not caused by brain tumor alone, but it may result from meningitis or abscess, in fact anything which produces intra- cranial pressure. Optic neuritis occurs in from 80 to 90 per cent, of all cases of intracranial tumor. It may be absent, even though a brain tumor of con- siderable size exists. The senses of s:neil and hearing may be impaired by tumors impinging on the olfactory or auditory nerves, and there may be pruritus and other modifications of cutaneous sensibility ; also neuralgic pains. If the tumor is on the floor of the fourth ventricle, there may be polyuria and glycosuria. Finally, sooner or later the appetite may fail and the nutrition suft'er, although the opposite condition of large appetite and good nutrition may obtain. In the terminal stage there may be irregularity of breathing (Cheyne-Stokes) and slowing of the pulse, while the final issue is often pre- ceded by a febrile movement. The local temperature in brain tumor is usu- ally raised from 92° to 95° F. (33° to 34.9° C), and even 98° F. (36.7° C). 2. Focal Symptoms. — These are symptoms peculiar to the seat of irrita- tion or destruction, and become, therefore, of value in diagnosis. They are the results either of irritation or destruction of nervous tissue, irritation caus- ing contraction and spasm, while destruction causes paresis and paralysis. For convenience in localization the brain may be divided, as in Fig. 132, after C. L. Dana, into: 1. The prefrontal area, including all anterior to a line starting from ihe upper end of the ascending branch of the fissure of Sylvius at right angles to another drawn between the frontal and occipital ends of the brain. 2. The central region, bounded in front by the line just named and behind by a line limiting the posterior central convolution prolonged down- ward to the Sylvian fissure. ^ 3. The parietal lobe, 4. The occipital lobe. 5. The temporal or temporosphenoidal area. 6. The pons and medulla oblongata. 7. The cerebellum. The boundaries of these territories are shown, as far as possible, in the accompanying illustration. In addition there are: (8) The corpus callosum; (9) the great basal ganglia and capsules ; ( 10) the corpora quadrigemina, and pineal gland ; (11) the crura cerebri ; (12) the base of the brain. I. Tumors of the prefrontal area, especially on the right side, often give no localizing symptoms whatever, motor or sensory, w^hile general symptoms TUMORS OF THE BRAIN. 1077 may also be absent and the tumor truly latent. Then, again, general symp- toms may be well marked, including mental torpor and imbecility, childish- ness, irritability, and emotional phenomena. These symptoms are the same whichever si-de of the brain is affected. If the tumor extends downward into the inferior frontal convolution, it may cause aphasia ; or if backward, it may occasion irritative spasm or destructive paralysis. Involvement of the optic tract may cause hemianopsia and optic neuritis ; of the olfactory system, anosmia ; if the tumor invades the orbit, oculomotor paralysis and protrusion of the eye. Percussion tenderness may aid in localizing the tumor. 2. Tumors in the central or motor region may cause irritative lesions, resulting in spasm. If the tumor is in the upper third of this area, the spasm may begin in the toes, in the ankles, or in muscles of the leg ; if in the middle third, spasm beginning in the fingers, in the thumb, in the muscles 2. Localized spasms and epilepsy, with sensory aurse; local palsies, slight an- esthesia, motor aphasia, agraphia. I. No symptoms or mental dull- ness, irritability, chiidishness, lack of power of attention; later, motor spasms or paralysis, anos- mia, eye symp- toms. Percus- sion tenderness. Ascending limb of fissure of Sylvius. 3. No symptoms or mus- cular anesthesia, aprax- oculomotor ( third nerve) symptoms, word blindness. With deep lesions, anesthesia; if the lesion penetrates sufficiently deep, hemianopsia. 4. Hemian- opsia, word- blindness, and mind- blind- ness. 7. Cerebellar ataxia, vertigo, vomiting, forced movements, occipi- ,- tal headache ; later, zontalL./bulbar symptoms. = F.of S. 6. Crossed paralysis; of tongue and limbs bulbar palsy. Fig. 132. — Showing Focal Symptoms of Brain Tumor — {after Dana). of the wrist or shoulder ; if in the lower third, in the muscles of the face, the angle of the mouth, or tongue. In a word, the phenomena of Jacksonian epilepsy are present. All of these may be preceded or associated with sen- sory disturbance, such as numbness and tingling, and may be limited to one muscle group before extending to another, constituting the " signal symp- tom " of Seguin. There may be an aura, and the muscular sense is also sometimes affected. Destructive lesions cause paralysis, and this may have the same dis- tribution as the convulsions which sometimes precede. If on the left side in right-handed persons, aphasia and agraphia may result. 3. Tumors of the parietal area may produce no symptoms or sensory and motor phenomena, but there may be impairment of stereagnostic percep- tion. With the involvement of the angular gyrus and lower parietal lobule I078 DISEASES OF TEIE NERVOUS SYSTEM. may come word-blindness and mind-blindness. If the tumor is upon or near the central area, spasms and paralysis of the various muscular groups described under 2 may develop. Paralysis of the third nerve has occurred in connection with tumors in the neighborhood of the angular gyrus ; no satis- factory explanation for this has been offered — possibly it is due to pressure at a distance. 4. Tumors of the occipital lobe, if in the cuneus or neighboring parts, may produce homonymous hemianopsia ; and if double, total blindness ; if elsewhere on the left side, there may be mind-blindness ; and if the tumor extends also into the angular gyrus, word-blindness, along with hemianopsia ; if obtruding further forward into the parietal lobe, hemianesthesia, hemia- taxia, and perhaps some hemiplegia from involvement of the internal capsule may occur. 5. Tumors of the ternporosphenoidal area on the right side rarely pro- duce symptoms ; on the left side, in the posterior part of the first and upper posterior part of the second gyrus, they cause word-deafness. Disturbances of the senses of smell and taste may result from involvement of the hippo- campal convolution. 6. Tumors of the pus and medulla oblongata produce two sets of phenomena : (a) Irritation or destruction of fibers in the pons and medulla oblongata. (&) Pressure on the nerves emerging in this region. Either may occur alone or both jointly. Lesions here are especially apt to produce alternate paralysis : that is, involvement of the cranial nerves on one side and the limbs on the opposite side. If the tumor is in the cerebral peduncle, there may be a palsy of the third nerve on the same side and a hemiplegia on the opposite side ; if lower down and in the pons, a palsy of the fifth on the same side and hemiplegia on the other ; if still lower down, it may involve the sixth nerve, producing internal strabismus, the seventh producing facial paralysis, and the eighth causing deafness. If the tumor is very large, it may produce a hemian- esthesia as well, and there may be forced movements of the body, either toward or from the side of lesion. Conjugate deviation of the eyes away from the side affected may also occur. This is in direct contrast to the conjugate deviation sometimes noticed in cerebral lesions, in which the head and eyes are turned toward the side of lesion. Tumors of the medulla oblongata may produce hemiplegia and hemi- anesthesia, and, if the tumor is large, symptoms of bulbar paralysis. From irritation of nerves on the same side, the ninth, tenth, eleventh, and twelfth, ■difficulty in swallowing, irregular action of the heart, irregular breathing, and vomiting may arise. Sometimes also there is retraction of the head, or sensory symptoms including numbness and tingling and finally convulsion. If the cerebellum is impinged upon, there may be unsteadiness of gait. 7. Tumors of the cerebellum produce very characteristic symptoms, though here, too, there may be latency if the growth is limited to the hemi- spheres. If the middle lobe is invaded, vertigo, vomiting, headache, optic neuritis, and choked disc, with blindness and cerebellar ataxia, are present. Optic neuritis is more common in cerebellar than in cerebral tumors. The pressure causing choked disc is not directly on the occipital lobe or optic tract, but is generally on the cranial contents, and possibly interference with the circulation of fluid in the ventricles causes pressure on the optic chiasm l»y means of an excess of fluid in the third ventricle. More rarely nystag- TUMORS OF THE BRAIN. 1079 mus and neuralgic pains in the neck and occiput occur. The irregular and staggering gait of cerebellar ataxia is very striking, the patient reeling like a drunken man, or he may be thrown sideways or forward, rarely backward, by forced motion. If the medulla oblongata is compressed by the tumor, vomiting from this cause may ensue, also bulbar symptoms and glycosuria. 8. Tumors of the corpus callosum are rare. The symptoms are similar to those of tumors in the third and lateral ventricles of the brain, extending peripherally. They cause general symptoms of brain tumor, with gradually developing hemiplegia, and later paraplegia. With this there are mental dullness and drowsiness and indisposition to speak. The cranial nerves are not involved. 9. Tumors of the basal ganglia and the internal capsule produce symp- toms similar to those that occur in the corpus callosum. They are partly pressure symptoms. There is progressive hemiplegia, with which there is apt to be hemianesthesia. Sometimes there are choreic and athetoid move- ments if the tumor involves the optic thalamus and adjacent parts of the internal capsule. Tumors of the caudate nucleus alone, or of the lenticular nucleus alone, are generally latent ; so are those of the anterior three-fourths of the optic thalamus, except that choreic and athetoid movements referred to may be noticed, due to irritation of fibers of the internal capsule, or, as supposed by some, to irritation of the anterior cerebellar peduncle. Tumors in these areas are very likely to give pressure symptoms. A large tumor of the thalamus may involve the fibers of the optic radiation and cause hemian- opsia or sometimes hemianesthesia. This may be differentiated from hemianopsia due to lesions of the occipital lobe by the presence of the hemianopic pupillary reaction, in accordance with which a ray of light thrown on the insensitive part of the retina will not produce a reflex contraction of the pupil. Optic neuritis is apt to be an early symptom of tumors in this vicinity. 10. Tumors of the corpora quadrigemina usually involve the crura as well. They are characterized by inco-ordination, forced movements, and oculomotor palsies, to which may be added hemianopsia or blindness due to destruction of the primary optic centers ; the pupillary reflex is lost and there is nystagmus. 11. Tumors of the cms from involvement of the third nerve are espe- cially characterized by oculomotor paralysis on one (the same) side and hemiplegia on the other. Tumors of the crus are, however, rare. 12. Tumors of the base, if of the anterior fossa, produce symptoms much like those of tumors of the prefrontal area, adding, however, anosmia from destruction of the olfactory lobe ; while there may be also involvement of the optic and oculomotor nerves and of the orbital contents. Tumors of the middle fossa and of the interpeduncular space produce pressure on the optic chiasm with consequent neuritis and bitemporal hemianopsia, by which lesions of this area are distinguished from those in the anterior fossa. Diagnosis. — This consists first in the recognition of the presence of tumor from the general symptoms, and then the determination of its loca- tion in either hemisphere from the focal symptoms. The same symptoms may be produced by any agency cafusing pressure on these structures. Choked disc, which is so constant a symptom of tumor, may be caused by Bright' s disease, lead encephalopathy, and anemia. The albuminuria, hyper- trophy of the right ventricle, polyuria, and tube-casts usually help to recog- io8o DISEASES OF THE XERFOUS SYSTEM. nize the first. Other symptoms of lead poisoning indicate that disease, and the usual symptoms of anemia point to it. Meningeal thickeni)ig, hemor- rhage, aneurysm, and abscess may also produce pressure symptoms. The nature of the tumor may be determined in part by what has been said of the preference for certain localities and the age of the patient, and in part by the history, say of tuberculosis or syphilis or primary growths elsewhere. The surface temperature is of uncertain value in diagnosis. Death may be sudden, especially from growths near the medulla oblongata. It is usually the result of increasing pressure. The X-ray has recently been applied to the diagnosis of brain tumor with uncertain results ; a change in the percussion note over a tumor is also of doubtful value. Prognosis. — This is generally unfavorable. It is true that in some rare instances the brain tumors cease to grow after a time. \"arious observers find the ratio of removable tumors from 5 to 10 per cent. Of 1121 cases collected from different authors by M. Allen Starr in his article on " Tumor of the Brain "" in Dercum's " Xervous Diseases," 80, or 4.25 per cent., were regarded as operable, but four-fifths of all persons operated on perish. \\'hen due to syphilis, they may in some cases be melted away by mercurials and iodids. Calcification is a rare, but happy, temiination of tuberculous growths. The duration of tumor averages two or three years ; the extremes average from a month to many years. Treatment. — This is medicinal, hygienic, and operative. The first is limited in its purpose to the cure of syphilitic tumors and, perhaps, in a slight degree, to tuberculous. The astonishing effect of the mercurial and iodin treatment upon syphilitic new formations is nowhere so well shown as upon cerebral gumma. Unless syphilis can be excluded with absolute cer- tainty, the iodid of potassium should be given in any case in ascending doses, limited only by their effects. In the absence of syphilis the larger doses are not well borne. In addition, mercury should be used, at first preferably by inunction until the specific effect is produced, after which it may be discon- tinued, to be renewed as indicated. Instead of inunction, the bichlorid may be given internally in doses of 1-12 grain (0.005 gm.) three times daily, or until the physiological effects are produced. A\'hen the tumor is once under control, it is still necessary to keep up the treatment in such doses as experi- ence may determine to be necessar}-. Usually the iodid of potassium is suffi- cient for this purpose. When, however, the s}"mptoms of tumor disappear and remain absent many years under iodids, the diagnosis of tumor may be doubtful. On the other hand, I have a patient in whom for thirty years the disease has been kept in check^by a dose of sixty grains (4 gm.) a day, which must sometimes be doubled for a time. The evidence in this case seems as conclusive as possible, since following acknowledged infection there occurred secondary symptoms of syphilis, the full train of classic symptoms of brain tumor, including ophthalmic symptoms studied by an experienced ophthal- mologist. If mercury is necessary in this stage, the hiniodid may also be used in doses of from 1-24 to 1-12 grain (0.0025 to 0.005 gm.), as required, though I have not the confidence in it that I have in the separate use of the iodid of potassium and the bichlorid of mercury. In tyroma the usual constitutional treatment of tuberculosis by cod-liver oil, iron, and other tonics, with nourishing food and healthful indoor and outdoor life, is to be carried out. The usual remedies indicated to relieve pain are to be used, bromids, if necessary, in large doses, phenacetin, antifebrin, and antipyrin. and, if SUPPURATIVE ENCEPHALITIS. 1081 necessary, morphin. The ice-cap may be used, and, above all, leeching tried. The most magical effect is sometimes produced by free leeching, though it is unfortunately temporary. Other symptoms should be treated by appro- priate remedies. The hygienic treatment is of the greatest importance. Excesses of every kind should be avoided, alcohol should be rigidly excluded, as well as all sexual excitement and mental excitement of any kind, for the slightest incre- ment of blood in the brain may bring on a convulsion and cause death. Exploratory operation being much less dangerous than formerly, with the aseptic precautions of the present day, should be made whenever the tumor can be localized with any approach to accuracy. Although cerebral localization has been developed to a very high degree, it must still happen that we frequently fail to locate a tumor accurately. SUPPURATIVE ENCEPHALITIS. Synonyms. — Suppurative Iniiammation of the Brain; Cerehritis; Abscess of the Brain. Definition. — By encephalitis is meant inflammation of the substance of the brain as contrasted with inflammation of its membranes. What is spoken of as inflammation of the brain in popular parlance is really inflammation of the membranes of the brain, or meningitis. A literal application of the term is here intended. Etiology. — The causes of cerebritis are: (i) Traumatic; (2) an adja- cent focus of inflammation extending to the brain substance; (3) pyemia. Under traumatic causes are included blows upon the head and falls, more commonly those attended by fracture or punctured wound ; although it is not necessary that there should be even a scratch upon the skin. Under adjacent disease, whence extension of inflammation is especially frequent, is to be included caries of the petrous portion of the temporal bone due to disease of the middle ear or labyrinth, the most common of all causes of abscess of the brain. Disease of the orbit or of the nasal pas- sages is another focus of the same kind. The route of such a communica- tion may be through either the sinuses of the brain or the lymph paths. Pyemic abscess of the brain is rare. Causal foci are malignant en- docarditis, gangrene of the lung, chronic bronchitis with bronchiectasis, bone disease, suppuration of the liver, and the specific fevers, among which may be included la grippe. Encephalitis occurs most frequently between the ages of ten and forty, and about three times as often in the male sex as in the female. Morbid Anatomy. — Abscesses of the brain are usually solitary, though there may be two or three, or even more. The abscesses may be from one-half to three inches (i to 8 cm.) in diameter, rarely more, though an entire lobe has been involved. The abscess itself is a very interesting product. Unless very recent, it is surrounded by a distinct wall which is composed of three layers. The inner is smooth, made up for the most part of granular fatty cells. Outside of ^his is a layer of germinal tissue con- taining spindle cells and more perfect fibrillated tissue. Externally again is another layer of fatty cells. The pus within the abscess is usually green- ish-yellow in color and acid in reaction, while its corpuscles are distinctly io82 DISEASES OF THE NERVOUS SYSTEM. nucleated. The cone outside of the abscess is edematous, the cells are swol- len, sometimes disintegrated, with blood points scattered throughout, becom- ing sparser as the periphery is extended. The locality of the abscess is preceded by the condition known as red sojtening, which is often spoken of as the first stage of the inflammation, but it is most important to remember that red softening is not peculiar to abscess. It consists simply of brain substance broken down into a reddish, blood-stained pulp. In this substance are found fragments of nerve-fibers, drops of myelin, pus-corpuscles, and granular fatty cells. The termination of cerebritis is not always in abscess. It is barely possible, before the stage of abscess is reached, for a condition of yellozi' softening to supervene, and the so-called apoplectic cyst may be the final result, or even cicatricial tissue may develop. The cerebrum is involved four times as often as the ^cerebellum, the left hemisphere more frequently than the right, and the temporo-sphenoidal lobe more than any other. The cause has something to do with the location : Ear disease places the abscess in the temporal lobe or cerebellum ; if in the tympanum, the cerebrum rather than the cerebellum ; if the mastoid cells and labyrinth, the cerebellum. Symptoms. — ^^"hile inflammation of the brain is spoken of as acute and chronic, more strictly speaking it is rather primary and delayed, the symptoms of the so-called chronic form being essentially the same as those of acute cerebritis, but characterized by their late appearance after the cause \vhich precedes them. In acute cases the symptoms develop rapidly and may run their course in a few days, while in the forms known as chronic the symptoms are scarcely less rapid after they once set in, which may be weeks, months, and even longer, after the operation of the cause. These symptoms are the result of pressure, — direct or indirect, — of destruction of the brain substance, or of poisoning due to absorption of putrid matter. They are much the same as those of meningitis, with which, indeed, abscess is often associated, especially if there is injury. The most striking are headache, often severe and persistent; vomiting; vertigo; mental dullness, succeeded sometimes by delirium and sometimes by coma. Con- vulsions are often present, and are epileptoid in character. Optic neuritis is also one of the symptoms. There is usually fever, as shown by elevation of temperature. At other times the temperature is normal or subnormal. The pulse is usually slow — from sixty to seventy. The symptoms may set in with a chill after the latent period. The toxic symptoms are those usual to toxic states — viz., chill, irregular fever, prostration, emaciation, exhaus- tion. Paralysis in the form of hemiplegia sometimes occurs. The paralvsis, however, is not always hemiplegic, and may be limited to the arm and face, especially in abscess of the temporo-sphenoidal lobe, which may compress the internal capsule. If on the left side, there may be aphasia. Other cranial nerves beside the optic are sometimes involved. When the abscess is in the parieto-occipital region, there mav be hemi- anopsia. It is especially in abscess of the cerebellum that vomiting occurs, and staggering if the middle lobe is affected. Of the chronic form it has already been said that the symptoms, though long delayed, are the same as those of the acute form. Such delay, how- ever, does not always cover all symptoms, since during the latent stage the patient may have headache or vertigo in a mild degree, and especially may he be irritable and depressed, while he may even have a convulsive seizure SUPPURATIVE ENCEPHALITIS. 1083 during this preliminary period. It occasionally happens that there are n6 symptoms at all, and cases have occurred, more particularly of abscess in the frontal lobe, in which there were no signs or symptoms before death. Phlebitis of the superior petrosal and lateral sinuses is especially com- mon when the abscess is caused by disease of the ear, since the former re- ceives a vein from the internal ear, and the latter receives the mastoid veins. Edema about the car and neck and hardness of the jugular veins should sug- gest phlebitis, while rigidity of the neck and cranial nerve paralysis even more unerringly point to meningitis. Diagnosis. — This is easy in acute cases, being substantiated by the history of injury, rigor, and fever, followed by the brain symptoms described. Almost as certain is the diagnosis when such symptoms follow chronic ear disease or localized putrid lung disease. It is to be remembered, how- ever, that general cerebral symptoms may be produced by pus in the middle ear. These should be treated by puncture of the tympanum, and should the symptoms persist, after puncture abscess may be suspected. In like manner meningitis and abscess may be confounded, and with reason, because, in the first place, meningitis may be produced by the causes that produce abscess ; and, second, meningitis may be caused by abscess, and both may occur together. Meningitis, however, affects the cranial nerves more than abscess, unless the abscess is seated in the pons, and usually men- ingitis succeeds more promptly upon its cause. It is to be remembered that tumor of the brain may produce symptoms identical with those described. The chief distinctive symptom in abscess is the presence of fever. Prognosis. — This, unless we admit a curable form described by Striim- pell, is always ultimately fatal unless we have the rare good fortune to reach it with the trephine. Acute cases last from eight to fourteen days, rarely thirty days ; the delayed cases may not show their first symptoms for months. In the curable form referred to, Striimpell says pronounced symptoms of focal disease exist for a time and suggest a tumor, but after some months or even a longer time they gradually abate, and recovery is complete. The nature of the symptoms is such as to suggest a seat in the cortex, for there is usually paresis of some part of the body, often associated with symptoms of motor irritation and impairment of speech. Treatment. — A certain prophylaxis may be exercised in the proper treatment of disease of the ear, for it is often the neglect of this which leads to the abscess. Such prophylaxis includes measures which secure free dis- charge and antisepsis. Beyond this the only treatment for abscess which promises anything toward a favorable result is operation, on which account the surgeon should be promptly associated in the treatment of the case. The use of the trephine has saved a few cases. For the details of the oper- ation the student is referred to text-books on surgery. Encephalitis witout Abscess. — When, on the other hand, inflamma- tion of the surface of the brain accompanying meningitis is eliminated, and, on the other, softening of the brain, formerly thought to be the result of in- flammation, but now known to be due to the arrest of blood supply, a number of cases of encephalitis without abscess remain, in some of which a necropsy was obtained. io84 DISEASES OF THE NERVOUS SYSTEM. CHRONIC HYDROCEPHALUS. Definition. — A collection of serous fluid either between the meninges or in the ventricles of the brain. The former constitutes intermeningeal hydrocephalus, or hydrocephalus extenms, or hydrocephalus ex vacuo. The latter is ventricular hydrocephalus, or hydrocephalus internus. The seat of effusion in hydrocephalus externus may be either in the subdural space — i. e., between the dura mater and the arachnoid — or in the subarachnoid space. The first was formerly regarded as the most frequent ; later its- occurrence came to be denied, but more recently, by means of frozen brain sections, it has been demonstrated. Since the subarachnoid space communicates with the ventricles of the brain, the two forms of hydrocephalus may coexist. Both external and internal hydrocephalus may be diffuse or circumscribed. When circumscribed there result in the case of the former cystic spaces in the membranes, and in the latter vesicular distention of portions of the ventricles. External Hydrocephalus occurs in connection with atrophy of the brain, and is not of much clinical importance. Internal Hydrochephalus. This is divided into congenital and acquired. Congenital Hydrocephalus. — This pre-exists before birth, and may be present to such a degree as to retard the birth of the head. More frequently it is not recognized until some time after birth. Etiology. — This cannot be said to be certainly known. Virchow early ascribed it to inflammation of the ependyma; Rindfleisch rather to an ob- struction to the circulation in the choroid plexus. Drunkenness and syphilis in parents, and accidents in pregnancy, are held responsible ; occasionally, also, tumors of the brain. More than one child in a family is sometimes affected. Morbid Anatomy. — The head is characterized externally by its spherical shape and large size, its smooth eyebrows and protruding eyes,. the last being due to depression of the orbital plate of the frontal bone. It is often so great that the eyelids cannot close over the eyes. The size of the head thus obtained is often enormous — from eight to ten inches (20 to 25 cm.) in diameter in a child of three or four years. On the other hand, the face appears very small. On closer examination the cranial bones are found separated and exceedingly thin, at times almost as thin as paper. In the membranous interspaces are often found Wormian boues. The veins may be seen beneath the skin, and fluctuation may sometimes be obtained through the scalp. On incising the brain a variable quantity of limpid fluid passes out. The quantity is sometimes enormous, reaching twenty pounds (40 kilos) or more. The cerebral cortex is greatly thinned, the thickness on the convex- ity being reduced to but a few millimeters. The gyri and the basal ganglia are compressed, and the ventricles are dilated. The commissures are stretched and even torn. The foramen of Monro is a wide opening, and the third ven- tricle is dilated and sometimes also the fourth. Tlie ependyma is thickened,, the choroid plexuses are vascular, sometimes little changed. CHRONIC HYDROCEPHALUS. 1085 Symptoms. — These consist largely of the external morbid states just described, but in addition there is slowness of physical and mental develop- ment. The child learns to walk late and is very feeble and apt to be men- tally deficient, although it is sometimes bright. Convulsions may occur and the reflexes be increased. Diagnosis and Prognosis. — The rachitic head may be mistaken for the hydrocephalic, but the latter has not the broad forehead with prominent frontal eminences ; it is rather spherical and smooth. The congenital case rarely lives to be more than four or five years old, though it may attain adult life. Acquired Hydrocephalus. — Etiology. — This is also commonly ascribed to some inflammatory process, although it is said to be sometimes idiopathic. Especially is it a consequence of suppurative and tuberculous meningitis, when it is spoken of as acute acquired hydrocephalus, though chronic inflam- matory processes may also cause it. Derangements in the circulation in the choroid plexus a»d in the ependyma of the ventricles may, however, be responsible. Especially may a tumor in the third ventricle, at the base of the brain, pressing upon the venae Galeni or on the straight sinus of the dura mater, be a cause ; or closure of the foramen of Monro, by which the ventricles communicate with the membranous spaces. Even lung or heart affections and growths in the mediastinum and neck may produce the needed obstruction. Morbid Anatomy. — In cases of acquired hydrocephalus, even though beginning tolerably early in life, — say the seventh year, — as well as in adults, the skull does not necessarily expand, and the head may not enlarge. Indeed, the head may even be smaller than natural, as in cretins. In these instances the brain substance must yield, and is reduced in thickness, at times to a few millimeters only. In other cases the skull yields, its plates become thin, the fontanels grow larger, and an appearance like that of con- genital hydrocephalus may result. Symptoms. — The symptoms of acute acquired hydrocephalus are never distinctive, on account of the rapidity in the course of the disease which pro- duces and obscures it. Of chronic acquired hydrocephalus the most striking symptom is, as a rule, the marked distortion in the size and shape of the head already described. The weight of the head is sometimes so great that it inclines to fall to the side or backward or forward, and must be supported by the hands of the pa- tient. Other symptoms may, at times, be decidedly delayed, and the child may make some progress in studies. At times there is early headache. Signs of mental imbecility sooner or later make their appearance, manifested first, perhaps, — as in congenital hydrocephalus, — by absence of develop- ment, but progressing until the child lives an almost vegetative existence, having to be fed and cared for like an infant, even though several years old. There may be conznilsive contractions, tremors, ataxic gait, paresis, and paral- ysis; in fact, all the symptoms which succeed on irritative and destructive lesions of the nervous system. The symptoms of tumor of the brain may be quite closely simulated, especially when the cranium does not enlarge with the growing distention of the yentricles. There may be choked disc, atrophy of the optic nerve, and total blindness. There may be prolonged attacks of drowsiness, or coma, with slow pulse, while sudden death is not uncommon during epileptiform convulsions or apoplexy. io86 DISEASES OF THE NERVOUS SYSTEM. Spontaneous evacuation of the fluid sometimes takes place by the nose, mouth, ear, or orbit. Diagnosis.— This is commonly easy. It is only in cases in which the cranium does not expand that the symptoms of brain tumor may lead to a diagnosis of the latter condition instead of hydrocephalus. Prognosis. — This is usually unfavorable. Generally the child lives from two to five years, though it may perish in a few months or live for from ten to fifteen years, or, as in a case of Bright's, to twenty-nine years, or even longer. It has happened that spontaneous recovery has followed the evacuation of fluid previously described. The absorption of small amounts of fluid is also possible. Treatment. — This consists primarily in the treatment of the disease which is responsible for the hydrocephalus if it can be discovered ; sec- ondly, in the treatment of the symptoms which may arise, and next, in attempts to cure the malady. Some favorable results have followed the removal of the fluid by puncture of the ventricles, although there has been failure in the majority of instances. Measures should be taken to make the removal gradual, if possible, thus attempting to imitate the spontaneous efforts of nature, which have occasionally been followed by recovery. To this end the slow removal of the fluid — by puncture of the subarachnoid space between the third and fourth lumbar vertebrse^ias been recommended and practiced by Quincke. At this point, too-, the spinal cord is not very likely to be injured. It is more particularly in congenital hydrocephalus that operation is indicated. If operation is deemed undesirable, attempts may be made to get rid of the fluid by diuretics and purgatives, although with little prospect of success. lodid of potassium may be tried, with the faint hope that the hy- drocephalus is due to a syphilitic tumor which might thus be melted away. Blisters may also be applied. ACUTE DELIRIUM. 1087 GENERAL AND FUNCTIONAL DISEASES— NEUROSES. The term neuroses is applied to nervous affections in which there are functional disturbances corresponding to which there is no known anatomical lesion. ACUTE DELIRIUM. Synonym. — Bell's Mania. Definition. — An acute and violent febrile delirium of unknown cause and undetermined lesion, running a course of from two to three weeks, and usually fatal. Historical. — The disease was first described in 1849 by Luther Bell, of the McLean Asylum. Symptoms. — These set in suddenly and consist in violent, active deli- rium, in which the patient talks and moves incessantly, with a speech that is incoherent and unintelligible and movements which are aimless and irresist- ible or rhythmical as though with a purpose. This is kept up for hours and hours, notwithstanding the use of the most powerful anodynes, until the patient becomes exhausted, the whole presenting a picture which is at once revolting and pitiable. At times sleep is obtained for an hour or two, but immediately on waking the active movements and delirium begin. The rhythmical movements may be like those oi the salaam convulsions, up and down, as of one chopping wood or working a pump-handle. Throughout there is high fever, the temperature ranging from 102° to 104° F. (38.9° ta 40° C). The tongue is dry, the pulse rapid and feeble, the skin, in like manner, dry and often covered with petechial spots or pustules and bullae or bruises, the result of the violent acts of the patient. There seems, however, no pain, or tenderness other than is due to these causes. Morbid Anatomy.— As stated in the definition, there is nothing defi- nite. There may be venous engorgement of the meningeal veins and of the cerebral cortex, with perivascular exudation and cellular infiltration of the lymph sheaths and perivascular spaces. There is often engorgement of the bases of the lungs, and deglutition pneumonia has been found. Diagnosis. — At first the disease may be mistaken for any of the acute fevers which sometimes begin with violent delirium, especially for typhoid, but the course of the temperature and absence of other distinctive symp- toms soon eliminate any doubt. The same may be said of certain fonns of puerperal mania, and more rarely pneumonia of the meningeal type and of cerebral meningitis itself. The incessant violence is, however, peculiar to Bell's mania. Prognosis. — This is almost always fatal. Treatment. — This must consist of measures to control the mania, of which hypodermic injections of morphin are almost alone efficient, and these often only feebly so. Chloroform or ether must sometimes be em- ployed, because' of the dangerous doses of morphin which seem necessar>^ io88 DISEASES OF THE NERVOUS SYSTEM. Blood-letting has apparently been of service in some cases, and there cer- tainly is no contra-indication to it in the early stage of most cases, the patients being commonly very strong and vigorous. The cold bath may be employed, but is not an easy treatment to carry out, because of the difficulty in con- trolling the patient. PARALYSIS AGITANS. Synonyms. — Chorea scelotyrbe she festinans (Sauvages) ; Chorea pro- cur siva (Bernt) ; Shaking Palsy; Parkinson's Disease. Definition. — A chronic nervous disease characterized by muscular weakness, tremor, or shaking in the extremities, muscular rigidity, and for- ward-bent gait. Historical. — The disease was first fully described by Parkinson, of London, in 1817, so accurately that nothing of importance has since been added to his description. Etiology. — Shaking palsy is commonly a disease of the second half •of life, but occasionally occurs between thirty and forty, and has been ob- served as early as the twentieth year. It is a little less frequent among women than men — 11 to 14. Among the causes held responsible for it are exposure to cold and wet, fright, mental excitement, business worry, injury, — whether to nerves or other parts of the body, — alcoholism, sexual excesses, and the infectious diseases, including malaria, while heredity is said to have a certain influence. The etiology of the disease is largely a matter of con- jecture and inference. Perhaps exposure to cold is the best determined ■cause. Morbid Anatomy. — This is unknown so far as essential lesions are concerned. Various lesions have been described, while the brain, spinal cord, and peripheral nerves of the most typical cases have been examined with results not entirely satisfactory. As the phenomena are similar in kind, if not in degree, to those of senility, it is held by Dubief, Borgherini, Roller, Sass, Jacobson, Ketscher, and Sanders that they have for their anatomical basis the lesions of senility somewhat intensified, and differs from true senility only in its earlier onset. Most recent studies conclude that this is not the case, and that paral- ysis agitans is a disease siii generis, although there are many changes in the spinal cord, brain, and nervous system which are common to the two affec- tions, consisting essentially in increase in interstitial tissue and proliferation of neuroglia in the spinal cord, medulla oblongata, pons, and the motor cor- tex in a less degree. Charles L. Dana* says : " The most logical conclusion one can reach is that in paralysis agitans there is early a functional disturb- ance and later a destruction and degeneration of the dendrites of the anterior horn cells which interfere with the even flow of motor impulses, and finally lead to motor weakness and rigidity, owing to the cell being practically cut off from the brain." Dana continues : " The difference between this con- dition and that found m spastic paraplegia due to a sclerosis of the voluntary motor tracts is manifest, for there the dendrites of the anterior horns which subserve reflex purposes are normal, while in paralysis agitans all are some- Avhat affected. The rigidity of this disease is much like that found late after total transverse cord lesions." * "Paralysis Agitans and Sarcoma," " Am. Jour, of the Med. Sci.," November, 1899. PARALYSIS AGITANS. 1089 H. C. Gordinier,* on the other hand, says the primary seat of the pathological changes is in the blood-vessels, starting with an endarteritis and peri-arteritis and consequent proliferation of the neuroglia in the immedi- ate neighborhood, with the production of patches of perivascular sclerosis, which are characteristic of the disease. Also that " the alterations which have been observed in the nerve-cells of the anterior cornua and cranial nerve nuclei, together with the shght changes. in the cells of the motor cor- tex, are secondary, due, in all probability, to a gradual diminution of nutri- tion dependent on the vascular changes." The truth is, the pathology of this disease is unknown, and is at present a subject for speculation. Symptoms. — The disease is not a very rare one in this country, and the county almshouses almost always contain one or more cases — easily recognized by the characteristic shaking or tremulousness of the hand. Though commonly gradual in onSet, the symptoms may come on quite suddenly, and at first only after exertion. Indeed, there may even be a prodrome in the shape of neuralgic pains, paresthesia, dizziness, and the like. The more sudden cases follow fright or trauma. The tremor is most marked in the fingers and hands, where it commonly begins, and whence it extends to the arms and lower extremities. The upper arm muscles are rarely in- volved. It most frequently passes from the right arm to the right leg, thence into the left arm, and thence into the left leg ; or the course may be crossed — that is, from the right arm to the left leg. It may remain in one limb to the exclusion of the others. In the fingers the movement between the thumb and index-finger is frequently that of rolling pills, but the movement may not always be characteristic. At the wrist that of pronation and supination. In the feet it is most marked at the ankle-joint. It affects the writing, mak- ing it trembling, as in the aged, and ultimately it becomes impossible to write. The muscles of the head and face are last involved, sometimes not at all, and when present, the motion is vertical and quite rhythmical, usually about five times in a second. At first the tremor ceases during sleep, but continues during the waking state even when the muscles are at rest, but tiltimately it continues also even during sleep — in fact, sleep is sometimes prevented thereby. It frequently is partially arrested by voluntary motion and is increased by emotion. Should rigidity become excessive, the motion mav cease. The rate of tremor varies greatly, being at first slower, and increases in rapidity as the disease advances. Roughly, it may be put down at from three to five times a second. There may be intermissions of the tremor of days and even weeks. isiKq Muscular weakness is a less striking symptom, but may be estimated by the dynamometer, arid increases with the duration of the disease and the intensity of the tremor. It is most striking at least in the extensor muscles, the flexors being disposed to rigidity and spasm, which eatly produce a slowness and stiffness of motion which is characteristic. It is this flexor spasm which brings the thumb and forefinger into the writing or pill- rolling position. At other times, hyperaction of the interossei muscles over that of the common extensors of the fingers results in the position so char- acteristic of arthritis deformans — that is, with the first phalanx bent, the second extended, and the terminal phalanx also bent. Ultimately extension is impossible. Occasionally the opposite state of fixed extension exists^. -'•"''• * " The Pathology of Paralysis Agitans," December, 1899. 69 I090 DISEASES OF THE NERVOUS SYSTEM. The attitude and gait ultimately assumed by the subject of shaking- palsy are also the result of rigidity, which sooner or later affects most of the muscles. The head is bent forward, the back is bowed, the arms are held away from the body and flexed at the elbows, and the knees are approxi- mated so that they are often rubbed in walking; while the general appear- ance is that of a man in danger of falling forward. The position of the body due to flexion also gives rise to a " propulsive '' gait, caused by carrying for- ward the center of gravity, so that, when started, the patient is apt to " get a-going " and cannot stop until he comes up against some object. On the other hand, a push backward, bringing the centers of gravity behind the point of support, is apt to make the patient fall, because he cannot move back fast enough to save himself by " retropulsion." Charcot regards both these phenomena as " forced movements," but Striampell prefers to explain them by simple physical laws, as previously described. Sometimes the characteristic position of the patient exists without the shaking, and for this the name "paralysis agitaris sine agitationc " has been employed. The facial expression is also very strikingly altered. The face is indeed without expression, stiff and mask-like, giving rise to the name " Parkin- son's mask." There is often a dribbling of saliva from the partially closed mouth. On the other hand, sometimes the mouth is kept closed, and is found full of saliva — a condition ascribed to delaye-d deglutition rather than to increased secretion. The speech is slow, hesitating, and monotonous, and the voice may be piping and shrill. On the other hand, if the lips and tongue share in the tremor, the speech is stuttering, as though the patient were in a hurry to speak — quite different from the scanning speech of insular sclerosis. The remaining nervous and organic functions are essentially normal. Sensation is usually unaltered, and the bowels and bladder are unaffected, as. is also the temperature, although it is said that the surface temperature is sometimes elevated. Charcot has noticed an alteration of the temperature sense. There is sometimes a tendency to unnatural perspiration. Diagnosis. — This is usually very easy, and can generally be made at a glance. Multiple sclerosis resembles it in some respects. Both have tremor, but in multiple sclerosis this is shown more particularly when the patient attempts to do something, as to bring a glass of water to his lips or approximate his fingers. The speech is rhythmical, " scanning," instead of stuttering, as in shaking palsy ; there is nystagmus, and the disease begins almost invariably in the lower extremities, while the attitude is not that of paralysis agitans. Chorea is characterized by movements, but these are ir- regular and more intermittent.- Prognosis.— A well-established case of paralysis agitans is not curable by medicines. On the other hand, the disease lasts indefinitely, the patient getting slowly worse, with perhaps the intermissions alluded to, until he dies of some intercurrent disease or from the effects of some accident growing" out of his condition. Treatment. — Under the circumstances this must, for the most part, be by tonics and general hygienic measures. As the disease advances the patient should be guarded against accident; and especially when in bed his position should be changed for him if he cannot change it himself, as is often the case. Cases have improved under the use of the iodid of potassium and arsenic, and hyoscin has been especially recommended by Erb — hypoder- ACUTE CHOREA. 1091 mically, in doses of from 1-20 to 1-12 grain (o.cx)3 to 0.005 gm.) of the muriate. Good results have also been reported from the use of atropin, of which from i-ioo to 1-60 grain (0.00066 to o.ooii gm.) may be used sub- cutaneously or by the mouth. Measures calculated to improve the general health are indicated, such as sea-bathing, massage, electricity, fresh air, and outdoor life. Other Forms of Tremor. Synonym. — Ballisuius. In addition to the tremor in paralysis agitans, a similar tremor occurs under other circumstances, sometimes without assignable cause, when it is known as simple tremor, or it may be induced by fright or overexertion. A hereditary tremor has been described by C. L. Dana. Senile tremor is the well-known form of tremor which comes on with advancing years, at times earlier than others, but usually not until after seventy years. The existence of a tremor due to senility w^as denied by Charcot, but is accepted by most neurologists. Toxic tremor is due to a number of toxic agents, among which tobacco and alcohol are the most frequent. Lead is another of these causes. Finally, hysterical tremor occurs as a part of hysterical phenomena in women. As- thenic tremor is due to simple weakness, and is especially seen in exertion durinsf convalescence from acute disease. ACUTE CHOREA. Synonyms. — Chorea minor; Mild Chorea; Sydenham's Chorea; St. Vitus" Dance. Definition. — A disease chiefly of the young, characterized by irregular, involuntary muscular contractions, associated at times with psychical dis- turbance, often with rheumatism and endocarditis. The term chorea is derived from the Greek x^P^^oc, dancing. History. — The term chorea Sancti Viti was first applied by Paracelsus (1493- 1541) to an affection of a totally different nature, a sort of hysterical dancing mania which prevailed in epidemic form in the fourteenth, fifteenth, and sixteenth centuries in Germany and the Netherlands, for which the subjects sought relief by pilgrimages to certain shrines, among which was that of St. Vitus, in Zabern, whence the disease was called St. Vitus' dance. From other shrines it received other names, as St. John's and St. Anthony's dance. Chorea minor was first recognized by Sydenham in the sixteenth century, and was also called by him St. Vitus' dance, though a widely different affection from the St. Vitus' dance of Paracelsus. Etiology. — The disease, though not confined to children, occurs far more frequently among them, notably from the time of the second dentition — the sixth or seventh year — to the fifteenth year. More than three-fourths of the entire number of cases occur during this period. Among adults it is relatively more frequent from the fifteenth to the twenty- fourth year. Occa- sionally it occurs in old age, when it is known as chorea senilis. Chorea is about twice as frequent in the female sex as in the male. Heredity has always been an acknowledged factor in its causation, but is probably less sig- nificant than was once supposed. It has even been claimed that the disease is sometimes congenital in the ofiispring of a choreic mother. It is more 1092 DISEASES OF THE NERVOUS SYSTEM. frequent in neurotic families. As to temperament, it is well known that hig-h-strung, excitable, nervous children, as contrasted with the dull and phlegmatic, are especially liable to the disease. It is principally in these that overstudy is seen to have a predisposing effect. Psychical influences are undoubtedly potent ; thus, fright causes a large number of cases, while grief causes many, and even joy some. The so-called Huntingdon's chorea, which is hereditary, is not the same as Sydenham's chorea, although Charcot did not make this distinction. Sydenham's chorea affects children of all social grades, but is more common among artisans and the lower classes. It is rare in the ne^ro. Wharton Sinkler, who has especially investigated this point, has seen but one case in a full-blooded negro, while William Osier, at the Johns Hopkins Hospital, out of 175 cases found 5 in the negro race. It is apparently unknown among Indians in their natural state. The season of the year appears to have an undoubted influence. Morris J. Lewis, whose studies have been most thorough in this direction, finds that the fewest attacks occur in October and November and the greatest number in March and April. Hermann Eichhorst, on the other hand, says that the greatest number of cases occur in the autunin and winter months. The disease prevails more generally in towns than in the country. Imitation, commonly regarded as an exciting cause, has been shown by modern studies to play a less important role than was thought, many cases described as thus originating being .really hysteria. Trauma precedes a cer- tain number of cases. Reflex irritation, especially digestive disturbances, and intestinal worms were regarded as potent causes by the older observers ; but here again Osier's studies have failed to find any causal relationship. The chorea of pregnant women has been referred to this category. The causal relation of eye-strain to chorea has been emphasized by Stevens, but is practically denied by George de Schweinitz, who concludes, from an exami- nation of more than 100 cases, that, while ordinary chorea and many forms of facial spasm — habit spasm, etc. — are materially benefited by correcting refractive errors and anomalies of the ocular muscles, he does not believe there is any proof to show that eye-strain is of itself responsible for their origin, with perhaps the single exception of habit spasm affecting the orbicu- laris and adjacent facial area. It may be such chorea which Howard F. Hansell cured in Da Costa's clinic * by atropin, paralyzing the ciliary muscle and preventing the effort at accommodation until the habit was broken up. The association of arthritis and chorea was observed by the earliest students of the subject, and was distinctly recognized in England as early as 1802, but the exact causal relation of the two diseases has, perhaps, not yet been made out. That they are frequently associated and that there is close connection between the two affections is admitted by English and French writers, but the Germans find the association much less frequent. Steiner, for example, found only four cases of rheumatism in 252 cases of chorea. English observers find from 20 to 70 per cent, of cases of associated joint affection, while in this countr\', where rheumatism is apparently less frequent in children, the range of percentage found by various observers is from 15.5 to 54 per cent. That the arthritis precedes the chorea in a large number of cases is generally conceded, the latter disease developing with the subsidence of the former, or not until convalescence has been well established. Hence * Da Costa's " Medical Diagnosis," eighth ed., 1895, p. 221. ACUTE CHOREA. 1093 that the rheumatism is the cause of the chorea seemed at one time estab- Hshed, but recent views as to the probable infectiousness of rheumatism and the possible infectiousness of chorea changed the conditions. As the nature of the virus of rheumatic fever is unknown, it may be that chorea is caused by a similar poison. This theory is further sustained by the fact that the infectious diseases play an acknowledged role in the etiology of chorea. Scarlet fever, diphtheria, measles, typhoid fever, gonorrhea, secondary syphilis, puerperal fever, pyemia, multiple suppurative polyarthritis, have all been followed by chorea ; but with the exception of acute rheumatic poly- arthritis and some forms of septicemia, the number of cases thus associated is not large. On the other hand, acute exanthemata developing in the course of chorea usually check the disease. Anemia has been held to be a cause, and probably is a predisposing cause, although frequently also a result. In fact, the studies of Charles W. Burr and others go to show that anemia is less frequently associated with chorea than has been commonly supposed. The relation of hysteria to chorea is interesting from the close resemblance, at times, of the two conditions. It has already been said that the cases of so-called imitation chorea are often hysteria, and, on the whole, the asso- ciation of the conditions is rather coincidental than causal, but some cases may be truly imitation in children not hysterical. Poisons are acknowl- edged causes in a few instances. Carbon dioxid and iodoform are among those which appear to have caused acute attacks of chorea of short duration. Morbid Anatomy. — There is no definitely ascertained morbid anatomy for chorea, and the lesions which have been found are the result of the compli- cations or are incidental. The most constant of these associated lesions are endocarditis, in 85 per cent, of Osier's cases ; pericarditis, 26 per cent. ; com- bined heart lesions, 90.4 per cent. ; pneumonia, 12 per cent. ; less numerous were acute pleurisy, pyemia, and phlebitis, also noticed. As to the nervous system, the symptomatology would lead us to expect the essential lesions in the cortex of the brain, and C. L. Dana has analyzed the recorded autopsies, of which there were only 39 in which the state of the nervous system was accurately described. In 16 there were intense cerebral hyperemia, periarterial exudation, erosions, softened spots, minute hemor- rhages, and occasional emboli. The changes were most marked in the deeper parts of the motor tracts, particularly in the lenticular nuclei and the thalami. These changes are the same as those described by W. H. Dickm- son in 1876. Essentially similar were the lesions found in two of Osier's cases. In two reported by Bevan Lewis there was apoplexy, one cerebellar and one cerebral and extraventricular. The so-called chorea corpuscles described by Ellischer are in no way characteristic. The same may be said of the swelling and turbidity of certain of the large pyramidal cells in the deeper layers of the cortex in the Rolandic region described by F. C. Turner, The changes in the ganglion cells of the spinal cord described by H. C. Wood in canine chorea have been found also by Triboulet, but he agrees with others who hold that canine chorea is a very different disease from human chorea. Nature of Chorcct. — This, it must be admitted, is as yet unknown. It has been intimated that the symptoms are of a kind which would naturally result from lesions in the motor cortical area. No constancy in such lesions is demonstrable. A cerebral seat for chorea is rendered likely by the exist- ence of hemichorea, the association of chorea with mild psychical derange- ments, and by the fact that choreiform movements are sometimes symptoms 1094 DISEASES OF THE NERVOUS SYSTEM. of undoubted brain lesions — posthemiplegic hemichorea. The embolic theory which was suggested by Senhouse Kirkes, and supported by him, Hughlings Jackson, Broadbent, Tuckwell, and others, was based upon rhe presence of foci of embolic softening found in a few instances in connection with endocarditis, but has gained few supporters. The theory which is at the present day naturally attracting most atten- tion is the infectious theory, but the limits of a text-book do not permit its developmental consideration. Suffice it to say that Pianese, of Xaples, has apparently isolated from the nervous system of a choreic patient a bacillus which he was able to cultivate successfully, and the cultures from which caused death in animals ; also that while the acuter forms present many, if not all, of the conditions necessary to the conception of an infectious disease, the course of the milder forms, their etiology, notably their negative morbid anatomy, seem to demand that the disease be regarded for the present as a neurosis — that is, a disease of functional derangement without known anatomical basis. Symptoms. — Premonitory symptoms, both motor and psychical, usually precede the onset of chorea. They include restlessness and inability to sit still, and an altered disposition, manifested by irritability and perversity. These symptoms, often misunderstood by parents, are sometimes the occa- sion of reproof and even severe punishment to tlie child — a course which accelerates and aggravates the disease. A close study of the symptoms permits of their division into three separate groups, determined chiefly by their severity : 1. A mild form, including the majority of cases in which the affection of the muscles is slight, the speech scarcely involved, and the general health slightly disturbed. 2. The severe, in which the choreic movements are general, power of speech is lost, and the patient is unable to go about and help himself. 3. The maniacal, or chorea insaniens, characterized by intense cerebral excitement. It is, however, unnecessary to separate the symptoms of each variety. The motor phenomena are those first observed. They consist in peculiar jerky movements which begin most frequently in the upper extremi- ties, especially in the right hand, rarely in the legs. Thev may even be general from the first, though the earliest symptoms often escape notice. Speech is affected, sooner or later, in one-fourth of the cases. The extent varies greatly from slight hesitancy to incoherency — ^the difficulty being in the muscles of articulation rather than in phonation. As a rule, the move- ments cease during sleep, though they sometimes persist even then. It is not generally believed that the movements extend to the muscles of organic life, though associated irregular and rapid action of the heart has been ascribed to choreic spasm of the papillary muscles. As the disease con- tinues muscular zveakness becomes manifest in a general want of strength rather than paralysis, though the weakness may be distributed hemiplegic- ally or even monoplegically. It may even precede the jerking movements. Very rarely the pulse may be slow in the feeble state that follows chorea. Sensory symptoms are less conspicuous than motor. Pain is rare, though its presence has been characteristic enough in some cases to obtain from them the name " painful chorea " from AA^eir Mitchell. Painful points over the sites of emergence of spinal nerves have been pointed out, though they must be rare. Numbness, tingling, and pricking sensations are ACUTE CHOREA. 1095 occasionally met, and may be a part of the phenomena of multiple neuritis sometimes present. Headache^ sometimes very severe and paroxysmal, may occur, while epileptiform seizures are also a rare symptom, and when they occur are probably not a part of the chorea. The reflexes are variously aftected, the knee-jerk being normal in about half the cases, in the remainder increased or absent. Trophic lesions are almost unknown. Mental symp- toms, in the majority of cases, are not very conspicuous, though there are in some severe cases extreme manifestations, including melancholia, hallu- cinations, and even mania, which have their climax in chorea insaniens. Most important are the symptoms of cardiac disease, in regard to which W illiam Osier makes the startling statement : '' There is no disease in which endocarditis is so constantly found postmortem as chorea. It is exceptional to find the heart healthy." The symptoms which are, therefore, to be ahvays carefully sought include a systolic apex murmur, palpitation, and irregular heart action, although the child rarely complains of the latter or of pain about the heart. It is further important to note that in a majority of these cases the endocarditis is independent of acute arthritis, unless we hold with Bouillaud that in young subjects the heart acts as a joint. Organic murmurs at the base are very much more uncommon, most of the murmurs here being functional. They are heard with greatest inten- sity in the area of the pulmonary artery, but are audible sometimes in the aortic area as well. In a large proportion of all cases in which a murmur is heard at the base or along the left margin of the sternum in the second, third, and fourth interspaces it is functional, but a soft systolic murmur in this area with systolic pulsation in the cervical veins may be caused at the tri- cuspid orifice. On the other hand, endocarditis sometimes occurs zvithoiit symptoms or physical signs, while the disappearance of physical signs does not prove that endocarditis was not present. A presystolic murmur is also at times present,, indicating mitral stenosis — in 19 per cent, of Osier's cases. On the other hand, the comparative rarity of simple aortic valve involvement is con- spicuous, this being more uncommon than combined aortic and mitral dis- ease, or even combined mitral and tricuspid disease. The tricuspid valves may alone be attacked. A to-and-fro murmur, indicating pericarditis, may be present in from 8 to 25 per cent., and in more than half of these it is associated with endocar- ditis. It is to be remembered that both forms of organic heart disease, and especially endocarditis, may occur in chorea without rheumatism, — e. g., in 66 per cent, of Osier's cases, — also that such endocarditis may lay the foundation of permanent organic disease. Occasional skin affections make their appearance in chorea, the larger proportion being due to the prolonged administration of arsenic, so much used in the treatment of this disease. The forms for which the arsenic treatment is more or less responsible are erythematous and papillary eruptions, herpes, and the pigmentation frequently resulting from the prolonged administration of this drug. Eruptions also occur independent of arsenic administration. They are usually purpuric and associated with arthritis, similar in form to the purpura so often associated with rheuma- tism, and include some of the forms of- multiple erythema — as erythema nodo- sum, purpuric urticaria, or simple purpura. C. H. Brown* has reported *" Journal of Mental and Nervous Disease," August, 1893. 1096 DISEASES OF THE NERVOUS SYSTEM. a remarkable case of subcutaneous nodules composed of young granulating- tissue in a case of chorea in a boy of eleven. Fever is a rare symptom in chorea, except as the result of complica- tions, of which arthritis is the most common, but endocarditis and peri- carditis may also cause fever. The rare instances are cases of chorea in- sanicns, in which the temperature may rise to 105° F. (40.5° C). Diagnosis.— This is usually easy. Simple tremor, athetosis, paralyslld be given in full doses, 1-30 grain (0.0022 gm.) three times a day, and increased to 1-20 grain (0.0033 fei^^-^' which should' be kept up. Ergot is said to have been useful in restoring the power of muscles involved in the palsy, 74 1 170 THE INTOXICATIONS. ARSENICAL POISONING. Acute Arsenical Poisoning. — Acute arsenical poisoning is usually the result of accidental or intentional ingestion of Paris green or " Rough on Rats," prepared and sold for the destruction of rats, mice, vermin, and insects. Occasionally it is taken also with suicidal intent. Symptoms. — These are intense abdominal pain, at first gastric, with vomiting; later intestinal, with diarrhea and tenesmus, which may be fol- lowed by collapse and death. The symptoms are not unlike those of cholera,, including rice-water stools, cardiac weakness, and cyanosis. Sometimes a skin eruption makes its appearance, and sometimes blood and albumin appear in the urine. Fatal cases terminate in one or two days. Recovery from these acute effects may be followed by paralysis. Treatment. — The ingestion of a poisonous dose of arsenic is apt to be followed by free vomiting. But even in the event of emesis, mustard or sulphate of zinc, from ten to thirty grains (0.068 to 0.1944 gm.), should be administered, and the stomach well washed out with draughts of warm water. With the emetic or before it the antidote should be administered. The best antidote is freshly precipitated sesquioxid of iron, which forms,, with arsenic, an insoluble compound. It must be freshly prepared, taking any of the sesqui solutions of iron, preferably the chlorid, and neutralizing it with sodium carbonate or magnesia. The precipitate, being hastily washed by emptying on muslin or a filter, pouring water on it and allov»^ing it to drain, should be freely administered. Dialyzed iron may be used, but it is best also precipitated with ammonia or other alkali before using. In extreme cases the tincture of the chlorid of iron, Monsel's solution, or any of the sesqui preparations may be substituted for the precipitated ses- quixod. After the emetic has acted, and while the antidote is being given, castor oil should be administered to carry off the poison from the bowels. Chronic Arsenical Poisoning. — This is ascribed to wall-papers cov- ering occupied apartments, sometimes to arsenic long administered as a medicine, to artificial flowers, and clothing fabrics. The glazed green and red papers are those especially dangerous. Occasionally, arsenic medici- nally administered may produce the symptoms of slow arsenical poisoning.. Symptoms. — Chronic arsenical poisoning may be suspected in the presence of unexplained anemia and debility, irritation of the conjunctiva,, mouth, pharynx, and lower digestive tract, numbness, tingling, and gas- tralgia; also nervous symptoms and altered nutrition in special parts. All these symptoms may, however, be produced by other causes. Paralysis may also ensue, resembling that of lead palsy, but affecting rather the lower extremities, especially the extensors and peroneal group, whence may arise the characteristic steppage gait of peripheral neuritis. Deranged electrical reaction may be present before any loss of power, but on differential exami- nation a weakened power of wrist extension and feeble power to spread the fingers may be detected. Treatment. — The patient should be removed from the exposure and the symptoms be treated as they arise. The iodid of potassium may be used> PTOMAIN AND LEUKOMAIN POISONING. u/i PTOMAIN AND LEUKOMAIN POISONING. Ptomain, from the Greek tit cajna, a cadaver, is a word suggested by the Italian toxicologist, F. SeHni, for substances generated in the decomposition of organic matter, which more recent studies have shown to be the resuh of bacterial action. Ptomains are basic, uniting with acids to form salts. Leukomains are similar basic substances formed in the living body. Ptomains differ greatly in their character and properties, certain ones being intensely poisonous, others harmless. For the former L. Brieger suggested the name toxins, retaining that of ptomains for the non-poisonous basic products; but, as Victor C. Vaughan suggests, there are difficulties in the way of such classification, because a ptomain may be poisonous under cer- tain conditions and harmless under others. Leukomains are more usually harmless, although they may also pro- duce disease under certain conditions. Among ptomain poisons are the agencies which are responsible for various forms of meat poisoning, poisoning by milk products, by shell-fish and fish. Meat Poisoning. — This succeeds the eating of various forms of meat which has been the seat of a decomposition in the whole or some one of the constituents of the mass. Sausage poisoning, also called botulismus and allantiasis, follows the eating of infected sausage. Numerous outbreaks have occurred in Germany, more particularly in Wurtemberg and adjacent Baden. In 1820 Kerner had collected reports of 76 cases, of which 37 were fatal, and in 1822 he had increased the number to 155, with 84 fatal. The poisonous qualities are re- ferred to defective methods of preparation which permit decomposition. Ham poisoning not due to trichina has occurred in England, Germany, and Switzerland, while poisoning has also been traced to beef, mutton, veal, turkey, and goose-grease, and in America to canned meats. Some of these must be ascribed to muriate of zinc and tin, but others are doubtless due to the meats. Poultry, especially if kept too long, and game birds also prove poisonous at times. Symptoms. — The symptoms of various epidemics vary somewhat, but the following are more constant, after a period of incubation of from one to forty-eight hours : nausea, vomiting, cramps, and diarrhea — in a word, acute gastro-intestinal irritation. To these may be added dryness of the mouth, constriction of the throat, difdciilty in szuallowing, vertigo, indistinctness of vision, dilatation of pupils, while sometimes constipation substitutes diarrhea. Thirst, headache, and muscular weakness may also be present. The symptoms may begin at once without incubation in a feeling of lan- guor and general m.alaise, loss of appetite, nausea, and griping pain in the belly. In fatal cases the symptoms of cholera are simulated, such as cramps in the legs or arms, or both, muscular twitchings, stiffness of the joints, drowsiness, coldness of surface, pinched features, blueness of fingers and toes and around the sunken eyes — in a word, the symptoms of collapse. On the other hand, the temperature sometirr^es rises to 101° to 103° F. (38.3° to 39.4° C.), with a pulse of from 100 to 128. Poisoning by Milk and its Products. — The causes of poisoning by cheese claimed attention as far back as 1827, when analyses of poisonous 1 172 THE INTOXICATIONS. cheeses were made by Hunnefeld. The older view that the poisons are fatty acids has been refuted, and Vaughan isolated a ptomain in 1884 which he has called tyrotoxicon (rypoV, cheese, and to^zko?', poison). Tyrotoxicon was not, however, always found by Vaughan in cheeses of acknowledged poisonous properties. In 1885 he found tyrotoxicon in milk which had stood in well-stoppered bottles for about six months, and in 1886 Newton and Wallace obtained it from milk which had poisoned a number of persons in a hotel at Long Branch, N. J. Since then tyrotoxicon has been isolated many times from poisonous milk. Finally, in 1886, Vaughan obtained ty- rotoxicon from ice-cream which had proved poisonous, and since then it has been frequently found in such cream. A number of cases of poisoning after eating " cream puffs " have been reported in Philadelphia and else- where, in which doubtless the same ptomain is responsible. A family un- der my observation was poisoned by blanc mange, of which all had eaten freely, and which had been made for several days. Symptoms.— The symptoms of milk and cheese poisoning are those of gastro-intestinal irritation, comparable in various degrees to those described as due to meat poisoning, etc Poisoning by Shell-fish and Fish (Lchthysmus) . — The mussel fur- nishes the most frequent source of poisoning from this cause, instances of which were reported as early as 1827 by Combe. A ptomain was isolated by L. Brieger in 1885, from poisonous mussels, at Wilhelms- haven, where numerous instances occur. Brieger has called it mytilo- toxin, from inytilis, a mussel. It is found chiefly in the liver of the mussel, but whether in a special poisonous mussel or a mussel which becomes poisonous under certain circumstances is not settled, though the latter would seem to be true, since Schmidtmann found that non-poisonous mus- sels placed in the waters of Wilhemshaven Bay became poisonous, and poisonous mussels from the latter became harmless after being placed in the open sea. Symptoms. — Both cooked and raw mussels may produce the poison- ous symptoms. Three sets are described : First, those of gastro-intestinal irritation, similar to those described as due to meat poisoning and which may terminate fatally within two days, the autopsy revealing inflamed stomach and intestines. In a second set of symptoms the nervous system seems to bear the brunt of the poison, and these cases are said to be the most frequent. The symptoms include a sense of heat and itching, usually beginning in the eye- lids, but soon extending over the whole face and sometimes over a large portion of the body. An erup^^ion, vesicular and papular, makes its appear- ance and intensifies the itching. The eruption is often followed by asth- matic breathing. Sometimes the dyspnea precedes the eruption, the face be- comes livid, the patient unconscious, and there are convulsive movements of the extremities. In other cases there are delirium, convulsions, coma, and death within three days. In other nervous cases there are numbness and coldness, frequent pulse but no fever, the pupils are dilated, and death takes place in a couple of hours with symptoms of collapse. In a third set of cases a symptom like intoxication by alcohol is pres- ent, followed by paralysis, coma, and death. Treatment of Ptomain Poisoning. This js mainly symptomatic — the purgative and emetic effect of the GRAIN POISONING. 1173 poison general!}- promptly gets rid of any residue which may be in the stomach or intestinal canal. But if there is any reason to believe that these are not emptied, purgatives should be administered, and of these calomel is probably the best because it is less apt to be rejected. In addition counterirritation by mustard, hypodermic injection of 1-4 grain (0.0165 gm.) niorphin, repeated if necessary, to relieve pain, digitalis from ten to thirty minims (0.66 to 2 gm.), and strychnin 1-30 grain (0.0022 gm.) administered in the same manner to counteract collapse may be given. Stimulants by the mouth should be given if retained, and to this end cham- pagne becomes very suitable, or milk mixed with carbonated water may be given in small quantities. GRAIN POISONING. For a century or more districts have been subject to ailments which have been traced to the use of certain grains as food, some of which have been found to be spoiled or the seat of disease. People in some parts of France, Germany, Switzerland, Italy, Spain, and India have been thus affected. I. Ergotism. — Ergotism is one of these ailments. It is a disease found to succeed upon the use of meal contaminated with the sclerotmm, an inter- mediate stage of development of the claviceps purpura, a fungus which in- fests the rye grain. An ergot is this sclerotium, which appears at the base of the grain as a hard, dark-hued " spur," which, as it grows, lifts up the diseased and withered mass of the original grain. Wheat, barley, and rice may also become spurred. The growth of the fungus is favored by wet seasons. The disease prevailed in France, Switzerland, and Germany much more commonly from the tenth to the eighteenth century than at present. The cause of ergotism was discovered in 1830 by Thuillier. Two forms of chronic ergotism are recognized, one convulsive or spas- modic, the other gangrenous. Spasmodic Ergotism. — In this form there is a prodromal period of from ten to fourteen days, during which there are a peculiar sense of weariness and anxiety, a tingling and sense of formication in the skin, especially of the fingers and toes, gastro-intestinal irritation manifested by vomiting, purging, and colicky pains, accompanied sometimes with slight fever. Then spasmodic symptoms set in. These consist at first in involuntary twitch- ings, which soon pass into painful continuous contractions, the arms being flexed and the legs and toes extended. The cramp lasts for an hour or more, followed by a period of exhaustion, which may be succeeded by an- other painful convulsion. There may be delirium, melancholia, or de- mentia. The urine may be suppressed or violent dysuria may be present from spasm of the bladder. Pustules, boils, whitlows, and other evidence of deranged nutrition may appear. Cardiac contractions are slow and feeble, the arteries are' constricted and contain little blood. Death m.ay occur from cardiac paralysis, and is often preceded by convulsions or para- lytic symptoms. The duration of the illness is from four to eight weeks or longer. Sclerosis of the posterior columns of the cord was found in some of the cases which came to necropsy. Thus, Tuczek and Siemens found it four times in nine autopsies, which represented, also, the deaths in a group of twentv-nine cases. 1 1 74 THE IKTOXICATIONS. Gangrenous Ergotism. — This form is ushered in by the same prodrome as that described for the spasmodic. On this succeeds, from the third day to the fourth week, an erysipelatous redness in some peripheral locality, as in the toes and fingers, ears, and nose. This is followed usually by dry gangrene, but the moist form, which may be confined to a finger or toe or may involve the whole hand or foot, may also appear. The disease may not go beyond the erysipelatous redness. For acute ergot poisoning see concluding section. 2. Pellagr.\. — This is a disease thought to be due to a fungus which infests moldy maize or Indian corn. Lombroso and others have isolated a ptomain from the meal made of such corn. The disease occurs in Lom- bardy, the South of France, and in Spain, especially among the poorer classes in the country districts, where the meal of maize is largely used. It begins almost invariably in an erythema in the spring of the year, which is followed by a scaly and wrinkled condition of the skin, especially in the parts exposed to the air. Occasionally crusts form, and beneath these pus is found. Along with these skin diseases there are digestive derangements, salivation, dyspepsia, and even dysentery. The disease lasts a few months, when improvement sets in. In the more severe and chronic forms there may be headache and backache, the strength and, mental faculties are af- fected, sensation is obtunded, and cramps with convulsions supervene, such as in ergotism. The morbid anatomy is vague. There may be fatty degeneration and a pigmentation of the viscera. 3. Lathyrism^ or Lupixosis. — This is a condition resulting from the use of meal made from the chick-pea, or grain of a variety of vetches, more particularly the lathyrus salivus and lathynis cicera. It is used in admix- ture with barley and wheat in India, Italy, and Algiers. According to James Irvine, the symptoms supervene in India when the proportion ex- ceeds I- 12. The symptoms are, first, gastro-intestinal irritation, then a condition of spastic paralysis, which may pass on to complete paraplegia. The arms are rarely, if ever, aft'ected. Xo associated morbid change has been discovered. Treatment of Grain Poisoning. This consists, primarily, in the removal of the cause and the substitu- tion of wholesome food ; in removal, also from the district, if possible, and suitable treatment of symptoms. SECTION XII. EFFECTS OF EXPOSURE TO HfGH THOUGH BEARABLE TEM- PERATURE. Such effects are easily separable into two groups, covered by the terms heat exhaustion and thermic fever. HEAT EXHAUSTION. Definition. — A condition of syncopal exhaustion with vasomotor paral- ysis and lowering of body-temperature, caused by exertion under high temperature. Such condition may arise quite independently of the direct rays of the sun. The heat may be that of confined rooms and may be arti- ficial heat. Symptoms. — The sense of great zveakness, often experienced in hot weather after some unusual exertion, exhibits the mildest degree of this con- dition. In the more severe forms a sense of faintness, associated with pallor, dissiness, at times blindness, and the starting of cold perspiration are the first symptoms. Sometimes the victim can get to a place where he may sit or lie down ; at other time he faints away before assistance can reach him. Then follows a condition of unconsciousness or semi-consciousness, whence, under favorable circumstances, he may respond to gentle stimulus by ammonia or wine and then fall into a sleep, from which he will awake in an hour revived. In more severe cases the collapse is more permanent, the pulse is ex- tremely feeble and frequent, the skin continues leaky, while there may be great restlessness and muttering delirium. It is characteristic of this form of heat affection that there is extreme adynamia with lowered body-tempera-' .ture. H. C. Wood, whose name is inseparably associated with the subjects of heat exhaustion and thermic fever, reports a case with a temperature as low as 95° F. (35° C), with complete collapse. Diagnosis. — Heat exhaustion is characterized by lowered temperature and feeble pulse, as contrasted with the opposite in thermic fever. It is im- portant that the two conditions should not be confounded, because of the widely different treatment required. The syncopal attack from cardiac fail- ure or from concealed hemorrhage much more closely resembles heat ex- haustion, being associated also with feeble pulse and lowered temperature, but as the treatment is identical, the distinction is less important. The fall in temperature is, however, less decided in syncope. Treatment. — The patient should be put to bed at once with his head horizontal or slightly raised. When possible, stimulants should be ad- ministered moderately by the mouth — brandy, whisky, or ammonia with digitalis. If this is not possible, digitalis and strychnin should be given hy- podermically, from ten to thirty minmis (0.66 to 2 gm.) of the former and 1-30 grain (0.0022 gm.) of the latter. Friction should be applied, and dry heat by hot-water bags or cans. 1175 1176 EFFECTS OF EXPOSURE TO HIGH TEMPERATURE. THER^IIC FEVER. Synonyms. — Heat Fever; Sunstroke; Coup de soleil. Definition. — A state of high fever induced by exposure to heat, natural or artificial. Etiology and Pathology. — In this country the majority of cases occur in the summer season in those exposed to the direct rays of the sun, though they occur also among those exposed to high temperature within doors, as in sugar refineries, fire-rooms of ocean steamers, laundries, and the like. A heated atmosphere charged with moisture, impeding, there- fore, evaporation, produces fever much more rapidl}- than a dry heat, which is in fact slow to produce it. The habitual use of alcohol is found to be a potent predisposing cause — at least alcoholics succumb verj^ much sooner to the influence of overheat than temperate persons. The pathology of the two conditions of heat exhaustion and thermic fever is thus explained by H. C. Wood : " There is in the pons or higher por- tion of the nervous system a center whose function it is to inhibit the pro- duction of animal heat, and in the medulla oblongata a center (probably the vasomotor center) which regulates the dissipation of bodily heat. Fever is due to a disturbance of these centers, so that more heat is produced than nor- mal and proportionately less thrown off. Let it be supposed that a man is placed in such an atmosphere, that he is unable to get rid of the heat which he is forming. The temperature of the body will slowly rise, and he may suffer from a general thermic fever. If early or late in this condition the inhibitory heat center becomes exhausted by the efifort which it is making- to control the fomiation of heat, or becomes paralyzed by the direct action of the excessive temperature already reached, then suddenly all tissues will begin to form heat with the utmost rapidity, the bodily temperature rises- with a bound, and the man drops over with one of the forms of coup de soleil. " Heat exhaustion," on the other hand, " with lowered temperature, rep- resents a vasomotor palsy — /. e., a condition in which the existence of the heat paralyzes the center in the medulla oblongata, and the heat is dissipatedl more rapidly than it is produced." It must be admitted that the explana- tion of heat exhaustion is less satisfactory than that of thermic fever. Morbid Anatomy. — The high temperature characteristic of heat fever remains a long time after death. Hence putrefaction sets in early. Rigor mortis also occurs promptly. The blood remains liquid. There is general" venous engorgement, especially of the lungs and cerebrum. In early au- topsies the left ventricle is found contracted, the right dilated. S5miptoms. — A sense of uncomfortable burning heat and feeling of oppression may precede the " stroke " which fells its victim, who quickly becomes unconscious and comatose, perishing sometimes instantly, at other- times in a few hours. In other cases there are intense headache, disainess, oppression, nausea, and vomiting, occasionally diarrhea. Chrainatopsi-a, or colored vision, may be present. Sooner or later unconsciousness sets in, and may be associated with muttering delirium and intense restlessness. In this- condition the patient is commonly admitted to hospital with face flushed, eye suffused, skin hot and dry, temperature from 107° to 112° F. (41.6° to 44.4° C), the breathing labored, sometimes stertorous, the pulse frequent- THERMIC FEVER. 1177 and full. The pupils at this stage are usually contracted, though at first dilated. The urine is scanty, sometimes albuminous. Usually there is relaxation of the muscles, but at times there is a convuJswe tendency, shown by twitching and jactitation, and occasionally by epileptiform convulsions. The skin, usually dry, may become moist and bathed with perspiration, which does not, however, reduce the temperature. Wood speaks of a peculiar odor exhaled by the entire body as characteristic. J 178 EFFECTS OF EXPOSURE TO HIGH TEMPERATURE. In fatal cases the stupor deepens, the pulse becomes more frequent and loses even its seeming strength, then is irregular, the inspiration is labored and irregular, and toward the last shallow, or assumes the Cheyne-Stokes type previous to death. Death does not usually take place for several hours. In favorable cases improvement is indicated by a falling tempera- ture and a return to consciousness. Recoverx may be complete, but more rarely a permanent condition re- sults in which there may be more or less constant mental weakness, as evi- denced by incapacity for sustained mental effort, while exposure to moderate degrees of temperature produces great excitement or headache or pain in the upper cervical region. Epileptic convulsions sometimes occur. In these cases there is probably a certain degree of meningitis. Attention has lately been called by C. F. Close * to cardiac dilatation as a symptom of thermic fever. Mention has already been made, when treating of fevers, of the form of continued fever occurring in the south of the United States, where it is Icnown as " Florida fever " and " country fever," and in India and the West Indies as iievre i)if!amiiiatoire, for which John Guiteras proposes the name ■continued thermic fever, but which more recently he is inclined to ascribe to a septic origin. Diagnosis. — The diagnosis of heat fever presents no difficulties. The distinction between it and heat exhaustion has been alluded to. Prognosis. — The prognosis depends partly upon the severity of the ■case and the promptness and thoroughness of treatment. A few cases are almo.st instantaneously fatal. If the cooling treatment can be applied prop- erly, a decided majority — fully 60 per cent. — recover. A temperature of 110° F. (43.3° C), though indicating gravity, should not discourage. Treatment. — ^The success of treatment of thermic fever depends al- together upon our ability to lower the temperature. To this end the pa- tient should be placed in a hath of zcafer to which ice is freely added to keep the temperature down as low as it can be, which in summer is not likely to be below 60° F. (15.54° C.). The surface of the body is further vigorously rubbed zvith ice. In the absence of bathing facilities the patient should be placed on a mattress covered with a mackintosh and be rubbed with pieces of ice. The refrigerating effect may be further increased by ice-water enemas. This treatment should be regulated by the thermometer in the rectum, and abated as the temperature approaches the nonnal, and renewed as it again rises. After this, or in addition to this, treatment should be symptomatic. For ry high fever, delirium, infiltration of the lungs, and fatty degeneration of the liver have been observed. Death may take place either from exhaus- tion as the result of extreme irrftation. or later in the disease from the same cause preceded by anemia and gradual loss of strength. Usually, however, improvement sets in about the fourth or fifth week, though convalescence in bad cases is slow, and many weeks elapse before recoverv is complete. Diagnosis. — It is usually the unexpectedness of the disease which leads to delay in diagnosis. The resemblance of the symptoms to those of typhoid fezrr and muscular rheumatism has been referred to. vet in the presence of a possible cause — as, for example, a German picnic or other feasting occa- sion where the favorite ham or sausage has formed part of the feast — such symptoms should immediately excite suspicion. The discovery by Dr. Thomas R. Brown in 1897* that eosinophilia is constantly associated with * "Johns Hopkins Hospital Bulletin," April, 18Q7. NEMATODES, OR ROUND WORMS. 1193 trichiniasis is important and when present is confirmatory of the existence of the disease. A differential blood count should therefore be made in sus- pected cases. When doubt exists, the harpoon, designed for obtaining samples of muscle for examination, should be unhesitatingly used, under ether or local anesthesia, and the part removed carefully examined under the microscope. Treatment. — Here, as so often elsewhere, an " ounce of prevention is worth a pound of cure." Such prevention consists in thorough official in- spection of all pork brought to market, because cooking may fail of its pur- pose for the reasons already mentioned. For a similar reason swine should be grain-fed, rather than allowed to feed on offal. It is doubtful whether any direct measures can be used for arresting the disease after the muscles have once been invaded. It is a simple conflict of the mastery between the strength of the patient and the life of the trichinae. In the majority of cases the former triumphs, though death is hot infrequent from the causes named. If the disease is recognized early, the alimentary canal should be treated with vermicides and purgatives, with a view to getting rid of all the sexually mature worms which may happen to remain there, since it will be remembered that successive broods develop from the same mother-worm while in the intestinal tract. Glycerin, given in a tablespoonful (30 c. c.) dose hourly, is said to destroy the trichinae. Benzine, in one- to two-dram (4 to 8 gm.) doses in capsules, and picric acid in dose of from five to eight grains (0.3 to 0.5 gm.), are also recommended, but are regarded as less re- liable. To relieve the pains, hypodermic injections of morphin, 1-4 grain (0.0165 gm.), or warm baths may be used. Restoratives and stimulants should be given to keep up strength. C. Anchylostomiasis — Uncinariasis. Definition. — A term applied to the invasion of man by the anchylos- toma or sclerostoma duodenale, also known as the unciitaria diwdenalis, dochmius anchylostommn, strongylus quadridentatus, and strongylus diwdenalis. Description. — The male is from eight to ten mm. (0.3149 to 0.3937 inch) long, and has a prominent expansion or bursa at the tail end. The female is from 12 to 18 mm. (0.4724 to 0.7086 inch) long; both are provided with hook-like teeth, by which they attach themselves to the mucous mem- brane. The ova, which are abundant in the stools, are ovoid, 0.052 mm. (0.002 inch) long and 0.03 mm. (0.0012 inch) broad, provided with a thin, transparent shell and deposited in a state of segmentation. The habitat of the worm is the duodenum and the upper jejunum of man and certain anthro- pomorphous apes, it is said, throughout the inhabited globe ; but beyond some apocryphal descriptions by physicians of the South American States, it is unknown here. Max Braun also says it is sporadic only in the colder countries, being more prevalent in southern latitudes, especially those of Italy and Poland ; in fact, it has been largely spread by laborers from these countries throughout Germany and Austria-Hungary, the West Indies, and Brazil, the St. Gothard tunnel being' one of the localities in which it was first studied. The larvae are developed in damp earth and distributed by wind and water. Many of the victims are earth-eaters. Late years have shown a remarkable increase in anchylostomiasis in this country, for a dis- 1194 ANIMAL PARASITES. semination of accurate knowledge of which we are indebted to Dr. Allen Smith of the University of Texas. Symptoms. — The parasite fastens itself to the mucous membrane by the hooked teeth described, and feeds upon blood drawn therefrom. At first only causing gastro-intestinal irritation, there gradually results an anemia variously known as Egyptian chlorosis, brickmaker's anemia, tunnel anemia, and mountain anemia. The rate of development of the anemia varies, being sometimes very rapid. There occur also colicky pains, diarrhea, and small hemorrhages. A consequent symptom is extreme weakness and indisposition to effort mental or physical. Hypertrophy and dilatation of the, heart have been found. Diagnosis. — The diagnosis is rendered easy by the conditions surround- ing the victims and confirmed by the discovery of eggs in the feces. At autopsy they may be found clinging to the mucous membrane in the duo- denum and upper ileum. Anchylostomiasis, like trichiniasis and filariasis, is associated with eosinophilia. The latter condition is therefore helpful in diagnosis. Treatment. — In treatment prophylaxis is most important. All water used by laborers should be disinfected. Thymol is said to be a specific, and should be given in thirty-grain (2 gm.) doses in wafers at 8 a. m. and 8 p. M., a purge of castor oil or magnesia being given after the second dose. Should the first effort fail, it may be repeated in a week. The diet should l>e liquid — ^milk and soups. D. Filariasis. Definition. — A condition constituted by the presence of several species of nematode worms, known as filarise. (a) Filaria sanguinis hominis. A term applied to the several varieties of filaria which infest the blood of man. Of these, three species will be described : I. Filaria Bancrofti. — The adult filaria thus named was first discovered T^y Bancroft in Queensland in 1876, and soon thereafter by T. R. Lewis in Calcutta. Before these discoveries the larva only was known, having been discovered by Demarquay in Paris in 1863 in the hydrocele fluid of a Havanese. The adult male is 83 mm^ (3.2677 inches) long and 0.4 mm. (0.0157 inch) in diameter, head rounded, tail pointed, and spirally rolled. The female is about 155 mm. (6.1023 inches) long and 0.7 mm. (0.0275 inch) thick. The worm is about as thick as a human hair. The egg is 0.038 mm. (0.0015 inch) long and 0.014 mm. (0.005 inch) wide. The normal habitat of the sexually mature worm is the lymphatic vessel of different parts of the hody of man, though it has been found also in the left ventricle of the heart. The female is viviparous, exceptionally oviparous, producing an enormous number of young larvae, which pass from the lymphatic stream into the blood and are thus distributed over the body. They are from 0.27 to 0.34 mm. (0.0106 to 0.0133 inch) long, 0.007 to o.oii mm. (0.0003 to 0.0004 inch) Tjroad, rounded anteriorly and pointed behind. The larvae are found in the peripheral circulation after sundown in a ■drop of blood taken for the purpose. The numbers increase until midnight, NEMATODES, OR ROUXD WORMS. 1195 Avhen they again become less numerous. From midday to evening there are no filarise to be found. The cause of this interesting fact cannot be ascribed to the periodic production of broods, since ^Mackenzie has shown that the order is reversed if the patient sleeps during the day and is a\\'ake during the tiight, under which circumstance the filariae are found in the blood in the day. This is, however, not without exception. It would seem, as suggested by Linstow, that the event has something to do with sleep, and that during sleep the peripheral blood-vessels widen and again contract during awaking; that the filariae cannot pass the contracted capillaries of the superficial skin, but rest in the larger blood-vessels in the deeper portion, to come out with the widening which accompanies sleep. Their number in the blood has been variously estimated at 140,000 by Carter, and by ]^IcKenzie at from 30.000 to 40,000. The Ularia Bancroftl is met in the blood in all tropical countries, espe- cially India, China, Japan, and Brazil. It has also been found in the Southern United States in persons who have never been out of the country, first by Guiteras and later by others. 2. Filaria Pcrstans. — This second variety of filai'ia sanguinis hominis was also found by ]\Ianson in a larval state in the blood of a negro in West Africa. It is distinguished from the other filariee of man by its small size,— 0.2 mm. (0.0078 inch) long, — its active motility and contractility. INIan- 5on is inclined to ascribe to this the sleeping disease of negroes, and to it also the skin affection known among negroes as kraii'-krazv, which is a papillopustular eruption, probably the same as Xielly's dennatose parasi- taire, the parasite of which was called rhahditis XicUy (Blanchard, 1885). The posterior extremity is obtuse: the anterior has a retractile rostellum. 3. Filaria diiirna, also described by 3.Ianson, is seen in the blood only in the larv-al state, agreeing in this respect with filaria Bancrofti, dift'ering, however, from the latter in that it appears in the blood only in the day. It was discovered by Alanson in the blood of negroes on the west coast of Africa. ]\Ianson considers that filaria loa represents the adult stage. Etiology. — Patrick ^lanson discovered the young filaria, together with human blood, in the intestine of the mosquito, and thus secured the key to the problem of the transmission of the parasite from one person to another. He also noticed that the larvae underwent a certain degree of development in the intestine of the mosquito, changing in form and size. On the sixth or seventh day they are 1.5 mm. (0.0599 inch) long and cylindrical, and at this time change their habitat to water through the death of the mosquito. which takes place after the deposit of eggs. Few mosquitos, however, live long enough to permit the development in their intestine of the filaria to the stage at which it is sufficiently mature to survive in water. ^lanson con- cludes, however, that man becomes infected by drinking water which holds the mature filariae. Manson's studies have been confirmed by Lewis, and although his conclusions are not undisputed, they seem likely. Symptoms. — ^The early presence of filariae in the blood does not occa- sion subjective symptoms, and may last years without impairment of health. Sooner or later, however, as a rule, there appear anemia, enlargement of the spleen, and fever, with lymphatic tumors in difterent parts of the body. A differential blood count at this stage would be likely to discover eosino- philia. Later there develops, in consequence of lymphatic obstruction, pos- sibly caused by the parent filaria, possibly by the ova, elephantiasis, espe- cially of the scrotum (lymph scrotum) and lower extremities. To these 1 196 ANIMAL PARASITES. succeed enlargement of the lymphatic glands, chyluria, or hematochyluria already described, chylocele, more rarely nephritis, pyelitis, cystitis, and even peritonitis. Parasites are by no means always found in the blood in cases of elephantiasis or lymph scrotum. The mechanism of these phe- nomena is thus described by Manson himself: " A parent filaria is lodged in the left thoracic duct. In some way not yet under- stood it injures the walls of the vessel, causing ulceration or inflammatory thickening. In time this lesion leads to stenosis of the duct. Farz passu with the development of the stenosis the thoracic duct on the distal side of the stricture dilates, owing to the rising lymph. After a time the stricture becomes so narrow that the lymph and chyle no longer find their way past it to the left subclavian vein. They seek; however, to reach the blood by another route; a retrograde movement down the thoracic duct sets in, and so, by way of the pelvic lymphatics in the walls of the abdomen and the anasto- mosis between these and the lymphatics of the upper part of the body, the chyle from the intestines and the lymph from the lower extremities find their way into the circula- tion by the right thoracic duct. Possibly there are other routes, as by the lymphatics of the esophagus, diaphragm, and back. It is certain, however, that a frequent course pursued is that described, which is much the same as that pursued by the blood in the case of obstructed portal circulation. To accommodate this diverted chyle and lymph, the lymphatics by which they pass become enlarged and in many places varicose. The tendency to varicosity is very evident in such places as the scrotum, mucous membrane of the bladder, or wiierever the lymphatics are abundant and feebly supported. In many instances these varices, when superficial, can be seen or felt and their nature readily recognized. If the ingulno-femoral glands are involved, the varicose groin glands, so characteristic of filaria infection, are produced. Sometimes the varix is apparent on the surface of the abdomen even, as in a case related by Sir William Roberts and in another by Havelhing. That these varices are really part of an anastomosis conveying chyle from the abdominal viscera to the blood is proved by the nature of their contents, which are usually milky-white or slightly red-tinted chyle — not clear and limpid lymph, such as comes from the legs. As the lacteals are the only source of chyle, these chylous contents of the varicose lymphatics must have come from that source, and the route followed must have been the retrograde one described. Now if the lymphatics of the bladder happen to be involved in the compensatory anastomosis, and if they give way, as the lymphatics of the scrotum so frequently do in similar circumstances, the result is a leakage of chyle in the bladder, and chyluria. It is evident from this that the embryo filariae, although they are generally present in the blood and the urine in chyluria, have nothing whatever to do with its production. This is further proved by the fact that in some few cases of genuine and persistent tropical chyluria no embryo filaria can be found either in blood or urine. Proper treatment of chyluria is in principle the same as the treatment of acquired varix in any accessible region. This should consist of rest, elevation, lowering of the tension in the lymphatic vessels by the use of saline purgatives, limited and appropriate food, and abstinence from fluids as much as possible. Certain drugs have been vaunted as specifics for chyluria. Temporary recovery from time to time is the rule, and the drug which was being used at the time the urine cleared spon- taneously from the healing of the rupture in the varix of the bladder is often credited with the cure. I cannot understand how a drug introduced by the mouth can possibly cause the closure of a gaping varix in the bladder." Treatment. — ^No treatment appears to be of any value in exterminating the filarise in the blood. The symptomatic treatment should consist in rest, lowering of the tension of the lymphatics by saline purgatives, by appropriate food, and limitation of fluids ingested. No drugs have any influence, though it is not unnatural that, being used at the time of the spontaneous intermission, they should secure a reputation for curative powers. (b) Filaria dracunculus. Synonyms. — Dracontiasis ; Guinea-worm- Disease. Description. — Dracontiasis is a term given to the presence of the filaria dracuncnhis or filaria niedinensis, or guinea-worm. The female, until recently alone known, is from 50 to 80 cm. (20 to 32 inches) long or longer, and from 0.5 to 1.7 mm. (0.0196 to 0.0669 inch) NEMATODES, OR ROUND WORMS. 1197 thick. Quite recently R. H. Charles found, along with two females re- moved from a dead body at Lahore, a much shorter worm, about four cm. (1.6 inches) long, attached by its hinder extremity to one of the females at a point about four cm. (1.6 inches) from its head, which he inferred to be the male attached to the vagina of the female, dying after impregnation, as is the case with some other parasites. Then, too, the vagina atrophies, as both it and the vulva are absent in the mature worm. As to the development of the worm, the mature female contains enor- mous numbers of living embryos, which are discharged into the water of ponds. After a few days they probably enter the cyclops, a small crustacean, and there reach a certain stage of development, when they are imbibed with drinking-water by man and reach their ultimate destination, as described, in the subcutaneous and intermuscular connective tissue, especially in the lower extremities, about the foot-joint. To this it obtains entrance through the stomach, whence it penetrates the intestine and passes to the subcutaneous connective tissue, where it attains its full development, lying for a long time quiescent under the skin, and where it can be felt like a cord. Later it excites suppuration, and with the rupture of the abscess is discharged. It is also found elsewhere, as in the back, scrotum, perineum, the upper extremities, eyelids, and tongue. L'sually one worm only is found, rarely several. It is wide-spread, occurring in all races, ages, and in both sexes. Van Harlingen described a case in a man who had always resided in Philadelphia. Accord- ing to Braun, the fiery serpents described by ]\Ioses were guinea-worms. The term A paKOvriov^vdiS applied by Agatharchides one hundred and forty years before Christ, and Galen called the disease dracontiasis. Diagnosis. — The worms are easily recognized under the circumstances named. Treatment. — As to treatment, the indication is to remove the worm intact after the abscess is opened, because of the irritation excited b}- the escape of the living embryos. The method of procedure directed is to roll the worm around a piece of smooth wood, each day a little, in order to prevent retraction, until the whole worm is withdrawn. It is said that the leaves of the plant amar pattee are a specific cure, Avhile asafetida, when given in full doses, is also said to be poisonous to the worm. (e) Other Filarice. Numerous other filarise, of less importance, have been found from time to time in man. Among them I select from Braun : 1. The filaria immitis, the common Ularia sanguinis of the dog, found twice in man by Bowlby, in one instance associated with hematuria. He found, in the case of an Arab, numerous filarise in the portal vein, eggs in the thickened bladder-wall, kidney, ureter, and the lung ; in another eggs were found in a tumor of the rectum in a seventeen-year-old youth. 2. The aiaria loa, a delicate worm, from 30 to 40, rarely 70, mm. (i.ii to 1.57 to 2.75 inches) long, found between the conjunctiva and the eyeball in negroes on the West Coast of Africa", whence it has spread to South America and the West Indies. 3. The filaria ocnli huinani vel lentis, which in several instances was removed with lenses the seat of cataract, of which it seems to have been the cause. A. The filaria labialis. found in a pustule in the lips of a child. 1 198 NEMATODES, OR ROUND WORMS. 5. The aiaria hoininis oris (Leid)-), obtained from the mouth of a child. 6. The aiaria lynipliatico vcl hronchiaUs, found in lymphatic glands of the lungs and in the trachea and bronchi. E. Other Nematode Worms. 1. The tricJw€CpIiaIus d is par, an interesting worm of which the anterior portion, equal to three-fifths of the body, is very delicate and hair-like, while the hinder portion is much thicker. It is from four to five cm. (1.6 to 2 inches) in length, the male being somewhat shorter. The hinder. end of the female is conical and pointed, while in the male it is more obtuse and rolled like a spring. The ova are oval, 0.05 mm. (0.0012 inch) long, and provided with a button-like projection like that on the end of a lemon. Its habitat is usually the c?ecum of man, rarely the appendix vermi- formis, and exceptionally the small intestine. Usually they are few in num- ber and give rise to few or no symptoms. In some instances large num- bers are found, and serious brain symptoms have been ascribed to them, in other cases anemia. It is said to be one of the commonest parasites in man the world over, in either sex and at any age except infancy. Beri- beri has been ascribed to it. The larvae are probably developed from the eggs in water, and are possibly ingested in drinking-water. The ova are very resisting to the destructive agents to which they are ordinarily sub- jected. Large numbers are found in the feces. 2. The eustrongyhis gigas, or strongylus gigci'S, is an enormous nema- tode, the male of which measures 240 cm. (2.1 feet), and the female 100 cm. (3 feet 4 inches) long and 12 mm. (0.5 inch) thick. It lives in the pelvis of the kidney, more rarely in the abdominal cavity of the seal, dog, wolf, horse, and other animals, and exceptionally in man. 3. The strongyloides intestinalis, or anguilhila intestinalis et stercoralis, is a small nematode worm, first found in 1876 in the stools of French sol- diers in Cochin China suffering with severe diarrhea. They are found in all parts of the intestine and in the biliary and pancreatic ducts, producing- diarrhea only when present in large numbers. IV. ACANTHOCEPHALI. Synonym. — Thorn-head Worms. Description. — These are nematode-like worms in the intestinal canal, which are provided at the anterior end with a retractile proboscis furnished with hooks, hence called thorn-headed. Of these the gigantorhynchns, or echiiiorhynchtis gigas, is a large worm^ the male being from ten to fifteen cm. (4 to 6 inches), "and the female from thirty to fifty cm. (12 to 20 inches) long, which attains its full development in the intestine of the hog, attaching itself to the mucous membrane by its thorn head. The intermediate host is the cock-chafer grub in America and the June bug. As these insects may be accidentally swallowed by man, it is not impossible that the parasite may develop in his intestine. ARTHROPODA. 1199 V. ARTHROPODA. Of these, both the arachnides and insecta contribute to human para- sites. A. Arachnoidea. (a) Acarince. 1. Sar copies or acarus scabiei — the itch insect. This is the most fre- quently met of the arachnide parasites. Its oval, nearly circular little body,, provided with horns and bristles, is barely visible to the naked eye under favorable circumstances, the male being from 0.2 to 0.3 mm. (0.0078 to 0.0118 inch) by 0.145 to 0.19 mm. (0.0057 to 0.0074 inch) ; the female, from 0.33 to 0.45 mm. (0.0129 to 0.0177 inch) by 0.25 to 0.35 mm. (0.0098 to 0.0137 inch. The female lies at the end of a burrow in the epidermis, in situations where the skin is most delicate, as between the fingers, at the elbows, and under the knees, in the groin, and on the penis, very seldom in the face, but in any delicate part. In this burrow, some millimeters to a centimeter long, the female deposits her eggs. The male is seldom seen, dying after copula- tion, and the female after depositing her eggs. The eggs hatch in from four to eight days, and in about fourteen days the larvae are sufficiently matured to make their own burrows. The disease is communicated by personal con- tact or by clothing. Symptoms. — These are first an intense itching which incites to scratch- ing, which, in turn, causes excoriations, papules, vesicles, and pustules. Diagnosis. — The diagnostic feature is the shining little vesicle readily recognized by a moderate magnifier in the webs of the fingers, though it is often obscured and obliterated by the eruption and marks caused by scratching. Treatment. — This is very simple. Sulphur ointment is a prompt specific. The body should be first bathed thoroughly with soft soap, and then as thoroughly anointed with the ointment, which should be allowed to remain until the next day, when there should be another bath, followed by another vigorous application of the ointment. Three or four days of this treatment should suffice. An ointment of naphthol, one dram to the ounce (4 gm. to 30 gm.), is recommended. 2. Demodex folUculormn, a minute parasite from 0.3 to 0.4 mm. (0.0118 to 0.0157 inch) long, which resides in the sebaceous follicles, with the grease of 'vhich it can sometimes be squeezed out. It is oftenest met on the face and nose. It is said to be present in about 50 per cent, of persons, but this is probably exaggerated. It usually gives rise to no symptoms, but is said sometimes to be the cause of obstruction of the follicles and pro- duces thus the little worm-like accumulations of fat which may be squeezed out of the follicles, and which cause inflammation and acne. Treatment. — Acne is well treated by a lotion of corrosive sublimate, 2 to 1000, and it may be by its effect on tiie demodex that it is useful. 3. Lepns aiittimnalis, or harvest bug, is a minute red parasite, from 0.3 to 0.5 mm. (0.0118 to 0.0196 inch) long, which has three pairs of legs, with rows of bristles upon its back and belly. It prevails in summer on I200 ANIMAL PARASITES. grasses and plants, attaches itself to the skin of man and animals by its hooklets, and gives rise to irritation.. Treatment. — It is successfully destroyed by sulphur ointment and cor- rosive sublimate, 2 to 1000. 4. Ixodes riciniis is a minute oval tick, the male being 1.2 to 2 mm. (0.0474 to 0.0787 inch) long, and brownish-red in color, the female four mm. (0.1574 inch) long, yellowish-red, when distended with blood bluish- gray, twelve mm. (0.4724 inch) long^^ six to seven mm. (0.2362 to 0.2755 inch) broad, which infests the skin of sheep, cattle, dogs, horses, and men, <:ausing irritation and inflammation. It may generally be removed by rubbing or greasing with any sort of oil or vaselin. {h) Lingnafiilida', or Pcntastomcs. The pentastomes include the pentatomum tccnioides, or lingitatiila rhi- ■naria, and the pcntastoiuuui coiistrictiim or porccphalus constrictiis. 1. The pentastomum tcBnioides is a lancet-shaped worm, already de- scribed in connection with parasites of the liver. The adult infests the frontal sinuses and nostrils of the dog, more rarely of the horse, and has "been found in the nostrils of man. 2. The pentastoniiiiii constriciuui has as yet been met only in the larval state. It is milk-white in color, with golden-yellow hooklets, 13 mm. (0.51 18 inch) long and 2.2 mm. (0.0866 inch) wide, provided wath twenty- three rings. It has been found by Pruner encysted in the liver of two negroes in Cairo, by Bilharz in two instances encysted in the liver and mucosa of the bowel, and by Aitken in the liver and lungs of an English soldier in the West Indies. B. Insecta. Of these, the order rhyncota is represented by pediculi or lice and the cimex or bed-bug, the diptera by the pulex or flea. - (a) Rhyncota. Pediculi (Phtheiriasis; Pediculosis). — Of these, three varieties infest "human beings of filthy habits : I. The pediciilus capitis, or head-louse. The male is from i to 1.5 mm. (0.0393 to 0.059 inch) long, the female from 1.8 to 2 mm. (0.0708 to 0.0757 inch) long. The color varies somewhat with the races. In the white it is gray with a dark border, in the negro and Chinaman darker. Its eggs are 0.6 mm. (0.0236 inch) long, of which the female lays about fifty, w^hich mature in about a week, and in eighteen days are ready to re- produce. The eggs are attached to the hairs, and are easily visible, being known as nits. The head-louse is found the world over, upon the hairy heads of men and sometimes in other parts of the body where there are hairs. Even when they are quite numerous they mav produce no symptoms. Gener- ally, however, they cause itching and scratching, especially when the louse bores deep into the skin and produces pustular dermatitis, wath resulting ARTHROPODA. 1201 crusts and scabs in which the hair becomes matted and tangled, forming the plica polonica, so called from its frequency in Poland. 2. The pedicuhis vestimenti, or body-louse, is considerably larger, bemg from two to five mm. (0.1574 to 0.1968 inch) long and whitish-gray in color, the back part of the body being wider than the thorax. Its eggs are from 0.7 to 0.9 mm. (0.275 to 0.0354 inch) long, and about seventy are laid by the female. It lives on the clothing in which it deposits its eggs, about the neck, back, and abdomen. The puncture incident to sucking is often covered by a hemorrhagic point. It, too, causes itching and scratching, with irritation and inflammation of the skin, and in old cases a roughness and pigmentation causing dark spots and a condition known as morbus er- rorum or vagabond's disease, which has been mistaken for Addison's dis- ease. 3. The pedkulus pubis, phthirius inguinalis, or crab-louse, is smaller than the head-louse, grayish-yellow or grayish-white, the male being from 0.8 to I mm. (0.0314 to 0.0393 inch) long, the female 1.12 mm. (0.0441 inch) long. The eggs are pear-shaped, from 0.8 to 0.9 mm. (0.0314 to 0.0354 inch) long, and from 0.4 to 0.5 mm. (0.0157 to 0.0196 inch) wide. They infest the parts of the body covered by shorter hairs, such as the pubis, axilla, and eyebrows. The pediculus pubis does not wander so much as the pedicuhis capitis or vestimenti, but adheres more closely to the skin and there removal is often with difficulty. These lice rarely give rise to symptoms. Treatment. — Of Pediculosis. — For the head-lice: The hair should be cut short and burned, the head thoroughly washed with soap and water, and then anointed with mercurial ointment or washed with tincture of coc- culus indicus, or with coal-oil or turpentine, or carbolic acid, i to 50. Coc- culus indicus is to be preferred because of its freedom from odor. The wash- ing should be repeated for several days in succession. The treatment for the crab-louse is the same, but, as mentioned, it adheres firmly to the skin, and it is generally necessary to pick off the indi- vidual louse. To get rid of the body-louse the clothing, if not too valuable, should be burned, but may be boiled, or, when this is not admissible, treated by superheated steam. The"itching promptly disappears with its cause, but, if necessary, it may be allayed by a warm bath to which four or five ounces (120 to 150 gm.) of sodium bicarbonate are added. Repeated bathing with soft soap should be done until it is absolutely certain that the parasite and its ova are removed. 4. The cimex lectularius, or common bed-bug. This familiar insect is reddish-brown, oval in shape, from four to five mm. (0.0574 to 0.1968 inch) long, and three mm. (0.1181 inch) wide. The female lays three or four times a year about fifty eggs, 1.12 mm. (0.0441 inch) long, which require about eleven months for their perfect development to the sexually ripe con- dition. They live in the crevices of beds, floors, and rafters, in furniture, behind wash-boards and wall-paper, in the habitations of man. During the day they lie concealed; at night they wander in search of the blood of the human being, which they draw by means of a long proboscis. The peculiar odor of the insect is due to a secretion of a special organ with which the bug is provided. Human beings are variously susceptible to the bite of the bed-bug, some 76 I202 ANIMAL PARASITES. being quite indifferent to it, others being, as it were, special favorites of the httle creature. Treatment. — The irritation is confined to the moment of the bite. The aim to be sought is the extermination of the insect. This is often diffi- cult when a thorough lodgment is secured, and it is often necessary that all wall-paper should be removed as well as loose woodwork. Bedsteads should be thoroughly scalded and then treated with the following: Two tablespoonfuls of metallic mercury should be thoroughly beaten up with the white of one egg until a froth is attained. Apply freely with a small paint- brush, filling in carefully all cracks and crevices. The pest is ^ess apt to invade iron bedsteads, but even these must not be neglected, for they, too, in careless hands, may become infested. Solution of corrosive sublimate, 2 to 1000, may also be applied in the same manner. (b) Dipt era. 1. The pill ex irritans, or common flea. Of these little creatures, the male is from 2 to 2.5 mm. (0.0787 to 0.1181 inch) long, the female as much as four mm. (0.1574 inch), red or dark-brown in color. It is also highly capricious in its tastes, disturbing some persons not at all, others seriously. It is not a parasite of man, and invades him usuaHy because of its great abundance in certain places and countries. Though of world-wide dis- tribution, it is more troublesome in hot countries where cleanliness of household, city, and person is a matter of indifference. The eggs are not laid on human beings, but in the cracks of boards, sweepings, and wooden spit-boxes. Treatment. — The essential oils applied to the infested parts cause the retreat of fleas when applied. 2. The piilex penetrans, or sand-flea or jigger. The female buries her- self in the skin of human beings as well as of dogs, swine, and other mam- mals, producing painful irritation, circumscribed swelling, and even suppu- ration. It especially attacks the feet. It prevails in tropical countries, especially in Central and South America. The eggs are land-hatched. Treatment. — The flea may be picked out with a needle, after which the essential oils are rubbed in on the parts to keep it away. 3. Myiasis. — The diptera also contribute to parasites through their larvae, which are deposited sometimes in open sores which have been neglected, and sometimes in the nasal passages and cavities — the ear, phar- ynx, vagina, etc. The condition is called myiosis, from the Greek MVia^ a fly. The most common of these is myiosis vulnerum, in which an ulcer be- comes filled with maggots, which are the larvae of the blue-bottle or common flesh fly, sarcophaga carnaria. Myiosis nariinn, aiiriiini, conjimctivce, vagims, etc., are due to the lucilia maceUaria. whose larva is deposited in these situations usually when they are diseased, and may produce serious mischief, perforating mucous mem- brane and even cartilage. The larvae of the lueilia nohilis have also been found in the auditory passages, producing ringing of the ears as a symp- tom. The larA^ae of sarcophuga magniUca have been found in ulcers and other situations, throughout Europe, and especially in Russia. Cutaneous myiasis is commonly due to the larva of the hypodernia bovis or bot fly, the female of which lays her eggs on the skin of cattle and ARTHROPODA. 1203 sheep, in which the larva bores its way and forms the gad boil, about as large as a pigeon's tgg. Rarely in tropical countries this happens in the skin of man. Cutaneous myiosis is sometimes caused by the larva of the musca vomitoria, one of the domestic flies. More frequently it causes in- ternal myiosis, having been swallowed and again discharged by vomiting. More rarely dipterous larvae are found in the feces, including those of the common house-fly and the trichomysa fnsca, which has also been vomited. SECTION XIV. SUMMARY OF SY^IPTOMS FOLLOWIXG OVERDOSES OF POISONS. {Alphabetically Arratiged). To WHICH 13 Added a Table of Minimum Dose which Has Caused Death, and Maximum Dose Followed by Reco\'Erv. Aconite {Monkshood ; Wolfsbane ; Blue Rocket). — All parts poison- ous. The tincture may be mistaken for sherry or whisky ; it has an ex- ceedingly acrid taste. Symptoms. — These appear quickly, and consist of an acrid taste m the mouth, a feeling of warmth in the stomach, followed by a tingling sensation throughout the body : muscular weakness, slow, weak pulse ; vomiting may be present ; collapse follows. The mind is clear to the last. Treatment. — Stomach-tube or emetics : recumbent posture, with feet somewhat elevated. Stimulants freely, such as ammonia, ether, digitalis, atropin, and strychnin. Heat to the extremities, and artificial respiration for two hours. Alcohol. — Taken in the form of spirituous beverages. Acute alco- holic poisoning. A brief period of excitement, with flushing of the face, followed by unconsciousness, stertorous breathing, rapid and, finally, weak pulse, vomiting, a subnormal temperature, delirium, complete muscular re- laxation, at times convulsions ; the pupils are usually dilated. Recovery commonly takes place in a day or two, but remissions may occur. Odor of alcohol on the breath. Treatment. — Evacuation of stomach by pump ; emetics, like apomor- phin, i-io grain (0.0064 gm.) ; washing out the stomach. Stimulation by ammonia, coflfee, digitalis, strychnin, or even faradic current to muscles of respiration. Delirium Tremens. — Delirium, with hallucinations; great restlessness and insomnia ; slight fever, pulse rapid and soft. Treatment. — Withdrawal of alcohol : bromids in large doses, or chloral, aided by a cold bath to produce sleep ; nourishing food and stimulation if the condition demands it. even by alcohol. Ammonia. — Taken by mistake or with suicidal intent in the form of " household ammonia," water of ammonia, spirit of hartshorn, and in lini- ments. Symptoms. — At once, burning pain in the mouth, throat, esophagus, and stomach : the lips and tongue are intensely swollen and inflamed ; vom- iting of blood-tinged mucus, suffocative cough, with rapidly increasing dyspnea. The face is pale, pulse is rapid and thready, and collapse soon develops. Death may follow at once or some days later, from the violent gastro-enteritis and stricture of the esophagus. I204 ANTIMONY— ARSENIC— ATROPIN. 1205 Diagnosis. — Odor of ammonia on the breath, vapors of the corre- sponding salt when a rod dipped in hydrochloric acid is held before the mouth, together with the sudden onset of the symptoms. Treatment. — Neutralization with vinegar or some other dilute acid at once, the acid being mixed with some bland oil, if possible. If the patient lives, treat the results of the violent inflammation. Tracheotomy should be performed, if there is danger of death from edema of the larynx. Antimony. — Taken as a tartar emetic, the tartrate of antimony and potassium. A heavy, white, odorless, slowly soluble powder having a sweet- ish, metallic taste ; charring on heating to redness. Symptoms. — ^Metallic taste in the mouth, burning pain in esophagus, stomach, and abdom.en, dysphagia, violent vomiting and purging of serous material, cramps in the stomach and muscles of the arms and legs. Finally, the symptoms of collapse — cold, clammy skin, great depression, respirations shallow, pulse weak and thready. There may be convulsions, delirium, and coma. Treatment. — If no vomiting, apomorphin, i-io grain (0.0064 gm.), or another emetic ; tannic acid as a chemical antidote, followed by washing out of stomach; external heat, stimulants to combat the collapse, and opium when the acute symptoms have disappeared. Arsenic. — Used in the form of arsenious acid in rat-poisons, in fly- paper, and to preserve stuffed birds and animals. Paris green, used as potato- bug poison, is an arsenite of copper, hence the symptoms are similar. Ar- senious acid, or white arsenic, is an odorless, tasteless, white powder, quite heavy, and but slowly soluble in water. Symptoms. — These appear usually in the course of an hour, and are those of violent gastro-enteritis, so severe as to suggest Asiatic cholera. Burn- ing pain in throat and stomach, persistent vomiting of brown matter streaked with blood, though the vomited matter may be green from bile. Purging of serous and bloody material, and finally collapse. Fatal in a day or two, though a remission sometimes occurs on the third day. Nervous symptoms may appear, and at times a case of arsenic poisoning closely simulates acute yellow atrophy of the liver. Treatment. — Early stage, stomach-tube, or emetics. Chemical anti- dote, the freshly prepared hydrated oxid of iron, made by precipitating the solution of tersulphate of iron by ammonia; the tincture of chlorid of iron may be used instead of the solution. Mix and strain, wash, and administer the magma. The best antidote is the ferri oxidum hydratum, U. S. P., or ferri oxidum hydratum cum magnesia, the latter acting also as a ourgative. Otherwise treat the collapse. Atropin {Belladonna). — The deadly nightshade. Used as a mydri- atic and in liniments. The leaves impart a narcotic odor to the tincture, but recognition depends upon the physiological effect. Symptoms. — The throat is dry. the pupils are dilated, the pulse is rapid and hard ; respirations are quickened and deepened ; there is great rest- lessness, occasionally talkative delirium. An erythematous rash is some- times present. The urine contains the alkaloid, hence it will cause dilatation of the pupil if dropped into the eye of an animal. Treatment. — Tannic acid, followed by the stomach-tube or emetics. i206 SYMPTOMS FROM OVERDOSES OF POISONS. Physiological antidotes : Morphin, physostigrnin, and pilocarpin. Artificial respiration for two hours. Catheterize, as patients frequently suffer from retention. Meet collapse by proper stimulation. Belladonna. — See Atropin. Bromin. — A dark-red, very heavy liquid, emitting reddish vapors re- sembling chlorin. The fumes, when inhaled, cause convulsive cough, bloody expectora- tion, dyspnea, and spasm of the glottis. Treatment. — Fresh, moist air and cautious inhalations of ammonia. Bromism. — The symptoms of chronic gastro-intestinal disturbance such as fetor of the breath, anorexia, diarrhea ; great depression of all the functions, especially the sexual function, with languor and mental apathy. A general eruption of acne is an early sign. Treatment. — Stop the administration and aid elimination. Carbolic Acid (and Creasote) is a colorless or reddish liquid, or a crystalline solid, when pure; w^hen impure, the color varies from this to black. It has a characteristic odor. Symptoms. — These appear quickly. Burning pain in the mouth and stomach, though there may be no pain. \'omiting may be absent. Soon coma sets in, with feeble respiration, collapse, and convulsions. The urine is smoky, but the most characteristic sign is the white eschar on mouth and lips, with the odor of the acid on the breath. Treatment. — Any soluble, non-poisonous sulphate, such as sulphate of magnesia or sulphate of sodium, as a chemical antidote. Stomach-tube or emetics, followed by washing out stomach with a solution of a sulphate. Oil to counteract the escharotic effect. Treat the collapse with heat, stimu- lation, etc. Carbonic Acid Gas. — The choke damp or after-damp of miners. May be accidentally inhaled in overcrowded rooms, in fermenting vats, over lime-kilns, or wherever the products of complete combustion cannot es- cape. Symptoms. — Headache, dizziness, vomiting, and great drowsiness, with relaxation of the muscles ; hurried respiration, with violent action of the heart. Soon coma ensues. Treatment. — Fresh air, if need be; artificial respiration, kept up steadily and unceasingly ; ammonia by inhalation ; oxygen, if obtainable ; cold douche to the head and chest, with stimulation as occasion requires. Carbonic Oxid (Carbon Monoxid) is formed during the incomplete combustion of carbon, and is a direct poison, while carbonic acid gas, the product of complete combustion, kills merely by exclusion of oxygen. Treatment as for carbonic acid gas. Caustic Potash or Soda. — Taken in the form of " lye." Symptoms. — An acrid, burning taste, the burning extending down to the stomach, followed by vomiting, purging, and collapse. The mucous membrane of the mouth shows evidence of corrosion. CHEESE POISONING— CONIUM. 1207 Treatment. — Olive oil, to saponify the alkali ; demulcent drinks, dilute acids, like vinegar and lemon-juice, to neutralize. If the patient lives, the resulting stricture of the esophagus requires dilatation. Cheese Poisoning. — Decayed cheese owes its poisonous properties prob- ably to tyrotoxicon. Usually there is severe gastro-enteritis, with vom- iting and purging. Treatment. — The stomach-tube may be used if vomiting has not been very free ; subsequent lavage ; sedatives for the irritation. Chloral. — A popular somnifacient and sedative. Occurs in deli- quescent crystals with characteristic odor and acrid, burning taste. Symptoms. — Profound unconsciousness, complete muscular relaxation; sensibility diminished or lost ; the pulse becomes feeble and rapid, the respira- tions are diminished in frequency and may be stertorous ; the temperature is depressed more than by any other toxic agent. Treatment. — Evacuate the stomach; keep up the temperature by ap- plication of heat ; rouse the patient ; stimulate ; use artificial respiration in conjunction with the battery. Chloroform. — Identified by its peculiar ethereal odor and sweet, pun- gent taste; a heavy, volatile, non-inflammable liquid, not miscible with water. Symptoms. — First stage of narcosis, excitement, muscular rigidity, les- sened sensibility to pain. Second stage, muscular relaxation, anesthesia of conjunctiva, insensibility to pain. Third stage, stertorous breathing, dilated pupils (not responding to light), abolition of all reflexes, muscles ab- solutely relaxed. Death usually by failure of circulation. The symptoms are the same if the chloroform is taken by the mouth. Treatment. — In case the chloroform was used as an anesthetic, lower the head, slap a wet towel on the patient's chest ; pull out the tongue to see that the mouth is clear ; artificial respiration at the rate of twenty respira- tions a minute, aided by the cautious use of the battery (intierrupted cur- rent). When taken internally, stomach-tube or emetics ; flicking with a wet towel ; stimulation with coffee by rectum ; whisky by mouth, if possible. CocAiN. — Solution used as a local anesthetic, particularly in eye sur- gery. Symptoms. — Vertigo, headache, paroxysmal dyspnea, rapid weak pulse, elevated temperature, mental excitement, blindness, delirium, coma, and convulsions. Some of these may be caused by the local application of solu- tions to mucous membranes. The pupil is dilated, but the power of ac- commodation remains in part. Treatment. — Nitrate of amyl, stimulants, atropin, caffein, and ammonia. Death is unusual. CoNiUM (Poison Hemlock; Common or Spotted Hemlock). — Not a native of this country, hence cases of poisoning must be restricted to the use of the preparations. The plant and some of the preparations have a peculiar fiodor, resembling the urine of mice. Symptoms. — Prominent is the loss of muscular power, the patient stag- I208 SYMPTOMS FROM OVERDOSES OF POISONS. gering as if intoxicated ; the arms and chest are affected later on, and death may ensue from paralysis of the muscles of respiration. In other cases there are delirium, stupor, coma, and convulsions ; the pupils are dilated, and ptosis is a peculiar symptom. Treatment. — Stomach-pump or emetics; tannic acid, stimulants, heat, artificial respiration. Copper. — The sulphate, blue stone or blue vitriol, is used in the artSv. Recognized by its crystalline shape, blue color, and acrid, metallic taste. Articles of food are frequently prepared in imperfectly cleansed copper ket- tles ; a bright piece of steel, such as a knife, will show a deposit bi metallic copper a few minutes after immersion in a liquid containing copper. Verdi- gris (subacetate) is another source. Symptoms. — A metallic, astringent taste in the mouth ; griping andi colicky abdominal pains ; vomiting, purging, accompanied by tenesmus, the stools being mucous or bloody. Respiration embarrassed, small, quick pulse,, weakness, great thirst, coma, death. Treatment. — Stomach pump or emetics if vomiting has not emptied the stomach ; demulcents, like milk and eggs ; chemical antidotes are soap, sodium carbonate, and the yellowish prussiate of potash. Opium should be used as a sedative. Digitalis {Foxglove). — A native of Europe. The tincture has a dis- tinct odor of tea, the drug itself lacking a narcotic odor. Symptoms. — Vomiting and purging of green material; pulse slow, later rapid and irregular; headache, occasionally delirium and convulsions; the skin is cold and clammy, and the pupils are dilated. Coma and death come on quite suddenly, though the mind may be perfectly clear. Treatment. — Stomach-pump or emetics if necessary ; tannic acid, twenty grains (1.33 gm.), repeated frequently; strong tea; stimulation with whisky,, ammonia, or hot coffee ; maintain recumbent position for some time after all. symptoms have subsided. Ergot. — Used to produce abortion. Symptoms. — ^A large dose produces cramps in the legs, arms, and', chest, dizziness, weakness, pulse small and pupils dilated, skin cold; there- may be vomiting and diarrhea. Chronic ergotism, produced by eating bread tainted with ergot of rye,, causes muscular cramps, paresis, delirium, and convulsions ; in other cases; a dry gangrene. It occurs in Europe. Fish-poisoning. — Tainted fish probably contains ptomains, while sev- eral kinds of fish are constantly poisonous. Symptoms. — Vomiting, irritation of the eyes, great depression, and severe nettle-rash. Treatment depends upon the symptoms. Hydrochloric Acid. — See Mineral Acids. Hydrocyanic Acid (Pnissic Acid). — The pure acid is an exceedingly poisonous gas. In medicine it is employed as a two per cent, aqueous solu- tion. Contained in oil of bitter almonds distilled from the seed; not fourrdi lODIN— MERCURY. 1209 in the artificial or the purified natural product. Its salt, the cyanid of potassium, is employed as a quickly acting poison for the destruction of animals. Contained also in cherry-laurel water. Symptoms. — Patient is nearly always insensible in two minutes if a fatal dose is taken. Loss of motor power, giddiness, slow respirations, pupils insensible to light, eyes protruding, pulse weak ; frothing at the mouth, perhaps tetanic convulsions. The odor o^ oitter almonds is about the patient. Treatment. — Stomach-tube or emetics, stimulants, hot and cold douche ; artificial respiration, kept up steadily, as the patient is probably safe if tided over the first half-hour. Apply mild interrupted current to region of heart. loDiN. — May be taken by mistake; the tincture has the odor of iodin, which somewhat resembles chlorin. Symptoms. — The symptoms of a violent gastro-enteritis, such as burn- ing pain in the throat, stomach, and abdomen, with vomiting and purging. The vomited matter may be yellow from iodin, or blue if starch is present in the stomach. Treatment. — Starch (arrow-root) in any form as chemical antidote; stomach-tube or emetics ; opium as sedative. Iodoform. — Rarely taken internally, but toxic symptoms may appear when used freely as an antiseptic dressing. Symptoms. — Most marked among these are great somnolence, slight nocturnal delirium, headache, hurried breathing and rapid pulse. These,, with a slight elevation in temperature, often resemble cerebral meningitis^ A rash may accompany the intoxication. Treatment. — If taken internally, emetics, etc. Substitute another anti- septic as a dressing and aid elimination. Lead. — Taken as sugar of lead (acetate), Goulard's solution (subace- tate), lead water (subacetate), white lead (carbonate). Symptoms. — In acute poisoning there are the symptoms of a violent gastro-enteritis, with colicky pains, especially about the umbilicus, and re- lieved by pressure ; abdominal walls hard ; cramps in the legs ; convulsions. Treatment, — Rid the stomach of the poison; use dilute sulphuric acid or a non-poisonous sulphate as a chemical antidote ; demulcents with opium for the pain. Chronic Poisoning. — Constipation, with colicky pains centering around the navel ; abdominal walls retracted and hard ; pulse apt to be hard and corded; headaches; paralysis of extensor muscles of forearm (bilateral wrist-drop) ; a blue line on the gums, due to a deposit of sulphid of lead. Treatment. — A thorough course of potassium iodid; treat the con- stipation ; avoid further trouble by cautioning lead-workers to clean their hands thoroughly, and by the use of culphuric acid internally. The colic may require opium. Meat Poisoning. — Vide Ptomain Poisoning. Mercury (Corrosive Siihlimate; Bichlorid of Mercury; Merciiric Clo- rid, or the Perchlorid). — Used in aqueous solution as bed-bug poison, as an insecticide, to preserve specimens, and as an antiseptic surgical dressing. 12 lo SYMPTOMS FROM OVERDOSES OF POISONS. Symptoms. — In concentrated form it is corrosive, hence mouth and iips are swollen and white ; a metallic taste ; esophagus, stomach, and ab- domen are the seat of intense pain ; there are vomiting and purging of jnucus and bloody material ; scanty, albuminous urine ; collapse. Treatment. — Stomach-pump or emetics ; white of egg as chemical anti- dote ; demulcents ; stimulants. Mineral Acids. Hydrochloric Acid (Muriatic Acid: Spirit of Salt), Symptoms. — Similar to those mentioned under sulphuric acid, though the acid is not so powerful and leaves no distinctive stain. It may be recognized by its odor and by the white fumes formed when the gaseous acid comes into contact with ammonia. Medicinally and in the arts hydro- chloric acid is used in aqueous solution, the commercial variety tinted yellow from a trace of iron. Treatment. — Same as for sulphuric acid. XiTRic Acid {Aqua fortis). — A colorless, moderately heavy liquid of peculiar and characteristic odor, staining organic tissues yellow. S5miptoms. — The same as those mentioned- under sulphuric acid, though the characteristic yellow stain may be found on the lips. Treatment. — As for sulphuric acid. Sulphuric Acid {Jltriol; Oil of J'itriol). — A very heavy, colorless, odorless liquid, having a very acid taste and mixing with water with the production of great heat. Used largely in the arts. Turns organic matter l)lack. Symptoms. — Burning pain from mouth to stomach ; lips and mouth white, the vomited matter stained bloody and black ; dysphagia ; unconscious- ness ; collapse. Treatment. — Immediate neutralization, or at least dilution, 'of the poison; soap and water, chalk, magnesia, lime-Avater, bicarbonate of sodium, or, in their absence, water in large quantity ; demulcents and opium as a sedative. A''. B. — Sulphuric acid may kill by edema of the glottis or by the secondary effects resulting from esophageal stricture and destruction of the gastric mucous membrane. MoRPHix PoisoxiXG. — See Opium Poisoning. ^Mushroom Poisoxixg. — Harmless varieties may prove poisonous to some individuals. Agaricus muscarius is the most poisonous variety, con- training the active principle muscarin. The fungus is bright red, with yel- low spots. As a rule, highly colored fungi, with an astringent, styptic taste and a pungent odor should be avoided ; they frequent especially dark and shady places. Symptoms. — Excitement, violent colic, vomiting, and diarrhea ; breath- ing stertorous ; surface cold ; pulse slow ; death from cardiac failure. Treatment. — ^Evacuate stomach and bowel ; heat : stimulation ; atropin as physiological antidote. NicoTix. — The liquid, volatile alkaloid of tobacco. An acrid, oily NITROBENZOL— PHOSPHORUS. 121 1 liquid of amber color, smelling of tobacco. A very deadly and quickly act- ing poison. Symptoms. — Nausea, vomiting, faintness, great weakness ; pulse rapid and feeble ; mental confusion ; sight dimmed ; skin cold and clammy. Treatment. — Rid the stomach of the poison ; administer tannic acid ; strychnin ; heat ; stimulants ; place patient in the recumbent posture. NiTROBENzoL (Nitrobenzene; Oil of Mirhane ; Artificial Oil of Bitter Almonds). — Used in the preparation of anilin dyes and in the arts on ac- count of its flavor (soaps, etc.). Recognized by its highly characteristic odor. Symptoms. — Usually not evident for an hour or two. Headache, weari- ness, nausea ; the mind gradually becomes confused ; there is great anxiety and cyanosis appears, the latter becoming extreme, until the whole body is blue. Stertorous breathing, coma, death by asphyxia or failure of heart. Treatment. — As the poison is slowly soluble, wash out the stomach, even if a long time has elapsed since its administration; stimulants (whisky, not until after evacuation of stomach, because it renders the poison more soluble); artificial respiration; interrupted current. Opium Poisoning (Acute). — Taken accidentally or with suicidal in- tent in the shape of morphin or laudanum. Symptoms. — Drowsiness, stupor, deep breathing; if due to laudanum, smell if it is on the breath ; contracted pupil, slow, full pulse. For a time patient may be aroused by shouting into the ear. Treatment. — ^Evacuate stomach by stomach-pump or tube, wash out thoroughly ; administer strong cofifee ; flagellation and electricity to keep patient awake; if respiration fails, atropin and strychnin hypodermically ; also electricity to phrenic nerve; artificial respiration. Oxalic Acid. — Mistaken for Epsom salt; taken with suicidal intent. Occurs in prismatic, colorless, odorless crystals, with a very sour taste. Volatile without charring at a red heat. Symptoms. — Those of a violent, rapidly fatal gastro-enteritis, asso- ciated with cramps in the legs ; the mouth may be white. Collapse comes on quickly. Convulsions occur occasionally. Treatment. — Carbonate of calcium in any form ; chalk, whitening, or marble-dust; lime, lime-water. In an emergency whitewash from a wall. Follow by a purgative of castor oil. Phosphorus. — Employed in the form of a paste as a rat and roach poison ; matches are sometimes sucked for suicidal purposes. The paste is recognized by its peculiar garlicky odor, and by the luminous fumes it emits in the dark. Symptoms usually do not appear until after the lapse of a few hours. At first the ordinary signs of irritant poisoning appear, such as pain and vomiting, the ejected material being luminous in the dark. A garlicky taste in the mouth, and the odor of phosphorus may be perceptible on the breath. Later on there is severe abdominal^ pain, also pain in the region of the liver; this organ may be enlarged. The symptoms subside, but from the third to the fifth day more serious ones develop : jaundice, accompanied by pain and vomiting; discharges of blood from, the bowel, with extravasations beneath 12 12 SYMPTOMS FROM OVERDOSES OF POISONS. the skin. The urine may be suppressed or scanty, albuminous, and bile- stained ; bowels constipated or loose, the stools clay-colored and sometimes phosphorescent. Death after grave nervous symptoms, such as headache,, delirium, convulsions, stupor, and coma, and may occur very suddenly. Convalescence is much protracted if patient recovers. Treatment. — Emetic of five grains (0.33 gm.) of sulphate of copper, which acts also as a chemical antidote. Permanganate of potassium in dilute solution. French oil of turpentine acts also as an oxidizing agent, but cannot be obtained in this country. Otherwise the treatment is symptomatic. Ptomain Poisoning. — Ptomains are alkaloidal bodies, the products severe abdominal pain, vomiting, purging of bloodstained material, partial paralysis, convulsions, and collapse. Treatment. — Stomach-tube or emetics ; demulcents ; stimulants ; heat. Ptomaine Poisoning. — Ptomaines are alkaloidal bodies, the products of the decay of animal tissues. These are probably the cause of the poison- ous action of tainted meat and fish, cream-puffs, ice-cream, blanc mange,. and cheese. Poisonous Fish. — Sickness and vomiting, great depression, irritation oi the eyes, severe nettlerash. Shell-fish is especially apt to produce a rash in susceptible persons. Poisonous meat contains ptomains, those produced when stale meat is just beginning to decay being more virulent than others which replace the first when decomposition is well under way. Ices, Ice-cream. — The cheap varieties are colored with anilin dyes, which may not be free from arsenic. Again, the highly poisonous alkaloid, tyrotoxicon, may have formed in the milk used, and to this principle most cases of poisoning of this kind are traced. Symptoms vary — dryness of throat, vomiting, and purging are those most commonly observed. Treatment must be symptomatic. Silver Nitrate (Lunar Caustic). — Used in the form of the fused nitrate as a caustic. Otherwise in colorless, rhombic crystals, freely soluble, with astringent metallic taste. Yields a white precipitate with chlorids and stains organic matter black. Symptoms. — Partly gastro-intestinal and partly cerebro-spinal. Vom- iting of white material which rapidly becomes black ; vertigo, unconscious- ness, epileptiform convulsions. Treatment. — Common salt to be given immediately, followed by stomach-pump or emetic. Otherwise symptomatic. Strychnin. — An alkaloid occurring in nux vomica and ignatia. Ap- pears in the form of white, prismatic, odorless crystals which have an intensely bitter taste. Used as a vermin killer. Symptoms. — Ordinarily these appear quickly. A sense of suffocation, great difficulty in breathing, from paralysis of the muscles of respiration ; great anxiety, though the mind is perfectly clear ; twitching of the muscles, finally amounting to tetanic convulsions, with intervals in which the patient SULPHURETED HYDROGEN— ZINC. 1213 is exhausted and bathed in perspiration ; opisthotonos ; death from asphyxia, or, between the attacks, from exhaustion. In tetanus there is usually the history of a wound ; symptoms develop much more gradually; the muscles of the jaw are early involved, and trismus is much more marked than spasm of the respiratory muscles, and the con- vulsions are tonic. Treatment. — Emetics or stomarh-tube at once — after the spasms have once set in, the introduction of a tube would excite them ; tannic acid ; nitrite of amyl ; chloroform or ether, by inhalation ; artificial respiration, if possible. SuLPHURETED Hydrogex has the characteristic odor of rotten eggs. It forrns the bulk of the gas emanating from sewers and cess-pools, some ammonium sulphid and nitrogen occurring with it. If dilute, the symptoms are nausea, diarrhea, depression, and headaches. In more concentrated form it produces unconsciousness, frequent respiration, rapid pulse, dys- phagia, dilated pupils insensible to light, tonic convulsions, and a tempera- ture as high as 104° F. (40° C.) during the convulsions. In a state ap- proaching purity sewer gas kills almost instantly ; in moderate amount it frequently causes death in twenty-four hours, all efforts to restore con- sciousness proving useless. Treatment. — Fresh air ; artificial respiration for many hours ; ammonia by inhalation ; stimulation. Zinc. — The chlorid, in solution, is used as a disinfectant (Burnett's Disinfecting Fluid). A very heavy, corrosive, colorless liquid, of astringent taste. It partakes of the nature of a corrosive poison. Symptoms. — Burning sensation in throat and stomach, perhaps signs of local corrosion. Nausea, vomiting, purging, dyspnea, convulsions, coma, death. Treatment. — Carbonate of potassium or sodium in water ; milk ; eggs ; tannic acid ; opium as a sedative. I2I4 SYMPTOMS FROM OVERDOSES OF POISONS. MINIMUM DOSE WHICH HAS CAUSED DEATH, AND MAXIMUM DOSE FOLLOWED BY RECOVERY. Name OF Poison. Aconite, . . Alcohol, . . Ammonia, Antimony, . (Tartar Emetic) Arsenic, . . . Atropin, . . Belladonna, . . Carbolic Acid, Chloral, . . . Chloroform, Cocain, . . . Colchicin and Colchicum, Copper Subace- tate (Verdigris) Copper Sul- phate, . . . Digitalis, Gelsemium and Gelsemin, Minimum Dose which HAS Caused Death. From merely tasting Fleming's tincture to f3j (3-7 c.c.) Flem- ing's tincture. l4 pint gin (236.56 c.c), 2 bottles of port (= II oz.) (29.57 c.c. alcohol). In a boy ot seven j'ears, f | iv (120 c.c.) brandy. f 3ij (7-4 c.c.) 'aqua ammonite fortior. 2 grains (0.132 gm.). %" grain (0.0495 gm.) in a child. Less than i (0.099 gm )• grams Maximum Dose with Recovery. f 3 iij ( II. I c.c. ) Fleming's tincture I quart gin (946.24 c.c); I quart whisky (946.24 c.c); 2 bot ties port ; i}4 pints (236.56 c.c.) mixed gin and brandy. f 1 J (29-57 c.c.) aqua ammoniae fortior. ! ss (15.84 gm.). 3]— 313 (3.96-7.92 gm.). Recovery probable after i gr. [ grain, ly^ grains (0.066 to o.ogg byi gm.). Child two years old, i grain (0.066 gm.), child four years old, grain (0.033 gm.) f 3 j (3.7c.c.)liniment.,f §ss (15 c.c) lini- ment; 3 iij (11.88 2 grains (0.132 gm.). ■^ grain hypodermic- ally ; yij- grain stomach. Usual Fatal ■Dose. Fatal Period. f 3 j (3.7 c.c). 10 grains (0.66 gm.); 20 grains (1.32 gm.); 30 grains (1.98 gm.). 15 drops (0.9 c.c.) in- haled ; 30 drops (1.8 c.c.) inhaled ; f | ss (0.15 gm.) f§j (0.3 c.c.) internally, )4 grain (0.033 gm.) in a child of eleven (in forty seconds); i2grs (0.792 gm.) (injected into urethra); 24 grs. (i.584gra.) (injected into rectum). '/^ grain (0.022 gm.) (alkaloid) f 3 iiss (9. 25 c.c) wine of root ; f 3 iiiss (12.25 c.c) of root. §ss, § j (i6to32gm.). Child sixteen months old, from merely sucking crj'stals; fj, (32 gm.) in an adult. Uncertain. f?jfl. ext. (3.7 c.c);i mxij fl.ext.(in a child)l gm.) extract. f3j (3-7 c.c). 180 grains (11. gm.); 460 grains (30.36 gm.). f § ij (60 c.c.) taken internally ; f § iv (120 c.c). 24 grains (1.584 gm.) (by stomach). f § j wine (29.55 C.C.); ^ grain alkaloid (0.0495 gm.). j (32 gm.) adult. f § ij (60 C.C.) tinc- ture ; 3 j (4 gm.) powdered digitalis. f §ss (15 c.c.) aqua ammo niae fortior. 3 j (4 gm-)- lyz to 2 grains (0.099 too. 165 gm.). >^ to 3^ grain (0.033 to 0.0495 gm.). f§ss. (14.785 c.c.) of the pure, f 3 j(3-7 c.c.) of the impure, acid Usually three or fourhours. One-half hour to several 'days. A few hours, months, or even years. An hour up to several days. Death usually within twen- ty-fourhours. Death usually within twen- ty-four hours. Death usually within twen- ty-fourhours. Death usually within an hour. One-half hour or less. Twenty-four hours. Fourto twelve hours. Four to twelve Irours. About twen- ty-fourhours. Three to four hours. MINIMUM DOSE WHICH HAS CAUSED DEATH. 1215, MINIMUM DOSE WHICH HAS CAUSED DEATH, AND MAXIMUM DOSE FOLLOWED BY '9JECOY^KY—{Conimued). Name of Poison. Hydrochloric Acid, . . . Hydrocyanic Acid, . . . Minimum Dose which HAS Caused Death. Maximum Dose with Usual Fatal Recovery. Dose. (Cherry-laurel Water), . . . (Oil Bitter-Al- monds) (natu- ral unpurified), (Potassium Cy- anid), . . . lodin, .... Iodoform, . . Lead (Acetate), (Goulard's So- lution), . . . (White Lead), Mercury Bi- chlorid, . . iff ss (15 CO.) in an adult , f 3 j (3.7 c.c.) in a child. 45 )fi (2.7 c.c.) diluted acid (2 per cent.). Insensibility from merely smelling the strong acid. ill] (60 c.c). 17 drops. (contains about 10 to 15 per cent. HCN). 5 grains (0.33 gm.). 20 grains (1.32 gm.). 3 grains (0.198 gm.). f 3 ]' ( 3-7 c.c. ) Scheele's acid (4 per cent.). Morphin, Nitrobenzol(Oil of Mirbane), . Opium, Oxalic Acid, Phosphorus, Potassium Hy- droxid (Caus. tic Potash), Saltpeter, . . Silver Nitrate, Strychnin, . . i^ grain (0.0495 gm.); I grain (0.066 gm.). From merely tasting it; 8 or 9 drops (0.4 to 0.54 c.c). f3ij (7-4 c.c) lau- danum ; 2^ grains' (0.165 gm.) extract ;i 3 j (3.96 gm.) lauda-j num ; 2 or 3 drops. (0.12 to 0.18 c.c)j laudanum in a very young child. 3i] (0.132 gm.); 3j (3.96 gm.) in a boy of sixteen. Lessthanigrain(o.o66 gm.). Childdied from sucking 2 matches. Another from swal- lowing the tops of 8 matches. 40 grains (2.64 gm.). 3] (32 gm.). f 3iv (15 c.c). 3iv (16 gm.). Ij (32 gm.). f |xij (360 c.c). !J (32 gm.). I j (32 gm.). 75 grains (4.95 gm.); 20 grains ( 1.32 gm.). f 3 ss (1.85 c.c). f 3 ij (60 c.c.) lauda- num ; f § iv to f § V (120 to 150 c.c.) laudanum. ss (16 gm.). After sucking 300 matches. ij (64 gm.). f zss (15 c.c.) for an adult ; f 3j (3-7 c.c) for a child. 45 }n to f3j (2.7 to 3.7 c.c). 10 to 30 drops (0.6 to 1.80 c.c). 3 to 5 grains (0.198 to 0.33 gm.). Fatal Period. From a few hours to many weeks. Ten to fifteea minutes. Few hours to several davs. 3 to 5 grains From ten (0.198 to 0.33 hours to gm.). 50 per cent, of cases fatal. 2 to 6 grains'Seven eleven days. to (0.132100.596 twelve hours, gm.). Four to hours. five 30 grams. ^ ). yV grain (0.0041 gm.) 10, 12, 40 grains inachildof 2^ years;! (0.66 to 0.792 to Yz grain (0.033 gm.) 2.64 gm.) in an adult. 4 to 5 grains Seven to (0.264 to 0.33 twelve hours, gm.). 5ss(i6gm.). jWithin one I hour. A little lessjOne to five than I grain. I days. 3ss (16 gm.). § j to § iss (32 A few hours, to 48 gm.). % to I grain's minutes to (0.033 to 0.066 several hours, gm.). In adultsdur- ing or after the 4th or 5 th p aroxy sm; children i-3d convulsion. APPENDIX TABLES FOR REDUCING THE METRIC SYSTEM INTO THE ENGLISH. {Troy Weight.) xi? — Grains to Grams 0.00033 0.00034 0.00035 0.000357 0.00036 0.000377 0.000388 0.0004 0.000413 0.000425 0.00044 0.000455 0.00048 0.00049 0.0005 o 000528 0.00055 0.000574 0.0006 GRAms TO Grams. Grains to Grams. 0.000628 A = 0.0055 0.00066 A = 0.0066 0.00694 \ = 0.0082 0.0073 1 = 0.0094 0.0077 \ = O.OII 0.0082 ^ = 0.0132 0.0085 \ r= 0.0165 0.0094 i := 0.022 O.OOI 1 = 0.033 O.OOII I r= 0.066 0012 2 = 0.132 0.00132 3 = O.I9S 0.00146 4 = 0.264 0.00165 5 = 0.33 0.00188 6 = 0.396 0.0022 7 = 0.462 0.00264 8 = 0.528 0.0033 9 = 0.594 0.0044 10 = 0.66 Grams to Grains. I = 15-43 2 = 30.86 3 = 46.29 4 = 61.72 5 = 77-15 6 = 92.58 7 = 108.01 8 = 123.44 9 = 138.87 = 154-3 X pound avoirdupois = 453.5925 gm. I ounce " = 28.3495 gm. I grain " = 0.0648 gm. Grains to Milligrams. I = 64.8 2 = 120.6 3 = 194.4 4 = 259.2 5 = 324 6 = 338.8 7 = 453-6 8 = 518.4 9 = 583.2 10 =: 648 r dram or 60 = 3.89 gm. I ounce or 480 — 31. 1 gm. FLUID MEASURES. I teaspoonful distilled water = i fluid dram I dessertspoonful distilled water = 2 fluid drams I tablespoonful distilled water = 4 fluid drams I wineglassful distilled water I fluid ounce distilled water 16 fluid ounces distilled water = i pint = 2 fluid ounces =: 3.7 c. c. 7.4 c. c. 14.8 c. c. 59.14 c. c. = 29.57 c. c. {circa 30 c.c.*) = 473.11 c. c. {circa 480 c.c.) * A fluid ounce of water which measures 30 c.c. does not. weigh 31. i gm., because an ounce of ■water really weighs but 455.7 grains Troy, and not 480 grams. 1216 APPENDIX. 1217 •TABLES FOR REDUCING THE METRIC SYSTEM INTO THE ENGLISH FLUID MEASURES— (C^w/z/n/;^^). JVIiNiMS TO Cubic Cen- timeters. I = 0.06 2 =r 0.12 3 ^ 0.18 4 = 0.24 5 = 0.31 10 = 0.62 15 = 0.92 i6i = I 20 = 1.23 30 = 1.85 40 — 2.46 Fluie Ounces to Cubic Centimeters I = 29-57 2 := 59-14 3 = 88.71 4 = 118.28 5 = 147-75 6 = 177-42 7 = 206.99 8 = 236.56 9 = 266.13 10 = 295-7 12 = 354.84 16 = 473-12 Cubic Centimeters to Minims. I = 16.2 2 =: 32-4 3 = 48.6 4 = 64.8 5 = 81 6 = 97.2 7 = II3-4 8 = 129.6 9 ■=. 145.8 Liters to Fluid Ounces 1 = 2 = 33-8 67.6 3 = 101.4 4 = 5 = 6 = 135-2 169 202.8 7 = 236.6 C = 270.4 9 =: 10 =: 304.2 338 Fluid Drams to Cubic Centimeters. I = 3.7 2 = 7-4 3 = II. 1 4 =: 14.8 5 = 18.5 6 = 22.2 7 = 25-9 8 = 29.6 9 = 33-3 10 = 37 Liters to Pints. I =: 2.1 2 = 4-2 3 = 6-3 4 = 8.4 5 = 10.5 6 = 12.6 7 = 14.7 8 = 16.8 9 = 18.9 10 = 21 Cubic Centimeters to Fluid Drams. I = 0.27 2 = 0.54 3 = 0.81 4 = 1.08 5 = 1-35 6 = 1.62 7 = 1.89 8 = 2.16 9 = 2-43 10 = 2.7 Pints to Liters. I = 0.473 2 = 0.946 3 = 1. 419 4 = 1.892 5 = 2.365 6 = 2.838 7 = 3-3II 8 = 3-784 9 = 4-257 10 = 4-73 LINEAR MEASURES. Centimeters to Inches TO Centi- I Inches to Milli- Millimeters to Inches. meters. meters. Inches. I = 0.3937 I = 2.54 I = 25-4 I = 0.03937 2 = 0.7974 2 = 5.08 2 = 50.8 2 = 0.07874 3 = 1-1817 3 = 7.62 3 = 76.2 3 = 0.11811 4 = 1.5784 4 = 10.16 4 = 101.6 4 = 0.15784 5 = 1.9685 5 = 12.7 5 = 127 5 = 0.19685 6 = 2.3622 6 = 15-2 6 = 152.4 6 = 0.23622 7 = 2.7559 7 = 17.78 7 = 177.8 7 = 0.27559 8 = 3.1496 8 = 20.32 8 = 193.2 8 = 0.31496 9 = 3-5433 9 = 22.86 9 = 228.6 9 = 0.35433 10 = 3-9370 10 = 25.4 10 = 254 10 = 0.3937 Feet to Meters. Meters 1 Feet. I = 0.3048 I = 3-28 2 = 0.6096 2 = 6.56 3 = 0.9144 3 = 9.84 4 = I. 2192 4 = 13.12 5 = 1.524 5 = 16.4 6 = 1.8288 6 = 19.68 7 ^ 2.1336 7 = 22.96 8 = 2.4348 8 = 26.24 g — 2.7432 f 9 = 29-52 10 -= 3.048 10 =t : 52.8 77 A micromillimeter = o.ooi millimeter. Symbol (i. I2l8 APPENDIX. TO CONVERT DEGREES OF FAHRENHEIT'S THERMOMETER TO CENTIGRADE, AND VICE VERSA. Centigrade to Fahkenheit. Fahrenheit to Centigrade. I — 1.8 2 = 3.& 3 = 5-4 4 = 7-2 5 = 9 6 = lo.S 7 = 12.6 8 = 14-4 9 = l6.2 10 = iS To use this table, convert the given number of degrees Centigrade into degrees Fahrenheit, and add 32°. I = 0-555 2 = I. II 3 = 1.665 4 = 2.22 5 = 2.775 6 = 3-33 7 = 3.885 8 = 4.44 9 := 4.95 lO ^ 5-55 To use this table, subtract 32° from the given number of degrees Fahrenheit and convert the remainder into degrees Centigrade. INDEX. Abasia-astasia, 1133 Abscess, mediastinal, 556 of the brain, 1081 of the heart, 612 of the liver, 465 of the spleen, 485 paranephritic, 735 perinephric, 735 postpharyngeal, 323 Absorption, to determine rate of, 341 Acanthocephali, 1198 Acarinae, 1199 Acidity of gastric contents, estimation of, 23^ Aconite poisoning, 1204 Acromegaly, 1139 Actinomycosis, 198 bacteriology of, 199 course of, 199 diagnosis of, 199 morbid anatomy of, 199 of brain, 199 of lungs, 199 of skin, 199 symptoms of, 199 treatment of, 200 Active congestion of kidney, 693 Acute albuminuria, 696 alcoholism, 1155 angioneurotic edema, 1 136 anterior poliomyelitis of children, 918 arsenical poisoning, 1170 articular rheumatism, 289, 771 atrophic spinal paralysis of adults, 921 Bright's disease, 696 bronchial catarrh, 517 bulbar palsy, 954 catarrhal dysentery, 104 gastritis, 342 nephritis, 696 degeneration of internal organs of newborn, 836 tlelirium, 1087 desquamative nephritis, 696 diarrhea, 378 diffuse nephritis. 696 dyspepsia, 342 Acute enceohalitis der Kin- der, 1063 febrile jaundice, 300 gastric catarrh, 342 hydrocephalus, 249 ileocolitis, 386 Acute : intestinal catarrh, 378 leptomeningitis, 1040 miliary tuberculosis, 244 nasal catarrh, 497 nephritis, 696 parenchymatous hepatitis, 469 tonsillitis, 315 phthisis, 247 poliomyelitis in adults, 921 in children, 918 renal dropsy, 696 rheumatism, 289 softening of the brain, 1056 tracheobronchitis, 517 tubal nephritis, 696 yellow atrophy of the liver, 469 diagnosis of, 471 etiology of, 469 histology of, 470 prognosis of, 471 symptoms of, 470 treatment of, 471 urine in, 470 Adams - Stokes syndrome, 622 Addison's disease, 681 diagnosis of, 682 morbid anatomy, 681 prognosis of, 682 symptoms of, 681 coloration of skin, 681 treatment of, 682 Adenie and lymphadenie, 664 Adipositas universalis, 821 Agenese cerebrale, 1063 Ageusia, 975 Agraphia, motor, 978 Ague, 65 Ainhum, 1143 Akinesia algera, 863 Alalia, 977 Albumin digestion, ^27 examination of products of, 337 tests for, 686 Albuminoid disease, 726 liver, 457 Albuminous nephritis, 696 Albuminuric. 684 extrarenal, 684 general remarks on, 684 physiological or function- al, 686 renal, 685 immediate cause of, 685 Albuminuric retinitis, 719 Alcohol poisoning, 1204 I2ig Alcoholism, 1155 acute, 1 155 diagnosis of, 1155 symptoms of, 1155 chronic, 1156 morbid anatomy, 1156 symptoms of, 1157 digestive apparatus, .1158 kidney changes, 11 57 liver, 1 158 lungs, 1 1 57 nervous system, 1157 vascular changes, 1158 treatment, 1159 Alveolar ectasia, 531 Amaurosis, 689 hysterical, 989 toxic, 988 uremic, 988 Amblyopia, 989 tobacco, 989 American disease, 1129 gout, 793 Amimia, 978 Ammonia poisoning, 1204 Amnesic aphasia, 976 Amoeba coli, 465 Amusia, 976 Amyloid disease, kidney, 726 liver, 457 diagnosis of, 458 etiology, 457 morbid anatomy, 457 prognosis of, 458 treatment of, 458 Amyotropic lateral sclerosis, 956 Analgesic paresis, with panaritium, 943 Analgic panaritium, 943 Anarthfia, 972 Anchylostomiasis, 1193 Anemia, general, 644 local, 644 lymphatic, 664 diagnosis of, 666 etiolo.g}', 664 morbid anatomy of, 664 prognosis of, 667 symptoms of, 665 treatment of, 667 of the brain, 1046 primary or essential, 648 chlorosis tarda, 648 diagnosis of, 650 etiology of, 648 from pernicious anemia, 651 from secondary anemia, 651 morbid anatomy of, 648 1220 INDEX. Anemia : prognosis of, 651 symptoms of, 649 murmur, 650 treatment oi, bSi progressive per nicious, 652 diagnosis of, 65? etiology of, 652 morbid anatomy of, 656 prognosis of. 657 symptoms of, 653 blood changes, 654 Eichhorst's corpus- cle, 656 treatment of, 657 secondary or symptomatic, 645 diagnosis of, 647 due to drain of chronic disease, 645 due to hemorrhage, 645 from inanition, 645 symptoms of, 646 treatment of, 647 splenic, 668 diagnosis of, 669 etiology of, 668 morbid anatomy of, 668 prognosis of, 669 symptoms of, 668 treatment of, 669 toxic, 646 Anemias the, 644 Aneurysm, differential diag- nosis of, 636 from aortic incompet- ency, 637 from mediastinal tumors, 636 from pulsating em- pyema, 637 intracranial, 1062 distribution, 1062 of the abdominal aorta, 635 of the branches, 635 of the celiac axis, 635 of the aorta, 627 of the ascending aorta, 634 of the descending aorta, 634 of the heart. 636 etiolog>' of. 627 false, 627 dissecting, 627 traumatic, 627 true, 627 varix o r anastomotic. 627 of the hepatic artery, 636 of the innominate, 636 of the pulmonary artery, 636 of the renal artery, 636 of the splenic artery, 635 of the subclavian, 636 of the superior mesenteric artery, 636 of the thoracic aorta, 628 physical signs of, 632 Aneurysm : diastolic shock, 633 Drummond"s sign, 633 Glasgow's sign, 633 Perez's sign, 633 Scheele's sign, 633 points of election, 628 symptoms of, 629 capillary pulse, 631 Cardarelli's sign, 631 pain, 629 pressure, 629 tracheal tug ging, 631 voice, 630 of the transverse part of aorta, 634 physical signs, 632 Traube's sign, 637 prognosis of, 637 treatment of, 638 varieties of, 627 Angina follicularis, 316 Ludovici, 314 maligna, 132 membranacea, 132 pectoris, 620 diagnosis of, 622 from hysterical form, 622 ■ from intercostal neu- ralgia, 622 morbid anatomy of, 621 prognosis of, 622 symptoms of, 621 numbness, 621 oppression, 621 pain, 621 paroxysm, 621 treatment, 623 Anisocoria, 1000 Anorexia nervosa. 357 Anosmia, 974 Anthrax, 194 bacillus, 194 diagnosis of, 196 external, 195 malignant, edema, 195 pustule, 195 in animals, 195 incubation. 195 intern-al, 196 intestinal anthrax, 196 wool - sorter's disease, 196 etiolog].' of, 194 morbid anatomy of, 195 prognosis of, 196 symptoms of, 195 treatment of, 196 Antimony poisoning, 1205 Aortic incompetency, 582 Aortic insufficiency, 582 physical signs of, 584 capillary pulse, 584 Corrigan pulse, 582 Duroziez's double murmur, 585 T r a u b e ' s double sound, 585 Aortic : sphygmogram, 583 symptoms of, 583 stenosis, 586 and insufficiency, 587 etiology of, 583 physical signs, 586 sphygmogram, 586 symptoms of, 586 Aphasia, motor or ataxic, 977 or loss of faculty of speech. 975 various forms of, 972 Aphemia, 977 Aphtha, 307 Aphthae epizooticse, 200 Apoplexy, 1048 cerebral hemorrhage, 1048 arterial distribution, 1048 diagnosis of, 1054 etiology of, 1048 morbid anatomy of, 1049 prognosis of, 1054 symptoms of, 1050 treatment of, 1055 embolism and thrombosis of the cerebral vessels, 1056 diagnosis of, 1059 etiologj^ of, 1056 morbid changes in, 1057 prognosis of, 1060 relative frequency, 1056 symptoms of, 1057 treatment of, 1060 Appendicitis, 394 bacilli, 399 catarrhal, 397 chronic, 404 complications and se- quels, 404 definition of, 394 diagnosis of, 405 differential diagnosis of, 405 etiology of, 399 exciting causes, 399 gangrenous, 402 history, 395 intestinal or parietal, 398 morbid anatomy of, 397 of catarrhal, 397 of intestinal, 398 of ulcerative, 397 obliterans in, t^qj pathology and morbid an- atomy, 397 perforation in, 403 predisposing causes, 399 prognosis of, 407 recurring. 404 relapsing. 404 symptoms of, 400 rigidity of muscle, 401 tenderness, 400 tumor, 401 treatment of, 407 diet, 408 INDEX. I22I Appendicitis : medicinal, 408 operative, 407 ulcerative, 397 Apraxia, 973 Aprosexia, 317 Arachnoidea, 1199 Argyll Robertson pupil, 999 Arrhythmia, 616-619 Arithmomania, 1098 Arm-jerks, 850 Arsenical poisoning, 1170 acute, 1 1 70 chronic, 1170 Arterial pyemia, 573 Arteriocapillary fibrosis, 624 Arteriosclerosis, 624 etiology of, 624 morbid anatomy of, 624 sphygmogram in, 626 symptoms of, 625 treatment of, 626 Arthralgia saturnina, 1167 Arthritis deformans, 775 etiology of, 775 morbid anatomy of, 776 nature of, 776 symptoms of, 776 multiple, 777 partial o r monarthritic, 778 Arthritis gonorrheal, 210 Arthropoda, 1199 arachnoidea, 1199 acarinse, 1199 linguatulidae or pentas- tomes, 1200 insecta, 1200 diptera, 1200 rhyncota, 1200 Ascarides, 1189 Ascaris lumbricoides, Ii8g Ascites, 493 character of fluid, 495 chylosus, 495 differential diagnosis of, 494 from cyst of the omen- tum, 496 from hydronephrosis, 495 from overdistended bladder, 495 etiology of, 493 physical signs of, 494 symptoms of, 493 treatment of, 496 Aspiration pneumonia, 228 Associated movements, 847 Astereognosis, 863 Asthma, bronchial, 526 cardiac, 558 humidum, 525 uremic, 68g Atactilia, 975 Ataxia, hereditary, 937 Ataxia, progressive locomo- tor, 926 Atelectasis of the lung, 230 Atheroma of the blood-ves- sels, 624 Athetosis, 1067, 1 119 Athyrea, 676 Atrophia musculorum lipo- matosa, 1151 Atrophic bulbar paralysis, 951 spinal paralysis, 918 Atrophy, 1151 acute yellow, of the liver, 469 diagnosis of, 471 etiology of, 469 morbid anatomy of, 469 symptoms of, 470 treatment of, 471 facio-scapulo-humeral type of, 1 153 juvenile hereditary, Erb's form of, 1 152 muscular, 1151 idiopathic, 1151 primary myopathic, forms of, 1 151 progressive, peroneal type of. 1 153 Atropin poisoning, 1205 Auditory hyperesthesia, lOiS or eighth nerve, lesions of, 1013 Automatic chorea, iioi Autumnal catarrh, 501 fever, 17 B Babinski reflex, 849 Bacillus dysenterise, 106 Bacillus typhosis, 18 Bacillus X, 84 Bacteremia, 181 Ballismus, 1091 Banti's disease, 668 Barbadoes distemper, 83 Barlow's disease, 834 Basedow's disease, 672 Basilar meningitis, 249 Bedbug, 1201 Bednar's aphthae, 309 Beef tape-worm, 1182 Bell's mania, 1087 palsy, 1006 Beri-beri, 879 Big jaw, 198 Bilateral spastic hemiplegia, 1066 mental defects of, 1067 Bile-duct, carcinoma, 451 cicatricial contraction, 452 other affections of, 451. parasites, 452 stenosis, 452 Bile-passages and gall-blad- der, diseases of, 436 Bilharzia hsematobia, 1181 Biliary cancer, 451 colic, 445 Bilious fever, 65 headache, 11 12 remittent fever, 83 typhoid fever, 300 Birth palsies, 1066 Bisulphid of carbon poison ing, 1 1 64 Black death, 114 plague, 114 vomit, 85 Blackwater fever, 79 Bladder and rectum, mech- anism of function, 847 Bladder, catarrh of, 759 diseases of, 759 hemorrhoidal veins of, 769 morbid growths of, 769 muscular spasm of, 766 symptoms of, 766 treatment of, 767 of incontinence, 767 of retention, 768 neuroses of, 765 stone in, 765 paralysis of, 765 Blepharospasm, 1012 Blood, 641 and blood-making organs, diseases of the, 641 minute structure of, 641 blood plaques, 641 cell forms not found in normal, 643 large lymphocyte or large mononuclear cell, 642 nucleated red corpus- cles, 643 me g a b 1 a s t s , 643 microblasts, 643 normoblasts, 643 p o 1 y m orphonuclear or polynuclear cells 642 basophilic or mast cells, 643 eosinophiles, 642 neutrophiles, 642 red blood discs, 641 sm,all lymphocyte, 642 transitional 1 e u k o - cytes, 642 Blood-striking, 194 Blood-vessels, diseases of, 624 Bloody flux, 104 murrain, 194 Body louse, 1201 Bone tumor, 198 Bothriocephalus latus, 1182 Bowel, carcinoma of, 428 diagnosis of, 429 from chronic inflam- matory thickening, 430 from circumscribed peritoneal exudate, 429 from floating kidney, 429 of part of bowel in^. volved, 430 prognosis of, 430 symptoms of, 428 treatment of, 430 1222 INDEX. Bowel : embolic ulcer of. 394 hemorrhagic infarct of, 392 intussusception of, 410 invagination of, 410 nervous affections of, 424 derangement of mo- tion, 424 nervous cramp, 425 of sensibility. 425 enteralgia, 425 diagnosis of, 425 secretion neurosis, 427 treatment of, 427 obstruction of, 409 b}' fecal matter, 412 by foreign bodies, 411 by morbid growths. 412 by stricture, 412 strangulation of, 409 syphilitic ulcer, 394 twists and knots in. 411 ulceration of, 393 Brachial plexus. 1032 lesions of, 1032 Bradycardia, 559-6i5 explanation of. 615 treatment of, 620 Brain, abscess of, 1081 affections of the blood- vessels of. 104s anemia of. 1046 diseases of, 963 general and functional. 1087 of the membranes of, 1038 hyperemia of, 1045 inflammation of, 1081 edenia of. 1047 sclerosis of, 1069 syphilis of, 1144 tumors of the. 1074 diagnosis of, 1079 etiolog>'_ of. 1074 prognosis of. 1080 symptoms of. 1075 of basil ganglia or in- ternal capsule, 1079 of base of the. 1079 of central or motor region. 1077 of cerebellum. 1078 of corpora quadngem- ina, 1079 of corpus callosum, 1079 of crus. X079 of occipital lobe, 1078 of parietal area, 1077 of pons and medulla oblongata. 1078 of prefrontal area. 1076 of temporosphenoidal area on right side, 1078 treatment. icSo Breakbone fever. 90 Breathing, alterations in, m nervous disease, 866 Bright's disease, acute, 696 chronic, 707 Broadbent's sign, 563 Broca's convolution. 972 Bromin poisoning, 1206 Bronchial asthma. 526 diagnosis of, 529 from cardiac asthma, 529 from hysterical dysp- nea, 529 from spasm of the glottis, 529 etiolog>' of, 526 morbid anatomy of, 527 physical signs in, 528 prognosis of, 529 S3'mptoms of. 527 treatment of, 529 tubes, diseases of, 517 Bronchiectasis, 524 diagnosis of, 525 from abscess of the lung. 525 from circumscribed em- pyema, 525 from phthisical cavity. 525 etiology of, 524 morbid anatomy of. 524 physical signs of, 525 symptoms of, 525 treatment of. 525 Bronchitis. 517 acute, 517 diagnosis of, 518 etiology of, 517 morbid anatomy of, 517 physical signs of, 518 prognosis of. 518 symptoms of, 517 treatment of, 518 capillary, 228 chronic, 519 diagnosis of, 52? etiology of, 519 morbid anatomy of. 520 physical signs of, 521 prognosis of. 522 symptoms and course of. ' 520 treatment of, 522 foreign resorts in the, 523 plastis. or fibrinous, 530 diagnosis nf. 531 etiologA' of. 530 morbid anatomy of. 530 physical signs of. 531 symptoms of, 530 treatment of, 531 Bronchocele. 670 Bronchopneumonia. 228 tubercular, 256 Bronchopneumonic phthisis, 247 Bronchorrhea. 520 Brown atrophy of the heart, 608 Bruit de diable. 650 Bubo, oarotid. 313 Bubonic plague, 114 Bubonic plague: bacillus of, 115 diagnosis of, 116 etiology of, 114 morbid anatomy of, 115 prognosis of, 116 symptoms of, 115 treatment of, 116 serum therapy, 117 varieties of, 115 bubonic form, 115 malignant adenitis, pestis minpr, 115 pneumonic form, 115 siderans or fulmin- ant. 115 septicemic form. 115 Buccal psoriasis. 312 Buhl's disease, 836 Bulbar palsy, acute, 954 asthenic. 954 progressive, 951 Cachexia, malarial, 66 thyroidea vel strumipriva vel thryeopriva, 676 Cachexie pachydermique, 676 Caisson disease, 910 Camp fever. 55 Cancer in hepatic fissure. 484 of the gall-bladder, 450 of the esophagus, 325 of the pancreas, 483 of the pericardium. 56G of the peritoneum, 492 of the transverse colon, 484 Cancrum oris, 311 Canker, 307 Capillary bronchitis, 228 Capillary pulse. 584 Capillar^'- pulse in aneu- rysm of the aorta, 631 Carbolic acid poisoning, 1206 Carbonic acid gas poisoning, 1206 oxid poisoning, 1206 Carbuncle fever, 194 Carcinoma of the bowel, 428 of the liver, 471 massive form. 472 nodular form. 472 radiating form, 472 with cirrhosis, 472 ventTiculi. 366 Cardarelli's sign. 631 Cardiac asthma, 558 disease, 558 general svmptomatology of. 558 muscle, degeneration of, 608 albuminoid. 608 amyloid, 610 calcareous, 610 Cardiothyroid e x o p hthal- mos, 672 Catarrh, acute bronchial, 517 INDEX. 1223 Catarrh : chronic bronchial, 519 nasal, 498 of the bladder, 759 Catarrhal fever, 162 pneumonia, 228 Catarrhus aestivus, 501 Cauda equina, lesions o f, 949 Caudate nucleus, 983 Caustic potash or soda, 1206 Cavities in lung, 255 Cellulitis of the neck, 314 Central ganglia, 983 Centrum ovale, 982 Cephalodynia, y72 Cerebellar hereditary ataxia, 938 Cerebellum, disease of, 984 changes of, due to throm- bosis and embolism, 1057 form o£ lesion of, 985 Cerebral disease, 963 localizations of, 963 summary of facts bearing on, 986 hemorrhage, 1048 hyperemia, 1045 palsies of children, 1062 softening, 1056 vessels, a summary of the effects of plugging of, 1058 Cerebritis, 1081 Cerebrospinal fever, 167 brain in, 168 complications and se- quelae, 172 cranial nerves in, 169 diagnosis of, 172 from muscular rheu- matism, 173 from tubercular men- ingitis, 173 from typhus fever, 173 ■etiology of, 168 forms of, i6g abortive, 172 chronic, 172 intermittent, 172 malignant, 171 mild, 172 ordinary, 169 sporadic, 175 incubation period, 169 Kernig's sign of, 171 morbid anatomy of, 168 predisposing causes of, 168 prognosis of, 174 Quincke's lumbar punc- ture in, 173 sequelae of, 172 spinal cord in, 168 treatment of, 175 Cervical plexus, 1031 Cestodes, 1181 cysticerus cellulosae, 1188 echinococcus disease, 1188 geographical distribution, 1 189 Cestodes : intestinal, 1181 visceral, 1188 Charbon, 194 Charcot's disease, 956 Cheese poisoning, 1171 Cheirospasmus, 11 15 Cheyne-Stokes breathing, 866 Chiasm and tract, lesion of, 992 Chicken-pox, 156 complications in, 157 infantile paralysis, 157 varicella gangraenosa, 157 eruption in, 156 incubation in, 156 Children, reflex convulsions of, II II Chill, the congestive, jj Chills and fever, 65 Chloremia, 648 Chloral poisoning, 1207 Chloranemia, 648 Chlorism, 1163 Chloroform poisoning, 1207 Chlorosis, 648 Choked disc, 989 Choking quinsy, 194 Cholangitis, chronic catar- rhal, 444 suppurative, 445 Cholecystitis, acute infec- tious, 448 diagnosis of, 449 etiology of, 448 morbid anatomy of, 449 symptoms of, 449 treatment of, 450 Cholelithiasis, 441 etiology of, 441 morbid anatomy of, 441 Cholera, 91 bacillus of, 92 examination for, 103 postmortem test in, 104 Schottelius' culture method in, 104 of Koch, 96 of Prior and Finkler, 96 collapse in, 94 diagnosis of, 95 diarrhea, 94 differentiation from chol- era morbus, 95 epidemics of, 91 etiology of, 92 examination of the dejec- ta of, 96 Koch's views of, 92 medium of infection, 92 morbid anatomy of, 92 prognosis of, 96 symptoms of, 94 incubation, 94 stage, of collapse, 94 of preliminary diar- rhea, 94 of reaction, 95 treatment of, 97 Cholera : directions to nurses, 99 enteroclysis, 102 Haffkine's method, 98 of attack, 99 protective inoculation, 97 algida, 91 Asiatica, 91 infantum, 389 diagnosis of, 390 etiology of, 389 prognosis of. 390 symptoms of, 390 treatment, 390 infectiosa, 91 maligna, 91 morbus, 384 diagnosis of, 385 etiology of, 384 prognosis of, 385 symptoms of, 385 treatment of, 385 nostras, 384 Chorea, acute, 1091 diagnosis of, 1096 etiology of, 1091 morbid anatomy of, 1093 nature of, 1093 symptoms of, 1094 chronic hereditary, 1099 progressive, 1099 diagnosis of, iioi morbid anatomy of, 1 100 prognosis of, IIOX treatment of, iioi electric, 1097 hysterical, iioi major, iioi mild, 1091 minor, 1091 postchoreal paralysis and postparalytic, 1102 procursiva, 1088 spastica, 1067 Choreic movements, 846 Choreiform affections, IO97 Chronic angina, 321 anterior poliomyelitis, 958 bronchial catarrh, 519 catarrhal dyspepsia, 343 gastritis. 343 nephritis, 707 degeneration of the motor nerve nuclei, 958 diarrhea, 382 diffuse meningo-encephali- tis, 1070 nephritis, 707 endocarditis, 574 enlargement of the ton- sils, 317 enterocolitis, 382 follicular pharjnigitis, 321 gastric catarrh, 343 hereditary chorea, 1099 interstitial hepatitis, 458 malaria, 79 nasal catarrh. 498 nasopharyngeal obstruc- tion, 317 1224 INDEX, Chronic : parenchymatous nephri- tis, 707 rheumatic arthritis, 775 rhinitis, 498 tubal nephritis, 707 ulcerative phthisis, 254 valvular disease, 574 Chronically contracted kid- ney, 716 Chvostek's sign, 1120 Chyluria, 752 Cimex lectularius, 1201 Circumflex nerve, lesions of, 1033 Cirrhosis of the liver, 458 atrophic, 460 biliary, 460 diagnosis of, 463 from amyloid liver, 463 multilocular hydatid, disease. 463 tubercular peritoni- tis, 463 etiology, 458 Glissonian, 469 hypertrophic, 460 morbid anatomy of, 460 of atrophic, 460 of biliary, 460 of hypertrophic, 460 prognosis of, 464 symptoms of, 461 of atrophic, 461 of biliary, 462 of hypertrophic, 462 ' treatment of, 464 Cirrhosis, of the lung, 233 Cirrhotic kidney, 716 Clergyman's sore throat, 321 Coagulation necrosis, 135 Coated tongue, 304 black, 304 bright red. 304 dry brown, 304 strawberry, 304 Cocain poisoning, 1207 Cocainism, 1163 Coccygodynia, 883 Celiac affection in children, 391 Colica pictonum, 11 64 Colitis, mucous, 382 Colon, dilatation of, 422 Color of tongue, natural, 304 Combined lateral and pos- terior sclerosis, 939 sclerosis, 939 Compression myelitis, 943 Congenital absence of kid- ney, 746 Congestion of the brain, 1045 of the kidney, 693 Congestive chill, 77 Conium poisoning, 1207 Constipation, 420 treatment of, 421 in infants, 422 Constitutional diseases, 771 Constriction of the bowel, 409 Consumption of the lungs, 252 Contagious carbuncle, 194 Contracted kidney, 716 Contracture des nourrices, 1119 Conus meduUaris, lesions of, 949 Convulsions, epileptiform, 846 reflex in children, mi Convulsive tic, 1012 Copodyscinesia, 11 15 Copper poisoning, 1208 Coprolalia, ioy8 Cord, spinal, diseases of membranes of, 899 Coronary arteries, sclerosis of. 610 Corpora quadrigemina, 984 Corpulence, 821 Corrigan pulse, 582 Cortex, functional assign- ments of, 964 lesion of the sensory tract of, 972 irritative, 972 motor areas of, 964 sensory areas of, 970 Cortical areas covermg speech, 972 whose function is un- known or uncertain, 981 epilepsy, 1106 Coryza, 497 Costiveness, 420 Coup de soleil, 11 76 Cow-pox, 152 Crab louse, 1201 Cranial nerves, diseases of, 987 Cretinism, 678 congenital, 678 endemic, 678 sporadic, 678 treatment of, 679 Cretinoid idiocy, 678 state supervening in adult life in women, 676 Crises, tabetic, 932 Croup, catarrhal, 506 false, 506 spasmodic, 506 treatment of, 507 Croupous enteritis. 392 nephritis. 696 pneumonia, 212 Crura cerebri, 984 Cruveilhier's atrophy, 958 Cryptogenetic s e p ticemia, 298 Curschmann's spirals, 528 Cutis tensa chronica. it4i Cyanotic induration of kid- ney, 694 Cycloplegia, 999 Cynanche contagiosa, 132 gangrenosa, 314 tonsillaris, 315 Cysticercus cellulosse, 1 183 Cystitis, 759 bacteria in, 759 Cystitis : calculous, 760 diagnosis of, 760 morbid anatomy of, 759 symptoms of, 759 treatment of, 761 of acute, 761 of chronic, 761 Cysts, echinococcus, endoge- nus, .^79 hydatidosus, 479 veterinorum, 479 of the pancreas, 484 D ' Dandy fever, 90 Deafness, nervous, 1013 Degeneration of the heart, amyloid, 610 calcareous, 610 fatty, or metamorphosis, 603, 608 circumscribed, 609 parenchmatous or albu- minoid (cloudy swells ing), 608 diagnosis of. 609 - prognosis of, 608 treatment of, 609 Deglutition pneumonia, 228 Delayed conduction of sen- sation, 861 Delirium, acute, 1087 cordis, 617 tremens, 1158 Delusions, 865 Dementia paralytica, 1070 diagnosis of, 1073 etiology of, 1071 morbid anatomy of, 1071 prognosis of, 1073 symptoms of, 1071 treatment of, 1073 Demodex folliculorum, 1199^ Dengue, 90 diagnosis of, 91 from acute rheumatism,. 91 etiology of, 90 prognosis of, 91 symptoms of, 90 treatment of, 91 Dentition, derangements due to, 304 Depurative disease, 726 Derangement of speech of irritative origin, 980 prognosis of, 981 treatment of, 981 Derbyshire neck, 670 Dermatosclerosis, 1141 Dettweiler's pocket spit-cup,. 276 Devonshire colic, 1164 Diabetes insipidus. 817 diagnosis of, 819 etiolosrv of, 817 morbid anatomy of, 817 pathogenesis, 796 pathology, 796 INDEX. 122S Diabetes : physical and chemical character of the urine, 818 prognosis of, 819 symptoms of, 817 duration of, 818 treatment of, 820 hygienic, 821 medicinal, 821 mellitus, 795 acetone m, 80s beta oxybutyric acid in, 805 . coma in, 801 geographical and racial distribution, 795 diacetic acid in, 805 test for, 808 glucose in. 803 test for, 807 glycosuria, 803 morbid anatomy of, 799 pathogenesis of, 796 prognosis of, 809 symptoms of, 800 eczema, 801 gangrene, 801 inosite, 80S polyuria, 800 thirst, 800 uric acid, 805 treatment of, 809 diabetic coma, 816 dietetic, 809 diet table, 811 hygienic, 813 medicinal, 814 of complications, 816 pruritus, 816 Diagram showing order of, teeth eruption, 305 Diarrhea, alba, 391 chronic, 382 chylosa, 391 nervous, 424 Diazo reaction, 29 Digestive system, diseases of, 304 Digitalis poisoning, 1208 Dilatation, bronchial, 524 of the colon, 422 symptoms of, 424 treatment of, 424 of the heart, 600-603 Diphtheria, 132 complications and seque- lae, 137 ataxic symptoms, 137 bronchopneumonia, 137 capillary bronchitis, 137 heart, 137 nephritis, 137 paralysis. 137 tendon reflexes, 137 toxic neuritis, 137 contagiousness of, 132 diagnosis of, 137 from diphtheroid fauci- tis, 137 from scarlet fever, 138 epidemic, 134 etiology of, 133 Diphtheria : forms of, 135 laryngeal, I35 nasal, 135-136 constitutional infec- tion in, 136 pharyngeal, 135 in animals, 134 K 1 e b s-Loeffler bacillus, 135 morbid anatomy ot, X34 prognosis of, 138 symptoms of, i35 laryngeal cough, 136 of nasal, 136 period of incubation, 135 seats of invasion, 135 treatment of, 140 antitoxin, 140 administration of anti- toxin for immuniza- tion, 141 complications and se- quelae, 144 constitutional, 142 prophylactic, 144 serum therapy, 140 . . Diphtheritic e n docarditis, 570 enteritis, 392 Diphtheroid sore throat, 132, 137 Diplegia, 844 facialis, 953 Diptera, 1202 Disseminated nodular scle- rosis, 1069 Distomum Buskii, 118 capense, 1181 conjunctum, 11 80 endemicum, 1180 felineum, 1181 haematobium, 1181 heptipaticum, 1180 lanceolatum, 1180 perniciosum, 1180 pulmonalis, 1181 sinense, 1180 Westermanni, 1181 Diver's paralysis, 910 Double vision in disease of motor nerves of the eye, 1002 Dracontiasis, 1196 Dubini's disease, 1098 Duchenne-Aran's disease, 958 Duchenne s disease, 926-951 Duodenal ulcer, 359 Duodeno-cholangitis, 439 Dysentery, 104 Amoebic, 109 complications, no diagnosis of, in etiology of, 100 prognosis of, ill symptoms of, IIO treatment of, iii bacillary, 106 complications and se- quelae, 108 diagnosis of, 109 Dysentery : etiology of, 106 morbid anatomy of, 107 prognosis of, 109 symptoms of, 108 . treatment of, in serum, 112-113 bilious, los catarrhal, 104 diagnosis of, 106 etiology of, 105 morbid anatomy of, 105 symptoms of, 105 treatment of, m chronic, 113 morbid anatomy of, 113 treatment of, 113 croupous, 106 diphtheritic, 106 pseudomembranous, 106 tropical, 109 ulcerative, 106 vaccines, 112 Dyspepsia, 350 atonic, 352 flatulent, 352 intestinal, 352 nervous, 350 diagnosis of, 351 etiology, 351 symptoms of, 351 treatment of, 3S2 Echinococcus or hydatid disease, 1188 Echolalia, 1098 Echokinesis. 1098 Eclampsia, infantile, nil uremic, 688 Edema, angioneurotic, n55 of the brain, 1047 Ehrlich's Biondi stain, 641 Ehrlich's triple stain, 641 Eighth nerve, lesions of, 1013 Electrical excitation of mo- tion, 854 Elephantiasis grsecorum, 287 Eleventh nerve, lesions of, 1026 Elodes icterodes, 83 Embolic pneumonia, 235 Embolic pneumonia, non-septic, 235 septic, 237 Embolism of cerebral ves- sels, 1056 Embryocardia, 617 Emphysema of the lung, 531 alveolar, 531 atrophic, 532 compensatory, 532 interlobular or interstitial,. 531. 53S pseudohypertrophic, 532 senile, 532 vesicular, 532 diagnosis of, 535 etioloev of, 532 morbid anatomy of, 533 1226 INDEX. Emphysema : physical signs of, 534 prognosis of, 536 symptoms of, 534 treatment of, 536 Empyema, 541 pulsating, 545 Encephalasthenia, 1129 Encephalitis, sup purative, 1081 diagnosis of, 1083 etiology of, 1081 morbid anatomy of, 1081 prognosis of, 1083 symptoms of, 1082 treatment of, 1083 Endarteritis chronica defor- mans, 624 Endocarditis, acute, mild or simple form, 567 diagnosis of, 569 etiology of, 568 morbid anatomy of, 568 prognosis of. 569 symptoms of, 569 treatment of, 570 chronic, 574 severe or malignant form, 570 diagnosis of, 573 etiology of, 570 morbid anatomy of, 571 prognosis of, 574 symptoms of, 571 treatment of, 574 ulcerative, 570 Endocardium, diseases of, 567 English sweat, 301 Enteralgia, 425 Enteric fever, 17. See Ty- phoid. Enteritis, amoebic, 109 acute dyspeptic of chil- dren, 386 diagnosis of, 387 etiology of, 386 prognosis of, 387 symptoms of, 387 treatment of, 387 chronic catarrhal, 382 diagnosis of, 383 etiology, 382 morbid anatomy of, 382 prognosis of, 383 symptoms of, 3S2 treatment of, 383 croupous, 392 diphtheritic, 392 follicular, 388 phlegmonous, 392 pseudomembranous, 392 simple acute catarrhal, 378 diagnosis of, 381 etioloscy of, 378 morbid anatomy of 379 symptoms of, 379 treatment of, 381 Enterocolitis, acute, 388 diagnosis of, 389 etiology of, 388 morbid anatomy of, 388 prognosis of, 380 symptoms of, 388 treatment of, 389 Enteroptosis, 376 Eosinophiles, 642 Ephemeral fever, 297 Epidemic cerebrospinal me- ningitis, 167 cholera, 91 erysipelas, 177 hemoglobinuria of i n- fants, 836 parotitis, 161 pneumonia, 212 roseola, 122 Epilepsia acuta, liii nutans, 1099 Epilepsy, 1102 diagnosis of, 1107 etiology, 1103 morbid anatomy of, 1104 prognosis of, 1108 symptoms of, 1104 of clonic spasm, 1105 of coma, 1 105 of grand mal, 1104 of hysterical, 1107 of Jack son ian, 11 06 of petit mal, 1106 of physical, 1106 of toxic spasm, I105 treatment of, 1109 asylum, mo of convulsion, 11 10 Equilibrium, disturbance of, associated with de- fect of hearing, 1013, 1017 diagnosis of, 1017 etiology of, 1017 pathology of, 1017 prognosis of, 1018 svmptoms of, 1017 treatment of, 1018 Erb's form of juvenile he- reditary atrophy, 1152 Ergot poisoning, 1208 Ergotism, 1173 Erichsen's disease, 1132 Erroneous projection, looi Erup-tive-disease table, 157 Erysipelas, 177 bacillus of, 177 complications of, 179 diagnosis of, 180 epidemic of, 177 etiology of, 177 facial, 178 prognosis of, 180 relapses and recurrences of, 178 sequelae of, 179 symptoms of, 178 incubation, 178 treatment of, 180 Esophagismus, 324 Esophagitis, 324 acute, 324 chronic, 324 Esophagus, 323 cancer of, 325 dilatation of, 326 diffuse or total, 326 disease of, 323 diverticula, 327 pressure, 327 traction, 327 exploration of, 323 Estivo-autumnal fever, 65, 76 Essential contractions, 1066 paralysis of children, 918 Eustronglyus ,gigas, 1198 Exophthalmic goitre, 672 External popliteal nerve, lesions of, 1037 Eyeball, lesions of t h e motor nerves of, 998 Eyes, phenomena of paraly- sis of motor nerves of, lOOI Facial hemiatrophy, 1138 nerve, lesions of, 1006 paralysis of, 1006 diagnosis of, loio etiology of, 1006 infranuclear or peri- pheral facial, 1007 monoplegia, 1007 nuclear, 1007 supranuclear, 1006 symptoms of, 1008 spasm, 1012 etiology of, 1012 prognosis of, 1012 symptoms of, 1012 blepharospasm, 1012 treatment of, 1012 Falling fits, 1102 False croup, 506 measles, 122 Family periodical paralysis, II 35 Famine fever, 59 Farcy, 197 acute, 197 chronic, 197 Fssciola hepatica, 1180 Fatty degeneration of the heart, 603, 608 infiltration of the heart, 609 of the liver, 456 diagnosis of, 456 etiology of, 456 morbid anatomy o f, 456 prognosis of, 456 treatment of, 456 metamorphosis of heart, 608 Febricula, 297 Fehling's test solution for sugar, 807 Fetid stomatitis, 308 Fever, estivo-autumnal, 76 and ague, 65 breakbone, go cerebrospinal, 167 INDEX. 1227 Pever : ephemeral, 297 glandular, 302 famine, 59 intermittent, 73 malarial, 65 Malta, 63 miliary, 301 mountain, 54 paratyphoid, 54 pernicious malarial, yj relapsing, 59 remittent, 76 scarlet, 124 ship, 55 . simple continued, 298 typhoid, 17 typhus, 55 yellow, S>2i Fibrillary contractions, 846 Fibrinous pneumonia, 212 Fibroid, heart, 610 phthisis, 265 Fibrous myocarditis, 610 Fifth nerve, lesions of, 1004 paralysis of motor por- tion, 1005 of sensory portion, 1005 Filaria Baricrofti, 752, 1195 bronchialis, 1 198 diurna, 119S dracunculus, 1 196 hominis oris, 1198 imitis, 1 197 labialis, 1197 loa, 1 197 lymphatica, 1198 oculi humani vel lentis, 1 197 perstans, 1195 sanguinis, 1194 of the dog, 1 197 Filariasis, 1194 Flat worm, 1180 Flea, 1202 Flint murmur, 580, 585 Floating kidney, 747 diagnosis of, 748 etiology of, 747 symptoms of, 748 treatment of, 749 Flukes, 1 1 80 blood, I 181 bronchial, 1181 liver, 1 180 Folic pourquoi, 1098 Follicular dysentery, 388 enteritis, 388 stomatitis, 307 tonsillitis, 316 Foot and mouth disease, 200 etiology, 200 incubation, 200 symptoms of, 200 treatment of, 201 Fourth nerve, lesions of the, 1000 Friedreich's ataxia, 937 Functional diseases of ner- vous system, 1087 Functional paralysis, other forms of, 1 133 Gall bladder, cancer of, 450 atrophy of, 446 dilatation of, 442 Gallop rhythm, 617 Gall-stone, 441 acute impacted, 443 diagnosis of, 443 etiology of, 441 inflammation of, 448 prognosis of, 444 symptoms of, 443 chronic impacted, 444 symptoms of, 444 due to obstruction of the common duct, 444 due to chronic ob- struction of the cystic duct, 444 diagnosis of. 446 treatment of, 447 preventive, 448 Gangrene of the lung, 221 of the spleen, 194 Gangrenous stomatitis, 311 Gastralgia, 353 diagnosis of, 353 etiology of. 353 prognosis of, 353 symptoms of, 353 treatment of, 353 Gastrectasia, 373 acute, 373 Gastric cancer, 366 Gastric contents, chemical examination of, Zi^ fever, 297, 342 neurasthenia, 350 Gastritis, acute catarrhal, 342 diagnosis of, 343 etiology of, 342 morbid anatomy of, 342 prognosis of, 343 symptoms of, 342 treatment of, 343 chronic catarrhal, 343 diagnosis of, 345 etiology of, 343 morbid anatomy of, 344 prognosis of, 345 symptoms of, 344 treatment of, 345 dietetic of, 345 diphtheritic, 350 mycotic, 350 phlegmonous or suppura- tive. 349 traumatic and toxic, 349 Gastrodiaphany, 332 Gastro-enteric fever, 17 Gastroptosis, 376 Gastroscopy, 332 General paresis. 1070 Geographical tongue, 312 German rneasles, 122 Giant urticaria, 1136 Gilles de la Tourette's dis- ease, 1098 Gin liver, 458 Girdle pains, 931 Glanders and farcy, 197 diagnosis of, 198 etiology of, 197 incubation, 197 morbid anatomy of, 197 prognosis of, 198 symptoms of, 197 treatment of, 198 Glandular fever, 302 Glasgow's sign, 633 Glenard's disease, 376 Glissonian cirrhosis, 469 Globulin, test for, 687 Glossitis. 311 desiccans, 312 parenchymatous. 311 Glossolabiolaryngeal paral- ysis, 951 Glossopharyngeal nerve, lesions of, 1018 Glossy skin, mi Glottis, edema of, 513 Goitre, exophthalmic, 672 diagnosis of, 675 etiology of. 672 prognosis of, 675 symptoms of. 673 Stellwag's sign, 673 Moebius' sign, 673 von Graefe's sign, 673 treatment of, 675 simple, 670 etiology, 670 morbid anatomy of, 670 symptoms of, 671 treatment of, 671 Gonorrheal arthritis. 210 complications of, 211 morbid anatomy of, 210 symptoms of, 211 treatment of, 212 varieties of, 211 infection, 210 Gout, 780 etiology of, 780 morbid anatomy of, 784 pathology of, 781 retrocedent or metastatic, 786 symptoms of, 785 of chronic, 787 of irregular or atypical, 786 of typical acute, 785 pharyngitis. 785 thread test for uric acid, 781 treatment of. 787 dietetic. 787 hygienic. 790 medicinal, of acute, 790 of retrocedent. 793 Gouty kidney, 716 Grain poisoning, 1173 ergotism. 11 73 gangrenous. 1174 spasmodic. 1173 lathyrism or lupinosis, 1 1 74 pellagra. 1174 treatment of. 1174 1228 INDEX. Granular kidney. 716 liver, 458 pharyngitis. 321 Graphospasmus, 11 15 Graves' disease. 672 Green sickness, 648 Grip, 162 Guinea-worm disease, 1196 Giinzburg's reagent, 334 H Habit chorea, 1097 spasm, 1097 Hallucinations. 865 Hammond's disease, 1119 Hay asthma. 501 Hay-fever, 501 etiology of, 501 symptoms of, 502 treatment of. 502 Headache, bilious, 1112 paroxysmal, 11 12 sick. 1 1 12 Head-banging, 1099 Hearing, modifications of, in nervous disease, 865 Heart, abscess of, 612 aneurysm of. 613 atrophy of, 608 brown, 608 chronic valvular defects of, 574 congenital defects of, 590 dilatation of, 599, 603 diagnosis of, 605 etiology of, 603 physical signs of, 604 symptoms of, 604 treatment of, 606 Nauheim baths, 606 disease, relation of, to kidney disease, 753 diseases of, 558 fatty degeneration of, 603 fibroid degeneration of, 610 irritable, 604 nervous palpitation, 614 diagnosis of. 614 treatment of, 614, 619 neuroses of, 614 rupture of, 613 Heat exhaustion, 1175 fever, 11 76 Heber den's nodosities, 777 Heller's test for albumin, 687 Hematorrhachis, 903 Hematothorax. 548 Hematuria, idiopathic, 749 Hemeralopia, 989 Hemiachromatopsia, 994 Hemianopsia, 992 heteronymous, 992 homonymous, 992 lateral. 992 nasal, 992 temporal, 992 Hemicrania, 1112 _ Hemiplegia spastica cere- bralis, 1063 infantile, 1063 Hemoglobinuria, 79, 750 paroxysmal, 751 toxic, 751 Hemopericardium, 566 Hemophilia, 837 etiology of, 837 morbid anatomy of, 837 prognosis of. 838 symptoms of, 838 treatment of, 838 Hemorrhagic infarct of the bowel. 392 lung, 235 _ Hemorrhagic nephritis, 696 Hemorrhoids. 431 diagnosis of, 433 etiolog\% 431 symptoms of, 432 external, 432 internal, 432 treatment of. 433 Hepatic arterj- and vein, dis- eases of, 455 intermittent fever, 445 Hepatitis, suppurative, 465 diagnosis of, 467 etiology of, 465 prognosis of, 467 symptoms of, 466 treatment of, 467 Hereditary ataxic para- plegia, 937 diagnosis of, 938 etiology of, 937 morbid anatomy of, 937 prognosis of, 938 symptoms of, 937 treatment of, 938 Hobnail liver, 458 Hodgkin's disease, 664 Holy rollers, iioi Hooping-cough, 157 Huntington's chorea, 1099 Hutchinson's teeth, 207 Hj'brid measles, 122 scarlet fever, 122 Hydrocephalus. 1084 , internal, 1084 congenital. 1084 diagnosis, 1085 etiologv'. 1084 morbid anatomy, 1085 prognosis. 1085 symptoms. 1085 treatment. 1086 acquired. 1085 diagnosis, 1086 etiology. 1085 morbid anatomy, 1085 prognosis. 1086 SA-mptoms. 1085 treatment. 1086 Hydrochloric acid poison- ing, 1210 Hydrochloric acid, test for, 334 Hvdrocvanic acid poisoning. 1208 Hydronephrosis, 745 Hydropericardium, 566 Hydroperitoneum, 493 Hydrophobia, 184 diagnosis of, 187 etiology of. 184 incubation, 184 morbid anatom}' of, 185 Pasteur Institute, 188 prognosis of, 187 symptoms of, 185 treatment of, 188 Hydropneumothorax, 549 Hydrorrachis, 950 Hydrothorax, 548 Hyperemia of brain, 1045 etiology of, '1045 morbid anatomy of, 1045 symptoms, 1045 treatment of, 1046 of the liver, 452 active, 454 treatment, 454 passive, 452 etiology, 452 morbid anatomy of, 452 symptoms of, 453 treatment of, 453 Hyperchlorhydria, 354 - diagnosis of, 355 etiology of, 354 prognosis of. 355 symptoms of, 354 treatment of, 355 diet, 356 Hyperpepsia, 354 Hypertrophic cirrhosis of the liver, 460 symptoms of, 462 Hypertrophy of heart, 599, 600 diagnosis of, 602 etiology of, 600 morbid anatomy of, 601 prognosis of, 603 symptoms of, 601 treatment of, 603 Hypnosis and suggestion, 1 125 Hypoglossal nerve, lesions of, 1030 diagnosis of, 1031 etiology of, 1030 prognosis of, 1031 S3'mptoms of, 1030 treatment of, 103 1 Hysteria, 1121 diagnosis of. 1 126 etiology of, 1121 prognosis of, 1127 symptoms of, 1122 treatment of, 1127 Hysterical epilepsy, 1125 fever, 1124 Hysterical, stigmata, 1122- 1124 Hysterogenous zones, 1126 I Ichthyosis lingualis, 312 Icterus, 436 gravis, 469 neonatorum, 439 Idiopathic anemia, 653 INDEX. 1229 Ileus paralyticus vel ner- vosus, 412 Illusions, 865 Impacted gall-stone, 443, 444 Infantile convulsions, liil diagnosis of, iiii etiology of, mi prognosis of, 11 12 symptoms of, iiii treatment of, 11 12 palsy, 918 scurvy, 834 treatment of, 834 Infectious diseases of doubt- ful nature, 297 Inflammatory rheumatism, 289 Influenza, 162 complications of, 165 diagnosis of, 165 etiology of, 163 incubation of, 164 morbid anatomy of, 164 prognosis of, 166 symptoms of, 164 treatment of, 166 varieties of, 164 Inhalation tuberculosis, 2S'Z Insular sclerosis, 1069 Interglobular emphysema, 531 Intermittent fever, Jt, diagnosis of, 75 incubation of, y^ prognosis of, 76 symptoms of, 72 treatment of. 80 Internal capsule, lesions of, 983 Interstitial suppurative ne- phritis, 730 Interstitial nephritis, chronic, 716 Intestinal obstruction, 409 acute and chronic, 409 diagnosis of, 415 etiology of, 410, 411, 413 prognosis of, 418 symptoms of, 413 treatment of, 418 Intestines, diseases of, 378 obstruction of, 409 Intoxications, iiSS Intracranial aneurysm, 1062 tumors, 1074 Intrathoracic tumors, 553 Intussusception, 410 treatment of, 418 Invagination, intestinal, 410 lodin poisoning, 1209 Iodoform poisoning, 1209 Iridoplegia, 999 accommodative, 999 reflex, or Argyll Robert- son pupil, 999 skin, 999 Irritation of auditory nerve, 1016 Irritative fever, 297 J Jacksonian epilepsy, 1106 Jail fever, 55 Jaundice, 436 obstructive, 437 diagnosis of, 440 symptoms, 437 treatment, 439 of the new-born, 439 simple catarrhal, 439' diagnosis of, 440 etiology of, 439 morbid anatomy of, 439 prognosis of, 440 symptoms of, 439 treatment of, 440 Jerkers, iioi Jumpers, iioi K Keloid of Addison, 1142 Kendall's fever, 83 Keratosis mucosae oris, 312 Kernig's sign, 171 Kidney, abscess of, 735 amyloid, 726 diagnosis of, 729 duration of, 728 etiology of, 726 morbid anatomy of, 726 prognosis of, 729 symptoms of, 728 treatment of, 729 anomalies of form and po- sition, 746 congenital absence of, 746 floating, 747 horseshoe, 747 lobulated, 747 cirrhotic, 716 congestion of, 693 active, 693 passive, or cyanotic in- duration, 694 diagnosis of, 695 morbid anatomy of, 694 prognosis of, 695 symptoms of, 695 treatment of, 695 contracted, 716 cysts of, 744 congenital, 744 dermoid, 745 differential diagnosis of, 745 echinococcus or hydatid, 746 hydronephrosis, 745 retention or obstruction, 744 treatment of, 746 derangement of circula- tion, 693 diseases of, 693 fatty and contracting, 709 gouty, 716 granular, 716 lardaceous, 726 large white, 707 movable, 747 relation of disease of, to heart disease, 753 small white, 709 Kidney : stone in, 736 tuberculosis of, 283 tumors of, 742 diagnosis of, 743 symptoms of, 742 treatment of, 744 waxy, 726 Kinepox, 152 Knee-jerk, 849 Koplik's sign, 120 Krouomania, 1099 Labyrinthine vertigo, 1017 Lacunar tonsillitis, 316 La Grippe, 162 Lagophthalmos, 1008 Landry's paralysis, SiJJ, 922 Lardaceous disease of the kidney, 709, 726 liver, 457 Large white kidney, 707 Laryngeal muscles, paral- ysis of, 514 treatment of, 517 Laryngitis, acute catarrhal, S05 chronic catarrhal, 508 etiology of, 508 morbid anatomy of, 508 prognosis of, 508 symptoms of, 508 treatment of, 508 syphiHtic, 513 tubercular, 511 diagnosis of, 512 etiology of, 511 morbid anatomy of, 51I prognosis of, 512 symptoms of, 511 treatment of, 512 Laryngoplegia, 515 Larynx, 503 bilateral abductor paral- ysis of, 1021 diseases of, 503 examination of, 503 spasm of, 1023 tensor paralysis of, 1022 total paralysis of, 1021 unilateral abductor paral- ysis of, 1022 Lata, IIOI Lateral sclerosis, amyo- trophic, 9S6 Lathyrism, 1174 Lead poisoning, 1164 etiology of, 1164 morbid anatomy of, I166 prognosis of, 1168 symptoms of, 1166 blue line, 1167 treatment of, 1168 Leprosy, 287 anesthetic form of, 288 diagnosis of, 2S8 etiology. 287 morbid anatomy of, 288 prognosis of. 289 symptoms of, 288 treatment of. 289 1230 INDEX. Leprous neuritis, 88o Leptomeningitis, acute, 1040 diagnosis of, 1042 etiology of, 1040 morbid anatomy o£ 1041 prognosis of, 1043 symptoms of, 1041 treatment of, 1043 cerebral, 1040 chronic, 1043 spinal, 901 acute, 901 chronic, 902 Leukemia, 658 diagnosis of, 662 etiology of, 659 morbid anatomy of, 659 prognosis of, 664 symptoms of, 660 blood changes, 661 treatment of, 664 Leukocytosis, 663 Lithemia, 793 diagnosis of, 794 etiology of, 793 prognosis of. 794 symptoms of, 793 treatment of, 794 Little's disease, 1066 Liver, abnormalities of posi- tion of, 435 abscess of, 465 active h3'peremia of, 454 acute yellow atrophy of, 469 altered shape of, 435 amyloid, 457 atrophic cirrhosis of, 460 diagnosis of, 463 etiology, 458 morbid anatomy of, 460 symptoms of, 461 biliary cirrhosis of, 460 carcinoma of, 471 changes in hepatic artery and vein, 455 cirrhosis of, 458 diseases of, 435 blood-vessels of, 452 dislocation of, 435 echinococcus disease of, 477 fatty. 455 infiltration of, 456 metamorphosis of, 457 floating, 435 hydatid cyst of. 452 hyperemia of, 452 hypertrophic cirrhosis of, 460 diagnosis of, 463 etiology of. 458 morbid anatomy of, 460 prognosis. 464 symptoms of, 461 treatment. 464 lardaceous. 457 morbid growths of, 471 parasites of, 477 passive hyperemia of, 452 red atrophy of, 452 sarcoma of, 472 Liver : syphilis of, 475 Lobar pneumonia, 212 Lobular pneumonia, 228 Local asphyxia, 1136 Localization of cerebral dis- ease, 963 Lockjaw, 190 Long thoracic nerve, lesions of, 1032 Ludwig's angina, 314 Lues venerea, 202 Lumbago, 772 Lumbar plexus, lesions of, 1036 Lung, abscess of, 221 cavities in, 256 cirrhosis of, 221 diseases of, 531 emphysema of, 531 fibroid induration of 221 gangrene of, 221 hemorrhagic infarct of, 235 metastatic abscess ol, 237 tuberculosis of, 238 tumors of, 537 carcinoma, 537 diagnosis of, 538 peribronchial cancer, 537 physical signs, 538 Lupinosis, 1174 Lymphadenitis, simple, 557 tuberculous, 557 Lj^mphadenoma, 664 Lymphadenosis, 664 Lymphatic glands, tubercu- losis of, 279 Lymphatism, 667 Lyssa, 184 M Maladie de la tic convulsif, 1098 Malaria, chronic, 79 Plasmodium of, 80 Malarial cachexia, 79 fever, 65 algid form, 78 blood changes, 72 in chronic, J2 cachexia, 79 chronic form, 72 clinical varieties, 72) comatose form, 77 estivo-autumnal, 65, 76 favoring causes, 71 geographical distribu- tion, 71 hematuria, 79 incubation of, 72, intermittent form of, 72, irregular forms of, 78 latent form of, 78 morbid anatomy of, 72 Plasmodium, 66 prophylaxis against, 80 quartan, 65 quotidian. 65 remittent form, 76 seasons favoring, 71 tertian, 65 Malignant jaundice, 469 lymphoma, 664 pustule, 194 Malleus humidus, 197 Malta fever, 63 distribution of, 63 etiology of, 63 morbid anatomy of, 65 symptoms of, 63 treatment of, 65 Mania-a-potu, 1158 treatment of, 1160 Marsh fever, 65 Mastication, spasm of mus- cles of, 1005 ' Measles, 118 complications and sequelae of, 121 contagiousness of, 118 diagnosis of, 121 morbid anatomy of, 119 pneumonia in, 121 prognosis of, 121 recurrent attacks of, 119 symptoms of, 119 bronchitis, 119 incubation, iig Koplik's sign, 120 ■ treatment of, 122 Meat poisoning, 1171 Median nerve, lesions of, 1035 Mediastinal abscess, 556 disease, 551 tumors, 553 diagnosis of, 556 morbid anatomy of, 555 pathology of, 553 symptoms of, 554 treatment of, 556 Mediterranean fever, 63 Megrim. 11 12 Membranes of the brain, diseases of, 1038 Membranous croup, 132 Meniere's disease, 1017 Meningeal apoplexy, 903 Meningocele, 950 Mercury poisoning, 1209 Merycismus, 352 Metastatic abscess of lung, 237 Miasmatic fever, 65 Migraine, 11 12 diagnosis of, 11 13 etiology of, 11 12 morbid anatomy of, III3 prognosis of. 11 14 symptoms of, 11 13 treatment of, 114 preventive, 11 14 Migran, 1112 Miguet, 307 Mild chorea, logi Miliary fever, 301 diagnosis of, 301 duration of, 301 etiology of, 301 morbid anatomy of, 301 prognosis of, 301 symptoms of, 301 treatment of, 302 Milk sickness, 201 Miltzbrand, 194 INDEX. 1231 Mimetic facial paralysis, 1006 spasm, 1012 Miosis, 999 Miryachit, iioi Mitral insufficiency, 576 etiolog>- of, 576 mechanism of, 576 murmur. 578 physical signs, 577 symptoms of, 576 treatment of, 593 stenosis, 578 etiology of, 579 mechanism of. 578 murmur in. 579 physical signs of, 579 symptoms of, 579 treatment of, 593 Mogigraphia, 1115 Monoplegia facialis, 1006 Morbilli, 118 Morbus maculosus, 835 neonatorum, 836 Werlhofi. 835 virgineus, 648 Morphin habit, 1161 poisoning, 1210 Morphinism, 1161 Morphea, 1142 Morvan's disease, 943 Motor agraphia, 978 aphasia, 977 function of the stomach, to test, 341 Mountain fever, 54 sickness, 55 Mouth-breathing, 317 Mouth, diseases of, 304 Mucous colitis. 382 Multiple arthritis deform- ans, 7jy neuritis, 872 sclerosis of brain and cord, 1069 Mumps, 161 complications of, 161 diagnosis of, 162 etiology of, 161 morbid anatomy of, 161 prognosis of, 162 symptoms of, 161 incubation, ibi treatment of, 162 Muscle- jerk, 849. 850 Muscular system, diseases of, 1150 Musculospiral nerve, lesions of, 1033 Mushroom poisoning, 1210 Myalgia, 771 Mycotic endocarditis, 560 Mydriasis, 999 Myelitis, diffuse, acute and chronic, 911 diagnosis of, 916 etiology of. 911 morbid anatomy of, gi2 prognosis of. gi6 symptoms of. 913 treatment of. 917 acute anterior polyomyeli- tis of children, 918 Myelitis : diagnosis of, 920 etiology of, 918 morbid anatomy of, 918 prognosis of, 920 symptoms of, 919 treatment of, 920 Myelocele, 950 Myocarditis, 610 acute suppurative, 612 diagnosis of, 612 etiology of, 610 physical signs, 611 prognosis of, 612 sj^mptoms of, 611 treatment of, 612 Myocardium, diseases of, 599 INIyoclonia, 1098 Myodegeneration, 610 Myositis, 1 1 50 acute, 1150 chronic, 1150 infectious, 1150 progressive ossifying, 1150 rheumatic, 11 50 Myotonia congenita, 1153 Myxedema, 676 diagnosis of, 679 etiology of, 677 morbid anatomy of, 677 prognosis of, 679 symptoms of, 677 treatment of, 679 N Neapolitan fever, 63 Nematodes, or round worms, 1 189 Neoplasmata cerebri, 1074 Nephritis, acute parenchy- matous, 696 complications of, 701 pneumonia, 701 diagnosis of, 701 etiology of, 696 morbid anatomy of, 697 glomerular chan- ges, 698 interstitial chan- ges, 698 tubal changes, 698 prognosis of, 702 symptoms of. 699 urine, 699 treatment of, 703 chronic interstitial, 7t6 complications of, 722 diagnosis of, 722 etiology of, 716 morbid anatomy of, 718 prognosis of, 722, symptoms of, 719 cardiac, 719 dimness of vision, 721 hypertrophy of the left ventricle, 720 urine, 720 Nephritis : treatment of, 723 chronic parenchymatous, 707 complications of, 711 diagnosis of, 711 morbid anatomy of,. 707 prognosis of, 712 symptoms of, 709 duration of, 711 urine, 710 treatment of, 712 diet, 713 hygienic measures, 713 septic and pyemic, 730 suppurative interstitial, 73a diagnosis of, 733 etiology of, 730 morbid anatomy of, prognosis of, 740 symptoms of, 722 urine. 732 treatment of, 734 Nephrolithiasis, 736 diagnosis of, 739 X-ray in, 740 etiology of, 727 morbid anatomy of, 736 prognosis of, 734 symptoms of, 738 treatment of, 740 Nephroptosis, 747 Nerve, phrenic, affections of, 1 03 1 circumflex, 1033 median, 1035 musculospiral, 1033 suprascapular, 1033 treatment of lesions of, 1036 tumors of, 886 ulnar, 1035 Nervous deafness, 1013 etiology of, 1013 symptoms of, 1014 treatment of, 1015 diseases, alterations in breathing and pulse 866 in vision and hearing, 865 mental phenomena in, 865 sensory motor phenom- ena, 863 aftersensation i n, 861 delayed conduction of sensory im- pressions, 861 muscular sense. 862 sense of locality, 861 of pain. 861 o f temperature, 861 tactile sensibility, 860 vasomotor and trophic phenomena, 863 1232 INDEX. Nervous : exhaustion, 1129 fever, 17 hypersecretion of hydro- chloric acid, 354 system, diseases of, 840 bladder and rectum, control in, 847 general symtomatolo- gy of, 843 histology of, 840 phenomena of motion in, 843 athetosis, 846 cataleptic rigidity, 847 choreic movements, 846 constant or co-ordi- nate spasm, 847 co-ordination, 845 epileptiform c o n - vulsion, 846 fibrillary c o n t rac- tion, 846 motor i rritation, 845 nystagmus, 847 rhythmical contrac- tions, 846 single contractions, 846 tremor or trembling motions, 846 Neuralgia, 880 diagnosis of, 884 etiology of, 880 prognosis of. 884 symptoms of. 881 treatment of, 8S4 varieties of, depending upon nerves in- volved, 881 brachial, 882 c e r vicobrachial, 882 cervico - occipital, 882 of the feet, 883 of the fifth pair, 881 of the phrenic- nerve, 882 of the spinal col- umn, 883 dorso-intercos- tal. 882 lumbo-abdomi- nal, 883 Neurasthenia, 1129 diagnosis of, 11 30 etiology of, 1129 morbid anatomy, 1123 prognosis of, 1131 symptoms of, 1130 treatment of, 1131 Neuritis, endemic. 878 Neuritis, localized. 867 diagnosis of, 86g etiology, 867 morbid anatomy of, 867 prognosis of. 869 symptoms of, 868 Neuritis : treatment of, 869 multiple, 872 diagnosis of, 876 etiology of, 872 morbid anatomy o f, prognosis of. 877 symptoms of, 873 treatment of, 878 progressive interstitial hy- pertrophic of infants, 939 Neuroses, 1087 Newborn, acute degenera- tion of internal organs of, 836 hemorrhagic diseases of. 836 _ _ syphilitic diseases of. 836 Nicotin poisoning, 1210 Ninth nerve, lesions of, 1018 Nitric acid poisoning. 1210 Nitrobenzol poisoning, 121 1 Noma, 311 Nose, diseases of, 497 Nutmeg liver. 452 Nystagmus, 998 O Obesity, 821 symptoms of, 822 treatment of, 822 Obstruction of bowel, 405 Occupation neuroses, 11 15 Ocular pals3^ 1003 treatment of, 1003 Olfactory nerve. 987 Oliver's sign, 631 Onomatomania. 1098 Ophthalmoplegia. 1002 Opium poisoning, 121 1 Opplar-Boas bacillus. 368 Optic atrophy, 991 gray, 992 nerve, affections, 989 and tract, 987 neuritis, 989 etiolog>' of, 990 morbid anatomy of, 989 symptoms of, 991 Organic acids of stomach, determination of, 336 Oriental plague, 114 Osteo-arthritis, 775 Osteomalacia, 829 diagnosis of. 830 etiology of, 829 morbid anatomy of, 830 pathogeny, 830 prognosis of. 831 symptoms of. 830 treatment of. 831 Oxalic acid poisoning, 121 1 Oxyuris vermicularis, 1190 Ozena, 498 Pachymeningitis. cerebral 1038 external, 1038 hemorrhagic, 1038 Pachymeningitis : internal, 1038 pseudomem b r a n o u s, 1038 purulent, 1038 spinal, 900 cervical hypertrophic, 900 external, 900 hemorrhagic, 900 internal. 900 Painless whitlows, 943 Palpable kidney, 747 Palsies, cerebral, of children, 1062 Paludal fever, 65 Pancreas, cancer of, 483 diagnosis of, 484 morbid anatomy of, 483 symptoms of, 483 cysts of, 484 diseases of, 481 Pancreatitis, acute, 482 diagnosis of, 483 etiology of, 482 morbid anatomy of, 482 prognosis of. 483 symptoms of. 482 treatment of, 483 chronic, 483 Pandemic chorea, iioi Papillitis. 989 Paradoxical c o n t ractions, 853 Paresthesia, 978 Paralysie generale spinale anterieure sub-acute of Duchenne, 921 Paralysis, acute ascending, spinal, 922 diagnosis of, 923 etiology of, 922 prognosis of, 923 symptoms of, 922 treatment of, 923 agitans, 1088 diagnosis of, 1090 etiology of, 1088 morbid anatomy of, 1088 prognosis of, 1090 symptoms of, 1089 treatment of, 1090 combined, of the interary- tenoid and thyro-aryte- noid muscles, 516 o f t h e abductors o f t h e glottis, 51S of the cricothyroid mus- cle, 51S of the arvtenoid muscles, 516 of the laryngeal muscles, 514 of the thyro-epiglottidean and aryteno-epiglottid- ean muscles. 515 of the thyro-arytenoid muscle, 516 of the tongue, the soft palate, and lips, 951 Paramimia, 978 INDEX. 1233 P a r a m yoclonus, multiple, 1091 Paranephritis, 735 diagnosis of. 736 etiology of, 735 morbid anatomy of, 736 symptoms of, 736 treatment of, 736 Paraphasia. 97S Paraplegia, ataxic, 939 diagnosis of, 940 etiology of, 939 morbid anatomy of, 939 prognosis of, 940 symptoms of, 939 treatment of, 940 cerebralis spastica, 1067 spastic, 1067 Parasites, animal, 1179 of the liver, 477 Parasitic stomatitis, 307 Paratyphlitis, 394 Paretic dementia, 1070 Parkinson's disease, 1088 Parotid bubo, 313 Parotitis, acute, 313 chronic, 314 epidemic, 161 secondary, 162 Paroxysmal headache, 11 12 Parry's disease, 672 Pasteur's treatment of hy- drophobia by attenuated virus, 188 Pythogenic fever, 17 Peduncles, cerebellar, dis- ease of, 985 Peliosis. 831 rheumatica, 831 Pellagra, 11 74 Pentastomes, 1200 Peptic ulcer, 359 Perez's sign, 633 Pericarditis, 559 acute, 559 diagnosis of, 564 etiology of, 559 morbid anatomy of, 560 physical signs, 562 Bamberger's sign, 561 Broadbent's sign, 563 Ewart's sign, 562 Friedreich's sign, 563 of chronic adhesive, 563 . ^ . pleuropericardial fric- tion sound, 564 Retch's sign. 565 prognosis of. 565 symptoms of, 561 treatment of, 565 Pericardium, cancer of, 566 diseases of, 559 Perihepatitis, 468 diagnosis of, 468 etiologj' of. 468 morbid anatomy of, 468 prognosis of, 469 symptoms of, 468 treatment of, 469 Perinephric abscess, 735 78 Periodical oculomotor pa- ralysis, 1003 Periosteal cachexia, 834 Peripheral nerves, affec- tions of, 867 neuritis, 872 Perisplenitis, 485 Peritoneum, cancer of, 492 diseases of, 487 tuberculosis of, 282 Peritonitis, acute, 487 diagnosis of, 490 etiology of, 487 morbid anatomy o f, 488 physical signs, 489 prognosis of, 490 symptoms of, 488 treatment of, 490 of acute general, 488 chronic, 491 circumscribed, 491 hysterical, 490 in typhoid fever, 47 Perityphlitis, 394 Pernicious anemia, 652 malarial fever, 77 algid type, 78 asthmatic tj'pe, 77 bilious type, 77 comatose type. 77 hematuric type, 79 temperature, 77 treatment of, 80 Pertussis, 157 Pestilential or putrid fever, 55 Petechial fever, 55, 167 Petit mal, 1106 Pharyngitis, acute catarrhal, chronic catarrhal, 321 phlegmonous, 322 ulcerative, 322 Pharynx, circulatory de- rangement of, 320 diseases of, 315 hypertrophy of adenoid tissue of, 317 spasm of, 1020 Phlegmonous tonsillitis, 315 Phosphorus poisoning, 121 1 Phrenic nerve, affections of, 1031 Phthisis, acute, 247 bronchopneumonic, 247 chronic ulcerative, 254 fibroid, 265 florida, 247 pneumonic form of, 248 pulmonalis, 252 Piles, 431 Pin worm. 1190 Pityriasis ethiopius. 1143 Plague, bubonic, 114 Platyhelminthes, 1180 cestodes, 1181 intestinal. I181 diagnosis' of, 1185 prognosis of, 1186 symptoms of, 1185 treatment of, 1186 Platyhelminthes : prophylaxis, 1188 trematodes, 1180 blood fluke, 1181 bronchial fluke, 1181 liver fluke, 1180 Pleura, diseases of, 539 hydatid disease, 551 morbid growths of, 551 carcinoma, 551 chondroma and lip- oma, 551 sarcorna, 551 tuberculosis of, 544 Pleurisy, 539 acute, 539 diagnosis of, 544 etiology of, 539 morbid anatomy of, 540 physical signs of, 542 Skoda' s r e s o n ance, 543 prognosis of, 545 pus-formation in, 541 resolution in, 540 serous accumulation in, 540 symptoms of, 541 treatment of, 546 blood-letting, 546 lapping, 547 chronic, 547 treatment of, 548 diaphragmatic, 544 encysted or circumscribed, 544 exudative, 547 hemorrhagic, 544 interlobular, 544 latent, 547 plastic, 547 pulsating, 547 suppurative, 544 tubercular, 544 Pleurodynia, 883 Plumbism, 1164 Pneumogastric nerve,lesions of, 1019 cardiac branches of the, 1024 diagnosis of, 1023 etiology of, 1020 gastric and esophageal branches of the, 1024 involving the nucleus and trunk, 1019 laryngeal branches of the, 1020 etiology of, 1020 symptoms of, 1021 pharyngeal branches of the, 1020 etiology of, 1020 symptoms of, 1020 pulmonary branches of the, 1024 treatment of, 1025 Pneumonia, aspiration or deglutition, 228 broncho-, 228 diagnosis of. 231 etiology of, 228 1234 INDEX. Pneumonia : morbid anatomy of, 229 physical signs, 231 prognosis of, 231 symptoms of, 230 treatment of, 232 chronic interstitial, 233 diagnosis of, 235 etiology of, 233 morbid anatomy of, 233 physical signs of, 234 prognosis of, 235 symptoms of, 234 treatment of, 235 •croupous, 212 bacillus of, 213 complications of, 222 diagnosis of, 222 duration of stages of, 216 etiology of, 213 in children, 223 incubation, 216 in the aged, 223 larval, 212 migratory, 212 morbid anatomy of, 214 stage of congestion, 214 of gray hepatiza- tion, 214 of red hepatization, 214 of yellow hepatiza- tion, 215 mortality in, 223 nature of, 214 physical signs of, 216 first stage, 216 second stage, 217 Skoda's resonance, 218 third stage, 218 prognosis of, 223 symptoms of, 216 delayed resolution, 220 herpes, 220 phlegmasia alba do- lens, 220 prune-juice expecto- ration, 219 ermination, 220 by abscess of lung, 221 by fibroid induration or cirrhosis, 221 by gangrene of lung, 221 by resolution, 220 by tubercular phthisis, 222 treatment, 223 serum, 227 embolic, 235 non-septic, 235 septic, 237 streptococcus, 220 Pneumonic phthisis, 247 Pneumonitis, 212 Pneumopericardium, 566 Pneumothorax, 549 Pneumothorax : diagnosis of, 550 etiology of, 549 physical signs of, 549 Hippocratic succussion, 550 metallic tinkling, 550 symptoms of, 549 treatment of, 550 Podagra, 780 Poisons, overdoses of, 1204 Polioencephalitis inferior chronica, 951 Poliomyelitis, acute, 918 in adults, 921 diagnosis of, 921 treatment of, 921 in children, 918 diagnosis of, 920 etiology of, 918 morbid anatomy of, 918 prognosis of, 920 symptoms of, 919 treatment of, 920 subacute and chronic, 921 superior, 1003 Pollen catarrh, 501 Polyneuritis, 872 Polysarcia adiposa, 821 Popliteal nerve, lesions of, 1037 external, 1037 internal, 1037 Porencephalia, 1063 Postchoreal paralysis and postparalytic chorea, 1102 Post erior spinal sclerosis, 926 Posthemiplegic mobile spasm, 1 102 Postpharyngeal abscess, 323 Pressure paralysis of the spinal cord, 943 Presystolic murmur, 580 Primary lateral sclerosis, 924 Professional spasm, 11 15 Progressive bulbar palsy, 951 diagnosis of, 953 etiology of, 951 morbid anatomy of, 951 prognosis of, 953 symptoms of, 952 treatment of, 953 facial hemiatrophy, 1138 general paralysis of the insane, 1070 muscular atrophy, type Duchenne-Aran, 958 neural muscular atrophy, 1153 pernicious anemia, 652 spastic paraplegia, 939 spinal muscular atrophy, 958 diagnosis of, 961 etiology of, 958 morbid anatomy of, 959 prognosis of, 962 symptoms of, 960 Progressive bulbar palsy: treatment of, 962 Prosopalgia, 881 Proteolysis, 337 Protozoa, 11 79 parasitic infusoria, 1180 psorospermiasis, II79 Protracted simple continued fever, 298 diagnosis of, 299 etiology of, 298 prognosis of, 299 symptoms of, 299 treatment of, .299 Prune-juice expectoration, 219 Pseudo-angina 622 Pseudohypertrophic emphy- sema, 532 Pseudohypertrophy of mus- cles, 1151 Pseudoleukemia, 664, 668 Pseudomembranous croup, 136 Pseudomembranous enter- itis, 392 Psychical epilepsy, 1106 Ptomain poisonmg, 1212 treatment of, 1212 Ptosis, 998 Ptyalism, 313 Puking fever, 201 Pulmonary consumption, 252 insuflficiency, 589 stenosis, 590 Pulmonohepatic angle, 331 Pulse, irregular, 616 anacrotic, 618 delirium cordis, 617 dicrotic, 618 embryocardial, 618 explanation of, 616 gallop rhythm, 617 peculiarities of, 616 varieties of, 616 Pulsus bigeminus, 617 bisferiens, 618 paradoxus, 617 trigeminus, 617 Purpura, 831 arthritic, 834 treatment of, 836 hemorrhagica, 835 treatment of, 836 Henoch's, 835 scorbutic, 832 simple arthritic, 834 symptomatic, 831 Putrid sore mouth, 308 Pyemia, 181 arterial, 573 diagnosis of, 183 etiology of, 181 prognosis of, 183 symptoms of, 182 treatment of, 183 Pyelonephritis, 730 Pylephlebitis, 455 Pyiethrombosis, 454 Pyopneumothorax, 549 Pythogenic fever, 17 INDEX. 1235 Q Quigila, 1 143 Quincke's lumbar puncture, 174 Quinsy. 315 etiology of, 315 morbid anatomy of, 315 symptoms of, 315 treatment of, 316 R Rabies, 184 Rachitis, ^^24 Railway brain, 1132 spine, 1132 Raynaud's disease, 1136 pathology of, 1137 prognosis of, 11 38 symptoms of, 11 36 treatment of, 11 38 Reaction of degeneration, partial, yOi significance of, 857 Rectum, cancer of, 430 mechanism of control of, 847 neuralgia of, 426 Red atrophy of the liver, 452 granular kidney, 716 Reflexes, 1065 ankle, 849 cutaneous, 848 deep-seated, 1036 patellar, 1033 periosteal, 850 segments of cord presid- ing over, 853 tendon or deep, 853 their significance, 852 Reichmann's disease, 354 Relapsing fever, 59 diagnosis of, 62 etiology of, 59 incubation in, 60 morbid anatomy of, 60 prognosis of, 62 relapse in, 62 spleen in, 60 symptoms of, 60 treatment of, 62 Relation of locality to symp- toms in cerebral disease, 963 Remittent fever, 65, 76 chill in, 70 diagnosis of, 76 prodromal symptoms of, 76 treatment of, 80 Renal cirrhosis, 716 associated witn hypertro- phy of the left ventricle without valvular dis- ease, 753 relation of, to heart dis- ease. 753 dropsy, 687 infarct, 758 sclerosis, 716 Ren mobilis, 747 Rennet, action of, 340 Respiration and deglutition, muscles of, affections of, 1021-1024 Respiratory system, diseases of, 497 Retina, affections of. 987 functional disturbances of, 988 hemorrhage into, 988 hyperesthesia of, 989 organic disease of, 987 Retinitis, 988 albuminuric. 988 syphilitic, 988 Revaccination, 154 Rheumatic fever, 289 complications of, 293 diagnosis of, 294 etiology' of, 289 morbid anatomy of, 291 prognosis of, 294 symptoms of, 291 prodrome, 291 recurrence, 292 subcutaneous nodules, 292 treatment of, 294 joint, 77-, myositis, 771 purpura, 831 Rheumatism, 771 acute articular, 289, 771 See Infectious Dis- eases, chronic articular, 773 morbid anatomy of, 772, symptoms of, 774 treatment of, 774 muscular, 771 diagnosis of, 772 etiology of, 771 symptoms of, 771 cephalodynia, 772 lumbago, 772 pleurodynia, 772 stift' neck or torticol- lis, 772 treatment of, 772 Rheumatoid arthritis, 775 Rhinitis, acute, 497 chronic, 498 atrophic. 499 hyperatrophic, 499 symptoms of, 499 treatment of, 499 sj-philitic, 207 Rhyncota, 1200 Rhvthmical contractions, 846 or hysterical chorea, iioi Rickets, 824 complications, 828 diagnosis of, 828 etiologv' of, 824 morbid anatomy of, 826 shape of chest, 827 progn6sis of, 828 symptoms of, 827 treatment of, 828 Riga's disease, 307 Rock fever, 63 Rocky Mountain fever, 54 Rose cold, 501 Rotch's sign, 563 Rotheln, 122 Rubella, 122 diagnosis of, 123 etiology of, 123 incubation of, 123 prognosis of, 124 symptoms of, 123 treatment of, 124 Rubeola, 118, 122 notha, 122 Sacral plexus, lesion of, 1036 treatment of, 1037 Salivary glands, diseases of, inflammation of, 2)^:^ Salt solution, normal, com- position of, 102 Sarcoma of the liver, 472 diagnosis of, 474 symptoms of, 473 Saturnism, 1164 Scarlatina, 1^4 simplex, 126 (See also Scarlet Fever) scarlatina anginosa, 128 maligna, 128 miliaris, 12& Scarlet fever, 124 Loeffler's bacillus, 128 complications and se- quelae, 128 diagnosis of, 130 etiology of, 1.24 epidemics of, 128 hemorrhagic, 128 morbid anatomy of, 125 prognosis of, 130 symptoms of, 125 raspberry tongue, 126 strawberry tongue, 126 treatment of, 131 Scheeles sign, 633 Schistosoma haematobium, 1181 Sciatica, 870 diagnosis of, 871 etiology of, 870 symptoms of, 870 treatment of, 871 Sciatic nerve, lesions of, 1036 Sclerema, 1141 Scleroderma, 1141 Sclerose cerebrale, 1063 en plaques, 1069 Sclerosis, amyotrophic lat- eral, 956 diagnosis of, 950 etiolog}' of, 956 morbid anatomy of, 956 symptoms of, 956 treatment of, 958 of brain and spinal cord, io6g diagnosis of, 1070 etiology of, 1069 1236 INDEX. Sclerosis : morbid anatomyofj 1069 symptoms of, 1069 treatment, 1070 of the coronary arteries, 610 toxic. 939 Scotoma, 996 Scrivener's palsy, 1 1 15 Scrofula, 279 Scurvy. 832 diagnosis of, 833 etiology of, 832 morbid anatomy of, 833 prognosis of. 833 symptoms of, 833 treatment of, 833 infantile, 834 deviation of vision, lOOl Senile tremor, 1091 Septicemia, 167 and pyemia, 181 bacilli, 181 diagnosis of, 183 etiology, 181 prognosis of, 183 symptoms of. 182 treatment of, 183 Serratus palsy, 1032 Seven-day fever, 59 Seventh nerve, lesions of, 1006 Shaking palsy, 1088 Ship fever, 5S Sick headache, 11 12 Silver nitrate poisoning, 1212 Simple angina, 320 continued fever, 298 or round ulcer, 359 Sixth nerve, lesions of, af- fecting the eyeball, lOOi Skodaic sign, 536 Slow consumption, 254 nervous fever, 17 Slows, 201 Smallpox, 145 complications of, 149 contagium, 146 diagnosis of, 150 forms of, 149 confluent, 149 discrete. 149 hemorrhagic, 149 purpura variolosa, 149 variola hemorrhagica pustulosa, 149 variolse sine variolis, : 149 varioloid, 149 morbid anatomy of, 147 prognosis of. 150 symptoms of, 148 incubation, 148 muscular pain, 148 initial rashes, 148 diffuse scarlatinous, 148 measly. 148 treatment of, 150 special modes, 131 Small sciatic nerve, lesions of, 1037 Smoker's tongue, 312 Soor, 307 Sore throat, 320 Spasm, constant or co-ordi- nate. 847 of muscles of mastication, 1005 tonic and clonic, 845 Spasmodic tabes dorsalis, 924 Spasms of the muscles of respiration and degluti- tion, 1099 Spastic diplegia, 1066 paralysis of children. 1066 paraplegia, 1067 diagnosis of, 1068 etiology, 1067 morbid anatomy of, 1067 symptoms of, 1067 treatment of, io58 Spastic infantile hemiplegia, 1063 Spastic rigidity of the new- born, 1066 spinal paralysis, 924 diagnosis of. 925 etiolog}', 924 morbid anatomical conditions, 924 prognosis of, 925 symptoms of, 924 treatment of, 925 Speech areas in cortex of brain, 964 derangements o f, irritative origin of, 980 to test derange- ments of, 980 S p h y g m ograms, 578, 580, 583, 586, 618, 619, 626 Spina bifida, 950 Spinal accessory nerve, le- sions of. 1026 symptoms of, 1026 spasm of, 1026 symptoms of, 1027 cord, acute affections of, 908 • anemia. 908 congestion, 908 embolism. 908 thrombosis. 908 affections of, 888 the membranes of. 899 the substance of, 904 chronic affections of, 924 compression of. 943 diagnosis of, 945 etiology. 943 morbid anatomy of, 943 prognosis of. 945 symptoms of, 943 treatment of. 945 hemorrhage into the substance of, 908 Spinal : cord, localization, 892 secondary systemic de- generations of, 905 after cerebral le- sions, 906 after injuries of the Cauda equi- na, 907 after t r a nsverse lesions of the cord, 906 membranes, hemorrhage into, 903 extrameningeal. 003 intrameningeal. 903 medullary, 903 nerves and branches, dis- eases of, 1031 paralysis of children, 918 Splanchnoptosis, 376 Spleen, abscess of, 485 amyloid. 486 atrophy of, 486 diseases of, 485 echinococcus, 486 hemorrhagic infarct, 486 in anthrax, 195 in cirrhosis of the liver, 462 in leukemia, 659 in malaria, 72 in typhoid fever, 22 in typhus fever, 56 neoplasm of, 486 rupture of, 485 wandering. 486 Splenic apoplexy, 194 fever, 194 Splenitis, 485 Split spine, 950 Sporadic cerebrospinal fe- ver. 175 cholera, 384 Spotted fever, 167 St. Anthony's fire, 177 Starch and sugar, digestion of, 340 Status epilepticus, 1105 lymphaticus, 667 Stenocardia, 620 Steppage gait, 874 Stereognosis, 863 Stigmata, hysterical, 1122, 1 124 Stomacace, 308 Stomach, action of, rennet in, 340 cancer of, 366 bacillus of. 368 diagnosis of, 370 etiology of. 366 morbid anatomy of, 367 prognosis of, 372 secondary, 367 symptoms of. 368 treatment of, 372 chemical examination of contents of. 332 determination of acid salts in, 334 INDEX. 123/ Stomach : determination of loosely combined HCl i n, 335 of organic acids in, 336 examination of prod- ucts of albumin di- gestion in, 337 reaction of, 333 determination of rate o^ absorption from, 341 digestion of starch and sugar in, 340 dilatation of the, 373 diagnosis of, 375 physical signs of, 373 morbid anatomy, 373 prognosis of, 375 symptoms of, 373 treatment of, 375 dietetic, 376 diseases of, 329 d i a g nostic technique for, 329 . . , external examination of, 329 auscultation, 332 palpation, 330 percussion, 330 Stomatitis, acute catarrhal, 306 aphthous, 307 mercurial. 309 mycotic, 307 syphilitic, 309 . ulcerative, 308 treat ment of different forms of, 310 prophylaxis against, 310 Struma exophthalmica, 672 simple, 670 Strychnin poisoning, 1212 St. Vitus' dance, iioi Sudor anglicus, 301 Suffocative catarrh, 228 Sugar and starch, digestion of, 340 Suggestion and hypnosis, 1125 Sulphureted hydrogen poi- soning, 1213 Sulphuric acid poisoning, 1210 Sunstroke, 1176 Suprarenal capsule, diseases of, 681 Suprascapular nerve, lesions of, 1033 Surgical kidney, 730 Swamp fever, 65 Sweating disease of Picar- dy, 301 Swelled head, 198 Sydenham's chorea, 1901 Syphilis, 202 acquired, 203 initial sore, 202 primary, 202 secondary, 202 tertiary, 202 Syphilis : congenital, 203 contagiousness of, 202 diagnosis of, 207 hereditary, 203 germ inheritance, 203 sperm inheritance, 203 transmission, 203 morbid anatomy of, 203 fibroid induration, 204 gumma, 205 mucous patch, 204 papular eruption, 204 pustular eruption, 204 syphilides, 204 macular, 204 squamous, 204 venereal wart, 204 Hutchinson's teeth, 207 of brain and spinal cord, 1 144 of the liver. 475 diagnosis of, 476 symptoms of, 476 treatment of, 477 of the nervous system, 1 144 diagnosis of, 1147 etiology of, 1144 morbid anatomy of, 1144 prognosis of, 1148 symptoms of, 1145 treatment of, 1148 Syphilitic ulcer of bowel, 394 Syringomyelia, 941 diagnosis of, 942 etiology of, 941 symptoms of, 941 treatment of, 942 Tabes dorsalis, 926 course of, 934 differential diagnosis of. 934 etiolosfv of, 926 morbid anatomy of, 927 prognosis of, 934 symptoms of, 929 arthropathies, 933 cerebral, 933 gait, 931 . girdle pains, 931 inco-ordination, 931 motor phenomena 930 reflex, 932 Romberg's sign. 930 sensory, 931 vasomotor and troph- ic phenomena, 933 visceral pain, 932 treatment of, 935 mesenterica, 282^ Tabetic crises, 932 Tables for conversion of metric into English sys- tem, 1216 Tachycardia, 615 explanation of, 615 paroxysmal, 615 treatment of, 619 Tachycardia strumosa, 672 Tactile sensibility in ner- vous diseases, 860 Tape-worm, 1181 intestinal, 1181 visceral, 1188 Temperature, effects of high, 1 175 Tendon reflexes, 852 Tenth nerve, lesions of, 1019 Test breakfast, 2i2>2 dinner, 22>2> for free HCl, 334 Boas" test, 334 for lactic acid, UfJel- mann's, 337 Tests for albumin, 686 contact method with ni- tric acid, or Heller's, 687 heat and acid, 686 picric acid, 687 for globulin, 687 Tetanilla, 11 19 Tetanoid pseudoparaplegia, 1067 Tetanus, 190 bacillus of, 190 diagnosis of, 192 etiology of, 190 morbid anatomy of, 191 predisposing causes of, 191 prognosis of, 193 symptoms of, 191 treatment of, 193 varieties of, 190 idiopathic, 191 neonatorum, 191 traumatic, 191 Tetany,' 11 19 The pox, 202 The rose, 177 Theories of cardiac hyper- trophy in renal disease, 753 Thermic fever, 1176 treatment of, 1178 Thick neck, 670 Third nerve, lesions of, 998 Thomsen's disease, 1153 Thornhead worms, 1198 Thread worms, 1190 Thrombosis and embolism, 454 of cerebral sinuses and veins, 1056-1061 primary, 1061 secondary, 1061 Thrush, 307 Thyrocele. 670 Thyroid gland, enlargement of, 673 neoplasms of, 680 glands, diseases of, 670 1238 INDEX. Tic, complex co-ordinated, 1099 douloureux, 88 simple, 1097 generalized, 1097 localized, 1097 with explosive utterances, 1098 Tinnitus aurium, 1016 etiology of. 1016 treatment of, 1016 Tobacco habit, 1164 Tongue, inflammation of, psoriasis of, 312 Tonic contraction of ex- tremities, 1066 Tonsillar abscess, 315 Tonsillitis, 315 acute parenchymatous, 315 chronic, 317 diagnosis of, 319 etiology of, 317 morbid anatomy of, 3^7 prognosis of, 319 symptoms of, 317 treatment of, 319 follicular, 316 Tonsils, diseases of, 315 Tooth rash, 305 Tropical diagnosis of cere- bral lesions, 963 Torticollis, or wry-neck, 1027 congenital, 1027 pathology of, 1029 spasmodic, 1028 treatment of, 1029 Trachea, diseases of, 517 Tracheobronchitis, a c u t e j 517 Tracts within the bram, 982 Transverse myelitis, 911 Traube's half-moon space, 331 Traumatic hvsteria, 1132 neuroses, 1132 Trembles, 201 Tremor, hereditary, 1091 hysterical, 1091 other forms of, 1091 asthenic, 1091 senile, 1091 simple, 1091 toxic, 1091 Trichiniasis, 1191 Tricuspid incompetency, 588 physical signs of, 589 jugular pulse, 588 stenosis, 589 physical signs of, 589 Trifacial nerve, lesions of, 1004 diagnosis of, 1005 symptoms of, 1005 paralysis of motor portion of the, 1005 of sensorv portion of the, 1005 treatment of, 1006 Trigeminus, lesions of, 1004 Trophic derangements due to nervous diseases, 864 Tube-casts, 690 blood, 6go cylindroid, 692 epithelial, 690 granular, 692 hyaline, 691 mucous, 692 oily or fatty, 692 pus, 690 waxy, 691 Tubercle, 242 anatomy and histology of, 242 calcareous infiltration of, 244 caseation of, 243 degeneration of, 243 fibroid change in, 244 histogenesis of, 243 retroactive inflammation, caused by, 244 softening of, 243 solitary, 243 Tubercular consumption, 252 peritonitis, 282 ulcer of bowel, 393 Tuberculin test for tuber- culosis, 264 Tuberculosis, 238 bacillus of, 238 to stain, 238 etiology of, 238 age, 240 climate, 240 defective food, 240 Fleck's studies, 239 heredity, 239 locality, 240 race, 240 shape of chest, 241 traumatism, 241 acute, clinical varieties, 245 general miliary or ty- phoid form, 245 miliary meningeal form, 249 diagnosis of, 251 etiology of, 249 morbid anatomy of, V 249 prognosis of, 251 symptoms of, 250 * treatment of, 251 miliary pulmonary form succeeding b r o n- chitis, chronic tuber- culosis, whooping- cough, or measles, 247 pneumonic phthisis, 247 chronic fibroid. 265 physical signs, 265 prognosis of, 266 symptoms of, 265 treatment (see o f ulcerative) chronic ulcerative, 254 diagnosis of, 263 Tuberculosis: morbid anatomy of, 252-254 physical signs, 257 prognosis of, 265 symptoms of, 257 treatment of, 266 climatic, 266 hygiene and die- tetic, 268 medicinal, 269 special symptoms, 273 pneumptherapy, 272- prophylactic, 275 serum-, 271 of the heart and blood vessels, 286 of the kidney, 283 miliary granulations in,. 283 morbid anatomy of, 283; primary foci in, 283 symptoms of, 283 treatment of, 284 of the lymphatic glands, 279 diagnosis of, 280 etiology of, 279 prognosis of, 280 symptoms of, 279 tabes mesenterica,, 280 treatment of, 281 of the mammary glands,. 286 of the ovaries, Fallopiaa tubes, and uterus, 285 of the pelvis of the kid- ney, ureters, and blad- der, 284 of the peritoneum, 282 of the pleura, 281 of the serous membranes, 281 of the testes, prostate gland, and seminal ves- icles, 285 Tuberculous leptomeningi- tis, 249 lymphadenitis, 279 Tumors of the spinal cord and membranes^ 946 diagnosis of, 947 prognosis of, 949 symptoms of, 947 treatment of, 949 varieties of, 946 Twelfth nerve, lesions of,, 1030 Typhlitis, 394 Typhoid fever, 17 abortive form of, 32 albuminuria in, 28 antiseptic treatment of,, 50 atypical forms of, 31 bacteriology of, 18 bed-sores in, 47 blood changes in, 30 boils in, 3^ INDEX. 1239 Typhoid : bone lesions in, 34 Brand bath treatment of, 41 cardiac comphcations in, 34 chills in, 31 cholecystitis in, 35 circulatory system in, 22 complications in, 32 constipation in, 46 contagiousness of, 19 cystitis in, 48 delirium in, 28 diagnosis, 36 diazo-reaction of urine in, 29 diet in, 41 disinfection of stools in, 52 Ehrlich's reaction in, 29 eliminative and antisep- tic treatment of, 50 etiology, 17 expectant symptomatic treatment of, 45 hemorrhage in, 46 hemorrhagic form of, 32 herpes in. 24 in children, 23, 40 incubation of, 23 indications for alcohol in, 45 influence of age on, 20 influence of seasons on, 20 management of conva- lescence in, 48 meteorism in, 26 methods of reducing temperature in, 44 milk leg in, z^ mode of conveyance of, 20 morbid anatomy of, 21 nervous or meningeal form of, Z2 parotitis in, 23i perforation in, 28-47 peritonitis in, 47 Peyer's patches in, 21 predisposing causes of, 20 prodromal symptoms, prophylaxis in, 52 pulmonary form, 32 relapses in, 35 renal form, 28 rose-colored spots in, 23 sequelae of, 32 serum-therapy in, 51 skin rashes in, 22, splenic enlargement in, 21-24 temperature in, 23 thrombosis in, 32 tonsillar form of, 32 treatment of, 41 by cultures of serum, 51 Typhoid : treatment by diet and rest, 41 expectant symptom- atic, 45 of convalescence, 48 of special symptoms, 46 tube rcular phthisis in, 34 tympanitic distention in, 46 typhoid spine in, 34 unusual form of onset, 31 urine in, 23 walking form of, 23 Widal reaction, 2>7 Typhus abdominalis, 17 exanthematicus, 55 fever, 55 etiology, contagiousness, 55 diagnosis of, 36 eruption of, 56 incubation of, 56 morbid anatomy, 56 prognosis of, 58 symptoms of, 56 treatment of, 58 icterodes, 59, 83 tropicus, 83 U Uffelmann's test for lactic acid, 337 , Ulcer, gastric and duodenal, 359 . . course and termination of, 362 diagnosis of, 362 from cancer, 363 etiology of, 359 morbid anatomy of, 360 prognosis of, 364 symptoms of, 360 hemorrhage, 361 treatment of, 364 operative, 366 Ulceration of the bowel, 393 Ulcerative colitis, 382 Ulcerative endocarditis, 570 Ulcus ventriculi pepticum, 359 Ulnar nerve, lesions of, 1035 Uncinariasis, 1193 Undulant fever, 63 Unilateral progressive facial atrophy, 11 38 Uremia, 688 symptoms of, 688 treatment of, 705 Uric acid, thread test, 781 Uricacidemia, 793 Uricemia, 793 Urinary organs, diseases of, 684 V Vaccina, 152 Vaccine disease, 152 bacteriology of, I53 Vaccine : disease, humanized lymph in, 153 operation in, 153 phenomena of, I53 rashes, 154 Vaccinia, 152 hemorrhagica, 154 nature of, 152 Vaccinosyphilis, 155 Vagus nerve, lesions of, 1019 Valvular (cardiac) defects, 574 congenital, 575 morbid anatomy of, 575 relative frequency of, 591 disease, chronic, prog- nosis of, 592 treatment of, 593 of dropsy, 598 of dyspnea, 597 of irregularities of heart action and palpitation, 599 lesions, associated or com- bined, 592 Valvulitis, 567 Varicella, 156 Variola, 145 Variolae sine variolis, 149 Vasomotor and trophic de- rangements, 1 136 Vesical catarrh, 759 , Vesicular emphysema, 532 Vesicular or herpetic stoma- titis, 307 Visceroptosis, 376 tiology of, 376 symptoms of, 377 treatment of, 378 Vision, modifications of, in. nervous disease, 865 Vocal cords, paralysis of, 516 W Warty or verrucose endo- carditis, 568 Wasting palsy, 958 Water cancer, 311 Waxy kidney, 726 liver, 457 Weil's disease, 300 Wernicke's scheme, 974 Whooping-cough, 157 complications and sequelae of, 159 diagnosis of, 159 morbid anatomy of, 158 prognosis of, 160 shape of chest in, 158 symptoms of, 158 treatment of, 160 Winckel's disease, 836 Woolsorter's disease, 196 Word-blindness, 976 Word-deafness, 976 Word-image, 972 Writer's cramp, 1115 etiology of, 11 15 1240 INDEX. Writer's cramp: Y Yellow fever: diagnosis of, 1117 jaundice in, 86 treatment of, 1117 Yellow atrophy of the heart, morbid anatomy of, 85 Wry-neck, 1027 610 prognosis of, 88 of the liver, acute, 469 prophylaxis of, ^ ^ fever, 83 slow pulse of, 87 X albuminuria in, 86 symptoms of, 86 bacillus icterodes of, 84 treatment of, 88 Xerostomia, 313 diagnosis of, 87 by serum, 89