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NATIONAL LIBRARY OF MEDICINE
NLM D01D7DMtD 1
NATIONAL
LIBRARY
MEDICINE
Washington,D.C.
NLM001070469 
 
 
 
 
A TREATISE
PRINCIPLES AND  PRACTICE
OF
MEDICINE;
DESIGNED FOR THE USE OF
PRACTITIONERS AND STUDENTS OF MEDICINE.
BY
        AUSTIN FLINT, M.D., LL.D.,
LATE PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE
      IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK, ETC.
           SIXTH EDITION,
REVISED AND LARGELY REWRITTEN BY THE AUTHOR.
[, M.D.,    V
               ASSISTED BY
        WILLIAM H. WELCH,
   PROFESSOR OF PATHOLOGY IN JOHNS HOPKINS UNIVERSITY', BALTIMORE,
                 AND              j
        AUSTIN  FLINT, M.D., LL.D.,   V
PROFESSOR OF PHYSIOLOGY IN THE BELLEVL'E HOSPITAL MEDICAL COLLEGE, NEW YORK.
l)<>Zz$-
      PHILADELPHIA:
LEA BROTHERS  & CO,
          1S86. 
>MTS
  F623t
    19 s:*
   Entered according to Act of Congress, in the year 1886, by

               LEA BROTHERS & CO.,

in the Office of the Librarian of  Congress.  All rights reserved.
     AVestcott & Thomson,                         Collins Printing .House,
Stereolypers and Electrolypers, Philada.                         Printer, Philada. 
PREFACE.
   The Preface to the fifth edition of this treatise, Avritten in December,
1880, might Avell serve as a preface to this, the Sixth Edition, as regards the
general statements of the author's aims and labors in bringing " the work,
in all respects, up to the level of the present state of advancement in both
the Principles and the  Practice  of Medicine.  Time and  effort  have not
been  spared for this end."
   The treatise embraces in its scope, General Pathology, as Avell as Practical
Medicine;  and, Avhile each  of these departments  of knowledge Avas in  no
inconsiderable degree advanced by  zealous Avorkers in  different  countries
during the period betAveen  the publication of the fourth edition, in 1<S73,
and the issue of the fifth edition, in 1881,  the progress, especially in General
Pathology, Avithin the five years  since 1881 has been immense.  Certain of
the advances Avithin  this half-decade Avere of such interest and  importance
that the author added, in 1883, an Appendix to  the  fifth edition, in order
that the remarkable researches of Koch  and others on  the bacillus tuber-
culosis should  be put before his readers  as soon as these observations had
assumed a  permanent place among the  established  facts in medical science.
It is  almost unnecessary to  add that these and other recent observations in
bacteriology have been incorporated in this, the  Sixth Edition, in the body
of the Avork.   The claim, in the Preface to the fifth edition, " that the elim-
inations, substitutions, and additions rendered it essentially a neAV  work,"
can Avith equal propriety be made for the present edition as compared Avith
the edition issued in  1881.
   The careful and thorough  revision, of which this edition is the result, Avas
practically completed  by the author's  own  hand,  in March,  1886, with the
assistance,  as in the revision  for the fifth edition, of Dr. William H. Welch.
The labor  which has  since  been expended on the Avork,  by Dr. Welch and
by the writer  of this Preface, has been mainly  that of carrying the book
through the press.  After the final  revision had  become far advanced, the
author made arrangements, Avhich have been carried out in exact accordance
with his vieAVS  and wishes, by which he Avould be  spared the labor of close
proof-reading.  This part of the Avork has been performed, perhaps, with even
more anxious and critical care than if it had been  done under his own eye.
  It can hardly noAV be considered indelicate to allude to certain qualities
of mind,  developed  by training and  opportunities most unusual, which
enabled the author to produce, as the crowning Avork  of his long professional
life, this treatise on the Principles and Practice of  Medicine.
  The basis of  the  work is  an unbroken  series of records of cases  in
                                                                3 
4
PREFACE.
private practice and in  hospitals, begun in 1833  and continued  for  more
than half a century, covering sixteen thousand nine hundred and tAventv-
two folio pages of manuscript, Avritten AA'ith  the author's oAvn hand.   These
records embrace carefully-Avritten histories of cases  in  all departments of
practical medicine, observed under  varied  conditions of life, climate, and
general surroundings.  Soldiers in  camp and barracks;  the rich and the
poor; those affected with diseases  incident  to  lives of ease and  luxury and
paupers in hospitals; the pioneers of Western New York and the inhabit-
ants of the metropolis;  patients in the Avards of the almshouse and hospitals
of Buffalo, of the Marine Hospital in Louisville, Kentucky, the great Charity
Hospital in New Orleans, Louisiana,  the Bellevue Hospital, the Charity Hos-
pital, the dispensaries, and similar institutions in the city of New York; cases
observed in the experience of a quarter of a century as a general practitioner,
and  of more than  another  quarter  of a century as a consulting physician,
including the epidemics Avhich have  occurred in this country  Avithin the last
fifty years,—the experience derived from these various sources of obser\*a-
tion, carefully recorded, studied, and analyzed, Avas finally used in the com-
position of this treatise, the  first edition of which appeared in 1866.  In the
mean time, the author's original contributions to practical  medicine, embod-
ied in  special  treatises,  in  communications published in  medical period-
icals, and in Transactions of medical societies, have left  their impress  upon
many departments  Avhich, in recent  years, have been classed as specialties;
although he was always a physician, never a specialist.  A  student of the
history of practical medicine will often find observations and  ideas, assumed
to be of recent date, which had  been anticipated by the author many years
before.
   It would be tedious to enumerate the systematic works, original articles,
revieAvs, etc.  published  by the author Avithin  the  last fifty years ; but the
scientific spirit which pervades all of his Avritings  is well illustrated by the
folloAving extract from  the  Preface  to  the  fifth edition of this work:
   " In  making  changes, the  author has not  been influenced by any sense of
obligation to maintain  consistency of vieAvs Avith the previous  editions  of
this  treatise, or Avith other Avorks which he has written.  Whenever state-
ments are found to vary from those  made at a prior date, the simple expla-
nation  is that the latter, in the light  of more recent reflection and  enlarged
knowledge, seem to him no longer  tenable.  He has  endeavored to reo-ard
his own writings, in this  point of vieAV, divested of  the partiality of author-
ship, and to subject them to as critical an examination as if they were the
Avritings of another."
   Added to  a  literary training and a recorded experience almost Avithout
parallel, was an exceptional  knowledge and  application of the best methods
of teaching  medicine, rendering the author one of the most popular and
successful medical  teachers  of his time; a  statement which will be echoed
by thousands of practitioners, throughout this country and in foreign lands
avIio have attended his lectures.  The lectures  given by the author, in 1885-
86, completed his  fiftieth regular course on the Principles and  Practice  of
Medicine.
   Such, in brief, is the history of the  author  of this treatise as  a practitioner 
PREFACE.
5
writer and teacher.   While sentiments of affection and veneration have led
the Avriter to take the responsibility of recording this history here, thev have
not carried him beyond the limits of accurate statement, or, he hopes, those
of propriety and delicacy.

  In  the Preface to  the  fifth edition the author " tenders his thanks to the
present publishers for  a  continuance of the courtesy and kindness Avhich
rendered most agreeable  his relations, for a quarter of a century, Avith their
predecessors, Blanchard & Lea and Henry C. Lea."   Judging by the popu-
lar criterion of commercial success, the  publishers can  certainly  testifv to
the appreciation,  on  the  part of the profession, of the completeness Avith
which each  one of the preceding five editions has been made to  represent
the actual condition of medical knoAvledge at the time  of its publication;
and it may be safely asserted that during the last tAventy years no systematic
Avork on the Principles  and  Practice of Medicine, printed in the English
language, has  been  more  extensively circulated and  read,  and has had
a greater influence  on the practice of  English-speaking  physicians, than
has the  present  treatise.   It is  also safe to  say that the Avork is iioav more
carefully and thoroughly revised and rewritten, and  is presented in a better
scientific and literary form, than any one of the former editions.
  While it  is  unnecessary to specify all of the changes which have been
made in the  Sixth Edition, it may not be out of place to indicate some that
are important  as tending  to  perfect its symmetry and to bring the matter
closely up to the existing state of knoAvledge in the department of  Practical
Medicine.   The  most important of these additions  and alterations are the
folloAving:
  Among the  entirely new articles, special attention  may be  called to the
folloAving:  Infectious Tumors; Syphilitic Disease of the Lungs; Cerebral
Syphilis; General Considerations relating to  Inflammatory and Structural
Diseases of the Spinal Cord ; Spastic Cerebral Paralysis of Children ; Hered-
itary  Ataxia; Myxcedema; Multiple Neuritis ; General Pathology of Fever;
and Milk Sickness.   In addition to  these neAV features, many articles have
been  entirely reAvritten; and in nearly every article changes  and additions,
some  of them very important, have been made.
  In  certain parts of the work, especially in Section  IV., articles have been
rearranged so as to follow each other in a more rational and logical sequence
than  in former editions.
  As already stated, the Sixth Edition contains a full consideration of recent
discoveries concerning the bacterial origin of various infectious diseases, as
Avill be rendered evident by a consultation of the article on Vegetable Para-
sites  in the  chapter  on Etiology, and articles in the chapters treating of
Tuberculosis, Typhoid  FeA*er, Cholera, etc.
  Five diagrammatic engravings have been  introduced, in connection Avith
the nervous system, with the vieAV of illustrating the descriptions involved in
treating of the topical diagnosis of cerebral and spinal diseases.
  By  careful condensation and rearrangement and by the  rigid omission
of  obsolete  matter   the  many  additions contained  in this  edition  have
been  accommodated  without an increase in the  number  of  pages, but in 
6
PREFACE.
no instance, it is believed, have clearness  and accuracy of description been
sacrificed to brevity.
  As in the case of the  fifth  edition, the labor of revision has been shared
by Dr. William H. Welch, Professor of  Pathology in the Johns Hopkins
University and formerly Professor of Pathological Anatomy and  General
Pathology in the Bellevue Hospital Medical College.  Dr. Welch  has con-
tributed, in  Part I., the  first  seven chapters and a large part of the eighth
chapter.   He has also revised, and in great  part rewritten, the descriptions
of anatomical characters  of the diseases considered in the rest  of the volume,
and has Avritten the articles or parts of articles relating to bacteriology.  In
the Avords of the Preface to the fifth edition, " It is believed  that  these
portions of the work Avill serve as a digest of the  essential  facts  pertaining
to general and special pathological anatomy, as far as this important branch
of study bears upon practical medicine."  As regards the entire Avork, Dr.
Welch Avrites that  the " revision throughout has  been thorough and com-
plete ; and it is believed  that the new edition has taken cognizance of all of
the more important discoveries in pathology and clinical medicine since the
previous edition Avas issued."
  In the Avords of the author, repeating  the language of the  Preface to the
first  edition, " In submitting  the Avork to the judgment of his felloAV-teach-
ers and practitioners, the author ventures to  hope that it may be found to
represent fairly the existing state of the science of medicine with respect to
the subjects  of  Avhich it treats, and to reflect  the views of those who  exem-
plify, in their practice, the present stage of progress of medical art."
                                                      Austin Flint.
   New York, August, 1886. 
CONTEXTS.
                   INTRODUCTORY  CHAPTER.
                                                                         PAGE
Scope of the term Medicine—Use of the term in Contradistinction to Surgery and
   Obstetrics—Subdivisions of the Different Departments of Medicine, or Specialties
   —The General Object of this Work—Meaning of the phrase Principles and Prac-
   tice of  Medicine—Definition of Pathology—Division  into General and Special
   Pathology—Nomenclature of Diseases—Subdivisions of General Pathology ; name-
   ly, Morbid Anatomy, including Morbid Changes of the  Fluids of the Body; Eti-
   ology ; Symptomatology ; Diagnosis ;  Prognosis, Prophylaxis, and Therapeutics—
   Relations of these Subdivisions to Special as well as to General Pathology—Defini-
   tion of Disease—Definition of Health—Relationship of Pathology to Physiology—
   Progress of Pathological Knowledge.....................   IT
                               PART  I.

        PRINCIPLES  OF  MEDICINE,  OR GENERAL  PATHOLOGY.


                              CHAPTER  I.
                   DISTURBANCES OF THE CIRCULATION.
Local Anaemia—Hypereemia—Hemorrhage—Thrombosis and Embolism—Dropsy..    2."

                             CHAPTER  II.
Inflammation..................................34

                             CHAPTER III.
                 ACTIVE ALTERATIONS OF  THE TISSUES.
Pathological New Formations—Regeneration—Hypertrophy—Tumors—Carcinoma .   3?

                             CHAPTER IV.
           ACTIVE ALTERATIONS OF THE TISSUES (Continued).
Infectious Tumors—Syphilis—Leprosy—Glanders—Actinomycosis—Tubercle—Scrof-
                              CHAPTER V.
                 PASSIVE  ALTERATIONS  OF THE TISSUES.
Atrophy—Necrosis—Parenchymatous Degeneration—Cloudy Swelling—Fatty Meta-
   morphosis—Mucoid  and Colloid Degenerations—Amyloid or Waxy Degeneration
   —Hyaline Degeneration—Calcareous Degeneration—Pigmentation.......
                                                                     7 
8
CONTENTS.
                              CHAPTER  VI.

                  GENERAL  PATHOLOGY OF THE BLOOD.
                                                                            PAGE
Plethora—Ansemia—Hydrseniia—Anhydraemia—Hyperinosis—Hypinosis — Leucocy-
   tosis—Alterations in the Gases  of the Blood—Increase of Oxygen—Effects of
   Breathing Compressed Air—Deficiency of Oxygen—Apnoea—Changes in the Albu-
   men, Fat, and Inorganic Salts of the Blood..................  0~


                             CHAPTER  VII.

            GENERAL PATHOLOGY  OF  THE BLOOD (Concluded).
Glycohaemia—Acetonseniia—Urannia—Ammoniasmia—Uricaemia  or Lithsemia—Cho-
   lseniia—Cholestersemia—Melanaeniia—Septicaemia—Pyseinia..........  69


                            CHAPTER VIII.

                 THE CAUSES  OF DISEASE, OR ETIOLOGY.

Etiology a branch of General and  Special Pathology—Its Importance—Internal or
   Intrinsic and External  or Extrinsic  Causes—Ordinary and  Special or Specific
   Causes—The terms  Contagion, Infection, Miasm,  Virus, Venom  defined—Other
   Poisons belonging to Toxicology—Traumatic Causes—Spontaneous  Diseases—Pri-
   mary and Secondary Causes—Complications and Intercurrent Diseases—Predispos-
   ing and Exciting Causes—Congenital  and  Inherited Predispositions to Disease—
   Co-operating or Accessory  Causes—Diathesis—Cachexia or  Dyscrasia—Endemic
   Diseases dependent on Emanations from the Soil—Epidemic Diseases produced by
   Causes existing in the Atmosphere—The Causes of Contagious Diseases exclusively
   Derived from those  Affected with these Diseases—Fomites—Portability  of the
   Special Causes of Diseases not Contagious—The Causes of Contagious and Infectious
   Diseases probably Living Germs  or Organisms—Vegetable and Animal Parasites.  83


                              CHAPTER  IX.

               SYMPTOMATOLOGY.—DIAGNOSIS.—PROGNOSIS.

Pathognomonic Symptoms—Diagnostic Symptoms—Subjective and Objective Symp-
   toms—Signs—Clinical History of Diseases and the  Different  Modes by which it is
   Obtained—Stages of Disease—Precursory or Prodromic Events—Sequels—Diagnosis
   —Reasoning by Way of Exclusion—Differential Diagnosis—Prognosis—Prognos-
   tics .....................................  84


                              CHAPTER  X.

                 PROPHYLAXIS.—GENERAL THERAPEUTICS.

Experience the Basis of Therapeutical Knowledge—Two Sources of Experience: Anal-
   ysis of Recorded Cases with Reference to the Duration or Termination of Diseases,
   and Observation  of  the Immediate Effects of  Therapeutical Measures—Rational
   Inference as a Means of Arriving at Principles of Therapeutics—Importance of
   Knowing the Intrinsic Tendencies of Diseases toward  Recovery, or otherwise—
   Active Measures to be Employed only when clearly Indicated—The Expectant Plan
   of Treatment—Conservative Medicine—Importance of Hygienic Measures of
   Treatment—Modes of Dying  resolvable into Apncea and Asthenia—Classification
   of Therapeutical Measures, according to the Objects to be Accomplished, into Pro-
   phylactic, Abortive, Curative, Palliative, Hygienic, and Sustaining Measures. .  .  101 
CONTENTS.
9
                     PART   II.

PRACTICE  OF MEDICINE, OR  SPECIAL  PATHOLOGY.
INTRODUCTION
Of the Different Aspects under which Individual Diseases are to be Considered in
   Treating of the Practice of Medicine, or Special Pathology;  namely, Anatomical
   Characters, Clinical History, Pathological Character, Causation, Diagnosis, Prog-
   nosis, Prevention, and Treatment—Sense of the term Individual as applied to a
   Disease, and the several Grounds of Individuality—Varieties of a Disease—Defini-
   tion of the terms Acute, Subacute, and Chronic—Symptoms or Events incidental
   to Diseases sometimes, for convenience, considered as Individual Diseases—Self-lim-
   ited Duration of Certain Diseases—Nosology—Nosological Arrangement adopted
   iu  this Work.....
PAGE
111
                           SECTION   FIRST.

          DISEASES  AFFECTING THE  RESPIRATORY SYSTEM.

                                CHAPTER I.
                              ACUTE  PLEURITIS.
 Division of the Diseases affecting the Respiratory System into Inflammatory and Non-
    inflammatory.—Acute Pleuritis : Anatomical Characters ; Clinical History; Path-
    ological Character; Causation;  Diagnosis; Prognosis.............. 115


                                CHAPTER II.

                         ACUTE PLEURITIS (Continued).
 Treatment of Acute Pleuritis—Measures indicated in the First Stage.—General Con-
   siderations relating to Bloodletting  in Acute Inflammations.—The Use of Opium
   in Acute Pleuritis and other Acute Inflammations.—Measures indicated in the
   Second and Third Stages of Acute Pleuritis <.................1:24


                              CHAPTER III.
                          VARIETIES  OF PLEURITIS.
Chronic Pleuritis: Anatomical Characters; Clinical History; Pathological Character;
   Causation ; Prognosis ; Diagnosis ;  Treatment;  Thoracentesis.—Empyema, Pyo-
   thorax, or Suppurative Pleuritis; Diagnosis;  Prognosis; Treatment.—Pleuritis
   with  Pneumothorax,  Pneumo-hydrothorax, Pneumo-pyothorax,  or Pneumo-
   haemothorax: Anatomical  Characters; Clinical History; Causation; Diagnosis;
   Prognosis; Treatment.—Pneumothorax.—Circumscribed Pleuritis.—Hydrothorax . 131


                              CHAPTER  IV.
                                PNEUMONITIS.
Seat of the Inflammation.—Varieties: Acute Lobar Pneumonitis: Anatomical Cha-
   racters ; Laws of the Disease; Clinical History; Causation ; Diagnosis; Pathological
   Character; Prognosis............................l."l 
10
CONTENTS.
                               CHAPTER  V.

                          PNEUMONITIS (Continued).
                                                                            PAGE
Treatment of Acute Lobar Pneumonitis.—Lobar Pneumonitis in Children.—Lobular
   Pneumonitis.—Atelectasis.—Suppurative  Pneumonitis.—Embolic  Pneumonitis.—
   Abscess of the Lung.—Pneumonokoniosis, Anthracosis,  etc.—Brown or Pigment
   Induration of the Lungs.—Hyperaamia of the Lungs.—Hypostatic Congestion.—
   Hypostatic Pneumonitis.—Pleurodynia and Dorso-Intercostal Neuralgia ....  lo'7

                              CHAPTER  VI.

                           PULMONARY PHTHISIS.
Anatomical Characters; Clinical History; Pathological Character; Causation. .  . .  1S4

                            CHAPTER  VII.

                     PULMONARY  PHTHISIS (Continued).
Diagnosis; Prognosis;  Treatment........................198

                            CHAPTER  VIII.

Fibroid Phthisis.—Acute Miliary Tuberculosis.—General Tuberculosis.......214

                              CHAPTER  IX.
                                 BRONCHITIS.
Acute Bronchitis affecting the Large Bronchial Tubes: Anatomical Characters; Clin-
   ical History;  Pathological Character ; Causation ; Diagnosis; Prognosis;  Treat-
   ment.—Subacute Bronchitis.—Acute Bronchitis in Young Children.—Acute Bron-
   chitis affecting the Small Bronchial Tubes.—Epidemic Bronchitis.—Influenza.—
   Bronchitis  with  Fibrinous   Exudation.—Circumscribed  Bronchitis.—Chronic
   Bronchitis..................................218

                               CHAPTER  X.

           EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PERTUSSIS.

Emphysema of the Lungs: Varieties; Anatomical Characters;  Clinical  History;
   Pathological Character; Causation; Diagnosis; Prognosis; Treatment.—Asthma:
   Clinical History; Pathological Character;  Causation;  Diagnosis; Prognosis;
   Treatment.—Pertussis, or Whooping Cough..................235

                              CHAPTER  XI.
   PULMONARY HEMORRHAGE.—PULMONARY GANGRENE.—PULMONARY
                     G3DEMA.—CARCINOMA.—HYDATIDS.
Pulmonary Hemorrhage.—Bronchorrhagia.—Pneumorrhagia.—Hemorrhagic  Infarc-
   tion.—Pulmonary Gangrene.—Pulmonary OZdema.—New Growths within  the
   Chest.—Hydatids.—Syphilitic Disease of the Lungs..............261

                             CHAPTER  XII.
                DISEASES OF  THE LARYNX  AND TRACHEA.
Affections of the Larynx  and Trachea.—Points relating to the Anatomy and Physiol-
   ogy of the Larynx which are Involved  in the  Consideration of Diseases  in this
   Situation.—Acute Simple Laryngitis: Anatomical Characters; Clinical  History;
   Pathological Character; Causation ;  Diagnosis; Prognosis; Treatment.—Subacute
   Laryngitis.—Chronic Laryngitis.—Laryngitis Hypoglottica.—Laryngitis with Fib-
   rinous Exudation : Clinical History ; Pathological Character; Causation; Diagno-
   sis; Prognosis;  Treatment.—CEdema  of the Glottis.—Spasm  of the  Glottis.—
   Nervous Cough.—Nervous Aphonia.—Paralysis of the Laryngeal Muscles.—Morbid
   Growths within  the Larynx.........................277 
                                CONTENTS.                             11

                       SECTION  SECOND.
         DISEASES AFFECTING THE  CIRCULATORY  SYSTEM.
                              CHAPTER  I.
                               PERICARDITIS.
Introductory Remarks.—Acute Pericarditis: Anatomical Characters;  Clinical His-A°
   tory ;  Pathological Character;  Causation ;  Diagnosis;  Prognosis;  Treatment.—
   Chronic Pericarditis.—Pneumo-Pericarditis..................303
                             CHAPTER  II.
ENDOCARDITIS.—MYOCARDITIS.—DISEASES OF  THE CORONARY ARTERIES.
Simple Endocarditis:  Anatomical Characters;  Clinical History; Pathological Cha-
   racter ; Causation ; Diagnosis; Prognosis; Treatment.—Acute Ulcerative Endocar-
   ditis.—Myocarditis ..............................315

                            CHAPTER III.
       VALVULAR  LESIONS  WITH ENLARGEMENT OF THE  HEART.
Anatomical Characters; Clinical History;  Pathological Character;  Causation; Diag-
   nosis; Prognosis;  Treatment.........................325
                            CHAPTER  IV.
Hypertrophy and  Dilatation of the Heart.—Atrophy of  the Heart.—Obesity and
   Fatty Degeneration of the Heart.—Parenchymatous Degeneration of the Heart.—
   New Growths and Parasites in the Heart.—Rupture of the Heart.—Thrombosis
   of the Heart.—Embolism of the Pulmonary Artery..............342
                             CHAPTER  V.
Functional Disorder of the Heart.—Exophthalmic  Goitre.—Angina Pectoris.—Tho-
   racic Aneurism................................352
                        SECTION  THIRD.
       DISEASES  AFFECTING THE HEMATOPOIETIC SYSTEM.
                             CHAPTER  I.
               DISEASES OF  THE  HAEMATOPOIETIC SYSTEM.
Introductory Remarks.—Simple or Benign Amemia.—Chlorosis...........366
                             CHAPTER  II.
Leucocythaemia.................................372
                             CHAPTER III.
Pseudo-Leucocythseruia.—Hodgkin's Disease..................3*0
                             CHAPTER  IV.
Pernicious Anaemia...............................3*4
                             CHAPTER V.
Addison's Disease................................3^9 
12                               CONTENTS.

                       SECTION  FOURTH.

     DISEASES AFFECTING THE  DIGESTIVE  OR  CHYLOPOIETIC
                                  SYSTEM.

                               CHAPTER I.
     DISEASES OF THE  TONSILS,  THE  PHARYNX, THE OZSOPHAGUS,
                        AND THE PAROTID GLANDS.
                                                                           PAGE
Introductory  Remarks.—Tonsillitis.—Phai-yngitis.—Diseases of the CEsophagus.—
  Parotiditis.—Mumps.............................396

                              CHAPTER  II.
INFLAMMATORY DISEASES OF THE STOMACH  AND  OF THE DUODENUM.
Acute Gastritis.—Subacute Gastritis.—Chronic Gastritis.—Phlegmonous Gastritis.—
  Chronic Interstitial Gastritis.—Gastro-Duodenitis.—Duodenitis.........405

                             CHAPTER III.
                STRUCTURAL DISEASES OF THE  STOMACH.
Softening.—Gastric Ulcer.—Carcinoma of the Stomach.—Dilatation of the Stomach.
  —Degeneration of  the Gastric Tubes.—Waxy Degeneration  of the Stomach .  . . 421

                              CHAPTER  IV.
                FUNCTIONAL DISEASES OF THE  STOMACH.
Dyspepsia and Indigestion. — Polyphagia, etc. — Gastrorrhagia. — Inanition. — Gas-
  tralgia.......  .............................441

                              CHAPTER  V.
              INFLAMMATORY DISEASES OF  THE INTESTINE.
Anatomical Characters of Acute Dysentery.—Sporadic Dysentery.—Epidemic Dysen-
  tery*.—Chronic Dysentery.—Inflammation and Perforation of the Caecum.—Fecal
  Abscess.—Inflammation and Perforation of the Vermiform Appendix.—Colitis.—
  Proctitis.—Acute Enteritis.—Subacute and Chronic Enteritis..........463

                             CHAPTER  VI.

                STRUCTURAL DISEASES  OF THE INTESTINE.
Intestinal Ulcers.—Duodenal Ulcer.—Embolism of the Superior Mesenteric Artery.—
  Carcinoma  of  the  Intestine.—Waxy Degeneration of  the  Intestine.—Structural
  Lesions causing Intestinal Obstruction.—Intussusception.—Strangulated  Hernia
  within the  Abdomen.—Rotation or Twisting of Intestine.—Compression and Stric-
  ture of the Intestine.—Obstruction from Impaction of  Feces, Gall-Stones, Entero-
  liths, and Foreign  Bodies.—Functional Obstruction...............491

                            CHAPTER VII.

                FUNCTIONAL DISEASES  OF THE INTESTINE.
Diarrhoea. — Enterorrhagia. — Constipation. — Intestinal Colic. '■— Enteralgia. — Lead
  Colic.—Colic from Copper.—Passage of Gall-Stones...............509

                           CHAPTER VIII.

     SPORADIC CHOLERA.—CHOLERA INFANTUM.—ASIATIC  CHOLERA.
Sporadic  Cholera: Clinical History; Pathological  Character; Causation;  Diagnosis;
   Prognosis;  Treatment.—Cholera Infantum.—Epidemic  Cholera: Anatomical Cha-
  racters; Clinical History; Pathological  Character; Causation;  Diagnosis; Progno-
  sis ; Prevention ; Treatment..........................53" 
CONTENTS.
13
                              CHAPTER  IX.

                             INTESTINAL WORMS.

                              rermicularis.—Tricocephalus dispar.—Ascaris mvs-
   tax.—Taeniae.—Trichina spiralis.—Anchylostoma duodenale..........  . 559

                              CHAPTER  X.

                      DISEASES OF THE PERITONEUM.
Acute Diffuse Peritonitis: Anatomical Characters; Clinical History; Pathological Cha-
   racter ; Causation ; Diagnosis; Prognosis; Treatment.—Circumscribed Peritonitis.—
   Chronic Peritonitis.—Hydro-peritoneum....................r>? j
                             CHAPTER  XI.

                         DISEASES  OF THE LIVER.
Suppurative Hepatitis.—Chronic  Interstitial  Hepatitis (Cirrhosis).—Hypertrophic
   Cirrhosis of the  Liver .—Syphilitic  Hepatitis.—Acute Yellow Atrophy  of the
   Liver....................................593

                             CHAPTER XII.

                   DISEASES OF THE LIVER (Continued).
Fatty Liver.—Parenchymatous Degeneration of the Liver.—Waxy Liver.—Cancer of
   the Liver.—Other New Growths in the Liver.—Hydatid Tumors of the Liver.—
   Multilocular Echinococcus.—Other Parasites in the Liver.—Pigmentary Deposits
   in the Liver.—Hypertrophy and Atrophy of the Liver.—Changes in the Position
   and in the Shape of the Liver.—Congestion of the Liver.—Portal Thrombosis.—
   Adhesive and Suppurative Pylephlebitis...................610

                             CHAPTER XIII.

            DISEASES  OF  THE  BILIARY PASSAGES.—JAUNDICE.
Inflammation of the Biliary Passages.—Dilatation of the Gall-bladder; Cancer of the
   Gall-bladder.—Jaundice, or Icterus.—Functional Affections of the Liver.....62a

                             CHAPTER XIV.

Diseases of the Spleen.—Diseases of the Pancreas.................637
                          SECTION  FIFTH.

            DISEASES  AFFECTING THE NERVOUS SYSTEM.

                               CHAPTER I.

DISEASES RELATING TO THE CEREBRAL AND THE SPINAL  CIRCULATION.
Cerebral  Hyperemia — Cerebral Anaemia.—Cerebral  Embolism  and Thrombosis.—
   Thrombosis of the Cerebral Sinuses.—Capillary Embolism and Thrombosis of the
   Brain.—Cerebral  Hemorrhage.—Topical Diagnosis of Cerebral  Diseases.—Men-
   ingeal Hemorrhage.—Insolation, or Sunstroke.—Hyperaemia and Anaemia of  the
   Spinal Cord and its Meninges.—Spinal  Hemorrhage..............644

                              CHAPTER II.

  INFLAMMVTORY  DISEASES OF THE  MENINGES OF   THE  BRAIN  AND
      OF THE SPINAL COED.-HYDROCEPHALUS.-HYDEORRHACHIS.
Pachymeningitis and Hematoma  of the Dura Mater.—Simple Acute Cerebral  Men-
 '  iugitis: Auatomical Characters;  Clinical History; Causation; Diagnosis;  Prog- 
690
14                               CONTENTS.
                                                                             PAGE
   nosis ;  Treatment. —Chronic  Cerebral Meningitis.—Tuberculous  Meningitis.—
   Acute Spinal  Meningitis.—Chronic Spinal Meningitis. —Cervical  Hypertrophic
   Meningitis.—Cerebro-spinal Meningitis:  Anatomical  Characters;  Clinical  His-
   tory ;  Pathological Character ; Causation ; Diagnosis; Prognosis;  Treatment.-
   Hydrocephalus.—Hydrorrhachis.—Syringo-myelus..............

                              CHAPTER III.
      INFLAMMATORY AND  STRUCTURAL  DISEASES  OF THE BRAIN.
Encephalitis.—Abscess of the Brain.—Inflammatory Softening of the Brain.—Diffuse
   Sclerosis of the Brain.—Cerebral  Paralysis of Children.—Infantile  Spastic Hemi-
   plegia.—Chronic Bulbar Paralysis.—Acute Bulbar Paralysis.—Intracranial Tu-
   mors.—Cerebral Syphilis..........................."!•">

                               CHAPTER  IV.
  INFLAMMATORY AND  STRUCTURAL DISEASES  OF  THE SPINAL COED.
General Considerations relating  to  Inflammatory  and Structural Diseases of the
   Spinal Cord.—Myelitis, Acute  and Chronic.—Cerebro-spinal Sclerosis.—Locomotor
   Ataxia, or Posterior Spinal Sclerosis.—Hereditary Ataxia.—Acute Anterior Polio-
   myelitis.—Acute Anterior Poliomyelitis  in  the Adult.—Subacute and  Chronic
   Anterior Poliomyelitis.—Progressive Muscular Atrophy.—Progressive Unilateral
   Facial Atrophy.—Spastic Spinal Paralysis.—Amyotrophic  Lateral Sclerosis.—Com-
   pression of the Spinal  Cord.—Intraspinal Tumors.—Pseudo-hypertrophic (or Myo-
   sclerotic) Paralysis.—Scleroderma.—Myxcedema................728

                               CHAPTER  V.
       FUNCTIONAL  DISEASES  OF  THE  BRAIN AND SPINAL CORD.
Coma.—Saturnine Encephalopathy.—Vertigo and Meniere's  Disease.—Paralysis, Re-
   marks on.—Treatment of Functional Paralysis.—General Paralysis.—Hemiplegia.
   —Paraplegia.—Acute Ascending  Paralysis.—Nervous Asthenia, or  Neurasthenia.
   —Spinal Irritation..............................767

                               CHAPTER VI.

                         DISEASES OF  THE  NERVES.
Neuritis.—Multiple Neuritis.—Peripheral Paralysis.—Paralysis of the Third Cranial
   Nerve.—Paralysis of the Fourth  Cranial  Nerve.—Paralysis of the Fifth Cranial
   Nerve.—Paralysis of the Sixth Cranial Nerve.—Paralysis of the Motor Portion of
   the Seventh Cranial Nerve.—Paralysis of the Eighth Cranial Nerves.—Paralysis of
   the  Ninth Cranial Nerve.—Local  Paralysis of other than Cranial Nerves.—Paraly-
   sis of the Cervical Sympathetic  Nerve.—Paralysis  from Lead.—Paralysis  from
   Arsenic, Copper, Mercury, and Phosphorus.—Neuralgia.—Trifacial  Neuralgia.—
   Cervico-occipital Neuralgia.—Cervico-brachial Neuralgia.—Dorso-intercostal Neu-
   ralgia.—Lumbo-abdominal Neuralgia.—Crural  Neuralgia.—Sciatic  Neuralgia.—
   Dermalgia.—Myalgia.—Cephalalgia......................783

                          •   CHAPTER VII.
                                THE  NEUROSES.
Chorea.—Anomalous Muscular Movements.—Local Spasms.—Tremor.—Epilepsy . .  . 813

                             CHAPTER  VIII.
                         THE  NEUROSES (Continued).
Hysteria.—Hystero-epilepsy.—Catalepsy.—Ecstasy.—Somnambulism.—Tetanus  . . . 836

                               CHAPTER IX.
                         THE NEUROSES (Concluded).
Rabies.—Delirium Tremens, Alcoholism.—Hypochondriasis.—Pathophobia.....649 
CONTENTS.
15
                         SECTION  SIXTH.

       DISEASES  AFFECTING  THE  GENITO-URINARY SYSTEM.

                              CHAPTER  I.

    CONGESTION OF THE KIDNEYS.—ACUTE AND CHRONIC BRIGHT'S
                                  DISEASE.
                                                                        PAGE
Active Congestion of the Kidneys.—Passive Congestion of the Kidneys.—Parenchym-
   atous Degeneration of the Kidneys.—Fatty Degeneration of the Kidneys.—Acute
   Bright's Disease.—Chronic Bright's Disease...................662

                             CHAPTER II.

ACUTE INTERSTITIAL OR  SUPPURATIVE NEPHRITIS.—DISEASES OF THE
              URINARY  PASSAGES— PERINEPHRITIC  ABSCESS.
Acute Interstitial or Suppurative Nephritis.—Pyelonephritis : Anatomical Charac-
   ters ; Clinical History; Causation; Diagnosis; Prognosis ; Treatment.—Pyelitis.—
   Pyonephrosis.—Hydronephrosis.—Renal Colic and Nephrolithiasis.—Perinephrit-
   ic Abscess..................................696

                             CHAPTER III.

STRUCTURAL DISEASES OF THE  KIDNEY.—HEMATURIA.—HEMOGLOBI-
   NURIA.—DIABETES INSIPIDUS AND DIABETES MELLITUS— SEXUAL DIS-
   ORDERS.
Renal Cysts.—Cystic Degeneration of the Kidneys.—Hydatids of the Kidney.—Renal
   Tuberculosis.—Carcinoma of the Kidney.—Movable Kidney.—Renal Haematuria.—
   Endemic Hematuria.—Haemoglobinuria.—Malarial Hematuria.—Chyluria.—Dia-
   betes Insipidus.—Diabetes Mellitus : Clinical History; Causation ; Diagnosis; Prog-
   nosis ; Treatment. — Involuntary  Seminal Emissions. — Spermatorrhoea. — Impo-
   tence   ....................................910
                      SECTION  SEVENTH.

              FEVERS  AND  OTHER  GENERAL DISEASES.

                              CHAPTER I.
CLASSIFICATION AND  PATHOLOGY OF FEVER.—FEBRICULA.—CONTINUED
                                  FEVERS.
Classification of Fevers.—The  General Pathology of Fever—Febricula—Typhoid
   Fever: Anatomical Characters and Clinical History..............944

                              CHAPTER  II.
                     CONTINUED  FEVERS  (Continued).
Causation of Tvphoid  Fever;  Diagnosis; Prognosis.-Typhus Fever: Anatomical
   Characters;  Clinical-History:  Causation; Diagnosis; Prognosis........963

                             CHAPTER III.
                     CONTINUED  FEVERS (Continued).
Treatment of Typhus and Tvphoid Fevers.-Relapsing Fever: Anatomical Charac-
   ters- Clinical History;  Causation; Diagnosis;  Pro-nosis; Treatment. —Erysipe-
   latous Fever -Epidemic Fever characterized by Mild Erythematic Pharyngitis .  976 
16
CONTENTS.
                              CHAPTER  IV.

                            PERIODICAL FEVERS.
                                                                           PAGE
Intermittent Fever: Anatomical Characters; Clinical History; Causation: Diagnosis;
   Prognosis; Treatment.—Pernicious Intermittent Fever............i/J"

                               CHAPTER  V.

                     PERIODICAL FEVERS  (Concluded).
Simple Remittent and Typho-malarial Fever: Anatomical Characters; Clinical His-
   tory ; Pathological Character and Causation: Diagnosis;  Prognosis; Treatment.
   —Pernicious Remittent Fever.—Yellow Fever: Anatomical Characters;  Clinical
   History; Causation ; Diagnosis; Prognosis; Treatment;  Prevention......1011

                             CHAPTER  VI.

                             ERUPTIVE FEVERS.
Variola, or Smallpox : Anatomical Characters ; Clinical History; Causation ;  Diag-
   nosis; Prognosis; Treatment.—-Varioloid, or  Modified Smallpox. — Vaccinia, or
   Cowpox.—Varicella, or Chicken-pox.....................102-?

                             CHAPTER VII.

                      ERUPTIVE FEVERS  (Continued).
Scarlatina, or Scarlet Fever: Anatomical Characters; Clinical History; Causation;
   Diagnosis; Prognosis; Treatment......................1051

                             CHAPTER  VIII.

                      ERUPTIVE FEVERS  (Continued).
Rubeola,  or  Measles: Clinical  History; Causation;  Diagnosis;  Prognosis; Treat-
   ment.— Roseola.—Rotheln—Dengue..................   . . 1065

                              CHAPTER  IX.

                       DIPHTHERIA.—MILK SICKNESS.
Diphtheria : Anatomical Characters; Clinical History; Pathological Character; Causa-
   tion ; Diagnosis: Prognosis ;  Treatment.—Milk Sickness............1074

                               CHAPTER  X.

       ACUTE, SUBACUTE,  AND CHRONIC ARTICULAR RHEUMATISM.
Acute Articular Rheumatism: Clinical History; Pathological Character;  Causation;
   Diagnosis; Prognosis; Treatment.—Subacute and Chronic Articular Rheumatism . 1092

                              CHAPTER XI.

                      GOUT.—RHEUMATOID  ARTHRITIS.
Gout:  Anatomical Characters:  Clinical History;  Pathological Character;  Causation ;
   Diagnosis; Prognosis; Treatment.—Rheumatoid Arthritis...........1106

                              CHAPTER  XII.

                   SCORBUTUS.—PURPURA.—HAEMOPHILIA.
Scorbutus, or Scurvy: Anatomical Characters: Clinical History; Pathological Charac-
   ter; Causation;  Diagnosis; Prognosis; Prevention; Treatment.—Purpura Sim-
   plex, Purpura Rheumatica, and Purpura Haemorrhagica.—Haemophilia   .... 1104 
THE
PRINCIPLES   AND   PRACTICE
                              OF

             MEDICIXE.
              INTRODUCTORY   CHAPTER.

Scope of the term Medicine—Use of the term in contradistinction to Surgery and Obstet-
   rics—Subdivisions of the Different Departments of Medicine, or Specialties—The Gen-
   eral  Object of this Work—Meaning of the phrase Principles and Practice of Medicine
   —Definition of Pathology—Division into General and Special Pathology—Nomencla-
   ture of Diseases—Subdivisions of General Pathology :  namely, Morbid Anatomy, in-
   cluding Morbid Changes of the Fluids of  the Body; Etiology; Symptomatology;
   Diagnosis; Prognosis;  Prophylaxis, and Therapeutics—Relations of these Subdivis-
   ions to Special as well as to General Pathology—Definition of Disease—Definition
   of Health—Relationship of Pathology to Physiology—Progress of  Pathological
   Knowledge.

     EDICINP],  in the largest sense of  the  term, comprehends  everything
     pertaining to the  knowledge and cure of disease.  In a more restricted
sense the term is used  in contradistinction to Surgery and Obstetrics.  The
latter are properly departments of Medicine  in the comprehensive sense  of
the  term, and, although they may be cultivated separately, they cannot  be
disconnected from principles which are common to them and to Medicine in
its restricted sense.   The medical profession embraces all who  devote them-
selves  to the study and practice of medicine proper, surgery, and obstetrics,
either  separately or combined.  The physician is a member of the profession
who devotes his attention to the  diseases  which belong to  the department of
medicine  proper—i. e.  medicine  in  the restricted  sense  of the term.  The
physician may, or may  not, undertake the  duties whicli belong to surgery and
obstetrics.  In this country most physicians are, of necessity, to a greater or
less  extent, also surgeons  and obstetricians—in other words, general practi-
tioners.  It is only in  cities and  large towns that practitioners can devote
themselves exclusively or chiefly  to  surgery  and  obstetrics as  separate
departments of medicine.   The distinction of physican, surgeon, and obstetri-
cian in this country is purely conventional.   The only degree  conferred  by
our universities  and  medical colleges is that of Doctor of Medicine, which
authorizes the  practice  of either or all the departments, and the same is true
of licenses to practise medicine.
  The  division  of medicine into the three  departments  which  have  been
named  is natural, and  has  contributed to the knowledge  acquired in  each
department.   Subdivisions have also been found  convenient and useful.  The
latter are commonly known as .specialties,  and  they who devote themselves to
M 
18                    INTRODUCTORY CHAPTER.

particular subdivisions are called specialists.  The more important of the sub-
divisions now recognized as specialties are affections of the eye  and ear, of
the skin, of the genito-urinary system, diseases peculiar to females, orthopaedic
surgery, disorders  of the  mind  and nervous system, diseases  of the throat,
nose, and  larynx,  and of the heart and lungs.   Specialties result  from  an
increase of knowledge rendering it difficult or impossible for one mind to com-
pass all that has been ascertained in each of the three departments  of medi-
cine.   The special cultivation of the several subdivisions  of  medicine leads
to a further development of knowledge relating to each  subdivision,  and
hence conduces to  the progress of medicine.   But as the great principles of
medicine  are common  to medicine proper,  surgery, and  obstetrics, so with
regard  to  the  subdivisions: they  cannot be  completely  isolated from  the
departments to which they respectively belong.  A particular class of affections
cannot be studied satisfactorily to the entire  exclusion of others and without
reference to the general laws of disease.   Directing the attention exclusively
to a specialty leads to the habit  of  attributing  to it  an  undue  relative promi-
nence,  and of regarding the diseases belonging to it as of  paramount import-
ance, when they may be secondary  or merely incidental to others which, from
being overlooked or not  sufficiently appreciated, fail to receive  appropriate
treatment.   It  is never advisable to pursue medical  studies with exclusive
reference to a specialty, or to adopt one at the  outset of medical practice.
  The object of this work is to  present the outlines of Medicine proper; that
is, of  Medicine in  contradistinction to Surgery and  Obstetrics.   The Princi-
ples and Practice of Medicine is a title of this  department considered as a
province of medical  teaching.   This title is here adopted in  preference to
others, used by English and American authors, such as the Theory and Prac-
tice of Physic, General and Special  Pathology, Pathology and Practical Medi-
cine, or the Science and Practice of Medicine.   The Principles and  Practice
of Medicine  comprehend everything pertaining  directly  to the knowledge
and cure of those diseases which the physician is called upon  to treat.  The
province of medical  teaching thus  designated properly enough embraces the
prevention of disease, and it ma}* include anything which  concerns  the con-
duct of the physician  in the treatment of  patients affected  with disease.
  The study of disease as a province of  scientific knowledge is called Path-
ology.   This province consists  of two important  divisions—namely, General
and Sjiecial Pathology.  It is desirable to have a  clear understanding of the
terms which distinguish these two  divisions of pathology.  Diseases are pre-
sented in particular forms or species, constituting  what are commonly known
as individual diseases.  The  circumstances which give to the different diseases
their individuality will  be noticed  hereafter.   Now, the  study of individual
diseases constitutes special pathology. On the other hand, there are morbid
conditions which are not peculiar to  any individual disease, but are  common
to a greater or  less number of diseases.   The  study of these conditions con-
stitutes general pathology.  Inflammation, for example, is a morbid condition
which  exists in a large number of individual diseases.  The study of inflam-
mation  as a condition common  to different diseases  belongs to general path-
ology,  while  the study of the  individual  inflammatory diseases belongs to
special pathology.   To  take  another illustration : a morbid condition which
enters  into a number of individual  diseases is called fever.   In this  sense of
the term fever it belongs to  general pathology,  but the study of the  different
forms of fever, or individual fevers, belongs  to special pathology.  The rela-
tion of general to special pathology is analogous to the relation of general to
special anatomy, the former describing the several tissues which enter into the
composition of  the different organs  of the body, and the latter  describing the
particular organs composed of the tissues.  As  the number of tissues is small 
INTR OD UCTOR Y  CHA PTER.
19
 in comparison with the number of organs, so the morbid conditions belongin-
 to general pathology are few as compared with the great number of diseases
 belonging to special pathology.
   The province of medical teaching, entitled the Principles and Practice of
 Medicine, comprises both general and special pathology.   The subjects which
 belong to the principles of medicine are derived from general pathology.  The
 principles of medicine and general pathology are, in fact, synonymous terms,
 each term having the same scope of application.  And, in like  manner, the
 subjects which belong to the  practice  of medicine  are  derived from special
 pathology.  These two  terms relate  to the same division of  pathological
 knowledge, the former term being somewhat more comprehensive in its scope
 than the  latter.   The principles  of medicine thus, on the one hand, and the
 practice of medicine on  the other  hand, constitute divisions which coincide
 with the  two divisions  of pathology distinguished as  general  and special.
 Moreover, these divisions are in  accordance with the distinctions  expressed
 by the terms Science and Art.  " Science is knowledge reduced to principles;
 art is knowledge reduced to practice."   The principles of medicine constitute
 medical science ; the practice of medicine is the exercise of medical art.  The
 object of this work being to present the  outlines of both the principles and the
 practice of medicine, or of both general and special pathology, or, again, of
 medical science and art, it will be divided into  two parts  corresponding to
 these divisions.  The outlines of  the Principles of Medicine, or General Path-
 ology, will form the First  Part  of the  work, and  the Second Part will be
 devoted to the Practice of  Medicine, or Special Pathology.  In adopting this
 arrangement, however, I shall not be  bound by it so closely  as to treat of the
 topics belonging to general pathology exclusively in the first part  of the work.
 It will  be more convenient  to defer the  consideration of some of these topics,
 and  to  treat of them incidentally in  connection  with individual  diseases.
 Moreover, I shall  treat of  general .pathology in its relation to medicine, pass-
 ing over or noticing very  briefly those  topics which are chiefly important in
 a surgical point of view.  Although the general principles of  pathology are
 common to both medicine and  surgery, certain topics have relations especially
 to either the one or the other of these departments.  The terms medical path-
 ology and surgical pathology are used in  conformity with this distinction.
   The subjects of General Pathology—namely, the morbid conditions common
 to a greater or less number of individual diseases—are to be  considered under
 various  points of  view;  hence this division of  pathology admits of several
 subdivisions.   One point of view relates to nomenclature, or the naming of
 diseases.   The  great desideratum in nomenclature, as  applied to diseases, is
 that  the  name of  each disease shall express the morbid condition  involved
 and its  situation.   The names which were formerly applied to different forms
 of disease were frequently fanciful, and many of  these are still in use, owing
 to the difficulty and inconvenience of displacing them after they have become
 established in medical literature;  and in not a few instances it is by no means
 easy, with our existing knowledge of the essential character of morbid condi-
 tions, to substitute more appropriate  names.  Some approach, however, has
 been  made toward  a nomenclature which shall measurably secure the advan-
 tages derived from this source in other branches of knowledge, more espe-
 cially in chemistry.  The existence  of inflammation,  which enters into so
 large a number of individual  diseases, is expressed  by the  suffix ids (t'rr^)
 added to  the  anatomical name of  the  part affected.  Thus, bronchitis, pneu-
monitis, pleuritis, peritonitis, etc. are names denoting the inflammatory cha-
racter of the diseases to which they refer and the particular structure which
is  the seat of the inflammation.  The suffix rhoea (psu) denotes  the  existence
of the morbid condition known as transudation, or flux, occurring in a situa- 
20
IXTR OD ECTOR Y CIIA PTER.
tion where the liquid escapes upon a mucous surface:  examples are enteror-
rhoea, bronchorrhcea, gastrorrhcea, cystorrhu-a, terms which  have not, as yet,
come sufficiently into vogue.   The suffix rhagia (Jn^vop-C) expresses a flow of
blood, or  hemorrhage  from a mucous  surface : examples are metrorrhagia,
gastrorrhagia, enterorrhagia, bronchorrhagia, in like manner terms which have
not displaced others in common use.   The suffix algia (alyoq)  signifies  a mor-
bid condition characterized by pain without inflammation.   Thus, neuralgia is
a general term applied to this condition affecting any nerve or  nerves ;  gas-
tralgia, enteralgia, pleuralgia, etc.  are terms severally  expressing the neur-
algic character of the affection and its seat.   Words ending in semia  (aipa)
are applied to certain morbid conditions of the blood:  examples are anaemia
(impoverishment of the blood), uraemia (morbid accumulations of urea in the
blood), septicaemia (putrid infection of the blood), and pyaemia (purulent
infection of the blood).  Words ending in uria (oupov) are applied to certain
morbid conditions of the urine : examples  are albuminuria, haematuria, oxa-
luria.  The prefix hydro (udwp') denotes a dropsical affection of the part named ;
as, hydrothorax, hydrocephalus, hydro-peritoneum,  hydro-pericardium.  The
prefix  pneumo (nveupa) denotes the  presence of air in  the part;  as  pneumo-
thorax, pneumopericardium.  The name of an inflammatory disease  to which
peri is prefixed signifies  inflammation of  the membrane investing  the  part
inflamed, and  the  prefix para denotes  inflammation of the neighboring con-
nective tissue:  examples  are perihepatitis,  perinephritis, parametritis, etc.
The suffix pathy (izaOoq) is used to express the fact of a morbid condition of
a part without indicating its character : instances are arthropathy and  encepha-
lopathy.  A termination  in  oma  signifies a tumor, as sarcoma,  carcinoma,
myxoma.
  It is thus seen that the effort to introduce names expressive of the charac-
ter  and seat of morbid conditions has, in  a measure, succeeded.  Further
improvement in nomenclature will  doubtless  be  made as our pathological
knowledge increases.
  An important subdivision of General Pathology relates to the appreciable
morbid changes of the solids and fluids of the body.   The study of all changes
appreciable  by the naked eye or with the help of the microscope constitutes
a branch of pathology of great importance called morbid anatomy.  Morbid
anatomy is not confined to the study of the changes which occur in the  tis-
sues or solid parts; it embraces any  changes which the eye can appreciate in
the fluids of the body.  The latter, not less than the former, are to be  distin-
guished as anatomical, whereas those changes which are  not visible either with
the naked eye or by means of the microscope, but require for their detection
processes of analysis or the employment of reagents, are usually considered as
falling, not within the scope of morbid anatomy, but within  the domain of
animal chemistry.  Morbid  changes not visible or not yet ascertained  with our
present means of observation are distinguished afunctional, and are  also said
to be  dynamic.  Doubtless in all the so-called functional  or  dynamic  devia-
tions from health there are  either molecular or cellular—that is anatomical__
changes at present inappreciable, or at all events undiscovered, which may be
hereafter  ascertained by  continued  investigation  with improved means of
observation.  Appreciable  anatomical changes are distinguished  as lesions.
The study of the minute anatomy of the tissues and fluids of the body with
the microscope is called Histology, and the  term Morbid or Pathological His-
tology is sometimes used to designate that part of morbid anatomy relating to
those abnormal changes which are the objects of microscopical  research.  The
study of the origin and development  of pathological processes is called Patho-
genesis.
  Anatomical changes, or  lesions, belong to  general pathology in so  far as 
IX TR OD UCTOR Y  CIIA PTER.
21
they are common to a greater or less number of individual  diseases.   Their
consideration, as involved in individual diseases, enters into special pathology,
or the  practice  of medicine.  Such is the extent as well as importance ^of
morbid anatomy that it constitutes a distinct branch of medical knowledge.
Ireatises are specially devoted to it; and these are to be studied, in conjunction
with the examination of morbid  specimens, in order to become fully and prac-
tically acquainted with the various  alterations in  structure, form, size, etc.
which are  incident to disease.   It is a fact, however, not  to  be lost sight of,
that lesions do not constitute,  but are the results  of, disease.   In other words,'
they are always  due to underlying morbid actions or processes which may not.
be  directly appreciable or well understood, but  in which really consists  the
local disease.   This fact, although obvious, is liable to be overlooked.  Lesions
are of course serious or otherwise according to  their character, their situation,
and the amount  of structural  change involved.   In Part First will be found
the outlines of general medical pathology, and  in Part  Second is given a con-
cise account of the lesions characterizing different  individual diseases.
   Another subdivision of  General Pathology relates to the causation of dis-
ease.   The study of the causes of disease is called Etiology.  As  belonging
to General Pathology, or  the  Principles of  Medicine, this  branch  of  medical
knowledge will  be considered in  Part First of  the work ;  and  the causes
involved in the production of each of the individual diseases will be embraced
in the account of the latter in Part Second.
   The  great  number and variety of phenomena or events to which disease
gives rise  constitute another subdivision of General Pathology.  These phe-
nomena or events are  called symptoms, and  their study constitutes a branch
of medical knowledge called Symptomatology or  Scmciulogy.    Considerations
relating to symptomatology, as  belonging to General  Pathology, will  claim
attention in Part First; and the symptoms of individual diseases respectively,
forming, as they do,  a highly important part of Special Pathology,  or  the
Practice of Medicine, will be considered in Part  Second.
   Closely  connected with  Symptomatology is another subdivision of  General
Pathology, called Diagnosis.  Diagnosis is the discrimination  of  diseases from
each other.  General  considerations relating to this branch of  medical know-
ledge will  enter into Part  First.   In treating of  individual  diseases in Part
Second the means of discriminating them will be found to possess an import-
ance second only to their treatment, and  to  be an essential  prerequisite  for
the latter.
   Another subdivision which will  claim  notice in  both parts of this work is
Prognosis,  or the prediction of the termination  of diseases.
   The  prevention  of disease  forms a branch  of  medical knowledge called
Prophylaxis.   This belongs alike to General  and  Special Pathology.
   Lastly, the treatment of disease is called  Therapeutics.   General principles
relating to the treatment of disease may be appropriately considered  in con-
nection with General Pathology.  This portion of the subject is distinguished
as General Therapeutics.   I shall devote to it, together with prophylaxis, a
chapter in  Part First.  It is hardly necessary to add that the  treatment of
individual  diseases, distinguished  as Special Therapeutics, is, in  a practical
view,  the most important of the different aspects under which  they are to be
considered, being, in fact, the great end of both  the principles and the practice
of medicine.
  It is thus seen that  the subdivisions of General Pathology,  which will be
taken up in the first part of this work, represent  also the different points of
view under which individual diseases are to be considered in  the second part
of the work ;  that is, individual  diseases, as well  as the morbid  conditions
common to a greater or less number of diseases, are to be  considered with 
00
INTRODUCTORY CHAPTER.
reference  to  the morbid  changes, either of solids or fluids, which they may
respectively involve,  together  with  their  causes, their symptoms, their dis-
crimination or diagnosis, their prognosis, their prevention, and their treatment.
Morbid anatomy, etiology, symptomatology, diagnosis, prognosis, prophylaxis,
considered as branches of medical knowledge, belong to General  Pathology,
and  to  these may  be added general  therapeutics ; and, on  the other hand.
Special Pathology, or the Practice of Medicine, considers the truths contained
in these subdivisions  of General Pathology in their application to individual
diseases.
   Pathology has been defined as the study of disease, but disease  has not yet
been defined.   The definition of disease is confessedly difficult.   It  is easier
to define it by  negation, to say what it is  not, than to give  a positive defini-
tion—that is, a definition based either on the nature or essence of the thing
defined or on its distinctive attributes.   Disease is an absence or deficiency of
health, but this is  only to transfer the difficulty,  for  the  question at once
arises, How is health to be  defined ?   And to define health is not less difficult
than to define disease.  If  all  the  tissues and organs  of the body have their
normal integrity and properties, if  the fluids of the body be  in  no respect
abnormal, if all the functions of the organism be completely  and  harmoni-
ously performed, health undoubtedly exists.  But this perfection of  health, is
purely ideal; it never actually exists.   An examination of the  bodies of the
healthiest persons would probably reveal lesions of some kind ;  certain devia-
tions from the  normal composition of the different fluids are not inconsistent
with  the evidences of health in other respects; functions of different parts
may be disordered to a certain  extent without sufficient disturbance to consti-
tute disease.   Gradations of health  are implied in  the qualifications of this
term in common use.  If  the term health expressed a well-defined state, it
would be a pleonasm to add to the term, as is often done, the adjectives good,
excellent, etc.; and, on the other hand, to speak of health as poor, bad, mis-
erable, etc. would involve  a solecism.  In  short, health and disease  are so
imperceptibly merged into each other that the line of demarcation cannot be
drawn with precision.  And this is true of other departments of  knowledge.
It is not easy, for example, to  settle upon the characters  which mark the
boundaries of the animal and the vegetable kingdom.   But as there  is rarely
any  practical embarrassment in distinguishing an animal from a vegetable, so
with regard to  health : if an important disease of any kind exist, the fact of
its existence is in most cases sufficiently obvious.  If, however, it be desirable
to define disease otherwise  than by saying that it is the absence or deficiency
of health, the  definition proposed by Chomel is. perhaps, as good as any other.
According to  this  author, disease  may be  defined  to  be  a  notable  disorder
affecting more or less of the constituent parts of  the  living organism as regards
either their material constitution or the exercise of their  functions.1
   By regarding disease as  the absence or deficiency of health we are led to
the consideration of the relationship of pathology to physiology.  Physiology
studies the operations which  go on  in the  healthy organism.   The morbid
conditions which are the  subject of pathological study  are  these operations
disordered  or  perverted.   Pathology  has been called morbid  physiology.
Both are, in fact, parts of one science, the science  of  life, or biology.   Both
are alike occupied with vital properties, actions,  and processes,  the difference
being that physiology investigates them under  the  circumstances of health,

   1"TJn desordre notable survenu, soit dans la disposition materielle des parties con-
stituentes, du corps vivant, soit dans l'exercise des fonctions."  For an enumeration of
the various definitions proposed by different writers, and some excellent  remarks on the
subject, the same author may be consulted: Elemens de Patholoyie generate, quatrieme
edition. 
INTRODUCTORY  CHAPTER.
23
and pathology under the circumstances of disease.  The division is arbitrary,
although sufficiently marked and appropriate.
  Such being the relationship of pathology to physiology, it might be expected
that the former would advance in proportion to the progress of the latter. This
is measurably true.  While our knowledge of pathological conditions does not
consist of deductions from what is known of the operations within the organ-
ism in health, but is derived from the direct study of  disease, every import-
ant physiological  discovery  sheds more or less light on the department of
pathology.  In  striving to penetrate  into the  nature  of morbid conditions,
it is evident that the  chief difficulty arises from the imperfection  of  our
knowledge of the  properties, actions, and processes of health.  There  will be
frequent occasions in the progress of this work to remark that the pathologist
may expect to be  better able to  explain the phenomena of disease  when  the
physiologist has succeeded in elucidating more fully the phenomena of  health.

  In  proceeding  now to  present  the  outlines  of  Medicine the aim  of  the
author will be to  give a truthful representation  of  pathological knowledge as
it exists at the present moment.  The progress of pathological knowledge has
wrought, within late years, much  change in both the principles  and practice
of medicine.  Concerning  further progress and  its effects, it would be in vain
to speculate; but  it is not to be expected that a faithful exposition of med-
icine as it exists at the present moment will  serve  as a lasting guide  for the
student and practitioner.   And  in the study of medicine next in importance
to an acquaintance with what is actually known is  a just appreciation of the
limits of our present knowledge.  The latter is  often  important as regards its
bearing on the treatment of  disease, and it conduces to a condition of mind
most favorable for either contributing  to, or keeping pace with, the  continued
progress of knowledge. 
 
                           PART   I.

PRINCIPLES  OF  MEDICINE, OR  GENERAL PATHOLOGY,
                         CHAPTER   I.

             DISTURBANCES OF  THE  CIRCULATION.

    Local Anaemia—Hyperaemia—Hemorrhage—Thrombosis and Embolism—Dropsy.

    THE subjects  embraced in General  Pathology may be classified and con-
     sidered under  the  following headings:

                    1. Disturbances of the circulation.
                    2. Inflammation.
                    3. Active alterations of the tissues.
                    4. Passive alterations of the tissues.
                    5. General pathology of the blood.

   The disturbances of the circulation embrace local anaemia, hypersemia, hem-
orrhage,  thrombosis  and embolism, and dropsy.


                           Local Anaemia.

   Local  ansemia, or ischsemia, signifies  a deficiency of blood in a part.   Gen-
eral anaemia, or oligemia, will be considered in connection with the pathology
of the blood.  Local anaemia  is due either  to an increase of the resistance
naturally offered to the flow  of blood through  a part  or to the presence
of new obstacles within or outside of the vessel.  Increase  of  the natural
resistance is caused by contraction  of the arteries in consequence of direct
stimulation  of their muscular coat  or  under  vaso-motor nervous influence.
The pallor of the skin from the effects of cold, and that of the  face  at the
onset of an epileptic paroxysm  or  in  consequence of violent emotions, are
examples of local anaemia in  consequence of spasm of the arteries.   Athe-
roma,  obliterating endarteritis, thrombosis, and embolism  may be cited  as
causes of local anaemia acting within the vessels ;  compression of  the arteries
by tumors, exudations, or bandages  illustrates the effect of external agents.
As will be explained in treating of embolism and thrombosis, the  presence or
the absence of anastomoses is of great  importance in determining the degree
of anamia which  follows the obstruction of a blood-vessel.  By  collateral anae-
mia is  understood the diminution in the amount of blood in a part in  conse-
quence of its excessive accumulation  in other parts.   An anaemic part is
generally pale, shrunken, dry, and, if exposed  to the air, cool.   The  effects
of lon^-continued and marked anannia of a  part are atrophy and frequently
fatty defeneration.   If the anaunia  be  extreme, death of tissue may result.
                                                              25 
 26            DISTURBANCES OF THE CIRCULATION.


                              Hypersemia.
   An increased amount of blood in the vessels of a part constitutes hyper-
 semia.   Two  forms of  hyperemia are recognized—active  or  arterial,  and
 passive or venous.   Active hyperaemia is also called fluxion.  The term con-
 gestion is generally employed as a synonym for hyperamia, although some
 understand by congestion only active hyperaemia.   In  active hyperaemia an
 increased amount of blood is brought  to a part by the  arteries.
   The usual cause of active hyperaemia  is a relaxation  of the muscular coats
 of the arteries of a part, so that there results a diminution of the resistance
 naturally offered by  the  arterial  tonus to the  circulation of the blood.   This
 relaxation may be the result of irritation of vaso-dilator  nerves (neuro-tonic
 congestion), or of paralysis of vaso-constrictor  nerves (neuro-paralytic con-
 gestion), or of some influence acting directly upon the coats of the arteries.
 Although  these three modes  of production of  active  congestion have been
 proven, it is  not  generally easy in a given case to determine  which of the
 three factors  is involved.
   Collateral or compensatory hyperaemia is the  transmission of an increased
 amount of blood to a part in consequence of local anaemia of another, usually
 an adjacent, part.  The sudden removal  of long-continued pressure upon the
 arteries may be a  cause  of active hyperamia;  as, for instance, the over-dis-
 tension of the abdominal vessels following rapid withdrawal of large accumu-
 lations of fluid in  the peritoneal cavity.
   In  active hyperamia the velocity of the blood-current is usually increased.
 The affected part  is bright red in color, swollen, and,  if superficial, warmer
 than  normal.   Active hyperaemia is  usually  an acute, transitory condition.
   Passive hypersemia is due to some obstruction to the flow of blood in  the
 veins. From the nature of the obstruction it is also  called mechanical hyper-
 amia and venous  hyperaemia,  inasmuch as it is venous  blood  which accumu-
 lates  in the parts.  Passive hyperaemia is frequently a chronic condition.  The
 abnormal hindrances may be either  within or without the veins.  Thrombi
 are the most frequent obstacles within the  veins.  General venous hyperamia
 follows obstruction to the flow of blood  through the heart.   The veins may
 be compressed from without by clothing, bandages, tumors, exudations, newly-
 formed fibrous tissue, etc.
  By hypostasis or hypostatic congestion is  understood venous hyperamia of
 dependent parts of the body under the influence of gravity and  of enfeebled
 heart's action.  In most parts of the body the anastomoses  between the  veins
 are so many that  a single vein, or even  several, may be obstructed without
 serious disturbance of the circulation.  Occlusion of the portal vein cannot
 be compensated for  thus by collateral  circulation.   Venous  hyperamia of
 the lower extremity also follows thrombosis of the femoral vein, inasmuch as
 the arrangement of  the  valves in the anastomosing veins does not permit
 the formation of  a  sufficient  collateral  circulation.
  In  passive hyperamia the blood is dammed back upon the  veins and capil-
 laries of  the  part, the  velocity  of  the  circulation  is  lessened, the vessels
 become over-distended with blood, frequently a  transudation of serum and
 a diapedesis of red blood-corpuscles ensue, and an increased amount of lymph
flows  from the obstructed region.  The  affected  part  is usually  bluish-red in
color, swollen, frequently cedematous, and,  if exposed to the  air, cooler than
normal.  The  diagnosis  of hyperamia  cannot always  be  made upon  post-
mortem examination, as the  distribution  of blood  may  vary greatly  from
that present during life.  This is  particularly true of active hyperaemia. 
HEMORRHAGE.
27
                             Hemorrhage.
   Hemorrhage is the escape of blood  through the walls of the vessels or of
the heart.   When the extravasation is through the ruptured wall of a vessel,
it is called hemorrhage by rhexis; when the red  blood-corpuscles are pressed
through the unruptured vascular wall, it is denominated hemorrhage by dia-
P'cbsis, or simply diapedesis.  When  the  hemorrhages are minute, they are
called petechise  or  ecchymoses; when  the  blood infiltrates  a  circumscribed
part of the tissues  uniformly without tearing them, the extravasation is a
hemorrhagic infarction ;  when  the  escaped blood forms a tumor, it is called
a haematoma.
   According to  the source of the blood, hemorrhages are classified as cardiac,
arterial, capillary,  and  venous.  The causes of hemorrhage by  rhexis are
various, and  the consideration  of many of them belongs to the  domain of
surgery.  Rupture of healthy vascular walls is usually due to  traumatism or
to local elevation of the blood-pressure.   Newly-formed  blood-vessels, such
as those in granulation-tissue  and in  tumors, easily rupture in consequence
of the imperfect development of their coats.  Of the diseases which weaken
the walls of the  vessels and favor their rupture, the most important are aneur-
ism, atheroma,  ulcerative processes acting from without, infiltration of the
vascular walls by new growths or inflammatory products, and fatty degen-
eration.   Elevation  of the general  blood-pressure probably never causes
rupture of healthy vessels, but it may contribute to the giving way of those
which are diseased.
   Hemorrhage  by diapedesis occurs in  venous hyperamia, in inflammation,
in hemorrhagic  infarctions, and in districts in which the circulation of blood
has been temporarily arrested for many hours.  In these  cases it is probably
due to nutritive changes in the vascular  walls, which  are thereby  rendered
more permeable.  These assumed changes, however,  cannot be recognized by
our present means  of investigation.   The  red blood-corpuscles pass  through
the walls of the veins, and especially of  the capillaries,  making their way
through the cement-substance  between  the endothelial cells.  Diapedesis  is
a passive process as far as  the red corpuscles are concerned.  Hemorrhages
by diapedesis are generally small, but exceptionally they are considerable.
It is not always possible  to determine whether an extravasation is the result
of rhexis or of  diapedesis.
   Many diseases are accompanied  by a hemorrhagic tendency, such as pur-
pura, scurvy,  phosphorus-poisoning, leucocythamia, pernicious anamia, and
a  number  of  infectious diseases, as septicamia, yellow fever, smallpox, and
malignant  endocarditis.   The  hemorrhage in many  of these cases  is doubt-
less due to a weakened  condition  of the vessel-walls in  consequence of the
disordered  composition of the blood ; but whether the blood escapes by rhexis
or by diapedesis has  not been established in the majority of instances.  In
some  septic diseases attended by capillary hemorrhages, such as malignant
endocarditis, hemorrhagic smallpox, and hamophilia neonatorum, blood-ves-
sels plugged with colonies of micrococci  have been  found in the ecchymosed
districts; but in  many similar cases no relation could  be demonstrated between
the hemorrhages and the presence of bacteria.
   The changes which take  place in  a  hemorrhagic  extravasation lead to the
o-radual absorption of most of its constituents.  The  fluid parts are absorbed ;
The fibrin becomes  granular and is taken  up; the white blood-corpuscles, in
part, wander into the tissues and the absorbents, but in greater part disinte-
grate  and are absorbed.  Some of the  red  corpuscles are carried away by the
lymphatics, others  remain  and undergo  pigmentary transformations.  The
formation of pigment takes place,  in  great part, in wandering cells, which 
28             DISTURBANCES  OF  THE CIRCULATION.

take up the corpuscles or fragments of them.  The resulting  granular and
crystalline  hamatoidin pigment may remain in the cells or be set free.  Thus.
only pigment may remain to tell of the former extravasation, and even this
pigment may be in time absorbed.  These changes may be complicated  by
acute and chronic inflammatory processes.  The formation of so-called apoplec-
tic cysts in the brain will be described  in treating of cerebral hemorrhage.


                   Thrombosis and  Embolism.

  A thrombus is a coagulum formed during life in the heart or in the vessels.
A thrombus is designated as occluding  when it completely fills the interior of
the vessel,  and as parietal when it only partially obstructs  the vessel  to the
wall of which  it is attached.
  The formation  of the  thrombus  is the result of some change in the vas-
cular walls.  The normal condition of the endothelial lining of the vessels
is essential to the preservation  of  the fluid state of the blood.   Structural
changes which impair the endothelium  are causes of thrombosis. ^ The most
important  of these changes are inflammation, atheroma, calcification, degen-
erations, tumors,  injury,  and compression  of the vessels.  Retardation of the
circulation is a most important cause of thrombosis.  It acts also by impair-
ing  the nutrition of the  vascular endothelium.   Thus are explained  the
thrombi formed in aneurisms and in varices.  The so-called marantic throm-
bi are the result of great weakening of the circulation from extreme debility
and from much-enfeebled heart's action.   The veins of the lower extremities
and of the pelvis, the appendix of the right auricle and  the apex  of the
right ventricle, and, in children, the cerebral  sinuses, are  favorite seats  of
marantic thrombi.  They often  begin  to  form in the  pockets  of the  valves
in the veins of the lower extremities.   A thrombus usually extends at least
from the point of its formation to the  nearest branch given off from  the
vessel; it may extend farther forward  and backward, and may grow into the
collateral branches.
   A thrombus is  composed of fibrin  and blood-corpuscles.  It is now gen-
erally believed that fibrin is the result of some reaction between fibrinogen
found in solution in plasmatic fluids and one or more substances produced by
the destruction of protoplasmatic  elements.  In the  mammalian blood the
protoplasmatic elements  which come into consideration are the leucocytes and
the minute bodies known as  blood-plates.   According to the popular theory
of  Schmidt, the leucocytes play the chief role and furnish fibrino-plastin and
fibrin ferment.  Of these, fibrin  ferment is the most important, if not the sole
active element.   That the blood-plates have an important share in the forma-
tion of thrombi seems to be established.
   Thrombi vary  in structure according to their formation from blood in mo-
tion or at rest.   Red, white, and mixed, thrombi are thus distinguished.  Red
thrombi are formed from blood  at rest—as, for instance, in a vessel enclosed
between two  ligatures—and are composed of red  and white corpuscles and
fibrin  combined in the same proportions as in a blood-clot outside of the body.
 Most thrombi are formed from the  blood in motion.  Such thrombi are gray-
ish or reddish-gray in color.   Zahn, who studied experimentally the produc-
tion of these thrombi in  the  mesenteric vessels of frogs, found that they
 were caused by  an accumulation of  white blood-corpuscles, and his conclu-
 sions  have been universally accepted.   It has, however, recently been shown
 by those who have observed the process  in the vessels of warm-blooded ani-
 mals that  the white thrombi  are  produced  by an accumulation of blood-
 plates.1 Recent white thrombi, when  examined microscopically, are found to
           1 Bizzozero, Lubnitzky, Eberth and Schimmelbusch, and Osier. 
THROMBOSIS AND EMBOLISM.
29
consist of fibrin, much granular  material, and a variable number  of intact
red and  white blood-corpuscles.  The granular material, according  to  the
older  view, is the result  of the disintegration of leucocytes, but according
to a later  view it consists of blood-plates or their  fragments.
  It is of great practical importance to be able to distinguish between thrombi
and decolorized post-mortem clots, particularly those which are found in the
cavities of the  heart, and  which are so often erroneously assigned by  the
inexperienced as the cause of death.  Thrombi are opaque, granular in appear-
ance,  distinctly stratified, and adherent to the wall of the vessels.  Decolor-
ized post-mortem clots  consist of  a lower,  red cruor mass and an upper
yellowish-white fibrinous material; they have a gelatinous, moist, translucent
appearance, are not distinctly stratified, and are not intimately adherent to
the vascular wall.
  A thrombus after its formation undergoes organization, softening, or calcifi-
cation.  The so-called organization of a thrombus results in the formation of
vascularized connective tissue in  the place of the  thrombus.   The thrombus
itself breaks down and  is  absorbed, taking  no part  in  the formation of the
new tissue.   The process of organization is essentially an obliterating endar-
teritis, the new connective  tissue  being derived  either from fixed cells in the
walls of the vessel (endothelium), or from wandering cells which have escaped
by emigration  from the vasa vasorum or the surrounding tissues.  The new
blood-vessels communicate  with the vasa vasorum and also with the lumen of
the occluded vessel.   Partly by the latter communication, but chiefly by the
contraction of the new connective  tissue, canals may be formed which con-
nect the interior  of the vessel  on the peripheral  side of the thrombus with
that on the central side.   By this so-called canalization of the thrombus, the
circulation may  be re-established nearly in  its old channels.
   It  is important to distinguish two kinds of  softening of a  thrombus.   The
one is simple, or bland softening ;  the other is mycotic, or septic softening.   In
simple softening the central part of the thrombus breaks down into a grayish
pulp which maybe more or less stained with altered blood-pigment, and which
in its gross appearance resembles  pus.   This pulp consists of fatty and albu-
minous granules,  fatty degenerated leucocytes, and blood-pigment. This form
of softening is particularly  common in the globular thrombi of the heart, which
are thereby made to resemble abscesses or cysts with purulent contents.   In
consequence of the softening, fragments of the thrombus are easily broken off,
and are transported by the blood-current as emboli, which in this case are of
a bland nature.   Far more serious is septic softening.   This  occurs in infec-
tious  thrombi.   Here the thrombus and the  softened mass contain bacteria,
chiefly  micrococci.  Portions of  the thrombus or of the softened material
enterino- the circulation form infectious emboli, which produce the most disas-
trous results, causing, wherever they lodge, metastatic abscesses.   It is these
mycotic  thrombi and emboli  which  cause  the most  important lesions of
pvamia.                                .     .        .         ...
  " Sometimes thrombi, particularly those in varices  and in  the  pelvic veins.
shrink and become impregnated with  calcareous salts, forming concretions
called phleboliths.                  ,  .  .   ,  „     ,     ,     ,       .,
   The effects and symptoms of thrombosis, in the first place, depend upon  the
mechanical  obstruction to  the  circulation.   The degree of  this obstruction
depends  upon the situation and the  extent  of the thrombus.  A parietal
thrombus  may produce so little obstruction  as to give rise to no symptoms.
Completelv-occluding thrombi  produce no mechanical hindrance when lodged
'  1 vessels "provided with anastomoses which afford a sufficient collateral circu-
lation  Thus a thrombus in one of the vena comites of an  artery forms no
apparent  obstacle to the circulation.  On the other hand, thrombosis of  the 
30             DISTURBANCES  OF THE CIRCULATION.

portal vein (pyle-thrombosis) or of the femoral vein (phlegmasia alba dolens)
is followed by well-marked symptoms of venous obstruction.  These symptoms
of venous thrombosis are passive hyperamia, with more or less transudation
of serum, and diapedesis of red blood-corpuscles.  The mechanical effects of
arterial thrombi are anamia of the part supplied  by the artery, and necrosis
with or  without hemorrhage.   These effects  are usually absent  when the
thrombus is seated in an artery the branches of which communicate freely by
anastomosis.   As these mechanical effects of arterial thrombi are the same as
those of  emboli, they will be more fully considered  presently while treating
of the latter.   On account of their slow formation, a sufficient collateral cir-
culation may be developed to render thrombi comparatively harmless in situa-
tions where emboli produce their characteristic effects.
  Independently of their mechanical action, thrombi maybe injurious by con-
taining some irritative infectious principle.  Such thrombi contain micro-organ-
isms and cause suppuration and sometimes  necrosis  in the vascular wall and
surrounding  tissues.
  An embolus is a plug of some  material transported by the blood-current
from one situation to another.   The  term embolism,  is applied to the  process
of obstruction of a blood-vessel by an embolus and to the disturbances resulting
therefrom.  An embolus may consist of any substance which  makes its way
into  the  circulation.   The  majority  of emboli are  the severed fragments
of thrombi.   But emboli may consist also of  bacteria or other parasites, of
bits of a  tumor, of fragments of diseased cardiac valves, of concretions of lime,
of clumps of pigment, of oil-globules, or of bubbles of air.
  It is plain that an embolus can hardly be arrested in its course through the
veins, with the exception of the vena porta,  or in the cavities of the heart,
since the course of the blood-current in them is from  smaller to larger vessels.
In rare  instances, however, when  there is some obstruction to the flow of
blood, a venous  embolus may take a retrograde course.  Thus, an  embolus
derived from a thrombus in one of the veins  of the  lower extremities may
lodge in one of the renal veins, its onward passage through the inferior vena
cava being impeded ;  as, for instance, by the obstruction to the return of blood
to the heart in a severe attack of  coughing (Von Recklinghausen).   In
general, however, embolism relates to the arteries and the vena porta,  while
a thrombus may be formed anywhere in the vascular tract.
  Disturbances of two kinds attend the lodgment of emboli.   The one kind
of disturbance  is due  to the mechanical  obstruction to the circulation; the
other kind of disturbance  attends  only infectious emboli, and is  dependent
upon  the presence  of  some poisonous principles, usually  bacteria, in the
embolus.
  While all  arteries of the body are open for the reception of emboli, it  is
noteworthy that in certain situations the obstruction  of  an artery by a  bland
embolus  is absolutely harmless, whereas in other parts it is followed by cha-
racteristic structural and functional changes.  The  main  condition  upon which
this difference depends is the character of the arterial distribution in the vari-
ous parts of  the body.  When an  embolus lodges in an artery supplied with
abundant anastomoses—for instance, a muscular artery or one of  the arteries
of the extremities—a collateral  circulation is usually established, which pre-
vents the part from suffering in its nutrition.   The  effect is  widely different
if insufficient anastomosis, or none whatever, exist between the occluded artery
and other arteries.  In certain organs and parts of the body the branches of
the arteries do not anastomose with each other, communications existing only
between  the capillaries and between the veins.  These arteries without anas-
tomoses are called by Cohnheim terminal arteries.  Such arteries are the pul-
monary,  the  renal, the  splenic, the arteries beyond the circle of Willis sup- 
THROMBOSIS AND EMBOLISM.
31
plying the basal region of the brain, the central artery of the retina, and the
coronary arteries of the heart,  The branches of the vena porta also form no
anastomoses with  each other.
   >\ hen an embolus lodges in an artery where  no sufficient collateral circula-
tion can be established, the part supplied by the obstructed artery is cut off
from its blood-supply and dies.  The mode of death is that designated as ana-
mic necrosis or coagulation necrosis.  The necrotic mass of tissue constitutes
an embolic infarction. In some situations there is usually an  extravasation of
blood into the  necrotic part.  The infarction is then spoken of as hemorrhagic;
when there is no hemorrhage the infarction is called a white or anaemic infarc-
tion.   The  essential, because the constant,  change in embolic infarctions is
not  the  hemorrhage, but the necrosis.
  The coagulation necrosis of embolic infarctions is  characterized by a disap-
pearance of  the nuclei of the cells  and by a coagulation of  their protoplasm
into a substance  resembling  fibrin.   The affected tissue is rendered hard in
consistence.   In  the brain, however, there  is so little protoplasm  that no
appreciable  coagulation can  take place, so  that the effect  of embolism of
a terminal artery of the  brain is softening  instead  of  hardening of  the
tissues.
  In hemorrhagic infarctions the blood is extravasated by diapedesis.  Blood
is sent from the surrounding  capillaries  or from minute arterial twigs into the
capillaries of the obstructed district, but not with sufficient force to propel the
blood with normal rapidity into the veins or to nourish the part.   As a result
of  this insufficient supply of fresh  arterial  blood the walls of the capillaries
and small veins suffer in their  nutrition and allow a diapedesis of red blood-
corpuscles.  Another possible source of  the extravasted blood is  a regurgita-
tion of the blood from the veins which connect with the capillaries, the arterial
supply of  which is shut off.   As the blood-pressure  on the peripheral side of
the  obstruction is reduced to nothing or almost nothing, there is apparently
no  reason  why this backward flow of blood should  not  take  place.   It  has,
however, been  shown by experiments of Litten that  a return flow  of blood
from the veins  is not essential to the production of a hemorrhagic infarction.
  It  is not very clear why some infarctions are  hemorrhagic and others are
white.  Probably, as suggested by Weigert, much depends upon  the charac-
ter  of the affected  tissue.   Where  the tissue  is lax, containing  wide spaces,
there is plenty of room for  the  infiltration  of blood.   Hence in the lungs
infarctions are always hemorrhagic.  In the kidney, on the  other hand, the
occurrence of coagulation necrosis renders  the  tissue so dense that the blood
cannot penetrate into the interior of the infarction.   Hence infarctions of the
kidney are always white in  the  centre, usually with a hemorrhagic  margin.
The consistence of the spleen after the occurrence of  coagulation necrosis is
such as to admit of the infarction being  either white or hemorrhagic, accord-
ing to the force of  the circulation.
  The organs in which embolic infarctions occur are the kidney, spleen, lungs,
brain, heart, retina, intestine, stomach, and  testicle.   Emboli in branches of
the portal vein do  not produce infarctions,  as the  hepatic  artery  can  sup-
ply the lobular capillaries.    Infarctions  are  generally wedge-shaped (not so
in the brain),  corresponding to the area  of distribution  of the obstructed
artery.   The base of the wedge is toward or usually at the periphery of  the
or->-an.  A hvperamic zone  containing  many emigrated white blood-corpus-
cles is found around the borders of the infarction.   This reactive inflamma-
tion results in  the formation of new connective tissue, which takes the place
of the infarction, many of the constituents of the latter being absorbed.   The
termination is in a cicatrix of fibrous tissue which contains  pigment when  the
infarction was hemorrhagic.   The special characters of embolic infarctions of 
32             DISTURBANCES  OF THE CIRCULATION.

different organs will be considered under the diseases of these organs in Part
II. of this work.
  The presence of disease of the arteries and an enfeebled  circulation  are
important factors in determining the effects of an  embolus.   Thus, embolism
of the femoral artery produces no permanent injury when the force of  the
circulation is  normal, but it may be  followed by gangrene  of the lower
extremities  if  the  heart's action  be feeble  and  the  anastomosing  arteries
atheromatous.
  Embolism of the  main trunk of the pulmonary artery, of certain  arteries
of the medulla oblongata, or of one of  the coronary arteries  of the heart
causes sudden  death.  In certain  situations and under certain circumstances
the ischamia caused by an embolus is of  short duration.  Thus, a temporary
loss of function disappears when the vessels  beyond the  seat of obstruction
are filled by collateral arterial  branches.
  In addition to their mechanical effects, infectious emboli, such as those com-
ing from the  cardiac valves  in malignant endocarditis or  from thrombi in
pyaemia, produce suppurative inflammation wherever they lodge.   Thus, even
capillary emboli, when infectious, produce abscesses.  The multiple abscesses
in pyamia are for the most part of embolic origin.
  Fatty emboli and emboli composed of  air-bubbles demand a few words of
separate consideration.
  The source of fatty emboli is usually to be found  in inflammation or trau-
matism  of parts rich in  fat.   The most  important cause is fracture  of  the
bones accompanied by  extensive laceration of the marrow.   The oil-globules
thus set free enter the open mouths of ruptured veins, and are transported to
the pulmonary  capillaries, which are often thereby  extensively occluded. The
fat may pass through the pulmonary capillaries and lodge in the glomeruli of
the kidneys, in the capillaries of the brain,  and in other capillaries of the body.
It has been proven by experiments that fatty embolism, even when very exten-
sive, is generally innocuous.
  The sudden entrance of a large quantity of air into the blood-current, such
as may  occur  by incision  of the large  veins near the heart, has been long
known as a cause of rapid death.  The fatal termination is due to the accu-
mulation of the air in the right  cavities of the heart, the contraction of which
is unable to force  the elastic  air  forward.  The air remaining in the ri«:ht
auricle  and  ventricle is an obstacle to the entrance of blood from  the venae
cava, and arrests  the  pulmonary  and systemic circulations.
                               Dropsy.

  A certain amount of serous fluid, known as the lymph, constantly transudes
through the capillary walls into the tissues.   When a greater quantity of this
fluid transudes than can be absorbed by the lymphatics and blood-vessels the
fluid accumulates in the  interstitial  spaces and cavities of the  body.  This
condition is called  dropsy.  The term  oedema is applied to the  accumulation
of serous fluid in the tissues, particularly in the meshes of connective tissue.
Subcutaneous oedema extending over  the  greater part of the body receives
the name of anasarca.  Dropsies of the serous cavities are designated by pre-
fixing hydro to  the  name  of the cavity affected;  thus, hydrothorax, hydro-
pericardium, hydro-peritoneum, or ascites, and hydrocephalus.  Hydrocele is
a serous accumulation  in the tunica vaginalis testis.   The term hydrons also
signifies a  serous effusion, usually into a cavity.  Accumulations of serous
fluid in glands and canals, the outlets of which are obstructed__for example
in the Fallopian  tube (hydrops tuba), in  the gall-bladder (hydrops  cystidis 
                                DROPSY.                             33

fellea)—are to be  distinguished from real dropsical effusions, although the
appearance  of the  fluids may be similar.
   A distinction may be made  between transudations and exudations, the term
transudation being confined to dropsical effusions, while exudation is applied
to inflammatory products.   The two terms are, however, often used synony-
mously.                                                           J   J
   Dropsies may be divided into three classes—inflammatory, mechanical, and
cachectic or hydrsemic.
   Inflammatory dropsy is  due to a moderate  degree of inflammatory altera-
tion in the coats of the blood-vessels.   The so-called collateral adema, often
found in the neighborhood of inflammatory infiltrations  and of tumors', is an
inflammatory oedema.  Of the same  nature are most cases of oedema glottidis.
of hydrocele, and of  internal  hydrocephalus.
   Mechanical dropsy is the result of some obstruction to the current of blood
in the veins.   Mechanical  dropsies may be general  or local.  The dropsy is
general when, in consequence of disease of  the heart or  of the lungs, the
return flow of blood  from  the vena cava is impeded.  The most frequent
of the mechanical  causes  of  general dropsy is valvular disease of the heart.
General dropsy is characterized by anasarca and transudation into the serous
cavities.   Examples of local dropsies due to mechanical causes are the hydro-
peritoneum resulting  from obstruction of the vena porta, as by thrombosis or
by cirrhosis of the  liver, and  the  oedema of one of  the extremities in conse-
quence of thrombosis or compression of  its  veins.
   It might be supposed  that  obstacles to the  flow of lymph in the lymphatic
vessels would cause an abnormal  accumulation  of  lymph in the  tissues and
serous sacs.   But it  has been found that not  only the peripheral lymphatics,
but  even the thoracic duct, may be completely occluded without producing
local  or general dropsy.   The lymph does not accumulate -under these cir-
cumstances, because  relief is  afforded by collateral  lymphatic channels, and
because the blood-vessels act as absorbents when the lymphatics are occluded.
   Hydremic or cachectic  dropsy is  the result of an impoverished and abnor-
mally watery state of the  blood.  This  state of the blood, which is called
hydramia, appears, however, to be the indirect and  not  the immediate cause
of the dropsy.  The experiments of Cohnheim and Lichtheim have  shown
that when the vascular  walls are healthy, artificial hydramia, produced  by
the injection of large  quantities  of  dilute solution of common salt into the
blood-vessels of animals, causes no  increased transudation  in the situations
in which dropsy occurs in man.   It is believed that the hydramia acts in the
causation of dropsy by inducing in the  vascular walls  some change which
renders them more  permeable.   The most  important  cause of hydramic
dropsy is  Bright's disease.   This form of dropsy, generally in a lesser degree,
may  attend  many  other cachectic conditions, such as tuberculosis,  cancer,
malarial  cachexia,  and chronic dysentery.   Cachectic  dropsy  is prone  to
appear in dependent  parts of the body, and  where  the  connective tissue  is
particularly lax in texture, as in the eyelids and  about the genitals.
   Dropsical  effusions  are  generally clear, transparent, colorless  or slightly
yellow, and  alkaline  in reaction.  They may  be stained  by an admixture of
blood or  of  biliary coloring matter.  They  contain the same  salts as the
plasma of the blood, and  in  about  the same proportions.  The  amount of
albumen  varies between 0.4 and 5 per cent., being  less than that present in
the blood-plasma.  Under like  conditions the percentage of albumen varies
with the  situation of the transudation in the following order: tunica vaginalis
testis  pleura, pericardium, peritoneum,  subcutaneous  tissue, subarachnoid
space's the percentage being highest in hydrocele and lowest in subarachnoid
oedema.  Of  the different forms of dropsy, the amount of albumen is greatest
3 
34
INFLAMMA TION.
in the inflammatory variety and lowest in  cachectic dropsy.   Dropsical effu-
sions differ from inflammatory exudations in the smaller  amount of  albumen
present, in the paucity of cells, and in  the absence or small quantity of fibrin
present.   Most transudations contain  fibrinogen ; hence dropsical transuda-
tions often coagulate spontaneously when  withdrawn  from the body, in case
fibrin ferment by the disintegration of  cells or by admixture with blood is set
free.  Examined microscopically, serous transudations are found to contain a
few leucocytes, and also red blood-corpuscles, the latter sometimes in abun-
dance.   In rare instances  transudations in the  pleural and in the peritoneal
cavities have been rendered milky in appearance by an admixture  of chyle
derived from the chyle-vessels, particularly the thoracic duct, in consequence
of their  occlusion or rupture.   Such  a transudation is  called hydrops  chy-
losus.
                        CHAPTER   II.

                           INFLAMMATION.

  A CCORDING to the classical  definition of inflammation, a part is acutely
XjL inflamed when it is hot, red, swollen, and painful.  But this enumeration
of the four cardinal  symptoms (calor, rubor, tumor, dolor) gives no informa-
tion as to the pathological nature of the process.  No topic in medicine has
been the subject of so much research and speculation as the nature of inflam-
mation, but even at the present time it is impossible to give a complete and
correct definition of inflammation from a pathological or an etiological stand-
point.   From the earliest times two opposing theories regarding  the process
of inflammation have  been held.  According to the one, the  essential phe-
nomena in inflammation are referable to the blood and  to the  blood-vessels;
according to the other, the  essential changes are in the solid tissues outside of
the blood-vessels.  A great advocate of the former theory was  John Hunter.
Recently it has been developed especially by Cohnheim.  Virchow, on the
other hand, rejecting the Hunterian  doctrine,  maintained that the primary
and chief effect of an inflammatory irritant is the excitation of the cells of a
part to increased functional and nutritive activity, and that hyperamia and
fluid exudation from the blood  are secondary to this  excitation.  When Vir-
chow made his researches on  inflammation, nothing was generally known
concerning the emigration of white blood-corpuscles or their wandering powers ;
and he naturally concluded, in the application of the law omnis cellula e cellula
that all cell-elements present in inflammatory exudation were produced  by
proliferation from the pre-existing fixed cells, most frequently  from the con-
nective-tissue cells.  The discovery by Recklinghausen, in 1863. of the exist-
ence of wandering cells, resembling pus-cells, in the tissues, rendered doubt-
ful the interpretation  which Virchow has  given to many of his observations.
A new era was  introduced  in the history of inflammation by Cohnheim's dis-
covery, in 1867, of the emigration of white blood-corpuscles from the vessels
and by his studies of  the inflammatory process on  living froirs.   It is true
that as long ago as 1846, Waller, an  English observer,  saw  the passage of
white blood-corpuscles through  the unruptured vessel-walls, but this isolated
observation had remained fruitless, and had  fallen into oblivion when Cohn-
heim repeated  the discovery. 
INFLAMMATION.
35
  The phenomena of inflammation were observed  first by Cohnheim  micro-
scopically upon the mesentery and tongue of the  curarized frog.   The first
effect of the application of an inflammatory irritant (the  mere exposure of
the mesentery to the air  suffices) is a dilatation of the arteries, then  of the
veins,  and,  last of all, of the capillaries.  At the  same time the  velocity of
the blood-current is increased.  After a variable time the blood begins  to flow
less rapidly, although the calibre of the vessels remains unchanged.  In some
of the  capillaries it may come to complete stagnation, or stasis, but this is not
essential or usual  except  when the action of the irritant is intense.   As the
rapidity of the blood-current lessens, the white blood-corpuscles accumulate
along the inner surface of the veins, where they  remain nearly  stationary.
The remarkable phenomenon of emigration now takes place.   A portion of a
white  blood-corpuscle soon  appears upon the outer  surface of a vein  or  a
capillary, as a bud-like process connected  by a delicate thread of  protoplasm
with the remnant of the corpuscle inside.  As the outer portion of the cell
increases  in  size the inner diminishes, until, finally, the  entire  corpuscle lies
free outside of the vessel.  The corpuscle  passes  through the cement-sub-
stance  between the endothelial  cells  lining  the vessel.   It  is not decided
whether the corpuscles make their way through the vascular walls by  their
active amoeboid movements,  as the name emigration would imply, or whether
they  are  pressed  through by a process of filtration.   Outside  of the ves-
sels they assume  amoeboid  movements and change  their shape and place.
While  the  inner  surface of the veins becomes plastered, as it were, with
stationary white blood-corpuscles, the  current of  red blood-corpuscles con-
tinues unabated  in the central part.   White blood-corpuscles migrate  from
the veins and the capillaries, but not from the arteries. Red blood-corpuscles
also pass through the capillary walls  by the passive process of diapedesis.
Their  number is not usually great, but exceptionally it may be so considerable
as to give a hemorrhagic  character to the exudation.  Coincidently with the
processes of emigration and  of diapedesis the fluid constituents of the blood
filter through the walls of the vessels.   This fluid exudation resembles in its
composition the plasma of the blood, but it  contains less albumen.   It con-
tains the fibrin-generators, and in most places finds the conditions necessary
for the spontaneous coagulation of fibrin.   A  fibrinous effusion is, in the
vast majority of cases, an inflammatory exudation.  In simple inflammations
of mucous membranes and in suppurative inflammations (abscesses) no fibrin
is formed.   By a  process of reasoning which cannot be  entered into here
Cohnheim concludes that these various  phenomena of inflammation  can  be
explained only upon the  assumption that  the effect of the inflammatory irri-
tant is to produce a molecular alteration in the walls of the  vessels, which
increases their permeability to  the  fluid and corpuscular elements  of the
blood  and  increases the  friction between the blood and the vessel-wall.
   While  the accuracy of  Cohnheim's observations of the process of inflamma-
tion in frogs has been established, and  their applicability to the same  process
in man has been recognized, there has been much controversy as to the part
taken  by the fixed cells  outside  of the vessels in the inflammatory process.
Do they produce  pus-cells, as Virchow taught?  It is maintained  by Cohn-
heim  that the sole origin of pus-cells is to be found in emigration of the
white  blood-corpuscles, and that the fixed cells in inflammation either remain
unchanged  or degenerate, or proliferate and produce other cells of their kind
(regenerative process), but never give rise to pus-cells.   On the  other hand,
Strieker and his school hold  to the original doctrine of Virchow, that all varie-
ties of fixed cells—connective-tissue cells, epithelial cells, nerve-cells,  muscle-
ce]js__proliferate in inflammation and produce  pus-cells.  The difficulty in
determining these points at issue lies chiefly in the fact that it has  not yet 
3fi
INFLAMMATION.
been found possible to observe satisfactorily the process of change in the
living  fixed cells during inflammation ;  so that we are compelled to infer the
nature of the process from a study of the phases, the interpretation of which
is often various and open to fallacies.  Especially is  this true of the  attempt
to interpret the significance of phases  apparently  transitional  between  one
form of cell  and another, and to judge of the origin of a cell from its form.
Hence the evidence that fixed  cells produce pus-cells is of a different nature
and less convincing than the proof  that pus-cells  come  from  emigrated white
blood-corpuscles.   It  is impossible  to describe here the many experiments
and observations made with reference to the settlement of this question.   It
must suffice to state that the weight of  evidence  is decidedly in favor of the
view that fixed cells do not remain passive in inflamed parts, but that they
become amoeboid, proliferate, and produce young  cells.  Unless we arbitrarily
lestrict our definition of pus, these young cells  are to be regarded as pus-cells,
which  may therefore be derived from either emigrated white  blood-corpuscles
or from  fixed cells.   The  dominating elements  in acute inflammation, how-
ever, are the emigration of white blood-corpuscles and the exudation of the
fluid constituents of the blood in consequence of  as yet undefined changes in
the vascular walls.
  As  is evident from the foregoing description, the products  of  inflammation
are fibrin,  serum, pus-cells,  and red blood-corpuscles.   In inflammation of
mucous membranes an increased secretion of mucus may take place.  Exu-
dations are  classified  as fibrinous, serous, purulent, hemorrhagic, and  mucous,
according to the relative proportion of the inflammatory products which they
contain.   Fibrinous exudation is best illustrated  by  the acute  inflammations
of serous membranes, where the fibrin is deposited as a  layer upon the serous
surfaces.  These fibrinous  layers  can be readily  stripped off, and are  some-
times  called false membranes or coagulable lymph.   More or less white and
red corpuscles are present in the meshes of the fibrin,  and in the interior of
the serous sac is a variable amount of fluid  containing also fibrin and exuded
cell-elements.  Fibrinous exudation may be present  also  in  inflammation of
the solid tissues, in the air-cells of the  lung, and upon mucous membranes.
Fibrinous exudation upon mucous  surfaces is  called croupous or diphtheritic
in accordance with a distinction to be explained hereafter.  Serous  exudations
bear considerable resemblance to transudations, but they are  generally richer
in albumen and in cells.  The  main distinction, however, is that they appear
with the signs of inflammation.  The exudation in so-called collateral oedema
(which is really inflammatory) is generally serous; likewise the  exudation in
the early stage  of many inflammations  of  mucous  membranes.  Inflamma-
tory affections of the skin are accompanied often  by the formation of vesicles
containing serous  exudation.   Although pus-cells are  present in all inflam-
matory exudations, it is only when  they are sufficiently abundant to render
it opaque that the exudation is  said to be purulent.   Pus consists of a fluid
part (liquor puris) and of cells.  Pus-cells are round, membraneless, and con-
tain usually two or three nuclei enclosed in a cell-body of protoplasm in which
as a rule, molecules of fat  are  present.   Pus-cells belong to the  widely-dis-
tributed group of cells known variously as leucocytes, lymphoid cells wander-
ing cells, embryonic cells, and small, round, indifferent cells. Their origin from
emigrated white  blood-corpuscles has been described.  It is believed that pus-
cells increase in number by division.  Inflammations producing pus  are sup-
purative.   The pus may be exuded upon free surfaces; it may infiltrate the
tissues (purulent infiltration), or it may  be contained in  cavities  produced by
the breaking  down of tissue.  Such cavities containing pus are called abscesses
It is probable that suppurative inflammations are due to the action of bacteria
When  the exuded red blood-corpuscles are sufficiently abundant to give a red 
IN FLA MM A TION.
37
color to the exudation, the inflammation is said to be hemorrhagic.  According
to Cohnheim, hemorrhagic exudations are referable to an intense action of the
inflammatory irritant upon the vascular walls.  Tuberculous, cancerous, vari-
olous, and scorbutic inflammations of serous membranes are liable to be hem-
orrhagic.   The source of the hemorrhage may be from rupture of the vessels
or from diapedesis.
   As has  already  been mentioned, the terms croupous and diphtheritic are
applied to  fibrinous exudations upon mucous membranes.   Unlike the inflam-
mations of serous  membranes, the ordinary  inflammations of mucous mem-
branes  are not accompanied by a fibrinous exudation.   The  term catarrhal
is sometimes applied to  these simple inflammations of mucous membranes
characterized  by  an  exudation  of serum,  mucus, and some   pus-cells.
According to  the careful investigations of Weigert, fibrin is present in the
inflammations of mucous membranes only  when the epithelial covering  is
partly or wholly  destroyed.   The  epithelium may be destroyed  from various
causes, among the  most important of which is coagulation  necrosis.  The
necrosis may extend deeper than the epithelium  into the subjacent tissues.
When only the epithelium is destroyed, the fibrinous exudation  lies upon the
membrana propria of the mucous membrane, from  which it  can  be readily
stripped off' without loss of  substance.  This form of exudation is called
croupous.   When the  primary necrosis  involves  the tissue-cells as well  as
the  epithelium,  the fibrinous exudation extends  from  the surface  into the
tissue  of  the mucous  membrane  and  cannot be removed without loss  of
substance.  This  second  form of  exudation  is denominated diphtheritic.  It
is to be observed that croupous and diphtheritic  exudations require destruc-
tion of the epithelium only in one  place, and that  they may extend thence
over the surface  of the  surrounding intact epithelium. The fibrin in croupous
and  diphtheritic  inflammations is derived partly  from the  blood, partly from
metamorphosis of  the  epithelial  and other cells, and  perhaps partly from
fibrinoid degeneration of  the intercellular  substance (Neumann).   (Further
details  concerning  these  varieties of inflammation will  be found in Part II.
of this  work, in connection with croup and diphtheria.)  It is to be noted that
the terms  croupous inflammation and diphtheritic inflammation are used in a
purely anatomical sense,  without reference  to the diseases called  croup and
diphtheria.
   The  term parenchymatous  inflammation  was  introduced by Virchow  to
indicate the origin of the inflammatory process in the  parenchymatous cells
of an organ.  These—for example, the hepatic cells—under the influence of
an irritant swell  up, become  more granular than normal,  proliferate or more
frequently undergo fatty  degeneration, and perhaps  return to their healthy
condition.   The  propriety of regarding these changes as  inflammatory is  at
least doubtful.  Most of them are also embraced under the names albuminous
or parenchymatous  degeneration.   Many writers, however, still  make use  of
the expression parenchymatous inflammation, especially  with reference to the
kidney, liver, and spinal cord.
  The terminations of inflammation may be various.   A complete restoration
of an inflamed part to  its normal condition  is called resolution.   This, as  a
rule, occurs only  in the milder grades of inflammation.  The fluid part of the
exudation  can  be  readily absorbed ;  emigrated white blood-corpuscles may
re-enter the blood-vessels  or may wander into the  lymphatics, or  they, as well
as red blood-corpuscles and fibrin, may undergo fatty degeneration and then
be absorbed.  The  formation of new connective tissue, or the organization of
the exudation, as  it is called, is a frequent termination of some forms of inflam-
mation, particularly of the fibrinous exudation on  serous membranes.  Such
organizing  exudations are sometimes called  plastic  or  adhesive.  Fibrinous 
38
ACTIVE ALTERATIONS  OF  THE TISSUES.
exudations in the bronchi are sometimes called  plastic (plastic bronchitis),
although no  connective  tissue is formed.  It is certain  that the  fibrin  is
absorbed, taking no active part in the development of new tissue.   The  new
connective-tissue  cells may spring from emigrated white blood-corpuscles or
from the pre-existing connective-tissue cells (including endothelial cells).  The
new tissue is at first very rich in  capillaries, derived from  the old capillaries,
and in cells.  Subsequently it becomes more fibrous, less vascular, and it  con-
tracts.  Considerable  accumulations of pus cannot be absorbed, but when not
evacuated they either remain without changing  their consistence or become
inspissated.   Such  dried masses  of pus may undergo cheesy and  calcareous
transformations, and, becoming encapsulated, remain innocuous.
  Chronic inflammations may be secondary to the  acute or subacute from their
origin.  In  the latter case they may be unattended by any free exudation.
Chronic inflammation  most frequently results in the formation of new  con-
nective tissue.
                      CHAPTER  III.

            ACTIVE  ALTERATIONS  OF THE  TISSUES.

  Pathological New Formations—Eegeneration—Hypertrophy—Tumors— Carcinoma.

                 Pathological New Formations.

   THE  active alterations of the tissues embrace the pathological new forma-
    tions.   These will be  grouped under the  headings regeneration, hyper-
trophy, and  tumors.
  The pathological new formations are the result of increased activity of cells
which are incited to abnormal growth and proliferation.   The usual process
of cell-proliferation is that known as indirect cell-division.   This is character-
ized  by so-called nuclear figures, which follow each  other in definite order
(karyomitosis).  These figures are produced by peculiar arrangements of little
threads  of nuclear substance which can be colored  by various staining  dyes
while the substance between the threads remains unstained.   Thus are formed
the so-called coil, wreath, star, aquatorial  plate, and spindle figures.  Out of
the mother  nucleus are produced two daughter nuclei.  This is accompanied
by division of the cell-body, each segment surrounding one of the nuclei. (For
the details of this process of cell-division, as  well as of other possible modes
of cell-production, works on normal histology may be  consulted.)
  The doctrine of the so-called  specialization  of cells bears  upon pathological
new growths.  Embryological researches have shown that, after the formation
of the three blastodermic layers,  the cells in  each produce only certain kinds
of cells and tissues—that, for instance, connective tissue and muscle  can
spring only  from the middle blastodermic layer, and epithelium only from the
external and internal blastodermic layers (part of the  genito-urinary epithelium
possibly excepted).   There is  much which  supports  the  view  that under
pathological conditions definite  cells can  be reproduced only by their kind__
that, for example, new epithelial cells are always the offspring  of pre-existino-
epithelium, and  cannot be  developed out of  connective-tissue cells or white
blood-corpuscles.  This view is best established for epithelial and nervous tis- 
REGENERATION
39
sue.   Connective-tissue cells, however, can be  produced apparently by emi-
grated white blood-corpuscles as well as by pre-existing connective-tissue cells.

                             Regeneration.

   The subject of the regeneration of tissues after their destruction by wounds
and pathological processes is treated of in extenso in works on surgical pathol-
ogy and will be considered  here only in outline.   Some structures are repro-
duced with  great ease, as,  for example, connective tissue and  epithelium ;
others with  more difficulty, as muscular  tissue and  peripheral nerve-fibres;'
and,  finally, others  not at  all, such as  the central  nervous system and  the
parencli3*uia of most  organs.
   Fibrillated connective tissue is present in nearly all  pathological formations.
It may be produced slowly out of the  pre-existing  connective tissue or it may
be formed out of germinal or granulation-tissue, as it is called.  This granula-
tion-tissue is composed chiefly of cells with scanty and ill-defined  intercellular
substance  and with blood-vessels without compact  walls.   The  cells  are of
various shapes—round, epithelioid,  fusiform, and branched.  The  granulation-
cells  may be derived from emigrated white  blood-corpuscles or  from prolif-
erated connective-tissue cells.  The  round cells become epithelioid and spindle-
shaped, and finally assume the various forms characteristic of connective-tissue
cells  ; the intercellular substance increases in amount, probably at the expense
of the cells, and becomes distinctly fibrillated, and the cells which constitute
the embryonic walls of the capillaries change into flat endothelial cells.   The
fully-formed fibrous tissue is not so rich as the granulation-tissue in cells and
blood-vessels, some  of which, therefore, are destroyed in the process of devel-
opment.
   New-formed blood-vessels are produced by solid protoplasmatic offshoots from
the walls of pre-existing  capillaries.  These offshoots unite  with other similar
offshoots and with the walls of existing capillaries.  These prolongations, at
first  solid, subsequently become hollowed out in their centre, the cavity thus
formed communicating with the lumen of the  capillary vessels and receiving
blood from  them.   At  the same  time nuclei develop, and the protoplasm
divides  around the  nuclei into  cells which now represent the endothelium of
the newly-formed capillaries.  By additions to their coats of connective tissue
and of smooth muscular  fibres, and by widening of their lumina, these  capilla-
ries may change into  arteries and veins.
   Among the circumstances under which  connective tissue and blood-vessels
are formed in the manner described may be  mentioned the  repair of wounds,
the healing  of  ulcers, and the development of adhesions after inflammation
of serous membranes.  The regenerative changes frequently proceed  side by
side  with inflammatory alterations,  from which they cannot usually be clearly
separated.
   Epithelium is endowed with an especially active power of regeneration. It
has   been  experimentally demonstrated1  that  incised wounds of the cornea
may  be completely filled by newly-developed  epithelial cells within twenty-
four  hours.   Nearly all recent observations go to prove that the new epithe-
lium is always  the offspring of the pre-existing epithelial cells.
   IJeireneration of  striated  muscular fibres occurs after their degeneration in
fevers, particularly typhoid fever, and in some other diseases, and sometimes
after their destruction by wounds,  especially subcutaneous  wounds.   Defects
in muscular  tissue, produced  by wounds, however, are more frequently filled
by cicatricial connective  tissue.   It is probable that the new muscular tissue
is produced only from the old muscular tissue  by proliferation of the muscle-
                    1 Yon Wyss, Yirchovfs Archie, Bd. 69, 1877. 
40            ACTIVE ALTERATIONS OF THE  TISSUES.

corpuscles.  Smooth muscular tissue can be produced apparently either from
pre-existing smooth muscle-fibre cells or from connective-tissue cells.
  The investigations concerning the regeneration of peripheral nerve-fibres have
been many, but have not led to entire unanimity of opinion.  Section of periph-
eral  nerve-fibres is followed by their rapid degeneration, extending from the
point of section to their peripheral terminations.  The degenerated peripheral
nerve-fibres are replaced by new axis-cylinders, which grow probably from the
intact axis-cylinders in the central portion of the nerve.  These axis-cylinders
subsequently become invested with myeline and tubular  sheaths.  Notwith-
standing some apparently  confirmatory observations, there is no conclusive
evidence that  nerve-elements are regenerated in the central nervous system
of the adult.   This is certainly  true as  regards the  reproduction  of  gan-
glion-cells.
  The consideration of the reproduction of bone and of  cartilage, belonging
almost exclusively to surgery, cannot be entered into here.
                            Hypertrophy.

  The term hypertrophy is applied to enlargement of a part from an increase
of its normal constituents, the structure and arrangement remaining essentially
unaltered.   Parts  which become  enlarged  in  consequence of a deposit of
materials  foreign to their  normal composition,  or  from a disproportionate
excess of certain of their  normal  constituents, are not, properly  speaking,
hypertrophied.   Two forms of hypertrophy have been distinguished—namely,
simple, or true  hypertrophy, and  numerical  hypertrophy, or hyperplasia.  In
simple hypertrophy there is an increase in the size of the anatomical elements,
but not in their number;  in  hyperplasia the  number of these  elements is
augmented.   It is not usually practicable to carry out this distinction, as the
two forms of hypertrophy are frequently combined.   Hypertrophy may pro-
ceed from a diminution of the disintegration  or waste naturally incident to
the life and activity of cells, while the process of assimilation continues in
normal force; but it more frequently results from  an excess of appropria-
tion, by the part, of nutritive supplies.  This  excess  of  nutriment is gener-
ally consequent upon exaggerated  and prolonged increase of the  function of
the part.  The  most frequent examples of hypertrophy are  the physiological
hypertrophy of  the voluntary muscles following persistent exercise, and the
pathological hypertrophy of the  heart when it is called upon to  overcome
abnormal obstacles to the circulation, such as are presented by valvular lesions.
Hypertrophy of the muscular tunic of the bladder in cases of  long-continued
urethral obstruction also illustrates the production of this lesion by prolonged
increase of function.
  Hypertrophy of one  of the kidneys usually ensues when the function of
the other is either lost  or greatly impaired.   This is found to be the result of
the removal of  one of the kidneys in an  inferior animal: under these circum-
stances the task of excreting  the  urine  falls upon a single organ, its func-
tional  activity is doubled, and, as  a result,  the  organ becomes enlarged
  The examples of hypertrophy  which have  been cited  are conservative
lesions and conduce to the welfare  of the body.  Microscopical  examination
in muscular and in glandular hypertrophies reveals an increase  in the number
and usually in  the size, of the muscular fibres and of the epithelial  cells'
The increase in amount of the connective tissue of a part which is for a  lono-
time hyperamic, especially when the hyperamia is due to inflammation, may
be referred partially to the augmented supply of nutriment, and thus is to be
considered as hypertrophic. 
TUMORS.                             41
                               Tumors.

  Tumors constitute pre-eminently the pathological new growths. The bound-
aries of the conception attached to the term  tumor cannot be easily defined.
Tumor literally means swelling, but not every morbid swelling is a tumor in
the technical sense.  Particularly to be separated from real tumors are swell-
ings due to inflammatory processes, to ©edematous infiltration, and also, though
less easily distinguished, those consequent upon hypertrophy.  Tumors are
composed of anatomical  elements similar to those present normally in the
body.   The terms homologous and heterologous no longer indicate the presence
or absence of elements wholly foreign to  the normal organism ; but morbid
growths are now called homologous when  their structure is similar to that of
the parts in which they are developed—for example, a fatty tumor in adipose
tissue ; while the term heterologous is applied to growths differing in structure
from the parts in which  they are seated—for instance, epithelial  tumors in
connective  tissue.
  Tumors  are  classified  and named  according  to the physiological type of
tissue of which they are  composed.  This basis  of classification, proposed by
Johannes Midler, has been firmly established by  the exhaustive researches of
Virchow.   We thus distinguish  tumors formed  after the type of connective
tissue in its manifold forms, of epithelium, of muscular  tissue, of nervous
tissue, and of blood-vessels.  Mixed tumors are those in which two or more
forms of tumor are combined.
   Cysts occupy a special place  among the tumors.   Many are to be classed
rather among the passive than the active alterations of the  tissues.   Three
forms of cysts may be  distinguished: first,  those due  to  dilatation of pre-
existing cavities  by  liquid accumulations  (such are the retention-cysts);
second, those resulting from  the formation of a pathological cavity by the
softening and  breaking  down  of tissue ; and third, those actually of new
formation, as the  dermoid cysts.
   An important  clinical  division of tumors is  into benign and mcdiguant.
The signs  of malignancy are the invasion of the surrounding tissues, the
property of local recurrence, the formation  of metastases, and the develop-
ment  of cachexia.   Benign tumors displace, compress, and perhaps lead to
atrophy of, the tissues in their neighborhood, whereas those tumors which grow
into and invade  the  surrounding tissues are generally malignant.   Tumors
which return in loco after their  removal  are frequently, although not  neces-
sarily, malignant.   Another evidence of  malignancy is  the  development in
various  parts of the body of secondary or metastatic  tumors of  the  same
structure as the primary  growth.  The metastases are due to the transporta-
tion by the blood- or lymph-current of  cells from  a primary or secondary
tumor.   The cachexia is the sequel of  the tumor, and not a primary dys-
crasia.  With  one exception, it  has not  been found possible to  determine
anatomical criteria of malignancy in  a tumor.   The exception is carcinoma,
which is always malignant.  From this statement it is not to  be inferred that
recovery may not take place after complete removal of the  tumor.  Some
forms of sarcoma may  prove  equally malignant, but  malignancy is  not a
necessary attribute of sarcoma  as  it is of carcinoma.   Of other  tumors, a
considerable  number prove, under exceptional circumstances, malignant.
  We possess very little  positive information as  to the causation of tumors.
The question has been much  discussed as to the local or the  dyscrasic  origin
of tumors, particularly of malignant tumors, but it now seems to be settled
in favor of their local origin.  Transmission  by inheritance has been shown
to be a predisposing influence in  the development of some tumors, particularly
carcinoma.   Local irritation,  such as results from injuries,  has  been  often 
42            ACTIVE ALTERATIONS OF THE TISSUES.

adduced  as  a  cause of the growth of tumors; but this influence of patho-
logical and of  physiological irritation has been doubtless exaggerated, and at
the most can be regarded only as an exciting cause. Cohnheim has advanced
the hypothesis that all true tumors (he separates from these a group  denomi-
nated'  infectious tumors, to be  mentioned presently) are the result  of some
abnormality in embryonic development.  According  to this theory of  the
embryonic'origin of tumors, the germs of the  tumor,  perhaps  consisting of
misplaced embryonic cells,'are  brought by  the  individual  into the world.
They may remain dormant for a variable length of time, and then, under the
influence of some exciting cause, possibly an injury, may begin to grow.  The
limits  of this  work will not permit a consideration of the ingenious arguments
by which this hypothesis is supported.
   There is a class of  tumors for which the name infectious has been proposed,
which are closely allied to inflammatory new  formations, and, in fact, are
classified among them by some writers.   They  are formed after the type of
lymphatic or of granulation tissue.  It is important to distinguish the infec-
tious tumors from other  tumors.  They will receive separate consideration in
the following  chapter.  Of the  other tumors  space will permit hardly more
than a mere enumeration.   Carcinoma, however, will be considered somewhat
more in  detail, on account of its frequency and importance.

    Tumors in  structure analogous to some of the different forms  of connective
tissue:                                                            .  .
    1. After the type of embryonic connective tissue—sarcoma.^ Of all varieties
of tumor, sarcoma and carcinoma  are undoubtedly the most important.  Sar-
 comata are composed mostly of cells, and are classified according to  the form
 of cell which  predominates. An important general division is into small-celled
 and large-celled sarcomata,  of which the former are usually the more  malig-
 nant.   The three leading varieties of sarcoma are—first, round-celled ; second,
 spindle-celled; and third, giant-celled  or myeloid sarcoma.  The  cells  are
 separated  from each other by  a small amount of intercellular  substance or
 stroma,  which may be formless  or fibrillated.   In most of the so-called alveo-
 lar sarcomata the cells in the apparent alveoli are not in immediate contact, as
 in carcinoma, but are separated  by a scanty amount of  intercellular substance.
 Where  this is not the case the  propriety of calling the tumor  sarcoma, and
 not carcinoma, is questionable.  Sarcoma is very often combined with  other
 forms of tumor,  as in  osteo-sarcoma, myxo-sarcoma, glio-sarcoma,  etc.
 Melano-sarcoma is characterized by the  presence of black pigment-granules
 in the cells.  Its most frequent point of departure is the choroid coat of  the
 eye  and the  integument.   As sarcoma springs from the universally dis-
 tributed connective tissue, there is hardly any part of the body from which
 it may  not take  its origin.  The giant-celled and the  ossifying sarcomata
 generally spring from bone or  periosteum.   It has already been mentioned
 that sarcoma embraces both benign and malignant growths.  The smaller the
 size and the larger the number  of the cells of  the tumor, the more malignant
 and rapidly growing is it as a rule.   Hence  the  round-celled sarcomata and
 the melano-sarcomata are the varieties most to be feared.
    2.  After the type  of mucoid tissue—myxoma.  Myxomata present more or
 less of  a translucent, gelatinous appearance.   They spring  from connective
 tissue.  They have been observed as multiple  tumors  growing from the inter-
 stitial tissue  of the  nerves (constituting a variety of false  neuromata),  but
 they  are generally local.   They are benign as  a rule.    Metastases have been
 observed.
    3.  After the type of lymphatic tissue—lymphoma, lymph-adenoma, lympho-
 sarcoma.   Most of  the new growths which have  been embraced under these 
TUMORS.
43
names are either hyperplasia, as is the case with the so-called lymphomata
of leucocythamia and pseudo-leucocythamia, or else they belong to the group
of infectious tumors.   Genuine tumors,  composed  of lymphatic tissue, do,
however, occur.
  4. After the type of neuroglia—glioma.  The gliomata are confined to the
brain, spinal cord, and retina.  The most typical gliomata  are  composed  of
peculiar  branched cells, called spider-cells and brush-cells,  similar to  those
present in the normal neuroglia or connective tissue of the central nervous
system.   They are often combined with sarcomatous tissue (glio-sarcomata).
They frequently appear in the brain, more as infiltrations than  as  tumors.
They do  not occasion metastases, but are  often the cause  of death from their
localization  in important parts.
  5. After the type of fibrillated connective tissue—fibroma.
  6. After the type of adipose tissue—lipoma.
  7. After the type of cartilage—enchoudroma.
  S. After the type of bone—osteoma.
  9. After the type of blood-vessels—angioma.
  The last  five varieties of tumor have clinically, as a rule, a purely local
importance.  Enchondroma  may exceptionally become generalized, and the
same is  true, in  a less degree, of the other forms, except angioma, which
never gives rise  to  metastases.
  Certain tumors of  peculiar and variable  character  occurring on the dura
mater, pia mater, and  serous surfaces, more  rarely elsewhere, originate  from
endothelial  cells.  They are  therefore called endotheliomata.
   Tumors composed of muscular tissue—my am at a :
  1. After  the type  of striated muscle—rhabdomyoma  or myoma striocellu-
lare.  Tumors  composed of  striated  muscle-cells are very rare, and are gen-
erally  congenital.  They have been  found in the kidneys, testicle, parotid
gland, and other parts.
  2. After  the type of smooth muscle—leiomyoma  or myoma hrvicelhdare.
  The most frequent seat  is the uterus, where, combined with more or less
fibrous tissue, the myomata constitute the so-called uterine fibroids.
   Tumors composed of nervous tissue—neuromata :
  It is customary to call all tumors growing  from  the nerve-trunks neuro-
mata.  It is therefore necessary to distinguish between true and false neuro-
mata.   Tumors  composed  actually of newly-formed  nerve-fibres occur, but
they are  rare, the majority of the  so-called neuromata being myxomata and
fibromata.   According to Klebs, glioma  develops from  nerve-elements.
   Tumors the most important constituent  of which is  epithelium—papilloma,
adenoma, carcinoma including epithelioma :
  A papilloma is composed  of papilla-,  often  very large  and irregular in
shape, which consist,  like normal  papilla, of vascularized  connective tissue
covered with epithelium of variable thickness.   This tumor is due sometimes
apparently to hypertrophy of the  papilla  in  consequence of chronic inflam-
mation.   The soft papillomata of the bladder, rectum, and  uterus  constitute
the most important forms,  and often occasion  considerable hemorrhage.
  An adenoma is composed of glandular tissue, in  which  the type of the
gland can be easily  recognized.   It always  develops from a  pre-existing
eland.   The acini, tubules,  or follicles  of an adenoma  are not  completely
filled  with the epithelial elements, but preserve a  lumen.   This fact, toge-
ther with  the distinctly-preserved  glandular type, distinguishes adenoma
from carcinoma.   As  important  examples of this variety of tumor  may be
cited adenoma  of the  breast, of the uterus, of the rectum, and of the ovary.
The large multilocular ovarian cysts are to be ranked among the adenomata. 
44
ACTIVE ALTERATIONS OF THE TISSUES.
                             Carcinoma.

  Pathologists now agree in making the criterion of carcinoma, or cancer (the
two terms are interchangeable), a definite anatomical structure, and no longer
call a tumor cancer simply because it possesses the signs of malignancy which
have been enumerated.  Other tumors, as well as cancer, may assume a malig-
nant course.   The essential feature of carcinoma is, not the presence of any
particular form of cell, for specific cancer-cells do not exist, but the arrange-
ment of the cells in spaces called alveoli, which lie imbedded in vascular con-
nective tissue called  stroma.  The name alveolus, as here applied, is some-
what misleading, as the spaces  may be of  any shape  or  size, and always
communicate with each  other.  Thus,  upon section,  the  cancerous alveoli
appear broad or narrow, round or elongated or branching, and contain from
three or four to several  hundred cells.  The cells within these alveoli  are
sometimes called the cancer-cells in distinction from the cells in the interven-
ing stroma.   These cancer-cells may be of the most variable size and shape;
they are at  least  larger  than white blood-corpuscles, and  in  a  general  way
may be said to resemble  epithelial cells in shape.  This resemblance is some-
times close,  at other times remote.  In their  relation to each other, however,
the resemblance to epithelium is exact.  The  cancer-cells in an alveolus lie in
close proximity to each other, not separated by any  intercellular substance, or
at least by no more than a  scanty cement-substance like that between epithe-
lial cells.  If the  cells be brushed or shaken  out of an alveolus, this space is
found to be  empty.  All of the tissue  between the alveoli  forms the stroma,
which consists  of fibrillated connective tissue, usually very vascular and at
times very rich in cells.  An old  and still employed classification  of cancers
is into  scirrhous, encephaloid or  medullary, and  colloid cancer.  This  subdi-
vision, not being based upon essential anatomical differences, is not very sat-
isfactory.   The  terms scirrhous and  encephaloid refer to the consistence of
the tumor.  A  scirrhus is a hard  cancer in which the fibrous stroma predom-
inates ;  encephaloid or medullary  cancer is soft  in consequence of the small
amount of stroma  and excess of cancer-cells.  There is no essential structural
difference between the two forms.   The encephaloid cancer is naturally the
more rapid in its  growth and the  more malignant.
   A more satisfactory classification of cancers is  into (1) flat-celled or squam-
ous  epithelioma;  (2) cylindrical-celled epithelioma; (3) carcinoma simplex;
(4) colloid carcinoma; and (5) melanotic carcinoma.
  Flat-celled epithelioma occurs in the skin  and in  mucous membranes cov-
ered by squamous epithelioma.  It is  particularly liable to occur  where the
skin becomes continuous  with mucous membrane,  as in  the lips, eyelids,
vulva, and glans penis.  Frequently in this form of cancer  some  of the flat
epithelial cells contained in the alveoli undergo the metamorphosis into kera-
tin, as occurs normally with the epidermal cells, and these horny cells become
compacted together into little balls called epithelial or cancroid pearls.  Skin
cancers, although malignant, are less likely to produce metastases than most
other forms of cancer, and when early and  completely removed recovery is
often permanent.
   Cylindrical-celled epithelioma occurs in mucous membranes covered by cylin-
drical epithelium—namely, in  the stomach, intestine, and corpus uteri.  It is
often difficult to distinguish between  these tumors and adenomata occurring
in the same  situations.  The distinction is to  be  based on the preservation of
the normal gland-type in adenoma, while the  glandular  arrangement is irreg-
ular and not typical in carcinoma.
  The term  epithelioma in  the restricted sense is confined to the two  preced-
ing forms of cancer, while the name carcinoma  simplex is used to designate 
CARCINOMA.
45
the  ordinary cancers, in which  the cells are not distinctly flat or cylindrical,
but  rather resemble  glandular  epithelial cells.  Most of  the  so-called  scir-
rhous and encephaloid cancers  belong  to this group.
   In colloid  cancer the alveoli  contain partly cells and partly a translucent,
gelatinous material which is thought to be derived by colloid metamorphosis
from the cancer-cells.  The alveolar structure of colloid cancer being gener-
ally  evident to the naked eye, this variety has received also the name alveolar
cancer, although, strictly speaking, every cancer is alveolar.   The  nature of
colloid cancer, and  even the propriety  of classifying it with other  forms of
cancer, have not  been established.   It grows most frequently  from the
abdominal viscera or peritoneum, and  is less likely to produce  metastases
than other forms of cancer.
   In melanotic carcinoma  black or brown pigment is present in the tumor.
Most of the tumors which have  been  described as melanotic  cancers are in
reality melanotic  sarcomata.
   A subject which has been discussed of late years more than  any other per-
taining to the pathology of carcinoma relates to the origin  of cancer-cells.  It
has  been the teaching of Virchow, in accord with his scheme of pathogenesis,
that cancer-cells develop out of connective-tissue cells.  On the other hand,
the  belief has gained ground, chiefly through the researches of Thiersch and
of Waldeyer, that cancer-cells not only resemble epithelial cells in  shape and
in relation to each other, but that they are actually the offspring of epithelial
cells.   It is Waldeyer's view that all varieties of cancer are of epithelial ori-
gin,  and are therefore, strictly  speaking, epitheliomata.  The epithelial origin
of the  flat-celled  and of the cylindrical-celled cancers has been established
beyond doubt; but the  epithelial derivation of the  great majority of the
other  forms  of  cancer, in which the cells less perfectly preserve the type of
epithelium, has been rendered  extremely probable.   Nevertheless, there are
exceptionally tumors which in  structure must be  ranked as cancers, but  in
which the cells  not only have not been proven to spring from epithelium, but
are almost certainly derived from connective-tissue cells (including endothe-
lium).  As our means of determining the genesis of cells are so imperfect, it
seems best for  the present not to introduce the epithelial origin of the  cells
as an element in our definition of cancer, but to rely solely upon the alveolar
structure above described, and to do this notwithstanding  the belief that the
great majority of  cancers are of epithelial origin.
   In their  growth  the  cancer-cells push their way especially into lymph-
vessels and lymph-spaces,  so that oftentimes  the alveoli  are dilated lymph-
spaces.  The metastatic  or secondary  growths which are such a frequent
accompaniment of cancer preserve, with very few exceptions, the type of the
primary growth.   The material, doubtless consisting  of cells  from the pri-
mary tumor, which causes the  metastases, is transported  especially by the
lymphatic  vessels,  so that the neighboring  lymphatic   glands   are early
involved.   The metastases may  also  occur  through  the  blood-vessels, as  is
the  rule with  sarcoma.
   Carcinoma is purely local in  its origin and is not  preceded by any dyscra-
sia.   The cancerous cachexia  follows the development of the primary  and
secondary growths.   As cancer most frequently develops after forty years of
age.  the time of life becomes an important factor in the differential  diagnosis.
Nevertheless, cancer may occur  early in life.  In fact, cancer of the kidney
is  more frequent in children than in old persons.  On account of the frequency
of cancer of the breast and of the uterus, females are more subject to cancer
than males.
   Carcinoma may grow from any organ possessing epithelium.  Primary  can-
cers  of bone, lymphatic glands, serous membranes, and other parts devoid of 
46            ACTIVE ALTERATIONS  OF  THE TISSUES.

epithelium, are certainly very rare.   A frequent metamorphosis in cancers
is fatty degeneration  with disintegration  of the cell-elements.  In this way
ulcerations are produced.  By combined  fatty degeneration and  increase of
the fibrous  stroma a cancerous tumor may  be much reduced  in  size  and
activity, but  it is  doubtful whether recovery ever  takes place in this  way.
                       CHAPTER   IV.

     ACTIVE  ALTERATIONS  OF THE  TISSUES (Continued).

 Infectious Tumors—Syphilis—Leprosy—Glanders—Actinomycosis—Tubercle—Scrofula.

                         Infectious Tumors.

   THE  infectious tumors may be regarded as inflammatory new formations
    due to the presence  of certain  specific viruses, which, so far as known,
are vegetable parasites.   These tumors, which are not to be confounded with
genuine tumors, have many common characteristics.   They are composed
chiefly of a  lowly-organized tissue  resembling granulation-tissue.   Hence
Virchow called these tumors  granulomata.  The vascular  supply of these
new growths  is generally very  imperfect, so that they are liable to degenerate
and die.  They occur in the form of multiple nodules, often widely distrib-
uted over the body.  With the nodules  are  often combined diffuse growths
of the same tissue, as well as ordinary inflammatory changes.  The presence
of a specific virus is  proven by the inoculability of these tumors in animals
which are susceptible to the disease.  This specific virus has, in all cases as
yet known (with the  exception of actinomycosis), been found to be some form
of bacteria.
   The infectious  tumors  are the nodular masses produced by syphilis, lep-
rosy, glanders, actinomycosis, and  tuberculosis.  Of  these  diseases, the only
one of which  a full consideration falls within the scope of this work is tuber-
culosis.
   Syphilis  is attended by many inflammatory lesions  which do not differ
anatomically from ordinary inflammations.  The syphiloma or gumma, however,
presents certain structural peculiarities.  A gumma is a nodule, usually larger
than a tubercle, composed at first almost  wholly of lymphoid cells.   Subse-
quently, the  centre  of the nodule undergoes a peculiar hard, caseous  meta-
morphosis.   Around this  caseous  centre  is usually a zone  of dense  fibrous
tissue, and in the  periphery of the nodule, as well as in the  surrounding tis-
sue, are accumulated round and fusiform cells.  Blood-vessels are present in
gummata.  Gummata may be  found in  the liver, membranes of the brain,
heart, testicle, bone,  skin, and other parts.   They often in part disappear
spontaneously or  under appropriate  treatment.
   In 1884, Lustgarten, in AVeigert's laboratory, discovered in syphilitic prod-
ucts a bacillus which is  probably to be regarded as the  specific virus  of the
disease,  although further observations are  necessary before a positive opinion
can be formed.  The  syphilis  bacilli very closely resemble in appearance the
tubercle bacilli.  They are of about the same size and shape as  the tubercle
bacilli, and they often appear  as somewhat curved  or bent rods.  The ends
of the bacilli are  slightly thickened.   They may contain clear, oval  odisten- 
TUBERCLE.
47
ing spots, which are probably spores.   The bacilli are found in the interior
of cells, either singly or in groups.  They occur, as a rule, in  very scanty
numbers, and long search is often required to discover them.1  According to
Lustgarten, they are constantly present in syphilitic products, but all observ-
ers have not been so fortunate in finding  them.  They have not as yet been
cultivated  outside of the  body.
   The lesions  of Leprosy occur  most frequently  in the skin  and in  the
nerve-trunks, but they may be found in various mucous  membranes and in
the viscera.  The most characteristic of these lesions  are  nodules made up
mostly of  lymphoid  and epithelioid cells.  The lesions  of leprosy contain
characteristic bacilli, often in  enormous numbers.   These bacilli, which  are
doubtless the cause  of the disease, may be found free or  enclosed in cells.
They are found  especially in large  spheroidal or  irregular clumps.   The
bacilli lepra are slender, often  pointed rods, 4-6 p in length.  They form
spores.   They are best stained  by  the same method as that employed for
tubercle  bacilli, but, unlike the latter organisms, they are also colored by the
ordinary staining processes for bacteria.  Cultivation and inoculation experi-
ments with the leprosy bacilli are as yet imperfect.
   Glanders is a contagious  disease  of horses which may be transmitted to
man.  The nodules  of glanders are most frequently found in the nose of the
horse, but  in this animal as well as in man the nodules may be found in  the
skin, the mucous membranes, and the viscera.  The nodules usually suppu-
rate,  and extensive ulcerations  often  take  place.   Small bacilli, not unlike
those of tuberculosis, but nevertheless distinguishable from them,  are found
in the lesions of glanders.  These  bacilli can be cultivated outside of the
body in blood-serum, and the disease can be readily produced by the inocula-
tion of the pure cultures.  The evidence that these bacilli are the  cause of
glanders is therefore conclusive.
   Actinomycosis is a  disease produced by a peculiar vegetable parasite
called actinomycis,  or  ray-fungus.   The disease affects cattle, swine,  and
human beings.   It has been most frequently observed in the jaws   of cattle,
but it may also affect the lungs,  intestinal tract, and  other parts.  The disease
is characterized by new growths  of granulation-tissue, which often contain
foci of  suppuration,  and  which may  in  some places be transformed  into
fibrous  tissue.   The new growths are frequently extensive, and they  were
formerly mistaken in many cases for sarcomata.   The parasite  occurs in the
granulation-tissue and  in the pus in the form of ray like masses,  often visible
to the naked eye as little yellowish or whitish specks.  According to Bostrom,
actinomycis belongs to the highly-developed forms of schizomycetes; others
regard it as a fungus.   Inoculation and cultivation experiments have yielded
positive results.

                                Tubercle.

   Tuberculosis is a disease produced by infection with  a specific  vegetable
parasite  known as the bacillus tuberculosis.  This organism, the discovery of
which by Koch was announced in 1882, is a slender rod  2  to 5  p.  long (one-
quarter to one-half  the diameter of a human  red  blood-corpuscle).   It often
appears bent or slightly curved.  Its most characteristic physical property is its
behavior toward staining agents.  While, on the one hand, it stains  with more

   1 The syphilis  bacilli may be stained by the following process (De Giacomi's): The
preparation is first stained for twenty-four hours with fuchsin ;  it is then washed  for a
few seconds in distilled water to which  a few drops of liquor ferri chloridi  are added ;
it is then decolorized for a few seconds in concentrated liquor ferri chloridi,  after which
it is treated  as usual, with alcohol, xylol or oil of cloves, and Canada balsam. 
48
ACTIVE ALTERATIONS OF THE TISSUES.
difficulty than most bacteria, on the other hand, after it has been stained by the
proper methods, it retains the staining dye after treatment by acids and other
agents which extract the color from other bacteria.1   The bacillus tuberculosis
can be cultivated outside of the body in sterilized gelatinized blood-serum.  The
organism develops in these cultures very slowly, and most favorably at about
the temperature of the human body.  It does not grow at a temperature less
than 30° C. (86° F.).  The bacillus multiplies by transverse  division.  Within
the body it develops oval spores, of which from  two to six may be present in
a single rod. Tubercle bacilli containing spores may preserve their vitality at
least for many months in the dry state outside of  the body,  but under  ordi-
nary circumstances they cannot multiply out of  the body, as they do  not find
the proper conditions of temperature.  The tubercle bacillus is therefore to
be regarded as a genuine parasite requiring for its growth and multiplication
conditions  found naturally only  in the animal body.
  It need  hardly be said that the discovery of the  bacillus tuberculosis has
greatly  elucidated the pathology of the tuberculous processes.   In the  pres-
ence of this organism we  possess a  certain proof of the tuberculous nature
of a given lesion.
  Infection by the  tubercle bacillus  may take place through  the  respiratory
tract, the digestive  tract, wounds of the skin, or the genito-urinary passages.
The poison is most  frequently absorbed by the respiratory tract.
  Of the   lesions produced by the invasion of tubercle bacilli, the most cha-
racteristic, anatomically, are little nodules called miliary tubercles.   When
young,  and before they have undergone degeneration, these tubercles are
gray and translucent in color, somewhat smaller than a millet-seed  in  size,
and hard  in consistence.   Examined  microscopically, undegenerated miliary
tubercles  are  found composed of a reticulated basement-substance and epi-
thelioid cells, giant-cells, and lymphoid  cells.   In  the  centre of a typical
tubercle are one or  more giant-cells surrounded by a zone of epithelioid cells,
while the lymphoid  cells are  most abundant in the  periphery of the  nodule.
In some instances a tubercle is made up wholly of epithelioid cells; in other
cases  scarcely any but lymphoid cells may be found.  It has been held that
the first step in the formation of a tubercle is the accumulation of lymphoid
cells, which change into epithelioid cells, and these into  giant-cells.   The in-
vestigations of Baumgarten, however, have rendered it probable that the first
effect of the lodgment of the tubercle  bacillus is a  proliferation of the fixed
cells of a part  (epithelial  cells, connective-tissue cells), resulting  in the  pro-
duction of epithelioid  cells.   The  lymphoid  cells are emigrated white blood-
corpuscles, which  infiltrate the  primary nodule of  epithelioid  cells.   The
tubercle giant-cells  are large cells containing many  nuclei, which are  usually
arranged in the form of a more  or less  complete ring in the periphery of the
cell.  Tubercle  giant-cells  are produced  by  repeated division of the nuclei
of epithelioid  cells, the cell-body not taking part  in the division, in conse-
quence  of  impairment of its structure by the presence  of bacilli (Weigert).
Tubercles are devoid of newly-formed blood-vessels,  and the old vessels  soon
become  impervious.
  Partly in consequence of this lack of  vascular supply, but chiefly by the
action of the tubercle bacilli, miliary tubercles do not long remain in the con-
dition which has been described.  The cells in the central part of the tubercle
soon lose their nuclei, and their protoplasm is converted into  a hyaline mass
or breaks  down into a granular  detritus.   These changes, which are due to
coagulation necrosis, are embraced under the  names hyaline degeneration and
cheesy degeneration.   The majority of miliary tubercles found at autopsies
  1 As already remarked, the bacillus of leprosy stains under the  same conditions as
the bacillus tuberculosis. 
TUBERCLE.
49
present three zones—namely, a central caseous necrotic  mass, a middle zone
of epithelioid cells associated often with giant-cells, and  a peripheral zone of
lymphoid cells.  Miliary tubercles may increase in size by peripheral growth,
but  large  tuberculous nodules are generally formed by  the  coalescence of a
number  of miliary  tubercles.
   Miliary  tubercles are not the sole tuberculous products.   The  tubercle
bacilli may cause  the diffuse growth of  a tissue identical in  structure with
that of miliary tubercles ; that is, composed of a basement-substance contain-
ing epithelioid, giant, and  lymphoid cells.   This diffuse tubercle-tissue  also
undergoes cheesy degeneration.  Such diffuse tuberculous masses are some-
times  called infiltrated tubercle.
   Ordinary inflammation—that is, inflammation with the production of fibrin,
serum, and pus—is also often associated with tuberculous lesions, and is prob-
ably to be regarded as a direct effect of the action of the tubercle bacilli.
   The minute structure of  the tuberculous lesions varies considerably with
the character of the  tissue in which  they occur.   Peculiarities of structure
due to this cause will be' considered in Part II. of this work in connection with
the tuberculous diseases of special organs, so far as these diseases fall  within
the scope of a work on practical medicine.
   Tubercle bacilli are found in all tuberculous  lesions.   They are generally
less abundant in the caseous than in the cellular parts of the  tubercle.  In the
caseous wall of phthisical cavities communicating with the external air, tuber-
cle bacilli, however, are exceptionally abundant,  Giant-cells are favorite seats
of the bacillus.
   Tuberculosis may be local or general.   Thus  the disease may be localized
in the skin (lupus), in the lymphatic glands, in the joints, in the lungs, in the
kidneys, etc.   The  tubercle  bacilli are frequently conveyed by the lymphatic
current.   When large quantities of the bacilli rapidly gain access to the  gen-
eral blood-current, as when tuberculous masses grow into the pulmonary veins
or the thoracic duct, an eruption of miliary tubercles occurs  throughout most
of the organs of the body, constituting the disease called acute miliary tuber-
culosis.
   The infectious nature of the tuberculous  products  is proven, not only by
their diffusion throughout the body in the manner described, but also by their
inoculability in animals.   That the infectious agent consists of the bacilli  is
proven by the fact that inoculation of pure cultures of the bacilli, which after
a certain number of generations contain nothing else which was present in the
original  tuberculous material, no less surely produces artificial tuberculosis  in
animals.    That the bacilli constitute the essential or specific  cause of tubercu-
losis is proven by the facts that inoculation by no other substance  than tuber-
culous material is capable of producing tuberculosis in animals, and that these
organisms  are constantly present in tuberculous lesions.l

  1 The observers who believe that they have produced tuberculosis in animals by inocula-
tion with  indifferent substances  have mistaken the nodules which form around foreign
particles for genuine tubercles.   These nodules differ from tubercles in the absence of
infectious properties, in the  absence of tubercle bacilli, and in the absence of cheesy
degeneration.  Another source of error has been a lack of proper precautions in exclud-
ing unforeseen infection with the tuberculous virus.
  Tuberculous  caseous material and tuberculous pus may prove infectious even when
tliev are free from bacilli.  The substance then contains the spores of the bacilli. These
spores we are unable at present to recognize, but their existence is demonstrated by the
subsequent development of bacilli in the substance and in the tubercles produced by its
inoculation.  Anv other assumption would lead to the unwarranted doctrine of spon-
taneous generation of the bacilli.
4 
50           PASSIVE  ALTERATIONS OF THE TISSUES.
                               Scrofula.
  The term scrofula is of very old  date, and is used with a rather compre-
hensive and indefinite latitude of signification.  It is applied to a diathesis or
constitutional condition observed especially in young persons who are the off-
spring of tuberculous  parents  or  who  are in bad  hygienic  surroundings.
Scrofulous persons are liable to inflammations, particularly of the mucous
membranes, lymphatic  glands, skin, and periosteum.  These inflammations are
of a chronic character; the exudations have a tendency to  cheesy  degenera-
tion rather than to resolution or  organization.  The inflammatory products are
rich in cells, many of which  are larger than those usually present  in inflam-
mation.  The  lymphatic glands, especially those  of  the neck,  enlarge, often
coalesce with  each other,  and undergo  cheesy metamorphosis.  The  name
scrofula was adopted with reference to these glandular swellings in  the neck.
The various affections attributed to  scrofula often disappear as the individual
grows older and the hygienic surroundings are improved.  There is an inti-
mate  relation  between  scrofula  and  tuberculosis.  The cheesy deposits  in
scrofulous lymphatic glands are generally tuberculous.   Many writers do not
recognize  the  existence of scrofula as  a special cachexia independent of
tuberculosis.
                        CHAPTER   V.

            PASSIVE  ALTERATIONS  OF THE  TISSUES.

Atrophy—Necrosis—Parenchymatous Degeneration—Cloudy Swelling—Fatty Metamor-
   phosis—Mucoid and Colloid Degeneration—Amyloid or Waxy Degeneration—Hyaline
   Degeneration—Calcareous Degeneration—Pigmentation.

   THE passive alterations of the tissues will  be considered under the heads
     atrophy, necrosis, degenerations,  and infiltrations.


                               Atrophy.

   The term  atrophy expresses  a  condition the reverse of hypertrophy.  In
atrophy  the  histological elements of a part  diminish  in  size or in number
without undergoing further change  of  structure.   Diminution of volume and
of weight characterizes atrophy, unless a deposit of fat or of some other sub-
stance compensates for the loss of material.   An atrophic organ is generally
dry,  firm, and anamic.  Atrophy may be  a physiological  process, as is the
case  with the normal involution of the thymus gland and of the fem'ale genital
organs. Senile atrophy is perhaps also to be included among the physiological
atrophies, although pathological causes are often present,  An insufficient sup-
ply of nutriment is a most efficient cause of atrophy both  local and  general
Examples of local atrophy due to this cause  are the wasting of the "hepatic
parenchyma in cirrhosis of the liver and the atrophy of  parts subjected to
pressure  (compression  atrophy).  A general  atrophy,  although in  unequal
degree, of the organs and tissues of the body is the result of insufficient sup-
ply of food and of malassimilation.  Functional inactivity is another cause of
atrophy.  This atrophy may be in  part explained  by the diminished blood- 
NECROSIS.
51
 supply which  is known to attend suspended function.   As examples of this
 functional atrophy may be cited the wasting of the muscles in paralysis, of
 the bone in ankylosis, and of the intestine below a preternatural  anus.   The
 withdrawal of nervous influence may be a cause of atrophy.   A rapid atrophy
 of the  voluntary muscles follows degeneration and  atrophy of the multipolar
 ganglion-cells in the  anterior horns of the  spinal cord, or lesions  suspending
 the functions of the  peripheral nerves which  connect the muscles with  these
 ganglion-cells.  So rapidly does this atrophy progress that it cannot be attrib-
 uted  merely  to loss of function.  It seems  necessary  to assign a  trophic
 or nutritive function to these ganglion-cells.   Examples of this'neurotrophic
 atrophy are progressive muscular atrophy, infantile spinal paralysis, and  per-
 ipheral palsies.
  The  microscopical examination of  atrophied parts reveals a diminution in
 number or in  size of the cells, usually both.   A division  into simple atrophy,
 in which  there is only a diminution in size, and numerical atrophy, or aplasia,
 in which  there is diminution in number of cells, is  not of practical  import-
 ance. ^ In the atrophy of adipose-tissue cells  Flemming observed an  infiltra-
 tion of the  cells with serum and an increase in the number of nuclei.  This
 so-called  atrophic proliferation  shows that increase  in nuclei is not sufficient
 evidence  of an active  proliferation process.   In the neurotrophic muscular
 atrophies there is also an increase in number of the muscle-corpuscles and
 an  increase of the interstitial  tissue.  In  atrophy of the heart a deposit of
 brownish pigment usually occurs in the atrophic muscular fibres, hence the
 name brown atrophy.  In atrophy of  the kidney, and sometimes in muscular
 atrophy, especially in pseudo-hypertrophic paralysis, an excessive deposit of
 fat occurs  about the kidney and  between the muscle-fibres.


                                Necrosis.
  The death of any  part of the body is called necrosis.   Necrosis  of external
 parts of the body, attended by  shrinkage and mummification of  the  tissues,
 is called  dry gangrene.  Necrosis  accompanied by putrefaction of the  dead
 tissues  is called moist gangrene.   The putrefaction is due to the action of a
 ferment generated by certain bacteria.  Simple  necrosis, with softening and
 liquefaction of  the tissues, is called colliquative necrosis.   Necrosis with coag-
 ulation of the  dead  tissues  is  called coagulation  necrosis.
  The causes of necrosis are manifold, but  they may be grouped under two
 headings—-first, agencies which  directly destroy  the vitality of the cells;
 second,  arrest  of the  circulation.  Frequently  the two classes of causes are
 combined in their action.
  The  agencies which cause disintegration of the  cells  may be classified as
 mechanical,  chemical, and thermic.  There is also to be included, the action of
 certain  specific  poisons,  such as those of snake-bites and of various micro-
 organisms.
  The causes which  arrest the  circulation may act  primarily on the arteries,
 veins, or capillaries.  Obstructions in the arteries lead to necrosis in situations
 where no sufficient collateral  circulation can be established,  as in the kidneys,
 the spleen,  some parts of the brain, etc. (See Embolism  and Thrombosis.')
 Venous  obstruction  can hardly  lead to necrosis, on account of  the relief
 afforded  by abundant collateral channels.    If all  the  veins of a  part be
 occluded  when arterial is combined  with  venous obstruction, necrosis fol-
lows as in  strangulated  hernia and in the constriction of a part  by a  tight
bandage.  Obstructions in the capillaries attended by necrosis are generally
due to  agencies which in addition impair the life of the tissue-cells.  The
-ran-n-ene of the extremities which  follows the prolonged ingestion of ergot 
52           PASSIVE ALTERATIONS OF  THE TISSUES.
is usually attributed to the contraction of the small arteries induced by this
substance.   The endemic occurrence of ergotism from eating diseased grain
seems  to have disappeared.
  Under pathological conditions the resistant power of the  body may be so
diminished that comparatively slight causes suffice to produce necrosis.  Thus,
in feeble, bed-ridden persons moderate pressure and uncleanliness often  pro-
duce necrosis in  the form of bed-sores (decubitus).  These bed-sores may
occur in a very short time, even in twenty-four hours, after injuries and dis-
eases involving the gray matter of the  spinal cord.  This acute necrosis is
attributed  to  neuropathic  disturbance.  Diabetes  mellitus is a disease in
which  the resistant power of the  tissues is greatly  weakened, and  in which
gangrene  is not infrequent.   Senile gangrene is usually the result  of the
obstruction  of  arteries which are already extensively atheromatous, so that a
collateral circulation can with difficulty be established.
  The  appearance of necrotic  parts  varies with  the   form  of  necrosis.
Necrosed  bone and tendon may preserve their normal appearances.  In dry
gangrene, which is represented by certain forms of senile gangrene and of gan-
grene following frost-bites, the  dead  tissues are  dry, shrivelled,  and dark in
color.   In moist gangrene the affected part is humid, of a dark color from
diffusion of blood-pigment, of a penetrating odor, and it contains various new
gaseous and chemical substances.  Of the latter,  some are crystalline, such as
leucin, tyrosin, hamatoidin,  fatty acids, and triple  phosphates.   Bacteria of
different forms are found in great abundance. Moist gangrene is usually met
with only in parts of the body exposed to the air, as the extremities, the lungs,
and the uterus.    Gangrene  in internal organs  may, however,  occur by the
transportation  thither of the bacteria of putrefaction, as  by means of emboli
detached from putrid thrombi.  Colliquative necrosis is illustrated by anamic
necrosis of  the brain, in which the  affected part is soft, sometimes almost
liquid, inconsistence, and contains fragments of disintegrated brain-substance.
The liquefaction is probably due to the absence of coagulable material in the
brain.
   Essential for the production of coagulation necrosis are—-first, that  the tissue
contain a sufficient amount of coagulable substance ;  second, that the dead tis-
sues shall be richly permeated by lymphatic fluid  ; and third, that fermentative
or  other chemical agents hostile to coagulation shall be  absent.   The coagu-
lable  substance in the tissues is protoplasm and possibly other albuminous
 substances.  That the dead tissues shall be pervaded by lymph  requires that
they shall be more or less completely surrounded by living tissues.  Agents
 which  antagonize  coagulation are the bacteria which cause suppuration  and
 decomposition, and the  epithelium covering mucous membranes.
   The chemical  process of coagulation is to be regarded as a combination of
 the fibrinogen contained in lymphatic and other  plasmatic fluids, with certain
 substances  (fibrin ferment and fibrino-plastin ?) furnished  by the death of
 protoplasm.  In the  coagulation of fibrin in the blood and in inflammatory
 exudations the fibrin ferment  is furnished by the destruction of leucocytes.
 In the coagulation necrosis of tissues the tissue-cells furnish  certain constit-
 uents of  fibrin, and are themselves directly transformed  into fibrin or a sub-
 stance resembling it.
   Coagulation necrosis  may affect entire organs or parts of organs or  indi-
 vidual cells.   It occurs in a great variety of lesions, the most  important of
 which are  infarctions, atheroma of vessels, tubercular  cheesy foci, tumors,
 typhoid fever, relapsing fever, diphtheria, smallpox, and the waxy degenera-
 tion of muscles.
   The most characteristic microscopical change  in a part which  is the seat of
 coagulation necrosis is the loss of nuclei in the cells.  The  cell-protoplasm 
FATTY METAMORPHOSIS.
53
often presents a hyaline, homogeneous appearance, and it may be distorted in
shape.   Subsequently there is usually granular disintegration of the affected
tissue.   The gross and microscopical appearances and the chemical processes
are not  the  same in all of  the different forms of coagulation necrosis, but it
is  impossible  to enter  here further into histological details, some of which
will  be  referred to in  appropriate places  in the following part of this work.
Some pathologists include many of the changes which have been described
as belonging to coagulation necrosis under the name of hyaline degeneration,
which will be described subsequently.


      Parenchymatous Degeneration—Cloudy Swelling.
   The names parenchymatous degeneration or inflammation, albuminous infil-
tration, granular degeneration, and cloudy swelling are used as synonyms for
the same metamorphosis.   This change consists in the appearance in cells, and
sometimes in intercellular substance, of abundant albuminous granules.  Espe-
cially subject to this alteration are the muscular fibres and the parenchyma-
tous cells of the glandular  organs, particularly the renal epithelium, the hepat-
ic cells, and the peptic cells.   The affected parts appear swollen, opaque as
if boiled, and the  normal  markings, as of the hepatic acini and of the  renal
stria, appear obscured.  The microscopical examination shows  the cells swoll-
en and  filled with fine granules, which dissolve in acetic acid and in potash,
but are insoluble in ether.  In the kidney the epithelium  of  the convoluted
tubes, and in the  liver the hepatic  cells, are normally  so  granular that the
macroscopical appearances are more  conclusive  as  to the existence  of this
change than the microscopical.  The muscular fibres of the  heart are  liable
to this change.  They then contain albuminous molecules  which obscure the
normal striation.  The cells in inflamed parts undergo parenchymatous degen-
eration.
   The most important causes of cloudy swelling are infectious diseases, such
as typhus and typhoid fever, pyamia, puerperal fever, diphtheria, and poison-
ing with phosphorus,  arsenic, or the  mineral acids.   Cloudy swelling has
been developed within six hours  after extensive burns (E. Wagner).   The
view of Liebermeister, that it is  solely the influence of high  temperature in
general diseases which causes  this metamorphosis, has  been  abundantly dis-
proves   Cloudy swelling is sometimes followed by fatty degeneration.  If
its causes disappear, there is usually  a return to the normal condition.   Par-
 enchymatous degeneration undoubtedly impairs the function  of the affected
parts.

                       Fatty Metamorphosis.

   It is customary to distinguish between fatty infiltration and fatty degenera-
 tion of cells   In  fatty infiltration or fatty growth the  fat has been believed
 to come from without the cells, and to infiltrate them  in the form of large
 drops and  in fatty degeneration  to be derived by direct metamorphosis from
 the cell-substance, and to appear  in  the form of molecules.   But these dis-
 tinctions cannot be  maintained.  Thus, in  so-called fatty infiltration, while
 the fat may be derived from without, it is equally certain that it may be pro-
 duced directly from  the protoplasm of the cells.  Thus,  no  one would con-
 *idPr  the  drops of oil so frequently found in  growing cartilage-cells as
 evidence of  fatty defeneration; still,  the fat  here can  hardly  be formed
 ntbprwise than from  the  substance  of the cells.  Again, there  can be  no
 nmer example of  fatty infiltration than  the absorption of fat by the  intes-
 tinal epithelium, in  which, however, the fat appears  in  the form  of  fine 
54
PASSIVE ALTERATIONS OF THE TISSUES
granules.   Most  writers consider the fatty liver resulting from  poisoning by
phosphorus as an instance of fatty degeneration, although here the fat appears
in large drops.
   The chief distinction  between fatty infiltration and fatty degeneration—to
continue to use the old terms—is more chemical than morphological.  In fatty
infiltration of a cell the protoplasm is displaced by the fat, but does not suffer
materially in its integrity except by a slow process of atrophy from  compres-
sion ; if the fat  be derived  from  the  albuminous  constituents  of  the  cell,
these are, in great part at least, renewed.  In fatty degeneration, on the other
hand, the cell-substance is  directly converted into fat, and is not at all, or
only insufficiently, regenerated.  Hence fatty degeneration is also called fatty
atrophy.   A considerable degree of fatty infiltration may exist without inter-
fering materially with the function of the affected cells, although in extreme
degrees this must suffer.  But fatty degeneration is a much more destructive
process, and interferes  to a much  greater  extent with the function  of the
cells.  It  is not always possible  to draw a sharp  line of distinction  between
fatty infiltration and fatty degeneration.   The problems involved are certainly
more complex than was formerly believed.
   In  determining the  nature  of the process it is  of the greatest importance
to take cognizance  of the cause.  The  accumulation of fat in the organism
is the result of its incomplete  oxidation.   The causes of fatty metamorphosis,
therefore,  are—-first,  excessive  supply or excessive formation  of fat; and
second, diminished oxidation of the fat.
   Too abundant ingestion of rich food, especially of fat and of carbohydrates,
leads to obesity or  the  excessive accumulation of fat in its natural depots.
Constitutional  peculiarities,  often  hereditary, the  nature  of which  is not
understood, favor the  development of corpulence.  An excessive formation
of fat seems to be  sometimes the result of increased nutritive activity, as
in growing cells.   The causes leading to diminished  oxidation of the fat may
be  general  or  local.  The  general causes are—first, interference  with the
absorption of oxygen in consequence of disease  of the  respiratory organs;
second, diminution  of the hamoglobin  of the blood;  and third,  agencies
which check the normal oxidizing processes.  Diseases of the respiratory
organs in  themselves rarely, if ever, lead to fatty metamorphosis, but they
increase the efficiency of other causes.  The various agencies which diminish
the number or impair the quality of the red blood-corpiiscles, these being the
carriers of oxygen, are important causes of fatty degeneration.   In&this
group  of  causes  are to  be reckoned progressive  pernicious anamia, icterus
gravis, and other diseases attended by profound  anamia, as leucocythamia,
chlorosis,  chronic pulmonary tuberculosis, and in less degree other chronic
cachexia.  Phosphorus and some other poisons lead  to destruction of the red
blood-corpuscles and consequent fatty metamorphoses.  There  is some reason
to believe that an insufficient supply of oxygen favors rapid  tissue-meta-
morphosis, with the formation  of fat.   Especially  in phosphorus-poisonine
does there seem  to be an excessive formation of fat as well  as diminished
oxidation.   The use of alcohol favors the  accumulation of fat by diminish-
ing its normal oxidation.  The parts which are most subject to  fatty defen-
eration from general causes are the liver,  the kidneys, the muscles, especially
the cardiac muscle, and the coats of the small arteries.
   Local fatty degeneration can be attributed  generally to an insufficient sup-
ply of oxygenated blood.  It  is to be remembered that complete  cessation of
the Wood-current leads  to necrosis, and  not  to fatty degeneration.   In cir-
rhotic livers  the  hepatic cells are often fatty from the interference with the
circulation through  the  organ.   Pus-cells are usually fatty from imperfect
nutrition.   For the same reason other inflammatory exudations undergo fatty 
AMYLOID  OR  WAXY DEGENERATION.
55
degeneration.   The opaque ring so often observed in the outer margin of the
cornea of old  people, called arcus senilis, is due to fatty degeneration of the
corneal corpuscles.
  A fatty organ is generally anamic, of a }*ellowish color, and of diminished
consistence.  In fatty degeneration of muscles the fibres contain a large num-
ber of molecules and small drops of oil.  The stria are obscured, and may dis-
appear.  In the fatty infiltration of muscles the fat is deposited always in large
drops in the cells of the interstitial tissue, and not in the muscular fibres.   In
fatty degeneration the cell may be completely destroyed, leaving only a fatty
detritus.  The description of the gross and  microscopical appearances in the
fatty metamorphosis of different organs  belongs  to  Part II. of this work,
where, especially, the sections  devoted to fatty  heart and to fatty liver may
be  consulted.


               Mucoid  and  Colloid  Degenerations.
   M~ucoid degeneration consists in  the transformation of the albuminous con-
stituents of cells or of intercellular substance  into mucin, which gives the
tissues a gelatinous, translucent  appearance.  Mucin  is an albuminoid sub-
stance devoid of sulphur, held in solution only by an alkali, and therefore pre-
cipitated by acetic acid, in an excess of which it is insoluble.  It is normally
secreted by epithelial cells of  mucous membranes and of  certain glands, and
it is widely distributed in the  embryonic tissues.   Mucoid degeneration may
affect  either cells or intercellular  substance.  It occurs occasionally in  car-
tilage, the marrow of bone, and  especially in tumors.  In the myxomata the
intercellular tissue  is composed  chiefly  of  a substance containing mucin.
   The colloid metamorphosis is allied to the  mucoid.  It affects  chiefly cells.
The colloid material  appears in the form of  drops, either free or within cells,
and it  may appear more  diffusely.  It is of firmer consistence  than mucin,
contains sulphur, and is  not precipitated by acetic acid.   In its gelatinous,
homogeneous appearance it resembles mucin.  The colloid material  accumu-
lates in great amount in the follicles of the thyroid gland in goitre.   The col-
loid change may also affect the cells in tumors.
   The causes of these metamorphoses are not understood.
                Amyloid or Waxy Degeneration.

  The degeneration called  waxy, amyloid, or lardaceous is characterized by
the appearance, especially in the walls of the vessels, but also elsewhere, of
a homogeneous, firm, inelastic, translucent substance similar in its composition
to the albuminous matters, but more resistant to putrefaction and to the action
of the "-astric juice.  The most important property of this new substance is
its reaction with certain coloring agents, which are therefore employed for its
detection.  Treated with iodine, it is  stained mahogany-brown ; with iodine
and  sulphuric acid, often blue ; and with methyl-violet, red.  The substance
was called amyloid from its supposed resemblance to starch, but it is now known
to be'a nitrogenous substance.  For detecting the amyloid degeneration with
the naked eye, a solution of iodine alone (diluted Lugol's solution) is most

  The waxy degeneration may be local, but it generally affects a number of
organs.  The parts most frequently involved  are the spleen, liver, kidneys,
lymphatic glands, and the intestinal mucous membrane.  Other parts may be
 fleeted  as  the large vessels, the  heart-muscle, the suprarenal  capsules, and
tl e small vessels  in most organs.   If the degeneration  be well marked, the 
56
PASSIVE ALTERATIONS OF THE  TISSUES.
affected part presents a characteristic  translucent,  grayish  appearance,  and
is usually more or less swollen and hard in consistence.  The waxy material
is exceptionally deposited in large  nodules, constituting the waxy tumors.
Waxy degeneration has been observed as a purely local change in tracheoma-
tous granulations  of the conjunctiva, and  rarely in other parts.  As a rule,
the degeneration appears first in the walls of the small arteries and about the
capillaries;  thence  it may extend to the surrounding tissue, which in some
cases appears to be primarily involved.  It has  usually been held that a waxy
degeneration may invade cells, connective  tissue,  and, in fact, nearly all  the
histological  elements.  It appears, however, to be confined to the basement-
substance between the cells.   The so-called structureless membranes, such as
the membrana propria of the uriniferous  tubules, may undergo  the change.
The waxy substance  is often deposited in irregular clumps.  The  cells  are
compressed  and atrophied.   The vascular walls become  converted into a hya-
line, swollen mass which encroaches upon the lumen.  The endothelium is for
a long time  preserved, and the circulation continues until the vessel is nearly
obliterated.   The anatomical peculiarities presented  in the amyloid  degener-
ation  of different organs will be described  in  Part II.
   The causes of waxy degeneration are chronic suppurations, particularly of
bone, and certain cachexia, especially the syphilitic, the tuberculous, and, in
a less degree, the cancerous, the gouty,  and the malarial.  In rare instances
no  apparent cause  can be  assigned.  The  degeneration  may be developed
within a few months from  the onset of suppurative processes.   It  appears,
as a rule, first in the spleen.  It is difficult to tell exactly what symptoms  are
referable to waxy degeneration, as it is associated with severe  wasting dis-
eases.   In the kidneys it  seems  to  be  always associated with  more or less
change  in the interstitial tissue and in  the epithelium.   Waxy  degeneration
of the intestines  leads to  chronic diarrhoea.
   The source of the waxy material, whether from the blood or from the albu-
minous substances in the tissues,  is not known.
   There appear in  various parts of the body, both  normally  and patho-
logically, spherical  or irregular masses which  usually  present  a concentric
arrangement, and which are called corpora amylacea.  They often  assume a
blue color when treated with iodine or with  iodine and sulphuric acid.   They
are not known to have any relation  to waxy degeneration.   So far as ascer-
tained, they  have no pathological importance.  They occur especially in the
prostate gland  and  in  the central nervous system, in  the latter being par-
ticularly abundant in chronic inflammatory  processes.
                   -   Hyaline Degeneration.

   Hyaline degeneration is the transformation of  the  tissues into  a homo-
geneous, translucent, glistening material which stains deeply with eosin and
carmine and is unaffected by acids.   This  substance, which much resembles
the amyloid^ material, is distinguished from it by the absence of the iodine
reaction.  Von Recklinghausen attributes hyaline degeneration to the forma-
tion  in the cells and the deposit in  the tissues of a substance which  he calls
hyalin.   This  hyaline  transformation  is not  unusual in  the walls  of small
blood-vessels.  According to Von  Recklinghausen, hyaline degeneration plays
an important role in  many pathological processes.   Changes which others
attribute to colloid metamorphosis, to coagulation necrosis,  or  to  fibrinoid
degeneration, he refers  to  the development of hyalin.    Hyalin may  occur
in the form of thrombi in the vessels. 
PIGMENT A TION.
57
                      Calcareous Degeneration.
   An infiltration of the tissues with the phosphate and carbonate of lime,
mingled usually with traces of the same magnesia salts, constitutes what is
called calcareous degeneration, calcification, or cretefaction.  This change is not
to be confounded with ossification, although the latter term is often applied to
it erroneously.   In  ossification there is a formation of true bone.  In  calci-
fication the salts of  lime are deposited at first in the form of  irregularly scat-
tered granules which appear dark by transmitted and bright by reflected light,
Large calcareous masses may be formed by increase in number and size of
the granules.   Calcified tissues are recognized by their hard, sometimes stony,
consistence, and by the  solubility of the earthy salts in strong acids, usually
with  the evolution  of bubbles of  gas.   The salts are  deposited  both in  the
intercellular substance and in  the  cells.
   Virchow has described, under the designation lime metastases, the deposit
of the salts of lime in various parts of  the body, particularly in the arteries,
lungs, and stomach, in cases of extensive caries and of cancerous disease of
bone.   This calcification he  attributes  to the presence in the blood of an
absolute excess of lime salts derived by absorption from the diseased bone.
With the exception  of these  cases, to which Virchow has called attention, it
does not appear that calcareous degeneration can be referred to an abnormal
quantity  of lime in  the blood.
   In  the vast majority of cases of calcification the lime is deposited in tissues
previously diseased.   Especially prone to calcification are tissues which have
undergone fatty degeneration or coagulation necrosis.  Thus, Litten observed
calcareous particles  in renal epithelial cells, in which coagulation necrosis had
developed, in  twenty-four hours after temporary ligation of the renal artery.
We find calcific  deposits in cheesy masses, in  old  inflammatory products, in
desiccated pus, in tumors,  and in  and  about parasites.  Of great practical
importance is the calcification  of  the cardiac  valves in chronic endocarditis
and of the arteries,  either with or without  inflammatory changes.   Calci-
fication of the internal  and middle coats of the arteries belongs among the
usual changes in old age.   What is usually called calcification of cartilage is
ossification  or a change "preparatory to  ossification.  Calcification  may be a
conservative process, as when it checks the  growth of tumors, or it may be
detrimental, as when it affects the arteries or cardiac valves.

                             Pigmentation.

   Abnormal pigment in the body may be derived  from the  coloring matter
of the blood, or it may be elaborated by the protoplasm of cells,  or it may
be introduced from  outside of the body.
   The hamoglobin  of extravasated red blood-corpuscles may be converted
into  yellow or brown pigment-granules, or into red rhombic crystals  called
hamatoidin or bilirubin.  The crystalline hamatoidin  differs from  the gran-
ular  pigment  in  the absence of iron.  According to Langhans, the transfor-
mation  into hamatoidin occurs, not from diffused blood-coloring matter, but
from  red blood-corpuscles or their  fragments which have been taken up by
cells  especially leucocytes.   The  yellowish-brown  pigment-granules in the
blood and in various  organs in the melanamia of severe malarial intoxication
are derived from the  destruction of red blood-corpuscles.
  The pigment found in melanotic tumors, in  freckles, in  chloasma, in the
skin  and  certain mucous membranes in Addison's  disease, and that present
in atrophied muscle  (brown atrophy), is produced in the interior of cells—
whether from  blood-coloring matter or not is uncertain.   Fatty  molecules are 
58
GENERAL  PATHOLOGY  OF  THE BLOOD.
sometimes deeply stained with yellow or brown pigment, the source of which
is not known (lipochrome).
  Examples of pigment introduced  from without are the black particles of
carbon always found in the lungs of adults, inhaled iron particles, pigment in
the skin and lymphatic glands resulting from tattooing, and particles of silver
deposited in the tissues after the prolonged use of nitrate of silver.
  Melanin  is a name which is applied to most of the black pigments found in
the body, without regard to their origin.
                       CHAPTER  VI.

            GENERAL  PATHOLOGY  OF  THE  BLOOD.

Plethora—Anaemia—Hydremia—Anhydraemia— Hyperiuosis—Hypinosis—Leucocytosis
  —Alterations in the Gases of the Blood—Increase of Oxygen—Effects of Breathing
  Compressed Air—Deficiency of Oxygen—Apncea—Changes in the Albumen, Fat, and
  Inorganic Salts.

   THE  morbid conditions to be  now considered  embrace alterations in the
    quantity or in the quality of the entire mass of the blood.  The means
for regulating the composition  of the blood in health are such that  the  mass
of the blood is easily kept within physiological limits, notwithstanding changes
in diet and in physical surroundings.  Disturbances of this physiological reg-
ulation  are  generally  referable to morbid processes  in the solids, and hence
the changes embraced in the general  pathology  of  the blood are  not  inde-
pendent  affections of  the blood itself, as  they were regarded  by the humoral
pathologists, but they result usually from disease  of  the solid tissues, includ-
ing the blood-forming organs.   There are some  alterations  of the blood  in
which this connection has not been traced, and without doubt morbific agents
may exercise their injurious influence primarily  upon  the blood as  well  as
upon  other  tissues; for the blood'is sometimes, although not very appropri-
ately, regarded as a tissue with cells and fluid  intercellular substance.   The
so-called dyscrasise depend upon anomalies in the composition of  the blood
of a chronic nature, and  usually, if  not  always, are secondary to diseases of
the solid parts.   The physiological relations  of the  blood to  the solid  parts
are so intimate and important as to render it intelligible that morbid altera-
tions in  its  composition  lead secondarily to changes in the  solids, as well  as
that  diseases of the solids affect the composition of  the blood.
  Alterations in the blood may affect, severally or combined, the corpuscular
elements, the water, the organic ingredients of the plasma—namely, albumen
and fibrin-generators,  the  gases, and  the  inorganic salts.  Morbid conditions
of the blood, due to the introduction of substances  not entering into its nor-
mal composition, are  also to be included  in the consideration  of its  general
pathology.


                               Plethora.

  Plethora  signifies an increase  either in the total amount of the blood or  in
the number  of the red blood-corpuscles beyond the healthy limit.  The former 
PLETHORA.
59
of these conditions constitutes polyaemia, the latter polycythsemia.  Individuals
with a certain group of symptoms have, since remote times, been designated
as plethoric, upon the assumption that the symptoms were due to an excess of
blood. The symptoms referred to are abnormal redness of the face and mucous
membranes ;  fulness of the pulse ; increase of the heart's impulse,  with tend-
ency to palpitations; a sensation of  warmth and of  fulness, especially in the
head  and  chest;  and sometimes epistaxis  and hemorrhages from different
mucous membranes.   Constitutional tendency, overfeeding, idleness and lux-
urious habits, and the arrest of periodical or habitual hemorrhages, are the
leading causes assigned  for  this condition of supposed  plethora.   Bloodlet-
ting, reduced diet, and increased exercise often relieve the symptoms.   While
the symptoms and the means of relief certainly suggest an excess of blood,
yet an increase in the amount of  blood  or  of red blood-corpuscles in this
condition has not been  proven, and recent experiments on animals  render
improbable the  existence of a  permanent polyamia,
   Temporary plethora may be produced by transfusion of blood from one ani-
mal into another of the same species.  In this way the  amount of blood in a
dog may  be doubled without evident discomfort to the animal after the injec-
tion,  and  with  only a brief  rise in the blood-pressure  during the operation.
It is thus shown that the blood-vessels are capable of holding much more than
the normal amount of blood.   It is an interesting fact, however, that the
transfusion of this large amount impairs so much the elasticity of  the vessels
that  they cannot at once accommodate themselves even to the  normal quan-
tity of blood, and the animal dies upon the immediate withdrawal  of a quan-
tity of blood even less  than that injected.  Within a few  hours after the
transfusion the quantity of  blood-plasma is considerably lessened, and after
two or three days it returns to the normal amount.  This reduction is effected
chiefly by increase in the urinary secretion.   The excess in red blood-corpus-
cles persists somewhat longer.   A true polycythamia exists.  But in a few
days, at the most  in from two to four weeks, the number of red blood-corpus-
cles is also reduced to the normal quantity.  This  destruction of red blood-
corpuscles is indicated by increased excretion of urea.   If blood be injected
equal in amount to 150 per cent, of the total quantity of blood in the animal,
death ensues with symptoms of exhaustion, vomiting, and hamaturia.
   If   the  blood of one  species of animal be  injected  into  that  of another
species, the effects are entirely  different.   If  by transfusion of lamb's blood
into the veins of a dog the quantity be increased only one-fifth, the death of
the dog  ensues, as a rule, on  the first  or second  day.  Even half of that
quantity produces severe symptoms, especially  hamoglobinuria and a general
tendency to hemorrhages.   The injurious  effects of the transfusion  of for-
eign  blood may be explained, in part, by the fact that the serum of the blood
of& certain species dissolves the  red corpuscles of other  species.
   It  has been discovered by Kohler1 that the injection  into the jugular vein
of a  small quantity of serum rendered rich in fibrin ferment by spontaneous
coagulation  of  the blood, and   subsequently straining through  linen,  causes
often  although not invariably,  the rapid death of the animal  from  coagula-
tion of the blood in the right  cavities of the  heart, the pulmonary artery,
and its  branches.   The transfusion of blood which has been defibnnated by
stirring does not produce these  harmful effects.
   It  is apparent that these experiments on animals  throw much doubt upon
the existence of  true plethora in  man, without absolutely disproving the
possibility of its occurrence  as  a permanent condition.   There is certainly no
nroof that the symptoms hitherto embraced under the name  plethora  depend
upon  either polyamia or polycythamia.  It has been  suggested that their
                  1 Ueber Thrombose u. Transfusion, Dorpat, 1877. 
60
GENERAL PATHOLOGY OF THE BLOOD.
cause is to be found in impaired function of the vaso-motor nerves, the regu-
lators of the circulation.

                               Ansemia.
  Local anamia or ischamia dependent upon local disturbances of the circu-
lation  has been already described  (vide p. 25).   Under  the name general
anamia are included diminution in the  mass of blood, or oligsemia ;  diminu-
tion in the number of red blood-corpuscles,  or ejUgocythsemia ;  and diminution
in the amount of  hamoglobin  in the red blood-blood corpuscles, or achroio-
cyfhsemia.  In many cases of anamia some of the red corpuscles are much
reduced in size.  These small corpuscles are called microcytes.1  These micro-
cytes are regarded by some  as  red blood-corpuscles in process of formation,
by others as atrophied or degenerated red corpuscles.  Hydrsemia, or diminu-
tion of the solid ingredients of  the plasma, especially the albumen, is also an
element in most forms of anamia.   But the essential  element in anamia is
diminution in the  hamoglobin  of the blood.  It  is to this loss of the color-
ing matter of the blood that the most obvious and characteristic symptom of
anamia-—namely,  the  pallor—is  due.  It  was formerly  believed  that  the
quantity of  hamoglobin in the blood is  directly proportional to the number
of red blood-corpuscles, but recent observations have shown that red blood-
corpuscles in disease vary in the percentage of hamoglobin which they con-
tain, so that reduction in the  amount  of hamoglobin in the blood does not
necessarily involve a  corresponding  diminution in the  number of red  cor-
puscles.   Still, a greater  or less loss of red blood-corpuscles  is an almost
constant change in anamia, and the cases are exceptional in which the extent
of this loss is not an approximately correct index  of the degree of anamia.
  In  anamia, therefore, we may have changes in the  quality as well as in
the quantity of red blood-corpuscles.  On the one hand, the amount of hamo-
globin in individual corpuscles  may be  diminished, or, on the other  hand, it
may be increased.   The normal amount of  hamoglobin  (oxyliamoglobin) in
the blood is estimated at  from  12  to 14  per  cent.  The amount  may be
reduced in anamia even  as  low as to  2 per  cent.  Cases of chlorosis have
been observed with the normal  number  of red corpuscles and with less than
half the proper amount of hamoglobin (achroiocythamia).   Instances  of
oligocythemia have been recorded in which the  hamoglobin was not reduced
in proportion to  the number of  red blood-corpuscles.   In such cases the con-
dition  of the blood is better than would be  indicated by simply counting the
number of red blood-corpuscles.
  In health the  number of red blood-corpuscles in a cubic millimeter of blood
is estimated at from four and a  half to five millions.  This number in anamia
is often reduced one-half, and in extreme anamia it may fall even below half
a million. The average diameter of the human red blood-corpuscles in health
is between seven and eight micromillimeters.  There are  in health some cor-
puscles smaller and some larger than  the average.  In anamia  there is often
a large number  of corpuscles, called microcytes, whose  size is between two
and six micromillimeters, and on the other hand there may be some corpuscles
measuring twelve to fifteen micromillimeters in diameter (megalocytes).  The
large corpuscles  are found especially, although not exclusively, in pernicious
anamia.   The shape of the  corpuscles in anamia  may also deviate from that
of the normal biconcave discs with round contours.  The name poikiloajfosis
is used to designate the condition of blood in which the  corpuscles present
manifold variations of shape.  Nucleated red blood-corpuscles are sometimes
found in the blood in anamia.
  The total volume of blood is not necessarily reduced in  anamia out  of
     1 Some understand by microcytes only small, spherical red blood-corpuscles. 
AN.EMIA.
61
proportion to the loss  of weight  of the body, except in the case of acute
anamia immediately following  hemorrhage.  It may, however, be dispropor-
tionately  lessened.  Thus in  two cases  of pernicious anamia reported by
Quincke the quantity of blood was estimated  to be from 4 to 5 per cent, of
the weight of the body, instead of 8 per  cent., the normal proportion.
   If  the  anamia be severe  and chronic, secondary changes are produced in
the organs and tissues of the body.  Of these changes none is more import-
ant or more  characteristic than fatty degeneration of the heart,  as has been
emphasized especially by Ponfick.  Fatty degeneration  of the  walls of the
vessels, of the liver, the kidneys, and sometimes  of the  voluntary  muscles,
may  also be induced, but in less  degree.  Ecchymoses  and a  hemorrhagic
diathesis may be the result of profound anamia.  Atrophy of different organs
of the body is a natural result of long-continued anamia.   The  nervous cen-
tres suffer the least in their nutrition.  An interesting change in the marrow
of the bones has  been observed in  profound chronic anamia, and is probably
to be regarded as  secondary.   This change  consists in the appearance of red
in the place of the yellow medulla  which is  normally  present in the long
bones of adults.  The fat disappears, the  number of medullary cells is greatly
increased, and  a considerable number of nucleated red blood-corpuscles make
their  appearance.  This alteration is a  return of the yellow marrow to the
condition  it presents  in foetal and infantile  life.   Some  think  that  this
change in the  osseous  medulla  has to do with the regeneration of red
blood-corpuscles.
   Although it has long been known that if  the cause of anamia be  removed
the red corpuscles are renewed in a comparatively short time, we possess little
positive  knowledge as to the mode of regeneration.  Experiment  and patho-
logical observation point especially to the spleen and marrow of  the bones,
perhaps also to the lymphatic glands, as  organs in which red as well  as white
blood-corpuscles may be formed.   There are three  leading views as to the
new formation of human red  blood-corpuscles in the adult.   According to
one view (Hayem's), they are formed from little bodies identical with the
blood-plates  of Bizzozero, and called by Hayem hamatoblasts,  which are
found in the circulating blood; according to  a second  view (Neumann's),
they  are formed in the marrow of the bones from leucocytes by a transforma-
tion of the protoplasm into  hamoglobin  and a subsequent disappearance of
the nucleus ; according to another view (Bizzozero's), they are formed  in the
marrow of the bones by indirect division of nucleated red  blood-corpuscles.
According to the two  last  views,  which are  more probable than the  first,
nucleated  red  blood-corpuscles represent the young or embryonic blood-
corpuscles.
   Anamia may be divided into an acute and a chronic form.   The best exam-
ple of acute anamia is that produced by copious hemorrhages.  This  also
affords the purest example of oligamia.  A considerable amount of blood—in
dogs over one-quarter of the entire mass—may be withdrawn from healthy indi-
viduals without permanent damage.  The loss  of one-half of the  entire vol-
ume  of blood  is usually fatal.  Females, as a  rule, are more tolerant of loss
of blood than males.   Infants are especially susceptible to the evil effects of
the withdrawal of blood.  A  large quantity  of  blood—in dogs over a quarter
of the whole volume—may be removed without more than a temporary low-
ering  of  the blood-pressure.   Under the  influence of the vaso-motor nerves,
which are affected by anamia as by an irritant, the vessels adapt themselves
within very wide limits to varying amounts of blood without permanent alter-
ation  of the  blood-pressure.  In healthy individuals a very considerable loss
of blood  is repaired within a  short time, at the  most in three or  four weeks.
The blood  is very soon restored to its normal  volume by the absorption  of 
 62            GENERAL  PATHOLOGY  OF THE BLOOD.

 water.   As  the red  blood-corpuscles and the  albumen  are  not so easily
 renewed, the specific gravity of the  blood  is now diminished.   A condition
 of  hydramia has replaced the oligamia.   The  white  blood-corpuscles are
 sooner restored than the red.   In proportion to their number, there are fewer
 white than red corpuscles lost by hemorrhage.  The former are of less  weight,
 more viscid, and do not so readily escape  from the vessels.  Then the  lymph,
 the flow of which is increased by severe  hemorrhages, constantly brings new
 leucocytes to the blood, so that soon after a considerable hemorrhage the  num-
 ber of white corpuscles, in proportion to  the red,  is increased.   A temporary
 relative leucocytosis is thus  produced.   The food restores to  the blood  its
 normal amount of albumen.  The red-blood-corpuscles are also regenerated,
 although more slowly.
   The symptoms  of acute  anamia  are of  course grave in proportion to the
 amount  of blood lost.   They are weakness, pallor, coldness of the surface,
 feeble and rapid pulse, dimness of  vision, dyspnoea, muscular spasms,  espe-
 cially in the  calves of the legs, and, if the  loss of blood be sufficient,  uncon-
 sciousness and epileptiform  convulsions from anamia  of the brain.  Death
 results from hemorrhage, not in consequence of the loss of red  blood-corpus-
 cles or of any particular constituent of the  blood, but from the diminution in
 the total volume  of blood.   To this  diminished  volume the heart and the
 blood-vessels cannot at once adjust themselves.   The symptoms are  more
 marked  when the hemorrhage  occurs in  persons previously healthy than in
 those already enfeebled.  The immediate treatment consists in means to arrest
 the hemorrhage, in maintenance  of the  recumbent posture  with the  head
 lower than the feet, and in the administration of stimulants.  If transfusion
 be  necessary, the same purpose is accomplished by the infusion of dilute  solu-
 tion of common salt (0.6 per cent.) as by transfusion of  blood, and the for-
 mer  procedure is  simpler  and less dangerous than the latter.
   The most important  causes of chronic anamia are the following : 1, repeated
 hemorrhages, as menorrhagia, or hamatemesis ;  2, the loss of essential constit-
 uents of the plasma, particularly albumen, as in chronic albuminuria, pro-
 longed lactation, chronic dysentery and diarrhoea,  or prolonged suppurations ;
 3,  defective supply  of nutriment (anamia  of inanition);  4, affections occa-
 sioning indigestion and vomiting, as chronic  gastritis, or ulcer of the stomach ;
 5, chronic wasting diseases, particularly tuberculosis  and cancer; 6, the poi-
 sons of chronic infectious diseases, as malaria, or  syphilis; 7, certain mineral
 poisons, especially lead and mercury.   Anamia more acute in its development
 may attend  acute  infectious diseases, as yellow fever, typhoid fever, and the
 entrance into the blood of poisons which  rapidly destroy the red corpuscles,
 as phosphorus and  the biliary salts.   There is,' further,  an important  class
 of anamias for which,  with our present knowledge, no cause can  be assigned.
 This class embraces leucocythamia, pseudo-leucocythamia, Addison's disease,
 chlorosis, and pernicious anamia.  Profound and  often fatal anamia, without
 apparent cause or obvious structural changes in the body, exclusive of those
 which may  be secondary to  the  anamia, is known as  primary, idiopathic,
 essential, or pernicious anamia.  The  most  reasonable hypothesis as to these
 anamias without known  cause is that they depend upon disturbances  in the
 blood-forming organs, which may be embraced under  the generic  name hama-
 topoietic system.   As  these  forms of anamia  constitute, for the most part,
 well-defined diseases, susceptible usually of diagnosis, it will be convenient to
 treat of them in Part II. of this work under the  heading " Diseases  of the
 Hamatopoietic System,"  although, as has  already  been stated, our knowledge
 of the formation of blood-corpuscles after birth is incomplete.
  As is evident from the  enumeration of its causes, symptomatic anamia is
incident  to a variety of diseases, in  connection with which it will hereafter 
HYDREMIA.
63
be referred to.   It is proper here to mention the common and most diagnostic
symptoms, although they may  be  modified  by the primary  disease.   Such
symptoms are pallor of the  face and mucous membranes, impairment of mus-
cular and mental energy, functional  disorders of the  nervous system, especi-
ally neuralgia and so-called  spinal irritation, coldness of the surface, dyspnoea
on exertion, impaired digestion,  palpitation of the heart, a pulse either small
or full, but compressible.  It is important to note that in persons who have an
unusual  vascularity of the  face  anamia  may exist not only without notable
pallor, but even with  a rosy complexion.  Of special importance in the diag-
nosis of anamia is the presence of certain  physical  signs.   There  is  often
present in anamia a soft bellows murmur  accompanying the first sound of the
heart,  and heard most distinctly at  the base of the heart  and in  the  larger
arteries,  the carotid, the  subclavian, etc.  To constitute evidence of anamia
there must be wanting the signs of organic  lesion of the heart and large ves-
sels.   In conjunction  with this murmur a continuous humming sound, some-
times musical, is heard when the stethoscope is applied over the veins  of the
neck.  This sound, due to the movement of blood in the veins, is called the
venous hum, or, after the French, bruit  de diable.  These murmurs are dis-
tinguished from those denoting  lesions, as inorganic, hamic, or anamic mur-
murs.   The arterial murmur is  present in only a certain proportion of cases,
but the venous hum may be heard almost invariably.
   Symptomatic anamia is sometimes  amenable  to treatment, at other times
not, according  to the nature of  the primary disease.   It  may be  noted that
anamia is not incompatible  with embonpoint.  The first indication is to ascer-
tain and remove if possible the cause or causes on which the anamia depends.
The most important measures in restoring  the quality and quantity  of red
globules  are—-first, a nutritious alimentation, into which  meat should  enter
largely ;  second, iron  as a special remedy, the effect  of which in increasing
the amount of hamoglobin and the number of corpuscles is often remark-
able;  third, other tonics, as arsenic, quinine,  strychnine,  and stimulants to
render the digestive functions more active ;  and fourth, a regimen calculated
to increase the energy of  the assimilative functions, consisting in exercise in
the open air, change of climate, recreation, etc.

                              Hydraemia.
   By hydraemia is understood a  relative or an absolute increase in the amount
of water in the blood in proportion  to the solid ingredients.  It  is the dimi-
nution in the amount of albumen which forms the chief element in hydramia.
Less emphasis is laid in this  connection  upon  the loss of blood-corpuscles,
although, as  has been mentioned already, anamia and hydramia are usually
associated. The salts and extractive matters of the blood are  left out of con-
sideration.   Hydramia  is  essentially hypalbuminosis, relative or absolute.
There  are three possible forms of hydramia : in the first, the  amount of
water is  normal,  but the solids  are diminished ; in the second, the solids are
normal in quantity, but the amount of water is increased  ; in the third, the
amount of solids is diminished, and that  of the water is  increased.   In the
third form the highest degree of hydramia  is reached.  The various causes
of anamia, involving loss of the solid  constituents  of the blood, are  also
causes of hydramia.  The most extreme hydramia is that produced in many
cases of  chronic  nephritis or  Bright's disease, in which there is not only a
continual drain  of  albumen from the blood, but the  excretion of water by
the kidneys is lessened.  The conditions are here present for  the production
of the third form of  hydramia.  In Bright's disease the specific gravity of
the blood-serum has been  known to sink  from 1030 to 1013, the percentage 
64
GENERAL PATHOLOGY OF THE BLOOD.
of albumen from 8 to 4, corresponding to an increase in the amount of water
from 90 to 95 per cent.
   General oedema has long been considered to be a most characteristic symp-
tom of hydramia.  The abundant serous  transudations in various parts of
the  body  in Bright's  disease have been  referred directly to the extreme
hydramia of this disease.   It was naturally supposed that the less concen-
trated  the plasma, the  more readily it would  transude through the walls of
the vessels.   The experiments  of Cohnheim and  Lichtheim,1 however, have
demonstrated that hydramia, even when present in a degree never met with
in man, is not a direct  cause of  general oedema, but that this  oedema  follow^
only when the nutrition of the vascular walls is impaired and they are thereby
rendered more  permeable.  Inasmuch, however, as the hydramia favors this
weakening of  the vessel-walls, it still must be considered an important indi-
rect cause of dropsy.

                            Anhydraemia.

   A too  concentrated  state of  the blood in  consequence of an absolute
increase in its solid constituents  is  not a recognized pathological  condition.
We  know nothing of  absolute  hyperalbuminosis  as a morbid state  of the
blood.   Anhydrsemia, or a thickened  condition of the  blood  from loss  of
water,  is  familiar to us in man only as a change resulting  from excessive
serous  discharges from  the intestine, particularly as a  result of cholera.   In
cholera the  blood may become so concentrated as to  flow with  difficulty and
to present an almost tarry consistence.  As there  is  an  effort  to repair the
loss  of water by absorption, the  organs and tissues become shrunken and dry,
the secretions  are diminished or checked,  the circulation  is slow, the blood-
pressure is reduced, and the pulse  becomes feeble or  imperceptible.  The
appearance of the salts of potassium in the plasma indicates that red blood-
corpuscles are  destroyed.   If reaction ensue  after the  choleraic discharges
cease,  the blood  is  rapidly restored to its normal percentage of water  by
the  absorption of fluids taken  into the  system.


                     Hyperinosis; Hypinosis.

  An abnormal  increase in  the  amount  of fibrin in  the blood constitutes
hyperinosis;  an  abnormal  diminution of  the  fibrin is  called  hypinosis.   In
former times,  when  venesection  was  more frequently  practised, physicians
paid much attention to  the amount of fibrin in the blood, to the rapidity with
which it coagulates, and to the appearance of the coagulum.  It is now recog-
nized that many fallacies existed in the former methods of analysis, and that
estimates  of the fibrin do not have the diagnostic value  formerly attributed
to them.   The statements formerly made as to increase or  diminution of fibrin
in the blood  were based  upon the amount of coagulum formed  after death or
in blood withdrawn by venesection, or upon the rapidity with which coagula-
tion  occurred.   Fibrin,  however,  does not exist preformed in the blood. ^The
quantity of fibrin which coagulates from the blood is believed to depend less
upon the amount of fibrin-forming substance in the blood than upon the pres-
ence or absence of conditions which favor or impede the coagulation.
  Imperfect coagulation of the blood, or hypinosis in the old sense, has been
observed  in  some acute infectious diseases, in acute icterus,  in death from
asphyxia,  and  in death  from certain poisons, such as sulphuretted  hydrogen
and  hydrocyanic  acid.   Increase of fibrin,  or  hyperinosis, occurs in inflam-
mations, in pneumonia, in acute  rheumatism, and  in erysipelas.
                      1 Virchow's Archiv, Bd. 69, p. 106. 
ALTERATIONS IN THE GASES OF THE BLOOD.        65
  The so-called buffy coat, or crust a infiammatoria, is due to the slow coagula-
tion of the fibrin, so that the red corpuscles have time to sink and  leave the
upper layers  of the  coagulum uncolored.   This appearance in blood removed
by venesection is not characteristic of  inflammation  and has no diagnostic
value.

                            Leucocytosis.

  According to the nomenclature proposed by Virchow, a temporary increase
in the number of white corpuscles in the blood is called leueoeytosis ;  a perma-
nent and usually much  greater increase constitutes the disease called leucocy-
thsemia or leukaemia.  The number of white corpuscles in the blood  is subject
to much greater variation, within normal limits, than is that of  the red cor-
puscles.   The proportion is  usually estimated as 1 white  to 050-500 red.
Leucocytosis, indicated by a moderate increase in the  number of white cor-
puscles, has been observed, as a physiological condition, during digestion and
in pregnancy.   Leucocytosis  is present in inflammations  attended  with pro-
fuse suppuration.  It is also observed in fevers.  A relative, and sometimes an
absolute, leucocytosis is often present in anamic conditions, as already men-
tioned.   The increase in white corpuscles in these conditions rarely approaches
in degree that found in  the disease leucocythamia, in which the proportion of
white  to  red may be as 1 to 10, 1 to 3, and even in one case 3  white were
present to 2 red.  In leucocythamia the  number of red corpuscles is  dimin-
ished, and the symptoms are mainly those of anamia.  This disease will be
considered in Part II. of this work, in the section treating of  diseases  of the
hamatopoietic system.


             Alterations  in the Gases of the Blood.
  The gases  contained  in the blood are oxygen, carbonic acid, and  nitrogen.
The oxygen  is, for the most part, in unstable combination with hamoglobin
in the form of oxyhamoglobin.   There may be also a small amount of oxy-
gen simply dissolved or absorbed  in the plasma.   The oxygen may be  easily
driven out of the blood  by certain other gases, as carbonic  oxide, or by a
vacuum.  Carbonic  acid gas  exists in the plasma and in the red corpuscles of
the blood only in combination with alkalies or alkaline salts; none is held in
simple solution  (P. Bert).   Nitrogen is simply absorbed.  Of course, the
stable  combinations of  these  gases in the blood do not here enter  into con-
sideration.
  Probably the  only influence which can  increase the quantity of oxygen in
the blood  sufficiently to give rise to morbid symptoms  is  the inhalation of
compressed air; and" here the evil  effects are due less to the increased  quan-
tity than  to  the increased tension  of the oxygen in  the blood.1   Death in
compressed  air  may result as well  from excess of carbonic acid in the blood
as from excess of oxygen.  The effects of changes in the barometric pressure
have been ably studied  by Paul Bert,'2 who investigated the influence of com-
pressed and of rarefied air upon men and animals.  He found that evil  effects
are felt under a pressure of six  atmospheres;  that  in  animals  convulsions
appear  when  the pressure reaches twenty atmospheres;  and  that   death
rapidly ensues when the pressure  equals twenty-five  atmospheres. As the
hamo'-lobin  in normal  arterial  blood  is  nearly or quite saturated  with oxy-

  »T v Liebi"- (Munchmer cirztl. Iifrlliyenzbl.,  No. 19, 1879) explains the injurious
influence  of compressed air by  the mechanical hindrance which  it  offers to  expira-

  * La Pression barometrique, etc., Paris, 187S. 
QQ
GENERAL PATHOLOGY  OF THE BLOOD.
gen (Herter), it is mainly the  dissolved oxygen of the  plasma which is aug-
mented  by inhaling compressed air.  According to Bert, death  ensues when
the proportion  of oxygen  in  the  arterial blood  is  augmented one-third.
Under the influence of" this superoxygenation of the blood the  oxidation
of the tissues is  diminished, the production of carbonic acid, the  excretion
of urea, and  the  destruction of sugar  in  the  blood are  lessened, and as a
result the  temperature  is lowered.
  The study of  the  effects of high atmospheric pressure upon  man  has
acquired especial interest in consequence of the extensive  use made of coin-
pressed  air in  engineering  operations.   In diving-bells, in mines  in  which
compressed air is used to keep water from flowing into the  shafts, in the cais-
sons employed in the sinking of piers, men are subjected to the influence of
compressed air, but the  degree of compression  rarely suffices in itself to  pro-
duce  grave symptoms.   Some  inconvenience  may be felt  from pain  in the
ears and sometimes in the frontal and maxillary sinuses.  There is, however,
danger in  passing rapidly from highly-compressed air into the normal atmo-
sphere if the  stay in the former have been long. A number of fatal accidents
have  occurred from  ignorance  or negligence in this  respect.  Hoppe-Seyler,
and subsequently Bert, found that if the pressure have been considerable and
it be too rapidly removed, nitrogen is set free in the blood in the form of gas-
eous bubbles, which, collecting in the right side of the heart, stop the circu-
lation and cause sudden death.   Nitrogen is absorbed by the blood in accord-
ance with  Dalton's law for the absorption of gases by fluids, and consequently
accumulates in  the blood in  considerable quantity in compressed air.   There
have been observed occasionally to follow the removal of the pressure certain
symptoms, to which A. H. Smith1 has given the name of the caisson  disease,
and the  explanation of  which is not established.   The most frequent  and
important of  these symptoms are pain in one or more of the extremities, and
sometimes in  the trunk, epigastric pain  and vomiting, paralysis  more  or less
complete,  general or local, most frequently confined to the  lower half  of the
body, headache, and vertigo.  According to Smith, the  duration of the cais-
son disease varies  from  three or four hours to six or eight  days.  The paral-
ysis may disappear within twelve hours or may continue for weeks.   Death
occurs only in cases which are severe from  the  first.   Smith refers the symp-
toms, at least in severe cases, to congestion of the  brain and spinal  cord.   It
is, however, not improbable that at least some of  the symptoms may be due
to the liberation of bubbles  of nitrogen in  moderate  amount or in situations
not immediately endangering life.   Morphine,  atropine, and especially ergot,
were found useful in relieving the pain.  The main reliance, when the symp-
toms are urgent, and especially when life  is endangered soon after removal
of the pressure, is return to compressed air.  Bert has  proposed the inhala-
tion of  oxygen to displace the free nitrogen  from the blood by  diffusion.
   Air compressed not  more than  from one to five atmospheres  has been
employed as  a therapeutical agent, chiefly in certain  pulmonary disorders.
The influence of moderately-compressed air is to diminish the number of pul-
sations of the heart and to increase  the  capacity of the  lumrs by compression
of the intestinal gases.   According  to Bert, the maximum  of oxidation takes
place  under a pressure of three atmospheres.
   A condition attributed to excess of  oxygen in  the  blood  is a temporary
cessation of the respiratory acts which is observed to follow violent and full
inspirations, and which has been studied chiefly by physiologists on animals
the condition being induced by vigorous artificial respiration".  To the cessa-
tion of breathing as thus produced the term  apncea is limited by some Her-
man writers; but  this term, as usually applied, embraces the various condi-
            1 The Effects  of High Atmospheric Pressure, Brooklyn, 1873. 
ALTERATIOXS IX THE GASES OF THE BLOOD.        67
tions which occasion  dyspnoea.   In the latter comprehensive sense, inclusive
of serious disturbances of hamatosis, whether accompanied or not by a sense
of the want of breath, or dyspnoea, the term will be used in this work.
   Deficiency of oxygen in the blood is of  much  greater pathological  import-
ance than  its increase.  If the quantity  of oxygen in the blood be greatly
diminished, there follows a group of  symptoms  to which the names  suffoca-
tion, asphyxia, and  cyanosis are applied.  Causes which reduce the  amount
of oxygen in the blood sufficiently to produce suffocative symptoms  are—1,
diminution in the  supply of oxygen to  the pulmonary capillaries, as  from
breathing in rarefied air and in small  closed  spaces; also from obstruction or
compression of the air-passages, as in croup ; from diseases which lessen the
respiratory surface  of the lungs  or interfere with their function, as pneumo-
nia,  phthisis,  pneumothorax,  asthma, oedema;  from  interference  with the
respiratory centre, as in certain affections of the central nervous system and
in narcotic poisoning;  2, obstruction to the  circulation in the lungs, as from
embolism of the pulmonary artery and in valvular  lesions of the  heart; 3,
diminution in the amount of  hamoglobin in the blood, such as results  from
profuse  hemorrhages;  4, displacement of oxygen from its  combination with
hamoglobin by other gases which enter into a firmer combination, as carbonic
oxide, from which  many intentional  and  accidental cases of poisoning  have
resulted (nitric  oxide also displaces the oxygen, but being irrespirable need
not  here be considered) ; 5,  rapid  reduction of oxyhamoglobin by  gases
which seize  the oxygen, such as sulphuretted  hydrogen, and probably also
phosphuretted,  arseniuretted,  and antimoniuretted  hydrogen, which further
decompose the  blood.   Mention  here should also be made  of the asphyxia
of new-born children (asphyxia neonatorum), which  is due  to separation of
the placenta or  to closure of  the umbilical vessels before birth.   After  death
from rapidly-produced suffocation the blood is of  a dark  color, and  usually,
although not always, fluid or imperfectly  coagulated; the right cavities of
the heart are, as a  rule, distended with blood, the mucous membrane of the
larynx and trachea  is  congested;  and  ecchyinoses are frequently present
beneath the pleura and pericardium.   In  consequence of the fluid condition
of the blood  there is  hypostatic congestion of most organs, and  unusually
marked  livid spots (Jivores mortis) on the  most dependent parts of the surface
of the body.  Chemical analysis  of the blood  just before  death  shows the
oxygen  to be  nearly or entirely absent and the carbonic acid to be more or
less increased  in amount.  After poisoning by carbonic oxide, the  blood is
bright red instead of dark, unless this  gas has been partly or wholly con-
verted into carbonic acid.
   The symptoms of suffocation are, at first, dyspnoea, as indicated by increase
in the rapidity  or  in  the depth of the  respiratory movements,  or  in  both;
convulsions, which are usually  absent when the  suffocation  is not rapidly
induced, and which even in  rapid suffocation may fail, as in  drowning; low-
ering  of the  temperature; elevation of  the blood-pressure ;  at first slowing
of the pulse from irritation of the vagi, then increased  rapidity from  paral-
ysis •  dilatation of the pupils ; protrusion of the eyeballs (exophthalmos), and
a dark blue, so-called cyanotic hue of the  surface  of the  body.  At  a late
stage  these symptoms may  become  considerably  modified.  This is the
asphyctic  stage proper.  In  it the color  becomes  less dark, the dyspnoea is
lessened or disappears, the pulse is small and  frequent, reflex excitability is
lessened and finally unconsciousness, anasthesia, and death follow.   Sugar
may appear in the urine in cases of suffocation.  The  symptoms which have
been enumerated are modified in individual cases, especially by  the  rapidity
with which the oxyiren in the blood is lessened in  amount,  Dyspnoea, with
more or less marked  suffocative  symptoms, is an important element  in  many 
68
GENERAL PATHOLOGY OF THE BLOOD.
 diseases which will be considered in Part II. of this work.   There has been
 much dispute as to whether the symptoms  of  suffocation, particularly dysp-
 noea, are due to the loss of oxygen in the blood or to the excess of carbonic
 acid.  It is now quite certain that in  rapid suffocation  the dyspnoea is  due
 chiefly to the diminished quantity of oxygen.   It  is possible to produce all
 of the symptoms of asphyxia in animals by lessening the amount of oxygen
 without increasing the amount of  carbonic  acid in the blood (Pfliiger), and
 although a large accumulation of carbonic acid  in the blood also  causes dysp-
 noea, the amount of this gas found in the blood in most cases of asphyxia is
 not sufficient to explain the symptoms.  The  treatment consists in removal
 of the cause, if possible, and in efforts to increase  the quantity of oxygen in
 the  blood.   This increase  is best  effected by  the  employment  of artificial
 respiration and by the inhalation of oxygen.   In poisoning by carbonic oxide
 the transfusion of blood has proved successful.  Special therapeutical  indica-
 tions will be considered  in the second part of this work.
  Although, as has  been mentioned, in  most cases  of suffocation there is an
 excessive amount of carbonic  acid in the blood, this excess does not usually
 suffice to produce dyspnoea.  It is, however, possible to produce this symptom
 by inhaling air containing a large quantity of carbonic acid, even if there be
 no diminution of oxygen.  The asphyxia is developed more slowly than when
 resulting from lack of oxygen.  The experiments of Raoult1 have shown that
 the presence of carbonic acid  in the inspired air diminishes the  quantity of
 carbonic acid produced in the body, and especially the amount of the oxygen
 consumed.   The experiments of Friedliinder and Herter2 upon animals demon-
 strate that if the quantity of oxygen be normal, inhalation of air containing
 an excess, but less than  20 per cent., of carbonic acid produces symptoms of
 irritation,  such  as  increased frequency of respiration  and increased  blood-
 pressure, but no really poisonous effects ; but if the amount of carbonic acid
 be increased to about 30 per cent., symptoms of depression follow, the breath-
 ing becomes slower and  weaker, the blood-pressure sinks, voluntary and reflex
 movements are weakened and finally abolished, the temperature falls, and the
 animal dies  in the course of a few hours.  If  the quantity of carbonic acid
 be increased to the maximum, the symptoms of depression follow very rap-
 idly, and death occurs frequently within  half an  hour.   According to Bert,
 symptoms of carbonic-acid poisoning do  not appear until all of  the alkali in
 the blood has been saturated with carbonic acid  and the gas begins to  be  dis-
 solved in the plasma.


   Changes in the  Albumen,  Fat, and  Inorganic Salts of
                             the Blood.

  These changes can  be dismissed with a few words.   Enough  has already
 been said in connection  with  hydramia and anhydramia  concerning  altera-
 tions in the quantity of albumen.  Fat is  probably always  present  in  the
 blood-plasma in health.   Its average amount is  estimated at 2 to 3 parts  per
 1000, but the quantity varies considerably within normal limits.   The amount
 of fat in the blood is increased during the digestion of fatty substances, when
the  blood may acquire a milky or chylous appearance from the molecules of
fat.  In diabetes the blood often  has  a  slightly milky appearance from an
increased amount of fat.  This condition of the blood is  called lipsemia.   It
is said  that in certain diseases of the liver, in phthisis, and in chronic alcohol-
ismus  there  is increased amount of fat  in the blood.   This  chylous condi-
 tion  of the blood is, of  course, not to be  confounded with the  entrance of
                1 Comptes rendus. t. 82, p. 1101.
                2 Zeitschr.f. Physiol. Chemie, Bd. 2, p. 99, 1878. 
GLYCOH^EMIA.
69
oil-drops into the blood after fractures and in certain morbid conditions.  This
tatty embolism has already been described.  (See Embolism and Thrombosis)
Ue are riot able to assign any pathological importance to a chylous condition
of the blood.1                                             J
  Although the inorganic salts are present only in small amount in the blood
  j1""?3^0 1U0°' °f  Which  ab°Ut  one-half  is chloride  of sodium),  they
undoubtedly have an important part in  the vital processes.  The effects of
their  withdrawal  from  the food are  described in works on physiology and
can hardly claim pathological importance.   Some writers have attributed the
symptoms  of scorbutus to a deficiency of alkaline carbonates or to a lack of
potash salts in the blood, but we possess  no  very satisfactory chemical analy-
sis of the blood of scorbutic individuals.  There seems to be no diminution
in the chlorides of the  blood  in pneumonia and in the fevers, notwithstand-
ing sometimes an entire absence of chlorides in the urine in these affections.
The diseases rachitis and osteomalacia are supposed by many to depend  upon
an  insufficient amount of the salts  of  lime  in the  blood.   According to
C. Schmidt, there  is a definite relation between the quantity of albumen and
that of salts in the blood,  diminution  in the  albumen being  attended  by
increase  in the  salts.
                       CHAPTER   VII.

      GENERAL  PATHOLOGY  OF THE  BLOOD (Concluded).

 Glycohsemia—Acetonsemia—Uraemia—-Ammoniaemia—Uricaemia or Lithaemia—Cholaemia
               —Cholesteraemia—Melausemia—Septicaemia—Pyaemia.

                             Glycohaemia.
    GLYCOHSEMIA signifies the presence of sugar in  the  blood.  A small
     amount of grape-sugar exists normally in the plasma of the blood.  This
 normal amount is  estimated at from 1 to  2£ parts per  1000.  The  quantity
 of sugar is about the same in venous and in arterial blood, and does  not seem
 to be essentially influenced by the diet, beyond the fact that sugar is  absorbed
 from the inte'stine by the portal vein.
   If the quantity of sugar in the blood exceed a certain amount (2\—3 parts
 per 1000, according to Bernard), sugar appears  in the urine,  constituting the
 condition  called glycosuria.  Many  physiologists  indeed believe that a trace
 of sugar is present in the normal urine, the quantity being so  small as to be
 unrecognizable by  the  ordinary tests.  Glycosuria  may be a temporary con-
 dition in health and in disease, or it may be long continued.  Prolonged gly-
 cosuria is attended  by a group of characteristic  symptoms, and is  called dia-
 betes mellifus,  a disease which will  be considered in Part II. of  this work.
 Certain considerations  pertaining  to  the  pathogeny of  glycohamia  as  a
morbid state find  their place appropriately under the general pathology of
the blood.  The amount of  sugar in  the  blood of diabetic individuals may
be 9 parts  to  1000 of serum (Hoppe-Seyler).   There has been found in
  1 Sanders and Hamilton {Edin. Med. Journal, vol. ii. p. 47, 1879),  however, consider
lipaunia and the resulting fatty emboli as the cause of the dyspnoea and other symptoms
of diabetic coma. 
70
GENERAL  PATHOLOGY OF THE BLOOD.
diabetes increased decomposition of the nitrogenous constituents of the body,
as indicated by an excess in the excretion of urea out of proportion even to
the large amount of ingesta.   Quincke found an increased amount  of iron in
various organs of the body, indicating increased destruction  of red blood-
corpuscles.  In the milder cases of diabetes the sugar may be made to disap-
pear from  the urine by  withholding  saccharine and  amylaceous articles of
food; in the  more  severe cases the sugar remains, although  in diminished
amount, during a diet of strictly animal food.  Permanent glycosuria may ap-
pear as a symptom of certain affections of the central nervous system, particu-
larly tumors and hemorrhages involving the medulla oblongata.  With this occa-
sional exception there are found in diabetes mellitus no pathological changes to
which the increase of sugar in the blood can be referred  with any certainty.
  There are  many  theories as  to  the nature of diabetes mellitus, but none
has yet obtained  general acceptance.   Most of these  theories are little more
than conjectures based chiefly  on  physiological experiments,  the results of
many of  which  are still in controversy, or,  with  our present knowledge,
neither admit of interpretation nor  shed much  light  upon  diabetes as it
occurs in man.   A temporary  glycosuria can be produced in animals  in a
great variety of ways, of which the  longest known and most celebrated is
puncture of the floor of the  fourth ventricle, the piqure of Bernard.   This
is thought to cause vaso-motor paralysis of  the  blood-vessels of  the liver,
and  to hasten thereby the circulation  through the organ.   Among  other
methods of producing glycosuria experimentally, may be mentioned injuries
of various parts of the brain and  of the spinal  cord, destruction of sympa-
thetic ganglia or division of sympathetic nerves in different situations, irrita-
tion of the depressor nerve, poisoning with  curare, carbonic oxide, and most
narcotics, injection  of  large quantities  of solutions of common salt into the
blood,  and, in cats, simple fixation and tracheotomy.
   There are two possibilities  as to the accumulation of sugar in the blood.
One is that there is increased access  of sugar  to the blood; the other, that
there is diminished consumption  of  sugar in the system.   An  increased
amount of sugar has  been supposed to come from different sources—from
the liver, from the intestine, from the muscles, or from the tissues in general.
The theory of the hepatogenous origin of diabetes mellitus is the one which
has been most widely accepted since the researches of Bernard upon the gly-
cogenic function of the liver.   There  are  two modifications of the  theory
that in diabetes  an  increased quantity of sugar passes from the liver into the
blood.   In order to understand these  two forms of the hepatogenous theory,
it is necessary to know that it is thought not only that  glycogen  is formed
out of sugar, but that it is also  converted into sugar.  According to one view,
in diabetes the  production of sugar in the  liver is abnormally great.   This
may be  clue  to increased formation  of glycogen  or  of  sugar-ferment, or it
may be  the  result  of  too rapid passage of glycogen from the hepatic  cells
into the blood,  where it is converted into  sugar.  Pavy  supposes that the
liver produces sugar in  diabetes,  but not in health.  Another form  of the
hepatogenous theory is that the sugar which is brought to the liver by the
portal  vein,  whether in  normal or in  abnormal quantity, is  not  converted
into glycogen, but  passes unchanged  through the liver into the hepatic vein.
According to the former view, there is an increase of the sugar-forming func-
tion of the liver;  according to the latter,  its glycogen-forming function is
interfered with.  Many of the  advocates of each view hold that the primary
change is  increased rapidity of the portal  circulation  in  the liver.   This
assumption is based  upon experiments  intended  to show that  temporary
glycosuria is produced in animals by paralytic  distension of  the  blood-ves-
sels of the liver.  The theory that diabetes depends upon an increased nro- 
GLYCOHuEMIA.
71
duction of sugar in the liver is founded on the doctrine that the formation of
sugar from glycogen is a normal function of the liver.  This theory has been
opposed by investigations which have resulted in a denial of the existence of
a sugar-forming function in the liver.1
   In favor of the  theory that diabetes mellitus is due to the non-conversion
.of  sugar  into glycogen in  the  liver, the  following  experiments  have  been
adduced:  If  sugar be injected  into the jugular  or  the crural vein of  an
animal, it soon  appears in the urine, whereas  a larger  amount may  be
injected into  the  mesenteric vein without  causing  glycosuria.    Cases are
reported in which  the ingestion of sugar or of amylaceous substances has.
induced glycosuria in  cirrhosis of the liver, a disease in which a considerable
part of the hepatic parenchyma is  destroyed  and the  portal circulation is
obstructed.   Bernard  produced  glycosuria by feeding with  sugar and  amyla-
ceous  substances animals in which the  portal vein  was closed.   On the other
hand, it has been shown that puncture  of the fourth  ventricle does not cause
glycosuria if the animal has been poisoned with arsenic  or phosphorus, sub-
stances which induce fatty metamorphosis  of  the liver.
   The theory of Huppert is perhaps the best presentation  of the view that
diabetes mellitus  depends  upon diminished oxidation  of the sugar.  The
researches of  Pettenkofer and Yoit regarding the nutritive  changed in a dia-
betic patient led them to advocate this  theory.   According to these investi-
gators, diabetes mellitus is  due to  a general  disturbance of nutrition, in
consequence  of  which  the albuminous  constituents of the body undergo
abnormally rapid metamorphosis.  Proof of this they find  in the amount of
urea excreted, which exceeds that produced from the ingesta.  Hence diabetic
individuals rapidly emaciate.  Sugar, like urea,  they  consider to be a  normal
product of the decomposition of albuminous substances.   In health this sugar
is rapidly  oxidized.   In diabetes it is  claimed  that less  oxygen is  absorbed
than normal, notwithstanding the increased amount of oxidizable  substances
in  the blood.   This diminution in the absorption of oxygen is attributed to
destruction of red blood-corpuscles, or to their abnormal constitution in conse-
quence of their participation in the general malnutrition of the body.   Inas-
much as the sugar  produced in increased  amount by metamorphosis of albu-
men does  not find the proper quantity of oxygen for its combustion, it accumu-
lates in the blood  and causes abnormal  glycohamia.  The observations  of
Quincke2 are not in harmony with Pettenkofer and Yoit's explanation of the
diminished absorption  of oxygen.  Quincke found not only no reduction in
the amount of hamoglobin  in the blood in diabetes, but in one case even an
actual  increase.  The diminished consumption of the sugar in diabetes has
been attributed  also to a reduction of the alkalinity of the blood, and  to the
absence of some ferment which is supposed under normal conditions to disin-
tegrate the sugar.
  Dickinson3  believes that  diabetes mellitus is always the  result of changes
in the  central  nervous system.   The most important of these changes he con-
siders  to be  dilatation of the arteries and  of  the perivascular spaces, and
minute hemorrhages with disintegration of nerve-elements.   Changes  similar
to those described by Dickinson, however, have  been found  in other diseases,
and are not constant  in diabetes.  While it is true, as has been mentioned,
that in certain cases of diabetes mellitus marked changes have been found in
the brain, especially in the pons and medulla oblongata, there is not sufficient
evidence for believing  that all cases of  diabetes  are of nervous origin.

  1 Abeles, CE*tr. med. Juhrb., 1875, p. 269;  Von Mering, Arch. f. Anat. u. Phys., 1877,
p. 379;  Bleile, ibid., 1879, p. 59.
  2 Virchow7s Archiv, Bd. 54, p. 542.
  3Med  Timt-s and Gaz., March 9, 1870, and Treatise on Diabetes, 1875. 
72            GENERAL PATHOLOGY OF THE BLOOD.

   It can serve no useful purpose to describe other theories which have been
proposed or to attempt to criticise further those which have been cited.  They
all rest upon too uncertain a foundation.  Until we have more positive know-
ledge as to the source of sugar in the healthy organism, and as to its  meta-
morphoses, we cannot hope for any satisfactory explanation of the abnormal
accumulation  of sugar in the blood and in the urine in diabetes mellitus.
   The transient appearance of  a  small quantity of sugar in the urine in vari-
ous diseases has no more pathological importance than the occasional appear-
ance of a trace of albumen.


                             Acetonaemia.
   Attention was first called to acetonamia by the recognition, in  the  urine
and in the expired air of diabetic patients, of some substance which  imparts
an aromatic,  fruity, chloroform-like odor resembling that of acetone.  Ace-
tone, or some  substance yielding acetone, was proven to be frequently present
in the  urine in cases of  diabetic coma.  The theory of poisoning of the  blood
by acetone was constructed to explain these cases of coma.  In many of  the
cases there was found in  the urine a substance which imparted to it a bur-
gundy-red color upon the addition of a solution of ferric chloride  (Gerhardt's
reaction).  This reaction was considered proof of the presence of acetone or
of an acetone-yielding substance.
   There is no proof that acetonamia is a condition of any pathological import-
ance.  The usual tests for the recognition of acetone in the urine are not very
satisfactory.   As  to the occurrence of acetone in the urine,  however, in a
variety of conditions, there can  be no doubt.  It is even  claimed by Von
Jaksch that acetone is  a normal  product of tissue-metamorphosis, and that a
minute quantity is constantly present in the urine.   Pathological acetonuria
he finds in fevers, diabetes, cancer, and various diseases of thegastro-intestinal
tract.  The substance which responds  to the  ferric-chloride test is not acetone,
but it is probably diacetic acid.
   There is no proof that  acetone, diacetic  acid, or ethyl-diacetate possesses
toxic properties in the  human  organism.  The coma and other disturbances
attributed to them may  occur without their presence,  and, on the  other hand,
acetonuria and diaceturia may exist without any characteristic symptoms.


                               Uraemia.

   By uraemia  is understood the accumulation in the blood of excrementitious
substances of  the urine.   The  term  is usually applied to a group of symp-
toms which appear when the function of the kidneys is interrupted or much
impaired.   The most important of the uramic symptoms are coma and epi-
leptiform  convulsions, preceded often by headache, vomiting,  and  diarrhoea.
The  convulsions usually  precede the coma, but  either may appear  alone.
Amaurosis, dyspnoea, and maniacal  delirium are also  to be  included anion-*'
the occasional manifestations of  uramia.   In the majority of cases uramia
is  the  result of some form of acute or chronic diffuse inflammation of the
kidneys (Bright's disease). It may attend any disease in which the excretion
of urine is more  or less completely  suspended, as double hydronephrosis
stricture of the urethra, cystitis, etc.   In  uramia, as a rule, the quantity of
urine, and especially the quantity of urea excreted, are diminished, the urine
is albuminous  and contains casts,  and  dropsy is present or it has preceded the
attack.  There are, however, exceptions, especially as regards the quantity of
urine and  the  presence of dropsy.  We Cannot account  for the fact that  in
one case uramia appears, and in another it  fails, although the conditions are 
URAEMIA.
73
 apparently the same in both. Notwithstanding much research, no thoroughly
 sat 1 si act ory explanation of the uramic phenomena has yet been reached.
   lhe oldest and still  most prevalent theory is that uramia is due  to the
 accumulation of urea in the blood.  The arguments which have been adduced
 in support of this view are that urea, introduced into  the  blood of animals,
 produces symptoms similar to those of uramia in man, and  that  in  uramia
 urea  is in excess in the  blood.   In  opposition  to  this view, however, the
 majority of experimenters agree that the injection even of large quantities of
 urea into  the blood of healthy  animals is harmless.1   Urea may be fed freely
 to dogs without injurious effects if the animals  be  allowed  to  drink  water.
 Inasmuch as urea is rapidly eliminated by healthy kidneys, these experiments
 do not prove that urea  is innocuous when its excretion  from the body is
 checked.  In order to determine the effects of urea under conditions in which
 it cannot so readily be eliminated, it has been injected into the  blood of ani-
 mals  whose kidneys have  been removed.    Uramic  symptoms develop in
 nephrotomized  animals which  survive the operation, in every case sooner or
 later.   That the appearance of these  symptoms is hastened by  the injection
 of  urea has not  been established.   Voit found that  symptoms resembling
 those  of uramia are produced if the rapid elimination of urea fed to  dogs be
 prevented by withholding water.   The same effects were observed after feed-
 ing in the same way some other substances, such as  benzoate of soda.   Voit,
 therefore,  does not attribute specific  poisonous properties to urea, but  thinks
 that uramic symptoms appear when the accumulation in the blood of a variety
 of substances, including urea, uric acid, potash salts, creatinin, and extractive
 matters, becomes so  great that the products of tissue-metamorphosis cannot
 be  carried off.   These waste products collect not only in the blood, but in the
 tissues, and here check that interchange between the tissue-elements and the
 nutritive fluids  which is essential to the proper performance of cell-function.
 The results hitherto obtained  by experimentation  with urea cannot  serve
 as a basis  of support for the doctrine that urea is the sole poisonous agent
 in uramia.
   The blood of uramic individuals has been analyzed with  the view of deter-
 mining the injurious ingredients.   The blood of animals in which the kidneys
 have been  extirpated or the ureters tied has been found to contain urea in ten-
 fold its normal amount if the animals survive the operation from two to four
 days.   These experiments  show that urea is not formed exclusively in the
 kidneys, but that  it is produced elsewhere and conveyed to these organs by
 the blood.   Normal blood contains 0.01 to 0.08 per cent, of urea.  The quan-
 tity of urea has been found much increased in the blood  of uramic patients.
 Bartels mentions  a case in which 0.8 per cent, of urea was found.  Hoppe-
 Seyler found 0.127 per cent.  These amounts are larger than have usually been
 found  in uramia.   But other excrementitiotis  substances as well as urea are
 present in  excess.   A notable increase of extractive  matters (0.86 per cent.,
 Unppe-Seyler) has been found, the importance of which is not to  be  under-
 estimated  because they have  hitherto  defied chemical analysis.   There is one
 factor  which disturbs the certainty with which urea accumulates in the blood
 when the function of the kidneys is suspended—namely, the vicarious elimina-
 tion  of urea by other organs.   Urea may  be excreted vicariously by the
 stomach, intestine, and skin.  It has also been found in larger percentage in
  ^eltz and Hitter found that when urea in large doses produced convulsions it was
always contaminated with ammonium salts.  It never produced convulsions when pure
(Cmnpt. rend as, t. 86, No. 15, 1878).
  Picard recentlv  finds, in opposition to most observers, that the rapid injection of
concentrated solutions of urea into the jugular vein of dogs produces uraemic symptoms
with fatal termination.  He does not attribute the symptoms to the direct action of the
urea  but to  suspension of the renal  excretion {Gaz. med. dt Paris, 1879, No. 5). 
74            GENERAL PATHOLOGY OF THE BLOOD.

dropsical effusions than in the blood.  In the stomach and intestine urea is
readily converted  into  carbonate  of ammonia.   Urea has repeatedly been
observed in uramia as a crystalline deposit upon the skin.   The bile has also
been found to contain an abnormal amount of urea.
  While urea has been found in excess in  uramic blood, there have been also
cases of uramia in which the amount of urea in the blood has been slightly,
if at all, increased.  In  one  case  Jacobsen1 found  the quantity of urea  too
small to admit of quantitative estimation.  On the other hand, a large quan-
tity of urea has been found in the blood  without the coincidence of  uramic
symptoms.  Unless in these analyses there has been some error, it seems quite
certain that there are cases of uramia in which the symptoms are not due to
the retention  of  urea in the blood.
  A theory of uramia elaborated by Frerichs with great skill, which obtained
at one time  considerable credence, is now generally discredited, at least  as
regards its  applicability  to most cases.  This  theory is that uramic  symptoms
are due to the presence in the blood of carbonate of ammonia  produced by
decomposition from the urea.   There is no evidence for Frerichs's assumption
that urea is decomposed into carbonate of ammonia in the blood.  This decom-
position, however, takes place in  the stomach  and intestine, carbonate of
ammonia having been  recognized often  in the vomit  of uramic patients.
There is  no doubt that carbonate of ammonia may be absorbed  by  the  blood
from the intestine, and  that in certain cases, which are rarer than was once
supposed, it may be detected in the breath.   It  is true that the injection of
carbonate of ammonia into the blood of animals produces more marked  symp-
toms than does the introduction of urea.   The most constant of these  symp-
toms are convulsions, followed often  by coma, with infrequency of  the pulse
and respiration.   But while carbonate of  ammonia always produces one and
the same group of symptoms, mainly those of irritation, on the other hand the
manifestations of uramia are various, and only in a certain proportion of cases
are they analogous to those produced by the  ammonia salt.   Carbonate of
ammonia has been detected in small quantity in the blood in uramia, but it
has also been found to  be absent in many cases.
  Traube referred the uramic phenomena to cerebral oedema and consequent
cerebral  anamia.  The  oedema he attributed to  hydramia and  high  arterial
pressure—conditions which are often, but  not  invariably, present in uramia.
(Edema and anamia of  the brain  are found when no uramic symptoms have
been manifested during  life,  and  they are by no  means  constantly present
after death from uramia.   (Edema of the brain may often be regarded with
more propriety as the result rather than as the cause of convulsions.
  It is held by some writers that uramia is not always produced in the same
way, but that in different cases the causes are different,  Bartels was  an emi-
nent advocate of this eclectic view.  Jaccoud attempts even to  diagnosticate
between uramia due to  toxamia and that due to oedema of the brain.  But
no essential  differences  have been detected, as  regards symptoms, between
cases of uramia in which the blood was loaded with  urea and those in which
no excess could be determined ; between those in which carbonate of ammonia
was found in  the blood  and those  in which it was absent; or between cases
accompanied  with hydramia  and  those  without this pathological  condition.
  It is only  established with regard to the cause of  uramia that this condi-
tion is  the result of an abatement of the function of the kidneys  and that this
abatement  is  followed by an accumulation of excrementitious  substances  in
the body.  It is  inconceivable that the accumulation in the blood and tissues
of waste products should not have  an injurious effect.  Perhaps the followin*"
explanation of the uramic phenomena is  most in harmony with clinical and
    1 Ziemssen's Cyclopaedia of the Pmctice of Medicine, Eng. trans., vol. xv. p. 130. 
URIC.EMIA—LITH.EMIA.
75
experimental observations : The uramic symptoms are the result of the reten-
tion in the system of excrementitious materials.  It is the entire mass of waste
products, and not any single element,  which is  the source of trouble.  The
nature of these waste materials is very imperfectly known.   They probably
consist mainly of nitrogenous substances  in different  conditions of the meta-
morphosis of which urea is the final stage.  The non-elimination of the excre-
tory products causes  an incomplete metamorphosis of the waste nitrogenous
elements.^ ^ These are retained, not only in the blood, but finally in the tissues.
The  nutritive processes are thereby disturbed.  As the uramic symptoms are
chiefly of nervous origin, it is necessary to emphasize especially the disturb-
ance of nutrition of the nervous system.


                          Ammoniaemia.
   The occasional absorption of carbonate of ammonia produced from urea
excreted by the intestine has been mentioned already.   Whether the amount
of carbonate of ammonia which thus gains access to the blood ever suffices to
produce  poisonous symptoms is uncertain.  There  is, at  least, not sufficient
ground for believing that uramia is, in reality, ammoniamia.   An ammoniacal
state of  the  blood  has also been  referred to the absorption  of carbonate of
ammonia formed in decomposed urine in  cases of retention of urine and of
cystitis,  from  stricture of the  urethra,  enlarged prostate, paralysis  of the
bladder,  pyelitis, etc.   Musculus succeeded in isolating  from the urine, in a
car-e of cystitis, a ferment capable in a short time of transforming urea into
carbonate of ammonia.  Pasteur and Joubert found  this ferment only when
bacteria  were present, and they believe that it is produced by these organisms.
Leube and Graser have isolated no less than five different forms of  bacteria,
some from  ammoniacal urine  and others from the air, which are capable of
transforming  urea  into carbonate  of ammonia.   The organisms which cause
ammoniacal  decomposition of the  urine gain access to the urine from outside
of the body, chiefly by catheterization.  Some writers have considered ammoni-
amia as  the cause of the symptoms often observed in the late stages of cystitis
and of pyelitis.  These  symptoms are irregular chills, fever, dryness of the
mucous membranes exposed to the air, vomiting, diarrhoea, delirium, somno-
lence, and coma.  Ammoniacal  exhalations from the lungs and the skin are
sometimes observed.  As suggested by Rosenstein,1 these symptoms are rather
those of  septic infection than  of ammoniamia.   They do not at all resemble
the symptoms induced in animals  by the injection of carbonate of ammonia.
Convulsions are among the most constant and prominent effects of poisoning
with carbonate of ammonia, but they are absent in this so-called ammoniamia.


                        Uricaemia—Lithaemia.
  Uric acid exists in minute quantity in  the blood in health.   Its abnormal
accumulation constitutes the condition to which, in  the first edition of this
work (1866),  was applied the name uricamia.  Subsequently the  name
lithamia was applied  to  it by Murchison.   Garrod has shown that an abnor-
mally large  quantity  of uric acid  is present  in  the blood in  gout,2   It may
also exist in increased amount  in chronic  lead-poisoning, leucocythamia, and
some  other conditions.  The exact form in which uric acid exists in the blood
is  not known,  but it  is  probably  the neutral urate of soda.   The acid urate
of soda is much less soluble than the neutral salt.   The accumulation of uric
acid in the blood is a  constant attendant  of gout, and is regarded by Garrod
  1 "Ueber Ammonifpmia," Deutsche Zeitse.hr. f. Prac. Med., No. 20, 1874.
  2 Garrod On the Nuture and Tr<alment of Gout and Rheumatic Gout, London, 1859. 
76
GENERAL  PATHOLOGY  OF  THE BLOOD.
 as the cause  of most of the gouty symptoms.  The most  characteristic of
 these symptoms is the deposition, in various situations, of concretions of urates,
 accompanied  often by inflammatory processes.  The gouty concretions—or
 tophi, as they are called—consist of urate of soda, probably as an acid salt,
 combined often with  urate of magnesia and of lime, and carbonate and phos-
 phate of lime.  These deposits are  found in  and about the joints, especially
 the small joints of the foot and hand, in the cartilage of the pinna of the ear,
 in the pyramidal portion of the kidney, in tendon, in the skin, nerves, vessel-
 walls, in the  membranes  of the cord, and  in  the spongy substance of  bone.
 According to Ebstein, the  urates are  deposited only in  necrotic foci.   The
 concretions consist partly of acicular crystals and  partly of granules.  True
 gouty inflammation is always accompanied with  a deposition of urate of soda
 in the inflamed part.   The  kidneys  are often  diseased in the late  stages of
 gout, being small and granular, with increase of connective tissue, deposits
 of urates in the pyramids, and frequently waxy degeneration of the glomeruli
 and vessels.   The  urinary secretion in gout was found  by Garrod to be defi-
 cient in uric acid, especially just before a paroxysm.   Stockvis found at the
 onset  of a gouty paroxysm the  excretion of urea and  of the  earthy  phos-
 phates diminished.   Others have  found  the excretion of phosphoric acid
 augmented during the attack.   In the intervals between the paroxysms the
 excretion of uric acid may be either  normal or diminished.  The causes which
 have  been  assigned for an excess of  uric acid in  the blood are the insufficient
 excretion of the acid, its increased formation  in the system, and diminished
 alkalinity of the blood or lymph, whereby the neutral  urates  are  converted
 into the less soluble acid urates.   Upon the assumption  that uric acid is con-
 verted in the  system  into urea  by oxidation  the theory has been  advanced
 that the uric-acid diathesis is the result of incomplete oxidation  of the nitrog-
 enous products of metamorphosis.   A deficiency of oxygen,  however, has
 not been shown to exist in  the uric-acid diathesis.   It will  be  impossible to
 give  any satisfactory explanation of uricamia  until we learn  more of the
 origin of uric acid in  the body and of its metamorphoses.   The most import-
 ant elements in the etiology of the  gouty diathesis are heredity, the use of
 wines and  malt  liquors, and a diet rich in albuminous and fatty substances.
 Over-indulgence in these  articles of diet is believed to cause an increase in
 the proportion of acids and  of acid salts, and  so to favor the precipitation of
 acid urates.   Digestive disturbances, which are  frequent in  gout,  may like-
 wise be attended by the generation of organic acids, the absorption of which
 may reduce the alkalinity of the blood.  It seems probable that the deposit
 of urate concretions  depends  not only upon increased  formation and dimin-
 ished excretion  of  uric acid, but also  upon  lessened solvent power of the
 blood  and  other fluids of the  body.
  The designation " uric-acid  diathesis"  is  used by  some physicians in a
 rather indefinite way  to describe various morbid states which may not at any
 time be accompanied  by deposits of urates, and in which there is no proof
 of an excess of uric  acid  in the blood.1  In  the cases here referred to the
 urine is habitually highly colored, excessively acid, and it  often deposits urates,
 uric acid, and oxalate of lime.   The patients  generally  live luxuriously  and
 have a tendency to  embonpoint.   They suffer from digestive disturbances' and
 are sometimes hypochondriacal.   There  is a tendency to the formation of  uric-
 acid gravel and calculus.   In some of the patients here described the symptoms
 of small granular kidney, with increased arterial tension, subsequently develop.

  1 Murchison on Diseases of the Liver, New York,  1877; DaCosta in Am. Journ. Med
 Sciences, Oct., 1881 ; more recent contributions have been  made by McBride  Lvman
 Hudson, and Potter (vide paper by Landon Carter  Gray in the New York Med ''tmim  '
Jan. 16, 1886).                                                             ' 
                    CHOLAHMIA—CHOLESTERJEMIA.                 7 7


                    Cholsemia—Cholesteraemia.
  The presence of the essential constituents of the bile in the blood consti-
tutes the  morbid condition called  cholsemia.   The constituents which come
chiefly into consideration  are  the  biliary coloring matters, bilirubin and bili-
verdin, and the salts of the biliary acids—namely, glycocholate and taurocho-
late  of soda.   If the coloring matter of  the bile  be present in the blood in
sufficient amount, it appears after a time (forty to sixty hours) in the urine
and  in the tissues, to which it gives a yellow color.   This  condition is called
icterus, or jaundice.   The  biliary coloring matter may appear in nearly all the
tissues.  The central and peripheral nervous system  and cartilage, however,
are very slightly, if at all, stained.  All of the  fluids except the saliva,1 tears,
and  mucus may be  colored yellow.  The biliary coloring matter may be easily
recognized by Gmelin's  test  with nitroso-nitric acid.  The biliary coloring
matters and the biliary salts are formed in  the liver, and do not pre-exist in
the blood.  There is reason to believe that under  pathological conditions bili-
rubin may be formed in the blood from dissolved hamoglobin.  A number of
substances,  such as water,  the  biliary  acids and  salts,  ether, chloroform,
ammonia, and certain  acids, when  injected  into the blood  cause  the destruc-
tion of some of the red blood-corpuscles, and  the appearance first of hamo-
globin, and afterward of biliary coloring matter, in the urine. Certain poisons
and  infectious principles are believed to  act in  the same way in human blood.
Icterus as thus induced by changes in the blood itself is called haematogenous,
in distinction from the  usual  form,  which  is  designated  as  hepatogenous.
Hepatogenous cholamia is dependent upon the absorption of the biliary color-
ing matter and of the biliary salts after their formation in the liver.  The bile
is probably absorbed, not  directly by the blood-vessels, but by the lymphatics
of the liver,  and is conveyed  by the thoracic duct to the blood.   The causes
of hepatogenous jaundice are—-first, obstruction to the passage of bile, either
in the small  or large ducts;  second, interference  with  the respiratory move-
ments of  the diaphragm which aid in the propulsion of the  bile; third, low-
ering of the  blood-pressure in the portal vessels.  As yet, no certain differ-
ential symptoms  between  hamatogenous and hepatogenous icterus  have been
established.   Some  pathologists are even unwilling to admit the existence of
hamatogenous jaundice.   The  biliary salts are  found in small quantity in
the urine in hepatogenous icterus,  but it is not easy to detect them.   Their
absence cannot  be considered, with our  present  knowledge, a  sure  sign of
hamatogenous icterus.   These salts  are known to undergo certain modifica-
tions in the blood,  so  that only a small  quantity of those absorbed appears
unchanged in the urine.   In jaundice the  biliary coloring matter exists, for
the most part, dissolved in the fluids or diffusely infiltrated in the tissues, but
it may present itself in the  form of  brown granules or of rhombic  crystals
of bilirubin,  especially in  the liver and  in the kidneys.  The influence of
biliary salts in the blood has been experimentally  studied upon animals.  The
injection of glycocholate  of soda  causes  destruction  of a certain  number of
red blood-corpuscles, diminution  in the  rapidity of the pulse, slowing of the
respiration, sinking  of the temperature, ecchymoses, and a  weakness of the
voluntary muscles.   Apathy and  a certain  degree of somnolence  are present
even in the milder grades of icterus.
  All clinical observers have met with exceptional cases of cholamia in which
the bile appears to have an intensely noxious influence on the nervous system,
causing convulsions, coma, and death.   The hamic condition to which these
effects'are referable  has been called " cholamic intoxication."  If uramia be
excluded, this condition denotes the presence in the blood of a constituent or
  1 According to Fenwick, bile may appear also in the saliva {Lancet, Sept. 1, 1877). 
78            GENERAL PATHOLOGY  OF  THE BLOOD,

of constituents of bile other than the bile-pigment or the biliary salts, for the
latter are present in cases of ordinary hepatogenous  jaundice in which  no
grave effects are manifested.  Facts, physiological and  pathological,  point to
the accumulation  in the blood of cholesterin as affording a rational interpre-
tation  of the phenomena  of cholamic intoxication, or, as  it  has been also
called, grave jaundice.   In 1862. A. Flint, Jr., demonstrated that the choles-
terin  in  bile is a result of an excretory function of the liver  not previously
recognized,  and  that it is an excrementitious principle derived chiefly from
the disassimilation of nervous tissue.  He also made examinations showing
no  increase of cholesterin in the blood in a  case of ordinary hepatogenous
jaundice, but a notable increase in  a fatal  case of jaundice with cirrhosis of
the liver and ascites.  To a morbid increase of cholesterin in the blood  he
applied the name cholesteramia.1   Subsequent observations have tended to
confirm the pathological conclusions based on these investigations.  In  1873,
Mtiller produced, by the injection of cholesterin into the blood of dogs, phe-
nomena  resembling those of the so-called grave jaundice.2   In 1872,  Picot
ascertained  the existence  of  cholesteramia in a fatal case of grave jaundice.3
It is believed by  some that there are excrementitious substances  other  than
cholesterin which  may be retained in the blood when the secretion of bile is
arrested by extensive destruction of the  hepatic  parenchyma or otherwise.
The non-secretion of bile is  called acholia.  It is  to  be borne in  mind that
acholia does  not  necessarily involve cholamia.   The  toxical effects of  an
accumulation of  cholesterin  and of other  excrementitious principles  may
occur  without as well as with jaundice.   It is  not  improbable  that a defi-
cient elimination of cholesterin may occasion more or less of those indefinite
ailments which are commonly embraced under the name biliousness, and which
are relieved by remedies  supposed  to increase the functional  activity of the
liver.  It should  be added that with regard to the  pathological  importance
and relations of cholesteramia there is not unanimity of  opinions, and that
experiments have been reported which contradict those of Miiller.4


                              Melansemia.

   In melanamia  the blood  contains black granular pigment in the  form of
small  roundish or angular granules.   This condition  is a result  of  malaria.
It is most marked in the pernicious forms of intermittent and of remittent
fever, and is  present only in slight degree in the  milder grades  of intermit-
tent fever.   It  may be found also  in  chronic  malarial cachexia.  The pig-
ment may be found in any vascular  part.   In the spleen, liver, marrow of the
bones, and  lymphatic glands the pigment is not  only within, but frequently
outside of,  the  blood-vessels.   In  other  parts the pigment is mostly  intra-
vascular.  The pigmented organs  may assume a dark,  slate-like color.   The
pigment may be contained in leucocytes, in red blood-corpuscles, and in fusi-
form cells such  as exist  normally  in the  spleen.   Often the  pigment-cran-
nies appear  to be free, but careful examination will  then usually show that
the  pigment  is contained in  little round or oval pale hyaline  or  slightly
granular  bodies.
   It  is generally agreed that the pigment of  melanamia is formed out of
the  coloring matter  of red  blood-corpuscles, a certain  number of which are

  1 Vide  " Experimental Kesearches upon  a New Excretory Function of the  Liver
etc.,"  Am. Journ. of Med. Sciences, Oct.,  1862: also Textbook of Physiology, 1876.
  2 Archiv fiir Erperimentelle Pathologie und  Pharmakoloqie, Leipzig, 1873.'
  3 Journal de I'Avatomie et de la Physiologic, par M. Robin, Mai et Juin 1872.
  4 Vide Krusenstern, " Zur Frage fiber das Cholestearin " Virchovfs Archiv PA 65 n
n n  i»7."-                                                         '       ' ^" 
                     SEPTICEMIA  AND PYAEMIA.                  79

destroyed in the  process.  There  are  different views as to the  situation and
manner in which the  pigment is  formed.
  The oldest view  is  that of Virchow and  Frerichs, who believe that the
pigment  is  formed  in the spleen  out of red  blood-corpuscles which  have
either escaped from the blood-vessels or are contained in venous thrombi, and
that it is thence conveyed by the portal vein to the liver, where it accumu-
lates in considerable quantity, and whence it passes into the circulation.   The
chief support of  this view is that the spleen is much enlarged, and is  more
deeply pigmented than  any  other organ.
  Another  and perhaps now more generally accepted view is  that the pig-
ment is formed in the circulating blood out of red blood-corpuscles which are
destroyed by the  malarial poison.   According to  this theory, the accumula-
tion of pigment in the  spleen is explained  by the retention of  pigment  there
in the same manner as fine particles of any kind, such as cinnabar or carmine,
when injected into  the blood, accumulate in this organ.   The formation of
malarial  pigment in the blood occurs mainly during a febrile malarial parox-
ysm.  The  pigment often disappears from the circulating blood in the course
of two or three days after a malarial paroxysm, but melanamia may continue
for months  after  the cessation of the attack.
  Laveran, and Marchiafava and  Colli, have found in some of  the red blood-
corpuscles of malarial  patients, especially  during the paroxysm, round, oval,
or fusiform bodies  which stain with methylene-blue and some  other staining
dyes.  These bodies may be very minute  or they may occupy most of the
corpuscle.  Some of them are endowed with  amoeboid movement.  They may
occur outside of the corpuscles.  They often contain malarial pigment,  Coun-
cilman has  found that the apparently free pigment is in reality contained  in
little pale bodies which seem to be identical with those described by Laveran
and by Marchiafava and Celli.  The latter authors  believe that these bodies,
which first  appear in the interior of red blood-corpuscles, are  parasites, and
that they elaborate the pigment out of the  hamoglobin.   Satisfactory  proof
as  to the nature  of these bodies has not been furnished. They  will be further
considered in the article on intermittent fever.
   In melanamia the number of red blood-corpuscles is diminished, either with
or  without  an increase of the white corpuscles.

                      Septicaemia and Pyaemia.

   The  diseases septicamia and  pyamia will be  considered briefly, as they
belong to the domain of surgical rather than of medical pathology.  The  study
of  the nature of these diseases involves extremely complicated and unsettled
questions.  A variety of affections of a grave nature, which may  follow wounds,
are designated as septic.   Our knowledge of the causes of these septic affec-
tions is too imperfect to enable us to classify them etiologically.  An old and
 still prevalent theory is that septicamia, as the name implies, is due to putrid
infection, and pyamia to purulent infection.  There can, however, be  little
doubt that under the generic name septicamia  are included different morbid
conditions, and that not all of these are referable to putrid infection.  So much
confusion has arisen as to the nature of the septic diseases that some prefer to
group them all under the name septicamia or under the name  pyamia.   The
distinction, however, which is generally  used as a basis of classification  is the
presence or absence of metastatic abscesses.  As this distinction does not rest
upon an etiological basis, it is an unsatisfactory ground of classification, but
perhaps it is the  most useful one at present.
   Septicaemia.—Most of the experiments and pathological  investigations
intended to elucidate the nature of septicamia are based on the assumption 
80
GENERAL PATHOLOGY OF THE BLOOD.
that septicamia is due to infection with some  poison or poisons contained in
putrefying substances.  It has been found that if animals be inoculated with
fluid containing the products of decomposed albuminous substances, symptoms
and  pathological changes are induced analogous to those observed in certain
forms of septicamia in man.   It has been  established  by the researches of
Pasteur that putrefaction is due to the action of bacteria.  The question there-
fore  arises whether putrid infection is produced by the absorption of chemical
substances generated  by bacteria or by the entrance and growth of the bac-
teria of putrefaction  in the circulating blood.  A number of chemical sub-
stances  of an extremely poisonous nature  have been isolated  from putrid
material.  Some of these substances resemble alkaloids in their properties
and  composition, and have  received the name of ptomaines.   Undoubtedly,
therefore,  when a  focus of putrefaction exists in  the body, then ptomaines
may be  absorbed and  poison the system.  A certain number of cases of sep-
ticamia are to be explained by the absorption  of ptomaines.  For such cases
the names putrid  intoxication, sapramia,  and  ptomainamia have been pro-
posed.   Of  course in  these cases of putrid intoxication  the intensity of the
symptoms depends upon the quantity and  the  virulence of the  noxious sub-
stances  absorbed, and if the putrefying material be seasonably removed the
symptoms will disappear.
  Whether  septicamia is ever produced by the entrance and development in
the blood of the ordinary bacteria of putrefaction is uncertain.   Only a small
number of these bacteria have been isolated, and these do not seem to possess
marked  pathogenic properties.
  Many, probably most, cases of septicamia  are  caused  by infection  with
micro-organisms the characters of which  are  very imperfectly known.  The
name septicamia is given  to a considerable number of  diseases which have
been produced experimentally in animals by inoculation with different kinds
of bacteria.   There is no evidence that these different forms of experimental
septicamia  are in  any instance identical with human septicamia.   In sep-
ticamia in man different forms  of bacteria  have been found in the blood both
during life and after death.  The forms most frequently found are micrococci,
and of these at least some  seem to be identical with micrococci  observed  in
pyamia.
  Septicamia is observed most frequently  after wounds, especially those com-
plicated by  injuries of bone and by contusion  or laceration of the soft parts.
Its first symptoms appear usually in from two to four days after the infliction
of the wound and before suppuration has been fairly established.  The changes
which render a wound a source of infection are believed to  be those of decom-
position brought about  by  the agency of bacteria.  The discharge from the
wound is thin and  ichorous ; the surrounding parts are cedematous and some-
times gangrenous.   Septicamia may be caused also  by gangrene, by ill-con-
ditioned abscesses, and by inflammations in general.   Usually, although not
always, the focus of infection  communicates with the open air.   The hectic
fever of phthisis, the suppurative fever of  smallpox and certain  other second-
ary fevers, are considered by some as due to septicamia.   There is some rea-
son to believe that the healthy respiratory and intestinal mucous  membranes
can absorb  septic  poison generated outside of the body.
  The  changes found after  death from septicamia are mostly of a negative
character.    Decomposition  sets in rapidly.  The blood  is dark-colored and
coagulates imperfectly.  Ecchymoses  may be found in the serous membranes
and in other  parts.   The spleen is often swollen  and soft.  Parenchymatous
degeneration of the liver, heart, and kidneys is  present.   The  solitary folli-
cles  and Peyer's  patches may be swollen.   Enteritis is less common in the
septicamia  of man than in  that  induced in  animals.   Multiple abscesses 
SEPTICEMIA AND PYJEMIA.
81
are absent.  There  may be  inflammation  of the  pleura  or  of other serous
membranes.
   Septicamia may be ushered  in  by a chill, but this is not constant, and
repeated chills do not occur.   There is, as a rule, a continuous, usually high,
fever without distinct type.  The skin is dry and  hot, or  at times there may
be  profuse perspiration.  There is usually a yellowish hue of  the skin, but
the icterus is not intense.  The pulse is small and frequent.   The tongue and
lips are dry.  Diarrhoea is inconstant.   The urine  is scanty and high-colored.
It  may  contain  albumen.   From  the onset the  patient is indifferent  and
apathetic.   There may be low delirium.   Death is preceded by stupor, and
frequently by decline of temperature.   The duration may vary from a day or
two to several weeks.  It is usually about a week.   It is supposed that septic
poisoning in a mild or moderate degree not infrequently  occurs, and ends in
recovery;  but in the cases in which the symptoms denote a grave affection
the proportion ending fatally  is very large.
   The principles involved in  the prevention of septicamia embrace especially
the treatment of wounds, for which works on surgery must be consulted.  The
different modes  of antiseptic dressing and  the open treatment of wounds are
the means which have  been most successful.   After the  symptoms  have
developed, large  doses of quinine and of  salicylic acid have been adminis-
tered, on the ground that they possess antiseptic properties.  Stimulants  are
required to support the strength of the patient.
   Pyaemia.—As the name denotes, pyamia was  originally supposed to be
caused  by the entrance of pus  into the blood.  The disease, however, is no
longer attributed to the  direct absorption  of pus-corpuscles.   The leucocy-
tosis frequently  observed in pyamia indicates increase of  white blood-corpus-
cles.  It may be considered as  established that pyamia is due to infection by
certain micro-organisms.  The leading anatomical characteristic of pyamia is
the presence of  metastatic abscesses in different parts of the  body.   We  now
know that suppurative inflammations  are almost always  caused by the inva-
sion of bacteria.   It is probable that severe chemical  irritants are also capable
of causing suppuration, but such irritants rarely come into  consideration in the
etiology of suppurations in human beings.   Of the different kinds of bacteria
which have been found in acute abscesses, those most frequently met with,
and most  important, are  various forms of Staphylococcus pyogenes and the
Streptococcus pyogenes.   The question arises whether the bacteria found in
pyamia are peculiar to this disease or  are identical with the bacteria of  ordi-
nary pus.   Contrary to what might naturally be supposed, the  evidence thus
far goes to show that the bacteria found in  the blood and in the pus of py-
amic patients are the  same as the bacteria observed in  ordinary abscesses.
The Streptococcus pyogenes,  either alone or  associated with Staphylococcus
pyogenes, is the  organism  which has been most frequently found in pyamia.
We must therefore believe that the same  organisms which  cause compara-
tively harmless local abscesses may also cause pyamia when they gain access
to the blood in sufficient numbers.
  Wounds and  surgical operations, especially those  involving  bone, are the
most  common causes of pyamia.  The  latter does not  occur  usually until
after  suppuration is established.   The discharge  from the  wound  becomes
thin and scanty, and there is oedema of the surrounding parts.   Pyamia fol-
lows also suppurative periostitis and osteomyelitis, puerperal endometritis, and
rarely other internal suppurations.  The affections included under the name
puerperal fever  embrace  both  pyamia  and septicamia.   Pyamia develops
most frequently  in hospital  wards and  in uncleanly surroundings.  Some-
times  no primary focus of suppuration or wound can be  detected.   The dis-
ease is then distinguished as primary or idiopathic  pyamia.
6 
82
GENERAL PATHOLOGY OF THE BLOOD.
   Especially characteristic of pyamia is the development of thrombosis of the
veins, either within or in the neighborhood of the parts affected with suppu-
rative inflammation.   These thrombi do not organize, but soften and give rise
to infectious  emboli.  The thrombosis  may be accompanied by phlebitis  or
inflammation of the wall of the vein, but this is not necessary.  The emboli
(except when the thrombosis is in some of the rootlets  of the portal vein) are
carried  first to the lungs, where they cause abscesses  which are  frequently
surrounded by hemorrhagic infarction or lobular pneumonia.  Abscesses may
be present also  in the spleen, the kidneys, the heart,  the  liver, the muscles,
and  other parts of the body.   These abscesses may be produced by emboli
derived either from the primary thrombus or from secondary thrombi formed
in the veins near the pulmonary abscesses.  There  is  also reason to believe
that secondary  abscesses may  be formed, independently of thrombi, by the
agency  of white blood-corpuscles and  of micrococci  which accumulate  in
small vessels of the  affected part.  Suppurative inflammation of the joints
and of serous membranes is usually present in pyamia.   Mycotic  endocar-
ditis is sometimes found.   There may be inflammation of the lymphatic ves-
sels (lymphangitis) and swelling of the lymphatic glands  near the primary
source of infection.   The spleen is usually swollen, and the same parenchy-
matous degenerations are present as  in other acute infectious  diseases.
Micrococci have been repeatedly observed in the blood and in  the abscesses.
Colonies of micrococci in the vessels and in the uriniferous tubes are  easily
recognized, as a rule,  in the early stages of the abscesses in the kidney.  The
blood usually is well coagulated, and there is less tendency  to rapid decompo-
sition than in septicamia.
   The clinical  history of pyamia is characterized  by repeatedly-recurring
chills, more or less pronounced, occurring irregularly  and  followed by pro-
fuse sweating.   Fever is persistent, varying, as shown by the  thermometer,
in different cases, the  greatest amount of heat being directly after the chill,
the mercury rising at  this time from 104° to 108°.  The skin becomes sallow
and  not infrequently  distinctly jaundiced.   The intelligence is but little  or
not at all disturbed.   There may be pain in the chest, with cough  and fre-
quent  respiration, and physical exploration may show pleuritis  with effusion,
or bronchial  rales with  broncho-vesicular respiration at different points on
either side of the chest or on both sides.   Pain may be felt in the knee and
other joints,  and effusion within the synovial membrane may be discovered.
At length persistent  collections, not preceded  by the usual  local symptoms
of phlegmonous inflammation—•' cold abscesses," as they are sometimes called
—may be found in different situations, sometimes in one or  more of the limbs
and sometimes on the  trunk.  The formation of purulent matter in these sit-
uations is sometimes extremely large.   Suppurative inflammation of the eye,
leading to sloughing and the evacuation of the humors, is an occasional event!
This has been observed chiefly in cases of pyamia following parturition.  The
affection in. most cases runs a rapid course, the duration being  from eight  to
ten days.  With less intensity  the  disease may continue  from two to four
weeks, and occasionally it becomes chronic, lasting for several months.   In
the latter case the duration depends on the secondary abscesses, which by
their continuance  become  properly  sequels  of the pyamia.  In the vast
majority of cases the  affection ends fatally.  Death  seems, in some  cases,  to
be attributable  to asthenia incident to the morbid condition  of the  blood  and
sometimes to the  secondary affections of the viscera.   In the cases which
recover the local effects consist  chiefly of subcutaneous purulent  collections
and arthritic suppuration.  The foregoing enumeration  of the leading symp-
tomatic events embraces points by means of which, generally, the discrimina-
tion of pyamia can be made without difficulty. 
ETIOLOGY.
83
  The indications  for treatment in pyamia are essentially the  same  as  in
septicamia.
  The prophylaxis embraces disinfectant measures of vast importance, with
reference to which surgical treatises are to be consulted.
                       CHAPTER  VIII.

             THE CAUSES  OF DISEASE,  OR  ETIOLOGY.

 Etiology a branch of General and  Special Pathology—Its Importance—Internal or
    Intrinsic and External or Extrinsic Causes—Ordinary and Special or Specific Causes—
    The terms Contagion, Infection, Miasm, Virus, Venom defined—Other Poisons belong-
    ing to Toxicology—Traumatic Causes—Spontaneous Diseases—Primary and Secondary
    Causes—Complications and Intercurrent Diseases—Predisposing and Exciting Causes-
    Congenital and Inherited  Predispositions  to  Disease—Co-operating or Accessory
    Causes—Diathesis—Cachexia or Dyscrasia—Endemic  Diseases dependent on Emana-
    tions from the Soil—Epidemic Diseases produced by Causes existing  in the Atmo-
    sphere—The Causes of Contagious Diseases exclusively derived from  those affected
    with these Diseases—Fomites—Portability of the  Special Causes of Diseases not Con-
    tagious—The Causes of Contagious and Infectious Diseases probably Living Germs or
    Organisms—Vegetable and Animal Parasites.

    ETIOLOGY is that  branch of medicine which treats of the causes of  dis-
      ease.  As one of the divisions of the Principles of  Medicine, or General
 Pathology, it treats of  causes with reference to diseases  considered, not indi-
 vidually, but in  groups, or to disease in general.   The  consideration  of the
 causes of  individual diseases  forms an important part of Special  Pathology,
 or the Practice of Medicine.  Etiology therefore enters into the range of top-
 ics belonging to the first and to the second  part of  the work.   Following the
 general  plan pursued in the foregoing chapters, I shall limit  myself here to
 certain distinctions and definitions which are to be understood as  preliminary
 to entering on the study of individual diseases, deviating from this plan only
 in making some remarks on the causation of diseases by living organisms.
   Knowledge of the causes  of disease is  important as the  basis of prophylaxis,
 or the prevention of disease.   It is obvious that in proportion as we are able
 to trace diseases to their sources we may expect to  extinguish causes or obvi-
 ate their morbific influence.  Knowledge of causes also is important as  enter-
 ing into the management of diseases, for it  not  infrequently happens that
 causes continue  to  be operative after disease  has  been produced, and their
 removal is of course a prime object in order to effect a cure.  It will be appar-
 ent, when  we come to inquire  into the causes of individual diseases, that  the
 amount of our  present knowledge  in  this  direction  is  limited.  Modern
 researches, however, have developed much information, and not a little  prog-
 ress has been made in the prevention of  diseases in consequence of increased
 knowledge of etiology ;  but  there yet remains a wide field for further develop-
 ments.
   Causes are intrinsic or infernal, and  extrinsic  or external.  Examples of
external  or extrinsic causes are infectious miasms, viruses, different poisons,
together with the many agencies of disease by means of wounds or injuries.
On the other hand, examples of internal or intrinsic causes are an accumula- 
84           THE  CAUSES OF DISEASE,  OR ETIOLOGY.

tion of urea in the blood, an excess of uric acid in gout, a morbific principle
in rheumatism, supposed to be lactic acid, etc.
   Among the internal causes belong those which originate  in the mind; and
these play an important part in the production of morbid phenomena.  Over-
exertion of the  faculties of the mind, mental application  unduly prolonged,
and intense or long-continued emotional excitement lead to disorders of the
nervous system, together  with more or less impairment of the  vital forces.
Insanity and  minor forms of mental derangement may not infrequently be
traced to these causes.  The bodily functions are weakened, partly from direct
influences pertaining to the nervous system, and in part because the operation
of  these causes involves neglect of hygienic conditions of health which relate
to diet, muscular exercise,  recreation, etc.  Long-continued mental depression,
whether produced by the causes just named or other causes, often stands in
a causative relation to disorders of digestion and  anamia.   An absorbing
sentiment or passion may induce  disorders by  leading to  neglect of the means
of  preserving health.  Finally, a  concentration of the attention on the bodily
functions, over-anxiety concerning  health, and a craving for  the interest or
sympathy which illness is expected to awaken in others are important elements
entering into many cases of disease, especially  in women.  The knowledge
and the tact of the physician are often called into requisition in estimating
the  agency of the  various  causes  referable  to the  mind.
   Causes may be distinguished as ordinary and  special or specific.  Ordinary
causes  are  those to which all persons are more or  less exposed.   Atmo-
spheric vicissitudes are ordinary causes.   They are generally supposed to be
involved very frequently in  the  causation of  disease and to give rise  to  a
great variety  of diseases.   Special or specific causes are  often extraordinary
in their occurrence ; that is, persons are exposed to them only at certain times
or in certain situations, and each cause gives rise invariably to one form of
disease.   The causes of typhus, smallpox, etc. are  examples of special or
specific causes.  The cause which produces periodical fever is not capable of
producing  typhus,  that producing typhus will never give rise to periodical
fever, and the same is  true of other causes belonging in this category.  The
existence of a special cause may  be inferred from the specific  character of a
disease, although the nature and  source of the causative  agent  are not under-
stood.  It  is  certain, for  instance, that diseases possessing phenomena  and
laws so distinctive and uniform as those which belong to the clinical history
of epidemic cholera, typhoid fever, yellow fever, etc. must each have its own
special  cause.
  In this connection may be defined the terms contagion and infection.  The
term contagion denotes a causative agent  (a contagium) produced in a person
affected with a particular disease, and capable of giving  rise to the same dis-
ease when introduced in the  body of another  person.  A contagium  may be
contained either in a palpable morbid product—for example, the contents of
a variolous  vesicle  or  pustule—or  in  the impalpable emanations from  the
body.   In the former it is  said to be fixed, and in the latter it is said to be
volatile.  A morbid product containing a fixed  contagium  is called  a vims.
An impalpable emanation  containing a contagium is, with  etymological pro-
priety, called  a miasm,  but the term miasm is  restricted by writers  at  the
present day  chiefly  to  those  impalpable causes of disease which originate
without the body, and  the  diseases to which they give rise  are distinguished
as miasmatic diseases.   A  familiar example of a miasm is the  special cause
of the periodical fevers, called malaria ; and these fevers are miasmatic dis-
eases.   The term infection  denotes  any causative agent which, under certain
conditions, is capable of unlimited increase or multiplication.  With this defi-
nition an infectious  disease  may or may not be communicable by means of  a 
TOXIC CAUSES.
So
 contagium.   If communicable, it is  an infectious  contagious disease;  if not
 communicable, it is an infectious miasmatic  disease.   Liebermeister proposes
 the name miasmatic contagious disecises for those which, as is supposed, require
 a causative agent produced within the bodies of persons affected, but an agent
 which it is requisite should undergo certain changes after having been thrown
 off from the body before becoming capable of giving rise to disease in others.
 Examples of diseases which  are thus distinguished  are  typhoid fever  and
 epidemic  cholera.   The  doctrine that the causative agent hi contagious dis-
 eases is a living germ or organism  (contagium vivum), and that  this is  also
 true  of  miasmatic  infections and  miasmatic  contagious diseases, will be
 referred to in the  concluding portion of this chapter.
   A contagious disease may be derived from an inferior animal.  Rabies, for
 example,  is derived  from the dog or cat, and glanders from the horse.   Dis-
 ease in man  may also be produced by the  introduction  into the system of a
 product from an inferior animal which, as regards the animal  furnishing it,
 is a normal  product.   Such  a causative  agent is a  venom.   The so-called
 venomous animals produce, physiologically, an agent which, received into the
 system of man or of another animal, gives rise  to  disease.   Thus, certain
 serpents and  insects  have special  glands furnishing  secretions which cause
 disease and even death when introduced  into the human body.  These secre-
 tions, normal as regards the animals  which furnish them, are Venomous.
   Various morbific substances which are  neither viruses nor venoms, not  giv-
 ing rise to either contagious  or  miasmatic diseases, are embraced under the
 name  poisons.  Their morbid effects are proportionate to the quantity of
 poison received into the system.   Here is a striking difference  as contrasted
 with viruses, the morbid effects of the latter bearing little or no proportion to
 the quantity received.   The number of these poisons is great,   Their study
 constitutes  an important  branch called  toxicology.   Examples are arsenic,
 lead, prussic  acid, etc. etc.   They offer differences  as  regards the gravity of
 their morbid effects.  Some are quickly fatal in a small quantity, as prussic
 acid, strychnine, aconite, etc.; others act more slowly and with less virulence,
 as mercury, lead, etc.  None of  these poisons increase within the body,  and
 hence the diseases to which they give rise are not communicable.
   The effects of these poisons are manifested in different parts of the body.
 Certain poisons exert effects  on  particular parts.  Thus, alcohol  and opium
 exert their effects on the brain, arsenic on the intestinal tract, strychnia on
 the spinal cord, mercury on the  mouth, phosphorus  on  the liver, aconite on
 the heart, etc.  Many, however,  act simultaneously on a greater or less num-
 ber of parts.   As regards their effects on the  blood, some are merely mixed
 or in solution, and act directly on parts to which  they are carried in the cir-
 culation.  Oxalic acid, arsenic, mercury,  lead, prussic acid, alcohol, etc. have
 been discovered in the blood.   In other instances chemical combinations take
 place in the blood.   A striking illustration of this is afforded by  one of the
 experiments  of Bernard.  Emulsin and  amygdalin are not poisonous sepa-
 rately, but they combine and form prussic acid.   Injected separately into the
 veins in different animals, they do  no harm.   If, however, they  be succes-
 sively injected into the veins of the  same animal, they combine in the blood
to form prussic acid, and the animal  dies  as if struck by lightning.  On the
other hand,  the blood prevents certain combinations which take place readily
out of the body.  An experiment of Bernard illustrates  this fact.   Cyanuret
of potassium and lactate of iron in combination form Prussian blue.  Injected
successively in the veins, they do not combine in the blood, but the combina-
tion takes place and  Prussian blue  is formed  after both have entered  the
urine or within the intestinal canal.
  It may  be added that  the terms contagion, miasm, virus, poison, are often 
86            THE  CAUSES OF DISEASE, 'OR ETIOLOGY.

used interchangeably, and  not according to the strict definitions which  are
given in the foregoing paragraphs.
  Certain causes are distinguished  as  traumatic;  and this name is applied
to distinguish the diseases produced by this class of causes.   A traumatic
cause gives rise to a local disease by acting in an appreciable  manner on  the
part affected.   Traumatic diseases are those thus produced.  Anything which
occasions an injury or wound of a part, and consequently disease of that part,
is a traumatic cause.   The name signifies a wound.  A bronchitis caused by
the inhalation of an irritating vapor is produced traumatically.  A  calculus
in the pelvis of the kidney  which gives rise to pyelitis, and  a stone  in  the
bladder which occasions cystitis,  are traumatic causes.   The causes thus dis-
tinguished, therefore, may be either internal or external, although in the great
majority of cases they belong to  the latter class.
  Diseases  not traumatic, and which do not proceed from any appreciable
causative agency, are said to be spontaneous or idiopathic.   The former term,
as thus applied, is to be taken in a conventional, not a  literal, sense.  It  is
obviously incorrect to  say of any disease that it  originated spontaneously.
Every disease must have its adequate determining cause.   But many diseases
are developed without  our being  able,  in the existing state of knowledge, to
refer them to their  causes;  and the term spontaneous, applied  to those dis-
eases, means simply that they proceed from causes which are unknown.  Pleu-
ritis, pericarditis, and other affections developed  frequently in  the course  of
Bright's disease were formerly considered as spontaneous ;  but now that their
development is attributable to the action of excrementitious principles accu-
mulating in the  blood, the term has ceased to be applicable to them.  The
number  of  so-called spontaneous diseases will diminish in proportion as our
knowledge of etiology advances.
  Causes are distinguished  as primary and secondary.   A secondary cause
is an  effect  of disease.  Urea, for example, accumulating in the blood, gives
rise to various local  affections—pleuritis, pericarditis, etc.   But  the accumu-
lation of urea is an  effect of some disease of the kidneys which interrupts the
eliminative function of these  organs.  Urea in excess in  the  blood is thus a
secondary cause of disease.   A primary cause, on  the  other  hand, does not
proceed from  a prior disease.  All  external traumatic causes, for  instance,
are primary.  The  same distinction is  made  among diseases;  that  is, some
are primary and others secondary—protopathic and deuteropathic.  Primary
diseases proceed from primary causes, and those  called  secondary are due to
the effects of pre-existing diseases; in  other words, to secondary causes.  A
large proportion of  the diseases the existence of which is first ascertained are
secondary.   They involve in their causations antecedent affections.  Not infre-
quently a number of diseases are  thus linked together in a consecutive series.
In the examination of patients, therefore, it is not sufficient to have discov-
ered a disease, but, having discovered one disease, it remains to  be ascertained
whether other  diseases do not exist sustaining  to the disease first discovered
a relation  either of cause or effect.    Clinical  researches have  developed
important facts with respect  to the causative relations  existing  between dif-
ferent diseases, and these facts are of great utility in medical practice.
  Secondary and subordinate diseases  are distinguished as complications.  A
complicating disease is one  which occurs in  the course of another  disease
with which it is supposed to  have  some pathological connection.  Pneumo-
nitis,  for example,  developed in  the course of typhoid or typhus  fever  is
a complication of the  latter.  Pneumonitis generally has a  complication__
namely, circumscribed  pleurisy.  A disease  is said to be  intercurrent when
it occurs  during  the  progress  of another  disease, without  necessarily 
PREDISPOSING AND EXCITING  CAUSES.            87
 having any dependence on the  latter.  Lobar pneumonitis, for example,
 occurring  in a  patient affected  with pulmonary phthisis, is an  intercurrent
 affection.
   As just^stated, causes  of  disease may be themselves effects of disease, so
 that certain diseases  may be  said to  stand  in a causative relation to other
 diseases.   On the other hand,  some diseases  afford  protection against others.
 As an illustration, emphysema of the lungs  and  pulmonary phthisis  may be
 cited.   The latter disease  occurs  in  patients affected with the former so
 rarely as to show that it exerts  a protective influence.   Another  illustra-
 tion is afforded by disease  of the heart and pulmonary phthisis.   A phthis-
 ical affection occurs so rarely when cardiac disease occasions much disturbance
 of  the circulation that the latter must  be considered as affording more or  less
 exemption from the former.
   Another division  is into  predisposing and exciting causes.   Predisposing
 causes induce a liability  or  tendency to  certain forms of  disease.  Exciting
 causes, acting on persons already predisposed to certain  diseases, determine
 their occurrence.  Predisposing  causes may be alone sufficient to give rise to
 disease, or they may  only suffice to place the system in a condition favorable
 for the occurrence of disease.  In the  latter case  the disease occurs when
 exciting are superadded  to  the predisposing causes.   To  cite  an  instance:
 A person under the  influence of  predisposing causes is in a condition favor-
 able for the occurrence of acute rheumatism  ; in  this condition he is  exposed
 to  atmospherical  vicissitudes, and the  latter  determine an  attack of this  dis-
 ease.  The exciting  cause—namely, the atmospherical vicissitudes—would
 not, alone, have been adequate to  give rise to an  attack of rheumatism ;  and
 the former—namely,  the predisposing causes—alone  might have been inad-
 equate, but conjointly they  occasion this disease.   Exciting causes  act  the
 part of the match when everything is ready for an explosion.  It is thus seen
 that predisposing  causes  determine the  nature of the disease,  and exciting
 causes the date of its occurrence.
   A predisposition to some  form of disease may be inherent in the constitu-
 tion, or congenital.  Some persons have inborn tendencies to certain diseases.
 This fact  is strikingly illustrated  by the  occurrence of phthisis successively
 in  different members  of  the same family, a large  number of brothers  and
 sisters being carried off by this disease.   This congenital predisposition may
 remain completely latent  until the period of  life in which the disease is most
 liable to be developed; and we sometimes see a whole family of children,  one
 after the other,  fall victims to this disease when they severally reach a certain
 age.  A predisposition to  certain forms of disease may not only be congenital,
 but inherited,  and a  constitution involving  a tendency to disease is trans-
 mitted from parent to offspring.   Among the diseases perpetuated  in this
 way are  phthisis, gout, cancer,  asthma, and syphilis.
  The predisposition  to a disease, whether congenital  or  acquired,  may  be
 strong or feeble.  Various  circumstances may act  as co-operating or  acces-
 se>ry causes; that  is,  acting  in conjunction with the constitutional tendency.
 Thus, in  a person predisposed to phthisis the development of this  disease
 may be greatly promoted by  unfavorable hygienic  circumstances, such  as
 sedentary habits,  deficient ventilation, and inadequate  alimentation.   These
 co-operating causes, in conjunction with an existing predisposition, may serve
 to develop the  disease when, without their aid, the predisposition might  not
have been sufficient.   There is  reason to believe  that persons with  a feeble
predisposition to this  disease often escape if they be exempt from the opera-
tion of co-operating  causes.   The  latter, moreover, are to a greater  or  less
extent controllable, while the  predisposition, especially if it be congenital, is
beyond control.    Diseases thus  are preventable, notwithstanding a predis- 
88            THE CAUSES OF DISEASE,  OR ETIOLOGY.

position to them, in so far as they depend on the union of co-operating causes.
Herein lies a truth of great practical importance.
  Diseases which originate from special causes often  appear to require for
their  production co-operating  causes.   Facts  seem to  show, for example,
that yellow fever, periodical fevers, and epidemic cholera, which undoubtedly
involve the agency of special causes, would in many cases not have occurred
had not other than the special causes contributed to their  production.   By
eradicating, as far as possible, all unfavorable hygienic influences, special
causes may be  rendered, to a great extent or perhaps completely, inopera-
tive.  The special causes we may not be able to remove;  but co-operating
causes are to  a great extent within our  control, and by removing the latter
the diseases are rendered  preventable.
  A constitutional predisposition  to a particular form  of disease constitutes
what  is called a diathesis.  A diathesis, therefore, may be either congenital
or acquired;  and the  diseases  which  are considered as  generally, if  not
always, involving a constitutional predisposition, or diathesis, are sometimes
distinguished  as diathetic diseases.  A cachexia or dyscrasia  involves a diath-
esis, and sometimes  more.  These terms denote  not merely a constitutional
predisposition to  disease,  but that condition of  the  system  which  exists
when the  disease  is  actually developed.  A person born with a  tendency to
phthisis,  for  example, has the phthisical  diathesis, and this diathesis event-
uates in  the tuberculous cachexia when the  person becomes  affected with
phthisis.
  The term vulnerability has been of late applied to a condition of the system
favorable for the morbific operation of any  causes, either ordinary or specific.
The sense of this term differs from that  of  predisposition, the latter denoting
a tendency to a particular form of disease, whereas vulnerability denotes a
susceptibility  to all morbific  agencies.  Vulnerability  thus, in contradistinc-
tion to predisposition, does not determine the nature of the diseases produced
by different causes.   The term vulnerability, in fact, means  neither more nor
less than a general susceptibility to the causes of disease.
  Our present knowledge, for the most part, of the special or specific causes
of disease  is based on logical  inference rather than on  demonstration ;  but
certain conclusions respecting their  origin and  diffusion  may be logically
determined.   One of  these  conclusions  is  that  some  morbific  agents
(miasms)  emanate from the  soil.  This  may be inferred  with respect to
the special causes giving rise to diseases  called endemic.  Endemic diseases
are those which prevail within circumscribed territorial limits;  that is, their
prevalence does  not  extend  beyond  sectional boundaries.   Now, this fact is
sufficient for the inference that the source  of  the  causative miasms is in the
soil, because, of  the elements which enter into climatic  influences, those pecu-
liar to any particular district are terrestrial.   Again, in the diseases called
epidemic—namely, those  which  prevail  successively  or simultaneously, at
variable intervals, in  different  and often widespread territorial  districts—the
morbific  agents, whatever  may be their source, must be transported through
the atmosphere or brought in some way from situations more or  less distant.
The causes of epidemic disease are migratory.  In some instances they trav-
erse successively almost every portion of the habitable globe.   This  is  true
of epidemic bronchitis, or influenza, and of epidemic cholera.  It is altogether
improbable that the  special causes in these and other  epidemics  originate in
the different sections  of country over which their prevalence extends.   Dis-
eases  are  said to be  pandemic when they  are  spread  simultaneously over a
whole country or population.  The special causes which give rise to conta-
gious diseases are derived from the bodies of those affected with these  dis-
eases ; and with respect to certain of these diseases  it is  probable that the 
PARASITES.
89
special causes are exclusively thus derived. It may fairly be doubted whether
smallpox  ever originates from any other source, notwithstanding the occur-
rence of cases in which it cannot be traced to contagion.   Yet the first case
of smallpox  which ever  existed must, of course, have  been an exception to
this  law,  and it is possible  that there  are still occasional  exceptions.
   Diseases are communicated not only by coming into contact with, or in
proximity to, patients, but by means of what are called fomites.   This term is
applied to inanimate substances, such as clothing or articles of merchandise, to
which contagious matter has adhered.   In this way certain  diseases, such as
smallpox  and  scarlatina, may be disseminated at points far  distant from the
source of their special causes.  The term fomites is generally restricted to the
transmission  of the matter of contagion.  But it is certain that other special
causes of disease may be transmitted in the same way.   Facts, for example,
show that the special cause of yellow fever is capable of transportation.  And
if this be  true, it is correct to say. that a disease may be portable although not
communicable.


                               Parasites.
   The study of parasites has acquired great interest and prominence since it
has been proven that many and important diseases are of parasitic origin.  It
has long been a logical inference that the infectious diseases are caused by the
invasion of micro-organisms.  The hypothesis of a living contagion was most
skilfully advocated upon a priori grounds by Sir Henry Holland, Henle, and
J. K. Mitchell.  Only upon this hypothesis  can be satisfactorily  explained
such characteristic features of infectious diseases as the period of incubation,
the development of the disease from the reception of an  infinitesimal quantity
of virus,  and the almost limitless multiplication  of the virus, so that the mi-
nute quantity received by a single individual, by its proliferation, may suffice to
infect an  entire community.   It  was once urged against  the theory of animate
contagion that the causation of infectious diseases might be explained by the
action of chemical ferments; but this argument has turned  to the advantage
of the germ  doctrine, since it has been  proven that the ferments either are, or
are produced by, living organisms.
   The purely deductive  argument  as  to the causation of infectious diseases
by living germs has  been supported during the last twenty, and  especially
during the last ten, years by a mass of trustworthy observations and experi-
ments which render the doctrine  of a living contagium no longer a theory, but
an established fact for a number of infectious diseases.   Upon this basis of
facts the  argument by analogy becomes  of great  force in support of the germ-
origin of other infectious diseases in which causative organisms have not  yet
been discovered.
   What is necessary in order to prove that  a given  disease is caused by  a
special micro-organism ?  This proof is  absolute and complete when for a given
disease three conditions are fulfilled:  first, the determination of the constant
presence of a special micro-organism associated with the  lesions of the disease ;
second, the isolation of this organism by a series of pure cultures;  and third,
the  production of the disease  by the inoculation of the isolated  organism.
This rigid proof has been fulfilled for splenic fever, tuberculosis, glanders,
erysipelas, and a number of diseases of inferior animals.   Hardly less com-
plete is the proof that the spirochatte Obermeieri is the cause of relapsing fever.
Here the organism is of a peculiar character, is constantly present in  the blood
in the paroxysms of  the disease, and the inoculation  of blood  containing  the
parasite causes the disease.   Inasmuch as one or both of the last two condi-
tions of the  absolute proof cannot always be  fulfilled—since it  is not possible 
90           THE  CAUSES OF DISEASE, OR ETIOLOGY.

in all cases to find a suitable medium for the cultivation of suspected organ-
isms, and inoculation experiments upon animals yield negative results when
the animals are not susceptible to the disease—the question arises as to the
value to be attached to  the mere presence of micro-organisms in the lesions of
a given disease.   The answer is, that when a special form of micro-organism
is constantly found associated with the lesions of a disease in situations where
foreign organisms do not normally occur, there can be very little doubt that
the organism is the  cause  of the disease.  In opposition to this view it  has
been and is still urged  that the organism is  the result, and not the cause, of
the disease—that the disease simply  affords  suitable conditions for the lodg-
ment and  growth of the  organism.   This  argument was  not  without some
plausibility in the early period of bacterial investigation, but the force of the
argument has been greatly impaired by the failure to establish its correctness
in any single instance;  while, on  the other  hand, whenever it has been pos-
sible to cultivate  and  inoculate a special form of micro-organism  constantly
associated with the lesions of a disease in situations where foreign organisms
do not occur, the suspected organism has been proven to be the cause of the
disease.  Thus, it is reasonably certain that the bacteria which are  found con-
stantly in the internal  lesions of typhoid fever are the cause of this  disease,
although no animal  may be found in whom it it possible to produce this  dis-
ease experimentally.
   Especial caution is required in drawing conclusions from the presence of
organisms upon  surfaces in communication with the exterior of the body, as
upon the various mucous membranes; for upon many of these surfaces bacte-
ria are normally present in large  number.    But even  here, when it can be
established, as in the case of the bacterium  of Asiatic cholera, that an organ-
ism with distinctive  characters is constantly associated with the lesions of a
disease, and is never found in  the body except in  connection with that dis-
ease, it may be assumed that this organism is the cause of the disease.
   Bacteria.—The  living  organisms which  have thus far been  proven to
be the  causes of infectious diseases belong for the most  part  to the class
of schizomycetes  or bacteria.   The term bacteria is used, although not with
etymological correctness, to include the whole class of organisms more scien-
tifically designated as schizomycetes (fissure-fungi).  It is  not  necessary to
suppose that all infectious  diseases are due to bacteria; it  may be that  other
organisms, such as some of the Protozoa, are concerned in  the causation of
certain  diseases.
   The bacteria  are simple, microscopic, vegetable cells, usually very  minute,
composed of protoplasm and perhaps  an enveloping membrane.  In shape the
bacteria are round, rod-like, or spiral.  They occur singly, in pairs, in chains,
or in clumps.  Clumps of bacteria imbedded in  a  gelatinous substance  are
called colonies or zooglcea, and they present an extremely characteristic  appear-
ance.  Bacteria  multiply, often with  great rapidity, by transverse  division or
by the formation of  spores.  The spores are  vastly more resistant to destruc-
tive  influences than the bacteria themselves.   Both bacteria and spores are
destroyed by  steam  at  a temperature of 100°  C. (212° F.).
   It is not possible  at  present to make any satisfactory classification  of bac-
teria.  For purposes of description Cohn's  classification is  convenient  viz.:
first, round bacteria, called sph aero-bacteria or micrococci; second,  short rod-
shaped bacteria, called micro-bacteria ; third, longer rod-shaped bacteria called
desmo-bacteria or  bacilli;  and fourth, spiral  bacteria, called spirilla and
spirochata.  These  four classes may be reduced to three by eliminating the
term micro-bacteria,  and calling, as is now customary, all rod-shaped bacteria
whether long or short, bacilli.
   In order to determine the species  of a particular kind of bacterium it is 
PARASITES.
91
necessary to know not only its form, but the manner and  conditions of its
growth  and its  physiological properties.  Nothing could  be more erroneous
than to suppose that because two bacteria resemble each  other, or are even
identical in form, they are therefore of the same species.  One of these bac-
teria may be perfectly harmless and the other a deadly poison.  The criteria
which are usually employed, as far as possible, in determining the characters
of any form of bacterium are—its morphology, the peculiarities of its growth
in different culture-media, such as nutrient gelatin, agar-agar, blood-serum,
steamed potato,  bouillon, and its physiological properties, such as presence or
absence of injurious effects by inoculation in animals, and presence or absence
of fermentative changes by inoculation in suitable fluids.
   According to  their biological  properties bacteria are described as chromog-
enous,  or  color-producing ; zymogeuous, or  fermentative ;  and pathogenic, or
disease-producing.   The  only kinds of bacteria which will  be considered in
this work are the pathogenic, and of these only such as are  concerned in the
causation of diseases in human  beings.  Some of these bacteria will  be fur-
ther considered in Part  II. of this work in connection with the  diseases in
which  they are found.
   The Micrococcus gonorrhoeae,  sometimes  called  gonococcus, is constantly
present in gonorrhoeal  secretions, whether derived from  the urethra, vagina,
uterus, or  conjunctiva.   Usually two micrococci are closely joined together,
forming a diplococcus.   The diplococcus may resemble  a single biscuit-shaped
micrococcus of  large size. The gonorrhoeal  micrococci may be found between
the cells, but their most characteristic morphological property is their appear-
ance in the interior of pus  and epithelial  cells.   According to  Bunim, the
gonococcus grows slowly at a temperature of 30° to 34° C. upon  gelatinized
blood-serum.  He succeeded in producing  gonorrhoea by inoculation of the
urethra with a pure culture  of  the organism.   Further inoculation and culti-
vation experiments are needed, although there can be little doubt that the
organism is the  cause of gonorrhoea.
   The micrococci of pus occur singly  or in   irregular  clusters called  staphy-
lococci or in chains called streptococci.   A  variety of  species have been dis-
tinguished, chiefly by the appearances of  their cultures.   The  forms most
frequently found in the pus  of acute abscesses are the Staphylococcus pyogenes
aureus and the Staphylococcus pyogenes (dims. Next in frequency is the Strep-
tococcus pyogenes.   No less than nine different species of micrococci in pus
have been  distinguished.  Frequently, two  or more forms  of micrococci are
associated  in  the same abscess.   The streptococci seem to occur especially
with the more severe phlegmonous inflammations,  such as those with an ery-
sipelatous tendency.   The micrococci of pus can be cultivated in gelatin and
in ao-ar-agar.  By the inoculation of  some  of the pure  cultures  in  animals
and in  human  beings  abscesses have been  produced.
   The micrococcus of erysipelas is a streptococcus which  can be-cultivated in
nutrient gelatin.   Inoculation of its pure  cultures in man and  in  animals
causes erysipelas.    According to Passet, a  streptococcus found in abscesses
cannot  be distinguished from  that of  erysipelas.
   The micrococci of osteomyelitis seem to be identical with the staphylococci
and the streptococci of ordinary abscesses.   As has already been mentioned
(p. 81), the same is true of the micrococci found in pyamic  abscesses.
   In fetid pus, bacilli are usually found as well as micrococci.  In malignant
endocarditis, micrococci apparently identical with Staphylococcus pyogenes and
Streptococcus pyogenes are found.
   In many  infectious diseases, such as scarlatina, variola, morbilli, diphtheria,
typhoid fever, and acute  yellow atrophy of  the liver, micrococci are found
occasionally, but not constantly.  There is no evidence that these micrococci 
92            THE CAUSES OF DISEASE,  OR ETIOLOGY.
are the cause of the diseases.  These septic micrococci, when  they occur in
the internal organs, are probably the result of a secondary or mixed infection
which seems to be common in this class of diseases.
   The bacillus anthracis  occurs  in  the form  of  immobile rods 5 to 20 p
long  and 1  p broad,  with  flattened ends, and often arranged  in chains.
Within the body the rods multiply  solely by transverse division, but outside
of the body they may grow into  long threads in which glistening spores are
developed.  The spores are very  much more resistant  to  destructive  agents
than the bacilli.  The bacilli and spores are incapable of development  at a
temperature below  15° C. (;V.»° F.) or above 43° C. (110° F.).  They require
oxygen for their growth.   The bacilli anthracis  are constantly found  in  the
body  in  splenic fever.  They can be  readily cultivated outside of  the body
in nutrient gelatin  and in various other media.   Inoculation of the pure cul-
tures in animals susceptible to splenic fever always produces the disease.   By
cultivation of the bacilli  of splenic  fever at a temperature of 42° to 43° C.
(107.5° to 109.5° F.), their virulence may be weakened or entirely destroyed,
although the organisms still retain their normal appearance and capacity of
development.
   The bacillus of typhoid  fever is a  short, thick  bacillus with  rounded ends.
It is found in colonies in the intestinal lesions, the swollen mesenteric glands,
the spleen, and sometimes in other organs.   It can be  readily cultivated in
nutrient gelatin,  agar-agar,  blood-serum, and on potatoes.   This  organism
will  be fully considered  in the  article  on Typhoid Fever.
   The bacillus of malignant  oedema  resembles  the bacillus anthracis, but can
be distinguished from it  by its mobility and  by  slight differences  of form.
Its spores are widely distributed, occurring in earth, hay-dust, and putrefying
fluids.  It has been found in a few  instances in  man as the cause of a fatal
inflammatory oedema.   This bacillus can be cultivated in gelatin, blood-serum,
agar-agar, and in potatoes under circumstances where the entrance of oxygen
is excluded.   Inoculation of the cultures in animals causes the characteristic
disease.  The growth of the organism is attended by the development of gas
and fetid substances, which probably poison the system.
   The bacillus of rhinoscleroma is a short bacillus constantly  found in the
peculiar hard growths  of this disease,  which has  been  observed especially in
South-eastern Europe.  Cultivation  and inoculation of  the bacillus  have not
yet succeeded.
   The so-called bacilli of croupous  pneumonia are elliptical  bacteria  which
were first described by Friedliinder as micrococci.  A characteristic  but not
peculiar  feature of these  bacilli  is  the presence  around them of  a  gelat-
inous capsule which can  be stained  by certain aniline  dyes.   These  bacilli
are frequently but  not constantly present in the  exudation  of lobar pneu-
monia.  They grow in gelatin-cultures in masses compared in shape  to a nail.
Pneumonia, usually of the lobular variety, has been produced  in  animals by
inhalation of the organisms and by inoculation in the pleura and lungs.   The
inoculation experiments, however, are not very conclusive.  In view of  this
fact, and in view of the inconstancy  in the presence of these  bacilli, there is
much doubt as to the etiological  significance of the organisms  described  by
Friedliinder.   The  micrococcus of sputum septicaemia (Sternberg) and other
forms of bacteria have also been  assigned as the cause  of pneumonia.
   Under the heading  of Infectious Tumors (p. 42) mention has already been
made of the bacilli of tuberculosis,  of leprosy, of syphilis, and of  (/landers.
The  tubercle bacilli will  be also considered in  connection with  Pulmonary
Phthisis.  The bacilli of cholera,  which by some  are considered to be spirilla
or vibrios, will be described in connection with Asiatic cholera in Part II.
   The spirocheete Obermeieri is a spiral bacterium 16 to 40 p. long.   It is 
PARASITES.
93
constantly present in the blood during the attacks of relapsing fever, and is
absent in the intervals.   In the fresh blood it is in rapid motion.  The inocu-
lation  of  blood containing the  organism produces relapsing fever.   The
spirochate has not been  satisfactorily cultivated.   (For further details  see
the article on  Relapsing  Fever in Part  II.)
  The peculiar organisms found in actinomycosis have already been described
(p. 47).  Mention  has  also  been made of the bodies found by Laveran, and
by Marchiafava and Celli, in  the blood of malarial patients, which  will be
further considered in the  article  on  Intermittent Fever.
  There are various possibilities as to the  mode of action of bacteria in  the
system, but we possess very little  positive information upon the subject.   It
has been  suggested that pathogenic  bacteria  may produce  their injurious
effects by withdrawing nutriment from the cells and tissues of the body, by
acting as  ferments which cause abnormal metabolism and produce noxious
substances (ptomaines), and by acting as  chemical or as mechanical irritants.
  Fungi.—Mould-fungi belonging to the common species, mucor, aspergillus,
and penicillium, are not infrequently found growing in  necrotic  tissues ex-
posed to the air.   The spores  of certain varieties of mucor and of aspergillus
when injected  into the blood of animals  are capable of growing in certain
organs into mycelium, but the development never reaches the stage of fructi-
fication.  No  instances are known of a similar invasion of the human  body
with the mould-fungi.   In a number of diseases of the skin, fungi have been
discovered which constitute an essential  pathological element in these affec-
tions.   These fungi are Achorion  Schoenleinii in favus, Tricophyton tonsurans
in herpes tonsurans, and  Microsporon furfur  in pityriasis versicolor.   The
botanical position  of these fungi is not known.   The fungus found in aphtha
or thrush is called Oidium albicans, but there is doubt as to its being a true
oidium.
   The yeast-fungi, called saccharomyces,  are  often  found  in the fermenting
contents of the stomach in various diseases of  this organ.  These  fungi  are
concerned in alcoholic fermentation.
   Animal Parasites.—The animal parasites belong to the three divisions
Protozoa, Arthropoda, and Vermes.
   1.  The  Protozoa  are the  most lowly   organized members  of the animal
kingdom.   The Infusoria, which form a class of Protozoa, have been observed
frequently in the  contents of  the intestine, especially in cholera and in inflam-
matory conditions of the mucous  membrane.   It has not  been  proven that
they are in any way associated with.the cause of disease.   The Infusoria
most  frequently found are  Cercomouas intestinalis} Trichomonas vaginalis,  and
Paramacium  coli.  Amoebae  have been  found occasionally in the intestinal
contents in dysentery.  The  Psorospermiae, which  have been found  in  the
liver, in pleuritic  exudations, and in the intestinal mucous membrane, are
usually classified among the Protozoa, but tb<e"ir exact nature is problematical.
They have been recently described as Coccidia.
   2.  The arthropod parasites include animals from the subdivisions Arachnida
and Insecta, which infest usually  the skin.   To the Arachnida belong  the
Aearus folliculorum, frequently found in comedones, but without pathological
importance; the Aearus or Sarcoptes scabiei,  which is the cause of the disease
known as scabies or itch ; the Pentastomum  constriction and the Pentastomum
deuticulatum, which have  been frequently discovered'  in the liver.  Under
Insecta are included the different species of lice—viz. Pedicidus capitis, Pe-
diculus pubis, and  Pedicidus vestimenti.
   3.  Animals of the division  Vermes, or  worms, are the most frequent of all
animal parasites.   The parasitic worms are embraced under the subdivisions
Nematoda or round-worms, Trematoda or suctorial worms, and Cestoda or Tse- 
94         SYMPTOM A TOL 0 G Y.—DIA GNOSIS.—PR 0 GNOSIS.

niada, which include the tape-worms and the old order of cystic worms.  The
Nematoda are Ascaris lumbricoides, found often in the small  intestine ; Oxy-
uris vermicularis, vulgarly known as the  pin-worm, found in the large intes-
tine ;  Tricocephalus dispar, in the  cacum ;  Strongylus gigas, in the pelvis of
the kidney; Anchylostoma duodenale, in the duodenum ; Anguilhda stercoralis,
in the intestine and bile-ducts  in an endemic diarrhoea which prevails  in
Cochin-China;   Trichina  spiralis,  in the  muscles;  Fiiaria mediuensis,  or
Guinea-worm, in  the areolar tissue, where it  causes painful abscesses  (in
tropical climates); Fiiaria sanguinis, found in  the tropics in large numbers
in the blood, where it may cause chyluria and hamaturia.   Under Tremadota
are included Distoma hepaticum  in the biliary ducts; Distoma lauceolatum, or
liver-fluke, in the same situation ;  and Distoma haematobium  (of Bilharz) in
the portal vein, and, together with its eggs, in other situations, especially the
kidneys, bladder, and intestine, where it may  cause severe  affections.  The
Distoma haematobium is a frequent parasite in Egypt and in Abyssinia.  The
Cestoda include the  fully-developed tape-worms and their larva; or scolices.
The immature  cestoid worms or scolices  which are parasitic  in man are Cys-
ticercus cellulosae, the scolex of Taenia solium; and the echinococcus or hydatid,
the scolex of Taenia, echinococcus, a small tape-worm which  infests the dog.
 Cysticercus cellulosae may be present in any part of the body.  It is of most
importance usually in the brain.   The echinococcus is most frequent in  the
liver, but it may exist in other parts.   The fully-developed tape-worms  in
man  are  Taenia solium, Taenia medio-cane/fata,  and Bothriocephalus latus,  or
Swiss tape-worm.  Rare  forms are Taenia  nana,  Taenia filavo-puncfata, and
 Taenia  cucumerina.   Most  of  these worms receive  consideration in Part
II. of this work.
                        CHAPTER  IX.

         SYMPTOMATOLOGY.—DIAGNOSIS.—PROGNOSIS.

Pathognomonic Symptoms—Diagnostic Symptoms—Subjective and Objective Symptoms
  —Signs—Clinical History of Diseases and the Different Modes by which it is Obtained
  —Stages of Disease—Precursory or Prodromic Events—Sequels—Diagnosis—Reasoning
  by Way of Exclusion—Differential Diagnosis.—Prognosis—Prognostics.

   THE study of the symptoms of disease forms a division of the Principles
    of Medicine, or General Pafhology, called Symptomatology or Semeiology.
The consideration  of symptoms  will occupy a large proportion of the space
to be devoted to each  individual disease in  treating of the  Practice of Medi-
cine, or Special Pathology, in the second part of this work.  It will suffice to
present in this chapter certain distinctions  and  definitions which should be
understood before  entering on the study of individual diseases.
  Under the name symptoms are embraced all appreciable morbid phenomena
occurring in connection with disease.  The  name signifies " to fall together,"
and denotes concurrence of events.   To repeat the often-quoted comparison
by Galen,  symptoms accompany  diseases as  the shadow follows the substance.
By means of symptoms the existence of disease is  made  apparent and the
character  and seat of different  affections are ascertained.
  Certain  symptoms are  distinguished as pathognomonic.   A pathognomonic 
SYMPTOM A TOLOG Y.
95
symptom is one which  denotes  invariably the existence  of a particular dis-
ease.   It derives this significance from the fact that it occurs only in connec-
tion with one disease.  Whenever such a symptom, therefore,  is present, it
represents that disease,  and in itself suffices for its recognition.   The number
of pathognomonic symptoms is quite small.  As an illustration, a semi-trans-
parent, viscid, rusty-colored  matter of expectoration belongs exclusively to
pneumonitis.  It is therefore  a pathognomonic symptom, always  denoting
the existence of that disease.  In like manner the  crepitant rale obtained by
auscultation is so  distinctive of the same  disease as to be nearly pathogno-
monic.  It would be difficult to cite many  additional examples.
   A symptom is said to be diagnostic when it occurs more frequently in con-
nection with a particular disease than with  other diseases.  Just  in proportion
as it is restricted to a few diseases is  its diagnostic import marked; that is,
it denotes the presence  of some  one of these diseases, and its value in diag-
nosis is the greater the smaller their number.  Different symptoms differ as
regards their  respective diagnostic  value.   Some  are  highly diagnostic ; in
other  words,  they point  strongly to the existence of  particular  diseases.
Others are moderately, and  again  others  slightly, diagnostic.   The measure
of diagnostic significance depends on  the frequency of concurrence with  a
particular  disease  and  the infrequency of concurrence with other diseases.
   Symptoms are either subjective or objective.  Subjective symptoms  are those
which relate to the sensations  or  feelings of the patient, and  which, conse-
quently, the physician  can appreciate only through the patient's description
of them.  Objective symptoms, on the other  hand, are those which the physi-
cian observes for himself,  and for a correct appreciation of which he is in no
wise  dependent on the patient.   As regards  subjective symptoms, the physi-
cian is exposed to  error in consequence of inability on the part  of the patient
to describe  them  clearly.   In  young children this class of symptoms is not
available.   This is true  also of idiots, the insane, and in the  delirium inci-
dent to different  diseases.  As regards these  symptoms, too,  the physician
is liable to  be  deceived  by intentional misrepresentations on the  part  of
patients ; and he  is liable to be deceived unintentionally by a tendency on
the  one hand  to  exaggeration, and on the other hand to depreciation  of
morbid sensations or feelings.   Owing to  these sources  of error much tact is
often  requisite in  placing a proper estimate on subjective symptoms.  Objec-
tive symptoms are not open to the same  liabilities to error.   The physician
 judges of these by the exercise of his own  senses, and if he fail to discover
or place a  proper  estimate upon them the fault consists in his own want of
attention,  judgment, or  skill.   Objective  symptoms are thus much  more
reliable than subjective  in  the investigation of cases of disease.
   The exaggeration of pain or suffering  of any kind and of  morbid  sensa-
tions is common—sometimes because patients are led to form an exaggerated
idea of their subjective symptoms; sometimes with a view to awaken interest
or sympathy ; sometimes for malingering  purposes ; and sometimes to secure
areatcr attention  on the part of the physician  and more efficient treatment.
Factitious and exaggerated  ailments enter pretty largely into the cases which
the practitioner is  called upon  to treat.
   A symptom, as already defined, is  any manifest morbid  phenomenon  or
event. Occurring concurrently with a disease, it  may or may not have a
pathological connection with that disease.  Its  pathological connection with
the  disease may be  such as to render it a pathognomonic symptom  or  more
or less diagnostic; and, on the  other hand, it may be present as a mere coin-
cidence.  If the latter be true, it has no  pathological  connection with the
disease, and  is devoid of diagnostic  significance.  This difference among
symptoms has  been expressed by calling them signs when  they are either 
96          SYMPTOMA TOLOG Y.—DIAGNOSIS.—PROGNOSIS.

pathognomonic or more or less  diagnostic.   According to this distinction, a
symptom becomes a sign whenever it denotes, in a greater or less degree, the
existence  of a particular  disease.   The  term signs, however, has come con-
ventionally to be used in a different sense.   It is usual to apply this term to
the phenomena obtained by certain methods of investigation distinguished as
physical—namely, percussion, auscultation, etc. These phenomena are called
physical signs, but for convenience the word  physical is often omitted, and is
considered as understood when the term  sign is alone used.  In this sense of
the term signs it is used in contradistinction to symptoms, the latter embracing
all other phenomena manifested in connection with disease.  The phenomena
thus included under the name signs are of course objective, and will be found
to be the most reliable of those by means of which the  existence, seat, and
character  of certain diseases are  ascertained.
  The symptoms and  signs which occur during the  course  of a disease are
the events which make up its clinical history.   This phrase is applied to  a
description of the manifest phenomena taking place from the beginning to the
end of  a disease, together with the order of their  succession and  the laws
which govern them.   Or, instead  of clinical history, it is proper to say the
natural history of a disease  when the disease is allowed to pursue its course
unaffected by disturbing influences of any kind, and when  no attempt is made
to arrest, abridge, or modify its course by therapeutical measures.
  How is the clinical  or natural history  of a disease to be obtained ?  There
are three methods which may be employed.  One method consists in selecting,
as types of the disease, a few well-marked cases, and basing the description of
the disease on the events observed in these cases.   This method is defective,
because some symptoms belonging to the disease might be wanting, and some
symptoms not belonging to  the disease  might be present in these few repre-
sentative or typical cases.   Moreover, this method is inadequate to show the
relative importance of particular symptoms.  Another method is to make out
a history from recollection after having observed a greater or less number of
cases.   A history thus obtained must be  imperfect from the obvious inability
to retain in the memory all  the  events which occurred  while the cases  were
under observation, together  with  the order  and  relative  frequency of their
occurrence.   The third method is  the only one by means  of which  an accu-
rate clinical  history of a  disease is  to be  obtained.  It consists, first, in the
accumulation of a certain number of cases fully and carefully recorded; and
second, in  an analysis of the recorded cases with reference  to the symptomatic
phenomena  which occurred, the relative frequency of their occurrence, the
order of their succession,  the number of  deaths and  recoveries, the duration
of the  disease, etc.  By this method are ascertained events  which are con-
stantly  present, and therefore have an essential relation to  the disease; events
which are incidental to the disease, being  present more or less frequently ; and
events the presence of which is purely accidental.   There are  many diseases
which have not, as yet, been sufficiently studied after this method, and here.
therefore, is ample scope for further clinical labor.  Among the diseases which
have  been studied after this method may be mentioned  typhoid and typhus
fever and  acute lobar pneumonitis.  The  knowledge of the clinical history of
these and  some other diseases obtained by means of  this  method within late
years exemplifies its advantages.
  The clinical history  of a disease is divided into  several distinct periods or
stadia,  which are commonly called stages.   The first stage may be distin-
guished as the invasion or access of the  disease.  This period dates from the
first morbid  manifestations, and extends to the time when  the disease may be
considered as fully developed or established.  The duration of this stao-e varies
in different diseases and in different cases of the same disease.  Generally the 
DIAGNOSIS.
97
duration is  governed by certain laws proper to different diseases.   Some dis-
eases are characterized by the abruptness of their development, the stage of
invasion being very short or  altogether wanting.   The  career or  course of a
disease extends from the date  of its development—that is, from the end of the
stage of invasion-—to the time when the disease may be considered as ended.
This period is frequently subdivided into two or more stages.  The stage of
convalescence embraces  the period between the end of the disease and the
complete restoration  of  health.
  The clinical history of a  disease properly embraces phenomena  which may
precede the stage of invasion  or access.  They are distinguished as precursory
or prodromic events ; and in some diseases is to be included a period which is
called the period of incubation.   The latter term,  signifying hatching, relates
to the time  which elapses after the reception of certain  special causes of dis-
ease before any morbid manifestations take place.  For example, after inoc-
ulation with the virus of smallpox a certain number of days elapse before any
morbid  phenomena make  their appearance.  But in the  mean  time occult
operations are going on in the system, and when these are sufficiently advanced
the period of invasion or access begins.  The significance of the term incuba-
tion is thus apparent,   It  is rendered especially significant by the germ doc-
trine of the causation of many diseases.  The existence of a period of  incu-
bation is one of the points  in evidence of the truth of this doctrine.   Again,
the clinical history of a disease  should include phenomena which may occur
after recovery from a disease, provided they be dependent  upon  it.  Certain
diseases are liable to be followed by certain  consequences, which are  called
sequelae or sequels.  Thus, after recovery from scarlatina, albuminuria and gen-
eral dropsy occur in a certain number of cases.  These are  results of this dis-
ease, and hence belong to its  history as sequels.   In  like manner, phthisis is
likely to be a sequel of  measles, motor paralysis follows diphtheria, etc.
  As a general statement, diseases, in  respect of the phenomena and laws
belonging to their  natural history, present in different times and places great
uniformity ; they are essentially the same in different parts of the world, and
they undergo little or no material changes from age to age.  This statement
is believedto be correct, although it is in  opposition to  views somewhat prev-
alent.   The different  phases  and modifications which the same diseases may
present, not only at different  times  and places, but in different cases at  the
same time and place, are, for the most part, to be explained by the  coexistence
of affections which may  have  been antecedent or which are  developed as com-
plications.

                               Diagnosis.

  One of the most important of  the aspects under which individual diseases
are to be considered is in their Diagnosis.   The term diagnosis means the dis-
crimination of diseases ; that is, ascertaining their character  and  seat.   The
practical importance of  a correct discrimination of  diseases with  reference to
their management is sufficiently obvious.   How is it possible to bring to bear
upon a  case of disease established principles of treatment until the character
and seat of the disease are ascertained ?  Diagnosis and treatment are, in fact,
the two practical ends of the  study  of medicine.   Diagnosis is also important
with reference to obtaining  knowledge of the clinical history of diseases.  In
collecting cases for analysis, if different diseases be confounded the results of
the analysis will be vitiated.  In  like manner, correctness of diagnosis is  the
basis  of therapeutical experience.  Conclusions  drawn from  the effects of
measures of treatment in a series of cases will, of course, prove fallacious if
the series  include  cases of different diseases which have  been  confounded.
7 
98         SYMPTOMATOLOG Y.—DIAGNOSIS.—PROGNOSIS.

Here is a source of not a little of  what has been called false  experience in
practical medicine.  Diseases which were formerly confounded are now known
to be distinct, and can be readily  discriminated from each other.   For exam-
ple, the eruptive fevers, measles,  scarlet fever, and  smallpox, were once con-
sidered as different varieties of one disease.   Physicians did not undertake
until recent times to discriminate between pleuritis, pneumonitis, and bron-
chitis ;  now the diagnostic  characters of each are  well ascertained, and are
sufficient for its  recognition.  Still more recently, typhus and  typhoid fever
have been shown to be essentially distinct diseases.
   Differences in  skill and tact  among practitioners of medicine relate espe-
cially to diagnosis.  In medical consultations it is here chiefly that points for
discussion and  disagreement arise.   It is here that the  want of aid and coun-
sel is oftenest felt by the physician.   The diagnosis involves more  embarrass-
ment than the management of diseases.   This fact  is not appreciated  by the
people at large, many of whom undertake to decide respecting the nature and
seat of the disease whenever their friends are ill.
   The diagnosis of a disease may be  based on the presence of a pathognomonic
event.  Thus, the characteristic expectoration  or the  crepitant rale denotes
the existence of pneumonitis.  But, as already stated, there are but few symp-
tomatic phenomena which are truly  pathognomonic.  Moreover, they are not
present in all cases of the diseases which they  denote;  hence their absence is
by no means proof against  the  existence of the diseases.  The characteristic
expectoration and the crepitant  rale, for example, are wanting in not  a very
small proportion of  cases of pneumonitis.  It is  evident, therefore, that  the
diagnosis of a  disease cannot often be based on pathognomonic  events.    And
next in importance as regards the basis of diagnosis is the  presence of diag-
nostic symptoms.  As a rule, in  proportion to the degree of diagnostic sig-
nificance belonging to the symptoms present and to  their number, is the diag-
nosis of a disease easy and  positive. In these respects different diseases and
different cases  of the same  disease differ widely ;  in  some instances the diag-
nostic symptoms  present are few in number and weak, while in other instances
they are many and strong.   It  is with special reference to the  relative diag-
nostic value  of the different events which make up the clinical history of a
disease that this history is  important  to the  physician.
   The laws of disease are often of  importance in relation to diagnosis.  For
example, typhoid fever rarely affects persons over fifty  years  of age.   When,
therefore, persons beyond this  period of life are said  to have typhoid fever,
the chances are that an error has been made in diagnosis.  Certain diseases,
as a rule, occur but once in  the  same person.   The probabilities, therefore, in
a case of doubtful diagnosis  are  against the existence of a disease of this class
if it  be ascertained that the patient has already had the disease.  Certain
physical signs  situated within a  circumscribed space  at the summit  of the
chest denote phthisis, while  the  same signs situated  elsewhere might point to
some other affection, owing to the law that a phthisical affection, in the vast
majority of cases, first occurs at or near the apex of  the lung.  Similar illus-
trations might  be multiplied: the laws  regulating the  development of a dis-
ease, the succession of events, its  duration,  its  sequels,  etc., often furnish val-
uable aid in its diagnosis.   Here,  too, the practical importance of knowledge
of the clinical  history of diseases is apparent.
  A highly effective method of reaching the diagnosis of a disease is called
•■ reasoning  by  way of exclusion."  In a case of doubt as regards  diagnosis
the problem is  generally  to decide  between a certain number of diseases.  The
existing disease is one of two, three,  or more diseases which may be suspected
to exist.   Now, if it  be difficult to decide which one of these is the existing
disease from  the positive proof relating to diagnostic events and laws, it may 
PROGNOSIS.
99
be practicable to decide that there is insufficient evidence of the existence of
one or more, and therefore the latter are excluded.  By this process of elimi-
nation the number of diseases is diminished, and may be reduced even to one
disease, the  diagnosis thus being made on the principle  of  exclusion.
  In discriminating a disease  from one of several diseases with which it has
more or less symptomatic phenomena in common, the amount of positive evi-
dence in behalf of its existence is to be considered, and also the evidence
against the  existence of the  diseases from which it is to be discriminated.
This comparison of one disease with other diseases, with reference to the pos-
itive and negative  evidence of its existence, constitutes what is called differ-1
ential diagnosis; and  to discriminate a disease in the manner just described is
to differentiate it.   Thus, typhus and typhoid fever have  many symptoms in
common, but differ from each  other in essential points.   The differential diag-
nosis of these diseases has reference to the circumstances which  denote the
presence of the one  and the  absence of the other.
  Diagnostic  skill is  required not alone in differentiating diseases, but in the
discrimination of cases in which  diseases are either simulated or their exist-
ence fancied.  The knowledge and tact of the physician are here not infre-
quently called into requisition.   The judgment  must  rest  mainly on devia-
tions  from  the established laws of different diseases as regards symptomatic
phenomena, etc., and the  absence of objective phenomena which in  certain
diseases are invariably present.  It follows that the practitioner, other things
being  equal, will be  successful as a diagnostician in such  cases in proportion
to the accuracy  and extent of  his knowledge of the phenomena and  laws of
different diseases.   Diseases are simulated for the attainment of certain ends.
Thus,  soldiers feign diseases with a view to escape active  duty or to obtain a
discharge from  the service; prisoners feign  diseases to secure pardon or the
comforts of a hospital;  and cases are not rare of persons  simulating various
affections to excite  sympathy and  become  objects of interest.  Feigning dis-
eases  for these or other ends is called malingering, and persons  attempting
the deception are malingerers.  One mode of malingering is to pretend that
diseases which actually exist are more  severe than they really are.  Among
the  diseases  which  malingerers  are apt  to feign  are epilepsy, paralysis,
phthisis, aphonia,, amaurosis,  and insanity.
   Practical skill in diagnosis  requires mental qualifications which all do not
possess in equal measure.   Aside from these, the amount of  skill which may
be acquired will be proportionate  to the  knowledge of,  and familiar acquaint-
ance with, different diseases as regards their clinical histories.   It would be
absurd to suppose that  diseases are to be recognized by an intuitive  percep-
tion, and that some  persons have a peculiar innate gift in this direction.  A
diagnosis not based on  adequate  pathological  information is always open to
more  or less of the chances of error which pertain to guessing.   The mental
qualifications of the skilful diagnostician do not differ  essentially from  those
required for other than medical investigations—namely, accuracy of observa-
tion, the ability to reason correctly, sound judgment, and good sense.


                              Prognosis.

  The division of medicine called Prognosis treats of the means by which the
course and  termination  of  diseases may be foreseen.   It  is  often important
to form  a  correct judgment  concerning the way in which diseases may be
expected to  end, with reference to communications with patients and their
friends.  They may desire—and if so it  is proper they  should receive—infor-
mation on this  point.   Nor should  the  physician be  unmindful  of the faet
that persons in general are likely to estimate his knowledge and ability by the 
 100        SYMPTOMA TOLOG Y.—DIA GXOSIS.—PROGXOSIS.

 correctness of his judgment in this regard.   Recollecting  this fact, the pro-
 tection of his own interests, in addition to other considerations,  will dictate
 a certain amount of reserve in  his predictions.   But a correct judgment  as
 regards prognosis may be important with reference to treatment.   Therapeu-
 tical measures are sometimes to  be withheld in view of the complete hopeless-
 ness of the condition of  the patient, and  under these circumstances  persist-
 ence in the  use  of remedies is  not only  superfluous, but likely to do harm.
 On the other hand, therapeutical measures may  be  employed with reference
 to the danger of death without regard to the nature or seat of the disease.
 A disease equal  in all respects  in different  cases may destroy the lives of
 some, while others recover,  owing to  the diversity which  exists in different
 persons as regards  the ability to sustain  and overcome disease;  and in the
 management  of diseases  it is often the chief aim  of the physician, in the lan-
 guage of Cullen, to obviate the tendency  to death.
   Prognostics are those  circumstances on  which  a prognosis is based.  They
 relate, of course, mainly  to  the  symptoms of disease.  Formerly, before the
 nature, seat,  anatomical  changes, etc. of  different forms  of disease were as
 well understood  as now, all  the  circumstances connected with diseases were
 considered with direct  and special  reference to their significance  as prognos-
 tics.  The  consideration  of  these is appropriate in treating  of the Principles
 of Medicine,  or General  Pathology, but  it will suffice to consider them inci-
 dentally in connection  with individual diseases.   A few points which relate
 to the physiognomy or obvious appearances, and  which render the prognosis
 unfavorable,  may here be enumerated by way of  illustration.
   Notable  emaciation  and pallor,  existing in connection with any chronic
 affection, are  unfavorable prognostics.  Lividity of the prolabia and face, if
 persisting, generally denotes  great danger.   Great frequency and feebleness
 of the pulse, exclusive of diseases of the heart, and especially in acute dis-
 eases, point  to a fatal termination.  Great prostration is usually an alarming
 symptom.  Spasmodic inspiration, if not dependent on  pulmonary disease,
 precedes the  development of coma, unless it be referable to  hysteria.  Coma,
 if it last more than one or two days, will be likely to end in  death.   Paralysis
 of the sphincters, leading to involuntary evacuations, and  loss of the mus-
 cular power  of deglutition,  often  denote  impending dissolution.   Impaired
 capability of  feeling the presence of liquid in the air-passages, and inability
 to make the  effort requisite for its removal by expectoration,  are forerunners
 of the moribund  state.   A notable increase of the animal heat, as  ascertained
 by the thermometer, if persisting, is to be reckoned among the  prognostics
 denoting imminent danger.   Finally, the  characters pertaining to the physi-
 ognomy which constitutes  the  Hippocratic  countenance—so  called  because
 they were described by  the ancient Father of Medicine—denote the mori-
 bund state.   These characters are marked pallor with more  or less lividity
 pinching of  the  nostrils, sinking of the  eyes,  hollowness of the temples'
 coldness and  transparency of the ears, dropping of the lower jaw  etc.  The
change in physiognomy in this  state is  so great  that persons  are'sometimes
hardly  recognizable.   The features, to use a French expression,  are  decom-
posed, and  a  glance at the face  often suffices to show  that death  is nigh at
hand. 
PROPHYLAXIS.
101
                          CHAPTER   X.

            PROPHYLAXIS.—GENERAL  THERAPEUTICS.

 Experience the Basis of Therapeutical Knowledge—Two Sources of Experience: Analysis
   of Recorded Cases with Reference to the Duration or Termination of Diseases, and
   Observation of the Immediate Effects of Therapeutical Measures—Rational Inference
   as a Means of Arriving at Principles of Therapeutics—Importance of Knowing the
   Intrinsic Tendencies of Diseases toward Recovery, or otherwise—Active Measures to
   be Employed only when clearly indicated—The Expectant Plan of Treatment—Con-
   servative Medicine—Importance of Hygienic Measures of Treatment—Modes of Dying
   resolvable into Apncea and Asthenia—Classification of Therapeutical Measures, accord-
   ing to the Objects to be accomplished, into Prophylactic, Abortive, Curative, Pallia-
   tive, Hygienic, and Sustaining Measures.

                              Prophylaxis.
    THE prevention of disease is an object connected with pathological stud-
     ies.  It constitutes a division of medicine called Prophylaxis.  The name
 " preventive medicine " has of late been applied to it.  It is one of the  several
 aspects under which individual diseases are to be considered.  As regards the
 beneficent fruits of  knowledge, it holds a place  not inferior to that of thera-
 peutics.   Many diseases  are  preventable by removing or obviating their
 eauscs;  and it is with reference especially to  this application that the study
 of  causes, or etiology, is of  great practical  importance.   The  knowledge
 already  acquired of  the  causation  of certain diseases has  proved of much
 value.  A striking illustration of this is afforded by our present acquaintance
 with the  poisonous effects of lead.  It is only within  late years that  certain
 diseases have been traced to the action  of this poison.  The diseases thus
 produced  were doubtless of frequent occurrence before their causation was
 understood.   The  physician is now able sometimes to determine that diseases
 are thus  produced, although he may not  be able to ascertain in  what manner
 lead has been introduced into the system ; characters pertaining to the  disease
 show that they have  originated from this source.  This  statement is true of
 that form  of  paralysis called wrist-drop and of the form of  neuralgia  known
 as saturnine colic.
  The recognition of the germ doctrine as affording the  most rational  expla-
 nation of certain of  the  special or specific causes of disease  has led to the
 employment,  with great effect for the prevention of  infectious diseases, of
 measures the efficacy of which apparently depends on their agency in destroy-
 ing the low forms of  vegetable life.   In this agency consists the efficiency of
 certain of the so-called  disinfectants.   The prevention of infectious diseases
 will  be more and  more  efficient in proportion to the increase  of knowledge
 of disease-producing  organisms,  together with  the conditions under  which
 they are multiplied.   An essential  etiological  factor in the causation  of cer-
 tain  infectious diseases, in addition to the presence of specific organisms, is
 the existence of peculiar local  conditions.   These  conditions  constitute the
 predisposition to certain diseases.   They may be distinguished as diathetic
 conditions.   They  are as essential to the  development  and multiplication of
pathogenetic organisms as the presence of the latter.  Their removal is not less
effectual for the prevention of infectious diseases than  measures which are
directly destructive to the organisms.  Preventive medicine may  therefore 
102         PROPHYLAXIS.—GEXERAL  THERAPEUTICS.

accomplish as much by finding means for the removal of these conditions as
by the discovery of disinfectants; and it may be that the time will come when
the means will have been discovered of so sterilizing the human soil that it
will be incapable of giving productiveness to the germs of disease.1  Unknown
special causes  may  be indirectly controlled, to a certain extent, by removing
accessory or co-operating causes.  In this way sanitary measures are efficient
in protecting against epidemic and endemic diseases.  Much has been accom-
plished in behalf of prophylaxis, but much remains to be accomplished.  Sani-
tary reforms relating to  ventilation, sewerage, cleanliness, etc., there is reason
to believe, do very much toward the prevention of disease, and hence  these
are  among the most important of  the  modes by which  philanthropic efforts
may be rendered useful to mankind.  The  prospect of diminishing the mor-
tality from certain diseases relates more to prophylaxis than to therapeutics.


                        General  Therapeutics.
   The division of medicine devoted  to  the  treatment of disease is  called
 Therapeutics.   The  consideration of therapeutical measures, as regards  the
evidence of their  usefulness, the rationale  of their operation, the indications
for their employment, etc., constitutes general therapeutics.  The general prin-
ciples  of therapeutics are usually considered in connection with the Principles
of Medicine, or General  Pathology.  The consideration of the  treatment of
individual diseases  enters into  Special Pathology, or  the  Practice of Medi-
cine, and constitutes special therapeutics.   It  will suffice  here to offer a few
remarks  relating to general therapeutics, reserving the different therapeutical
measures for  consideration in  connection with the  treatment  of  individual
diseases  in the second  part  of this work.
   It is needless to offer any remarks on the importance of therapeutics.   The
treatment of disease, next to  its prevention,  is the great end of all  studies
relating to pathology, general and special.  It is, however, the most difficult
of all  the branches of medicine for the teacher.   It  is so, not alone from
uncertainty as  regards the correctness of therapeutical principles, but because
principles undoubtedly correct in their general application are to be greatly
modified in adapting them to the varied circumstances  pertaining to individ-
ual cases of disease.  The  same disease, under different circumstances, may
claim  not only widely different modifications  of  treatment, but therapeutical
measures directly  opposite in character.   There are abundant occasions  for
citing illustrations of this fact in treating of individual  diseases.  It is impos-
sible to  formulate rules for the application of therapeutical  measures.   If
this  were possible, the practice  of  medicine would be a mechanical, not a
rational,  art.   All  that the teacher and author  can hope to do is to present
general principles, together with the more important considerations involved
in their application; and their successful  application requires not only know-
ledge, but reasoning powers, judgment, good sense, and practical tact.
   How are the facts and principles of therapeutics obtained?   Mainly  by
experience.  The question then arises, How are the results of experience, as
regards the utility  of  therapeutical measures,  obtained?   There are  two
sources of experimental  evidence in behalf  of  the utility of  a  particular
method of treatment in  any disease.  One source of evidence relates to the
termination  and duration of the disease  in a series of cases in which the
method of treatment has been  employed.  The superiority of a method is
shown  by a larger  number of  recoveries and an average duration shorter in
such a series than  in other series of  cases treated otherwise.  This statistical
  1 Vide  article by Dr. Ezra M. Hunt in the Philadelphia Medical Xews, Sept  15
1883. 
GEXERAL  THERAPEUTICS.                  103
investigation is open to certain fallacies.  No two series of cases of a disease
are in all particulars exactly alike.  Cases  differ in  the  degree  of severity
and extent of disease, in the constitutional condition of patients, in the exist-
ence or otherwise of complications,  and in a great variety of circumstances
pertaining to season, climate, age, habits, etc.  The results of a  comparison
of  different series of cases in respect of termination  and  duration are to be
accepted as the basis of experience only on the ground that the differences in
the different series mutually compensate for each other.   Hence the number
of  cases embraced in a series should be large, and the results of the compari-
son should be confirmed or corrected by being repeated with successive series
of  cases collected at different times  and places and  by  different observers.
Moreover, pains  should be taken to group together cases resembling each
other as closely as possible.  Observing carefully all  proper precautions, the
results  obtained by this kind of investigation are of great value  if deduced
from data faithfully recorded by honest observers and  competent diagnosti-
cians.   The memory is wholly inadequate for such an investigation.   More-
over, recorded  facts  afford the  only  security  against prejudice and bias.
Unrecorded  experience is by no  means valueless, but it  is of little relative
value  as compared with  the results of the analysis of  recorded data.
   Another source of experimental evidence relates to the immediate  effects
of  therapeutical  measures  irrespective of the termination or duration of dis-
eases.    The usefulness of remedial measures may be apparent  from their
immediate effects, although there may be no proof  that the disease has been
abridged or although  it  may end fatally.   A method of treatment may be
useful in a certain number of the cases in a series,  although  in the majority
of  cases it may be injurious.  For example, let it  be assumed that  in the
larger number of cases of lobar pneumonitis bloodletting  does harm—it may
nevertheless do  good  in  a small  number of cases ;  and, conversely, if it be
assumed that this remedy is useful in the majority of cases, it may be perni-
cious in some cases.   So  with regard to other measures in other diseases.
   It is thus evident that  after the utility of particular therapeutical measures
in certain diseases, as the rule, has been ascertained by means of a sufficient
number of facts  derived from the first  source of experimental  evidence, it is
vastly important for the physician to exercise discrimination in the application
of  these measures to individual cases.   And it is to be borne in mind that in
the practice of medicine the physician  deals with cases of disease separately,
not in aggregates.  The general principles of therapeutics have a relation to
individual cases  of disease not unlike that of the  rates of life insurance to
the liability to death of particular persons.  It is easy to  calculate the proba-
bilities  of the duration of life  in  a large number of persons of a given age,
and to determine exactly  what it is worth to insure  the lives of a large num-
ber, but no one  thinks of applying to an insurance office to know how long
he  is to live.
  Rational  inference is a means of arriving at therapeutical principles.  If,
for example,  it  be  known that a person has swallowed  a corrosive  poison,
reason and common sense at once  dictate the propriety of endeavoring either
to expel it or to neutralize it by an appropriate antidote.   But in such a case
experience must be resorted to to know whether either  of these objects be
practicable, which of the  two is to be preferred, and the best means of effect-
ing each.   Analogical and a-priori reasoning may lead to  the employment of
measures in the treatment of  diseases, but the results  of experience  are
necessary to establish their therapeutical value.   Talent and genius may be
shown in originating methods of cure, but the practical test of their efficacy
is afforded by experience.   It is true that false experience has abounded in
medicine, but if experience be open  to fallacies, this  is true to a far greater 
 104         PROPHYLAXIS—-GENERAL  THERAPEUTICS

 extent of theoretical or speculative reasoning.  It is worthy of note that our
 knowledge of the most important  remedies has been acquired wholly by ex-
 perience, without any explanation  of their modus operandi.   Examples are
 the  salts of quinia as a remedy  for periodical fever, mercury and  iodine in
 certain forms of syphilis, etc.
   The intrinsic  tendency of a disease to recovery or otherwise  is to be con-
 sidered with reference to the value  of therapeutical measures.  Knowledge of
 the natural history of diseases is important as the true  point of departure for
 therapeutics.   Much has been acquired within late years in this branch of
 knowledge, but  much remains to be acquired.  Diseases which were formerly
 supposed to tend to a fatal result if not treated by means of active remedies
 are now known to end generally  in recovery if  left alone.  Examples are
 acute pleuritis  and  uncomplicated lobar pneumonitis.    The importance  of
 increasing  our  knowledge of the  natural history of diseases by collecting
 cases which have pursued their course without active treatment is to be kept in
 mind by those desirous of contributing to the advancement of therapeutics ;
 and  opportunities of accumulating such cases  should not be neglected, always
 provided that the welfare of the  patient be not compromised by withholding
 measures which there are good grounds for believing will prove useful.
   It may be laid down as a golden rule in therapeutics that active measures
 of treatment are  only to be  employed in cases  in which they seem to the
 physician to be  clearly indicated.   The severity of disease and the danger of
 the patient, be  they never so great, do not alone  constitute  grounds for the
 employment of  active measures.   If they be not useful they  are likely to
 do harm.  Therapeutical measures,  in proportion to their power, are powerful
 for either good  or harm, and must therefore be  either indicated  or contra-
 indicated.   In  the language  of  another, the  physician " should  be content
 with doing nothing  when  ignorant how to do good."
   The term expectant, as applied to the treatment of  disease, is  often used,
 and  its true sense is not always  observed in its application.  The treatment
 of a disease by  expectation consists in watching carefully its progress, and in
 meeting with appropriate  measures unfavorable events as they arise.   This
 plan is  not inconsistent with  the employment of active measures of  treat-
 ment ; but these are resorted to  not  simply because the disease exists, but
 with reference to  events connected with the  disease.   In this  sense of the
 term the treatment of a disease is expectant whenever the physician does not
 attempt to  abridge or arrest it, but  strives  to  aid in conducting  it to a favor-
 able  termination.
   The progress  of medicine within  late years as regards  therapeutics is cha-
 racterized by the  development of a principle  which may  be distinguished  as
 conservatism.  This term may be applied to medical  as to surgical practice,
 and denotes an  object which has not heretofore been sufficiently considered__
 namely, the avoidance of useless and  injurious therapeutical measures.   Con-
 servative medicine does not interdict the use of the most potential of remedial
 agencies, but it  enforces  discrimination and circumspection  in their use,
 recognizing fully their potency for  evil as well as for good.   The conserva-
 tive  physician is by no  means a  mere spectator of the progress  of disease
 but in wielding  the resources of therapeutics he  is careful to preserve the
 powers of life, following the injunction of Chomel, not to treat  disease, but
 patients affected with disease.*
   The management  of cases  of  disease involves  not  only the  exercise of
 judgment  in the employment  or  otherwise  of  therapeutic measures, but
 attention to hygienic regulations.   And in a better appreciation of these the
practice of medicine  at the present time offers a  striking contrast with the
        1 Vide A. Flint, Essays on Conservative Medicine and Kindred Topics. 
GENERAL  THERAPEUTICS.
105
past.   It may perhaps safely be said that the greater success attending the
management of diseases now than heretofore is due as much to improvements
as regards  diet, ventilation, etc. as  to the more  judicious use of medicinal
agencies.
   In the treatment of diseases involving danger to life  the mode of dying is
to be  considered.   It  is always  a  useful inquiry  at the  bedside, By what
mode  of dying will  the  case  under treatment  end if the  patient do not
recover ?   The answer to  this question will often  furnish the  indications for
treatment by means of which the  danger may be  forestalled; and here, it is
plain, is the source of indications under circumstances in which it is the aim
of the physician to " obviate the tendency to death." It suffices for all prac-
tical purposes to  reduce the different modes  of dying to two—namely, by
apnoea and by asthenia.
   Death by apnoea is produced by interruption of the function of respiration.
The type of this mode of dying is furnished in cases of strangulation.  Death
by this mode occurs when produced by affections involving obstruction to the
passage of air to the  air-cells  of the lungs, such as acute laryngitis, oedema
of the glottis, foreign bodies in the air-passages, and capillary bronchitis.   It
occurs sometimes  when a considerable portion of the pulmonary organs is
rendered incompetent to receive air, as  in pleuritis with  large effusion, pneu-
monitis  affecting  both lungs, and extensive  pulmonary  phthisis.  It also
occurs when the respiratory movements are arrested by an  affection  of the
medulla  oblongata involving the suspension of the influence  by which these
movements are sustained.  When death occurs from coma the mode of dying
is by  apnoea.  In  this mode of dying the embarrassment of respiration is out
of proportion to the disturbance  of the circulation, and  when  death takes
place purely by this  mode the action of  the  heart continues after the cessa-
tion of respiration.
   Death by asthenia, on the other  hand, is due to the failure of the circula-
tion.   The action  of the  heart may be suddenly arrested by paralysis from
over-distension of the ventricles, by the pressure of blood from an aneurism
opening  into the pericardium, by pericardial effusion, and  by the coagulation
of blood within the cavities.   But in all diseases which prove fatal by adyna-
mia or exhaustion  the mode of dying is  by asthenia, and when  death takes
place purely by this  mode respiration continues for a greater or  less period
after  the pulse has ceased to be appreciable at  the wrist.  Apnoea, however,
is frequently combined with asthenia in producing death ;  the  diminished
muscular power renders the patient unable to prevent the  accumulation  of
liquid in the air-passages, and the respiratory  function also may be interfered
with by  congestion and oedema of the lungs  due to exhaustion.  So, also,
asthenia is frequently combined with apnoea in fatal affections of the organs
of respiration.  In fact,  in  a large  proportion of cases  the  two modes  of
dying are  combined, either the one  or the other  mode predominating.
   With a  view to reference in the second part of this work, a classification
of methods of treatment  based on the general  objects which the physician
aims to accomplish in the management of individual diseases  will  be conveni-
ent.  These objects are embraced in the following classes:
   1. Prophylactic or  Preventive Measures.—Vaccination is a preventive meas-
ure with respect to smallpox.   Quinia, given to protect against intermittent
fever  is  a  measure belonging to this class.  Measures to eliminate excremen-
titious principles from the blood when their  deficiency in the urine is ascer-
tained, before the manifestations of uramia take  place, is an example.  The
ejection of poisons from the stomach and the employment of antidotal reme-
dies belong in the same category.
   These prophylactics apply to individual cases.  A wider range of prophy- 
106         PROPHYLAXIS.—-GENERAL THERAPEUTICS.

lactic measures takes in the destruction of the special causes of disease by
disinfectants, the avoidance of exposure to these causes by removal or isola-
tion, the observance of  the laws of health as regards habits  of life, etc. ;  in
short, everything belonging to  public and private hygiene.  Preventive medi-
cine, with this comprehensive scope of application, cannot be here considered.
The prevention of particular diseases will, however, enter into their consider-
ation  in the part of this work devoted to the Practice of Medicine.
   2. Abortive, Measures.—The  measures in this class  are those employed with
a view to arrest  the progress  of a disease  at  the outset—to cut it short or
strangle it.   Quinia given in large doses in  intermittent fever is an abortive
remedy.   It is not easy to cite many examples of this  class.   The range  in
which abortive measures are effective,  with our present knowledge, is small.
Here is abundant room for further developments in therapeutics.
   3.  Curative Remedial Measures.—Those measures  which abridge the dura-
tion of a disease, diminish its severity or danger, and, in general terms, modify
or  influence it  in  a favorable manner, may  be distinguished as curative.
Quinia is a  curative remedy in the cases  of  periodical fever in which it  is
not abortive, and also in certain cases of neuralgia.   Mercury and  iodine are
curative in  cases of syphilis.   Opium  is a curative  remedy in peritonitis, in
spasmodic affections like colic,  and in sporadic  cholera.   Many other examples
of this class might be cited.
   It is probable that remedies which are curative or abortive in certain dis-
eases act  by destroying morbific germs or  organisms; that is, the remedies
are parasiticides.   xVssuming the correctness of the  germ  doctrine as applied
to all infectious diseases, an important object  in therapeutics is to ascertain
what particular remedy is  destructive  to the  germs  or organisms peculiar to
each of these diseases.   Experience teaches that  a remedy which arrests one
infectious disease may  have  no effect upon  another.   For  example, quinia
arrests and  prevents malarial fever, but has no prophylactic or curative influ-
ence upon relapsing fever; and so, in  order to have  controlling remedies  for
all infectious diseases, it may be necessary to discover as many different para-
siticides as  there are varieties of disease-producing organisms.
   4.  Palliative Measures.—The measures belonging  to this  class  are  those
which are employed with the object of relieving pain  or suffering of any kind.
These measures are directed, not to a disease per se,  but to the symptoms or
effects of a disease.   But they may, to a greater or less extent,  exert a cura-
tive influence.   It is conceivable that relief of pain or suffering may conduce
to the favorable termination of a disease in some cases.
   5.  Sanitary or Hygienic  Measures.—The measures of this  class relate  to
pure  air, temperature,  diet, cleanliness, moral  influences, etc.   Medicine has
certainly  derived as much advantage from  this class of late years as from
curative remedial measures.   The improvements which have taken place in
the management of  diseases,  as regards air,  water, food,  exercise, etc., are
very  great, but there  is room for still further improvement.
   6.  Sustaining or  Supporting Measures.—The measures of this class consist
of tonic remedies,  alcohol, and alimentation.   The  objects are to obviate a
tendency to death by asthenia  and to  forestall a degree of prostration dan-
gerous to life.   Sustaining measures are applicable  to the treatment of all
diseases  which, if they prove fatal, will destroy life by  asthenia, and they
are indicated with  an  urgency corresponding  to the  danger of dying by this
mode.  These, together  with  palliative and  hygienic  measures,  constitute
the treatment of all  diseases which cannot be  arrested and  which  are not
amenable to curative  measures.   Not a few  diseases will be found in this
category.
   The terms analeptic and restorative are applied to measures relating to diet, 
GENERAL  THERAPEUTICS.                  107
regimen, and remedies when the object is, in general terms, to bring the sys-
tem back to its normal condition.  Supporting measures have reference more
especially to acute diseases which threaten life. Analeptic measures are those
called  for when the general health is deteriorated, although there may be no
disease which  involves danger  to life—when, in other words, the system is
below par.   They are often called building-up measures, and are indicated in
a large majority of disorders and chronic ailments.
  A very good division of therapeutical indications is  into—1st, the  indica-
tions  which relate to  the removal or  abatement of causes, or Causal  indica-
tions;  2d, Symptomatic  indications, or those  having  reference to the symp-
toms, irrespective of the nature and seat of  the disease; and 3d, Pathological
indications—that is, the indications derived from a knowledge of existing dis-
eases considered with reference to their character, situation, and intrinsic tend-
encies.
  Measures of treatment are sometimes classified and named from their action
being in opposition to a particular morbid condition; thus, formerly, the term
antiphlogistics was much in vogue, this name being applied to measures which
were  considered as opposed to inflammation.   Of late, certain measures the
immediate  effect of which is the diminution of the temperature  of the body
are often distinguished  by the name antipyretic.   Quinia and some other
remedies are  called  antiperiodic, from their efficacy  in  arresting affections
which are  characterized  by intermittency; remedies which are  antagonistic
to the  effects  of syphilis are called  antisyphilitic, etc.  It is, however, an
error to suppose  that it is a governing principle in  therapeutics to employ
remedies or measures the action of which upon the body in health is the oppo-
site of the effects or manifestations of disease.  This principle is expressed by
the term  allopathy, a term applied  by Hahnemann to denote a therapeutical
doctrine the reverse  of  homaopathy.   Legitimate medicine recognizes no
such  restricted and  exclusive dogma as these two terms alike denote; and
hence  the  name allopathy is to be by no means  accepted, but should be con-
sidered as  a term of  unmerited reproach.
  An  important precept in therapeutics is the observance of simplicity in
prescribing  remedies.   As a  rule, remedies differing in  their effects  should
not be given in combination or at the  same time.  Different remedies  should
be conjoined only when they co-operate for a common  object;  such, for exam-
ple, as a cathartic or a diuretic operation.  This precept is important, not only
because different  remedies are likely to conflict with each other, but because
it is difficult to judge of their  efficacy severally.  To  observe the  separate
effects of particular remedies in individual cases is essential in order to obtain
that experience which will be useful to the same patient at other times and
in other cases of the same disease.  The experience of the physician accus-
tomed to prescribe together multifarious remedies must, of necessity, be con-
fused and uncertain.   Moreover, complicated prescriptions are objectionable
on the score of their  tending to invest the  practice of medicine with an un-
worthy mystery.  These  remarks of  course do  not apply to uniting with a
curative remedy medicines designed to correct incidental effects  which it is
desirable to avoid, or to diminish the  repulsiveness of  a remedy  or to secure
for it a better tolerance.  These objects in  the combination of medicines are
important.   Not the least conspicuous of the modern improvements in medi-
cal practice relates to the use of alkaloids and concentrated remedies, together
with other  contrivances to divest remedies of a nauseousness which was for-
merly, as  a matter of  course, associated with the idea  of a drug.
  In the popular mind the practice of medicine is too closely connected with
the  use of drugs.  Not disparaging  the  value of these, it is desirable  for the
public  to understand that the  proper office of the physician is to observe cases 
 108         PROPHYLAXIS.—-GENERAL  THERAPEUTICS.

 of disease, and to either prescribe or withhold remedies according to the indi-
 cations.  To forbear medicinal interference is as important in some cases as is
 active treatment in other cases, and to exercise this forbearance often requires
 on the part of the physician much firmness, on account of not only the expec-
 tations, or it may be solicitations, on the part of patients and others, but of his
 own anxiety to render efficient services.  It should be an object with medical
 men to endeavor to  correct popular errors  in regard  to the use of  drugs and
 other  therapeutic measures.
   A considerable share of medical  practice consists  in the treatment, not of
 the individual diseases which are to be taken up in  the  second part of this
 work,  but of disturbances of health  which  have  no well-defined  places in
 medical nosology.   These disturbances often proceed from the operation of
 morbid causes, intrinsic or extrinsic, which  it should  be  the aim of the phy-
 sician  to ascertain, and, if possible, to remove.  The  development  of serious
 diseases may doubtless in this way frequently be prevented.   In many cases
 the knowledge and skill of the physician  are  called into requisition to deter-
 mine that no serious or well-defined disease exists.   It is by no  means the
 sole office of  the physician to treat diseases.   To indicate the  cause of dis-
 ease, more especially the voluntary violations of the laws of health ; to enjoin
 such a course of  life as shall  seem most  likely to afford security against dis-
 ease and promote physical and  mental vigor; to decide  in cases  of disease
 against the employment of active therapeutical measures,—these  are duties
 not less important than  the  employment of potent  remedies whenever the
 latter  are required.
   In the management of disease mental influences  are often of not a little
 importance.   The physician  may in  many cases effect much by judicious
 encouragement and   by stimulating  the voluntary  efforts  of the  patient.
 Hopefulness  and a  strong will  are curative  agencies which are  frequently
 powerful  auxiliaries  to  medicinal remedies, and they  are  sometimes more
 potent  than  drugs;  on the other hand, despondency and a lack of  resolution
 have a  depressing effect which in some cases tells  greatly against  recovery.
 Certain disorders may be produced  and prolonged  indefinitely by mental
 causes, the removal of which is essential to  a cure.   Too much concentration
 of the attention on the functions  of the body is a common source of disorder
 among  persons who  from want of occupation  unfortunately become unduly
 engrossed with their physical condition ; and in  such cases  to divert the mind
 from the body is  an object not less important and difficult than in other cases
 to secure a proper degree of care for existing ailments.   The ability to exert
 those mental  influences which are suited to different  cases conduces in no
 small measure to  success in practice;  and this ability requires, in addition to
 natural powers, knowledge of human character and a tact which is acquired
 by experience. A cheerful mien and manners calculated to inspire confidence
 are by  no means beneath the attention of the physician, but,  on the contrary,
 they are to be cultivated as highly useful professional attainments.   Medicine
 in its practical aspect involves knowledge, judgment, and skill as regards not
 only the employment of the  several  classes  of the  therapeutical  measures
 which have been  enumerated,  but the mental influences suited to the circum-
 stances  peculiar to individual cases of disease.
  The  history of  medicine shows  many  and  great mutations in the prevailing
 doctrines of therapeutics  at different periods.  The medical practice of the
present day in many respects  is  in striking contrast  to  that current a half
century ago,  and  it  is by no  means improbable that a comparison with the
present day at the end of the next half century will reveal points of contrast
not less striking.   These mutations, so far  from being a reproach, illustrate 
GENERAL  THERAPEUTICS.
109
the progressive  character of medicine.  Therapeutical principles can never
become unchangeably fixed until the utmost limits of attainable pathological
knowledge are reached and  nothing further  remains to be ascertained by
experience.   It  would be absurd  to  claim for medicine this  perfectibility,
but continued improvement in the management of disease may be reasonably
expected.  Future  improvement will doubtless embrace the  addition of new
remedies and  measures of treatment, more extended and precise knowledge
of those already in use, and the correction of  errors which  probably now, as
heretofore,'render sometimes the efforts of the physician not only  inadequate
but prejudicial.
   The uniformity of the laws of disease at different periods and places has
been already referred to.  The bearing of this on the stability of therapeutics
is obvious.  So  also with reference to the same application, it is important
to assume that  the system  of man is not liable to  alterations which render
the operation of therapeutical  agencies widely  different at periods  not far
removed from each other.  The opinion held by some that  such  alterations
have  occurred within the memory of those now living does not rest on any
solid basis.   Admitting to the  fullest extent diversities attributable to race,
climate, occupation, hereditary  influences, etc.,  these do not invalidate  the
statement that  the human constitution  remains essentially unchanged as
regards  the  application  of  established therapeutical principles.  Were  the
truth  otherwise, it would strike  at the  root of  medical   experience.   If
changes requiring  a revolution in therapeutics were liable to  occur  with
each  successive  generation, it is evident  there could be no  permanent prin-
ciples  of medical practice; the fruits of experience in our day, which so
many  are striving  to  develop, would be  not only useless,  but an injury to
those  who are to come  after us.
   The medical student and practitioner should have  a just appreciation of the
relative agency  of nature and of art in the recovery from disease.  It is cus-
tomary and convenient to personify disease, speaking of it as of an enemy to
be recognized, attacked, and,  if possible,  vanquished.  Remedies  and thera-
peutical methods are said to be  curative, as if  diseases  were overcome exclu-
sively by them.   The mind should not be  deceived by these figurative expres-
sions.   In reality, recovery from disease is always effected by nature ; that is,
by the agency of processes  inherent in the organism.  All that art can do is
to remove obstacles to the operation of natural processes and to promote their
favorable operation.   Take as an example a remedy which  is considered as
specially curative—namely, quinia in periodical fever; this  remedy, strictly
speaking, does not cure  the  disease, using the term cure in  its conventional
sense, but it removes something  on which the continuance of  the disease
depends.   This  something  removed,  nature  effects the cure.   As  another
example, opium does  not cure peritonitis,  but by promoting rest of  the
inflamed part and  tolerance  of the disease it affords aid to  nature  in effect-
ing the cure.  In like manner, all remedies and therapeutical measures exert
their so-called curative effects in  one or  the  other  of these two ways.  The
expression vis medicatrix naturae, which has been used from time immemorial,
represents the agency of nature in the cure of disease.  That the physician
is the  servant,  not the master,  of  nature  (medicus naturae  minister, non
mao-ister est), and  that, using the term cure in its  literal  sense, he has the
care of diseases, but  nature  effects the recovery (medicus  curat  sed natura
sanat  morbos),  have long been recognized truths,  as these old aphorisms
prove.
   Let it not be  considered that  to attribute supreme agency to nature is to
disparage art.   The triumphs of the  latter are made none the less beneficent
and brilliant by  subordination to the former.  The achievements of the human 
110         PROPHYLAXIS.—GENERAL  THERAPEUTICS

mind in every direction are dependent on circumstances and laws determined
by a higher power.1

  This chapter  concludes the First Part of this work, the part devoted to
the Principles of Medicine, or General Pathology.   A succinct account  of
the changes belonging to general pathological  anatomy has been presented,
together with certain distinctions, definitions, and general considerations relat-
ing to etiology, symptomatology, diagnosis, prognosis, prophylaxis, and thera-
peutics. These subdivisions of the Principles of Medicine have_been considered
as fully as is deemed important by way of preparation for entering on the study
of individual diseases.  The latter w'ill be considered in the remainder of the
work, which is to be devoted to the Practice of Medicine, or Special Pathology.
  1 The relative agencv of nature and of art in  recovery from disease is clearly and
coo-ently set forth  by Alexander Harvey, M. D.,  in his First Lines of 'Therapeutics,
1879. 
                         PART  II.

PRACTICE  OF  MEDICINE,  OR SPECIAL   PATHOLOGY,
                      INTRODUCTION.

Of the Different Aspects under which Individual Diseases are  to be Considered in Treat-
   ing of the Practice of Medicine, or Special Pathology ; namely, Anatomical Characters,
   Clinical History, Pathological Character, Causation, Diagnosis, Prognosis, Prevention,
   and Treatment—Sense of the term Individual as applied to a Disease, and the several
   Grounds of Individuality—Varieties of a Disease—Definition of the terms Acute. Sub-
   acute, and Chronic—Symptoms or Events incidental to Diseases sometimes, for conve-
   nience, considered as Individual Diseases—Self-limited  Duration of Certain Diseases
   —Nosology—Nosological Arrangement adopted in this Work.

    THE Practice  of  Medicine, or Special Pathology, treats of individual dis-
     eases.  In this  department of medical study individual diseases are con-
sidered under several  different  aspects.   One  of these aspects relates to the
appreciable  changes found  after death.  These changes  belong to morbid
anatomy.   Some diseases are  characterized  by  morbid appearances  in the
parts affected, and other  diseases are not accompanied by any lesions which
are  appreciable.   The latter are distinguished as functional diseases.   The
term anatomical  characters of a disease expresses the changes  belonging  to
morbid anatomy which occur in connection  with  that disease.   This term
will be  adopted as the title, usually, of  the first aspect under which diseases
not functional will be considered.
   Another  aspect relates to the phenomena or  events  which  compose the
clinical history of a  disease.   Under this head will  be embraced precursory
or prodromic events, the  symptoms which  accompany the access and  those
which occur during  the career  of the disease under consideration,  the  order
of their succession,  the laws regulating  the development and progress of the
disease, etc.   This will constitute  the second of the different  aspects under
which individual diseases, severally,  are  to  be considered.
   A third aspect relates  to  the pathological  character of a disease.   This
aspect embraces what is known of the nature  and  seat of the morbid condi-
tions which  constitute or enter into  the  disease under consideration.
   A fourth  aspect relates to etiology, or the  causation of a disease.  Under
this head will be stated what is known of the cause or causes  of  each indi-
vidual disease.
  A fifth  aspect relates to diagnosis, or the discrimination  of diseases.   The
application  of  the methods  of investigation  which  by means of symptoms,
laws, etc. enables the physician to  recognize the disease under consideration,
and to distinguish it from other diseases, will be considered under this head,
Physical signs, whenever these are available in the diagnosis of a disease,
will  be  embraced under  this head.
                                                               ill 
112
INTRODUCTION
   A sixth aspect  relates to prognosis.  This  aspect embraces the intrinsic
tendencies of diseases as regards termination in death or recovery.   The cir-
cumstances which denote, on the one  hand,  a favorable, and, on the other
hand, an  unfavorable, progress of diseases will come  under the head of the
prognosis.  And the consequences more or less remote, or sequels, may some-
times be conveniently embraced under this head.
   A seventh aspect relates to the treatment and prevention of a disease.  The
consideration  of the  treatment of each disease will embrace the indications
for therapeutic measures and the remedies which experience has shown to be
useful in  that disease.   Hygienic measures will also enter into the considera-
tion of treatment.  Prophylactic measures of  treatment will claim considera-
tion in treating of  different diseases, and the measures which remove or obvi-
ate the causes of disease will often be  found to be not less important than the
judicious application of principles of  therapeutics.
   Before entering upon individual diseases it  may be well to  inquire what is
meant by this use  of the  term individual, and whence  does a disease derive
its individuality.   An individual disease differs from other diseases sufficiently
for it to be regarded as separate  and  distinct.   The sense of the term  indi-
vidual in  this application is analogous to  that of species in natural history.
The individuality of a disease is established by distinctive features pertaining
to its clinical history.   These distinctive features may be derived exclusively
from the seat of the disease.   Thus, pleuritis  and pericarditis are inflamma-
tory diseases of a  serous membrane, and have essentially the  same patholog-
ical character; but the different anatomical relations of the  pleura and of the
pericardium furnish sufficient points of distinction to constitute each of these
affections an individual  disease.   In other instances  distinctive  features are
derived from the processes  belonging  to disease.  Inflammatory diseases, for
example,  differ essentially from those which are not inflammatory.  Again,
certain diseases derive each an essential distinction from its exclusive  depend-
ence on a  special  cause.   It  is sufficient  to show that a disease  is produced
by a special  cause to establish its  claim to be regarded as an individual dis-
ease.
   An individual disease is  to be distinguished from individual .cases of dis-
ease.  An individual  case of disease  has  a relation to an individual disease
like  that of a particular man to the human species.   The  study of  individ-
ual  cases  of disease  belongs to clinical medicine.  Some individual diseases
embrace several varieties.   Empyema and pneumo-hydrothorax  may be con-
sidered as varieties of pleuritis, both consisting in inflammation-of the pleura,
the former differing from ordinary pleuritis in the fact that the liquid con-
tained in the cavity of  the  pleura is purulent, and the latter differing in  the
fact  that air and liquid are contained  in that  cavity.  The several types  of
intermittent fever  distinguished as tertian, quotidian, etc. are different varie-
ties of one disease.  In the progress of medicine certain  diseases have come
to be considered as essentially distinct which were  formerly regarded as dif-
ferent  varieties of  one disease.   This  is true of all the eruptive fevers.   It
is  probable that certain diseases now considered as individual will be hereafter
found to be divisible into two or more.
   Differences as regards severity and duration  constitute a basis of the divis-
ion of  a disease into  varieties.   The same disease  may be  either acute, sub-
acute, or chronic.   A disease is acute when  it has a certain degree of intensity
and runs a rapid career.  In general, an acute   disease is of  sufficient gravity
to confine the patient to the bed.  The subacute variety of  a disease lias less
intensity, frequently not compelling the patient to keep the  bed,  and perhaps
not preventing him from being about  or even pursuing  his usual occupation.
The  chronic variety exists  when a disease  is subacute and has continued for 
INTRODUCTION.
113
 a considerable period.  Some  diseases are never  chronic.  This  term, for
 instance, is not applicable to typhus  or  typhoid fever.   The  division'into
 varieties, based upon  the differences just  named, is  especially applicable to
 inflammatory diseases.
   The list of individual diseases embraces  some, recognized as such for the
 sake of  convenience, which in reality are only effects or symptoms of diseases.
 Jaundice, for example, is an effect or symptom occurring in connection with
 different diseases.  Dropsy is in the  same category.   It is, however, conveni-
 ent to consider jaundice and the different forms of dropsy as if they were indi-
 vidual diseases.   In fact, if  we were better acquainted with the primary or
 elementary forms of disease,  it would probably appear that not a few of the
 diseases now considered as individual are only manifestions of morbid condi-
 tions at  present occult, the latter constituting the true diseases.
   A point of distinction among diseases, interesting  and  of much  practical
 importance, relates to duration.  Some diseases continue for a definite period,
 never exceeding certain  limits in  this regard.   The  duration of certain dis-
 eases is  regulated by fixed laws; that is, they rarely end until after the lapse
 of a certain number of days, and  never exceed a certain  number of  days in
 their continuance.   The continued and eruptive fevers are examples of  dis-
 eases the  duration of which  has definite limits.   Intermittent fever, on  the
 other hand, has no fixed or definite  duration if its  course be not interfered
 with.  Diseases which tend intrinsically to  end after a certain time are distin-
 guished  as self-limited.  The  laws of different diseases with respect  to  self-
 limitation  are often  to be taken into  account in the  employment of therapeu-
 tical measures; and it is obvious that  these laws are to be considered in  est-
 imating  the amount of curative influence  exerted  by methods of treatment.
 One of  the most striking and important of the characteristics of modern
 medicine is  the knowledge which  has been acquired of the self-limitation of
 different diseases.   Facts have shown that even pulmonary phthisis  in  some
 cases ends  in  recovery from  an intrinsic tendency thereto.
   In treating of individual diseases some  classification of them  is  essential.
 The classification of diseases constitutes a division of medicine called nosology.
 The  history of medicine  furnishes  many  nosological systems,   the  relative
 merits of which  it would be useless to  discuss.  Undoubtedly, a scientific
 mode of classifying diseases would be to arrange them after essential points
 of distinction  relating to  their pathological character;  but with  our  present
 knowledge  of  the pathological character of different diseases to do this is
 impracticable.   A nosological arrangement on this basis must be  deferred for
 a future  period, when pathology shall  have advanced far beyond its present con-
 dition.  The same remark is applicable to any arrangement based on difference--
 as regards the causes of diseases.  Our present knowledge of etiology is  not
 sufficient to furnish the  basis of a permanent nosology.   Inasmuch as  the
 chief object of a classification  is convenience, the proper course to  be pursued,
 evidently, is to adopt a provisional plan which will best subserve  this object;
 and the  most convenient classification at the present time  is that which  has
 of late years been adopted by the majority of authors and teachers.  This
 consists in dividing diseases into first, general; and second, local.   General dis-
 eases are those which  involve more or less  disturbance of  the whole  system,
 this disturbance not having been preceded by any known local affection, local
 affections, if they occur, being developed secondarily.   To  this class belong
 the essential fevers.   Under the head of constitutional diseases it is conveni-
 ent to include some in which  the local manifestations have no fixed  seat and
 sometimes  differ  in character.   Rheumatism and gout are constitutional dis-
eases, the chief manifestations consisting of local affections differently situated
in different cases and at different periods in the same case.  The local affection,
       8 
114
INTRODUCTION.
however, is in each essentially the same wherever seated. Syphilis is another
constitutional disease manifesting itself in local affections which differ not only
in situation, but in character.  The want of fixedness or uniformity in the
seat of  local affections proceeding  from constitutional  disease,  and  their
diversity in character in some  instances, are the grounds for  placing  certain
diseases in this class.   A large proportion of the affections nosologically con-
sidered as local probably proceed from constitutional disease ;  but as the local
affections are fixed and uniform, and our knowledge of the constitutional dis-
ease is, for  the most part, inferential, it is more convenient  to arrange them
in the second division.
   The second  division, or local  diseases,  will  embrace  all  which are  not
reckoned as general or constitutional.   The number of local  diseases  is far
greater than that of the diseases embraced in the first division.  It is necessary
to arrange them into subdivisions.   The most convenient plan is to distribute
them into groups corresponding to the distribution of the different organs of
the body into physiological systems.  According to this plan  the different
local  diseases are subdivided  as follows:

            1. Diseases affecting the  respiratory system ;
            2. Diseases affecting the  circulatory system ;
            3. Diseases affecting the  haematopoietic system ;
            4. Diseases affecting the  digestive or chylopoietic system;
            5. Diseases affecting the  nervous system ;
            6. Diseases affecting the  genito-urinary system.

   The foregoing arrangement of local diseases will  be adopted, and they will
be considered in sections corresponding to the groups just enumerated.  After-
ward a section will be devoted  to general diseases.
   Of the diseases belonging to these several groups, those only will be con-
sidered which are medical as distinguished from surgical.  The  surgical dis-
eases are those which are either external or in  accessible situations.  Thus,
diseases of the mouth, throat, and nasal passages, of the anus and rectum, of
the urethra  and  bladder, of the  eye  and ear, and of the  vagina  and uterus,
fall within  the province of surgery.  Diseases of the skin, being  external,
belong to surgery, notwithstanding that they receive special attention from
the physician perhaps  oftener than  from the  surgeon.  As an additional
reason for not  including them among the diseases  to be considered in this
work, there  are  many treatises devoted  specially to their  consideration. 
             SECTION   FIEST.

DISEASES  AFFECTING  THE  RESPIRATORY  SYSTEM,
                        CHAPTER   I.

                          ACUTE PLEURITIS.

Division of the Diseases affecting the Eespiratory System into Inflammatory and Non-
   inflammatory.—Acute Pleuritis: Anatomical Characters; Clinical History; Patho-
   logical Character; Causation; Diagnosis; Prognosis.

    OF the diseases affecting the respiratory system, an obvious division is based
     on the existence or non-existence of inflammation.  Inflammatory diseases
are seated respectively in three important structures comprised in the organs
of the  respiratory apparatus—namely, the mucous membrane lining  the  air-
passages, the serous membranes which invest the  lungs, and the  pulmonary
parenchyma.  Inflammation affecting the structures just named gives rise to
pleuritis1 or pleurisy, pneumonitis or pneumonia, and bronchitis.   These  will
be  treated of in the order  in which they have just been  enumerated.   The
first disease to be considered—namely, pleuritis—may exist as an acute and as
a subacute  or chronic affection, the inflammation being  diffused over  the
affected membrane.  These two varieties of the disease will claim separate
consideration.  Other varieties,  to be  considered  separately, are  empyema,
pneumo-hydrothorax, and  circumscribed pleuritis.   It will be convenient to
notice, in connection with these  varieties of pleuritis, the  dropsical affection
known  as hydrothorax.

                            Acute Pleuritis.
  The  pleura, like  other serous membranes, is divided into a visceral and  a
parietal  layer.  The free surfaces of these two layers  are smooth, polished,
and  covered with a single layer of fla't nucleated cells  called epithelial cells or
endothelial cells.2   These cells rest upon fibrillated connective tissue  contain-
ing  a  network of elastic  fibres,  blood-vessels, and lymphatic  vessels.   The
pleural cavities contain normally  a small quantity of serum.
  Anatomical Characters.—The first noticeable change in acute pleuritis
is redness of the pleura from active hyperaemia  of the  vessels within  and
beneath the affected portion of the  pleural membrane.  Small extravasations
of blood, or ecchymoses, are not infrequently present  at an early stage of the

  1 With a view to uniformity as regards nomenclature, the terms pleuritis and pneu-
monitis are used instead of pleurisy and pneumonia.
  2 It has until recently been held that the peritoneal, pericardial, and  pleural cavities
are lar<-e lymph-spaces lined by a variety of connective-tissue cells called endothelium.
RecenAnvestigations have cast" doubt upon this view, and have made it probable that
these serous cavities are derived from the endoblast, and that their lining cells are epi-
thelial  in origin.
                                                                115 
116
ACUTE  PLEURITIS.
inflammation.   The  pleura loses its glistening appearance, and becomes dull
and opaque in consequence of desquamation of the epithelium and beginning
exudation.
  Very soon the surface of the pleura becomes  covered either in patches or
continuously with a  delicate  layer of fibrin.  The fibrin  appears first in  the
form of little clumps, which increase in thickness and coalesce with each other.
The  opposing surfaces of the pleura are  agglutinated by the  fibrin.   The
fibrinous exudation was called by the older writers coagulable lymph and false
membrane.  The fibrin varies in its microscopical appearance, being sometimes
granular, sometimes homogeneous, and sometimes finely fibrillated.   Certain con-
stituents of the fibrin are furnished by the exuded liquor sanguinis, others by
the altered tissue-elements and leucocytes.  In some cases of pleuritis, par-
ticularly of the circumscribed variety, fibrin containing a few pus-cells is the
sole inflammatory product.   This form of the affection is called fibrinous  or
dry pleuritis (pleuritis sicca).
  More commonly, acute pleuritis is of the serofibrinous variety.  In this
variety, in addition to the fibrinous coating of the pleura, the cavity contains
serum, varying  in quantity from a few ounces to  several pints.   The serum
may be  clear, but it  is usually turbid  from  admixture with pus-cells and
flocculi of fibrin.  Upon microscopical  examination both  pus-cells and  red
blood-corpuscles are found in the fluid.    The red blood-corpuscles may  be so
abundant as to stain the fluid red.   The  pleuritis is then called  hemorrhagic,
a variety  observed especially in certain  dyscrasiae, such as scorbutus, and in
tuberculous and cancerous disease  of the  pleura.
  If the inflamed pleura be examined microscopically, a considerable number
of emigrated white  blood-corpuscles are found both in the pleural tissue and
in the  fibrinous layers on its  surface.  Part of the epithelial cells which nor-
mally  cover  the pleura undergo  necrosis  and desquamate, and  a part, less
severely  affected by the inflammatory  irritant, proliferate  and  produce  flat
cells of various shapes with  vesicular nuclei.  Some of  the connective-tissue
cells in the pleura swell up and also proliferate.  The lymphatics of the pleura
are dilated, and frequently contain fibrin, pus-cells, or proliferated endothe-
lium.  In from four to six  days after the onset of the inflammation new-formed
capillaries, which are offshoots from  the pleural capillaries, make their appear-
ance in the deeper parts of the  layer of  fibrin and cells covering the pleura.
If at the height of the inflammatory process a microscopical section through
the false membrane  and the subjacent pleura be examined, the following lay-
ers  can be distinguished : superficially, a layer of fibrin containing pus-cells ;
beneath this, a layer of embryonic  or granulation-tissue composed of blood-
vessels, leucocytes, and variously shaped larger cells which  are  derived from
the epithelial  cells  and the connective-tissue cells of the  pleura, and are
intended for the formation of new connective tissue ; and thirdly, the pleural
membrane itself, containing dilated blood-vessels, leucocytes, and proliferating
connective-tissue cells.   In the layer of granulation-tissue more  or  less  fibrin
is also present.  Some pathologists regard the proliferative changes in the epi-
thelial and connective-tissue  cells as purely regenerative, and separate  them
from the  strictly inflammatory processes  in  the blood-vessels which give rise
to the exudation of serum,  fibrin,  and  pus.
  The terminations of acute pleuritis are  either in  death, in resolution, in
chronic pleuritis, or in empyema.
  If resolution take place, the serum is absorbed,  the fibrin, pus-cells, and red
blood-corpuscles disintegrate and are likewise absorbed, and the granulation-
tissue  is  changed into fibrillated connective tissue.   In this formation of con-
nective tissue, fibrillated basement-substance appears between the cells, which
are gradually changed into flat, fusiform, or branching connective-tissue cells. 
CLINICAL HISTORY.
117
 Some of the cells and  some of the blood-vessels disappear.   The  remaining
 blood-vessels, which at first  have thin, easily-ruptured walls, acquire more
 compact coats.  The new connective tissue develops both in the form of dif-
 fuse fibrous thickening of the pleura, and in the form of thread-like or band-
 like adhesions between the two pleural  surfaces.  The long adhesions are pro-
 duced by villous outgrowths of the granulation-tissue into the fibrin and fluid
 which during the inflammation separate the pleural  surfaces  from each other.
 It is probable that they may also be caused  by stretching of short adhesions
 by the movements of the pleura.   It will be noted that after the most favor-
 able termination of pleuritis  the pleura does not return to its normal state,
 but is left with a new growth of connective tissue, which binds the  pleural
 surfaces together over a great or less extent.   In this way the pleural cavity
 may become entirely obliterated  by adhesions.  The adhesions are at first
 weak,  and may be broken  by  active exercise or by acts of coughing.  Hemor-
 rhage  into the pleural cavity may in this way occur.
   If after the lapse of three or four weeks the inflammatory products con-
 tinue  to increase, or remain stationary, or  diminish very slowly, the  disease
 has passed into the chronic  stage.
   When pus-cells  accumulate in sufficient  number, the exudation becomes
 purulent and the disease is called empyema.   Chronic pleuritis and empyema
 will be considered subsequently.
   The effects of  large accumulations of fluid in the  pleural  cavity upon the
 lungs  are  of importance.  If the  lung be  not restrained  by adhesions, it is
 pressed upward and inward against the vertebral column.  If the fluid accu-
 mulation  be very extensive, the  compressed  lung loses all the physical cha-
 racters dependent  upon the  presence of air in the air-cells.   It resembles a
 mass of flesh, and is therefore said to be carnified.  The pulmonary structure,
 however, remains intact, and  it is capable of being inflated after death nearly
 or quite to the same extent as if it had not undergone this  compression.   A
 similar expansion may take place during life after the absorption of the fluid.
 So large an accumulation  of  liquid, however, occurs much oftener in chronic
 than in acute pleuritis.
   Pleuritis may be general or circumscribed.  Primary or idiopathic pleuritis
 is general.   Circumscribed pleuritis—which, as already remarked, is often
 dry—is usually secondary to  some affection of parts  adjacent to the pleura.
 Circumscribed  pleuritis may  affect the pulmonary, the costal, the  diaphrag-
 matic,  or  the  mediastinal  pleura.  Even  in circumscribed pleuritis the two
 opposing surfaces of the pleura  are usuall}* inflamed—a circumstance which
 goes to show that the inflammatory irritant is contained in the exudation, for
 the opposed surfaces of the pleura have different vascular supplies.

   Clinical History.—The most convenient division of acute pleuritis into
 stages  is to consider as the first stage the  period from the attack to the time
 when an  appreciable quantity of  liquid  effusion has taken place ; the second
 stage will extend to the time when the liquid begins sensibly to diminish; and
 the third stage will comprise the period occupied in the absorption  of the liq-
 uid. The first stage, or the period anterior to an appreciable amount of liquid
 effusion, is usually of short duration.  The physical  signs may show* the pres-
 ence of liquid within a few hours from the  date of the attack.  This stage
 rarely extends  beyond  twenty-four hours.  The second stage is of variable
 duration.   The accumulation of liquid may go on with more or less rapidity.
 When  the maximum amount is reached, the quantity may remain  stationary
for some time or  absorption  may speedily begin.  The liquid  may diminish
under  the effect of treatment, and  renewed effusion  take place.  The disease
does not, of course, advance beyond the second stage in the cases in which  it 
118
ACUTE PLEURITIS.
eventuates in chronic pleuritis.  If a considerable quantity of liquid remain
at the end of from three to four weeks, the disease is to be considered as hav-
ing become  chronic.  In  cases which pursue a favorable course considerable
progress should be made in the removal of the liquid after this lapse of time.
The duration of the third stage, or  the stage of absorption, is quite variable.
Generally, some liquid remains when the general symptoms denote convales-
cence, and even after the patient has  apparently recovered.   The  physical
signs may show the presence of fibrin for some time after the date of convales-
cence.   From what has been stated it follows that the duration of the career
of the disease is from two to four weeks.
  The invasion is often sudden and without premonition.  In a certain propor-
tion of cases, however, pain or soreness is felt for one, two, or three days before
the development of acute inflammation.  The  development of acute inflam-
mation  is characterized  by symptoms which sufficiently mark  the date of its
occurrence.   It  is  sometimes ushered  in  by  a well-pronounced  chill, accom-
panied  perhaps with rigors.  Chill  and rigors, however, are by no  means so
frequent, or, as a  rule, so marked,  as  in  cases  of pneumonitis.  Not infre-
quently chilly sensations and slight shiverings only are experienced.
  Pain  in the affected side attends the  onset of acute inflammation in a large
majority of cases.   The  pain is  usually intense.   It is sharp, cutting, or
lancinating in character.   It is felt  especially in the act of inspiration; and it
increases during inspiration, often becoming so severe that the act is instinct-
ively  arrested  before being completed.  Coughing and sneezing  occasion
severe  pain.  The movements of  the  body are painful, but in  a far  less
degree  than the respiratory movements.   The pain is referred to the middle
and lower third of the affected side of the chest, and  is often diffused over
the anterior, the lateral, and sometimes  the posterior portion.   It is not,  as a
rule, circumscribed or limited to a small space.   The morbid sensitiveness of
the inflamed pleura seems to me adequate to account for the production of
acute pain as a result of  the movements  of the pleural surfaces upon each
other and the stretching of the membrane, without requiring  the hypothesis
that either  intercostal neuralgia or an affection of the  costal muscles  is
superadded  to the inflammation.   Pain, with the characters  just described,
is almost uniformly present in acute pleuritis, but cases occur in which  it is
not marked, and is even wanting, other symptoms showing  the inflammation
to be acute.
   Pyrexia is  coincident with the  development of the inflammation.   The
pulse is increased  in frequency, rarely, however, exceeding 100 per minute.
The temperature of the  surface is raised.   The thermometer in  the axilla
shows more  or less intensity of fever, but the rise rarely exceeds 102°.   As
a rule, there is less pyrexia  than in cases of pneumonitis.  The usual  con-
comitants of symptomatic fever—namely, thirst, anorexia, pain in  the head
and loins, restlessness, muscular weakness, etc.—are more or less marked.  The
intensity of the fever and of the general  or constitutional disturbance varies
much in different cases of this as of other inflammations.   In rare instances
the fever is intense, the  temperature  rising to 105° or higher, with a  cor-
responding intensity of other constitutional symptoms (pleuritis acutissima).
In  most of these  instances  the pleuritis is of the suppurative variety, or
empyema.
   A comparison of the two sides of the chest as regards temperature shows
a slightly higher temperature on the affected  side, the difference being a frac-
tion more than one degree.
   Cough is usually present, but it is sometimes wanting.   The pain in cough-
ing leads instinctively to  efforts to  repress it, and this gives to the  mode of
coughing a character denoted by the term  suppressed.  The patient succeeds, 
CLINICAL HISTORY.
119'
to a certain extent, in these efforts.  The expectoration  is slight or wanting,
and when present it consists of simple mucus.   The exceptions to this rule
are the cases in which the development of pleuritis is preceded by bronchitis.
When these  affections are associated  it is merely a coincidence; there is no
tendency in  either one  to  give rise to the other.
   The respirations are increased in  frequency,  but not greatly.  Their  in-
creased frequency at this period is due to an  arrest of the inspiration before
it is completed, in consequence of pain.  The patient instinctively multiplies
the respiratory acts to  compensate for the want  of  a full inspiration.  As a
rule, the patient in lying chooses a position on the healthy side, the weight
of the body upon the  affected side increasing the pain and soreness.   This
rule is by no means without exceptions.  Not infrequently the  decubitus is
either dorsal or diagonal.
   These  symptoms constitute the clinical  history of this disease during the
first  stage, or prior to  effusion.  They continue into the second  stage,  but
after  a certain amount of effusion  has taken  place they are materially modi-
fied.  The pain  is notably  lessened,  and  may  disappear except  on forced
breathing.   The acts of coughing are less painful and the efforts at suppres-
sion are less  apparent.  The pyrexia diminishes, and may even cease during
this  stage.   Other evidences  of constitutional disturbance  are less  marked.
The  patient  seems better,  and may be able  to sit up and perhaps walk about
the room.  The respirations are more or less frequent.   Their frequency now
depends  on  the  compression of the lung by liquid.  Their frequency will be
great, other things being equal, in proportion to the quantity of  liquid and
the rapidity of the effusion.  If a considerable amount of liquid  be rapidly
effused, the respirations are rapid ;  the patient suffers from a painful sense of
the want of breath, or dyspnoea, and may be  obliged to maintain the sitting-
posture.   If the quantity  be not large, and the effusion  have not taken place
rapidly, the  patient will not be likely  to suffer from dyspnoea while remain-
ing quiet, but exercise will cause panting and a sense of the want  of breath.
Even with the pleural sac distended with liquid, the only effect on the breath-
ing may be  an  increase of the frequency of the acts to twenty-five or thirty
per minute,  without  suffering so long as  the  patient  remains  quiet.   The
diminution or cessation of pain is due to the restrained movements of the
pleural surfaces upon each other in consequence of the presence of the liquid
and fibrin, the  latter  perhaps agglutinating  the portions of  those  surfaces
which are in contact.   The change as regards fever and other constitutional
symptoms proceeds, in part, from the removal of-the conditions causing pain,
and partly because, after exudation has taken place, the disease is mitigated
from  an  intrinsic tendency to  decrease.  The patient now, as a rule, prefers
to lie upon the affected rather  than the healthy side, as  in this position he is
able to expand  more freely the opposite lung.   To this rule, however, there
are exceptions, and the decubitus in  this  stage, as in the first  stage, is fre-
quently  either dorsal  or  diagonal.
   During the stage of absorption pain  is either wanting or  is  produced only
by muscular efforts ; fever has disappeared ; cough  diminishes  or ceases ; the
respirations become less and less frequent, and are  less hurried  by exercise ;
the appetite  and digestion return, and the  normal condition of all the func-
tions  is gradually restored.  During this  stage  the patient is convalescent;
he is  able to  be out of doors, and perhaps to resume in  part his  usual avoca-
tion and  habits.    Convalescence  is declared, and the symptoms,  both general
and local, may appear to denote that  recovery has taken place while some
liquid effusion still remains; the fibrin is not fully  absorbed, and  the forma-
tion of new tissues leading to permanent adhesions  is going on.   A sense of
weakness in the affected side, together with some soreness or pain on unusual 
*120
ACUTE  PLEURITIS.
exertion,  frequently continues for some time after  the termination of the
career of the disease.
  Strumpell states that in the  first stage of the disease, while effusion  is
taking  place, the secretion of urine is notably diminished, and  that the
beginning  of the absorption  of the  effused liquid  is  shown by a notable
increase in  the quantity of urine.   This increase may thus  serve to indicate
that the disease  has  advanced  to the second stage.*
  In  primary or  idiopathic pleuritis the inflammation,  as already  stated,  is
diffused over the pleural  membrane; it is general,  not circumscribed.  If
circumscribed, it  is a  complication of some other  pulmonary affection, as  a
rule.   It will be  seen  hereafter that it occurs as a complication of pneumo-
nitis and pericarditis, but it is generally, under  these circumstances, subacute.
Primary pleuritis  does not lead  to  pneumonitis, except that the  air-cells in
immediate proximity to the pleura are sometimes involved ;  nor does it involve
any tendency to bronchitis.  It is a unilateral disease—that  is, it affects the
pleura of one side only.   The exceptions to this rule are so infrequent that
the disease, when bilateral or double, may  be presumed to  be secondary to
another pulmonary affection, generally  tuberculosis.

  Pathological Character.—This disease is an example  of acute inflam-
mation affecting  a serous  membrane, and may be  regarded as a type  of all
acute inflammations of serous membrane.  The general  pathology of inflam-
mation has been  considered in the first  part of this work, together  with the
local variations when different structures are inflamed.  Pleuritis and inflam-
mations of other  serous membranes are characterized by fibrinous exudation
as a constant event. (Vide p. 37.)  This event, the accumulation of liquid in
the closed cavity, and the development of connective tissue are characteristics
of these inflammations.

  Causation.—Acute pleuritis  may be either primary or secondary.   The
disease is  primary when  it occurs  independently  of  any  other  affection.
Primary or idiopathic pleuritis  is attributed in certain cases to the action of
cold.   This has so long been considered as a frequent source of a  great num-
ber of diseases that patients at once are led to refer an attack to some expo-
sure, often, doubtless, when it had no causative agency or at most acted only
as an  exciting cause.   Still, it is probable that the disease sometimes origin-
ates in  this way.   Acute  pleuritis may be produced  traumatically by contu-
sions, especially if accompanied with fracture  of  the ribs, and by penetrating
wounds.  It is remarkable, however, that severe injuries of  the  chest  often
occur without giving rise to general pleuritis.
  Primary pleuritis is much less frequent than was  formerly supposed.  In
the majority of cases of pleuritis careful examination, both before and  after
death, shows the pleuritis to  be secondary to some local  or constitutional
disease.  Affections of parts adjacent to  the pleura play  an important role in
the causation of pleuritis.  The most important of these local affections which
cause  secondary  pleuritis  are  lobar  pneumonitis, lobular pneumonitis, pul-
monary tuberculosis, infarctions, abscesses and gangrene of the lung, cancer
and perforations of the oesophagus, caseous  tubercles in the bronchial °lands,
caries of the vertebrae and ribs, and inflammations in  the mediastinum.   The
various inflammations of the peritoneum and of the  pericardium often lead
to pleuritis.
  Pleuritis is a frequent  complication of many infectious  diseases,   such  as
scarlatina, variola, pyaemia, septicaemia, and acute articular  rheumatism.  It
occurs also  not infrequently in Bright's disease, scorbutus, and  gout.
 1 Lehrbuch der Speciellen Pathologic und Therapie der inneren Krankheiten, Leipsic, 1SS5. 
DIAGNOSIS.
121
  Pleuritis may be secondary to other diseases of the pleura, such as cancer,
sarcoma, and tubercle.
  In  cases which appear to  be primary pleuritis, careful search  should be
made for some hidden cause, such as tuberculosis or Bright's disease.   In
some  cases, however, no cause can  be  discovered.

  Diagnosis.—Although the symptoms which enter into the clinical history
of acute pleuritis  are sufficiently characteristic  to point to the existence of
the disease, they are  not sufficient for the diagnosis in all cases.  The charac-
teristic  pain is  not peculiar to the disease.  The  pain in some cases  of inter-
costal neuralgia and pleurodynia is  as strongly marked as in acute pleuritis,
and these three affections were formerly often confounded in practice.  More-
over, the pleuritic  pain  in some cases of pneumonitis is as  intense as when
the pleuritis is a primary disease, and the former disease has not infrequently
been  mistaken  for the latter.  On the other hand, acute pleuritis is  liable to
be overlooked  in the cases in which pain is slight or w*anting.  More or less
fever is present in acute pleuritis, but this symptom may be associated acci-
dentally with intercostal neuralgia ; it is likely  to be present in pleurodynia,
and it exists, of course,  in pneumonitis.  The diagnosis is to be based on the
physical signs taken  in connection with the symptoms.   The  latter are of
importance, and, indeed, are essential  in determining whether the affection be
acute or not.   The  differential diagnosis consists  in  discriminating  between
the disease  under  consideration  and  intercostal neuralgia,  pleurodynia, and
pneumonitis.
   The  diagnosis in the  first stage, with the aid of physical  signs,  cannot
always  be made with positiveness.  Examination of the chest by inspection
will show restrained  movements on the side to which the pain is referred, the
movements on the opposite side being increased, while on percussion distinct
disparity between the two  sides may not be found ;  and on auscultation the
murmur of respiration is more or less weakened on the affected side.  These
signs are due to the  fact that the pain leads instinctively to a diminished use
of the  lung on the side  affected, while the use of the other lung is increased.
They are equally present when the  pain is incident to the affections from
which this disease is to be discriminated.  A slight friction  murmur may be
discovered in this stage; and if present its diagnostic significance is important.
It shows that pleuritis exists, and the discrimination  then  lies  between pleu-
ritis  as a  primary disease or as  a  complication of pneumonitis.  To decide
this point at once is  not always easy.   The diagnostic sign of pneumonitis—
namely, the crepitant rale, if present—settles the question ; but as  this sign
is by no means present uniformly in pneumonitis,  its absence does not author-
ize the  exclusion of that disease.   The same  remark is  applicable  to the
characteristic expectoration of pneumonitis.  It must be confessed that in  a
certain  number of cases this differential diagnosis requires  some  delay.   A
friction murmur is heard in  only a certain proportion of cases during the first
stage, and if absent the signs belonging to the second stage  are essential  in
order to render the  diagnosis positive.
   The  signs belonging to the second  stage are usually present  without much
delay.   If the  disease be  idiopathic pleuritis, after the lapse  of twelve  or
twenty-four hours effusion  will have taken place in sufficient quantity to be
apparent.   The signs now denoting the  existence of the disease are those due
to the effusion.  The diagnosis is based upon these signs, in  conjunction with
the symptoms  and  history, and on the absence of the signs of pneumonitis.
   The  signs of effusion  are  obtained  by percussion,  auscultation, palpation,
and inspection.  On  percussion, dulness or flatness is found at the base of the
chest, extending upward in proportion to the quantity of liquid, the patient 
122
ACUTE  PLEURITIS.
 being in a sitting posture.   By the finger, which serves as a pleximeter, there
 is also perceived an increased sense of resistance  on percussion.   The upper
 limit of the dulness or flatness, the position of the body being vertical, is not
 on a  continuous horizontal  line extending over the posterior, lateral, anterior
 aspects of the chest.  In most instances  it is higher behind  than in front.
 Prof. G. M. Garland has found that on the posterior aspect the  effusion  is
 represented by a curved line resembling the letter en.1  Having ascertained on
 the anterior aspect of the affected side a  point which divides the  dulness or
 flatness below from the resonance  above while the patient is sitting, changing
 the position of the patient to recumbency on  the  back frequently induces a
 marked change in the dividing-line between dulness or flatness and the reso-
 nance ;  the liquid gravitating to  the  posterior part of the chest, the lung
 descends in front and furnishes resonance for a greater or less distance below
 the point which was coincident with the level of the  liquid while the patient
 was sitting.   This latter test of the presence of liquid is not available in all
 cases.  If the pleural surfaces above the  level of  the liquid  be united by old
 adhesions or agglutinated  by fibrin, the liquid and  lung will  maintain the
 same relation  in different  positions of the body.   The  failure of this test,
 therefore, is not proof against the presence of liquid.  The  test, however, is
 available  in a large majority of cases.  The resonance over the  lung above
 the level  of the liquid, if the latter rise  to a third, a half,  or  perhaps two-
 thirds the height of the chest, is increased, and acquires in part a tympanitic
 quality, constituting vesiculotympanitic resonance.   That this vesiculotym-
 panitic  resonance may be due to emphysema of the upper lobe of  the lung I
 have had an  opportunity of demonstrating.  A hospital case presented the
 signs of pleuritis with considerable effusion, the vesiculotympanitic resonance
 above the liquid being marked.  The patient unexpectedly and suddenly died,
 and the cause of death was found to be a large thrombus in the left ventricle,
 the cardiac walls having undergone fatty degeneration.   The lower  lobe  of
 the lung on the affected side was condensed, and the upper lobe was consider-
 ably  emphysematous.
   On auscultation  the respiratory murmur is either  suppressed or is feebly
 appreciable  below the level of the liquid.  Above the  liquid  it  is usually
 weak as compared with the murmur on  the  opposite side.   If the  lung be
 considerably reduced in volume  by the  amount of liquid, the  respiratory
 sound becomes broncho-vesicular  and the vocal resonance is increased.   If
 the liquid be  sufficient  to  compress the  lung into a solid  mass, the latter
 furnishes the  bronchial respiration.  The bronchial respiration is heard over
 the site of the compressed lung.  It is usually limited to that  site, but in a
 certain proportion of cases it is diffused over the greater part or the whole of
 the affected side.  The normal vocal resonance, as  a rule,  is either suppressed
 or diminished  over that portion of the affected side which corresponds to the
 space occupied  by the liquid; but if the accumulation  of  liquid be  large,
 bronchophony may be produced either  over the compressed lung or the por-
 tion in contact with  the  liquid.  The bronchophony has  sometimes a tremu-
 lous or  bleating character,  and is then aegophony.  If  the chest be filled
 with  liquid, bronchophony is sometimes  diffused  over  the  whole  of the
 affected side.
   Vocal fremitus  is either  arrested or  diminished  by  effusion, as  a  rule.
 From this fact is  derived valuable evidence of  the presence  of liquid when
the effusion is in the right pleural  cavity, in consequence  of the  greater
amount  of fremitus  over the right side in health.  If the question be as to
the presence of liquid in the right  pleural  cavity, and the  fremitus be greater
on the left than on the right side, the evidence of liquid is strong.  There are
                       1 Vide Pneumono-dynamics, 1878. 
DIAGNOSIS.
123
 some rare exceptions to the rule that the vocal resonance and fremitus are
 either diminished or suppressed over the space  occupied by the  effusion.1
   If the quantity of liquid be large enough to distend the pleural sac, the
 intercostal depressions may be diminished or destroyed at the inferior, ante-
 rior, and lateral portions of the chest.   This  constitutes valuable evidence of
 the presence of liquid.
   Other  and marked  signs of effusion are  present if the quantity of liquid
 be sufficient to dilate the chest.   This occurs exceptionally in acute pleuritis.
 It occurs much  oftener in the chronic  variety of the disease, and the signs
 referred to will  be noticed in  connection with the diagnosis of the latter.
   The  physical  signs  not only lead to a positive  diagnosis after the first
 stage, but they  show the amount of liquid  in the pleural sac—a point  of
 importance with reference to treatment.   By means of daily explorations the
 physician is  able to ascertain whether the effusion be increasing or diminish-
 ing, and the rate of either the increase  or diminution.  The information thus
 obtained is highly important as a guide in the employment of  therapeutical
 measures.  This information cannot be  obtained  from the symptoms.   The
 signs, therefore,  are essential not only to the  diagnosis, but to a proper know-
 ledge of the progress of the disease.
   After absorption, to a greater or less  extent, of the liquid, the pleural sur-
 faces coming into contact over a larger area, and roughened  by fibrin which
 has now become dense and  closely adherent, a friction murmur is frequently
 produced.  This is sometimes so loud as to be  heard by the patient.  It may
 continue into convalescence, ceasing when the pleural surfaces  have become
 united  by means of newly-formed  tissue.   A friction murmur, however, by
 no means occurs invariably, even at this stage  of the  disease.
   The  occasional occurrence of a pleural, cardiac friction sound in cases  of
 pleuritis  affecting the  left side is to be borne  in mind.   The movements  of
 the  heart sometimes  occasion  a  rubbing of pleural surfaces sufficiently  to
 cause  a  sound which, having the  cardiac  rhythm  and being heard  when
 breathing is  suspended, may seem to denote  pericarditis.   The sound is lim-
 ited to the  left border of the heart,  and pericardial effusion  is  of course
 wanting.  Pericarditis, when  this sign is present, it must be  confessed, is
 not at once easily excluded.   An  error  of diagnosis in  this regard is  more
 likely to occur  from the fact that this disease  is  not a very  infrequent
 complication of  pleuritis.

   Prognosis.—The prognosis  in  cases of acute  primary or  idiopathic  sim-
 ple pleuritis is always favorable,  provided the disease be uncomplicated and
 the constitution  of  the patient be not enfeebled.   Without any therapeutical
 interference it would very rarely prove  fatal.    I have collected several  cases
 in which the disease passed through its course favorably without  any treat-
 ment.   It may possibly prove fatal  in consequence of a large amount of effu-
 sion occurring very  rapidly, death taking place  by apnoea, produced, probably,
 by congestion of the lung on the unaffected   side (collateral fluxion), in addi-
 tion to the loss of function of the lung  on the affected side from compression
 by the liquid.   I have known an instance in which  the  death of  a hospital
 patient suddenly and unexpectedly seemed fairly  attributable to the fact that
 the pleural sac was greatly distended with rapidly-effused liquid.   Developed
 as a sequel to other diseases, or in the course of a grave affection, or in persons
 with broken constitutions,  it may destroy life  by asthenia.  Acute pericarditis
is  sometimes developed simultaneously  with, or during the progress of, pleu-
  1 Vide article by the author, entitled " Large Pleuritic Effusion in the Right Side,
without Notable Diminution  of Vocal Resonance and Fremitus," Am. Journ. of Med.
Sciences, April, 1882. 
124
ACUTE  PLEURITIS.
ritis, and these associated diseases are liable to prove fatal.  Their occasional
coincidence is to be borne in mind, or the pericarditis  in  this connection, if
not carefully sought for, will be likely  to be overlooked.   As  already stated,
the development of pneumonitis  consecutive to pleuritis is  not to be expected,
nor is there much danger that an acute  simple pleuritis, after its development,
will  eventuate in suppuration,  constituting the variety of the disease called
empyema.  In short, the intrinsic tendency of the disease is  to recovery, a
fatal termination being due  very rarely  to the disease per  se, but to affections
with which it may be associated.
                        CHAPTER   II.

                  ACUTE PLEURITIS  (Continued).

Treatment of Acute Pleuritis—Measures indicated in the First Stage—General Consider-
   ations relating to Bloodletting in Acute Inflammations—The Use of Opium in Acute
   Pleuritis and other Acute Inflammations—Measures indicated in the Second and Third
   Stages of Acute Pleuritis.

   THE objects of treatment in acute pleuritis differ in its different stages,
    and the latter therefore claim, severally, distinct consideration with refer-
ence to therapeutic indications.   The objects  in  the first  stage are to arrest,
if  possible, the progress of the disease, to diminish its intensity, if it be not
arrested,  to limit  the amount of morbid products, and to  relieve  suffering;  in
other words, the treatment relates to the employment of abortive, curative,
and palliative  measures.   The indications in the first stage of this disease are
essentially the same as in the early period of most acute inflammations.  The
general principles which should govern the treatment in this stage, therefore,
will be here considered, and simply referred to hereafter  in connection with
other diseases to which they are measurably applicable.
   Owing to its brief duration, patients are frequently not seen until the first
stage has passed.  Can the disease be arrested at this stage if the opportunity
offer and a positive diagnosis be made ?  Admitting that  physicians formerly
did sometimes succeed,  as they believed, in  cutting short the disease, it must
be said in answer to this question that  there  are no known  abortive  means
which can be relied upon.  Bloodletting  and other  so-called antiphlogistic
measures formerly employed for this object have certainly not been success-
ful in a sufficient number of cases to warrant their  employment  to an extent
which will render them likely to do harm if they be not successful.  Assum-
ing that  the disease goes on to the second stage, the question then is, What
curative  and palliative measures are to be  employed ?   This  question  leads
at once  to the consideration  of bloodletting.
   A great change has  taken place with  respect to  bloodletting  in the  treat-
ment of acute inflammations.  This measure was formerly  thought  to  be
highly important, and was rarely omitted.  It is now considered by many as
seldom, if ever, called for.  The infrequent use of the  lancet now, contrasted
with its frequent use forty years ago, constitutes one of  the most striking  of
the changes in  the  practice  of medicine which have occurred during this
period.   It can  hardly  be doubted that this measure was formerly adopted
too indiscriminately, and often employed  too  largely ; but the  natural tend- 
TREATMENT.
125
ency being to pass from one extreme to another, the utility of bloodletting
in certain  cases at the present time is  perhaps not sufficiently appreciated.
  Experience and pathological reasoning combine to  show that bloodletting
rarely has a direct controlling effect  upon an inflammatory disease.   It may
exert a  powerful immediate effect as a palliative measure, but whatever cura-
tive power it may possess is exerted indirectly.   Its therapeutic action in
general  consists in lessening the frequency and force of the heart's action,
and diminishing arterial  tension and the intensity of pyrexia.   In the early
period of an acute inflammation accompanied by notable pyrexia and arterial
tension  the abstraction  of blood affords relief, and may contribute to a favor-
able progress of the disease.  It should enter into the treatment of a certain
proportion of cases, provided other and more conservative means for the same
ends were  not available.
  The evils of bloodletting  arise from its spoliative effect upon  the blood.  It
diminishes the  red globules, and these, during the progress of an acute dis-
ease, are not readily reproduced.  It induces thus the anaemic  condition, and
in this way impairs the vital powers.  It will be likely to do harm, therefore,
whenever it  is  important  to economize the powers of life, and it may contrib-
ute to a fatal result in diseases or cases  of disease  which involve danger of
death by asthenia.
   The  useful  effects  of bloodletting may frequently, if  not  generally, be
obtained by  other means which  require  less circumspection in  their employ-
ment, because  if injudiciously resorted  to  they are in a less degree hurtful.
The mass of blood may be  temporarily lessened by saline purgatives and dia-
phoretic remedies, conjoined with a restricted ingestion  of food and liquids.
Depletion  is obtained in this way without impoverishment of the blood.  The
frequency and force of the  heart's action may be affected  by nauseant seda-
tives, such  as  tartar  emetic, ipecacuanha, etc., and by direct  sedatives—
namely, digitalis, aconite, and the veratrum viride.   By antipyretic remedies
and measures for the abstraction of heat the pyrexia may be lessened without
the expenditure of blood, and thus the evils of bloodletting be avoided.  The
advantage of bloodletting consists mainly in the promptness of its operation.
Several hours  are required to  secure  results from  the  means employed  in
lieu of  bloodletting, whereas the effects of the latter are produced in a few
moments.
   In accordance with these views, bloodletting is never indicated  by the fact
simply  that  acute inflammation  exists; it  is a measure  directed  not  to the
disease per se,  but to  circumstances associated with the disease.  The state
of  the  circulation and other circumstances furnish  the indications for the
employment of this measure.  It may be admissible  if, with the development
of  inflammation, there exist notable pyrexia, the patient being robust and in
good health  when attacked, and  the disease not involving danger of  death by
asthenia.  The measure is  admissible, under the conditions just stated, when-
ever the promptness with which its effects are obtained renders it desirable to
adopt it in preference to  other measures producing the same effects with more
or  less  delay.   Per contra, bloodletting is  not admissible when the develop-
ment of inflammation  is not accompanied by notable pyrexia, when  the patient
was not in good health when  attacked, when the constitution  is  feeble, and
when the disease involves danger of death by asthenia.   These rules of prac-
tice, while they accord to bloodletting therapeutic value, undoubtedly restrict
its use  within  narrow  limits.
   Applying these rules to the disease under consideration, a patient in the first
stage of acute pleuritis, robust, suffering from severe pain and  dyspnoea, with
high fever, the pulse moderately accelerated and  not weak, will derive imme-
diate relief from the abstraction  of from ten to sixteen ounces of  blood.  The 
126
ACUTE  PLEURITIS.
 loss of this quantity of blood under such circumstances in a disease like this,
 which does not tend to destroy life by asthenia, will give rise to no evil results,
 but will be likely to affect favorably  the progress of the disease.   On the
 other hand, a patient feeble or anaemic, with a pulse more or less frequent,
 but denoting diminished power of the  heart's action, should not be bled, not-
 withstanding the local symptoms would undoubtedly be thereby relieved.  By
 impairing the vital powers the loss of blood will  do harm, and is  not admis-
 sible under these circumstances merely as a palliative remedy.   And in the
 first case, if the  local  symptoms do not urgently call for immediate relief,
 other measures may be substituted  for  the  bloodletting.   It  may be added
 that, aside from the immediate relief afforded in  acute  pleuritis by bloodlet-
 ting, it has been theoretically considered as preventing, in a measure, fibrinous
 exudation by lessening arterial tension.
   Before leaving the  consideration  of  bloodletting several incidental points
 may be  briefly  noticed.
   This measure is perhaps more applicable to the  treatment of inflammation
 affecting the pulmonary organs than to the treatment of other inflammatory
 affections,  in consequence of the relations of the  former to the  circulation.
 The free passage of the blood through the pulmonary circuit seems to  be
 promoted, and the functional labor which the lungs have to perform is dimin-
 ished by the abstraction of blood.  At all events, relief of the pain and dysp-
 noea attendant  on the early stage of acute inflammation of any of the pul-
 monary structures  is more quickly and effectually procured by bloodletting
 than by other measures.  Were it  not for its ulterior effects, it would  be
 invaluable as a palliative measure in pleuritis and other inflammatory affec-
 tions within the chest.
   In another mode the abstraction of blood may sometimes be  peculiarly use-
 ful in affections  of the lungs involving considerable or great  obstruction  to
 the passage of blood through the  pulmonary circuit.  This obstruction occa-
 sions an accumulation of blood within the cavities  of the  right side  of the
 heart; hence there is congestion of the systemic veins, giving rise, if sufficient
 in degree, to lividity or cyanosis.  The accumulation of blood  in the cavities
 of the right side of the  heart  under  these circumstances weakens the force
 with which the  ventricle  and auricle contract,  and  paralysis of this  portion
 of the heart from over-distension may follow.   The formation of a heart-clot
 may be a consequence of this accumulation.   In certain cases  bloodletting
 may be advisable with a view to diminish the accumulation of blood  in the
 cavities of the right side of the heart;  but it is to be employed  for that end
 only when the contraindications which have been mentioned are not present.
   After bloodletting, the pulse sometimes appears  to indicate increased power
 of the heart's action.   The artery seems to strike against the finger with
 more force  than before  the  abstraction of blood.   Formerly, practitioners
 were misled by this effect upon the pulse, and bloodletting was employed  as
 a means-of  increasing the power of the heart's action.  The sensation which
 the finger receives in these cases is delusive, and is  caused  by the quickness
 of the movements of the artery.   This has been shown by the sphymograph
to depend on the diminished tension  of  the arteries following the abstraction
of blood.   It is to be borne in mind, in estimating the power  of the  heart's
action  by the sensible characters  of the  pulse, that the sense of resistance
which is felt and the amount of pressure required  to compress  the  artery are
the evidences of  strength.
  To a certain extent the advantages of bloodletting, inclusive of the prompt-
ness of its operation, may be obtained by arresting temporarily or retarding
the circulation in a part more or less remote from the seat of  the  inflamma-
tion.   A ligature applied to  one or more of the extremities will effect this 
TREATMENT
127
object; so also will the removal of atmospheric pressure over a considerable
space.  There  is reason to think that these measures as substitutes for blood-
letting  have not been sufficiently considered.   It is probably owing  to  their
effect in withdrawing temporarily a certain quantity of blood from the circu-
lation that dry cups and various so-called revulsive applications to the surface
of the  body are of utility in  the  first stage of acute inflammation.   A con-
siderable number of dry cups applied  to the chest constitute an efficient sub-
stitute  for bloodletting, often  affording  promptly notable  relief of pain  and
dyspnoea.
  The evils of indiscriminate and excessive bloodletting are manifested  by a
larger rate of mortality in those diseases which tend  to destroy life by asthe-
nia, and it can  hardly be doubted that the death-rate has been diminished  by
a much more sparing use of the lancet within late years.   But the results of
injudicious bloodletting are manifested in cases which end in recovery as well
as in  those which end fatally.   These results  consist in protracted convales-
cence and subsequent feebleness.  The cases of different inflammations treated
formerly  by bloodletting, together with  other measures entering  into the
so-called antiphlogistic method, and the cases now treated otherwise, present
a striking contrast as regards the condition of patients during convalescence
and  after recovery.
  The opinion  held by some that diseases have  undergone a notable  change
within the memory of those now living  has been already referred to.1  They
who hold this opinion suppose  that bloodletting and other antiphlogistic meas-
ures are less appropriate now than formerly, in consequence of such a change.
With a professional experience of over fifty years, I do not hesitate to express
a conviction  that acute inflammations  at the  present day  are essentially the
same as they were as far back  as the time just named, and that antiphlogistic
measures were neither more nor less appropriate then than now.
  In  addition to general bloodletting or  the employment of venesection, much
importance  was formerly  attached  to the abstraction of  blood by  cups or
leeches applied in the neighborhood of the inflamed part.  Local bloodletting
in some cases is more  convenient than venesection; but, so far as the  abstrac-
tion of  blood is concerned, it  is difficult to conceive that it is a matter  of
much importance from what part  of the body or vascular  system it is taken.
Whether it be  abstracted by means of cups, leeches, or the lancet, the benefit
or injury will depend  on  the quantity withdrawn in a given period.   What-
ever advantage may accrue from the removal of a certain amount of blood by
cups or leeches over the extraction of the same amount by venesection must
be derived from the operation of the former as a revulsive measure.
  With these remarks, leaving the consideration of bloodletting, and reverting
to the question concerning the curative and palliative measures to be employed
in the first stage of acute pleuritis, we are led to the consideration of opium.
And with respect to this remedy certain  considerations may here be presented
which will apply to the treatment  of other inflammations.
  A great change has taken place with respect to the use of opium in acute
inflammations.   It  was formerly used with much reserve, under the appre-
hension that, acting as a stimulant, its influence, upon the  local  disease must
be unfavorable.  It was regarded as antagonistic  to the antiphlogistic plan
of treatment.  Clinical experience and sounder  pathological views, however,
have led to the knowledge of its great value in the treatment of inflammatory
affections wherever situated.   It is valuable,  not alone as a palliative but as
a curative remedy.   Its palliative  efficacy is of course intelligible, and we can
also to some extent understand  its curative influence.  By relieving  pain it
diminishes the  determination of blood to the inflamed part;  for pain  is alone
                               1 Vide p. 110. 
128
ACUTE  PLEURITIS.
sufficient to occasion an increased afflux of blood to a part.   This fact is
illustrated by cases of neuralgia affecting a  superficial nerve.  Neuralgia of
the supraorbital nerve, for example, occasions a determination of blood to the
conjunctiva, so that this membrane appears to be inflamed, and the congestion
disappears as soon as the pain is relieved by a full opiate.   Opium exerts also
a curative influence by preventing or diminishing the constitutional disturb-
ance which inflammations are apt to occasion ; it places the system in a con-
dition to tolerate better the local affection.   The severity of  an inflammatory
disease  depends much on the amount of constitutional  disturbance which
it  occasions; and  with respect  to the  latter different cases  differ widely,
although in each the degree  and extent of the  local affection be the same.
Life is often destroyed, not in consequence of the injury done to the inflamed
part, but because the vital powers are inadequate  to bear the continuance of
the disease.  These considerations afford some insight into the utility of
opium, especially when patients are able to take  this remedy without incon-
venience, there being, as is well known, a  great difference  among  different
persons in  this  regard.  The evidence  of  the curative value of opium, of
course, is derived from experience, and  there is  ample ground  for the belief
that by its judicious use in  acute inflammations not  only is  their course
divested of much of the suffering  which would otherwise be experienced, but
their intensity  is  lessened,  and  the  danger of  death  diminished  in those
inflammations which tend to destroy life by asthenia.   The  immediate effect
of this remedy is often very strikingly manifest  in improvement  as regards
the local and general symptoms.
   Considering,  now, the use of opium in  the  first  stage  of acute pleuritis
after the abstraction of blood, if this be deemed  advisable, or after a saline
purgative, if this be  employed in lieu  of  bloodletting, it  will generally be
judicious to  prescribe opium,1 in some form, in  doses sufficient to relieve
pain and place the system fairly under an anodyne influence.  If the pain be
severe and the constitutional  disturbance considerable, the use of opium  need
not be delayed for the operation of a purgative, but may be at once entered
upon.   This is  perhaps the most judicious  course in the majority of cases, a
purgative being deferred until a distinct anodyne impression  has been pro-
duced and  maintained for some  hours by opium.  Conjoined with the  use
of opium, sedative  remedies, addressed  to the circulation, may be employed.
These should not  be pushed to  the extent of  producing disorder.  If, for
example, tartar emetic be given, it should not be carried beyond the point of
slight  nausea, and  the  veratrum viride, if given,  should occasion no  appre-
ciable effects beyond a  reduction of  the  frequency of the heart's action.
These remedies, it is to be borne in  mind,  are  addressed, not to the disease
per se, but to the symptomatic phenomena of the  disease.
   Aconite is a valuable sedative remedy in the early stage  of this as of other
acute inflammations.  The most effective mode of administration in order to
secure promptly and fully its remedial effect is that recommended by  Rin-
ger—namely,  half  a drop or  a  drop  of the tincture to be  given every ten
minutes or quarter  of an hour for two hours, and afterward the dose repeated
hourly.  Smaller doses are to be given if the pulse become feeble or there be
much prostration.
   A summary of the treatment of the first stage of acute pleuritis, then, will
embrace bloodletting in some cases, the use  of opium given sufficiently to
relieve  pain  and tranquillize the system,  a saline purgative, and  remedies
designed to act as sedatives  upon the circulation.   Blisters should not be
applied in this stage.  They occasion general disturbance more than enough to
  1 The word " opium" is here used as a general term, including the alkaloids, mor-
phia and codeia. 
TREATMENT.
129
counterbalance any effect by way of revulsion.  They add an inflammation of
the skin to the existing inflammation of the pleura.  A sinapism, turpentine
stupes, or fomentations to  the chest will secure  all the benefit of  vesication
without the annoyance and other evils  of the latter.   Moreover, a blister is
an obstacle in the way of those examinations of the chest which are of import-
ance as affording the  only reliable information  respecting the progress of the
disease.   The employment of cold in the form of the bath, the wet sheet, or
sponging  the  body, and other antipyretic measures, are rarely called for  in
this  disease, inasmuch as a high temperature (hyperpyrexia) is  of excep-
tional  occurrence.  These measures, however,  are indicated if the body-heat
rise  to  104° or 105°, as occurs in  the so-called pleuritis acutissima.
   The application of  cold to the affected side by means of the ice-bladder or
by napkins  dipped in ice-water and renewed every five minutes is a safe and
efficient measure for the relief of pain.   Theoretically, the application of cold
for a local effect may be considered to be useful by causing contraction of the
vessels and  thereby lessening inflammatory exudation.
   Preventing the  respiratory  movements of the chest on the affected side, by
means of long  strips of adhesive plaster encircling this side and  extending
partially over the  side not affected, affords notable relief of the lancinating-
pain felt in the acts of inspiration.

   In the second  stage, so  long as  the quantity of effusion is small and  a
further accumulation may be expected to take place, the indications belong-
ing to the first stage  may continue.  If the  pain be still acute and  the fever
have not abated,  measures to relieve  the  former «.nd  lessen  the latter are
indicated.   Bloodletting is  rarely called for, but  depletion  by purgatives
may be useful, not only by lessening  fever, but by restraining the amount
of effusion.   Diaphoretic remedies are useful by  contributing to  the two
ends just stated.   Opium is indicated in proportion to the pain and constitu-
tional  disturbance, and sedative remedies addressed to the circulation may be
employed.
   These measures cease to be appropriate when considerable effusion of liquid
has  taken place, when pain is no longer a prominent symptom, and when the
pyrexia  has either ceased or become much diminished.   The object of treat-
ment now is to  promote absorption of the effused liquid.   The means which
may be employed  for this object are hydragogue purgatives, diuretics, blisters,
and  the use of certain remedies which  have been supposed to act directly as
sorbefacients.
   Hydragogue  purgatives act most promptly and efficiently. The more active
hydragogues, which  are drastic  in their operation, should  be  given circum-
spectly, and generally need not be employed.  Reference is had to such rem-
edies as elaterium and gamboge. The saline purgatives, such as the bitartrate
of potassa,  either alone or in combination with jalap (pulvis  purgans), the
citrate  or the  sulphate  of magnesia, are to be preferred as sufficiently effec-
tive and  less severe.  These will sometimes  effect a  rapid decrease of the
liquid.
   Diuretics arc sometimes equally but  less rapidly effective.  They effect the
object with less perturbation and are less debilitating.   The union of two or
more diuretic remedies is more likely to prove effective than a single remedy
of this class.   Half an ounce of the infusion of digitalis, freshly made, given
three or four times daily, and either the bitartrate or the acetate  of potassa
given in addition, form a combination which is often efficient.
   Restriction in the  amount of fluids  ingested is  an  important point with
reference to absorption.   The elimination of water by the bowels  or kidneys
is of little avail if the patient be allowed to take  as  much into the system
9 
130
ACUTE  PLEURITIS.
as is  eliminated.  The  quantity should be  as  small as is  compatible  with
comfort.
  Blisters in this stage of the disease doubtless contribute to the object under
consideration.   If other means  be effective,  however, they may be dispensed
with.   Their interference  with examinations  of  the chest is  a matter of con-
siderable consequence, and the annoyance which they  frequently occasion
is not an inconsiderable objection.   If employed, small blisters successively
applied  in different situations,  removed as soon  as vesication  commences,
the vesicated  surfaces being allowed  to dry up rapidly, accomplish all the
good  to be  effected in  this way, with the smallest amount of inconvenience
both  to the physician and patient.
  Remedies which have  been  supposed to act as sorbefacients are mercury
and iodine.   Mercury I have long  ceased to  employ in this disease.   Of
doubtful efficacy, the annoyance and  other evils incident to mercurialization
render it objectionable.  The efficacy of iodine is perhaps equally doubtful,
but it is not open to similar objections. It may be given internally or applied
externally in the form of  either the  ointment or tincture.
  It is an important injunction  not  to continue  perturbatory measures  with
a view to promote absorption too  long nor too push  their use too far.  The
decrease of effusion after it has reached a certain point is likely to go on slowly,
for  reasons already stated.  Whenever this point is  reached, cathartics and
diuretics should be discontinued  or employed with great moderation, else  they
will be  likely to do harm rather than good,  by weakening  the patient; and
if at any time these measures appear to impair the  general condition, the pro-
priety of continuing them is doubtful.  A leading  object in the second stage
of the disease is to maintain the constitutional strength.  For this object the
diet should be nutritious;  tonic  remedies are useful, and a little wine or spirit
may be  allowed.   These measures should constitute the treatment after those
designed to promote absorption have been sufficiently carried out,  and should
take the place of the latter whenever there is evidence of the strength giving
way.
  It  is very  rarely the  case that  this disease  tends to a fatal  ending by
asthenia.  Should such a  tendency be  manifested by  the symptoms—namely,
frequency and feebleness of the pulse, muscular prostration, etc.—the meas-
ures which constitute the  supporting treatment are of course indicated.  These
measures, which form the  most important part of the treatment of the diseases
involving danger by asthenia, consist of alcoholics,  nutritious alimentation,
and tonic remedies.  They will  be noticed more fully in  connection with dis-
eases in the treatment of  which they are oftener called for. (Vide Treatment
of Pneumonitis, Chapter IV.)
  A fatal result in acute pleuritis may be due to rapid and excessive effusion
of liquid, as already stated.  If  the liquid accumulate sufficiently to endanger
life, it should be at once withdrawn from the  chest by aspiration.   This meas-
ure is much more frequently indicated in chronic pleuritis, and will be  consid-
ered in connection with the latter variety of  the disease.

  The measures which have reference to the promotion of absorption may
continue to be indicated in the  third stage ;  that is, for a certain  period dur-
ing the  progress of absorption.   When these measures have been  carried to a
sufficient extent, and the amount of liquid is considerably reduced, the  patient
is to be considered as convalescent.  During convalescence the chief object is
the re-establishment of the health of the patient.  This is to  be done by  tonic
remedies, a nutritious diet, and  other hygienic means.  Solid food, embracino-
a fair proportion  of meat, may be  allowed  whenever  taken with relish and
digested.   Alimentation is important; and if the appetite be small and the 
TREATMENT.
131
digestion weak, remedies  to  improve both are  indicated.  No apprehension
need be felt  that a diet as nutritious as can be taken without inconvenience
will do any harm ; on the contrary, the more nutritious the food which can
be taken and digested, the more rapid the convalescence.   Wine, spirit, or
beer in small quantities, taken with meals, will  expedite recovery.   Going
out of doors and gentle exercise are to be encouraged.   The patient will gain
more  rapidly as regards  appetite, digestion, and strength if not confined too
long within doors, and with  proper precautions no risk of harm is  incurred.
The  removal of the  liquid which remains, the absortion of fibrin, and the
development of new tissue leading to adhesion will go on rapidly in  propor-
tion  to the rapidity with which improvement in the general condition takes
place.
  In  the foregoing account of  the  treatment of simple  acute pleuritis it  is
assumed that, exclusive  of a small number of cases  in  which this  disease
destroys life either by asthenia or apnoea, its course  is toward convalescence
without becoming  chronic.  This is the rule, to which there are exceptions.
If the disease become chronic, the measures of  treatment indicated are those
which will be considered  in connection  with chronic pleuritis.
  The prevention of acute pleuritis hardly claims consideration.   The abrupt
and rapid  development of the disease precludes the employment of prophy-
lactic measures, and there are no premonitions which warrant our anticipation
of its  occurrence.
  Marked  dulness  on  percussion  over the affected side, especially at the
inferior portion, continues for  some time after  the effusion  has disappeared,
the symptoms, general and local, denoting  recovery, and the vesicular murmur
of respiration being heard over the whole of the affected side.   This shows
that fibrin  remains to be absorbed, but it  need  occasion no apprehensions.
After the effusion has disappeared, as shown by vesicular breathing and vocal
resonance  extending  to the base of the chest, considerable  dulness  remains,
and generally continues  for several weeks.
                        CHAPTER  III.

                     VARIETIES OF  PLEURITIS.

Chronic Pleuritis:  Anatomical Characters;  Clinical History ;  Pathological Character;
   Causation; Prognosis; Diagnosis; Treatment; Thoracentesis.—Empyema, Pyothorax,
   or Suppurative Pleuritis: Diagnosis; Prognosis; Treatment.—Pleuritis with Pneumo-
   thorax, Pneumo-hydrothorax, Pneumo-pyothorax, or Pneumo-haemothorax: Anatom-
   ical Characters; Clinical History; Causation; Diagnosis;  Prognosis; Treatment.—
   Pneumothorax.—Circumscribed Pleuritis.—Hydrothorax.

    OF the varieties of pleuritis, the first to  be considered is the simple or ordi-
     nary chronic form of  the disease.   Other varieties are suppurative pleu-
ritis or empyema, and pleuritis with pneumothorax.  Circumscribed pleuritis
will  claim  some  consideration.   This chapter will be devoted to these affec-
tions, including a brief account of pneumothorax without pleuritis,  and of
hydrothorax. 
132
VARIETIES  OF PLEURITIS.
                         Chronic Pleuritis.

  Anatomical  Characters.—The  anatomical characters in simple chronic
or sero-fibrinous  pleuritis are essentially the same as in the acute form.   The
pleural  cavity contains  serum and fibrin in variable relative proportions, but
as a rule the quantity of fibrin is less and the accumulation of liquid greater
than in acute pleuritis.   Effusion frequently takes place to such an extent
that  the affected side is more  or less dilated.   The lung is then compressed
into a small solid mass, usually situated at the upper'and  posterior part; the
thoracic walls are expanded in  every direction ; the intercostal  spaces are
pushed  out to a  level with the ribs  or even beyond this  level,  and show no
depresssion with the act  of inspiration ; the diaphragm  may be depressed,
pushing downward the abdominal organs situated in proximity to it—namely,
the stomach, spleen,  and liver; the lateral pressure  may be sufficient to move
the heart from its normal  situation,  and, if the effusion be  in the left side, the
heart may be carried quite  into  the space belonging to the right side of the
chest.
  The  dilatation decreases as absorption of the liquid takes place, and  con-
traction of the affected side succeeds.  The latter  arises  from  the fact  that
compressed lung does not readily resume its former volume when the pressure
of the  liquid is removed, in  consequence of the layers of fibrin with which it
is more or less   invested, and sometimes because  pleuritic adhesions have
already taken place.   Other things  being equal, the extent of contraction is
in proportion  to the amount of the previous dilatation  and  its duration.
Usually, the dimensions of  the  affected side in every direction  are lessened,
the shoulder is lowered, and lateral spinal curvature is likely to ensue.   In
some cases in which  the  lung  expands to a certain point  and becomes fixed
by permanent adhesions at that  point, the removal  of the liquid below leads
to a deep depression; the chest  presents an appearance as if the lower  ribs
had been  crushed inward.  The contraction succeeding  a  large  effusion  is
generally permanent.  It  becomes less marked  after several months or years
in some cases, and if the patient be young it  may in the progress of time
nearly  disappear.  In a patient  who had  chronic  pleuritis with very large
effusion at the age of seventeen years, followed  by great contraction, I found,
ten years afterward,  the two sides  presenting  only a slight disparity.   The
formation of new connective tissue  in the shape of fibrous thickening of the
pleural membrane and of bands of adhesion between the pleural surfaces is
more extensive  after chronic  pleuritis than after  the acute form.

  Clinical History.—Chronic pleuritis, in the great majority of cases, is
a subacute affection  from the first.  Occasionally it  follows the acute form of
the disease.  The chronic is a more frequent affection than the acute—a  fact
which shows that the latter  does not usually precede the former, as has been
stated by some authors.   Of 33 recorded cases which I analyzed with refer-
ence to this point many years ago, the inflammation was  subacute from the
first in 29.   The left side is affected oftener than the right, as in acute pleu-
ritis.   Of 42 cases, the left side was affected in 23. Of 78 cases analyzed
by Blakiston, the left side was affected in 58.
  This variety of pleuritis is often developed imperceptibly, and, as far as the
symptoms are concerned,  it  may be one of  the most insidious and latent of
diseases.  It is  often  overlooked by those who do  not  employ the physical
methods of examination.  Its development is not, as in the vast majority of
cases of acute pleuritis, characterized by pain.   Pain is often either wanting
or so slight as scarcely to attract attention.  In some cases, however, the  pain
is moderate or considerable, but falling much short of that intensity which 
CHRONIC PLEURITIS.
133
belongs to the acute  affection.  Tenderness  over the chest is  slight or mod-
erate, and may be  wanting.
  Cough and expectoration are frequently wanting, and are rarely prominent
symptoms.  The cough, if present, is  dry, short, hacking, and the matter of
expectoration  consists of mucus, transparent or slightly opaque.   If there
be considerable expectoration and  the  matter expectorated be muco-purulent,
either  bronchitis coexists  or the  pleuritis is associated  with  phthisis.
  The frequency of the respirations is increased, assuming the pleuritis to be
accompanied by a large effusion of liquid.  The increase, however, may be
moderate while the patient is at rest, but it becomes marked on  exercise.
Deficiency of breath  is  also  shown by inability to  speak with a  sustained
expiration, the speech  being interrupted at short intervals for a fresh inspi-
ration.  Dyspnoea  is  rarely  present except  on  exercise.  Here, as in acute
pleuritis, the embarrassment of  breathing depends much on the rapidity with
which the effusion  takes place.  The suppression of the  respiratory function
of an entire lung in this affection, if it be slowly induced, does not usually
occasion lividity of the face or prolabia.
  The pulse is generally more or less accelerated, ranging from 80 to 120 per
minute.   It is small and compressible.   There is, however, considerable  vari-
ation in different cases as regards these characters of the pulse.  The surface
of the body frequently presents more  or  less capillary congestion.   Sweating
is apt to occur, especially during the night, and may be profuse without having
been preceded by a chill or  febrile movement.   Irregular, slight chills,  how-
ever, are not unusual, leading sometimes to the error of supposing the disease
to be malarial.
  The appetite is sometimes notably impaired, but sometimes it is  preserved
and the digestion continues good.  Diarrhoea occurs in some cases.  Generally,
the  countenance is pallid, denoting anaemia,  but this is not true of  all cases,
and a healthy aspect is sometimes maintained.   Emaciation  is not usually
marked, except when the  disease is associated  with  phthisis.   The strength
is often retained  in  a  remarkable degree.  Patients  usually  do not take to
the  bed, and they  may be able to be up and out of doors even with one side
of the chest filled with liquid.  I have known repeatedly persons in this con-
dition to continue pursuits which required active muscular exertion.
  This sketch of the symptomatology applies, of course, to cases of chronic
pleuritis not associated with other  affections furnishing symptoms which are
combined with those belonging to  the disease  under consideration.  It may
be associated with  phthisis.   The  coexistence of the  latter affection renders
cough more prominent, and  gives rise to a more or less abundant expectora-
tion.  Emaciation  and muscular feebleness are also more marked.   Pericar-
ditis coexists  in  a small proportion of cases.  With  this complication the
circulation is more disturbed, there is more  suffering  from dyspnoea, and the
symptoms in general  denote  greater gravity of disease.  The affection may
be developed in the course of either acute or chronic disease of the kidneys ;
under these circumstances general dropsy  may be  present, emaciation  and
feebleness are greater, and the  tendency to asthenia is more  apparent.  In
like manner, other affections which  may be associated  modify  and add to the
symptoms  pertaining to the pleuritic  inflammation.
  The duration is variable, but the career rarely ends until after several weeks,
and  generally  it extends over several months.  As regards stages, when acute
pleuritis has not preceded, cases do not come under observation until more or
less  effusion has taken place, and, it may be, not until the pleural sac is  filled
with liquid.   It suffices to consider the  career of the  disease as consisting
of two stages—one embracing  the period during which the liquid either is
accumulating  or remains  stationary,  and the  other  embracing  the period 
134
VARIETIES OF PLEURITIS.
during which absorption of the liquid is going  on.   After absorption has
made  a certain  amount  of progress  the patient may be  regarded as conva-
lescent.

   Pathological Character.—Simple chronic  sero-fibrinous pleuritis  is a
subacute  inflammation, differing from the  acute form  of the disease  only in
a  lesser degree of the  inflammatory condition.  The  inflammation  has no
special character, but is  of a low grade of intensity, with  a tendency to con-
tinuance  for an indefinite period.

   Causation.—Chronic pleuritis may be produced  traumatically.  It may
sometimes be due to cold.   It occurs occasionally during the course of affec-
tions of the kidneys.   In many cases it proceeds from  internal causes which
are not understood, and  it is then said to be  spontaneous.   In a small pro-
portion of cases the chronic follows the acute disease.   In  much the larger
proportion the  inflammation is subacute from  the first.
   An  important point  of  inquiry  relates to  its pathological  relations to
phthisis.   According  to  some  authors, it  is  generally consecutive to  and
dependent upon a phthisical affection.  There  has been no  evidence  of this
in a large majority of  the cases which have come  under my observation.  Of
42 cases analyzed  several years ago, the evidence of  coexisting phthisis was
present in only 3, and of a large number of cases which  I have since observed
I am sure that  the two affections have been associated in  but a small propor-
tion.   As, however, the  occurrence of pleuritic effusion retards and  contrib-
utes to the  arrest  of the progress  of phthisis, the  association of the two
affections  may  sometimes  exist without being apparent.
   Chronic as well as  acute pleuritis occurs  rarely in infancy.  It is not of
infrequent occurrence  in childhood  and early  life, but it  is  most frequent
between puberty and  middle life.   It  is of rare occurrence in the aged.

   Prognosis.—Simple  chronic pleuritis,  not  associated with  phthisis  or
complicated with any  serious affection, and occurring  in a  healthy  subject,
tends  to recovery.  A fatal result may take  place in  consequence of a rapid
and large  accumulation of liquid, but instances of this  are  exceedingly rare.
If death occur, it is generally from associated affections or complications.
   Recovery takes place,  leaving the  affected side more or less contracted, and
sometimes the contraction is so marked as, in connection with the lateral cur-
vature of  the spine which it occasions, to produce a considerable and perma-
nent deformity.  In general, however, the contraction which follows is attended
with little or no inconvenience, and is not observed unless the chest be denuded
and the two sides compared.
   A permanent dislocation of  the heart to the right  side of the sternum is
sometimes an effect of the removal of a large collection  of liquid from  the
right pleural sac; and in some cases of pleuritis with large effusion in  the
left side the heart, which was dislocated by the lateral pressure of the liquid,
is  found on the right side  of the sternum after recovery from the pleuritis,
adhesions  having taken place which prevent it from returning to the left side
after the liquid is removed.
   Phthisis becomes manifest  sooner or later after recovery in a certain  pro-
portion of cases.   In some of the cases in which this disease appears to  be a
sequel it may have existed prior to  the pleuritis and  have undergone arrest.
The  proportion of cases  in which phthisis follows is not sufficiently large to
show a predisposition to this disease  derived from the pleuritis.  The opinion,
frequently and  perhaps commonly entertained, that chronic pleuritis,  when it
does not supervene on a phthisical affection, predisposes  strongly to the occur- 
CHRONIC PLEURITIS.                     135
rence of the latter, I believe to be incorrect.   This belief is based on my own
experience.  It is sustained by statistics communicated many years since by
Blakiston.1   Of 53  cases  observed by  that  author, the patients remaining
under observation for  several years after recovery, not one became affected
with pulmonary tuberculosis.   This result is striking, for it might be expected
that out of so large a  number of cases of any disease, occurring, as does pleu-
ritis,  for the most part at an early age, a certain proportion would be likely
in the course of several years to become phthisical.  In estimating the influ-
ence of this or  any disease  in determining the  subsequent development of
phthisis, the liability  to  the latter,  irrespective  of antecedent  affections, is
of course to be taken into  account.
   The idea that chronic pleuritis affecting the right side of the chest denotes
phthisis has been disproved by statistics reported by Bowditch.2
   The  mortality from chronic pleuritis, even without regard to associated
affections and complications, is  not  great.  The rate  of mortality probably
does  not exceed that  which several  years ago I deduced from my recorded
cases—namely,  17 per cent.
   Recovery is understood to imply  the removal, by absorption, of the effusion.
The disease, however,  may terminate  in another way, leaving  no local  symp-
toms, the patient  regaining  good  health.   This consists in the  affected side
of the chest remaining permanently filled with  liquid. The following case,
illustrative  of this termination, came under  my observation  in the Charity
Hospital of New Orleans in  1861 :
   The patient, a man  aged  about  forty-five, stated that he had been ill and
confined to the bed for four days, having previously been in  good health.
In answer to inquiries suggested by the marks of cupping on  the left side, he
stated that he had had  pleurisy several years before.   The left side was dilated,
everywhere  flat  on percussion, and  the  respiratory murmur  suppressed.
Death occurred on the third day after  his admission, and my notes do not
contain data showing  the probable cause of  death.   The  man presented a
robust appearance, and declared that he was quite well when seized with
illness four  days before  his  admission.   His habits were intemperate.   On
examination of the chest  after death, the  left  pleural sac was found to be so
resisting that it was removed entire and brought  to the college.  The sac was
then  opened with  some difficulty,  and a large amount of turbid liquid, esti-
mated to be two gallons, removed.   After the liquid had escaped, the pleural
sac was sufficiently rigid to retain the shape which it had before being opened.
A calcified fibrous tissue,  from one-eighth  to one-quarter of an inch in thick-
ness,  lined  the entire  pleura.  The parietal portion of the membrane could
in some places be stripped from this calcified  tissue.   Calcareous matter was
abundantly  deposited  in the  latter.   The lung was  compressed into a solid,
small mass  which resisted efforts  at  insufflation.
  Another case, illustrative of a similar permanency of effusion, came  under
my observation  in  private practice.   A lawyer, aged  about  thirty, had an
attack of pleuritis, which  confined him for some time to the bed, nine years
before my first examination, in 1861.  Five years afterward he was in excellent
health, being entirely  free from any pulmonary symptoms except deficiency
of breath on exercise.  Flatness on percussion  existed over the whole of
the left side, with  suppression  of respiratory sound and vocal resonance,
except at the summit,  where bronchial respiration and bronchophony existed.
These signs were considered  as  denoting  liquid  in  sufficient quantity to fill
the pleural sac and  compress the lung into a solid mass.  The patient  stated
that he had been repeatedly examined since the attack of pleuritis nine years
     1 Practical Observations on Certain  Diseases of the Chest, etc., Amer. ed., 1848.
     2 American Journal  of the Medical  Sciences, January, 1863. 
136
VARIETIES OF PLEURITIS.
before, and there had been no change in the condition of  the chest since his
apparent recovery from that disease.

  Diagnosis.—Owing to the  latency of chronic pleuritis as regards the sub-
jective  symptoms in many cases,  the existence of intrathoracic  disease is
often overlooked by those who do not employ  physical exploration.  Of the
cases which have come under  my observation, in not a few the patients have
been supposed to have either dyspepsia, irregular malarial fever, hepatic trou-
ble, or some ailment not connected with the chest.  If the  symptoms point
to the existence  of intrathoracic disease, patients are  often supposed  to  be
phthisical, and  the  cough, deficiency of  breath, night  perspirations,  etc.
rationally favor such a conclusion.   A positive diagnosis can hardly be made
without the aid of physical signs.
  The signs on which, taken  in connection with the history and symptoms,
the diagnosis may be based are  those denoting  pleuritic effusion.  The signs
of effusion are the same in  chronic as in acute  pleuritis, and  need  not be
again stated; but in chronic more frequently than  in acute  pleuritis  the
accumulation of liquid  is  so  large as to occasion  more or  less dilatation of
the affected side, and then are superadded signs obtained by inspection  and
palpation, notice  of which was  deferred  in  treating of the acute disease.
  Dilatation of the affected side by liquid is  apparent to the eye, and may
be ascertained by mensuration either with graduated tape or calipers.   The
intercostal spaces are  pushed out  to a level with the  ribs, and may be bulg-
ing.   The  side  is motionless or nearly so in the acts of respiration,  the
movements of the opposite side  being  exaggerated.  By applying the fingers
within the intercostal spaces, and making  peripheral and diametrical percus-
sion, a sense of fluctuation is  sometimes obtained.   The heart is  moved from
its  normal situation, as ascertained  either by palpation or  auscultation.   If
the effusion be in the left  side,  the apex-beat and  the maximum  intensity of
the heart-sounds are on the right side of the sternum, and  they are  carried
toward the left lateral portion of the chest if the effusion be in the right side.
The diaphragm is depressed, pushing downward the abdominal organs in con-
tact with it.   The addition of these signs renders the diagnosis of pleuritic
effusion  still more complete  and positive than the signs which denote the
presence  of liquid without dilatation.
   The presence  of liquid is  demonstrated by the  introduction of a small
exploring trocar, previously disinfected.  A hypodermic syringe, the  needle
being sufficiently strong to obviate danger of its being broken off and remain-
ing in the chest, answers for  the exploratory puncture, or a small aspirating
needle may be used.   This should be  resorted to in all cases, both of acute
and of the  different varieties of chronic pleuritis, in  order to  ascertain the
character as well  as the presence  of liquid.   With as well as  without  this
exploration there is one liability to error in diagnosis—namely, carcinomatous
or sarcomatous infiltration of  an entire lung, which may cause an enlargement
of its volume, and, a certain amount of pleuritic effusion coexisting, the sis;ns
may seem to denote simply chronic pleuritis.  An exploratory puncture demon-
strates  the  presence  of liquid.   The  diagnosis can then  be settled only by
aspiration.  Removing the liquid, the affected side  remains  enlarged ;  the
needle or trocar even passes into a solid  mass, as shown by its remaining
fixed; that is, the point not movable while in the  chest.
   A sanguinolent effusion, if scorbutus be excluded, renders the coexistence
of  phthisis  probable.
   During the stage of absorption the signs show the  progressive diminution
of  liquid until the quantity is no longer  sufficient to occasion dilatation, and
from this point  the continued  decrease in quantity is  ascertained as in acute 
CHRONIC PLEURITIS.                     137
pleuritis.  The contraction of the affected side which follows chronic pleuritis
is more marked than that succeeding the acute affection.

  Treatment.—The main objects of treatment in simple  chronic pleuritis
are twofold—namely.first, to effect the removal of the  effused liquid;  and
second, to develop and sustain the powers of the system.  For the first object
the measures which may be employed  are the same as in the second and the
third stage of acute pleuritis, consisting of the milder hydragogues. diuretics,
small blisters applied in succession over different portions of the affected side,
and the use of iodine internally and externally.  Bloodletting, general or local,
is never indicated in chronic pleuritis.
  In pursuing measures with reference to the first object, the second is not to
be  overlooked  or neglected.   Cases are  often injudiciously treated in conse-
quence of the  attention  being too much engrossed with the measures to  pro-
mote absorption; and these measures will do harm if continued too long or
pushed too far.  After a certain amount of effect has been  produced, if these
measures cease to be further effective, they should be discontinued,  at least
for a  time;  nor  should they  be persisted  in  if they fail to have any effect.
Harm is  produced by their injudicious  employment in proportion  as  they
debilitate.
   The  second object  calls for tonic  remedies,  nutritious  alimentation, the
moderate use of alcoholic stimulants, and gentle exercise out of doors. These
measures are always important, and  they are pre-eminently so if from asso-
ciated affections, complications, or the general condition  of the  patient the
powers of the  system be notably lowered.   I have repeatedly seen a marked
change for the better occur at once, followed  by progressive  improvement in
all  respects, on the discontinuance of measures having reference to the absorp-
tion of liquid, and the substitution of measures for building up  the  system.
Hygienic measures — namely, nutritious  diet and  exercise  in the open air
under proper  restrictions—are especially important.
   A  mode of effecting the first object—namely, the removal of the  liquid—
requires  distinct  consideration.  Reference is now had to  the operation of
paracentesis or thoracentesis.  The propriety of puncturing the  chest when
the accumulation of liquid is sufficient to place the patient in imminent  dan-
ger is unquestionable.   But it is a question whether it  be not advisable to
puncture although the  patient  be not in great distress or danger.   It is
clearly an object to get rid  of the liquid, and the point  is whether it be
better to  resort to the direct mode—that is, to puncture and withdraw it—or
to  endeavor to effect  the object indirectly by purgatives, diuretics, etc.
   Formerly, this operation was performed only as a dernier ressort, when little
was to be expected from any  measure.   It was deferred as long as  possible,
sometimes on account of doubt as to the diagnosis, and because the perfora-
tion  and  introduction of air involves  danger of an increase of  the inflamma-
tion.    A considerable opening was necessary in order to give free exit to the
liquid, and it was difficult to  prevent air from  entering the pleural cavity.
Objection 'to the  operation on  the  score of diagnosis is now removed by our
present knowledge of physical signs.  Moreover, the operation was divested
of  all severity, and the  liability to the introduction of air provided  against,
by the application of suction  in 1850.  The introduction  of air, aside  from
the entrance of organisms  giving  rise to putrefactive changes, is objection-
able, because its presence is an obstacle  to the full  expansion of the  lung
after the liquid  is removed, and  with  the air enter germs which  occasion
putrefactive and  suppurative processes.   Its introduction is prevented by the
employment of a suction force in withdrawing the liquid.    The  operation is
rendered  trivial, because with suction  a  small exploring trocar suffices to 
138                   VARIETIES  OF PLEURITIS.
make the puncture, which causes very little pain and  closes as  soon as
the canula is removed.
  The credit  of the introduction of the practice of withdrawing  the liquid
through a small canula by means of suction—or, as it is now called, aspira-
tion—is due to Bowditch.  He operated in this way 250 times on  154 per-
sons  in the course of twenty  years.   In no  instance was any  permanent
injury referable to the operation.   It  was in some cases  repeated several
times during  the  progress of the disease.  In a considerable proportion of
cases recovery appeared to be attributable to the  operation.   Immediate and
great relief was obtained in cases which ultimately proved fatal.   Bowditch
has been  led  by his experience to operate in all cases in which the quantity
of liquid induces either permanent or occasional dyspnoea of a severe charac-
ter, and in all cases in which the pleural cavity is filled, if, after a  reasonable
amount of general treatment, the liquid do not diminish.
  My own experience in the practice of the operation has been considerable,
and I can testify in behalf of its innocuousness,  the relief which  it  affords,
and  its value as a  means of rescuing in some  instances patients from a con-
dition of imminent danger to life.  The conclusions of Bowditch, as just stated,
are not only sustained by his large experience, and at the present time by the
experience of many others, but they are consonant with  common sense.   If,
by an operation trivial  with respect to pain or any evil effects, and  easily per-
formed, the effusion may be withdrawn at  pleasure, this mode is certainly to
be preferred to measures which are indirect, not very reliable, requiring  con-
siderable time, and producing more  or  less disturbance  and debility of'the
system.  An  important advantage  of  the operation is,  the liquid  being
removed before the lung has been subjected to long pressure and has become
adherent by dense layers of fibrin or perhaps organized tissue, the  expansion
takes place more fully and is followed  by less deformity of the chest  from
contraction of the affected side.  It is a noteworthy fact that directly after
the operation the temperature declines and may fall to the normal standard.
  Thoracentesis by means of  a  small  trocar  with the  aid of suction, the
puncture made at a convenient  point either behind, laterally, or in  front, is
admissible whenever the pleural cavity remains filled with liquid after a brief
trial of the measures  designed to promote  absorption ;  and  the operation
should not be delayed whenever the accumulation  of liquid is sufficient to
involve danger or  distressing dyspnoea.
  For many years, in  place of the  suction-pump employed by Bowditch, I
have used a simpler apparatus—namely, a small trocar and a canula  fitted to
screw upon the flexible suction-tube of Davidson's syringe.  The canula should
be provided with a stopcock.   The trocar  and canula being introduced  into
the chest, the trocar is  withdrawn and the canula attached to the syringe;
the liquid is then  removed by  means of the  expansion of the India-rubber
bulb after its compression with the hand.  I have used this apparatus in many
cases with satisfactory  results.  It has also been used with success by many
others.  After a certain quantity of liquid has been withdrawn, the patient
often is seized with cough and experiences a distressing sense of constriction
in the chest.   These symptoms probably arise  from the atmospheric  pressure
upon the thoracic wall  and from the disruption of the pleural surfaces, united
by fibrin,  by the expansion of  the compressed lung.  They may also be in
part  due to the suction force exerted laterally upon the lung of the healthy
side.   They may  be delayed,  and sometimes  avoided, by withdrawing the
liquid very slowly,  thus allowing time for  the expansion of the compressed
lung and the gradual accommodation of the parts to fill the vacuum  occasioned
by the removal of the liquid.   When these  symptoms  occur the further
removal of liquid should be  postponed  for another operation.  As regards 
CHRONIC PLEURITIS.
139
 the quantity removed at one operation, much will be gained by following the
 injunction to withdraw the liquid slowly, especially when the'patient be-ins
 to cough and complain of  constriction.  The advantage of mv apparatus over
 the suction-pump is its greater simplicity, the ease with which it is managed
 and a less liability to get out  of  order.
   More recently an instrument for aspiration—or aspirator, as  it is  called—
 constructed on a different plan, was introduced by Dieulafoy.  The peculiarity
 of  Dieulafoy's  aspirator consists  in  first  producing  a  vacuum in  a »iass
 receiver, and  then opening a  communication between the latter and a caiiula
 or hollow needle introduced into the chest.   The objections to the instrument
 are—first, being complicated,  it is likely to  get out of order; and second, it is
 expensive as compared with the suction-pump, and especially with that devised
 by me.   A  little appendage  has been added to the  canula to be attached to
 Davidson's syringe,  so that it may  be in an  instant connected with  the latter.
 It is  easy to secure  more expansive force than  is obtained by the ordinary
 syringe  used for enemata,  by  having an  instrument  made  especially for
 aspiration, with a larger and thicker  India-rubber bulb.
   A  much simpler instrument than the aspirator of Dieulafoy, on the same
 principle, is a glass  bottle from which, by an arrangement for  that purpose,
 the  air is withdrawn  by means  of a  small  syringe,  and  the communication
 with the canula within the chest then  opened'through a tube connecting  the
 latter with the bottle.  This kind of aspirator is as efficient as the more costly
 one of  Dieulafoy.
   Dieulafoy's aspirators are provided with small trocars  and hollow  needles.
 The  latter should never be used in aspirating the chest.   The  sharp needle-
 points are liable to  tear the  lung  with which it may come in  contact after
 a  certain quantity  of liquid has  been withdrawn,  giving  rise to pneumo-
 thorax.
   Failure in aspiration may be caused  by the trocar  carrying before it a por-
 tion of  false membrane which prevents the  liquid from being reached.  With
 a view to obviate this difficulty, the trocar  should be pushed with a certain
 degree of quickness and force into  the chest,  Another difficulty is the plug-
 ging  of the end of the canula with floating  pieces of  fibrin.  This obstruction
 may generally be removed by forcing  some of the fluid back again through
 the  canula  into  the chest.
   Instances have been reported of  grave symptoms, and even death, resulting
 from aspiration.  They have been most frequently reported by French writers,
 who affixed  to the condition the  name expectoration sero-albumineuse  derived
 from  one of the most  prominent  symptoms.   The condition  is  characterized
 by  dyspnoea,  cough, with expectoration of frothy,  watery,  and sometimes
 blood-stained liquid, and the symptoms of collapse.   A probable explanation
 is  the hyperaemia which follows  removal of pressure  from the  capillaries of
 the compressed  lung, these capillaries being more or less impaired in their
 nutrition  by long-continued pressure.   Recovery is  common, following the
 administration of heart-stimulants.   I believe that the risk is  almost nil,  if
 the fluid be withdrawn slowly and aspiration be suspended as soon as cough
 or dyspnoea is produced.  But even if  this statement be not  admitted, the
 risk is too small to constitute  a serious objection to the measure if  it  be indi-
 cated.  I may add that during the past twenty years aspiration has been prac-
 tised almost weekly in the wards of Bellevue Hospital, and I have not heard
 of a single instance in which any serious consequences have resulted  from it.
 Only  one such instance has come within my cognizance in private practice.
 In this instance  an alarming dyspnoea  followed the removal of a large quan-
tity of pus.   This effect was temporary, and the case ended in recovery.   It
is probable that  the  effect in that  instance  was attributable  to a  too rapid 
140
VARIETIES  OF PLEURITIS.
withdrawal of .the liquid.   I  had previously withdrawn a large quantity of
pus  in  this case without any unpleasant symptoms.


        Empyema—Pyothorax—Suppurative  Pleuritis.

   These names denote a form of pleuritis characterized by the accumulation
of a purulent liquid in the pleural cavity.  The term empyema expresses only
the  existence of pus  without indicating its situation.  Pyothorax is a better
name, but this does not express  the existence  of pleuritic  inflammation.
Suppurative  pleuritis is a simple title suggested as  more fully expressive
of the  affection.
   Suppurative pleuritis  may  be either acute or subacute  at the beginning,
but it becomes chronic.   It  is a more severe form  of inflammation than sero-
fibrinous pleuritis.  At the beginning the inflammatory products may be the
same in both diseases,  but  in suppurative pleuritis  the  emigration of white
blood-corpuscles is greater, causing the fluid in the pleural cavity to acquire a
purulent character.  Sometimes the fluid is thick,  creamy pus, but usually it
is thin and sero-purulent or  fibrino-purulent.   There is less fibrin in the exu-
dation than in sero-fibrinous pleuritis, suppurative  inflammation  checking the
production of fibrin.  The pleural membrane itself  is more severely affected
than  in acute  pleuritis.   It is thickened and converted  into a kind of gran-
ulation-tissue,  containing leucocytes, new connective-tissue cells,  and  new
blood-vessels.   The   inflammation  may  even  extend  to  the subpleural
tissues.
   Suppurative pleuritis, at least in the great majority of  cases, is not to be
regarded as an  intense  variety of ordinary sero-fibrinous pleuritis, but as an
inflammation  depending upon some special cause. The micro-organisms which
have been found in suppurative inflammations elsewhere  have been observed
in this affection.  There are various micro-organisms capable of inducing sup-
puration, so that the specific infective agent is not the same in all cases.  It
is not probable that sero-fibrinous pleuritis can eventuate in suppurative pleu-
ritis without the addition of some new special agent of infection.   The inflam-
mation has generally a suppurative character from the first, but in some cases
the emigration of white blood-corpuscles is for some time insufficient to render
the exudation distinctly purulent.
   In rare instances the walls  of the  pleural  cavity become gangrenous  and
the cavity contains a brownish, fetid fluid.  The pleuritis is then designated
as gangrenous or putrid.  Putrid pleuritis is usually secondary to gangrene of
the lungs, but it may  occur  as an independent affection.  The putrefaction is
the result of  the invasion of the pleura with the bacteria  of decomposition.
In putrid pleuritis are  found bacilli  as well as micrococci.
   Sometimes, as a result of empyema, but more frequently in connection with
putrid pleuritis, the  ribs become  carious and the  parietal pleura is easily
detached from  them.
   There are  no distinctive  points pertaining to the  symptomatology of sup-
purative pleuritis, and it is not necessary, therefore,  to consider  under a  dis-
tinct head its clinical history.
   As regards causation, suppurative pleuritis maybe produced traumatically.
It is sometimes secondary to lobar pneumonia.   It  may be developed in pyae-
mia  or  as a complication of other  acute  infectious  diseases, and it may be
secondary to abscesses in adjoining parts, as in the  lungs, the chest-walls, the
liver, or the peritoneum.  In many cases it occurs as  an idiopathic or primary
disease.  As  already stated, the special cause is probably,  in most if not in
all cases, infection with a special form of micro-organism, usually the micro-
cocci  of suppuration. 
       EMPYEMA—PYOTHORAX—SUPPURATIVE PLEURITIS.    141

   Diagnosis.—The signs as well as symptoms in suppurative pleuritis are
not distinctive  of this disease.  They represent the presence of more or less
liquid in the pleural cavity, and they are essentially the same when the liquid
is purulent as when it is sero-fibrinous.  The  point  of inquiry in regard  to
diagnosis is  whether there be  any  means of determining that the liquid is
purulent.  This  is an important point with reference to prognosis and treat-
ment.  The  occurrence  of chills, more  fever,  hectic paroxysms,  etc. is not
reliable in this differential diagnosis.   As a rule, however, the axillary  tem-
perature is higher than in simple pleuritis.  The symptoms and signs, in  fact,
exclusive of spontaneous perforation of the thoracic walls, will hardly  war-
rant a positive  diagnosis.  But the  purulent character of the liquid may  be
inferred  with considerable confidence if the quantity progressively continue
to increase notwithstanding the employment of measures to  promote absorp-
tion.   A serous effusion  is generally either diminished or retarded by the use
of hydragogues, diuretics, etc., but these measures are not likely to exert any
influence upon  a purulent liquid.
   A positive diagnosis, however, may be easily made by an exploratory punc-
ture.   A small trocar or  the needle attached to a hypodermic syringe may  be
introduced into the chest and a little of the liquid withdrawn, when the gross
and microscopical characters of the specimen thus obtained will at once settle
the question.   This procedure is Mrarrantable as a means of  diagnosis in  view
of the bearing  on the prognosis and treatment,  Indeed, the operation is  so
slight as to be in no wise objectionable.  The needle should be  sufficiently
strong not to incur  the  risk of fracture, leaving a portion within the chest.
I have known of several  instances in which  this accident  has  occurred.
   Spontaneous perforation  of the walls of the chest occurs, after a time, in
cases of suppurative pleuritis.   When this  occurs, before ulceration  of the
integument ensues, a soft fluctuating tumor makes its appearance over or near
the point of perforation.  The appearance of such a tumor, developed rapidly
without having been preceded by  inflammation exterior to the thoracic walls,
is at once significant of this  variety of  pleuritis.  The size of the  tumor  may
be observed to vary with  forcible acts of inspiration  and  expiration.   The
action of the heart upon the liquid within  the  chest may communicate a pul-
sation to the tumor, and this may  at first lead to  a suspicion of aneurism ;
but an examination  of the chest,  by furnishing the evidence of the pleural
sac being filled with liquid,  will show the  character of the affection.   If the
tumor be not  opened, inflammation of the integument from distension and
ulceration supervene, and the pus makes its  escape  from the tumor and the
pleural cavity.   " Paracentesis from necessity," as it is called, has  then taken
place.  This result is almost exclusively due to  suppurative pleuritis, but I
have  known an  instance in which spontaneous perforation  took place when
the liquid did  not have the gross  characters  of pus.
  In  a  smaller  proportion  of cases a spontaneous evacuation occurs  in
another direction.  Perforation of the lung takes  place, and the pus  finds
its way into the air-passages.   The occurrence of this event is marked  by a
sudden and copious purulent expectoration. This expectoration continues for
an indefinite period.   With rare exceptions, air enters the pleural cavity, and
the disease is converted into pneumo-pyothorax, which will presently be  con-
sidered under a separate  heading.   Perforation successively  of both the walls
of the chest and of the lung sometimes occurs.

  Prognosis.—Suppurative inflammation of the pleura is a more  serious dis-
ease than simple  pleuritis,  whether acute or  chronic.  Inasmuch  as the pus
cannot be  removed by  absorption,  but must be evacuated either  sponta-
neously or by puncture, the  condition is analogous to that of a large abscess 
142
VARIETIES OF PLEURITIS.
which, after opening, continues to discharge through a fistulous orifice. After
the purulent contents of the pleural cavity are evacuated, the membrane con-
tinues to furnish pus, and thus the discharge continues indefinitely.  Emacia-
tion, debility, hectic paroxysms, etc. result from  long-continued suppuration,
and death takes place by slow asthenia.   An unfavorable termination may be
due, as in certain cases of simple pleuritis, to the coexistence of phthisis, peri-
carditis, or some other serious affection.   In the case  of a patient ten years
of age which came under my observation sudden  death followed perforation of
the lung, the discharge of pus taking place rapidly and causing  suffocation by
filling the bronchial  tubes.
   Recovery from  suppurative  pleuritis, however, is by no means infrequent,
and may reasonably  be hoped for if the patient have a  good constitution and
the affection be uncomplicated.  The prognosis is more favorable in children
than  in adults.  The purulent discharge continues  for  weeks, months, and
perhaps years, but progressively diminishes ; pleuritic  adhesions take place,
the affection becoming more and more  circumscribed, until  at length they
become universal, and the  recovery  is completed, leaving the  affected  side
considerably or greatly  contracted.

   Treatment.—In  the treatment of suppurative pleuritis no reliance is to
be placed on measures to cause  absorption  of the purulent  liquid.  If the
pleural cavity contain pus in considerable quantity, it will not be absorbed;
but if life  be sufficiently prolonged and  thoracentesis  be not  resorted to, it
will  sooner or later make  its  way either into the  air-passages or  through
the thoracic walls.   Hydragogues, diuretics,  blisters,  etc. will not only prove
unavailing, but they do harm by impairing the powers of the system.  Thora-
centesis should be performed as soon as  the  purulent character of the liquid
is ascertained.  Aspiration may be employed and  repeated, but in many cases,
owing to the reaccumulation of pus, this  mode  of performing thoracentesis
will prove unsatisfactory.   An opening should be made  at the bottom of the
pleural sac, allowing the pus to escape freely.   Air will  of course  pass into
the chest, and, since  this is unavoidable, its ingress and  egress should be
unobstructed.  A small  orifice, not  sufficient for the free  escape of the pus
and allowing air to be pent  up within the  pleural  cavity, is injudicious.  Hav-
ing made a free opening, allowing all the pus to  escape, the orifice should be
kept open by the introduction  of an oakum tent.  This  is preferable to the
insertion of a drainage-tube, which is a foreign body within the pleural cavity,
and therefore objectionable.  The pleural  cavity  should be daily cleansed by
the injection of tepid water to  which a very small quantity of carbolic acid
(not more than  1 per cent.) is added.   For the injection a  double-tubed
catheter and Davidson's syringe suffice.   If this  be not  done, the pus within
the chest  is liable  to become fetid from the  introduction  of putrefactive
germs, and septic fever is thereby induced.  I have repeatedly demonstrated
these effects by  omitting  to wash out the pleural  cavity for  a day or two.
Billroth has enjoined caution against danger  from injecting a cold liquid into
the pleural cavity.  It  may cause death  by shock.1  In  cases of  putrid or
gangrenous pleuritis  antiseptic  injections  are especially  important.   If  car-
bolic acid be used, the quantity should be extremely  small, in  order to avoid
toxical effects.   Other antiseptic solutions which may  be used are  those of
thymol or salicylic acid.   I should  add that  I have known a complete with-
drawal of the pus by a single  aspiration to  prove sufficient, but the proba-
bility of this result is small.  Aspiration repeatedly performed has succeeded
in several cases under my observation, but these cases are exceptional. There
is no objection  to giving  aspiration a fair trial before resorting to a free open-
                1 Vide Am.  Journ. of Med. Sciences,  April, 1882. 
              PLEURITIS WITH PNEUMOTHORAX,  ETC.          143

 ing.  Indeed, this is generally advisable.   In children, simple aspiration not
 infrequently effects a cure.
   Of late years there has been considerable discussion as to the best method
 of operative procedure in case of suppurative pleuritis.  There is agreement
 as to the necessity of risking a free  opening into the chest, but many are
 opposed to subsequently washing out the pleural  cavity.  The  resection of
 one, two, and even six  or eight ribs in order to favor sinking in of the chest-
 wall and closure of the pleural cavity  has been  recommended.   This pro-
 cedure  seems to me highly objectionable.   I have  known of two instances in
 which death was fairly attributable to this operation.  Trephining the ribs
 is less objectionable, and may be advisable in some cases.1
   If spontaneous perforation  of the chest-wall take place, as denoted by the
 development of a fluctuating tumor, the  latter may be at once opened ; but if
 the perforation be at a point so far above the bottom of the sac that a portion
 only of the  pus  is  evacuated, more  or  less remaining constantly below the
 point of perforation, a counter-opening  may be  requisite.   Aspiration, how-
 ever, may be fairly tried before resorting to this measure and  before making
 an incision into  the subcutaneous tumor.
   If perforation of the lung  take place  aspiration should  be  employed, and
 if this  do  not succeed a free incision  into the chest-wall should be made, pro-
 vided the pus be not fully discharged by expectoration.  The  fact that  only
 a portion of the pus within the pleural cavity is expelled  through the pulmo-
 nary orifice is readily ascertained by means of the physical signs.  In most
 instances perforation of the lung converts the disease into pneumo-pyothorax,
 but sometimes pus passes through the opening into the bronchial tubes with-
 out the entrance of  air into the pleural space.
   To support the powers of the system is  an object  of still greater  import-
 ance in the treatment of suppurative than  of simple chronic pleuritis.  The
 importance is greater because there is more danger of death by asthenia, and
 in favorable cases the duration  of the affection  is  longer.  The  measures to
 be employed for this object are the same  in both forms of the disease.


    Pleuritis with Pneumothorax—Pneumo-hydrothorax—■
           Pneumo-pyothorax—Pneumo-hsemothorax.
   The  term pneumo-hydrothorax denotes  the  presence of air or gas and
 liquid in the pleural cavity.   As the liquid, however, is either sero-fibrinous
 or purulent, hydrothorax, which signifies a purely serous liquid, is not strictly
 appropriate ; the liquid is  due to inflammation and the affection is a variety
 of pleuritis.   It would be more  correct  to  say pleuritis with pneumothorax.
 Pneumothorax denotes the presence of air  without liquid.   The latter affec-
 tion is  rare, but  it occurs and  claims  separate notice.

   Anatomical Characters.—Gas escapes with more or less force after the
 knife penetrates the chest in making the post-mortem  examination.   If the
 patient  have survived sufficiently long after  the perforation, the pleural cavity
 usually contains an inflammatory exudation. This exudation is in most cases
 purulent (pyo-pneumothorax); and in rare instances it is sero-fibrinous (sero-
 pneumothorax.  Sometimes the perforation is attended by hemorrhage  into '
 the pleural cavity  (haemato-pneumothorax).  If  the disease  be associated

  1 Vide article by Dabney, in American Journ. of Med. Sciences, October, 1882; abstract
of Konig's treatment in same journal, April,  1881;  article by  T. G. Richardson  in
Jidci-iiiiI of the American Medical Association, vol.  i. No. 2.  Keference to recent liter-
ature of the subject mav be found in Virchow and Hirsch's JahresbericM, under heading
" Pleuritis," 18S4 and 1885. 
144
VARIETIES  OF  PLEURITIS.
with pulmonary gangrene, and exceptionally in other cases, the air and liquid
are fetid in consequence of putrefaction.
  The size of the  perforation varies.   It is  usually small when  the affection
supervenes on phthisis, but in cases  of  gangrene it may be  quite large.
Usually, the site  of the perforation can  be demonstrated  by inflating the
lungs through the  trachea.  Sometimes, however, it is impossible to find the
perforation.
  The perforation  may be found  open  or  closed, or in the form  of a valve-
like structure which allows  air to enter, but not to escape from, the  pleural
cavity.  The tension of the enclosed  air is usually greatest  when the per-
foration is valvular.  The perforation  may be closed by a fibrinous layer.
  The lung on the affected  side  is compressed into a solid mass if  this  be
not prevented by  old  adhesions.

   Clinical History.—The occurrence of perforation of the lung is  usually
marked  by acute pain denoting  the development of pleuritis.   The introduc-
tion of  air and the speedy effusion of liquid give rise generally to  notable
dyspnoea,  with  accelerated breathing,  accompanied  frequently with lividity.
The pulse is in most  cases rapid  and feeble.   These  symptoms show the
supervention of a  serious affection  of  some  kind, and point to the chest as
its  seat.
  In some cases the accelerated breathing and dyspnoea continue to be prom-
inent symptoms, the patient suffering  greatly, and perhaps being unable  to
lie  down (orthopncea),  the affection ending  fatally, usually under these cir-
cumstances after the lapse of a  few days, and it may end fatally in the course
of a few hours.  But in other  cases the  violence of the symptoms subsides
after  a  short time, and the  dyspnoea may be moderate  or wanting, save  on
exercise.   In some instances even considerable exercise  is practicable.  As
regards  strength and the general  condition there is much variation in differ-
ent cases.  In the  majority of  cases patients are confined to the room and
bed, but sometimes they are able  to be out of doors, preserving appetite and
not presenting a notably morbid aspect.  Much will of course depend on the
condition  as regards the affections of which  this is a complication.
   As an exception to the rule,  pleuritis with pneumothorax from perforation
is developed gradually and imperceptibly.  It may remain for a greater or less
period quite latent.  In  some instances the accumulation of liquid becomes
large, the air disappears, and the affection is converted into simple pleuritis
with effusion.   In  several instances of  this kind which have fallen under my
observation thoracentesis  was  resorted to, and the communication between
the air-passages and pleural cavity through the  perforation was resumed
after  the  liquid was withdrawn.

   Causation.—It is estimated that from 80 to 90 per cent, of all cases  of
pneumothorax  are due to the rupture  of a phthisical  cavity into the  pleural
cavity.  Although  this rupture usually occurs in an advanced stage of phthisis,
it may take place  before any suspicion of this disease exists.   The perfora-
tion is more frequently at the middle or inferior portion of the lung  than at
the summit.  Gangrene, abscesses, and  hemorrhages in the lungs are rare
causes of pneumothorax.   It is sometimes due to the bursting of an  emphy-
sematous  bleb situated just beneath the pleura.   As in such cases the  air may
not contain any inflammatory irritant,  the pneumothorax may exist without
any inflammatory exudation.   Bronchiectasis may lead to rupture.  Next in
frequency to phthisis  as  a  cause of pneumothorax is the  ulceration of an
empyema into  the lung.  When an empyema opens spontaneously through
the thoracic walls,  it may be that  no pneumothorax follows, because the open- 
              PLEURITIS  WITH PNEUMOTHORAX,  ETC.          145

ing is sinuous and in some cases acts like a valve.   Injuries of the chest which
cause  laceration of the lung are attended by pneumothorax.   The most fre-
quent  of these is fracture  of the ribs.   Simple stab-wounds of the  lung
may occur without causing pneumothorax.   A very small number of cases
of pneumothorax  are the result of communication between the pleural cavity
on the one hand and the oesophagus, the stomach, or the intestine on the other
hand.   Ulcerative and cancerous diseases  of these organs may lead to this
abnormal communication.
   It is held by some authorities  that gas may be spontaneously generated in
the pleural cavity by the  decomposition of inflammatory exudations or  of
blood.   This view, however, is not proven.   The failure to find a  perforation
cannot in itself be considered evidence  of the spontaneous generation of gas.

   Diagnosis.—When this affection  is developed with  marked  symptoms  in
the course of phthisis, its  existence  should  certainly be at once  suspected;
but  the symptoms are not  sufficiently distinctive  of this affection,  as  con-
trasted with  pleuritis and  effusion without  the presence of air, to warrant a
positive differential diagnosis.  Moreover, as just stated, the affection is some-
times  latent, the  symptoms not  warranting even the diagnosis of pleuritis.
A positive diagnosis, in short, must be  based on physical signs, and these are
easily  obtained and very explicit.
   The presence of air in the pleural  cavity renders the'resonance on percus-
sion purely tympanitic.  If the quantity  of liquid be  small  or  moderate,
tympanitic resonance may extend over the  whole of the affected  side, being
propagated from the level to the bottom of the liquid.   If the liquid be large
or considerable in quantity, dulness or  flatness will be found at the base and
extending upward (the patient sitting) to a certain height, tympanitic reso-
nance  existing above.   Under  these  circumstances  the relation of resonance
and  dulness or flatness will always be found to vary with  the changed posi-
tion of the body  of the patient.  The tympanitic resonance sometimes has
an  amphoric character.
   Respiratory sound is  sometimes wanting over the whole  of the affected
side.   Over the compressed lung bronchial respiration may often  be found.
The ordinary cavernous respiration is sometimes heard, but  in most  cases
amphoric respiration and amphoric voice or  echo are present, either limited  or
diffused over the whole of the  affected side, and metallic tinkling is generally
conjoined.  The presence of these striking  and distinctive signs renders the
diagnosis easy and positive, taken in connection with other signs.
  Succussion  almost invariably develops a splashing sound, frequently hav-
ing the same kind of musical  intonation as  the respiration, voice, and tink-
ling sounds.   This proof of the presence of air and liquid is positive, and it
enables the diagnosis to be made in an instant.
  The affected side is frequently dilated, and presents the same appearances
as in cases of dilatation from liquid either in simple or suppurative  pleu-
ritis.
  Leyden has called attention to the rare occurrence of abscesses containing air,
situated just below the diaphragm, either on the right or the left side, oftener
on the  right,  between the  diaphragm  and  the upper surface of the  liver.1
The  diagnostic features of these abscesses were first  recognized  by Barlow
and Wilks in 1845.  Leyden calls the affection pneumothorax subphrenicus.
Cossy  calls it false pneumothorax.   The abscesses result from perforating
ulcers of the stomach or duodenum from which gas  is derived, circumscribed
peritonitis having  been produced.  The signs of pyo-pneumothorax are pres-
ent.  Leyden  diagnosticated the affection in  two  cases, each  connected with
                  1 Zeitschrift fur klinische Medicin, Bd. 1, p. 320.
       10 
146
VARIETIES  OF PLEURITIS.
perforating ulcer of the stomach.   The differential points are—the  presence
of  the  respiratory murmur  from the clavicle down to  the third rib;  the
extension  of the respiratory murmur downward by deep  inspiration ; and, at
first, absence of cough and expectoration.  The  abscesses may burst event-
ually into  the  lungs.  A capital point in the diagnosis is the history of the
development of the abscess with the signs of peritonitis following symptoms
referable to the stomach or intestine.

   Prognosis.—The  prognosis  in  cases of pleuritis with pneumothorax is
always  unfavorable.   In  this statement traumatic cases are excluded;  the
prognosis in these cases is generally favorable.   Of the cases of empyema in
which pneumo-pyothorax is produced  by perforation of lung there is a fair
prospect of recovery if other circumstances be favorable.   If  the  affection
be  connected with pulmonary gangrene, death takes place generally within
a short period.   Other things being equal, when it occurs in the course of
phthisis a fatal termination is  speedy in proportion to the progress which
the latter  affection has  made.   There is a wide variation in different cases
as  regards its duration before a fatal  ending; in  many cases it ends fatally
within a few days  or weeks, but sometimes life is prolonged for months^ or
even years.  It may continue for an indefinite period, the patient experiencing
so  little inconvenience as to consider  himself in  fair health.  The following
unique  case will  serve to verify this statement,  and also to  illustrate  the
latency of the affection  occurring in  connection  with  phthisis:
   I received from Dr. J. H. H. Burge of Brooklyn, N. Y., the left lung which
he had  removed at a post-mortem examination made two or three days before.
The patient, aged  eighteen, an  accountant,  was seized four days before  his
death with an  acute affection which proved  to be pneumonitis  affecting the
lower lobe of the  right lung.  At the  time of the attack  he  considered him-
self in  fair health.  He was attended by Dr. Burge, who  found  the physical
signs denoting pneumonitis, and the affected  lobe was found after death in
the second stage of this disease.  On  an examination of the chest, in addi-
tion  to the  pneumonitis  Dr. Burge discovered  the  signs of pneumo-hydro-
thorax  affecting the left side.   Metallic tinkling and amphoric respiration
and voice were well  marked.  The upper portion of the chest on this side
yielded a tympanitic, and the lower portion a dull, resonance on percussion.
   On inquiry as to the previous health the patient declared that he was well
when attacked with the acute  disease ;  that is, four days before his death.
On close questioning, however, it was ascertained that he had  had a slight
cough  for a year, but so slight that he thought nothing  of it.   He was  not
conscious  of any  deficiency of  breath, was  not subject  to pain  in the  side,
and, in  short, there were no symptoms pointing to so grave an affection as
pleuritis with  pneumothorax.
   The left lung was completely condensed from compression.  The lower lobe
was readily inflated; the  upper  lobe but  slightly, owing to the free escape of
■air through  a perforation as large as a crow's quill situated  on the  anterior
aspect of this lobe about midway from the upper to the lower extremity.  On
closing  the aperture this lobe was readily inflated.  The perforation  was gap-
ing, the orifice being surrounded by a  cartilaginous rim.   On passing a probe
into the aperture it entered a small cavity of about the size of an American
walnut.   The cavity was  smooth and lined by a  membrane.  This  was  the
only  cavity in  the left lung, and there  were no phthisical deposits.  The
whole surface  of the lung was covered with fibrin, which was dense  and
closely  adherent.   The pleural  cavity contained more than a quart of turbid
liquid which was  not fetid.  When  this side of the chest was opened air
escaped with force, emitting no fetor.  The upper portion of the right  lung 
PXE UMO THORAX.
147
contained several  phthisical  cavities,  the  largest of the size of an English
walnut, with small phthisical deposits.

  Treatment.—The treatment of pleuritis with pneumothorax in most cases
embraces only palliative and sustaining measures.  The  severity of the pain
and the distressing dyspnoea frequently call urgently for measures to procure
relief.   Opium, soothing applications to the chest, and the ethereal prepara-
tions are indicated for this object.  The powers of the system are to be sus-
tained  by tonic  remedies, alcoholic stimulants, and a nutritious diet.  These
measures will generally serve only to  mitigate  the sufferings of the patient
and prolong life ;  and in the rare cases in which the affection  continues  for
months, years, or indefinitely, and is not incompatible with comfortable health,
there is no special treatment to be pursued, the  main object being to invigor-
ate and support  the powers of the system.
  If the patient suffer greatly from dyspnoea arising  from dilatation of  the
affected side, the  chest may be punctured as a palliative measure.  I  have
resorted to this operation  to the great  relief of  the patient.  The air will be
likely to reaccumulate and the side become again dilated as  before ; but I
have known this not to  occur for  some  weeks, and  the operation may be
repeated as often as called for by the- dyspnoea arising from the dilatation.
  These remarks on the treatment have reference to pneumo-pyothorax occur-
ring in connection with  phthisis, and not to the perforation  of lung from
without inward in cases of suppurative pleuritis.  The treatment of pneumo-
pyothorax  when thus secondary  to the latter disease  has been already con-
sidered. (Vide p. 42.)  It is a question whether, when occurring in cases of
phthisis, a free incision into the  chest and a permanent  opening may not be
advisable.   I have resorted to this measure in a few cases with notable relief,
and, apparently, life has  been thereby prolonged.  It is within the range of
possibility that this procedure may effect a cure.  If the phthisical affection
be small and cease to progress, the perforation possibly may become  closed
by  adhesions, and recovery from  the pleuritic disease takes place.  Consider-
ing that there is  no prospect of effecting a  cure by  any other method of
treatment, and that the condition of the patient is not injured  but improved
by  making a free opening into the chest, there can be  no objection  to resort-
ing to  it,  In making a free opening into the chest in a case of pneumo-hydro-
thorax an anaesthetic should not be administered.  I am cognizaut of a case
in which death was due to the liquid  making its way from the pleural cavity
through the open  perforation  into the  bronchi and trachea and being inspired
into the opposite lung.   This occurred while the patient was under the influ-
ence of chloroform and the operation  for  opening  the chest was in progress.
  When the chest, after perforation of the lung in cases of phthisis, becomes
filled  with  liquid, this should not be withdrawn for  a considerable period.
Permanent closure of the perforation  may sometimes ensue.  An instance of
recovery under these circumstances has not fallen under my observation, but
I have known several weeks to elapse after aspiration before  pneumothorax
again occurred.

                           Pneumothorax.

  The term pneumothorax denotes the presence of air, without liquid, in the
pleural cavity.  Under these circumstances pleuritis either does not exist or
it is not accompanied by  effusion.  This affection is certainly extremely rare.
Its occurrence has been  doubted, but its existence is  sufficiently established.
In  cases of pneumothorax without pleuritis the perforation  of lung  is  not
incident to cither  gangrene or phthisis, but is probably  connected  generally, 
148
VARIETIES  OF PLEURITIS.
if not  invariably, with  emphysema, which may not be general but  circum-
scribed.  Emphysematous  dilatation  of the air-cells, perhaps  confined  to a
few lobules at the margin of a lobe or an emphysematous bleb, may lead to a
minute rupture through which air is forced by the acts of breathhig into the
cavity  of the pleura.   Under these circumstances rupture may be caused by
lifting  a heavy  burden, severe  coughing, or violent exertions of any  kind.
The perforation, as remarked by Gairdner, may be  no larger than a pinhole.
The presence of the air does not excite pleuritis, but the accumulation may
be sufficient to compress the  lung into a solid mass, as in pleuritis with large
effusion, dilating the  affected side and removing the heart from its  normal
situation.
   Pneumothorax without  effusion  from  pleuritis  is characterized  by the
absence of the symptoms and signs denoting inflammation and the presence
of liquid.   The  patient  suffers  chiefly  from  the  mechanical  effects of the
presence of air.   These effects relate exclusively to the respiration and circu-
lation.   There is little or no febrile movement; the  appetite, digestion, and
nutrition are not affected, and the vital powers are maintained.   If  the  affec-
tion  were to  end  fatally, it  would be by apnoea, assuming  that  pleuritis is
not developed sooner or later.   It is unquestionable that this  affection  may
end in  recovery.  Under the influence of compression the  perforation  may
become sealed up by a circumscribed pleuritis with the exudation of fibrin, or
by the adhesion  of the pleural surfaces at the point of perforation, the lung
again expanding and resuming its function.  Gairdner has quoted the report
of a remarkable case illustrative of the occurrence of pneumothorax without
pleuritis, and of its favorable course and termination.1 Gairdner regards this
case as unique in  respect of the distinctness of the  clinical facts  on which
the diagnosis  was  based.   A case equally striking, and not less distinct as
regards the diagnosis, has fallen  under my observation. The important points
taken  from the  history of  this case, which was recorded  very  fully, are as
follows:
   A Polish peddler, aged twenty-nine, was admitted into hospital January 29,
1856.   He stated that twelve days  before his admission, being  apparently in
perfect health, he was attacked  suddenly with a sharp pain  in  the region of
the left nipple, accompanied  with shortness of breath.  This occurred  while
he was carrying  his pack, which  weighed about seventy pounds.  He  had no
cough  or expectoration.  The pain soon disappeared, but the want of breath
obliged him to give up his occupation and led him to the hospital.  He was a
vigorous man, weighing about one hundred and  seventy-five  pounds.  He
presented a healthy aspect, complaining only of deficiency of breath on exer-
cise.    This difficulty did not prevent him from being up"  and walking freely
about  the ward.
   The  left side  was dilated and  the  intercostal depressions obliterated; the
resonance  over this side was purely tympanitic, and auscultation furnished
a well-marked amphoric echo without any respiratory sound.   Subsequently
amphoric respiration became extremely well marked, together  with metallic
tinkling.  The heart-sounds  showed  the  heart to be to  the  right  of the
sternum.
 ^ After a month there was considerable improvement with regard to the defi-
ciency  of breath on exercise. The dilatation  of the  left side was no longer
apparent, and the intercostal  depressions became visible ; vesicular respiration
extended from the summit to the nipple, and the amphoric sounds, with the
metallic tinkling, had  disappeared.
  Three weeks afterward the patient felt sufficiently improved to  leave the
hospital and  return to his occupation.   The respiratory murmur on  the left
                  1 Clinical Medicine, Edinburgh, 1862, p. 381. 
CIRCUMSCRIBED  PLEURITIS.                 149
side was  feeble, but everywhere appreciable, with no abnormal modification
save in intensity, and no amphoric sounds.  The impulse of the heart was
felt on the  left side  of the  sternum.
  The patient consulted me a month  after his  discharge  from the hospital.
He had returned to his occupation of  peddling,  carrying his pack on his back
as before.  He had experienced no difficulty from want of breath until three
days before his visit  to me, but  for  three days  the deficiency of breath on
exercise  had been considerable.   On  examination of the chest the left  side
was everywhere tympanitic; there was no respiratory murmur on that side,
and the  heart was on the right  side  of the sternum.  No amphoric sounds.
He complained of nothing but the want of breath; excepting this he  was
well.
   I did not see the patient afterward  for eleven months.   At the end of  that
time he called  to see me with  another  patient.  After his former call upon
me he gave up peddling and became  a  farm-laborer.  He  now appeared and
reported  himself to  be perfectly well.   The respiratory murmur  was  every-
where heard over the left side, but was slightly weaker than on the  right
side.   The  apex-beat of the heart was  in its normal situation.   The left side
laterally  and posteriorly presented to  the eye slight contraction.
   This was a  case of  simple pneumothorax  without pleuritis.   A pinhole
perforation  at a weak point  or the rupture of  an emphysematous bleb prob-
ably took  place  in consequence  of the muscular  exertion  of  carrying his
pack.  He  had nearly recovered  when, on resuming his occupation, the per-
foration  was reopened and the pneumothorax reproduced.  Recovery again
took place, and after the lapse of several months appeared to be permanent.
   A sufficient  number of cases of pneumothorax without pleuritis to  serve
as a basis for the clinical  history  and prognosis are not  yet  available.   The
infrequency of the  affection is  such  that the  collection of a considerable
number of cases  for analysis cannot soon be expected.   The  case just  given,
and the  case reported  by Gairdner,  go to  show that a favorable prognosis
may be entertained.   The physical signs are those of pneumo-pyothorax  or
pneumo-hydrothorax, excluding those  denoting the presence of liquid.   The
affection is to be differentiated  from diaphragmatic hernia.
   As regards treatment, it is obvious that no special course of medication is
called for.  The  compression of  lung probably favors the healing up  of the
perforation, so  that it would not  be advisable to  puncture the chest in  order
to allow the air to escape.  Active exercise or  muscular  efforts, as in  strain-
ing, are  to  be  avoided, not only  during the continuance  of the affection, but
for some time  after recovery, lest the orifice may be reopened, as in the case
just detailed.  Soothing  embrocations  to the  chest will  be  useful as palli-
atives, but nothing can be  gained by active counter-irritation.   A nutritious
diet may be allowed.  Cathartics, diuretics, and rubefacients are not  indi-
cated.

                      Circumscribed Pleuritis.

   The frequency with which pleuritic adhesions over a limited area are found
after death is proof that circumscribed pleuritis often occurs.  But the inflam-
mation which results in these adhesions is often subacute, and generally occurs
without  giving rise  to much pain or other disturbance.   As already  stated,
circumscribed pleuritis is secondary  to some  pulmonary affection, especially
phthisis  and pneumonitis.   It differs  from a primary general pleuritis  in not
giving rise to  pleuritic  effusion.   Fibrinous exudation  is sometimes  small,
and perhaps may be altogether   absent, the adhesions  taking  place  purely
by a hyperplasia or proliferation  of  the connective tissue.  Limited  to the 
150
VARIETIES  OF PLEURITIS.
pleura investing the diaphragm (diaphragmatic or phrenic pleuritis), inflam-
mation  is supposed to  give rise to symptoms which are distinctive—namely,
hiccough attended with pain,  and  pain referable to the diaphragm in the acts
of coughing.   It  may be doubted, however, if  these symptoms  foe  sufficient
to mark the situation of inflammation or to distinguish  inflammation  from
pleurodynia.  If from  the  symptoms circumscribed pleuritis be suspected,
the treatment  indicated embraces  moderate counter-irritation, soothing appli-
cations  to the  chest, and  anodyne remedies.   The successive  attacks of cir-
cumscribed  pleuritis which occur  during the progress of phthisis, and which
lead to firm adhesions, are seldom accompanied by much pain and  only call
for palliative measures.
   Circumscribed collections of sero-fibrinous or purulent liquid  are  usually,
if not always,  preceded by general pleuritis, which has led to  the adhesions
surrounding the space  in  which the  liquid is  contained.   These collections
may be situated at the lower part of the chest, between the  lung  and dia-
phragm or between the  lobes.   The previous history and  the appearances of
the chest will generally show the  prior  existence of general pleuritis.  The
diagnosis of circumscribed collections of liquid is not always easy.   For the
physical signs  the reader is  referred to works which treat more  fully of
thoracic  diseases.   The  treatment embraces  the measures  for promoting
absorption,  and if the liquid be  purulent, this fact having been demonstrated
by means of the exploring trocar, it is advisable to effect its removal by a free
opening after a trial of repeated  aspirations.  The latter have been successful
in some cases under my observation.


                            Hydrothorax.
   Hydrothorax, using the term  correctly, is not a  variety of pleuritis, but it
is noticed in this connection because, as far as certain symptoms and physical
signs are concerned, it has points in common with pleuritis  accompanied by
liquid effusion.   In the proper sense  of  the term it denotes a dropsical affec-
tion.  The effused  liquid  is serum devoid of fibrin.   The effusion  is not a
result of inflammation or any other affection of the  pleural membrane, but
proceeds from those conditions relating to the blood and circulation on which
dropsical effusion in other situations depends.   It very rarely, if  ever, occurs
alone, but is an element of general dropsy ;  that  is, dropsical effusion exists
at the same time in  the  peritoneal cavity and  in  the subcutaneous areolar
tissue, the latter constituting either oedema or  anasarca.   As a rule,  in cases
of general dropsy the  hydrothorax is  subsequent to the anasarca  and to
hydroperitoneum.
  The signs which denote the presence of liquid  in the  pleural cavity are
applicable alike to inflammatory and  dropsical  effusion.   The proof afforded
by the change of level of  the  liquid, corresponding with changes of the posi-
tion of the body, is more  constantly available in hydrothorax, because fibrin
is not present to agglutinate the  pleural surfaces and lead to permanent adhe-
sions.  But the  distinctive feature  of this affection  is the existence of  effusion
in both pleural cavities.  Hydrothorax is  bilateral, provided the pleural cavity
on one side  be not abolished by  universal adhesions due to a previous attack
of pleuritis, whereas pleuritis  when it is  primary is unilateral.  The  amount
of dropsical effusion, however, in both sides is  generally  not uniform.  It is
not uncommon to find in the pleural cavity on  one side a quantity of liquid
considerably larger than is contained in the cavity on the other side.   It  may
then be laid down as a rule that if the physical signs  show the presence of
liquid in  both sides and general dropsy coexist,  the affection is hydrothorax.
A friction murmur is of course not developed in this affection. 
ACUTE LOBAR PNEUMONITIS.
151
  Symptoms denoting inflammation—namely, pain, cough, and febrile move-
ment—do not belong to the clinical history of hydrothorax.  The respirations
are increased in frequency, and the patient suffers from deficiency of breath or
dyspnoea in proportion to the amount of dropsical effusion.  Existing in both
sides,  it is obvious that the embarrassment of respiration  will be the same as
if all  the liquid were in one pleural  cavity, and twice as much as if  the effu-
sion in one side were  unaccompanied by an equal effusion in the other side.
If there be considerable effusion dyspnoea  will be marked, amounting per-
haps  to orthopnoea, and death by apnoea may be due to the amount of effu-
sion.   Cardiac lesions producing obstruction of the mitral orifice especially
favor  the occurrence of hydrothorax after these lesions have led to dilatation
of the right cavities of the heart,
  The measures  of treatment in hydrothorax are those indicated in general
dropsy, and  these need not be considered in this  connection.  Aspiration
should  be resorted to as a palliative measure if the amount of effusion be
sufficiently large to occasion much suffering, although not sufficient to endan-
ger life.   If  there be  any danger from apnoea, aspiration is to be employed
without delay.   It is an  unobjectionable measure.   I have resorted to  it
frequently.   As  there  is  no  obstacle to the expansion  of the compressed
lung in cases of hydrothorax, all the effused liquid  may  be at once  removed
without the distress which is liable to accompany aspiration in cases of pleu-
risy.
   It should be added that, in some cases  in which it is dependent on mitral
obstruction, hydrothorax is greatly out of proportion to the amount of drop-
sical  effusion in other  situations.  I have  repeatedly observed  prompt, com-
plete,  and permanent  relief procured  by  the hydragogue  operation  of
elaterium in  these  cases, but, as  a  more  prompt  and less  debilitating
measure, aspiration is to  be  preferred.
                        CHAPTER  IV.

                            PNEUMONITIS.

Seat of the Inflammation.—Varieties: Acute Lobar Pneumonitis: Anatomical Characters;
   Laws of the Disease; Clinical History;  Causation; Diagnosis; Pathological Charac-
   ter ; Prognosis.

    HAVING considered in the preceding chapters inflammation affecting the
      serous membrane investing the lungs, inflammation seated in the pulmo-
nary substance or parenchyma is next  to be considered.   The latter is called
pneumonitis or pneumonia.    Pneumonia is the  name commonly used, but
pneumonitis is the more appropriate term,  being in conformity with  the plan
of distinguishing inflammatory affections by the  suffix ifis.   The latter term
will be  adopted in  the headings, but  elsewhere the two names will be used
indifferently.  The  question at once arises, What constitutes the parenchyma
or substance of the lungs?   These terms  relate  to  the pulmonary lobules,
which are  composed of air-cells,  infundibula, alveolar passages, and bron-
chioles.   A bronchus after it enters a  lobule is called a lobular bronchus or
bronchiole;  it divides dichotomously  once or  twice, and terminates in the 
152
PNEUMONITIS.
alveolar  passages, into which open the air-cells, air-vesicles, or alveoli.  The
alveolar  passages  also divide a few times, and end  in funnel-shaped spaces
called infundibula, the walls of which are composed of thickly-placed air-
vesicles.   The lobular bronchi are devoid of cartilage-plates  and of mucous
glands, and are lined with a layer of low cylindrical ciliated  epithelial  cells.
The walls  of the  air-cells  and alveolar passages are composed of a homoge-
neous basement-substance  containing a few oval nuclei  of connective-tissue
cells and a rich network of elastic fibres and of pulmonary capillaries.  They
are lined with a single layer of  flat polygonal cells, some of which are small,
nucleated,  and granular, others larger, non-nucleated, and homogeneous in
appearance.  It  is only the nucleated, granular, epithelial cells which  take
any active  part in  inflammatory diseases of the lungs.  In acute pneumonitis
the inflammation is seated in the air-cells and  bronchioles.   The differences
in structure between the membrane  composing the wall of these parts and
the bronchial mucous membrane, together with a difference of function and
of blood-supply, will serve to account for the fact  that  the  inflammation in
pneumonitis may be limited to  the pulmonary substance, and  also the fact
that in bronchitis  the  inflammation rarely extends to the pulmonary paren-
chyma.  This  is  in accordance  with  a pathological  law — namely,  that
inflammation of a  structure does not, as  a rule, extend to another structure,
however  proximate, which has  important anatomical differences or which
differs as regards its functions.   Some  striking examples  of  conservatism in
disease will be found to hinge  upon this pathological  law.   The fact also
that the  lining membrane of the  air-cells is not,  strictly speaking, a mucous
membrane  will account for important differences pertaining to the inflam-
matory products of pneumonitis  when compared  with bronchitis and  other
mucous inflammations.  The relation of the air-cells to the terminal branches
of the pulmonary artery is also involved  in the pathological phenomena of
inflammation of the parenchyma of the  lungs.
  The different forms of pneumonitis may be classified as fibrinous or lobar,
catarrhal or lobular, purulent, fibrous, and caseous or tubercular.  Caseous
pneumonitis and  fibrous pneumonitis will be considered in connection  with
phthisis.


        Acute Lobar Pneumonitis—Pneumonic Fever.
  Acute  lobar pneumonitis is the  disease called by German writers croupous
pneumonia.  By  others, especially French  writers, it  is sometimes called
fibrinous pneumonitis.  According to the view which will  be presented  in
treating of the pathological character of  the disease, each of these names is
incorrect, and they all imply that the disease is a purely local inflammation,
whereas there are sufficient grounds for regarding it as an essential fever.  A
more  appropriate name, therefore, is pneumonic fever.  The name acute lobar
pneumonitis is here  retained in conformity with usage and for the sake of
convenience for reference.

  Anatomical Characters.—The first appreciable  change resulting from
acute inflammation is the same here  as  in other  situations—namely, active
congestion  accompanied by transudation  of serum.   This is known as the
first  stage  or stage of congestion or  engorgement (engouement).    The
inflamed portion of the lung is  heaver than  in its healthy state; on section
the cut surfaces  present a dark-red appearance, and a bloody, frothy liquid
flows  in  abundance.  The  affected portion of the  lung presents the  same
appearance as in  oedema with  marked congestion.   The microscopical exami-
nation shows the pulmonary capillaries widely distended with blood, and the 
ACUTE  LOBAR PNEUMONITIS.
153
air-cells filled with a serous fluid containing red blood-corpuscles in abundance,
a few white blood-corpuscles, and larger granular cells which are the epithe-
lial cells washed off  by the  watery transudation  from the  blood.  In this
stage the affected  portion of the lung does not sink in water.
  In the second stage, usually called the stage of red hepatization, the air-
cells and bronchioles become filled  with a solid exudation and cease to con-
tain air.   The  solidified lung is of a brownish-red color, non-crepitant, and
presents an appearance not unlike that of the liver, whence the name  hepat-
ization.  Upon its cut or torn surface it presents a very characteristic granular
appearance, due to the projection of the little  solid masses which distend the
air-cells and bronchioles.  In  a lung previously affected with emphysema these
granules are very large  and  distinct.  AVhen examined soon after death the
cut surface is dry ; later, a viscid, turbid, reddish fluid may be made to escape.
The substance  of the lung breaks down under  the pressure of the finger more
readily than in  its healthy state; that is, it is more friable.  Its volume is
about equal to that of the lung in  a state of full inspiration, and it does not
collapse when the chest is opened.   Its weight is much  increased; a single
lobe solidified by inflammatory exudation increases in weight from one to two
pounds, and an entire lung solidified may acquire an additional weight of four
pounds.   Owing to the absence of air, portions of the solidified lung sink
when  thrown  into water.   Examined  with the microscope, the substance
filling  the air-cells  and small bronchi is  found to be composed  of a network
of fibrillated fibrin containing in its meshes a large  number of pus-cells or
white blood-corpuscles and of red blood-corpuscles.  A few desquamated and
proliferating epithelial cells  of  the  alveoli and a variable  amount of amorph-
ous granular matter are also present.  The reddish color  of  the lung in this
stage is due to congestion and to the large number of red  blood-corpuscles
present in  the  exudation.   Some  of the air-cells  often  appear to  be  com-
pletely filled with  fibrin and red blood-corpuscles, conveying the impression
of an  extravasation  of blood.   Probably most of the red  blood-corpuscles
escape by  diapedesis.  There can  be little doubt  that  the pus-cells are emi-
grated white blood-corpuscles.  The lung-texture is not essentially altered by
the inflammatory process.   It contains, especially in the interlobular connec-
tive tissue,  some emigrant cells.
  When the brownish-red color of the  solidified  lung gives place to a gray
color, the lung is said to be in the stage  of gray hepatization.   The  granular
appearance is then less distinct and the surface is moist.  The red blood-cor-
puscles are fewer in number, but the pus-cells  are more abundant and contain
molecules  of fat.  The lung may present the appearance of gray hepatiza-
tion after death within a few  days from the onset of the disease, or the aspect
ma*}* be that of red  hepatization after the disease has lasted  two  weeks or
more.   Most frequently the  lung is found in the condition of mottled hepat-
ization ; that is, of mixed gray and  red.  It is usually considered  that gray
hepatization is a later stage  of red hepatization, the  inflammatory  products
being in process of absorption.   Absorption may take  place with great rapid-
ity.  The  statement  by Rindfleisch and  others that the greater part  of the
exudation  is expectorated is certainly incorrect.  The matter  expectorated,
in general, bears no  proportion to  the quantity of exudation, and  there are
cases in which the exudation  disappears without any expectoration.
  In the  third stage, or stage of absorption,1 the red blood-corpuscles lose
their  coloring  matter, the pus-cells undergo  fatty  degeneration, the  fibrin

  1 Anatomically, it is customary to reckon four stages  of pneumonitis—viz. engorge-
ment, red hepatization, gray hepatization, and resolution. As red hepatization and gray
h'epatization cannot be distinguished from each other clinically, they are here combined
into one stage, that of consolidation. 
154
PNEUMONITIS.
becomes granular, and  an effusion of serum takes place, so that a kind of
granulo-fatty emulsion  is formed suitable for absorption by the lymphatics
and  blood-vessels.   In  favorable cases  after the removal of the exudation
the air-cells are found to have sustained no damage.  The pulmonary struc-
ture remains intact  while the exudation remains, and its functional capacity
is fully  restored after  the  exudation disappears.
   When after death the color of the inflamed lung is yellow or grayish-yel-
low, the  granular appearance absent, the tissue  soft and  exuding a creamy
fluid, the lung is said to  be in the condition of purulent infiltration.  The
exudation which fills the air-cells consists almost wholly of pus, and pus-cells
are present abundantly in the interlobular tissue, but the lung-tissue is not
broken down.   This condition of purulent infiltration is thought to favor the
formation of pulmonary abscesses in which collections of pus  take place in
cavities resulting from breaking  down of the lung-tissue.  Gangrene  of the
affected  portion of lungs sometimes  occurs, but this, as well as the  occur-
rence of abscess, is extremely rare.  Lobar pneumonitis never terminates
directly  in caseous degeneration, as has been claimed by some writers.  When
phthisis  intervenes upon lobar pneumonitis an infection with the tuberculous
virus must have occurred.
   It is probable that in rare instances lobar pneumonitis terminates in inter-
stitial pneumonitis characterized by a new growth of connective tissue in the
walls of the air-cells.   Little nodules of connective tissue may grow  from
the alveolar walls into the  interior of the air-cells, which are thereby more
or less completely occluded.  There is, however,  a difference of opinion  as to
whether  these  cases of interstitial pneumonitis  apparently following  lobar
pneumonitis are not from the beginning a peculiar form  of pneumonia not
to be identified  with the ordinary lobar variety.  The  symptoms, however,
at the onset of the  disease  may not be distinguishable from those of lobar
pneumonia.
   Pleuritis with fibrinous exudation is developed in the portion of the  pleura
covering the affected lobe or lobes of the lung.   This concurrent pleuritis is
never absent  except in those rare cases in which the pneumonitis has  not
extended to the  surface of the  lung.   The  pleuritis is circumscribed and
dry ;  much liquid effusion occurs only as an exception to the rule.   To these
exceptional  cases with liquid effusion may be applied the term pleuro-pneu-
monia, although in a strict sense  nearly  every case of pneumonia  is pleuro-
pneumonia.
   More or less bronchitis, affecting the  bronchial  tubes within the affected
lobe or lobes, usually exists with pneumonitis.   In some  cases, however, the
pneumonitis passes through its whole course without affording  any evidence
of this circumscribed bronchitis.   Bronchitis affecting the bronchial tubes'of
both lungs is sometimes, but rarely, present with pneumonitis.  When  these
two affections are combined  it is accidental; bronchitis, as the primary affec-
tion, does not tend to the  development of pneumonitis, and the latter has no
tendency to  give rise to bronchitis save within the affected lobe or lobes.
   Of the various forms of bacteria which may be found in the affected bronchi
and air-cells in lobar pneumonitis, at present the most important are the ellip-
tical organisms which are described by Friedliinder as micrococci, but which are
classified by some authorities preferably as bacilli.   These oval bacteria occur
frequently in pairs and  sometimes in chains.  Their special morphological cha-
racteristic is the presence of a gelatinous capsule which can be stained by cer-
tain aniline dyes.  This capsule, however, may exist around other forms of bac-
teria. Friedliinder's  capsule cocci are found in the exudation especially during
the stage of red and of mottled hepatization, and less abundantly in gray hepat-
ization.   The pure  cultures of the cocci in nutrient  gelatin are compared in 
ACUTE  LOBAR PNEUMONITIS.
155
their  form to a nail, the head of the nail being represented  by the knob-like
growth of the organisms on the  surface of the gelatin, and the rest of the
nail by the growth in the  line produced when the gelatin is stabbed by the
wire used in planting the organisms.   These bacteria  have been found not
only in the lungs after death, but also in the sputum during life, and in san-
guinolent fluid withdrawn by a hypodermic syringe from the hepatized  lung
during life.  Injections of the  pure  cultures into the lungs of mice causes
lobular pneumonia,  pleurisy, and invasion of the blood  by the organisms.
Pneumonia has been  produced  by the injection  of the organisms into the
lungs of dogs and of Guinea pigs, but the  effects are  inconstant.   Rabbits
seem  to  be refractory  to the inoculation of the organisms.
  The evidence that the capsule  cocci of Friedl'ander are the infectious agents
in lobar  pneumonia  cannot be considered conclusive.   Among the objections
to accepting them as the cause of pneumonia may be mentioned their incon-
stancy, the presence of other bacteria in pneumonia,  and the possibility of
producing  similar results in  animals by the inoculation  of different  kinds of
bacteria.  Bacteria morphologically identical with the so-called cocci of pneu-
monia have been found in the sputum in the absence of pneumonia.   Further
observations and experiments are necessary in order to determine the  real sig-
nificance of the pneumonic  cocci.1   It may be added, however, that  if acute
lobar pneumonia be correctly regarded as an infectious disease, its pathological
connection with a specific micro-organism is a rational  inference.  The ques-
tion, then, is whether  the bacteria described by Friedliinder have a special
pathological connection with  this disease, or whether a special parasitic organ-
ism is yet to be discovered.
  To the foregoing sketch of the anatomical characters may be added certain
laws of the disease, which are best presented in this connection. One of these
relates to the situation  of the pulmonary affection.  Pneumonitis attacks, in
the great majority of cases, the lower lobe, and the lower lobe of the right
oftener than of  the left lung.  Exceptionally, it sometimes attacks primarily
an upper lobe, and in these cases, as a rule, the disease is more severe ;  but
to this rule there are  exceptions.   The disease very  rarely, if ever, attacks
two lobes simultaneously, but it  invades not infrequently in succession a sec-
ond and  even a third lobe.   The inflammation does not extend from one lobe
to another, but whenever a new lobe is affected it is the seat of a new inva-
sion.   The lobes of one lung may be successively invaded or a single lobe on
both  sides; or, an entire lung being  first affected, a lobe of the other  lung
may be  attacked.   In the two latter cases the pneumonitis  is said to be
double.  The  name  " crossed pneumonia " has been  applied  to the  disease
when the lower lobe of one lung and the upper lobe of the opposite lung are
affected.
  The inflammation extends at least  over an entire lobe, as the name lobar
pneumonitis implies, in the great majority of cases.  There are exceptions to
this rule.  I have known some instances in which the physical signs clearly
showed the occurrence of inflammation extending over a limited area, with-
out any evidence of  the circumscribed  pneumonitis being a complication of
any other pulmonary disease.  In a  lobe invaded secondarily—that is. one
lobe being already affected—the  inflammation is sometimes found after death

  1 It is claimed by Sternberg and by Friinkel that the micrococci which are sometimes
found in the sputum of healthy persons, and which when inoculated into rabbits cause
a severe and fatal form of septicaemia (Sternberg's sputum septicaemia), are the probable
specific cause of acute lobar pneumonia.  These sputum micrococci have been found in
the lung in lobar pneumonia, and are more common in pneumonic sputum than Fried-
lander's bacilli.   No positive proof of the  correctness of these views has been brought
forward. 
156
PNEUMONITIS.
to have extended  over a portion only of the lobe.  This fact I have repeat-
edly noted, but perhaps had the  life of the patients been prolonged the whole
of the lobe would have been affected.
   The whole of the lobe first invaded is not at once affected.  The inflamma-
tion begins at a certain point or at several  distinct points, and extends from
lobule to  lobule until the  entire lobe is involved.  The  point or points of
departure may be  at either  the  upper or 4ower extremity of the lobe, and at
either the superficies or  centre of the lobe.  The diffusion of  the inflamma-
tion over the lobe takes place  with more or less rapidity; sometimes a few
hours  suffice, but  in  some  cases it occupies  several days.  The progress of
the solidification from the exudation may be determined very accurately from
day to day or from hour to hour by means of physical signs.
   The inflammation very rarely ends with the  occurrence of engorgement
only,  without exudation.   Solidification almost always occurs, and, when the
inflammation is not secondary to another pulmonary disease, usually extends
over  the  lobe or lobes invaded.
   With respect to the situation  and extent of the affection, the following are
the results  of  an  analysis  of 121  cases:1 In 29 cases it was limited to the
lower lobe of the right, and  in 25 cases to the lower lobe of the left, lung.   It
extended  over the whole of the  right  lung in 27, and over the whole of the
left lung in 9 cases.   It was limited to the upper lobe of the right lung in 8,
and to the upper lobe of  the left lung  in 3 cases.   It was seated in the lower
lobe of both lungs in 8 cases.

   Clinical  History.—The division of acute pneumonitis into stages is based
upon  differences as regards the anatomical characters at different periods of the
disease.  The first  stage embraces the period during which the affected lobe is
in the state of  active  congestion or  engorgement.  This stage is  called the
stage of engorgement.   The disease is considered as passing into the second
stage when the affected lobe or a greater part of it has  become  solidified  by
the inflammatory exudation.  This  stage is called  the  stage of solidification
or hepatization.   In the third stage the affected  lobe is in one of  two condi-
tions.   If the disease pursue a favorable course, the third  stage begins when
it is evident  that absorption of  the exuded matter is going on, and convales-
cence takes place during  this period.   This may be  called the stage of resolu-
tion.    If the disease pursue an unfavorable  course the third stage is one of
purulent infiltration.  If this stage occur the disease  generally ends fatally.
   The duration of each of these stages varies much in  different cases.  The
stage of engorgement may last for only a few hours. I have known an entire
lobe to be solidified by two  pounds of exudation  matter, as determined after
death, in less than  twelve hours.   Not infrequently this stage does  not extend
beyond twenty-four hours.   But sometimes the solidification  occupies two,
three, or four days, and in some  cases even a longer period.   In the major-
ity of cases  this stage is from  twenty-four to forty-eight hours in duration.
The stage of solidification  may also be of short duration.  I have known
resolution to begin and to make  considerable  progress in twenty hours.  But
this may not be evident for two, three, or four  days, or even  for  a con-
siderably  longer period.  In the majority of  cases the duration of this stage
is from two to four  days.  The stage of resolution  is still more variable.
There is a notable  difference in different cases as regards the rapidity or slow-
ness with  which the solidifying deposit is removed.  It is very rarely the case
that the resolution is completed  in less than three or four days, and generally
eight or ten days are required.  In  some cases two or three weeks elapse
  1 " Clinical Report on Pneumonia, based on an Analysis of 133 Cases," by the author.
Vide American Journal of the Medical Sciences, January, 1861. 
                    ACUTE LOBAR PNEUMONITIS.                 157

before the air-cells  are restored to their  normal condition, and occasionally
the resolving process is even much more protracted.   If the disease pass into
the purulent stage, death usually takes place within a few days;  but if the
disease  end in recovery,  many  days and  perhaps weeks  elapse  before the
normal  condition is restored.
   In  the  great  majority of cases acute pneumonitis begins with a well-pro-
nounced chill, frequently accompanied by rigors.  The  thermometer in the
axilla shows an increase of temperature, although  coldness exists as a sub-
jective  symptom.   The  invasion is usually abrupt, with few  or no premo-
nitions.  The attack is liable to occur during the night.  Coincident with or
speedily following the chill is the occurrence of pain.  Sometimes, however,
pain is not felt  until several  hours after the chill.  The pain is frequently
severe.   It is acute, lancinating, and in all respects  identical with the  pain
in acute pleuritis.   It  proceeds  from  the  pleuritis  developed in conjunction
with  the  pneumonitis.   As a rule,  the intensity of  the pain is in proportion
to the amount of coexisting pleuritis; but it is true alike  of  pleuritis  thus
developed  as  a  complication and  when it occurs primarily that it  is some-
times attended with little or no pain.   Cases of pneumonitis differ consider-
ably as regards  this symptom, and it may be quite prominent or present in a
moderate degree or altogether  wanting.   The  pain  is usually referred to a
circumscribed space at or near the nipple of the affected  side.   This limitation
of the pain is a point distinctive of  pneumonitis as compared with pleuritis.
   Cough is usually present at or soon after the invasion.   It is more or less
prominent.   It is sometimes wanting.   It is painful in proportion as pain is
a prominent symptom irrespective of the cough.  The  cough is frequently
accompanied by expectoration.   The matter  at first expectorated is scanty,
transparent, and viscid, and in a certain proportion of cases  it soon  assumes
characters which are  highly  distinctive  of the disease.   It becomes semi-
transparent, adhesive,  and has a reddish  tint like that of iron  rust;  hence it
is commonly known as the rusty expectoration.   This  appearance is due to
a small quantity of blood which has become  intimately mixed with the mat-
ter in its passage from the smaller to the  larger bronchial  tubes.  The adhe-
siveness is such that when a considerable quantity has accumulated it adheres
so closely to the bottom of the vessel as to remain when  the vessel is inverted.
The rusty expectoration is by no means uniformly present.   The matter is in
some cases semi-transparent and adhesive without the reddish  tint.    It may
have a  yellowish tint, as if mixed with  a little bile, which, however, is not
the  fact,   It sometimes  contains blood in abundance, and when the blood is
of a dark  color it is what is called the prune-juice  expectoration.   The cha-
racteristic oval bacteria surrounded  by a capsule maybe found in the  sputum,
as has already been described, but  they are  not invariably present.    It is to
be borne in mind that expectoration in some cases of pneumonitis is entirely
wanting.
   Pyrexia exists at the outset, together with  pain in the head, loss  of appe-
tite, thirst, prostration, heat of skin, etc.  The pulse varies much in frequency
in different cases, ranging from  80 to 120, and is more or less full and  hard.
The thermometer in the axilla indicates more  or less  increase of heat, the
increase in mild cases not exceeding  104° F.  An  increase above this  point
always  denotes  severity of the  disease.  A  sudden increase of temperature
points to the invasion  of  a new lobe or to some intercurrent affection.  Cases
differ greatly as regards general or constitutional disturbance, the system being
much more tolerant of the disease in some persons than in others.
   The  respirations  are  increased in frequency.  This may depend on the
pleuritic pain if it  be marked, and also on the interruption of the function of
haematosis in  the portion  of lung affected. 
158
PNEUMONITIS.
   These are the  important symptoms belonging to the  clinical history of
 the beginning and during the first  stage of the disease.  During the stage
 of solidification the symptoms change.   Pain, if it have existed, diminishes
 or ceases.   Cough and expectoration continue, but the cough is less hard and
 painful and the expectoration is effected  with  more facility.   The  matter
 expectorated loses its rusty appearance, and  becomes opaque, less adhesive,
 and more abundant.  It is now the expectoration of resolving bronchitis.  It
 is furnished chiefly by the bronchial tubes within the affected portion of lung,
 and is abundant in proportion as the bronchial mucous membrane is involved
 in the  inflammation.  On microscopical examination of the sputa  fibrinous
 casts of the minute bronchial tubes may be found.   The pyrexia continues,
 but  with diminished intensity.   The pulse in this  stage  may  be small  and
 deficient in strength, especially if more than one lobe be involved, owing to
 the obstruction to the pulmonary circulation,  which  diminishes  the  quantity
 of blood received from  the lungs by the left auricle, and owing also to the
 amount of material withdrawn from the  blood and deposited in the air-cells.
 The respirations are increased in frequency  out of proportion to  the increased
 frequency  of the  heart's action,  in  consequence of  the  solidified portion of
 lung  taking no part in the respiratory function.
   These are the modifications of the  symptoms, assuming a single lobe only
 to be affected and that the course of the disease  is favorable.   The invasion
 of another lobe is rarely accompanied by a  chill.  The pyrexia  persists or is
 increased,  and  the respirations become more frequent, accompanied perhaps
 by labored breathing, marked dilatation of  the alae nasi, and  dyspnoea.  The
 affection, however, of an entire lung does  not always give rise to symptoms
 denoting great  gravity of disease.   The pyrexia is not always intense, and
 maybe slight; the respirations  maybe  but little  increased in frequency;
 cough and expectoration may be not only not prominent,  but wanting, and the
 system may be but little disturbed.
   The  symptoms during the stage of resolution denote progressive  improve-
 ment.  The pyrexia diminishes and ceases.  The cough  and expectoration
 become less and less, the respirations  resume their normal frequency, the
 appetite returns, the strength is increased, and, in  short,  convalescence is
 declared.  In some cases the fever ceases  abruptly, a  copious  perspiration
 preceding the defervescence.  It is customary to  say that the disease in these
 cases ends with a crisis.  In most cases the defervescence is gradual (lysis), and
 without the occurrence of any event which may properly be called critical.
 If, however, the disease pass into the stage  of  suppuration, the symptoms
 denote  an  unfavorable course.  The pulse  becomes more and more frequent
 and feeble.  The expectoration is abundant and  purulent.   The respirations
 are frequent.   The strength of the  patient fails, and death  takes place  by
 asthenia, the  accumulation of morbid  products  in the  air-tubes frequently
 contributing to the fatal  termination.
   There are certain symptoms belonging to  the clinical history of pneumonitis
 which are  not included in the foregoing sketch of its symptomatology.  One
 of these relates to the urine.  While the process of exudation is going on,
 and after solidification has taken place, until resolution  begins  the  chlorides
 frequently are greatly diminished or disappear from the urine. The disappear-
 ance  of the chlorides from the urine is not peculiar to pneumonitis.   It is
 observed in other  diseases.   It is not, therefore, a diagnostic character of the
 disease, but it constitutes evidence either  that the  exudation is going on or
'that resolution has not begun.  It is stated that the chlorides are  found in
 abundance in the matter expectorated during  the time of their disappearance
 from the urine.  The quantity of urine is in general  more or less diminished.
 The urea eliminated exceeds the amount  in health, and, owing to the  dimin- 
ACUTE LOBAR PNEUMONITIS.
159
 ished quantity of water, the urates are often deposited in abundance when the
 urine becomes cold.   The increase of urea denotes an abnormal destructive
 metabolism of nitrogenous substances.   It is not uncommon for the urine  to
 contain a trace or a moderate quantity of albumen.  The presence of albumen
 is probably due to  systemic venous congestion or to an altered condition of
 the blood, as in other acute general diseases.   Albumen in abundance in the
 urine denotes coexisting renal disease.
   Delirium not infrequently occurs in acute pneumonitis.  It may be mild
 and merely incidental to the pyrexia;  but it is sometimes a prominent symp-
 tom.   It may be active, the patient attempting to  get  out of bed, resisting
 efforts of restraint, and perhaps using violence ; or  it may be of the low, inco-
 herent, muttering kind, such as occurs in  typhoid  fever.  Delirium is more
 likely to occur if the upper lobe be affected than if the affection be limited
 to the lower lobe.  It is evidence of gravity of the  disease in proportion as it
 is prominent, active, and persisting.  It is likely to occur in spirit-drinkers.
   A dusky redness of one or  both cheeks, the margins of the  redness being
 abruptly defined, is frequently observed, and, if the hectic flush of pulmonary
 tuberculosis be excluded, is quite  distinctive of  acute pneumonitis.   When
 confined to one cheek it does not follow, as was formerly supposed, that the
 pulmonary inflammation is seated on the same side.  It is not uncommon for
 an herpetic eruption to occur upon  the  face, more especially around the mouth.
   Slight jaundice is an occasional  concomitant, due to  duodenitis.   It  occurs
 especially in spirit-drinkers.   Its occurrence is probably accidental.   At all
 events, it is not associated often enough to show  any pathological connection
 between pneumonitis  and  hepatic disease.   Owing to  the accumulation  of
 blood in the right cavities  of the heart, and the consequent congestion of the
 systemic veins, the  liver sometimes becomes more or less enlarged.
   The occurrence of abscess and gangrene is  accompanied by symptomatic
 phenomena denoting these events.   The collection of pus in an abscess leads
 to a sudden and copious purulent  expectoration if  the life of the patient  be
 sufficiently prolonged,  and the existence of a cavity may be determinable by
 physical signs.  This is a grave event, but it by no means necessarily renders
 the disease fatal.   It  occurred in  4 out of 133 cases which  I recorded and
 analyzed, and 2 of these 4 cases ended in recovery.  I  have  notes of a case,
 in addition to the 4 cases just  referred to, in which a series of purulent col-
 lections were expectorated and the recovery was complete. The infrequency
 of gangrene is shown by its having occurred  in  but  1 of 133 cases.  The
 disease proved fatal in that case.   Since the analysis of these cases I have
 known  gangrene to occur to a limited extent  in a  case which  ended in
 recovery.   Its occurrence  is shown   by  the characteristic  fetor attending
 expectoration, together with the appearance of decomposed pulmonary tissue
 in the matter expectorated.
   The combination of  other affections  with acute pneumonitis will of course
 involve the addition  of symptoms derived therefrom.   In malarial districts
 it may be conjoined with periodical fever.   This is an  important complica-
 tion as regards danger and therapeutical indications.   The existence of the
 pneumonitis  may serve to interrupt to a greater or less  extent the regular
 succession  of periodical paroxysms, and  the latter  may tend  to obscure the
phenomena of the pulmonary affection.   Pneumonitis  occurring in  the
intemperate is liable  to lead to the development of delirium  tremens.  The
complication is always serious, and is  important with reference to treatment.
It occurred in 8  of 133 cases.  Pericarditis  is another grave complication.
This occurred in 8 of 133 cases.
  The  supervention of certain symptoms is expressed by the term typhoid
pneumonitis.   This term  denotes  the existence  of symptoms analogous to 
160
PNEUMONITIS.
those which  belong  to  typhoid fever, of which the most prominent is low,
muttering delirium.   A distinction is here to be made between typhoid pneu-
monitis and typhoid fever with pneumonitis as a complication.  Pneumonitis
is liable to be developed in the course of typhoid fever, the latter being the
primary affection ; but in  the so-called typhoid pneumonitis the latter is the
disease, certain of the typhoid phenomena being superadded. In other words,
the typhoid state may be developed in connection with pneumonitis as  with
other affections,  but  this  typhoid  state does  not involve the essential fever
designated as typhoid.  There  is not sufficient ground  for  considering " alco-
holic pneumonia " as a distinct  variety, but habits  of spirit-drinking occasion
certain distinctive features—namely, jaundice  and the phenomena of delirium
tremens; the ability  to resist  and recover from the disease is also thereby
impaired.
   The duration  of acute pneumonitis,  when  uncomplicated,  varies within
pretty wide limits.   Dating from  the attack  to the time when the patient
could be pronounced convalescent in 30  cases,  the shortest was five and the
longest twenty-three days.  The mean duration was a  fraction over twelve
days.  In 14 fatal cases the shortest duration  from the  attack to the time of
death was  three, and the  longest  twenty days, the mean  duration being a
fraction over ten days.
   A notable decrease of temperature sometimes precedes the fall of the  pulse
and  improvement in  other symptoms; and the defervescence, if the disease
be uncomplicated, is usually rapid.  It is then said  to  end by crisis instead
of lysis.   The pulse  during convalescence is not infrequently below the nor-
mal frequency, falling in some cases to 40 per  minute.

   Causation.—Statistics  show that no period  of life involves either exemp-
tion  from, or a notable proclivity to, this disease.  It occurs under five years
of age, but not often.  Cases are less infrequent between the ages of five and
ten.  Of 118  cases, the patients  all were over ten years of age ; 13 were under
twenty; 44 between twenty and thirty years; 37 were  between thirty and
forty years;  17 were between forty and fifty years; 7 were between fifty and
sixty years ;  and in no case was the age over sixty.  Cases, however, are not
infrequent after the age last named. The disease occurs much oftener among
males than females.   The  analysis  of my cases with reference to occupation
does not show that any particular calling predisposes to this disease, but the
proportion of laborers  engaged in outdoor work over those  employed within
doors shows  that they are most liable to the disease  who  are exposed to the
vicissitudes of the weather.   Not infrequently  the attack is excited by some
unusual exposure, such as working in the cold and wet or sleeping "out of
doors at night.   The large proportion of hospital cases  in which patients are
addicted to excessive drinking shows  that causative  influences proceed from
intemperance.  In 10 of 37 cases in which the habits were noted the attack
followed  a debauch.   It is  questionable whether  the  abuse of alcohol acts
directly as a cause;  probably the  disease is caused by circumstances inci-
dental to intemperance, such as exposure to cold, etc., these acting as exciting
causes.
   The association of  periodical fever and pneumonitis has  already  been
adverted to.   My observations  do  not show the existence  of any  patholog-
ical  connection between these  affections.  There is no  ground  for the  con-
clusion that persons  subject to  intermittent fever are  thereby more prone to
pneumonitis, or that  the latter affection tends to reproduce an attack of the
former.  Their coexistence is due to the coincidence of the causes  proper to
each.
   With respect to causative influences pertaining  to  other pulmonary  affec- 
ACUTE  LOBAR PNEUMONITIS.
161
tions, facts  show that bronchitis  does  not eventuate in pneumonitis.  The
same is  true of pleuritis.   Tuberculous  patients are not particularly prone
to the disease, and when it does supervene it may or may not affect the upper
lobe, in which the deposit of tubercle is most abundant.  Certain pulmonary
affections—namely, emphysema, asthma, and chronic pleuritis—are  so infre-
quently associated with  pneumonitis as to show that, instead of involving  a
predisposition to this disease, they afford  more or less protection against it.
Pneumonitis is not often developed in persons affected with organic disease
of the heart.
   Pneumonitis occurs as a complication  of other than pulmonary diseases.
It is not infrequently developed in the  course of typhus and typhoid fever,
rubeola,  dysentery, etc.  The different affections of the kidneys have been
supposed to stand in a causative relation to it.  My  own experience does  not
furnish  evidence of such a relation.  In  not one of 133 cases  analyzed was
the  disease  preceded by albuminuria.
   It occurs  in certain seasons of the year in preference to other seasons.  It
occurs everywhere much oftener during the winter than during the summer
months, and in  our  Northern  States cases are more  frequent in the  spring
months than at any  other season.  In this country  the disease  occurs in  the
Middle and  Southern much oftener than in the Northern States.  It prevails
much more  in some years than in  others.   In sections of the Southern States
it prevails at times sufficiently to be considered as endemic.  It is the prev-
alent disease during the winter  months in these States, and, affecting espe-
cially the negro population, often  proves the scourge of the sugar and cotton
plantations of the South.  It is a severer disease in  the Southern  sections of
the  country than at the North, being more  liable to extend beyond a single
lobe and proving fatal in a larger proportion of cases. This liability is greater
in the same district in some years than  in others.  In some years also there is
an unusual  tendency in the disease to attack primarily an upper lobe.   Such
a  tendency  is manifest at the time  of writing these  remarks.   Within two
months  (October and November) in  hospital practice I have met with five
cases in  which the disease has been limited to  an  upper lobe, being about
one-half the cases which occurred under my observation  during this period.
   In a large proportion of the cases  of acute pneumonitis the disease is appa-
rently developed spontaneously; that is, it is not referable to any  obvious caus-
ative agency.  When it appears to follow exposure to cold, it is probable that
this  acts only as an exciting cause co-operating with the action of a  special
cause.   Litten has described cases of acute  lobar pneumonitis following two
or three  days after  contusion of the chest without  any external wound.  It
is possible that in these cases physical  changes in the lung produced  by  the
contusion favored the development of a special infectious agent of pneumo-
nia.   Direct injury of the lung, as in stab-wounds and gunshot wounds,  has
no tendency to  cause lobar pneumonia.
   Clinical evidence seems inadequate to prove contagiousness.  Instances in
which persons in the same neighborhood and members of the  same  house-
hold are  attacked successively may  be  explained by supposing an exposure
in common to an extrinsic cause.  Vet  if  it be demonstrated that  the disease
can  be produced in an inferior animal  by inoculation, this  fact is proof of
communicability, and its apparent incongruity with clinical experience is to
be accounted for, as in the instance of pulmonary  phthisis, by supposing  a
peculiar predisposition, or, in other words, a favorable soil, to be an essential
factor in the causation.   The  supposed dependence of this disease upon  a
specific parasitic organism  has been  referred to in connection with the ana-
tomical  characters.   An attack  affords   no  protection against subsequent
attacks.
11 
162
PNEUMONITIS.
  Diagnosis.—Acute pneumonitis  in some cases is accompanied  by symp-
toms which are highly distinctive.  If a patient  be seized with  a  chill fol-
lowed  by febrile  movement, together with  a  pleuritic stitch  referred  to a
circumscribed space near the nipple, and the characteristic  rusty expectora-
tion occur, the diagnosis is readily made without the aid of physical signs.
But these symptoms are by no  means constantly present.  The  disease is not
infrequently entirely latent as  regards  diagnostic symptoms, and it is often
overlooked by those who do not  employ physical exploration.  ^  Even if its
existence be revealed  by symptoms irrespective  of signs, the  situation  and
extent of the  affection can  only be ascertained  by means of the  latter.  With
the aid of  signs the diagnosis in the great majority of cases is made without
difficulty.  The diagnostic symptoms are especially liable to be absent and the
disease to be developed insidiously when it is associated with other diseases.
Not  infrequently an  examination of the chest  reveals its  existence  unex-
pectedly.   I have been  accustomed to  characterize it  under these circum-
stances as sneaking pneumonia, using the language of  personification  which
is so often used in speaking or writing of diseases.   The term " asthenic pneu-
monia  " has been applied to it when the symptomatic characters  which belong
to typical cases are wanting. On the other hand, the term " frank pneumonia "
is often used to distinguish cases in which these characters are well  marked.
  Patients with this disease do  not  always take at once  to the  bed.   It is
not very uncommon  to meet with  cases in dispensary practice,  the disease
having gone on to the  second stage.  These  may  be distinguished as " walk-
ing cases."  A young woman  once consulted me at my house, complaining
chiefly of weakness and  loss of appetite, with a slight cough.   The tempera-
ture  in the axilla was 103°, and physical exploration showed solidification of
the entire lower lobe of the right lung.   She had taken a long drive the pre-
vious day, thinking it might be of benefit to her, and she had come two miles
to see  me.   The history rendered it certain that the disease was  acute lobar
pneumonitis.
  In the first  stage the signs on  which the diagnosis is to be based are slight
or moderate dulness on percussion and the crepitant rale.  The  latter, if per-
sistent and well marked, is almost pathognomonic.  Care must be  taken, how-
ever, not to confound this rale with the subcrepitant, its distinctive characters
being  its fineness,  dryness, and  limitation to  inspiration.  With a distinct
appreciation  of these  characters  it should  never be  confounded  with  the
so-called subcrepitant  rale, which, however fine, is a moist, bubbling sound,
and liable to be heard  in expiration  as well as  in  inspiration.   Care must be
taken not to mistake for the crepitant rale the sound produced by  movements
of the stethoscope  on  the  chest  if covered with hair, and the  crepitus of a
fractured rib.   It is also to be  borne in  mind that after rising  to the sitting
posture a feeble patient with any disease may furnish  for a few deep inspira-
tions a true crepitant rale  on the posterior  aspect  of the chest.  But the
crepitant rale  is not uniformly present in lobar  pneumonia.   In its absence a
positive diagnosis may require some delay until a sufficient number of lobules
are solidified  to give rise  to an appreciable modification  of the  respiratory
murmur.   The modification is that which I have  described under the name
broncho-vesicular respiration1—a modification  approximating,  more or less,
toward the bronchial  or tubular respiration.  With the  occurrence of this
modification the dulness on percussion becomes more marked. In  most cases,
if the  disease be observed  from the beginning, the signs of the second stage
are soon declared.  In hospital practice and in  many cases in private practice
  1 Vide Physical Exploration of the  Chest and the  Diagnosis  of Diseases affecting the
Respiratory  Organs, 2d ed.,  1866; also, Manual of Auscultation  and  Percussion, 3d ed.,
1885. 
                     ACUTE LOBAR  PNEUMONITIS.                 163

 the disease has already advanced to this stage when the patient is first exam-
 ined.
   When the solidification is sufficient in degree and has extended sufficiently
 over the affected lobe to furnish the signs of  that condition, the  diagnosis, if
 it have not  been already fully made, is  rendered clear by the presence of
 these  signs.   Bronchial respiration, bronchophony, and  whispering bron-
 chophony  are the signs denoting the condition of solidification. They are  first
 manifested over a limited portion of the affected lobe, and are thence diffused
 over its whole extent, either quickly or  gradually according to  the rapidity
 or slowness with which the whole  lobe becomes solidified.   The progress of
 the second stage may be determined  by the extension of these signs.  They
 are generally all present, but if one be wanting  the others will be likely to
 be present. It is exceedingly rare for all  to be absent. Dulness on percussion
 is now  marked, amounting perhaps nearly or  quite to flatness.  This dulness
 or flatness extends over a space corresponding to that occupied by the solidi-
 fied lobe;  or, percussing anteriorly, the boundary-line separating the dulness
 or flatness from the pulmonary  resonance is found to pursue a course coinci-
 dent with  the situation of the interlobular fissure—namely, obliquely upward
 and outward from the fourth or fifth costal cartilage toward the axilla.  And
 this boundary-line is the same  whether the patient be sitting or lying upon
 the back:   This is assuming that the pleural cavity does not contain liquid,
 which is ascertained by the  signs indicated in connection with the  diagnosis
 of simple  pleuritis.   The crepitant rale, if it have existed in the first "stage,
 may continue, more  or less  diminished, during the second  stage, or  it may
 disappear after the  affected  side has become solidified.   The moist and  dry
 bronchial  rales are liable to be heard in  this stage.
   The  invasion of a second or third lobe is denoted by dulness on percussion
 and the auscultatory signs of solidification, the crepitant rale rarely occurring
 in the lobes which become secondarily  attacked.  By means of the signs of
 solidification—namely,  broncho-vesicular  and  bronchial respiration, and bron-
 chophony  with the loud and whispered voice—the extension of  the affection
 to other lobes  in  addition to the  one  first invaded is  speedily ascertained.
 If the upper lobe become solidified, it is sometimes  flat on percussion,  and
 sometimes it yields a tympanitic resonance which occasionally has an amphoric
 intonation.
   The beginning of resolution and its progress from day to day are shown by
 modifications of the  signs denoting solidification.  The bronchial respiration
 gives place to the broncho-vesicular, and  the  latter progressively approaches
 more and  more to the normal vesicular murmur, into which it becomes finally
 merged when the resolution is  completed.  The characters of bronchophony
 are gradually lost.  Dulness on percussion becomes less and less marked,  but
 some degree of dulness  over the affected lobe or lobes continues for some time
 after the auscultatory signs show the exudation to have been removed. Dur-
 ing the progress of resolution the  subcrepitant rale is frequently heard,  and
 sometimes the crepitant rale reappears, constituting the crepitant role redux.
   If the disease pass into the stage of suppuration, the dulness or flatness on
 percussion continues, and the moist bronchial  rales,  due to pus in the  air-
 tubes, are prominent.   The auscultatory  signs of solidification continue,  but
 are less marked.   If abscess of the lung take place, and the patient's life be
 prolonged until a discharge of the pus into the bronchial  tubes occurs, cavern-
 ous respiration may become well marked.
  The occurrence  of suppurative pleuritis is shown by the signs of that affec-
tion.  AVith this complication, the  affected  side may  be  dilated, the  intercos-
tal depressions are obliterated, and obvious contraction of the chest may  fol-
low recovery. 
164
PNEUMONITIS.
  Pathological  Character.—Acute lobar pneumonitis, in the nosological
systems of the present as of past time, is placed among the local  diseases,
and in regard to certain questions it has been regarded as the type of a purely
inflammatory affection.   This view of its pathological  character is now held
to be erroneous.  The pulmonary affection is doubtless inflammatory ; but it
is the local manifestation or  the anatomical characteristic  of an infectious
febrile disease, sustaining to the  latter a relation analogous to that which the
affection of the solitary and agminated intestinal follicles sustains to typhoid
fever.  If this doctrine be true, the proper place for the disease in the nosology
is among the essential fevers. It is here retained in the class of diseases of the
respiratory system for convenience of reference so long as its claims to be trans-
ferred to the division of the general diseases are not generally recognized.  The
name acute lobar pneumonitis denotes only a local inflammatory disease.   A
more correct name is pneumonic fever (febris pneumonica)—a name used by
the older writers, and corresponding to the popular term " lung fever" formerly
in vogue in some parts of this country.1
   Assuming that there are grounds  sufficient for adding to  the list of essen-
tial fevers febris pneumonica, or  pneumonic fever, we may define the disease
as follows:
   It is a fever characterized anatomically by  an abundant exudative deposit
in the air-vesicles of  a single lobe, or of two and sometimes three*  lobes of
the lungs, with, in general, circumscribed bronchitis  and dry pleurisy.   It is
a fever which rapidly reaches its  maximum intensity, and has a short career,
the duration averaging about eleven days.   It  proves  fatal  chiefly in conse-
quence of associated 'diseases, complications, or accidents, and in the mode of
dying asthenia usually predominates.  It depends on  a cause or on causes
specific in  character, the nature  of  which is not at present  established.  It
sometimes aborts spontaneously, and it is in some instances arrested  by reme-
dies.   If not arrested, it may  be favorably modified, its duration abridged,
and the danger to life diminished by treatment  addressed, not  to  the pul-
monary affection,  but to the  fever.

   Prognosis.—The prognosis in cases of acute pneumonitis will depend on
the extent of lung involved, the intensity of the pyrexia, the diseases with
which it may be connected as an  intercurrent affection, its complications, the
previous constitution  of the patient, etc.  These circumstances will affect the
gravity and danger to such a degree that, in respect to  the probable termina-
tion,  cases differ as much as if  they were cases of different diseases.   Occur-
ring  as a primary disease, limited to a lower  lobe, remaining uncomplicated,
and the person affected having a  fair constitution, the intrinsic tendency is to
recovery ; indeed, recovery is not only the rule, but the exceptions are exceed-
ingly infrequent.  Of the 133 cases which I have analyzed, in only 2 of the
fatal cases was the disease limited to one lobe  and not complicated or  asso-
ciated with other important affections.  In one of these two  cases the inflam-
mation was seated in an upper lobe and  eventuated in abscess.   In  the other
case the absence of complications was predicated on  the examinations during
life, a post-mortem  examination not having  been made.
   Even if more than  one lobe be involved, provided the disease be primary
and uncomplicated, a  favorable termination may reasonably be expected in a
subject not enfeebled by age or other causes.  I have known recovery to take
place in a case in which an entire lung was involved  and the patient situated
under as unfavorable  hygienic circumstances as could  well be imagined.  In
the case referred to the patient was  attacked when working alone in a shanty
   1 The grounds for holding this doctrine were embodied  by me in a paper published
in the Transactions of the New York Medical Society for 1877. 
ACUTE LOBAR PNEUMONITIS.
165
during the winter season in the swamp near New Orleans, there being at the
time two inches of  water on the ground.  After the attack he was unable to
leave the bed for any purpose for a week, and during this time he was entirely
alone.   He had a quart of brandy, which he drank during the week.  His
habits, as he stated, were temperate.   At the  end of a week he was visited
by some one (not a  physician) who gave him thirty grains of calomel.   After
this he  remained alone  for ten  days.   A friend at length came to him, gave
him some doses of  quinia, and removed him first to his own house and after-
ward  to the Charity Hospital  of New Orleans.  The physical signs on his
admission into the hospital showed pneumonitis affecting  the whole  of the
right lung, and resolution progressing.   He remained in hospital  six days,
convalescence going  on rapidly, and  at  the end of that time he was  well
enough to be discharged.
  I have reported  another case in which the patient for four days after the
attack remained without food or drink  in a lumber-yard, with no shelter but a
pile of boards.   During this time there was  a snowstorm and the temperature
was as low as 10° F.   On the fourth day he was admitted into Bellevue Hos-
pital.   The physical  signs showed solidification of the lower lobe  of the left
lung.   On the fourth day after his admission defervescence occurred, and four
days afterward he was up and dressed.
  The gravity and  danger, then, in cases of this disease proceed not so much
from the disease per se  as from coexisting affections and other incidental cir-
cumstances.  Developed in the course of continued fever,  measles, or other
diseases, it  may lead to a fatal  termination.  In aged  and feeble  persons  it
may end  fatally without any coexisting  disease, especially if more  than  a
single lobe be involved.  Occurring in persons affected with organic  disease
of the  heart, it is  likely to prove a serious affection.   I have known it to
destroy life in  the  first stage when developed in this  connection.   The  pul-
monary symptoms  are rendered more  severe and the danger is increased by
antecedent  emphysema.
  Complications  which  are  likely to render  it fatal are pericarditis, intermit-
tent fever,  and delirium tremens.  These   complications  invest cases with
much gravity and  danger, hut recovery takes  place in a certain  proportion
of cases notwithstanding their existence.   An occasional complication to be
included in  this category is acute diffuse nephritis, as shown by the presence
in the  urine of albumen, tube-casts, and blood.   In drunkards an occasional
fatal complication  is  cerebral meningitis.  The  gravity and danger from all
these complications are of course greater  if the disease invade more than
one lobe.
  There is  a liability in the course  of this  disease to an occurrence which
claims especial  notice—namely, coagulation  of fibrin in the right auricle or
ventricle ; that is, to heart thrombus.   This  is of not infrequent occurrence in
fatal cases of pneumonitis.  It occurs  especially when an entire lung becomes
involved, and in cases of double pneumonitis.  In such cases the obstruction
to the passage of  blood through the  lungs, caused by the presence of the
exudation, involves an  over-accumulation of blood within the right cavities
of the heart.   The right ventricle and auricle  are enfeebled  by  distension,
and this condition, in conjunction with hyperinosis, leads to  coagulation.  On
examination after death, in the right ventricle is a dense thrombus devoid of
red corpuscles, closely intertwined with the  tendinous cords and adherent to
the ventricular walls.   Thrombi formed ante-mortem, and not infrequently the
immediate cause of death, are to be distinguished from those produced in the
last moments of life and from post-mortem clots. (Vide Part I. p. 29.)  Their
formation sometimes may be determined with much confidence during life.  In a
a case presenting no symptoms which denote  imminent danger a sudden change 
166
PNEUMONITIS.
takes place for the worse ;  the circulation is notably disturbed, as shown by the
frequency, feebleness, and irregularity of the pulse; there is a sense of the
want of air;  the expression is haggard and anxious; cyanosis is more or less
marked ;  the patient falls  speedily into a moribund state ; and this unexpected
change is not connected with an  extension  of the  disease to a new lobe or
any newly-developed inflammatory complication.   Under these circumstances
the formation of a  heart-clot  is  highly  probable.  The probability of this
accident is rendered stronger if a newly-developed cardiac murmur be discov-
ered and referred to the right side of the heart;  and it is sometimes practicable
to appreciate the absence  of  the tricuspid valvular element of the first sound
of the heart.1
   The invasion of a second lobe in a feeble  subject may be accompanied by
notable prostration, amounting sometimes to a state  of  collapse.   In the pre-
vious editions of this work the synopsis of a case was given  in which the
patient was  apparently moribund, restoration  taking place under the free
administration of alcohol.  I have met with cases in which a primary inva-
sion occurring in aged persons produced such a degree of prostration and dis-
turbance of the  heart's action that death by rapid asthenia seemed imminent,
life being apparently saved by free alcoholic stimulation.
   As regards anatomical  changes  pertaining to the lungs, gangrene, abscess,
and  the stage of purulent infiltration render the prognosis  extremely unfa-
vorable.   Yet I  have known recovery to  take place in cases in which the
symptoms  denoted  the occurrence of these events.
   Symptoms which are. unfavorable as prognostics are the following:  Fre-
quency and feebleness of the pulse; great frequency  and  labor of respira-
tion ; lividity of the prolabia and face ;  an abundant purulent or muco-puru-
lent expectoration ;  bloody, dark-colored sputa, commonly known as the prune-
juice expectoration ; active,  violent  delirium ; low, muttering delirium,  with
prostration and  subsultus tendinum, constituting the typhoid state.  Cases
presenting the symptoms last stated are often distinguished as cases of typhoid
pneumonitis.
   In the majority of  fatal cases of acute pneumonitis  death takes place by
asthenia in combination with apnoea, the former predominating.  Death purely
by apnoea may occur if two  or  three lobes become  rapidly involved, but its
occurrence is rare.  The occurrence of an abundant pleuritic effusion increases
the danger from  apnoea.  So also does the occurrence of  the disease in persons
affected with emphysema  and in cases of  pertussis.  G^denia of  the portions
of  lung  not affected by  the pneumonia (collateral oedema) is  an immediate
cause of  death  by  apnoea  in  some cases.   This may be  an inflammatory
oedema, or, when general, it  occurs, according  to the experimental observa-
tions of Prof. Wm. H. Welch, when the  left ventricle of the heart becomes
disproportionately weak as contrasted with the right ventricle.   In general,
life is not lost in consequence of the extent of interference with respiration,
but, owing to concomitant affections or other circumstances, the vital powers
give way and the patient dies from exhaustion or heart-failure.   This  is an
fact important in its bearing on  therapeutical  indications.
   When  convalescence takes place, it generally progresses until the recovery
is complete.   The disease never  becomes chronic, unless it may be so con-
sidered when resolution is extremely slow.  Exceptionally, instead of  reso-
lution  being completed  within a few  days, it  persists  for several weeks,
recovery  at length taking place.   A relapse never  takes  place.   It is rare
for phthisis  to become developed as a sequel of lobar  pneumonitis.  When
phthisis appears to  be a sequel, it probably existed prior to the pneumonitis.
  1 For cases of thrombosis  of the right side of the heart, with remarks, vide Clinical
and Pathological Observations in India, by Sir Joseph Fayrer, p. 95 et seq. 
ACUTE  LOBAR PNEUMONITIS.
167
If the upper lobe be primarily attacked, it has been  supposed that the prior
existence of phthisis  may be inferred.  There may be some ground for this
inference, but I  have often known the inflammation to be limited to the
upper  lobe in cases in which the anterior and  subsequent history furnished
no evidence of phthisis.
                         CHAPTER   V.

                     PNEUMONITIS (Continued).

Treatment of Acute Lobar Pneumonitis.—Lobar Pneumonitis in Children.—Lobular Pneu-
   monitis.—Atelectasis.—Suppurative Pneumonitis.—Embolic Pneumonitis.—Abscess of
   the Lung.—Pneumouokoniosis, Anthracosis, etc.—Brown  or Pigment Induration of
   the Lungs.—Hyperaemia of the Lungs.—Hypostatic Congestion.—Hypostatic Pneumo-
   nitis.—Pleurodynia and  Intercostal Neuralgia.

    THE different stages of acute pneumonitis furnishing different therapeutical
     indications, the treatment of'  each  stage is to be considered separately.
   The question whether the disease may be  arrested relates to the first stage.
Measures which have heretofore been considered as abortive are bloodlet-
ting, cathartics, and other remedies entering into the so-called antiphlogistic
method of treatment,  Experience has  abundantly shown that these measures
cannot be relied upon for the arrest of  this more than of other inflammations.
Admitting that they sometimes succeed, the probability of success is not suf-
ficient to warrant their  employment under circumstances which will be likely
to render their operation hurtful should they  not prove successful.   Full
doses of quinia—that is, from 20 to 40  grains—given  either at once or within
eight or ten hours, may arrest the disease.   This statement is based on my
own experience as well as on the  testimony of others.  If a patient be seen
in the first stage, an effort should be made to render  the disease  abortive by
means of this remedy, inasmuch  as it  does no harm,  aside from  the annoy-
ance of cinchonism. if it do  not succeed; on the contrary, a favorable influ-
ence upon the course of  the disease is produced either by its antipyretic effect
or in other ways when it fails as an abortive remedy.  The disease sometimes
aborts spontaneously; that is, without treatment,   A few instances have fallen
under my observation.   The probability, however, of the  abortion occurring
spontaneously is so slight that if in several cases it follow treatment employed
for that end, it may fairly be considered as a successful result of such treatment.
Rational objects of treatment, exclusive of that employed  for an arrest of the
disease in the first stage, are to lessen  the intensity of the inflammation, to
lower the temperature of the body, to relieve pain, and to promote toleration
of the disease.
   As regards  bloodletting,  irrespective of  its employment  as an  abortive
measure, the reader is  referred to  the general considerations presented in
Chapter  II. Part II. (vide  p. 124 et seq.).   It is  admissible in certain cases
as a  palliative,  and perhaps to some extent a curative  measure, in  view of the
promptness of  its  operation.   The circumstances which warrant  its  employ-
ment are—high fever, the pulse more or less resisting compression, or, in other
words, arterial tension and a  robust constitution.   It is contraindicated when- 
168
PNEUMONITIS.
ever the fever is not high, when the pulse is frequent and weak, and when
the patient  is anaemic or has a feeble  constitution.   The relief of pain and
embarrassment of breathing  by bloodletting is often immediate and marked.
The efficiency of this measure as a palliative is due in part to its effect on the
general circulation and to the diminution of the functional labor of the lungs;
but the relief may be in part  explained by the effect in diminishing congestion
of the portions of the pulmonary organs not inflamed (the  collateral fluxion
of Virchow), and also by the effect in lessening the accumulation of blood in
the cavities of the  right  side of the heart.  In  most of  the cases, however,
in which the same ends can be secured by other means than bloodletting, the
former are to be preferred.  These consist in depletion by  saline purgatives
and in sedative remedies.  After the operation of a saline purgative, if the skin
be hot and the pulse  frequent, tartar emetic or some antimonial preparation
may be given as a nauseant sedative; but the doses should  not be carried  to
the extent of producing marked or distressing nausea.  The veratrum viride
may be given under the same restriction.  In  this  country not a few prac-
titioners regard this remedy as possessing notable curative  as  well  as palli-
ative  efficacy.  These  remedies  are contraindicated by feebleness or a tend-
ency to depression.   Aconite is an effective sedative remedy, and is to be
preferred to  the sedatives just named  whenever it be desirable to avoid the
depressing  effects of the latter.  Opium may  be given  with  propriety and
advantage  in  the first stage  in doses sufficient to relieve  the pain and tran-
quillize the  system.  Blisters are  injudicious, but dry cups,  sinapisms,  or
stimulating  liniments  may  be employed.   Stupes  or  warm  fomentations
applied to  the chest are useful.   In many cases a saline  purgative- followed
by some form of  opium, the  latter continued  at intervals, together with
soothing applications to the chest, will meet  the indications  pertaining  to
the first stage.   German authors extol cold applications over the part of the
chest  corresponding to  the affected portion of the lung by means either of
napkins which have been dipped in cold water, and which are  to be renewed
every  five  minutes, or the  ice-bag.   It is  stated  that  after a  few hours
patients are sensible of  relief, and  often  both the respiration and the pulse
become less  frequent.   Not infrequently the  temperature of the body  is
notably reduced.  In some cases, however, patients  complain  of the appli-
cation, and if so  it should not be continuedT   It by no means follows  that
because  warm  applications are useful  the application of  cold  is not  also
useful, or vice versa ; either may have a favorable effect, the modus operandi
of each differing from that of the other.   Warm  applications soothe  and act
as revulsives; the  application of cold  diminishes the determination of blood
to the part and relieves  pain by  obtunding the  sensibility.
   If the fever be high, as denoted by a temperature of 103° or more, anti-
pyretic measures  are  indicated, as in the diseases which are generally recog-
nized  as essential fevers.  These  measures are the employment of cold for
the direct abstraction of heat  from the body and the administration of quinine
in full doses, the  latter often antagonizing an  excessive production of heat.
Antipyrine may be  substituted for  quinia if the  latter be not well tolerated
or if  it prove inefficacious.   Cold  may  be employed by means of the  bath,
the wet  sheet, or sponging  the body.   Of these  different modes,  the two
latter  are less inconvenient both for the patient and others than the first, and
the last mode will in most instances suffice.  The object is to reduce the tem-
perature to  as near the normal maximum as practicable.  Whenever, after
this object is effected, the temperature rises, cold is to be  again applied.   It
is desirable  that  the employment of these measures  be under the  personal
direction of the physician or  an experienced assistant.   An alcoholic stimu-
lant  should  be given  whenever the bath, the  wet sheet, or sponging  is 
ACUTE  LOBAR PNEUMONITIS.
169
employed.   My own  practical knowledge of these measures in this  disease
is not large, but as far as it goes it is confirmatory of their safety and use-
fulness.1  They are opposed by existing popular notions; hence in  private
practice patients submit with reluctance at first, and  the physician incurs a
risk of being blamed  if the cases do not do well.  These difficulties are not
in the way of the use of quinia and other antipyretic drugs.   Quinia is the
most efficient of these.  It should be given in  the same way as with refer-
ence  to an  abortion of the disease.  This remedy may suffice  for  the anti-
pyretic object, rendering the cold-water treatment unnecessary, and  it may
be conjoined with the latter.  Exposing the surface  of  the body to  cool or
cold air is not without considerable  antipyretic  effect, and is unattended by
any risk, although from prevalent ideas it seems hazardous to  the minds of
most persons.   The axiom that patients with fever  do  not "  take cold " is
one  which it is extremely desirable should become  popularized.  Popular
apprehensions on this  score often  stand in the way of proper ventilation in
cases of disease.
  The treatment in the second stage has reference to the  promotion of resolu-
tion, palliation of symptoms, and supporting the powers of the system.  Blood-
letting in  this stage is not admissible, and depletion by means of salines is not
called for.   It is not an object to divert the blood from the solidified lung, for
the exudation has already deprived it of blood, and the amount of exudation
involves the withdrawal from the blood of a  pound or more of  solid  matter
even when the  inflammation is limited to a single lobe.  Hyperaemia of the
lung on the unaffected side (collateral fluxion), with oedema, occurs less often,
as it seems to me, than has been supposed.  It is indicated  by  increased fre-
quency of the respirations and dyspnoea, accompanied  by  the development of
fine, moist rales over  the unaffected side.  The application of a considerable
number of dry cups over  the chest is the most  effectual measure for relief.
Experience has shown the inutility of remedies formerly  employed as  sorbe-
facients—namely, tartar emetic in large doses and mercury.
  Repeated  applications  of  the tincture of  iodine  will secure  a  sufficient
amount of counter-irritation if any be desirable.  Blisters are not advisable,
on account of the general disturbance which they are liable to occasion and
their interference with physical examinations of the chest.  If pain and sore-
ness continue in this stage, stupes with w*arm water only  or with some stimu-
lating liquid, as the liniment of turpentine, will afford relief.   The latter will
not  be  required if the tincture  of iodine have  been applied.
  Opium is a valuable remedy in the  second as well as  in the  first stage.  It is
indicated  not only by the continuance of pain, but by vigilance, restlessness,
and symptoms denoting constitutional disturbance. I have repeatedly observed
a rapid and  notable diminution of the frequency of the pulse and of the res-
pirations, with refreshing sleep and a condition  of comfort, to follow full doses
of opium.  The free use of opium does  not delay the  beginning or retard the
progress of resolution.   An accumulation of mucous secretion in the bron-
chial tubes  contraindicates the use  of  opium  in full doses.
  Remedies  to  promote expectoration, as a rule, are not  indicated.  The use
of remedies of this class is  based on the erroneous idea  that  the matter of
exudation is expectorated.  Clinical observation shows that the removal of
this matter  may go on with great rapidity without  any expectoration.  The
expectoration in the second stage of the  disease is due to bronchitis limited to
the affected  lobe or lobes.  The mucous products rarely accumulate in the
bronchial  tubes to  an extent  to occasion inconvenience, except as a  conse-
  1 For report of cases treated by the wet sheet by the author, vide Gaillard's Medical
Jnnrind,  March,  1881; also,  Transactions of the Nev)  York  State Medical Association,
vol. ii. 
170
PNEUMONITIS.
quence of a degree  of  exhaustion sufficient to render the muscular power
inadequate to efficient efforts of expectoration ; and under these circumstances
expectorant remedies will not afford relief.                        ,
  Sedative remedies, such  as aconite  and the veratrum viride, are admissible
in this stage if there be considerable  or high fever without a tendency to
asthenia.  They should be cautiously given, so as not to incur risk of con-
stitutional disturbance or depression.   A high temperature in this as in the
first stage  calls for  antipyretic treatment, and the same  measures  may  be
employed.   These measures are indicated whenever the thermometer shows
a temperature  at or above 103°.
  To support the powers of life is the leading general indication in the second
stage.  Resolution will  be sure to begin and continue if the life of the patient
be  sufficiently prolonged.   The danger is generally, not from  the amount  or
persistence of the solidification of lung, but from failure of the vital powers
before the resolution takes place.  This disease belongs among those distin-
guished as  self-limited; if uncomplicated and not attended  by accidents, it
runs a definite career ending in restoration, provided the powers of life  hold
out.  These considerations, together with  the  results of clinical experience,
enforce  the  importance of the supporting treatment.
  The indication for supporting measures as regards urgency varies much in
different cases.  In  general terms, it is  urgent in  proportion to the danger
from asthenia.   It should govern the treatment in cases sometimes character-
ized as asthenic, and  whenever there are grounds for distrust of the adequate-
ness of the vital powers to carry the patient safely through the disease.  It is
a serious  mistake to defer supporting measures until the symptoms denote
imminent danger from failure of the powers of life.   If deferred so long  they
will probably be too  late.   The observing and skilful practitioner will foresee
and endeavor to forestall a degree of prostration attended with imminent dan-
ger.  The constitution of the  patient, his previous health, and his habits are
to be taken  into account in judging early of the ability to sustain the disease.
Other things being equal, in a warm climate patients are  less able to sustain
the  disease  than in cold or temperate  climates ; supporting treatment, there-
fore, is oftener and earlier called for in the former than in the latter.  In cases
which are distinguished as asthenic and typhoid the reliance for successful
management must be on supporting measures.  These views are the  more to
be  impressed  because it is undoubtedly true that until lately the minds of
medical men have been  so much occupied with  the means of subduing inflam-
mation as to overlook the fact that means employed for this end not only often
conflict with those which are more important for recovery, but  may be  posi-
tively injurious, if not,  indeed, destructive to life.   The  attention has  been
directed too much to the disease  and  too little to the patient.
  The supporting treatment embraces tonic remedies,  alcoholics, and nutri-
tious diet.   Of tonic remedies, quinia is to be preferred.   Alcoholics  form an
essential part of the supporting  treatment, as in all other  diseases whenever
the  object is to keep the patient  alive until the disease has reached  the end
of its career and advanced into the stage of resolution.   The  principle is the
same as  in  other essential fevers; and here,  as in the management of the
latter, alcoholics are  indicated to an  extent commensurate with the danger
from failure of the  vital powers.  In   certain cases of  pneumonitis, as in
typhus or typhoid fever and other diseases, there is often a remarkable toler-
ance of alcohol, and  the only  guide as regards quantity is the effect as mani-
fested by the symptoms.  No abstract rules can be  laid  down  as applicable to
all  cases, but  careful observation must furnish  the rule proper to each  indi-
vidual case.  Here, too, as in the continued  fevers, because alcoholics are
vastly important in  some cases it is not to be  inferred  that they are invari- 
ACUTE  LOBAR PNEUMONITIS.
171
ably indicated or that they can  never do harm ; on the  contrary, if pushed
to an injudicious extreme they are potent for evil, as they are potent for good
when judiciously used.
   As regards the circumstances under which the use of alcoholics is  to  be
begun, they are always indicated  as soon as evidence appears of any tend-
ency to failure  of the powers of life.  And of this the action of the heart,
as represented  by the pulse  and by  the systolic sound over  the apex,  is the
criterion.   Feebleness, great  frequency, and a pulse vibratory or thrilling but
compressible, denoting  increased activity but diminished power  of the ven-
tricular contractions ; also, feebleness of the  first sound on auscultation over
the apex, and, in addition to  feebleness, the shortness and valvular quality of
this sound,—these are the characters which indicate supporting measures,  of
which alcoholics are an essential part.  Given at first in small or moderate
doses, the effect is  to be  watched, and  the  quantity increased  in proportion
to the urgency of the indication.   The habits of the patient as regards the
habitual use of  alcoholic drinks  are of course to be  taken  into account.
Whenever the question  arises in the management of a  case whether alcoholics
be advisable or not, it should be  borne in  mind that  to  begin earlier  than
they are required is far preferable to subsequent delay ;  for with  proper care
they can be suspended  without  any injury  having been done, whereas  the
time  lost  by beginning too  late cannot be  regained.
   Alimentation is an essential  part  of the  supporting treatment.  It is  as
important to nourish patients affected with pneumonitis as those affected with
any febrile or other disease whenever there  is danger from failure of the vital
powers.  The statement that patients with pneumonitis should be encouraged
to take nutritious food during the whole course of the disease is based  on
considerable experience, and  alimentation should enter into the treatment in
proportion  as the symptoms denote a tendency to asthenia.  Milk with farina-
ceous substances and animal  broths  should  form the diet, thus combining a
proper variety  of alimentary principles.  The desires and taste of the patient
may generally  be trusted.
   These remarks on the supporting treatment are not  specially applicable to
pneumonitis, but apply  alike  to cases of any disease the gravity or danger of
which is manifested by  symptoms  denoting  failure  of the vital  powers, and
they will be referred to in connection with the  treatment of  other affections.
As applied  to  pneumonitis, they relate chiefly to cases in which this disease
is rendered  grave or dangerous  either by the extent of lung  involved or  by
coexisting affections. It  will be borne in mind  that in a large proportion  of
the cases in which  the  disease is  limited  to a single  lobe  and disconnected
from other affections there is little or no intrinsic tendency to a fatal termi-
nation.  In such cases no active treatment is required, either with a view  to
lessen the intensity of inflammation or to support the powers of the system ;
patients pass through the disease satisfactorily under simple palliative  meas-
ures.   I have treated many cases simply with attention to hygiene. It  by no
means follows that because this  disease exists remedies are to be employed;
they are to be  employed  only when  there are indications calling for thera-
peutical interference.
   In  cases  of  pneumonitis associated with  intermittent fever quinia should
be given promptly and in efficient  doses.  The paroxysms should be arrested
as speedily as possible, as the patient may be placed in great  danger by their
repetition.   In a malarial region, or if the patient have been  subject to inter-
mittent fever, it is judicious to forestall the  possible development of the latter
affection by moderate doses  of quinia.   The malarial  cachexia impairs the
power of  resisting  the disease ; hence  it is more likely to  prove fatal  in
malarial regions, even when uncomplicated  with intermittent  fever. 
172
PNEUMONITIS.
  Cases  of pneumonitis  complicated  with  delirium  tremens  call  for  the
pretty free use of opium,  together  with alcoholics and a nutritious  diet.
Delirium and vigilance, if protracted, are likely to lead to a fatal termination.
Pericarditis as a complication adds greatly to the gravity and the danger, but
by  perseverance  in  the judicious employment of supporting measures the
patient may be  carried safely  through  this  combination of diseases.  The
occurrence of gangrene furnishes an additional indication for support. Pneu-
monitis  occurring in  connection with  the continued or the eruptive fevers
generally gives  rise to the indications for supporting treatment.
  During the progress of resolution the principles of treatment which  have
just been  presented are applicable until the improvement in  the local  and
general  symptoms, in connection with the physical signs, denote convales-
cence.  When  convalescence is established, as already  stated, there is  no
danger of a renewed attack.  There is, therefore, no need of extreme precau-
tions in order to prevent a liability to relapse.  Experience shows that a solid,
substantial  diet may be entered upon as soon as the patient is  fairly on the
road to recovery, and that the recovery is more rapid than if the  appetite be
too much restrained.  As a rule, ordinary wholesome, digestible articles of
food may be allowed when they are desired  by the patient.  Permitting or
encouraging the patient to sit up will  be found not to retard  recovery, but,
on the other hand, apparently to hasten  the  progress  of resolution.  Early
going out  of doors is  not  objectionable.
  If  the disease proceed to the suppurative  stage, purulent  matter being
either infiltrated or forming abscesses, the prognosis is extremely unfavorable,
but perseverance in the  employment of supporting measures  is sometimes
successful.   It may be  added that timely  and  efficient support probably
affords the best security against suppuration, which happily is extremely rare.
  I havesfor several years advised the carbonate or muriate of ammonia dur-
ing the progress of the disease with a view  to prevent  cardiac thrombosis.
Of course it is difficult to obtain clinical proof of the protective  efficacy of
this or any other remedy against  that  accident.   There can  be  no objection
to the use of this remedy on therapeutical grounds, since it does not in any
manner affect unfavorably  the  progress  of  the disease.   Dr. A. Patton  of
Indiana, in a paper advocating  the  free  use of this remedy throughout the
disease—that is, from  5 to  10  grains every three hours—states that of 96
cases in which  this  constituted all the medicinal  treatment, in only 2 cases
was the disease fatal.1  It is probable that digitalis, given with a  view to
increase  the power of the heart's action, is useful  in preventing heart-clot.
This remedy has seemed to me often signally useful when  the  action of the
heart is feeble or irregular,  and also to be  of use as a nervous  sedative when
delirium and vigilance are prominent symptoms.


             Acute Lobar  Pneumonitis in  Children.
  Acute pneumonitis, the solidification extending over an entire lobe, some-
times involving a second lobe, and presenting after  death the anatomical  cha-
racters which have been  described as belonging to this disease  in the adult,
occurs in young children, although infrequently as compared with its occur-
rence after this period of life.  It is a much graver  disease in young  children
than in  adults, proving fatal in a large proportion of cases.  From the absence
of the subjective symptoms and the difficulty of obtaining physical signs the
diagnosis is less easy, and the disease is not infrequently overlooked.
  The attack is sometimes ushered  in  by a convulsion.  This  may  mis-
  1 Am. Jonm. Med. Sci., Oct., 1870.  Of 207  cases treated chiefly with this remedy by
Dr. J. P. Thomas, only 3 were fatal.  (Vide Virginia Medical Monthly, April, 1880.) 
           ACUTE LOBAR  PNEUMONITIS IN CHILDREN.        173

lead by directing  attention to the  head.  Dulness,  drowsiness, or  stupor
sometimes  accompanies the progress  of  the  disease, and these symptoms
may mislead  in the same way  if the symptoms referable to the  chest be not
marked.  Vomiting is not a rare symptom at the onset of the disease.  The
expectoration, being swallowed, cannot be observed in young children.  As
regards local  symptoms, the disease may be latent in the child, as it not infre-
quently is  in the  adult.   But in a certain  proportion of cases  the existence
of  sharp pleuritic  pain is manifested by the expression, and also by the cry
in  acts of  coughing or whenever a deep  inspiration is taken.  A diagnostic
symptom of  frequent  occurrence is a moaning or grunting  sound  with the
expiratory  act.   Attention to this  symptom is especially important, as it
points very strongly to the existence of pneumonitis.  Increased frequency of
the respirations and dilatation of the nostrils show the existence of some pul-
monary affection  compromising the respiratory  function.  The respirations
in  some cases are very frequent, numbering 40,  50, 60,  and sometimes even
many more, per minute.   One or  both cheeks may present a circumscribed
flush.   If  the progress of the disease be unfavorable, lividity of the prolabia
and face becomes marked;  more or less acceleration of the pulse occurs, and
the frequency in some cases is very great, amounting to from 150 to 200  per
minute.
   When the existence of some acute affection of the chest is declared by the
symptoms, the differential diagnosis lies between primary pleuritis, capillary
bronchitis, the so-called lobular or broncho-pneumonitis, and lobar pneumo-
nitis.   The first of these affections being extremely rare under five years of
age, the problem is usually to differentiate the latter from the two other affec-
tions.   In  solving  this problem the physical  signs are to be relied upon, and
the reliance  is also upon  these for  the diagnosis in cases in which the  symp-
toms denoting an acute thoracic affection  are not marked.  The physical signs
are generally available with care and patience, notwithstanding the difficulty
of exploring the chest in the  young child.
   The crepitant rale is oftener wanting in pneumonitis affecting  the child than
the adult,  but it is present in  a certain proportion of cases, and is of course to
be sought after.   This sign belongs exclusively  to pneumonitis, whereas fine
bubbling (subcrepitant) rales belong to capillary bronchitis. If there be doubt
as  regards  the discrimination  between the crepitant and the bubbling rales, it
is to be borne in mind that capillary bronchitis is a bilateral  disease, and the
bubbling rales will be present in both sides; whereas in the great majority of
cases pneumonitis in the  child, as in the adult, is unilateral, and the crepitant
rale will be limited accordingly to one side.  Dulness on percussion  is readily
determinable in the child; and this is an important point in the differential
diagnosis.  Bronchial respiration and bronchophony may generally be obtained
in  the child by perseverance in auscultation, the cry answering for the voice.
These signs  do not belong to capillary bronchitis, and  are rarely present in
lobular pneumonitis.  In  short, the diagnosis is to be based on the same signs
as  in  the  adult, but  patient efforts may be requisite to obtain them.  As
regards primary pleuritis,  the signs  denoting  effusion  are available in the
child as well as in the adult, and their absence warrants the exclusion of that
affection.
   The  treatment of acute  lobar pneumonitis in  children involves  the same
principles  as the treatment of the disease in adults, with those modifications
which therapeutical measures require in their application to infantile life.  It
is questionable whether bloodletting be ever advisable in young children, even
when the diagnosis is clear in the first stage of  the disease.   As a  rule, this
measure is not to be employed, and the exceptions to the rule, if there  be any,
are few ; depletion  by salines may take its place.  Antimonial preparations, 
174
PNEUMONITIS.
 if given at all, are to be  prescribed with great caution, and in general other
 and less depressing nauseant sedatives are to be preferred.   The veratrum
 viride, if given, should be prescribed in small doses and its effects very care-
 fully watched.  Aconite,  in children as well as adults, is a useful sedative in
 this affection.   Blisters should not be employed.   A sinapism or turpentine
 stupes may be applied to  the chest, followed by a poultice or the water-dress-
 ing.  Particular attention should be given to  the  latter, in order to see that
 either the entire chest or  the whole of the affected side is covered with several
 thicknesses of flannel and  a layer of oiled muslin.  The spongio-piline is a good
 substitute  for  the poultice or the water-dressing.   Opium  need not be with-
 held, but it must be  given with  circumspection.  Finally, as much depends in
 severe cases, in the child  as in  the adult, upon the early, judicious, and  per-
 sistent employment of supporting measures.  In children, as in adults, under
 certain  circumstances there is a remarkable tolerance of alcoholics.   I have
 notes of the case of a child of a medical friend (age fourteen months), present-
 ing  the utmost gravity of symptoms, the pulse 200 and the respiration 120
 per minute, in which brandy was increased to at least an ounce  hourly, and
 under this amount the  pulse fell rapidly to 124 and  the respiration to  50 per
 minute, the carbonate of  ammonia and a little morphia constituting the addi-
 tional treatment.  Recovery took place.   This case is cited in illustration of
 the  extent to which in  some cases the  employment of alcoholics may be  car-
 ried.  It does not follow that they are to be generally employed excessively
 or largely.  The same rules are to  be observed in their use in children as  in
 adults, with a view,  on  the one hand, to secure the benefits of alcoholics, and,
 on the other hand, to avoid the  evils of their over-use.


  Lobular Pneumonitis—Broncho-pneumonitis—Atelectasis.
   Lobular pneumonitis is also frequently called catarrhal pneumonia, from the
 fact that the exudation is  chiefly cellular. This latter name, however, is inap-
 propriate, because the term " catarrhal" is only applicable  to inflammations
 of mucous membranes, and the wall of the air-cells and alveolar passages
 cannot be considered properly a mucous membrane; and, moreover, fibrin is
 sometimes  present in the  exudation of so-called catarrhal pneumonia as well
 as in that of lobar pneumonitis.  The  name cellular pneumonia, employed  by
 Virchow is not sufficiently distinctive.  The terms broncho-pneumonitis, imply-
 ing  the coincident affection of the  bronchi and of the air-cells, and  lobular
 pneumonitis,  signifying  the lobular  dissemination of  the inflammation, are to
 be preferred.
  Lobular pneumonitis  is  a secondary affection, and almost always secondary
 to inflammation of the smaller bronchi.  It is frequent in childhood, but rare
 in adults, except in the debilitated  and the aged.   In the  new-born  and in
 very young children  it is  usually preceded and accompanied by atelectasis or
 collapse of a greater or less number of pulmonary  lobules (apneumatosis).
 Atelectasis may attend lobular pneumonitis occurring later in life, but it is a
 less constant accompaniment.  Portions of the lung-tissue in the condition of
 atelectasis contain no air; they  are non-crepitant and sink  in water.   They
 present a bluish-red appearance through the pleura, and a more brownish-red
 color on cross-section.   They have a smooth surface,  a firm consistence, and
 are depressed below the level of the surrounding lung-tissue.  They can  be
inflated by blowing through the bronchi.  In many  cases, but not always,
occlusion of the bronchi immediately connected with  the atelectatic spots can
be demonstrated.  The most frequent source of obstruction is  an accumula-
tion of the products  of inflammation in the smaller  bronchi.   The air-cells
connected with the occluded bronchi collapse after the absorption of the con- 
                     LOBULAR PNEUMONITIS, ETC.                175

 tained air.   Microscopical examination of the collapsed lobules shows disten-
 sion of the pulmonary capillaries with blood, and the  presence  of granular,
 desquamated epithelial cells in the collapsed alveoli.   Atelectasis of portions
 of the lungs may be a congenital condition in the new-born  and in infants a
 few days or weeks old, the affected lobules having never been inflated, in  con-
 sequence either of weakness of the respiratory efforts or of obstruction of the
 bronchi by mucus, meconium, etc.  Acquired atelectasis is far more frequent
 in children than in adults.   The name atelectasis is also sometimes applied to
 the condition called carnification of the lungs, the air having been expelled
 by pressure from without as by an extensive fluid accumulation in the pleural
 cavity.  Atelectasis  of whatever form is  more  frequent  in the lower lobes
 than in the upper.   Single circumscribed  lobules may be  affected, or even a
 whole lobe.   When there is extensive atelectasis the remaining  parenchyma
 of the  lung is  usually  in  the  condition of vicarious  vesicular  emphysema.
   There has been much controversy as  to the relations between atelectasis
 and lobular pneumonitis. Formerly, writers regarded atelectasis as congenital
 pneumonia, and  since the  true nature of the condition has been recognized
 it has usually been held that  collapse of  the air-cells in  itself leads to  the
 development of lobular inflammation.   It is  probably not correct to regard
 either acquired  pulmonary collapse or a persistence of the foetal state of the
 lungs as alone a cause of inflammation.  We  may consider that lobular pneu-
 monitis occurs only when there is present  within  the alveoli an irritant capa-
 ble of inducing inflammation.   Most foreign particles, and  particularly the
 stagnating secretion  of the inflamed  bronchial  mucous  membrane, are  irri-
 tants capable of exciting bronchitis and lobular pneumonitis by entrance  into
 the small bronchi and the  air-cells, whether  or not they completely obstruct
 the bronchi and lead to atelectasis.
   The  pathological  changes occurring in lobular  pneumonitis  have been
 divided into the  same three stages  as in  lobar pneumonitis—namely, first,
 congestion or engorgement;  second, red hepatization  ; and  third, gray hepat-
 ization.   Such  a division is, however,  less  important and  well defined in
 lobular than in lobar pneumonitis.   In a typical case of lobular  or broncho-
 pneumonitis disseminated throughout both lungs are  small firm spots varying
 in size from a pea  to a pigeon's egg.   The color may be  brownish-red,  red-
 dish-gray, gray, or yellowish, and the periphery  is usually darker than the
 centre.   The  surface is lustreless, smooth or slightly  granular, and somewhat
 elevated above  the  surrounding lung-tissue.  The  consolidated  pulmonary
 substance is non-crepitant and  sinks in w*ater.  When the solidified lobules
 are situated at the surface of the lung the overlying pleura is coated with a
 delicate layer of fibrin.  Usually, drops of muco-pus can be squeezed out of
 the smaller bronchi.  The  microscopical examination of the solidified lobules
 shows the  air-cells to be filled, though less distended than in  lobar pneumo-
 nitis, with pus-cells, epithelial cells, and  some  granular  matter in varying
 proportion.   In some cases the  pus-cells predominate; in  other  cases, large
 granular cells with vesicular nuclei, thought  to  be alveolar  epithelial cells.
 Red blood-corpuscles are  usually present, but not  in such  number  as in
 lobar pneumonitis.   The presence of large numbers of pus and epithelial
 cells in the alveoli, the  comparatively  small number  of red blood-corpuscles,
 and the absence of fibrin may be  considered  to be the characteristics of  the
 exudation  of  broncho-pneumonitis  as distinguished from the  lobar  form.
 Sometimes,  however, fibrillated  fibrin  may be found  in  the exudation of
 lobular  pneumonitis,  and in fact, as far as  the inflammatory products  are
 concerned,  there is every grade of transition between a typical, purely cellu-
lar exudation and the fibrino-cellular and  almost hemorrhagic exudation of
lobar pneumonitis.  Mucus and cells are sometimes inspired from the bronchi 
176
PNEUMONITIS.
into the alveoli.   The walls of the inflamed bronchi are often infiltrated with
leucocytes.   The inflammation  may  extend by continuity to the air-cells
immediately adjacent to these inflamed walls.   There may be some dilatation
of the bronchi.   A'arious forms of bacteria have been found in  the inflam-
matory exudation in the bronchi and air-cells,  and doubtless in many cases
bacteria  stand in a  causative relation to the  disease.
  There  is great variety in the extent of lung  involved in the inflammatory
process.   The pneumonitis may be confined to  a few lobules, as, for instance,
those surrounding a  hemorrhagic infarction  or  a new growth ; there may be
countless nodules of consolidation scattered throughout both lungs, or even
all the lobules of a lobe may become involved.  In the  rare  cases of lobar
consolidation from  lobular  pneumonitis  the fact that the  lobules are not
simultaneously but successively involved gives to the surface a peculiarly
variegated appearance  different from that  observed in  lobar  pneumonitis.
The surface is also less granular than in the latter disease.   As to the origin
of the cells which fill the  alveoli, it  is customary to regard the pus-cells as
emigrated white blood-corpuscles.  Whether the alveolar  epithelium play an
active part in the inflammatory process is a matter of dispute.  There is no
proof of the production  of  pus-cells from proliferating epithelial cells, and,
in those cases in which the number of large epithelium-like cells in the alveoli
seems greater than can be accounted for by a mere desquamation  of the epi-
thelial lining, it is not necessary to assume active proliferative changes in the
epithelium, as it is abundantly proven that wandering leucocytes can become
transformed into epithelioid cells.
  The most frequent termination of lobular pneumonitis is in resolution. As
in lobar  pneumonitis, the cell-elements undergo fatty degeneration, and by
transudation of serum  a kind of emulsion is formed capable of absorption.
When the broncho-pneumonia persists, for a  long time, the  alveolar walls
usually become  thickened  by a new growth of connective  tissue.
  It has  been held  by most authorities that the inflammatory  products of
lobular pneumonitis may undergo caseous metamorphosis which leads to the
development of pulmonary phthisis.   We now know that in such cases infec-
tion with the tubercular virus exists.   It is probable that in  some cases the
existence of broncho-pneumonia favors  the lodgment and development of
the tubercle bacilli.  It is, however, an  error to confound with ordinary
broncho-pneumonia the  lobular caseous pneumonia so often found in phthis-
ical lungs.   The  latter  affection is anatomically and etiologically a distinct
disease.

  Clinical History.—Inasmuch  as  a bronchitis affecting both sides  (bilat-
eral)  precedes and  accompanies the  collapse of lobules  in  lobular pneumo-
nitis,  the symptoms  of that disease are always present.   As will  be seen in
treating of Bronchitis in a  following chapter   (Chapter IX.), the  symptoms
attributable to the bronchial inflamation  vary according to its extension into
tubes of  small size.  In addition to cough and  expectoration, increase in the
frequency of the respirations, dyspnoea, and cyanosis may be accounted for
by  the bronchitis alone  if  tubes of  small  size become  involved (capillary
bronchitis).   These  symptoms  are more marked in proportion  to the  num-
ber of lobules  collapsed and inflamed.  The  symptoms  are  chiefly  due to
the pneumonitis  if  the bronchitis be limited  to tubes of large or medium
size.
  The bronchial  inflammation  may be acute  or subacute.   The  pyrexia is
proportionate to  the acuteness of the bronchial  inflammation and  to the
extent of lung affected.  This will, therefore, vary considerably in different
cases.  The symptoms relating to the frequency and other characters of the 
LOBULAR PNEUMONITIS,  ETC.
177
pulse offer variations dependent on the intensity of the fever and the obstruc-
tion to the passage of blood through the pulmonary vessels.   Corresponds<:
variations in other constitutional symptoms are incident to the fever and dis-
turbance of the  circulation.  It follows that broncho-pncumonitis may be a
disease  of great  severity and danger, or it may be comparatively devoid of
gravity.   Some cases are characterized  by notable fluctuations during the
course of the disease, owing to an  increase at different periods  of the num-
ber of lobules implicated.   The symptoms on successive days  may fluctuate,
collapsed lobules becoming inflated or an additional number "of  lobules  becom-
ing affected.

   Diagnosis.—The  diagnosis relates to tw*o factors as regards the  symp-
tomatic phenomena—namely, the bronchitis and  the collapsed or inflamed
lobules.   A third factor is  the  occurrence  of emphysematous lobules (lobu-
lar emphysema).  The physical signs  denoting the bronchitis are the moist
bronchial or bubbling rales, which are  coarse, fine, or subcrepitant according
to the size of the tubes in which they are produced.  Rales  varying in  coarse-
ness or fineness may  be combined.   The  collapsed and inflamed lobules may
furnish  no  distinctive signs if in the  form  of small nodules, disseminated,
and about equal in number on the two sides.   Broncho-vesicular or bronchial
respiration, increased vocal  resonance, and bronchophony, together with  dul-
ness on percussion within a circumscribed space on one side or on both sides,
may be found wherever a sufficient  number of lobules in  close proximity to
each other  are affected so  as  to  give rise to solidification extending  over a
considerable area. Lobar pneumonitis is excluded by the fact that the solidi-
fication  does not extend over an entire lobe.  On the other hand, the signs of
solidification show something  more  than bronchitis, this  disease  alone  not
giving rise  to these  signs.   If  no signs  of solidification be discovered,  it is
difficult or  impossible to differentiate  broncho-pneumonitis from  bronchitis
affecting tubes of small  size.   In severe  cases inspection shows retraction of
the lower part of  the chest on  both sides with the  acts of inspiration,  and
sinking in  of the soft parts above the clavicles, as  in  cases  of capillary
bronchitis.   Emphysematous lobules of  the  upper lobes  will give rise to a
vesiculotympanitic  resonance on percussion.

   Causation.—Age is to be regarded as  the most important  element in the
causation.   The fact that in a very large majority of cases the  subjects are
either infants or  children or persons advanced in years, is probably to be
explained by the much greater tendency in bronchial inflammation to  extend
to the smaller bronchi in the two extremes of life.   The affection  occurs not
infrequently as a sequel of  the  eruptive  fevers, rubeola, scarlatina, or small-
pox ; also of whooping cough, diphtheria, and, more rarely, of the continued
fevers.  It may be produced traumatically in persons of any age by the  inhala-
tion of chlorine or  other gases, of vapors, and of irritating substances of various
kinds. Exposure  to the latter causes may be incident to certain occupations.
(See Pncumonokoniosis, p. 180.)  The pneumonitis which is liable to accompany
exudative laryngitis  (croup) in children is a broncho-pneumonitis.  Its occur-
rence in cases of whooping cough is  not infrequent.  In the insane, the deliri-
ous, and the greatly  enfeebled, with  obtunded sensibility of the air-passages,
foreign particles, such as bits of food, the buccal fluids,  etc., are likely to be
inspired into the small bronchi and air-cells, giving rise to lobular pneumonia,
which in these cases  may be of a rather diffuse character.   This is the  aspira-
tion  pneumonia  (Schluck-pneumonie) of  German  writers.   Not infrequently
the inspired foreign particles are so irritating that  the inflamed foci terminate
in abscess, and occasionally they lead to gangrene.
       12 
178
PNEUMONITIS.
   Treatment.—The  therapeutic indications  have reference,  first, to the
bronchitis, and  second,  to  the inflammation and  the collapse of lobules.
The former are the same as in cases of bronchitis irrespective of the  lobu-
lar conditions, and they will  be  considered  in  a  following  chapter.   The
prompt and efficient treatment of bronchitis, especially in the young and old,
is important by way of preventing the  collapse and inflammation of lobules.
Energetic inspirations are important in order to  prevent collapse of lobules
and for the inflation  of  those  already collapsed.   For these objects the air
which the patient breathes should be cool or even cold, and  the  vital powers
should be  sustained by  nutritious stimulation and alcoholics.   Jiirgensen's
method of exciting deep inspirations  by the cold affusion or a douche directed
upon the nucha may be employed.  If there be hyperpyrexia, it is to be combated
by the cold bath or by sponging the  surface of the body, as in other diseases
whenever antipyretic treatment is indicated, and by quinia, antipyrine, or other
antipyretic remedies.   Alcoholics and digitalis are indicated by feebleness of
the heart's action, as in cases of acute lobar pneumonitis.   Emetics are indi-
cated in children by accumulations in the bronchial  tubes, which the patient
does not remove by voluntary expectoration.  The emetic selected should not
produce prolonged nausea or much prostration.  The dorsal decubitus should
not be constantly  maintained,  changes  of  position being important as pre-
ventive of collapse of lobules.

   Congenital atelectasis in the newly born is denoted by rapid, short acts of
breathing, feebleness  of the cry, difficulty  in  nursing  from want of breath,
and cyanosis.  The absence of cough and bronchial rales  suffices to exclude
bronchitis.  Congenital malformations  of  the heart  are  excluded  by  the
absence of their physical  signs.  The  respiratory  murmur is  feeble,  espe-
cially at the lower and posterior portions of the chest.  The lower part of
the chest in front is  retracted in the act  of inspiration.
   Inasmuch as the deficient  expansion of the lungs is due to weakness of the
respiratory acts,  the strength of these should  be increased by the momentary
application of cold water to  the chest, exposing the body for a few moments
to cold air, and exciting in various ways crying efforts.  Care should be taken
to free the nostrils and throat from accumulations of mucus.


      Suppurative   Pneumonitis—Embolic Pneumonitis—
                      Abscess of the Lung.

   Suppurative pneumonitis is  characterized  by  the formation  of pus  and
breaking down of lung-tissue.   Sometimes the pus infiltrates the  walls of
the bronchi or of the blood-vessels, or follows  bands of  interstitial tissue
(dissecting pneumonia).   The most important form  of suppurative pneu-
monitis is  that  which results in  the  formation  of abscess.  The  abscess-
cavity usually varies  in size from that of a pea  to that of a hen's egg. but
in some cases the  abscess takes in  the greater part or the whole of a  lobe.
The shape of the cavity may be round or irregular.  The walls of the abscess
are usually ragged.  In cases of long standing a fibrous capsule forms around
the abscess.
   As has already been mentioned, lobar pneumonia and lobular pneumonia
rarely terminate  in  abscess.  Abscesses may  be produced by the inspiration
of foreign irritating particles,  as in  many cases of aspiration pneumonia (p.
177).  Wounds  of  the lung, especially when  attended by the  lodgment of
foreign bodies, may give  rise to abscess.   In  new-born children there  is  a
form of septic pneumonia which frequently terminates in  abscess.  In this 
                 SUPPURATIVE PNEUMONITIS, ETC.              179

form of pneumonia an enormous number of micrococci are found in the air-
cells.   In chronic phthisis  suppurative  processes in the walls of cavities,
and sometimes in other  parts of the lung, may be an important pathological
element.
  The most frequent form of suppurative pneumonitis is that  produced by
infectious emboli, which cause metastatic abscesses in the lungs.   The source
of the emboli is usually to be sought in thrombi formed in veins  leading from
some centre of infection, such as external wounds, inflammation of the uterine
veins  in puerperal women, bed-sores, abscess of the middle or external ear and
of other situations, and ulcerative endocarditis.   The embolus brings with it
some poison which acts as an intense inflammatory irritant.  It is not always
possible  to find the primary thrombus, nor can  an embolus in all cases be
demonstrated.  It is probable that the poison may be carried by the blood in
a finely molecular form.  Metastatic or pyaemic pulmonary abscesses vary in
number  from one to several hundred, and in  size from a pin's head to those
involving an entire  lobe.   They may  or may  not be accompanied  by the
mechanical effects of emboli;  that is, by hemorrhagic infarctions, which are
to be described subsequently.
  The pleura covering an abscess  is  inflamed, and there is often a general
pleuritis, which may also be of a purulent character.  The abscess may rup-
ture into the pleural cavity.
   Micrococci  are always present in the pus.   The  same micro-organisms
which cause suppuration elsewhere also occasion  suppurative  inflammation
of the lung. (See Part I. p. 36.)
   The most  important aid in the  diagnosis of abscess of the lung  is the
examination of the sputum.   The color of the sputum is usually yellow, like
that of ordinary  pus, but it may be green or  brownish.  The odor is usually
somewhat offensive, but it  has not the fetor of gangrene.  Of the utmost
importance is the presence in the sputum of particles of lung-tissue, which
can  often be detected  even with the  naked eye.   These particles are found
by microscopical  examination to contain elastic fibres (which are usually
absent  or scanty in gangrene of the lung), fatty crystals, amorphous pig-
ment, and especially haematoidin crystals.   Micrococci, which  do not stain
blue with iodine like certain ones in  gangrene,  are present  in large number.
 The physical signs of a cavity may be detected if the abscess be of sufficient
 size,  but these signs  are not in themselves  distinctive of abscess.  Other
 symptoms, such  as  pain,  dyspnoea,  pyrexia, rigors, and  sweats, are often
 present.  In  pyaemia  it is generally  impossible to disconnect the  general
 symptoms which are indicative of the pulmonary affection from those which
 belong to the clinical  history of pyaemia.   In pyaemia it is rare that the dif-
 ferent foci of inflammation in the lungs involve areas sufficient to give rise  to
 characteristic physical  signs.
   The  prognosis is almost necessarily fatal in  pyaemic pulmonary abscesses.
 In other forms of pulmonary abscess, such as  that secondary to pneumonia,
 the prognosis is comparatively favorable—more favorable than in gangrene
 of the lungs.   The affection, however, is in all cases  grave.
   The  treatment is to be directed especially to sustaining measures.   Qui-
 nine  may be given in large doses.  The air of the room should be kept pure,
 and inhalations of antiseptic vapors, such as  thymol or carbolic acid, may be
 tried.  A case of large abscess of the lung which  was first diagnosticated as
 empyema was treated successfully by Teale by means  of  incision and free
 drainage.1
                          1 Lancet, 1884, vol. i. So. 2. 
180
PNEUMONITIS.
       Pneumonokoniosis—Anthracosis—Siderosis,  etc.

  Under the generic name pneumonokoniosis, proposed by Zenker, are included
the various  affections of the lung produced by the inhalation of dust-like par-
ticles.   A considerable  number of such inhalation-diseases is already known.
The one longest recognized is the lesion caused by the inhalation of coal-dust.
A moderate amount of  black coal-pigment is found in the  lungs of all adults,
more especially of those living in cities ;  but in the lungs  of  those  who have
been exposed for a long time to a dense atmosphere of coal-dust the carbon-
particles accumulate to such an extent as to cause a lesion called anthracosis
of the lungs.  This lesion is produced  especially in coal-miners.   The par-
ticles of  coal are carried by the current of inspired air  into  the air-vesicles
or alveoli.   Thence, either free or enclosed in cells, which  are probably emi-
grated white blood-corpuscles, they make their way into the alveolar septa,
and are still further conveyed through the  lymph-spaces and lymph-vessels
into the interlobular and peribronchial connective  tissue.   Some of the par-
ticles reach the bronchial glands, and  exceptionally may  even be carried to
the cervical or abdominal lymphatic glands.  The lungs and bronchial glands
are black;  the microscope shows the coal-pigment to be chiefly in the inter-
lobular connective tissue and in the bronchial glands, but it is also present
inside of cells in the alveoli  and in  the walls of the air-vesicles.   Extensive
anthracosis  may exist without any changes  in the  lung  other than  chronic
bronchitis and the presence of some large  cells containing  pigment in the
alveoli.  Frequently,  however, it  is  combined with other  chronic  inflam-
matory changes, particularly with  chronic  interstitial pneumonitis.   Dense
fibrous bands and  nodules deeply pigmented are found.   The walls of the
alveoli are thick, and their lumina obstructed or even obliterated by the new
growth of fibrous  tissue.  Firm pleuritic adhesions are present,   Combined
with these  chronic interstitial changes bronchiectatic and  ulcerative  cavities
may be  present.  Anthracotic lungs may be  the  seat also  of chronic pul-
monary tuberculosis, in which  case tubercles and  tuberculous pneumonitis
will be found.1   To pulmonary anthracosis with chronic  interstitial inflam-
mation, with  or without the presence of tubercles, the  name coal-miner's
phthisis  is  applied.   The coal-particles, when  of sufficient size, can  be rec-
ognized  as  such under the microscope;  often, however, they are not to be
distinguished from  melanotic pigment derived from the  blood.   The coal-
particles are often present in the expectoration of those  affected with anthra-
cosis pulmonum.
   The term siderosis pulmonum denotes the accumulation in the pulmonary
structures of the oxide of iron.  This  oxide forms a very fine, brownish-red
dust.  It is inhaled by workmen  employed  in dyeing, polishing mirrors, and
other mechanical  arts  in which it  is used.  Accumulating  in the lungs, it
causes a reddish  pigmentation.  Its morbid  effects were first  studied  by
Zenker.2  They are essentially the  same as in  anthracosis,  the  color being
red instead of  black.
   Chalicosis pulmonum is the name given to the pulmonary changes induced
by  the inhalation  of stone-dust.   It  is also  called stone-cutter's phthisis.
The chemical examination of these lungs shows the presence of an excess of
silica.   The changes are similar to those  of  anthracosis and of siderosis, with

  1 It is claimed  by recent observers that tubercle bacilli are usually absent in coal-
miner's phthisis,  in  which case the process is  not to be regarded as  tuberculous.
According to Cohnheim, coal-particles, as such, cause no irritative changes in the lung,
and when inflammatory changes are present irritating substances  are inhaled with the
particles of coal.
  2 Deutscles Archiv f. klin. Med., Bd. 2,  p. 116. 
HYPEREMIA  OF  THE LUNGS, ETC.             181
the exception of the  greater disposition to the formation of  nodules and
diffuse masses of fibrous tissue.   These have a gray centre and  dark periph-
ery.   The  foreign  particles  can be recognized microscopically, but not so
readily as in the previous affections.
   \ arious  other forms of pneumonokoniosis  have been  described, such as
those due to the inhalation  of  particles of tobacco,  of cotton,  of grain, of
various metals, etc.
   The clinical history  of the different  varieties of pneumonokoniosis is  that
of bronchitis, which is generally chronic, associated, in a  certain number of
cases, with fibroid  phthisis.
   The removal of the  patient from the continued  operation of the cause  is
of course the first  object  of  treatment.  In  other respects the  indications
relate to the diseases  which are incident to the pneumonokoniosis.


         Brown or  Pigment Induration of the Lungs.

   The lesion thus entitled, described by Virchow in 1847, is referable to the
long-continued passive congestion  incident to valvular  disease of the left
side  of the  heart,  particularly  to  obstruction and to regurgitation at the
mitral orifice.  Lungs thus affected do not  collapse on opening the chest as
much as  when they are healthy.  They are heavy, inelastic, dry,  crepitating
but  little on pressure, of  a  leathery consistence, and they have  a peculiar
reddish-brown, yellow, or  salmon color.  On section, reddish or brown  spots
may be seen, due to ecchymoses.  The microscope shows that  the essential
morbid condition is a dilatation  of the pulmonary capillaries, loops of which
often project  far into the alveoli and partially obstruct their lutnina.   The
air-cells are  still further  obstructed by the presence of large epithelial cells
containing yellow or brown pigment, which cells may  accumulate in sufficient
number to fill the alveoli.   Pigment is  also found within the capillary vessels,
in the capillary walls, and in  the interstitial  tissue, both free and enclosed in
cells. The pigment is derived from red  blood-corpuscles which escape through
the capillary walls by  diapedesis, in part also  by rupture  of the walls.   The
walls of  the  air-cells and  the interstitial tissue often appear hypertrophied.
Iiindfleisch describes also an  hypertrophy of the smooth muscle-fibres of the
pulmonary parenchyma in this affection.
   The symptoms denoting  the lesion are not definite, but it must increase the
dyspnoea which is connected more directly with the cardiac disease.


Hyperaemia of  the  Lungs—Hypostatic  Congestion—Hypo-
                        static Pneumonitis.
   Active congestion  or hyperaemia of the lungs, irrespective of inflammation,
is rarely  if ever a primary morbid condition, and is hardly  to be  considered
as an individual affection.   It may be produced by  increased  power of the
heart's action, arising either from transient  causes, such  as the  ingestion of
alcoholic stimulants and mental  emotions, or from  hypertrophy of the right
ventricle.   It may be  caused by the inhalation of stimulating  or irritating
vapors.   Whenever the circulation in  a considerable  portion of the lungs  is
interrupted, more or less abnormal determination of blood must  take place in
the portions to which the flow of blood is unobstructed, as in cases of emphy-
sema, lobar pneumonia, pleuritis, etc.
   Passive hyperaemia  or congestion is of more frequent occurrence, but  is
never primary or idiopathic.   It is an effect of mitral  cardiac lesions causing
either obstruction or regurgitation,  or both combined.  It is also consequent
on feebleness of the action of the heart, especially of the right ventricle, as in 
182
PNEUMONITIS.
cases of dilatation  or  of fatty degeneration.   In cases  of general  dropsy it
occasions a disproportionate amount of hydrothorax.  It gives rise to brown
or pigment  induration  of the  lungs. (See p. 181.)
  Passive hyperaemia  occurring in  the dependent portions of the lungs  is
called hypostatic congestion.  The conditions which favor the production of
hypostatic  congestion  are enfeebled heart's action and the maintenance of
the body in one position for a long time.  It is met with in acute infectious
diseases, in  the aged,  and in  the course of chronic diseases which occasion
general debility.  The higher  grades of hypostatic congestion result  in  a
transudation of bloody serum.   The condition of lung thus produced has
been  called splenization.   The affected lung-tissue is  of  a dark-red  color,
crepitates less than in health, and  upon section a large quantity of blood and
serum oozes out.  In prolonged or in severe hypostatic congestion the so-called
hypostatic pneumonia is frequently developed.   It has been disputed whether
this is to be regarded as an inflammatory affection or not.  It seems to involve
a low degree of inflammation.   The lung-tissue is dark-red, friable, non-crepi-
tant, and sinks  in water. The  whole  lower lobe or only portions of it  may
be implicated.   Microscopical examination  shows the pulmonary capillaries
widely distended with blood, and the air-cells filled with blood-corpuscles, des-
quamated epithelial cells, and sometimes fibrin.   The inflammatory condition
is  more  analogous  to  certain forms  of lobular pneumonitis  than  to  lobar
pneumonitis.
  Congestion of the lungs, whether active or passive, compromises the respi-
ratory function—-first, by diminishing the capacity of the  air-cells ;  and second,
by lessening the quantity of  decarbonized and oxygenized blood returned  from
the lungs to the systemic circulation.  The  respirations  are increased in fre-
quency, and a sense of the want of air, or dyspnoea, is felt,  caeterisparibus, in
proportion to the degree and extent of the  congestion.   As regards physical
signs, congestion, if marked or considerable, undoubtedly causes a certain
amount of  dulness on percussion; but this is not determinable if  both lungs
be alike congested, or in cases in which congestion of one lung follows certain
affections in the other side of the chest, as in pleurisy with effusion, pneumo-
hydrothorax, etc.   Congestion  also undoubtedly diminishes the intensity of
the respiratory murmur;  but if the  murmur be changed in character—that
is, if it be  bronchial or broncho-vesicular—there is  solidification  from some
cause.  It is not probable that simple congestion gives rise to adventitious
sounds  or rales, nor does it occasion  any vocal signs.
  The treatment of active hyperaemia must have reference, of course, to the
causative conditions and the circumstances under which it  occurs.  The dis-
turbance of respiration, not  only when  the hyperaemia is bilateral, but when
unilateral, as when  one lung is consolidated or compressed, may be so  great
as to call for venesection.  In most  cases, however, dry cups applied to the
chest, revulsives, and  cardiac sedatives suffice  for relief.
  In hypostatic congestion, on the other hand, measures to increase the power
of the heart's action are indicated—namely, digitalis, alcoholics, and alimen-
tation.  As a preventive  measure in cases  of prolonged  disease, especially
if the patient be feeble, constant recumbency on the back  is to be  avoided;
the position of the body should be changed  at intervals.  Deep inspirations
from time to time should be enjoined.   In  this way hypostatic pneumonitis
may be prevented.  The occurrence of the latter in different diseases not infre-
quently contributes to a fatal termination.   In all diseases accompanied by
much prostration or of long duration, or when the subjects are  feeble, import-
ant objects of treatment are the prevention  and removal of hypostasis in the
dependent portions of the  lungs.  These objects are often of prominent
importance in cardiac  diseases. 
     PLEURODYNIA AND DORSO-INTERCOSTAL NEURALGIA.   183

  (Edema of the lungs will  be considered  under a separate heading. (Vide
Chapter XL)


        Pleurodynia and  Dorso-Intercostal Neuralgia.
  A brief consideration of these affections is included in this chapter, because,
from similarity as regards pain, they are  liable to be confounded with either
acute pneumonitis or pleuritis.   Prior to the employment of physical explora-
tion this mistake was by no means  uncommon, and it is still made by those
who depend on symptoms alone.   The term pleurodynia is applied to'a pain-
ful  affection of the muscles entering into the composition of the thoracic walls.
Intercostal or  dorso-intercostal neuralgia denotes a neuralgic affection  of  the
intercostal  nerves.
  Both affections may be characterized by pain  resembling that of either acute
pneumonitis or pleuritis;  that is, a lancinating  pain felt especially in the  act
of inspiration.   They may be accompanied by a dry cough which  is acutely
painful.  In  case  of  pleurodynia there may be pyrexia, and this  may acci-
dentally exist in cases of intercostal neuralgia.  How are these  affections to
be discriminated from inflammation of the pleura either primary or occurring
as a complication of inflammation of the pulmonary parenchyma?
  Intercostal  neuralgia, as a rule, is not accompanied by pyrexia.   But this
affection has a diagnostic criterion which  is readily available.  It consists in
the existence of tenderness usually  in three isolated points—namely, behind,
near the dorsal vertebrae;  laterally, in  one, two, or three intercostal spaces;
and anteriorly, in one or more intercostal spaces near the sternum or over the
epigastrium.   Sometimes tenderness exists in  only two  of these situations.
The tenderness is frequently confined to a very limited space in each  situa-
tion, a  space perhaps  small enough to be covered by the finger.   On the oppo-
site side of the vertebrae, and between the tender points in  the three situations,
pressure or percussion is well borne.   In addition to this diagnostic test, phys-
ical exploration fails to discover  the evidence of either pleuritic or parenchy-
matous inflammation—namely,  in primary pleuritis a friction  murmur and
the signs  denoting pleuritic  effusion, and  in pneumonitis the crepitant rale
and the signs  of solidification.   The affection occurs much oftener on the left
than on the right side.  Both sides may be affected, but this is extremely rare.
  Pleurodynia lacks a similar positive test; that is, the tenderness is not lim-
ited to isolated points, but is more or less diffused.   The diagnosis, therefore,
must rest on the exclusion of intercostal neuralgia by the absence of the evi-
dence just stated, together with the absence of  the signs both  of pleuritis and
pneumonitis.  Pain in pleurodynia and intercostal neuralgia is more marked,
as a rule, in movements of the  body than in the respiratory movements, the
reverse being true of the pain  in pleuritis and pneumonitis.  This remark
applies  more especially  to pleurodynia.  The  tenderness in  both affections
varies, being sometimes slight and  sometimes exquisitely acute.
  Of the  two affections, pleurodynia is much  the less frequent.   Before the
diagnostic criterion of intercostal neuralgia had been pointed out by Bassereau
and Yaljeix, cases of this affection were doubtless often  considered as rheu-
matic, and hence cases of the neuralgic affections have apparently increased
of  late  at the expense of pleurodynia.  Intercostal neuralgia is of frequent
occurrence.   Cases are often met with both in private practice and  among
patients treated at hospitals and dispensaries, but more especially the latter.
The poorer  classes are more liable  to  it  than  those in  comfortable circum-
stances.  It occurs oftener among females than males.   Persons affected are
frequently anaemic.   It is liable to be developed during  the progress of pul-
monary phthisis.   It  occurs  especially  as a sequel of intermittent fever. 
184
P ULMON1R Y PHTHISIS.
   The degree of suffering from these affections varies much in different cases.
They are  sometimes so slight as merely to occasion annoyance, but in some
cases the pain is sufficiently severe to shorten the inspirations, thus rendering
the respirations frequent, as in acute pleuritis, and occasioning great distress.
In  the  neuralgic affection exacerbations of pain are frequently experienced.
They vary  greatly in different cases, as regards  duration, occurring some-
times as transient affections, but in some cases  persisting for a long period.
Pain  and soreness  in the  chest are  sometimes assumed by malingerers, but
a ready proof of the reality of the affection  is the diagnostic test—namely,
the limitation of the tenderness to the three points on one  side of the chest.
This proof is reliable, unless the  malingerer have had shrewdness enough to
discover that this test is  relied upon for the diagnosis.
   The treatment of both affections embraces measures to relieve pain if it be
severe or considerable.    Opium may be required  internally or hypodcrinically
for this object.   Local  applications may suffice if the pain be slight or mode-
rate ; for  example, liniments containing chloroform or aconite, or the bella-
donna plaster.  In cases of intercostal neuralgia quinia is an effective remedy,
whether the affection be a sequel of intermittent fever or  not.   The quinia
should be given in doses sufficient to occasion slight  cinchonism, and con-
tinued in such  doses for one or two weeks.   If anaemia exist, this  condition
claims appropriate treatment.   The citrate of iron  and quinia or the tincture
of the chloride of iron may be prescribed with  reference to this condition.
In obstinate cases flying  blisters are useful.    Valleix considers these as most
likely to prove  effective.   The application of dry cups will  sometimes  afford
relief.
                         CHAPTER  VI.

                      PULMONARY  PHTHISIS.

    Anatomical Characters ;  Clinical History ; Pathological Character ; Causation.

   THE discovery by Koch, in  1882, of the  bacillus tuberculosis  has eluci-
    dated  not only the etiology, but also the  pathological anatomy, of pul-
monary phthisis.   The  proof that,  the  tubercle bacillus is the specific cause
of tuberculosis  may be considered complete.   This  proof has  established
Laennec's doctrine of the unity of phthisis—a doctrine which has been main-
tained in all previous editions of this work.  In the presence of  the tubercle
bacillus we possess a certain criterion of the tuberculous nature of a morbid
process.  We now know that the characteristic inflammatory lesions of phthis-
is are as much the result of the tubercle bacillus as is  the tubercle granulum
itself.
  Anatomical  Characters.—In most cases of pulmonary phthisis  all of
the structures which  compose  the lungs are  the seat of morbid changes.
There are lesions of the bronchi, of the  alveolar passages and air-cells, of the
blood-vessels,  of the lymphatic vessels, of the interstitial connective tissue,
and of the pleura.   The characteristic  lesions of  phthisis are  tubercles  and
inflammatory  processes with a  tendency to caseous  degeneration.   Other
lesions  which are  often  present  are  ordinary  inflammations,  congestion,
emphysema, atelectasis, and oedema.  Another morbid change of great import- 
                     ANATOMICAL  CHARACTERS.                 185

ance is the formation of cavities.  The multiplicity of lesions  and of struc-
tures involved, and the differences in  diff'erent  cases in the combination  and
relative preponderance  of these lesions, render the morbid  appearances so
manifold that it may be said that no two cases of phthisis are exactly alike.
  The dominating element in the pathological anatomy of pulmonary phthisis
is tubercle.  For an account of  the histological structure and the nature of
this  product the reader is  referred to Part I. of  this work (p. 47).   Tuber-
culous nodules or granules are to be found, either with the naked eve or with
the  microscope, in  the  majority of cases  of phthisis.  When  young, these
nodules are gray or translucent,  but they oftener appear opaque and  yellow-
ish, having undergone partial or complete caseous degeneration.  Sometimes
they are transformed into fibrous tissue, and then they are dense in consist-
ence and grayish or slate-colored.  The  ultimate  submiliary granula coalesce
to make small and large nodules, varying in size from a millet-seed to a pea,
and  often larger.  A favorite and early  situation for the formation of miliary
tubercles is in the walls of  the small bronchi, especially in the terminal bron-
chioles where they open into the alveolar passages.  Tubercles may be found
in any part of the  lung—namely, in the walls of the bronchi, of the blood-
vessels, of the lymphatic vessels, in the interlobular and interalveolar tissue,
in the air-cells, and in the  pleura.  Many tubercles are composed of groups
of air-cells filled with epithelial and lymphoid cells with or without giant-cells.
The  walls of these  air-cells are  often, but not  necessarily, thickened by  an
accumulation  of epithelioid and lymphoid cells.  In  the  majority of cases
tubercles are formed primarily at the apex of the  lung.  Sometimes the same
tissue which composes  tubercles occurs, not in  a nodular, but in  a diffuse
form.
  In acute miliary tuberculosis, which will be described subsequently, miliary
tubercles  are  found scattered throughout both lungs.   In these cases  the
tubercle bacilli are  conveyed to the lungs by the blood-current.   In many
cases of phthisis an eruption of  miliary tubercles is found for a variable dis-
tance around a cheesy focus or an old tuberculous nodule. Here the tubercle
bacilli  are conveyed  by the lymphatics.  The  usual mode of  access of  the
tubercle bacilli to the lungs is  by the respiratory  passages.   In this mode of
access the first effect of the bacilli is to cause the  production of tuberculous
nodules in the air-cells, the  alveolar passages, and  the terminal bronchi, where
the bacilli lodge.
  The production of cheesy pneumonia is an  effect of the tubercle bacilli  not
less  important than the  production of tubercles.  This form of pneumonia has
been called also tuberculous pneumonia, desquamative pneumonia, and infil-
trated tubercle.   The air-cells are filled  with epithelioid cells, lymphoid cells,
usually but  not always fibrin,  and sometimes  red  blood-corpuscles.  The
alveolar walls are frequently infiltrated with  cells.  The solidified portions of
lung are at first moist and reddish-gray in color ;  later they become gray  and
dry,  and finally cheesy.  In rare instances caseous  pneumonia involves a whole
lobe  ; usually it is lobular in distribution.  The smaller bronchi are generally
involved.   They contain caseous  plugs and have thickened caseous walls
(caseous peribronchitis).
  Inasmuch as tubercles are often formed partly or wholly by accumulations
of cells in  the alveoli, it is manifestly difficult, and after cheesy degeneration
has  ensued often impossible, to  draw any sharp  line  of  distinction between
tubercles  and foci of cheesy pneumonia.  This  distinction, however, is  less
important than was formerly supposed, inasmuch as the tubercle bacilli  are
present in the caseous pneumonia as well as in the tubercles, and are the cause
of both processes.
  In most cases of rapid or the  so-called galloping pilithisis (phthisis florida) 
186                    PULMONARY PHTHISIS.
more or less extensive patches of caseous pneumonia form the greater part of
the lesions.  Tubercles, however, are usually present at the same time.  When
a large number of tubercle bacilli gain access to the lung through the respira-
tory passages, as  often happens in children by the bursting of a caseous bron-
chial  gland into  a  bronchus, then caseous  pneumonia  rapidly develops,  and
involves  a large  portion of the lung at once.   A  similar result may follow
when  a cheesy focus or a cavity in any part of the lung opens into a bronchus,
and thus allows a large number of bacilli to be inspired into other bronchial
tubes.
   Changes in the blood-vessels of the lung are of importance in the pathol-
ogy of phthisis.  Tubercles are non-vascular structures,  as has already been
explained.   The  pre-existing  vessels,  where the tubercles develop, become
obliterated, partly by thrombosis and partly by an accumulation of epithelioid
and lymphoid cells in their lumen.  A similar process of obliteration  occurs
when  tuberculous pneumonia undergoes cheesy degeneration.  The blood-sup-
ply of the lung is furthermore greatly impeded by an inflammatory thickening
of the inner coat of many of the small and medium-sized arteries, by which
process  the lumen  of the vessel is  gradually encroached upon, and may be
finally obliterated.    This process is  called endarteritis  (jbliteraus.   Endo-
phlebitis obliterans is also frequent.  Tubercles may  be found in all of the coats
of the blood-vessels.  Tubercles, and  especially cheesy masses which  invade
the inner coat of the pulmonary veins, are of grave significance, for in  this
way the  tubercle bacilli may enter the blood-current and be transported to all
parts  of  the body,  causing a general miliary tuberculosis.  The obstructions
to the blood-current which have been described undoubtedly favor the  cheesy
degeneration of tubercle and  of pneumonic products, but  probably to a much
greater  extent the  cheesy degeneration is a direct effect of  the action of the
tubercle  bacilli.  This cheesy degeneration, as has already been  mentioned
(p. 48),  is  a  form  of coagulation necrosis.
   Mention has already been made of the presence of tubercles and of  cheesy
inflammation in  the  coats of the bronchi.   The mucous membrane  of the
bronchi is always inflamed in phthisis.  Ulcers, usually of tuberculous origin,
are frequent.   The various forms of peribronchitis, called tuberculous, caseous,
purulent, or fibrous, are sufficiently explained by these terms.  Some form of
peribronchitis is a constant attendant of phthisis.
   Inflammation of the interstitial tissue of the lung, leading to the formation
of new connective tissue, is called chronic interstiti<d jmevmonifis, and is pres-
ent in some degree  in all cases of chronic pulmonary phthisis.  The new tis-
sue encroaches upon the pulmonary parenchyma, causing the obliteration of
air-cells  and shrinkage of the affected portion of the lung. New fibrous tissue
may be formed directly from tubercle-nodules, from diffuse tubercle-tissue, or
as  a  result of chronic interstitial  inflammation.   Fibroid phthisis, which is
characterized by an  excessive formation of fibrous tissue and retraction of the
lung, presents sufficient clinical peculiarities to demand special consideration,
which will be given in the next article.
   Pulmonary phthisis is always accompanied by pleuritis, usually of the dry
form.  The pleuritis leads to the formation of vascular adhesions, which are,
as a rule, most extensive and firmest at the apices of the  lungs.
   It  is  customary  to find around  tubercle-nodules and foci of  cheesy pneu-
monia the air-cells filled with the ordinary products of inflammation. Patches
of ordinary catarrhal or of fibrinous pneumonia may also occur in parts of the
lung which do not contain tubercles or caseous masses.  Pneumonia  of  this
form  does not undergo cheesy degeneration unless the  affected part of the
lung  be  invaded by tubercle  bacilli.
   Of non-inflammatory  changes  deserving  mention,  there  are  pigmentation 
ANA TOMICAL  CHAR A CTERS.
187
with coal-particles and with melanin, particularly in newly-formed fibrous tis-
sue; calcification of caseous material;  atelectasis; compensatory emphysema;
congestion and  localized and general oedema.
  After  a variable period cavities  are formed in the  majority of  cases of
phthisis.  These are  of  two  kinds—those due to dilatation of bronchi, bron-
chiectases, and those resulting  from the softening of cheesy material and its
removal through the  bronchi, ulcerative cavities.  The bronchiectatic cavities
are common, especially in connection with much increase of connective tissue.
They do not attain a  large size without leading to ulceration of the bronchial
wall and the formation of excavations.  The ulcerative cavities enlarge, partly
by softening of  caseous  deposits in their walls and  partly by suppuration of
the walls.   Cases differ much as regards the number and the size of the cav-
ities.   The greater part of a lobe,  usually the upper lobe, may be converted
into a single cavity.   The cavities are generally irregular in form, with ridges
of pulmonary tissue in their  walls, and are often traversed by bands of fibrous
tissue containing blood-vessels, the rupture of which may be  the source of
dangerous hemorrhage.   In  cases of fatal haemoptysis the source of  the hem-
orrhage is usually to be found in an aneurism of some artery in the walls of
a cavity.   These  aneurisms  are usually about the size  of  a pea and project
from the  side of the  artery into the cavity.   In  recently-formed cavities the
walls are often sloughy ; in  old cavities the walls are dense and firm, like the
pyogenic membrane  lining an old sinus.  Cavities  sometimes  open  into the
pleural sac  and give rise to  pyo-pneumothorax.   This accident is usually
prevented by pleuritic  thickening  and the  formation of adhesions between
the  pleural  layers.
   As the expectoration  contains tubercle bacilli, it is common to  find tuber-
culous lesions in the respiratory tract above  the lungs, especially in the larger
bronchi, the trachea, and  the larynx.   These lesions are usually in the form
of tuberculous  ulcers, and are in nearly all cases secondary to the pulmonary
affection.
   Hv swallowing sputum which contains the tubercle bacilli the tuberculous
 virus may gain  access to the intestinal tract  and cause tuberculous ulceration,
 which is  found  most frequently in the lower part  of the  ileum.   From the
 intestine the bacilli  may be readily conveyed to the peritoneum,  the  mesen-
 teric glands, and the liver, which in many cases of phthisis are found to con-
 tain  miliary tubercles.
   The morphological and biological properties of the tubercle bacilli have
 been  described  in the  former part of this  work (p. 48).  The  number  of
 bacilli present  in  different  cases of phthisis is  subject to considerable varia-
 tion.  In some cases they are abundant and occur in dense  masses; and in
 other cases they are  scanty  and found only after long search.  The bacilli are
 present in the  bodies of cells, particularly of epithelioid  and of giant-cells,
 and  also free between  the  cells.   They are  always present in the beginning
 of tuberculous processes, and also when the tuberculous  formation is in rap-
 id progress.  The bacilli are usually few or  entirely  absent in cheesy matter,
 but there are exceptions to  this rule.  When the cheesy substance is in com-
 munication  with  the atmosphere, as in  the walls  of phthisical cavities, the
 bacilli are generally abundant.    Cheesy matter, even if bacilli  are absent,
 usually contains  the spores of the bacilli, as is evident from  the possibility
 of producing artificial  tuberculosis by the  inoculation of cheesy  substance
 which is free from bacilli.  We are at present unable to demonstrate by col-
 orine; agents the free spores of tubercle bacilli.
   The most important  biological  properties  of the bacilli of tuberculosis  are
 the development of  spores,  the  slow growth  of the bacilli, and the fact that
 the  bacilli  are  incapable of development   at a  temperature  below 28° C. 
188
PULMONARY PHTHISIS.
(82.4° F.) and  above 42° C. (107.6°  F.), the most favorable temperature
for their growth being about that of the human body.  In the ordinary con-
ditions of nature,  therefore, the bacilli  do not develop outside  of the bodies
of human beings or of animals.  The bacilli or their spores retain in the dry
state their virulence, at least for many months, outside of the body, as has
been proven by inoculation-experiments  with  dried  phthisical sputum.
   In most cases of pulmonary phthisis the primary infection takes place by
inhalation of tubercle bacilli.   These bacilli may lodge in  the small bronchi
or in the air-cells,  or they may be carried into the substance of the lung  by
the lymph-current or by transportation in wandering cells.   The first effect
of the bacilli is to cause proliferation of  the fixed cells by indirect division,
as has been  shown by the observations  of Baumgarten.   This cell-division
results in an accumulation of  epithelioid cells, which represent the beginning
formation of tubercle.   There is subsequently an emigration of white blood-
corpuscles, which accounts for the appearance of lymphoid cells in the periph-
ery, and  later in the interior, of the tubercle-nodule.    From  this primary
tubercular formation, which is most frequently  in the apex of the  lung, the
bacilli make their way into the adjoining  lung-substance through the lymph-
spaces and the lymph-vessels and give rise to new tuberculous growths.  From
these primary tubercles, especially after they have undergone cheesy degener-
ation and have ruptured into the bronchi, the bacilli, often in large quantities,
can enter the bronchial tubes, whence they are partly expectorated ; but, unfor-
tunately, they are  often inspired into other bronchial tubes,  possibly those  of
the opposite lung.   This secondary invasion with bacilli from tuberculous foci
already existing in the lung gives rise to  new tuberculous growths, and espe-
cially to patches of cheesy pneumonia.  Thus, partly by the peripheral growth
of tuberculous  nodules  and infiltrations,  partly by conveyance of the bacilli
through the lymphatic vessels and spaces, and partly by the entrance of the
bacilli into the bronchi, one area after  another  of the lung becomes the seat
of tubercles or  of caseous pneumonia.   This  extension  of the tuberculous
process is most frequently from the apex toward the base of the lung.   The
tubercle  bacilli  may also  enter  the blood-current, as has  already  been  ex-
plained.   In this way the tubercular virus may  be carried to other orsrans  of
the body.  It is readily understood that through  the  lymphatic current  the
bronchial glands often become  tuberculous in  cases  of phthisis.

   A simple  and convenient division of phthisis into  stages is based on the
marked difference, as regards anatomical characters, before  and after the for-
mation of cavities.   The  first stage embraces  the period during which  the
tuberculous products accumulate and soften, up to their evacuation in a lique-
fied state.  The  second stage extends from the time when cavities are formed
to the termination  of the affection.  A stage of softening, distinct, on the one
hand, from the period during which the caseous products  are solid or semi-
solid, and on the other hand from the cavernous stage, is superfluous, for the
existence of such a stage  cannot be predicated  with  any degree of  certainty
on either symptoms or signs.   As regards the two stages—namely, before
and after excavation—it is to be borne in mind  that frequently, if not o-ener-
ally, both are represented  at the same time in different portions of the lungs.
After cavities have been formed in certain portions more recent tuberculous
products  in other portions are still either firm or are undergoing the process
of softening.
  In this division into two stages it is assumed that the affection goes on to
the formation of cavities.  This is the rule, yet exceptions to the rule are not
very infrequent.   If the tuberculous products be scanty and  disposed in small
disseminated nodules or tubercles, they  may be absorbed.   In some  cases the 
CLINICAL HISTORY.
189
animal constituents of the deposit may be infiltrated with lime salts and be-
come  hard, calcareous bodies, which  may remain imbedded in the  lung, or,
ulcerating into the bronchial tubes, they are expectorated.  In these modes
a cure of the local affection takes place in a certain proportion of cases.  But
a cure may also take place after the affection has gone on to the second stage.
It is well  ascertained that cavities, even of considerable size, may gradually
contract, and at length perfectly cicatrize.   In some cases in which  cicatriza-
tion does not take place, cavities become  lined with a non-secreting  membrane,
and they may remain nearly  innocuous for an indefinite period.

   Clinical History.—In sketching the clinical history of this affection the
symptoms attending its development and presented during the first stage will,
in the first place, claim  attention.
   The affection is often remarkably insidious in its development.  In a pretty
large proportion  of cases the pulmonary symptoms which may be considered
as denoting the tuberculous affection are neither preceded nor accompanied
by ailments of any description which lead  the patient  to suspect the exist-
ence of any disease.  In the majority of cases, when  the patient  first comes
under the observation of the physician the previous history renders it proba-
ble that the affection has existed for  several  weeks or perhaps months.
   Of  the pulmonary symptoms, the first which occurs is cough.  Unless the
affection be developed coincidently with an attack of  bronchitis, which is not
common, the cough is at first and for some time slight, dry, hacking, and per-
haps it excites little or no attention.  Occasionally, however, it is from the out-
set a prominent  symptom.   The  expectoration, for some time wanting, is at
first small, and consists of frothy, glairy mucus.   It  progressively increases,
becoming gradually more abundant, and at length solid and opaque.  These
symptoms proceed from irritation and circumscribed bronchitis. Haemoptysis
frequently takes place  shortly after  the occurrence of  cough  and expectora-
tion.  In some cases it precedes these symptoms.  It is often the event which
first excites any  apprehension of  serious disease and leads the  patient  to seek
 medical advice.   If cough and expectoration have existed for some time prior
 to this event, the patient had  not heeded them, thinking they were due to a
 slight cold  and  that they would shortly  disappear.
   Pain in the chest does not belong  to  the disease per se.  Pain,  however, is
 liable to occur at times  more or less  frequently during  the  first stage of the
 disease, and is due to circumscribed pleuritis.  The pain is sharp,  lancinating,
 or stitch-like, referred  to  the  summit of the chest, and frequently shooting
 beneath the scapula.  It varies  at different times and in  different cases  in
 severity, being rarely  sufficient to  keep the patient in bed, or even  within-
 doors, and it may continue for  one, two, or three days.   In the  progress of
 the disease the pain in  these attacks is referred  successively to both sides of
 the chest, and it  may be more  severe and frequent on  the  side in which the
 amount of disease is the smaller.   The attacks are considered by patients  to
 be rheumatic or  neuralgic.   They possess considerable diagnostic  significance,
 but they are of  very little importance  as indicating the amount or  the  prog-
 ress of the disease.  Intercostal  neuralgia occasionally occurs, and is to be
 recognized by the diagnostic points which have been presented in treating of
 thataffection.1   The respirations are usually increased in frequency, and the
 increase,  other  things  being equal,  is  in  proportion to the  amount of the
 phthisical disease.  This symptom may not attract the  notice  of  the  patient.
 It is  apparent especially on exercise.   Even  when, owing to  the amount of
 disease, lividity  is marked,  dyspnoea is  not always complained of.
   Among other than pulmonary symptoms the condition of the circulation, as
                               1 Vide p. 183. 
190
PULMONARY PHTHISIS.
represented by the pulse, holds an important place.   During the first stage
more  or less  acceleration  of the pulse is the rule,  and this acceleration,
although not  great, is an important diagnostic  symptom.   The acceleration
differs much in different  cases.  In general, it is in proportion to the activity
of the disease.   If the  pulse be frequent the  disease is likely to be rapidly
progressive.
  The temperature is more or less raised in proportion as the disease is pro-
gressive.   The thermometer thus aids in the diagnosis of the disease, and if
the diagnosis  be not doubtful it affords evidence of the disease being pro-
gressive or otherwise.  When it is a question as to the diagnosis, increase of
temperature is evidence for, and absence of any increase is evidence against,
the existence of the disease.  In well-marked cases the increase is a  measure
of the activity of the disease, whereas a normal temperature denotes  that the
disease is non-progressive.
  Daily exacerbations of fever may occur in the first stage.  Toward evening
the acceleration  of  the  pulse is increased, with increased  heat of skin,  and
sometimes  a marked sensation of burning in the soles  and palms;  the cheeks
may present a bright circumscribed flush, and after some hours the exacerba-
tion goes off with'perspiration.  The exacerbation is sometimes preceded by a
chill.   Chills also occur without being followed  by notable febrile movement.
They may  be pronounced and accompanied by rigor,  or they are  slight  and
transient, consisting in some cases of occasional shiverings  or a sensation as
if water were  trickling  down the back.  Well-marked chills, followed  by
increased  heat and perspiration,  may occur with such regularity  that  the
patient is supposed to have  intermittent fever, and under these circumstances,
if the pulmonary symptoms be slight, the affection of the lungs may be for
some  time  overlooked.   I suppose there are few physicians of much experi-
ence in  situations where  they are liable to meet  with intermittent fever who
cannot recall cases in which this error of diagnosis has been made.  Fever of
limited duration may be  due to an intercurrent circumscribed pneumonitis.
   As regards  appetite and digestion, there is much diversity in different cases.
In general, the desire for food and the ability to digest it are diminished.   In
some  cases there is almost entire loss  of appetite, and even a repugnance to
food.   This is an unfavorable feature  of the disease.   Disorder of digestion
is sometimes so prominent as to appear to be the chief malady.  The physi-
cian should be on his guard against considering the cough  in  such  cases as
merely dyspeptic or sympathetic.   Antipathy to fat is by no means constant;
some  patients take fatty  articles of food freely without  repugnance and with
relish ;  and on the other hand not a few patients who  are not phthisical have
an antipathy to fat.
   Diarrhoea occurs  in  the  first stage in a certain  proportion  of  cases.  It
may  exist with  and without a tuberculous affection of the  intestinal  canal,
usually seated  in the  small intestine.   Persisting or  frequently recurring
diarrhoea, accompanied by cough, be the latter  never so slight, should  excite
suspicion  of pulmonary  phthisis, and the  existence  of this affection  being
ascertained, a  tuberculous  affection of the intestinal canal as a  secondary
affection is probable.  This affection results from swallowing the expectora-
tion.  Diarrhoea having this significance is an  unfavorable symptom, dimin-
ishing the  prospect of  improvement.   The seat  of the affection is usually the
Peyerian and  solitary glands.  It leads to ulcerations  differing from  those
which are  characteristic of typhoid fever in a tendency to extend in a trans-
verse direction and  to occupy only portions of the elliptical patches; also in
having hardened and raised margins.   Tuberculous ulcerations are sometimes
found in the large as well as in the small intestine, and  they may be confined
to the former.   The ulcerations may  lead to circumscribed peritonitis,  and 
CLINICAL HISTORY.
191
the peritoneal inflammation sometimes becomes general.  Perforation of the
intestine occasionally takes place, giving rise to general peritonitis, provided
the peritoneal surfaces over the ulcerated space within which  the perforation
occurs have not become adherent from previous circumscribed inflammation.
Intestinal hemorrhage sometimes takes place, and I have known it to prove
the immediate cause  of  death.
   Impaired nutrition, denoted by diminished weight, is frequently one of the
earliest symptoms.   As a rule, reduction in weight continues so long as  the
disease is progressive; on the other hand, the disease  may be considered  as
non-progressive if the  patient be  not  losing weight,  and still more if he  be
gaining in flesh.  Defect in the chylopoietic processes  is shown by anaemia,
which  in most cases  is an early  symptom and  is frequently marked.
   The muscular strength progressively  diminishes if the  disease  be  pro-
gressive, but here there  is much variation in  different cases.  Patients are
rarely compelled to keep  the bed  in  the  first  stage, and they are generally
able to be  out of doors.   Deficiency of breath in some cases  precludes  an
amount of  active exercise or labor for which muscular strength is  sufficiently
retained.
   Suppression of the menses is a symptom significant  of the  progress of the
disease ; the menstrual discharge diminishes  in quantity, and in  the course
of the disease ceases.   Patients often attribute importance to  the suppression
as a cause of  their other ailments.  It is, however, an  event incidental to the
disease, and does not claim special treatment.   Facts  do not  show that  sup-
pression of  the menses from other causes  exerts an influence in  the devel-
opment of phthisis.
   This disease does not tend directly to impair the intellectual faculties.  The
intellect frequently remains bright and  active  notwithstanding the progress
of the disease.  The feelings are  usually cheerful and  buoyant.  Patients are
hopeful respecting their  condition ; they depreciate their symptoms  and are
reluctant to admit that they have a serious malady.  This state of mind some-
times amounts to an infatuation which renders it difficult to obtain from  the
patient  a fair account of  the symptoms, and it is necessary for the physician
to rely chiefly on the statements of others and his own observations.  To such
an extent is the absence of anxiety characteristic of the disease that an oppo-
site  frame   of mind militates somewhat against the  existence of phthisis.
Patients are readily persuaded that  they are improving, and  hence they fall
an  easy prey  to quacks.   They sometimes dislike to be told the  truth, and
take offence at  an  intimation that they  are consumptive.
   Proceeding to notice the points in the clinical history which distinguish the
second stage, it is to be borne in mind that it is not easy, nor  is it practically
important,  to draw an exact line  of demarcation between  the two stages.
While the local affection  has advanced to the second stage in one part, usually
near the apex, the different gradations of the first stage may be represented
in other parts.  The disease is to be  considered  as having  advanced to  the
second stage when it has led to  the formation of a cavity or of cavities  of
sufficient size to give rise to certain distinctive signs and symptoms.  The
symptoms of the first  stage  continue into the  second, in  most cases being
increased and modified by the  existence  of  cavities.
   The cough in the second stage usually becomes more prominent.   It  may
be less irritable, and more exclusively for expectoration.   It is troublesome
and difficult in proportion as the contents of the cavities are not easily evacu-
ated, owing to their size, want of free communication with the bronchial tubes,
etc.   The expectoration consists of liquefied phthisical products, matter fur-
nished by the lining  membrane of the cavities, and secretion from the bron-
chial mucous membrane.   The quantity of expectoration is very  variable, 
192
P ULMONAR Y PHTHISIS.
amounting in some cases to only a few ounces, and in other cases to a pint
or more daily.
  The appearances of the expectoration vary.   It is oftenest muco-purulent,
with more or less predominance of the characters of pus.  In  proportion as it
is purulent the sputa  do not remain distinct, but run together to form a homo-
geneous  mass.   Sometimes a collection of the  liquid expectorated presents a
thick, opaque appearance, not unlike  that of pea-soup or gruel.   The  sputa
are sometimes  solid,  remaining distinct, and in falling upon the  bottom of a
vessel  assume  a  flat, round  appearance like that of  a  coin, and hence are
called  nummular sputa.  The sputa  occasionally present yellow striae, which
consist apparently of pus.   The  edges of  the  sputa are  sometimes ragged;
another appearance is that of small particles, resembling boiled rice, contained
in the  matter expectorated.   It is very rare for a semi-softened, cheesy,  mor-
bid product to be expectorated;  but  in a  case  under my  observation several
masses of this description were raised, evidently due  to  an unusually large
ulcerated orifice being established between a collection of tuberculous  prod-
ucts and a bronchial tube of considerable  size.  In  this case the signs  of a
cavity were developed directly after the expectoration of a large amount of
matter which contained the  partially  softened  masses.   A sudden expectora-
tion of matter in considerable quantity, presenting a purulent or pyoid appear-
ance, denotes the  opening by ulceration of a  so-called tuberculous abscess.
Not infrequently this occurs repeatedly during the progress of  the  disease,
but in many cases the ulcerated  opening is at first small, and the liquefied
matter escapes  gradually into the   bronchial  tubes.   The constituents, as
shown by the  microscope, are  pus-corpuscles,  epithelium, fatty granules,
blood-discs, the yellow elastic fibre, and tubercle bacilli.
  The quantity of matter expectorated is, in  general, in proportion  to the
number and  size of the  cavities.  It is usually more  abundant in the morn-
ing than  at  any other time, owing to its  having accumulated during sleep.
Toward the close of life the act of expectoration becomes difficult on account
of muscular  feebleness, and  the consequent accumulation in the  air-passages
not infrequently  hastens death.  Occasionally  the matter  expectorated and
the breath of the  patient emit considerable fetor, due to putrefaction of the
contents  of cavities.
  Haemoptysis occurs less frequently in the second than in the  first  stage;
and occurring in the  second stage it may  be due to the rupture of the bands
of pulmonary tissue which so often traverse tuberculous cavities, these bands
sometimes containing vessels of sufficient  size to furnish an  abundant hemor-
rhage, or more frequently to rupture  of the minute aneurisms  in the  walls
of the cavities, to which reference has been made in the account of the ana-
tomical characters.  Sometimes the   loss of blood in this way is  sufficient to
destroy life,  but  such instances  are  rare.   The hemorrhage, however, may
contribute to a fatal result.
  Hoarsenesss or huskiness, and sometimes extinction  of  the voice, denote
laryngitis, which  may be developed in the first  as well  as in  the second stage.
Its occurrence is presumptive proof of pulmonary  phthisis, the latter,  as a
rule, existing prior to the  laryngitis.
  Lancinating  pains  incident to circumscribed  pleuritis recur in  the second
as well as in  the first  stage from time to time.  Occasionally, both in the first
and second  stage, the pleuritis becomes general and occasions more or less
liquid  effusion.  So far as my observations go,  they confirm  the statement by
Louis, that double pleuritis  with  effusion denotes the pre-existence of tuber-
cle.  Acute pain, suddenly developed, with embarrassed  breathing, accelera-
tion of pulse, and prostration, point to perforation of the lung, and the si^ns
of pleurisy with pneumothorax are to be sought for. 
CLINICAL HISTORY.
193
  The pulse, as a rule, is more accelerated in the second  than in  the first
stage.   Febrile exacerbations are oftener present  and more marked, with
burning of the soles and palms.   The night-perspirations  are often copious,
causing debility and great  discomfort.
  The appetite and digestion are more or less impaired, cases differing greatly
as regards the symptoms connected with the ingestion of food.   Diarrhoea is
more  frequently present, and is a more prominent  symptom in the second
stage, being connected  often with intestinal ulcerations.  If profuse  and per-
sisting, it has been distinguished as colliquative diarrhoea.  Colliquative diar-
rhoea  occurs at an advanced  period of the disease, although tuberculosis of
the intestines does not exist.   It is then due to defect of intestinal digestion
and to transudation from impoverishment of the blood.   With the  progress
of the disease  the body progressively diminishes in weight, and the patient
is often reduced to an extreme degree of emaciation.  The strength varies
greatly in this stage.   The patient may be confined  to the  bed for a greater
or less period before  death, but not infrequently strength is preserved suffi-
ciently for  him to be up much  of the  time, and even  to go out of doors,
within a few  days or even  a few hours  of death.
  Bulbous  enlargement  of the ends  of  the  fingers, with incurvation of the
nails, forming what are called clubbed fingers, is occasionally observed.   This
peculiar  appearance is characteristic of phthisis,  but it is not pathognomonic.
It may be strikingly marked in connection with organic  disease of the heart
without  phthisis.   It  occurs in cases  of fibroid  phthisis oftener than in the
form  of  the disease under  present  consideration.  The toes may present  a
similar appearance, but  in a less marked  degree.  These  appearances  occur
only in cases in which the disease has existed for a considerable period.   Of
1776 cases analyzed by Pollock, the fingers were more or less clubbed in 654,
being a fraction under 27 per cent.
   The mental  condition in  the second stage is frequently not less character-
istic than in the  first.  The expectation of improvement, prolonged  life, or
even  recovery, amounts  in  some  cases to an insane delusion.  Patients are
sometimes occupied in forming plans for the future when it is obvious to any
observer that they are  on  the verge  of the grave.   They may insist to the
last that there  is  no danger.  Over and over again in the  hospital  wards I
have been  asked by patients reduced almost to skeletons, and too  feeble to
sit  up for a moment, if there was any danger or if they would recover.   But
whenever patients affected  with this  disease are satisfied that there  is lit-
tle or no hope of recovery, they generally become  quickly and completely
resigned.
   (Edema of the feet  and ankles is a symptom of the second stage, denoting
notable failure of the circulation.  For a  time this may occur only after sitting
or standing, disappearing after the recumbent posture has been maintained for
some hours; but at length it is permanent, and may increase and extend over
the whole  of the lower extremities, rendering them unwieldy.  When the
oedema becomes thus  marked, extensive,  and  permanent, thrombosis of the
iliac or femoral veins is to be suspected—an event which is liable to occur in
this disease.  Coagulation in the vein on one side will account for the oedema
in some cases in which it is either limited to or is much greater in one of the
lower limbs.  If  the oedema be diffused over the body, constituting anasarca,
coexisting  disease of the kidneys is to be inferred;  but the latter is a  rare
complication of pulmonary phthisis.
   The clinical history is affected in no small  degree by complications  and
coexisting affections.   The occurrence of tuberculous disease of the intes-
tines, tuberculous laryngitis, pleuritis with pneumothorax, and disease of the
kidneys  has been already referred to.   Chronic peritonitis is an occasional
       13 
194
PULMONAR Y  PHTHISIS.
complication.   The researches of Louis demonstrated that chronic peritonitis,
not traumatic, is almost invariably dependent on tuberculosis  in this situa-
tion, and hence, from  the  existence of the  peritoneal  affection, pulmonary
phthisis  may be inferred.   Acute peritonitis from  perforation is sometimes
incident to the tuberculous  affection within the intestinal canal.  Meningitis,
usually tuberculous, occurs as a rare concomitant in the adult, but  is not infre-
quent in early life.  This  coexisting affection accounts for the development
of delirium and coma in certain cases.  Perineal abscess, leading  to fistula, is
another complication occurring in a certain proportion of cases,  proceeding, as
microscopical examinations have shown, from tubercle in this situation.  Clin-
ical observation appears to show that, as a  rule, when this complication occurs
the amount of tubercle in the lungs is small or moderate and the  progress of
the pulmonary affection is slow.  An accumumulation of fat within the liver-
cells is a morbid  condition observed in a considerable proportion of cases,
occurring oftener in women than in men.   Authors  of works on  the diseases
of the  skin have noted the occasional occurrence of tinea versicolor in phthis-
ical patients.
   The duration of this disease  is extremely  variable.   In  the vast majority
of cases it is essentially a chronic  affection,  but  sometimes it runs  a rapid
course, passing through its changes and destroying life in a few weeks.   The
disease in such cases has been known as " galloping consumption," or phthisis
florida.  It is  different  from that known  as acute miliary tuberculosis, which
will be noticed under a distinct heading. Distributing fatal cases  into groups
according to the duration of the disease, exclusive of the  rapid cases  just
referred  to, one group  will  consist  of cases  in which the disease  continues
from three to  six months ; in another group death  takes place between  six
months and a  year; in  a third group  the  career extends from  one  to  two
years; and in  another group the fatal termination is held in abeyance for
many  years.
   Limiting attention to the cases in which sooner or later the disease proves
fatal, its march is extremely irregular.   It is not uncommon for  little or no
progress to be apparent for  several successive weeks, months, or  even years,
and then the disease to advance with  more or less rapidity.  Distinct devel-
opments occurring at  successive periods are frequently points of departure
for the onward march  of the disease;  but cases differ much as regards the
local destruction and  the  rapidity with which softening, ulceration, and the
formation  of cavities take  place.   (Further  remarks on the  march  of the
disease will be offered under the head of Prognosis.)

   Pathological Character.—The  pathological character of tuberculosis
has been considered in  Part I. of this work (p. 48).   In a practical point of
view pulmonary phthisis involves the co-operation of two pathological factors.
One of these is the bacillus tuberculosis.   This is an essential factor.   The
colonization of this micro-organism within the lungs is the primary step in
the production of pulmonary phthisis.  Certain local conditions favorable for
the multiplication of the parasite are not less essential than the  presence of
the latter.   The nature of  those local conditions which form the soil suited
for the cultivation of the parasite is unknown.   Certain conclusions deduced
from clinical observations will be noted in connection with  the causation of
the disease.  These unknown conditions  constitute  a predisposition  to  this
disease.  This term, " predisposition," in its application to pulmonary phthisis,
designates what has hitherto been expressed by the  terms tuberculous  consti-
tution  or diathesis.

   Causation.—The causes of pulmonary phthisis relate, first,  to the specific 
CAUSATION.
195
micro-organism, the  bacillus tuberculosis ;  and  second,  to  the conditions
which  constitute a tuberculous  predisposition  or diathesis.   The disease is
never produced without the parasite, but the efficiency of  this agent depends
on the predisposition  or diathesis.  The latter alone is incapable of producing
the disease.  If the introduction of the parasite  into the air-passages could
be prevented, the disease would not be produced,  no' matter  how strong the
predisposition ;  and, on the other hand, if  the predisposition  be wanting the
disease will not be produced, no matter how great  the exposure to the specific
cause.  Absolute prevention of exposure to the specific cause is only possible
in situations in which tuberculous disease  docs not exist, either in man or
lower animals.  The exposure is  greater, other things being equal, the greater
the prevalence of the disease, and in proportion as circumstances favor prox-
imity to patients affected with it.   When it is considered that about one-sev-
enth of all human beings die of  phthisis, it is  not difficult to account for the
wide distribution of the tuberculous virus.   The  fact that protection against
the introduction of the parasite is impossible in most places renders the causes
of the tuberculous  predisposition especially important.
   The bacillus tuberculosis is not capable of multiplication outside of the
animal body under the ordinary conditions of nature,  and hence pulmonary
phthisis is not  only  an infectious  but a contagious disease.  The parasite is
the contagium.  The contagiousness of this  disease—which has long been a
moot  question—is  not easily established by clinical evidence, the  instances
being  so  many in which  circumstances'favorable  to  communicability are
present without its being communicated.   Moreover, the doctrine of chances
explains the occurrence of a disease so prevalent as this in a certain number
of those  who  are brought more or less  intimately into  close  proximity to
phthisical patients.   That the tubercle  bacillus  is the living contagium of
tuberculosis the  experiments  of Koch and others have established demon-
stratively  by the inoculation of  certain of  the  lower animals with pure cul-
tures  of this micro-organism.  The disease is never produced  without the
agency of this contagium;  but many persons are exposed  thereto with impu-
nity, for the reason  that  in them the tuberculous  predisposition  does not
exist.  The apparent  incongruity between the proof  of contagiousness
afforded by inoculation in  certain of the lower  animals, and the uncertain
evidence  obtained by clinical observation, is to be accounted for by  the fact
that for  the contagion to be  effective the  predisposition is requisite; and
this predisposition  does  not exist in all  persons or at all times in the  same
person.
   The most fruitful source of  tuberculous  infection is to be found  in dried
phthisical  sputum.  Experiments  have shown that currents of air do not carry
bacteria off from fluids or moist surfaces, but when the substances containing
the bacilli are dry, these organisms are readily transported with particles of
dust in the atmosphere.   Tuberculous infection  may  come  from  the  lower
animals, but probably much less  frequently  than from  the human  body.
That it may come from the milk  of tuberculous cows is certain.  In  children
especially  it is liable to be  derived from this source.
   Facts show the tuberculous predisposition or diathesis in a certain propor-
tion of cases to be congenital and inherited.  Why a peculiarity of constitu-
tion rendering a person specially liable at a certain age to  this disease should
be transmitted from parent to  child, cannot be explained,  any more than the
fact that peculiar traits of  physiognomy or of mental character are inherited.
The conclusion  rests on observation.   It is a matter of common remark that
the offspring of consumptive parents often become tuberculous.  But it is to
be borne in mind that owing to the frequency of the disease a tolerably large
proportion  of phthisical patients  must have a  consumptive  parentage  from 
196
P ULMONAR Y PHTHISIS.
mere coincidence;  and it may be true that, sufficient consideration not having
been accorded  to this fact, hereditary influence has  been overrated.   Facts
show that the tuberculous predisposition is sometimes inherent in the consti-
tution  and inherited.   To what extent a congenital  influence is involved in
cases in which  circumstances do  not render it evident must be left for con-
jecture.   It is  not irrational to suspect its existence  in a large proportion of
the cases in  which proof is impossible.
  The  predisposition  has relation to age.  The disease  is most  liable to be
developed between twenty  and thirty.  The  other decennial periods of life
are arranged  in the following series, according  to the rate of predisposition :
thirty  and forty, ten  and twenty, forty and  fifty, fifty and  sixty, birth and
ten, sixty and seventy, seventy and eighty, eighty and  ninety, ninety and a
hundred.   No age is exempt from a liability to the disease, and it may affect
the foetus in utero.  Tuberculous  cavities are rare in infancy.  Dr. Leuf of
Brooklyn, N. Y., has  communicated to me a case  in which cavities existed in
a child not quite six months old.
  Climate  appears to  exert an influence either for or against the development
of the  disease.   The  prevalence of the  disease is less in climates  either uni-
formly warm and  dry or uniformly cold  and  dry  than in  those which are
moist and subject to frequent alternations of  cold and warmth.  A high alti-
tude seems to  afford  protection  against  the disease.  Jaccoud states that
observations for fifteen consecutive years warrant him in asserting that in
Alpine situations elevated 4000 feet tuberculosis is almost  unknown; and
especially is this true  of villages  at an elevation  of 5500 feet, where, in the
language of the country, there are " nine months  of winter and three months
of cold weather."  According to Dr. Hjaltelin, who  resides in Iceland, the
inhabitants of that country enjoy exemption from phthisis.   The disease pre-
vails to a much greater extent in  cities  than in the country.   The researches
of Bowditch  go to show that in the State of Massachusetts  cases occur more
frequently in places in which the  atmosphere is rendered humid by streams
or marshes.  Dr. Buchanan's observations show that in England  cases are
comparatively rare in dry, elevated situations.  There is  no foundation for
the opinion that malaria affords any protection against the disease.   Newly-
settled places are frequently exempt for  some time  from its prevalence to
much extent; but the explanation of this fact is  that the pioneers who com-
pose the  early  population in these places  are  persons generally  of sturdy,
vigorous health, and  the habits of life in  such a population are protective
against this  disease.   As regards  season, the  disease is oftener developed
during the spring  months and the hot months of summer than at other sea-
sons of the year.  The disease prevails more  among those whose  pursuits
are sedentary  than  among those  whose occupation  involves outdoor life.
Want of exercise, defective ventilation, deficiency of light, and the depress-
ing emotions  apparently contribute to the production  of  the  tuberculous pre-
disposition.
  The  infrequency with which the disease is found in the post-mortem exam-
inations of those who  have died from intemperance has led to the supposition
that the use of alcohol antagonizes the  tuberculous predisposition.1  There is
reason  to believe that habits of diet unduly restricted as regards variety and
quantity, either from choice or necessity, may contribute to the development
of the  disease.
  Pregnancy has been supposed to antagonize the tuberculous predisposition,
and marriage has sometimes been advised as a prophylactic and even curative
measure.   Facts, however, do not afford support to this supposition.  In the
collection of  cases which I have analyzed,  87 were married and under forty
                         1 Herard and Cornil, op. cit. 
CAUSATION.
197
years of age.  Of these 87 cases, the disease was developed during pregnancy
in 10, and in 12 within a few weeks or months after confinement.1  The infer-
ence is, that pregnancy, either directly or indirectly, has a decided and con-
siderable influence in the etiology of the disease.  The researches of Grisolle
and Dubreuil show that the development of the disease not infrequently takes
place during pregnancy, and when tuberculous patients become pregnant the
progress of  the disease is hastened rather  than retarded.2  Clinical facts are
opposed to the notion that the progress of the disease is retarded by lactation.
   Certain diseases exert an influence on the one hand to promote, and on the
other hand to prevent, the development of tuberculosis.  It rarely occurs in
1 persons affected with pulmonary emphysema.  Persons affected with cardiac
lesions which interfere with  haematosis rarely become  tuberculous.  On the
other hand, measles and typhoid fever leave the  system in a condition  favor-
able for the development of tuberculosis.   Are they who suffer in early life
from  a scrofulous affection of the lymphatic  glands of the  neck especially
prone to pulmonary  tuberculosis in after-life ?  I have been led to think that
this question may be answered in the  negative.  I have  collected a number
of cases in which young and middle-aged persons presenting the characteristic
cicatrices on the  neck were free from  tuberculous  disease of  the  lungs ;  and
on the other hand it is rare to find these cicatrices in persons  who are affected
with  pulmonary   tuberculosis.   Assuming  tuberculosis and  the scrofulous
cachexia  to be identical, as has been proved by the presence  in  both of the
bacillus tuberculosis, it  would seem that  the predisposition  is,  as  it were,
exhausted by the affection in the glands of the neck, and that afterward it is
not likely to recur.   Contrary to what might  be  expected a priori, anaemic
persons rarely  become tuberculous.  The association of ana-mia with pul-
monary tuberculosis, except as a complication  or an effect, is rare.  It is rare
for phthisis to follow an attack of lobar pneumonitis or acute pleuritis.  Sta-
tistics show that  these affections have not a causative relation to pulmonary
phthisis.
   Bronchitis,  acute  or  chronic, has  no  tendency to eventuate  in phthisis.
This assertion contravenes not only a prevailing popular notion, but a tradi-
tional opinion still held by not a few physicians.   I make the assertion, how-
ever, with the utmost confidence in its correctness, inasmuch as it is based on
the study of a large number of cases  with reference to the earliest symptoms
and signs.  Moreover, it accords with  the  clinical researches of Louis, which,
so far as they go, are  not  less valuable to-day than  when  they  w*ere  made,
more than half a, century  ago.
   Bronchial hemorrhage (bronchorrhagia) was considered by older writers, and
recently  by Niemeyer, as causative of phthisis.  This is an error.  Bronchial
hemorrhage may occur irrespective of any connection with tuberculous  dis-
ease, but  when a  connection exists the latter precedes and is causative of the
former.
   To the conformation of the thorax was formerly attributed  considerable
causative agency. This doubtless arose in part from observing that phthisical
patients  often present contraction of the chest, occurring as an effect of the
disease.   Persons with great  deformity of the chest are not  specially liable
to phthisis.   So also the idea that the  exercise of the voice may  be a predis-
posing or exciting cause has  become  obsolete; and  observation  shows that
if any influence  be  derived  from this source it is conservative rather than
causative.
   The opinion appears to be entertained by some writers that chronic pharyn-
  1 Phthisis, in a Series of Clinical Studies, Philadelphia, 1875.
  2 The Eliincnts of  Prognosis in Consumption, by James Edward Pollock, M. D., Lon-
don, 18G5. 
198
P ULMONA R Y PHTHISIS.
gitis, which is an exceedingly common affection in this part of the world, has
a tendency to eventuate in pulmonary phthisis.  This opinion is erroneous.
After a large opportunity of observing cases of chronic  pharyngitis, I have
come to the conclusion that it generally denotes a  condition  of the system
unfavorable  to phthisical disease.  The sebum-like matter which is  liable to
accumulate in the glands of the tonsils, and to be ejected by coughing in the
form of round hard pellets, is sometimes  mistaken for tubercles.  These  may
be distinguished from obsolete tubercles or pulmonary calculi by their being
unctuous to the touch and emitting when touched a fetid odor.
  In conclusion, of the agencies concerned in the causation of the tubercu-
lous predisposition, it is difficult  to estimate their relative importance.   In
view of the necessary existence of this predisposition in the development of
pulmonary phthisis, this is a diathetic disease ; but it is impossible  to  deter-
mine whether the diathesis be always innate, or whether in a certain propor-
tion  of cases it is acquired.  Do the causes which contribute to the develop-
ment of the disease produce the diathesis, or do they act as auxiliary causes,
the diathesis  already existing ?  Our present knowledge does not enable us to
answer this question.  Yet the limited knowledge which we possess  is of
much value in  its  practical application to  prophylaxis and treatment.
  We cannot define anatomically  the  tuberculous  predisposition;  in  other
words, in the present state  of our knowledge we are ignorant of the anatomi-
cal  conditions on which this  predisposition  depends.  We can think of it
only as a certain quality of lung-tissue which makes the  latter a favorable
soil for the multiplication of the tuberculous bacilli.   Using the language of
metaphor, we may say that the cells are unable to conquer in a struggle for
existence with the bacilli.  It is probable that those who are naturally resist-
ant to the action of the bacilli may become tuberculous when exposed to  the
virus in large quantity, as in the case of a wife or a nurse constantly in close
proximity to  a tuberculous patient.
                      CHAPTER  VII.

                PULMONARY  PHTHISIS (Continued).

                      Diagnosis; Prognosis ; Treatment.

    DIAGNOSIS.—The diagnosis of pulmonary phthisis rests mainly upon an
     examination of the sputum and upon physical signs.   The discovery of
tubercle bacilli in the sputum is almost certain  evidence of the existence of
pulmonary tuberculosis.   The possibility of  these bacilli being accidentally
present in the sputum of persons unaffected by tuberculosis is so slight  that
it need hardly be considered, and certainly any possible error from this source
will be eliminated  by examinations of the sputum repeated from time to time.
It very rarely happens that bacilli are absent for any considerable  length of
time from the sputum of phthisical patients.  Failure to find the bacilli, how-
ever, is less satisfactory as an evidence of the absence of  phthisis than is the
recognition of the bacilli as an evidence of the existence of phthisis.  Never-
theless, when the sputum is repeatedly examined for a long time without the
discovery  of bacilli, the existence of phthisis is improbable.  Cases  which are 
DIAGNOSIS.
199
sometimes described as non-bacillary forms of phthisis are generally, in so far
as there is no error of observation, cases  of some non-tuberculous form of
chronic pulmonary disease, particularly chronic bronchitis with bronchiectatic
cavities.  Bacilli are sometimes very abundant in phthisical sputum ; at other
times they are few and are discovered only after long  search.  No definite
rules can be laid down as to the relation between  the number of bacilli and
the rapidity of progress and the  extent of the tuberculous  disease.
   On account of the diagnostic importance of the subject, directions will here
be given for staining the tubercle  bacilli in the sputum, but it must be men-
tioned that considerable familiarity with microscopical technique and observa-
tion is required for the successful  employment of the methods described.
   The best method of staining the tubercle bacilli is that devised by Ehrlich.
The staining fluid is prepared  as follows:  Shake thoroughly  aniline oil and
distilled water in the proportion of about 5 parts of the oil 'to 100 parts of
water. After about ten minutes, filter the  mixture through a  filter moistened
with distilled water.   If drops of oil be still present in the filtrate, it is
necessary to  filter again.   To  the  clear filtrate add  enough  of a saturated
alcoholic solution of fuchsin or of  gentian-violet to produce a dark color, with
a slight opalescent scum on the surface.  (The  alcoholic solution of the stain-
ing dye is saturated when after standing a number of days some of the stain-
ing substance remains undissolved at the bottom of the bottle. This alcoholic
solution can be kept permanently.)  The filtered mixture of  aniline oil and
water may be prepared fresh every time it is used, or a staining fluid of the
following composition may be preserved for about two weeks:  100 parts of
filtered aniline oil and water, 11 parts of saturated alcoholic solution of fuch-
sin or of gentian-violet, and 10 parts of absolute alcohol.
   In order to prepare the specimen, portions of sputum should not be  taken
at random, but, if they be present, little whitish or yellowish particles should
be selected from  the sputum  and transferred to a cover-glass, where such a
particle is to be spread over one surface of the glass in as thin and as uniform a
layer as possible.  This is accomplished either by means of a scalpel or needle
or by pressing two cover-glasses together and then drawing them apart,  The
specimen  should be allowed to  dry thoroughly, and then the cover-glass, with
the specimen uppermost, is passed  with moderate rapidity three times through
the flame of  a Bunsen burner  or of a spirit-lamp.  In this process the speci-
men should  not be burned.
   The cover-glass, thus prepared, is  now  placed, specimen  side downward,
upon the surface of the  staining  fluid, where it remains for  from twelve to
twenty-four hours.   The staining process may be  hastened,  although the
results are  somewhat less satisfactory, by  heating  the fluid  to  beginning
ebullition.   In this way a specimen may be stained in ten minutes.
   The cover-glass, on which the specimen is now deeply stained, is transferred
to a mixture of 1 part of pure nitric acid and 3 or 4 parts of water.  Here the
specimen remains a few seconds, at the most half a minute, after which most
of the color is extracted.
   From the acid the cover-glass is transferred to alcohol (60-70 per cent.),
where most of the remaining  color  is removed.  A  few seconds to half a
minute in the alcohol suffices.  The cover-glass is now removed from the alco-
hol, and, if necessary, after a second  washing in fresh alcohol it is allowed to
dry.  After it is dry the  specimen may be mounted in Canada  balsam or it
may be examined in xylol, oil of cedar, or, without previous drying, in glyce-
rin, or even in water.  After removing the specimen from the alcohol a com-
plementary stain, although it is not necessary, may be obtained by placing the
cover-glass for a few seconds in a  weak aqueous solution of Bismarck brown
(if gentian-violet be employed) or of methylene-blue (if fuchsin be employed). 
200
PULMONARY PHTHISIS.
  For recognizing the bacilli  it  is very  desirable to make use  of an oil-
immersion  objective and an Abbe's illuminating  apparatus.   The  tubercle
bacilli appear as slender rods about one quarter to  one half the diameter of
red  blood-corpuscles,  and frequently curved or  slightly  bent.  They are
stained either blue or red according to the  staining  dye used.   The bacilli of
leprosy stain by the same procedure as that  adopted for tubercle bacilli, but
an error from  this cause is  not likely to occur.
  It is particularly important to examine the sputum  for bacilli in the early
stages of phthisis before the phthisical signs are  distinctive.   By  the  dis-
covery of the bacilli in cases of early haemoptysis great assistance has  been
rendered in diagnosis.
  Elastic fibres are often present in phthisical sputum, even in an early stage
of the disease.    They afford evidence of  destruction  of lung-tissue.  They
may be readily discovered by boiling the sputum for a short time with a solu-
tion  of caustic  potash or of caustic soda  (1 to 6), as recommended  by Fen-
wick.  The sediment may be collected in a conical  glass, and after settling a
portion of  the  sediment may be transferred to a slide by a pipette.  The fibres
may be recognized by their glistening  appearance and  curled shape.  Some-
times they preserve their  alveolar arrangement.
  The physical conditions when the local  affection is  considerable or when
the disease is advanced to the second  stage  are  represented by well-marked
physical signs.    The diminished volume of lung at the apex causes a depres-
sion at the summit of the chest, and, owing to pleuritic adhesions, the expan-
sion at the summit is less than on the  opposite side. The scapula on the side
most affected is restrained in its movement upward  in  inspiration, contrasting
in this respect  with the opposite scapula.  These signs, obtained by inspection,
are available in a certain proportion of cases.  Percussion elicits relative dul-
ness, and sometimes even flatness.  Exceptionally,  over the solidified portion
of lung the resonance is tympanitic.   A tympanitic resonance over a circum-
scribed space and the varieties  of this resonance  called cracked  metal and
amphoric denote  cavities.  The respiratory sound obtained  by auscultation is
either bronchial or broncho-vesicular or cavernous, and not infrequently these
different signs  are found in  different  situations  in the same case.  The  first
represents  considerable  or complete  solidification, the second  moderate or
slight solidification, and the third  a cavity  or cavities.  The  cavernous respira-
tion in some cases has an amphoric quality.   The  correlative vocal signs are
usually present—namely, either bronchophony with the loud  and whispered
voice, or exaggerated vocal resonance, and in rare cases pectoriloquy.  More
or less of these auscultatory signs are  available in the  great majority  of cases.
   It is only in cases in which the local affection  is  moderate or small, the
symptoms  being  at the same time less marked, that the diagnosis from phys-
ical  signs is difficult; and the difficulty in  such cases is rarely great, provided
the  physician  have  a  good practical  knowledge of physical  exploration.
Inspection may in these cases furnish the same signs, but less marked than in
cases of a  considerable local  affection.   As a rule, slight or moderate but dis-
tinct dulness on  percussion  may  be ascertained.  The exception to this  rule
is when more or  less of the  pulmonary lobules become emphysematous, and
then the resonance is altered, although not diminished ; it is vesiculotympan-
itic.  A comparison of the respiratory murmur on  the two  sides at the  sum-
mit  will  be likely to show abnormal changes—namely, the characters of the
broncho-vesicular respiration. So also on a comparison as regards vocal signs,
the vocal resonance and the bronchial  whisper may be found to  be increased.
The same is true of vocal fremitus.
   In addition to these signs there are several occasionally present which infer-
entially are evidence of phthisis.    These may be distinguished from  those 
PROGNOSIS.
201
already enumerated as the accessory signs of  the disease.  Fine bubbling or
the subcrepitant rales  heard within a circumscribed space at the summit of
the chest on one  side are highly significant of tubercle.  They proceed from
secondary circumscribed bronchitis.   A crepitant rale, in like manner limited
to a small space  at the summit on one  side, has the same significance, beinc
due  to secondary  circumscribed pneumonitis.   Crumpling  and crackling
sounds  are  significant, provided  they  be limited to the summit on one side.
A pleural friction sound limited to the summit on one side denotes a second-
ary circumscribed pleuritis.  Other accessory signs are an abnormal transmis-
sion of the heart-sounds and an interrupted or jerking respiration.  The diag-
nostic  significance of  all these signs, it will  be observed, depends on their
situation  at  the  summit of the chest on one  side.  Separately, they are not
sufficient for the  diagnosis, but coexisting with the direct signs—namely, dul-
ness on percussion, broncho-vesicular respiration, exaggerated vocal resonance,
and increased bronchial whisper—they serve to confirm these signs and render
the diagnostic evidence positive.
   The diagnostic points pertaining to symptoms to which attention is  to  be
directed are as  follows:  (a)  Cough and expectoration,  not succeeding  an
attack of acute bronchitis and not  connected with chronic pharyngitis, the
cough at first  dry, and afterward an  expectoration at  first small and  trans-
parent, and becoming  gradually more abundant and opaque,   (b) Stitch-pains
at the summit, not connected with intercostal neuralgia,   (c)  Chills not ref-
erable to malaria,  (d) Haemoptysis : this is  always a symptom of great sig-
nificance, but the fact is to be borne in mind  that  it occurs in a certain pro-
portion of cases without  being associated with  tubercle,   (e) Accelerated
breathing.   (/)  Loss  of weight.    (g) Pallor  or anaemia  not otherwise
explicable.   (/')  Hoarseness or  huskiness of voice proceeding from chronic
laryngitis,  (t) Chronic peritonitis  not  traumatic,  (j)  Suppression of the
menses.   (/»•) Buoyancy of mind instead of  despondency.
   In certain cases the solidification represented by physical  signs at the time
of an examination of the chest  depends to a greater or less extent on an inter-
current, transient, circumscribed pneumonitis.  This can only be ascertained
by repeated  examinations  of the chest after  certain intervals of time.  The
solidification, so far as due to superadded simple or ordinary pneumonic inflam-
mation, will  be found to disappear, leaving that which is caused exclusively
by the  phthisical affection.  It is important  to bear in mind the liability to
a  temporary increase  of solidification of lung in  cases of phthisis  from  an
intercurrent  pneumonitis  which may not reveal  itself by any  distinctive
symptoms.

   Prognosis.—The prognosis  is extremely unfavorable, in view of the fact
that in many if  not most parts of the world the mortality from this disease
exceeds that from any other, exclusive of fevers and affections which prevail
epidemically or endemically.  Yet the mortality from the disease has undoubt-
edly diminished within the past half century.   This must be obvious to med-
ical observers  whose  professional experience extends  back for that period.
The fact is also shown by the statistics published  by the registrar-general of
Great  Britain and by the mortuary reports of the large cities in this  country.
The explanation of the fact is  to be found in  improved views as regards  the
management of the disease.  The diminution  which has  already taken place
in the  death-rate from this disease affords  ground for the hope that its  for-
midable character may  be still  further mitigated.
   The  different modes in which the disease may pursue  a  favorable course
have  been  already stated.  The generations of  bacilli  may die  out  or  be
destroyed, and  the tuberculous  products  may either  be absorbed or calcifica- 
202
PULMONARY PHTHISIS.
tion may occur, forming the so-called obsolete tubercles or calculi; and these
may remain quiescent or they may find their way into the bronchial tubes and
be expectorated.   Cavities may completely cicatrize.  In these modes com-
plete recovery may take place.  This, of course, is the most satisfactory ter-
mination.   Next to this is the persistence of cavities without any fresh prod-
ucts, the cavities giving but  little inconvenience for an indefinite period, and
even through a long life.   According to these different modes in which the
course of the disease is favorable, cases may be divided into those in which an
arrest takes place without recovery and those in which the arrest is followed
by recovery.  Whether recovery follow or not depends on  the extent of the
local affection and other circumstances.   Not infrequently the disease  ceases
to progress, with or without recovery, and after the lapse of months or years
a recurrence occurs.  The latter,  then, is not  properly a continuance of the
disease, but a renewed invasion by  bacilli.
   The facts relating to  the  proportion of instances  in which  the  disease
ceased to progress, either with or without  complete recovery, as developed
by the analytical  study of the  collection of cases  recorded by  me during a
period of thirty-four years, are as follows:  Of  670 cases, the  list embracing
a few  cases of  acute tuberculosis and interstitial  pneumonia,  44  ended in
recovery.   In my work on Phthisis, published in 1875, the details of the his-
tory of each of these  cases are given sufficiently  to render evident the cor-
rectness  of the diagnosis  and the fact of recovery.   In 31 cases the  disease
was either arrested or ceased to progress, complete recovery from the  lesions
incident thereto not taking place. Thus, in 75 cases either recovery took place
or the disease became non-progressive.   The ratio of recoveries (1 to 15) is
not fairly shown by these facts, inasmuch as  the termination in a considerable
number of cases was not ascertained.   This statement of course applies equally
to the ratio of cases in which the disease is either arrested or its progress ceases
without recovery. A fair conclusion is that in not an extremely small propor-
tion of cases complete recovery may be hoped for, and that this conclusion is
equally true in respect to the  disease  becoming  non-progressive without com-
plete recovery.  A recurrence of  the disease after periods  varying  from one
and a half to more than six years was noted in 6 cases.   In 5 of these cases
the recurrent disease terminated fatally. In the single case in which the recur-
rent disease did  not prove fatal a second recurrence took  place more than
twenty years ago, the patient  now living and being  free from any pulmonary
affection.
   I  may  claim, in behalf of my clinical studies in relation to  phthisis, the
establishment of the  fact that in a certain proportion of  cases this disease is
self-limited; in other words, it ends  in  recovery from  an intrinsic  tendency
thereto.   Of the 44 cases ending in  recovery, in 23 there was no medicinal
treatment to which an arrest of the  disease  could be attributed.  In  several
there was no medicinal  treatment whatever,  and in the remainder the treat-
ment  consisted  of simple tonics,  cough palliatives, or remedies  to  meet
other  symptomatic indications.  In none could the  treatment be considered
as curative.  Of the 31 cases in  which  the disease became non-progressive
without complete  recovery, in 15 there was no medication by which, as might
be supposed, the  disease  was  controlled, and in several  none  whatever.  In
respect to hygienic treatment,  in some cases  of both groups there was no
change whatever  in the habits of life; in other  cases  there  were changes
involving more favorable  circumstances pertaining to hygiene ;  but in a con-
siderable number those changes were not of such a character that a potential
influence  could be attributed  thereto.   It is probably correct to say that the
changes  may have favored  recovery  or non-progression,  but were inadequate
to cause an arrest of  the disease.  The histories in these ten groups substan- 
PROGNOSIS.
203
tiate self-limitation in cases  of  phthisis.   The disease may cease to progress
and end in recovery because it is self-limited.
  Assuming that phthisis in a certain  proportion  of cases is a self-limited
disease, the practical bearing on the conclusions to  be drawn from  medicinal
and hygienic  treatment is  important.   If the  disease may end in  recovery
exclusively from self-limitation, this must  be more or less operative  in  the
cases  which recover  under different measures of treatment.  Self-limitation
is a factor co-operative in certain  cases with curative measures, and,  it may
perhaps  be added, sometimes effective in  spite  of measures  which tend to
obstruct its operation.  On the other hand, when this  factor is  feeble  or
wanting curative treatment is not likely to prove of much avail.   Evidently,
in drawing conclusions respecting the curative effect of remedies allowance is
to be made for this factor.   The  extent  of its  co-operation doubtless  differs
much in different cases, in some being sufficient  in itself, and in others either
considerable, moderate, or slight.   Considering  that its agency has not been
hitherto recognized, it is easy to explain the well-known fact that from time
to time various  methods  of treating phthisis apparently successful in some
striking  instances have failed  speedily to meet  the expectations excited by
their apparent success.  Whatever was really due more or less to self-limita-
tion was attributed solely to the methods of treatment, and when the  former
was feeble or  wanting the latter gave little or no evidence of curative  power.
This is the rationale of the "post  hoc,propter hoc" fallacy which has  always
had much to do with false deductions from therapeutical experience.1
   The most rational explanation of the manner in which this disease ends by
self-limitation is to suppose that the conditions which are essential for  the
multiplication  of  the bacilli, and which  constitute the tuberculous  predis-
position  or diathesis,  after  a time cease to exist.   The vegetable  parasite is
destroyed because the soil becomes incapable of maintaining longer its exist-
ence.   These  conditions, it may be supposed, are greater and  more  enduring
in some  persons than in others, and the variation in this respect explains  the
differences in  different cases of  phthisis as regards the period  in the progress
of the disease when the ending by self-limitation takes place.  In our present
ignorance of the nature  of the conditions on which depend the life of a par-
asite, our  information in respect to the foregoing question must be derived
from  clinical  observation.
   The symptoms which  warrant hope, and sometimes  an expectation of a
favorable  course  and  termination, relate  especially  to  the circulation,  the
body-heat,  alimentation,  and nutrition.  Persistent frequency of the pulse,
fever,  anorexia, and  progressive emaciation oppose  reliance on  self-limita-
tion.   Per contra, encouragement on this score is warrantable  when the pulse
is but little if  at all more  frequent than  in health,  the temperature  of  the
body not much if any raised, the appetite in a  great measure retained,  and
loss of weight inconsiderable. These and other symptomatic conditions which
render it possible if not probable that the disease tends intrinsically to recov-
ery may be summed up in one word—tolerance.   In proportion as phthisis is
well tolerated there is room for  hoping that it will prove self-limited.  If  the
tolerance be deficient, self-limitation is proportionably weak or wanting.  Other
things being equal, the chances of recovery by self-limitation are greater the
smaller the amount of phthisical lesions and the space in which they are local-
ized.   I have been led to believe that phthisis not infrequently ends by self-
limitation before it has made sufficient progress to develop well-marked physi-
cal signs.  In  other words, there are abortive cases of this as of other diseases.
How often are the traces of an  old, small phthisical affection found  in bodies
  1 Vide  paper entitled " Self-limitation in Cases of Phthisis," by the author, in the
Archives of Medicine, New York, June, 1879. 
204
P ULMONAR Y PHTHISIS.
 dead  with various diseases!   I  have met  with not a few instances  of, as I
 supposed, abortive  phthisis.   These cases are likely  to be  misapprehended,
 the more because the general belief  is that exceptions to the rule of  prog-
 ress are extremely rare.
   I have learned, however, from histories which  I have recorded and reported,
 that self-limitation may be exemplified notwithstanding a large area of solidi-
 fication followed by cavities of considerable size.  The most reliable of the
 points on which a hopeful  prognosis is to be predicated  in these cases is the
 confinement of the affection within circumscribed limits; that is, absence of
 signs  denoting progressive extension or general diffusion.   The extent and
 degree of lesions, if circumscribed, do  not prevent  the disease from being
 self-limited, but they stand in  the way of complete recovery.  In most of the
 cases  of non-progressive phthisis  without recovery the  lesions do not admit of
 restoration, although the phthisical disease  may be said to have  ceased; the
 lesions in these cases remain as sequels, like, for  example, the intestinal ulcer-
 ations resulting in tropical climates from acute dysentery.
   It is doubtful if any definite conclusion can be drawn from the number of
 bacilli in the sputa as regards  the tendency to self-limitation.   The complete
 disappearance  of  bacilli, however, in a series of  specimens  is  proof that the
 tuberculous disease is arrested.
   Aside  from  the symptoms and  signs to be taken into account in  forming a
 judgment respecting self-limitation, my clinical studies have shown  that age
 and sex  have  no special significance.   They show, what could not have  been
 anticipated, that heredity is not incompatible with an intrinsic  tendency to
 recovery.   I  will add that my histories afford  evidence  that  profuse  and
 repeatedly occurring haemoptysis, chronic laryngitis, pleurisy with effusion,
 and perineal fistula are by no means in all cases  unfavorable as regards prog-
 nosis based on  self-limitation.
   The disease  proves fatal generally by asthenia.  It is rare for the destruc-
 tion of lung to be so great as to destroy life  by apnoea.  The patient is
 gradually worn out by the protracted disturbance  occasioned  by the  dis-
 ease, conjoined with progressive  emaciation and exhaustion.   The  develop-
 ment  of  pneumo-hydrothorax  from perforation  may  prove fatal in a short
 time,  and then sometimes  by  apnoea.    Acute  peritonitis  from  perforation
 has  been known to  occur, and  this  affection  is likely  to  prove rapidly
 fatal.   Meningitis is another   complication which hastens the fatal  termi-
 nation.
   Haemoptysis is very rarely   an  immediate cause of death.  A few such
 instances, however, have fallen under my observation.   A profuse and rapid
 flow of blood may occasion death by suffocation, the  blood filling the bron-
 chial tubes.  A case of this kind has  fallen under my observation.   In two
 cases among those which I have  analyzed death was attributable to profuse
 hemorrhage from  a phthisical  cavity.   The  analytical studies of Ware  and
 Walshe proved that, as a rule, haemoptysis is a favorable  event as regards
 prognosis.  My own  clinical  studies led to the conclusion  "that  cases in
 which  haemoptysis occurs show a larger number of recoveries,  and a nota-
 bly  greater proportion  of instances of arrest and of tolerance,  than cases
 in which haemoptysis does not occur."
   Dunin has reported the sudden death of a patient  affected  with phthisis,
in which  air was  found in the  blood-vessels, the source of  the air not being
discoverable  and no other cause  of death being apparent.
   Arogel has reported a case in  which a cheesy affection of a bronchial  gland
led to  a communication between a bronchial  tube  and the  right subclavian
vein, causing sudden death.
   Duguet has  reported a case  in which a thrombus  from the  crural vein 
TREATMENT.
205
gave  rise to embolism of the pulmonary artery and sudden death, the symp-
toms  of phlegmasia dolens not having been present.1

   Treatment.—Regarded from  a rational standpoint in the light of the
parasitic doctrine,  the treatment of phthisis  has  reference to two objects.
The first  object  is the destruction of the  parasite by the direct  agency of
some   substance  which is either  inhaled  or introduced  into  the blood.
Various  agents  destructive out  of the body to bacteria  have already been
employed by  inhalation, but  thus far without encouraging  results.   The
great obstacle in  the way of thus directly destroying the parasite is the diffi-
culty of the conveyance of the parasiticide in the form of either an inject-
able powder or in vapor to the colonies of the parasite, without the employ-
ment  of this agent in a quantity sufficient to prove a source of danger.  It
remains for further experimental observations to furnish data for determining
whether the  progress of this disease  can  be arrested by disinfecting agents
brought into contact  with the parasite by means of the  circulation.   It is
possible  that some of the remedies which experience has shown to be use-
ful may act as parasiticides.  The second rational object of treatment is the
removal of the tuberculous predisposition or diathesis.   In the present state
of our knowledge the prospect of success  in  arresting the disease or retard-
ing its  progress  depends on the successful employment of measures  for this
object.   In  our  ignorance of the nature of the  conditions expressed by the
terms tuberculous predisposition  and diathesis our present knowledge of these
measures must be derived wholly from clinical experience.
   It is of course immensely desirable  for  the  arrest to take place as quickly
as possible while the local affection is  limited and the pulmonary danger pro-
portionably small;  and with a view to a speedy arrest  the importance  of an
early diagnosis can hardly be overrated.
   Is  the  tuberculous predisposition or diathesis removable by any known
special  remedy or remedies ?   This question is to be answered in the  nega-
tive.   Various remedies have  been  supposed to  exert a  specific curative
influence.  Thus within  the  last half century  wood-naphtha, cod-liver oil,
phosphate of lime, the hypophosphites, the chlorate of potassa, and the ben-
zoate of soda  have successively been  advocated as effecting a cure in  cases
of pulmonary tuberculosis.   Few  if any  at  the  present  moment consider
these  or any other  remedies as specifically curative.  This, however, is by no
means saying that remedies are not  useful in cases of pulmonary phthisis.
Important indications  are to be fulfilled by remedies, but in the present  state
of our knowledge more reliance is to be placed on hygienic than on medicinal
measures of treatment.
   Certain therapeutic measures  heretofore  employed, to  a greater or less
extent, under the guidance of false pathological views, do harm rather  than
good.   In this  category belong bloodletting, either general  or  local, blisters
and other severe modes of counter-irritation, mercurialization, antimonial and
other  nauseating preparations, emetics, and cathartics.   These are contra-
indicated.  In general  terms,  everything  is to  be  avoided which tends to
impair the appetite, disorder digestion, and lower the vital powers.
  The measures -which clinical  experience has  shown to be useful, and some-
times  effective, in either arresting or  retarding the progress of the  disease,
are those  which  strengthen and  invigorate.   These  terms, although lack-
ing scientific  precision, have a practical  significance sufficiently intelligible.
Directing  attention to the measures which fall  under the head of hygiene,
these  relate to diet, exercise in  the open air, clothing, mental encouragement,
and change of climate.
                    1 Virchow u. Hirsch's JahresbericM,  1882. 
206
PrL.VOA.fi2V PHTHISIS.
  The diet should be  generous as regards quantity, quality,  and variety.
The articles should be highly nutritious and adapted to the digestive powers.
All the varieties of wholesome food which the patient is able  to  take with
relish should be allowed, and  the  appetite should be encouraged as much as
possible.  With respect to the  kinds of food to be particularly recommended,
there are no general rules applicable to all patients.   Meats, milk, farinaceous
articles, and the different vegetables are to be combined  in  relative propor-
tions according to the choice, habits, and experience in individual cases.   It
is desirable that cream, butter,  and other fatty articles should enter into  the
diet as largely as possible without inducing disgust and disorder  of  digestion.
The same remark applies to sugar.  The intervals between  taking food should
be such as will secure the largest amount of nutriment which can  be taken
and digested during the twenty-four hours.  In short, it is far from desirable
to arrange any fixed system embracing details of dietetics to which all patients
are  expected to conform.   The  object  is to nourish  the body to the fullest
possible extent, and  this requires in every case the co-operation of the phy-
sician and patient.  Deficiency of  appetite, especially for  nutritious articles
of diet, and weak or  disordered digestion, are serious difficulties in the way
of successful management.  Much  may be done  by persevering efforts  on
the part of the  patient, and he should therefore be made  to  understand the
object which it is  desired to  attain.
  A diet  consisting  largely, or even chiefly, of fresh milk has  undoubtedly
proved sometimes successful, and a trial of it may be advised when  the appe-
tite is deficient  or  when  other articles of food occasion dyspeptic  disorders.
Goat's milk, mare's  and ass's  milk, are rarely used  in this country.  They
have  heretofore been, and  are still to  some  extent,  in European  countries
considered as  preferable  to  the milk  of  the  cow.   In order  to carry  out
effectually the  '; milk cure," as it is sometimes called, milk should not only
constitute the chief article of diet, but it should be  taken  largely.
  Exercise in the open air—or, as I should prefer to say, out-of-door life—is,
of  all measures, the most important.   In 1863,1 I analyzed the recorded his-
tories of 62 cases in which an  arrest took  place, with  a view  to the points in
the treatment  which were common to all or a greater or less number.   In  20
of  these cases the arrest took  place under hygienic  measures without medi-
cinal  treatment.   In these cases the  most important point of agreement
related  to  change of habits as regards exercise  and out-of-door  life.   In
respect  to this  point there  was also  an  agreement  in the  cases  in which
medicinal measures were  employed.   The following extract  from  the paper
contains a summary of the  facts, with the general  conclusions : " The most
striking and valuable of the results of the analytical  study of these cases is
their almost uniform agreement as regards change of habits  with respect to
exercise  and out-of-door  life at the  time of the arrest.   Excluding 7 cases
in which the  arrest was attributable solely to  self-limitation, and 2 cases in
which the facts with  respect to this point were not noted, of the  remaining
53  cases, in  all save 3  the  histories  show  a  greater  or  less change  of
habits to have been made; and in  many cases the change consisted in relin-
quishing sedentary callings for other pursuits in order to  carry out more
effectually the desired reformation.  There are grounds for 'believing that the
advantage of a change of climate mainly consists in its being subsidiary to a
change of habits as regards exercise and out-of-door life."
  Phthisical patients should sleep in  well-ventilated rooms.   In conformity
with popular notions they frequently fear the cool or cold air of night.   A
fire may be kept in  sleeping-rooms in the winter  season, but the windows
should be kept open.   Dr. James  Blake of San  Francisco, California,  has
                     1 Trans. N. Y. Acad, of Med., 1863. 
TREATMENT.
207
reported several cases in which most favorable results followed living  in  the
open air during the summer months, at an elevation  of from 3000 to 5000
feet above the sea, in the Coast Range of the mountains of California, where
the temperature is very equable and no rain falls for five or six months.  The
patients did not even sleep in  tents, but were in the  open air during  night
and day.
  Exercise in the  open air should be accompanied  by either mental recrea-
tion  or occupations  which  interest the mind.  It  should, as far as possible,
be incidental to pursuits which engage the attention.  Adopted simply as a
hygienic measure,  it will  rarely be persisted in.  It is often essential, there-
fore, for patients to make a radical change in business, or, if they be able to
devote  their time  to the restoration  of health, hunting, sporting, travelling,
etc. are to be resorted  to  as means of securing the union  of out-of-door life
with an agreeable exercise of the mental faculties.   Over-exercise  of the
muscles is to be  avoided.  Patients sometimes, supposing that the benefit
from muscular exercise is proportionate to its amount, canry it to the  extent
of producing a degree of fatigue and exhaustion which is injurious.  It is not
from the amount of physical exertion, but of out-of-door life with such exer-
cise as is well borne, that benefit is to be expected.
  The body should be protected against atmospherical changes, the  tempera-
ture and  functions of the skin  being maintained  by warm  clothing.   The
garments worn next  the surface  should be made  of a  material which  is a
non-conductor  of  heat—namely,  either wool or silk ;  but a superfluity of
clothing is to be avoided.  The object is to provide adequate protection with-
out an undue accumulation of  heat and perspiration.  In a cold or temperate
latitude during the winter season a waistcoat of buckskin or chamois leather,
worn during the  daytime over a light woollen or silk shirt, is to be recom-
mended to patients of either sex  as securing proper protection without  the
inconvenience of being  bundled  with  an overplus of garments.   The feet
should be well guarded against cold and wet.  Properly clothed, the patient,
if he be strong enough to go out of doors, should rarely be kept within doors
by the state of the weather, but  should resolutely keep up  habits of out-of-
door life despite the ordinary changes  of temperature and winds, remaining
in the  house only on inclement  days.
  I have frequently known the sponge-bath to be taken daily by tuberculous
patients with apparent benefit.   It may be safely  tried and  continued, pro-
vided it be followed  by an  agreeable glow.   The temperature  of the water
used should be from 64° to 68  F.  It  is to be borne in mind, with reference
to this measure as well as exercise in  the  open air,  that the  susceptibility to
attacks of bronchitis is less the more the exposure, and also that  an  attack
of bronchitis does  not usually exert any unfavorable influence on the tuber-
culous disease.  Many patients are deterred  from going  out of doors when
the weather seems unfavorable, by needless apprehension of taking cold.
  The  proportion  of  cases  in which  an arrest of  the disease is apparently
either effected or promoted  thereby is sufficient to authorize the physician to
encourage patients strongly to employ the hygienic measures which have been
briefly  considered.   The influence of the disease on the mind is to induce
either an expectation  of recovery  without  effort or  resignation to death.   It
is important to make  patients understand  that very much depends  on their
own exertions.  One of the difficulties in the way of successful management
is a passive, patient, tranquil frame of mind which cannot  be aroused to vig-
orous  efforts.   Persons endowed  with  resolution, energy,  and perseverance,
other things being  equal,  are more likely to  struggle successfully with  the
disease than they who are deficient in these mental  qualities.  The measures
which have been considered, if not successful in effecting an arrest of the dis- 
208
PULMONARY PHTHISIS.
ease, tend to retard  its progress and render the condition  of patients most
comfortable while life lasts.
  Change of climate, as a means of effecting a cure of pulmonary tubercu-
losis,  has been a fruitful topic of discussion.  It does not fall within  the
scope of this work to  enter into a full discussion of this question.  I shall
present briefly certain considerations in connection with the question in indi-
vidual cases, " Shall  I try change of climate ? and if so where shall I go ?"
  It may be assumed that a change of climate is frequently useful, and it
appears sometimes to effect an arrest of the disease.  The judgment of patients
or their friends in the matter is not of much value, because it is usually based
on the knowledge of a few cases, or  perhaps of a single case, in which bene-
fit may or may not have been apparently obtained.
  It may be taken for granted  that  there is no specific influence in any  cli-
mate.   It would be  therefore  needless  to inquire  if there be one  particular
place on the globe to be preferred  above all others.   Observation shows that
different climates are suited to different cases.  In general, the advantages
which belong to climate pertain  to altitude,  uniformity, and dryness.  As
regards the latter, while a dry  climate is generally preferable, some patients
appear to do best in  situations in which  the atmosphere is warm and humid.
With respect to temperature, a uniform, cold climate is best for  some  cases,
and a uniform, warm climate, for other cases.  Of  late years the custom  has
been gaining ground of sending patients to a cold latitude, and I have known*
of a number of instances in which the climates of Minnesota and Colorado
have proved highly  serviceable.   Altitude  is a marked element  in these  cli-
mates, as in St. Moritz and Davos in  Switzerland.  On the other hand, I have
known of many instances in which a change to a warm climate has appeared
to accomplish all that  could be desired.  What circumstances  are to  guide
in deciding  whether a cold or a warm climate will  be likely to  prove more
advantageous?   The feelings and choice of the patient are to have consid-
erable weight.  If when in health  more  vigor and enjoyment  are experi-
enced in summer than in winter, a warm climate will  probably be better, and
if the reverse be true a cold climate is to be preferred.  The condition .of  the
patient as regards feebleness is an essential point.   If so feeble as not to be
able to live out of doors in cold weather, or  if the reaction from the impres-
sion of cold be slow and imperfect, a warm climate  is more  suitable.  It is
rarely proper to send patients to a cold climate  if the disease be  consider-
ably advanced, and,  as a rule, a cold  climate is better  suited to men than to
women.   These remarks with respect to temperature  will  necessarily apply
to climates of which  a  high  altitude is a prominent  feature.
   With reference to the particular place  to  be  selected, it  should contain
resources for  occupation and  mental interest.   There  must be inducements
for out-of-door life.  I have known patients accustomed to active habits to suf-
fer intolerably from  ennui in going to places where the supposed  excellence
of climate was the  only inducement.   It  is often  better to move from  one
place to another than to remain stationary ; as soon as a  place becomes tire-
some it is best to leave it.  Travelling in foreign  countries without ,any spe-
cial regard for climate is often the best plan, the advantage consisting in the
interest and inducements to out-of-door exercise  derived from a  succession
of new  scenes.   A sea-voyage in  warm latitudes is generally useful, and if
patients be fond of the sea a long  voyage, if practicable, may be advised.
Many patients under my observation have resorted  to sea-voyages ;  and I can
affirm that while in  not a few instances the  benefit has been marked, I have
never known any harm to ensue.  I have known several instances in which
patients in an advanced stage of the disease, the strength being much reduced,
have taken long voyages with  notable improvement.   A change is often use- 
TREATMENT.
209
ful when there is no superiority on the score of climate, because it is in this
way only, in certain cases, that relief from the cares and anxieties of business
can be secured.   As a rule, it is desirable to avoid places which are specially
resorted to by phthisical patients, for the reason that seeing constantly exam-
ples of the  different phases of the disease is likely to have an unfavorable
moral effect,  On this score sanitaria for phthisical patients are open to objec-
tion.  Well-managed sanitaria, however, may have advantages relating to the
systematic employment of regiminal measures, to diet, etc.
  The habits and tastes of the patients are to be considered.  Persons who are
dependent on the associations and comforts of home and friends for their hap-
piness will not be likely to be benefited by being sent away, especially if alone
and among  strangers.  The stage of the disease and the rapidity of its progress
are points of  great  importance.   It  is cruelty to send to  a distance  patients
who are in a condition  admitting of but little prospect of improvement, and
who will  probably not live to return.  The  symptoms and the  amount of
damage which the lungs have sustained, as determined by physical signs, are
to be taken into account before deciding with regard to change of climate;
and if a change  be made and  prove  effectual, it becomes  an important ques-
tion whether,  if  practicable,  the change shall  not be permanent.  The  safest
course, undoubtedly, is to take up a residence  in a climate in which  the dis-
ease  is less liable to  be reproduced than in the climate in which it has  been
already developed.  Finally, in forming an opinion of the importance of change
of climate it is to be considered that the progress of the  disease will  be unfa-
vorable in a large proportion of cases, whatever may be the change or changes
made.  An arrest of the disease is not to be expected, save in a minority of
cases.  The fact that  of the persons who make trial of change of climate
the  number who are not apparently benefited greatly exceeds the number
who  find this measure either successful or beneficial should not discourage
resorting to the measure so long as in a small proportion of cases it proves
effective.   Another consideration is to be added—namely, a change of climate
 not  infrequently appears to  retard the progress of the disease, rendering the
 patient more comfortable and prolonging life, although an arrest of the disease
be not effected.
   In my  series of  clinical  studies  relating to phthisis1 I  endeavored to
 deduce  some  conclusions  from  the  cases  in which  change  of climate
 entered  into the histories.   In 74 cases this was an important, and  in  some
 instances the chief, measure  of treatment.   Of these 74  cases, in 9 the disease
 ended in  recovery, and in 13 it became non-progressive.  The proportion of
 22 out of 74 cases is large enough to warrant the conclusion that a  salutary
 influence was  due to  climate.   Moreover, studying the histories closely,  it
 appeared that in 34 additional cases there was evidence of improvement, leav-
 ing only  11 cases in which no benefit followed the change of climate.   While
 self-limitation  doubtless played an important  part, it cannot  account for these
 results to the exclusion of climatic influence.
   The  results relate  to  different climates  collectively.   A  great number of
 places were resorted to by different patients—Minnesota, Colorado, California,
 New Mexico, the Southern States of the Union, Nice, Mentone, Egypt, South
 America, etc.   My  cases were insufficient to determine the comparative value
 of different climates.   In undertaking to do this we have  to deal  with a com-
 plex problem.   A fair comparison would require the histories of a considerable
 number of patients in each  one of the various resorts embraced within the
 range of inquiry. There  must at least be an approach to uniformity in  all the
 cases as regards the stage of the disease, the  extent of the local affection, and
 other circumstances.   No single observer can accumulate data  sufficient for
                                  1 Op. cit.
         U 
210
PULMONARY PHTHISIS.
such an  undertaking.   It would, however, be  fair to take the results of all
climates as a standard for reference, and bring into comparison the results of
the analytical study of a considerable number of cases observed at any one or
a greater or less number of the different places of resort.  This might be done
by observers residing in  these  different places.  In this way very valuable
data could be obtained for judging of the comparative advantages of different
climates.  The value  of such data would  be incomparably greater than any
theoretical opinions in regard to altitude, dryness of the  atmosphere, temper-
ature, the presence of  ozone, pine-woods' exhalations, etc.   If, in addition to
comparing results in particular places with those of different climates collect-
ively, a comparison were to be made with the proportion of cases in which there
is either recovery or cessation of progress without change of climate, it would
be practicable to estimate, with some  approximation to accuracy, climatic
influences disconnected from the accessory circumstances, prominent  among
which is self-limitation.   Single examples of recovery, however  remarkable,
are entitled  to little weight as evidence of the curative effect either of climate
or of any particular measure of treatment.   In some of  the most striking of
the instances which have fallen under my observation the recovery took place
without change of climate and without any important medication.
  In conclusion, while it must be a great relief  to physicians  to have formed
convictions  which prompt a ready and  positive answer to the  question so
often asked, " What part of the world is best  suited for phthisical cases ?"
it will be long before such convictions can have as a basis adequate numerical
facts.  Meanwhile, they whose minds  are  not  committed to  a belief in the
superiority of a particular climate over all other climates must exercise judg-
ment according to circumstances in  individual cases as regards, first, the pro-
priety of a  change; second, the climate to be selected; and third, whether
or not a change should be permanent.
  As coming within the scope of  hygienic  management, marriage may be
referred to.   Physicians are  sometimes consulted respecting the propriety
of fulfilling a marriage  engagement when one of the  parties  is affected with
phthisis.   My clinical  studies  (op.  cit.) go  to  show  that the  effect of mar-
riage on a phthisical patient, irrespective of pregnancy, is not unfavorable—
a conclusion perhaps at variance with the opinion generally held.   Regarded
from a purely medical  standpoint,  the objections  relate to the  unfavorable
influence of pregnancy if the wife be affected, the risk of phthisical offspring,
and  the possible communication of the disease from the husband to the wife
and vice versa. The physician should state these objections. Whether, regarded
from other points of view, they should prevent marriage  in particular cases is
not a question for him to decide. My experience is that, whatever advice be
given, the sentiments determine the action in these cases.
  Passing to consider remedies which enter into  the management, I place
under this head  alcohol, without discussing the question whether it be prop-
erly so regarded, or whether, as was claimed by Todd, it  be alimentary rather
than medicinal.   Clinical experience shows  that in  a certain  proportion of
cases alcohol  has a salutary effect.   In some cases this  effect is marked ;  in
other cases  alcoholics in any form are not well  tolerated, and if  their use be
persisted in they may prove hurtful.  If the immediate effect be that  of a
cordial—that is, if they produce a sense of comfort;  if they be followed by a
feeling of increased strength and a greater disposition  to exercise ; and if they
do not  excite the  circulation  or nervous system,—benefit may be  expected
from their use.  Per contra, if their immediate  effect be discomfort; if they
be followed  by a feeling of increased weakness  and less disposition to exer-
cise; and if they excite the circulation or nervous system,—they will not do
good, and they may do harm. 
TREATMENT.
211
  As regards quantity,  they may be  given as freely as they can be taken
without discomfort, without a sense  of weakness or indisposition to exertion,
and without excitation of the circulation or nervous system.  The limitation
in quantity is to be determined  by  the same  circumstances  which indicate
their use, or, in other words, by their immediate effect.   And, guided by these
circumstances, it will  be found that  some patients will  tolerate a large, some
a moderate, and some only a small quantity.    Phthisis is one of the diseases
which  in  certain  cases  induce a remarkable  tolerance  of alcohol.    Some
patients who cannot take, without excitation, alcohol in any form in  consid-
erable  doses, are able  to  take it without this effect, and with benefit, in a very
small quantity  repeated after short intervals.
  The form to be used is  another practical point of inquiry.  Whatever be the
form used, I believe  the remedial principle to be alcohol.  But no one form
is equally applicable to all cases.  Some patients are benefited  especially by
spirits, some by wine, and some by malt liquors.  The selection of the form
to be  used in  individual  cases  must be decided by  the preference  of the
patient and experimental  trials.   As a  rule, food should  be taken with
alcoholics.
  The extracts of malt  now in vogue cannot  be regarded  as substitutes for
alcoholics,  and  it seems  absurd to attribute to them anything beyond a cer-
tain amount of alimentary value.
  With regard to cod-liver oil, without discussing the propriety of classing
it among remedies, I  proceed to  state the practical points connected with its
employment in  cases of phthisis.  All clinical observers unite in according
to it more  or less value.   Its usefulness in a certain proportion of cases can
hardly be doubted.  Of the cases of arrested or  non-progressive phthisis which
I have analyzed, in several the treatment consisted exclusively in the use of
cod-liver oil and hygienic measures.   Hoav much importance is to be attached
to an intrinsic tendency  to recovery  and how much to hygiene in these cases
cannot be determined, but an examination of the circumstances belonging to
the individual histories goes to show that a certain  amount of salutary influ-
ence belongs to the oil.   Practically, the question of the use or non-use of
the oil relates to individual cases.   Clinical  observation  shows  that it is not
useful in all cases.  I shall give, briefly, the rules which my  own experience
has  led me to adopt respecting  its use and non-use.
  If it be taken without great repugnance, if it do not  impair the appetite
or digestion, or occasion  derangement of the bowels, it may  be expected to do
good.  If  it produce  any of the  effects just named, its  propriety is question-
able.  It is best to begin with a small quantity and increase to the maximum
quantity, which is  from half an ounce to an ounce three times daily, taken near
the time of meals, either before or after, as choice or experience may dictate.
It is generally best tolerated after meals.  Of the different oils, some patients
tolerate best the pale  and others the  brown variety.  I have repeatedly known
patients to take by preference the crude oil obtained at fish-markets.   If the
pure oil  be not well  tolerated, some one of the  preparations  containing lime
or other ingredients to divest it of its  repulsiveness may be substituted.   Of
course, in a given  volume  of the latter patients get a quantity of oil dimin-
ished by the bulk of  the added material.  Observations  made by Dr. A. H.
Smith  and  other members of a  committee of the New  York Therapeutical
Society show that the addition of fifteen minims of  ether to each half ounce
of oil "enables patients to take this remedy when, without the addition of the
ether, it disagrees.  The  ether may  sometimes be given with  advantage half
an hour after the oil has been taken.1   Caoutchouc dissolved in  the spirits of
turpentine  and prepared as a confection, has been largely used by Dr. T. R.
                   1 Vide N. Y. Med. Journ., March, 1879. 
212
PULMONARY PHTHISIS.
Varick, instead  of the cod-liver oil, with  apparent benefit,1   Glycerin has
been thought to be useful as a carbonaceous medical food.
  Arsenic is supposed by some to exert a certain influence on phthisis.  The
testimony based on clinical experience by  different observers is discrepant.
It is a fair conclusion from this fact that the remedy is sometimes useful and
sometimes without any appreciable  utility.  My own experience leads to this
conclusion.  In a certain proportion of cases it appears to be useful.  In order
to secure benefit from it the remedy should be given in small doses—one or
two  minims  of  Fowler's solution—repeated three or four times daily.  The
doses should not be increased.   The remedy in small doses may be continued
for a long period, but if the dose be increased its toxical effects  are liable to
occur and its discontinuance becomes necessary.  This is an essential point in
the use of  this remedy in cases of phthisis.
  The hypophosphites have been  much  used in the treatment of phthisis
within the last  ten years, and as regards their utility there is the same dis-
crepancy of testimony as with respect to arsenic.   The same  conclusion may
be drawn  from  this fact as in the instance of arsenic.   They are useful in a
certain proportion of  cases.  Arsenic and  the hypophosphites may be given
in combination.
  The bichloride of mercury is another remedy which, like the two foregoing
remedies, is considered by some  observers  to have a curative influence.  It
is possible that whatever efficacy pertains to arsenic, phosphorus, and mercury
is due  to a direct effect upon the parasite; that is, they act as parasiticides.
This  remark  will perhaps  also apply to alcohol.  It  is, however, a more
probable supposition that these remedies modify favorably, in some manner,
the conditions on which depends the existence of the parasite.   Arsenic is not
destructive to the bacillus tuberculosis out of the body.2
  All  remedies which improve  appetite, digestion, assimilation, and  nutrition
are in a greater or less degree useful.   Hence quinia, salicin, strychnia or
nux  vomica, the bitter tinctures or infusions,  and the mineral  acids meet
indications in cases of  this disease.  The chalybeate tonics are not without
utility. That they favor the occurrence of haemoptysis is an opinion  not
well grounded, and had they this effect it might be evidence  for rather than
against their utility.
  Certain pulmonary symptoms claim attention.  Expectorant remedies, as a
rule, are not called for.  They diminish appetite, occasion nausea, and disturb
digestion.    But remedies  to allay  superfluous  cough—that  is, cough  not-
required for expectoration—are  useful.  For this end the  succedanea of
opium—namely, hyoscyamus, conium, belladonna, hashish, chlorodyne, and
hydrocyanic acid—may be prescribed, but if these prove inefficient,  opium in
some form  is required.   The paregoric elixir will often  suffice.   Patients
should be  instructed  not to yield to the disposition to cough, but to resist  it
whenever  it is  not effective.  The  habit of coughing unnecessarily is, in a
great measure, under voluntary control.  Soothing inhalations are sometimes
useful  in allaying the irritation which excites cough.   The vapor of water or
spray impregnated with conium or opium may be inhaled.  I have known the
vapor  of chloric ether to  be highly useful as a palliative.   All  irritating
inhalations are hurtful.  The oxalate of cerium, in doses of  from 5 to 10 grs.
three times daily, has  been employed with much success  as a cough-palliative.
Its effect upon the stomach is that of a tonic.3
  With reference to the injection of tuberculous cavities with a solution of
the nitrate  of silver   or other medicated  liquids through the larynx  and
  1 Yide N. Y. Med. Record, Nov. 1, 1873.
  2 Yide Verhandlungen des Vereinsfur innere Medicin zu Berlin, 1884.
  8 Vide article by Dr. Robert Cheesman, in the N. Y. Med. Record, June 12, 1880. 
TREATMENT.
213
trachea, it is sufficient to say that, aside from the  difficulty of the operation
and the impossibility of limiting the application of the injected liquid to cav-
ities, a palliative  effect is all that can be expected  from this measure were it
never so successfully executed. This statement applies to the injection of cav-
ities after making an opening into them through the cbest-wall. Prof. Pepper
has reported Yl cases in which two hundred and ten injections into cavities
were  made, the objects being disinfection of the cavities  and the promotion
of cicatrization.  In no instance  was  harm done, and  the apparent results in
several  instances were beneficial.1
  Certain complications furnish  indications for treatment,  Attacks of dry,.
circumscribed pleurisy call for mild revulsive and soothing applications, such
as sinapisms, liniments, or the belladonna plaster.   Local bleeding by leeches
or cups is never required.   The pain  incidental  to  these attacks generally
passes off in a few days at farthest.   The treatment  of coexisting laryngitis
will  be considered in Chapter  XII.   Diarrhoea dependent on tuberculous
enteritis is to be  kept  in check by astringents and opiates, the latter being
used with as  much  reserve as is consistent  with  the object to be attained.
Chronic peritonitis claims only  palliative measures.
  In the progress of the disease symptoms  other  than those relating to the
chest require  palliative  measures.   The night-perspirations  are frequently
a source of great discomfort.  The mineral acids, especially the dilute  sul-
phuric acid and  gallic or tannic  acid,  frequently afford relief   The  external
application of an astringent, such as  alum dissolved  in spirit, is sometimes
effective.   Belladonna or atropia is an effective  remedy.   Dyspnoea may be
mitigated by  ethereal preparations.
  Paroxysms  or exacerbations of fever are sometimes,  in a  measure, con-
trolled by full doses of quinia.  If the temperature  be high  this remedy is
indicated as an antipyretic.   If quinia be not well tolerated  or  if it prove
inefficacious, antipyrine may be substituted.  Sponging of the body may be
resorted to  in  order to reduce  a high  temperature.
  A comparison of the measures of management  now generally  pursued in
this disease with the measures in vogue half a century ago shows a complete
and  radical change.   Formerly, general and local  bloodletting, cathartics,
emetics, mercurials, counter-irritation, low diet, and confinement within doors
were  sanctioned by teachers and writers, and  entered more or less  into  the
treatment usually adopted.   At the  present time the measures which  are'
most  approved are, in all  points, the  reverse.   The latter are based  on more
correct  pathological  views and the results of clinical  observation.   It is not
unreasonable to hope that at some future  time a remedy or remedies may be
discovered capable of exerting a  special influence over the disease, but in the
mean time reliance is  to be placed on  an  early diagnosis, the employment of
remedies which, directly or  indirectly, may exert, to a greater or less extent,
a salutary influence, and, above all, on the hygienic measures  which  tend to
invigorate and strengthen the  system.   The hygienic  measures just  referred
to are to  be enjoined with a view to  the  prevention  of pulmonary phthisis.
These  measures are operative by affecting the  conditions on which  depends
the tuberculous predisposition or diathesis.  Prophylaxis  is, of course, com-
plete  if the introduction  of the  infecting parasite can be prevented.  As a
measure for prevention a residence is  desirable  where  there  are  few or  no
cases  of phthisis.  This effective precaution, however, is  generally impracti-
cable.   Exposure to the infection should  be restricted as far as practicable.
Healthy persons should not occupy the same bed, and, except when required
by  the  dictates of humanity, the same  room  at night,  with tuberculous
patients.  Free ventilation of  rooms occupied by patients should be enjoined.
                   1 Trans. Amer. Med. Assoc, 1880, p. 239. 
214   FIBROID PHTHISIS.—ACUTE MILIARY  TUBERCULOSIS, ETC.

The sputa should be disinfected by carbolic acid or some other efficient agent.
The flesh and milk of tuberculous cows have  been shown to be capable of
producing the disease;  hence danger in this direction is to be avoided.
                     CHAPTER   VIII.

   FIBROID  PHTHISIS.—ACUTE  MILIARY  TUBERCULOSIS.—
                    GENERAL  TUBERCULOSIS.

                          Fibroid Phthisis.

   THERE is no sharp line of demarcation between fibroid phthisis and other
    forms of chronic pulmonary phthisis from a pathological point of view;
but in its typical  manifestations, regarded from a clinical standpoint, it pre-
sents peculiarities sufficient to warrant separate consideration.  In such typi-
cal cases the lung is shrunken in size, with a corresponding  retraction of the
chest-wall and often a lateral deviation of the spine.  The external appearances
are like those which follow chronic pleurisy.  The pleura is much thickened by
the development of firm connective tissue, and the pleural surfaces are adhe-
rent.  In the substance of the lung there are firm, dense bands and masses or
nodules of fibroid tissue, frequently deeply pigmented.  Cheesy and calcareous
masses are often lodged in the black or  grayish indurated  tissue.  There are,
as a rule, abundant and extensive  bronchiectases.   Ulcerative cavities may
also be present.  One lung is usually in a more advanced  stage of the disease
than the other.   Usually, tuberculous granula are evident to the naked eye.
The microscope shows the presence of  tubercles, often of the most exquisite
giant-celled type, in the  lung.  These undergo the fibroid metamorphosis to
which reference has already been made.  They are frequently situated in the
bands of fibrous tissue.  Tubercles with cheesy centres are also usually pres-
ent.   Some of the larger fibroid masses may present the  tubercular tissue in
a diffused  form.   In  addition to the tubercles there is chronic inflammation
of the interstitial  tissue of the lung.   The alveolar septa, the interlobular,
and the peribronchial connective tissue become increased in amount.  The air-
cells and bronchi  are compressed,  and  many of them obliterated.  The new
connective tissue  may be rich in  lymphoid  cells, or the cells may be few in
number and  spindle-shaped.  According to the amount of  caseous or tuber-
culous pneumonitis present there exist all stages of transition between typical
fibroid phthisis and the ordinary form of pulmonary phthisis.
   The names chronic interstitial pneumonitis and cirrhosis of the lung (Cor-
rigan) have also been applied to this form of phthisis.  The majority of the
cases of so-called  fibroid phthisis are tuberculous, as has been described ; but
at least some of the Cases of chronic pulmonary inflammation resulting from
the inhalation of fine  foreign particles, such as bits of steel, of coal, etc. (knife-
grinder's, coaler's phthisis, etc.), seem to be examples of pure chronic broncho-
pneumonia and interstitial pneumonia.

   This variety of  phthisis  is comparatively rare.   In an exceedingly small
proportion of cases it  is preceded by acute pneumonitis; but in these cases the
occurrence of the two diseases is probably due to coincidence.  This may also 
FIBROID PHTHISIS.
215
be said  of the cases  in which it has been observed to follow bronchitis.   In
the majority of cases the age  of  patients is  under forty years.
  The local symptoms  are cough with more or less  expectoration, and want
of breath on exercise.  The sputum usually contains tubercle bacilli.  The
matter expectorated is often notably fetid, and  sometimes  suggestive of gan-
grene.  Circumscribed gangrene occasionally occurs, but the fetor is generally
due to the decomposition of muco-pus, from its detention in  the cavities inci-
dent  to bronchiectasis.  Haemoptysis, either slight  or profuse, occurs in a
considerable proportion of cases.
  The disease may exist for an indefinite period without  notable emaciation
or debility ;  but sooner or later hectic  paroxysms  occur,  diarrhoea is  not
uncommon, the  appetite fails, and  there  is of  course a  corresponding defect
of nutrition.  The fingers often become clubbed.  General dropsy occurs in a
considerable proportion of cases.   This is due to dilatation of the right side
of the heart, an effect of  the obstruction of the pulmonary  circulation; that
is, assuming the absence of valvular cardiac lesions.
  As regards physical signs, aside from the  contraction  of the chest there
is more or less dulness on percussion, rarely flatness, and the resonance eli-
cited is often tympanitic.   The  tympanitic quality  is marked in proportion as
bronchiectasis is a concomitant  lesion, and  of  course it is  most marked when
the dilated bronchial  tubes are  free from morbid  products.   Saccular dilata-
tions may occasion cracked-metal and amphoric resonance.   Either ordinary
cavernous or  amphoric respiration  may  be heard  in certain situations.   In
other situations the  respiration may be  bronchial  or broncho-vesicular.   In
some situations the characters of cavernous and bronchial respiration  may be
combined.  On the other hand, there may be absence  of respiratory sound
over more or less of the affected portions of the chest.   The vocal signs are
those denoting pulmonary solidification and cavities—namely, bronchophony,
increased vocal resonance, and  sometimes pectoriloquy.  Bubbling and gurg-
ling rales are often  present.   The dilatation of the right side of the heart
may give rise to a tricuspid regurgitant murmur and to a jugular pulse. The
shrinkage of the lung may cause considerable  displacement of the heart.  If
the left lung be the seat  of the  affection, the  heart  is raised  and carried to
the left;  if the right lung be affected, the heart is sometimes removed to the
right side of the sternum.
   As regards diagnosis,  the ordinary form of phthisis is  excluded  by the
extent of the damage,-taken in  connection with the  fact that the affection is
especially marked on  one side, by the absence of the emaciation which gener-
ally characterizes the former, and by the  long duration, often with little or no
progress.  This differential diagnosis is less easy when the affection is bilateral
than when it is unilateral.  Affections with which it may be confounded are
chronic pleurisy and  carcinoma.   Chronic pleurisy,  after  the removal of the
effused liquid, does not furnish the  signs of solidification, and  perhaps  of
cavities, which belong to  the clinical  history of this disease.   Carcinoma of
the  lung  is generally secondary to  carcinomatous disease in  some other situa-
tion ; the cancerous cachexia is often marked; there is progressive and per-
haps rapid wasting of the body ;  and the progress of the disease is more rapid.
The presence of the characteristic bacilli in the sputum is, of course, proof
of the existence of tuberculous disease.   In this variety of  phthisis they are
less  abundant than in the ordinary  form of the  disease, and repeated examina-
tions may be required for their  discovery.
   Fibroid phthisis  involves lesions which do not admit of recovery.   Sooner
or later the disease ends fatally.   But in many instances life is destroyed by
some complication or  an intercurrent affection.   An acute  pneumonitis affect-
ing a lobe of the sound lung, or an attack  of acute bronchitis, may prove fatal. 
216   FIBROID PHTHISIS.—ACUTE MILIARY TUBERCULOSIS, ETC.

The  ability to resist any severe disease  is,  of  course, impaired.   Alone, the
disease ends fatally by slowly-progressive exhaustion ; but, existing alone, it
may be tolerated  for a great number of years.

  The treatment has for its most important object maintenance of nutri-
tion  and strength.  The measures for this object are remedies to promote
appetite and  digestion, a nutritious and  abundant alimenation, together with
climatic and hygienic  influences which tend  to invigoration.  Palliative meas-
ures, having reference to cough and expectoration, are indicated.  Expectorants
are useful by preventing the detention of muco-pus in the bronchial tubes, the
decomposition of which increases the bronchial  inflammation.  The inhalation
of the vapor of turpentine is useful.  Antiseptic inhalations are indicated  if
the expectorated matter or the breath be fetid.

     Acute  Miliary Tuberculosis—General  Tuberculosis.

  Acute miliary tuberculosis is characterized by the presence of miliary tuber-
cles in most of the organs of the body.  It is caused  by the entrance of tuber-
cle bacilli into the blood-current and their transportation to most parts of the
body.
  The organs  almost constantly affected are the lungs, the  liver, the spleen,
and  the medulla of the bones, and with  nearly equal frequency the kidneys,
the thyroid gland, the heart, the choroid coat of the eye, the lymph-glands,
and  the  serous membranes.   The  affected  organs are usually studded with
small, grayish, firm nodules, which  present the  tuberculous structure already
described  in  Part First (p. 48) and in  the article  on Pulmonary Phthisis.
Some of the tubercles, particularly those in  the liver, are  so small that they
can be seen only with the microscope.   The longer the duration of the case
the larger are the  tubercles and the more extensive  the cheesy degeneration
of their centres.  The lungs are hyperaemic, and the air-cells contain a small,
rarely a large, amount of  desquamated epithelium and of inflammatory prod-
ucts, particularly in the neighborhood of the tubercles.  Acute inflammation
of the bronchial mucous membrane coexists.   More  or less enlargement of
the spleen is usually present.  Certain peculiarities in the structure and the
distribution of the tubercles in particular organs will be  subsequently men-
tioned in connection with tuberculous  disease of these organs.   All tubercles,
at least at the beginning of their formation,  contain bacilli.   The bacilli may
be very few and difficult to find.
  In most but not in  all cases it is  possible  to demonstrate at the  autopsy  or
by  subsequent microscopical  examination  the  mode in which the tubercle
bacilli gain access  to the  blood-current.   The mode of infection varies in dif-
ferent cases.   It is usually to  be found  in  some old tuberculous focus which
may or may not have given rise to symptoms during life.   In many cases a
tuberculous nodule or mass has ruptured into  one of the  veins, particularly
into  one of the pulmonary  veins.   A frequent instance of this is the bursting
of a caseous bronchial gland into a pulmonary  vein.   In some  cases the gen-
eral infection has occurred  from tuberculosis of  the thoracic duct or from rup-
ture of tuberculous material into the duct.  The seat of entrance of the bacilli
into the blood may be demonstrable only by microscopical examination -,1 but
then the chances of discovering it are much less than in the instances which
have been mentioned.  It is hardly necessary to say that the idea once enter-
tained that any indifferent  cheesy mass in the  body might be  the source of
  1 As in a case reported by Pergkammer (Virchow'''s  Archiv, Bd. 102, p. 397), in which
the invasion of blood-vessels  in the bronchial lymphatic glands by enormous numbers
of bacilli could be demonstrated. 
ACUTE  MILIARY TUBERCULOSIS—GENERAL  TUBERCULOSIS.   217

general tuberculous infection is not true.  The primary cheesy mass must be
of tuberculous origin  in order to cause general tuberculosis.
  As has already been mentioned, the focus of local tuberculosis—which in
most if not in all cases antedates  the general tuberculosis—may or may not
have given rise to characteristic symptoms.  All varieties of local tuberculosis,
such as pulmonary  tuberculosis, tuberculous disease of the bones and of the
joints, genito-urinary tuberculosis, and tuberculosis of the lymphatic glands,
may be followed  by acute  miliary tuberculosis.
  In some cases it is impossible to find any  tuberculous products which seem
to antedate the general tuberculous infection.  Whether in these cases the
primary tuberculosis is overlooked, or whether in rare instances in some unex-
plained way tubercle  bacilli may  directly invade the blood in  large numbers
from without, is  uncertain.   Acute  miliary tuberculosis frequently develops
in persons apparently in perfect  health.  It  does not  often develop in the
course of pulmonary  phthisis.
  In cases of acute miliary tuberculosis tubercle bacilli have been found in
the blood both during  life and at the autopsy.   They have been found in blood
withdrawn during life  from the spleen by a  hypodermic syringe.

  With reference to the symptomatology and diagnosis, it is to be noted that
the name  acute  miliary tuberculosis is  limited to cases in which tubercles
involve, not a  single organ, such  as the lungs, the  pia mater, or the genito-
urinary tract, but a  large number of organs.  The lungs may be predominantly
affected,  but tubercles exist also in other parts.
  Cases of this disease are rare;  they occur mostly after puberty and before
the middle period of life, but no age is exempt from a liability to the disease.
  The general symptoms denote  a febrile disease.   The temperature of the
body is more or less raised, but there is much variation in  this regard in dif-
ferent  cases.   There is sometimes hyperpyrexia.   Variations in the pyrexia
at different periods in the  same case are sometimes marked.   The pulse is
usually rapid, ranging from 120  to 140  per minute.  There is complete  ano-
rexia and  the  prostration  is great.
  The respirations  are usually notably frequent, from 30 to 60 per minute.
Cough is more or less prominent.  The expectoration varies, and is sometimes
small or even  wanting.  Tubercle  bacilli have been found in the sputum, but
this  is exceptional.   The expectoration proceeds from secondary bronchitis.
It may contain blood in streaks.  Haemoptysis is an occasional event. Among
the cases given in  my work on  Phthisis is  one in  which the disease began
with a profuse haemoptysis.  Another instance has more recently come  under
my observation.  In some instances there  is much suffering  from dyspnoea,
but patients do not always complain of a sense of the want of breath  even
when the  respirations are notably hurried.   Cyanosis is often  a prominent
symptom.  Double  pleurisy  with  effusion occurs in some instances.
  The shortest duration in the cases which I have observed was eleven days.
It rarely  exceeds two months.  Although there is great interference with the
respiratory function, asthenia predominates in the mode of dying.
  The disease may  have no distinctive physical signs.   If tubercles be dis-
seminated  about  equally in both lungs,  they  do not occasion an appreciable
dulness on percussion  or the auscultatory signs of solidification.   Some dry
and moist bronchial rales,  due to bronchitis, may be heard at different points,
but these are not  constant.   The fact that physical exploration gives a nega-
tive result  is to be taken into account in the diagnosis.   This result excludes
other pulmonary diseases which might give rise to the pulmonary symptoms—■
namely, lobar pneumonia, the common form  of pulmonary phthisis, and capil-
lary bronchitis.  The  basis of the diagnosis is  the exclusion  of these affec- 
218
BRONCHITIS.
tions and  the fact that the symptoms point to some  grave intrathoracic and
general disease.
  The difficulty in the diagnosis relates chiefly to  the  differentiation  from
typhoid or typho-malarial fever.   With  these diseases acute miliary tuber-
culosis is  apt to be confounded.   This error is likely to be made if, as some-
times happens, cough with expectoration, rapid breathing, dyspnoea, and cya-
nosis are not as prominent as they are in the majority of cases.   Moreover,
in some cases of acute miliary tuberculosis fever heat ceases in the course of
the disease.  Typhoid and typho-malarial  fever are to be  excluded by the
absence of the diagnostic characters  of these affections.  Positive  proof of
the existence of  tuberculosis is  obtained, of course, if examinations of the
sputum show the presence of the bacillus tuberculosis.   This proof,  how-
ever, may not be  obtained in cases of miliary tuberculosis.  There are not
as yet sufficient  observations to determine how  frequently tubercle bacilli
may be found in  the blood during life in case of acute miliary tuberculosis.
The recognition by the ophthalmoscope of tubercles in the choroid coat of
the eye may  render great assistance in diagnosis.

  The treatment of acute  miliary tuberculosis may be  dismissed  with a
very few words.  The condition of the patient is hopeless, and  all that the
physician  can do  is to palliate  symptoms and sustain the  powers of life.
This is one of the diseases in relation to which recovery is proof of an error
in diagnosis.
                        CHAPTER   IX.

                             BRONCHITIS.

Acute Bronchitis affecting the Large Bronchial Tubes: Anatomical Characters; Clinical
   History;  Pathological Character; Causation; Diagnosis;  Prognosis;  Treatment.—
   Subacute Bronchitis.—Acute Bronchitis in Young Children.—Bronchitis affecting the
   Small Bronchial Tubes.—Epidemic Bronchitis.—Influenza.—Bronchitis with Fibrin-
   ous Exudation.—Circumscribed Bronchitis.—Chronic Bronchitis.

   THE preceding chapters have embraced inflammatory diseases  affecting the
     pleura and the pulmonary parenchyma.   It remains to consider inflam-
mation seated in the lining membranes of the  bronchial tubes.  Inflammation
in this situation constitutes the disease called bronchitis.  This, in its ordinary
form, is  the  most  frequent  of  the  pulmonary inflammations, and is  a very
common  affection  in  all parts of the globe.   A highly important variety of
the disease is based upon the size of the bronchial tubes affected.  Generally
the  inflammation is limited  to  the large bronchial  tubes.  In  an infrequent
and  much graver  form  the inflammation affects the small  tubes.  The latter
form is usually, but, as will  be seen, incorrectly,  called capillary bronchitis.
Inflammation of the bronchial mucous membrane may be acute,  subacute, or
chronic, and varieties of the  disease  are based on these differences as regards
the  degree and duration of the inflammation.  Bronchitis may  be  a compli-
cation of certain diseases, such as pneumonitis and phthisis, or it may not be
preceded by any disease of the lungs.  As a complication of other pulmonary
affections it is more limited than when it is the primary affection, and may be 
  BRONCHITIS AFFECTING THE LARGE  BRONCHIAL  TUBES.  219

distinguished as circumscribed bronchitis.  A form of the disease is character-
ized by the exudation of fibrin, and may be denominated fibrinous bronchitis.
Finally, bronchitis characterizes an epidemic disease commonly known as influ-
enza.   These several varieties of the disease will claim separate consideration
after having considered the ordinary form—namely, bronchitis affecting the
large  bronchial  tubes.  The  term  catarrh has been used to denote inflamma-
tion of a mucous structure, giving rise to a mucous or a muco-purulent prod-
uct.  As the term bronchial catarrh expresses neither more nor less than bron-
chitis, it is superfluous and may be dispensed with.   Proceeding to treat first
of ordinary acute bronchitis, it will be considered as occurring after infantile
life, and afterward certain points relating to the disease as it occurs in young
children will be briefly noticed.


  Acute Bronchitis affecting  the  Large  Bronchial  Tubes.

  Anatomical  Characters.—Acute simple bronchitis begins with hyper-
aemia  of the mucous membrane, often accompanied, in severe cases, with little
ecchymoses.  The mucous membrane becomes swollen and soft.  The  con-
gestive redness  and  the swelling  apparent  after death in the affected tubes
may be uniform or more marked  in patches or zones.   The appearance  with
respect to redness after death here, as in other  situations, is not to be consid-
ered as evidence of  the degree of  hyperaemia present during life, for in parts
open to observation—for example, the conjunctiva, mouth, and  throat—red-
ness  marked  during life may diminish or  even disappear after  death.  The
inflammatory products  consist  of  mucus, pus-corpuscles,  and serum mixed
with desquamated epithelial  cells.  Sometimes, especially in the  early stage
of the disease, the product is chiefly mucus, when it appears translucent and
viscid ; at other times it is yellowish, when  it contains abundant pus-cells.  A
coating of muco-pus is found  upon  the inflamed mucous membrane after death.
  In ordinary bronchitis the  inflammation,  as already stated, is limited to the
large bronchial  tubes.   The tubes  on both sides are equally affected, provided
the affection be  not incident to an  antecedent pulmonary disease.   With this
exception,  bronchitis  exemplifies the law  of parallelism ; it is a bilateral or
symmetrical  disease.    In  this respect it  differs  from pleuritis  and lobar
pneumonitis.

  Clinical History.—Acute bronchitis is generally preceded by inflamma-
tion of the mucous membrane of  the nasal passages, or coryza.   The inflam-
mation begins in the nostrils  and travels downward, either affecting or passing
by the pharynx and larynx in its passage to the bronchial tubes.  The period
occupied in the passage varies from a few* hours to one, two, or three days.  In
a certain proportion of cases the bronchial tubes are attacked at once without
any affection of  the air-passages above.
  The symptoms offer marked points of contrast with acute  pleuritis and
pneumonitis.   Pain is not a prominent symptom, but the patient has a sense
of constriction  and  of soreness or rawness.  These  painful sensations espe-
cially accompany acts of coughing.  The pain is of an obtuse  or contusive
character, and is situated beneath the sternum.
  The attack is rarely accompanied by a distinct chill, but chilly sensations,
followed by flashes of heat, are frequently repeated during the career of the
disease.  The appetite may be more or less impaired, but is not usually lost.
Lassitude is complained of, with a  general feeling of  malaise.
  The pyrexia is moderate.   The pulse has not the  frequency and strength
which it has in pleuritis and pneumonitis.  The heat of the  surface is  not
notably raised. 
220
BRONCHITIS.
  The cough is at first painful, but not sufficiently so to be suppressed.  It is
at first dry, the secretion of mucus being  for a time scanty.   Deep inspira-
tions, breathing cold air, and the exercise of the voice excite acts of cough-
ing, which occur in paroxysms and consist of a deep inspiration followed by
a series of expiratory efforts.   If the paroxysms of coughing be frequent and
severe, the traction of the diaphragm occasions pain  and  soreness, referred to
the false ribs and  the  ensiform  cartilage.  The patient feels as  if a  more
abundant expectoration  would give relief, and desires  to have the  cough
loosened.   The expectoration  is at first small, glairy, frothy, and viscid, and
occasionally streaked with blood.  In the progress of the  disease, after two,
three, or four days the expectoration becomes more abundant, and consists
of thick, yellowish, or greenish sputa.  The cough is then said to be loose,
the acts  of  expectoration being easier, unattended by pain or soreness, and
followed by a sense of comfort.   The mucous secretion is rarely sufficient to
accumulate  in the  tubes and occasion embarrassment of  respiration.   This
may happen, however, in young children, in the aged, in feeble persons, and
in patients with paralysis affecting either  the diaphragm or the costal  mus-
cles.  The presence of a collection of mucus in the large bronchi or trachea
is felt, and  the patient is led to make voluntary efforts  of coughing for its
expulsion.    The increased  amount of  the inflammatory  products and the
change  in character denote diminution  or resolution of the inflammation.
  Respiration is not sensibly affected.  No portion of the lung is withdrawn
from the exercise of its function, as in pleurisy and pneumonitis.  Dyspnoea
is not produced, save in the exceptional cases in which, from feebleness or the
want of voluntary efforts of coughing, the mucous secretions accumulate suf-
ficiently to obstruct the bronchial tubes, provided the bronchitis be not super-
added to emphysema or some  other pulmonary affection  and  the muscles of
respiration be not paralyzed.
  The affection is not accompanied by much debility.   Patients are generally
not confined to the bed, and they may not confine themselves to the house.
  The average duration of acute bronchitis is ten or twelve days.  In severe
cases after five or six days patients are usually able to be out of doors.
  The disease may be divided  into two stages.  The  first stage embraces the
period during which the expectoration  is  scanty, transparent, and  viscid.
The  second stage extends from  the  time when the  expectoration becomes
abundant, opaque, and thick,  to convalescence.

  Pathological  Character.—Acute  simple bronchitis is an inflammation
affecting a mucous membrane, leading to a secretion of mucus  and the pro-
duction of muco-pus in  greater or less abundance.   Resolution takes place
in the bronchial  membrane without the occurrence  of ulcerations.

  Cavsation.—Primary or idiopathic bronchitis is attributed to the agency
of cold.  This is implied in the designation by which the  affection is popu-
larly  known—namely,  " a cold."   Exposure to cold  is  supposed to pro-
duce  this  disease by interrupting the  eliminative  functions  of  the  skin,
whereby an  increased duty is thrown  upon  the pulmonary  mucous  mem-
brane,  and  by inducing internal  congestion.   This view  of the  causation
is inconsistent with the fact that great exposure, in a large  proportion  of
cases, is not followed by bronchitis, and  also with the fact that  in  many
cases bronchitis is not traceable to any unusual exposure.  It is reasonable to
conclude that the disease is due to a morbific agent in the atmosphere.   This
is of course  to be  inferred when the disease prevails as  an epidemic; but
it is a matter of common observation that a greater or less  number of per-
sons are likely to  be simultaneously affected when the number is not enough 
  BRONCHITIS AFFECTING  THE LARGE BRONCHIAL TUBES.  221

to constitute an epidemic.  That the  special morbific agent is a micro-organ-
ism—in other words, that the disease is parasitic—is rendered probable by
the absence of any appreciable  causation in a large proportion of cases, and
by the fact that the bronchial inflammation is preceded  in most cases by
coryza, frequently  by  laryngitis, and sometimes by pharyngitis, these affec-
tions  successively  occurring  after intervals  of several hours  or days.  It
seems rational to attribute these successive  affections to  the migration of the
parasites downward, and the formation of  colonies  in the parts  successively
affected.1   The disease is more frequent in cold  and temperate latitudes than
in the  tropics; and in the  former it prevails  especially in the  spring and
autumnal months.   It presents a contrast to acute lobar pneumonitis, which
occurs oftener in warm than in cold climates.
  Bronchitis occurs secondarily to, and forms an element  of, other diseases.
It belongs to the clinical history of rubeola, or  measles.  In connection with
this disease it is frequently acute.  It  occurs in typhoid fever, but is rarely
acute in connection with that disease.  Developed in connection with diseases
situated  elsewhere than in the  pulmonary organs, it is symmetrical, as when
it occurs primarily ;  but, developed  as a complication  of pneumonitis and
phthisis, it may be limited to one side—that is, unilateral—and is confined
within a  circumscribed  area.
   It may be produced  traumatically by irritating gases  received with the
inspired breath.  Inhalation of chlorine gas will produce it.   I have known
a severe attack produced by  inhaling the fumes of  sulphuric acid.  In  some
persons, owing to an idiosyncrasy, the bronchial membrane  becomes inflamed
by constituents of inspired air which are  innocuous when inhaled by most
persons.    The  powder  of  ipecacuanha,  emanations from  newly-mown hay
and from feathers,  the pollen of certain plants  in the atmosphere during the
summer and a portion of the autumnal season,  and  even fragrant odors, will
produce bronchitis in those having a peculiar  susceptibility to these causes.
Frequently in these cases to the bronchitis is  added  asthma; and this idio-
syncrasy  will be noticed in  connection with the latter affection.  (Vide Chap-
ter N.)
   As a rule, the liability to bronchitis is  less  in  proportion  as  persons are
habituated to free exposure in the open air. It is much more liable to attack
persons .who spend most of their time in  warm  apartments than those whose
occupations  keep them out  of doors.   Soldiers, surveyors, explorers,  and
hunters, who are accustomed to  sleep at night in tents or in  the open air,
rarely " take cold," but  it is a matter of frequent observation that after hav-
ing been  for some time accustomed to camping  out of doors bronchitis occurs
on  resuming in-door quarters.  If the  parasitic doctrine be  admitted,  these
facts point  to  the  importance of peculiar  local conditions favorable to the
multiplication  of the parasite.

   Diagnosis.—Acute bronchitis is to be  discriminated from  pleuritis and
acute lobar pneumonitis, more  especially the latter   The  points relating to
symptoms which are involved  in this  differential  diagnosis are  as  follows :
the absence of  lancinating  pain,  the  pain which  is felt  being  substernal;
the presence of  more  or less expectoration  which is  not rusty, but either
devoid of blood  or containing  it in  the  form  of streaks;  absence of accel-
erated breathing and  dyspnoea;  absence of the circumscribed  flush of the
cheeks ;  and the pre-existence of coryza, with, perhaps, soreness of the throat,
and subacute laryngitis.  These points are  chiefly negative, and they are not
sufficient for a positive  diagnosis in all cases, because the  symptoms belong-
  1 Yide "Suggestions as to the Etiology, etc. of  Acute Coryza," by the author in Jour-
nal of the American Medical Association, Nov. 14,1885. 
222
BRONCHITIS.
ing to pleuritis or pneumonitis, which are wanting  in  bronchitis, are not uni-
formly present in cases of  the  two former diseases.   The clinical history,
however, and the results of physical  exploration render the diagnosis easy
and  positive.
   The  physical  diagnosis is based chiefly on  negative points.   Percussion
elicits the resonance of  health.  The vocal resonance is  unaffected.   The
respiratory murmur  may be  weakened, but  is  not otherwise altered.   Sup-
pression of the murmur over a portion of the chest may occur temporarily
from obstruction of a bronchial  tube by an  accumulation of mucus.   These
negative points  warrant the  exclusion  of pleuritis and pneumonitis.  The
dry and moist bronchial rales may or may not  be present at the time when
the explorations  are made.   Their  presence and diffusion more  or less over
both sides are indicative of the existence of the disease, but the absence of
the disease is not to be inferred because these signs  are wanting  when the
chest is examined.   They are oftener wanting than  present, the  conditions
giving rise to the dry rales not existing, and the mucus in the bronchial tubes
being too adhesive or thick to produce bubbling sounds.

   Prognosis.—Acute ordinary bronchitis, not associated with  other affec-
tions, is a dangerous disease only when it occurs in the young, the aged, or the
feeble.  The danger in these classes of patients arises from  the accumulation
of the products  of inflammation within the bronchial tubes, and from the
occurrence of collapse  of pulmonary lobules  or broncho-pneumonia.  The
danger relates to  apnoea.  The disease does not lead to great prostration and
danger from  asthenia.   Exclusive of the classes of patients just named, it is
generally a disease of little or no gravity.  In the great majority of cases it
passes through its course and the recovery is complete, but  it may eventuate
in chronic bronchitis.  Associated with certain  other  affections, it may give
rise to much  suffering and danger.  Occurring, for example, in patients affected
with pulmonary emphysema, it occasions  more or less  dyspnoea, and it  may
prove fatal if the amount of emphysema  be great.   So in cases of spinal
paralysis affecting the costal respiratory movements the accumulation of the
bronchial  secretions, from  inability to expel  them by the action of the dia-
phragm, alone may occasion death by slow apnoea.
   The disease has no tendency to induce either pleuritis or acute lobar pneu-
monitis, and, contrary to a general impression, it rarely precedes the develop-
ment of pulmonary phthisis.

   Treatment.—Acute bronchitis may be prevented in some instances, on the
appearance of coryza, by a full opiate.   A quarter of a grain of  the sulphate
of morphia, half  a grain or a grain  of codeia, a proportionate dose of any of
the preparations of opium, or ten grains of either Dover's or Tully's  powder,
may be given to  an adult for this object at bedtime, accompanied by a hot
pediluvium and some warm stimulating  drink,  such as weak punch or toddy
or an infusion of  some of the aromatic herbs, and followed in the morning by
a saline purgative.  If this plan of  treatment do not succeed, it may mitigate
the severity of the disease.   A full  dose of a salt of quinia (a scruple to an
adult) will  often act as a prophylactic, or, if given at once when the bronchial
tubes become affected,  as an  abortive remedy.  Twenty grains of salicin,
repeated once or twice after an interval of two hours, will be likely to pre-
vent  or arrest the disease.   The  Russian  or Turkish bath  is  sometimes
effective.
   If it be true that the efficient cause is a parasitic organism, topical  treat-
ment for  its destruction  is  a rational  object of  prophylactic  treatment.
Destruction of the parasite in the nostrils of course prevents the  migration 
SUBACUTE BRONCHITIS.                   223
and colonization in the parts below.  Certain topical applications within  the
nostrils have been found efficacious.  One of these  is  the  German remedy,
known as the Brandt-Hagen remedy, consisting  of carbolic  acid 80  grains,
alcohol \ ounce, liquor ammoniae 80 minims, and  distilled water '1\  drachms.
This liquid  is poured  upon a sponge placed within a paper cone, and  the
vapor inhaled through  the nostrils.   Camphor and quinia in equal parts com-
bined, pulverized, and  inhaled, is a popular remedy  said to  be efficacious.
  If the disease become established, it  does not claim  active measures of
treatment in view of the almost uniform  tendency to recovery  with mere
attention to hygiene.   Bloodletting is not called for  except in  some rare cases
in which the patient is full-blooded and the symptomatic fever unusually
intense.  Depletion by means of saline laxatives and reduced diet will gener-
ally suffice.   If the attack be severe, confinement to the bed for  a few days
may be advisable in order to secure uniform warmth and moisture of the  sur-
face.   Patients are more comfortable when moderately perspiring.   In severe
cases an abundance of moisture in the apartment soothes the inflamed mem-
brane and renders the patient more  comfortable.
  Opium is thought by many to be contraindicated in the first stage.  It is
supposed to interfere with the free secretion of mucus and to render expectora-
tion difficult.  This is  an inference from  the effect of opium on the secretions
in health ;  but,  so far  from these results  being  produced, opium hastens  the
second stage.  The free secretion of mucus is  not  the cause, but the conse-
quence, of  an  abatement of the inflammation, and by  contributing  to  the
latter opium virtually  acts as an expectorant.   Opium, therefore,  is indicated
in the first stage of bronchitis,  as it  is in most acute inflammations.  In  the
second stage it is indicated only when the cough  is out of proportion  to  the
expectoration ;  that  is, when the  cough is more  than  is needed  to free  the
bronchial tubes.  Opium is contraindicated if, owing to the feebleness of the
patient, the efforts of expectoration  are inadequate  to  prevent accumulation
in the bronchial tubes.   The inhalation of warm  vapor or spray affords relief
and promotes the secretion of mucus.
   During the  acute stage, if pain and soreness  of the  chest be prominent
symptoms, sinapisms or stimulating liniments are  useful.  These symptoms
do  not demand blisters or other active measures  of counter-irritation.
   The stimulating so-called expectorants are not  indicated  in the first stage.
In so far as they have the  property  of exciting the bronchial mucous mem-
brane  they tend to increase the inflammation.  They are rarely indicated in
the second stage.  If  the affection linger and threaten to become  chronic, the
sulphate of quinia and other tonic remedies, together with a nutritious  diet
and an invigorating regimen, are the most efficient  measures  for recovery.  I
have been  led by experience to regard the iodide of potassium or the hydri-
odic acid and  chlorate of potassa as useful  remedies in both the first  and
second stage of acute  as well as of chronic bronchitis.

                        Subacute Bronchitis.

   The  difference, as regards symptoms and therapeutic indications, between
the acute and subacute forms of bronchitis is  such that a passing notice of
the  latter  under a distinct head is called for.
   Subacute  bronchitis is, in common language, a slight cold,  beginning  usu-
ally with coryza, and  running  the  same course as  acute bronchitis, but  with
less severity, and perhaps  not involving  the  same extent of the bronchial
mucous surface.  The affection is not of sufficient gravity  to keep patients
 within  doors, and in the majority of cases they  do not call  upon the physi-
cian, but either allow it to run its course or resort to some  domestic remedies. 
224                         BRONCHITIS.
   This form of bronchitis may frequently be arrested ;  but if not  it claims
only a saline laxative, followed by a little anodyne, such  as  one-eighth of a
grain of the sulphate of morphia or a quarter of a grain of codeia every four
or six  hours in syrup.  It is not necessary to enjoin confinement within doors.
As it is desirable not to exaggerate, as well as not to depreciate, the importance
of diseases, it should be understood by physicians and patients that common
colds do not tend to eventuate in inflammation of the lungs or in phthisis.
A certain amount of care  is advisable  and  mild remedies are useful, but  it
would  be injudicious to subject patients to active measures of treatment or
to needless precautionary restrictions.


              Acute Bronchitis  in Young Children.

   Acute bronchitis  in young children  offers an important peculiarity in  the
greater liability  to  collapse of pulmonary  lobules and broncho-pneumonia.
(See p. 174.)
   Collapse of pulmonary lobules is incidental  to bronchitis in young children,
in consequence of the accumulation  of mucus in the bronchial tubes.  The
tubes  consisting of  branching cylinders diminishing in calibre, it is easy to
understand that plugs of viscid mucus in certain situations may obstruct the
ingress of  the inspired air into the air-cells, without obstructing the egress of
air from the cells in expiration ;  hence collapse occurs of the lobules to which
the obstructed  tubes are distributed.   In  expiration the plugs are moved by
the current of air from the  smaller into the  larger tubes, but in  inspiration
the current moves them into a position in which the  progress of air is inter-
rupted.  It is  supposed that collapse may occur when the current of air in
expiration  as well as in the act of  inspiration is obstructed, the air which is
thus pent up in the lobules being absorbed.   In proportion to the  number of
collapsed lobules the respiratory function  is  compromised, and danger from
apnoea may attend this accident.  It is more liable to occur in  young children
than in adults, because children  do not promote expectoration by voluntary
efforts, and also  because the respiratory acts are less vigorous.   It  occurs
especially  in feeble  children.  It does not, however, belong exclusively to
acute bronchitis in young  children  ; it occurs in aged persons, and may take
place in those of any age who are constitutionally weak.  It is also incidental
to chronic bronchitis in children and  adults, and  it enters, as will be seen
hereafter, into the causation of emphysema  of the lungs.
   The occurrence of collapse of pulmonary lobules may be strongly suspected
in the course of acute bronchitis if  the  respirations  become frequent, with
dilatation of the alae nasi, accompanied perhaps with lividity, and if the symp-
toms and signs of acute lobar pneumonitis be wanting.   Physical exploration
does not always furnish definite signs of this  accident.   Relative  dulness on
percussion  may be found on  one side  if there  be a marked disparity between
the two  lungs  as regards the number of lobules which  are collapsed.   The
respiratory murmur  is more feeble over the posterior than over the anterior
portion of  the  chest, and if  relative dulness on percussion exist on one side
the murmur of respiration will be more feeble on  that  side.   Mucous rales
are more or less abundant.
  In the treatment of bronchitis in  young children the liability to this acci-
dent is to be considered.   Mild emetics are indicated  with a view  to promote
the expulsion of  mucus from the bronchial tubes..  They  are  admissible
because they occasion  less disturbance than  in adults.   They are indicated
because in  young children the acts of coughing are for the most part purely
reflex ; that is, voluntary efforts to  expectorate are not  made.   They should
not, however, be repeated too frequently, and antimonial  emetics should never 
  BRONCHITIS AFFECTING THE SMALL BRONCHIAL TUBES.  225

be employed.   Apomorphia, administered hypodermically, has  been  recom-
mended as an emetic and expectorant; but the grave effects which have some-
times followed small doses render the use of this remedy of doubtful expe-
diency,  especially in  young children.   Remedies  to maintain  nausea are
contraindicated on  account  of their depressing effect; an emetic should  be
given to produce prompt vomiting, and afterward nauseant remedies withheld
until a repetition of the emetic be deemed advisable.  In the interval, tonic
remedies, a nutritious diet, and perhaps  alcohol, are called for to  support the
general  strength.   Opium  is to  be  given with great  circumspection, since it
may favor  the  accumulation of mucus in the bronchial  tubes.   The chief
objects of treatment, in short, are twofold: first, to supply the want  of vol-
untary efforts of expectoration by the judicious employment of  emetics ; and
second, by sustaining measures to maintain the force  of the respiratory acts.
The iodide of potassium,  given pretty  freely, has  seemed to me to  have a
curative effect.   Measures to excite  deep  inspirations, referred  to in connec-
tion with broncho-pneumonitis (vide p. 176),  are to  be mentioned as entering
into the  treatment.


   Acute Bronchitis  affecting the Small  Bronchial  Tubes.
  An extension  of  inflammation from the larger and medium-sized tubes to
those of small  size gives rise to the variety of bronchitis commonly called
capillary bronchitis.  This application  of the term capillary is  not strictly
correct.  The truly capillary tubes—that is, the  ultimate subdivisions of the
bronchial  tree, or the bronchioles—are  not the seat of inflammation  in this
affection.   They  are involved in pneumonitis.  The bronchial  branches  of
small size, but  not  the  smallest, are affected  in so-called capillary bronchitis.
The larger tubes are  generally first affected, and  the small tubes become
involved by a more or  less rapid extension of the inflammation.   The affec-
tion has heretofore been known  by various  titles,  such as catarrhus senilis,
peripneumonia notba, bastard pleurisy, suffocative catarrh, etc.
  This affection  differs widely from  ordinary acute  bronchitis as  regards  its
clinical  history and danger.   It  is an  exceedingly grave affection,  proving
fatal, especially in young children, in a large  majority of cases.    The  danger
proceeds from  obstruction  to the current of air to  and from  the  air-vesicles.
The obstruction is  due to the small size of the affected tubes; the swelling
of the mucous membrane  and the  presence  of muco-purulent  liquid,  which
in the larger tubes do  not interrupt the free passage of  air, occasion  in the
small tubes serious  interference, and, as the affection is bilateral,  fatal apnoea
is liable to  be produced.
  In acute bronchitis  of the small bronchial tubes the inflammation is much
more intense than in acute simple bronchitis of the large tubes.   The small
bronchi contain muco-pus, which escapes in small drops when  a section of the
lungs is made.  Upon  microscopical examination  the walls  of the  affected
portions of the bronchi  are found infiltrated with emigrated white blood-cor-
puscles, and frequently  inflammatory products exist in the air-cells immedi-
ately adjacent  to the  inflamed  bronchi.  Obstruction  from  plugging of the
tubes with muco-pus leads to collapse of pulmonary lobules.   These collapsed
lobules become secondarily inflamed.  It is thus seen  that the lesions are not
confined to  a  simple  inflammation  of the mucous membrane  of the small
bronchi, but embrace also inflammation of the other coats of  the bronchi and
of the air-cells in connection with the bronchi.  There is, therefore, in most
cases, broncho-pneumonitis.   The lungs are generally hyperaemic, and are
often oedematous.  There is usually compensatory emphysema of the superior
and anterior parts of the lungs.
       15 
226
BRONCHITIS.
  The mechanical  obstruction and the incidental  circumstances  just  stated
afford an explanation of the symptoms which make up the clinical history of
this  variety of bronchitis;  and as regards its  clinical history it presents a
striking contrast to acute  bronchitis limited to the larger tubes.  The respi-
rations  are frequent in proportion to the  bronchial obstruction.   In young
children they may be increased to 60 or 70 per minute.  Dyspnoea exists in
a degree corresponding  to the  acceleration of breathing.   In severe cases it
amounts to orthopncea,  the patient keeping the sitting  posture  and suffering
extremely for the want of breath.   The speech is short and jerking; the alae
nasi  dilate ;  the face is congested and swollen ;  and the countenance expresses
anxiety and distress.  Lividity is marked, partly in consequence of imperfect
oxygenation of the blood, but more especially of its accumulation in the
right cavities  of the heart (cyanosis).   There  is great restlessness.   The
pulse is notably frequent, but not accelerated in proportion to the respirations.
Cough is more or less prominent, and is difficult and ineffectual from the want
of breath.   The expectorated  matter coming from the small  tubes does not
contain  bubbles of  air;  its specific gravity is greater than that of water, and
it has sufficient consistence to preserve the form of  the tubes.   In its passage
along the large tubes it becomes mixed with mucus from  the  latter, which
contains air and consequently floats on water.  The characteristic expectora-
tion  consists of mucus floating on water, with which are connected filaments
sinking  below the surface.
  The symptoms distinguish sufficiently capillary  bronchitis  from bronchitis
limited  to  the larger tubes, but they do not  always suffice for the discrimi-
nation of this from other  affections.  It should never be  confounded  with
laryngeal  affections occasioning obstruction (simple  or pseudo-membranous
laryngitis), for in these  affections the voice is affected,  the  cough  is charac-
teristic, and the respirations are labored, but not  notably accelerated.  Atten-
tion  to the points just named will show the affection to be  seated within the
chest.   The diseases with which it is most liable to be confounded are pneu-
monitis, asthma, and ordinary acute bronchitis with  collapsed lobules. It may
generally be discriminated from these  affections  by means of physical signs
taken in connection with the symptoms.  The resonance on percussion is not
diminished in capillary bronchitis, and over the upper lobes it  may be greater
than in  health, owing to an emphysematous condition of the air-vesicles.  The
presence of muco-purulent liquid in the small tubes gives rise  to fine bubbling
(subcrepitant) rales.  As the affection is bilateral, the rales are heard on both
sides, and especially on the posterior aspect of the chest,  The  respiratory
murmur is  weakened.  The  anterior,  superior, and middle portions  of the
chest in a young  child may become  largely dilated, presenting the character-
istic  deformity of long-continued and great emphysema, this  appearance dis-
appearing after recovery.
  Lobar pneumonitis is to be excluded  by the absence of the symptoms and
signs diagnostic of that disease.  Dulness on percussion extending over one
or more lobes is wanting.   Pneumonitis is generally abruptly developed, and
is  not preceded or  accompanied by bilateral bronchitis.   It is rare for pneu-
monitis  affecting but one lobe to occasion so much disturbance of the respira-
tion  as takes place in severe cases of capillary bronchitis.  The crepitant rale,
if it  be present, denotes pneumonitis, and if this affection exist and have
advanced far enough for  bubbling rales to become developed,  the latter are
confined to one  side only, except in the rare instances in which  the pneumo-
nitis  is  double.   The temperature of the  body  is, as a rule,  higher than  in
capillary bronchitis, the thermometer in the latter rarely showing an eleva-
tion  above 102° F.
  Asthma is not accompanied  by pyrexia.   The respirations are not rapid, 
  BRONCHITIS AFFECTING  THE SMALL BRONCHIAL TUBES.  227

but labored, the labor being  especially marked in expiration (expiratory
dyspixea).   They are accompanied by loud  sibilant and sonorous  rales.  It
is a paroxysmal affection, the dyspnoea  not  persisting  as in  capillary bron-
chitis ; and unless the case happen to be one in which asthma is experienced
for the first time, the liability of the patient to this affection is  known.
  The discrimination from acute bronchitis of the larger tubes with collapsed
lobules or broncho-pneumonitis  is more  difficult.   The  differential  diagnosis
must  be based on the greater gravity of the  symptoms, the clearness of the
resonance on percussion, and the diffusion over both sides of the subcrepitant
rales  in cases of capillary bronchitis.
  Extensive broncho-pneumonitis supervening  upon capillary  bronchitis  of
course increases the gravity of  the  local symptoms and the danger.  A rise
of temperature to 103° or 104° renders this complication probable, but by no
means certain, for, exceptionally, these temperatures are observed in cases of
capillary bronchitis without the pneumonic complication.  The occurrence of
the latter cannot always be ascertained  by means  of physical  signs.
  Pleuritis with  large  effusion  may give rise to accelerated breathing, livid-
ity, etc., but this affection is readily excluded by the  absence  of the signs
denoting the accumulation of  liquid in the  pleural cavity.
  Capillary bronchitis  occurs  especially in young children, and next  in fre-
quency  in  the  aged,  but it is occasionally met with in adults.   It  is  always
a disease of gravity, but  particularly  so at  the two extremes of life.   In
young children and  the  aged  it  proves fatal in a very large  proportion of
cases.  It  destroys  life in some  cases rapidly.   I have  known it to prove
fatal  in less than twelve hours after  the symptoms  denoted gravity of dis-
ease.   The  average  duration in fatal cases in  children is from three to five
days.  The duration is longer in adults, and  the  disease is much  less grave
after  childhood  and during middle age.   In cases ending in recovery, conva-
lescence becomes established after  a duration varying  from a week  to two
weeks.   Happily, it is by no means  a disease of frequent  occurrence even in
young children.   In the mode of dying apnoea  predominates;  and the prog-
ress toward a  fatal termination is denoted  by  increasing lividity, the pulse
becoming more and more frequent and feeble, the skin  covered with clammy
perspiration, the  labor and frequency of the respirations, together with cough
and  expectoration, diminishing  toward  the  close of life from muscular  pros-
tration.   Thrombosis, or the  formation of  a clot in the  right side of the
heart, is an occasional accident which  may  prove the immediate cause  of
death.

  Treatment.—Bloodletting  may  be employed at the  onset under those
conditions by which  the  employment  of this remedy in other  inflammatory
affections is to be regulated.  It is not admissible in young or feeble subjects,
and in employing this or any other debilitating measure the physician should
not lose sight of the fact that it is important to economize the strength of the
patient in order that  the laborious efforts of  breathing  may be  carried on for
a length of time sufficient for the resolution  of the disease.  The danger and
distress incident to the disease  arise chiefly from  the deficiency of  fresh sup-
plies  of air in the air-cells ;  and if bloodletting be injudiciously  practised, the
patient  suffers  from  the  want  of both  blood and air.   The importance  of
economizing strength should also enforce circumspection in the use of saline
depletants and sedative remedies.   These should not be pushed to  the extent
of producing prostration.   The difficulty consists in  mechanical obstruction,
which neither these nor any therapeutical measures will immediately remove.
The safety of the patient depends  on the maintenance of life until the disease
passes through its career.   The inhalation of oxygen affords marked relief 
228
BRONCHITIS.
of the dyspnoea.   Breathing warm vapor is not only highly useful as a palli-
ative  measure, but it does  not a little toward promoting resolution  of the
inflammation.   It  should  form an important part of the treatment; and  the
most  effective  method is to keep the atmosphere of the room constantly and
abundantly charged with  steam during the course of the disease.  Water in
several vessels should be  kept at the point of ebullition by means of heat in
fireplaces, stoves, or burning gas.  The temperature of the room should be
kept at a high  point,  85°  to 90°.   The iodide of potassium should  be given
freely.
  Emetics in young children are advisable for a reason already stated—namely,
to supply the want of voluntary efforts of expectoration.  Care, however, is
to be taken not to  repeat  them so often as  to occasion  exhaustion.   The  use
of apomorphia has been  already referred to (p. 225).   Laxatives are useful
by diminishing the contents of the intestines, and thereby giving space for
more effective action of the diaphragm  in respiration.   Revulsive applications
to the chest are useful, but blisters are of doubtful utility.
  The great object being to carry the patient safely through the disease,  sup-
porting measures are early indicated, and they are important in proportion as
the symptoms denote failure of the vital powers.


                 Epidemic Bronchitis—Influenza.

  For the last four or five centuries medical observers  have noted the  occur-
rence from time to time of an epidemic affection characterized  by bronchitis.
In most countries  it is commonly known by the name  influenza, after a term
introduced by the Italian writers in the  seventeenth century.  In  France it
is called la grippe.   As an  epidemic  it is  remarkable for its  extensive and
rapid diffusion, sometimes extending within a brief period over many different
and widely-separated  countries.  During its prevalence a vast number  of per-
sons of all ages are simultaneously affected.   In some epidemics the fatality
has  been  large, but  in most fatal cases other affections are  developed, espe-
cially the so-called capillary bronchitis and broncho-pneumonitis.  The fatal-
ity is limited chiefly to the aged and to persons with feeble constitutions.
  The inflammation of the nostrils which usually precedes the bronchitis often
extends into the frontal and maxillary sinuses, to the lachrymal ducts and
conjunctiva, and into the Eustachian tube.   Frontal headache is a prominent
symptom.  Epidemic bronchitis is accompanied by more marked  general symp-
toms than the sporadic form—namely, chills, pyrexia, lassitude, debility, ano-
rexia, etc.   In the epidemic  much oftener than in the sporadic affection the
general symptoms seem to be out of proportion to the bronchial affection, and
to denote an essential fever rather than a purely local disease.  It often ends
in free perspiration or with diarrhoea.
  A special cause is involved in the production of this as of every other epi-
demic disease.  The nature, source, and mode of action of the special cause
are not established.   It has been attributed to ozone in  the atmosphere by
Schoenbein and others, to  animalculae by Holland, and to cryptogamic produc-
tions by the late Prof. J. K. Mitchell.   The  special cause doubtless exists in
the atmosphere, and is independent of appreciable atmospheric changes. This
fact  was exemplified in the Massachusetts General Hospital during the exten-
sive  prevalence of this epidemic in 1832.   Nearly all the patients in the hos-
pital were affected, although the wards were kept day and night at a uniform
temperature.   Being an infectious disease, the parasitic doctrine not only
offers a rational view  of its etiology, but, reasoning from analogy, is a  logical
inference.
  The disease  is  generally mild, but,  as already stated, it is  liable to lead to 
            BRONCHITIS WITH FIBRINOUS EXUDATION.        22(J

the development of local affections other than bronchitis, and may in this way
prove fatal.  Gairdner's observations go to show that  during  the prevalence
of influenza other diseases are usually severe, and that the rate of mortality
from all diseases is increased.   The duration of an attack of influenza is from
three to six days.
   In  the treatment  of epidemic bronchitis bloodletting  is rarely  if ever
required.   In healthy, vigorous subjects brisk  purging has seemed  to  me
useful.   This should not be resorted to if the patient be feeble or advanced
in years.   Aside from  purgation, diaphoretic remedies and opium will meet
the therapeutic indications.    Associated affections claim appropriate  treat-
ment, but debilitating or depressing measures are to be employed with greater
circumspection than if the affections were primary.  In  aged and feeble per-
sons tonic and supporting  measures may be  highly important.  The remarks
in reference to the disinfectant treatmenf of sporadic  bronchitis (p. 223) are
of course applicable  to  influenza.


             Bronchitis with Fibrinous  Exudation.
   A variety of bronchitis  is  characterized by a fibrinous exudation on  the
inflamed mucous  surface.   This characteristic  feature  is expressed by  the
names  diphtheritic, pseudo-membranous, plastic, croupous, or croupal, which
have been applied to it.  It is frequently associated with inflammation of the
larynx  and trachea, attended with a  similar exudation, constituting the affec-
tion known commonly as  true croup and occurring also in certain cases of
diphtheria.   But  reference is here made to bronchitis with this  peculiarity
occurring independently of a similar affection  of the  larynx  and trachea.
Exclusive of the  cases in which it accompanies  croup and  diphtheria, it  is  a
rare variety of bronchitis.   The exudation is similar to that in the bronchitis
secondary to croup.  It forms a dense membraniform layer, which at first is
closely  agglutinated to the mucous surface, but  sooner or later, loosened and
detached by a suppurative process, is expectorated.  When expectorated, the
false membrane, as it is called, either has the form of  patches or strips, or it
is thrown off entire from portions of the bronchial tubes, and when carefully
displayed may be found to consist of casts representing more or  less of  the
bronchial subdivisions.   Aside from the form of casts  of the tubes, the fibrin-
ous character of the expectorated matter may be ascertained by microscopical
examination and by chemical reagents.  It  presents the fibrillae which charac-
terize exuded fibrin in other situations.   Placed  in a solution of acetic acid,
it becomes swollen, whereas mucus contracts and is  thereby rendered  more
dense.
   The fibrinous casts are expectorated in a globular mass enveloped in mucus,
and without close examination they are liable to be overlooked.  When  the
mucus is carefully removed, the casts, displayed in liquid, sometimes represent
a bronchial stem of considerable size with subdividing branches which have
extended to the smallest ramifications.  These exudative casts are to be dis-
tinguished from those produced by the coagulation of  blood within the  tubes
in some cases of bronchorrhagia.  The latter do not, like the former, present
lamina*  or  concentric layers, and the}* contain blood-corpuscles in greater or
less quantity.   They are of course preceded by  haemoptysis.
  The inflammation in cases of bronchitis with fibrinous exudation is either
acute, subacute, or chronic.   Occurring in young  children, it may  occasion
sufficient obstruction  to seriously compromise respiration,  and  it frequently
proves fatal.  Affecting adults, however, if not complicated with other grave
affections, it rarely destroys life, and in the majority of cases the recovery is
complete.   I  have met with a case in which it was associated  with  asthma 
230
BRONCHITIS.
and emphysema.  Fibrinous bronchitis has been associated in many cases with
phthisis.  I have  known  it to occur in connection with acute lobar pneu-
monitis.
  There are  no symptoms or signs by means of  which the diagnosis of this
variety of bronchitis can be made out  prior to the  expectoration of false mem-
brane or bronchial  casts.   When  this occurs the character of the affection is
of course manifest.  This expectoration is preceded and accompanied by vio-
lent  paroxysms of coughing.  It is followed by a muco-purulent expectora-
tion, which may be bloody.   The symptoms are relieved by the removal  of
the fibrinous exudations or casts.  The  expectoration of the  latter may be
repeated after intervals of days, weeks, months, or even years.  The charac-
ter of the disease, if it prove fatal before  the expectoration  of false mem-
brane takes place, may be suspected, but the symptoms and signs show only
the existence of bronchitis with  obstruction of bronchial tubes and perhaps
collapse of pulmonary  lobules.   This  variety of bronchitis sometimes recurs
repeatedly in the same person.   I have met with cases in which a large num-
ber of bronchial casts  (forty or fifty) were  expectorated at as  many different
times.
  The principles of treatment are essentially the same as in  cases  of acute
or chronic bronchitis  without this peculiar  feature, and they need not  be
separately considered.   Warm  vapor or spray inhaled will aid in  the sepa-
ration  of the false membrane.


                    Circumscribed  Bronchitis.
  As already  stated,  bronchitis when  circumscribed is incidental  to some
other pulmonary  disease.  It is developed in pneumonitis, being limited to
the lobe or lobes affected,  and is the chief source  of  the expectoration in this
disease  if it  do not go on to the suppurative stage.  It occurs in pulmonary
phthisis, and is limited to the tubes in  proximity to the seat  of the  deposit
of tubercle.  The  bronchitis in this disease furnishes the expectoration prior
to the softening and discharge of the tuberculous product.  As thus developed,
bronchitis claims no special attention in  a therapeutical point of view.


             Chronic Bronchitis—Fetid  Bronchitis.
  Chronic bronchitis may follow the acute form or it may be  subacute from
the beginning.  It is far less frequent than acute bronchitis. It occurs much
oftener in aged persons than during the  early and the middle  period of life.
It is associated with asthma, pulmonary emphysema, and cardiac lesions, espe-
cially those involving mitral stenosis or incompetence of the mitral  valve.
  The hyperaemia  is less intense than in  acute bronchitis.  The color of the
mucous membrane may be bluish-red or it may be  grayish or slate-colored.
The morbid products upon the'membrane are similar to those in acute bron-
chitis, but usually with greater predominance of mucus.  More  extensive
changes, however,  may occur in  the bronchial wall.   This, on  the one hand,
may become  thickened by the  development of new  connective tissue, or it
may become  thinned in consequence of atrophy of the connective tissue  and
muscular fibres.  With the production of new connective tissue little papil-
lary excrescences are  often  formed upon the mucous membrane.   In conse-
quence of loss  of elasticity of the bronchial wall  from destruction of its elas-
tic fibres, in some cases there results dilatation of the tubes, or bronchiectasis.
The pulmonary tissue immediately  surrounding a  dilated bronchus is usually
indurated by increase of the interstitial tissue.  Three forms of bronchiectasis
may be distinguished—namely, the cylindrical, the fusiform, and the saccu- 
             CHRONIC BRONCHITIS—FETID BRONCHITIS.         231

lated.  Bronchiectasis may accompany simple chronic bronchitis, but  it is
more  likely  to be  produced  when  the  bronchitis  is associated  with some
affection  giving rise to  dyspnoea, such  as emphysema, old pleuritic thick-
ening with  adhesions, fibroid phthisis, etc.   Sometimes  one or  more large
cyst-like  cavities, with smooth walls lined by ciliated epithelium, are found
in the lung.  These are  bronchiectases, and may be sometimes  congenital.
  The symptoms  relating directly to the  bronchial inflammation  are essen-
tially the same as  in acute bronchitis, differing only in intensity; but con-
nected with these symptoms frequently are others proceeding from associated
affections.
  Pain is generally wanting,  or the patient complains only of  a sense  of
uneasiness or constriction beneath the sternum.   If cough be frequent and
violent, soreness may be felt at the  base of the chest on both sides or at the
epigastrium, due to the traction of the diaphragm on the ribs.  Febrile move-
ment is slight or wanting.  A  slight  exacerbation of fever at night  is observed
in some  cases.  The appetite may continue  good  or it  may  be  more  or less
impaired.  The nutrition is frequently not much if at all affected.  The loss
of weight with the continuance of the disease is not marked, as it usually is
in cases of pulmonary phthisis.   The patient usually does not present pallor
or a notably morbid aspect.
  More  or  less  cough always exists.  In frequency and severity it varies
much in  different cases.   It is paroxysmal, violent, and difficult in proportion
to the small quantity and tenacity of liquid products within the affected tubes
and in proportion as the smaller tubes are involved.   The expectoration also
varies much in different cases. It is sometimes abundant, consisting of mucus
with serous transudation.  When the latter  is copious the affection has  been
called bronchorrhcea.  It may consist of  large, solid, greenish or  ash-colored
sputa, and in some cases small pearl-like masses are raised after much cough-
ing.  In cases  characterized  by the latter the disease has been called, after
Laennec, dry catarrh.   The sputa may at  times be streaked with  blood.   In
general the  expectoration is muco-purulent,  the purulent characters not infre-
quently  predominating,  and  sometimes it  appears to consist  of pure pus.
Formerly it was thought to be highly important to determine whether the
expectoration were purulent  or not, the presence of pus being supposed to
denote something more than bronchitis.  This is now deemed a  point of com-
paratively little importance since it  is ascertained that pus is  formed on a
mucous  surface.   A very copious expectoration of pure pus, however, does
point to  some other source than bronchitis, such as the discharge  of  a tuber-
culous abscess, the  third stage of pneumonitis, abscess of the liver, evacuating
through  the  lung, empyema with perforation, etc.  The diversified characters
which belong to the expectoration in different forms of the disease are of less
value in  a diagnostic view than  was  formerly supposed, since the  knowledge
which has been acquired of physical signs furnishes a far more reliable source
of information respecting intrathoracic conditions.  The  obvious  differential
characters by which mucus and pus  may be  distinguished from each other are
as follows:  Mucus  is transparent  or semi-transparent;  it  is  more  or less
viscid; it is stringy and  not  miscible with water ; it retains bubbles of air,
and  consequently floats on water.   Pus is opaque, less viscid  than mucus,
miscible  in  water, and in  water it  sinks to the bottom.  These  differential
characters are  combined  in varying proportions when  the matter of expec-
toration  is muco-purulent,
  The matter of  expectoration in  some cases of chronic,  as also of acute
bronchitis, is notably fetid, having the  characteristic  odor of decomposed
animal substances.   The affection is then said to be fetid bronchitis.  _ Gener-
ally, this characteristic fetor denotes either gangrene of lung, bronchitis with 
232
BRONCHITIS.
 dilated bronchial tubes, or decomposition of matter within phthisical cavities ;
 but it may occur independently of any of these conditions.  Gangrene may
 be excluded by the absence, on microscopical examination, of any appearance
 of expectorated pulmonary tissue, and dilated  tubes  by the absence of the
 signs of that physical condition.  The diagnosis is to be made by excluding
 these diseases, together with pyothorax and perforation of  lung, the expecto-
 ration in the latter sometimes having a notable degree, of fetor.  The expla-
 nation of fetid bronchitis is that circumstances pertaining to morbid products
 within  the  tubes  are favorable for the  action of the putrescence-producing
 bacteria derived from the atmosphere.   These bacteria, together with acicu-
 lar  crystals of the fatty acids, are found in the sputum, particularly in  little
 whitish particles present therein.
   Chronic bronchitis of course involves the same causes as the acute in the
 cases in which it is preceded by the latter.   It  may be  produced and main-
 tained  by the inhalation of irritating  particles of stone or metal in the exer-
 cise of certain occupations.   Its  continuance  in some cases is referable to
 organic affections of the heart, consisting of obstructive or regurgitant mitral
 lesions.  These act by inducing  pulmonary congestion.   It is  an  affection
 incident to  old age, occurring without any obvious  causative  agencies.  It
 occurs in  youth and middle age irrespective of apparent causes, and is often
 associated with asthma and emphysema.   To these affections it stands in the
 relation of a cause rather than an effect.   In cold latitudes it  is sometimes
 manifestly dependent on climatic causes, recurring with  each successive  win-
 ter, and disappearing  during  the  summer season or on removal to  a warm
 climate (" winter cough ").
   It is not an  affection which tends directly to destroy life.  In the  aged it
 may sometimes predispose  to the  development of capillary bronchitis, and
 thus indirectly prove  serious.   In  connection with the  feebleness of advanced
 years  it may lead to  collapse  of pulmonary lobules, and in this way shorten
 life.  Its  existence in a  patient prostrated with any  other disease  involves
 danger from  the accumulation of morbid products in the  bronchial tubes.   It
 may lead  to  the development of asthma and pulmonary emphysema—affec-
 tions which, although  not  immediately dangerous, diminish the  duration of
 life.  Aside from these contingencies,  the evil to be apprehended is  the  per-
 manency of the affection.   It is liable to become established, persisting for
 years, and in aged persons for the remainder of life.   The existence of chronic
 bronchitis does not involve an increased liability to the development of  pul-
 monary phthisis.
   The diagnosis of chronic bronchitis involves discrimination from pulmonary
 phthisis.  This would be difficult, and sometimes impossible, were the inves-
 tigation to be  limited to the symptoms;  hence before  physical  signs were
 studied these two  affections were of necessity confounded.  The importance
 of  the  discrimination is obvious in view of the great difference  between the
 affections  as  regards  prognosis.   The  differential diagnosis is to be based on
 the absence of the symptoms and signs which are diagnostic of phthisis.   In
 other words,  it is concluded that the latter does not exist, from  negative evi-
 dence or reasoning by way of exclusion.  The absence of symptoms which
 belong to  the clinical history of phthisis is also to be considered, such as  pro-
 gressive marked emaciation, haemoptysis, and accelerated breathing.   These
 symptoms are  wanting in chronic bronchitis.   The physical  signs  in  this
 variety of bronchitis are the same as in the acute form—namely, the presence
 of dry and moist bronchial rales,  the  resonance on percussion and the vocal
resonance  unaffected,  and the respiratory murmur weakened and sometimes
suppressed over a portion of the chest from temporary obstruction of bronchial
tubes, but its characters, aside from weakness, unchanged.  The parasitic  doc- 
            CHRONIC BRONCHITIS—FETID BRONCHITIS.         233

trine of phthisis has  rendered  the microscopical  examination of the sputum
important in the differentiation  of this affection from chronic bronchitis. The
absence of the bacillus tuberculosis in a single specimen, however, is not suf-
ficient to exclude phthisis, but  the  negative  result in repeated examinations
goes far toward the  exclusion of  that  disease.
  The coexistence of pulmonary emphysema is to be determined by symptoms
and  signs diagnostic  of this affection, which will  be  considered in the next
chapter.
  In the treatment of chronic bronchitis bloodletting or other depletory meas-
ures are never indicated.   The affection  seldom  exists under circumstances
which render it desirable to  lower the powers of  life.   Counter-irritation  by
means of  croton oil or stimulating liniments is sometimes useful.  The diet
should be nutritious, but not stimulating, consisting of milk, eggs, fowl, fish,
and  farinaceous articles.  Meat, however, is  not to be interdicted if the sys-
tem be enfeebled.   Wine  and alcoholics are to be avoided, except when meas-
ures to support or strengthen  the  system are indicated.  Attention to the
surface of the body is important,   In  a cold or variable climate woollen or
silk  garments should be worn next  the skin.   An undergarment of buckskin
or chamois leather, worn over light woollen or silk, affords during cold weather
great protection and  saves the inconvenience of an undue quantity of cloth-
ing.   The object is to secure uniformity of the temperature of the surface and
to maintain the functions  of  the skin.
  Medicines may be employed  with a view to palliation and cure.  If  cough
be troublesome, exceeding that required for expectoration, soothing remedies
are called for.  Opium, however, is to be  prescribed with circumspection ; in
the first place, lest the habit of using it be formed—a consideration to be taken
into account in all chronic affections ; and  in  the second place, in feeble sub-
jects and under circumstances in which there may be  danger from an accu-
mulation in the bronchial tubes, serious consequences may follow blunting that
sense of the presence  of morbid products which induces acts of expectoration.
Moreover, the use of  opium tends to impair the digestive powers.  For these
reasons other anodynes, such as hyoscyamus, conium, belladonna, and hydro-
cyanic acid, are generally  to  be preferred.
  As a rule,  the  remedies which are  called expectorants are not indicated.
The nauseant  expectorants do harm by their depressing effect and by disturb-
ing the appetite  and  digestion.  The stimulant expectorants, such as squills,
senega, etc., are of doubtful  efficacy, and if not useful  are more  or less
hurtful.
  Certain remedies, however, sometimes exert a curative effect.   The iodide
of potassium (or the iodide of ammonium) is one of these, and perhaps the one
most  likely to be  successful.  Five or  ten grains three or four times  daily
may be given at first, and before abandoning the remedy as useless the dose
should be  increased to the  limit of tolerance.  This  remedy is  not  always
tolerated even in moderate or small doses, and it is by no means always suc-
cessful, even when  large doses occasion no inconvenience.   The muriate  of
ammonia is in some cases a  curative remedy.   I  have known it to  effect a
prompt  cure,  the  disease having  existed for ten years.  The chlorate  of
potassa, half an ounce of a saturated solution given twice or three times daily,
in some instances  proves  highly useful and may  effect a cure.  The  balsam
of copaiba is  a  remedy the value of which in this disease  is not generally
appreciated.  It  has no value in certain cases, but its curative effect is some-
times so marked that it would  seem to  be almost a specific remedy.  The
spirits of turpentine occasionally prove  equally efficacious.  A good method
of giving  the latter is in what the late  Prof.  Clark of Boston  called the con-
tinuous  dose—namely, a drop in an emulsion every one or two hours through- 
234
BRONCHITIS.
out the day.  Other balsamic remedies, the balsams of Tolu, Peru, and sandal-
wood, are among the curative remedies, to which are to be added tar and the
compound tincture of benzoin.  The bromine  salts  are to be mentioned  as
useful remedies.   This  list might be  extended.  As  an illustration of the
great number of remedies which have  been found useful in bronchitis, the
National Dispensatory enumerates under  this head one hundred and twenty-
two  articles.
  Frequently, marked benefit as regards the bronchitis is derived from tonic
remedies in conjunction with measures to invigorate the  system.   The salts
of quinia and the  preparations of  iron  are  often highly useful.   These and
other tonic remedies  are indicated if the powers of the system be  reduced  or
the patient be anaemic.  A generous diet is to be conjoined, and wine or alco-
holics  may be  taken moderately with  advantage.  Out-of-door life in such
cases should be added.   This plan  of treatment is applicable to a pretty large
proportion of the  cases of chronic bronchitis;  and  to improve the general
health and restore vigor are important  objects in the treatment of this  as
of any other  chronic local  affection.
  It is an object of treatment in some cases to diminish the amount of expec-
toration when  this is excessive.   For  this  end astringent remedies may  be
prescribed, such as tannic acid, the persulphate or pernitrate  of iron, and the
preparations of zinc.  After a bronchitis, however, has become habitual, espe-
cially in the aged,  it sometimes appears to be, as it were, an element of health.
At  all events, patients complain of  the discomfort arising from the suspen-
sion or diminution of the  expectoration, and for this  reason opiates do not
afford  relief.    Under these  circumstances  expectorants  are useful  as pal-
liatives.
  The inhalation of  the spray from medicated liquids,  produced by an atom-
izer, may be  resorted to for several objects.   A solution of the astringent
remedies just named may sometimes be useful  as a topical application in the
form of a spray, with a view to diminish  profuse expectoration.   Oftener it
is an object to  facilitate expectoration.   Spray from a solution of the muriate
of ammonia—gr. j to gr. xv to the  ounce—is useful in  this way.  Opium and
other narcotics brought into direct contact  with the affected membrane may
be of service by allaying the irritation which occasions troublesome superflu-
ous cough.   The vapor of tar is a soothing application.   In fetid bronchitis
antiseptic inhalations are indicated.  For this object the vapor of the oil  of
turpentine—a  solution of carbolic acid from gr. j to grs. iv  to the ounce, in
the  form of  spray—may be inhaled, or  a similar strength of a solution  of
permanganate of potassa.  The bisulphite of soda in scruple doses, given every
two hours by the mouth, is an efficient  antiseptic.  Medicated spray is to  be
employed with care as regards the strength of the solutions atomized and the
frequency or continuance of the inhalations, bearing  in mind that remedies
held in solution pass rapidly into the blood  and may produce toxic effects.
  Change  of climate is sometimes  advisable.   A removal from  a cold and
variable climate to a situation in which the temperature  is mild and equable
may be attended with marked relief, and perhaps lead  to  recovery.  Benefit
may be looked for especially in  the  cases in which there is either immunity
from the disease or marked amelioration during the summer season. 
                             EMPHYSEMA.                         235




                        CHAPTER  X.

    EMPHYSEMA  OF THE  LUNGS.—ASTHMA.—PERTUSSIS.

Emphysema of the Lungs:  Varieties; Anatomical Characters; Clinical History; Patho-
   logical Character; Causation; Diagnosis; Prognosis; Treatment.—Asthma: Clinical
   History ; Pathological Character; Causation;  Diagnosis;  Prognosis ; Treatment.—
   Pertussis, or Whooping  Cough.

                            Emphysema.
    EMPHYSEMA in general signifies  the presence of air in  the  interstitial
     connective tissue.  In the lungs,  however, it is necessary to distinguish
two  kinds of emphysema.  In  one form there  is an escape of air  into the
interlobular and  subpleural  connective  tissue.   This form is analogous to
emphysema in other situations, and is  called interlobular or interstitial emphy-
sema.   The other and the more common variety is called vesicular emphysema,
and consists in an abnormal accumulation of air within the air-cells,  whereby
they become distended and their walls  often atrophied.
   Interlobular emphysema  arises from rupture of the  air-cells,  causing a
communication between them and  the interlobular connective tissue.  This
sometimes follows perforating wounds  of the  chest or injury  of the lung by
the extremity of  a fractured rib.  It may also result from violent  paroxysms
of coughing, as  in whooping cough, especially when  the  lung has been pre-
viously affected with vesicular emphysema.  Its favorite situation is the ante-
rior  border  of the upper lobe.   Just  beneath the pleura little air-bubbles,
often arranged like  rows of beads, can  be  seen  in the  course of the  septa
between the lobules.   The air sometimes detaches the pleura so as to form air-
blebs of considerable size.   A  subpleural  air-tumor may be  as large as  an
English walnut or even larger.  Bouillaud has reported  a case in which  an
air-tumor existed as large as the stomach.   It is important not to mistake  for
interlobular emphysema a post-mortem  generation of gas in  the  interstitial
tissue of the lungs as a  result of decomposition—a condition not infrequently
found after death.  In rare cases the subpleural air-blebs  rupture during life,
and  pneumothorax,  with or without  pleuritis,  results.   Another very rare
occurrence is the passage  of the air from beneath the pleura along the root
of the  lung  into the connective tissue of the mediastinum, and thence into
the subcutaneous tissue of the neck.   In this way the emphysema may
become diffused over more or less of the  body.
   Vesicular emphysema—and this is usually meant when the term  pulmonary
emphysema is used—may occur as an independent affection preceded or accom-
panied by chronic bronchitis.  This is known as substantive  or idiopathic emphy-
sema, in distinction from vicarious, compensatory, or symptomatic emphysema,
the latter terms being applied to an abnormal  accumulation of air in the air-
cells of certain portions of the lung when  the  penetration of air into other
portions has been obstructed ; as,  for  instance, by pneumonitis, tuberculous
deposits, tumors, effusions in the pleural cavity, pleuritic adhesions, occlusion
of the bronchi, etc.   Vicarious emphysema does not necessarily appear in  the
immediate neighborhood of the obstructed alveoli.  Like all forms of emphy-
sema, it affects  most frequently the anterior borders and  the  upper  lobes  of
the lungs.  When one  lung is compressed or hepatized the other is  often
emphysematous.
   The names acute emphysema and insufflation are given to a dilatation  of 
236   EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

the air-cells frequently met with in the lungs of those who  have suffered
from  severe dyspnoea during the last days or hours of life.   It is usually
observed in the  apices and the borders  of the lungs.   The  air-cells may
be  dilated  to  twice  their  normal volume.   The  elasticity of  the alveolar
walls  is impaired, but  in distinction from  chronic  emphysema  they present
no evident  structural changes.  Acute emphysema or insufflation of the lungs
accompanies chiefly acute diseases of the respiratory organs or other diseases
terminating rapidly with dyspnoeic symptoms.  It is due to repeated forced
inspiratory efforts.
  In  a well-marked case  of chronic vesicular emphysema the  lungs  are
enlarged.   Upon  opening the chest they do not retract like healthy lungs,
but remain in  contact along their anterior borders, so that the pericardium
may be covered.   Their contractility is impaired.  The diaphragm may be
pushed down  to  the seventh or eighth rib, and the  adjacent viscera  corre-
spondingly displaced.   The heart is pushed downward and backward, and in
consequence of hypertrophy and dilatation  of the right ventricle, which are
usually present, extends farther to  the  right than normal.  The borders  of
the lungs  are  rounded  and puffy; the emphysematous portions do not crepi-
tate upon pressure or incision, as do normal lungs, but have a soft, cushiony
feel.  The  imprints of  the  fingers remain a long time.   The lungs  appear in
general pale, anaemic, and  dry, but often present patches and striae of black
pigment.    The dilated air-cells  can  be  distinguished with the naked eye.
The air-spaces, much  larger than a pin's  head, are the result of rupture of
the interalveolar  septa and coalescence of  the air-cells.  Such air-spaces or
blebs  frequently  attain the size of a pea, and they may be  considerably
larger.  Large air-blebs, from the size of  a pea to that  of a pigeon's egg,
sometimes  project above the lung-surface, and  may become so detached as
to be pedunculated.   Upon microscopical examination  it is  seen that  the
dilatation  begins  in  the alveolar passages  and infundibula.  They become
expanded and  the alveolar septa are less prominent.  The alveolar  walls  are
thinned, and finally become perforated, at first usually in their centres.  The
holes  between the alveoli enlarge, and the  air-cells coalesce, so that by con-
tinuation of the process larger and smaller air-sacs are formed.   The process
appears to  be a gradual atrophy of all of the elements composing the alve-
olar walls.   The finer elastic fibres early disappear, the  larger ones diminish
in size and frequently rupture, and the capillary network becomes  coarser by
obliteration of a  certain number of capillary vessels.  This destruction  of
pulmonary capillaries  is  not  attended with hemorrhage, as the  vessels
become impermeable before they disappear.  The most important symptoms
of emphysema are referable to this loss of  pulmonary blood-vessels.  A par-
tial compensation for this  disturbance of  the pulmonary circulation  exists
in the anastomoses between the pulmonary and the bronchial and  subpleural
vessels.  Fatty particles are often found in  the alveolar walls, probably from
fatty  degeneration of the  alveolar epithelium and  of the  capillary endothe-
lium.   An apparent thickening of the alveolar  walls may result from their
being compressed and  crowded together by dilated air-vesicles.   Rindfleisch,
however, claims to have seen an actual hypertrophy of the  smooth muscular
elements which, according to him, exist in the alveolar w*alls.  There is noth-
ing in the pathological appearances of chronic emphysema which supports
the view, otherwise not improbable, that a primary vice of nutrition in  the
alveolar walls  antedates the development of the emphysematous condition in
many cases.   Substantive  emphysema is most developed in the upper lobes
and along  the anterior borders of the lung, also along the lateral  borders of
the base of the lung; but  it may be diffused over the whole lung-surface and
in its substance.  It is accompanied by chronic  bronchitis, which may either 
EMPHYSEMA.
237
precede or follow the emphysematous condition.   The bronchial mucous mem-
brane is  coated with muco-pus, the bronchial wall may be thickened,  and
sometimes  dilatations of the bronchi are present,   In  consequence of the
obliteration of pulmonary capillaries there is obstruction to the flow of blood
through the lungs, leading to hypertrophy and dilatation of the right ventri-
cle, and frequently to venous congestion in the  various viscera.  The enlarge-
ment of the heart is compensatory so long as hypertrophy predominates over
dilatation ; but it becomes  a source of grave  consequences when the latter
predominates, giving rise to chronic congestions of  the liver, spleen,  kid-
neys, stomach, and  intestines.    These conditions are similar  to  those  met
with in valvular  lesions of the heart, and  will be more fully described in
another connection.
   The emphysematous condition, especially  in vicarious  emphysema, may be
limited to a few vesicles.   Its practical importance of course depends upon
the extent of lung  involved.
   A pathological condition of  the lungs which  bears little resemblance to
true emphysema has  received  the  name  of senile emphysema.   It  is  also
called  senile atrophy of the lungs.   Here,  instead of an abnormal accumu-
lation  of  air  in  the lungs, these organs are  smaller and contain less  air
than normal.   In consequence  of atrophy of the alveolar  walls the air-cells
coalesce  and form  larger air-spaces.   These, however, do not result  from a
dilatation of the  alveoli, but from a gradual shrinkage and disappearance of
the lung-tissue.  These atrophic lungs are usually deeply pigmented, and take
up less space than normal in the thoracic cavity.  Senile atrophy of the lungs
does not lead to hypertrophy of the right ventricle.

   Emphysema developed in a person free from tubercle undoubtedly dimin-
ishes the liability to tuberculous disease.  The two affections are rarely asso-
ciated, exclusive  of  the cases in which pulmonary lobules in the  vicinity of
tuberculous deposits become secondarily emphysematous.   In these cases the
emphysema is vicarious.  A reason for the protection against tubercle afforded
by emphysema may perhaps be found in the diminished quantity of blood
within the emphysematous portions of lung, and  in  the fact that the  por-
tions affected with  emphysema—namely, the upper lobes—are the primary
seat of tubercle in the immense majority of cases.   The condition of emphy-
sema is also, to some extent, incompatible with haemoptysis.  Pneumonitis, as
a rule, is  not developed in an emphysematous patient.   I have met, however,
several exceptions to this rule.

   Clinical History.—Emphysema, existing to  an  extent to  compromise
 considerably the  respiratory function, is characterized by habitually  labored
 breathing  and inability to take active exercise without suffering from want
 of breath.  The labored breathing is manifested especially in expiration.  The
 rhythm of the respiratory acts is altered; the inspiration is shortened and the
 expiration prolonged.   As chronic bronchitis  generally coexists, cough and
 expectoration  are  habitually more or less prominent  as  symptoms.   The
 cough is usually violent, paroxysmal, and  characterized by a series of pro-
 longed, spasmodic expiratory efforts, as in whooping cough.  The expectoration
 varies much in different cases as regards quantity and  character.  The acts of
 expectoration are difficult, and the sputa are frequently accompanied by an
 abundant, frothy, serous liquid resembling soapsuds.   Not infrequently sputa
 streaked with blood are expectorated.
   The affection is chronic and unaccompanied by fever.  The pulse is feeble
 and the body cool.   Owing to an accumulation of blood within the right cav-
 ities of the  heart, the surface  of the  body presents venous congestion, and 
238    EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PERTUSSIS.

this, together with deficient oxygenation  of the  blood, may give rise to a
cyanotic  hue.  In  extreme cases lividity is  marked.   The paroxysms of
coughing are accompanied with great congestion of the face and turgescence
of the cervical veins.   Symptomatic  phenomena, aside from those referable to
respiration  and circulation, are accidental.   The appetite and digestion may
not be notably impaired;  the body for a  considerable period may be well
nourished,  but after a time slow, progressive emaciation takes place.   The
countenance  has  an expression of distress which, conjoined with tumidity
and a dingy or livid hue, renders the physiognomy somewhat characteristic.
At an advanced period anasarca may occur as  a consequence of  dilatation of
the right side of the  heart.  Albumen in small  quantity  may be found in
the urine,  this being  an  effect of congestion  of  the  kidney ;  and conges-
tion  of the  liver and  spleen may  render these  organs  appreciably  larger
than in health.
   These  symptoms  accompany the affection when  it exists to an extent to
considerably  compromise  respiration.   Existing  in  a moderate  or  slight
degree, there is  no habitual want of breath or labor of breathing.  But the
respiration is disturbed by active exercise; the patient is short-winded on
attempting to run or walk fast; and this difficulty is apparent also in  speak-
ing, singing,  and  especially in  paroxysms of laughter.  Cough  and expecto-
ration  are usually present, having the same characters as when  the affection
exists to a  greater extent, but  less marked.   Congestion, tumidity, and lividity
are present—not habitually, but during paroxysms  of coughing or any violent
physical  exertion.  The functions of the  body generally may present little
or no disturbance.  Different cases exemplify all gradations between the two
extremes as regards the symptoms belonging to the affection.
   Many  persons affected with emphysema are subject to paroxysms of labored
respiration and dyspnoea which are due  to another  affection—namely, asthma.
Acute ordinary bronchitis occurring in a  person  affected with emphysema
occasions symptoms of embarrassed respiration, which  do not belong  to the
clinical history of bronchitis occurring  in  a healthy person.  The reason of
this is to be found in the anatomical changes which characterize emphysema.
   The development of emphysema  is  generally slow.  In  the  majority of
cases the previous  history  shows the  origin  of  the affection,  as indicated
by deficiency of breath on exercise, to be dated back many  years,  frequently
extending to childhood, and not infrequently beyond the recollection of the
patient.  Exceptionally, it may be developed with rapidity.   Notable tempo-
rary emphysema  occurs in  paroxysms  of  asthma  and in cases of capillary
bronchitis.   The  affection  has  no  fixed duration, usually continuing and pro-
gressively increasing during the patient's lifetime.

   Pathological Character.—Exclusive of  the senile or atrophic variety,
emphysema involves permanent dilatation  of the air-cells, with, frequently,
more or less destruction of the cell-walls  and coalescence of the cells.  In
so far as destruction of air-cells takes place, it is obvious that the area of the
respiratory surface  is diminished,  and the function of respiration in this way
compromised.  The dilatation  of  the cells involves a loss of  the elasticity of
the lungs, so that the accumulation  of  air  within  the cells  offers an obstacle
to the  contraction of the chest in the act  of expiration.  Consequently, the
air in the cells is not sufficiently renewed for the purpose of respiration, and
the air stagnates  in the cells.   In these ways  the  affection  compromises the
respiratory function.   The distension of the cells involves pressure upon the
terminal  branches  of the pulmonary artery, and in this way the  pulmonary
circulation  is obstructed.  This obstruction is further increased by  diminished
respiratory function.  The obstruction to the pulmonary circulation occasions 
EMPHYSEMA.
239
an over-accumulation of blood in the  right cavities of the heart;  hence the
venous congestion of the  face  and neck, and, to a greater or less extent, of
the surface  generally, with, in some  cases, cyanosis.  Hence, too, sooner or
later supervenes dilatation  of the right side of the heart.
  The pathological character of emphysema furnishes an explanation of the
symptoms which make  up the clinical history  of the affection.  When the
respiratory function is so i'ar compromised that the functional capacity of the
lungs is insufficient, while the  respiratory acts  are performed without effort,
want of breath is felt and the respiration becomes labored.  But if the emphy-
sematous condition be slight or moderate, no difficulty is experienced habitu-
ally, because there is still functional capacity enough for ordinary respiration.
The quantity of lung in health exceeds the amount required, there being a
reserve provided for any unusual demand on the respiratory function,  as in
muscular  exercise.  If, therefore, the  extent to which the respiratory func-
tion be compromised do not exceed the amount of  lung held in reserve, no
difficulty is experienced save when an  extra demand is made on the function.
Under these circumstances exercise, which involves  an extra demand, cannot
be taken without the want of breath being felt.  The patient, who is habitu-
ally using the lungs to their fullest functional  capacity, is disturbed by any
interference  with respiration.   Ordinary bronchitis, which in  a healthy person
requires only a  little of the reserve lung to be brought into play (a fact of
which the patient is not conscious), occasions, if there be no lung in reserve,
difficulty arising from the slight diminution of the calibre of the larger bron-
chial tubes which is incident to this disease ; hence,  patients with emphysema
existing to much extent  suffer from dyspnoea and labored breathing in ordi-
nary bronchitis.   The cough  in  connection with emphysema arises from the
coexisting  bronchitis, and the difficulty of expectoration is in  consequence
of the impaired elasticity of the lungs, the expiratory efforts  in coughing not
being brought to bear readily on the contents of the bronchial tubes.
   The venous  congestion of the face  and of  the surface generally is due to
obstruction caused  by over-accumulation of  blood in the right cavities of
the heart.   The lividity is in a great measure due to the same condition, but
in part perhaps to deficient oxygenation of  the blood.  The smallness and
weakness of the pulse also proceed from an  obstruction to the free passage
of the blood through the pulmonary  circuit.

   Causation.—The mode in which dilatation of  the air-cells is  produced
has given rise to  much discussion. Laennec, who  was the first to describe
distinctly this lesion, attributed it  to obstruction of the bronchial tubes from
the products of bronchitis.   Regarding the inspiratory act as more powerful
than the expiratory, he supposed air to be forced through imperfectly obstructed
tubes in inspiration, and to remain imprisoned in the cells in consequence of
the want of  sufficient expulsive  force  in expiration.  The dilatation, accord-
ing to this theory, is produced by the rarefaction   of the imprisoned air by
heat, and by the reaction of the  force of expiration in coughing, etc.  upon
the cells already filled with  air.  This  theory  is certainly not tenable in view
of the fact that of the two  acts of respiration the expiratory is a third  more
forcible, and still more when voluntary and spasmodic efforts are brought to
bear upon it.   The more powerful the efforts  of expiration  in coughing, etc.,
the less ought to be the  liability of accumulation of air in the cells commu-
nicating with obstructed tubes.  An explanation of the mode of production
has been  advocated  by Gairdner  of Glasgow which differs  essentially from
the theory of Laennec.   Gairdner attributes  the affection  to obstruction of
bronchial tubes incident to  bronchitis ; but he supposes that the obstruction
from collections of plugs of mucus leads to collapse, instead of dilatation, of 
240   EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PERTUSSIS.

the cells  which communicate with the obstructed tubes, in the manner already
adverted  to in the chapter on Broncho-pneumonitis (p. 174).  The current of
air in the act of expiration may remove the mucus from its situation in tubes
of small  size into larger tubes, where the obstruction is less ;  but the effect
of the inspired current will  be to carry it back from the larger to the smaller
tubes, the mucous plugs thus  acting  like a ball-valve upon the  orifice of a
syringe, obstructing the entrance of air to the cells, but permitting the escape
of air from the cells.  Moreover, owing to the  greater force of the expiration,
the expired air may be  driven past obstructions which arrest  the current of
air in inspiration.  Collapse  of more or less of the pulmonary lobules being
thus produced, a larger  amount of air enters  the  cells communicating with
unobstructed tubes, and these cells become consequently dilated.  The dila-
tation of cells, in other  words, is supplementary to the diminished volume of
the lungs due to collapsed lobules, and is produced under these circumstances
in the  act of inspiration.   In support of  this explanation, Gairdner states
that observation shows the  tubes connected with emphysematous lobules to
be unobstructed, and  that close  examination of lungs affected with emphy-
sema will show the traces of collapsed lobules.  Moreover, experiments  of
introducing into the air-tubes in inferior animals foreign bodies, such  as shot
and wads of  paper, have been found to lead to collapse  of lobules connected
with the  tubes in which these bodies become lodged, and dilatation of lobules
connected with other  tubes.   This explanation will account for  the produc-
tion of emphysematous  lobules so frequently found in connection  with tuber-
culous deposits, the latter inducing solidification  and diminished volume of
the portion of the lungs in  which they are  situated.   The  term  vicarious
emphysema expresses  the fact that it is  supplementary to diminished  volume
of lung.
  There  is reason to believe that by prolonged, forcible efforts of expiration,
as in long-continued  exertions  at lifting or pulling, playing on wind instru-
ments, glass-blowing, or  in voluntarily blowing through a partially obstructed
tube in the manner which has  been to some extent practised as  a means of
preventing and curing consumption, the elasticity of the lungs may be dimin-
ished and permanent dilatation  produced.   It is well known that  the chest
may be in  this way considerably enlarged, and deficiency of breath on exer-
cise is sometimes a result.    Expiratory efforts thus may sometimes co-operate
with  collapse of pulmonary lobules in the causation of emphysema.  The
paroxysms of whooping cough and the labored efforts of breathing in attacks
of asthma may be more or less involved in the causation.
  The mechanism of the causation of emphysema by expiration is as follows:
During violent acts of coughing the glottis is contracted and offers an obstacle
to the free escape of air,  and  the muscles  involved in the acts of  coughing
exert their  effect especially  upon the inferior portion of the  chest.  Under
these circumstances the air, not escaping  through the  glottis, distends the
upper  lobes of the lungs,  and this distension,  often repeated,  leads to dilata-
tion of the air-cells in  these lobes.  This explanation accounts for  the fact
of the upper lobes being especially  the  seat of emphysema, and that the
anterior  portions of the chest in some cases project  beyond  the limits of a
forced inspiration in health.  It is obvious that this explanation applies also
to the production of emphysema by forcible acts  of expiration  produced
otherwise than in coughing.   Accepting this explanation, the  fact that phys-
ical signs show emphysema,  as a rule, to be more marked  in the  left than in
the right upper lobe may be thus accounted for.  In coughing  and all forcible
expiratory efforts the lower portion of the chest is  more  contracted on the
left than on  the right side,  owing to the presence of the liver on  the latter
side. 
EMPHYSEMA.
241
  The force with which the distension of the upper lobe takes place in violent
coughing  is appreciable by palpation over the clavicles and between the ribs
in thin persons.  It was strikingly exemplified in the case of Groux, in whom
there was a congenital absence of a portion of the sternum.   Forcible bulging
within this  wall was produced by coughing and by voluntary strong expira-
tory efforts.
  The inspiration  theory, as set forth by Gairdner, suffices to explain vicari-
ous emphysema, but the expiration theory seems necessary for the explanation
of substantive or idiopathic emphysema.  Something, however, in addition to
violent expiratory  efforts is requisite, in view of the fact that a comparatively
trifling expiratory  pressure will produce the affection in one person, while in
many persons severe paroxysms of coughing, etc., continued for a long time,
do  not occasion it.  This  view is  supported  by another fact—namely, that
heredity is involved in the causation.   Giving proper weight to  these" facts,
it may be assumed that in many if not  most cases a causative  condition is
some error  of nutrition  which  impairs the  elasticity  of the alveolar walls.
  The diminution  of the elasticity of the ribs  and  costal cartilages incident
to advancing age favors the production of emphysema.  This change involves
diminished extent  and force of expiration, with undiminished, if not increased,
power of inspiration. The result is, when the chest is expanded  in inspiration,
the lungs  already contain a surplus of air.  The lessened elasticity  of the lungs
in old persons has  the same effect, keeping the organs permanently expanded.
  The fact that emphysema belongs among  the hereditary affections was first
established by James Jackson, Jr., of Boston,  who found  that in 18 out of
28  cases  one  or both parents  had been similarly affected.   The  affection
may be developed  at any period of life.   In a large proportion of cases it
begins in  infancy  or childhood.   Its  slowly  progressive increase  explains
the fact that patients frequently attain middle life before  the affection has
advanced  sufficiently to  occasion  great inconvenience.

  Diagnosis.—The symptoms described under the head of the Clinical His-
tory render the affection  probable when it  compromises  considerably  the
respiratory  function.  The probability is increased  by the coexistence of
asthma in a large  proportion  of cases.   The physical signs, however, render
the diagnosis positive, and  when the affection is moderate or slight the signs
are indispensable to the diagnosis.  If asthma be not associated, patients are
often supposed to  have phthisis by those  who rely on the symptoms in mak-
ing the diagnosis.
  The enlarged volume of the upper lobes  of the lungs in certain  cases of
emphysema  gives  rise to distinctive signs  obtained  by inspection.   In  the
cases in which the characters of the  " emphysematous chest" are  strongly
marked the diagnosis may be at once  made with the eye.  The upper and
middle thirds of the chest on its anterior aspect are expanded, and present a
globular or barrel-shaped form.   This projection extends from the summit to
the sixth rib.   The obliquity of the ribs is diminished, and the angle formed
by the junction of the ribs with the costal cartilages  is  more obtuse than in
health.  The inferior portion  of the chest is relatively and actually contracted.
The dorsal spine becomes curved anteriorly.  In extreme cases  these changes
amount to a deformity which is highly characteristic.  The superior  costal
respiratory movements are lessened, and  in labored breathing the  ribs and
sternum are raised together, as if they  formed a solid bony case.   The lower
anterior portion of the chest is contracted, and  the soft parts above the clavi-
cles and sternal notch are depressed in  inspiration.  The chest is drawn per-
manently  upward  by the sterno-cleido-mastoid muscles and the scaleni, so
that the neck  appears to be shortened.   The upper part of the chest during
       16 
242   EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PERTUSSIS.

the act of expiration is in the same condition as at the end of a forced inspi-
ration.  The intercostal depressions are usually strongly marked.  The heart's
impulse is frequently seen and felt in the epigastrium.
   These  visible changes are present in  cases in  which the emphysema exists
to an  extent to compromise considerably the function of respiration, and  in
which the  volume of the lungs is notably increased.  The signs  are  more
marked on the side in which the emphysema is greatest, this  side being,  in
my experience, generally the left.  If the emphysema be comparatively slight
or moderate, the size, form,  and movements of the chest will not be sensibly
altered.  An abnormal relative fulness, however, may be observed on one side
below, and  perhaps above, the  clavicle, with deficient superior costal move-
ment.  This disparity of the summit  between  the two sides as regards  size
and  mobility is to be  distinguished  from a similar disparity due to contrac-
tion  of one side  from phthisis.
   Percussion elicits  an  abnormally intense resonance, the  character of the
resonance being altered.  The vesicular and the tympanitic quality are  com-
bined ; that is, the resonance is vesiculotympanitic.  This vesiculotympanitic
resonance is  more marked  on  the  side corresponding to the lung which  is
the more emphysematous ;  that is, generally the left side.   The exaggerated
resonance being greater on one side, care must be taken not to consider the
resonance as diminished on the side in which it is less  exaggerated.  The pitch
of the resonance  is  always  higher on the  side  which yields the greater res-
onance, whereas if the disparity be due to diminished resonance  or dulness on
one  side, the pitch is higher on that side.   That the resonance is  vesiculo-
tympanitic over the upper lobe  on the side on which  it is least marked—that
is, usually the right  side—may be shown by comparing this resonance  with
that over the lower lobe on the same  side.
   The murmur of respiration is weakened in proportion to the degree of the
emphysema.  If the affection exist to such an extent that the  respiration  is
habitually labored, the inspiratory sound  may  be shortened (deferred)  and
the expiratory sound prolonged.   The expiratory sound, however prolonged,
is  lower  in pitch than the inspiratory, as  it is  in health.   The changes in
intensity and rhythm are the only modifications proper to emphysema.   Not
infrequently over portions of the  chest  corresponding to  parts of the lungs
which are not highly emphysematous the labored efforts of breathing evolve
an exaggerated vesicular murmur.  The weakness and alteration of rhythm
are likely to be more marked on the side corresponding  to the greater degree
of the emphysema,  Sibilant and sonorous  rales, due to coexisting bronchitis
or asthma, are often present  in cases of emphysema.
   The normal relation between  the two sides, as  regards vocal  resonance and
fremitus, continues.   In some cases, owing to the  displacement of the heart,
the resonance on percussion  within the precordial region is abnormally clear.
   In  arriving at the diagnosis by means of the  foregoing signs, it is to be
considered that other affections, such  as phthisis, pleuritis. and pneumo-hydro-
thorax, are excluded by the  absence of signs which should be found if these
affections existed.  The signs are also to be taken in connection with diag-
nostic points embraced in the clinical history—namely, the  character of the
cough and expectoration, the absence of marked emaciation  notwithstanding
the duration of the pulmonary symptoms, and in many cases the coexistence
of asthma.
   In  the foregoing account  reference has been had  to the ordinary form of
emphysema—namely, the form characterized by  dilatation of the air-cells.
The  atrophic form, or senile  emphysema, offers certain marked  points of dif-
ference, especially as regards the physical signs on inspection. The size of the
chest, instead of being increased, may be notably diminished.  The  obliquity 
EMPHYSEMA.
243
of the lower ribs may be much greater than in health, leaving sometimes but
little space between the base of the chest and the pelvis.  The resonance on
percussion may be diminished.

  Prognosis.—Emphysema, even in the cases in which it is most marked,
rarely if ever involves in itself immediate danger.  It is not a fatal affection
per se, but it diminishes the power  of the  system to resist intercurrent or
superadded diseases. It leads to dilatation of the heart, which further impairs
the ability to overcome other diseases.   But, aside from danger to life, it  is
an affection which, if it exist to an extent to compromise respiration, inca-
pacitates for physical exertion and renders life uncomfortable.  Existing in a
less degree, it  is  a  source  of much  inconvenience and annoyance from the
deficiency of breath on exercise.
  In so far as it involves destruction of the alveolar walls and the coalescence
of air-cells, it is an irremediable lesion.  And  in the majority of cases the dila-
tation of the air-cells which takes place is permanent;  the tendency, in fact, is
oftener to increase rather than to decrease.   I have known, however, marked
improvement to take place, as shown by the physical signs.  In a case in which
the enlarged volume of the upper lobes was sufficient to give rise to the cha-
racteristic deformity in a marked degree, the improvement was so great that
the chest resumed nearly its normal  form.  In so far, therefore,  as the lesion
consists in dilatation of the cells, it is not necessarily irremediable.

  Treatment.—The treatment of emphysema has reference, first and chiefly,
to the bronchitis with which it  is  generally associated.  The  object  is to
relieve, and if possible  remove, the  bronchial  inflammation.  In  proportion
as the bronchitis is relieved the  condition of the patient  is rendered  more
comfortable, notwithstanding the  emphysema continues undiminished; the
emphysema is less likely to increase, and it may undergo diminution.
  With  reference to this object the measures to be pursued are those indi-
cated in  chronic  bronchitis  not connected  with emphysema.  The treatment,
in fact, so far as this object is concerned, resolves itself into the treatment of
chronic bronchitis, which has been considered in the preceding chapter.  Trial
should always be made of  the  iodide of potassium or of  ammonium  or of
sodium.  The effect is in some cases truly marvellous, but in other cases these
remedies produce little or no effect.  It may not be amiss to remind the inex-
perienced practitioner that  some persons cannot continue the use of the iodide
of potassium in consequence of great irritation of the fauces ; and I have met
with an instance in which it always produced violent vomiting and general dis-
turbance.  The eruptions on the face to which it frequently gives rise  are an
annoyance which may be submitted to if it  exert a curative effect as regards
bronchitis. When the remedy is well borne it may be continued, in moderate
doses, for a long period without  any unpleasant consequences.   If moderate
doses do not prove efficacious, they may be increased up to the limit of com-
fortable tolerance.  The syrup of hydriodic acid is sometimes better tolerated
than the iodides.   The chlorate of potassa,  the  bromide of potassium, and
the muriate of ammonia should also  be tried  if the iodide of potassium prove
ineffectual.  If   these be  unsuccessful, the  various  other remedies  which
experience has shown to be useful in cases  of chronic  bronchitis should be
tried.
  Tonic  remedies and the regulation of  diet and regimen with a view to
invigorate  the system form an important part  of the treatment.   If these
measures fail, change of climate, if practicable, should be advised.
  As there is reason to believe that violent  paroxysms of cough  contribute
to perpetuate and increase  the dilatation of  the cells,  palliative remedies for 
244    EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

this symptom are called for, provided the bronchitis  on which it depends
cannot be removed.  The effects of labored breathing in paroxysms of asthma
probably have the same effect; and  if this  affection coexist, it is  desirable,
with  reference to the  emphysema,  to relieve  the paroxysms as  speedily
as practicable.  It is important for the patient  to  avoid, as  far as  possible,
attacks  of acute  bronchitis, and when they occur  they should  be  cured as
quickly as possible.  Flatulence of the stomach or bowels and constipation
contribute to  dyspnoea by mechanically  interfering  with the  play of the
diaphragm.  They are to  be  avoided by a regulated  diet and appropriate
remedies.
  Exercise, as far as it can be taken without inconvenience, is not to be inter-
dicted, but exertions which  induce labored breathing are  to be abstained from.
Prolonged efforts  of expiration, as  in  public speaking, singing, and  straining
at stool, are to be avoided.
  The treatment by inhaling compressed air and breathing into rarefied air is
recommended  by  German authors as often  beneficial and sometimes effecting
a cure.  It has thus  far found little favor in this country.  Its employment
requires caution lest it do harm.   There is abundant testimony by competent
observers  of its value in  cases of emphysema.1
  The affection distinguished as atrophic  or senile emphysema  admits of no
permanent relief.   Ethereal preparations and remedies  to  palliate dyspnoea,
together with  measures  to support the system, comprise  the treatment.
                               Asthma.

   The term asthma, used in a properly restricted sense, is applied to a disease
which has well-defined symptomatic  features, and which, in the opinion of
most  authors at the present time, has an essential  pathological condition—
obstruction of the smaller bronchi, caused by spasm  of their muscular fibres.
The term has heretofore been applied in a loose way to dyspnoea dependent on
different pathological conditions.  For example, it has been customary to call
the dyspnoea dependent on diseases of the heart, cardiac asthma.  The true
pathology of asthma—that is, of the individual or substantive disease to which
the term should be restricted—seems to  me clearly that just stated, namely,
bronchial spasm.   All, however, do not so consider it, and other opinions will
be  noticed  in  connection  with the  pathological  character of the  disease.
Asthma  has no anatomical  characters.  It  is true that in  the great majority
of cases pulmonary lesions are found after death,  particularly those  which
belong to chronic  bronchitis and emphysema; but this fact shows only the
frequent coexistence of these affections  with  asthma.

   Clinical History.—Asthma is essentially a paroxysmal  disease.   The
clinical  history will therefore consist of  an  account  of the  characters  which
distinguish asthmatic paroxysms, together with the  laws of their recurrence
and the  condition  of health in the intervals.
  A paroxysm of  asthma may begin without warning or it may be preceded
by certain premonitions.  The premonitions vary in different cases.  Patients
are often able to predict an attack for some hours before its occurrence, some-
times  by a sense of drowsiness or heaviness;  sometimes, on the other hand, by
an unusual excitation of  the mind; and,  again, by  sensations the significance
of which they have learned by experience, but which  are not easily described.
The paroxysm  may be slowly developed—that is, an hour or two, and  some-
times  a longer period, may be required for its full development—or the attack
          1 Vide article by Hertz in Ziemssen's Cyclopaedia, Am. ed., vol. v. 
ASTHMA.
245
may be sudden and the intensity  quickly  reached.   It takes place,  in the
great majority of cases, during the  sleeping hours, and generally in the latter
part of the night or very early in the morning.
  The paroxysm is characterized by laborious efforts of breathing, prompted
by a painful sense of  the want of air, or dyspnoea.   The patient is unable  to
lie down, but sits with the  elbows on the knees or resting on some solid sup-
port, the mouth open  and gasping with each inspiration.  The respirations are
not increased,  but may be less in number than in health.  The inspiratory act
is performed with a spasmodic effort, and the expiratory act is prolonged and
accompanied with a wheezing sound.   Speech is difficult  from the want of •
breath, and words are uttered with interrupted  efforts.  Movements  of the
body are dreaded, and changes of position are made  slowly.   Cold air, from
its  density, affords relief, and the  patient desires the windows  to  be opened
without regard to chilliness of the body.  The face  is pallid, and  sometimes
presents with the pallor a cyanotic hue, giving to  the face a death-like appear-
ance.  Frequently perspiration is profuse.   Limpid urine in great abundance
is passed frequently, especially at the beginning of the paroxysm.  The pulse
is small and feeble, on account of an accumulation of blood in  the right cav-
ities of the heart  due to obstruction to the  pulmonary circulation.  The sur-
face of the body is cool or cold.   The temperature, as shown by the ther-
mometer, is either normal  or subnormal.   The  nostrils are widely  dilated.
The countenance denotes extreme anxiety and distress.  A frequent symptom
is an itching  sensation  under the chin,  which the patient endeavors ineffect-
ually to relieve  by rubbing, and the same sensation is frequently felt on the
sternum  and  between the  shoulders.
  Paroxysms  differ in severity.  A patient  suffering from a severe paroxysm
presents  a spectacle more  distressing than  can be well imagined,  and to one
not familar with  the disease he appears to be on the point of death. The
suffering is considerable, even when the paroxysms are so mild as  not  to
present to  the spectator a picture of great distress.   Their duration  differs.
They may continue for a  few minutes  only or  for  several days.  Usually,
after continuing for a few hours, either partial or complete relief occurs.   If
the relief be complete or nearly so, tranquil sleep follows, which is peculiarly
sweet and  refreshing.  "With the  diminution of  suffering  there are  usually
cough and more or less expectoration.
  Cough and  expectoration may be absent during  an asthmatic  paroxysm.
Usually, however, there is an expectoration of a small amount of viscid, trans-
parent, frothy mucus.   In  this mucus are frequently found grayish particles,
which, upon close inspection, are found to contain peculiar mucous bands of
varying length and diameter twisted in a spiral manner.  These spiral bands
often contain a central glistening thread.  They are sometimes called " Cursch-
mann's spirals," from the author who has described them most fully.1  These
spiral cylinders or bands are doubtless moulds of the small bronchial tubes,
and are probably composed of dense mucus.  They are considered  by Cursch-
mann as evidence of a peculiar form of bronchitis which he calls bronchiolitis
cxsudativa, and which he believes to stand  in intimate causative  relation  to
asthma.  The   sputum  also often  contains pointed  octahedral  crystals of
some organic  substance.   These are  Leyden's crystals, and  are believed by
him to  be, by their  irritation, the cause  in many  cases of the asthmatic
paroxysms.  Both  Curschmann's  spirals and Leyden's crystals  have been
found in  the sputum of persons not  affected with asthma, and  asthma may
occur without the presence of either of these   structures in the sputum.
The  expectoration is  sometimes  streaked with  blood,  and  occasionally
haemoptysis takes place.
                  1 Dadschcs Archiv f. klin. Med., Bd. 32, p. 1. 
246    EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PERTUSSIS.

  The paroxysms recur after intervals varying greatly in duration in different
cases.  They recur in some  cases with great regularity  after a stated period,
and in other cases the recurrences are  extremely irregular.   Some patients
suffer from a diurnal recurrence, and it is remarked by Salter that in these
cases  the affection is almost always associated with bronchitis or disease of
the heart.  Recurrence regularly after the  interval of a week or a fortnight
is  not uncommon.   Women sometimes  have  attacks only at the menstrual
periods.   Some persons experience an attack annually,  and it may occur
either in  the winter or summer season.  Examples of the latter are cases of
so-called  hay asthma, which will be  noticed presently  under another head.
When the paroxysms recur  irregularly they are sometimes attributable to a
special exciting cause, but  in other cases  the reason of  their recurrence is
not apparent.
  In the intervals the condition varies, the  variations depending  on  the exist-
ence or otherwise of associated affections.   Asthma is  not infrequently asso-
ciated with persisting chronic bronchitis, and under these circumstances more
or less cough and expectoration are habitual.   Emphysema is also a frequent
concomitant, and deficiency of breath on  exercise, or constant dyspnoea in pro-
portion to the amount of emphysema, characterizes these cases.  The habitual
dyspnoea in these cases is due to the emphysema, and is not  properly asthmatic.
Dilatation of the heart is another affection  not infrequently  coexisting which
may give rise to more or less dyspnoea.

  Pathological  Character.—The pathological  character of asthma has
been  already stated  in defining the  term as applied to an  individual disease.
It is  a neuropathic affection, tonic spasm  of the bronchial muscular fibres
being induced  by a morbid excitation  through  the  nervous system.  The
exciting  causes  of the  paroxysms doubtless exert their  effect  through the
excito-motor or  reflex nerves.  It is true that bronchitis  generally exists at
the time of the occurrence  of the  paroxysms, but bronchitis  exists often
enough without  asthma, and cases occur in which the  spasm  takes place  in-
dependently of bronchitis.   In the  latter cases the affection has been distin-
guished  as nervous asthma; but, with the pathological view just presented,
asthma is always  nervous, and these cases differ from  the  majority only in
the absence of coexisting  bronchial inflammation.   It is probable that inflam-
mation renders the muscular fibres more  prone to spasmodic action, and in this
way it is involved in the production of  the affection, not constituting, how-
ever,  an  essential part  of it.
  This view of  the  pathological  character of the  disease is believed to  be
substantially correct, but it is proper  to  state that opposing theories have
been  advanced by distinguished authors.   Wintrich, Bamberger, and  others
contend that bronchial spasm does not exist in asthmatic paroxysms, but that
the disturbance of respiration is to be  attributed mainly to tonic  spasm  of
the diaphragm.   This  theory is  based  on the evidence  of the diaphragm
remaining depressed and immovable during an asthmatic attack, and on the
fact that there is an abnormal expansion of the lungs, the latter being, as is
claimed,  inconsistent  with bronchial obstruction.  The  increased volume  of
the lung will perhaps account for the fixedness of the  diaphragm, assuming
this to be a clinical fact.  That a spasmodic obstruction of the bronchi should
be overcome by  expiration rather than by inspiration may  be, a priori, reason-
able, but this  idea should give way before clinical  facts.  The dry bronchial
rales  which are undoubtedly present, forming a marked feature of the disease,
demonstrate bronchial obstruction ;  and the complete disappearance of these
rales, together with that of the symptoms of the obstruction in some cases, as 
ASTHMA.
247
an effect of certain remedial agents, such as the inhalation of choloroform, is
proof that the obstruction proceeds from spasm.1
   A later theory, by Weber (1872), attributes the obstruction in great part to
a swelling of the mucous membrane in the smaller bronchi from dilatation of
the blood-vessels caused by a vaso-motor nervous influence.   This theory was
advanced many years ago  by Beau in France.   It does  not  do away with
spasm, but attributes to the swollen  condition  of the membrane  a certain
measure of obstruction.   This  theory is  not  devoid of substantial support
from clinical facts.  It is consistent with the frequent  occurrence of more or
less expectoration coincidently with relief of the asthmatic  condition, and it*
serves to explain the not infrequent existence of obstruction notwithstanding
the  employment of treatment for  the relief of  spasm.  That it is  a  patho-
logical  element of the disease is highly probable, but that it is an effect of
the  bronchial spasm, as held by Biermer and  Trousseau, is perhaps the most
rational  explanation  of its  occurrence.
   According to Curschmann, many cases of  asthma  are  due to a peculiar
chronic  affection  of the  small bronchi, which he designates as bronchiolitis
exsudativa, and which is characterized by the appearance in the sputum of the
spiral  structures already described.   This affection is often hereditary.  The
immediate cause of the asthmatic  paroxysm Curschmann believes to be bron-
chial spasm induced by the bronchiolitis.

   Causation.—The occurrence of asthma involves a peculiar susceptibility in
the bronchial muscular fibres to take on spasmodic action.   This susceptibility
does not exist in all persons.  It constitutes a predisposition  to the affection
which characterizes certain constitutions.   The majority of mankind, no mat-
ter  to what influences  they may be exposed, never have this affection.  The
predisposition  may be  transmitted by inheritance.  Of  those who become
asthmatics so  large a proportion have had  parents or progenitors who mani-
fested the same peculiarity of constitution that there must be admitted to be,
 in some  cases, an innate and inherited predisposition.  The fact of its being
 congenital is also shown by the occurrence of the affection not infrequently
 in earlv childhood and infancy, independent of any appreciable external causes.
 Whether  the peculiar susceptibility  be always congenital, or whether it be
 acquired in a certain  proportion of cases, it is  impossible to say.   It is not
 proof against  an  innate idiosyncrasy that  the affection frequently does not
 occur until  after youth, and is  sometimes  deferred until old age, and that it
 follows  some other  pulmonary affection, such as  whooping cough, bronchitis,
 or measles.
   The etiological  connection of asthma with  nasal  polypi and other morbid
 conditions seated  in the Sehneiderian  membrane,  especially hyperplasia of the
 erectile  tissue covering the inferior turbinated bones, and also with affections of
 the throat, has recently given rise to discussion.   Making allowance for the
 error of considering the embarrassment of respiration from obstruction of the
 nasal  passages as constituting  asthmatic dyspnoea, clinical facts have been
 reported which show that  in some cases  true asthma may be produced by a
 reflex influence originating  in the membrane of  the nose and throat,  This is
 true of  local affections elsewhere,  always assuming the existence of an  asth-
 matic predisposition as an essential element in the etiology.  The term " nasal
 asthma  " used by some late writers denotes only that in a  person whose bron-

   1 For a fuller exposition of the doctrine of Wintrich the reader is referred to the arti-
 cle  by Riesrel in Ziemssen's (h/elopwdia, Am. ed., vol. iv.   For its refutation in extenso,
 vide paper by Biermer, " Ueb'er Bronchial-asthma," in Volkmnnn's Sammhmg klinischer
  Vortrdge, INTO; see also  the  classical work by Salter, On Asthma: its Pathology and
  Treatment, Philadelphia, 1864. 
 248    EMPHYSEMA OF THE LUNGS.—ASTHMA.—PERTUSSIS.

 chial muscular fibres are liable to spasm, as an individual idiosyncrasy, certain
 local conditions within the nostrils may excite an asthmatic paroxysm.1
   For the development of  the affection, certainly in  most cases, in addition
 to the predisposition, exciting causes are requisite.   The exciting causes are
 various, and the facts with regard to these  show in some persons  a remark-
 able susceptibility to particular agencies which upon most  persons produce
 no  morbid effect.  A  striking illustration of an  idiosyncrasy in  this regard
 is the variety of the affection commonly called hay asthma.   The emanations
 from newly-mown hay produce in some persons coryza, bronchitis, and asthma,
 and  the latter affection may never occur save when produced by this particu-
 lar cause.   The term  hay asthma, however,  is  applied to  cases  occurring
 exclusively during  the summer season, although  the exciting cause may not
 proceed from hay.   We  meet wrth persons who  suffer for  a certain period
 during  the summer months with  asthma, associated  with coryza and bron-
 chitis, and during the  remainder of the  year they are entirely free from  the
 affection.   Sometimes  the annual visitations in successive years occur  pre-
 cisely on  the same date, and the duration is always about  the same.   For
 example, a medical friend of the  author is  attacked  early in September of
 each year with coryza and bronchitis, and subsequently paroxysms of asthma
 occur during the night.  He continues to suffer from  the former  affections
 and the nightly recurrence of the  asthma for six weeks.   The affections then
 disappear, and  except  during the  period just stated  his health  is excellent.
 Relief and exemption are obtained by removing at the period when  the affec-
 tions occur to a situation devoid of, and distant from, vegetation.   On going
 to sea the affections are sure to disappear after sailing  a  certain distance
 from  land.
  The affection known as " hay asthma "  or " hay fever," first described by
 Dr. John Bostock in 1819 under the name catarrhus aestivus, has been studied,
 as it occurs in the northern part of this country, by Dr. Morrill Wyman,2 and
 more recently by Dr. George  M. Beard.  The  latter gives the results  of an
 analysis of 200 cases.3   According to Dr. Wyman, there  are two forms of
 annually-recurring bronchial inflammation (catarrh) in  persons with a pecu-
liar idiosyncrasy.  The first is often called the  '-rose  cold"  or "June cold,"
beginning in the latter part of May or  early in June and continuing until
 early in July.   This corresponds  with the  affection  know*n  in  England as
 " hay asthma " or " hay fever."   The other form is  called  by Dr. Wyman
 catarrhus autumnalis, or autumnal  catarrh.   In this form the  affection begins
generally in the third  or fourth week of August, and ends in the latter part
of September or in October.  It rarely if ever continues after the occurrence of
 black frost.   Asthma occurs in a certain proportion of cases only.  The local
 symptoms denote irritation and subacute inflammation of the  nasal and bron-
chial  mucous membranes, together with some febrile movement and more or
less  constitutional disturbance.  The  affection  appears not  to exist  in  the
Southern  States or in the colder  regions  of Canada.   Dr. Wyman has  col-
lected a considerable number  of cases showing that relief may  be  obtained
by going to  certain  parts of the White Mountain region, Mount Mansfield
in Vermont (one of  the Green Mountains),  and the  Adirondack Mountains
in the State  of New York.
  1 For a full discussion of the several theories of  the causation of asthma by Cursch-
mann, Riegel,  Donders, A. Friinkel, B. Friinkel, Heoker, Schmidt, Lazarus, Lielug, and
Ungar, see Verhandlungen des Congresses filr innere  Medicin, Vierter Congress  1885.  In
this country Dr. John X. Mackenzie,  Dr. William H. Dalv, Dr. John  O. Roe, and
others have contributed papers on this subject. (Vide System of Medicine by American
Authors, article by Dr. W. If. Geddings, vol. iii. 1885.)
  2 Autumnal Catarrh (Hay Fever), New York, 1S72.
  3 Hay Fever, or Summer Catarrh, New York, 1876. 
ASTHMA.
249
  Dr. Beard's cases show that the affection occurs in July as well as in May,
June, and August, but  less often than in the  latter  months ;  also, that the
Southern  States and Canada are  not exempt from the disease, but that its
occurrence is rare.  It is a rare  disease west of the Mississippi, either  north
or south.   It is undoubtedly caused by the inhalation of some agent connected
with vegetation, and probably this agent is the pollen from  grass, flowers,
and trees.  The same cause evidently is not alike involved in all cases.   The
idiosyncrasy in some persons relates to emanations only in May or June, and
in others only to those in August ; and of those who have the predisposition
some are affected at a particular place  at a particular time, and others at the
same place and time are not  affected.   The vegetable emanations, therefore,
must be derived from different sources.  The discovery of the sources of the
causation  in a certain number of cases will not  apply to other cases. Assum-
ing the morbific agent to be the  pollen from plants, the idiosyncrasy in differ-
ent persons has relation to different plants.  The fact that removal during the
summer and autumnal  months  to certain situations secures  exemption from
the disease to some and not to others  is thus intelligible.  Dr.  Beard's obser-
vations give evidence of heredity  as involved in the peculiar  idiosyncrasy.
   A curious idiosyncrasy is exemplified in  the author's personal experience.
This consists in the production of coryza, bronchitis, and asthma by an emana-
tion from  feather beds  or pillows.  Repeated attacks  on sleeping away from
home,  especially in inns and  steamboats, had occurred before the source was
discovered.   All feather pillows, and even feather beds, do not  furnish the
special emanation, and the circumstances  on which the latter depends I have
not  ascertained.   The  poisonous  principle  is  not connected with the odor
which  is  sometimes perceived.   I cannot determine  beforehand whether a
strange bed will excite an  attack  or not.  If the feathers be of the (to me)
poisonous kind, shortly after retiring labored respiration, cough, and wheezing
begin,  and progressively increase until I am obliged to get up, when the diffi-
culty passes off' in a few hours, leaving a little bronchitis, which continues for
a day or two.   I have  never experienced the  least degree of asthma except
as a result of an emanation from feathers.
   Dr. Richard M.  Crane  of Hagerstown, Md., has communicated to  me a
case under his observation in which attacks  of  asthma were distinctly traced
to sleeping beneath a feather bed made of duck feathers.  The cause was not
ascertained until after four years of suffering from the affection.  It had not
existed previously, the  patient  being fifty  years of age, and there was no
return  of  the  affection  after an ordinary feather bed, made of geese feathers,
was substituted for the  bed which furnished the causative emanation.
   Inhalation of the powder of ipecacuanha in  some persons produces similar
effects.   Several examples of  this idiosyncrasy  have been  reported.   On
relating my own  experience at  a meeting of a medical society on  one  occa-
sion, a member of the  society gave an account of a  case in  which the same
effects  were produced by an  emanation from the body of the  horse, so that
the person was debarred from riding  or  driving  on  that  account.  I have
recently heard of another case  of this kind.  Beard cites  other  instances.
Salter  gives several examples in  his work  on asthma.   Asthmatic attacks are
sometimes brought on by emanations from the bodies of other animals, as the
cat, rabbit, etc.
   In persons subject to asthma  the paroxysms are liable to  be induced by a
variety of exciting causes, but individual cases differ as regards a particular
susceptibility to certain of these  causes.  In  some cases the inhalation of dust
is particularly likely to bring on an attack.  I have known a patient specially
susceptible to the  dust  of grain and  that arising when carpeted rooms  are
swept.   The fumes of burning sulphur produce asthmatic breathing in  those 
 250    EMPHYSEMA OF THE LUNGS.—ASTHMA.—PERTUSSIS.

 subject to the affection.   Indigestion in some  cases proves an exciting cause
 oftener than anything else.  Some can refer paroxysms frequently to consti-
 pation.  Salter  relates a case in which the  application of  cold to the  instep
 was sure to provoke  an  attack.   Mental emotions sometimes act as an ex-
 citing cause.   Occasionally the paroxysms are habitually  connected with the
 menstrual function.
   In the great  majority  of the cases of asthma, bronchitis coexists.   In a
 certain proportion  of  cases the  bronchitis is  constant  or habitual, and the
 frequency of the paroxysms depends  in a measure  on the bronchitis ; for if
 the latter affection  be  relieved  or removed the asthmatic attacks become less
 frequent.  The  susceptibility to the exciting causes of spasm is increased by
 the existence of bronchial inflammation.  In other cases the attacks of asthma
 occur  whenever bronchitis or a common cold occurs.  Finally, climatic influ-
 ences are involved  in the causation, for it is a matter of frequent observation
 that the same persons are much more liable to recurrences in  some situations
 than in others.  It is  also a matter of common observation with some asth-
 matics residing in a locality in which they are subject to frequent recurrences
 that atmospherical  changes are likely to induce an attack.
   Asthma occurs more frequently in  males than in females, the proportion
 being as two to  one.   In the majority of cases  it is developed prior to twenty
 years of age.   It occurs not very infrequently in infancy.

   Diagnosis.—The diagnosis  in well-marked cases  is not  difficult.   The
 features of the asthmatic paroxysms are quite distinctive.  First paroxysms
 occurring in young children may occasion some perplexity, but with proper
 knowledge and care the disease should not be confounded with other  affec-
 tions.   Capillary bronchitis is distinguished by the frequency of the respira-
 tions, the acceleration  of the pulse  with more or less fever, and the diffusion
 over the chest of the subcrepitant rale.   In asthma the respirations are not
 accelerated, but labored, the pulse is not notably frequent, and the dry  bron-
 chial rales are abundant.  The dyspnoea incident to diseases of the heart often
 goes by the name of asthma, but the breathing in this form of dyspnoea is not
 labored, especially the expiratory acts, and accompanied by wheezing, as it is
 in asthma, and the difficulty in breathing is more or less habitual.  Moreover,
 heart lesions adequate to  the  production of dyspnoea are determinable by
 physical signs.   Asthma  and cardiac  lesions, however, may be  associated.
 If asthma have existed for some time, it is usually associated with  emphy-
 sema, and this  association is  diagnostic;  yet  it is  to  be borne  in  mind
 that emphysema sufficient to  occasion  dyspnoea, which may become greatly
 increased with a fresh occurrence of bronchitis,  may exist  without asthma;
 in other words, the  dyspnoea due to emphysema and coexisting  bronchitis is
 not properly called  asthma.  In addition  to the abundance and diffusion of
 the dry bronchial rales, the physical  signs  during a paroxysm are enlarge-
 ment  of the chest  in  its  upper and anterior regions,  with diminished respi-
 ratory  movements, vosiculo-tympanitic resonance  on  percussion, and  suppres-
 sion  of the respiratory murmur.   I have met with instances repeatedly of
 laryngeal spasm  that have been considered as asthma.  The diff'erential points
 are, however,  distinctive.   In laryngeal  spasm the inspiration is  slow and
 labored.   In  asthma   the  labor  and  slowness are  in the  expiration.   The
 former has been well  termed inspiratory,  and the latter expiratory, dyspnoea.
 Laryngeal  spasm is accompanied by stridor  referable  to the larynx, and the
latter moves up and  down with  inspiration and  expiration.  The dry bron-
 chial rales and  the other physical  signs  referable to  the chest are wanting
if there be  only laryngeal spasm. 
ASTHMA.                            251
   Prognosis.—A paroxysm of asthma, however severe or protracted, involves
no immediate danger  to life.  Formidable as may appear an attack of great
severity, and intense as is the  suffering, it is doubtful if a  fatal termination
ever  took  place.   In  view, however, of the  suffering, the tendency  of the
disease to  become  confirmed, with an  increasing  liability to recurrences, its
existence must  be  regarded as a great calamity.   If the paroxysms be pro-
duced by a particular exciting  cause, which, being known, may be avoided,
the disease imposes simply more or less  inconvenience ; but  when  they are
liable to be produced by various causes which cannot be guarded against, it
is truly a grievous  affliction ; and it is calamitous, of course, in proportion to
the frequency with which the paroxysms recur and their severity.
   Asthmatics are  not  infrequently long-lived, yet that it  may  shorten the
duration of life  cannot be  doubted.   The labored efforts of breathing in the
paroxysms contribute to the development and increase of emphysema.   Dur-
ing the paroxysms  also, the circulation through the lungs being  impeded, the
right ventricle  and auricle are unduly distended with blood returned by the
systemic veins, and hence  the  disease  occasions dilatation  of the right  side
of the heart.  The chances of  long life are lessened by these lesions.   More-
over, if the paroxysms be frequent and severe they can hardly fail to impair
the vital powers and diminish the ability to resist other diseases.   If asthma
secure, to a certain extent, exemption from  pulmonary phthisis and pneumo-
nitis, this advantage is perhaps  overbalanced by the fact that  pneumonitis,
when  it does occur, is likely to prove  fatal, and that the supervention of
a  severe attack of bronchitis may destroy  life.

   Treatment.—The  management of asthma embraces—first, the treatment
of the paroxysms ; and second, the treatment in  the  intervals.
   During a paroxysm  the objects of treatment  are to lessen  the suffering and
bring the paroxysm to an end as speedily as possible.  The measures for these
objects have reference to spasm  as the essential pathological condition.   The
measures to relieve spasm are  various, each  of which  proves efficacious in
some cases and not  in others.   Frequently the  past experience of the patient
is the best guide as to the particular measure which will  be most likely to
afford  relief.  In cases of  asthma unaccompanied  by bronchitis a full  opiate
is sometimes quickly and completely successful; but in the  larger proportion
of cases it will  not succeed in  cutting  short the paroxysm or in affording
marked relief.   Of  other narcotics, stramonium is one which should be tried.
The usual mode  of administration is to smoke the dried leaves or the fibres of
the root either in a pipe  or prepared as a cigarette.  This measure in some
persons acts like a charm, and may be confidently relied upon  as  a prompt
and effectual mode of obtaining  relief;  but in the great majority of cases it
either  produces  no  effect or merely mitigates  the  severity of the  paroxysm.
Asafoetida,  dracontium or skunk-cabbage, and the Indian hemp are sometimes
efficacious.   The  ethers, given  internally, are to some  extent useful as palli-
atives, and  occasionally they produce complete relief.   Belladonna is  some-
times signally efficacious,  given  as recommended  by  Salter and  Ringer—
namely, 10  minims  of the tincture  repeated every two  or three  hours  unless
disturbance  of vision be produced.   The bromides  in  full  doses  sometimes
afford marked relief.  A paroxysm is  sometimes made to abort by a full dose
of quinia—from 20  to  30 grs. to an adult.
   Mirked relief is  frequently obtained and the paroxysm is sometimes cut
short  by nauseant remedies—namely, antimony, ipecacuanha, lobelia inflata,
and common tobacco.   The two remedies last named are especially efficacious
in  a certain proportion  of cases.   The common  tobacco will be more likely to
be successful if  the patient be not accustomed to  its use.   With a view to 
 252    EMPHYSEMA OF THE LUNGS.—ASTHMA.—PERTUSSIS.

 the relief of the  spasm these remedies  need not be carried to the extent of
 producing vomiting;  if not effectual when  nausea is induced, it will be use-
 less, if not injurious, to push them farther.  I have  known a paroxysm to
 be arrested  at once  by bloodletting, but this is a measure too potent to be
 employed, except occasionally in persons who are robust and full-blooded.
   The inhalation of the vapor of ether is often an effective measure of treat-
 ment.   Not  infrequently the  paroxysms  are  completely controlled by it, the
 patient passing in a few moments  from  a condition of great sufffering  into
 one of ease and comfort.  These  cases are among those which afford the most
 striking examples of the resources of practical medicine.  The dry bronchial
 rales,  which  before the inhalation were loud and universally diffused over the
 chest,  sometimes disappear as soon as complete relief is procured by the inha-
 lation—a fact proving conclusively  the existence and the cessation of spasm.
 Unhappily, this measure, like the others, is efficacious  only in a certain  pro-
 portion of cases.  It should be  tried always, provided there  be no circum-
 stances to contraindicate  it.  The hydrate  of chloral  succeeds in a certain
 proportion of cases, but in view of the possibility of alarming effects it should
 rarely  be  resorted to.  The inhalation of chloroform  is often successful, but in
 view of danger ether is always to be preferred.  The inhalation of the  nitrite
 of amyl affords temporary  relief, and in  some instances arrests a paroxysm.
 Four or five  drops may be inhaled from a  handkerchief.  Iodic ether or iodide
 of ethyl is recommended by Thorowgood as highly useful in some cases.  Ten
 drops  may be inhaled three  or four times  daily.  This remedy may be conve-
 niently inhaled by dropping it on a piece of  patent lint held in the palm of
 the hand.1
   The vapor of arsenious acid is to be included among the remedies which are
 useful administered by inhalation.   Arsenical cigarettes have been employed
 with success, each cigarette containing from  a half a grain to a grain of the
 acid.2
   The inhalation  of compressed air is recommended  by German authors.
 Trousseau found  the  inhalation  of the vapor of  ammonia useful in some
 cases.   Duclos succeeded in sometimes  arresting a paroxysm by the  appli-
 cation  of  aqua ammoniae to  the fauces by means of  a probang.   Others who
 have made trial of this measure  have found it in some cases  to succeed,  but
 in other  cases to increase the dyspnoea.3   Dr.  Monell states that he has suc-
 ceeded in  obtaining relief in an attack of asthma by prolonging as far as
 practicable the expiratory act, then waiting as long as possible before  inspir-
 ing, and  retaining the air  at  the end of the  inspiration as long as possible,
 this plan being continued for  fifteen minutes.  He states that he has repeat-
 edly obtained immediate relief in  this way, and that he knows of several cases
 in which the  plan has proved successful.4
   It is hardly necessary to say that  if there be ground  to suppose  the attack
 to have been brought on by overloading  the  stomach or by constipation, an
 emetic or  a cathartic is indicated; and of  course the patient is to be removed
 from the  action of any known exciting cause, such as  the emanations from
 hay, feathers, etc.   The apartment should be  large, high, and airy.   Warm
 and stimulating pediluvia  afford some relief.  Strong coffee, taken hot, is
 generally  useful as a palliative.   It may be rendered more efficient  by adding
 two or three grains of the  citrate of caffeine.  Another palliative "measure
 which  sometimes proves to be curative is to  be added.   This consists in  dif-
 fusing  throughout the apartment the fumes of burning nitre-paper—that is,

  1 Vide Lcttsomian Lectures on Bronchial Asthma. 1885.                     2 Ibid.
  3 The tincture of quebracho is recommended  by Penzoldt and others in asthma  and
other diseases attended by dyspnoea.
  4 N Y. Med. Record, Aug." 15, 1866. 
ASTHMA.
253
bibulous paper dipped in a saturated solution of the nitrate of potassa and
dried—or by burning pastilles prepared for that purpose.  Some patients find
great  relief from this measure, and occasionally the paroxysms are arrested
by it.
  The treatment in the intervals has for its object prevention of the parox-
ysms.   The removal of the predisposition would be the most effectual  mode
of accomplishing this object.   This, however, is not to  be expected; and the
object is to be attained by measures having reference to circumstances which
increase or act upon that susceptibility of the bronchial muscular fibres con-
stituting the predisposition to the affection.
  When,  owing  to a peculiar  idiosyncrasy, paroxysms  are excited by a par-
ticular  cause, such as  emanations from  hay, feathers, etc., avoidance of
exposure  to  the cause, if possible, is obviously  indicated.  It is doubtful if
any remedy will produce insusceptibility to the action of the particular  cause
or secure exemption so long as the exposure to  the cause continues.  In the
cases  of the  so-called hay asthma which have come  under my observation a
great  variety of remedies have been tried, but all without much avail.   The
patient  must either endure the continuance of the affection for several weeks,
or seek a situation where he is not  exposed to the exciting cause.  Inasmuch
as the cause of this variety of asthma enters the air-passages by the nostrils,
and occasions coryza before it reaches the  bronchial tubes, the attempt has
been made to neutralize  it by topical applications within the nostrils.  Liquid
injections or  atomized fluids have been employed for this purpose.  Helmholtz
found in  his own person  that a solution of quinia injected into the nostrils
was preventive  of  effects  other than  the coryza; and this result has been
obtained  in some other  cases.  This treatment has, however, much oftener
failed than succeeded.  Experiments with other remedies have not furnished
striking results; but this plan of prophylactic treatment merits more attention
than it  appears as yet to have received.
  Recent  observations  having shown  that  paroxysms may  be excited by
polypi  and other affections of the  hose, and by affections of the pharynx,
anpropriate local measures of treatment are to be directed to these situations,
and in  general terms any existing local affection which may be suspected of
having  a causative relation to the asthmatic paroxysms  should, if practicable,
be removed.
  In a  large proportion of the cases of asthma  the  liability to paroxysms  is
more  or less increased by the existence of habitual  or  chronic bronchitis.
The  relief or cure of the  latter  affection  in  these cases is  the immediate
object of  treatment.   The iodide of potassium or of  ammonium should
always  be tried.   I have  known  patients who were rendered comparatively
comfortable as regards the recurrences of asthma by the  use of this remedy.
In small  or  moderate doses it may be continued indefinitely  without any
apparent  injury.   I have known  from  5 to 10 grs. to be taken  most of the
time during  four or five years, the patient finding that thereby he was pro-
tected against a recurrence of the paroxysms.  The  remedy will be useful in
proportion to its curative effect on the bronchitis;  it is, however, useful in
some cases in which the coexisting  bronchitis is slight and when no apparent
effect  upon the latter is produced.  The hydriodic acid has proved in  some
cases  as effectual as  the iodides.  In the  treatment of  asthma, as of chronic
bronchitis without asthma, the doses of the iodides may be gradually increased
so as to amount  to 50 or 60 grains per diem.   The bromides are serviceable
in certain cases,  and they are well borne by some who cannot take the iodide
of potassium without unpleasant effects.  The  chlorate of potassa  is  some-
times  useful, and the other measures indicated  in  cases of chronic bronchitis
may be employed.  The  arsenical medication—that is, arsenic in small  doses 
 254    EMPHYSEMA OF THE LUNGS.—ASTHMA.—PERTUSSIS.

 continued  for a considerable  period—has  been found  in  some cases highly
 useful.  The  same is to  be said of sulphur.
   If measures addressed  to the  bronchitis prove ineffectual, or if the parox-
 ysms recur when bronchitis does not coexist, and they be  not referable to
 particular  causes which may  be  avoided, nothing is  to be depended on  but
 change of residence.   And  it  is probable  that  most  asthmatics may find
 some place in  which they will be comparatively if not entirely free  from the
 affection.   Facts showing the immunity obtained by change  of residence are
 remarkable as illustrative of an apparent capriciousness of  this affection.
 Persons residing in  the country  often find relief by living in  cities or large
 towns.  A change from the most salubrious part of a city to a part where
 the  atmosphere is  smoky and insalubrious  as regards the general health
 sometimes  secures exemption from  the  affection.  A change  of apartments
 from one story to another or to a different exposure has been known to prove
 effectual.   I have known  a patient to suffer  nightly from  a  severe attack
 directly on the seashore, whereas the nights  were passed comfortably a mile
 inland.   There are no fixed laws  with respect to the best climate or situation
 for asthmatics; and each case  has its own law, which is to be  ascertained only
 by experience.   In beginning  trials of change of residence, a place should be
 selected in  which the  climatic influences are the opposite of those belonging
 to that in which the patient resides; that is, if the residence be in the coun-
 try,  the city may be  tried, and vice versa; if  on the seashore, an  inland situ-
 ation, and vice versa; and so with regard to temperature, moisture, elevation,
 etc.   The  principle  to be  acted  on  is, that  there  is a place in  which each
 martyr to  this complaint  will suffer  less, and perhaps  be entirely free from
 it, and  the  plan should be to make  repeated  trials until the desired spot is
 found.  I  could cite from the cases which have come under my observation
 several in which this plan has proved successful.   It is  to be enjoined, when-
 ever practicable, as soon as it is evident that other measures will  not secure
 the  patient against the suffering  incident to  the frequent recurrence of the
 affection.
   At the present time, in this country, the climate of  Colorado  is regarded
 as the  most favorable for asthmatics.  That residents  in that  climate are
 rarely affected  with  asthma, and that persons  who suffer from  the disease
 generally find  relief  there, cannot be doubted in view  of ample testimony ;
 yet it has happened to me to be consulted in the case of a boy about twelve
 years of age who had suffered from the disease  since  early childhood, and
 who has recently come from  Denver, where he had  lived  from birth.  A
 brief stay,  however,  in Colorado or elsewhere secures exemption only during
 the  time of sojourn  ; persistent relief requires a permanent  change  of resi-
 dence.  Hence  it is  generally an object with  patients to find some place
 where, aside from exemption  from this disease, it  is for their interest and
 happiness to dwell.


                 Pertussis, or Whooping  Cough.

   This  affection belongs among  the diseases of children, but it occasionally
 occurs after childhood and at  all  ages.  In the cases occurring after adoles-
 cence it is  important that the physician be prepared to recognize it.   The
 affection has no anatomical characters except  those  of ordinary bronchitis.
 Other morbid  appearances found after death are due to complications which
will  be noticed in connection with the clinical history.

   Clinical History.—The names of this affection derive their significance
from certain characteristics pertaining to the  cough.  The first or the form- 
PERTUSSIS, OR  WHOOPING  COUGH
255
ing stage embraces a period prior to the appearance of these characteristics.
The primary symptoms  are  those  of simple  coryza and bronchitis.   Fre-
quently during this period there is nothing which denotes  the  aft'ection to be
other than a common cold.  But in the majority of cases the cough  is more
violent, the acts of coughing persist for a longer time, and they progressively
increase in duration  and  violence.  There  is also more or less  febrile move-
ment, which is more  marked and continues longer than in ordinary bronchitis.
At length the cough becomes distinctly and in a marked degree paroxysmal,
and the distinctive features of the affection  relate especially to the paroxysms.
The duration of this first  stage varies from one  to two weeks.  After the affec-
tion has advanced to the  second stage, the patient is generally aware for a few
moments previous  to a paroxysm that it is impending.  A child engaged in
play suddenly is quiet, and the countenance expresses  apprehension and dis-
tress.  The morbid sensations are those of constriction and an irritation in
the larynx  and trachea.   These premonitions are  sufficient  to arouse the
patient when asleep.   The paroxysm is denoted by cough, which is charac-
terized by a series of violent expiratory acts succeeding each other so quickly
that the patient  is  unable to take an inspiration between them.   The number
of  these acts varies, according to the severity  of the paroxysms, from six to
twenty.  A long and labored inspiration  then takes place,  giving rise to a
crowing sound evidently due to spasms  of the glottis ;  this is the whoop
which enters into the name of the affection.   Another series  of coughing
expiratory acts succeeds,  followed  again  by the  sonorous  inspiration or
whoop ; and these alternate acts of  coughing and  whooping are  repeated
until  the  paroxysm ends.   The  contraction of the lungs by  the spasmodic
acts of coughing interrupts  not only inspiration, but the pulmonary circu-
lation, so  that  an  accumulation of blood  takes place in the right cavities of
the heart.   These effects are shown by notable congestion  and lividity of the
face and turgescence of  the  cervical veins.  Tears flow in abundance.   The
suffering from dyspnoea  is in proportion  to the violence  and  length of the
paroxysm.  The contents of  the stomach  are  frequently expelled, and at the
close of the paroxysm more or less mucous  secretion is expectorated.   In
proportion to the violence and length of the paroxysm the patient is fatigued
or  exhausted.   However severe the paroxysm, there  is scarcely any imme-
diate danger either  from apnoea or syncope.   I  have never  known  of an
instance of death in a paroxysm.  A medical  friend, however,  has related to
me a case in which  the breath was lost, and was restored  by resorting to the
procedure known as  Marshall Hall's ready  method.
   The paroxysms  in different  cases differ  widely  in  severity, duration, the
degree in which the characteristics  are marked, and in frequency of  recur-
rence.  When  extremely severe they  occasion great distress, and  serious
incidental events are liable to occur.  On the other  hand, when quite mild
they are comparatively trivial.   Only one  or two of the spasmodic expiratory
acts may  occur, or they may be repeated so that the paroxysm lasts  for sev-
eral minutes.   The whoop is more or less loud and long in proportion to the
amount of spasm of the  glottis.  Although generally present and  marked—
being, as the name  implies, the  most characteristic feature  of  the paroxysm
—it is sometimes slight  and sometimes wanting.  In the latter case  the  cha-
racter of the disease" has to be determined  by other diagnostic features.  A
few paroxysms only may occur  in the twenty-four hours, or they may recur
during night and  day at short intervals.   They may amount  to even a hun-
dred within the twenty-four hours.   In almost all  cases they occur in greater
number in  the night than during the daytime,  and in some  cases they occur
only at night.   Exceptionally they are more  frequent during the  daytime.
The paroxysms which occur in  sleep are, of course, not produced by any 
256    EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PERTUSSIS

obvious exciting cause.   This may  be true of paroxysms occurring in the
waking hours, but physical exertion and mental  excitement, especially the
latter,  appear not infrequently to determine the occurrence of a paroxysm.
Children are liable to experience  a  paroxysm whenever a fit of crying takes
place.  A patient may have  a paroxysm on witnessing a paroxysm in another
patient, this fact illustrating the power of involuntary imitation.
  Various events are incidental to the paroxysms, especially when the latter
are severe.  One of the most frequent of the incidental events is hemorrhage.
Epistaxis is the most common form  of hemorrhage.  Not infrequently blood
flows from the nostrils in more or less abundance with every paroxysm, and,
the loss of blood inducing notable anaemia, this  favors the persistence of the
hemorrhage.   Haemoptysis  is  an occasional  form of hemorrhage. _  Blood
sometimes escapes from the conjunctiva or accumulates  beneath  this mem-
brane.   Trousseau cites  a case in which a naevus situated on the face was the
seat  of hemorrhage with each paroxysm.  Blood has been  known to be forced
from the ears.  The primary and chief cause of the hemorrhage is the venous
congestion arising from  accumulation of blood within the right cavities of the
heart.   The urine and feces, or both, are  sometimes expelled  involuntarily
during the paroxysm.  Intestinal  hernia is sometimes produced.  Rupture of
air-vesicles is an accident which sometimes occurs, giving rise to interlobular
emphysema; and the air, finding its way along  the areolar tissue connected
with the primary bronchi and  trachea, may produce emphysema of the neck,
and even  extend  over the entire  body.1  Dilatation of the air-cells, or vesic-
ular  emphysema, is another incidental event.   It is questionable whether this
be not due to the bronchitis associated with whooping cough rather than to
the violent action of coughing;  but the latter doubtless contributes to  its
production.  When  the  paroxysms  recur frequently,  and  are generally
accompanied by vomiting, the system suffers from innutrition.   Here is a
source of anaemia in addition to the hemorrhages.   Convulsions occur in
some cases, especially in children, being attributable to the cerebral conges-
tion  occasioned  by the  venous obstruction  at the right  side of the heart.
   In the intervals between the paroxysms, aside from complications or inter-
current affections, the general  condition will depend on the frequency of the
paroxysms, their severity, and the  incidental events.  The patient is enfee-
bled in proportion as the paroxysms are long,  violent, and frequent, also in
proportion to the amount of hemorrhage and the interference with nutrition
by vomiting.  The face is pallid in  proportion to the anaemia.  The veins of
the neck furnish the venous hum, and the arteries a bellows murmur.  Cephal-
algia is a prominent  symptom  in some cases, arising from cerebral congestion.
The  febrile movement,  which  generally exists,  in a greater or less  degree,
during the first or forming stage,  as a rule disappears when the characteristic
paroxysms are established; that  is,  in the second stage.   If it continue into
this  stage or if it be reproduced, it is due to an unusual intensity of the
bronchitis or to some  inflammatory  complication.   The  face  is  swollen or
puffed, and this, with the pallor, renders the appearance quite characteristic.
Certain complications are liable to occur which add much to the gravity of
the affection.   Bronchitis is a part of the affection.
   If the  affection be uncomplicated, physical exploration of the chest elicits
good resonance on percussion, with perhaps the  dry or moist bronchial rales.
The  bronchitis in some cases  is  unusually acute, giving rise to fever  and
abundant mucous secretions.   Collapse  of pulmonary lobules  and broncho-
pneumonia are liable to occur  in young children.  The occurrence of vesicu-
lar emphysema has  been already mentioned.  The inflammation may extend
  1 Vide case reported  by Dr. Wm. P. Northrup in Am. Journ.  of Med. Sciences, July,
1883. 
                 PERTUSSIS,  OR WHOOPING  COUGH.              257

into  the minute  bronchial tubes, giving rise to capillary bronchitis.  This is
denoted by fine bubbling rales  diffused over the chest, in  conjunction with
great frequency  of the  respirations,  notable acceleration of the  pulse, and
lividity, the  resonance of the  chest  on percussion not being  diminished.
Pleuritis with effusion is another complication more likely to occur in adults
than in children.  These several pulmonary complications are rendered severe
and dangerous by the recurrence of the paroxysms of whooping cough.   Fre-
quently the latter become less violent and frequent when any of the  compli-
cations just named are developed, so that a premature improvement as regards
the paroxysms of whooping cough may be an  unfavorable omen.   When
whooping cough  is accidentally associated with some  acute disease,  such  as
measles or scarlet fever, the paroxysms of cough, as a rule, become less fre-
quent  and violent; these intercurrent diseases interfering  with the  natural
course of  the affection.   Finally, whooping cough appears to favor the devel-
opment of phthisis in some cases in which the tuberculous diathesis exists.
   The duration of the affection  is subject to considerable variation.  Excep-
tionally the affection ends  spontaneously  in a few days.    These cases are
infrequent, but the fact that the affection  is occasionally of short duration
when let alone is to be borne in mind with reference to the  supposed efficacy
of remedies in abridging or arresting it.  It is rare for the affection to end
within a  period  of six weeks.   In the majority of cases  it continues for a
longer period than this, and it sometimes persists for many months.  As a rule,
it gradually declines before it disappears, the paroxysms by  degrees becoming
less  frequent  and severe.   Frequently, for  a considerable  period after the
affection has ended, the characteristics are  manifested, to  a  greater or less
extent, whenever a bronchitis or common cold is contracted or cough is excited
by any cause.   Trousseau states that the affection  continues for a long or short
period in proportion to the duration of the symptoms prior  to the  character-
istic paroxysms; that is, if the latter are delayed  the  affection will  be  pro-
tracted, but if they are quickly developed the affection is not likely to last long.

   Pathological Character.—This remarkable affection  consists of three
pathological elements. Bronchitis is one of these. This is the initial element.
It is stated that this element is sometimes wanting, but examples must be
exceedingly rare.  Another element  is fever.   This is more or less  marked
in different  cases, but is seldom wanting during  the first or forming stage.
The fever, as a rule,  is out of proportion to  the  bronchitis, and is therefore
to be  regarded as not  symptomatic,  but idiopathic or  essential.    The most
prominent of the three elements relates to the nervous system. This is mani-
fested by the spasmodic expiratory movements in the  paroxysms of cough,
and  by spasm of  the  glottis giving rise to the whoop.  Some have considered
the affection as belonging among the neuroses, others have considered it to be
an essential fever, and by others it has been considered as a peculiar variety
of bronchitis.  It is neither of these  separately,  but collectively they consti-
tute the affection.  Dependent, as will be seen presently, on a special cause,
the  primary, essential pathological condition is general or  constitutional, of
which the bronchitis and  cough are  the local expressions.

   Causation.—Whooping cough is an infectious disease, and it is communi-
cated  by a contagium present  in  the bodies of  those  affected with it.   It
probably originates in no other way.  It is highly contagious, and few persons
pass through childhood without  contracting  it.   Young infants are liable  to
contract it.  No period of life is exempt from susceptibility to the contagium.
The  infrequency of the affection after childhood is accounted for by the fact
that the great majority of persons experience it before  adolescence. Having
        17 
258    EMPHYSEMA OF THE LUNGS.—ASTHMA.—PERTUSSIS.

been once experienced, the susceptibility thereafter  ceases.  This is the rule,
but exceptionally the affection occurs more than once.  The exceptions to the
rule  as applied  to this affection are not more frequent  than  to  the rule as
applied to other affections in the same category; for example, the eruptive
fevers.  The average period of incubation is not well ascertained.   It is vari-
able, the limits being one and two weeks.

   Diagnosis.—When whooping cough has advanced  beyond  the first or
forming  stage and  the characteristics  pertaining to the paroxysms are well
marked,  it is recognized without difficulty.   The whoop is a  diagnostic cri-
terion, but this is sometimes imperfect  and even wanting.  In these cases the
diagnosis is to be based on the occurrence of paroxysms presenting the cha-
racters of well-marked whooping cough minus the whoop, on the duration of
the affection, and on the fact of known exposure to the infection, together with
knowledge of the fact that the patient has not already experienced  the affec-
tion.  The affection  may be so mild  and short that there is considerable doubt
whether it  have really occurred, but such  cases are rare.  It is desirable to
make a probable diagnosis during the first or forming  stage; that is, before
the disease is fully declared by the characteristic paroxysms.   It  should be
strongly suspected when cough and febrile movement are out of proportion to
the bronchitis and unduly persistent.   Of course the prevalence of  the affec-
tion and known exposure are to be  taken into account.  Attention  has been
recently directed to the  occurrence of  ulcerations on either side of the frae-
num linguae as a diagnostic circumstance.  These are produced traumatically
by the lower teeth,  the tongue being partly protruded during paroxysms of
cough.  They occur  only when, from the violence of the paroxysms, the diag-
nosis involves no difficulty.   They  are wanting, of  course, in children before
the period of dentition.

   Prognosis.—Whooping cough is rarely fatal per se, jet indirectly it leads
to a considerable loss of  life.  Occurring in the course of other diseases—
for example, measles  or during the ailments incident  to dentition—it may
prove a serious  affection.   A fatal result is generally due to complications,
the more frequent and important of which have been stated—namely, capil-
lary  bronchitis, broncho-pneumonitis,  pleuritis, vesicular and interlobular
emphysema, and phthisis.  Young  children, especially  during dentition, are
sometimes  carried  off by convulsions.  As regards the affection itself,  the
gravity  and danger  are proportionate to the frequency and  severity  of  the
paroxysms, the duration of the  affection,  and the degree of anaemia and innu-
trition induced by hemorrhage and vomiting.

   Treatment.—The treatment of whooping cough  embraces curative and
palliative measures.   It must be admitted that there are no known means by
which the affection may  be arrested.   Measures are curative if they abridge
the  duration of the affection or diminish notably its severity, and  there  are
 various  remedies which possess more  or less curative power.
   Emetics  were formerly considered as curative, given every other day for
 the space of a week or longer at the beginning of  the  affection.   They were
 much extolled  by  Laennec,  who preferred ipecacuanha as the emetic drug.
 Others  have preferred the  sulphate of  zinc.   Trousseau advocates,  instead
 of the zinc or ipecacuanha, the  sulphate of copper, given in solution in small
 doses, according to the age of the  patient, the doses being repeated at short
 intervals until vomiting  is produced.   In view of the testimony in behalf of
 the treatment with  emetics,  its  efficacy in some cases cannot be doubted, but
 owing to its severity it is  nearly or quite obsolete in this  country.  This 
                 PERTUSSIS,  OR WHOOPING COUGH             259

method of treatment,  it is to  be borne in mind, is not admissible except
early  in  the  career of the affection.
  Of other curative remedies, some are addressed to the bronchitis and others
to the neuropathic element.  A combination of cochineal and the carbonate
of potassa,  commonly known  as the  cochineal mixture,  has  been much
employed in this  country.  This mixture consists of cochineal, half a  scruple ;
of carbonate of potassa, a scruple;  and of white sugar, a drachm,  in four
ounces of water.  A' dessert-spoonful is to be  given  three  times daily to a
child a year old, and the dose increased in proportion as the age is greater.
The disease is undoubtedly in some cases favorably modified by this prepara-
tion, as shown by diminution of the violence of the paroxysms  and of the
frequency of their recurrence :  these  effects of remedies can generally be
appreciated when the  affection has not already continued sufficiently long to
attribute  the improvement to a spontaneous decline.  It is not easy "to deter-
mine the fact  of the duration  being  abridged, as the natural duration varies
within wide limits.   This remedy probably acts  upon the bronchitis.   Meigs
considers the cochineal as inert, and states  that he has found the same benefit
from the carbonate of  potassa alone, dissolved in syrup of gum and water.1
  Alum,  which was  recommended highly  by Golding  Bird, is considered  by
Meigs as giving more decided and satisfactory results than any other remedy
which he has employed.  From  one  to six grains may  be given every four
hours, the dose being graduated to the age. Dissolved in some form  of syrup
and water, it is not an unpleasant remedy.   This remedy probably exerts its
curative effect by acting upon the bronchitis.
   Belladonna has been recommended as a valuable curative remedy by many
physicians in different countries.  Trousseau lays  down certain  rules with
regard to its administration which he deems essential in order to secure its
curative efficacy.  The dose at first should be  quite  small—one-tenth of a
grain of the extract  for a  child  a year old, and one-fifth of a grain for a
patient four or more years of age.  The quantity to be  taken in the twenty-
four  hours is to  be  given in a single  dose.  The dose is to be gradually
increased until its effect upon the severity or frequency of the paroxysms is
apparent.   It  should  then be  continued  steadily without  further  increase.
The action of this remedy is doubtless upon the neuropathic element of the
affection.  Some have regarded conium, stramonium, and hyoscyamus as not
inferior  to  belladonna in  this  affection.   The  leaves of the chestnut tree
(Castanea vesca) have long  had a popular reputation, and many physicians
have confidence in their curative effect.  The infusion is the form  generally
used, an ounce of the  leaves to a pint of boiling water and given freely.
   Strong testimony has been borne by not a few physicians to the curative
efficacy of nitric acid.   To  a tumblerful of well-sweetened water  the acid is
to be added until the acidity is of the strength of pure lemon-juice ;  of this a
dessert-spoonful is to be given  to  a child a year old every hour, and a larger
quantity over that age.
   Since  the bromides were introduced into medical practice they have been
employed considerably in  this affection, and with apparent benefit.  These
remedies are probably  useful as pharyngeal and laryngeal anaesthetics ; hence
they are addressed to the neuropathic element of the affection.
   Other remedies which have  been recommended, and which I shall simply
name, are tannic acid, asafoetida, arsenic, quinia, chloroform,  the oxide of
zinc, and ergot.  A  method  of treatment  which it was  claimed had proved
remarkably successful  was  some years since  brought before the French
Academy of Medicine—namely, inhalation of  the  fumes disengaged in the
purification of coal-gas.   It having been observed that children living in the
       1 A Practical Treatise on Diseases of Children, by J. Forsyth Meigs, M.  D. 
260   EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

vicinity of gas-works suffered but little from whooping cough  and recovered
after a short career of the affection, the effect was  tried upon a large scale,
and, as stated  by Commerege  and Bertholles in their reports  to the French
Academy, with signal benefit to a large proportion.  To secure the advantage
of this measure patients should inhale the fumes  at the place  where the gas
is purified, for  two hours at a time, for twelve consecutive days.1  It would
appear from the statements by Blache, Barthez, and Roger that this measure
is often inefficacious.   It is, however, sometimes promptly curative.
  Of the different remedies which have been noticed, all are  doubtless more
or less curative in a certain proportion of cases.   It may be  doubted if  any
of them ever have a specific  effect.  They are, severally, useful  in some  and
not in other cases;  the degree of the  usefulness  of each varies in  diff'erent
cases, and  with our present  knowledge the physician  cannot judge before-
hand  what particular remedy in any  individual  case  will be most useful.
Under these circumstances, if  those first selected prove  inefficacious, others
are to be  successively  tried.
  Palliative treatment  is important.   Relief may be afforded by opiates in
small doses if  they be well borne, by ethers, and  by hydrocyanic acid.   The
latter remedy is, of course, to be given with great  caution.  Strong coffee  has
been found to be sometimes useful  as a palliative.   The  hydrate of chloral
has been found to be an effective palliative  remedy, but the physician is not
justified in incurring risk of the occasional danger attending its use, even in
small doses, especially when  the patient  is a child and the object is simply
palliation.   Many of the antispasmodic remedies are useful  as palliatives;
of these, the value of musk  in this  as in other diseases is perhaps not suffi-
ciently recognized in this  country.
  Prof.  J.  Lewis Smith has  found the inhalation of  carbolic-acid spray
decidedly useful in diminishing the frequency and the severity of the parox-
ysms of cough.  Spray from the following mixture was inhaled from  the
steam atomizer three times daily, from two to five  minutes :  Acid, carbolic.
gss, potass, chlorat. gij, glycerinae "|ij, aquae 3VJ.2   Prof.  Smith calls atten-
tion to the apparent  effect of the  treatment, which of late years has  con-
sisted chiefly of palliative and sustaining measures,  upon  the mortality from
this disease.  Fifty years  ago, in  the  city  of  New  York  the  proportion of
deaths attributed to whooping cough  to the deaths  from all  diseases was 1
in 76, whereas at the present time it is less  fatal  than any other  severe con-
tagious malady.  Inasmuch as this is  an infectious disease, and is therefore
caused by the  presence of a specific micro-organism, a curative disinfectant
remedy administered  internally or by inhalation may hereafter be discovered.
Carbolic-acid spray and the fumes of coal-gas probably act as disinfectants.
  Hygienic measures form an important part of the treatment.  If there be
no complications which interfere with  exposure to the open  air, this should
by  all means be advised and enforced.  Under proper prudential restrictions
the more out-of-door life the better.  The diet should be nutritious.   If from
the frequency  of vomiting the system suffer from  innutrition, alimentation
becomes an important object of treatment.  The patient should take  food
often, and as soon after a paroxysm as possible. The times chosen for giving
food should be as remote from an expected paroxysm as practicable, and  eat-
ing at the most favorable times should be insisted upon despite the absence
of appetite. Solid is to be preferred to liquid food, as less likely to be rejected
by  vomiting.   Trousseau states that in some  cases  patients vomit with the
paroxysms which occur in the daytime, and not with those occurring during
the night; and in such cases food  should be taken  freely during the night.
      1 Vide American Journal of the Medical Sciences, April, 1865.
      2 Vide article in the American Journal of the Medical Sciences, Oct., 1879. 
PULMONAR Y HEMORRHA GE.
261
The stomach is sometimes made to tolerate food by minute  doses of opium.
Change of air is  sometimes of signal efficacy in modifying the severity of the
aff'ection and bringing it to a close.
  Hemorrhages,  if profuse  or  recurring frequently, claim haemostatic meas-
ures of  treatment.
 ^ Complications  call for the therapeutical measures appropriate under other
circumstances, making  due  allowance for the  effects of this aff'ection  on the
circulation, the  blood,  nutrition, and the general  strength  of the system.
  There is no known method of preventing the disease other than by isolation
as regards exposure to the contagium.
                      CHAPTER  XI.

  PULMONARY  HEMORRHAGE.—PULMONARY  GANGRENE.—
       PULMONARY CEDEMA.—CARCINOMA.—HYDATIDS.

Pulmonary Hemorrhage.—Bronchorrhagia.—Pneumorrhagia.—Hemorrhagic Infarction.
   - Pulmonary Gangrene.—Pulmonary (Edema.—Carcinoma within the Chest.—Hyda-
   tids.
                    Pulmonary Hemorrhage.

   PULMONARY hemorrhage may  have as  its source—first, the bronchial
    mucous membrane; and  second, the parenchyma of the  lungs.  When
from the former source, it is called bronchorrhagia, and from the second,pneu-
morrhagia.   The source of the hemorrhage  also may be exterior to the lungs.
The most frequent example of this is the rupture of an aneurismal tumor into
a bronchus.  Hemorrhage having its source  in the pulmonary parenchyma
may attend diseases in which the air-cells remain intact and diseases causing
destruction of the pulmonary  parenchyma,  especially pulmonary tuberculosis
and pulmonary gangrene.

  Bronchorrhagia exists in the majority of the cases in which haemoptysis
occurs.  The latter term should be limited to the spitting of blood, and should
be applied only to the cases in which pure or  unmixed blood is expectorated.
It is not properly applicable to sputa streaked with blood in cases  of bron-
chitis, or to blood intimately  mixed with mucus and inflammatory products
in the rusty expectoration of pneumonitis,  A true haemoptysis is  the raising
of blood, and blood only.   In bronchorrhagia the seat of the hemorrhage is
most frequently in the small  and terminal bronchi.  Hemorrhage from the
larynx, trachea, or large  bronchi is infrequent.   In the  rare  cases in which
the loss of  blood has occasioned death it has not been found possible to dem-
onstrate the source of the  hemorrhage.   The blood probably comes from rup-
ture of capillaries and other minute vessels in the mucous membrane of the
small  bronchi.
  It is important to determine, when blood is ejected from the mouth, whether
it  comes from the air-passages.   It  may come from the stomach, from the
posterior nares, and from the mouth or fauces.  If it come from the stomach,
it is ejected by acts of vomiting; it is likely to be commingled with other con-
tents of the stomach ; it has the characteristic acid odor of the latter; and it 
262  PULMONARY HEMORRHAGE, PULMONARY GANGRENE,  ETC.

gives an acid reaction, whereas pure blood is  alkaline.   Coming from the
stomach, it usually has a black grumous appearance, due to the action of the
gastric acids.   In some  cases of profuse  bronchorrhagia considerable blood
may be  swallowed  and afterward  vomited.  In  a  case which I  saw in  an
emergency, the blood coming most  profusely from  the  mouth and nose, the
source of the hemorrhage was  evidently within the air-passages.  Some hours
afterward, when the patient was seen by the attending physician, the haemop-
tysis  had ceased, and a  considerable quantity of blood was exhibited which
had  evidently been vomited.   In this case there were both haemoptysis and
haematemesis, the latter following the ingestion of blood derived from the air-
passages.  On the other hand, blood which has flowed into the stomach  from
the erosion of a large vessel, and is vomited before it becomes mingled with
the gastric juice, may retain its bright-red color and its alkalinity.  If it  come
from  the posterior nares, it is in  the form of dark, solid sputa  which are
removed by acts of hawking.   If it come from the mouth or  fauces, the fact
may generally be ascertained by a close inspection of  these parts.   AVhen it
comes from the air-passages, it is raised by acts  of  coughing, which are gen-
erally not violent; the blood rises into the trachea and larynx and is expelled
with slight efforts.  In the majority of cases the blood  is liquid, of a bright
arterial hue, and contains air-bubbles in more or less abundance.  If, however,
the hemorrhage have taken place  slowly into the  bronchial tubes, and the
blood have remained there for  some time before being expectorated, it under-
goes coagulation and acquires a dark or almost black appearance.
   The amount of haemoptysis varies much in different  cases.  It is  sometimes
quite small, only a drachm or so  of blood being raised; usually, however,
when the amount is  relatively small or moderate,  several drachms or a few
ounces are expectorated.   Not infrequently the  amount  is considerable.  It
is not rare for patients to lose during an attack of haemoptysis from half a
pint to a pint of blood, and sometimes a much larger quantity.  The blood is
expectorated with more or less rapidity.  The continuous duration of an attack
of haemoptysis may vary from  a few minutes to several hours, and even many
days ;  in the latter case, of course, the blood escaping slowly.  Occasionally
the flow  of blood is so rapid that it escapes simultaneously from the nose and
mouth, and death by suffocation may result from its accumulation  in the air-
passages.  A  single attack only may occur, or  attacks  may be repeated at
intervals varying greatly in duration in different cases.  In some cases attacks
recur daily or repeatedly during the day for a variable period.  In other  cases
the attacks recur after days, weeks, months, or  years.   After an attack  it is
common  for the expectoration to be more or less colored with haematin for
several days.  In proportion as it is rapidly discharged it is less frothy than
when the quantity expectorated  with each act of coughing is  small.  When
the haemoptysis is  rapid  and  abundant, if the  patient be not in  advanced
phthisis, the bursting of  an aneurism should be suspected.  The hemorrhage
from this source, however, is not always at first abundant and rapid, the open-
ing being for a time too small for the free escape  of blood.   In cases  of
phthisis advanced to the  cavernous  stage the haemoptysis may be  rapid and
abundant, leading sometimes to fatal syncope, the  hemorrhage being due to
the opening of a vessel  contained in one of the bands of pulmonary tissue
which frequently traverse tuberculous cavities, or to  the rupture of the minute
aneurismal dilatations which late observations have disclosed in the walls of
these cavities.
   In the majority of cases bronchial hemorrhage is in some way pathologically
connected with pulmonary phthisis, and from the frequency of this  connection
it is important as a diagnostic  symptom of that disease.   Not infrequently it
is the first event which awakens the  attention of patients to the existence of 
PULMONAR Y HEMORRHA GE.
263
pulmonary disease.  In a large proportion of cases it occurs more or less fre-
quently during the progress of phthisis.  In a certain proportion of cases it
occurs when physical signs do not afford evidence of the existence of phthisis,
these signs becoming developed sooner or later after its occurrence.  In these
cases it is probable that tubercles already exist in the terminal bronchi, and that
the hemorrhage is due  to a tuberculous ulceration into the blood-vessels in the
coats of the bronchi. In many cases of initial haemoptysis of phthisis tubercle
bacilli have been found in the blood  or sputum, and in this way valuable aid
in diagnosis may be afforded by the examination of the sputum.   Haemoptysis
should always excite a strong suspicion of tuberculous disease, yet its signifi-
cance in  this respect was undoubtedly overestimated by Louis in his treatise
on  phthisis.   Louis, having  questioned  a large number of patients affected
with various diseases other than tuberculosis, and finding that spitting of blood
had taken place in no instance save after injury of the chest or when the cata-
menia were suppressed, concluded that this symptom is almost pathognomonic
of phthisis.  Since the publication of that work, however, it  has been found
that cases are not very infrequent in which haemoptysis is not accompanied
or followed by either the symptoms or signs of tuberculous  disease.  A paper
communicated by the late Prof. John Ware contains statistical information of
special value with reference to this point,1 Ware in this paper gave the results
of an analysis of 386 cases of haemoptysis noted in private practice during a
period of about forty years.   Of these  cases, in 62 recovery from the bron-
chial hemorrhage took place, and the patients afterward were either known to
be living in ordinary health or to have died of  other diseases  having no con-
nection with the existence of tubercles.   The length  of time during which this
immunity continued varied from  two to thirty-seven years.  In  addition to
these cases, in 52 a similar complete recovery took place, and, so far as known,
there was no development of  tuberculous disease; but the  entire subsequent
history of these cases had not been obtained.   Making allowance, in a certain
proportion of the cases, for the probable occurrence of small  phthisical affec-
tions which were  arrested and did  not  return, these facts  show that neither
the existence of  phthisis nor a strong  proclivity thereto is to be positively
predicated on the occurrence of  bronchorrhagia.   They show*, moreover, that
as regards any immediate or remote evils bronchial hemorrhage may be innocu-
ous.  These conclusions are  corroborated  by the facts developed by my own
clinical  studies relating to phthisis.2
   Bronchorrhagia  is incidental to certain cardiac  lesions, especially those
involving obstruction at the mitral orifice.  These lesions  lead to bronchial
hemorrhage by inducing pulmonary congestion.   It ma}* occur in connection
with morbid conditions of the blood  and tissues, which  lead to hemorrhages
from  mucous  membranes in different situations,  as in  purpura haemorrha-
gica and scorbutus.  It occurs occasionally in asthma.  It may be produced
by  violent and prolonged muscular  exertions, without the coexistence of any
pulmonary or cardiac affection, and it has  been observed to occur from mus-
cular exertions, not excessive, if  conjoined with diminished pressure of the
atmosphere in elevated  situations, as  in ascending high mountains.   It may
be  produced  traumatically by injuries  and  wounds of the  chest.   It may
occur as a secondary hemorrhage when the  menses are  suppressed.   Well-
authenticated cases of this kind have  been reported, but they are exceedingly
rare.  I have  met with a striking example, the haemoptysis occurring regu-
larly for  the four years following the  suspension of the menses, and no other
pulmonary affection either accompanying or following the hemorrhage.  The
  1 "On  Haemoptysis as a Symptom,"  by John Ware, Al. D.,  etc., Publications of the
Massachusetts Medical Society, I860.
  2 Vide work on Phthisis, 1876. 
264   PULMONARY HEMORRHAGE, PULMONARY GANGRENE,  ETC.

3S6 cases analyzed by Ware did not include a single case in which the hem-
orrhage could be considered as compensatory for the menses.  Exertion and
mental excitement, by their effect on the circulation, may act as exciting causes
if, from pulmonary disease or other circumstances, a predisposition exist; but
clinical observation shows that in the larger proportion of cases the hemorrhage
takes place  without any apparent exciting  cause.  It takes  place frequently
during the night-time.
   The occurrence of haemoptysis generally occasions  much alarm  and anx-
iety.   If patients be seen at the time, the nervous agitation  and disturbance
of the circulation, which are often present, are attributable in a great meas-
ure, if not altogether, to the mental condition induced  by  the  attack.   The
first  duty of the physician is  to endeavor to remove needless apprehensions
from the mind of the patient.  Haemoptysis proceeding from bronchial hem-
orrhage may destroy life either by suffocation or by exhaustion from the loss
of blood, but the cases are so rare that the clanger of fatal  consequences  is
scarcely  to be  considered.   The physician may assure the patient of the
absence of any immediate danger; and, in general, the hemorrhage does not
lead  to any evil  results.  It  is suggestive of the existence of  phthisis, but
aside from its  symptomatic  significance it affords little occasion for alarm.
So far from favoring a tendency to  tuberculous  disease, there is ground for
the conjecture  that it is sometimes  preventive  of that disease; and when it
occurs in connection therewith, clinical observation  shows  that it exerts no
unfavorable influence on the progress of the disease,  but, on the contrary, its
influence seems, as a rule, to be favorable.
   In  exceptional cases  bronchial hemorrhage apparently leads to  either the
development or an increase  of pulmonary symptoms, together with  more or
less fever.   The immediate local and constitutional sequences are  sometimes
exceedingly grave, and death may take place within  a few days.  I have met
with  several cases  in  which, dating from an haemoptysis, rapid  breathing,
dyspnoea, frequency  of the pulse, and a high temperature occurred, the cases
ending fatally after a certain number of weeks or months.   Such cases, how-
ever, are rare.   Niemeyer held the opinion  that the retention of blood in the
bronchi and air-cells after an haemoptysis excites inflammatory changes which
lead to cheesy degeneration and phthisis.   He considered  phthisis to be the
result, and not  the cause, of this initial haemoptysis.   Experiments, however,
have  shown that the presence of blood in the bronchi and air-cells may excite
a  lobular, but  never a caseous, pneumonia  or  tuberculosis.   The  view of
Rindfleisch, therefore, is more probable, that the hemorrhage may hasten the
development of phthisical  symptoms by occluding the bronchi  and causing
atelectasis  and  lobular  pneumonia, but that in these  cases tubercles are
already formed before the haemoptysis and  stand in  a causative  relation  to
it.  In cases of death directly following a profuse hemorrhage the bronchial
tubes have  been found, post-mortem,  filled  with clots, and the obstruction
of respiration caused by these doubtless was the immediate cause of death.
Blood-casts  of the  bronchial  tubes are sometimes  expectorated.
   The measures  of  treatment directed to the haemoptysis must have  refer-
ence to the  profuseness  or otherwise  of the hemorrhage and the  associated
symptoms.   Venesection  heretofore has been  frequently  employed.   This,
however, is indicated only in cases in which the patient is full-blooded or the
pulse abnormally strong;  and such cases  are  comparatively few.   Even  in
these cases, unless  the escape of blood be unusually rapid and abundant, a
saline purgative  and sedative remedies are to be preferred to  bloodletting.
If the  hemorrhage  be  profuse and persisting,  cold may be applied to the
chest, as in hemorrhages in other situations.  This may be done  by means of
compresses wet with iced water or with ether, which latter refrigerates by its 
PULMONAR Y HEMORRIIA GE.
265
rapid evaporation.   The application of the ice-bag to the chest has been rec-
ommended, and I have resorted to it with apparent success  and without any
untoward consequences.   Revulsive measures may be  employed, consisting
of stimulating pediluvia, sinapisms, and  dry cupping.  To  diminish  the
amount of blood returned to the heart, temporary  ligation of the  extrem-
ities may be resorted to.  I  have witnessed a prompt  arrest of the hemor-
rhage by this  measure.  A popular remedy is common salt, which  usually
has been freely given before patients come under the care of the practitioner.
Its efficacy  is doubtful, but its  use serves to occupy the  attention of  the
patient  and friends  until medical advice is  obtained.
   In all cases  quietude of body is to be enjoined, the use of the  voice is  to
be  restrained, the apartment should be  kept cool, the head and shoulders
should be raised, the diet should be bland or unstimulating,  drinks should be
cold, and small pieces of ice may frequently be taken into the mouth. These
measures are  doubtless of more  or less importance, yet I  have repeatedly
known  patients  who, having become accustomed  to attacks of haemoptysis,
paid little or no attention to it, and kept about  their ordinary pursuits  as
usual, without apparently increasing or protracting the hemorrhage by this
course.   I have known a lecturer continue the daily use of the voice in pub-
lic speaking without any apparent injury.   The measures  just  enumerated
are  often continued too long, patients  being  anxious to  prevent a recur-
rence of the hemorrhage after it has ceased.   They  may  be assured  that
moderate exercise out of doors, a nutritious diet, etc. will  not be likely to
reproduce an  attack.
   Cough, if present, should be quieted by some form of anodyne. Anodyne
remedies  are also generally indicated  by the excited condition of the nerv-
ous  system. If the hemorrhage be slight or moderate, as a rule nothing is  re-
quired in addition to these remedies and  such hygienic regulations as may be
deemed prudent. If, however, the hemorrhage be considerable and prolonged,
haemostatic remedies are to be employed.   Of .these, probably  ergot is  the
most efficient.    From one to two drachms of the fluid extract may be given
hourly or half hourly according to the urgency of the  indication, the doses
being repeated for several hours if required.  Krameria and tannic or gallic
acid are  also  efficient  vegetable  astringent remedies.   Of the astringents
belonging to the mineral kingdom, the  acetate of lead has long been  con-
sidered valuable in this application.  The most efficient preparations of this
class, however, are the persulphate and pernitrate  of iron.  The inhalation of
astringent remedies in the form of atomized liquids or spray has  been found
effective for the arrest of hemorrhage.   For this  purpose solutions of alum,
tannin,  and the perchloride of iron may be employed.
   I have met with  a few cases  of persistent bronchial hemorrhage which
claim a separate notice.  The hemorrhage in these  cases was  slight, but it
continued for a long  period, without  other evidence  of pulmonary disease.
It was not referable  to disease of the heart, to suppression of the menses, or
to any  appreciable  cause.  Moreover, the  hemorrhage was  confined to  the
bronchial mucous membrane, and the blood did  not come  from either  the
mouth, throat, or  nasal passages.   The  hemorrhagic expectoration was  not
pure blood, but  a thin, bloody liquid.  I have notes of three such cases.   In
two of these cases, after expectorating almost daily more or less of a sero-san-
guinolent liquid during several months, recovery took place  under the use of
tonics and invigorating hygienic measures.  In the  third case the hemorrhagic
expectoration  continued  for  six years, during which  period the patient, a
young  woman,  from time to time came under my observation.  Repeated
examinations of the chest by others as well as myself failed to discover any
positive signs of pulmonary disease.  During the greater part of the  long 
266  PULMONARY  HEMORRHAGE,  PULMONARY GANGRENE, ETC.

period just named there was daily more or less expectoration of liquid con-
taining blood-coloring matter,  the quantity being always small.  Associated
with this symptom were anaemia and hysterical ailments.   Aside from these
nothing was discoverable.   The subsequent history of this case is unknown.

   Pneumorrhag'ia, or the extravasation of blood into the air-cells, and fre-
quently also into  the  interstitial tissue, is commonly known as  pulmonary
apoplexy.   There would be no impropriety in this use of the term apoplexy
if we adopted the custom of French writers of expressing by it extravasation
of blood in any situation ; but with us when applied to  a cerebral affection
it includes cases in which  there is no  extravasation of blood, and it  is not
customary to  apply it to  extravasation elsewhere than in the  brain, spinal
cord, and  lungs.  The name pneumorrhagia is to be  preferred.
   Extravasation of blood  into the pulmonary parenchyma may occur either
with  or  without laceration of the  pulmonary  tissue.   Extravasation with
destruction of pulmonary parenchyma  is called diffuse pulmonary apoplexy or
diffuse pneumorrhagia.  In circumscribed pneumorrhagia or hemorrhagic  infarc-
tion the blood is in the air-cells and interstitial tissue, but there is  no rupture
of the lung-tissue.  Hemorrhage with laceration of the pulmonary tissue is
most frequently the result, either of traumatism, such as stab-wounds and
gunshot  injuries of the lungs, or of  the rupture of an aneurism adherent to
the surface of the lungs.   The blood lies  in a cavity of which the walls con-
sist of torn lung-tissue.  The tissue surrounding the cavity is usually diffusely
infiltrated with blood.   There may be at the same time rupture of the  pleura
followed by a discharge of blood into  the pleural sac.  This  diffuse hemor-
rhage, with destruction of the  pulmonary parenchyma, is  less frequent, but
more serious,  than the circumscribed  form.
   In cases of  bronchial hemorrhage the blood may be drawn by inspiration
into the air-cells  and produce the appearance of hemorrhagic  infarction.
Blood may be  inspired likewise into the air-cells in cases of wounds  of the
lingual artery or of suicide by cutting the throat.  Hemorrhage  from phthis-
ical cavities and from gangrenous disintegration of the lungs  Ts noticed when
treating of these affections.  Excluding these conditions, the most important
causes of pneumorrhagia  without  laceration of pulmonary tissue  are  active
and  passive congestion of the lungs,  injuries  and  disease  of the central
nervous  system,  especially cerebral hemorrhage,  diseases  attended  by  a
hemorrhagic diathesis,  as scorbutus, purpura, yellow fever, and acute  yellow
atrophy of the liver, and  either thrombosis or  embolism  of branches  of the
pulmonary artery.
   The term hemorrhagic infarction is applied especially to hemorrhage follow-
ing embolism  of branches  of the pulmonary artery,  the most frequent and
important of the causes just mentioned.   These embolic infarctions are firm,
dark-red  in color,  and wedge-shaped, with the base of the wedge toward the
surface of  the lung and the apex toward the hilum.  In the majority of cases
the base of the infarction  reaches  the surface  of the lung, the  pleura over
the infarction being usually  coated  with  a delicate layer of fibrin.   These
infarctions may be single, but  they are  frequently  multiple.   They may
occupy the greater portion of a lobe, but usually they are about the size of a
walnut or pigeon's egg.  They are most common  in the posterior portion of
the lower lobe.  The affected portion of lung is free from air.  The microscop-
ical examination shows the air-cells filled with blood and  the alveolar septa
compressed and infiltrated with red blood-corpuscles.   There are  fewer  nuclei
than normal in  the walls of the alveoli, in consequence of coagulation necrosis
(p. 52).  The tissue surrounding the infarction is congested,  oedematous, or
solidified with  pneumonic  products.  Emboli may lodge in branches  of the 
P ULMONA R Y HEMORRHA GE.
267
pulmonary artery without causing hemorrhagic  infarctions.  Although the
branches of the pulmonary artery do not  anastomose with each other, and
therefore belong anatomically to the terminal arterial system, blood may be
brought to the capillaries of an  occluded  artery  by means of anastomoses
with the  bronchial  artery  and other small arteries  which enter  the lung
(Kiittner), and by means of surrounding  capillaries.   In  many cases  these
anastomoses suffice to carry on the circulation  in a district, the main  artery
of which has been obstructed by an embolus; but if the circulation be enfee-
bled by weakness of the right side of the heart, or if there be obstruction to
the flow of blood from the pulmonary veins into  the  left  side of the  heart,
the anastomoses no longer are sufficient, and a  hemorrhagic infarction results
within the district the artery  of which contains an  embolus.   Cohnheim's
explanation has been generally accepted, according to which the blood in the
infarction is derived by a regurgitant flow from  the veins leading  from the
affected district;  but according to Litten's experiments the blood "is brought
to the capillaries of the occluded artery by the small anastomosing arteries
mentioned above and by adjoining capillaries, the pressure in which does not
suffice to force the blood into the veins.   The blood escapes by diapedesis and
not by rhexis. (See Embolism and Thrombosis, Part I. p. 28.)  Infarctions are
more frequent in  the periphery than in the interior of the lungs, because the
anastomoses are fewer and the circulation feebler in  the former situation.  If
life be prolonged, the blood in a hemorrhagic infarction may be in great part
absorbed, and  only pigmented fibrous tissue, or possibly  only  a pigmented
stain, be  left  behind.
   In the majority of cases  hemorrhagic infarctions  in  the  lungs are  associ-
ated with cardiac  disease, especially with mitral obstruction or regurgitation.
They appear when the right cavities of  the heart have become weakened and
dilated and thrombi  have formed in the  right auricle or ventricle.  These
thrombi are the source of emboli which are carried into branches of the pul-
monary artery.  It is possible that thrombi may form in branches of the pul-
monary artery in heart disease.  Pulmonary  infarctions may be the result
also of emboli  derived from thrombi in  the  peripheral veins, as in  cases of
thrombosis of  the femoral vein.   It is not always possible to demonstrate a
source of emboli  in cases of pulmonary infarction.

   The diagnosis of either form  of pneumorrhagia is by  no means always
easy. Haemoptysis is of course present when the source of the hemorrhage is
bronchial  and the extravasation is due to the inhalation of blood into the cells.
This symptom  is  also present in the majority  of cases in  which the hemor-
rhage takes place within the  cells,  but  it may be wanting.  When present,
the haemoptysis may be either small or abundant; and the amount of extrav-
asation  is by no means  in proportion to the quantity of blood expectorated.
The respirations  are hurried and labored in proportion to the extent of lung
solidified by the extravasated blood.   Dyspnoea and a sense of oppression are
also proportionate to  the degree in which the respiratory function is compro-
mised.   These symptoms, however, are measurably  due  to  the coexisting
cardiac  lesions when  the  latter stand  in a causative relation to the hemor-
rhage.   Dulness  on percussion  will be  found  over a  space or  over  spaces
corresponding to the situation and extent of solidification.  This may  not be
appreciable if the extravasation be in the form of small disseminated nodules ;
but  if the extravasation  be diffused over a considerable  space, the dulness
becomes a very significant sign, provided tuberculosis,  pneumonitis,  and other
affections involving solidification can be excluded.   A feeble bronchial respi-
ration  may be  associated  with  the dulness on  percussion, or the respiratory
sound may be  suppressed  over the extravasation.  The presence of blood in 
268   PULMONARY HEMORRHAGE, PULMONARY  GANGRENE, ETC.

the cells and smaller air-tubes will be likely to give  rise to the subcrepitant,
and perhaps to a well-marked crepitant rale within  a limited space.   These
signs, suddenly  developed in  connection  with haemoptysis  and with  mitral
cardiac  lesions, may lead  to a diagnosis; but  in the  cases in which no_ blood
is expectorated a positive diagnosis is extremely difficult if not impracticable.
  Circumscribed extravasation,  incidental to . bronchial  hemorrhage,  is  not
necessarily serious ; and perhaps it occurs to a limited extent not infrequently
in cases of abundant haemoptysis followed by recovery.  If there be no  injury
of the pulmonary  structures and the blood simply infiltrate the air-cells, it
may be gradually removed by absorption  and  expectoration, the normal con-
dition being restored, as after solidification from pneumonitis.  If due  to  em-
bolism, the hemorrhage may lead to gangrene,  or the infarcted  portions may
become the sites of embolic pneumonia and the so-called metastatic abscesses.
The latter do not occur unless  the emboli contain infectious matter.  If these
results do not  follow, and  if the number and size of the spaces in which the
extravasation has taken place be not large, recovery may take place.   When,
however, the hemorrhage  into the air-cells and into the areolar tissue is con-
siderably diffused,  the  termination is usually fatal and death may take place
speedily.   Other things being equal, the  gravity of the symptoms and  the
immediate danger are in proportion to the amount of extravasation.

  The treatment of  different forms of pneumorrhagia must have reference
to the symptomatic indications in particular cases, in addition to analeptic  and
supporting measures.

                       Pulmonary Gangrene.

  Pulmonary  gangrene may be  defined as death or necrosis of lung-tissue,
accompanied by  decomposition.  It is one of the infrequent  pulmonary affec-
tions.  Its occurrence in cases of lobar pneumonitis and of hemorrahgic infarc-
tion has already been referred to.  Its most frequent causes  are those  which
either lower the vitality  of portions of the pulmonary tissue or favor  the
introduction into the lungs of  decomposing or infectious substances.  Among
the causes may  be  mentioned  interruption of  the blood-current by compres-
sion or embolism of the pulmonary or bronchial vessels; infectious diseases,
especially those  accompanied by the formation of septic emboli; penetrating
wounds of the lungs;  severe  contusions of the chest; decomposition  of the
contents of bronchiectatic  and  of tuberculous cavities ; the entrance of foreign
substances into the bronchi, such as bits of food in attempts to artificially feed
insane patients; the ulceration  of abscesses  and  of tumors (e.g. cancer of
the oesophagus) into the bronchi,  etc.   Pulmonary gangrene occurs more
frequently in males than in females, and also in those whose  powers of  resist-
ance are enfeebled by alcohol,  poverty, bad hygiene, or disease.  It sometimes
occurs in diabetes  mellitus.  It  may occur as  an idiopathic  affection in pre-
viously healthy individuals;  that is, without  any apparent cause.
  It is presented in two forms, which are distinguished as diffused and circum-
scribed. In the circumscribed form the gangrene occurs in sharply-defined spots
of variable size, usually between that of a bean and that of a hen's egg.  There
may be only one gangrenous  focus or there may be several foci.  They are
more  frequently situated  in the periphery than in the central parts  of the
lung, and more  frequently in the lower than  in the upper lobes.  The gan-
grenous spot  at first  is dark-brown or greenish,  dry and  friable.  Later it
undergoes softening, and  a cavity is  formed,  with sloughy walls, containing
an extremely offensive greenish  or brown fluid holding in suspension  shreds
of decomposed lung-tissue.  The microscopical appearances of the fetid  con- 
PILMONAR Y GANGRENE.
269
tents of the gangrenous  cavities are identical with  those of the sputa.   The
lung-parenchyma immediately surrounding  the gangrenous centre is usually
in the condition of lobular pneumonia;  and not infrequently it is the seat of
hemorrhages.   The gangrenous process  tends to spread peripherally.  In the
cases  in which the disease terminates  in  recovery the walls  of "the cavity
become cleaned off and free from the adherent shreds of lung-tissue ; a kind
of pyogenic membrane is formed;  and finally,  by adherence between the
opposite  sides of the cavity or by the growth of granulations, the cavity is
entirely obliterated, only a cicatrix remaining.  In the process of extension
of the gangrenous process  the blood-vessels are  usually  thrombosed before
they disappear; but sometimes  they are opened  before they become imper-
vious to  the blood-current, and  then severe and even fatal hemorrhage may
ensue. When the gangrenous patch reaches the surface of the lung, the  over-
lying pleura is covered with a layer of  fibrin.  Frequently, general pleuritis
results, which may be of a gangrenous character.  Sometimes the gangrenous
focus opens into the pleural cavity, giving rise to pneumo-pyothorax.  Thrombi
may form in the veins in  the neighborhood of the  sloughy  centres in the lung.
From this source infectious emboli may be carried to the various organs of
the body.  Intense bronchitis, sometimes of a diphtheritic character,  may
result from the irritation  of the  gangrenous matter.
   Diffuse gangrene may be secondary to  the circumscribed form, or it may
be diffuse  from the first.   The greater portion  of a  lobe, a whole lobe, or
even a whole lung, may be involved.  The pulmonary parenchyma is broken
down into a putrid, greenish, or blackish pulpy mass, without an evident line
of demarcation.  It  is always fatal.

   The symptoms in cases of gangrene  relate measurably  to the general con-
dition or  to associated  affections.    The  pulmonary symptoms due  to the
gangrenous condition  at  first are  those which belong to circumscribed pneu-
monitis, consisting of cough, some pain, and  accelerated breathing, and  after
a  time an expectoration,  more or less abundant, of  characteristic appearance
and odor.  The gross and  the microscopical appearances of the sputa  have
been studied carefully  by Traube1 and by Leyden and Jaffe.2   The sputa are
of a yellowish, greenish, or brownish color according to the varying amount
of pus and of blood present.  They  emit a penetrating, intensely fetid odor.
When fresh they are alkaline, but upon standing become  acid.   By allowing
the expectoration to  stand for a while  in  a  glass dish three distinct layers
become visible:  the upper is frothy, opaque, and of a dirty gray or yellowish
color ; the middle is clear and watery ; and the lower is greenish  and purulent,
or it may be brownish  from admixture with pigment or blood.  In this lower
layer  are  shreds of lung-tissue visible to the naked eye, and gray or whitish
masses.   Microscopical examination reveals granular detritus, pus-corpuscles,
triple phosphate crystals, drops of fat, and acicular crystals of the fatty acids,
often in bunches.  In  addition, granular or  angular fragments of brown or
black  pigment,  round and  rod-shaped  bacteria,  spiral bacteria,  leptothrix
threads, and infusoria are  met  with.  The  bacteria and fatty drops  and
crystals are often compacted together  into little  yellowish clumps  visible
with the naked eye.  The shreds of lung-tissue seen with  the naked eye are
of a dirty gray or black  color, and consist chiefly of granular  detritus,  dark
pigment,  and bacteria, with occasionally some elastic  fibres.   Elastic  fibres
are rarely  present, according to  Traube,  in the  gangrenous expectoration.
Later observations  show that Traube  underestimated the  frequency  with
which elastic fibres are  found  in gangrenous sputa; still, it  remains  true
                   1 Deutsche Klinik, 1853, 1859, 1861 et seq.
                   2 Deutsches Archiv f. klin. Med., ii. p. 488. 
 270   PULMONARY HEMORRHAGE,  PULMONARY GANGRENE, ETC.

 that the microscopical shreds of lung-tissue frequently found in the expec-
 toration of pulmonary abscess  contain  many  elastic fibres,  often  marking
 out  the outlines  of the alveoli, whereas  elastic  fibres are  more scanty  in
 the  sputum  of pulmonary  gangrene.1
   Pulmonary gangrene may  be  confounded  with  fetid  bronchitis, decompo-
 sition  in the  contents of dilated bronchi and of tuberculous cavities, and with
 pulmonary abscess.   The diagnosis is not to be based upon  the gangrenous
 odor of the breath and sputum  alone.   In fetid bronchitis and in  cases of
 decomposition  of  the contents of pulmonary cavities  microscopical  shreds
 of lung-tissue  are not present in the expectoration ; in pulmonary abscess
 they are often present, but they contain abundant elastic fibres, which are
 less abundant and are often  absent in  pulmonary  gangrene.   Again, pulmo-
 nary  abscess is not usually accompanied by the  fetor  of gangrene.
   In cases of circumscribed gangrene the  gangrenous portion of lung, together
 with the solidification from inflammatory exudation around this portion, fur-
 nishes dulness  or  flatness on percussion within a circumscribed space, which,
 in view of the most frequent situation  of gangrene, will  generally be over
 the scapula and below the  spinous ridge.  Within this space either the res-
 piratory murmur is wanting or there is a feeble bronchial respiration, with,
 perhaps, either exaggerated  vocal resonance or weak  bronchophony.   Moist
 bronchial or bubbling rales are likely to be heard within and around  this
 space.  If the patient  survive the sloughing and  removal by expectoration
 of the decomposed  mass, the  cavernous  signs  may be discovered.   I have
 repeatedly found a well-marked cavernous respiration, and I have observed a
 circumscribed depression in front corresponding to the situation and  size of
 the gangrenous cavity.

   As  regards prognosis, if circumscribed  gangrene do not occur under cir-
 cumstances which are dangerous, irrespective of the gangrene, recovery may
 take place.   The  chances  of recovery are  differently estimated by different
 writers, which perhaps may be accounted for by supposing that the diagnosis
 of gangrene is not infrequently based on  insufficient grounds.  It can hardly
 be doubted that the result is fatal in a large majority of cases.   Haemoptysis,
 as already stated,  sometimes takes place in connection  with the separation of
 the slough, and I  have known  the  hemorrhage to be so abundant as to prove
 the immediate cause of death.   Most of the cases end fatally in which the
 gangrene  involves the pleura, perforation of the lung  taking  place, followed
 by pleuritis with pneumothorax.

  The treatment  of  pulmonary gangrene is to be  directed more to the
 system than  to the local affection.  The affection never occurs under circum-
 stances which render depletion or other debilitating measures appropriate; on
 the contrary, such measures can hardly fail  to be pernicious.  Tonic remedies
 and the sustaining treatment are  indicated.   The diet  should be as nutritious
 as possible, and alcoholics are to be  given  with a freedom proportionate to
 the tendency to failure of the vital  powers.   The employment of opium in
 some  form is important, in order  to palliate  pain or undue cough and to allay
 constitutional irritation.  The chlorate of potassa has been suggested as likely
 to be beneficial, from its apparent usefulness in gangrenous affections of the
  1 According to the experiments of Filehne—" Ueber die Vorgiinge bei dem Lungen-
brande," Sitzungsberichte der Phys. Med. Soc. zu Erlangen, Jan. 11, 1877—in the sputum
of pulmonary gangrene a digestive ferment is present capable  of dissolving in alka-
line solution the elastic fibres and albuminous substances, but not acting on ordinary
white fibrous tissue,  which may be found in gangrenous sputum when the elastic fibres
are absent.  Elastic  fibres resist putrefactive changes much longer than those induced
by digestion. 
                         PULMONARY (EDEMA.                     271

mouth and throat.   The tincture of the chloride of iron  is suggested by the
same analogy.   Disinfectants by inhalation are indicated  as long as the sputa
contain decomposed matter and  the  breath has  a fetid odor.   The vapor of
turpentine poured  upon  boiling water is a disinfectant, and has otherwise a
salutary local effect.   Tar vapor, produced in the  same way, is useful.   A
solution of carbolic acid of the strength of from 2 to 4  per  cent,, atomized,
and inhaled  for a few minutes at short intervals,  is probably the best disin-
fectant.   Thymol and salicylic acid are recommended as appropriate as dis-
infecting inhalations.1


                         Pulmonary (Edema.

  Pulmonary oedema is always  dependent on other  pathological  conditions,
and is  not entitled to be considered as an individual affection.  It is, however,
an event  of frequent occurrence, and is  important as interfering with the
function of respiration, in not a few  instances proving the immediate cause
of death.   In oedema of the lungs there is a transudation of serum into the
interlobular  tissue, the alveolar  walls, and the  air-cells.2
  (Edema may be localized around  some diseased centre in the lung, as, for
example,  in the neighborhood of a pneumonitis, an infarction, abscess, tumor,
etc.  This is  distinguished as collateral oedema. In this case it probably results
from a moderate inflammatory change in the vessel-walls, by which their per-
meability  is increased.  This variety has also been called inflammatory oedema.
Hypostatic oedema, following hypostatic congestion and leading to the condi-
tion of lung called splenization, has already been referred to.
  These forms differ from general pulmonary oedema, which is usually under-
stood  by  the term  oedema of  the lungs.   Here a serous  transudation occurs
throughout  both  lungs, except  in  portions which may perhaps  present a
mechanical obstacle to the entrance of the serum in consequence of consolida-
tion, as from compression, inflammatory exudation, new growths, etc.  (Ede-
matous lungs are increased in volume and  weight;  retract less than healthy
lungs  upon opening the chest;  have a characteristic  boggy feel compared  to
that of a  sponge filled with water; and pit  on pressure.  They  are less buoy-
ant than normal  lungs, but they do not sink in  water.  The color is usually
red, but it may  be pale.  On  section,  a  serous or sero-sanguinolent  liquid
escapes in abundance, usually  mixed with air-bubbles.    The same frothy
liquid  is  present in the  bronchi and usually in the trachea.   Microscopical
examination  in cases of acute general pulmonary  oedema shows  the  pulmo-
nary capillaries widely distended with blood, and the contents  of  the alveoli
and  bronchi to  consist  of serum containing a  considerable number of red
blood-corpuscles, some  granular  epithelial  cells  washed off from the alveolar
walls  by  the transuding  serum,  and free  granular matter.   The  red blood-
corpuscles, which are always  present in  the serum, have  escaped by diapede-
sis.  The  serum infiltrates also  the  alveolar septa.
  (Edema of the lungs may occur  under various pathological  conditions.
There  is hardly a grave disease, acute or chronic, which  it may not compli-
cate.   It is also true that there is no disease of which it is a necessary accom-
paniment.  It occurs often during the death-agony, when it seems to be rather
  1 For an interesting case of pulmonary gangrene treated surgically by thoracentesis
and drainage,  with practical remarks, vide article by Drs. Fenger and  Hollister in the
Am. Joum. of Med. Sciences, Oct., 1881 ;  vide, also, the London Lancet, May 31, 1884, for
cases treated in the same manner by Mr. A. Pearce Gould.
  2 Posner  (Virchow's Archiv, Bd. 79, p. 362. 1880) finds that  the dropsical effusion  is
first into the walls of the air-cells, and that it  may be confined to them  (interstitial
oedema). Usually, however—and in the  higher grades of oedema always—the seium
escapes also into the air-cells. 
272  PULMONARY HEMORRHAGE, PULMONARY GANGRENE,  ETC.

an  accompaniment  than  the cause of death.   Of the affections during the
course or at the termination of which  it most frequently occurs may be
mentioned  acute  and chronic Bright's disease, valvular lesions of the heart,
pneumonitis, fevers  (especially those  of an  asthenic type), cerebral lesions
(especially hemorrhage  and traumatism), and cachexiae giving  rise to a
hydraemic state  of  the  blood.   It occurs  during these and other diseases,
especially when the heart's action becomes enfeebled.  It is frequently devel-
oped  suddenly, and  may disappear likewise  with considerable rapidity. _ It
may prove quickly fatal  by interference with respiration.   The great variety
of conditions in  which it appears, the inconstancy of  its development under
apparently similar conditions, the rapidity of its onset in many cases, and its
production during the death-agony are among the considerations which at first
seem to give to it a pathological position having no analogy to the dropsical
accumulations in other organs, and which render difficult the explanation of
its  production.
  That hydraemia, pulmonary congestion by obstruction at the mitral orifice,
and general weakness of the heart are only predisposing, not immediate, causes
of pulmonary oedema is evident from the fact that all these conditions may exist
in a high degree without the development of  oedema of the lungs.   This fact
is proved both by clinical observation  and by the establishment of these states
artificially in animals.   There must be added some other factor which  acts
as the immediate and exciting cause—a factor which is capable of developing
under various conditions, and one which can appear suddenly and as rapidly
disappear.  It is also to be  assumed that this factor must be something which
will increase the blood-pressure in the pulmonary capillaries; for that oedema
of the lungs is a mechanical oedema—that is, a result of increased tension in
the capillaries of the lung—is rendered probable by microscopical appearances
and by our knowledge  in  general  of dropsical effusions.  That mechanical
hindrance to  the outflow of blood from the  pulmonary veins, as by  mitral
stenosis, is capable of producing this elevated tension seems a priori probable;
but this is  a condition present in only a minority of cases of pulmonary
oedema, and the experiments of Welch,1 in reference to the cause of oedema of
the lungs, have shown that the obstacle must be greater, in order to produce
oedema, than can well occur in man.  He, however,  found that an efficient
cause of pulmonary oedema exists in paralysis of  the left side of the heart,
the force of the right side  being not at all or less impaired.   Neither gene-
ral paralysis of the heart nor weakness alone of the right ventricle suffices to
produce pulmonary oedema.  But, as was proved experimentally, it appeared
when the left ventricle was so  disproportionately weakened that it could not
propel into the general circulation the same amount of blood propelled by the
right ventricle into  the lungs.  The blood accumulated in the lungs until the
tension in the pulmonary capillaries became sufficient  for the transudation of
serum through  the vascular walls.  The  assumption  that  disproportionate
paralysis of the left ventricle is the immediate cause of  acute general pulmo-
nary oedema in man  would  explain many of its singular phenomena.  Such a
condition of the heart can be readily supposed to develop suddenly, to rapidly
disappear, and to arise during manifold diseases, especially when the  general
activity of the heart is impaired ; for  it is not denied that the general force
of the heart is weakened in most cases of pulmonary oedema ;  and, indeed, it is
hardly conceivable that the left ventricle should lose  its wonderful power of
adaptation to the obstacles which it has to overcome in propelling the blood,
before the whole heart had suffered in  its function.   (Edema of  the lungs
occurs during the death-agony, when the left ventricle loses  its power more
  1 William H. Welch, "Zur  Pathologie des Lungenodems,"  Virchow's Archiv f.  Path.
Anal, Bd. 72, 1878. 
P ULMON f R Y CEDE MA.
273
rapidly than the right, or dies faster, so to speak.   While the hypothesis of
Welch as to the immediate cause of pulmonary oedema is not controverted by
clinical facts, but, on the other  hand, seems to explain them better than any
other, we as yet know of no means of determining in man the relative force
of the two sides of the heart, and upon the absolute strength of  either right
or left ventricle only subordinate weight is placed.  Other influences adduced
to explain the cause of oedema of the lungs are impaired nutrition of the walls
of the pulmonary capillaries and vaso-inotor disturbance.1

   The symptoms of oedema are increased frequency of the respirations and
dyspnoea in  proportion to the extent of lung affected,  together with more or
less cough and serous  expectoration or bronchorrhoea.  The displacement of
air in the air-cells by liquid gives rise to dulness more or less marked on per-
cussion over a space corresponding to the cedematous portion of lung, and
within this space the respiratory murmur is weak or lost  or it may be feebly
bronchial or broncho-vesicular.  The vocal resonance may be increased.  The
presence of liquid in the smaller bronchial tubes is denoted by fine mucous or
subcrepitant rales.  It is stated that a true crepitant  rale may be produced,
but this  must  be extremely rare.  The diagnosis is to be  based on dulness
more or less diffused on both  sides of the chest, associated with moist bron-
chial rales, pneumonitis being excluded, and the existence of Bright's disease,
cardiac lesions, and other predisposing conditions being considered.

   The treatment must have reference to the circumstances under which the
oedema occurs.   Occurring in connection with  disease of the  kidneys, those
measures are  indicated  which  are applicable to  dropsical  effusion  in other
situations—namely, hydragogue cathartics and sudorifics selected and regu-
lated according to the circumstances belonging to  individual  cases.   When
incidental to disease of the heart the main reliance is upon revulsive measures,
in connection  with such remedies as  the condition of the  heart may claim
irrespective of this result.   In the cases in which it is dependent on adyna-
mia and  an impaired condition of the blood, tonic and sustaining measures are
called for.   The  liability of its  occurrence in connection with hypostatic con-
gestion in fevers and other protracted diseases, accompanied  by feebleness of
the circulation and depression of the vital  powers, renders it an  important
part of the treatment of these diseases to see that the patient be not allowed
to lie constantly in one position.   The  position of the body should  be fre-
quently  changed, in order to obviate the gravitation of blood  to the  depend-
ent  portions  of the lungs.
   The name acute, pulmonary oedema distinguishes cases in  which the oedema
occurs suddenly to such an  extent as to give  rise  to great dyspnoea, some-
times quickly causing death by apnoea.  In  such cases prompt  and efficient
measures of treatment are called for.  Venesection, if the action of the heart
be not extremely feeble, is the most promptly efficient measure for relief, and
should be resorted to at once when  the symptoms denote imminent danger.
Perhaps  under no other circumstances is  it more apparent that the physician
has saved the life of a patient than in certain cases of acute pulmonary oedema.
in which venesection was employed.  Occurring in connection  with dilatation
of the heart,  or  when accompanied with great feebleness  of the  pulse  and
cyanosis, the application of a considerable  number  of dry  cups  to the chest
may be substituted for bloodletting.  To these  may be added mustard to the
chest and stimulating  foot-baths.   Ethereal and alcoholic stimulants should
be given freely.   I have known the inhalation of  oxygen to afford marked
relief.
      1 See article by H. F. Borden, M. D., Boston Med. and Surg. Journal, 1880.
         18 
 274  PULMONARY HEMORRHAGE,  PULMONARY GANGRENE, ETC.


                 New Growths  within the Chest.

   Intrathoracic tumors  include  nearly  all  the  different varieties of new
 growths with which we are acquainted.   Their consideration in detail belongs
 to works on pathological anatomy.   Reference here will be made only to
 those rendered practically important by reason of their  frequency  or their
 gravity.
   Pulmonary carcinoma  may be  primary or  secondary.   Primary carcinoma
 of the lungs is a very rare affection.  As a rule, only one lung is involved,
 the right lung more frequently than the left.  Primary cancer of the lungs
 may be either of the cylindrical-celled variety, in  which case the tumor orig-
 inates in the larger bronchi, or  it may be of  the flat-celled variety, in which
 case the tumor originates  in the respiratory bronchioles or the air-cells.  In
 the latter form of carcinoma  the  stroma  consists of the pre-existing alveolar
 walls, and  the  appearances are sometimes not unlike a  diffuse pneumonia.
 Primary cylindrical-celled carcinoma of  the  lungs  usually appears as a cir-
 cumscribed tumor; primary flat-celled carcinoma may be either circumscribed
 or infiltrated.   Hemorrhages are likely  to occur in primary cancers of the
 lungs.  Sometimes softening and breaking down of the cancerous mass occurs.
 whence may arise cavities, abscesses, or gangrenous foci.   Secondary inflam-
 mation is present in the lung-parenchyma surrounding the cancerous deposit.
   Secondary cancer of the lungs is common.   It is frequently consecutive to
 cancer of the stomach and to cancer  of the breast, and  it may be  secondary
 to cancer in any part of the body.  The  relation of the lungs to the venous
 system  of the  body renders  these organs  the frequent seats of  secondary
 tumors in  general.  Secondary  pulmonary cancer is usually in the form  of
 nodules varying in size from that of  a pea to that of an orange, and dissem-
 inated throughout both lungs.  Sometimes the lungs, as well  as other organs
 of the body, are  studded  with  small cancerous nodules (general  or miliary
 carcinosis). Sometimes the lymphatic vessels of the pleura and of the lungs
 are filled with  cancerous  cells, in which case these vessels appear as a net-
 work of  white varicose bands.  The  secondary deposits in the lungs usually
 reproduce  the structure  of the primary  tumor.
   In pulmonary  carcinoma  the bronchial lymphatic  glands, and  not infre-
 quently the mediastinal, the cervical, and the axillary glands, are involved.
  A form of cancer, which is sometimes  described as endothelioma or endo-
 thelial cancer,  occurs primarily in  the pleura.   The  same form  of tumor
 is also described as originating in the lymphatic vessels  of  the pulmonary
 parenchyma.
  The pleura  may be studded with secondary cancerous nodules without
 any tumors in the lungs.   Cancer of the pleura is  often  accompanied with
 abundant liquid effusion in the pleural cavity.   The  effusion is  frequently
 hemorrhagic, and usually contains clumps of large epithelial  cells, described
 as grouped cells and budding  cells.   The  recognition of these clumps of cells
 in fluid  withdrawn from the pleura during life may give  valuable aid in diag-
 nosis.
  Of the malignant tumors within the chest, lymphosarcoma is among the
 most important.   Its takes it origin  in the cervical, the mediastinal, or the
bronchial lymphatic glands.   Lympho-sarcomata grow more frequently in the
anterior than in the posterior  mediastinum.   These tumors frequently extend
into  the lungs, advancing chiefly along the adventitia  of the blood-vessels
and of the bronchi.  The tumor is  composed  of cells, mostly  small round
cells,  enclosed in a network of anatomosing fibres like the framework of the
lymph-glands.   Caseous degeneration is rare, but a fibroid metamorphosis is
more  common. 
HYDA TIDS—ECHINOCOCCI.
275
   En chondroma may be a primary, but it  is usually a secondary, tumor of
the lung.

   The symptoms of intrathoracic tumors are both general and local.  In
suspected carcinoma  the  existence of the cancerous cachexia and the pres-
ence of carcinomatous tumors in other parts of the body must be considered
in arriving at a diagnosis.  Lympho-sarcomata present often the history of
pseudo-leucocythaemia or adenia of Trousseau.   In carcinoma  of the lungs
some diagnostic value is to  be attributed to enlargement of the supracla-
vicular lymphatic glands and to a  muco-hemorrhagic expectoration compared
in its appearance to currant jelly.   These  two symptoms are, however, not
pathognomonic or always present in pulmonary carcinoma.   The chest-wall
on the affected side may bulge ; sometimes, however, especially in hard cancer
accompanied by extensive induration, it is contracted.

   The diagnosis of new growths within  the  chest is to be based on the
symptoms taken in connection with the signs of solidification, and sometimes
the cavernous  signs.  The physical evidence is  often not  very distinctive.
Pulmonary phthisis  is to be  excluded by a careful investigation with refer-
ence to the  history  as well as to the existing  symptomatic phenomena.   The
coexistence  of carcinoma in some  other situation  or its previous existence is
to be taken  into account in  arriving at a diagnosis of carcinomatous intra-
thoracic  disease.
   The presence of tumors, great or small, gives rise to dulness or flatness on
percussion, with either  suppression of the respiratory murmur or the modifi-
cations which denote solidification.   The tumors may be so situated as to give
rise to symptoms and signs proceeding from pressure on important parts other
than the lungs.  The heart may be displaced.   The calibre of the trachea or
bronchi may be diminished.   Aphonia or laryngeal  spasm may be induced if
the recurrent nerve be involved. Congestion limited to the upper extremities,
head, and neck, and subcutaneous oedema, denote  obstruction of the superior
vena cava.  Pressure on the pulmonary veins may give rise to bronchorrhagia
and oedema of the lungs.  Compression of the oesophagus occasions difficulty
in the ingestion of food  and  drinks.  These results of pressure on adjacent
parts also belong to  the history of aneurismal tumors.  A tumor situated in
the tract of the aorta may simulate the physical signs of aneurism.   It may
pulsate and  give rise to a murmur.   I know, from my own observations, that
it mav occasion a double murmur; that is, a systolic and  a diastolic murmur.
The  enlargement of  one lung by a new growth, together  with either pleural
transudation or suppuration, may lead the physician  to suppose that he has to
deal  simply  with a case of pleurisy or empyema. The existence of the under-
lying graver affection can be determined only after removal of the liquid by
aspiration.   On the other hand, unilateral contraction of  the chest is sugges-
tive of fibroid phthisis.

   As regards treatment in  carcinoma and other new growths, all that can
be hoped for is the prolongation of life by a diet as  abundant and nutritious
as the digestive powers will allow, together with  the best available hygienic
influences and  tonic remedies.   Palliative treatment is  to  be  employed in
accordance with the symptomatic  indications.


                     Hydatids—Echinococci.

  Among the  extremely rare  affections of the  pulmonary organs  belong
hydatid productions.  These  may  either be developed within the lungs, or 
276   PULMONARY HEMORRHAGE, PULMONARY GANGRENE,  ETC.

they may have been developed in the liver and have made their way through
the diaphragm into the  pulmonary  organs in the manner in which hepatic
abscesses are  sometimes evacuated  into the bronchial tubes, circumscribed
peritonitis  and pleuritis  taking  place  and leading to adhesions  which pre-
vent the  evacuation  from  taking  place  into  either  the peritoneal or the
pleural  sac.
  Acephalocysts  within the lungs may remain latent for a variable period;
that  is, giving rise to few  or  no pulmonary symptoms.   Sooner or later,
however, they excite  inflammation of  the  surrounding  parenchyma and
bronchial tubes, and then occasion  pain, cough, expectoration, febrile move-
ment, etc.  They may  be discharged by ulceration into the  bronchial tubes,
leaving pulmonary cavities.   The affection is likely to be mistaken for pul-
monary tuberculosis.   Microscopical examination of the matter expectorated
may show the hooklets of echinococci or pieces of the sac with its character-
istic  striation and hyaline appearance.  Without the demonstration of one  of
these the diagnosis is impracticable.  The question as to the primary seat  of
the cysts is to be settled by the previous history, which, if they come from
the liver, will show the  existence of hepatic trouble  prior to the occurrence
of pulmonary symptoms.
  The presence of hydatids  in the lungs always involves great danger; and
the danger is  greater when they are derived from the liver than when they
are developed within the  lungs.  There is  no special plan of treatment.  Pal-
liative and sustaining  measures are to be adapted  to the circumstances  of
individual  cases.

                 Syphilitic Disease of the Lungs.

  The most common manifestation of syphilitic disease of the lungs is in the
form of a new growth  of connective tissue  (chronic  interstitial  pneumonia)
beginning at the root  of the lung  and following the  course of the larger
bronchi and blood-vessels.  By extension of the process to the pulmonary
parenchyma more or  less extensive patches of indurated connective  tissue
are produced in the central  part of  the lung.   In rare cases the growth  of
fibrous tissue is so great as to cause irregular lobulation of the lungs similar
to that found in syphilitic livers.
  In another  form of pulmonary syphilis there is new growth of fibrous
tissue  around the small  bronchi and  the blood-vessels, producing  peribron-
chitic and  perivascular fibrous nodules studding the  lung.
  Syphilitic ulcers may occur in the trachea and in the bronchi.  These often
cicatrize, and  may thus  lead to serious stenosis of the trachea  and of the
bronchial tubes.
  Gummata are found, although rarely, in the lungs, both in congenital and
in acquired syphilis.
  There is a  peculiar  form of syphilitic  pneumonia, sometimes described as
white hepatization, which is  not uncommon in new-born children affected with
syphilis.  In an early stage of the affection small nodules occur in the lungs;
later, a large portion or even the whole of the lungs is involved.  The lesion
consists in an  infiltration of the alveolar walls  with lymphoid  cells, and an
accumulation of cells, chiefly epithelial  in character, in the air-cells. This white
hepatization, so often found in stillborn syphilitic infants, is of more patho-
logical than clinical interest.
  Of late  years  many cases have been reported  as  examples of  syphilitic
phthisis.  Some of these cases  are  instances of syphilitic fibroid induration
with chronic bronchitis  and bronehiectatic cavities.   In most of  the  cases
which  have been  described as syphilitic phthisis,  and which have been exam- 
           ANATOMY AND PHYSIOLOGY OF THE LARYNX.     277

ined post-mortem,  the  lesions are not distinguished from  those of chronic
pulmonary tuberculosis with caseous pneumonia, and no  satisfactory proof
exists  of the syphilitic nature  of the disease.   No positive  proof of the
occurrence of a genuine pulmonary phthisis of  syphilitic origin exists.   As
we now possess in the tubercle bacillus, and  perhaps in  the bacillus of
syphilis, means  of  diagnosis of these morbid processes, we  may hope for  a
solution of the question as to  the  occurrence of syphilitic phthisis.
   The  diagnosis of syphilitic disease of  the lung can hardly be made  with
certainty.  Gummata and patches of central induration may be present in
the lungs without causing any symptoms.   If pulmonary symptoms be  pres-  ■
ent, such as cough,  expectoration, dyspnoea, pain in the chest, they are not
distinctive.  The  physical  signs  of consolidation or of cavity  (in  case of
bronchiectasis)  may be discovered.  A probable diagnosis may be based  upon
the history of  syphilis; the recognition of syphilitic lesions in other parts of
the body, especially in  the throat and in the  larynx ;  the exclusion of tuber-
culous  disease  of the lungs, particularly by examination of the sputum; and
the  amelioration or cure of the  symptoms  by  antisyphilitic treatment.
   Pulmonary tuberculosis may coexist with  syphilis.
                       CHAPTER  XII.

          DISEASES  OF  THE  LARYNX AND  TRACHEA.

Affections of the Larynx and Trachea.—Points relating to the Anatomy and Physiology
  of the Larynx, which are Involved in the Consideration of Diseases in this Situation.—
  Acute Simple Laryngitis: Anatomical Characters;  Clinical  History; Pathological
  Character;  Causation ;  Diagnosis ; Prognosis;  Treatment.—Subacute Laryngitis.—
  Chronic Laryngitis.—Laryngitis Hypoglottica.—Laryngitis with Fibrinous  Exuda-
  tion :  Clinical History;  Pathological Character; Causation; Diagnosis; Prognosis;
  Treatment.—CEdema of the  Glottis.—Spasm of the Glottis.—Nervous Cough.—Nerv-
  ous Aphonia.—Paralysis of  the Laryngeal Muscles.—Morbid Growths within the
  Larynx.

  IMPORTANT diseases affecting the respiratory apparatus are  seated  in
   the  larynx and trachea.  Diseases of the larynx frequently involve the
trachea, but  it is rare for the latter to be affected without the former, and it
will  suffice to consider tracheal affections incidentally in  treating of those  of
the larynx.
  Certain anatomical and physiological points pertaining to the larynx are
to be kept in mind with a view to a clear apprehension of the  diseases in this
situation.  The larynx  is composed of a number  of cartilages—namely, the
cricoid,  thyroid, arytenoid, and epiglottis.  The  epiglottis was formerly sup-
posed to be essential as a protection  against  the entrance of food and drink
into  the laryngeal cavity during the act  of  deglutition ;  the removal  of this
cartilage, however, in inferior animals has shown that its loss does not occasion
serious  inconvenience.   A hospital case in which it was completely destroyed
by syphilitic ulceration, as  determined by the touch and the laryngoscope,
has fallen under  my observation.   So long as ulceration existed there was
considerable  difficulty arising  from spasm of the glottis excited  by contact 
 278        DISEASES OF THE LARYXX AXD  TRACHEA.

 with food and drink, and deglutition was performed with the least annoyance
 while the patient was lying on the back. But after the ulceration had healed
 the difficulty nearly ceased, liquids and solids being swallowed without much
 inconvenience.   The quality of the  voice underwent some  change, and the
 patient, a young woman, stated that she had not the power of producing notes
 in singing as before.
   The small size of the rima glottidis  is an important point  in  connection
 with laryngeal diseases.  In  the adult male, after death, it is a triangular
 space an inch in length, and at the base about a quarter of an inch in width,
 the size being still smaller in women  and children.  The dimensions in life
 vary with the two respiratory acts.   When examined in a living animal, the
 vocal cords  are found to  separate  widely in inspiration and to  return in
 expiration, forming the respiratory movements of the glottis.   The respira-
 tory movements take place from a reflex influence communicated through the
 recurrent nerves. These points are of interest and importance in their practi-
 cal applications.
   Other movements of the  muscles of the larynx are  produced by volition
 in the acts of  speaking.  The larynx being the seat of the voice, modifica-
 tions of vocal sound constitute important symptomatic phenomena of disease.
 In the movements concerned in  phonation the will acts through branches of
 the spinal accessory contained in the recurrent laryngeal nerves.   The laryn-
 geal muscles are subject to spasm and  paralysis.
   The solidity  of the walls  of the larynx is an important point in  connection
 with certain affections.  The cricoid and  thyroid cartilages do  not  readily
 yield  to internal pressure, and hence arises obstruction from the presence of
 morbid  products  which encroach upon the  small space  between the vocal
 cords.   Another point to which reference will be made is the  abundance of
 areolar tissue beneath the  mucous membrane  above  the vocal cords.  This
 tissue is more abundant in the adult than in the child—a fact which will serve
 to account for certain differences as regards the effects of  disease  during  and
 after infantile life.
   The mucous  membrane  of the larynx  is covered, for the  most  part, with
 ciliated cylindrical epithelium.   Over the upper portion of the epiglottis, the
 true vocal cords,  and a portion of the posterior surface of the laryngeal
 cavity, however, the epithelium is of the  pavement  variety.   The mucous
 membrane is in most places  loosely attached by lax  connective  tissue  to  the
 subjacent muscles and cartilage, but  over  the  true vocal cords it is firmly
 adherent.   Hence in the latter situation submucous inflammatory and serous
 effusion cannot well occur.  Racemose  mucous glands  are  abundant in  the
 larynx.   None  are present in the true vocal cords.  The mucous  membrane
 and the submucous tissue are rich  in  elastic  fibres.
   Of the  affections of  the  larynx, those involving inflammation will be first
 considered.   Inflammation here may  be simple ; that is, not  distinguished by
 any unusual  features save those which are incident to  the  situation  of the
 affected mucous membrane.  On the other hand, it  may be  accompanied by
 fibrinous exudation.  The latter will  be considered under a separate head.
 Simple inflammation may be either acute, subacute, or chronic.   These three
 varieties are  to be considered separately.  The appropriate name for  inflam-
 mation affecting the larynx is laryngitis; this name should take the place of
 the terms angina and cynanche,  which were formerly in vogue, but are now
rarely used.  The  term croup is applied to  laryngitis with  fibrinous  exuda-
tion, and it has also been applied to simple laryngitis and  to a non-inflamma-
tory affection—namely, spasm of the glottis—occurring in children. The first
of these affections is sometimes  distinguished as true croup, while the others
are called, by way of distinction, false croup.   The term is an unfortunate 
                    ACUTE SIMPLE  LARYNGITIS.                 279

one and tends to produce confusion.  I  shall  consider the several  affections
to which the term has heretofore been applied separately under their  appro-
priate names.


                     Acute  Simple Laryngitis.
   Anatomical  Characters.—This  variety  of  laryngeal  inflammation  is
often called acute catarrhal laryngitis.   During life the mucous membrane is
reddened  and swollen, as demonstrated by means of the laryngoscope; but
after death the congestive hyperaemia is less marked, and may even entirely
disappear under  the pressure of the abundant elastic fibres.   Small  ecchy-
moses are not infrequently observed.  The inflammatory products consist of
serum  and pus mingled with an  abundant secretion of mucus.  The first
product is chiefly mucus ; later, this becomes  opaque from admixture with a
larger number of pus-cells, and in severe cases it becomes distinctly purulent.
Ciliated epithelial cells do not appear in the expectoration, and they  are not
usually desquamated.   The mucous glands are swollen, and  through their
orifices  often little  drops of muco-pus  can be pressed.   The  mucous  mem-
brane and submucous tissue always contain some pus-cells.  The amount of
swelling of the loose submucous tissue  varies  in  different cases.  In severe
cases it becomes so  swollen from infiltration with serum and  pus as to endan-
ger life by interference with respiration.  Sometimes erosions or even super-
ficial ulcerations of the mucous membrane are formed.   They either have
their origin from ecchymoses or they are follicular and seated  in the  mucous
glands.

   Clinical History.—The  symptoms of acute laryngitis are intelligible
when the morbid changes are considered in connection with the small size of
the rinia glottidis and the unyielding walls of the larynx.   Simple swelling
of the mucous membrane may produce more or less distressing symptoms and
danger due to narrowing of  the aperture of the glottis ;  but with submucous
infiltration added the  obstruction is increased, and may prove fatal by suffoca-
tion.   The  obstructive effect of the morbid changes explains  the  symptom-
atology and danger.  The chief element of danger is the submucous infiltra-
tion.   This occurs in  varying degrees, the severity of the local symptoms and
the danger being in proportion to its amount.
   The development of the disease may  be preceded by subacute laryngitis or
a common cold.  The voice is at first  hoarse, and, with the development of
acute inflammation, is lost.   The  aphonia is accompanied with a  stridulous
cough  and a small expectoration  of glairy mucus, which  may be streaked
with blood.  Febrile movement is more or less intense or it  may be wanting.
These symptoms may exist without notable difficulty of breathing, provided
the changes be  limited to the membrane and the swelling be not  great.
   With a greater amount of swelling, together with submucous infiltration,
labored respiration and dyspnoea  are added.   The obstruction affects  both
inspiration and expiration, but especially the former, owing to the fact that
the infiltration is  greatest above  the rima, where  the areolar tissue is most
abundant.   The respiration is  stridulous  or  noisy.  The patient  complains
of a sense of constriction at the larynx, or feels as if the cavity were filled
with a foreign substance.  The latter symptom may be called laryngeal tenes-
mus.   There is frequently more or less  difficulty in deglutition.  Liquids, by
coming into contact with the inflamed epiglottis, excite cough and add to the
distress.  The labor of breathing and the dyspnoea are increased by the occur-
rence of spasm of the arytenoid muscles.  The exacerbations of distress from
obstruction are due chiefly to a spasmodic  element,  Paralysis of the abductor 
280         DISEASES OF THE LARYNX AND  TRACHEA.

muscles may in some cases contribute to the obstruction.  The obstruction
will  then  be manifested more  in  the act of inspiration than  in  expiration.
  In cases of acute laryngitis with great obstruction the suffering is intense.
The face and eyes are swollen and congested, the countenance denotes anguish,
and after a time lividity occurs.  The distress is much increased during the
exacerbations caused by spasm, and  in the intervals of comparative ease the
patient manifests drowsiness, but is unable to obtain refreshing sleep.   With
the muscular efforts to enlarge the aperture of the glottis, the larynx rises and
falls  in the acts of inspiration and expiration.  There are frequent efforts to
cough and expectorate, as if to get rid of an  accumulation within the larynx.
The  cough may be dry and croup-like, but is oftener husky or abortive. The
larynx is sensitive to pressure.   Pitting  over the  pomum Adami has been
observed.   The respiratory acts are  less frequent than in health.   In a case
which  I have  recorded they were 12 per minute.
  With these symptoms in a large proportion of cases the disease ends fatally
if tracheotomy be not resorted  to.  The  mode of dying is by apnoea, and  it
may  take  place either gradually or suddenly in an  exacerbation of unusual
violence.
  Assuming that other affections do  not coexist, the symptoms, in  addition to
those which relate  directly  to the  laryngeal  obstruction, are incidental to
fever—deficient oxygenation  and decarbonization of the blood, together with
the suffering which belongs to the disease.  Slight delirium may occur toward
the close of the disease if it be  prolonged, but in general the mental faculties
are unaffected.

  Pathological Character.—In  simple acute laryngitis the inflammation
has no special characteristics.   The severity  and danger are not owing to the
intensity or extent of the inflammation.  The  same amount of inflammation
in other situations would constitute a trivial  affection.   The gravity is due to
the fact that the usual results of inflammation in this situation obstruct the
passage of air  through the larynx, in consequence of the small  size of the
rima glottidis and the unyielding laryngeal walls.   In children simple  acute
laryngitis gives rise to croupy cough and respiration, and hence this is one of
the different affections formerly embraced under the name croup.

   Causation.—Acute laryngitis, with the  symptoms  stated  in the  Clinical
History, in  the adult is extremely rare.1   It is less rare in infants and children
than after adult age.  Its infrequency is remarkable in view of the frequent
occurrence of inflammation in the pharynx ;  and the fact exemplifies the prin-
ciple of conservatism involved in the law  by which inflammation does not tend
to extend from one part to other parts, although  in immediate  proximity.   I
have seen a case in which the pharynx was  laid open by a gunshot wound in
the'neck,  so that the top of the larynx could be seen through the wound, and
yet  during  the progress of recovery there was no  evidence of the  slightest
laryngeal inflammation.
   Occasionally, however, laryngitis is developed  in connection with pharyn-
gitis.  This was observed  in some cases of the so-called epidemic erysipelas,
or -'  black tongue," which formerly prevailed in many parts of this country.
I  have known it to occur in  connection with the pharyngeal  affection  in
scarlatina.  The laryngitis which, in a subacute form, is common  in  rubeola
sometimes becomes acute.  Acute inflammation may be excited in variola by

  1 Some writers reckon as cases of acute laryngitis those in which the symptoms  denote
a less dangerous form of the disease than the one here considered under this  heading.
Of course  the disease is  less  rare if the term acute be extended to cases of moderate
severity. 
                     ACUTE SIMPLE LARYNGITIS.                 281

 the occurrence of the eruption in this situation.   Under the several circum-
 stances just named it is a secondary affection.   It may occur  as  a primary
 affection after exposure  to cold and  wet,  as in  the  case  of Washington.
   It might be conjectured that excessive use of the voice would be likely to
 predispose to this affection, but clinical observation furnishes little proof that
 such  is  the fact.   It may be produced traumatically by  the  inhalation of
 irritating vapors.   Many cases have  been reported in which young children
 have produced the disease by sucking boiling liquid and steain from the spout
 of a water- or tea-pot.

   Diagnosis.—The diagnostic characters of acute laryngeal inflammation are
 the loss of voice, and the husky, stridulous cough, in connection with the fever
 and other symptoms.  That  the  labor of breathing and the dyspnoea are due
 to the obstruction of the larynx is shown by the sensations  of "the patient, the
 diminished frequency of the respiratory acts, and the absence of physical signs
 denoting pulmonary disease.   In proportion as the aperture of  the  glottis is
 narrowed the respiratory murmur will be weakened, and this affords a better
 criterion of the amount of obstruction than  the sufferings of the patient.  The
 only difficulties in diagnosis relate to the discrimination of simple acute laryn-
 gitis from  laryngitis with fibrinous exudation, from oedema  of the glottis, and
 from spasm of the laryngeal  muscles.  In arriving at the conclusion that sim-
 ple acute  laryngitis  exists, the  affections just  named are  excluded by the
 absence of distinctive circumstances belonging to the clinical history of each.
 Suffice it to say here that the presence or absence of  fibrinous  exudation in
 cases of laryngitis is generally determinable; that oedema of the glottis may
 be ascertained ;  and that spasm without inflammation  or with  only subacute
 inflammation is wanting in characters which are  essential to the diagnosis of
 acute laryngitis.   If a satisfactory laryngoscopy  examination  can be made,
 the diagnosis is  demonstratively  established.

   Prognosis.—Acute  laryngitis  in  the adult is a  grave affection.   The
 gravity,  as already stated, depends in a great measure on the submucous
 infiltration.  Cases  without  this contingency occur, and may end favorably
 without very alarming symptoms.  The suffering  in these cases arises meas-
 urably from  spasm.   If the constant obstruction—/'. e. obstruction exclusive
 of that due to spasm—be sufficient to interfere greatly with respiration, the
 tendency is to a fatal result.   A  proportion of such cases will end fatally if
 life be not saved by timely surgical interference.   The course of the disease
 in fatal cases is  rapid.   It has been  known to  prove fatal in  seven hours.
 The  duration rarely exceeds a  week.
   In  young subjects this disease is less  severe and less likely to prove fatal
 than in adults, notwithstanding the smaller  size of the rima glottidis in early
 life, the difference  being probably due to the fact that submucous transu-
 dation is less in children.

   Treatment.—The treatment of acute laryngitis embraces general and local
 measures.  The general measures  are those designed to lessen  the intensity
 of inflammation  and to  promote resolution  and  the  absorption of serous
 transudation.  The employment of bloodletting is to be  guided  by the  same
principles  as in other inflammations, but the evils  and danger of abstracting
blood are not so great as in certain other inflammations—for example, lobar
pneumonitis—because there is not the amount of  morbid effects to be recov-
ered  from,  and it is therefore not so important to spare the  vital powers  for
the processes of  restoration.   The  danger in acute  laryngitis, it  is to be
borne in  mind,  is not  from  the extent  or  degree of the  inflammation or 
282        DISEASES  OF THE LARYNX AXD  TRACHEA.

from  the  lesions which it  may induce per sc, but it is incidental to the seat
of the inflammation.  And  if a fatal result take place, the dying is by apnu-a,
not by asthenia.  But in the use of bloodletting and other depressing measures
this consideration must be kept  in  view: the patient's strength  is not to be
so  far diminished as to incapacitate for the prolonged  muscular exertions
which the labor of breathing may  require.  Bloodletting should never be
practised  after the occurrence of lividity of the prolabia and face.   Under
these circumstances a fatal result  would be  hastened  by abstracting blood.
  The bowels  should be moved  efficiently  by cathartics of the  saline class.
Nauseant or the direct  cardiac  sedatives are indicated as in other inflam-
mations.   Nauseant  remedies should not be carried so far as to produce
vomiting, which  will  add greatly to the distress and tend  to aggravate  the
inflammation.   If antimony be used, it should be given  largely diluted, to
avoid its  local action on the throat,
  Mercurialization may  be advocated in this as in  some other affections on
the following  ground : Although the antiphlogistic and sorbefacient powers
of mercury have doubtless been heretofore greatly overestimated, it is by no
means certain  that it exerts no  remedial influence  in  these directions.  So
long,  therefore, as there  is  room to suppose  that it may be useful in any
degree, it  should be  employed  in  an affection  like  this, which  frequently
tends rapidly  to  destroy life by apnoea.   The general depressing effect and
other evils of mercurialization are of  little moment, provided  the remedy
prove  in  any  degree  useful in its  influence on the local  affection.  If mer-
curialization be determined on, it  should be induced early and rapidly, either
by  large doses  guarded with opium or by small doses repeated at short inter-
vals, mercurial inunction being added.
  Remedies to allay spasm and cough are indicated.   The spasmodic element
may be more or less prominent.   Its  degree of prominence is  shown by the
frequency and  severity of  the paroxysmal distress, whereas the amount of
obstruction due to the swelling  and infiltration is  shown  by the labor of
breathing in the intervals between the paroxysms or exacerbations.   Opium
and antispasmodic remedies are important in proportion to the amount of
suffering from spasm, but  opiates should not be carried  so far  as to blunt
the perception of the want of breath.   If belladonna be  found  to meet the
indication, it is to be preferred to  opiates.
  In  the  foregoing remarks on the general  measures of treatment reference
has been had especially to idiopathic or  primary laryngitis.  When the affec-
tion occurs as a  complication of  scarlatina, rubeola, or variola, and  if it be
associated with pulmonary or any other important disease, the same measures
may not be admissible.  This statement applies to  bloodletting, mercuriali-
zation, and other depressing  measures.   Inflammation  of the trachea fre-
quently, if not  generally,  coexists,  and bronchitis may be  developed in
accordance with the law respecting the extension of inflammation in the air-
passages—namely, that it tends to travel downward and but rarely  upward.
Of  course  the  general symptoms, febrile movement, etc. will be increased in
proportion  to the extent of mucous surface inflamed.
  The local measures of  treatment embrace fomentations or poultices applied
to the neck, with a blister,  perhaps, applied over the  sternum ; and the atmo-
sphere of  the  apartment should be charged  with  steam or the vapor of hot
water should be inhaled by means of a convenient apparatus.  The former is
vastly more effective,  and is therefore to be preferred.  The application  to the
throat of  compresses  dipped in ice-water and renewed at intervals of a few
minutes is a measure  which may be tried with safety, and if it afford relief it
may be often repeated, being continued as long as it is a source of comfort to
the  patient. Early in the disease it may act favorably as an antiphlogistic, 
           CHRONIC LARYNGITIS—LARYNGEAL  ULCERS.        283

and afterward it may afford relief by diminishing spasm.  According to Cohen,
it is indicated when the obstruction is caused in a measure by paralysis of the
abductors.
  When the membrane, on laryngoscopy examination, shows much tumefaction
above the vocal cords, Cohen advises scarification of the parts.   If this meas-
ure be not practicable or if it prove ineffectual, tracheotomy is to be employed,
provided the  obstruction  become so great as to  render danger of death immi-
nent.  Patients should never be allowed to die from strangulation for want of
timely surgical interference.  If the  danger be  purely orchiefly from apnoea,
this operation will prove  the means of saving life.   The important question
is, When is it  to  be  performed ?  It should not be  delayed until permanent
lividity  occurs; that  is,  lividity due  to the obstruction caused by  swelling
and infiltration irrespective of  spasm.  Persisting lividity denotes imminent
danger,  and  impairs  the  probability  of success from  the operation.  It is
advisable not to delay either scarification or tracheotomy, or  both, until livid-
ity occurs,  but to resort to surgical interference whenever the obstruction is
sufficient to occasion sinking in of the soft parts and retraction of the lower
part of  the chest  in inspiration.
  After convalescence is established the  recovery of  the voice is  slow, the
pitch and quality remaining altered  for some  time.
  The  treatment of acute laryngitis  in children,  owing to  its being a less
severe and grave  affection than  in the adult, claims  less vigorous treatment,
Cases frequently, if not  generally, do  well with simple palliative  measures.
Emetics may be  important in  order  to effect the  removal  of viscid mucus
from the larynx.   Death  may be produced solely  by obstruction due to the
accumulation of mucus  in  this situation.   It  will hardly be supposed  that
the larynx  may be so tolerant of obstruction from  this  source that, occurring
in a healthy child, efficient efforts of coughing  would not be excited and life
be destroyed  by slow apnoea; yet a  case  exemplifying the fact has fallen
under my  observation.

                       Subacute  Laryngitis.
  Subacute inflammation  of the larynx is of frequent occurrence, either as
preceding the development of bronchitis, or the inflammation not extending
to the bronchial tubes.   It  characterizes certain cases  of the  affection com-
monly known as " a cold."   The inflammation is of a low grade of intensity,
and is not accompanied by submucous effusion.  There is either  hoarseness
or aphonia, with cough and  an  expectoration at first transparent  and viscid,
and afterward opaque, thick, and loose. There is  no obstruction to respira-
tion.  Laryngeal  spasm in  the adult is rarely excited.   There is  little or no
fever.
  It is important only as involving some liability to an  increase in the inten-
sity of the inflammation  or  the development of the acute affection ; but the
liability to this  is small.   The measures of treatment are those  indicated in
cases of bronchitis or a  " cold."
  Subacute laryngitis exists in a certain  proportion of the cases  formerly
included under  the name croup.   The croup phenomena are due to  spasm,
the laryngitis being an unimportant element,  This variety of so-called croup
is unattended with danger, however violent  may be  the symptoms referable to
spasm.

             Chronic Laryngitis—Laryngeal Ulcers.
  Chronic laryngitis occurs  much more frequently than the acute  form ; it
occurs,  therefore,  often without having been preceded  by acute laryngitis. 
284        DISEASES OF THE  LARYNX AND TRACHEA.

Acute laryngitis, in fact, if it do not destroy life, ends in recovery without
eventuating in the chronic affection, and, on the other hand, in chronic laryn-
gitis the inflammation rarely becomes acute.
  In chronic inflammation the hyperaemia is less intense than in acute laryn-
gitis.   The mucous membrane has a grayish color, and often presents to  view
dilated  veins.  A  mucous or purulent secretion coats  its surface, which is
often  granular from enlargement of the mucous glands.   The vocal cords lose
their  smooth, glistening appearance, and are grayish or  opaque.  The flat
epithelium covering them becomes  thickened, and often in other portions of
the larynx the normal  cylindrical epithelium is replaced by  the pavement
variety.   By  development of new  connective tissue the mucous membrane
and submucous tissue often become thickened, and occasionally papillomatous
growths project into the cavity of  the larynx.   Instead of being hypertro-
phied, the mucous membrane in some cases is atrophied.  Ulcerations more
or less deep  and extensive  are frequent in chronic laryngitis due to specific
causes.
  In the majority of cases chronic  inflammation in this situation occurs in
connection with either  syphilis  or  pulmonary phthisis.  The  localization of
syphilis in this part is  rare, so  that  the existence of chronic laryngitis  con-
stitutes presumptive evidence of the existence of phthisis.  In  cases of pul-
monary phthisis with chronic laryngitis  it was formerly supposed  that the
latter precedes the former, and that the  disease  extends from the larynx to
the lungs.   The term laryngeal phthisis was used to distinguish the affection
in these cases.  Improvement in the means of detecting a tuberculous deposit
in the lungs, however, has led to a  knowledge of the fact that the laryngitis
in nearly all these  cases is  secondary, the pulmonary disease being first devel-
oped.   The  laryngeal ulcers which  complicate pulmonary phthisis are most
frequently seated on the posterior surface of the  larynx, just above  the com-
missure of the vocal cords.  In many cases a single small ulcer in this situa-
tion is found.   This may, however, extend in depth and surface, and others
may likewise appear.  The vocal cords may be nearly destroyed by phthisical
ulceration, and one or more small ulcers are often found on the epiglottis.  The
smaller ulcers are usually round, and the larger ones have  festooned borders.
The edges are thickened.   The ulcers appear to be always due  to the break-
ing down of tuberculous products.  Tubercle bacilli are  found in the walls
of the ulcer and in the secretion from  its surface.
  While phthisical ulcerations most frequently begin just above the vocal
cords, syphilitic affections are usually first developed in the upper portion of
the larynx.   Syphilitic  laryngitis in  general follows syphilitic  disease of the
pharynx and base  of the tongue.   In the later  stages  of syphilis laryngeal
ulcerations,  often of the most  destructive character if  not properly treated,
may be developed.   These usually  begin on the  epiglottis and extend down-
ward.   They may attack the vocal cords, and even  extend into the trachea.
They are accompanied usually with much induration and thickening of the
submucous  tissues.  When the ulcers  heal, sometimes  deforming cicatrices
are formed,  which  may lead, especially on  or  about the vocal cords,  to dan-
gerous  and  even fatal  stenosis.
  Inflammation  of the tissues immediately surrounding the laryngeal carti-
lages  is called laryngeal perichondritis.  Suppurative perichondritis is most fre-
quently the  result of syphilitic or phthisical ulcers in the  larynx.  It occurs
as a very rare complication in infectious diseases of an  asthenic type.  The
non-vascular cartilage  suffers in its nutrition, and often  becomes  partly or
wholly necrotic, so that loose pieces of cartilage, usually calcified or ossified,
are found bathed  in pus.  If the collection  of pus open into the laryngeal
cavity,  the  dead pieces of cartilage may  be coughed out.  A necrosed  frag- 
           CHRONIC LARYNGITIS—LARYNGEAL ULCERS.        285

ment of cartilage has been known to  become  lodged in the glottis  and to
cause death by suffocation.  Sometimes the perichondrial abscess opens exter-
nally, and through the opening necrosed cartilage may be discharged.

  The most characteristic of the symptoms of chronic laryngitis relate to the
voice.  It  becomes either hoarse, husky, or  stridulous, and  it may be lost;
that is, there is either difficulty of speech (dysphonia) or its extinction (apho-
nia). ^ If aphonia exist, the patient speaks in a husky whisper.  The extent
to which the voice is affected  is not a criterion of the extent to which the
vocal  organs are damaged by ulceration.   Slight ulcerations and  thickening
may lead to great huskiness, and  even extinction of the voice.   If notable
hoarseness  exist, more or less destruction of the vocal cords, enlarging the
rima glottidis, may  be suspected.
  As regards cough, its prominence as a symptom  varies in different cases.
It is modified like the voice ; that is, it is either hoarse, husky, or stridulous.
The expectoration also varies.  It may be  slight or more or less abundant.
Its  characters  may be  those of mucus, muco-purulent matter, or pus.   Not
infrequently it presents  bloody streaks, and it may be  fetid.  The bloody
streaks and pus point to ulceration ; the fetor  points to  caries of the carti-
lages.  Cough and expectoration, however,  it  is to  be  borne  in  mind, are
measurably due  to  the tuberculous affection of the lungs  with  which the
laryngitis is generally associated.   Some cases of tuberculous laryngitis are
characterized by violent paroxysms of cough resembling those of whooping
cough, and vomiting  may occur during the paroxysms.
  A marked difference in  different cases relates to deglutition.  In some cases
the act of swallowing is attended with no  inconvenience,  but in a certain
proportion  of cases it is a source of great distress.  The passage of food and
drink causes pain, excites spasms  of the glottis, thus occasioning  distressing
dyspnoea, and  frequently liquids are returned through the nostrils.   Patients
are obliged to confine themselves to the blandest articles of diet, and even
these are sometimes ingested with so much  difficulty that death is hastened
by  innutrition.  The difference in  different cases depends on the situation of
the ulcerations,  these extending sometimes  above the vocal cords  and upon
the epiglottis,  where the ulcerated surface comes in contact with the food and
drink in the act of swallowing, and sometimes being sufficiently below the top
of  the larynx  to be secure from this source of  irritation.

  The diagnosis of chronic laryngitis is easy ; the morbid characters of the
voice at once indicate the affection.  Its  connection with  pulmonary phthisis
is to be determined by a  physical exploration of the chest and examination
of  the sputa,  together with an examination into the previous history  and
symptoms.   If pulmonary disease  be  excluded, the  syphilitic source of the
affection  is to be investigated.  The  affection may be regarded as idiopathic
in cases in  which both syphilis and phthisis can be excluded; but, as already
stated, such cases are rare.

  The prognosis in cases of chronic laryngitis will of course have reference
to its pathological associations.  Its connection with phthisis does not render
the latter disease more rapidly progressive ;  on the contrary, the progress of
the tuberculous affection of the lungs  is, as a rule, more  slow with than with-
out this  complication, provided it do  not interfere with  alimentation.  Thus
associated,  however, the laryngitis  is rarely recovered from.   The  inflamma-
tion and ulcerations usually continue, but if not, the voice remains perma-
nently more or less  impaired.   Considerable  improvement may take place in
cases of tuberculous  laryngitis, although  the  affection  continue.   Chronic 
286        DISEASES  OF THE LARYNX AND TRACHEA.

laryngitis dependent on syphilis offers a better prospect of recovery.  The
voice, however, after  recovery  will be  very likely  to  remain permanently
affected.
  In my experience cases of tuberculous laryngitis have not presented nota-
ble  embarrassment of breathing from obstruction.   In not a few of the cases,
however, of syphilitic  laryngitis which I have seen there has  been sufficient
stenosis to render respiration more or less labored, and in some cases obstruc-
tion threatened life by apnoea.   In a number of cases which have come under
my  observation at Bellevue Hospital the operation of tracheotomy has been
resorted  to, and, apparently, the lives  of patients  thereby saved.  It  has
sometimes been resorted to  more than  once  in the  same case.

  The treatment  of chronic laryngitis, as  regards general  measures, will
have reference to its pathological relations.   In  the great majority of cases
the  treatment must be that  indicated by the coexistence of pulmonary phthisis.
If the aff'ection be traceable to syphilis, the antisyphilitic remedies are called
for—namely, mercury  and  the iodide of  potassium.
  As regards local  measures, counter-irritation over the neck by means of
the  croton oil or small blisters is sometimes  useful, even in cases of phthisis.
The local treatment, however, relates especially to applications to  the affect-
ed  part:  that  is,  within the larynx.    The  injection  of  medicated  liquids
and the  insufflation  of remedies in the form  of a  dry powder are objection-
able, owing  to the difficulty  of limiting  the application  to the diseased parts
and to the cough and  spasm which they are liable to excite.   A more satis-
factory method is the  introduction of a sponge attached to a  probang prop-
erly curved.  Owing to the  enlargement of the glottis which  takes place in
the act of  inspiration, the  introduction must be  made during the  act of
inspiration.   During the act, as is well  known, foreign  bodies of large size
are  sometimes  drawn  with the inspired  breath into the air-passages.  The
nature and seat of lesions within the larynx may be ascertained by means of
the laryngoscope, and  the knowledge thus obtained affords aid in  judging as
to the propriety of topical  applications and in  showing the particular points
at which they are to be made.
  The topical remedy most freauently  applied by means of the sponge is the
nitrate of silver.   A strong.^Ja-^on is commonly used—namely, from one to
two scruples to the ounce ojfl  HBId water.  The  sponge, moistened by this
solution, is carried between UPwlow  the vocal cords.   Spasm of the glottis
occurs, and  the liquid, being expressed  from  the  sponge, comes into contact
with the  whole of the interior surface  of the larynx.   This  application is
sometimes beneficial, affording immediate and  marked relief.  It may then be
repeated from time to  time.   In many cases, however, no relief is afforded,
and in these cases  after a  fair trial it is useless to persevere  in it.   In  the
cases in which the laryngitis interferes  with deglutition, relief may sometimes
be afforded by narcotics and  probably  by codeia.   The topical  application of
the  hydrochlorate of cocaine has recently been found serviceable.
  Tracheotomy  is to be resorted to in  cases of syphilitic laryngitis whenever
obstruction  endangers life.  The propriety of this operation as a means of
promoting recovery has been advocated.  For* this purpose the opening is to
be maintained for an indefinite period.   The advantage consists in the arrest
of the respiratory movements of the laryngeal muscles, which is a result of
breathing through  the trachea.1  This measure  has also been advocated in
cases of  laryngitis associated with pulmonary phthisis, the objects being com-
plete rest of the larynx and  the prevention of the passage of  the matter of
expectoration over the ulcerated surfaces.  It has proved a useful measure in
  1 Vide article by Thomas Bryant, in the Trans. Clin. Soc. of London, vol. i., 1868. 
            LARYNGITIS WITH FIBRINOUS  EXUDATION.        287

some reported cases.1   An  objection  to it  in cases of phthisis is the  obstacle
which a tube in the trachea offers to  free expectoration.  If found to be use-
ful, its usefulness will probably be limited to the cases in which the  laryn-
geal affection involves dysphagia and in this way interferes with alimentation.

  Inflammations  may  occur  in that part of the  larynx situated below  the
vocal  cords.   Inflammation in this situation is called laryngitis hypoalottica.
The inflammation may be confined to this region.  Acute subglottic laryngitis
is often attended  by great swelling of the submucous tissue  in  consequence
of infiltration with serum  and pus-cells.   The affection is a grave one  on
account of the obstruction to respiration.  Usually, both acts of respiration
are difficult.   The  diagnosis  is readily made  by  means of  the  laryngoscope,
which  reveals the situation of the swelling  to be just below the true vocal
cords.  Tracheotomy is frequently indicated by the severity of the symptoms.
  Chronic inflammation of  the mucous and submucous  tissues of this part of
the larynx is characterized by a  new growth  of connective  tissue (laryngitis
hypoglottica hypertrophica).  The affection is rare and of a peculiar nature,
being in some cases  apparently  dependent  upon the disease  called  rhino-
scleroma.


Laryngitis with Fibrinous Exudation (Membranous Croup).
  In Part  First  of this work (p. 37)  the  anatomical  characteristics of the
so-called croupous, diphtheritic, and pseudo-diphtheritic inflammations have
been briefly mentioned.  It is important to distinguish between the anatomi-
cal  signification of these terms and the clinical application of the names croup
and diphtheria.   In  croup we may  have diphtheritic as  well  as  croupous
inflammation, the difference depending chiefly upon the seat of  inflammation.
Decided as  are the differences between membranous or true croup and diph-
theria  as regards etiology  and clinical  history, essential points of difference
in respect of their  pathological anatomy have not as  yet been established.
In  both diseases there is a fibrinous  exudation.   In croup  the  larynx  is  by
preference attacked, in diphtheria the pharynx and sometimes the nasal pas-
sages ; but  croup  is  usually accompanied  with  fibrinous  exudation  in  the
pharynx, and diphtheria frequently with pseudo-membranous laryngitis.   In
both diseases the fibrinous  exudation, when seated in the trachea or the lower
portion of the larynx, is usually of the so-called croupous variety, and, when
seated in  the pharynx or  fauces, of the  diphtheritic or of  the  pseudo-diph-
theritic variety.   By  so-called true or membranous croup, however, is under-
stood a local  disease characterized  by fibrinous  inflammation  of the  upper
air-passages ;  by  the name diphtheria, an infectious disease with, in certain
cases, a similar localization of the fibrinous exudation.  In  this article refer-
ence is had only to  the affection heretofore known as true croup.  Diphtheria
is more appropriately  considered under general diseases than under  diseases
affecting the respiratory system.
  The term croup is of Scotch origin, and signifies strangulation. As already
stated, it has been used in a comprehensive sense  to signify a variety of affec-
tions in children  characterized*by a peculiar shrill, barking cough called the
croupal cough, and by difficulty in breathing.  These symptoms may accom-
pany in children  simple acute or  subacute laryngitis, and also  spasm  of the
glottis without laryngeal inflammation.  To such cases the name false croup
has been applied in distinction from true croup, the latter term being employed
only for the pseudo-membranous variety of inflammation.
  The extent of the fibrinous exudation varies in different cases.  The exu-
  1 Vide article by Dr. Beverley  Robinson, Am. Journ. of Med. Sciences, April, 1879. 
288         DISEASES OF THE LARYNX AXD TRACHEA.
dation, in the  form of a false membrane, is found in the larynx and trachea.
It is also present, as a rule, in the pharynx, on the  tonsils, soft palate, base
of tongue,  or epiglottis.  The larger bronchi are often involved, and in rare
instances those of small size.  The larynx may be  primarily affected, or the
false membrane may appear first in either the pharynx or the trachea.   The
false membranes are whitish or grayish, or brownish-red from admixture with
blood.   They  vary greatly  in extent,  thickness, and consistence.   On  the
mucous membrane of the pharynx or fauces the fibrinous exudation  appears
usually in patches.   In  the larynx  the favorite seat of the exudation is the
vocal cords, which are often uniformly  coated, and  sometimes so thickly that
the glottis is nearly occluded.  The false membrane  may be expectorated in
the form of shreds or  of tubular  casts of the larger bronchi, or rarely as
solid cylinders from the small  bronchi.   The membrane, when recent, is of
tolerably firm  consistence;  it may be found  on autopsy, however, as a soft,
pultaceous  mass coating the mucous membrane.  In  the trachea and  bronchi
it can,  as a rule, be readily stripped off from the subjacent mucous membrane ;
in the larynx it can also often be removed without tearing the mucous  mem-
brane ; but  it is  usually closely adherent on  the epiglottis and  true  vocal
cords ; in the pharynx and  on the soft palate  also it  is intimately connected
with the mucous membrane.  In  the bronchi, trachea, and lower portion of
the larynx  the fibrinous exudation is of the so-called croupous variety—that
is, the false membrane  consists  chiefly of fibrillated  fibrin  holding in its
meshes pus-cells,  red blood-corpuscles, and  sometimes epithelial cells; it lies
directly upon the basement-membrane in most places, the  epithelium  being
absent; the mucous membrane itself is swollen, hyperaemic, and contains a
variable number of emigrated white blood-corpuscles, and sometimes ecchy-
moses, but no  fibrinous exudation.   On  the epiglottis and in  the other parts
of the  throat the exudation  is often of  the  pseudo-diphtheritic variety—that
is, the  false membrane cannot be detached without loss of substance from the
subjacent mucous membrane—but there is no fibrinous material in the mucous
membrane itself.   The  exudation, however, may be  diphtheritic ;  that is, the
fibrinous substance is present not only upon the surface, but also in  the tis-
sues of the mucous membrane.   As has been explained  in Part First,  the
fibrinous material in the diphtheritic and pseudo-diphtheritic forms of inflam-
mation consists in part  of fibrillated fibrin and in part of  epithelial, pus-, and
connective-tissue  cells  which have undergone the   peculiar  metamorphosis
called  coagulation necrosis.  During the course of the disease the pseudo-
membranes may be repeatedly exfoliated and new ones formed in their place.
   Both rod-shaped and  spherical  bacteria are found  in the false membranes,
but it  is not proven that they are concerned  in the causation of the  disease.
   The lungs after death from fibrinous laryngitis often present spots of atelec-
tasis, also an emphysematous condition, especially of the  upper lobes, hyper-
aemia,  and  sometimes lobular pneumonitis, rarely the lobar form.

   Clinical History.—The symptomatic  phenomena in this variety of in-
flammation at the outset are the same as in simple laryngitis.   The local  and
general symptoms may not be as marked as in cases of simple acute laryn-
gitis.   The disease is often supposed to be nothing more than a common cold.
There  is more or  less cough, and the cough is hoarse or barking.  Hoarseness
or huskiness of the voice exists, and moderate fever.  The symptoms denot-
ing gravity of disease arise from obstruction due to  the exudation, in  connec-
tion with swelling of the glottis and the occurrence  of either spasm or paral-
ysis of the laryngeal muscles.  One, two, or three days may elapse before the
disturbance of respiration is sufficient to create any apprehension. Not  infre-
quently the general symptoms do not prevent the  child from being up and 
            LARYNGITIS  WITH FIBRINOUS EXUDATION.        289

engaging in play even after a certain amount of obstruction has taken place.
The  obstruction due to the exudation  and  swelling is shown  by labored
breathing in both acts  and by  dilatation of  the nostrils.   These evidences
may be apparent before  the obstruction is sufficient to occasion suffering from
dyspnoea.   The additional  obstruction due to laryngeal  spasm is shown  bv
the dyspnoea, which occurs in paroxysms or exacerbations.  Spasm may be
more or less prominent as an element of  this form of disease; but, as a rule,
it is  far less prominent than in the affections heretofore known as  false croup.
Hence, of all the  varieties of so-called  croup, this, in its development and
early progress,  is  the one least likely  to excite alarm.
  As the disease advances  the obstruction is increased.  The labor of breath-
ing becomes greater, and is attended with manifestations of distressing dysp-
noea.  The current of inspired  air is insufficient for the  free expansion of
the lungs, as denoted by contraction  of the lower part of the chest,  together
with sinking in of the soft parts above the clavicles and sternum in the  act of
inspiration.   The cough becomes stridulous and abortive.   The voice  or cry
is reduced  to a husky whisper.   The face is congested, and an expression of
anxiety and distress is  marked.  More or less fever continues.   The suffer-
ings are increased at variable intervals  in proportion as the spasmodic ele-
ment is prominent.   If  life be prolonged, the  cough at length becomes loose,
and portions of the false membrane are expectorated from time to time. The
obstruction may then gradually decrease  and recovery take place.   If the dis-
ease prove fatal, the mode of dying is by slow apnoea ; but not infrequently
the suffering from  dyspnoea diminishes toward the close of life, and the labor
of breathing may be so far lessened as to excite  delusive hopes of improve-
ment.   Convulsions  occasionally occur toward the  close of life.
  A cause of obstruction in certain  cases is paralysis of the posterior crico-
arytenoid muscles.   As a result of paralysis  of these muscles, dilatation  of
the glottis does not take  place in  inspiration, and  obstruction  during the
inspiratory act occurs  as  after  section  of  the recurrent  laryngeal nerves.
Immobility of the glottis is observed by laryngoscopic examination.  In so
far as the obstruction is due to this cause, it will be manifested in the inspira-
tory act.  This act may be accompanied by a laryngeal sound suggestive of
a sucking inward of  the glottis.  Another important incidental circumstance
increases  the interference  with respiration—namely, the accumulation  of
muco-pus in  the trachea and bronchial tubes,  the presence of the false mem-
brane in the larynx, and the feeble expiratory efforts, preventing expectoration.
The danger from accumulation below the larynx is of course incidental  to the
cases in which bronchitis coexists.

  Pathological  Character.—Fibrinous  exudation occurs  exceptionally
in  inflammation of a mucous  membrane.   It denotes  a  peculiar  kind  of
inflammation.  This peculiarity  of the inflammation belongs to  it from the
beginning.  It is not evidence of intensity of the inflammation ;  on the con-
trary, the inflammation  in this variety of laryngitis may be less intense than
in the simple acute variety7.  Acute simple laryngitis has no tendency to even-
tuate in fibrinous exudation ; and in  the  other affections of the larynx  which
have been commonly embraced  under  the  name croup  the form of disease
under  consideration,  distinguished  as  true   or membranous croup,  rarely
supervenes.

  Cat*sation.—This form of disease is generally  met with in young chil-
dren, but rarely in infantile life.   The age, in the great majority of cases,
is between two and seven years.  The  disease, however, may occur at any
period  from birth  to the age of two years, and at any period  after seven
       19 
290        DISEASES  OF  THE LARYNX AXD  TRACHEA.

years.   Boys  are  oftener affected than girls.   It occurs oftener  in some sit-
uations than in others ; a cold, humid, changeable  climate  apparently con-
tributes to its  occurrence.   Cases occur oftener in the spring and autumnal
months than at other portions of the year.  Happily,  it is everywhere  a rare
disease, excluding, it will be  borne in mind, its occurrence  as a complication
of diphtheria.  It may occur as a primary or a secondary  aff'ection.  Exclu-
sive of its occurrence in diphtheria, it is sometimes developed in connection
with the affection of the pharynx in scarlatina.  It occasionally follows measles.
The inflammation and  exudation, as already stated, generally involve more or
less of the pharynx, the point of departure being in some cases  the  larynx,
and in  other cases the pharynx, oftener the latter.

  Diagnosis.—Considering the great fatality of this disease, the diagnosis is
of great importance  with reference to the prognosis  and treatment.   It is to
be discriminated from acute simple  laryngitis, from subacute laryngitis with
spasm, and from a purely spasmodic  laryngeal affection which is presently to
be considered.  In each  of these affections laryngeal  spasm is more or less
involved, and the character of cough and respiration distinguished as croupal
is chiefly attributable to  that element.  The spasmodic  element is more likely
to be prominent, especially at the outset, in the other  affections  just named
than in this  aff'ection ; in other  words, in this, the so-called true croup, the
croupal phenomena are less marked than in either of the forms of the so-called
false croup.  The  insidious development of this  disease, which alone of the
affections formerly embraced  under the name croup is  attended with danger,
renders it  liable to be overlooked until the disease has  progressed  so far as to
give rise to serious obstruction.
  As contrasted with the  other affections just named, the slow, insidious
development  is one of the points involved in the differential diagnosis.  In
the so-called  catarrhal and the spasmodic  variety of croup the croupal phe-
nomena occur suddenly and violently, the attack almost always being in the
night,  When such an attack occurs without having been preceded by cough,
febrile movement, and alteration of the voice, it is  almost certain that the
affection is not true croup.  Alteration of the voice is an important diagnostic
feature.   This will distinguish membranous croup from a purely spasmodic
affection, but not from simple laryngitis,  either acute or chronic; the voice,
however, is affected  in a more marked degree in laryngitis with fibrinous
exudation.
  The presence of fibrinous exudation about the  epiglottis, and more or less
within the pharynx, is a point of great importance in the differential diagnosis.
With reference to this point the  observations  of Ware are valuable.  In his
analysis of cases  of the  several varieties  of croup,  out of 33 cases of true
croup—i. e. laryngitis with exudation—a pharyngeal exudation was observed
in all save a single case.  On the other hand, of  45 cases  of the  affections
included under the head  of false croup, an  exudation within the pharynx was
sought for and found to be wanting in every case.   Of 19 cases observed by
Meigs  with respect  to this  point, in all but 3 an exudation  occurred in the
pharynx either before or after the  development of the laryngitis.  In view
of these facts,  the presence  of  an  exudation within the pharynx, taken  in
connection with the  symptoms which denote laryngitis, renders it extremely
probable that exudation exists within the  larynx.  It is to be borne in mind,
however, that the pharyngeal exudation is sometimes wanting, and that its
absence in the larynx  cannot be inferred from  its non-existence in the  phar-
ynx with as much positiveness as its presence in the larynx  is to be inferred
from its existence in the  pharynx.
  In order to render the  diagnosis positive, if the co-operation  of the patient 
             LARYNGITIS  WITH FIBRINOUS EXUDATION.         291

 can be obtained, the laryngoscope should be employed.  The existence of the
 disease is of course demonstrated if the intralaryngeal space can be inspected.
   In the progress of the disease, if it do not destroy life, the discovery of
 patches of false membrane in the matters expectorated should be considered
 as the only reliable test of the correctness of the diagnosis.  The non-observ-
 ance of this test has led not infrequently to cases of simple laryngitis beino-
 regarded as cases of laryngitis  with  fibrinous exudation successfully treated!
   With  capillary bronchitis this affection  need never be confounded.  In
 capillary  bronchitis the  respirations are  frequent, panting, and gasping; in
 laryngitis  with exudation the  acts are labored and  difficult, and, as  a rule,
 not notably frequent.   The  embarrassed, noisy breathing, especially  during
 sleep, in cases  of enlargement of the tonsils may at first suggest the affection
 under consideration, but it is readily excluded by the absence of  the croupal
 cough and  of  hoarseness.   Retropharyngeal  abscess is to be excluded.

   Prognosis.—The tendency of this disease is to a fatal result.  Of 22 cases
 analyzed by Ware, 19 proved fatal.   Even if the affection be limited  to the
 larynx and uncomplicated, it will destroy  life in the great majority of cases
 if patients  be  not saved by surgical  interference.  The danger is of  course
 increased if the affection extend to the bronchial tubes, and in proportion as
 it extends toward  the smaller  tubes.  Not infrequently broncho-pneumonia
 exists as a complication, and this of course augments the danger.   The dura-
 tion of the disease in fatal cases is usually from four to six days.   In a small
 proportion of cases it kills in less than four days, or life is prolonged beyond
 six  days.   If  recovery take  place, convalescence is  reached after a gradual
 improvement, and is generally slow, the voice remaining more or less affected
 for a considerable period.

   Treatment.—Under measures  of treatment heretofore relied  upon  this
 disease proved  fatal in the vast majority of cases.   The treatment was based
 on the supposition that the exudation depends on the intensity of the inflam-
 mation, and with a view to reduce this intensity the measures known as anti-
 phlogistic were actively employed.  They have been employed sufficiently to
 show that they are not successful, and if they do not do good they can hardly
 fail to do harm.  With a view to the  proper objects of treatment, it is to be
 considered that cases  are rarely seen prior to the  occurrence of exudation,
 and that  the prevention of  exudation, therefore, is not  the end to  which
 therapeutical measures are to be directed.  It is also to be considered that,
 exudation having taken  place,  recovery is effected by the  separation of the
 false membrane, and that its separation takes place as a result of a suppura-
 tive process beneath it, this process requiring  several days.   These  facts
 being considered, the rational objects of treatment are to  prolong life until
 the  separation  of the  false  membrane can be  effected, and to promote the
 process by  which this  is  effected.
  Depletion  by bloodletting or  other  means is not indicated.  By reducing
 the strength of the patient it conflicts with the first object—namely,  the pro-
 longation of life.  On the contrary, the strength is to be supported, as far as
 practicable,  by  concentrated nourishment and the judicious use of alcoholics.
 Emetics, which have heretofore  been  used excessively in this disease, are to
 be employed with circumspection in order  not to  conflict with the first object.
 They have been given, and  frequently repeated, in order  to relieve  spasm,
and it is undoubtedly true that  for a short period after their operation  the
breathing  is  comparatively easy; but this  end may be  attained by  other
measures less objectionable  on  the  score  of depressing the  powers of life.
Another purpose of  emetics is to aid in detaching the false membrane.   But 
 292        DISEASES OF THE  LARYNX AXD TRACHEA.

 it is  useless to give emetics  for this purpose until the exudation has been
 loosened  by the process of suppuration.  Emetics, however,  are not to be
 entirely withheld.  In  children they compensate  for the want of voluntary
 efforts of expectoration.  They may aid in the expulsion of the false mem-
 brane when it becomes  detached.  A fact stated under  another head in this
 chapter is not to be lost sight of—namely, the  tolerance of  the larynx in
 young children of an  accumulation of mucus  sufficient to  occasion  fatal
 obstruction.   Emetics,  then, may be  given from  time  to  time, but not too
 frequently, and the emetic substances used  should be those which  excite
 prompt and efficient  vomiting without  producing  prolonged nausea  and
 depression.  This will  exclude antimony.   Ipecacuanha, powdered  alum,
 turpeth mineral, the sulphate of copper, and the sulphate of  zinc are among
 the articles which may be selected.  Of these articles, the turpeth mineral
 acts promptly  and efficiently,  without much depression or nausea.   This
 remedy was recommended as an efficient emetic in croup forty years ago by
 Dr. Hubbard of Maine.   It is to be borne in mind that the accumulation of
 muco-pus  in the trachea and bronchial tubes in  certain cases furnishes an
 indication  for the use  of emetics.
   Anodyne remedies are indicated to allay  spasm.   Opium, however, is to be
 given with great circumspection.   Belladonna and other of the narcotics, if
 they be found to answer, are to be  preferred.   Mercury is admissible on the
 ground stated under the head of Acute Simple Laryngitis ;  that is, the objec-
 tions  to its use are not to be taken into account in so dangerous a disease as
 this, so long as there is  ground to suppose that it will do any good.
   In  the early part of the disease cold applications to the neck may be tried,
 as in the  treatment of acute simple laryngitis.   These, as in cases of the
 latter form of laryngeal inflammation, have reference, first, to lessening the
 intensity of the inflammation—that is, to an antiphlogistic effect;  and second,
 to a sedative effect as regards spasm  of the laryngeal muscles.  To employ
 cold efficiently, compresses dipped in  ice-water may be applied  and removed
 at intervals of a few moments.  The continuance of these applications  and
 their  repetition  are to  be determined by  the relief which  they  appear to
 afford.  They should not be persisted  in if the patient resolutely resist them
 or if they  do not seem to give relief.
   Topical  measures of  an  opposite character  have reference to  the second
 object—namely, promotion of the  process  by which the false  membrane is
 separated.   The neck may be enveloped in a poultice or the water-dressing
 for the same  reason that these are deemed useful in  phlegmonous inflam-
 mation—namely, to  hasten  suppuration.   But  the most efficient topical
 application is the inhalation of  steam, and the best method is  to charge  the
 atmosphere of the room with as much of it as possible.   In a room  at a
 temperature of 80° or  85°, filled with  steam, patients  are free from spasm
 and breathe with comparative ease.   I have observed cases in which patients
 passed safely through the disease, the inhalation  of steam being  the  chief
 measure relied upon.
   From the fact that pseudo-membranous exudations are rapidly dissolved in
 lime-water, the inhalation of spray from lime-water has been resorted  to as
 a means of removing the false membrane  from the larynx  and trachea, and
 cases  in  which this  treatment was successful have been reported.   It  has
 proved successful in cases under my observation.   Pepsin has been employed
for this end.  Trypsin, one  of the  digestive ferments of the pancreas,  has
recently been used with success.1  Dr. E. M. Moore recommends the insuf-
flation of the bicarbonate of soda for  this  object.   Slaking  quicklime  is an
           1 Vide Diseases of Children, by J. Lewis Smith, 6th ed., p. 581. 
            LARYNGITIS  WITH FIBRINOUS EXUDATIOX.        293

effective mode of  securing this object, and at the same time of furnishing a
warm, pleasant vapor.  Breathing pure oxygen from time to time, and dif-
fusing  it  in abundance in the atmosphere of  the room, afford marked relief
of dyspnoea.
  The  topical  application of a strong solution of the  nitrate of silver has
been advocated.  The introduction of the  sponge probang into the larynx of
the child is difficult, owing to the  small size of the glottis and frequently the
want of co-operation on the part  of the  patient, yet it may be effected.  I
have witnessed  recovery in a  case  in  which  this  was  the  chief measure
employed.  The applications were  made twice daily.   When the false mem-
brane is loosened, the introduction of the sponge may be useful mechanically,
detaching the membrane and pushing it below the glottis, thus leading to its
expectoration.
   Lastly, the propriety of tracheotomy is to  be  considered.   For statistics
bearing on this subject the reader  is referred to treatises  on the diseases of
children.   The propriety  of the operation  hinges, not on the number of cases
in which it has proved successful, but on the answer to the question whether
lives are saved by it.  Now, it cannot be doubted that patients with this dis-
ease have been snatched  from impending  death by opening the trachea.  It
is. therefore, not only justifiable, but  the  practitioner is  bound, if possible,
not to allow patients to die from  suffocation for want of this operation.   Of
course,  the duty of resorting  to  it is  the more imperative the greater the
probability of its  success ; and a fair examination of statistics will show that
not a very small proportion of those who would otherwise die may be rescued
by it.
   The success of  tracheotomy depends much on its timely performance.   Its
failure in many cases is attributable to its having been too long deferred, but
it has proved  successful repeatedly as a dernier ressort under the most un-
promising circumstances.  As soon as the persisting obstruction—that is, the
obstruction due to  the  exudation, associated  perhaps with paralysis of the
dilating muscles of the glottis—compromises respiration sufficiently to render
it probable that the patient's life will not be prolonged until the separation of
the false membrane can  take place, the operation is  called for.   Its  success
doubtless  depends much on the  manner of its performance and  the  subse-
quent  management.  (For information on  these points the reader  is referred
to surgical works.)
   Sir William Jenner has pointed out an  objection  to  a premature perform-
ance of tracheotomy—namely, the effect of the operation  on the efficiency of
cough.   In an efficient act of" coughing first a deep inspiration is taken and
the glottis closes; then by means  of forcible expiratory efforts the  current of
expired air, dislodging from the bronchial tubes  their contents, carries them
into the trachea, and, the glottis suddenly opening, expectoration  is effected.
Now, with an opening in  the trachea an efficient act of  coughing cannot take
place ; hence there is a greater  liability  to  accumulation  in  the bronchial
tubes than if tracheotomy had not been  performed.   The danger from this
effect of the operation thus relates  to the bronchial tubes in the cases in which
bronchitis is associated with the laryngitis.1
   If the operation prove unsuccessful, it diminishes greatly the suffering from
obstruction, and is fully justifiable with a  view to euthanasia.

  1 Tubage of the larvnx, proposed by Bouchut  as a substitute for tracheotomy, has been
successfully emploved bv Dr. Joseph  O'Dwver of New York. (Vide Diseases of Chil-
dren, by J. Lewis Smith* 6th ed., p. 589.  Vide, also, article by E. Fletcher Ingals, in
Journal of the Am. Med. Association, Feb., 1886.) 
 294        DISEASES OF THE LARYXX  AXD  TRACHEA.


                       CEdema of the Glottis.

   This name denotes a serous or, more frequently, a sero-purulent effusion in
 the  submucous areolar tissue above the vocal cords.   In the  majority of
 cases,  therefore, oedema of the glottis is an inflammatory affection.  The effu-
 sion is situated chiefly in the ary-epiglottic folds, about the ventricle of Mor-
 gagni and the base of the epiglottis.   On the vocal cords the mucous mem-
 brane  is too intimately adherent to the subjacent  dense fibrous  tissue  to
 admit  of submucous effusion.  The ary-epiglottic folds and adjacent tissue
 are swollen, soft, and project from  each side as two semi-transparent, gelati-
 nous tumors, as  large as, or even  larger than, a pigeon's egg,  which, lying
 upon the glottis, are  sucked  inward with the  inspiratory act, and thus occa-
 sion obstruction.  The  current of air in expiration  separates and pushes the
 tumors upward, so that in cases of oedema  without laryngitis there is little
 or no obstruction in the expiratory act.   Upon cutting into  the ©edematous
 tissue  a serous or sero-purulent liquid escapes.  It is rare for pus-corpuscles
 to be so abundant  that the  effusion is distinctly creamy and purulent.   In
 most cases of  Bright's disease complicated with oedema  glottidis  the effusion
 is thin and watery, with comparatively few  blood-corpuscles.   The oedema
 usually exists on both  sides, but it is sometimes unilateral.  03dema may
 also occur in the lax submucous tissue just below the vocal cords (subglottic
 oedema).
   When oedema of the glottis is due to inflammation of the mucous  mem-
 brane in proximity  to the seat of the effusion,  it is analogous  to the subcuta-
 neous oedema which accompanies inflammation  of the skin in situations where
 the areolar tissue beneath is abundant and lax, as, for  example,  around  the
 eyes and on the penis—the  collateral oedema of Virchow.  This so-called
 collateral oedema is,  however, always  of inflammatory  origin.  (See Part I.
 pp. 34 and 36.)
   As causes of oedema  glottidis may be mentioned laryngitis,  pharyngitis,
 tonsillitis, retro-pharyngeal and cervical abscesses, injuries to the neck (par-
 ticularly cut-throat wounds), swallowing  irritant  poisons, such  as ammonia,
 sulphuric acid, etc.,  and  erysipelatous inflammation of the neck.  It also occurs
 in connection with certain general diseases, especially those complicated with
 laryngitis, as typhus and typhoid fevers, smallpox, septicaemia, phthisis, heart
 disease, and both the acute and chronic forms of Bright's disease.   It has been
 attributed to the action of cold.  It probably  never  occurs as an idiopathic
 affection.  It is important to add that it may occur as the first and only drop-
 sical affection connected with  disease of the  kidneys.   Its gravity and the
 necessity of prompt and  efficient interference render it vastly important to
 appreciate  the  pathological  condition  and to recognize  its existence.
   The occurrence of the oedema may be  sudden, and life  be destroyed in a
 few hours or even  minutes.1   In a case occurring in connection with mild
 pharyngitis the  suffering  from obstruction was developed  during the night,
 and the patient, leaving his apartment to seek for aid, fell upon the floor, and
 died before any assistance could be  rendered.   In a case in  which it occurred
in connection with tonsillitis the patient was left to sleep in an apartment by
himself, there being no  difficulty of breathing, and in the night-time  a rela-
tive  in  an  adjoining  room was  awakened by  his noisy breathing.  He was
found to be unconscious, and, although medical aid was  promptly called and
the trachea opened without  delay, the operation  was too late to prevent a
fatal result.
  Difficulty of breathing, due to obstruction  at the glottis, is  a prominent
  1 A case is reported in Guy's Hospital  Reports, April, 1855, which terminated fatally
within five minutes after difficulty from obstruction was experienced. 
(EDEMA  OF  THE GLOTTIS.
295
symptom.   This is associated with a sense of a foreign substance at the seat
of the obstruction, and a strong disposition to hawk and swallow.   The diag-
nostic point relating to the difficulty of breathing is, the inspiratory act Ts
alone or chiefly  obstructed, expiration being free.   The inspiration is arrested
before it is completed, being, as it  were,  suddenly cut short, and  both the
inspiration and expiration are accompanied by marked stridor.  If laryngitis
do not coexist, the voice is devoid of hoarseness or huskiness.  This will serve
at once to exclude laryngitis. I have met with a case, ending fatally, in which
there was no hoarseness  or huskiness of  the voice  and no appearance  of
laryngitis after death.  The diagnosis may be made positive by means of the
touch.   With the forefinger introduced into the mouth, carried to the base of
the tongue and applied  below the epiglottis, the oedematous  tumors may be
distinctly felt.
   If the embarrassment of breathing be not too great to permit a satisfactory
laryngoscopic examination,  this  will  render  the  diagnosis positive.  The
tumors may sometimes be seen  by depressing the tongue, without the aid
of the laryngoscope.
   Statistics have heretofore shown a  large fatality.   Bayle found that  in  17
cases only 1 recovery took place.  Of 40 cases collected by Valleix, 31 were
fatal.  Of 168 cases  collected by Sestier,  127 died.  With a  correct appreci-
ation of the pathological  condition,  a prompt recognition of it, and timely
surgical  interference, many, if not most, patients may be  saved.  It is fair to
attribute the large proportion of fatal cases heretofore to an imperfect know-
ledge of the affection, or  delay  in the  diagnosis, or want of promptness in
resorting to efficient interference.
   The affection  kills  by apnoea.   The object of treatment is to prevent suffo-
cation, and if the obstruction be sufficient to occasion much labor of breath-
ing, lividity, etc.no time  is to be lost in efforts to obtain relief by medication.
Either the larynx or  trachea must be  opened, or the method  of scarification,
as practised by Dr. Gairdon Buck, must be resorted to.   Buck's method con-
sists in introducing a curved bistoury, properly guarded, into  the mouth, car-
rying it below the epiglottis guided by the  left index finger, and scarifying on
both sides, so as to give exit to the effused liquid.   The scarification may be
repeated if required.1
   The difficulty in  the way of the performance of  this operation is greater
than might be supposed.   The increase of suffocation caused by introducing
the fingers  into the mouth, the movements of the  larynx  incident to  the
labored breathing, and the acts of vomiting which are excited, render it  not
easy to deliberately scarify the oedematous  parts.  In a case under my observa-
tion the result was unfortunate.  The tumors were not sufficiently scarified, but
wounds were made which  led to hemorrhage and  the flow of blood into  the
air-tubes.  Tracheotomy was subsequently performed, but too  late to save the
patient.   This case is referred to in order to enforce the importance of  being
prepared to meet with more difficulty than might be anticipated.   Without
assuming to adjudicate in a matter which is purely surgical, I am led to think
that the  simpler as well as the more effectual operation is  to open the larynx
or trachea.  Niemeyer stated that in  some cases the finger-nail will suffice to
open the oedematous tumors.  Strong  pressure with the finger  has succeeded.
  A case at  Bellevue Hospital  exemplified the  importance  of opening  the
trachea before the obstruction  threatens  immediate  death.  A  patient was
suffering considerably from  difficulty of breathing, but, as was decided, not
sufficiently to require laryngotomy.   The house  physician, however, made
  1 Vide Trans. Am. Med. Association, vols. i. and iv. Several cases successfully treated
by this method are reported  by Dr. Buck.  Cohen (op. cit.) has  used with success, for
scarification, a common gum-lancet. 
296        DISEASES  OF  THE LARYXX AXD  TRACHEA.

every preparation to perform  the operation at an instant's notice.   Suddenly
the difficulty of breathing increased, and the  physician was in a few moments
at the bedside, but too late to save the patient.  The liability to a very rapid
increase of obstruction proving quickly fatal is to be considered in deciding
upon the propriety of opening the larynx  or  trachea.  The operation  may be
advisable, as a  precautionary  measure, even if life be not at the moment
threatened, when the practitioner cannot remain with or near the patient until
dan-er is passed.   In the event of a physician being summoned to a case in
which  life is momentarily in danger, and when appropriate surgical instru-
ments are not at hand, the larynx or trachea should  be opened at once, with-
out dissection, with a pocket-knife.
   CEdema of the  glottis rarely occurs in infancy or  childhood, the reason
probably being that the areolar tissue at the situation where the oedema occurs
is less abundant and loose in  young subjects  than after puberty   The period
of life in which it is most  liable to occur  is between  the  ages of twenty and
forty.   It occurs  much  oftener in men than in women.
   (Edema in very rare instances occurs below the vocal cords.   This is dis-
tinguished as subglottic  oedema.  Its occurrence in this situation is not deter-
minable  by the touch.  The diagnosis can  only be made by means of  the
laryngoscope.   Scarification  is not practicable.  Tracheotomy  is indicated
under the same  circumstances  as in cases of obstruction from oedema above
the cords.  The obstruction calls for  this operation, although the diagnosis
of subglottic oedema may not have  been made.


                        Spasm of the Glottis.

   Spasm of the muscles closing the glottis is an important element in most
 of the affections of the larynx which have been considered.  To this element
 are attributable the croupal cough  and the paroxysms  or exacerbations of
 dyspnoea in simple acute and subacute  laryngitis in  children and in laryngitis
 with fibrinous exudation.  But spasm occurs also as a purely functional affec-
 tion ;  that is, irrespective of inflammation or lesion  within the larynx.  It is
 an element of several of the functional affections of the nervous system (neur-
 oses) to  be hereafter considered—namely, hysteria, epilepsy, epileptoid con-
 vulsions, rabies, and tetanus.  Occurring irrespective of  these connections, it
 may be  reckoned among the functional affections of the larynx.
    Spasm occurs in young children, affecting the respiration without inducing
 cou"-h.  This is the pathological condition when the infants are said to have fits
 of " holding the breath."  Respiration  is arrested until the face becomes con-
 gested and livid, and when  the spasm relaxes the  inspiration  may be  son-
 orous, as in pertussis.   In some children  these paroxysms occur more or  less
 frequently.  They are sometimes accompanied by carpo-pedal  spasm.  Con-
 vulsions may occur.  Death may take place in a prolonged paroxysm or in
 consequence of repeated paroxysms in rapid succession.  I  have known an
 instance of this kind.   The  affection is commonly known as laryngismus strid-
 ulus.  From a fancied connection with enlargement of the thymus gland per-
 sisting after birth, it has been called thymic asthma.
    This  affection  is purely neurotic.   It  involves a peculiar susceptibility to
 spasm in the  laryngeal muscles.  This  susceptibility may be incident to a
 certain  period,  as during weaning or dentition, but in some cases it appears to
 be an idiosyncrasy of infantile life.  When the predisposition exists, parox-
  ysms are liable to be excited by various causes acting physically and men-
  tally.   This susceptibility is sometimes  observed in different  children of the
  same family—a  fact in confirmation  of  its innateness. 
SPASM OF THE GLOTTIS.
297
  During a paroxysm  it is customary to  employ means to produce a strong
impression on the surface, as slapping the back or sprinkling cold water on
the face.   A ready and  effective mode of arresting a paroxysm is to  intro-
duce a finger into the throat.  The treatment otherwise involves the removal
of all  local causes of  irritation, such as the distension of the gums and the
retention  of fecal  matter, avoidance of causes inducing  mental excitement,
and measures to invigorate the  system.
  Spasm of the glottis occurring in children over two years of age, accom-
panied by laryngeal irritation and  cough, is  a frequent  affection, known as
spasmodic croup.  A  child  is suddenly attacked during  the night, having
perhaps gone to bed apparently in perfect health.  The breathing  is labored
and sonorous;  the cough  presents in  a  marked  degree  the shrill, ringing,
croupal character.   Great alarm is produced, and  the physician  is sent for in
urgent haste.   The  surface of the  body is cool; the pulse is small and per-
haps not  accelerated;  the voice  or cry is not hoarse nor  husky as in largyn-
gitis; the  affection, in short, is purely spasmodic.  It is  unattended by dan-
ger.   When  the violent symptoms are relieved  respiration is  found to be
unobstructed.   There  is no liability to its eventuation in so-called true croup;
that is, to laryngitis with fibrinous exudation.  It is to be discriminated from
the latter affection.   The points involved in this discrimination are as follows :
The  abruptness of the attack, which is not preceded by  symptoms denoting-
laryngitis ; the violence of the attack, in this respect differing from so-called
true croup; the absence of hoarseness or huskiness of the voice, of febrile
movement, and of fibrinous exudation in the pharynx ; and, finally, the speedy
and complete relief.   The  paroxysms may recur for two  or more  successive
nights.
  The treatment consists of a mild emetic if  there be reason to suppose
that the stomach  is overloaded, a hot  foot-bath, and warm fomentations to
the neck.   These measures are uniformly  successful.    The treatment of
these  cases is sometimes needlessly active, under  the impression that a seri-
ous affection is  threatened;  and  practitioners are  apt  to  congratulate them-
selves  and the  friends of the patient on their  success  in  preventing  true
croup.
  Spasm of the glottis may occur as a functional affection in the  adult.  It
is occasionally incidental to hysteria, and  may simulate,  as  regards some of
the symptoms, laryngitis or oedema of the glottis.   The diagnostic points are
as follows : The coexistence of hysterical  phenomena; the absence of huski-
ness or hoarseness of the voice ;  intermittency of the difficulty of breathing ;
the speedy relief obtained by anodyne remedies ; and the sudden development
of the  affection.  I have been consulted  in several cases in which spasm of
the glottis occurred in male  adults without  any  evidence  of disease within
the larynx or of intrathoracic disease.
  The  measures of treatment  are anodyne or antispasmodic remedies for im-
mediate relief, and  afterward  those indicated by  the  general condition and
those  employed in  analogous nervous affections.
  Spasm of the glottis may be occasioned by irritation of  the recurrent laryn-
geal  nerve from the pressure of a tumor or other causes.   It is one of the
symptoms of aortic aneurism, and,  occurring in a  person  over forty years of
age, it  should always excite a suspicion of aneurism.   I have reported a case
of aortic  aneurism  in  which the life  of  the  patient was destroyed by fre-
quently recurring paroxysms of laryngeal spasm.1

  1 American Medical Times, 1805.  Another similar case has fallen under my obser-
vation.  It is questionable whether in these cases the attacks of laryngeal  obstruction
be not due to paralysis of the abductor muscles. This inquiry will be referred to in
connection  with Aortic Aneurism. 
298         DISEASES OF THE LARYXX AXD  TRACHEA.


                          Nervous Cough.

  The term  " nervous cough " is used to designate a neuropathic disorder cha-
racterized by a dry, peculiar cough occurring without  laryngitis, bronchitis,
or any pulmonary'affection.  It may be  noticed with propriety among laryn-
geal affections, inasmuch  as the distinctive character of the cough relates to
the  larynx.   In most of the cases which I have seen the  cough has had a
peculiar barking tone, and  the  pitch has been  low, showing that the glottis
was dilated at the instant of coughing.  In  some cases, however, the tone is
shrill  and the quality of sound  croupal,  showing spasm of the glottis.  In a
case recently under observation  the cough  consisted  of a single, short, hoarse
bark,  often repeated  several times in  a  minute.   The cough is somtimes in
paroxysms, having a resemblance  to whooping cough.   The  peculiar sound
of the cough, together with its frequent recurrence and sometimes  its vio-
lence, renders it "distressing to  those whose  sympathies  are  excited,  and an-
noying to others.  Cohen,  who observed the movements of the glottis in a
well-marked case by means of the laryngoscope, states that the vocal  cords
came  together with force, and suddenly separated at the instant of the cough.
  This disorder rarely occurs in males.    It is often associated with more or
less of the symptoms embraced under  the name hysteria.   The cough has
been  called  tussis hysterica, and it is usually  included by  medical  writers
among the diversified hysterical manifestations.  It occurs  chiefly in chloro-
tic girls.   I have known it  to occur before the age  of puberty.   It is likely
to persist for a considerable period.
  The diagnosis is to be based on the peculiarity of the cough, its dryness—
except that the acts of coughing,  if frequent and violent, may occasion some
mucous  expectoration—and the negative result of careful physical  explora-
tions  of the chest.  The  diagnosis is strengthened, on the one hand, by the
coexistence of anaemia and of hysterical phenomena, and, on the other hand,
by the absence of rational symptoms pointing to phthisis.  The laryngoscope
should be employed in order to  render positive the exclusion of  other laryn-
geal  affections.
  The indications for treatment relate to  anaemia if it exist, and to other
morbid conditions affecting the nervous system.  Tonic remedies, a nutri-
tious  diet, out-door  life, and, in short, invigorating  measures, are indicated.
In addition to chalybeates may be mentioned quinia, small doses of strychnia,
and the  preparations of  zinc as  appropriate remedies.  Hygienic measures,
however, are of the first importance.   A change of climate is sometimes advis-
able if other measures fail.  A sea-voyage proved effective in a case under my
observation  after a long persistence of the  cough in spite of  various measures
of treatment.   As palliatives for the cough antispasmodic  remedies  may be
prescribed, but opiates are not advisable.
  This is one of the affections which may be induced  by involuntary imitation.
Cohen states that within his knowledge a school for girls was suspended in
consequence of the large number of cases.


    Nervous Aphonia—Paralysis of Laryngeal Muscles.

  Loss of voice,  or aphonia, is  incidental to the varieties of laryngitis which
have  been considered.  But it  occurs when not dependent on either inflam-
mation or lesions within the larynx; in  other words, as  a functional affection.
It is then known as nervous aphonia.   The loss of voice is due to paralysis
affecting the nerve of phonation—namely, the spinal accessory.  The affec-
tion  may be limited  to the voluntary movements of the laryngeal  muscles,
the reflex movements involved in respiration  being unaffected. 
XER VO US  APHOXIA.
299
  Functional  aphonia is met with not  infrequently in women, and is often,
but not always, associated with phenomena  embraced under the name hys-
teria.   As a purely neurotic  affection—that  is, not dependent on any lesion
of the nervous system—it is extremely  rare in the other  sex.   An obvious
distinction is between loss of voice and loss of speech, or aphasia,   Aphonia
may occur  from pressure on the recurrent laryngeal  nerve by an aneurismal
or other tumor, and the loss of voice should  direct  attention to this  as a pos-
sible  or probable cause.
  The diagnosis of nervous aphonia may be made by attention to the charac-
ter of the whispered voice.  The patient speaks in a pure,  soft whisper, with-
out effort.   On the contrary, if  the aphonia be due to laryngitis, the whisper
is stridulous or husky and  labored.  Moreover, in aphonia due to laryngitis
there  is more or less cough and expectoration, symptoms  generally absent in
nervous aphonia.   As the question  is  usually  to decide between nervous
aphonia and chronic laryngitis, and as the latter affection is generally asso-
ciated with  pulmonary phthisis, the absence of the symptoms and  signs of
the latter disease  will serve to confirm  the diagnosis.   Examination  with the
laryngoscope will establish the  diagnosis by showing that the larynx is free
from  lesions; and the absence  or the incompleteness of movements of the
glottis when an effort to speak is made may be ascertained  by inspection.
  Inspection with the laryngoscope shows that paralysis of laryngeal muscles
may be bilateral or  unilateral, and that the different muscles—namely, the
adductors and abductors, the tensors and the laxators—may be affected sepa-
rately.  Unilateral paralysis  of course  points to  some cause affecting the
pneumogastric nerve on one  side  only, and  it is especially suggestive of an
aneurismal  tumor  pressing  upon  one of the  recurrent  laryngeal  nerves.
Bilateral paralysis, however, may be caused  by pressure upon the  recurrent
laryngeal  or the  vagus nerve on  one side.  A  case under my observation
exemplified  the correctness  of  this statement.
   The localization of paralysis in the diff'erent muscles of the larynx, singly
or severally, is to be made by laryngoscopic examination.   As a rule, in func-
tional aphonia the adductor muscles are affected.  The patient is unable by
an effort of the will to approximate the vocal cords sufficiently for phonation.
In paralysis of the abductor  muscles the voice is more or less affected.   This
form  of paralysis will claim separate notice.  (For an account of the laryngo-
scopic appearances,  the symptoms, etc.  of paralyses  affecting the  diff'erent
muscles separately, the reader is referred to works which treat of diseases of
the larynx  in extenso})
  If  aphonia  be  purely neurotic—in other words, involving no lesion of the
nervous centres or pressure on either the par vagum or the  recurrent laryn-
geal nerve—recovery may be expected after  a duration of the  affection vary-
ing much in different cases.  The voice is sometimes restored instantaneously
and unexpectedly.   I have  met with cases in which repeated  attacks had
occurred.
  Treatment in these cases should be directed to the general condition. Tonic
remedies and invigorating hygienic measures are indicated.   Moderate coun-
ter-irritation may be useful.  Electrization of the laryngeal muscles  has been
found signally useful.  Both the induced  and the direct current are used  with
success.  The recovery of the voice sometimes follows a  single application or
even a single electrical shock; but in some cases the treatment to be success-
ful must be  continued for several weeks.   In some of the cases in which  elec-
tricity at once effects a cure  there is reason to think  that  the  success is due
to  a moral influence.   Other measures  often effective are  evidently opera-
tions through the mind.  Cohen states that he has  repeatedly effected a  cure
               1 Cohen, op. tit., treats fully of laryngeal paralyses. 
 300        DISEASES OF THE LARYXX AXD TRACHEA.

 by the use of the laryngoscopic mirror, the patient being led to suppose that
 its introduction was a curative procedure.   The  late Professor Ware some-
 times succeeded by telling patients that they could recover the voice by an
 energetic act of the will.   A violent mental emotion has sometimes produced
 sudden aphonia, and, aphonia  existing, has sometimes occasioned a  sudden
 restoration of the  voice.
   Whenever there is a partial restoration of the voice complete recovery may
 be expected by systematic efforts of speech, in the same way as the control of
 the will over other paralyzed  muscles is effected by means of persistent vol-
 untary exercise.   Beginning with the vowels most easily spoken, the prac-
 tice should extend to those more difficult of utterance, then to consonants and
 words of  one syllable, and finally to sentences.   After recovery the exercise
 of the voice within  the limit  of  fatigue is  to  be advised.
   Aphonia is sometimes feigned.   The malingerers are women actuated by
 a  desire to excite sympathy or to become objects of interest.   I  have met
 with two  cases in which the patients declared  their inability even to whisper.
 One of these patients communicated by signs and by writing, and the other
 by silent, inarticulate movements of the lips.   A curious feature in the first
 of these  cases was that during a  second visit, accompanied by her husband,
 while I was in conversation with him,  she  began to speak  in a low voice and
 took part in the conversation  during  the remainder of the  interview.  No
 comment  was  made on  this sudden recovery of voice  either by herself, her
 husband,  or by me.   I met her casually some  years afterward ; there was
 then  no impairment of  voice, and she made no  reference to  her aphonia
 except to ask if I recollected her consulting me.  The subsequent  history in
 the other case is unknown.  That  the  inability to speak is in  some instances
 a  self-delusion is probable.  This may have been the explanation  in the cases
 just noticed.

   Paralysis affecting the abductor muscles has important distinctive features
 when contrasted with the  paralysis of the adductors.   The  effect of bilateral
 paralysis  of the abductors is the approximation of the vocal cords, giving rise
 to more or less obstruction of respiration.  The obstruction is manifested espe-
 cially in inspiration.  The condition is  analogous to that observed  after the
 physiological experiment of dividing both recurrent laryngeal nerves. The
 vibration  of the cords with the current of inspired  air causes stridor.  There
 is  dysphonia, but not complete loss of  voice.   Dyspnoea exists in proportion
 to the obstruction.   There is danger of death from suffocation, especially if,
 as may happen, spasm of  the  adductors be  added to  the paralysis  of the
 abductors.
   In view of the indication for prompt treatment whenever the obstruction is
 sufficient  to involve danger, the diagnosis is extremely important. The laryn-
 goscope renders it positive, and  it cannot be  made  so  otherwise than  by
 inspection of the larynx.   In marked cases the vocal cords  are in close prox-
 imity, the aperture being reduced to a narrow  slit, and no dilatation takes
 place  in  the  act of inspiration.  Without a laryngoscopic examination the
 noisy, stridulous, inspiratory sound might suggest either laryngitis or oedema
 of the glottis.
   Tracheotomy  is  indicated whenever the obstruction involves  immediate
 danger.    The indication derives great force from the fact that with an open-
 ing into the trachea the affection is tolerated indefinitely.  Cohen cites a case
 within his cognizance in which a tracheal tube had been worn for more than
twelve years, the patient a judge who  was able to continue his duties  on the
bench.  He also cites three cases in which life was lost from a refusal to sub-
mit to the operation of tracheotomy.   If, from  the occurrence  of  spasm of 
MORBID GROWTHS.
301
the adductors, paroxysms be liable to occur  threatening life, there can be no
doubt concerning the propriety of tracheotomy as a prophylactic  measure,
provided the patients be not  under constant observation.
  Cases in which spasm of the adductors is not an element  may not require
surgical interference.  A case came under my observation at  my college-clinic
in which recovery took  place without an operation, the  treatment consisting
chiefly of  quietude and  asafcetida.  Dr. George  M. Lefferts  has reported two
cases of recovery without tracheotomy under the use of the iodide  of  potas-
sium, the patients having had  syphilis.1
  The  prognosis as regards recovery  from  the  paralysis will  depend on the
causative  conditions.   If the  paralysis depend  on lesions,  either centric or
peripheral, which are permanent, recovery is not to be expected.  Danger of
death from obstruction  is  permanently averted by a tracheal opening.   If,
however, the paralysis  be functional, or if it  depend on  syphilitic  changes,
as in the  cases reported by  Lefferts, the prognosis as regards recovery is
favorable.
  If the paralysis  be unilateral  and remain so. there is little or no  danger
from obstruction.  The voice is weak and stridulous, simulating chronic laryn-
gitis.  In a patient forty years of age aneurism of the aorta  should  always
be suspected, and should be sought for, especially in the site of the descend-
ing portion of the arch ; but the paralysis may depend on other causes, either
centric or peripheral, generally the latter.  An enlarged bronchial gland, car-
cinoma of the oesophagus, and  a mediastinal tumor may cause unilateral paral-
ysis by pressure on the recurrent laryngeal nerve.
   Bilateral paralysis of the abductor muscles is extremel}* rare.  The number
of reported cases is small; but it is probable that the pathological  character
of the affection wras not infrequently overlooked prior  to the date  of laryn-
goscopy.


                          Morbid  Growths.

   The most common tumor within the  larynx is  papilloma.  It takes its origin
bv preference from that portion of the laryngeal mucous membrane which is
covered with flat epithelium.  It may have a broad base or may be connected
with the  mucous membrane  by a  distinct pedicle.  It  consists essentially
of  hypertrophied and  newly-formed  papillae covered  with flat  epithelium.
Small papillomatous growths are not infrequent attendants  upon tuberculous
and syphilitic laryngeal ulcers and chronic laryngitis.  Papillomatous growths,
however,  may occur without  inflammation.  Other  important forms of new
growths are the laryngeal polypi, which may  be fibrous,  myxomatous, or
glandular.  Fibroma,  myxoma,  and adenoma do not,  however, necessarily
assume a  polypoid form in the larynx.   Carcinoma of the larynx,  when
primary, is usually of  the flat-celled variety, and takes its  origin from  that
portion of the larynx  lined with squamous epithelium, especially  from  the
true vocal  cords.  Cancer seated primarily in the larynx  is  rare, the disease,
in the cases in which  this part becomes affected by it, generally originating
in the  oesophagus or in  the neck exterior to  the  larynx.  Syphilitic and tuber-
culous new formations  have already been referred to.   A detailed considera-
tion of these and other rarer  forms of laryngeal tumors  must be sought in
works  treating specially of diseases of the throat.
   Morbid  growths occasion inconvenience, suffering, and  death by producing
obstruction.   Surgical interference becomes necessary when the  obstruction
is sufficient to endanger life.   A tube may be worn in the  trachea for an
indefinite period.  In a case in which a permanent artificial  opening becomes
                     1  Neiv York Med. Journal, Dec,  1878. 
302        DISEASES  OF  THE LARYXX AXD  TRACHEA.

advisable, it may be a question whether a large fistulous orifice might not be
established, rendering  the tracheal tube  unnecessary.   As bearing on  this
question,  the following  case  is of interest:  A  patient, aged about  forty,
admitted into one of my  wards in  Bellevue Hospital and suffering from the
effects of a debauch,  had a fistulous orifice in  the anterior  portion of the
trachea large enough to admit the end of the  forefinger.  This fistula followed
a wound received in a fracas, and had existed for seventeen years. It occasioned
little or no inconvenience in respiration.  There were no symptoms of inflam-
mation or irritation of the trachea or bronchial tubes, and he was entirely free
from  pulmonary disease; the only inconvenience  which it occasioned was in
speaking.   In order to direct a current of air through the  glottis sufficient
for the production of the voice, he was accustomed to  approximate the chin
to the sternum, and in this way he was able  to close the fistula.
   The laryngoscope has proved to be  of great practical value in determining
the existence, situation,  size,  and character  of morbid growths  within  the
larynx, and  in facilitating surgical operations for  their removal through  the
laryngeal  aperture.  Cohen states that prior to  laryngoscopy probably not
more  than seventy cases of  morbid growths within the larynx were  to be
found in medical literature, whereas within the last twenty  years thousands
of such cases have been reported.
   The larynx has been extirpated for the  removal of carcinoma, and an arti-
ficial larynx has  been substituted.  The first  operation of this kind was per-
formed successfully by Billroth.   (Surgical  works are to be consulted  for
this and other operative procedures  for tumors  of the  larynx.) 
          SECTION   SECOND.

DISEASES  AFFECTING  THE  CIRCULATORY SYSTEM.
                         CHAPTER   I.

                             PERICARDITIS.

Introductory Remarks.—Acute Pericarditis: Anatomical Characters; Clinical History;
   Pathological Character ; Causation; Diagnosis ; Prognosis; Treatment.—Chronic Peri-
   carditis.—Pneumo-Pericarditis.

    DISEASES affecting the circulatory system are seated either in the blood-
     vessels or in the central organ of the circulation—the heart.   There is a
group of affections existing independent of the organs of the circulatory sys-
tem and  involving certain  morbid  changes of the blood.   The  affections
belonging in this group are simple or benign anaemia, chlorosis, leucocythae-
mia, pseudo-leucocythaemia,  lymphatic anaemia, or  Hodgkin's disease, perni-
cious anaemia, and  to these may be added Addison's disease.  These affections
proceed from  defect or  disturbance  referable to the blood-producing organs.
They will be considered in a separate section (Section III.), under the head-
ing Diseases affecting the Haematopoietic System.   Morbid conditions of the
blood, not recognized as individual  affections, being common to different dis-
eases, are considered in Part First of this work.  Diseases of the  vessels,
entering, as they do, much more largely into maladies which belong to the
surgeon than  into those which fall within the province  of  the physician, are
fully considered by surgical writers.   Of the diseases of the arteries, aneur-
isms  situated within the chest and abdomen will alone claim attention in this
treatise.   Thoracic aneurisms will be noticed in this section, and those situated
within the abdomen will be referred  to in connection with abdominal tumors
in Section IV.  This section will be devoted chiefly to diseases affecting the
heart.
   The diseases of  the heart are  conveniently  arranged  in the  following
groups:  1.  Inflammatory affections;  2. Structural lesions; 3. Functional dis-
orders.  Inflammation affecting the heart gives rise to different diseases accord-
ing to the structure in which it is seated.   Inflammation of the serous mem-
brane investing  the heart (the pericardium) gives rise  to the  disease called
pericarditis.   Inflammation of the membrane lining the cavities of the heart
(the endocardium)  is another disease, called endocarditis.   Inflammation of
the substance  of the heart (the myocardium) is distinguished as myocarditis.
These  three inflammatory diseases  claim  separate consideration.


                         Acute Pericarditis.

  Pericarditis occurs as an acute and  as a chronic affection.   Acute peri-
carditis will be now considered, and  afterward  the  chronic  form of the dis-
ease.
303 
304
PERICARDITIS.
  Anatomical Characters.—Acute  pericarditis may be either diffuse or
circumscribed.   When circumscribed, the  inflammatory products  are usually
deposited at the base of the heart, near the origin of the great vessels.  Dif-
fuse pericarditis is the usual form.  The morbid appearances resulting from
acute inflammation in this  situation  are essentially the same as in inflamma-
tion of other serous membranes—for example, the pleura.   The serous mem-
brane is  at first reddened  in consequence of congestion  and small  ecchy-
moses.   The  inflammatory  exudation consists of fibrin, serum, pus-cells, and
red blood-corpuscles.   In  the majority  of  cases it is  sero-fibrinous, the pus-
cells not being  sufficient in number  to render opaque  the fluid  part  of the
exudation.   The exudation may consist almost wholly of fibrin, with very
little serum.  This has been  called dry pericarditis.   Under exceptional cir-
cumstances the red blood-corpuscles  are present so abundantly as to give to
the serum a reddish or brownish  coloration.   This constitutes hemorrhagic
pericarditis.   It occurs especially in  connection with tuberculosis or  cancer
of the pericardium and also as a complication of scorbutus.   Tuberculous
pericarditis may occur, although very rarely, without tuberculous deposits in
any other part  of  the body.   In rare instances the  exudation is purulent.
This may occur in pyaemia  and  in consequence of the extension  of a puru-
lent inflammation  in  the neighborhood, as in cases of suppurative pleuritis,
hepatic abscess, etc.  In acute diffuse pericarditis  the  fibrin is deposited  in
the form of a layer or a series of layers on the visceral and on  the parietal
surface of the membrane.  It is a peculiarity of this fibrinous pseudo-mem-
brane that its free surface  has a rough, shaggy appearance, due  to the pro-
jection  of a  number of filaments and villous processes (cor villosum, hairy
heart).   This peculiar disposition  is  attributable  to  the constant churning
action of the heart.
  The quantity of liquid  effusion in different cases of pericarditis  varies
greatly, amounting in some cases to  a few  ounces only, and in  other cases to
a pint or more.   It is  usually of a yellowish  color, and  contains  flocculi of
fibrin.   Wandering cells or pus-cells are present in  the fibrinous layer  and in
the serum, also in varying numbers in the  tissue of the serous  membrane
itself.  Whether these have any other origin than emigration from the blood
is still a  matter of dispute.
  If recovery take place,  the serum is  absorbed;  the fibrin undergoes a mo-
lecular disintegration, and  is absorbed.   At  the same time  new  connective
tissue in the form of adhesions is developed.  The  process of their  forma-
tion is the same as in pleurisy (p. 117).   The  pericardial sac may be com-
pletely obliterated by the firm adhesion of its two layers, or it may be par-
tially obliterated.  The adhesions  may  also develop in the form  of threads
and  bands stretching between the  pericardial surfaces.
  Purulent pericarditis runs a less  favorable course.  Several pints of pus
may accumulate in the pericardial sac.  It sometimes happens  that the pari-
etal layer of the pericardium ulcerates, and the pus may even escape exter-
nally by  a fistulous opening.  It is possible for only small accumulations of
pus  to be absorbed.
  The muscular substance  of the heart suffers more or less in its  nutrition in
all cases  of pericarditis.  The most  frequent change is parenchymatous and
fatty degeneration of the muscular fibres  situated  just beneath  the pericar-
dium.  The fibrous thickening of the visceral pericardial layer  which follows
pericarditis is sometimes accompanied by  the growth of fibrous tissue into
the subjacent muscular substance, and a consequent atrophy of the muscular
fibres in this  situation.
  The most convenient mode of dividing acute diffuse pericarditis into stages
is the same as that adopted in pleuritis.   The first  stage extends to the time 
ACUTE PERICARDITIS.
305
when liquid effusion takes place to an extent sufficient to be appreciated by
the physical  signs.   The  second  stage, or the stage of effusion, continues
until the liquid is absorbed.  The third stage extends from the absorption of
the liquid to the recovery, and this is generally the stage of convalescence.

   Clinical History.—The  symptoms are almost invariably made up, to a
greater or less extent, of those arising from coexisting afl'ections ;  for in the
great majority of cases the disease is associated with articular  rheumatism.
Bright's  disease of the kidneys, or pleuritis  with or without lobar pneumo-
nitis.   Under  these  circumstances  it is not always easy  to  determine to
what extent  certain symptomatic phenomena  are due to the cardiac disease.
As a rule, the development of the inflammation is attended with more or less
pain, which in some  cases is acute and lancinating, like the  pain in pleuritis,
and increased by forced  breathing, so that the disease has  not  infrequently
been supposed to be inflammation of the pleura.  The intensity of the  pain
varies much  in  different cases; it is not always a  prominent symptom, and
it  is sometimes slight or even wanting. The pain may be  increased  by acts of
deglutition, by eructations, and it  sometimes  is analogous to that in angina
pectoris.  The facies is that of suffering and anxiety.  A dry, irritable, sup-
pressed  cough is generally present.  Tenderness over the praecordia is more
or less marked, and pressure  in the epigastrium upward in a direction toward
the heart sometimes occasions acute pain.    The  pain  produced by a  deep
inspiration may cause  the  patient to shorten  this  act, and hence, by way of
compensation, the  number  of respirations per minute is  increased.   The alae
nasi may dilate  in inspiration.   Patients sometimes manifest suffering  from
an indefinite sense of distress, without  acute, localized  pain, and in women
hysterical phenomena may  be associated  with  the development of the disease.
The action of  the  heart is increased, amounting  sometimes to palpitation.
The pulse is more or less accelerated, quick, and vibratory.  Pyrexia and its
concomitants—namely, anorexia, debility, etc.—are present.  These are symp-
toms belonging to the first  stage.
   The duration  of the first stage is usually short.  An appreciable amount of
effusion may take place in a few hours, and it  is rarely delayed beyond one or
two days.  The acuteness of the local symptoms—namely, pain and soreness
—then diminishes,  and if  the  amount of liquid  effused be sufficient to fill
or distend  the pericardial  sac,  symptoms are  added which proceed from the
pressure of the liquid upon the heart.   These symptoms  are—a sense  of
oppression referable to the praecordia; a tendency to syncope  on exertion,
which leads  the patient to refrain  as  much  as possible  from movements of
the body ;  feebleness and irregularity of  the pulse, with a notable increase on
emotional excitement or any muscular effort;  dyspnoea, sometimes  amounting
to orthopnoea if the accumulation of liquid be large and  rapid;  feebleness of
the voice or even aphonia ;  and dysphagia, in some cases produced by pressure
of the distended sac on the recurrent laryngeal nerves and on the oesophagus.
Cyanosis and turgescence  of the  cervical veins are sometimes  marked, due
probably to pressure on  the  auricles and the venae cavae.   Venous pulse on
the neck is sometimes  observed.  Vomiting is an occasional symptom.  Sin-
gultus may be produced by pressure on the phrenic or branches of the pneu-
moo-astric nerve. Some cases are characterized by remarkable disturbance of
the nervous  system.   Mental aberration, consisting in  obstinate taciturnity
and indifference, alternating  with  paroxysms  of maniacal excitement under
the  influence of delusions  which  excite terror, is occasionally  observed.
Coma, chorea, and tetanic convulsions have  been  known to  occur. These
symptoms are likely to mask the cardiac disease and lead the practitioner to
suspect  disease  of the brain.  Autopsical examinations show  that in  these
       20 
306
PERICARDITIS.
cases neither inflammation nor any appreciable lesion of the  nervous system
exists, and hence the phenomena  are to be referred to functional  disturbance
of the nervous system.
  The severity of the disease, as denoted by the symptoms, corresponds to
the intensity of the inflammation and the amount of effusion.  If the inflam-
mation be slight or moderate and  the  quantity  of effused liquid small, the
disease may run its course without any symptoms denoting gravity, and the
symptoms  may not even  point to the existence  of any affection within the
chest.  In other cases it is one of the most distressing and formidable of dis-
eases.  The symptoms due to compression of course diminish as the  liquid
is  absorbed.   The absorption sometimes  goes  on very rapidly,  and  in  this
respect different cases present great variations.  If, instead of being absorbed,
the liquid continue to accumulate and life be not rapidly destroyed, the peri-
cardial sac  may  become  greatly  dilated  and the affection become  chronic.
The rapidity and completeness of recovery after absorption will depend on
the amount of inflammatory exudation.  This may be too  abundant to be
absorbed,  and the disease may end fatally after  continuing  for a greater or
less period in a chronic form.  In cases which go on favorably toward recov-
ery the action of the heart is feeble and easily excited during the stage  of
convalescence.

  Pathological Character.—Acute pericarditis does not differ essentially
in  character from other serous inflammations.   The same series of processes
which take place  in the  serous  inflammation considered in the preceding sec-
tion (Pleuritis) occur in this inflammation—namely, fibrinous  exudation  and
liquid  effusion, agglutination  followed  by permanent adhesion of the free
surfaces of the membrane, and sometimes the formation of  pus.  Suppura-
tive pericarditis, however, occurs  in a much smaller proportion  of cases  than
suppurative pleuritis, or empyema.  As in cases of pleuritis and other serous
inflammations, so in different cases of pericarditis, both the actual and  rela-
tive amount of fibrin and serum  differ greatly.   In some cases the quantity
of fibrin  is  small and the effusion of liquid  abundant; in  other cases the
fibrin is abundant with but little liquid ; and, again, in  other cases both fibrin
and liquid are either abundant or small.   Judging from the number of cases
which  I have seen, dry pericarditis—that is, the presence of fibrin  without
serous effusion—is  not  extremely rare.

  Causation.—Acute pericarditis  may  be produced  traumatically  by per-
forating wounds of the  chest or  contusions.   In one  of the cases which I
have  observed it was produced by a  wound inflicted by a one-tined fork.
Walshe refers to a case in which  the  pericardial sac  was  perforated in the
juggler's  trick of swallowing a sword, and fatal pericarditis was induced.  In
the museum of Bellevue  Hospital  is a remarkable  specimen in  which a set
of false teeth is contained within the  pericardial  sac.   The teeth were swal-
lowed during alcoholic coma, and. lodging  in the lower part of the oesophagus.
produced ulceration through this tube and into the pericardium, giving rise to
fatal pericarditis.
  Exclusive of its traumatic origin, the disease is almost always secondary,
and it is developed in the  course  of acute'articular rheumatism oftener than
in  connection with any other affection.   Occurring in the course  of rheuma-
tism,  it is distinguished as rheumatic  pericarditis.   It would appear, from
statistical  data, to occur  in cases of acute rheumatism in  a proportion  of
about 1 to  6.  Sibson, out  of 326 recorded hospital  cases  under  his  care,
found evidence of pericarditis in  63.J   Without having noted  sufficient data
                       1 Reynolds's System of Medicine. 
ACUTE  PERICARDITIS.
307
for analysis, I am sure that this proportion is considerably higher than in my
experience.   The comparative infrequency of this complication in the cases
which  have come under my observation I am disposed to attribute  to  the
prompt and efficient  employment of the alkaline  treatment which  for  many
years has been in vogue in this country.  Generally, the  development is in
the early part of rheumatism, after a greater  or less number of  the joints
have been affected,  but occasionally the pericarditis  precedes  the articular
aff'ection.   When it  follows the aff'ection of the joints, it is not due. as  was
formerly supposed, to a metastasis of the articular affection, but it proceeds
from the same morbid condition which underlies the latter.  Rheumatic peri-
carditis is  generally associated with endocarditis.  The latter  existed  in  54
of the 63  cases analyzed  by Sibson.
  Next in frequency  to its  development in the course  of rheumatism, it
occurs in connection with either acute or chronic disease of the kidneys.   It
is not very infrequent  in cases of chronic Bright's  disease; but it is a rare
concomitant of the renal affection  which follows scarlatina and in other cases
of acute diffuse nephritis.   It occurs most frequently with the small kidney
of chronic Bright's  disease.   Sibson's  statistics  show  that it occurs in as
many as 8 or 9 per cent, of all  fatal  cases of Bright's  disease.
   Fyiemia, scorbutus,  the continued  and  eruptive  fevers, erysipelas,  and
influenza  are  other  affections in connection  with which this disease has been
observed to occur.   It  is a not very infrequent concomitant of pleuritis  and
of pneumonitis, affecting either the right or left lung—oftener the latter.
Pericarditis may be  secondary to peritonitis  and to inflammation in the medi-
astinum.
  I  have met with a few cases in which a careful examination failed to  dis-
cover any pre-existing  or  coexisting  disease,  nor  was any  other affection
developed  so  long as the  patients remained under observation, the periods
extending only to the time when they had recovered sufficiently to leave  the
hospital.  The extreme infrequency of such cases renders it extremely prob-
able that whenever  pericarditis exists some  one of the affections just named
will be found  associated with  it.

  Diagnosis.—The events belonging  to the  clinical history  of acute peri-
carditis are not sufficiently diagnostic for the disease  to be discriminated, by
the symptoms alone, from  pleuritis, pneumonitis, or  pleurodynia.   Its coex-
istence with the two former of these affections could  not be ascertained,  and
its existence would  surely be overlooked in the cases in which the  symptoms
are but little marked.   The diagnosis must rest on physical signs.  The pres-
ence of inflammatory exudation gives  rise to an adventitious  sound or mur-
mur caused by the rubbing together of the pericardial surfaces in  the move-
ments of the heart.  This sign is  proof of the existence of pericarditis, and,
as the exudation  takes  place  usually within a few hours after the  beginning
of inflammation, the sign becomes available for diagnosis at an early period
of the disease.  The sign is called the pericardial or cardiac-friction murmur,
or sometimes,  in contradistinction  from  the  murmur produced  by  blood-cur-
rents within  the heart, an  exocardial murmur.
  The friction murmur is  to be  distinguished from  the  murmur produced
within the heart, called endocardial or bellows murmur, by attention  to  the
following points : It  is double; that is, consisting  of two adventitious sounds
for each beat of the  heart, one produced by the systolic and the other by the
diastolic cardiac movements.  The character of the murmur denotes friction;
that is, it is rubbing, grazing, or grating, and at a later period in the disease
it may be creaking, like the sound of new leather.   It is limited to the prae-
cordia, not propagated beyond the  borders of the heart, and it may  be limited 
308
PERICARDITIS.
to a portion of the precordial space.  As regards its intensity, it differs much
in different cases, and it may vary in the same case during an examination, the
variations being dependent on the force of the  heart's action.   It has not the
same  fixed  connection with the normal heart-sounds as have the endocardial
murmurs;  in  other words, it does not observe the same regularity in rhythm
as the latter.   This is a striking point of distinction.  It is  intensified, and
sometimes changed in character, by firm  pressure with the stethoscope.   In
connection with a rough friction murmur, fremitus is sometimes felt  by the
hand  applied  to  the  praecordia.
   A friction  murmur, if ever wanting in  the first stage  of  pericarditis, is
present so generally that  we arc warranted in basing an  exclusion  of the
disease on its  absence, provided sufficient time have  elapsed for inflammatory
exudation, and limiting  the question of  diagnosis  to  the  first stage.  The
murmur is  almost pathognomonic taken  in connection with the symptoms
and history;  yet there is  one source of  fallacy—namely, the production of
an intrapleural friction murmur  by the movements of the heart in cases of
pleuritis.   A  friction murmur accompanying the systolic and diastolic move-
ments of the  heart, continuing while  the  patient's  breathing  is voluntarily
suspended, may be thus produced irrespective  of pericarditis.   I  have met
with  several examples, the absence of pericarditis, notwithstanding a  well-
marked murmur with cardiac rhythm, having been determined by  examina-
tion  after death.  This is  called a cardiae-pleural friction murmur.  It is to
be suspected, if pleuritis be  known  to exist with  or  without pneumonitis.
when the murmur is limited to the border of the heart, the intensity of the
murmur varying much more than the ordinary cardiac murmur during the
periods of examination,  it  being  heard in some  cases only  at  the end  of
inspiration,  and  generally  being  affected more or less  by the respiratory
movements.
   In  the second  stage the occurrence of liquid effusion and its  amount are
determined  by percussion.   Abnormal  dulness or flatness exists over  an
increased area in the praecordial  region.   The pericardial  sac, if filled  with
liquid, forms a pyriform tumor, the boundaries of which are readily defined
by percussion.  The base  is situated below the level of  the apex-beat in
health ; the, left  border  extends beyond  the left nipple to a greater or less
extent, and the right border  between the  right margin of the sternum  and
the right nipple ; the apex is near  the  sternal notch.  The  situation, size,
and  shape of the area of  dulness or flatness  point to pericardial effusion.
If the pericardial sac be partially filled  with  liquid, the area of dulness in
the praecordia is abnormally widened at and below the apex of the heart, the
widening extending more  or  less upward in proportion  to the  quantity of
effusion.  Vocal resonance is diminished or absent within the area of dulness
or flatness, and also vocal  fremitus.  If the sac be distended with liquid, the
praecordia may be abnormally prominent and the intercostal depressions abol-
ished, as in pleuritis, within this region.  Mensuration will show the increased
size of the praecordia.  The extent of dulness  or flatness at different periods
of the disease will  show,  on the one hand, progressive increase,  or, on the
other hand, diminution of the quantity of liquid, and at length its complete
removal.  Dr. J. M. Rotch has called attention  to the fact that the pericardial
sac, when  filled, gives rise to flatness on percussion in the fifth  intercostal
space  on the right side—a fact  which I have clinically verified.
   The  friction  murmur  either diminishes  or  disappears after  considerable
effusion of  liquid has taken place.   Not  infrequently it continues, although
the pericardial sac may be filled with  liquid and even much dilated.  Under
these circumstances it is sometimes heard when the patient is raised to  the
sitting  posture, and it may disappear when the patient lies on the back.  If 
A CUTE  PERICARDITIS.
309
it have disappeared or been diminished during the stage of effusion, it returns
with increased intensity after the absorption of the liquid, and it then persists
until  agglutination of the pericardial surfaces  takes  place.  Occasionally it
continues during convalescence and after apparent recovery.
  The apex-beat of the heart is weakened and may be  suppressed by the pres-
ence of liquid.  If the accumulation of liquid  be considerable, the situation
of the beat is altered. It is raised to the fourth intercostal space, and carried
to the left as far as, or even beyond, the line  of the nipple.  The sounds of
the heart are rendered feeble and distant by the presence of liquid, especially
the first  sound, and this becomes short and valvular like the second sound.
  By means of these signs the diagnosis of pericarditis is  generally made
without  difficulty.  Bearing in mind the frequency  of its occurrence in artic-
ular rheumatism, daily examinations of the chest in cases of that disease with
reference to this complication should not be omitted.  The fact that it occurs
in cases  of Bright's disease should also be  borne in mind;  in fact, it is a good
rule, in examining  a  patient with any disease, not to omit an  exploration of
the praecordia.   Developed in  connection with pleuritis or pneumonitis, it
may be  overlooked, and the diagnosis involves more difficulty than when it
occurs in other pathological  connections.   The determination of  pericardial
effusion, if a large effusion also exist in the left pleural sac, is not always easy,
and the  chief reliance in such a case must be  on the presence of a friction
murmur, which  is produced, not without,  but within, the  pericardial  sac.  I
have  reported a case in which the heart was enveloped in either a carcino-
matous  or sarcomatous  growth, completely filling and distending the pericar-
dial sac  without altering its form.1   In this unique case the signs were those
of pericardial effusion, and this was the diagnosis.   It  is difficult to see how
pericardial effusion could be excluded in such a case, except by means of an
exploratory puncture, which might have been resorted to without harm.
   In  a case under my observation the  pericardium  became agglutinated over
the left half of the heart, and the right half of  the sac was filled with effused
liquid.   Such a case, if not observed from  the  beginning, offers a puzzling
problem  in diagnosis.
   The occurrence of delirium, coma, etc. in  some cases of pericarditis masks
the symptoms pointing to the latter.   An examination for the signs of peri-
carditis should not be omitted in cases presenting notable disturbance of the
nervous  system.

   Prognosis.—Acute pericarditis is in some cases a  very dangerous disease,
but  in other  cases comparatively mild.   The gravity depends much  on  the
intensity of the inflammation, the  amount  of inflammatory exudation, and
more especially the quantity of liquid effusion, together with the rapidity with
which it takes place.   A  large quantity of  liquid, rapidly effused, may lead
quickly  to a fatal termination.  Death in  such cases is caused by paralysis
of the heart  from compression, and cases have-occurred  in which  life was
destroyed in this way after the lapse of a few hours only from  the time of the
attack.   Generally, however, the duration  of  the disease in fatal cases is from
one to two weeks" and death takes place by slow asthenia.  In such cases the
immediate cause of death is either the prolonged compression of the heart by
liquid, or weakening of the heart's action as a direct effect of the inflammation
on the muscular fibres, or both causes  combined.   Sudden  death by syncope
is liable  to be produced  by muscular exertion, especially if there be much liq-
uid effusion.  A patient under my observation, affected with mild pericarditis,
died instantly on getting out of bed to go to  stool.
   The fatality in cases of acute pericarditis is  often  due, not so much to
                 1 Vide Treatise on Diseases of the Heart, 2d  ed. 
310
PERICARDITIS.
the disease per se, as to coexisting affections.   In fact, exclusive of the acci-
dents just referred to, the disease tends to recovery.  The danger varies greatly
with its different pathological connections.  Rheumatic pericarditis, not asso-
ciated with pleuritis or pneumonitis, is rarely fatal.  On the other hand, peri-
carditis developed in the course of Bright's disease proves fatal in a very large
proportion  of cases.   This difference is explained by the ability of the system
to sustain any important intercurrent affection  being widely different in these
two diseases.   Cases in which  the pericarditis occurs as a complication of
pleuritis or pneumonitis show a large fatality.  Traumatic cases generally end
in recovery, provided  the heart be not  injured.   Occurring as an idiopathic
affection and uncomplicated, the prognosis is  favorable.
   If  the disease do not prove fatal during its acute course, it either ends in
recovery or it becomes chronic.  Chronic pericarditis will claim separate con-
sideration.   In the cases which end in  recovery the usual result is adhesion,
by the intervention of  newly-formed tissue, of the pericardial surfaces over
the whole or the greater part of the organ.  In  a small proportion of cases the
adhesion is limited to a few small spaces.  Occasionally, patches of fibrous tis-
sue, without  adhesion of the two surfaces, are the only permanent effects of
the disease.  It is doubtful if  complete  absorption of the inflammatory exu-
dation ever takes place, followed  by no adventitious  tissue and leaving  no
trace  of the  disease.

   Treatment.—The widely different circumstances under which acute peri-
carditis occurs must of course  be  taken into account  in the treatment.  The
question as to the propriety of bloodletting and other  measures heretofore
distinguished  as  antiphlogistic  can only be entertained  in  the first  stage of
the disease and when it is idiopathic or traumatic or connected with rheu-
matism.   These measures are undoubtedly inappropriate when  it is developed
in the progress of Bright's  disease or when  it  is  secondary to  pleuritis or
pneumonitis.  In  general  terms, the propriety of these  measures admits of
consideration  only when the  pericarditis is either primary, or  secondary to
affections which do not in themselves impair considerably the ability of the
system to sustain an additional disease.  AVhen not associated  with other dis-
eases which are in themselves dangerous, it is to be borne in mind that peri-
carditis tends to recovery.
   In  the cases to which bloodletting must be limited the general principles
which are to govern its employment are the same as  in  other acute inflam-
mations. These principles have been considered.1  Some importance, perhaps,
belongs to  this consideration—namely, by diminishing the mass of blood the
heart is less excited and its labor diminished.  On the other hand, it is to be
considered  that the danger incident to the disease is mainly from paralysis of
the heart or impairment of its muscular power.   Giving due weight to these
considerations, bloodletting should be employed  with great circumspection,
even  in  the few cases in which the symptoms relating to  the circulation, in
the first stage of the disease, may  appear to indicate it.  It is never indicated
after  considerable effusion has  taken place.
   Depletion by means of saline purgatives is indicated,  in the first stage, by the
same  symptoms as in other acute inflammations.   This remark  is alike applic-
able to nauseant and  other sedatives.  These  should be limited to the first
stage.  They might prove pernicious if continued after effusion has occurred,
and hence  the great importance of determining the  presence of liquid and
its amount by physical signs.
   Shall the system be brought under the influence  of mercury in the first
stage?   This is a question which  different writers  and practitioners have
                             1 Vide p. 125 et seq. 
ACUTE  PERICARDITIS.
311
answered differently, some advocating rapid mercurialization as highly import-
ant, others regarding  it as needless and hurtful.   In  the cases in  which mer-
cury is by some considered important, and by many admissible, my experience
leads me to be satisfied to forego its use.
  Opium  is  of  great value in this as  in  other acute inflammations.   It is
indicated by pain  and constitutional disturbance, and is to be employed suf-
ficiently to relieve the general and local  symptoms.   The form of opiate and
the mode  of administration are to be determined by the circumstances in
individual  cases.
  Locally, mild revulsive  and soothing applications  are useful  in the first
stage.   Sinapisms, a  poultice, the water-dressing, or  the spongio-piline  satu-
rated with  a warm anodyne  infusion  may be  employed.   Blisters in this
stage should  not be employed.  Aside from their interference with  the  daily
physical explorations, which  are  vastly important, they do  more  harm by
adding to the pain and constitutional disturbance than good by way of revul-
sion.   By German writers cold applied to  the praecordia, as in the treatment
of acute pleuritis  and pneumonitis, is said to be useful.   The evidence of its
usefulness  is the  relief  of  pain, together  with  diminished frequency of the
heart's action.
  The indications  in  the second stage relate, first, to  the liquid effusion. If
the amount of  effusion be  sufficient to  enfeeble the heart by compression, it
is highly important to effect the removal of the  liquid as speedily  as possible.
For this end the praecordia  may be  painted daily  with the tincture of iodine,
or small blisters may  be  applied, removing them as soon as vesication begins,
and allowing the blistered surface to dry up rapidly.   Hydragogue cathartics
and diuretics may be  employed, as in pleuritis, taking care not to  carry these
measures so  far as to depress  the vital powers and weaken the heart's action.
This caution is of great importance, and it suggests a second indication which
may be present  in the second  stage—namely, to strengthen the heart's action
and support the powers of life by the timely and  judicious use of alcoholics,
tonics, and  nourishment.  Keeping in view the fact that the disease, if it
end fatally, destroys life by affecting directly the heart's action, the  measures
just named are  indicated with an  urgency  proportionate to the degree of fee-
bleness of  the circulation.   All measures which tend directly or indirectly to
weaken the circulation or depress the vital powers are contraindicated in the
second stage.  The  liability to fatal syncope on exertion is  to be  borne in
mind, and quietude should  be rigidly enjoined.   Feebleness and  irregularity
of the pulse in  the second  (and sometimes in the first) stage constitute an
indication for digitalis, which, however, should not be  given sufficiently to
retard  unduly  the heart's action.
  During the stage of convalescence  precautions against undue  excitement
of the action of the heart by  exercise, mental emotions, over-repletion of the
stomach, etc. are  more  important  than  during  recovery from  most  other
acute inflammations.   At  the  same time, convalescence will be expedited
and complete recovery secured by a  nutritious diet, tonic  remedies, gentle
gestation out of  doors,  and  other hygienic measures to promote speedy
recuperation.
  In the treatment of pericarditis developed in  the course of either rheuma-
tism  or renal disease  it may be important to take into account the  supposed
presence in the blood  of  a morbid material upon which the pericardial inflam-
mation depends.  The indication  derived from this view of the causation is,
in general terms, to remove, if possible, the continued operation of the cause
by measures  addressed to  the morbid  conditions  of  the blood belonging to
those  affections.   This part of the treatment, however,  will  be more appro-
priately considered hereafter  in connection w*ith  rheumatism  and renal dis- 
312
PERICARDITIS.
ease.   The  importance of measures  to prevent the development of pericar-
ditis in the course of these diseases will also be then  considered.
  If the disease  end  in recovery without becoming chronic, adhesion of the
pericardial surfaces to a greater or less extent may be expected to take place.
This result was formerly supposed to lead to progressive enlargement of the
heart, and therefore pericarditis was regarded as a highly  serious disease with
reference to its remote effects.   This is an error which arose from imputing to
pericardial adhesions the consequences of the valvular lesions which often coex-
ist.   It may be doubted if adhesions alone tend to produce enlargement, and
there is reason to believe that if not associated with valvular lesions  they may
give rise to little inconvenience.  The pericardial surfaces  are not infrequently
found,  in autopsical examinations, universally adherent as a result of ancient
pericarditis, without any  other  evidence  of  cardiac disease, when  no symp-
toms referable to  the heart had existed during life.   Universal adhesions may
be diagnosticated by finding the apex of the  heart immovable when  the body
is placed  in different  positions; by a visible retraction of the  chest-wall  and
epigastrium synchronously with the  ventricular systole; and  by the super-
ficial cardiac space remaining unchanged by a deep inspiration.   These phys-
ical signs denote adhesions not only  of the visceral and parietal surfaces of
the pericardium,  but  of the  external  surface to the adjacent lung and  the
parietes of the chest.   If the latter adhesions have not taken place, the data
for  a  diagnosis are wanting.
                        Chronic Pericarditis.

  Chronic pericarditis may be subacute from the beginning, or it may follow
the acute form  of  the  disease.  If acute pericarditis  do not end in  conva-
lescence  after the lapse of from  two to three weeks,  it becomes  a chronic
affection.  As regards anatomical characters, cases differ.   In some cases of
chronic pericarditis there is no liquid effusion, but the pericardial surfaces are
agglutinated by  several  layers of fibrinous exudation, which collectively may
be half an inch or more in thickness.   Under these circumstances the exuda-
tion is not absorbed, a low grade of inflammation  continues, and the disease
often  ends fatally after a variable duration.
  In other cases liquid effusion remains and progressively accumulates;  the
pericardial sac becomes  more  or  less dilated, and  it is sometimes  so  much
enlarged  as  to depress  the  diaphragm and occupy the greater part  of the
thoracic  space.   In a  case reported  by Dr. T. P. Satterthwaite  the liquid
removed  after death amounted to eight  pounds and four ounces.1   In a case
reported  by the  late Dr. Swett the quantity of liquid  was  at least a gallon.
  In  chronic  pericarditis without liquid effusion  pain is rarely prominent.
The  symptoms are  those  dependent on feebleness  of the circulation due to
the impaired muscular  power  of  the  heart, and on constitutional  irritation.
In the cases in which  large effusion exists the heart is weakened by compres-
sion,^ and  the  patient  suffers from dyspnoea caused by interference with  the
respiratory function.  The dyspnoea may amount  to  orthopncea if  the accu-
mulation of liquid be large.   Pain under these circumstances is rarely a  prom-
inent symptom.   The  symptoms mentioned as due to the pressure of the peri-
cardial sac filled with  liquid in  the  second stage of  acute pericarditis may be
still more marked when the sac is dilated by effusion in the chronic form  of
the disease.   These symptoms are—aphonia, from  pressure on the recurrent
laryngeal nerves ; dysphagia,  from pressure on the oesophagus ; cyanosis and
turgescence  of the  cervical veins, from  pressure on the venae cavae and the
               1 Richmond and Louisville Med. Journal, April, 1872. 
CHRONIC PERICARDITIS.
313
yielding Avails of the auricles; and singultus, from pressure on the phrenic
nerve or branches  of the  par  vagum.
  Chronic  pericarditis with effusion is not to be confounded with pericardial
dropsy (hydro-pericardium).  The latter occurs in connection with general
dropsy, and the accumulation  of serum is rarely, if ever, sufficient to dilate
the sac.   In  chronic as  in acute pericarditis  the  liquid is generally  sero-
fibrinous.   In rare instances it is purulent (pyo-pericardium).   The  effused
serum is sometimes  colored with  blood.  This  variety of pericarditis, called
hemorrhagic, does not claim separate consideration.  The term  haemo-peri-
cardium denotes  the presence  of blocd either  with or  without pericarditis.
Without pericarditis it may be a consequence of wounds which  penetrate the
pericardial  sac, and of the  rupture  of  either the heart or an aneurism.   In
most, if  not all, cases  of  so-called hemorrhagic  pericarditis  the  liquid is
bloody serum.   This occurs especially  in  pericarditis  associated with pur-
pura haemorrhagica and scorbutus.
  The  diagnosis, if liquid effusion  be not present, must often be inferential,
being based  mainly on  the knowledge of the existence  of antecedent acute
pericarditis.  Creaking  friction murmur  exists in  some cases,  notwithstand-
ing the agglutination of the pericardial surfaces.  If friction murmur be not
present and acute pericarditis be not known to  have existed, a  positive diag-
nosis is extremely difficult, if not impossible.   The heart is found to be more
or less enlarged, but there are no means of determining  that the enlargement
proceeds  from  a  deposit of fibrin.  If liquid effusion be  present the phys-
ical signs render  the diagnosis easy and positive.   Flatness on percussion
exists on the anterior surface  of  the  chest, extending on either  side  of the
sternum  toward the axillary region in  proportion  as the pericardial sac is
dilated.  Obliteration of the intercostal depressions, and even  bulging, may
be observed.   In  a young subject  there may be  notable projection  of the
praecordia.   Fluctuation in the intercostal spaces is sometimes felt.  Later-
ally, beyond  the  limit of the flatness on  each side, resonance  on percussion
and the respiratory murmur show  the presence of lung.  The heart's impulse
is suppressed, but a shock communicated by the action  of the  heart may be
felt.   A  friction  murmur is sometimes heard, even  when  the quantity of
effused liquid is very large.  The sounds of the heart are  feeble, the first
sound  being distant, more weakened than the second, and short and valvular
like the second sound.   These signs render the diagnosis sufficiently clear.
  The  prognosis  in cases of chronic pericarditis is  always  extremely unfa-
vorable.  The disease ends fatally after a duration  varying much in different
cases.
  The  indications  for treatment are to improve the tone of  the  system and
impart vigor to the heart  by tonic remedies, together with nutritious diet and
other hygienic measures.   The propriety  of much counter-irritation is doubt-
ful.  Everything which tends, directly or indirectly, to  weaken the heart or
the vital  powers is to be avoided.   In this point of view mercurialization is
objectionable.  If  there be much liquid effusion, diuretic remedies and small
blisters may be tried.  Hydragogue cathartics  in these  cases, if  the  patient
be feeble, are to be employed with great circumspection.   In  a case under my
observation  elaterium, given in small doses and producing  but  a moderate
effect, appeared to  hasten  the  fatal termination.  Iodine may be employed
as a sorbefacient, externally and  internally.
  The  question as to the propriety of paracentesis  relates chiefly to cases of
chronic pericarditis.  Instances, however, may  occur in which,  owing to a
rapid and large effusion of liquid,  this question may arise in  connection with
the acute disease.   If  life be in immediate danger  from the quantity  of
liquid,  whether the  inflammation be acute or not, there  can be no room for 
314
PERICARDITIS.
doubt concerning the propriety of withdrawing the liquid by aspiration , but
this  question  is not  restricted to the  cases in which it is indicated to avert
impending death.   May not the rules  of practice now generally accepted  in
cases of pleuritis with effusion and empyema be applied to similar conditions
in cases of pericarditis?  From a rational standpoint the answer is affirma-
tive.  Following these rules, if a large accumulation of liquid  remain undi-
minished  by other measures of treatment continued for a reasonable period,
aspiration should be employed, and the latter is always indicated in suppura-
tive  pericarditis.
   As preliminary to the operation there is apparently no objection  to an
exploratory puncture in order to demonstrate the presence of liquid and  to
ascertain  its character.  No harm can  arise from the puncture with a  needle
attached to a hypodermic  syringe.   Even should the  heart be punctured
therewith, no serious consequences would follow.   A needle, however, should
not be used in aspiration, except for  the objects just stated.  A small-sized
trocar is unobjectionable.  The suction  force by means of Davidson's syringe,
properly adapted, is preferable to that produced by Dieulafoy's  apparatus  or
its modifications, the-former  being  simpler and more easily managed.
   Roberts has tabulated 60 cases of paracentesis of the  pericardium.  Of
these cases, the number of  recoveries  was  24.   Of  the  fatal cases (36), 23
survived  the operation for  one day or longer,  the  average duration of life
being over  twenty-seven days, and the longest duration  one  hundred and
sixty days.1  These  results strongly sustain the propriety of the operation,
especially when it is considered in  how large a proportion of cases pericar-
ditis is associated with other grave affections, and that up to the  present time
the operation has generally  been en dernier ressort.
   The most eligible  point  for  making the puncture is  the fifth  intercostal
space between the sternum and the linea mammillaris, somewhat nearer  to the
former than to  the  latter.   It is probably  an  important precaution to with-
draw the liquid very slowly.  If the liquid  be  purulent, and, after repeated
aspirations,  pus continue to  reaccumulate, it is very evident that  a permanent
opening into the pericardial cavity affords the only hope of effecting a cure.


                        Pneumo-Pericarditis.
   This  name  denotes the presence of air or gas within the pericardial  sac  in
cases of pericarditis.   Air or gas may find its way into this situation through
a wound of the thoracic walls or of  the oesophagus, and through a fistulous
communication between the lungs or the stomach and the pericardial cavity.
Air may get access into this cavity through a wound of the chest, and peri-
carditis  not be  developed.   The  condition  then is  expressed by  the term
pneumo-pericardium.   I have  reported a case  exemplifying this statement.2
   The presence of air and liquid gives rise to splashing and sometimes  metal-
lic sounds with the movements of the heart, which are heard on auscultation.
Percussion  over the  praecordia elicits a tympanitic resonance.   These  cases
belong  among the curiosities of  clinical  experience.   The treatment  of
pneumo-pericarditis  involves  the  same  principles  as the treatment of peri-
carditis  without the  presence of  air or gas.
   Of 28  cases collected by Miiller,3 9 terminated in  recovery.   The  cases
due to traumatism offered the most favorable prognosis.  Of 14 such cases, 6
recovered.

  1 Paracentesis of the Pericardium, by John  B. Roberts, A. M., M. D., etc., 1880.
  2 Vide Practical, Treatise on Diseases of the Hart, 2d ed.
  3 Midler, " Drei Fklle von Pneumopericardie," Deutsches Archiv fur klinische Medicin,
Bd. 24, S. 158, 1879. 
SIMPLE ENDOCARDITIS.
315
                       CHAPTER  II.

  ENDOCARDITIS—MYOCARDITIS.—DISEASES OF  THE  CORO-
                          NARY  ARTERIES.

Simple Endocarditis: Anatomical Characters; Clinical History; Pathological Character;
   Causation;  Diagnosis;  Prognosis;  Treatment.—Acute Ulcerative  Endocarditis.—
   Myocarditis.

   INFLAMMATION of the membrane  lining the cavities  of the heart, or
   the endocardium, is called endocarditis.
   The inner  surface of the endocardium is  lined by a single layer of flat,
polygonal endothelial  cells.   Beneath  this  is a layer of connective tissue
extremely rich in elastic fibres.   This elastic layer, which  with  the endo-
thelium constitutes the endocardium, is connected with  the muscular wall of
the heart by  a layer of ordinary fibrillated connective tissue  in which may be
found scattered muscular fibres.  Blood-vessels are present in this  layer, but
the endocardium itself is non-vascular.   The  valves may  be regarded  as
duplicatures  of the endocardium, between the lamellae of which is a strength-
ening layer of fibrous tissue derived from the fibrous rings of the ostia.  The
semilunar valves  are devoid of blood-vessels, and the auriculo-ventricular
valves usually contain  only a few blood-vessels near their attached  borders
(Langer). Inflammation of the valves often leads to a new formation of blood-
vessels in their substance.
   The inflammatory lesions of the valves of the  heart are  most  frequently
situated, not upon the free edge of the valve, but upon  a  thickened line a
short distance  from  this edge, known as the line of closure of the valves.
   The inflammations of the endocardium  may be divided into  simple endo-
carditis,  which may be acute, subacute, or chronic, and acute ulcerative, or
malignant endocarditis.

                        Simple Endocarditis.
   A sharp line cannot be drawn between the acute and  the chronic  manifesta-
tions of  this disease.  A subdivision into verrucous or  papillary endocarditis,
in which the anatomical  lesions appear as warty excrescences on  the  endo-
cardium, and sclerotic or contracting endocarditis, in which the valves become
thickened and shrunken, has been made, but these two varieties of lesions are
so intimately related to each other, and so frequently combined,  that  they
will be considered under  a common heading.

   Anatomical Characters.—Endocardial  inflammation, in  the  great  ma-
 jority of cases, is situated  on the  valves  and chordae tendineae.   It is rela-
tively infrequent on the endocardium lining the cavities of the heart.   After
birth it is generally limited to the left side of the  heart.   In the  rare cases
of endocarditis of the right side after birth the left is  likewise generally
involved.  Before  birth endocarditis of the right  ventricle is most common.
Foetal endocarditis  has been often  observed, and in  the vast majority  of
cases it  is confined to the right  side.
   Redness,  which plays such an important part in the anatomical appearances
of the early stage of acute inflammations  in most situations, is not of much
importance in endocarditis.  A diffuse reddish staining of the  endocardium, 
316
ENDOCARDITIS,  MYOCARDITIS, ETC.
due  to post-mortem imbibition of dissolved blood-coloring matter, must not
be mistaken for inflammatory hyperaemia.  Nothing is known as to the exist-
ence of inflammatory exudation upon  the  free surface of the endocardium.
The  essential anatomical characteristic of endocarditis,  especially in its early
manifestations, is the appearance of so-called vegetations upon the endocar-
dium.   These vegetations may  be minute and in great number, giving only a
roughened appearance to the affected endocardium, or  they may attain the
size  of a pea  or  be even larger.  They are of all  shapes, and may be  con-
nected with the tissue of the endocardium by a broad  base  or by a narrow
pedicle.  They cannot be removed  from the endocardium without leaving a
loss  of substance.  This fact, together with their microscopical examination,
shows that they are outgrowths from the tissue of the endocardium, and not
merely fibrinous deposits from  the  blood, as was once  supposed.   They are
formed  by a nodular accumulation of young cells, partly emigrated white
blood-corpuscles and partly young connective-tissue cells, in the  upper  con-
nective-tissue layer of the endocardium.  They constitute a kind of granulation-
tissue over which  the endothelium  has disappeared.  New  blood-vessels are
frequently found in  these vegetations.  A more diffuse infiltration with leuco-
cytes, especially around the vegetations,  is  also met with in  the endocardium.
Upon the roughened surface of the vegetations white thrombi are deposited
from the blood.  These thrombi, which may be of considerable thickness, are
formed  chiefly of blood-plates, white blood-corpuscles, and fibrin (p. 28).  The
vegetations, with their caps of  fibrin, are favorable  points for the detachment
of emboli, which may consist either of  broken-off  thrombi  or of fragments
of the vegetations.  Less frequently than in acute ulcerative endocarditis,
loss  of substance of the endocardium may  occur  from breaking off of the
vegetations or by necrosis and fatty disintegration of the surrounding infil-
trated  endocardial tissue.  Thus, there may result  perforation of the valves,
or, on  the  other hand, valvular aneurism in consequence of  bulging of their
thinned and softened coats.
  In the subacute and chronic forms of endocarditis the vegetations are firmer
in their texture, and do not consist so much of  granulation-tissue as of fibril-
lated connective tissue.   These firm vegetations may be developed out of the
soft, acute vegetations, or they may have been slow  in their growth from the
beginning.  The valves are also much deformed by the thickening of their
substance in consequence of the development of new connective tissue, which
shrinks and causes retraction of the curtains.   At the same time, the chordae
tendineae are often shrunken and  thickened.  Abnormal adhesions between
the  edges of the valves or between the valves and the heart-wall are fre-
quently formed.   Regressive metamorphoses, in the form of necrotic foci, of
fatty degeneration, and of calcification of the vegetations and of the thickened
endocardium, are usually observed.  These various changes in acute and chronic
endocarditis lead to  the development of  valvular stenosis and insufficiency.

  Clinical History.—Authenticated  cases  of endocarditis  disconnected
from other diseases, which serve to mask its symptoms to  a greater or less
extent,  are wanting.  The clinical history of the disease, therefore, as far as
it is at present known, will require  but a brief space.   Our knowledge of the
disease  is confined chiefly to the cases in which it  occurs in connection  with
acute articular rheumatism, and in a certain proportion of  these  cases it is
associated  with pericarditis.  Pain referable to  the praecordia  is  rarely, if
ever, a prominent symptom.  The patient may complain of  an obscure sense
of distress in  the praecordia, not amounting to pain.   The action of the heart
may be morbidly excited.  The organ beats with abnormal quickness and fre-
quency, and its action may be irregular.  The action of the heart may be out 
SIMPLE ENDOCARDITIS.
317
of proportion to the force of the pulse.   The  local symptoms, in  short, as
regards the action of the heart, are those of palpitation.   In proportion to
the acuteness of the inflammation, doubtless febrile movement is  induced,
together with the symptoms  of constitutional disturbance which accompany
fever symptomatic  of  inflammation in other situations.   The local  and gen-
eral  symptoms, however, are often not prominent,  and  as far  as these  are
concerned the disease is not infrequently latent.   Hence  the existence of  the
disease was unknown prior to the early part of the present century.

   Pathological Character.—The morbid changes which  belong to sim-
ple endocarditis are  in many respects  the same as  in serous  inflammations.
Inflammatory products on the surface of the membrane,  if they occur in this
situation, are carried by the blood-current into the circulation.  The local
effects of the endocardial inflammation are warty growths, fibrinous  deposits,
adhesions, etc., an account of which has been given under the heading Ana-
tomical Characters.

   Causation.—Endocarditis, in the great majority  of cases, is not a primary
disease.  There is  reason, however, to believe that  it occurs  not very infre-
quently, and is overlooked in consequence of its latency as  regards cardiac
symptoms. This  may be inferred from the number of cases in  which valvular
lesions referable to inflammation are found in persons who have never had  the
disease in the course of which endocarditis is likely to be developed—namely,
articular rheumatism.   As recognized in practice,  it  is generally incidental to
the disease just named.  The proportion of cases  of rheumatism in which it
occurs is not settled.  The  statistics  of  different  observers show a  variation
of from f to 9 per cent.   A reason for this variation is that the existence of
the disease has been often assumed on insufficient evidence.   The ground for
this  statement will  appear in connection with the consideration  of the diag-
nosis.  The analysis by Sibson of 325 cases of acute rheumatism,  observed
by him, gave 7!) cases in which there was no evidence of endocarditis; in 161
cases the evidence  of endocarditis was  considered  as  positive; it  probably
existed in 13 cases, and it was  noted  as  threatened  in 63 cases.  It is prob-
able  that in some cases the evidence was considered  as complete  on insuf-
ficient grounds.  This statement will apply to cases in which the only evidence
was  a tricuspid regurgitant murmur or an aortic direct murmur, and to cases
in which valvular lesions may have existed prior to the  rheumatism.  The
cases of  probable and threatened endocarditis  cannot be said to have any
statistical value.   The frequency  of  rheumatic  endocarditis is  doubtless
affected in not a small  degree by the treatment adopted in the  early period of
rheumatism.   It  suffices to say that  endocarditis  occurs frequently in cases
of rheumatism.   Endocarditis, like  pericarditis, may perhaps  in some cases
precede the affection of the joints.   It may occur at any  time in the course
of a rheumatic attack, but it is usually developed  in the early or  middle
period.
   When developed  in the course of rheumatism, it  is not from the transfer-
ence of the affection of the joints to the endocardial membrane—that is,  not
by a metastasis—but, like pericarditis developed in the same connection, it is
produced by the causative condition which gives rise to the articular  affection.
   Endocarditis and  pericarditis are not infrequently associated in  cases of
rheumatism, and  this compound affection is called  eudo-pericarditis.  Rheu-
matic pericarditis rarely exists  without endocarditis.  The reverse  of this,
however, does  not  hold good:  endocarditis is not infrequently developed
without pericarditis.  In  Sibson's  cases endocarditis  without pericarditis
occurred  in  107, and endo-pericarditis existed in 54. 
318              ENDOCARDITIS,  MYOCARDITIS,  ETC.

  Endocarditis, either with or without pericarditis, is developed, in a certain
proportion of cases, in the course of Bright's disease.   It occurs occasionally
in the eruptive and continued fevers and in  cases of  pyaemia.   It may possi-
bly be produced by contusions of the chest.  Its occurrence in chorea is sup-
posed to be frequent.   Evidence of its existence was regarded as  sufficient in
13 of 34 cases  observed by Sibson.   The sufficiency of the  evidence, how-
ever, in all of the 13  cases admits of doubt.   This  frequency of its  occur-
rence is consistent with  the supposed  relationship of chorea to rheumatism.
Recurring attacks of  endocardial inflammation  not infrequently take place in
connection with existing valvular lesions of  the heart.

  Diagnosis.—The symptoms in cases of endocarditis are  insufficient for a
positive diagnosis.  The symptoms are even  less diagnostic than those which
belong to the  clinical  history of pericarditis, and the disease is oftener com-
pletely latent.  The diagnosis of this disease, as well  as of pericarditis, must
rest on physical evidence.   The  vegetations and fibrinous deposits  give rise
to an endocardial murmur, and the diagnosis is  to be  based on the develop-
ment of this murmur, taken in connection with the symptoms.   As the ana-
tomical changes are situated especially  upon  the curtains of the mitral valve,
at least in cases of rheumatic  endocarditis, the murmur is usually of mitral
origin.   The murmur is  of a soft or  bellows character.  It accompanies  the
first  sound of the heart; that is, it is systolic.   It is  heard  loudest at or near
the apex  of the heart, and may be limited to  this situation.  As a rule, if
prior to the endocarditis the  patient were free  from valvular lesions, the sys-
tolic murmur is not propagated far without the left border of the  heart.  The
anatomical changes which  occur during the  progress of simple endocarditis
do not involve immediate valvular insufficiency either at the mitral or aortic
orifice.   Hence, the mitral murmur does not proceed  from  an  actual regurg-
itant current from the ventricle to the auricle.   It is  not, then, correct to call
it a mitral regurgitant murmur.  It is  an intraventricular murmur, or it may
be called a mitral systolic murmur, this term not implying the occurrence of
regurgitation.
   Positive evidence of endocarditis is not  afforded  by the existence  of  the
murmur just named.  A mitral  murmur exists often without  denoting exist-
ing  inflammation.  It may proceed from valvular lesions  which are to  be
presently considered.  To be evidence of  existing endocarditis, the murmur
must be developed under observation ; in  other words, one must he satisfied
that  the  murmur  which is discovered did  not exist on a previous examina-
tion.  As it is in cases of rheumatism especially that endocarditis occurs,
let it be assumed that  on the  first examination of a patient affected with
rheumatism a mitral  murmur  is found.  The  murmur is not proof of endo-
carditis, for it is not known that the murmur did not exist prior to the rheu-
matic attack.  The existence of endocarditis is only probable, and the prob-
ability of the  disease is greater if this be the  first  attack of rheumatism.
But  if,  on  a first examination, no murmur be  found, and subsequently a
mitral  murmur become developed, it  is evidence of endocarditis.   The  evi-
dence is strengthened if  at  the same time praecordial distress  and excited
action  of the heart  point to  the occurrence  of a cardiac  complication.
   Reference has  been made,  thus far, to a mitral murmur only as evidence
of endocarditis.   Vegetations and fibrinous  deposits  at the  aortic orifice may
occur in this  disease, giving rise to  an  aortic  murmur.   An aortic direct
murmur, and also a pulmonic direct murmur,  however, are  not infrequent in
cases  of  rheumatism  without endocarditis,  more especially in women, being
due to the condition  of  the blood ; in  other words, being inorganic murmurs.
 Hence, a positive diagnosis of endocarditis  is  not to be based on these mur- 
SIMPLE ENDOCARDITIS.
319
murs, unless the_ symptoms at the same time denote a cardiac complication
and pericarditis is excluded.  Irrespective of cases of rheumatism, it is well
known that an aortic murmur with the first sound—i. e. systolic—is common
as an  inorganic murmur, and alone is never proof of endocarditis.  Insuf-
ficiency of the aortic valve as an  immediate effect of endocarditis must  be
rare.   Sibson, however, gives  some instances in  which this effect was shown
by  the occurrence  of an aortic  regurgitant murmur developed  during  the
rheumatism, and afterward disappearing.
  Endocardial  murmurs produced  by endocarditis may or may  not  remain
permanently.   I have repeatedly known a mitral murmur to disappear after
recovery from  rheumatism.  I have  known an  aortic  and a mitral murmur
to continue  for  several years after recovery,  and  at  length to disappear
entirely.  In cases  of endo-pericarditis  the endocardial exists with an exo-
cardial or friction  murmur.   In general, the  two murmurs  may be  readily
distinguished, and  each  referred to its  source.

  Prognosis.—In  the great  majority of cases  simple endocarditis involves
no  immediate danger.  The danger is  for the most  part  remote, relating to
the valvular lesions which  often follow. (Vide  Chapter III.)  The persist-
ence of inflammation  in a chronic  form  is  not determinable.  The continu-
ance  of an  endocardial murmur  is  not proof  that  inflammation persists;
and roughening of the membrane  from  either vegetations or thrombi which
remain will suffice to produce a murmur.  The  chief source of important mor-
bid effects, exclusive of valvular  lesions, is embolism.  Vegetations or masses
of fibrin of greater  or less size are liable to be detached, and, forming emboli,
occasion obstruction of arteries in  different organs.  Passing, of  course, into
the systemic circulation, they are most likely to become lodged in the spleen
and in the kidney, where they give rise to infarctions.   They may be carried
into the  central artery of the retina  and give  rise to impairment of vision.
Again, cerebral embolism may occur, and there have been  cases  in which
gangrene  of the lower limbs has resulted from  embolic obstruction of their
distributing  arteries.  In  the  latter case the arteries are generally  athero-
matous or the circulation is much enfeebled.  (For a general account of embo-
lism the reader is referred to Part I. of  this work.  Aide p. 30 et seq.) These
are accidents incident to endocarditis.   In general, as occurring  in its usual
pathological connection—namely, in the course of acute  articular rheumatism
—and disconnected from pericarditis, endocarditis involves no immediate dan-
ger and gives rise to no symptoms  denoting gravity of disease;  but it  is
frequentl}' latent, and is an important  complication, chiefly because  it may
be the foundation for valvular lesions which, after the lapse of many months,
or it may be many  years, occasion  serious consequences.

  Treatment.—Simple endocarditis, being  confined, generally,  to  the  left
side of the heart, and limited chiefly to the valvular portion of the endocar-
dium,  does  not occasion great constitutional disturbance.   Praecordial pain
and disturbed  action of the heart  indicate anodyne remedies and soothing
applications  to the chest.  Blisters  with reference  to  these symptoms are
of doubtful propriety.   Sinapisms  and stimulating liniments will secure  all
the advantages to  be derived from counter-irritation.
  Measures  addressed to the supposed  causative condition of the blood are
rationally indicated.  Occurring generally in connection with rheumatism, if
the local manifestations,  this affection of course included, depend on the pres-
ence of a morbid material in  the blood, it is plainly an object either to neu-
tralize or  eliminate  this  material.   The means to be employed for this object
will be hereafter considered in connection with  the  subject of rheumatism ; 
 320             ENDOCARDITIS, MYOCARDITIS,  ETC.

 but it may be here stated that the most important measure  is the adminis-
 tration of  alkaline  remedies in doses sufficient to produce and maintain alka-
 linity of the urine.   The importance of this measure  in order to prevent the
 occurrence of both endocarditis and  pericarditis in cases of rheumatism will
 enter into  the consideration of the treatment of the latter disease.
   The remote evil consequences of endocarditis  proceed from thickening,
 morbid growths, and the deposit of fibrin upon  the valvular portion of the
 endocardium.  It  is therefore  undoubtedly  desirable to limit  and remove
 these immediate effects of the inflammation.   The condition  of hyperinosis
 is  more  marked in  rheumatism  than  in  any other  disease, and  perhaps
 increases  the tendency to  fibrinous  deposits.   With this  view, measures
 addressed  to  that  condition  are  rationally indicated.   Alkaline remedies,
 there is reason to believe, lessen the liability to fibrinous deposits.   Mercury
 has been  supposed to  have this effect.   That it possesses  this power, how-
 ever, has been inferred rather than demonstrated, and the correctness of the
 inference  admits of doubt.   It may be doubted whether the  fibrin deposited
 upon the membrane be ever  absorbed ;  it either  remains or is washed  away,
 gradually or in mass, by  the current  of blood.  The importance of absolute
 rest during the endocardial  inflammation and for  some time  afterward has
 been enjoined  by Sibson, and more especially by Fothergill.1  The object  is
 to secure a normal  minimum of the heart's a-ction in order to  prevent changes
 in  the valves leading to permanent valvular lesions.  It is reasonable to sup-
 pose that these are promoted by an increased strain upon the valves  weak-
 ened by existing or recent inflammation ; hence,  everything is to be avoided
 which  will increase the strain beyond  that necessarily involved in  the tran-
 quil action of the  heart.  This precaution embraces  avoidance of not only
 physical exertion, but also mental  excitement, a stimulating diet, and the use
 of alcoholics.  It is to be  added, however, that a good nutrition is to a certain
 extent protection against these lesions.  A diet so reduced as  to  occasion
 impoverished  blood is  injurious.
   The practitioner should bear in mind  that the persistence of an endocardial
 murmur is not sufficient ground for persistent medication.   The persistence
 of  the murmur is not evidence that the inflammation continues.  The  medi-
 cinal treatment of endocarditis should cease when  the local and general symp-
 toms of the disease are no longer present.


                 Acute Ulcerative Endocarditis.

   Among  the synonyms  for this  affection  may  be mentioned diphtheritic,
 mycotic or bacteritic, malignant, puerperal, septic,  and pyaemic endocarditis.
 The name  acute  ulcerative  endocarditis is .perhaps not the  best, as simple
 endocarditis may be attended with the formation of ulcers, but it is the  name
 commonly  employed.
  Acute  ulcerative  endocarditis  is distinguished by the malignancy of its
 course.  It may be primary, but it is  usually secondary to  acute infectious
 diseases, and in either case it is accompanied  by symptoms of severe blood-
poisoning,  and usually by the development of multiple abscesses.  Acute
 ulcerative  endocarditis  is due  to  infection with  bacteria, which  are always
to be found  in the valvular lesions.

  Anatomical Characters.—The endocardium presents, in this disease, lit-
tle necrotic patches of an opaque, yellowish-white appearance.  By the break-
ing down  and separation  of these patches of dead tissue ulcers  are formed.
Both the ulcers and the patches of necrosis are usually covered  by reddish-
    1 The Heart and its Diseases, by J. Milner Fothergill,  M.  D., etc., 2d ed., 1879. 
                ACUTE ULCERATIVE ENDOCARDITIS             321

gray, soft thrombi, composed of bacteria, blood-plates, leucocytes, fibrin, and
red blood-corpuscles.   In the margins of the ulcers, and around  and subse-
quently within the necrotic foci, are accumulated small, round cells, probably
emigrated white blood-corpuscles.   The  substance of the affected valves to a
greater or less extent is swollen, softened, and lustreless.1
  Valvular aneurisms may be formed by bulging out of the thinned and soft-
ened endocardium at the base of the ulcers  in consequence of the pressure of
blood. These aneurisms, when  on  the mitral valve, project toward the auricle ;
when on the aortic valve, toward the ventricle.   Of grave import are the per-
forations and rupture of the valves which may result from  the ulcerative pro-
cess.   In a  similar way, rupture of the chordae tendineae may occur.  Frag-
ments of the valves or portions of the thrombotic deposits may be carried into
the circulation as emboli.
   Microscopical examination reveals constantly, both in the thrombotic depos-
its and in the  substance of  the valves, masses of bacteria, which  are nearly
always micrococci.  Although the  micrococci have been found in small blood-
vessels in the valves, it  is probable that they usually invade  the endocardium
from its free surface, being deposited from  the blood within  the heart.  The
immediate effect  of  the invasion  of the endocardium by the  micrococci is
to cause the  foci of necrosis which have  already been mentioned.   Outside
of the necrotic patches, which are  mostly or wholly devoid of nuclei,  there
appear emigrated white blood-corpuscles,  which  wander  into  the  necrosed
tissue.
   The bacteria which  are  present  in  acute ulcerative  endocarditis are  not
always of  the same nature.  Both staphylococci and streptococci have  been
observed, and in most cases these  organisms seem to be identical with  those
found in pus.  It is possible to produce artificially lesions identical with  those
of acute ulcerative endocarditis, by injecting into the blood of animals certain
of the micrococci which have been cultivated from  pus, after having first
mechanically injured  the endocardium.2
   Acute ulcerative endocarditis is  particularly prone to affect valves which
are already diseased, but it may occur, apparently without previous lesion of
the endocardium.
   Inasmuch as the emboli which  are  swept off  from the endocardium in this
disease contain  infectious   bacteria,  they produce   necrosis,  and usually
abscesses, wherever they lodge.   The  emboli of simple endocarditis, on  the
other  hand, produce only mechanical  effects, being non-infectious  or bland
emboli.  Among the  most frequent complications of  acute  ulcerative  endo-
carditis, therefore, are multiple abscesses in the kidneys, the  spleen,  and  other
parts of the body.
   Petechiae  are  often found in the  skin in this  disease.   Sometimes, but  not
always, it is possible to demonstrate colonies of  micrococci in the  capillaries
in or  "near  the hemorrhagic tissue.
  1 According to statistics of malignant endocarditis  collected  and analyzed by Osier
{The Lancet^Mavch 7, 18S5), the mitral valve alone was affected in 77 cases, the aortic
valve alone in 53 cases, the aortic and mitral valves together  in 41 cases, the heart-wall
in 33 cases, the tricuspid valve in 19 cases,  and the pulmonary valve in 15 cases.   In 9
cases the affection was confined to the right heart, the tricuspid valve being  involved o
times and the pulmonic valve 4 times.
  2 In several instances of acute ulcerative endocarditis the Staphylococcus pyogenes  aureus
has been found and cultivated.  Wyssokowitsch produced artificially acute ulcerative
endocarditis  by injecting, after lesion of the valves, various forms of bacteria, the most
important being Staphylococcus pyogenes aureus and Streptococcus pyogenes (p. 91). Ribbert
was able to produce, experimentally, mycotic endocarditis and myocarditis, without  pre-
liminary injury of the endocardium, bv injecting cultures of Staphylococcus pyogenes  grown
on potato. ' The material injected contained particles of the potato, which formed
emboli.
21 
 322             ENDOCARDITIS, MYOCARDITIS, ETC.

   It  is less easy than might be supposed to draw a  sharp line of distinction
 between acute simple and acute ulcerative endocarditis.  The macroscopical
 appearances may be the same in both diseases.   Some pathologists hold that
 all forms of acute endocarditis are of mycotic origin.  The weight of evidence,
 however, is in favor of the view that acute endocarditis may occur without
 the presence of  bacteria.
   Acute ulcerative endocarditis may occur as a primary affection.  How, in
 this case, the bacteria  enter the blood is not  known.  More frequently the
 disease is  secondary to some infectious process, particularly puerperal fever,
 pyaemia, and  acute  articular rheumatism, less  often  pneumonia, dysentery,
 diphtheria,  variola, scarlet fever, and typhus and typhoid fevers.   It is  not
 necessary to suppose that the specific organisms of all these infectious diseases
 are capable of causing malignant endocarditis, but it is more probable that the
 endocarditis is due in many cases to secondary infection with some form of
 micrococcus.   We know that such mixed infections are not rare in  the class
 of diseases  which here come into consideration.

   In acute ulcerative endocarditis occurring as a  secondary affection in connec-
 tion with acute rheumatism, puerperal fever, and pyaemia, the symptoms ref-
 erable to the endocardial affection are commingled with those of the associated
 diseases, and the affection is liable to be overlooked.  If endocardial murmurs
 be ascertained, they may be  supposed  to denote  only simple  endocarditis.
 Subjective  phenomena referable to the heart are not  marked and are often
 wanting.   The prominent symptoms are attributable  to infective matter con-
 tained in the blood.   Following an initial chill there is high fever, with nota-
 ble remissions, the latter occurring irregularly or sometimes simulating those
 of periodical fever.   There may be  repeated chills;  vomiting and diarrhoea
 are frequent symptoms; jaundice occurs not infrequently ; purpuric spots on
 the skin are of frequent occurrence;  prostration  is great; and death is pre-
 ceded by delirium and coma.   Local  symptoms in other organs than the heart
 arise from infective emboli.  The affection being generally seated  in the left
 side of the  heart, emboli are carried to the spleen and kidneys.   The  spleen
 becomes enlarged and tender on pressure.  Albuminuria may be present with
 or without renal embolism, and haematuria sometimes occurs.  In exceptional
 cases the right side of the heart is the seat of the affection, and then embolic
 abscesses may be produced in the lungs.   The symptomatology in  some cases
 is suggestive of typhoid fever, and  in other cases it accords with that  of
 pyaemia, so  that  the disease has been considered  as  presenting two  types,
 denominated typhoid and  pyaemic.
   When the disease is secondary  to pyaemia  it is  not easy to determine
 whether the pyaemic symptoms  be  referable in  any measure to  the  heart.
 Practically,  this question is not one of much moment.   The symptoms which
 have been enumerated,  occurring in cases of acute rheumatism and connected
 with the physical signs of endocarditis,  point to this endocardial affection.
 Further evidence of its existence is afforded by the rapid production of regurg-
 itant lesions of the aortic or the mitral valve, provided it be known that these
 lesions were not present prior to the  occurrence of the attack of rheumatism.
 The diagnosis, when the disease is primary, can  be made with more  positive-
 ness.  It is to be based on the symptoms and signs of an endocarditis followed
by the general and local symptoms which  denote pyaemia.  Pre-existing valvu-
lar lesions of the heart, however, render it difficult  to decide as to a recently
 developed endocarditis, so  that under these circumstances  the  diagnosis is
not easy.
  It is not known that recovery from acute ulcerative endocarditis ever takes
place.  With a prognosis based  on this fact, all that can be done  in  the way 
    MYOCARDITIS—DISEASES OF THE CORONARY ARTERIES.  323

of treatment, with  our present  knowledge, is to be guided by symptomatic
indications and  to  endeavor to  obviate  the tendency to death. "


       Myocarditis—Diseases of the Coronary  Arteries.
  Inflammation  of  the muscular structure of the heart is called myocarditis.
Various  forms of myocarditis are distinguished, but that form which is of
the greatest clinical  importance is the variety called  chronic interstitial, or
fibrous myocarditis, and fibroid  degeneration of the heart.
  In  the most important class  of cases of fibrous myocarditis  the primary
lesion is not inflammation,  but  is atrophy or necrosis of muscular fibres of
the heart in consequence of obstruction  to the circulation in the coronary
arteries.   Lesions  of the coronary arteries  causing obstruction are of great
clinical and pathological importance.  The most common of these lesions is
atheroma with calcification.  Another lesion is obliterating endarteritis, which
is not rare  in syphilis and may also  occur in  other conditions.  In conse-
quence of disease of  the arterial coats thrombi may form in the affected ves-
sels,  and, as the anastomoses of the  coronary  arteries are few, infarctions
follow this complete obstruction.  Less frequently, emboli enter the coronary
arteries and lead to similar results.   Infarctions in  the heart may be either
hemorrhagic or anaemic necrotic infarctions.  If the emboli be infectious, as
in acute  ulcerative  endocarditis, they  cause abscesses in the myocardium.  If
life be sufficiently  prolonged, the infarctions are replaced by cicatricial fibrous
tissue.   Some of  the fibrous plaques found in the cardiac  muscle are the
result of such infarctions.   More frequently the obstructions resulting from
disease of the coronary arteries  are not sufficient to cause typical infarctions,
but they cause  simple atrophy of the muscular fibres in circumscribed, scat-
tered patches.   This atrophy is followed  by a  new growth of fibrous tissue.
According to  a  view  which has much in  its  support, most  of the chronic
interstitial inflammations of organs are due to a primary atrophy of the paren-
chymatous elements.
  In  the form of fibrous myocarditis, here considered, which is due to disease
of the coronary arteries, grayish-white,  glistening  streaks and  patches  of
fibrous tissue are found scattered through  the substance of the myocardium.
These streaks and patches may  be in  any part  of the  muscular wall of the
heart, but they  are most frequently found  in the anterior wall  and apex of
the left ventricle and in the papillary  muscles.  They affect by preference the
outer layers of the myocardium, but they may be most abundant near the
endocardium.
  Another variety of fibrous myocarditis is that which is secondary to fibrous
thickening of the  endocardium or of  the pericardium.   Here new-formed
connective tissue grows from the thickened endocardium or pericardium into
the subjacent muscular tissue,  leading to  compression and  atrophy of the
muscular fibres.
  In  both forms of fibrous myocarditis the heart-wall is weakened, often suf-
ficiently to yield to the blood-pressure and to cause cardiac  dilatation.   A
spot  in the heart-wall thus  weakened  by fibrous growth may  bulge out in a
sacculated manner  and form an aneurism.   This is the usual method of devel-
opment of the so-called chronic partial aneurism of the heart. Such aneurisms
are most  frequently seated near the apex of the left ventricle,  more rarely at
the  base  of  the  ventricle, where they  occupy by preference the  situation  of
the pars membranacea septi, in the latter case bulging into the  right ventricle.
They  may lead to rupture of the heart.
  Thrombi are often found in these aneurisms as well as upon portions of the
endocardium overlying infarctions and fibrous plaques. 
324             ENDOCARDITIS,  MYOCARDITIS,  ETC.

  When hypertrophy of the heart is present in cases  of fibrous myocarditis,
the cause of  the hypertrophy is to be sought in concomitant valvular disease
or widespread arterio-sclerosis or chronic  Bright's disease.   Hypertrophy of
the right ventricle may be due to insufficiency of  the  left, in consequence of
myocarditis.
  In syphilis, patches of fibrous tissue may be found in the heart-muscle with
or without the presence of gummata.  Whether  in  such cases  the  fibrous
myocarditis be always  dependent upon obliterating arteritis  or other arterial
disease  is uncertain.
  Other forms of myocarditis are of less clinical importance.   Acute inter-
stitial myocarditis, rarely diffuse, more commonly circumscribed, characterized
by an accumulation of lymphoid cells, may  occur in  diphtheria  and other
acute infectious diseases.
  Better understood is suppurative myocarditis, or abscess of the heart.  The
abscesses  are usually small and  multiple, but a single large  abscess may be
formed.   The most frequent cause of cardiac abscesses are infectious emboli,
especially those derived from acute ulcerative endocarditis.   The pus may be
discharged into the pericardial sac, giving rise to purulent pericarditis, or into
one of the cavities of the  heart.  In the latter case the blood makes its way
into the abscess-cavity, thus leading  to the formation of acute cardiac aneur-
ism.  Acute  aneurism may also be  produced by deep ulcerations in cases of
acute ulcerative endocarditis.   Rupture of the heart may be a result of sup-
purative myocarditis.   Micrococci are present in the pus of cardiac as well as
of other abscesses, and are to be regarded as the cause of the suppuration.
  Some authors assume the existence of a parenchymatous myocarditis;  but
the changes which are described as belonging to parenchymatous myocarditis
are in reality those of albuminous  or fatty  degeneration of  the muscle,  and
will  be  described  subsequently.
  It should be mentioned that extensive disease, particularly  atheroma, of the
coronary arteries  may  exist without causing changes in the cardiac muscle.
In such cases it is probable that the circulation is not sufficiently obstructed
to lead to the changes which have been described, and to which,  as will subse-
quently appear, fatty degeneration of the heart-muscle is to be added.
  In all cases of  sudden death without other explanation careful examination
should be made of  the condition of the coronary arteries.

  It may be  inferred that the myocardium is the seat  of lesion  of  some kind
when cardiac symptoms  denote something  more than functional disorder,
and when enlargement from  other causes, pericarditis, endocarditis, and val-
vular lesions can  be  excluded.
  The effect  of obstruction of the coronary arteries and fibroid degeneration
of the heart is impairment of its functional power.   If this effect exceed a
certain degree, the symptoms denote persistent weakness of the heart's action.
The pulse is feeble, compressible, and  often irregular, and  in some cases is
notably infrequent.   Dyspnoea, at  first felt  only on  exercise,  may become
constant, ending at length  in orthopncea.   With notable disturbance  of  res-
piration is associated lividity of the  prolabia and  face.  General dropsy may
occur, and death  may take place slowly, as in cases of dilatation.
  The physical  signs  denote weakness  of  the heart's action,  usually with
more or less  enlargement of the organ.  Cardiac impulse is feeble or wanting.
The murmurs indicative of valvular lesions are not present, and these lesions
may be thereby excluded.   The  sounds of the  heart  are weak.   The  sound
of impulsion over  the  apex especially is weak, and may not be appreciable,
the systolic  sound being chiefly or  entirely valvular  in  quality.
  The diff'erential diagnosis lies between myocarditis, with obstruction of the 
                     ANATOMICAL  CHARACTERS.                  325

coronary arteries, fatty degeneration, and a purely functional disorder.  The
last-named affection is excluded by the persistence of the symptoms pointing
to heart-failure.  The symptoms of fatty  degeneration are essentially identi-
cal, and this affection is not therefore easily excluded.  Practically, tliis is not
important.  The  fact that the patient has had syphilis is in  favor of myo-
carditis.   Calcification of arteries which can be felt is suggestive of a  similar
alteration of the coronary arteries, but is not conclusive evidence.
   Sudden  death  is liable to occur in cases of myocarditis associated  with
obstruction of  the coronary arteries.  This may follow violent physical exer-
tion,  although  not preceded  by  symptoms denoting any important  cardiac
affection.
   Angina pectoris occurs in connection with obstruction of the coronary arte-
ries, either with or without  fibroid degeneration of  the heart.  Sudden death
is liable to occur without as well as with an attack of  angina.
   The treatment in cases of myocarditis is essentially the same as in cases
of dilatation  of the  heart.  (Vide Chapter III.)   The  objects  of treatment
relate to symptomatic indications  and  tolerance.  Avoidance of active phys-
ical  exertion and mental excitement is to be enjoined.   Assimilation and
nutrition  are to be promoted  by a nutritious diet and tonic remedies.  The
iodides  and arsenic  have been supposed to have a favorable influence.  The
former are indicated if there be evidence of constitutional syphilis.  Impend-
ing  danger from heart-failure is to be warded off by  alcoholic  or ethereal
stimulants.
                         CHAPTEK  III.

VALVULAR  LESIONS WITH  ENLARGEMENT OF  THE  HEART.

  Anatomical Characters ; Clinical History ; Pathological Character ; Causation ; Diag-
                         nosis ; Prognosis;  Treatment.

   THE structural lesions of the heart relate, in  the first place, to the valves
    and orifices of the heart.  These are known commonly as  valvular lesions.
Other lesions relate to the walls and cavities of the heart.  Enlargement of
the heart often proceeds from valvular lesions, and the latter sooner or later,
in the great majority  of cases, give  rise  to enlargement.   In  considering,
therefore,  valvular  lesions, I shall  also  consider  enlargement as dependent
thereon, and afterward notice enlargement  occurring without valvular lesions.

  Anatomical Characters.—Valvular  lesions, in  the  great  majority of
cases, are due to chronic endocarditis.  When developed after birth, they are
nearly always situated in the left side of the heart; that is, at the mitral or
the aortic orifice.   Tricuspid and pulmonic lesions are comparatively rare in
extra-uterine life.  Rheumatic endocarditis most frequently attacks the mitral
valve.   With chronic inflammation  of the aortic valve an atheromatous con-
dition of the  neighboring portion of the aorta is usually present, the processes
in the valves and in the inner membrane of  the aorta  being essentially simi-
lar.  Aortic lesions therefore, like atheroma, are more frequent  in advanced
life than in youth.   Chronic endocarditis of the aortic valve is often associ-
ated with a similar change in the mitral, particularly  in  its aortic, segment.
The  changes  in the  endocardium  produced by chronic  inflammation have 
 326  VALVULAR LESIONS  WITH ENLARGEMENT OF THE HEART

 already been referred to in treating of endocarditis.  The  morbid process in
 the valves may begin either acutely or  subacutely, or it may develop slowly
 and insidiously.   The essential change  is the formation, in the substance of
 the valve, of new fibrous tissue  of firm consistence and with a marked tend-
 ency to retract.  The thickening is usually most marked along the edges of
 the valves, where warty outgrowths of fibrous tissue are frequently observed.
 Calcification and  fatty degeneration of the  new connective tissue are often
 extensive.  The anomalies in  the valves resulting from  these  changes are—
 1, thickening and rigidity  due  to the formation of new connective tissue and
 the  deposit of the salts of lime;  2, shortening in consequence of  retraction
 of the newly-formed tissue;  3,  adhesion  of  the  valvular  segments to each
 other or  to the heart-  or vessel-wall; 4, valvular  aneurisms and rupture of
 the valves.  Shortening, rigidity, and sometimes rupture of the chordae ten-
 dineae may coexist.  Deposits of thrombi may be present on the  thickened and
 calcified valves, and serve as a  source of emboli.  Emboli may also be formed
 by ruptured fragments  of the valves or by the breaking off of calcific incrusta-
 tions.  The thickened valvular segments are  sometimes  united at their sides
 to such an extent  as to leave only a buttonhole-like slit  sufficient for the
 admission of the  end of the  little finger, or  sometimes, in the case  of the
 aortic valves, for the passage  only of a crow's quill.
   The importance of these various changes lies in the fact that they  consti-
 tute the vast majority of those structural alterations which  interfere with the
 function of the valves.   From a clinical point of view all  the diverse  altera-
 tions of structure embraced under the name valvular lesions may be arranged,
 according to their effects  upon  the circulation, into  the  following groups :
 First, obstructive lesions—that is, lesions which impede the flow of blood by
 producing contraction or stenosis of the orifices ; second, regurgitant lesions—
 that  is, lesions which  render  the  valves incompetent or insufficient,  conse-
 quently  allowing backward or  regurgitant currents;  third, lesions  which
 involve both obstruction and regurgitation; and fourth,, lesions which involve
 neither obstruction nor regurgitation, but which give rise to morbid sounds by
 roughening the surface over which the blood flows.  The lesions belonging to
 the last group are of  little or no  immediate importance, and, although  giving
 rise  to abnormal sounds known as  endocardial or bellows murmurs, they are
 innocuous.  The most frequent form of lesion is that which occasions both
 obstruction and insufficiency at the same time, one or the other of these  effects
 frequently preponderating.  Obstruction unaccompanied by any regurgitation
 is rare, while regurgitation without obstruction is not  infrequent.   In certain
 instances  we must recognize the existence of  so-called relative insufficiency of
 the valves. This is incident to cases of  marked dilatation  of the heart-cavi-
 ties, the ostia becoming so wide that the unchanged  valvular  segments are
 incapable of completely closing the dilated orifices.   This  condition is met
 with most frequently  at the tricuspid orifice in cases of extreme dilatation of
 the right  ventricle as  a  consequence of mitral disease.
  The lesions which  involve obstruction or  regurgitation  lead primarily to
 certain changes in the heart itself, and secondarily to alterations  in various
 other organs of the body.   These changes in the heart are at first of a nature
 to compensate more or  less completely  the impairment  of function  of the
 valves.   The mechanical  effects  of obstruction  or of regurgitation at any
 of the valvular orifices, when not compensated,  are a diminution in  the
 amourft of blood supplied to  the  aorta  and  general  arterial system  and a
 corresponding over-repletion of the systemic veins.   These effects are pro-
duced by stenosis and by  insufficiency from  valvular  disease of either  the
left or of  the right side of the heart.   The blood-pressure in  the  systemic
arteries is therefore lessened, while that  in the veins is  increased; and  the 
ANATOMICAL  CHARACTERS.
327
 result is  retardation of the general  circulation.  These effects of impaired
 function of the valves  are  at first  more or less completely compensated  by
 increase in  the capacity and the strength of certain  portions  of the  heart.
 Certain  cavities dilate and their walls become hypertrophied, so that, not-
 withstanding  the valvular defects,  the  arteries of the body  receive their
 proper amount of blood.   During what may be  termed the period of compen-
 sation the hypertrophy bears a harmonious relation to the dilatation ; when
 the compensation becomes  disturbed or destroyed,  the dilatation exceeds in
 proportion the hypertrophy.  During the stage of compensation, which may
 last for years, the individual suffers but little inconvenience from the valvular
 lesions.   Sooner or  later, in the majority of cases, the compensation  is dis-
 turbed, and various characteristic  symptoms and morbid changes ensue.
   In order to understand the changes in the heart it is well  to  consider indi-
 vidually the different valvular  lesions as to their effects.  In cases of  insuf-
 ficiency of the mitral valve (the most frequent of all valvular lesions),  during
 the systole of  the left ventricle a portion of the blood is sent back into  the
 auricle, and the aorta  receives a proportionately smaller amount of  blood.
 During the diastole  an  abnormally large amount of blood flows into the  left
 ventricle in consequence of the over-accumulation in the left auricle and the
 pulmonary veins.  The  left ventricle is  thereby over-filled, and as a  conse-
 quence its wall becomes hypertrophied.  At the same time the left auricle
 becomes dilated  and hypertrophied;  but the  hypertrophy of the thin-walled
 auricle cannot  compensate the over-accumulation  of  blood.   The blood is
 therefore dammed back upon  the  pulmonary veins, whence the increase  of
 tension is transmitted through  the pulmonary vessels  to the right ventricle.
 This  becomes  over-distended with blood, and in turn it becomes hypertro-
 phied.   Mitral  insufficiency is thus  compensated by the hypertrophy of the
 two ventricles, so that notwithstanding the  regurgitation at the mitral valves
 a normal amount of blood is transmitted  into the aorta.  The  muscular coat
 of the auricles is so thin that  they can accomplish  but little in the way  of
 compensating valvular  lesions.  It may be  that the compensation for mitral
 insufficiency is so complete that the  patient suffers  for a considerable period
 no inconvenience. When the compensation is destroyed the dilatation becomes
 excessive, the right  auricle becomes over-distended,  and the blood is dammed
 back  upon the general venous system.  The effects of this venous congestion
 of the various organs and  parts of the body will be presently described.
  In  mitral stenosis less  blood than  normal  flows into the left  ventricle
 through the contracted orifice during the diastole.   The blood  accumulates
 in the left  auricle,  which  dilates and  becomes  hypertrophied.  The  blood-
 pressure, as in mitral regurgitation, increases in the pulmonary vessels, and
 consequently the right ventricle becomes over-filled and hypertrophied.   Inas-
 much as  the  left auricle and  right  ventricle are rarely able  to completely
 compensate the obstruction, the left  ventricle receives less than the normal
 amount of blood, and, being called upon to do less work, it becomes atrophied.
 Mitral stenosis unaccompanied by regurgitation and consequent hypertrophy
 of the left ventricle, however, is rare.  It will be observed that while  mitral
 regurgitation is compensated by hypertrophy of both  ventricles, mitral stenosis
 is compensated essentially  by hypertrophy of the right ventricle, and is less
 fully counteracted.
  The immediate result of insufficiency of the  aortic valves is  that during
 the  diastole a  portion of the  blood  which  had  been  driven into  the  aorta
 by the  systole flows back  into the  left  ventricle.  The ventricular  cavity
 is thereby over-filled and  its  wall becomes  hypertrophied. so  that by its
increased  power  of contraction the excessive amount of blood which  accu-
mulates in the left ventricle during the diastole can be forced into  the aorta. 
328 VALVULAR  LESIONS WITH ENLARGEMENT OF  THE HEART.

In this  way the arteries can receive their normal quantum of blood notwith-
standing the regurgitation.  No valvular lesion, as a rule, is more completely
compensated than aortic insufficiency.   In consequence of the backward flow
of blood from  the  aorta the  left auricle cannot empty  itself  as  readily as
usual, and it therefore dilates and becomes hypertrophied.   The blood is then
dammed back  upon the lungs, and, as in the previous instances, the right
ventricle becomes hypertrophied and  dilated.   The tension in the right ven-
tricle may be  still  further increased  by simultaneous involvement  of the
mitral valve in the  endocarditic process, or rarely by relative insufficiency of
the mitral valve.
  In aortic stenosis  the left ventricle, being unable  to  completely empty
itself, becomes hypertrophied and dilated.  The degree of dilatation, how-
ever, is usually less  than in cases of aortic insufficiency.   Dilatation  and
hypertrophy of the left auricle and of the  right  side of the heart are pro-
duced in the  same way as in the valvular lesions already described.  The
most extensive enlargements  of the left ventricle met with are those con-
secutive to aortic insufficiency accompanied with moderate  stenosis.   Aortic
lesions  are  situated more favorably as regards  completeness of compensa-
tion than mitral, because the former defects are counteracted by hypertrophy
of  the  ventricle immediately behind  the valves, while the latter require
hypertrophy of the opposite ventricle, to which the increase of tension must
be  transmitted through the  pulmonary vessels.   When, however, the com-
pensation of aortic  lesions becomes  disturbed—in other words, when the left
ventricle is no  longer able to meet the increased demands upon its strength—
the grave symptoms  of venous stagnation follow with greater rapidity than
after disturbance of the balance in mitral lesions.
  After birth,  relative insufficiency of the tricuspid valve  is more frequent
than insufficiency due to chronic endocarditis of the valve.  In either case
the affection is usually secondary to  disease of the left ventricle.  As  the
result of tricuspid regurgitation, less blood than normal is sent to the pulmo-
nary vessels, and therefore the  pressure in the pulmonary veins and that in
the aorta are abnormally diminished.  On the other hand, in  consequence of
the over-accumulation of blood in the right auricle the right ventricle is filled
under increased pressure.  Hypertrophy  and dilatation of  the  right auricle
and of  the  right ventricle ensue in the  same  way as enlargement  of  the
opposite cavities in mitral regurgitation.  In uncomplicated tricuspid regurg-
itation the left ventricle does not enlarge, because  the pressure in the pul-
monary veins is not increased, and the aortic tension is  not elevated, notwith-
standing the regurgitation of blood into the general venous system.  Tricuspid
regurgitation is therefore imperfectly compensated.
  Stenosis  of the tricuspid valve, unaccompanied  by  insufficiency, has been
observed only  as a result of foetal endocarditis.  Uncomplicated tricuspid
stenosis belongs among the curiosities of medical experience.   It is the most
unfavorable of all valvular lesions as regards compensation.  It can be only
very imperfectly compensated by  dilatation and hypertrophy  of the right
auricle,  all of the other cavities of the heart receiving less  than the normal
amount of blood, and therefore becoming atrophied.  Tricuspid stenosis, as a
rule, is accompanied by other  valvular lesions.
  Stenosis and insufficiency of the pulmonic  valves are  well-recognized forms
of congenital  valvular disease.   Still, they  are very rare.   When of foetal
origin they are often  complicated with other anomalies, such as stenosis of
the pulmonary artery or of the conus  arteriosus, perforation of the septum
ventriculorum,  and  non-closure of the foramen ovale or of the ductus Botalli.
When uncomplicated they are compensated, often completely, by dilatation
and hypertrophy of the right auricle  and ventricle.   The  left side  of  the 
ANATOMICAL  CHARACTERS.
329
heart does not enlarge, but, on the other hand, it has been found atrophied.
These  lesions may develop in very rare  instances as a sequence or concom-
itant of chronic endocarditis of  the  left side.
  We have now considered the mechanism of the production of the primary
changes in the heart following valvular lesions.   It  has been shown that the
different  lesions may be  compensated to a greater or less extent by  hyper-
trophy and dilatation  of certain cavities of the heart.  The dilatation is
mechanically produced by  over-accumulation of blood;  the  hypertrophy is
the result of augmented nutrition of  the muscular wall  consequent upon the
demand for increased  activity of the heart.   In favorable cases  the  hyper-
trophy bears a certain  definite relation to the dilatation and to the degree of
obstruction or regurgitation, so that the  functional defects of the valves are
as nearly counteracted as may be.   In  unfavorable cases, even  very early,
the dilatation may so predominate over the hypertrophy that the  valvular
lesion  may never be as fully compensated as is possible.  This is likely to be
the case in persons very much enfeebled, especially when the valvular  defects
are acutely developed.
  In nearly  all valvular lesions, either  early,  or, more frequently,  after  a
variable  period of compensation, the dilatation comes to bear an excessive
ratio to the degree of hypertrophy, and  the blood is dammed back upon the
general venous system.   Changes  ensue referable to chronic venous conges-
tion or passive congestion of various parts  of  the  body.  A knowledge of
these changes is necessary to a proper  understanding of the symptoms  com-
mon to uncompensated valvular lesions.   They can only be referred to briefly
here, as their description belongs to other sections of this work.
  The compensation is sometimes disturbed  by  extension of the morbid pro-
cesses in  the valves, and in many cases it is impaired by fatty degeneration
of  the hypertrophied  muscular  tissue.   Depression of the general vitality
of  the patient and the occurrence of intercurrent disease likewise enfeeble the
heart.   In some cases, however, the  cause of the failure of  the heart is not
evident.
  In the lungs, as a result of chronic venous congestion, the condition already
described  as  brown or  pigment induration  is  developed (p. 181).    In this
state the  pulmonary  capillaries  are  distended  and  encroach upon the air-
cells.  Hemorrhagic  pulmonary  infarctions are  frequent, produced by emboli
in  branches  of the pulmonary artery (p. 266).  These emboli are derived
usually from thrombi formed in the right side of the heart.   It is not rare in
the later stages of valvular disease for thrombi to form, especially in the apices
of the ventricles and in the auricular appendices, in consequence of the retard-
ation of the blood-current.  Chronic bronchitis usually attends valvular lesions
of  the left side of the heart.   The condition of  the  heart during the stage of
non-compensation  is particularly favorable for  the production of oedema of
the lungs.
  In consequence of chronic passive congestion the condition called nutmeg
liver is developed.  The blood  being dammed back  upon the inferior vena
cava and hepatic veins, the  central veins of the hepatic lobules become dis-
tended, and  the lobules present a red  centre  and  light periphery.   In the
peripheral zone the hepatic cells  often contain fat.   This swollen state of the
liver may be followed by a so-called red atrophy of the organ—a condition to
be  hereafter described in  Section  IV.
  Chronic congestion  of the spleen  is evident  after death from  its  enlarge-
ment,  dark color, and  firm  consistence.   The  kidneys are  enlarged, and in
typical cases  of extremly hard  consistence  and of a  dark-red color.   This
condition was formerly mistaken  for chronic interstitial nephritis.   The  albu-
minuria of cardiac disease  is explained  by  increase of pressure in the  renal 
330 VALVULAR LESIONS WITH ENLARGEMENT OF THE HEART.

veins and consequent slowing of  the circulation, and the diminution  in  the
amount of urine excreted, by the diminished  tension in  the renal arteries.
Chronic congestion of the alimentary tract may induce chronic  inflammation
of the stomach and intestine.  Cyanosis  and anasarca, with transudation of
serum into the various serous sacs of the body, result from the general venous
congestion.   In  consequence of the retardation of the general circulation the
blood may coagulate in the peripheral veins and venous  sinuses of the body.
Thrombi so  formed  are called marantic  (p. 28).   They form an  additional
source of  origin  for emboli which are carried to the pulmonary artery.   Ven-
ous hyperaemia and arterial anaemia of the brain are among the consequences
of uncompensated valvular lesions.  The  lodgment of emboli in the cerebral
arteries, particularly in the middle cerebral or its branches, and the consequent
softening of  the anaemic portion of the brain, will be  considered in Section V.

  Clinical  History.—Valvular lesions, so  long  as  they involve neither
obstruction  nor  regurgitation, give rise  to no symptoms  of disease, and their
existence is  only ascertained by means of physical signs.  Lesions involving
either  obstruction  or regurgitation, or both, as a rule do not occasion  incon-
venience until they have led to enlargement of the heart.   Moreover, lesions
occasion suffering and are attended with danger in proportion as the dilatation
predominates over the hypertrophy.
  The first symptoms  proceeding from mitral obstructive or regurgitant lesions
pertain to the respiratory system.   Deficiency of breath  on  exercise is  for
some time the chief inconvenience.   This progressively increases in propor-
tion as the obstruction to the pulmonary  circulation  increases.   The patient
is at length  obliged to discontinue any active muscular exertion, but may be
comfortable while  remaining quiet.  Dyspnoea finally becomes habitual, and
is more or less prominent as a symptom after dilatation of the right ventricle
has taken place.  A  still further development  of this symptom  renders  the
patient unable to lie  down, then constituting orthopnoea.  This may be due,
in a measure, to coexisting  pulmonary conditions.   Cough and more or less
muco-serous  expectoration  are incidental to  congestion or a  low grade of
inflammation of the  bronchial mucous  membrane.  An abundant  serous
expectoration sometimes occurs, constituting  bronchorrhaea.  Haemoptysis is
not infrequent,  the hemorrhage usually being small. This event generally
denotes simply  bronchorrhagia, but occasionally blood  is extravasated into
the air-cells,  constituting  circumscribed pulmonary apoplexy or hemorrhagic
infarction.   Pulmonary oedema is  another intercurrent  event which is liable
to occur, increasing the suffering from dyspnoea.  Hydrothorax is still another
source of embarrassment of respiration.   Pigment  induration of the lungs
dependent on persistent congestion, caused  by regurgitant and obstructive
mitral lesions, enters into the rationale of  dyspnoea in many cases.
  After enlargement of the heart takes place, its action, so long as the hyper-
trophy predominates, is  abnormally strong.  This may  be perceived by the
hand placed over the praecordia.  The patient, however, rarely complains much
of palpitation, having become accustomed to the gradual increase of the power
of the heart's action.   The pulse is small and weak in proportion to the amount
of obstruction or regurgitation, each of these immediate effects of the lesions
lessening the quantity of blood propelled into  the aorta and its  branches by
the systole  of the left ventricle.   The quantity of  blood contained in this
ventricle at the  time of a systole may sometimes be so much lessened that it
fails to produce  a radial pulse; hence one source of intermission of the pulse.
Another source is an actual intermission of the ventricular systole.  Inequality
of the successive  beats of the pulse, as regards volume  and force, represents
unequal  supplies of  blood from the left auricle to the left ventricle.  Irreg- 
CLINICAL HISTORY.
331
 ularity in  the action  of the  heart  is not infrequent.   Intermittency of the
 pulse  and inequality of successive  beats, clue to deficiency of the supply of
 blood  to  the left ventricle, are  characters which denote  mitral contraction
 rather  than  regurgitation.
   The  characters pertaining to the  form of the pulse, as ascertained by the
 sphygmograph, in  cases of mitral  regurgitation,  are—notable variations in
 the length of the line of ascent  in diff'erent pulsations, shortness of this line
 in a greater  or less number of pulsations, its vertical direction, and  marked
 dicrotism in  the line of descent.  In  cases of mitral  obstruction the line of
 ascent  is longer  and the variations  in diff'erent pulsations  are less,  the direc-
 tion of this line being also vertical, and the line of descent showing dicrotism.
 These  characters denote quickness  of the ventricular systole, feeble  arterial
 tension, and  want of uniformity as  regards the quantity of blood  sent  into
 the  aorta  in  different  beats.
   Pain is rarely a prominent  symptom during the progress of mitral lesions,
 but  uneasiness and  an indefinite sense of distress, referred to the praecordia,
 may be complained  of.  Nor are there any notable symptoms referable to the
 nervous system.   There is  a marked contrast, as regards mental anxiety and
 apprehension, between the cases  in which the action of the heart is  disturbed
 by lesions and those in which the disturbance  is purely functional.  In the
 former mental depression is  proportionate to the physical  suffering, and pa-
 tients  are likely to  be apathetic with respect to danger ; in the latter the mind
 is depressed  out of proportion to the actual ailment and patients are harassed
 by imaginary fears,  if dyspncea be a prominent symptom, the loss of sleep
 adds to the sufferings of the  patient.  The sleep which is obtained is imper-
 fect  and disturbed  by frightful dreams.   It is  not uncommon for patients to
 be unable to lie down for  many weeks before death, short  periods of sleep
 being obtained by  inclining the  body forward and resting  the elbows on the
 knees  or  on  some  solid support.
   Sooner or  later, if life be  not cut off by some intercurrent affection, dropsical
 effusion takes place into  the areolar tissue and  serous cavities.  The lower
 limbs  generally first become  oedematous, afterward the  face and  body,  and
 more or less  liquid  accumulates within the  peritoneal and within the  pleural
 sac.   The  limbs and body sometimes become greatly swollen and the scrotum
 acquires an enormous size.  The skin on the lower limbs  under these circum-
 stances may  become er3Tthematous;  ulcerations or fissures are liable to occur,
 with abundant draining away of serum.   Other circumstances, in addition to
 dilatation of  the right side  of the heart, may contribute to  the occurrence of
 dropsy ; for example, anaemia.  The face is congested, and not infrequently the
 lips are livid.  The  dusky hue, due to congestion or cyanosis, combined with
 oedema, gives to the face an appearance  which contrasts with the pallid as-
 pect characterizing  general  dropsy from renal disease.  General dropsy arising
 from mitral lesions  occurs after enlargement by dilatation of the right side of
 the heart has taken  place, and  is  dependent mainly on  the venous obstruction
 which  the latter condition involves.  Tricuspid regurgitation, which may exist
 to some extent normally, is  increased in this condition, and adds to the venous
 obstruction.   This condition of the right cavities gives rise to turgescence of
 the cervical veins, especially when the patient is sitting or  standing, and  this
 turgescence is sometimes very great.  Under these circumstances  pulsation
 of the superficial veins of the neck, occurring synchronously with the auricular
 or ventricular systole, or with both,  is not uncommon.   Jugular pulsation is,
 however, observed in some cases without venous turgescence, and when dropsy
has not taken place venous pulsation of the veins of the extremities is some-
times observed.
  The  organs composing the digestive system suffer from  the congestion aris- 
332 VALVULAR  LESIONS WITH ENLARGEMENT  OF  THE HEART.

ing from dilatation  of  the right side of the heart.   Enlargement of the liver
is  sometimes observed.  Pulsation over  the  liver,  apparent  to the  eye and
touch, is an occasional effect of tricuspid  regurgitation with  hypertrophy of
the right ventricle.   The pulsation is  sometimes  so  strong  as to simulate
aneurism.  The appetite and digestion become impaired.   Prior to the occur-
rence of dilatation, however, the appetite and digestion may be but little dis-
turbed.  Nutrition may be but little affected even after the lesions have led to
considerable suffering.  Emaciation is not an early, nor at any time a marked,
effect of valvular lesions of the heart.  The kidneys  participate in the  conges-
tion, and the secretion of urine is scanty.   Albumen may be  present in the
urine as an effect of renal congestion without denoting degenerative or inflam-
matory disease  of the kidneys.  Hemorrhage  from  the stomach or intestines
is  an occasional effect of the congestion of the mucous  membrane in these
situations.   Hemorrhoids and epistaxis  belong in the same category.
   Aortic lesions involving  obstruction or  regurgitation usually give  rise, as
the first symptom, to inconvenience from the  increased power of the heart's
action  consequent upon hypertrophy of the left ventricle.   The patient com-
plains  of palpitation, especially on  exercise or under the influence of  mental
emotions.  The action of the heart is felt,  by  the hand over the praecordia, to
be inordinately strong, and the dress or portions of the body may show visible
movements with  each  ventricular  systole.   Pain is  more likely to be  present
than in cases of mitral lesions, and, irrespective of the painful affection called
angina pectoris, it is not infrequently a prominent symptom.  Cough, expecto-
ration, dyspnoea, and haemoptysis, dependent on pulmonary congestion and the
accidents incident thereto, occur  less frequently in connection with aortic
than with mitral  lesions.   Pulmonary congestion, dependent on dilatation of
the left auricle,  does not occur  until  the dilatation of the left  ventricle
becomes predominant, and the disease may end fatally  without this result
taking  place.
   If the lesions produce  contraction with little or no  regurgitation, the pulse is
simply weakened, but not in a notable degree even when the contraction is con-
siderable.  Under these circumstances, however, the pulse is frequently weak
in proportion to the power  of the heart's  action ; and the force of  the stroke
felt by the finger over the artery is in striking contrast to the impulse felt by
the hand over the praecordia.  If the lesions  impair the aortic valve so as to
involve considerable regurgitation,  the pulse  is somewhat distinctive  of this
fact.   The artery  strikes  against the finger with quickness, and  appears
instantly to recede; the  stroke is not sustained, and the  pulse is said to  be
jerking or collapsing,  giving a  sensation  as  if a " ball  of blood  were shot
through the artery."   This is due to the fact that directly after the ventric-
ular systole the aorta is emptied by the regurgitant  current, and  this  current
and  the direct current  come into collision  when  the  ventricle  contracts.
Another symptom  pertaining to the arteries in some cases  is distinctive of
free aortic regurgitation—namely, visible  movements of the arterial  trunks
which  are  superficially situated, such as  the carotid, temporal, subclavian,
brachial, etc.   The appearance caused by the movements of  these vessels is
sometimes very striking, and it  is so distinctive  that aortic regurgitation is
rendered highly  probable  by this  symptom alone.
   The tracings by the sphygniograph in  cases of aortic  obstructive  lesions
give an oblique and curved line  of ascent, denoting  the slowness with which
the blood is driven into the aorta, and in the line of descent  dicrotism is
either  slight or wanting.   In cases of aortic regurgitation the line of ascent
is  vertical, and dicrotism in the line of descent is marked.  If, as is not infre-
quent, senile induration of the arteries coexist, the  summit presents a plane
of greater or less length.  If this condition of the  arteries do not exist, the 
PA THOL 0 GICA L CHAR A CTER.
300
00
upper part of the diagram representing a pulsation is pointed, and the line of
ascent may be notched near its upper extremity.
  General dropsy occurs in  only a small proportion of cases of aortic lesions ;
that is, dropsy arising from  the cardiac  affection.  This  is owing to the fact
that life is generally destroyed before the lesions have led  to  predominant
dilatation of the right cavities of the heart.   Hence, turgescence of the cervi-
cal  veins and jugular  pulsation do not belong to the clinical history of aortic
lesions.   This statement also holds good with respect to congestion of the
abdominal  viscera and  the  kidneys.
  Aortic regurgitant lesions give rise to symptoms proceeding from a sudden
increase of the accumulation  of blood within the left ventricle  sufficient  to
embarrass the action of this ventricle by distension.   This ventricle becoming
overloaded by the regurgitant current in addition to  the direct mitral current,
the ventricular walls are distended  so as to weaken their power of contraction.
This is a rational explanation  of paroxysms of distress to which these lesions
give rise.   The action of the heart is irregular and spasmodic, and the patient
experiences a  sense of great  oppression at  the  praecordia, with  a feeling of
impending death.   These attacks are excited at first  by muscular exercise  or
mental emotions, but after  a time they may occur without any obvious excit-
ing cause.  They occasion  great distress, and sudden death may take place  in
an attack of unusual violence, the left ventricle being paralyzed  by over-dis-
tension.  They are more frequent and serious when dilatation of the left ven-
tricle predominates over hypertrophy, yet they may be more or less frequent
and violent, and may prove fatal while hypertrophy is  predominant.   The
occurrence of  these attacks renders  patients affected with aortic lesions more
anxious and apprehensive  than those affected with mitral  lesions.  The dan-
ger from over-distension of the ventricle is perhaps greater without than with
mitral  insufficiency.  The  latter,  as regards this danger, may be said to be
compensatory.
  Aortic and  mitral lesions, involving either obstruction or regurgitation,  or
both, in each situation, are  not  infrequently associated in  the same case.
Certain of the symptomatic  phenomena  arising from  lesions  at the  mitral
and aortic orifice are  then   combined.   Mitral obstruction as well as regurgi-
tation, however, may afford  some  protection  against the paroxysms of distress
and the liability to sudden  death incident to aortic regurgitation, by prevent-
ing over-distension and  paralysis of  the left ventricle.
   Tricuspid and pulmonic  lesions, as already stated, are  comparatively rare.
In the majority of  cases in  which they exist  they are congenital.  They are
therefore  most liable to be met with in young subjects.  Tricuspid  lesions,
in proportion as they involve  obstruction  or regurgitation, lead  primarily  to
dilatation of the  right  auricle, and  thence to systemic congestion.  General
dropsy under these circumstances is likely  to  occur early, without  having
been preceded  by  the  symptoms denoting pulmonary congestion.  Turges-
cence of the  cervical  veins  and venous pulsation are also early symptoms  in
such cases.  Lesions at the pulmonic orifice, involving contraction or regurg-
itation, in like  manner  soon lead  to dilatation of the right  auricle and the
symptomatic  phenomena dependent thereon.

  Pathological  Character.—The primary evils of  valvular lesions are
mechanical.  They do harm by obstructing  the direct or normal currents of
blood, and  by allowing abnormal or regurgitant currents to take place.  They
induce hypertrophy or morbid growth of the walls of the heart by increasing
the force of the heart's action, and thereby inducing hypernutrition.  This
result, it is to be borne in mind, is not an evil.   The hypertrophy resulting
from valvular lesions is  conservative. The augmented power of action which 
334 VALVULAR LESIONS WITH ENLARGEMENT OF THE HEART

the heart acquires with its  increased muscular growth enables it better to
carry on the  circulation despite the obstacles afforded by obstructive and
regurgitant  lesions.    The hypertrophy  is compensatory for the  obstacles
which  these  lesions  afford.  This fact has an important practical bearing  on
the management.  Dilatation of the cavities  is another  result of valvular
lesions.   This result, when  it  predominates over hypertrophy, is an  evil.
The heart is weakened in  proportion, as it becomes dilated.   The circulation
then suffers, not only from the obstacles afforded by the valvular lesions, but
from the inadequate power  of the heart's action.   As a rule, it is not until
dilatation predominates  over the  hypertrophy  that  distressing and grave
symptoms  of disease  of the heart are  developed;  and  the suffering and
danger increase as the dilatation progresses.
   It is important to bear in mind that valvular  lesions do not necessarily
involve existing  inflammation.   The atrophy and calcareous  degeneration
which  lead to contraction of  the valves, rigidity, rupture, etc. are not inflam-
matory processes,  although they may be, and in a  large proportion of cases
probably  are, the  after-effects  of inflammation.

   Causation.—In  the  majority of  cases valvular  lesions originate in  an
endocarditis  occurring  in  acute articular  rheumatism.   The  degenerative
changes which follow endocarditis  lead  to obstruction or regurgitation after
a period more or  less remote.  When the evils or inconvenience  resulting
from valvular lesions  are  sufficient to lead the patient to seek for medical
aid, it may be found that  one or more  attacks of rheumatism were experi-
enced  five, ten,  fifteen, or  twenty years  before ; and  when  cases first come
under  observation more or less enlargement of the heart has already taken
place.   Enlargement, indeed, has  probably existed for a long  time,  and  it
may not be until  the heart  becomes weakened by  dilatation that the patient
applies to the physician.  Moreover, rupture of the valves or tendinous cords
sometimes results from the violence of the heart's action, without any pre-
vious  structural  change.  Rheumatic endocarditis affects by preference the
mitral valves.  The congenital lesions generally affect the valves of the right
side.  On the other  hand, chronic  inflammation  of the aorta, leading  to  an
atheromatous condition, is likely to involve the aortic valves.  These  lesions
are more frequent in advanced than in early life, whereas the mitral  lesions
consequent on rheumatic  endocarditis are oftener  manifested  in the  latter
period.  Chronic non-rheumatic  endocarditis, however, often affects both the
aortic  and the mitral valves, more especially the  aortic segment of the latter.
Valvular lesions occur not infrequently as a remote effect of syphilis.

   Diagnosis.—The existence of  valvular  lesions can be  determined  with
positiveness  only  by means  of auscultatory signs.    By means  of  signs the
existence of lesions, their situation, and their  character  as regards  being
obstructive or regurgitant may generally be  ascertained.   Lesions situated
at the different valves and orifices are represented by endocardial  murmurs,
and the presence of these is evidence of the  existence and  situation of the
lesions.   It will  suffice  here to enumerate the several  organic murmurs pro-
duced within the heart, together with  the distinctive characters and signif-
icance of each.   They are  naturally arranged into  mitral, aortic,  tricuspid,
and pulmonic murmurs.
   Mitral Murmurs.—A murmur heard with the first sound of the heart—i. e.
 systolic, having its maximum of intensity at or near the situation of the apex-
 beat, or perhaps limited to that situation—represents mitral lesions.   These
 lesions may or may not involve insufficiency of the  valve  and consequent
 regurgitation.  If a regurgitant current exist, the murmur is properly called 
DIAGNOSIS.
ooO
a mitred regurgitant murmur; but as mere roughness of the valve probably
may give  rise to a murmur with  the characters  just  mentioned, without
regurgitation, the name just given is not always strictly correct.  A better
name is mitral systolic murmur, with or without regurgitation.  If the mur-
mur be diffused beyond the apex, around the left lateral surface of the chest,
and  heard on the back near the  lower angle of the scapula on the left, and
sometimes on the right side, mitral regurgitation may be inferred.   If the
murmur be heard only around  the  apex  and  over the body of the heart, it
does  not afford  proof  of  regurgitation ;  it may be a  mitral  systolic, non-
regurgitant,  or  an intraventricular murmur.    A  mitral  systolic murmur,
regurgitant or non-regurgitant, is not transmitted above  the heart,  and  is
not  heard over the carotid arteries.   This murmur may be soft (bellows-
like) or rough, and sometimes it is musical.  It is to be distinguished from
a murmur sometimes produced by the impulse of the heart  against the por-
tion of lung covering the apex.   This  exocardial murmur is called a  cardiac
pulmonary  murmur.   It is  usually limited to  the  inspiratory act and to a
space  over  or a little to  the left of the apex-beat.
   A murmur heard after the second  and just before the  first sound of the
heart—i. e. presystolic, continuing up to the first sound and instantly arrested
when  this  sound occurs—also  represents,  generally,  mitral  lesions.   This
murmur is  heard at or  near the apex, and is  usually confined  within a cir-
cumscribed area around the apex.   It is  almost  always rough, resembling
a  sound produced by throwing  the lips or tongue  into vibration with the
expired breath.   The letters rrrp, whispered, the  tongue vibrating with the
first three letters, represent the murmur, the letter p representing the first
sound  of the heart.   This murmur  is produced by contraction of the mitral
orifice in consequence of the union at their sides of the mitral curtains, form-
ing a buttonhole-like slit.   The  murmur  represents mitral contraction with
occasional exceptions.   In  some  cases  in  which  free aortic regurgitation
exists, the  left ventricle  becoming  filled  before  the  auricles contract, the
mitral curtains are floated out, and the valve is closed when the mitral cur-
rent takes place.  Under these  circumstances the murmur may  be produced,
although no mitral lesion  exists.   I have reported cases  in  which this mur-
mur was marked, the autopsy showing no  mitral lesions,  but aortic lesions
permitting free regurgitation.1   This murmur  is called  the mitral direct or
presystolic m irrmur.
   A mitral murmur, following  the second sound  of the  heart and  ending
before the first sound, is produced by the current of blood from the  auricle
to the  ventricle prior to  the  auricular contraction.  This murmur may have
the quality  which usually  characterizes the presystolic murmur, or it  may be
a soft  blowing sound.   It is heard at or a little above the apex.  This mur-
mur may be called the  mitral diastolic murmur.  It may be associated with
the  presystolic  murmur, and the two  murmurs will then  occupy the whole
of the long pause of  the heart.
   The murmurs produced by the direct and the regurgitant streams of blood
not  infrequently coexist.  Either may exist without the others,  the mitral
regurgitant being much the more frequent.
   Aortic  Murmurs.—A murmur with  the  first  sound, or a systolic murmur,
heard with its maximum of intensity at or above  the base of the heart and
propagated  into  the carotids, is called  an aortic direct murmur.   This mur-
mur may represent aortic  lesions, and  it is  then called organic, or it  may be

  1 Vide article on cardiac murmurs by the  author in the American Journal of  the Med-
ical Sciences, July, 1862.  A case in which a mitral presystolic murmur existed without
mitral lesions, free aortic regurgitation existing, is reported by Dr. John Guiteras in the
Philadelphia Medical News, Nov. 14,  1885. 
336  VALVULAR LESIONS WITH ENLARGEMENT OF THE HEART.

due to a morbid condition of the blood, without aortic  lesions, and it is then
called an inorganic, an anaemic, or a haemic murmur.   The following circum-
stances render it probable that the  murmur is inorganic or anaemic: The evi-
dent existence of anaemia; the absence of other signs of cardiac lesions; the
variableness of the murmur, being sometimes present  and sometimes  want-
ing, and differing much at different times  in  intensity ;  the presence  of mur-
mur in  the larger arteries, such as the  carotid, subclavian, etc., and a con-
tinuous  murmur  in  the  veins of  the neck, commonly known  as the ven-
ous hum.   Attention to these points  will generally suffice  for  determining
whether  an aortic direct murmur  be organic or inorganic.   The  organic
murmur  denotes  lesion of some  kind, but not necessarily obstructive; that
is, the lesion may simply render the membrane at or near the aortic  orifice
rough, without involving obstruction to the current.   The murmur  may be
soft or rough,  and it is sometimes musical.
   An aortic murmur with the second sound of the heart—i.e. diastolic,  heard
usually at the base, but in most cases  having its maximum a little below the
base,  on or near the left margin of the sternum—is called an aortic  regurgi-
tant murmur.   It represents insufficiency  of  the aortic valve, and consequent
regurgitation  from the aorta into  the left ventricle.   This murmur  may be
more  or less loud and prolonged ; it is generally soft, but sometimes rough,
and it may be musical.   According to Dr. Balthazar Foster, if the murmur
be heard at the apex of the heart, it denotes that  the insufficiency is due to
a  lesion  of the posterior segment  of  the aortic valve.
   A murmur is sometimes produced by the  backward current of blood  in the
aorta, the aortic valves being sufficient; that is, regurgitation into the ventri-
cle not taking place.  This is a very short  murmur, preceding and ending with
the second sound.  It is heard over the site  of the aorta in the second  right
intercostal space, close to the sternum.   It  may be called an aortic predias-
tolic murmur.
   The aortic direct  and regurgitant murmurs not infrequently exist in com-
bination, but  either may be  present without  the  other.   Aortic murmurs
coexist with mitral murmurs in the cases in which mitral and  aortic lesions
are associated.
   Tricuspid Murmurs.—Tricuspid lesions are  comparatively rare, and  hence
a  murmur referable  to  this orifice is  infrequent.   A tricuspid, regurgitant
murmur  occasionally exists, representing  regurgitation from the right ven-
tricle to the right auricle,  with, perhaps, hypertrophy of the ventricle.  It
occurs with the first sound, and is to be distinguished from a mitral  regurgi-
tant murmur by its being either limited to, or having its maximum of  inten-
sity at, the right inferior border of the  heart—namely, near  the ensiform
cartilage.  It is liable, without care, to be confounded  with a mitral  regurgi-
tant murmur.  A tricuspid direct murmur is exceedingly rare, owing to the
fact that lesions analogous  to  those which  give rise to a mitral direct mur-
mur  are infrequent at the  tricuspid orifice.
   Pulmonic Murmurs.—A pulmrmic direct murmur is not of very infrequent
occurrence.  It is heard with the  first sound of the heart, at or above the
base, over the pulmonary artery—namely,  in the second  intercostal  space,
near  the left  margin of the sternum.   It  is to be distinguished from  an
aortic direct murmur by its situation, as just stated, coupled with  its non-
transmission into the carotids.  It represents pulmonic lesions when  it  is not
inorganic or anaemic, as it not  infrequently  is.   The circumstances  which
render it probable that it  is inorganic are the same as when the  question
relates to  the organic  or inorganic character of an aortic  direct murmur.
   By means of the  foregoing murmurs the valvular lesions are  recognized
and localized, but it is important to bear  in  mind that neither the extent nor 
DIAGNOSIS.
337
gravity of lesions is determined by the murmurs.   Whether the direct mur-
murs  be produced  by lesions  which involve obstruction  or not cannot  be
determined by the  study of the murmurs alone ;  and whether the re«-uro-i-
tant murmurs proceed from much or little regurgitation must be ascertained
by other evidence  than that which the  murmurs  afford.   The intensity  of
the murmurs  is no  proof of the gravity of the lesions;  slight or innocuous
lesions may give rise to loud murmurs, and grave lesions may be represented
by feeble  murmurs.  Nor  does the character of the sound  as  regards soft-
ness,  roughness, or a musical  intonation furnish  any  definite information
respecting  the extent or  gravity  of  the lesions.   With reference to this
important point of  investigation, therefore, evidence is to be sought for else-
where.  Symptoms  relating to  the circulation,  which have  been  considered
under the head of  the Clinical History, shed light upon  this  point,  but  in
addition other physical signs are to be taken  into account.
  A  comparison of the sounds of the heart, as produced separately at the
aortic and pulmonic orifice, is one  source of information.  This comparison is
made by listening  successively to  the sound as heard in the  right and in the
left second intercostal space near the margin of the sternum, the sound in the
right  side  emanating from  the aortic, and the sound of the left  side from the
pulmonic, orifice.   If aortic lesions be indicated by the presence of the aortic
direct or regurgitant murmur, and the lesions be of such a character that the
aortic valve is impaired, the second sound, as produced  by this valve, will  be
more  or less weakened, or perhaps extinguished, and the alteration is  ascer-
tained by a comparison with  the pulmonic  second sound.  If, on the con-
trary, the  aortic sound be  unimpaired,  it  may be inferred that the  aortic
valve is intact.  A comparison of the aortic and the pulmonic sound is not
less useful in the cases in  which  mitral lesions are shown to exist  by the
mitral direct or the mitral  regurgitant murmur.  If there be much obstruc-
tion or regurgitation, or both, at the  mitral orifice, the  aortic sound will  be
weakened  by the diminished amount of  blood propelled into the aorta with
each  ventricular systole ; and  if the mitral obstruction or regurgitation, or
both,  have led to  hypertrophy of the right ventricle, the  pulmonic sound
will be intensified by the greater force with which the blood is propelled into
the pulmonary artery by the systole of the right ventricle.   Thus, by means
of this application  of auscultation useful  information is obtained respecting
the extent or  gravity of the lesions, the  existence and situation of  which are
revealed by the endocardial murmurs.
  Further evidence of the extent or gravity of valvular  lesions  relates to
enlargement of the heart.  Enlargement of the heart is an effect of valvular
lesions, and  is proportionate to  the amount  and duration of the obstruction
and regurgitation which the valvular lesions occasion.  Hence, the degree  of
enlargement is a criterion  of the extent  and gravity of the  valvular lesions.
The question then  arises, How  are  the existence and degree of enlargement
of the heart  to be  ascertained ?  The altered  situation of the apex, if not
attributable to extrinsic causes, is evidence both of the existence and the
degree of  enlargement.   The first effect  of enlargement is  to carry the apex
to the left of  its normal situation within the linea  mammillaris.   The next
effect is to  lower  its situation to the sixth, seventh, or  eighth  intercostal
space.  In proportion as the apex is  removed without  the left nipple and
lowered, is the amount of enlargement.   The situation of  the  apex is to  be
determined by the eye or touch, or, if it  can  neither be seen nor felt, by find-
ing the point where the systolic sound has its maximum  of intensity.   Other
evidence of enlargement is obtained by percussion.   The  dulness within the
area known as the  superficial  cardiac space, or  the space in which the heart
is uncovered  of lung, is increased  in degree and in  extent in  proportion as 
338  VALVULAR  LESIONS WITH ENLARGEMENT  OF  THE HEART

the heart is enlarged.   The left border of the heart is found by percussion to
fall one, two, or three inches without the left nipple, the situation of the right
border and the base of  the heart being in most cases but  little changed.
   Having determined the existence of enlargement and its extent, it remains
to ascertain the kind of enlargement;  that is, whether hypertrophy or dilata-
tion predominates.   The most important  signs in this discrimination are fur-
nished  by palpation.  If either the apex-beat or additional  impulses in the
intercostal spaces above  the  apex  be  felt by  the hand to be abnormally
strong,  and  especially if there be a heaving elevation of  the praecordia with
the  ventricular systole, hypertrophy  predominates.   The apex-beat under
these circumstances may be diffused, owing to the globular form which the
heart may assume when enlarged; the augmented power of the heart's action
is then  to be appreciated by the impulses above the apex or by the praecordial
heaving.  On the other hand, if dilatation predominate the cardiac impulses,
if felt at all, are  feeble.   Auscultation  also furnishes signs of importance in
this discrimination.  The systolic sound of the heart over the  apex is loud,
prolonged, and booming in  proportion  as hypertrophy predominates, and on
the contrary the sound is short and valvular in quality if dilatation predomi-
nate. Attention to these points, in  connection with  the symptoms, will enable
the physician to  judge of the kind of enlargement to which  the valvular
lesions  have given rise.

   Prognosis.—Valvular lesions not involving either obstruction or regurgi-
tation may remain innocuous for an indefinite period.  The physician should
be careful not to  attach undue importance to the presence of one or more of
the organic  murmurs.   These are frequently discovered  in examinations of
the chest  when patients complain of no symptoms referable to the heart, and
in persons who suppose themselves  to be in perfect  health.  If the lesions be
accompanied by  enlargement  of the heart, obstruction or regurgitation, or
both, may be inferred, and the lesions are not innocuous;  yet so long as the
enlargement is exclusively or  mainly hypertrophic, serious  evils directly
attributable to the  cardiac lesions  rarely occur.   The patient  under  these
circumstances,  as a rule, simply suffers more or less inconvenience.  The suf-
fering and danger, as already stated, depend  chiefly on the weakness arising
from predominant dilatation of one  or more of the cavities of the heart.  The
progress of enlargement is generally slow, and it is not uncommon for patients
affected with valvular lesions, together with more or less hypertrophy, to live
many years, and even to old age.

   The symptoms which denote danger, immediate or not remote, differ accord-
ing to the seat  of the valvular lesions.   In connection with mitral obstructive
and  regurgitant  lesions habitual and considerable dyspnoea, if referable to
the cardiac affection—that is, not dependent on a coexisting affection, such as
asthma—is evidence that the fatal  termination is not  very far distant.   The
supervention of general dropsy generally shows  that the end is near at hand.
Yet sometimes, under judicious  management, the dropsy  diminishes  or  dis-
appears, and life  is prolonged  for a considerable period.   Death takes place
suddenly in  some cases in which the valvular lesions  are exclusively mitral ;-
but, as a rule, if life be not cut off by some intercurrent affection, the patient
dies after  a period of suffering more or less prolonged.  In  cases of aortic
lesions involving  obstruction and regurgitation, especially the latter, danger
is indicated by  the occurrence of paroxysms characterized  by great praecordial
  1 My colleague, Prof. Janeway, has met with a  case in which, a thrombus having
formed in the left auricle, a portion, becoming detached, plugged  the mitral orifice and
caused sudden death.  This was diagnosticated before death. 
TREATMENT.
339
distress and by a sense of impending death, the action of the heart being irreg-
ular or tumultuous.  Sudden death is liable to occur in paroxysms of this kind,
the heart being paralyzed by over-distension of the left ventricle.   Sudden
death sometimes occurs in cases  of aortic lesions when little or no habitual
inconvenience from the  cardiac affection had been experienced and the exist-
ence of any  affection of the  heart was  perhaps  unknown.  It is rare for
lesions exclusively aortic to lead to general dropsy.  The immediate or prox-
imate danger is to be determined by the amount of obstruction or regurgita-
tion, especially the latter, in connection with the degree  of enlargement, par-
ticularly enlargement by dilatation.
   In  cases of tricuspid and  pulmonic  lesions  general dropsy  is an event
denoting a degree of weakness of the right side of the heart from dilatation,
which will be likely  to lead before long to a fatal result.
   In all  cases of valvular  lesions associated with much  enlargement, espe-
cially if  the enlargement be by dilatation, the prognosis is unfavorable.  The
patient will  die  sooner or later  with the cardiac affection if life  be  not
destroyed by some other disease, the occurrence of a fatal result being only
a  question of time  and the duration varying greatly  in different  cases.
   Death may  occur in consequence of certain local affections or accidents inci-
dent to the cardiac  affection.   Thus, pulmonary oedema and pneumorrhagia,
incident  to mitral lesions, may be the  immediate cause of a fatal result. Cere-
bral hemorrhage may be favored by dilatation of the right side of the heart and
by hypertrophy of the left ventricle.   The loss of blood by hemorrhage from
mucous surfaces  may in like manner  lead to a fatal termination.   The effects
of emboli derived from cavities of the heart are to be included in this category.

   Treatment.—The treatment  in cases of valvular  lesions has  reference,
first,  to the condition of the  heart as  respects  these lesions and coexisting
enlargement; second, to symptoms or events incidental to the cardiac affec-
tion ;  and third, to the general condition of the patient, the  condition of the
blood especially  claiming  attention.
   Valvular lesions, so long as they are either innocuous  or have not led to
enlargement of the  heart, claim  attention only with regard  to preventing or
retarding their progress;  and for this end  the strain  upon the valves occa-
sioned by the excessive action of the  heart is, as far as possible, to be avoided.
Very active muscular exertions, and the excitement of the circulation produced
by the abuse  of alcoholic stimulants  and by violent mental emotions, will be
likely to hasten or increase the  damaging effects of the lesions.  It is, how-
ever,  by no means  necessary to enjoin  great restriction  in the manner of
living in these cases; it is  sufficient  if  the habits  of life  be governed in all
respects  by prudence and moderation.   It is not advisable, under these cir-
cumstance's, for persons to consider themselves as invalids.  If, as is frequently
the case, the existence  of the  lesions be discovered accidentally or casually,
it may not be always judicious to communicate the fact to the patient.  If a
medical opinion  be  not  requested, and proper hygienic management  can be
secured without directing the patient's  attention to the  heart, much  needless
anxiety is  sometimes spared.   If, however, information be desired, it should
not be withheld, but explanations  may be made which will tend to prevent
an over-estimate of immediate danger.
   If  cardiac  symptoms have led the patient to apply to the physician, more
or less enlargement will probably be found associated with the lesions.  Let
it be supposed that the  enlargement  which exists is mainly due to hypertro-
phy ;  it  is not desirable to endeavor to diminish this hypertrophy.   Inas-
much  as whatever  obstruction  or regurgitation the  lesions  occasion must
continue, the  abnormal  growth of the walls of the heart is conservative; the 
340 VALVULAR  LESIONS WITH ENLARGEMENT OF  THE HEART.

comfort and  safety of the patient depend upon it, and  measures  which tend
to weaken the heart will  do positive harm.   On the  contrary, measures to
maintain the muscular tone  and vigor of the heart  are indicated.  The  diet
should be  nutritious.   The  appetite and digestion, if impaired, should be
improved by tonic remedies.   Moderate open-air exercise is to be encouraged,
very active exertions being interdicted.  In short, the  object is in every way
to invigorate and strengthen  the system.
   If dilatation predominate, the measures indicated are still those which tend
to give as far as possible, tone  and vigor to  the heart.   The labor of the
circulation may be  in some degree diminished  by  restricting the quantity
of  liquids  ingested, redundancy of  the  mass  of  blood being in this way
prevented.   Especial care, however, is to  be taken  not  to  impoverish the
blood.   The  diet is to be highly nutritious, although as dry as is compatible
with comfort; tonic remedies are to be employed, and moderate exercise out
of doors is still advisable.   In proportion as  the powers of the system are
lowered the  heart is weakened and dilatation favored.  The object  of man-
agement is, by strengthening and invigorating the system, to retard the prog-
ress of dilatation.
   A recent writer upon this subject, Oertel, advocates systematic exercise, and
especially mountain-climbing, as a means of increasing the muscular power of
the heart.1  There is foundation for this in both reason and experience. Quiet-
ude carried too far is perhaps likely to do more harm than over-exertion.   I
have known of instances in which pretty active exercise afforded notable relief
from symptoms referable to valvular lesions and enlargement of the heart.  In
a case under my observation  exercise by means of the  "health-lift"  was sig-
nally useful.  Patients exchanging habits of activity  for complete  rest are
likely to become  rapidly  worse.   Extremes in either direction are  to  be
avoided.   This may be  done by  enjoining such an amount of  exercise as
can be taken without any  sense of discomfort.  Within  that limit  exercise
is not  only allowable but beneficial.
   Thus far, the treatment has reference to the  condition of the  heart.  Of
the symptoms incident to the cardiac affection, irregularity, undue frequency,
and feebleness of  the heart's action call for treatment.   The  appropriate
remedies are  those  which diminish the frequency,  restore the rhythm, and
strengthen the action of  the  heart.  Digitalis is  an  invaluable remedy, regu-
lating the heart's action without diminishing, but, on the contrary, increasing,
the power of the ventricular contractions.  This remedy is therefore particu-
larly suited to cases in which the action of the heart is rendered irregular and
feeble by dilatation, and  it is not suited to cases in which the symptoms  and
signs denote hypertrophy.   The fact that the  diminished frequency of the
heart's action is due to a lengthening of the diastole renders important a cau-
tious use of the remedy in cases of free aortic regurgitation ; yet a considerable
increase  of the  power of the ventricular contraction may be a gain  overbal-
ancing any risk of an over-filling of the ventricular cavity from an increased
diastolic  rest.  The pulse, the apex-beat, and  the  intensity of the systolic
sounds  of  the heart, together  with the  subjective  symptoms,  enable the
physician to  judge of the safety  and utility of the remedy in  these  cases.
There is  little ground  for the traditional  notion that digitalis is peculiarly a
cumulative remedy,  the patient being liable to a sudden manifestation of its
toxic effects.  This remedy is specially useful in cases of enlargement depend-
ent on  mitral regurgitant lesions.  Digitalis in moderate doses (a grain or two
of the leaves, two or three drachms of the infusion, from ten to fifteen minims
of the  tincture, or one-sixtieth of a grain  of digitalin twice or thrice  daily) is
often well tolerated, and  may be continued with  advantage for a long period.
   'Vide Handbuch der Allgemeinen Therapie der Kreislavfs-Storungen, Leipsic, 1884. 
TREATMENT.
341
Not infrequently, however, after a time it causes gastric disturbance, which is
sometimes  avoided by changing the form  of  the  remedy or by the addition
of a carminative.  Generally, it is advisable to discontinue it when its good
effects  have been obtained, resuming it according to circumstances.
  Aconite  is a useful remedy when the  action of the heart is rapid, and it
may be substituted for digitalis if the latter be not tolerated.  It is not, how-
ever, a substitute for digitalis in respect of a tonic effect on the heart.  It is
specially applicable to cases in which disturbance of the heart's action is due
to functional disorder superadded to lesions, and when the  action is not nota-
bly weakened by dilatation.
  Belladonna, as a neurotic sedative, is sometimes of service, in this respect
belonging in the category of other  sedatives—hyoscyamus. hydrocyanic acid,
gelsemium, etc.   A belladonna plaster over the praecordia has a good effect.
I have known it to dilate the pupil.   Nauseant sedatives, as veratrum viride,
are not appropriate.   The latter lessens the frequency, but also the strength,
of the heart's action.   Nux  vomica or strychnia appears, either directly or
indirectly,  to have a tonic influence upon the heart.   Caffeine is a remedy of
much utility.  It  answers well in some cases as a substitute  for digitalis. Con-
vallaria and the  cactus grandiflorus are remedies which within late years have
been introduced as cardiac  tonics, increasing  the  force  and diminishing  the
frequency  of the heart's action.   They are to be  regarded  as succedanea of
digitalis, and trial of them  may be made, especially if digitalis  fail or be  not
well tolerated.  There is considerable discrepancy in the testimony of diff'erent
observers respecting the value of these remedies.  They are inferior to digi-
talis when  this remedy is well tolerated.   The  expectations attending their
introduction have not been sustained, but they are  valuable in some cases,
and they should not be allowed to fall into disuse.
   As  palliatives for cardiac dyspnoea, ammonia, the ethers, and dry cups
applied to  the chest are  serviceable.  Notable relief is obtained often by a
brisk hydragogue purgative from time to time.   So  far from inducing weak-
ness of the heart's action or general prostration, the effect  of this measure is
in these cases the reverse.   Bronchorrhoea  is not to be checked by opium, but
small doses, administered hypodermically or otherwise, not  infrequently afford
relief, and  are not hurtful if the patient do not suffer  from the after-effects of
this drug.  The objections entertained by many physicians to the use of opium
for the relief of cardiac dyspnoea is unfounded.   If well tolerated, the effect
of opium is that of a heart-tonic.
   General  dropsy is an event requiring treatment. Diuretic remedies should
be first tried, and if these prove inoperative hydragogue cathartics are to be
resorted to.  Of  these, elaterium is the most efficient.  Given in small doses,
this remedy may often be  continued  for  a long period without  producing
depression.  The bitartrate  of potassa with jalap and podophyllin are valu-
able hydragogues.  The Epsom salts answer exceedingly well in many cases ;
they are reliable, in general well  tolerated, and  the  amount  of hydragogue
effect is  easily regulated.   If only a mild hydragogue effect be desired,  the
bitter waters—Pulna, Friedrichshall, and  Hunyadi  Janos—may suffice.   In
the majority of  cases only partial  and temporary relief of  the dropsy is pro-
cured,  but  in some cases it  is completely removed, and it may not return for
a considerable period.   Diuretic remedies sometimes act very efficiently.   I
have known the infusion of parsley-root to  act with wonderful power as a
diuretic  remedy.  If  the  anasarca be so extreme   that the limbs  become
enormously distended,  a great number of  punctures  may  be  made with  the
point of  a'pin, not very sharp, the  punctures being so slight as not to draw
blood,  and through  them a large  amount of liquid  will  sometimes escape,
affording for a time  marked relief.  Vesications or cracks  in the integument 
342   HYPERTROPHY AND DILATATION OF  THE HEART, ETC.

of the lower limbs  in some cases occur as a consequence of the distension,
giving exit to an abundant flow of serum, with relief.   Incisions or  deep
punctures are attended  with a risk of gangrene.  In the treatment of the
dropsy, restriction of the amount of ingested liquid, as far as  is compatible
with comfort, is important.
  A highly important part of the treatment relates to the general  condition
of the patient, especially to coexisting anaemia.  Anaemia is not infrequently
associated with the lesions under consideration, and as a consequence func-
tional disorder of the heart is superadded to the disturbance caused by the
lesions. Irregular action of the heart or  excessive action, dyspnoea, and  even
dropsy, may be due  to the superadded functional disorder.  The error is not
infrequently committed of attributing the symptoms in such cases exclusively
to the lesions, and forming a prognosis more unfavorable than the latter act-
ually warrant.  By removing the anaemia the symptoms are relieved, and the
patient may  even seem  to recover completely  from  the cardiac  affection.
Anaemia existing in  connection with valvular lesions claims appropriate treat-
ment—namely, removal of the cause if it  be apparent; as, for example, lacta-
tion, the employment of chalybeate tonics,  with nutritious  diet and other
hygienic  measures.   Exclusive of anaemia,  the general  condition of  the
patient should be improved and maintained at the highest possible point of
strength  and vigor.   As a  rule, in proportion as  alimentation,  digestion,
assimilation, and nutrition are approximately normal,  the grave  effects of
heart lesions are less likely to  occur;  in other words,  the lesions  are  best
tolerated.  The importance of a  nutritious diet, remedies to promote  digestion
if it be defective, and hygienic agencies conducive to the welfare of the body
cannot be too strongly enforced as promoting tolerance and prolonging life.
                      CHAPTEE   IV.

HYPERTROPHY AND DILATATION OF THE HEART.—ATROPHY
  OF THE HEART.—OBESITY AND FATTY DEGENERATION  OF
  THE HEART.—PARENCHYMATOUS  DEGENERATION OF THE
  HEART.—NEW GROWTHS AND PARASITES IN THE HEART.—
  RUPTURE OF THE  HEART.—THROMBOSIS OF THE HEART.—
  EMBOLISM OF THE PULMONARY ARTERY.

          Hypertrophy and  Dilatation of the  Heart.
   THESE conditions will be considered  together, inasmuch as they are usually
    combined with each other.  They  may affect  the whole heart or  certain
sections of it, and are therefore classified as total  and partial hypertrophies
and dilatations.   The most important classification, however, is that based on
the capacity of the heart-cavities.  In simple hypertrophy the cavity is of
normal size, in eccentric hypertrophy it  is dilated.  In simple dilatation  the
muscular wall is of normal thickness,  in  hypertrophic dilatation  the wall is
hypertrophied, in atrophic dilatation it  is  thinned.   Hypertrophic dilatation
is often employed in the same sense as eccentric hypertrophy.  Rokitansky,
however, proposed to apply the term eccentric hypertrophy to enlarged hearts
in which  the hypertrophy predominates over the dilatation, and hypertrophic 
        HYPERTROPHY AND  DILATATION OF THE  HEART.    343

dilatation—or, as he called it, active dilatation—to cases in which the dilata-
tion  is decidedly in excess of the hypertrophy.  Of the different varieties,
eccentric hypertrophy is by far the most frequently observed.  Some writers
have assumed the existence of a concentric hypertrophy, a condition in which
the muscular wall is thickened and the cavity diminished in size.  Great cau-
tion, however, is  required  in estimating the capacity of the ventricles after
death.  If the heart be found firmly contracted, its cavities seem smaller and
its walls thicker than normal.  It is probable that cases of supposed concen-
tric hypertrophy  are only those of firmly contracted normal or hypertrophic
hearts.  It is also necessary not to mistake a relaxed and  flabby heart, such
as is often found after death from acute infectious diseases, for a heart affected
with  dilatation.  In so-called simple dilatation  the heart is evidently hyper-
trophied, as the normal thickness of the muscular walls could  not otherwise
be preserved.  In  fact, hearts affected with dilatation and thinning of the
walls—that is, with so-called atrophic  dilatation—usually  weigh  more than
normal, and are therefore hypertrophied.   Simple hypertrophy is  infrequent.
It may be  found  in connection with certain forms  of chronic Bright's disease.
   In a given case it is important to determine the degree of dilatation in pro-
portion to the hypertrophy, for while hypertrophy strengthens the muscular
power of the heart, dilatation enfeebles it; the  latter is therefore much  the
graver  of  the  two conditions, giving rise to nearly all  the symptoms.
   If the enlargement be confined to the right side of the  heart, the organ is
increased chiefly  in breadth and has a more rounded and less conical shape than
normal.   The rounded apex is formed by  the right ventricle.  When the left
ventricle is hypertrophied the heart is elongated, the apex being lower down
and farther  to the left than normal, and if hypertrophy be  combined with
dilatation the septum ventriculoruin is pushed over to the right side, encroach-
ing upon  the cavity of the right ventricle.  If the whole  heart be enlarged
its shape  is triangular with rounded  angles.  The name cor bovinum has,
from ancient times, been applied to a heart enormously enlarged.  The degree
 of hypertrophy varies much in  different  cases.  The  weight in  the major-
ity  of  hypertrophied hearts is between twelve and twenty  ounces.  Hope
 mentions one weighing forty-four ounces, and  Stokes  one which yielded the
 enormous  weight of four pounds two ounces, avoirdupois.  In determining a
 small amount of hypertrophy, it is necessary to  take into consideration the
 variations in weight within physiological  limits, as well as the age and gen-
 eral  physique of the individual.
   Hypertrophic  heart-muscle is brownish-red in color, and firm, almost board-
 like, in consistence.  The wall of an hypertrophied right ventricle has a pecu-
 liarly tough, leathery consistence.  After incision the walls remain open and
 rigid.  Both color  and consistence will be modified if the hypertrophic muscle
 have undergone  fatty degeneration, which is not infrequent.
   There has been much discussion as to whether, in hypertrophy of the heart,
 new muscle-fibres  are  produced  or  the pre-existing muscle-fibres simply in-
 creased in volume.  The formation of  new muscular fibres and the prolifer-
 ation  of the muscular nuclei seem to  be established.   It is probable that
 enlargement of the muscular fibres also occurs, as was thought by the older
 writers.
   Hypertrophy and dilatation of the heart are secondary affections, and con-
 secutive in the majority of cases to some mechanical obstacle to the circula-
 tion.  The obstacle  may be seated in  the heart  itself or in the pulmonic or
 the systemic circulation.
   The causes, seated in the heart, of hypertrophy and dilatation are—
      1. Stenosis  and insufficiency of  the valves in front.
      2. Insufficiency of the valves behind. 
344    HYPERTROPHY AND  DILATATION OF THE  HEART,  ETC.

     3.  Chronic pericarditis and pericardial adhesions.
     4.  Myocarditis with or without partial cardiac aneurism.
     5.  New growths in the heart.
  Weakening of the cardiac muscle from  parenchymatous and from  fatty
degeneration leads to dilatation  of its cavities.
  The obstruction may be in the pulmonic circulation, in which case  only the
right side of the  heart enlarges.  The most important of these causes are—
  1. Pulmonary  emphysema.
  2. Long-continued and large pleuritic effusions.
  3. Stenosis  of the pulmonary artery, either as a primary  change in the
artery itself or  by  pressure from  without,  as by aneurisms of  the  aorta,
tumors, etc.
  4. Curvatures  of the spine, causing compression of the lungs.
  Obstructions in the aortic  system causing hypertrophy and dilatation are —
  1. Atheroma of the aorta and larger arteries.  Many cases of senile hyper-
trophy are referable to this cause.
  2. Narrowing of the calibre of the aorta,  either as a congenital condition
or by pressure from without, as by tumors, etc.
  It is important to notice  that, contrary to former belief, aneurism of the
aorta does not lead to hypertrophy of the left ventricle.   This has  been dem-
onstrated by the  investigations of Axel  Key.1  Aneurism of the aorta  alone
does not tend to increase the tension in the left ventricle.  Very often, how-
ever, an atheromatous condition of the aortic valves or of the general arterial
system is associated with aneurism, and this  may be the cause of ventricular
hypertrophy.
  A well-recognized form of cardiac hypertrophy is that which is secondary
to certain forms of chronic Bright's disease, particularly to the small, granular
kidneys.   The explanation of this  is not thoroughly understood.  It will be
referred to under the head of Bright's Disease.  Suffice it to say here that it
is probably due  to some resistance to the blood-current through the  small
vessels.   This  form  may be  simple  hypertrophy, but it is  usually eccentric.
All of the other forms of cardiac hypertrophy are eccentric.   An index  to the
degree of distension  to which the ventricular cavity is  subjected is afforded
by  the condition of the papillary muscles.   Thus, in  aortic insufficiency,
which is  attended with  great increase of pressure in  the  left ventricle, the
papillary  muscles of  this ventricle are found  elongated, flattened, and in part
fibrous, especially at the origin of the chordae tendineae; in  the simple hyper-
trophy of Bright's  disease, on  the other hand, the papillary muscles are
enlarged  and rounded.
  The name primary or idiopathic  hypertrophy of the heart has been given
to  cases in which the disease has been  attributed to habitual over-exertion
of  the muscular system and to repeated nervous excitation  of  the  heart.
DaCosta, Peacock, Seitz, Fraentzel, Allbutt, and others have  called special
attention of late years to cardiac  hypertrophy  and dilatation referable  to
over-exertion, especially in the case of soldiers who have done heavy march-
ing in  a campaign.   Their observations render it  probable  that  long-con-
tinued  severe  muscular strain is an important element in  the production of
hypertrophy and dilatation  of the heart, but the infrequency with  which
these affections occur under  the conditions named leads to  the inference that
an  additional factor,  not yet understood, enters into their causation.
   The  hypertrophy  without valvular  lesion which has  been sometimes ob-
served  in cases of Graves's  or Basedow's disease (exophthalmic goitre) may
be  referred to the prolonged frequency of the heart's  action.
   Hypertrophy and dilatation of the heart are sometimes found as  apparently
                       1 Key, Nordiskt med. Arkiv, Bd. 1, 1870. 
        HYPERTROPHY AND  DILATATION  OF  THE HEART.    345

idiopathic conditions when they cannot be referred to any cause.  These cases
are sometimes described under the name weakened heart.

  The symptoms of hypertrophy are referable to the  increased power of the
heart's action.   Hypertrophic enlargement  of the  left ventricle leads to  an
abnormal force of the current in the  systemic arteries; the pulse  is stron^
and full, the face flushed, active  cerebral  congestion  is favored, and  certain
symptoms, such as pain, vertigo,  tinnitus aurium, are attributable  to the lat-
ter.   The patient feels the powerful  action of  the  heart, but he becomes
accustomed  to  it, and it  may occasion but little annoyance.
  If the hypertrophy have been induced by an impediment to the circula-
tion, it is conservative, as when it proceeds from  valvular lesions, and is not,
therefore, to be regarded as an evil.   It may, however, lead  or contribute to
serious accidents.  It is intelligible that hypertrophy of the left ventricle with-
out valvular lesions (these being, in a measure, protective) may favor cerebral
hemorrhage  in cases in which the arteries of the brain have become weakened
from  degenerative  changes.  In  like manner hypertrophy of the  right ven-
tricle may contribute  to pulmonary hemorrhage  and  give rise to oedema  of
the lungs.
   The diagnosis of hypertrophy must rest on physical signs, which are the
same as when the hypertrophy is associated with valvular lesions.   The fact
of enlargement and its degree are determined by the  altered  situation of the
apex-beat, together with  the enlarged area of the superficial and  the  deep
cardiac space.  That the enlargement is due, either exclusively or  mainly, to
hypertrophy  is  determined by the abnormal  force of the impulses  of the
heart, and by the prolongation, intensity, and booming character of the first
sound.1  The  absence of endocardial murmurs  is the basis of the conclusion
that the enlargement  is not connected with valvular lesions.
   Hypertrophy, when conservative or  compensatory, of course does not claim
treatment.   If it be congenital or there be sufficient  grounds for considering
it otherwise  than conservative, measures  to prevent  further growth  and to
obviate accidents are  called for.   Bloodletting and other measures which im-
poverish the blood are not indicated.   Anemia, by rendering the heart unduly
excitable, involves additional inconvenience and danger.  Excessive action of
the heart may  be moderated  by tranquillizing remedies, such as aconite,
hydrocyanic acid, and belladonna.  In the cases of  hypertrophy disconnected
from  valvular  lesions observed  by DaCosta among soldiers, marked  benefit
was obtained by the use of aconite, one or two  drops of the tincture being
given twice  or thrice  daily, and continued, without any increase of the dose,
for months.   The diet  should be sufficiently  nutritious,  but unstimulating.
Alcoholics are to be interdicted.   Liquids  should be taken sparingly.  Active
muscular exercise and emotional excitement are  to be avoided.

   Dilatation of the cavities of the heart may accompany hypertrophy without,
as well  as with, valvular lesions.  If  there be causes giving rise to hyper-
trophy which continue after the  morbid growth has reached  its  limit, dilata-
tion of necessity follows, and in time will  become predominant; but in most
cases excessive dilatation proceeds from weakness of the muscular walls, aris-
ing from fatty degeneration and other causes.  The muscular walls may yield
to distension and dilatation may take place when there is no abnormal impedi-
ment to the  circulation ;  and dilatation, however induced,  tends progressively
to increase.
  The symptoms of predominant dilatation are referable  to weakness of the
heart's action.   This weakness is shown by feebleness of  the pulse, coolness
                          1 Vide preceding chapter. 
346    HYPERTROPHY AND DILATATION OF THE  HEART,  ETC.

and cyanosis of the surface, and  if the right  cavities become considerably
dilated general dropsy ensues.  Fatal syncope may occur from an over-accu-
mulation of blood in the cavities in cases in which the organ is greatly enfee-
bled by dilatation.   The physical  signs show enlargement of the heart;  and
that the enlargement is  due to predominant dilatation is shown by the feeble-
ness of the cardiac  impulses and by  the weakness, shortness, and vavuar
quality of  the first  sound as heard over the apex.  The  absence  of valvular
lemons is inferred from the absence of endocardial murmur.      ...
  The indications for  treatment are the same as when the dilatation is in
association with valvular  lesions,  the  object, in general  terms, being to en-
deavor to  improve  the tone and  vigor  of  the muscular  walls.


                       Atrophy of the Heart.
  Simple wasting or atrophy of the heart is found in emaciated persons as
part of the general  marasmus.   Diseases attended with  prolonged cachexia,
notably carcinoma and  chronic pulmonary tuberculosis, are likely to  lead to
atrophy of the heart. An abnormally small size  of the heart has been observed
as a  congenital condition  in connection with imperfect  development of the
whole circulatory system,  frequently combined  with  arrested sexual develop-
ment.  Senile marasmus  may be  accompanied  with cardiac atrophy, but not
infrequently it is associated with hypertrophy in consequence of atheroma of
the large arteries.   Pressure upon the heart from without, as by tumors, peri-
cardial and pleuritic effusions, has also been adduced as a cause  of atrophy.
Atrophy of the left ventricle results from uncomplicated stenosis of the mitral
orifice, as has been already stated.   The heart may be reduced to  four ounces
in weight.  The coronary vessels,  taking no part in the atrophy, appear tor-
tuous and prominent upon its surface.   Atrophied hearts are sometimes cov-
ered  with  a considerable  amount  of adipose tissue, which  may  obscure the
actual reduction in size of the myocardium.
   Atrophy of the heart usually presents itself in  the form of so-called brown
atrophy.  The wasted muscle has a brownish color, and under the  microscrope
the muscular fibres are found  to  contain little granules of yellowish-brown
pigment, accumulated especially about the  nuclei.   A similar  pigmentation,
but in less degree,  is not uncommon in normal hearts.
   In a clinicarpoint of view this lesion is unimportant.  It occurs under cir-
 cumstances which divest it of evil consequences, if, indeed, it be not a  con-
 servative condition.

           Fatty  Degeneration—Obesity of the  Heart.
   By obesity of the  heart (called also fatty infiltration, deposition, or growth)
 is understood the accumulation of adipose tissue upon the surface  of the organ
 and  between the muscular fibres.  This condition  is met with  in  corpulent
 subjects, and sometimes without general obesity, especially in the  bodies of
 old persons and drunkards.  The fat accumulates first in the sulci in the course
 of the coronary vessels, and it may eventually cover the entire right and most
 of the left ventricle. A moderate accumulation of fat upon the outside of the
 heart cannot be considered of any importance; but when the fat is excessive
 in amount, and especially when it penetrates deeply into the myocardium, the
 muscular  fibres become atrophied from compression and the heart is enfeebled.
 It will be observed that in obesity of the heart the muscular fibres suffer only
 in so far as they are compressed.
    In fatty degeneration the muscular substance is metamorphosed into fat,
 which appears in a granular form in  the muscular fibres.   By Quain's fatty 
FATTY  DEGENERATION.
347
degeneration is understood this form.  Fatty degeneration may attack a heart
previously diseased, or the organ may have been previously healthy.   In the
former case the degeneration may be localized in the affected portion of the
heart;  in the latter instance the whole heart becomes fatty, but not of necessity
in an equal degree in all parts.  The fatty heart is of a pale yellowish color and
is soft  in consistence.  The yellowish color is usually more marked in certain
parts than in others.  It is usually most noticeable in the inner layers of the
myocardium, which are particularly liable to fatty degeneration.   These lay-
ers, as  seen through the endocardium, especially in the papillary muscles of
the left ventricle, present  a  peculiar mottled appearance which  is quite cha-
racteristic.  The fatty degeneration may be confined to the inner part of the
myocardium.
  Examined under the  microscope, the muscular fibres  are found clouded by
the presence of  large  numbers  of granules  and small globules of fat, fre-
quently arranged in longitudinal rows within the muscular substance.   The
transverse striation is obscured or entirely obliterated.   Some fibres are more
affected than others.  A small number of  fatty granules is not uncommon in
the cardiac muscle.  When of clinical importance, the degeneration is in such
amount that it  can usually  be recognized with the naked eye.  The fatty
material is undoubtedly a  product of the metamorphosis of the  albuminous
substance  of the  muscle.
  The  parenchymatous or granular degeneration  to be presently described,
which  accompanies many acute infectious diseases, such  as typhoid, remittent,
and puerperal fevers, acute yellow atrophy of the liver,  etc., may be followed
by a more or less extensive fatty degeneration.
  Fatty degeneration of the  heart, as already mentioned, is common in hyper-
trophied and dilated hearts, particularly during the stage of non-compensation.
It may be associated with fibrous  myocarditis  and  diseases of the coronary
arteries.   It is frequently present in parts adjacent to an inflamed  pericardium
or endocardium.  General causes are important in its  etiology, such as poison-
ing with phosphorus, arsenic, or mineral acids, and in  acute infectious diseases.
A most intense fatty degeneration of the heart attends certain profound anae-
mias, particularly pernicious  anaemia and leucocythaemia.
  The  symptoms of fatty  degeneration of the heart  are due to its inability to
carry on effectively the circulation.   Degeneration of the left ventricle occa-
sions feebleness  of the pulse.  The pulse may be  irregular.   It has been
observed to be notably  infrequent, the  number of  beats  sometimes falling as
low as  20  per minute.   The  infrequency of the pulse may be owing to many
of the  ventricular systoles being too feeble to propel the blood with sufficient
momentum to be felt at the radial artery.  Dyspnoea, especially on exercise, is
more or less prominent  as a symptom  according to the feebleness with which
the circulation  through the  pulmonary circuit takes place; and this symp-
tom is  more marked when  the right ventricle is affected.   Paroxysms of syn-
cope are liable to occur, accompanied by a sense of praecordial oppression and
distress.   These  denote distension of the cavities from  an accumulation of
blood.   Accompanying  these, paroxysms of  pain  referred to the praecordia,
and  sometimes extending  to one or both upper extremities, more especially
on the  left side (vide Angina Pectoris), are not uncommon.   The remarkable
rhythmical irregularity of breathing known  as  the  ': Cheyne-Stokes  respira-
tion " is sometimes observed, but it is by no means diagnostic of this lesion.1

  1 This is  described by Stokes "as a form of respiratory distress consisting of a period
of apparently perfect apnoea (/. e. absence of breathing), succeeded by feeble and short
inspirations, which gradually increase in strength and depth until the respiratory act is
cvrried  to the highest pitch "of which it seems capable, when the respirations, pursuing
a descending scale,  regularly diminish until the beginning of another apnueal period." 
348    HYPERTROPHY AND DILATATION OF THE HEART, ETC.

It occurs in uraemia, in  certain cerebral  affections, and  in  connection with
other cardiac lesions.  Seizures resembling  apoplexy,  characterized by tem-
porary loss  of  consciousness without paralysis, the surface being  pallid and
cool and the circulation extremely feeble, have been observed in persons who
have subsequently died of this affection.  These pseudo-apoplectic  seizures in
some cases  have been of frequent recurrence.    These symptoms  are also
present in cases of fibroid degeneration  or  myocarditis.
  The signs which accompany fatty degeneration are—feebleness or absence of
cardiac impulse, and weakness of the heart-sounds, more especially the systolic
sound, this sound sometimes suppressed over the apex, and if heard short and
valvular like the second  sound.  These signs are equally present as denoting
weakness of the heart from dilatation, fibroid  degeneration (myocarditis), and
obstruction  of the coronary arteries.   Sex is of some weight in the diagnosis,
men being the subjects much  oftener than women.   The  age of the patient
is to be considered.  Fatty degeneration rarely occurs in the male under fifty,
and in the female under forty years of age.  The tendency to obesity has not
great weight in the diagnosis, inasmuch  as  fatty degeneration  of the heart
occurs in lean subjects as well as in those prone to corpulency.   As regards
the arcus senilis, clinical  observation has  abundantly shown that this fatty
change in the  cornea occurs without  degeneration of the  heart, and vice
versa.
  To give rise to symptoms which point  to the heart as the  seat  of disease
the fatty  degeneration must be considerable.   Even if considerable, it may
not occasion sufficient weakness to give rise to any notable symptoms.  More
or less degenerative  change is not  infrequently found after death in cases in
which  it had not been suspected during life.
  Causal indications are  often not determinable with precision in  individual
cases.   Clinical observation appears to show that defective nutrition is con-
cerned in the causation.  The lesion is found in those who are underfed as well
as those who are overfed.  General anaemia, especially  pernicious anaemia, is
causative.  The lesion is not of frequent occurrence in connection with simple
or benign anaemia.   Defective nutrition of the heart from local  causes in not
a small proportion  of cases is, intelligibly,  an  etiological condition.  It is
incident to obstruction of the  coronary arteries  by calcification  or embolism,
and to defective circulation as a consequence of impaired recoil of the aorta
from atheroma  or aortic insufficiency.   It participates in the  acute degenera-
tion  of other organs in poisoning by phosphorus, and, it is said, also by min-
eral acids.  The pathological character of this lesion has been considered in
Part I. (Vide p. 54.)
  The objects of treatment are to develop the muscular vigor  of the  heart
to the  extent of its capability for  improvement in this respect.   The diet
should be nutritious, consisting of animal food  in  as large proportion as is
compatible with the  appetite and digestion.   Fatty food  is to be interdicted.
Farinaceous and saccharine articles should form a moderate proportion of the
diet.   Alcohol should  be  taken in moderation, if at all.   Moderate  exercise
out of doors is  important; it should not be carried to the extent of overtask-
ing the heart, but  may be taken within the limits of comfort;  that is, so as
not to occasion hurried  circulation, praecordial  oppression, or dyspnoea.
  The hygienic is  far more important than the medicinal  treatment;  yet
remedies  may  be  useful.  Tonic  remedies  are  generally indicated.   The
appetite and digestion, if  impaired, are to be  improved as much as possible.
if the patient be anaemic, this condition claims appropriate treatment.  Coex-
isting disorders of any kind are to be relieved.   The symptomatic effects  of
weakness of the heart will claim palliative measures.  These measures are the
same as when the weakness proceeds from dilatation. 
        NEW GROWTHS AND PARASITES IN THE HEART.     349


        Parenchymatous Degeneration  of the Heart.

  In parenchymatous as  in fatty degeneration the muscular substance  is
clouded and the striae are more or less obscured by the presence of a granular
material; but  in the former the granules are albuminous, in the latter, fatty.
Granular degeneration,  albuminous  degeneration, and  cloudy swelling are
synonymous terms  for this affection.  The name parenchymatous inflamma-
tion is sometimes used  improperly  in  the same sense.   Many of the  cases
formerly described  as simple softening of the  heart belong in this category.
The degeneration affects the whole  muscular  substance of  the heart.   The
heart is paler and of softer consistence than normal.  The granules of paren-
chymatous  degeneration  are paler, less glistening, and usually smaller than
those  of fatty degeneration, from which  they can  be  distinguished by their
solubility in acetic  acid  and insolubility in ether.  The granules  are formed
by some modification of the pre-existing albuminous substance, but it is not
known in  what  this modification consists.
  Parenchymatous  degeneration is found chiefly after death from acute infec-
tious diseases, such  as typhus  and typhoid fevers, puerperal fever, the exan-
thematous  fevers, erysipelas, cerebro-spinal meningitis,  pyaemia,  and septi-
caemia, also in  consequence of extensive burns and of poisoning by phosphorus,
arsenic, etc.  It can be produced artificially in animals by exposure to high
temperatures,  but the influence of this cause in man has been exaggerated.
Severe blood-poisoning is the most efficient cause.   The degeneration may be
developed with great rapidity.   Proof of this is afforded  by a case observed
by Wagner,1 who found  this change in  the heart and kidneys of a previously
healthy girl who died six hours  after extensive burns.   Fatty degeneration
is a frequent accompaniment and sequence of parenchymatous degeneration,
but there is no necessary connection between the two processes.   Without
doubt, parenchymatous  degeneration occurs in the course of many diseases
which  end  in  recovery  (Part  I. p. 53).
  This  lesion  explains  the weakness of  the circulation  out  of proportion  to
the adynamia  or general debility in certain diseases. The symptoms and signs
are those which represent notable feebleness of the heart's action.  As regards
the signs, diminished intensity  of  both sounds,  but  especially of the first
sound, characterizes the feebleness from this  as well  as from other lesions.
These  signs contraindicate depletory or debilitating measures of  treatment,
and, on the  contrary, furnish a reason for supporting treatment in addition to
the indications derived from the general condition of the system.


          New Growths and  Parasites in the  Heart.
  These have  no distinctive clinical  history, and  therefore will receive  only
the briefest mention here.  The most common new formations in the  heart
are tubercles and gummata.  Miliary tubercles are frequently found in the
heart  in cases of acute  general  tuberculosis.  They should  be  sought for'
especially in the endocardium of the conus arteriosus of the right ventricle.
Tubercles in the myocardium may give rise to myocarditis (tuberculous myo-
carditis).  Further than  this it is not known that they give rise to  any symp-
toms.   Cardiac gummata and syphilitic myocarditis have already been referred
to under the head of Myocarditis.  Carcinoma, sarcoma, lipoma, fibroma, myx-
oma, myoma strio-cellulare, have been observed in the heart.  Echinococcus
cysts, and more rarely cysticercus cellulosae, have been found in the heart.

  The interesting  subject of  congenital malformations  and diseases of the
               1 Handbuch des Allgem. Pathol., Leipzig, 1876, p. 413. 
350    HYPERTROPHY AND  DILATATION  OF THE HEART, ETC.

heart does not come within the scope of this work.   The reader is therefore
referred to works on pathological anatomy and to special treatises on the sub-
ject, including those  devoted  to  diseases of infants, for information concern-
ing the morbus  ceruleus  or blue disease, non-closure of the foramen  ovale,
of the ductus Botalli, of the septum ventriculorum, stenosis of the pulmonary
orifice and artery,  etc.


                       Rupture of the Heart.

   The most frequent cause of spontaneous rupture of  the heart is necrosis
with softening of a circumscribed part of the wall.   This condition, which is
sometimes called myomalacia, is due to  complete obstruction,  either by a
thrombus or an embolus, of a  branch of a coronary artery.  Other causes of
rupture of the heart are the bursting of a  cardiac aneurism or of an abscess
in the heart, or the extravasation of blood resulting from rupture of a branch
of a coronary  artery.   An ulcer of the stomach has been known to perforate
the heart.  Rupture of the heart very rarely happens in persons less than sixty
years of age.  Usually it causes  instant or speedy death ;  but if the perfora-
tion be small it  may be temporarily plugged by  a clot and life continue for
hours and even days.   I have known death to  be delayed for six hours after
the symptoms denoted the  occurrence of the rupture.   The  symptoms are
those which sudden compression  of the heart by the accumulation of blood
in the pericardium  would be expected to produce, together with  the loss of
blood. In most cases, however, there is no time before death for the observa-
tion of symptoms.  Rupture has been repeatedly observed to occur in con-
nection with a paroxysm of praecordial pain resembling angina pectoris.1  In
a case which came under my observation, the patient, a middle-aged man, had
had repeated attacks of severe angina, and  the heart gave no evidence, by
physical signs, of disease. Death  occurred suddenly, and a rupture was  found
of the left ventricle.   The rupture took place within a circumscribed  space
in which there was advanced necrosis, the muscular wall  being much softened.
A branch of the  left  coronary artery leading to the necrosed space was com-
pletely occluded by a  thrombus, and there was partial atheromatous occlusion
of both coronary arteries.  Except in the necrosed  space the heart had not
undergone fatty  degeneration.


Thrombosis  of the  Heart.—Embolism  of  the  Pulmonary
                                Artery.

   It is important to distinguish ante-mortem thrombi from the coagula formed
after death.  At autopsies the  right ventricle and  auricle are usually found to
contain coagulated  blood.  These coagula  are often in great part devoid of
blood-coloring matter, and they constitute the so-called decolorized post-mortem
clots.   The blood in these cases coagulates  so slowly after death that the red
blood-corpuscles  have time to sink ; hence the upper layers of the clot consist
mostly of fibrin and white blood-corpuscles, the latter being of lighter specific
gravity than the red corpuscles.  These post-mortem clots are yellowish-white,
succulent, loosely attached to the  heart-walls, and they send offshoots into the
pulmonary artery and  its branches.   They receive the imprint of the valves
and other irregularities with which  they lie in contact.   They have no clin-
ical significance.
  Fibrinous deposits may form in the heart during life.  The usual causes of
  1 For an analysis of 24 cases of spontaneous  rupture of the heart by Barth, vide
Archives generates de Medecine, Paris, 1871. For an analysis of over 100 cases by  Quain,
vide The Lancet, 1870. 
THROMBOSIS OF THE HEART, ETC.              351
their formation are the same  as those of the production of thrombi in gen-
eral—namely, slowing of the circulation and alterations of the inner layer of
the vessel.   The presence of fibrinous deposits on the inflamed and necrotic
endocardium, especially of the valves, in acute and chronic endocarditis, has
already been mentioned (p. 321).  Cardiac thrombi are liable to form in con-
sequence of the slow circulation attending excessive dilatation of the heart
and great weakness of the heart.   These are called marantic thrombi.  They
form especially in the recesses of the heart, where there is a natural obstacle
to the propulsion of the blood. They are to be sought, therefore, particularly
in the appendices  auricularum and between the  columnae carneae, especially
on the right side of the heart.   They also form in cardiac aneurisms.  When
these thrombi attain a considerable  size and  project into the heart-cavities,
they are often called cardiac  polypi.   These  ante-mortem thrombi  are of a
whitish, yellowish, or reddish-gray color, dull  in  appearance, adherent to the
heart-wall,  often friable in consistence, laminated in structure, and with the
free  surface  usually rounded  (vegetations globuleuses of Laennec).   The cen-
tral  portion of the  older thrombi  is often  broken down  into a creamy mass
which was  formerly mistaken for pus, and such thrombi were called  puriform.
The  creamy mass consists  chiefly  of granular matter.  The thrombus itself
is composed  mostly of  fibrin, blood-plates, and  white  blood-corpuscles, and
belongs to the so-called white thrombi.  Cardiac thrombi are usually small in
size, but they may take up the greater part of one of the heart-cavities, and
may even  extend  from one cavity  into another.   Organization of cardiac
thrombi  has  been  observed, but it  is very rare.

   The formation of thrombi of considerable  size within the right  ventricle
(heart-clot) has been referred to  especially in connection  with acute  lobar
pneumonia or pneumonic  fever, and also as occurring  in connection with
other diseases.  They  produce symptoms  attributable to obstruction at the
right side of the heart—namely, dyspnoea  and cyanosis,  with notable small-
ness and feebleness of the  pulse.   These symptoms develop  suddenly or
more or less  rapidly,  and are generally the forerunners of speedy death.
The  heart-sounds are weakened, and it may be practicable to determine that
the first sound is due to the tension of the mitral  valve, without the participa-
tion of the  tricuspid valve.   A tricuspid systolic murmur may be found which
had  not  existed previously.   Excluding pulmonary conditions which would
account directly for the foregoing  symptoms, and taking the latter in connec-
tion  with physical signs, the diagnosis may sometimes be made  with much
positiveness.
   Absolute rest, sustaining  measures of treatment, and saturation of the
blood with ammonia constitute, with our  present knowledge, the  measures
of treatment to be pursued.  The history of some cases  appears to  show
recovery, but there is  always room  for doubt in these cases respecting the
diagnosis.
   The fibrinous deposits upon vegetations or roughened spots, occurring gen-
erally within the left ventricle, are chiefly important  from their liability to
become  detached and to give rise to  emboli.   Heart-clots of large  size may
form ante-mortem in the left auricle when largely dilated as a result of valvu-
lar lesions.   They may also form in the left auricle when weakened by dilata-
tion or lesion of the muscular walls.

   Embolism of the main trunk of the pulmonary artery may be here noticed
as a cause of sudden or rapid death.   The embolus may be derived from a
thrombus formed within the  right ventricle  or  auricle, or from a  thrombus
formed in a large vein, most frequently the femoral vein.  The symptoms are 
352
FUNCTIONAL DISORDER  OF  THE HEART, ETC.
sudden, urgent dyspnoea, not explicable by physical signs, cyanosis, and cold-
ness of the extremities, the pulse becoming rapidly small and feeble and soon
extinct.
  Sudden and  complete  obstruction of  one of the primary divisions of the
pulmonary artery  may take place without  causing  death or giving  rise to
permanent notable inconvenience, as has been  demonstrated in  cases  under
my observation.1
                        CHAPTER  V.

FUNCTIONAL  DISORDER  OF  THE   HEART.—ENOPHTHALMIC
    GOITRE.—ANGINA  PECTORIS.—THORACIC  ANEURISM.

                        Functional Disorder.

   BY the term functional disorder is meant disturbed action of the heart not
    dependent on either  inflammation or structural 'lesions.  The beating of
the heart is sometimes  abnormally intense.   The  patient is conscious of its
violent action, as when it is temporarily excited by fear or some other strong
mental emotion.   This is commonly known  as palpitation.   The sense of vio-
lence  may be a subjective symptom  only, the force of the  heart's action not
being actually increased ; but generally the action is at the same time accel-
erated and irregular.  The irregularity is represented by the pulse, and is felt
when the hand is  placed over the praecordia.  The patient is also painfully
conscious of it; the organ appears sometimes to perform a rolling  or tumbling
movement, and  a sensation  is described as if the heart  were  in  the  throat.
Intermittency of the heart's  action is another  feature in  certain  cases.  The
action of the heart is for  an instant arrested; one, two, or three  beats are lost,
and generally irregularity of action  precedes and  follows the  intermissions.
Of these the patient is vividly sensible, and the feeling is that fatal  suspen-
sion  of  the heart's action may be  liable to take place.   These  rhythmical
aberrations may be accompanied with either violent or feeble action of the
heart.   The varieties  of functional  disorder occur in paroxysms which are
very variable as regards severity, frequency of occurrence, and  duration.
   In contrast to  paroxysmal disorders, there is an  affection in which the heart
beats regularly, but with great increase in frequency.  The number of beats
per minute may  be increased to 150 or even 200.   The increased frequency
may  persist  for  days, weeks, and even months.   This form of disorder  has
been named tachycardia (raybq xapd(a).  I have met with an instance of such
an increase in the frequency of the  heart's action, together with feebleness,
that  it  was  difficult to count the pulse, the disorder persisting  for  several
days,  accompanied by anorexia and a degree of pallor and  prostration which
seemed  to denote impending  death, recovery taking place, and examinations
prior  and subsequent to the attack  showing no  cardiac lesions.
   An occasional form  of  disorder is characterized by every alternate  ventric-
ular systole being so feeble as not to be appreciable by a radial pulse, the action
of the heart being more or less rapid.  On  auscultation, the heart-sounds are
found alternately loud and feeble.   I have known this  form  of disorder to
persist for several weeks.  This is liable to be mistaken for reduplication of
                 1 Vide Clinical Medicine, by the author, p. 248. 
FUNCTIONAL DISORDER.
353
the heart-sounds, there being four sounds to  each radial pulse.  The error
is  avoided  by comparing  the  radial with  the  carotid pulse.  The alternate
feeble  systoles are always strong enough to cause an appreciable pulsation
of the carotids.
  Reduplication of the heart-sounds denotes a  variety of functional disorder,
giving rise, however, to no definite  subjective symptoms and  occurring in
various pathological  connections.   Reduplication of both  sounds  may be
appreciable, or it may be limited to  one sound, which is usually the  second.
The reduplication is recognized easily  by one accustomed to  auscultation,
and the  proof is  the  occurrence of three or  four sounds  for  each  carotid
pulse.   A slight deviation from synchronism  in the contraction of the right
and the  left ventricle accounts satisfactorily  for  the reduplication of both
sounds, but not so satisfactorily for  a  reduplication limited to the second
sound.  The latter is best explained by  supposing  that  under certain condi-
tions of arterial pressure the recoil of the aorta and of the pulmonary artery
after the ventricular systole is not in  unison.  This will account  for a redu-
plication of the second  sound, although the  systoles of the  two ventricles
occur  synchronously.
   A variety of functional disorder to which the attention of  clinical observers
has not been much directed is diminished frequency of the heart's  action. In
a paper on this topic I have reported several  cases  in which  the  number of
ventricular  systoles was diminished to from 40 to 26 per minute.1  Physical
exploration  in these cases showed that  the disorder was not associated with
any organic affection of the heart.    The disorder was  associated  with more
or less cerebral disturbance, but the  evidence of intracranial inflammation,
embolism, and hemorrhage was wanting, and  in  every instance the disorder
was temporary.   I have met with  other examples  since the publication of
that paper.  The cardiac disorder is  evidently connected with  some centric
nervous  condition which  affects the heart through  the inhibitory action of
the pneumogastrics.  To  recognize the disorder as a functional one is import-
ant ; otherwise it is regarded as a symptom  pointing to some  grave cerebral
affection.   It was so regarded  in the  cases  which  I have reported.  Before
deciding that the disorder exists, two points  are to be  ascertained—namely,
first, that the radial beats represent accurately the ventricular systoles—that
is,  to distinguish this  from another variety of functional disorder which has
been noticed, in which every alternate  systole is  too  feeble  to produce an
appreciable  pulse at the wrist;  and second, that the patient  has not normally
an  infrequent pulse.   The  exclusion  of grave cerebral affections  by the ab-
sence of evidences of their existence  other than the infrequent  pulse is of
course important.  The cerebral affections which  diminish  the frequency of
the heart's  action  rarely, if ever, occasion so  great an infrequency as occurs
in some instances  in which it is purely functional.  As great or greater infre-
quency is observed in some cases of fatty degeneration  of the heart; hence
this lesion, as  well as other organic  affections, is to be  excluded.
   Infrequency of the  heart's action,  reduplication of the heart-sounds, and
the disorder characterized by alternate  systoles  too feeble  to be represented
by  a radial pulse are rare varieties of functional disorder.  The most frequent
varieties are the forms of disturbance first mentioned—namely, rapid action
either  violent or fluttering, irregularity, and intermittency occurring in par-
oxysms.   They are often  met  with in  practice.   The**- usually give rise to
great mental  apprehension.   The patient  has  a firm conviction of the exist-
ence of organic disease  and is in fear  of sudden death.   It is  sometimes
difficult to remove this  conviction  by the  most positive assurances to the
contrary.   Cases of functional disorder are distinguished, as a rule, by  much
                1 Vide The American Practitioner, January, 1876.
      23 
354       FUNCTIONAL DISORDER  OF THE HEART,  ETC.

mental anxiety and depression, in this respect differing from cases in which
disturbed action  is due  to  structural lesions.
  The causes of functional disorder  are  various.  It sometimes occurs in
so-called full-blooded persons addicted to the pleasures of the  table, digest-
ing and  assimilating readily, and  taking  but little  active  exercise.    It is
much oftener, however, associated with anaemia.   Anaemic persons are rarely
exempt from  more or less disturbance of the heart's action.  It may be pro-
duced by long-continued mental anxiety or depression.  It frequently occurs
in persons of an  anxious, worrying  disposition, and in those who are  consti-
tutionally disposed to melancholy.    The  effect which it produces on the
mind reacts on the disorder and tends to perpetuate it.   It appears in  some
cases to be dependent on indigestion or dyspepsia, and paroxysms are often
excited by dietetic errors.   The immoderate use of tobacco or of strong tea
and coffee gives  rise to it  in  some persons.  It is incidental  to  the gouty
diathesis.  The exhaustion following prolonged mental excitement and phys-
ical exertions may be accompanied by  it.  It prevailed  to a  great  extent
among soldiers during the late civil w*ar, excessive and persistent palpitation
often leading to discharge on the ground of disability  from supposed organic
disease of the heart.  Excessive  venery and habits of self-abuse  are  to  be
included among  the  causes.  The associated symptoms will of course vary
according to the different circumstances under which it occurs.   The diff'er-
ent causes of course act upon the nervous system ;  but it is not certain
whether  the particular nerves acted upon be the pneumogastrics, the  sym-
pathetic, or the nerves  and ganglion-cells in the substance of the heart.  A
predisposition seems  to  enter into the etiology.  Some persons apparently
have, as  an idiosyncrasy, an irritable  heart, and they generally have  other
evidences of what is called a  nervous temperament.
  It is extremely desirable,  in view of the comfort and welfare of the patient,
to determine with positiveness, in cases of functional disorder, that structural
lesions do not exist.  Several points connected with the history and  symptoms
have a bearing on the diagnosis.  The occurrence of the disturbance in parox-
ysms, the action  at other times being regular; the paroxysms occurring at
night rather than in  the  daytime, and frequently not being occasioned by any
obvious  cause, such  as muscular exertion or mental excitement; the  ability
of  the patient to take  active exercise without  palpitation or dyspnoea when
not  suffering  from the  disorder; and the  intensity of mental  anxiety and
apprehension,—are points which  render it probable that  the  difficulty is
purely functional.  These points,  however,  are not conclusive.   A positive
diagnosis is  to be based on the  exclusion of lesions of  structure, by the
absence of the physical  signs of the latter.  If, on a careful examination of
the chest, the  heart be found not to be enlarged ; if there be no murmur  pres-
ent,or if an existing murmur be inorganic; if the heart-sounds be normal  ;
and if, from the absence  of  persistent  weakness or irregularity of the heart's
action, fibroid or fatty degeneration of the heart and obstruction of the  coro-
nary arteries can  be excluded,—the  affection may be confidently pronounced
functional.  Without the negative proof afforded by physical exploration the
mind of  the practitioner must be in doubt as to the  diagnosis.   If he  give
a decided opinion, it is a guess which may prove to be either right or wrong.
If he avoid giving a decided opinion, the inference which the patient usually
draws is  that organic disease exists and that the physician is reluctant to tell
the truth.   I could cite, from cases which  have come under my observation,
not a  few in  which  patients were  for  many years rendered unhappy and
deterred  from engaging in  the active duties of life,  either by  an  erroneous
medical  opinion  that they  had organic disease of the  heart or by a  fixed
belief that such  was the fact, based  on the indecision of the physician. 
FUNCTIONAL DISORDER.
355
  The curative treatment of functional disorder must have reference to the cir-
cumstances with which it is connected.  Occurring in connection with what
is known as a "full habit," the measures  indicated  are—restriction of diet,
exercise  in the open air, with depletion by saline  laxatives and  perhaps by
small bloodlettings.  Occurring in connection with  anaemia, measures of pre-
cisely an opposite character are indicated—namely, those designed to restore
the normal condition of  the blood.  An investigation with reference to  the
source of the  disorder is to be made in all cases, and the  causes, if apparent,
are to be removed.  If connected  with dyspeptic  ailments, these are  to be
remedied by appropriate treatment; and if dependent on the gouty diathesis,
this will  claim suitable remedies.   In  the  great majority of cases the proper
treatment consists of tonic remedies, a nutritious diet, and an avoidance of
excesses  of all kinds; a proper amount of  sleep ; the interdiction  of  tobacco,
strong coffee, and tea; and out-door life with  mental  recreation ;  in short, an
invigorating system of hygiene.  Positive assurances of the absence of organic
disease, such as may be given  if based  on the  absence of all the physical signs
of lesions, will often go  far toward effecting a cure, the  disorder being  fre-
quently kept  up  by mental disquietude occasioned  by the fear of sudden
death.
   During the paroxysms palliative measures are called for. These consist of
ethereal  stimulants, antispasmodics, and occasionally opiates, with sinapisms
or stimulating liniments to the chest.  If paroxysms occur frequently a bella-
donna plaster  may  be constantly worn over the praecordia.  Blisters  or other
severe counter-irritants are never requisite.   Small doses  of aconite  are use-
ful if the action of  the heart be violent, and,  on the other hand, if the action
be feeble and irregular digitalis may prove of use.  Kunze and other  German
authors recommend as a palliative measure wearing an ice-bag  over the prae-
cordia.   A mouthful of brandy  or some  other  spirit, swallowed undiluted,
will  sometimes promptly arrest a  paroxysm.
   Persons who are  strongly predisposed to disturbed  action of the heart  are
liable to  suffer more or less from paroxysms of functional  disorder for  many
years or during their whole lives.   The mental anxiety in  such cases after a
time ceases, and patients become reconciled to this  as to other  physical evils.
The  frequent  recurrence of functional disorder for an indefinite  period does
not lead to the development of organic disease.   The physician is fully war-
ranted in giving  positive  assurance to the patient on this point.
   In  the  foregoing remarks on functional  disorder it has  been assumed that
structural lesions are not  present ;  but functional disorder and lesions may
be associated  when  the former is not dependent on the latter; in other words,
the causes which  give rise to functional disorder when the heart is free from
lesions will produce the same effect when cardiac lesions exist.  It is highly
important that the  practitioner appreciate  this fact.   Not infrequently  the
disturbance of the heart's action in cases in which organic  murmurs are found
is mainly or exclusively functional.  It is not uncommon  for practitioners to
err in considering all the symptoms referable  to the heart  as arising from
organic lesions, although  these  may be entirely innocuous.   Anaemia  coex-
isting with lesions may occasion  greatly disturbed  action  of the  heart, with
dyspnoea  and even  general dropsy, so that the patient may seem to be in  the
last stage of cardiac disease, and if the anaemia be  cured  the  recovery  some-
times appears  to be complete.   It should always, therefore, be a question in
cases of organic lesions whether more or less of the symptomatic  phenomena
may not be due to  functional  disorder arising from anaemia, deranged diges-
tion, or a morbid condition  of the nervous system produced by  tobacco,  coffee
or tea, mental depression, excessive venery, or gout.   This question  is to be
decided in the  affirmative when causes of functional disorder are discoverable, 
356       FUNCTIONAL DISORDER  OF  THE HEART, ETC.

and when the organic affection, as determined by the physical signs, appears
to be insufficient to account for the symptomatic phenomena.  In  proportion
as the latter are fairly attributable to  functional disorder, the  prognosis  is
of course less grave, and improvement may be expected from appropriate
treatment.

Enlargement of the Thyroid  Body and  Prominence  of the
  Eyeballs (Exophthalmic Goitre), associated  with  Func-
  tional Disorder of the  Heart.
  Within recent years the attention of clinical observers has been directed to
an affection characterized by enlargement of the thyroid body and prominence
of the eyeballs,  conjoined with  inordinate  action of  the heart.   These three
pathological  events form a  striking combination, giving to the affection  a
well-marked  individuality.   In  the absence of a name expressive of its cha-
racter, a German author, Hirsch, applied  to it  the  name Basedow's disease,
after a German observer who was among  the first to describe it fully;  and
the distinguished clinical teacher, Trousseau, in view of the prior claim of
the late Dr. Graves, proposed to  call  it Graves's disease.  The three events
just  named  evidently  have some  pathological connection, the  nature of
which is not yet  fully established.
  The prominence of the eyes  is the most remarkable of the triple event.
Existing in some  cases  in a marked degree, it  gives to the countenance  a
peculiar expression.   The projection of the globes  displays more or less of
the tunica albuginea, and  the  patient has a ferocious, staring  look, which,
existing in both  eyes, is at once diagnostic.  The projection is sometimes so
great as to prevent closure of the lids, and the eyeballs are partially exposed
during  sleep.  Vision  is generally not impaired, and the  appearance of the
eyes,  aside from the prominence,  is natural.   The condition of the eyes does
not involve pain, but the patient sometimes feels as if the eyeballs were being
squeezed out of the sockets.  Accompanying and sometimes preceding the
exophthalmus defective co-ordination of the movements of the eyeballs with
those of the  upper eyelids is observed.   If the patient look downward, the
eyeballs move without corresponding movements of  the lids.   This defective
co-ordination is not a feature in all cases.  The exophthalmus is  sometimes
more marked on one side, and it  may be unilateral.   Falling out of the eye-
brows and cilia  is sometimes observed.   The thyroid  body is more or  less
enlarged, the enlargement being  usually greater  on  the right side.   The
increase does not go on indefinitely, forming the immense  tumors which are
sometimes  seen  in cases of ordinary bronchocele, or goitre, but ceases  after
a moderate  or considerable augmentation of bulk  has  been attained.   The
swelling does not  give rise to  pain, but  it may occasion some obstruction
to respiration from pressure on  the trachea, and may  lead to  embarrassed
breathing and  modification  of  the voice  by interfering with the  function
of the recurrent laryngeal nerve.   The thyroid arteries are enlarged, and  a
strong  pulsation is felt over these  and the carotids, frequently  accompanied
by marked thrill.  Arterial and venous murmurs, frequently loud and some-
times musical, are  heard when  the stethoscope is placed over and near the
enlarged thyroid body.   The degree of the thyroid enlargement is often vari-
able at different times.
  Increased  frequency of the heart's beats (tachycardia)  is a constant  and
notable  feature.   In  some  cases  this amounts  to  a persisting  palpitation.
The pulse varies from 100 to 140 beats per minute.  Valvular lesions  and
enlargement  of the heart exist in  some, but by no means in all cases. When
present, they do not account  for the  functional disorder.  Loud inorganic 
          ENLARGEMENT OF THE THYROID BODY, ETC.       357

murmurs at  the  arterial orifices of the heart are not infrequent.   The  inor-
dinate action of  the heart may continue persistently for months and years.
  More or less anaemia coexists generally, but not invariably.  This has been
by some incorrectly  considered as an  essential pathological element of the
affection.  The anaemia,  however, is usually marked.  Other symptoms are
mental depression  and irritability, insomnia, amenorrhoea, abnormal  increase
of the appetite followed  by anorexia, hysterical phenomena, and emaciation.
The affection is essentially chronic.   In the  majority of cases it continues for
years.   It does not tend intrinsically to a fatal result, but patients are liable
to be cut off during its continuance by some intercurrent affection.  Recovery
takes place in a certain proportion of cases,  the improvement being slow, and
some degree of enlargement of the thyroid body and prominence of the eyes
often being permanent.  Fothergill quotes from Von Dusch 14 complete recov-
eries in  5li, and great improvement in 26 cases ;  and of cases observed by Von
Graefe, the ratio of recoveries was 20 per cent., and of great improvement, 30.
  The pathological character  of the affection is not established.  That the
three  pathological events are due exclusively to anaemia is disproved by the
occurrence of anaemia so frequently without these events, and by the fact
that there is not always coexisting anaemia.  The enlargement of the thyroid
body is  chiefly due to enlarged vessels.  The  prominence of the eyes is not
due to  enlargement  of the  globes.   In some autopsical  examinations which
have been  reported  an abnormal amount of areolar and adipose  tissue has
been found at the bottom of the orbit; but  that the protrusion is not chiefly
due to this cause is shown by the fact that it has been observed to cease after
death,  and  during life moderate pressure  suffices to  restore the globes to
their  normal situation.   Enlargement of the  vessels  behind the globes is
probably the chief cause.  The  prominence of  the eyes and enlargement of
the thyroid  body are  consecutive to the cardiac disorder.   Cases are observed
in which enlargement of the thyroid body is conjoined with  inordinate func-
tional activity  of  the  heart, without prominence  of the eyes, and  the two
latter may be associated without enlargement of the thyroid body.   Exam-
ples of each of  these variations have fallen under my observation.   I  have
met with cases of rapid action of the heart  persisting for a long period with-
out either  prominence of the  eyes  or enlargement of the thyroid bodies, in
which I suppose the affection  to be  the same minus these associated events.
Considering that the cardiac disturbance always precedes the two  other cha-
racteristic events,  that either  of the latter  may be  wanting, and  that both
involve  enlargement of  vessels,  a  fundamental morbid condition evidently
relates to the circulatory system;  but this condition probably involves a
prior neuropathic affection which, it is probable, pertains to the sympathetic
nerve.   In some instances morbid appearances after death in and around the
cervical sympathetic  nerve have been found, but  in other instances nothing
was discoverable.  The neuropathic condition is supposed by some to be seated
in either the cervical portion  of the spinal cord or the medulla  oblongata.
The affection in  the great majority of  cases occurs in females.  Of 50  cases
collected by Wilthuisen,  a Danish author, only 8 were male subjects.   In all
the cases which I have seen, save one, the  patients were females.   The dis-
ease  sometimes  shows an hereditary tendency.
  The indications for treatment relate to the functional disorder of the heart,
together with the morbid state of the nervous  system and the often-coexist-
ing anaemia.  Sedative remedies which tranquillize  the action of the heart
without producing depression  or interfering with the appetite and digestion
are indicated.   For this end, hydrocyanic acid, aconite, belladona, and digita-
lis may  be employed.   The anaemia calls for tonic  remedies, especially ferru-
ginous tonics; and the latter have  seemed to be beneficial in cases which I 
358       FUNCTIONAL DISORDER  OF  THE HEART, ETC.

observed.  Arsenic has been found useful, but in some instances it has appa-
rently done harm.  Iodine, with reference to the affection of the thyroid body,
is of doubtful utility.  In two cases under my observation, recovery in the one
case and notable improvement in the  other case occurred under the use of
the tincture of aconite.  In the first of these  cases the patient took one  minim
only of the  tincture  three times  daily,  but  continued  it for  three  years in
conjunction  with a chalybeate  tonic.   At the end  of  that  period  she  was
perfectly well and had  increased in weight forty pounds.  In the other case
the dose of the tincture was gradually increased to seven minims three times
daily, and was continued steadily for ten months without a chalybeate, anaunia
not existing in this case.  Several observers bear testimony to the usefulness
of galvanization, with the constant current, of the cervical sympathetic nerves.
Cases of recovery under this agent have been reported.   Ergot is among the
remedies which have been found of service.   Hygienic measures are of much
importance.   Freedom from mental depression  is to be secured as far as pos-
sible, and, whenever practicable, change of scene and other means of mental
recreation are advisable.  The  diet should be nutritious, and out-door  life is
desirable.  Trousseau advocated  the  employment  of cold water  after the
hydropathic method.


                          Angina Pectoris.

   The affection  known  as angina pectoris involves, as  an essential feature,
neuralgia, and might therefore be included among the diseases of the nervous
system.  It is considered here on account of its frequent connection with
cardiac lesions and with notable disorder of the heart's  action.   The follow-
ing description  will relate to typical cases of angina associated  with disease
of the heart.
   The affection is characterized by pain,  usually intense, burning, tearing, or
lancinating in character, emanating from the praecordia  or beneath  the ster-
num, and radiating thence in different  directions—namely, into both sides of
the chest, the back, and frequently the  left  shoulder;  extending down the
arm and sometimes to the  forearm ; occasionally felt in the forearm and hand,
and not in the shoulder and arm ;  in some cases extending more or  less into
both upper extremities,  and it has been known to extend into one or both of
the lower extremities; and, finally, it may shoot  upward into  the neck, tem-
ples, and jaws.   Different cases differ much  as regards the intensity of the
pain and the situations, among those just named, in which it is  felt.  The
pain in some  cases is  so intense as to be truly excruciating, and  is accompa-
nied by a feeling of constriction of the chest; in other cases it is moderate
or even  comparatively  slight.
   The affection is paroxysmal, and the pain is but one of the elements  which
enter into the paroxysm.   The action of the heart is generally more or  less
disturbed.  The beats are irregular, sometimes  violent or tumultuous  and
sometimes feeble.  In some cases  the  pulse is  notably slow.   An indescriba-
ble anguish or " heart-pang" is another element.  A vivid sense of impending
death is felt.   The  paroxysm is usually  developed suddenly, and the patient
feels compelled instantly to remain perfectly still, seizing hold of some firm
support in order to maintain a fixed position.   The patient is afraid to breathe
freely, although the power of doing so is not  lost.  Dyspnoea does not belong
to the paroxysms, save in so far as it may depend on existing cardiac lesions
or on  the  voluntary  restraint  of the respiratory movements.  A sense  of
numbness is felt in the  parts into  which  the pain extends.  The countenance
denotes anxiety and suffering.  The surface  is generally pallid, cool or cold,
frequently  bathed in perspiration, and sometimes cyanosed or livid. 
ANGINA PECTORIS.
359
   Cases differ greatly as regards not only the severity of the paroxysms, but
their duration and the frequency of their  recurrence.  They usually last for
a few moments only, but in some cases they continue for several hours.  Thev
may recur at wide intervals or frequently.  As a rule to which there are a
few  exceptions, if a paroxysm have been  once experienced other paroxysms
will  follow sooner or later.  Generally they become  progressively more" and
more frequent.   At first and  for some time they appear to be excited by
some notable cause, such as  unusual muscular exertion  or  mental emotion,
but after a time they are liable to occur from trivial causes  and without any
apparent cause.  They are sometimes produced  during sleep, apparently bv
distressing dreams.
   The aft'ection as thus  described is incident generally to organic  disease of
the heart, of the aorta, or of the coronary arteries, but, as far as at present
known, not  to  any one form of lesion.  It  is much oftener associated with
lesions at the  aortic than at the mitral orifice,  yet it occurs in only a very
small proportion of  the cases of aortic lesions.   It occurs in some cases of
fatty degeneration of the heart and of myocarditis without valvular lesions.
It is sometimes associated with aneurism of  the aorta.   The affection is rare.
Of over 150 cases of organic disease of the heart which I analyzed in 1850, it
occurred in only 7, and it occurred in  8 out  of 188 additional cases analyzed
in 1869.   That it has  a pathological connection with organic disease of the
heart is certain; but upon what particular condition or circumstance common
to different forms of organic disease it depends is not ascertained.
   Angina pectoris, especially if associated  with diseases of the heart, involves
liability to sudden death.  Death takes place suddenly in a paroxysm.   The
most reasonable way of accounting for the sudden death, as it seems to me, is
to attribute it  to  over-accumulation of blood within  the ventricular cavities,
and  arrest of the heart's action as a result  of paralysis from distension.   The
explanation, in fact, is the same as of sudden death  in cases of free  aortic
regurgitation and fatty degeneration.   The  liability to sudden death charac-
terizes cases in which the coexisting organic disease is of a kind to favor sud-
den over-accumulation of blood in the cavities.   Aortic lesions and fibroid or
fatty degeneration have this  effect.  If the  lesions do not lead  to this  effect,
patients rarely die suddenly, but linger on for an indefinite  period, with the
recurrence of  the  paroxysms more  or  less frequently.  Moreover, the over-
loading of the cavities of the heart will account for elements of the paroxysms
other than the pain—namely, the disturbed action of the heart, the indescriba-
ble anguish, and the sense of impending death.   If the lesions to which the
angina is  incident be  not  of a character to lead to  overloading and conse-
quent distension  of  the ventricular  walls,  the  suffering is mainly from  the
pain.  Some cases of angina  are of this description, very little disturbance of
the heart's action accompanying the paroxysm.  On the other hand, all  the
elements of a paroxysm of angina, except the pain,  are observed  not  infre-
quently in cases of aortic lesions with regurgitation or with  fibroid or fatty
degeneration ;  and sudden death is liable to occur in the paroxysms of distress
to which patients affected with these lesions are subject, the paroxysm lacking
only  pain to constitute angina pectoris.  The prognosis in cases  of angina is
always grave if physical signs  show the existence of  serious cardiac lesions;
and sudden death is to be expected if there be much aortic regurgitation, or
the habitual weakness  of the heart render probable impaired nutrition of the
organ from obstruction of the coronary arteries or degeneration of the  walls.
The danger, it is to be  observed, is not to be  measured by the intensity of the
pain  ; it is not the pain which kills, but the coexisting organic disease.
  Angina pectoris, as far as the neuralgic element is concerned, may occur
without any evidence of coexisting disease of the heart or the aorta.   Several 
360       FUNCTIONAL DISORDER  OF THE  HEART, ETC.

examples have fallen under my observation.  In these cases the paroxysms
generally lack those elements which are derived from cardiac lesions.  The ne-
cessity of keeping a fixed  posture while the paroxysm lasts is not felt in the
same degree ;  and the patient may writhe with pain and try frequent changes
of posture with the hope of obtaining relief.  The sense of impending death is
less or may be wanting.   There is less danger of sudden death, and the prog-
nosis as regards recovery is favorable.  These points are to be considered in
the differentiation of these cases from those in which the  angina  is connected
with disease of the heart; but the absence of cardiac lesions is determined by
the negative result of a careful physical exploration of the chest.   It is, how-
ever, to be considered that there are anatomical changes  not represented by
physical  signs—e.  g. defective  nutrition  from  obstruction of the coronary
arteries.   It may be stated that the danger in a given paroxysm is in propor-
tion to the feebleness and irregularity of  the heart's action, together with  a
feeling of impending dissolution.  In the endeavorto estimate the danger, the
nature and extent of lesions, as evidenced  by signs, are  to be taken into
account.   Much damage of the aortic valves, dilatation of  the left ventricle,
and weakness  of the  heart from fatty or fibroid degeneration are  the  condi-
tions which especially render paroxysms  dangerous.  Yet  there are cases in
which the paroxysms recur for  a long time without proving fatal, although
heart lesions exist,  and if the latter do not exist it is probably true  that there
is  little danger of sudden death.  I have reported several instances of recovery
in the second  edition of my work  on Diseases of the Heart (1869).  Such
instances  should not be lost sight  of in  the prognosis.
   Angina is  to be  discriminated from intercostal  neuralgia  and gastralgia.
Each of  these affections I have known to  be mistaken for it.   Paroxysms of
intercostal neuralgia are  sometimes  so severe as to rival, in the  intensity of
pain, attacks of angina.   In other respects the points of distinction are suffi-
ciently marked.  Both intercostal neuralgia  and gastralgia are distinguished
by their  own diagnostic traits, aside from  the absence of  those which  belong
to angina. This statement applies also to paroxysms of  pain caused  by the
passage of gall-stones. The most rational explanation of the immediate cause
of the paroxysms is that they are  due to deficiency of arterial blood in  the
walls of the  heart (ischaemia).
   Pertaining to the pathological character and relations  of the different  ele-
ments  in angina are discussions which  cannot be here  entered into.  The
neuralgic element probably has  its  primary seat in the cardiac plexuses,  and
the radiation of pain to the neck and upper extremities, as well as to other parts
of the  chest, may be explained by anatomical connections with branches of the
cervical  and  dorsal nerves.  As remarked  by Eulenburg, the pain  closely
resembles that referable to the sympathetic nerve in other situations; for
example, hepatic  colic, enteralgia, etc.   The disturbed action of  the  heart,
irrespective of cardiac  lesions, is  as unintelligible as when it occurs  in the
various forms of functional disorder.  To institute  several varieties of the
disease according to the  different  nerves supposed to be involved seems to
me to be, in the present  state  of our knowledge,  premature and  confusing.
Practically, however, the presence or absence of cardiac lesions and  the
degree of disturbance of  the heart's action in the paroxysms are important
points, especially in reference to prognosis and the  liability  to sudden death.
   The treatment embraces measures to afford relief in the paroxysms  and
those indicated in  the  intervals.   The palliative  measures embrace opium,
given promptly and sufficiently to relieve the pain.  It should be given  in a
form to act as speedily as possible.   The hypodermic method, if the physician
happen to be at  hand,  is to  be  preferred.   Alcoholic,  ethereal, and other
stimulants are indicated in proportion as the action of the heart is irregular 
THORACIC ANEURISM.
361
and feeble.  Revulsive applications to the chest  and extremities  are appro-
priate.  Swallowing pieces  of ice has been  found effective.  The nitrite of
amyl is a valuable remedy.  Five drops inhaled from  a  handkerchief held
over the nostrils will often  almost instantly  arrest a paroxysm.   It may pre-
vent sudden death, and trial of it should therefore  always be made, observ-
ing, of course, proper precautions in  its use.   The remedy is  efficacious in
only a certain proportion of cases.   Naturally, its  efficacy is  most marked
when  there is much  arterial tension, but it may relieve,  although this  ele-
ment  be wanting, by diminishing  the accumulation of blood  in  the heart-
cavities.  The  inhalation  of ether or of  chloroform  is to be  mentioned
among the resources for  arresting the pain  or mitigating  its severity.  The
inhalation of chloroform  should not be resorted to if the  action of the heart
be feeble.
  In the intervals the patient  should avoid, as  far as possible, everything
which  will be likely to provoke a paroxysm, such as active exercise, mental
excitement,  over-ingestion  of food, and the abuse  of alcohol.   Aside  from
prophylaxis, the measures  indicated are those  which have reference to the
causes of neuralgia, to the general health, and  in the majority of cases to
coexisting organic disease of the heart  or the aorta.  Anstie found arsenic,
in small doses long continued, extremely useful in preventing the paroxysms.
Others have recommended  this  remedy,  and, again, others  have  seen no bene-
fit from it.  A fair inference is that it is sometimes useful  and sometimes not,
as in  other  neuralgic affections.   Trousseau, who regarded  the  affection as
analogous to epileptic seizures and  called it  cardiac  epilepsy, advised the
long-continued  employment  of belladonna.   Electrization  of the  surface
within the praecordia has been found  useful both in arresting the  paroxysms
and postponing their occurrence.  The  cases most  likely to be amenable to
treatment are those in  which  the  angina  is purely neuralgic ;  that is, not
associated with  heart lesions.
   The  name angina is  singularly inappropriate  as  applied  to  this disease,
inasmuch as  neither the symptoms nor the danger have aught to do with
strangulation.  The term stenocardia has significance only as denoting a sen-
sation accompanying the  pain.  Of  the other  various names, most imply
erroneous views of the nature of the malady.  Cardialgia  would be an appro-
priate name had it not been applied to a gastric affection.


                        Thoracic Aneurism.

   An  atheromatous  condition of the arteries has been usually assigned as the
leading cause of spontaneous aneurisms.  This atheromatous process is at the
onset inflammatory ; it is an endarteritis chronica deformans (Virchow).  The
intima at first is swollen  and of a whitish or gelatinous appearance in patches.
In these swollen  patches are round, fusiform, and  stellate cells in increased
number.  The intercellular substance  is imperfectly fibrillated.  The endothe-
lial lining of the vessel is preserved.  Subsequently, necrosis with fatty and cal-
careous degenerations occurs in the cells and intercellular substance; and to
the resulting pulpy mass, often containing cholesterin, the  name atheromatous
abscess has  been inappropriately applied.   This  mass may be  discharged by
rupture of the endothelial  covering, and an atheromatous ulcer is the result,
   Recent investigations  have rendered it probable that undue importance has
been  assigned to atheroma as a cause of aneurism.  Atheroma  is most fre-
quent in old age, a  period of life in which aneurisms are  by no means most
common. The view is now held that the most frequent cause of spontaneous
sacculated aneurisms is  to be sought in changes in the  middle or muscular
coat of an artery.  It is this coat which normally gives the greatest strength 
362       FUNCTIONAL DISORDER  OF  THE HEART, ETC.

to the arterial wall.  The changes in the middle coat which lead to aneurism
are various.  A rupture of the elastic and of the  muscular fibres in a pre-
viously healthy, or more  frequently in a diseased, middle coat may be  the
result of traumatism or of some severe strain.  A frequent change in  the
media, especially in cases of atheroma, is a localized inflammation, character-
ized at first by an  accumulation of lymphoid cells,  and later by a growth of
fibrous tissue.   This mesarteritis, as  the inflammation is  called, leads to a
weakening of the  middle coat and consequent production of aneurism.
  The ascending aorta  is the most frequent seat of large aneurisms.  If, how-
ever, small or miliary aneurisms be reckoned, then the cerebral and the pul-
monary  arteries are most frequently affected.
  Thoracic aneurism occurs either in the form of  a diffuse dilatation, most
frequently of the ascending aorta, or in  the  sacculated form.   It is the sac-
culated  aneurism which is  specially considered in  the present article.
  According  to  Rindfleisch, aneurisms of the ascending portion and of the
arch of the aorta develop most frequently in the course of a spiral line which
corresponds to  the places against which the blood impinges  with  greatest
pressure.   This line begins  on the anterior  aspect of  the  bulb of the aorta,
gradually passes on the front of the ascending aorta  toward the right, crosses
the convexity of the artery just before the innominate  trunk is given off, and
from here passes very gradually to  the posterior and internal  aspect of the
descending aorta.
  Referring  the reader to other works for a fuller  account of aneurisms as
regards their  pathology and morbid anatomy, I shall consider in this article
aneurismal tumors  of  the thoracic aorta with  reference to their symptoms,
physical  signs, prognosis, and  treatment.  As bearing on the diagnosis, it
may be here  stated that aortic aneurism  is  a rare event under forty years of
age, and  that syphilis is often a remote cause.

  Aneurismal tumors may spring from the thoracic  aorta at different points.
Not infrequently they originate  within  the pericardium,  in  the  sinuses of
Valsalva, and  in  this   situation  rupture occurs before the  tumor  attains
to great size,  the hemorrhage  taking place into the pericardial sac, and  of
course causing instant  or very speedy death.   A fatal result  from aneurism
in this situation may occur without having been preceded  by any symptoms
of importance; death takes place unexpectedly, perhaps when the health was
apparently perfect.   The diagnosis is difficult and  perhaps impossible.  Of
703 cases analyzed by  Sibson,1 87 were within the pericardium.  The ascend-
ing portion of the  arch beyond the pericardium is the most frequent site.  In
193 of the 703 cases analyzed by Sibson the  situation was  in this  portion.
The ascending and transverse portions  are not infrequently both involved in
the dilatation.   This was the case in 140 of 703 cases.   The transverse por-
tion was affected alone  in 120 cases, and conjointly with the descending  aorta
in 20 cases.  The descending portion of  the arch was the seat in 72, and the
aorta below the  arch in 71 cases.  The aneurismal  tumors in  the larger pro-
portion of cases spring from the outer  aspect of the artery, but they may
spring from  either the inner, posterior, or anterior  aspect.
  Aneurismal tumors,  according  to their situation  and size,  give rise to cer-
tain symptoms and signs  by pressing upon  the different surrounding parts.
Unless referred to  their true source, these symptoms may mislead the physi-
cian by appearing to indicate other affections; and by  means of these  symp-
toms and  signs not only may aneurism be suspected, but, assuming its exist-
ence, its situation may  be inferred.
  Interruption of the circulation through the innominata and the left carotid
                           1 Med. Anatomy, fasc. v. 
THORACIC ANEURISM.                    363
and subclavian artery may arise either from the pressure of the tumor  on
these vessels or obstruction  by fibrinous plugs.  Feebleness or extinction of
the pulse in  the  radial,  brachial, or carotid  artery on one side is one of the
symptoms of aneurism, and  indicates its situation to be at the right or left
extremity of  the  transverse portion of  the arch.  When the  radial  pulse  is
not abolished, but more or less weakened, the contrast between  the  pulse of
the two  arms is well shown by a  comparison of the visible characters as
traced  by the sphygmograph.  A  notable  retardation of arterial pulsations
beyond the seat of the aneurism is sometimes observed.  Thus, when the
aneurism  is seated  between the points of  origin of the great vessels of the
arch of the aorta, the radial pulse is felt later on one side than on the other,
and if  the aneurism  be seated  in the descending aorta the pulsations of the
arteries below occur later than the pulse at the wrist.  An aneurismal tumor
springing from the ascending  or transverse portion of the arch may press
upon the superior vena  cava or the venae  innominatae, and induce venous
congestion limited to the  head and upper extremities or to one upper extrem-
ity, accompanied, perhaps, by more  or less oedema.  These symptoms  point to
the existence  of  aneurism and its  situation.
   An aneurism seated in the transverse portion of the arch may press upon
the trachea or one of the primary bronchi and interfere with respiration.  If
the obstruction of the  trachea be  considerable, the breathing is labored, and
may be accompanied with a noise, heard at  a distance, called  stridor.   Aus-
cultation will show feebleness of the respiratory murmur on both sides of the
chest if the trachea be pressed upon, but feebleness limited to one side and
the murmur exaggerated on the other side if one of the bronchi be obstructed.
Embarrassment of respiration may  proceed from pressure upon the recurrent
laryngeal nerve.  If the pressure be sufficient to interrupt the function of the
nerve on one side, laryngeal obstruction arises from an arrest of the  respira-
tory movements of the glottis  on that  side.  The embarrassment from  this
cause,  however, is not great.   The laryngoscope  in these cases shows the
vocal cord on one side to be paralyzed, while the respiratory movements of
the other cord continue, or after a  time the paralysis may become bilateral.
Spasm of the glottis may be induced if the relation of the nerve to the tumor
be such that  it is irritated  instead of its function being annulled.  I  have
reported a case in which, the left recurrent nerve being situated between a
calcareous deposit and  the aneurismal tumor, spasm of the glottis occurred
so frequently and  to such an extent as to prove fatal.1  Dysphonia and aphonia
are effects of either incomplete or complete  paralysis  from pressure on the
recurrent laryngeal nerve, and  the affection  of the voice is found to vary at
different times according to the varying amount of pressure.  These  laryn-
geal symptoms are likely to mislead by directing attention to  the larynx as
the seat of disease.   Tracheotomy has been repeatedly performed  under
the belief that the obstruction of respiration was due to an affection of the
larynx.  Pressure of the tumor on the pneumogastric nerve, as ascertained
after death, occasioned vomiting and pyrosis in a  case reported to me  by
Prof. McCready.
   Pressure on the oesophagus, when the tumor is situated  in the transverse
or descending aorta, may occasion obstruction to  the passage of  food.   This
symptom  should  excite  suspicion of aneurism, and  such a suspicion should
enforce caution in the use of bougies  to explore and  dilate  the oesophagus.
Pressure on the thoracic duct  has  been known to  occur, inducing marked
emaciation.  Pressure on  the sympathetic nerve is another effect of an aneur-
ismal  tumor, leading to  contraction of the pupil of the  eye on the affected
side.   If the tumor be seated  in the descending aorta, it is likely to lead to
                       1 American Medical Times, 1864. 
364       FUNCTIONAL DISORDER  OF  THE HEART, ETC.

erosion of the vertebral column, and may thus occasion paralysis by affecting
the spinal cord.   These cases are characterized by considerable pain, referred
to the back.  Neuralgic pains and  well-marked angina pectoris sometimes
accompany  aneurism seated in  the  ascending aorta.
  The diagnosis of thoracic aneurism is to be based on the presence of more
or less of the foregoing symptomatic  phenomena, taken in connection with the
physical signs of a tumor within the chest situated at some point in the tract
of the aorta.  The signs are very obvious when the aneurism has led to erosion
of the ribs and an external tumor, the latter pulsating, and perhaps presenting
a thrill, and the heart-sounds being heard with more or less  intensity when
the stethoscope  is placed over it, together with a single or double bellows
murmur.  The signs are less marked before the tumor makes its way through
the thoracic wall, but they may be sufficient  to render the  diagnosis positive.
Abnormal  dulness on percussion over a circumscribed  space in  the tract of
the aorta is an important diagnostic point.  This space will  be  on the anterior
surface of the chest if the aneurism spring from the arch,  and posteriorly if
it spring from the descending aorta  below the arch.   Careful  inspection and
palpation  may disclose pulsation, and perhaps thrill, before any external
tumor is apparent.   Undue  audibleness of the heart-sounds within the space
found to be dull on percussion, and a  single or double murmur not  trans-
mitted from the aortic orifice, are highly significant  signs.  They are, how-
ever,  by no means uniformly present, and therefore, while their presence  con-
tributes to  the diagnosis, their absence is  not  proof that aneurism does not
exist.
  The prognosis in cases of thoracic aneurism relates chiefly to the duration
of life.  The instances of recovery are few.   In the majority  of cases death
is the result of rupture of the aneurismal  sac. • The rupture may take place
in various  directions—namely, externally, or into the oesophagus, trachea,
bronchi, pleural cavity, heart,  venae cavae, spinal canal, pericardial cavity,
etc.   The rupture may be at first small, so  that  death takes place more or
less gradually, or it may be  large enough to cause  a sufficient  hemorrhage to
destroy life within a few moments.   I  have met with a case in which, after
a considerable hemorrhage caused by  rupture into a bronchus,  the opening
closed, and a fatal recurrence of the hemorrhage did not take place until after
several weeks, the patient in the mean time taking considerable exercise under
the advice of a practitioner  who scouted the idea of aneurism.  The progress
of the aneurism varies much in  different cases, the duration of life being in
some  cases  but a few months, and in  some cases several  years.   In  a  con-
siderable number of cases life is destroyed before rupture takes place.  Pres-
sure on the trachea,  oesophagus, vena cava, thoracic duct, or irritation of the
recurrent laryngeal nerve may lead to a fatal result, or  the patient may be
cut off by some  intercurrent affection.   Organic lesions of  the heart coexist
in a certain proportion of  cases.   These of course involve  distress and dan-
ger in proportion to their nature and extent, and  may prove  the immediate
cause of death.   Clinical observation shows  that  patients affected with  tho-
racic  aneurism rarely have pulmonary tuberculosis.
  Recovery from thoracic aneurism sometimes takes place,  but in general the
only results to be hoped for from treatment are palliation of suffering and  pro-
longation of life.  With reference to these results all active exertions are to
be avoided, and, as far as possible, emotional  excitement.   The body is to be
well nourished if possible, but the diet should be unstimulating and alcoholic
stimulants  should  be interdicted.  Liquids should be taken sparingly.   The
action of the heart, if abnormally strong, is to be diminished  by sedative
remedies, and perhaps, if  the patient be full-blooded, in some  cases by small
abstractions of blood.  It is highly important not to  impoverish the blood, 
THORACIC ANEURISM.
365
and anaemia if it exist calls for the treatment appropriate to that condition.
Pain and other incidental symptoms are to be palliated by appropriate reme-
dies.  If spasm of the glottis be induced through the recurrent laryngeal
nerve to such  a degree as to endanger life, laryngotomy is warrantable, if not
advisable, with a view to palliation and the prolongation of life.  This opera-
tion will of  course be of no avail if the obstruction be due to pressure of the
aneurismal tumor  on the trachea.
  The progress of the aneurism is retarded by the deposit of successive layers
of fibrin within the aneurismal sac.   It  is in this mode that a cure sometimes
takes place.  It is desirable, therefore, that the blood should be rich in fibrin,
and it is probable that the deposit is more likely to take place in proportion as
the action of the heart is slow.  Cardiac sedatives—namely, aconite, digitalis,
and the veratrum viride—may in this way be  useful.  Certain remedies have
a more direct  curative effect in some cases of aneurism.  At the present time
the iodide of potassium is to be relied upon more than any other known rem-
edy.  Cases in which a cure was  apparently effected  by this remedy have
been  reported  by Roberts, Balfour, Bouillaud, and others.  I have witnessed
remarkable  improvement under the use of this remedy in several cases.1  The
doses should be increased up to a point of comfortable tolerance and continued
for a considerable  period.  The iodide of potassium should be faithfully tried
in all cases  of thoracic aneurism.
1 Vide Clinical 3Iedicine, 1879. 
             SECTION   THIRD.

DISEASES  AFFECTING THE  HEMATOPOIETIC  SYSTEM,
                          CHAPTER   I.

         DISEASES  OF THE  HAEMATOPOIETIC  SYrSTEM.

           Introductory Remarks.—Simple or Benign Anaemia.—Chlorosis.

  IN this  section will be considered certain diseases which are believed to be
    the  result of disturbances in  the blood-forming functions.  It is, there-
fore, proper  to  refer these  diseases to the haematopoietic1 (or blood-forming)
system.   As the constituents of the  blood-plasma  are  derived more or  less
directly from the ingesta, we understand by the  haematopoietic system espe-
cially those organs and parts in which resides the function of  producing  the
formed constituents  of the blood—namely, the red  and  the white corpuscles.
The name cytogenic organs has also been employed in the same sense.   Our
knowledge as to the development of the blood-corpuscles and as to the situa-
tions in which they are formed is very imperfect, notwithstanding the abun-
dant researches devoted to these subjects, especially during the last few years.
The parts to which has been assigned, with more or less probability, the func-
tion of forming blood-corpuscles after birth are the lymphatic  glands,  the
spleen, the red marrow of the bones, and the blood itself.2   To these parts,

  1 From a\ya, blood, and ttoieo, to make.
  2 White blood-corpuscles are derived from the lymphatic tissues of the body, especially
from those organs where this tissue is  most  abundant—viz. the spleen, the lymphatic
glands, and the red marrow of the bones.  Red marrow, which in embryos and young
infants exists in all of the bones, is present in the adult in the bones of the trunk, but
is replaced by fatty marrow  in the long bones of the extremities.  In severe  forms of
anaemia the yellow or fatty marrow is often changed into red or embryonic marrow.
  It is  now generally held that the red  blood-corpuscles are in some way derived from
the nucleated red blood-corpuscles which are constantly present in the red marrow of
the bones, but the manner of their development is not understood.  Some believe  that
red blood-corpuscles are formed out of ordinary white blood-corpuscles, the  nucleated
red corpuscles  being a transitional stage in this formation (Neumann).  Another view
is that  certain colorless cells, which are thought to differ from ordinary white blood-
corpuscles in the possession of  vesicular,  reticulated  nuclei and in the mode of  cell-
division, give origin first to nucleated red blood-corpuscles, and these to ordinary red
corpuscles (Lfiwit).   Still others consider that the nucleated  red blood-corpuscles are
independent cells which by indirect cell-division produce red corpuscles (Bizzozero).
Karyokinetic figures are abundant in various cells found in the osseous medulla, includ-
ing the nucleated red blood-corpuscles.   Under normal  conditions, when the new red
blood-corpuscles  enter the circulation  they  are fully formed and devoid of nuclei.
There is no proof that red blood-corpuscles are formed after birth elsewhere than in the
marrow of the bones.   A full consideration of these as well as  of other problems in the
physiology of the blood-corpuscles will be  found in the " Cartwright Lectures on Certain
Problems  in the Physiology of the Blood-corpuscles," by William Osier, The Medical
News, April 3 et seq., 1886.
366 
                   SIMPLE OR BENIGN ANEMIA.                 367

therefore, may be  given,  at  least provisionally, the name  haematopoietic
system.
  The diseases treated of in this section are grouped together, not so much with
reference to the  anatomical parts  affected as in consequence of certain com-
mon characteristics.  In the majority of these affections we cannot explain, by
known anatomical changes, the alteration which exists in the  composition of
the blood.   This is true  in spite  of the fact that in many cases pathological
changes have  been recognized in parts  thought to belong to the  haemato-
poietic system.   It is probable  that  a  relation  of cause and effect exists
between  these changes and the blood-alterations, but the connection is ren-
dered  obscure by our ignorance  as to  the life-history  of the blood.   The
anatomical changes found in some of  the diseases considered in this section
are to be regarded as  secondary rather than as primary elements in the dis-
ease.  We must content ourselves frequently with establishing the existence
of some  disturbance in  the  blood-forming  function, without  attempting  to
refer the disturbance  to anatomical changes.
   A common and distinctive characteristic of the diseases of the haematopoietic
system is the  presence of anaemia, usually of a grave form.   This anaemia is
called essential, in that  it is not referable to diseases which interfere secondarily
with the composition of the blood, such as Bright's disease, cancer, and phthis-
is, but is attributable to a direct interference with the blood-forming  or blood-
destroying functions.   In many of the essential anaemias no anatomical change
has been  found  in the body which can,  with any probability, be assigned as
the cause of the anaemia; and in  others,  as  in leucocythaemia  and pseudo-leu-
cocythaemia, there are  morbid changes which may be considered as interfering
more or  less directly with  the formation of the  blood-corpuscles.   In these
diseases  the normal ratio  between the consumption and the  renewal of the
corpuscular elements of the blood is disturbed.   The destruction of the cor-
puscles may  be  abnormally increased (haemophthisis),  or the reproduction
of corpuscles may be  diminished below  the normal*amount (anaematosis), or
both conditions may be  combined.  It is usually impossible  to determine in
a given case which of these  causes is  at work.  The result of this dispropor-
tion between  consumption and renewal is  impoverishment of the  blood, or
anaemia, which,  together with the consequent disturbance of  nutrition, forms
the  dominating  factor in all of  these diseases.   It will  be found, therefore,
that these affections have much  in common in  their clinical  history.  They
are  for  the most part insidious  in  their onset and chronic in their course.
As a rule, their causes are obscure, and, with the exception of simple anaemia
and chlorosis, their prognosis is grave.
   For certain general considerations concerning  anaemia and the changes in
amende  blood the reader  is referred  to Part I. (p. 60).


                    Simple or Benign Anaemia.

   The terms  simple and benign  may  be used to designate anaemia  when not
pernicious or an  element  of the other  affections  embraced  in this section,
and when diseases of  which the  anaemic condition is symptomatic, such as
phthisis, empyema, carcinoma, etc., may also be  excluded.   It may be said
that, as  thus restricted, anaunia is only a symptom.   It occurs,  however,
under various circumstances, and for convenience  it may be considered in
the  light of an  individual disease with as  much  propriety as certain other
events which are symptoms—for  example, jaundice.    Simple or  benign
arnvmia, as just defined, enters  largely into medical practice.
   General anaemia, as  regards  anatomical distinctions  (oligaemia, oligocy-
themia,  etc.), together with its causation and effects, has been considered in 
368        DISEASES  OF  THE HEMATOPOIETIC SYSTEM.

Part I. (Vide p. 60.)   The obvious  causes are—first, loss of blood, or hem-
orrhages ; second,  defective assimilation ;  and third, expenditure of certain
blood-constituents,  as in  lactation   and  pregnancy.   Hemorrhages  occur
under a great variety of circumstances.   In women  menorrhagia and flood-
ing with labor are frequent  causes.   Defective assimilation may depend  on
a lack of food in sufficient  quantity or of food sufficiently nutritious; and
with abundant alimentation the processes of digestion may be so impaired as
to prevent proper assimilation.  Lactation and pregnancy are  frequent causes.
To  these causes may  be  added certain toxical agencies which  interfere with
haematopoiesis—namely,  lead, malaria, etc.  Simple  or benign  anaemia is  a
sequel of diseases which have kept in abeyance either alimentation  or assim-
ilation.   Women become anaemic much oftener than men, irrespective of the
causes which are peculiar to the  sex—namely, pregnancy, lactation, and
menorrhagia.
  Anaemia gives rise  to a multiplicity  of morbid phenomena representing
especially disorder of  the nervous system.   The more frequent and promi-
nent are  as follows: mental depression, anxiety  respecting health, irritability
of mind, want of buoyancy and energy, a feeling of  lassitude, and  a painful
sense of  inertia  or indolence.  The  feeling of incapacity for muscular exer-
tion is often  greater than the actual loss of muscular power.   The physical
and mental  powers are  especially depressed  during digestion.  Palpitation
of the heart is frequent, and organic disease is greatly feared by the patient.
Neuralgia in  various situations is likely to occur, and in women hyperesthesia
of the abdominal walls, simulating peritonitis.  The varied symptoms formerly
and recently described as due to spinal  irritation are liable to occur in con-
nection with anaemia.   The varied phenomena considered as hysterical are
often  associated with, and  more or less dependent upon,  anaemia.   The
special relations between the red corpuscles and the nervous system are
shown by the neuropathic phenomena to  which anaemia gives rise.  These
phenomena  may be said' to  constitute the pathological expressions of this
morbid condition of the blood.   The different  organs of the body in  cases
of anaemia are deficient  in functional power  in  proportion to  the  quantity
of blood which they receive in health.   The surface of the body is  cool and
the extremities are frequently cold.   The ability to endure  cold is  lessened.
There  is  diminished  endurance of  muscular as well as mental   exertion.
Generally, the  face, especially the prolabia, and  the mucous  membrane  in
situations where it can be seen, are pallid.   The facies often  at  once denotes
anaemia.   In some persons, however, the anaemic condition, as determined
by  physical   signs and its  pathological  phenomena, exists not  only without
pallor, but with  even a rosy complexion.  Pallor of the prolabia  may be
noticeable in the morning or  if the patient be fatigued, and it may disappear
under  excitement.  The action of the heart  is feeble  and easily disturbed,
becoming rapid  from slight causes.   The respirations are panting  on exer-
cise.  Digestion is labored.   The urine often has a low specific  gravity from
a deficiency of urea,  and is  notably limpid  from a  diminution of  pigment.
The cerulean eye—that  is, a dark-blue  tint of the globe, owing to a  semi-
transparency of  the conjunctiva—may be a more marked  feature than pallor
of the face or the prolabia.
  The symptomatic evidence generally  renders  the  recognition of anaemia
easy. ■  Certain  auscultatory  signs confirm the  diagnosis.   The continuous
murmur  in  the  neck,  known  as  the venous hum,  is rarely wanting, and is not
often  present if there be not anaemia.  A frequent sign is a systolic bellows
murmur, referable to the carotid arteries.  Not less frequently  systolic mur-
murs are heard at the base of the heart,  produced within the aorta and the
pulmonary artery.   The significance of  these murmurs depends  on their 
SIMPLE  OR  BENIGN AN JEM I A.
369
haemic origin, and this is rendered evident by the absence of signs denoting
lesions of the heart or arteries.   These haefhic murmurs are useful not only
in the diagnosis of anaemia, but  as criteria by which the physician is aided
in deciding whether  the  anaemic condition continue or whether it have been
removed by measures of  treatment.   The diagnosis may be rendered demon-
strative by ascertaining  the  number of red corpuscles and the amount of
haemoglobin.
   In  order to decide that the anaemia is simple or benign, the pernicious
form, leucocythaemia, and pseudo-leucocythaemia—diseases considered in this
section—are to be excluded,  and  also all  other important diseases which
involve, as a symptom or an effect, the anaemic condition.  To exclude these
diseases is generally not difficult.  Although, as has been seen, anaemia stands
in a causative relation to a large  number  and a great variety of pathological
phenomena, there are not present symptoms which denote a grave condition.
Pyrexia is  wanting, and the general nutrition of  the body may be well main-
tained.   With reference  to the exclusion of important diseases, it is neces-
sary that the physician be qualified to appreciate  the phenomena  referable to
the anaemia.   In most instances the causes of the anaemia are  apparent, and
their  existence is to be taken  into  account in the diagnosis.  Moreover,  the
diagnosis is often corroborated by the speedy  effect of appropriate treatment.
   The prognosis in  cases of simple or benign anaemia is generally good.
Provided the causes do not continue in operation, recovery may be expected.
Different cases differ much as regards the rapidity of progress toward recov-
ery.   In the exceptional cases which are treated unsuccessfully there  is reason
to conclude that the want of success may be due to an innate  defect in  the
haematopoietic system.
   Anaemia may be  associated with  other diseases, the latter  occurring in
persons already anaemic.  It  is of  great importance in  practice  to  take
cognizance of  this association.   The phenomena of  the associated diseases
are modified by the  antecedent and  coexisting anaemia.   Toleration of dis-
eases and recuperation are thereby  impaired.  Whatever may be the disease
thus  coexisting  with anaemia, but without  involving necessarily  any rela-
tion of cause or effect, the anaemic  condition  claims recognition, and is to be
considered  in connection  with  the indications  for treatment.  With  the dif-
ferent functional  affections of the  nervous system anaemia  is associated  as
a rule, standing often to  them, measurably, in a causative relation.   Clinical
observation does not afford proof of  its predisposing to phthisis, but rather
the reverse.
   In the treatment of anaemia causal indications are of primary import-
ance.   The causes in individual  cases are to  be  ascertained, and if possible
removed.   Hemorrhages  are  to be arrested or restrained.   Alimentary sup-
plies  should be sufficiently abundant and varied.  It  may be requisite that
lactation be discontinued.   It is sometimes advisable to caution against preg-
nancy.  Digestion and assimilation are to be promoted by appropriate med-
ical and hygienic treatment.  The patient is to be withdrawn from the opera-
tion of toxical causes, lead, malaria, etc., and  as  far  as practicable  from all
unsanitary  influences which indirectly  lead to the anaemic  condition.
   The quantity of wholesome  food should be equal to, but not exceed, the
digestive powers.  Appetite and digestion should be promoted by quinia, sali-
cin, and other tonic remedies.  The articles of  diet should be made attractive.
Dyspeptic ailments are to be treated  according to the  indications to be here-
after considered.  (Vide Section IV., Chapter IV.)  Out-of-door life, recreation,
change of scene, daily sponging of the body, sea-bathing,  and all  hygienic
measures which  have a  favorable influence  on assimilation and conduce to
invigoration are  useful.
       24 
370        DISEASES OF THE HAEMATOPOIETIC SYSTEM.

  The preparations  of iron have a specially curative agency.  Their modus
operandi,  with our  present knowledge, cannot be  satisfactorily explained.
Doubtless the fact  that iron  is  a constituent of the red corpuscles of the
blood affords a partial explanation.   Nothing in practical  medicine  is better
established  than the value of iron as a remedy in simple or benign  anaemia.
Its  value is  often attested by its efficacy even when the causes of the anaemia
cannot be removed and when other circumstances are unfavorable.  If in any
case it have no curative effect, there is reason to suspect that the anaemia is
not simple  or benign.  On the  other  hand,  the efficacy of the remedy is
evidence that the anaemia is  of that character.
  Of the different preparations of iron it is difficult to  give  decided prefer-
ence to any  one over the  others.  A physician is likely to have his favorite
preparation, but that the choice is not based on the  comparative merits  of a
considerable number is shown by the fact that almost every preparation has
its advocates.   Iron reduced by hydrogen, the citrate, the hypophosphite, the
tincture of the chloride, the tartrate, the  carbonate, and the compound mixture
are all  eligible preparations.  It is a good plan to change  from one  prepara-
tion to another after a few weeks, giving thus several, or it may be many, of
the different preparations in succession.
  The  chalybeate remedies should be given in moderate doses after meals—
that is, during the  process  of digestion—and in  order  to secure their full
efficacy they  should be continued uninterruptedly for a  considerable and
perhaps for a long  period.   It is well  to state  beforehand to a patient that
all the good which they may accomplish is not to be expected within a brief
period.   This statement will be  likely to secure  patience  and perseverance.
Patients often think that they do not tolerate  iron in any form.  In general,
they are self-deceived in this regard, as  may be demonstrated  by their ability
to take it with no inconvenience if it be given without their knowledge.
  Arsenic is  another remedy often of  much  efficacy in the treatment of
anaemia.  It should be given in small doses, which should not be increased,
and it should  be continued for a considerable period.   The effect of this rem-
edy is sometimes more marked than that of  chalybeates.
  Wine, especially Burgundy, is often  useful.   Here, as in other affections,
alcoholics are of use only when they have a cordial  effect, promoting assimi-
lation and perhaps diminishing waste of tissues, without any excitant effects.
Alcoholic excitation is always to be avoided, and the immediate effects, if in
any way  uncomfortable  or disturbing,  are  contraindicating.    Malt liquors
sometimes agree better than wine.  Spirits, as  a rule, are not appropriate.
As  to the kind of wine or  malt liquor to be preferred, experience in each case
is to be the  guide.   Cod-liver  oil, if it do not impair the appetite or disorder
digestion, contributes to the reproduction of red corpuscles.  If not well borne
the extracts of malt may be substituted.
  In cases of anaemia assurances of the absence of any grave disease and an
encouraging prognosis are often of much weight as a therapeutical factor.
Despondency  is an  effect of the  anaemic condition  upon the mind, and the
physician in many cases has it in his power  not only to remove gratuitous
apprehensions, but  to do  not  a little toward  a  cure by holding out proper
expectations of recovery.


                               Chlorosis.

  Although the chief element in chlorosis is undoubtedly anaemia, it presents
certain peculiarities which render its separate consideration appropriate.  The
impoverishment of the blood in chlorosis has reference chiefly to the red
corpuscles, and in a less degree to the albuminous constituents of the plasma. 
CHLOROSIS.
371
There is a reduction in the quantity of haemoglobin in the red  corpuscles,
either with  or  without a diminution in their number.   It is  especially  in
chlorosis that a reduction in the percentage of haemoglobin has been found
without a corresponding decrease in the  number of red corpuscles.  Cases
have been observed in which the number of red corpuscles was normal, while
less than one-half of the proper amount of haemoglobin was  present.  This
condition  of  disproportionate diminution of  haemoglobin is called achroio-
cythaemia or oligochromaemia.  (See Part I. p. 60.)  Usually, however, the
number of corpuscles  is lessened, as well as the  percentage of  haemoglobin.
  According to Virchow, an almost constant lesion in  chlorosis is arrest of
development of the vascular system, as indicated by the small  size and the
thin coats of the aorta and other arteries.  The intima of the arteries some-'
times contains  yellowish spots  and streaks in consequence of fatty degener-
ation.   Most observers do not consider  these irregularities in  the  vascular
system  as a constant  and essential change in chlorosis.   Arrest in  develop-
ment of the female generative organs has been observed in cases of chlorosis,
but, on  the  other  hand, they often present no abnormalities.   No especial
importance, therefore, can be assigned to anatomical changes in these parts
as entering  into the causation.
  Aside from the foregoing  differential points, the term chlorosis is applied
to anaemia occurring in girls at or near the period of puberty, usually between
the ages of  fourteen  and twenty-four, the causes often  not being apparent.
The term  denotes a greenish coloration pertaining to the facies, but  this  is
by no means a  criterion.  By some writers chlorosis is regarded as a neuro-
pathic affection not always associated with anaemia.  While anaemia is a con-
stant element, there are doubtless  causes which act upon the nervous system
primarily  and more directly than  by inducing impoverishment  of the blood.
The  development of the  affection  is evidently in some way connected with
the evolution of the sexual  system.  How far the causation may involve, on
the one hand, ungratified sexual desire, or, on the other hand, unnatural self-
abuse, it is difficult to say.  There is ground for the belief that  each of these
causative  agencies  is not infrequently operative.   Disappointment in love,
the loss of relations, and crosses  of various kinds may be involved.  These
less  apparent  and  other secret causes  may act  in  conjunction  with those
already stated  as  giving rise to  simple or benign  anaemia. (Vide p. 367.)
Blondes are said to be more liable to become  chlorotic than brunettes.  The
affection, however,  is not exclusively  confined to  girls.   It is  occasionally,
owing probably to  similar causative agencies, met with in  boys.
  The symptoms which have been enumerated  as  belonging to the clinical
history  of simple or benign  anaemia are more  or less marked in cases of chlo-
rosis.   Fantastic perversions of appetite are not uncommon in chlorotic girls,
manifested by a craving for chalk, slate, charcoal,  and other innutritive  sub-
stances.   These perversions are somewhat distinctive of chlorosis.  The other
points in the differentiation from  simple or benign anaemia are  those which
have been stated as characteristic  of the chlorotic affection—namely, the sex,
the age, the  absence of an obvious adequate causation, the probable connec-
tion with the sexual instinct, and in some instances the reduction in quantity
of the haemoglobin of the blood without diminution in the number of red
corpuscles.   As in simple or benign anaemia, the diagnosis requires an exclu-
sion of the graver diseases of the haematopoietic system and of other diseases
of which anaemia is a symptom.
  The treatment of  chlorosis embraces measures, the same as in simple  or
benign anaunia, relating to diet, out-of-door life, etc., adapted to the circum-
stances  proper  to individual  cases;  and the preparations  of iron, as  a rule,
are not  less  indicated and not less efficacious. The rules for their adminis- 
372
LE UCO CYTHJEMIA.
tration are the same.  Arsenic is sometimes highly useful.  Mental  hygiene
is of special importance in proportion as causative agencies relate to the mind.
Agreeable diversion and the moral effect of change  of scene  are often im-
portant measures of treatment.   Occupations and  sentiments which will dis-
place  sexual thoughts and desires in  some instances  have a radical  efficacy.
This statement will include the  instances in which self-abuse  can be  ascer-
tained.
                       CHAPTER  II.

                         LEUCOCYTHAEMIA.

   THERE is a group of diseases characterized by a new growth of lymphatic
    tissue in various parts of the body.  Lymphatic or adenoid tissue con-
sists of reticulated connective tissue containing in its meshes lymphoid cells.
This new lympathic growth may be homologous or heterologous.  It is homol-
ogous when  in the form of hyperplasia of pre-existent lymphatic tissue, as of
the spleen, lymphatic glands, and marrow of bone.   It is  heterologous when
lymphatic tissue  is produced in situations where it does not normally exist,
as in the liver, kidney, skin, etc.  It has been proposed to  call these  diseases
connected with hyperplasia of the lymphatic structures, lymphatic  diseases.
Common to  all of these diseases is profound  anaemia, generally progressive
and fatal.   The basis of classification usually adopted depends upon the num-
ber of white corpuscles present  in the blood.   When the pathological  changes
in the lymphatic tissues above mentioned are associated with marked  increase
in the number of white corpuscles, the name leucocythaemia is given to the
disease.  When the same pathological changes exist with anaemia, but with-
out excess of  white corpuscles, the disease  is called  pseudo-leucocythaemia.
Pseudo-leucocythaemia includes splenic anaemia, lymphatic anaemia, and prob-
ably some cases  of so-called progressive pernicious  anaemia.


                          Leucocythaemia.
   Leucocythaemia or leukaemia  is a chronic disease characterized by a persist-
ent and considerable increase in the number  of white corpuscles in the blood.
A temporary excess of white corpuscles, usually moderate in amount,  is called
leucocytosis. (See Part I. p. 65.)  Alterations in the  marrow of the bones,
enlargement of the spleen,  and hyperplasia of the lymphatic glands consti-
tute, either  singly or combined, the leading  anatomical changes in  leucocy-
thaemia.   Leucocythaemia is usually divided into three forms,  called  splenic,
lymphatic, or medullary according as the changes in  the  spleen, lymphatic
glands,  or the  marrow of the  bones  seem to be primary and predominant.
The medullary form is also called myelogenic leucocythaemia.   These forms
are usually combined with  each other to a greater  or less  extent, and hence
the terms  lymphatico-splenic, medullo-splenic, etc.  These subdivisions of leu-
cocythaemia are not associated with essential  differences in the clinical history,
and are of importance  chiefly as indicating that the anatomical changes may
predominate in certain  organs.  There has been much difference of opinion as
to the part primarily affected in leucocythaemia.  The prevailing view has been 
LEUCOCYTHAEMIA.
373
that the  primary alteration  is in the  spleen, or more rarely in the lymphatic
glands.   Changes in  the marrow of the bones  have been found, as a rule,
since  attention was called to  them by Neumann.  This  pathologist believes
that they  are  constant  and form  the primary lesion.   It seems, however,
probable that the  changes in the spleen, the lymphatic glands, and the mar-
row of the bones  are co-ordinate, and in proportion  to their degree of equal
importance;  but the changes  may  be extensive  in one part and insignificant
in the other parts.
   The pathognomonic change in the blood  may be  detected during life in a
drop drawn from  the finger,  or after death by  examining the blood in  the
heart and  vessels.  The blood  is paler  than normal, and  of a brownish-red,
sometimes  almost of a chocolate, color.  The clots found  in the heart and
vessels are of a yellowish color in  their superficial layers,  and of a soft, vis-
cous consistence, so that they bear  some resemblance to very thick pus.  The
proportion  of white corpuscles to red in health, although varying within wide
limits, is on the average about 1 white  to 500 red.   In leucocythaemia there
is often  1 white  to 10 or 8 of  the red, and there may be even 1 white to 3
or 2 red.   In one case related by Sorensen there were 3 white to 2 red.   In
the great majority of cases the proportion  during  the course of the disease
exceeds  1  white to 20 red  corpuscles.  Although in general the white cor-
puscles in leucocythaemia resemble the ordinary  white blood-corpuscles, there
are certain differences to be noted.    In  addition to  the ordinary polynuclear
white blood-corpuscles,  leukaemic  blood often contains a large number  of
mononuclear corpuscles, of  which some  are small with a narrow rim of proto-
plasm, like lymph-cells,  while  others are large with a broad mantle of proto-
plasm, like cells in the spleen and in  the marrow of the bones.  According to
Virchow, an abundance of  small corpuscles  is indicative  of lymphatic leukae-
mia, and an abundance of  large corpuscles, of splenic leukaemia;  but  there
are doubts as  to the correctness  of  this view.   Most of the leucocytes in
leukaemia  are  more  sluggish in  their amoeboid movements than  ordinary
white blood-corpuscles.1  Nucleated  red blood-corpuscles  may be present in
leukaemic blood, although  not  often in large number.  The blood-plates are
sometimes increased  in  number, but they may be fewer than normal.   The
number of white blood-corpuscles may vary considerably within a short time.
Eisenlohr describes a case in which the  excess of white corpuscles nearly  dis-
appeared during a febrile attack, to return again after its subsidence.
   The  number of red blood-corpuscles is  usually  considerably diminished,
although exceptionally it may be normal.  The red corpuscles may be reduced
to one or two millions, or even less, per cubic millimetre.   The red corpuscles
are usually of  normal appearance,  but they may present the various changes
described in the article on Anaemia in Part I. (p. 60).
   The fresh blood is  always alkaline, but it has a tendency to rapidly assume
an acid reaction.  The specific gravity of the blood is lessened.  The amount
of fibrin is said to be increased.
   Some  degree of splenic enlargement is usually present in all forms of leu-
cocythaemia.  In splenic leucocythaemia, which is the most frequent variety,

   1 Other peculiarities of the white corpuscles in leukaemia have been noted, especially
by Ehrlich.  Some of the corpuscles may contain molecules of fat, others, granules of
brown pigment.  There  is an increased  number of corpuscles containing granules which
stain with eosin (eosinophilic  cells).  There may be corpuscles containing  granules
which stain  with basic aniline dyes (Mastzellen).  These do not occur normally in  the
blood.  The mononuclear cells may contain  granules which stain  with neutral aniline
dyes, like granules normally found in polynuclear cells (neutrophilic granules),  ft has
been suggested that many of the corpuscles are not white blood-corpuscles, but are color-
less corpuscles, such as are intended normally for the formation of nucleated red blood-
corpuscles in the medulla of bone. 
374
LE UCOCYTHJEMIA.
 the enlargement is often extreme.  According to Gowers,1 the average weight
 of the spleen in splenic leucocythaemia is a little less than 6 pounds, and its ave-
 rage length, Hi  inches.  Leucocythamic spleens weighing 16 and 18 pounds
 have been recorded.  The increase in size  is usually uniform in  all directions.
 The notches upon the  anterior border, the recognition of which  may aid in
 the diagnosis, are often exaggerated.  The capsule of the spleen frequently
 presents thickened white patches.  There  may be adhesions between the sur-
 face of the spleen and surrounding parts.  The consistence of the organ is
 usually increased, but it may be soft, especially in the early stages.  The cut
 surface of the spleen may be uniformly brownish-red in color, or the  Mal-
 pighian bodies may be prominent as  whitish dots, or, when greatly enlarged,
 they may even appear as tumors in the substance of the spleen.  The whitish
 trabeeulae may be much thickened, especially in the late stages.  The spjeen
 sometimes presents on section a mottled appearance from the presence of dark-
 red or yellowish, wedge-shaped infarctions.  These are ascribed to  obstruction
 of certain of the splenic vessels  by the accumulation of white  blood-corpus-
 cles.   Softened spots due to hemorrhage and the disintegration  of the splenic
 pulp or to collections of pus have been met with in leukaemic spleens.  Micro-
 scopical  examination shows the change to  consist in  a hyperplasia of the
 organ; that is, in an increase of the normal elements  of the  spleen.  The
 hyperplasia affects chiefly the splenic pulp, but sometimes to a greater extent
 the Malpighian bodies.   Large cells containing coarse granules  either of pig-
 ment or of fat  are  common  in leucocythamic spleens.
   In the splenic  and medullary forms of leucocythamia, the lymphatic glands
 are often more  or less enlarged, and in the lymphatic variety an excessive
 hyperplasia of the glands  is an early symptom.   The abdominal, inguinal,
 cervical, and axillary glands are those most frequently affected.   The single
 glands may attain the size of a hen's  egg, but  they  are usually  smaller.
 Their  consistence is  soft, rarely hard, and their color  gray or  reddish-gray.
 The microscope  shows  an adenoid reticulum infiltrated with lymphoid cells,
 as in the normal glands.   Allied  to the  affection of the lymphatic glands
 there is  sometimes  a similar hyperplasia  of the follicles of the tongue and
 pharynx, of the  tonsils, and  especially of the solitary follicles and Peyer's
 patches in the intestine.
   The change in the marrow of the bones is to be included among the hyper-
 plasias of lymphatic structures.   The change consists in  the disappearance, to
 a  greater or less extent, of the fatty medulla normally present in the  long
 bones  of  adults, and its  replacement by  a tissue rich in lymphatic cells.
 Alterations have  usually been found in the long bones, the ribs,  the sternum,
 and the vertebra. The altered marrow has either a greenish-yellow, purulent
 aspect, or  a  dark-red appearance resembling that present in the bones of
 embryos and infants and in profound  anamias.   Neumann calls  the greenish-
 yellow transformation pyoid, and the dark-red,  lymph-adenoid.   There is less
 difference in the microscopical structure than the gross appearances would
 suggest.   In the pyoid alteration,  which is the more common, the yellowish
 color becomes somewhat reddened by exposure  to the air.  The  marrow is of
 a soft, pulpy consistence like that of creamy pus, but there is usually no real
 breaking down into pus, as a net-like  reticulum can be demonstrated between
the cells.   In the lymph-adenoid change the marrow is dark red  in color, and
of a gelatinous consistence firmer than that of the pyoid marrow.   The dark-
red and the  yellowish  colors may be found side  by side.  The  reticulum
between the cells is better developed  in the dark-red  than in the pyoid mar-
row.  In both there  is a rich capillary network.   In both the cells resemble
the normal medullary cells and those  present in the blood.  Sometimes large
       1 Article " Splenic Leucocythaemia,"-in  Reynolds's System of Mdicine. 
LEUCOCYTHAMIA.
375
granular, at other times smaller and less granular, cells predominate.  Nucle-
ated red corpuscles are present, but not usually in large number.  The hyper-
plasia, when excessive, is at the expense of the  surrounding bone-substance,
which thereby becomes more or less rarefied.  The sternum in rare instances
may become softened through its entire thickness, and swollen by hyperplasia
of the marrow and absorption of bone.   This softening may be detected dur-
ing life.  Similar changes have been observed  in the ribs and other bones
during life.   These changes in the marrow have  been studied most carefully
by Neumann, who regards them as the most constant and important of the
pathological changes in leucocythamia.  Cases have  been reported in which
the changes in the marrow seemed insufficient to account for the alteration in
the blood.1
  Changes are  also  observed in leucocythamia  in non-lymphatic  organs.
These changes are either diffuse or  circumscribed and nodular.  The diffuse
alteration consists in the distension of  capillaries and the infiltration of the
tissues with white blood-corpuscles.  The  circumscribed  changes, which are
not common, consist in the nodular  accumulation of leucocytes either with
or without a new growth of adenoid  reticulum between the cells.  To  these
nodular  accumulations the  names  heteroplastic leucocythamic growths,
lymphoniata, and lymph-adenomata  are applied.
  The liver is enlarged in the majority  of cases, especially those  of the
splenic variety.   A weight  of six or seven pounds is not uncommon.   Vir-
chow  describes  leukamic  livers weighing from  eight to fourteen  pounds.
The enlargement is due to a  distension of the capillaries with leucocytes,
and  to the infiltration of  the tissue  between  and within the  lobules with
these  cells, probably in consequence  of their escape  from the vessels.   Dis-
seminated whitish  nodules, usually  minute, but  sometimes of considerable
size, consisting of lymphoid cells, are  frequently found  in the interlobular
tissue.   These  nodules are called lymph-adenomata  when an adenoid retic-
ulum  can be demonstrated between  the cells.
  The kidneys are  not infrequently enlarged.   The changes are diffuse and
circumscribed as in the liver.   Parenchymatous alterations may or may not
be present.  Tizzoni  has described infiltration and nodules of lymphoid cells
in the testicles.   Leucocythamic  growths may  furthermore be  scattered
through  different  parts of  the body, as the alimentary tract, the lungs, the
serous membranes, the brain and  the retina, the  skin. etc.  Nuclear figures
indicating cell-proliferation have been found in  the  lymphoid cells in these
growths.
  Next to these accumulations of lymphoid cells,  the frequent occurrence of
hemorrhages  in  leucocythamia deserves mention.  Subserous  ecchymoses,
hemorrhages  into  serous cavities and from  mucous  membranes, and retinal
and cerebral hemorrhages may be mentioned as frequent and important.  The
gums and the mucous membrane of  the mouth and pharynx may be  swollen
and ulcerated.  The lymphoid growths in  the intestine may ulcerate.  Pro-
nounced  fatty degeneration, especially of  the  heart  and kidneys,  has  been
repeatedly observed.
  A arious abnormal substances have been  found in leucocythamic blood.
These  are bodies analogous to glutin,  hypoxanthin, leucin, tyrosin, and acetic
and formic acids.  These  substances have not  been uniformly discovered.
Some are normally present in  the  spleen.   There are frequently found after

  1 Fleischer and Penzoldt have reported a case of lymphatic leucocythaemia without
change in the marrow of the bones.  Leube and Fleischer have reported a case of leukae-
mia with lymph-adenoid marrow, but without changes in the spleen  and lymphatic glands.
Neumann also has observed eases in which the medulla of the bones was involved with-
out affection of the spleen or lymphatic glands. 
376
LE UCOCYTHJEMLi.
death minute colorless, elongated, octahedral crystals called Charcot's crystals.
They have been detected in the blood, the spleen, the marrow of the bones,
the liver, and even in other parts.   They are thought  to  be of an albumi-
nous  composition.   Although most  abundant in leucocythamia, they have
been  found in  other  conditions, and they may form after  death in  healthy
marrow.
  There  have been  several theories as  to the  relation in  leucocythamia
between  the morbid change in the blood and the hyperplasia of the lymphatic
structures.  Bennett, to whom we owe the first recognition, in 1S15, of leuco-
cythamia as a distinct disease, maintained that the change  in  the blood was
primary ; and the same view  has had its advocates  in  recent years.  Most
modern  pathologists,  however,  have accepted Virchow's  doctrine that  the
increase  of white corpuscles  in the  blood is  secondary to the  pathological
changes  in the  lymphatic  organs to which  is assigned a blood-forming func-
tion.  Some have emphasized chiefly the affection of the spleen, and others, that
of the marrow of the bones.  According to one theory, there is an insufficient
transformation of white into red corpuscles in the blood-forming organs and
in the blood ; according to another, there is increased production of white cor-
puscles,  an exaggeration of the cytogenic function.   The most probable view
seems to be that  there is increased formation of white corpuscles in the spleen,
the lymphatic glands, and in the marrow of the  bones, sometimes chiefly in
one, and  sometimes in  all of these organs.   From these hyperplastic organs the
corpuscles are swept in large  numbers into the blood and the lymphatic cur-
rents.  Either the production  of red corpuscles is diminished or their destruc-
tion is increased.1

   The development of leucocythamia, as determined by symptoms, is usually
slow and imperceptible.   Before the  character  of the disease  is determinable
general  debility,  indisposition to exertion, disorders of  digestion, and other
indefinite ailments  have existed for  one or  two years,  and sometimes for a
much longer period.  In exceptional  cases, oftener in children than in adults,
it is  developed  within  a  few  weeks.  Early and prominent  symptoms  are
those referable to impoverishment of the blood.   Pallor  of the face, pro-
labia, and  mucous membranes, and dark coloration of the eyeballs, are more
or less marked, as  in cases of benign anamia and  chlorosis, for which  the
disease  in its early stages is  liable  to  be mistaken.
   Coincident with the anamic symptoms is enlargement of  the spleen.  This
enlargement, if not great,  may not have attracted the attention of the patient.
The enlargement, however, is  often so great as  to form a splenic tumor which
occasions a projection obvious to the  eye.  The tumor may occupy a consid-
erable part of the  abdominal space.   It has been mistaken  for an  ovarian
tumor.   It may  cause dislocation of the heart,  and, by pressure on  the dia-
phragm,  interference with  respiration.  Pain and tenderness referable to  the
enlarged spleen are frequent but not  constant symptoms.
   In the so-called  lymphatico-splenic variety there  is swelling of the glands
of the neck, groin, and axilla, forming soft, movable tumors  rarely of much
size.  The mesenteric glands are sometimes enlarged, so  as to be  felt through
the  abdominal walls.   The bronchial glands may be enlarged, but rarely to
an extent sufficient to occasion notable bronchial  obstruction.   The glandular
swelling  may occur either  early or late in the progress of the disease.  If the
disease involve the marrow of bones  (medullo-splenic and  myelogenic leuco-

  1 The idea has been advanced that leucocythaemia and pseudo-leucocythaemia are infec-
tious diseases dependent upon some special organism in the blood.  Some pathologists
class the lymphomatous growths of these  diseases among the infectious tumors.  This
idea, which is not without some probability, is at present purely an hypothesis. 
SYMPTOMS.
377
cythamia), there may be found over these, particularly the sternum, tender-
ness and sometimes swelling, but, as a rule, local symptoms are wanting.
  Dyspnoea is a symptom more or less prominent, attributable to the paucity
of red corpuscles.  It may be  caused, in addition, by  enlargement of the
spleen and also of the liver, the latter occurring frequently.   The dyspnoea
is increased, and may be rendered extreme by hydrothorax in connection with
general dropsy and in some instances pleurisy with effusion.
  General dropsy occurs sooner or later  in a large proportion of cases.   It
may be independent of cardiac or renal disease, but the latter is a complica-
tion in some cases.  Hydro-peritoneum is sometimes produced by the pressure
of enlarged glands on the vena porta, and the accumulation of liquid may be
so large as to  call for paracentesis.
  The action of the heart is increased in frequency, often considerably, and
paroxysms of  palpitation, during which the pulse is 150 or more per minute,
are not uncommon.   Hamic murmurs are common, as in  benign anamia and
chlorosis.  The temperature of the  body is in most cases raised.  Different
cases differ in respect of the amount of  pyrexia.  It is  generally moderate
(from 100° to  102°  Fahr.).  Occasionally there  is hyperpyrexia.   Usually,
there are febrile exacerbations in the evening.   The temperature is found  to
fluctuate between wide limits at different times in the same case during the
progress of the disease.   The course of the disease is rapid  in proportion  to
the  degree of persistent  pyrexia.
  The liability to hemorrhage is such that a hemorrhagic diathesis  may be
said to constitute a prominent feature of  the disease.  Mosler emphasizes the
importance of recognizing this diathesis as contraindicating  surgical  opera-
tions in cases of leucocythamia.  He relates a case in which the patient nearly
died  from an  insignificant operation, the bleeding having been stopped only
by  continuous digital compression.1  Hemorrhages  may  occur early  in the
disease.  The most frequent seat is the nose. Epistaxis may prove the imme-
diate cause of death.  Enterorrhagia, gastrorrhagia, and menorrhagia are not
rare.  Bronchorrhagia and hamaturia have been observed.   Cerebral hemor-
rhage is a cause of death in  some cases.  Cutaneous ecchymoses are among
the  events incident  to the disease, and  extravasation beneath  the  skin, in
muscles, inclusive of the heart, and into joints. Eisenlohr has reported a case
in which peripheral paralysis of several cranial nerves was caused by hemor-
rhage into their sheaths.2  Friedliinder- has reported a case in which the symp-
toms of cerebral tumor were caused  by leucocythamic growths in the brain.
   Among events pertaining to the digestive system may be mentioned inflam-
mation of the pharynx and  mouth, accompanied sometimes with ulcerations
and sometimes with  bleeding  from  surfaces  not  ulcerated.   Tumors of the
character of lymphoma are sometimes developed in the throat.  The appetite
varies in different cases, and at different periods in the same case.  It may not
at first be diminished, and it may even be inordinate ; but in the latter part
of the disease there is generally anorexia.  Vomiting is an  infrequent symp-
tom.  Diarrhoea is  a frequent symptom, and  the  dejections are sometimes
dysenteric.  Jaundice is an occasional event.
  The urine has an excess of uric acid. Hypoxanthin, formic acid, and lactic
acid have been found in small quantities—not, however, constantly.  Albumen
in any considerable quantity and casts denote the existence of renal disease
as a complication.
  Salzer was the first to call attention to  persistent priapism without seminal

  '"Ueber hiimorrhligische Diathese bei Leukiimie," Zeitschrift fitr klin. Mediein, Bd. 1,
p. 2(>o. lie observed a case in which priapism  lasted seven weeks, and when this symp-
tom disappeared the power of erection was lost.
  2 Virchow's Archiv, Bd. 73.                                    * Ibid., Bd. 77. 
378
LEUCOCYTILEMIA.
emissions or sexual  desire  as  an occasional symptom  in  leucocythamia.1
Others have observed this symptom.  Dr. G. L. Peabody has reported a case.*
Another case has been  reported  by Dr. G. F. Wetherell.3
  The following morbid  appearances in the retina have  been observed  by
means of the  ophthalmoscope: A  pale appearance of the  retinal vessels,
hemorrhagic  spots  with white  centres from an  accumulation of lymphoid
cells,  whitish streaks, and cloudiness  of vessels about the optic papilla.  The
name leucocythamic retinitis has been applied to these changes.  They may
or may not give rise to notable disturbance of vision.  The  retinal hemor-
rhage may be sufficient to cause blindness.   Headache, vertigo, feebleness of
the mental faculties, delirium, and chronic  derangement of mind occasionally
enter into the clinical history.   To these may be  added  impairment of hear-
ing, furuncles, and  pustular  eruptions on  the skin.  In a case of leukamia
with  deafness Politzer  found leukamic growths  in the internal ear.
  The limits of the duration of leucocythamia are far apart.  In very rare
instances it runs a rapid course, ending within a  few weeks.   On the  other
hand, its  duration may extend  over  many years.   The  average  duration is
about two years.   It is not always  easy  to ascertain the  duration, owing to
difficulty of fixing  the precise date of the  origin of the disease.   The termi-
nation often depends on events which are incidental to the disease, or on com-
plications, such  as  hemorrhage, apoplexy from  extravasation,  pleurisy, renal
disease, diarrhoea, etc.  If not dependent on any of these events, death is pro-
duced by slow asthenia.

  The prognosis is as grave as possible after the disease has made a certain
degree of progress.  In some  instances, early in the course it has ceased to be
progressive and  recovery has taken place.   If, with great blood-changes, the
spleen becomes much enlarged,  and  more or less of the grave  events belong-
ing to the clinical history have taken place, there is little or no ground, with
our present knowledge,  for  any expectation  of recovery.   The  most to  be
hoped for is that  the  disease will  progress slowly, and  that events which
involve  immediate  danger may not  occur.   There are occasionally  marked
remissions in the progress of the disease.

  The clinical history of leucocythamia from the beginning to  the end of the
career of the disease contains  diagnostic characters, but these are not sufficient-
ly distinctive in all  cases  for the differentiation from  pseudo-leucocythamia
and pernicious anamia.  In an early period of the disease, when a diagnosis
is desirable, it is liable to be mistaken  for other  diseases  in  which  anamia
coexists with splenic enlargement.  A positive  diagnosis, however, is always
practicable by means of examinations of the blood.  Delay or failure in the
recognition of the  disease is owing  to neglect of the  means  by which  the
diagnosis is to be  made.
  The diagnostic criterion is a persistent and progressive increase of  the
white corpuscles of the blood beyond the  limit of the  variations embraced
under the name leucocytosis.  This name  embraces a greater or less increase
of the white corpuscles, occurring  as  a symptom  in  various diseases,  the
increase  falling short of that  which constitutes  the  criterion  of leucocy-
thamia.  (Vide  Part  I. p. 65.)  The  rule  generally accepted as  regards the
increase requisite for the diagnosis is a proportion of 1 white corpuscle to  20
red corpuscles.   As already stated, the proportion is often much greater than
this, the number of white being  sometimes  equal to that of the  red corpuscles.
  1 Bert. klin. Wochenschr., 1879.                   2N Y. Med. Journ.. May, 1880.
  3 N. Y.  Med. Record, Aug. 14,  1880.  Two other cases are reported in the A'. 1'. Med,
Journal, Sept.,  1880. 
TREATMENT.
379
 On the  other  hand, in the early part of the disease  the proportion  may be
 considerably less than 1 in 21); and  if on repeated examinations the propor-
 tion be found to progressively increase, there can hardly be doubt as regards
 the diagnosis.
   The method of examination ordinarily employed is to obtain a drop of blood
 by pricking the finger of the  patient, and, placing it in the field of the micro-
 scope, to estimate with the eye the relative proportion of the white  and red
 corpuscles.  A more  accurate method is to add to a measured quantity of
 blood a definite quantity  of a 5 or 6 per cent, solution of sulphate of soda, in
 order to dilute the blood  and  to prevent the red corpuscles from forming rou-
 leaux.   The field  of the microscope is divided into  squares, by the aid  of
 which the corpuscles can be easily counted.   The squares  are ruled either
 upon the eye-piece or upon the cell containing the diluted blood.1  It is to be
 observed that the  relative proportion of the white and red corpuscles does not
 show the degree of actual increase of the former, inasmuch as the red corpus-
 cles are  almost  always considerably, and sometimes very greatly,  reduced in
 number.   Hence,  the most exact method is to ascertain  the  number  both of
 white and red corpuscles  in a given quantity of blood by means of the hama-
 cytometer.

   Leucocythamia  occurs at all periods of life, it having been observed  in in-
 fants soon  after birth and in extreme old age.  In the great majority of  cases,
 however, patients  are between  twenty and fifty years of age.  It  is less rare
 in men than in  women.   Social position has no marked influence on its causa-
 tion.   It occurs in women sufficiently often after parturition  to  show some
 causative connection.  In a considerable proportion of cases patients with this
 disease have either had malarial fever or have been exposed to malaria.  The
 disease is less rare in malarial  districts than in  those in which the periodical
 fevers do not occur.  It  is therefore reasonable to attribute to malaria  a cer-
 tain degree of causative  agency.   The white  corpuscles have  been found in
 some cases  to contain black  pigment-granules, such as are characteristic  of
 malarial disease.  Mosler applies  to these cases the name melon o-lenh semi a.
   The  disease  in  a few instances  has been preceded  by local injury in  the
 splenic region.  There is little or no ground for attributing the  disease to
 syphilis.  In most cases the disease is developed in  persons who at the time
 of its development  were apparently in  good health.   These statements express
 all that is at present known of the etiology.

   Diminution of the volume of the spleen has been thought to be  an  import-
 ant object of treatment, under the supposition that the leucocythamia will
 be diminished in proportion.  With reference to this object, various measures
 have been  employed—namely, quinia in full doses, hypodermic injections of
 ergotin, the iodide of potassium, the cold douche, ice applied over the spleen, and
 the application of  electricity.   Each of these measures has appeared  in some
 cases to have produced in a limited degree the desired effect, but in other cases
 to be useless.   It cannot  be said that clinical  experience has established  the
 therapeutic value of any  measure  employed for the object just stated.   Ex-
 tirpation of the spleen  has been  resorted to in at least  16 cases, in all, save
 one, with a fatal result, death  resulting from either hemorrhage or peritonitis.2
 The liability to fatal hemorrhage is enough to render the operation unwarrant-
 able.   Were the operation warrantable, or were it practicable to reduce con-

  1 A convenient apparatus for counting the corpuscles is the hemacytometer of Gowers.
Still more exact  is the apparatus of Zeiss.
  - One successful case of extirpation of the spleen in leucocythaemia has been  reported
in Italy. 
380
PSE UD O-LE UCOCYTHEMIA.
siderably, by any measure  of treatment, the size of the spleen, it  is by no
means certain that the leucocythamia would be  controlled ;  the supposed
pathological connection between the latter and the splenic  enlargement being
theoretical.   Moreover,  the gravity of the disease  does not depend on the
excess of the white corpuscles in the blood.   In pseudo-leucocythamia and
pernicious anamia, kindred diseases in which there is not a considerable excess
of white corpuscles, the gravity is not less than in leucocythamia.
  Neither arsenic nor phosphorus nor any remedy has as  yet  been  found to
have a curative influence over this disease.  The treatment, therefore, resolves
itself into meeting symptomatic indications, and adopting means, medicinal
and hygienic, which  may  succeed in arresting the progress of the disease,
improving the general condition of the patient, and prolonging life.  These
objects of treatment will embrace the prolonged use of preparations of iron,
the various tonics which are likely to improve appetite and promote diges-
tion, hamostatic remedies  and appliances, an alimentation as  abundant  and
nutritious as possible, cod-liver oil as a nutrient, favorable climatic influences,
out-of-door life, mental diversion, and all available sanitary  measures with ref-
ence to nutrition and general invigoration.
                      CHAPTER  III.

       PSEUDO-LEUCOCYTTUEMIA—HODGKIN'S DISEASE.

   PSEUDO-LEUCOCYTHAMIA is the name of an affection in which ana-
    tomical changes similar to those in leucocythamia  are present, without
an increase of white corpuscles in the blood.   In many  cases the anatomical
changes are apparently identical  in both  diseases.   In  such cases it seems
unscientific to make one symptom—namely, the presence of an excess  of
white corpuscles—the  basis of classification.  In justification of this, how-
ever, it may be said that the difference in  the state of the blood not improb-
ably depends upon anatomical conditions which have not  yet been recognized.
Lymphatic, splenic, and perhaps medullary varieties may be distinguished in
pseudo-leucocythamia upon the same  grounds as in leucocythamia.  In the
majority of cases the lymphatic glands are primarily and most extensively
involved.  Hence  the lymphatic form  is the  one generally meant  when the
term  pseudo-leucocythamia is used  without qualification.   A  medullary
variety has not been recognized generally, but certain  cases of progressive
pernicious anamia probably belong  to this subdivision.   To  these reference
will be made in the next article.  In splenic pseudo-leucocythamia the spleen
is the part mainly affected.  This  variety has been called also splenic anamia
and simply hypertrophy or tumor of the spleen.   It  is not to be confounded
with the chronic  enlargement of the  spleen  due to malarial infection.  In
splenic pseudo-leucocythamia the  lymphatic glands are usually, if not always,
involved, but to a  less  extent  than  in  the  lymphatic variety of the disease.
As the affection of the spleen  and that of the lymphatic glands are usually
combined, it is no more possible  to draw a sharp line of distinction between
the  splenic and the lymphatic variety than between  the same forms of leu-
cocythamia.   AYhile the  splenic variety  of leucocythamia is much  more 
PSE UD O-LE UCOCYTHMMIA.
381
common than the lymphatic, the reverse is true in pseudo-leucocythamia.
The anatomical changes  in the spleen are similar to those in leucocythamia,
and need not be again described.   A nodular enlargement of the Malpighian
follicles is more  frequent  than in leucocythamia.
   The following names  are  in use to designate the lymphatic or most fre-
quent variety of  pseudo-leucocythamia: Hodgkin's disease,1  adenia  (Trous-
seau),  lymphatic anamia (Wilks), malignant  lymphosarcoma (Langhans),
malignant lymphoma (Billroth), and lymph-adenosis (Ranvier, Gowers).  The
name pseudo-leucocythamia was  introduced by Cohnheim.   It is probable
that a number of different pathological conditions have  also been described
under these names, especially the term lympho-sarcoma.   Scrofulous enlarge-
ments  of the lymphatic glands, enlargements  confined to a single group of
gknds, and the rare cases  of primary  sarcoma beginning in  one group of
glands and forming metastases in various parts  of the  body, but  not by
preference in other  lymphatic glands, are to be  excluded from the  disease
under consideration.  In this affection  several groups  of glands, sometimes
nearly all  in the body, are involved.   In a large proportion of cases the
spleen and  the  liver are enlarged.   Secondary deposits  may  be present in
most parts  of the body.
   The change in the  lymphatic glands consists  in an increase of the cells
and of the reticulum.   Virchow and  later writers distinguish two forms of
lymph-adenoma, the soft and the hard.  In the  soft variety  the glands are
large, soft,  almost  fluctuating, of a  gray or reddish-gray color, and  often
filled with  ecchymoses.   The  enlargement is due to a new growth of lymph-
oid cells,  between which is a delicate reticulum with wide meshes.  In the
hard form the consistence  of the  swollen  gland is firm, the color grayish or
yellowish-white, and with the hyperplasia of the  cells  there is a new growth
and a thickening of the reticulum or stroma, denser and  more  marked than
in the soft lympho-sarcoma.  There  are transitional forms between the hard
and the soft variety.  In many cases the  hard is a later stage of the soft
enlargement.  In the same  case the characters are  not always uniform.  Some
glands may be hard and others soft.  It is therefore not  desirable to  make a
sharp distinction between hard and soft lymph-adenoma,  although  there are
undoubtedly cases in which the hyperplasia of the reticulum  predominates
from the onset, the glands in no stage of the affection having been soft.  It
is the soft variety which corresponds more closely, in the anatomical  appear-
ances of the lymphatic  glands, with leucocythamia.   The enlarged glands
may reach  the  size of  a  hen's  egg.   They  may remain distinct or may
become  compacted  together  into  a  nodular mass, in  which  the individual
glands can no longer be distinguished.  In the latter case there has been either
a periadenitis or an extension  of the  lymphatic growth into the capsule of
the gland and  into the  surrounding  connective tissue.   The  skin over the
swollen glands is, as a rule, freely movable, rarely adherent. Upon section of
the glands the normal distinction between cortex and medulla is usually oblit-
erated.  In  the harder tumors, often shining and more or  less  hyaline masses
of fibroid tissue may be detected.  Fatty and caseous degenerations are very
rare, a circumstance which  distinguishes lymph-adenomatous from scrofulous
enlargements.  The  affection begins  oftenest in the cervical  glands.   It has
a tendency to involve especially the  glands along the  great vessels; hence,

  1 Hodgkin  published his observations in 1832 (Medico-Chirurgical  Trans., vol. xvii.
p. 69), before leucocythaemia was known. He  first called attention  to coincident enlarge-
ment of the  spleen and of the lymphatic glands as a distinct disease.   His description
included, undoubtedly, cases both of leucocythaemia and of pseudo-leucocythaemia.
Some writers apply the name Hodgkin's disease to lymphatic leucocythaemia as well
as  to pseudo-leucocythaemia. 
382
PSE UD O-LE UCOCYTILEMIA.
the retro-peritoneal glands are more  frequently affected than the mesenteric.
The starting-point  of the disease  may be  in the mediastinal glands.1  The
affection may remain for a considerable time  stationary  in  one group  of
glands without impairment of the  general  health, and then rapidly increase
and  become  generalized,  with the  development of marked cachexia.  The
glands may attain a large size without making compression upon surround-
ing blood-vessels, but in some cases there are severe symptoms resulting from
pressure on the vessels, the air-passages, etc.
  The spleen is  enlarged, according  to  Gowers, in four-fifths of the  cases.
The increase in size may  be enormous, but, as a rule,  it is much less than in
leucocythamia.   In the smaller number of  cases the appearance is that of a
diffuse hypertrophy of the splenic pulp ; in the majority there are disseminated
whitish growths in the form of nodules throughout the spleen.   These  are
probably hypertrophied Malpighian follicles and growths in the  periarterial
sheaths.   Infarctions may be observed as in leucocythamic spleens.   In  the
liver there may be lymphoid nodules or a diffuse infiltration of the interlobu-
lar tissue with lymphoid  cells.  In the latter case grayish  streaks surround
the acini.  The hepatic capillaries may be distended  with blood.   As pointed
out by Schulz, the  secondary lymphoid formations in  the different parts of
the body involve especially the walls of the vessels.  These secondary growths
have been met with in nearly  all parts of the body, as the kidneys, the serous
membranes, the testicles, the lungs, the brain, the retina, the skin, etc.   The
thymus,  the solitary follicles, ami Peyer's patches may be diseased, as in leu-
cocythamia.   The marrow of the bones may present a  reddish  appearance, as
in pernicious  anamia, and may contain  lymphomata.   It rarely shows the
pyoid alteration  found in  leukamia.   ■
  We  are  at present unable  to explain  the relations  between pseudo-leuco-
cythamia and leucocythamia.  We do not know why apparently identical
changes  in the  lymphatic  structures should be  attended in  one case  by
increase  of white  corpuscles  in the  blood,  and not in another  case.  The
theory that in pseudo-leucocythamia there is some obstacle to the passage of
cells from the hyperplastic lymphatic glands into the blood- or lymph-current
is plausible, but is not supported by any anatomical  facts.  Ackermann2 has
succeeded in  injecting the afferent and the efferent lymphatic vessels of both
the soft  and  the hard glands.  He  finds them pervious.   The fact that there
may be the same  changes in the spleen, lymphatic glands, and in other parts
in pseudo-leucocythamia as in leucocythamia is evidence against the view of
those who hold that in leucocythamia  these changes are the result of  a pri-
mary increase of white corpuscles in the blood.  In some cases, especially of
hard lymph-adenoma, the  origin of the growth appears  to be local; but in the
majority of cases several  groups of glands  are affected  simultaneously or in
rapid succession.   In such  cases a  primary  dyscrasia is assumed to exist.
  The symptomatology  of lymphatic pseudo-leucocythamia embraces the
events which  belong to the clinical history of leucocythamia—namely, general
debility,  feebleness of the circulation, hemorrhages, general dropsy, pleuritis,
and other complications, together with the varied phenomena referable to per-
sistent progressive  anamia.   A  distinctive  feature is the occurrence, uni-
formly earlier and more extensive,  of  enlargement of  lymphatic glands, and
often the development of lymphoid tumors where these glands are not nor-

  1 R. Schulz (Arch. d. Heilknnde, Jahrg. 15, p. 223, 1874) has analyzed 38 cases with
reference  to the frequency with which different groups of glands are affected.  The
cervical glands were affected in 28 cases, the retro-peritoneal in 21, the inguinal in 20,
the  mediastinal in 18. the bronchial in 14, the mesenteric in  14, the lumbar in 12, the
axillary in 9,  the cubital in 4, the popliteal in 1.
  2 " Ueber die malignen Lymphome," Diss. Bern., 1879. 
CA US A TION—DIAGNOSIS.
383
mally discoverable.   The cervical glands are affected in a great majority of
cases, and in most of these cases primarily.  The aggregated enlarged glands
may attain to a large size, causing much  deformity.  Next in  frequency the
axillary glands are affected.  The  glands in the anterior and posterior medias-
tinum, the bronchial, the cardiac,  the retro-peritoneal, the mesenteric, and the
inguinal glands, may be, severally or collectively, the seats of the local affec-
tion.   Lymphatic growths may be found in the tonsils, the thorax, the  soft
palate, the posterior part of the tongue, the oesophagus, and beneath the skin.
Perhaps the most remarkable case on record as regards the extensive distribu-
tion of  these growths or tumors was reported by Dr. James PI. Hutchinson.1
In this case, exclusive of enlarged cervical glands, of a tumor of the size  of a
hazel-nut on the upper eyelid, and of a large tumor  involving the sternum and
the anterior mediastinum, two hundred  and  thirty-nine tumors, ranging in size
from that of a small pea to half a walnut, were counted on the surface of the
body.   There were twenty  tumors on the surface of the brain.  A tumor
surrounded the bodies of the sixth, seventh, and eighth dorsal vertebra,  and
extended within  the spinal cord, causing complete paraplegia. Three hundred
small tumors were counted within  the lungs.  Small  tumors were scattered
over the peritoneal covering of the  intestines.  It is noteworthy that in  this
case the spleen and liver were  healthy.  An unusual  feature was the exist-
ence of intracranial  lymphatic growths.
   The pressure of the tumors in  different situations may give  rise  to import-
ant symptoms.  Pressure upon the larynx or trachea may obstruct respiration,
and death is sometimes  due to suffocation.  Paralysis of the laryngeal muscles
may be caused by pressure upon the recurrent laryngeal nerves.  Obstruction
of the bronchi may be  caused  by enlarged bronchial glands.   The heart is
sometimes dislocated.   The oesophagus in rare instances is obstructed.   The
cervical tumors may diminish the  arterial supply to the brain by pressing upon
the carotids, or they may induce venous congestion  by pressure upon the jugu-
lar veins or the vena cava. Deafness is not infrequently produced by growths
within the pharynx.   The pneumogastric nerve may be involved in a tumor,
and the action of the heart be thereby retarded.   Pain in the upper or lower
extremities may result  from pressure upon  the nerves in  the axillary and
inguinal regions.  The femoral vein may be compressed and oedema of the
lower limb follow.   Jaundice is sometimes  attributable to pressure upon the
bile-duct.   Gastric disturbances and diarrhoea may be symptomatic of lymph-
oid growths in the stomach and intestines.
   The duration of pseudo-leucocythamia, like that of leucocythamia, varies
from a few weeks to many years.   Of 42 cases analyzed by Dr. Hutchinson,
in 29 death took place within two years,  and  in  34 w*ithin three years.   The
average duration is a little less than that of leucocythamia.
   As regards causation, as little  is known of this disease as of leucocythamia.
In  the larger number of cases the age is between ten and  thirty years, but
the disease sometimes occurs in childhood and in extreme old age.  A decided
influence pertains to sex, a large  majority of patients being males.   An etio-
logical  agency referable to  antecedent diseases or to habits of life or to any
appreciable morbid influences  has  not been  established.  The disease often
occurs  in  persons who  at the  time of its development apparently were per-
fectly well.
   The  diagnosis  of lymphatic pseudo-leucocythamia is based upon  symp-
toms common to this disease and  to leucocythamia, taken in connection with
the affection of the lymphatic glands and the fact that there is not an increase
in the white corpuscles of the blood sufficient to constitute the leucocythamic
condition.  The  affected lymphatic glands do not undergo the processes of
      1 Vide Trans. College of Physicians of Philadelphia, 3d Series, vol. i., 1875. 
384
PERNICIOUS ANEMIA.
necrosis and  suppuration  which  characterize  scrofula ;  nor are there the
gradual invasion of adjacent parts and the ulcerations which characterize the
local  history of carcinoma.
   The prognosis is no better than in cases of leucocythamia.  The supposed
instances of recovery in an early stage  are open to the suspicion of an  error
in diagnosis.   There are probably very few if any exceptions to the rule of
a  fatal  termination when the disease is so far advanced  that  the diagnosis is
positive. The progress of the disease may be either slow or rapid.  It is rapid
in cases with pyrexia, profuse hemorrhage, and considerable  anasarca.  The
extent of the  distribution and the degree  of the glandular growths constitute
a measure of the tendency to a rapid progress.  The immediate cause of death
may be an important complication,  such  as disease of the  kidneys, purulent
pleuritis, etc.   The pressure of the  tumors on important  parts  may lead to
the fatal ending.  Irrespective of these causes, the disease proves fatal by
slow  asthenia.
   Measures of treatment have been directed especially to the affected glands.
The external application of iodine, the employment of cold and heat, frictions,
blisters, the injection into the tumors  of iodine, nitrate  of  silver, carbolic
acid, arsenic, and other topical remedies, and galvano-puncture, have all  been
tried, with but little if any satisfactory result.  Excision  of  the affected
glands has been repeatedly resorted to, but  the  efficacy of this measure has
not been established.  The removal of the tumors or their dispersion by any
local  treatment would  not  strike at the root  of the  disease.   An unknown
essential pathological condition  underlies the affection of  the  glands.   This
condition cannot be reached by any therapeutical appliances as yet ascer-
tained.  Excision, however, of enlarged glands may be advisable with a view
to relieve parts,  such  as the larynx or trachea,  sensory  nerves, etc., from
pressure. The internal use of arsenic, the doses  increased to the utmost limit
of toleration, and  conjoined with the injection of Fowler's  solution  into the
affected glands,  has been  advocated by Winiwarter as a useful method of
treatment, but the utility which he  attributed to it has not been confirmed.
   Aside from  any treatment  instituted with the hope of effecting a cure, the
objects and the measures are those stated in connection with leucocythamia.
                        CHAPTEE  IV.

                     PERNICIOUS  ANiEMIA.

   THE  name  pernicious anamia is given to a  severe, often fatal, form of
    anamia for which we are unable to assign a sufficient cause either before
or after death.   The disease has also been called idiopathic or essential ana-
mia.  This form of anamia was first described by Walter Channing of Boston
in 1842.  Subsequently, Addison described idiopathic anamia clearly and con-
cisely.  Since Biermer's publication upon progressive  pernicious anamia in
1872  special attention  has been directed to this disease.
   Pernicious anamia  may develop without  any apparent cause, in  persons
previously healthy and in good hygienic surroundings.  More frequently it
is  secondary to conditions which ordinarily impair the health or produce sim-
ple anamia.  Thus, pernicious  anamia has been observed especially among 
ANATOMICAL CHANGES.
385
those poorly housed, scantily clad, or imperfectly nourished; and also during
or after pregnancy, particularly after repeated  pregnancies.  Further causes
which  have been noticed are—exhausting discharges, such as diarrhoea, re-
peated  hemorrhages, mental anxiety, and excessive mental or physical exertion.
The disease has been observed to follow typhoid fever.  Endemic influences
have also been thought to be of some importance in the etiology of this dis-
ease.   An unusvfally large number of  cases has been  reported from  Switzer-
land and certain parts of  Germany.   In this country  it seems to be less com-
mon, although it is by no means arare disease.  Excluding cases dependent
upon child-bearing, pernicious  anaemia is  as common among men as among
women.  The  disease is  rare before twenty or after sixty years of age.
   It is important to note  that the causes which  have  been mentioned,
although they may  explain a  certain amount of anamia, do not account
for the pernicious character of  the anamia.  To explain this, it is necessary
to assume a profound disturbance of the blood-forming organs—a disturbance
which may be  either an excessive destruction or a lessened production of the
red blood-corpuscles, or both.
   An anamia as intense  as pernicious anamia may develop in  connection
with certain structural diseases, such as malignant tumors, chronic  Bright's
disease, phthisis, leucocythamia,  pseudo-leucocythamia,  syphilis,  chronic
malaria, chronic  diarrhoea, and  the  presence in the intestine of the  parasite
Anchylostomum duodenale.  The  anamia in  these  cases is  symptomatic,
whereas it belongs to the conception of pernicious or idiopathic  anamia
that no adequate cause can be found to  explain the anamia.
   It may happen that the exclusion of some  of the structural conditions
named  is not easy or even possible  during the  life of the patient; and  upon
post-mortem examination they may  escape detection or their recognition may
depend in  an unusual degree upon the knowledge and skill  of the pathologist.
Hence  it is that a certain amount of uncertainty surrounds the diagnosis in
many cases of pernicious anamia.   Thus, it has repeatedly happened that a
case supposed during life to be  an instance of pernicious anamia has proven
upon post-mortem examination to be one of latent cancer of the stomach. A
whole  group  of cases once supposed to belong to pernicious  anamia, and
described as tropical chlorosis  and as  the  anamia of workers in tunnels, has
been found to depend upon the  presence of the Anchylostomum duodenale. A
certain number of cases with all of the symptoms of pernicious  anamia has
been proven to depend upon degeneration of the gastric tubules, thus estab-
lishing a mode of causation of  profound anamia which was suggested by the
author as long ago as I860.1  It is probable that certain other obscure forms
of profound anamia, which now receive a  provisional shelter under the  name
of pernicious anamia, will be relegated by future investigations to other cat-
egories.
   The  most important of the anatomical changes in pernicious anamia
relate to the blood.   It is probable that in many cases there is a diminution
in the  quantity of blood out of proportion to the reduction in the weight of
the body.   Such a true oligamia was proven by Quincke  to exist in two of
his cases.  A diminution  in the mass of blood, however, is usually more a mat-
ter of inference than susceptible of actual proof.  An essential change in this
disease is  the loss of red blood-corpuscles, or oligocythamia, which may be
accurately estimated  by means  of the hamacytometer.  The blood appears
abnormally pale.   In pernicious anamia the number of red corpuscles may
be reduced to one-third or even  one-tenth of the normal amount.  Instead of
5.000,000 red corpuscles per cubic millimetre, it is common to find no more than
1.500,000.  The  number is exceptionally reduced to 500,000 or even lower.
                ' Austin Flint,  American Medical  Times, 1860.
     25 
386
PERNICIO US A NAM I A.
 The quantity of hamoglobin  is not  always reduced  in  proportion  to  the
 diminution of red blood-corpuscles, so that the actual degree of anamia may
 be less intense than is indicated by simply counting the  corpuscles.  It is con-
 sidered by Laache as somewhat characteristic of pernicious anamia, in contrast
 with chlorosis, that the percentage of hamoglobin in the red blood-corpuscles
 is greater than normal.   There may, however, be  extreme reduction in  the
 quantity of hamoglobin, as in  a fatal  case reported by Quinquaud, in which
 the percentage of hamoglobin was 2.6 (instead of the normal 12 to 14). More
 commonly than in any other form of anamia, the red blood-corpuscles present
 abnormalities in size and in shape.   There may be large corpuscles, 12 to 14
 /x in diameter, as well  as  small corpuscles less than 6 p. in  diameter.  There
 are frequently diversities in form described  under the name " poikilocytosis "
 (p.  60), such as pear-shaped, ring-shaped, cup-shaped, kidney-shaped corpus-
 cles, corpuscles with tail-like processes, etc.   There may be alterations in the
 composition of the red  blood-corpuscles revealed only by certain staining
 reagents.    Nucleated  red blood-corpuscles  are  sometimes—according  to
 Ehrlich usually—present.   Blood-plates are generally  fewer  than  normal.
 The white blood-corpuscles are usually not increased  in number, but  there
 have been a few curious cases observed in  which a sudden invasion of the
 blood with large numbers of leucocytes occurred, so that the pernicious ana-
 mia became an actual leucocythamia.
   The specific gravity of the blood is reduced in consequence of the diminu-
 tion in solid constituents.   In one case Quincke estimated the specific gravity
 at 1028, instead of  the normal  1055.
   The body is, as a rule,  not  emaciated, and there  may be decided obesity.
 The surface  of the body and the various organs  and  tissues are  extremely
 pale.   Small  extravasations  of blood are  usually found in different parts.
 The most frequent seats of ecchymoses  are the retina, the inner  surface of
 the dura mater, and the serous membranes.   The hemorrhages in the retina
 are usually small.  They are most  frequent near the  papilla and  along the
 vessels.   The ecchymoses  in the retina often  present  a whitish or  grayish
 centre.   More or less general  oedema, with dropsical  accumulations  in the
 serous cavities, is common.  There may be a slightly jaundiced tint of this
 fluid  as well  as  of the sclerotic coat and of the integument.
   Almost without exception in the fatal cases of  pernicious anamia  there is
 more or  less  fatty  degeneration  of the heart.   Often  this degeneration  is
 extreme and  extends throughout the whole thickness of the  heart.  The heart-
 walls are  usually flabby.   Fatty degeneration of the hepatic and of the renal
 epithelium has also been observed.
   The spleen may be  unchanged  or it may be  moderately swollen.   The
 lymph-glands, which  are  usually  normal in appearance, may  be somewhat
 swollen and of a  deep-red color, containing an unusual number of  red blood-
 corpuscles, among which may be nucleated red corpuscles.
   An interesting lesion of  pernicious anamia is a large accumulation of iron
"or some ferric compound in certain organs of the body, especially in the liver,
 the spleen, the kidneys, and the marrow of the bones.  If microscopic sections
 of these  organs  be treated with sulphide of ammonium, a great quantity of
 greenish-black granules of sulphide of iron can  be seen in the cells.  Thus,
 the hepatic cells may appear thickly studded with such granules.  This accu-
 mulation of iron points to an enormous destruction of red blood-corpuscles, for
 the iron is doubtless derived from this source.
   In the  great majority of cases of pernicious anamia, although  not invari-
 ably, the  fatty marrow which is normally present in the long bones of adults
 is changed  into  red or lymphoid marrow.  Microscopic examination of the
 altered marrow shows that the fat-cells have in great part disappeared, and 
SYMPTOMS.
387
have been replaced by large and small, coarsely and finely granular, medullary
cells.   In addition, as first pointed out by Cohnheim, there are often nucle-
ated red corpuscles  in considerable  number, which  would seem  to  indicate
an increase  in  the  blood-forming function of the marrow.  Cells containing
red corpuscles or their fragments are often found in large number both in the
marrow and in the spleen.  In a few cases there has  been observed a change
in the marrow resembling the  pyoid  alteration of leucocythamia.   Also in a
few cases lymphomatous growths have been found in the marrow of the bones,
in the periosteum, and in the kidney.
   These changes in the marrow have led to the idea  that at least some cases
of pernicious anamia may be regarded as  the  myelogenic form of  pseudo-
leucocythamia,  This view is probable, but an objection to it is that similar
changes, although  generally less intense,  are often present in  severe symp-
tomatic anamia.
   The anatomical changes found after death from  pernicious anamia are not
peculiar to  this disease,  but  may be present in profound anamia from any
cause.   Nor do these changes explain  the  pathogeny  of the  anamia.   As
already mentioned, the high  percentage of iron found  in  different organs is
evidence of  abnormally  great destruction of red blood-corpuscles, although
nothing is known  as to  the  cause of  this destruction.
   The symptoms of pernicious anamia, in so far as they represent a profound
and persistent anamic condition, are essentially those belonging to the clinical
history  of the grave hamatopoietic diseases already considered—namely, leu-
cocythamia and pseudo-leucocythamia.   Anorexia, nausea, and vomiting are
symptoms more constant and prominent than in the diseases just named.
More than  twenty-five  years ago, I ventured  to predict that the disease
would  be found to involve  degenerative changes  in  the gastro-intestinal
tubules.  In a certain number of cases  this  prediction has been found to
be correct. (See p.  439.)  In respect of the symptomatology it will suffice
to state the points embraced in the diagnosis.
   The liability to the error of mistaking  for pernicious  anamia that which
is symptomatic of some  obscure, grave local  affection, especially carcinoma,
has been already mentioned.   This error  cannot always be avoided.   Inves-
tigations, however, should always be directed to the discovery  of some local
aff'ection adequate to explain the anamia.  A positive  diagnosis requires the
exclusion  of any such affection.   A  diagnostic point bearing on this  inquiry
relates to the nutrition of the patient.   Addison called attention to  the fact
that in the  cases of idiopathic fatal  anamia which he described  emaciation
was  not marked, considerable embonpoint  being  often maintained.    As  a
rule, it is otherwise when anamia is symptomatic of a grave  affection like
carcinoma.  In some cases of pernicious  anamia, however, there is  extreme
emaciation.
   Leucocythamia  is excluded by the  absence  of the characteristic blood-
change expressed by the name.  The white blood-corpuscles are  not in suf-
ficient excess to denote that disease.   Pseudo-leucocythamia is excluded by
the absence  of  the affection of the lymphatic glands which characterizes the
disease  generally understood  by that name, more commonly known as Hodg-
kin's disease.
   The question arises not infrequently in cases of simple anamia and chlo-
rosis,  in which the  anamic  condition  is unusually intense and rebellious,
whether the anamia be not pernicious.  As bearing on  this  question  the
following  points are to  be considered:  An  adequate discoverable causation
renders  it probable that  the  anamia is benign.   Yet  an  anamia traceable
to causes which seem to be adequate may prove to  be pernicious.   Intract-
ability of  the disease after the removal of supposed causes and the  faithful 
388
PERNICIOUS ANEMIA.
 employment of appropriate  measures of treatment is proof of a pernicious
 character.    Certain  events  belonging to the clinical history  of pernicious
 anamia  rarely occur in benign  anamia and  chlorosis, however protracted.
 These events are hemorrhages  in  diff'erent situations, general dropsy, and
 pyrexia.  Pyrexial paroxysms of greater  or less intensity, of variable dura-
 tion,  and irregular in  their occurrence are frequent in pernicious anamia, as
 they  are also in leucocythamia and pseudo-leucocythamia.   The loudness
 of  the  hamic murmurs—cardiac,  arterial, and  venous—is somewhat  diag-
 nostic of pernicious anamia.   Notable  feebleness  of  the heart's  action,
 pointing to fatty degeneration,  has diagnostic significance.   Age is to be
 taken into  account;  in the majority of cases pernicious  anamia affects per-
 sons  in the middle period of life, whereas chlorosis in a large proportion of
 cases affects young  subjects.   It remains  to be determined by clinical obser-
 vations how much can be inferred from the abnormal  appearances of the red
 corpuscles  as regards the diagnosis.  Impaired  vision dependent on  retinal
 ecchymoses is to be included among the diagnostic  points, as well  as the
 existence of ecchymoses without an appreciable impairment of vision.   The
 employment of the ophthalmoscope  is thus of importance with  reference to
 the diagnosis.   According to Quincke,  ecchymotic spots in the retina are
 so frequent in pernicious  anamia, and so rare in other affections involving
 anamia, that  they have a significance almost pathognomonic.  That  author
 has also called attention  to  the  occurrence in some cases of a systolic pul-
 sation of the superficial cervical  veins without venous turgescence.  Func-
 tional insufficiency of the tricuspid valve is the probable explanation of  this
 sign,  which occurs sometimes temporarily in other connections.
  The prognosis is affected materially by the latitude  of the  signification
 of the term pernicious in this application of it.  If  a fatal termination be
 essential for the disease to be considered as pernicious, of course there is no
 possibility of recovery.  This is an extreme view.  It suffices for the appli-
 cation of the term pernicious that  the anamia present  an ensemble  of the
 characters  which distinguish  it  in  the  cases which do prove fatal.  Cases
 have  been  reported  presenting the requirements for  the diagnosis of per-
 nicious  anamia in which  recovery has  taken  place.  Taking the view just
 stated, Biermer  and Quincke report 6 recoveries  out  of 54 cases, and Pye-
 Smith has  collected 20 cases of recovery.
  The duration of fatal cases varies  from a  few weeks to several months.
 The average duration is less  than  that of leucocythamia and pseudo-leuco-
 cythamia.   Sudden  death  sometimes occurs from  syncope.   Cerebral hemor-
 rhage may be the immediate cause of death.   If the disease be developed
 during pregnancy, abortion or miscarriage takes  place, the patient speedily
 dying.  If death be not  caused  by either cerebral  hemorrhage or  syncope,
 the mode of dying is by  slow asthenia.1
  The objects and general principles of treatment are sufficiently obvious.
 The removal of all causes which may have  produced  the  disease or  which
 render it persisting and progressive is  an object of prime importance.   The
 substitution for these causes of all agents and influences which affect  favor-
 ably the functions concerned in assimilation and nutrition is the next import-
 ant object.   These objects are widely comprehensive,  but it is not necessary
 to go  into details.  The same principles are involved  as in the  treatment of
the anamia  in all the grave diseases affecting the hamotopoietic system.  Of
medicinal remedies,  arsenic has  been found to  be  the most valuable,  and
 should always be given  a trial.  The arsenic  should be  administered in
  1 For a full report of three cases, and an analysis of the cases published in America
 (39), vide article by Dr. J. H. Musser in Proceedings of the Philadelphia County Medical
Society, 1885. 
ADDISON'S DISEASE.
389
gradually increasing doses.   As  an  extreme  measure, the transfusion  of
blood has been resorted  to, but thus far without results affording encourage-
ment to  expect  from it more than a temporary advantage.  Reasoning a
priori, more than this cannot be hoped for from this measure, inasmuch as it
cannot reach the essential morbid conditions on which the anamia depends.
                        CHAPTER  V.

                      ADDISON'S  DISEASE.

   IX the year lS,">5,Dr. Thomas Addison1 described an affection characterized
    by disease of the  suprarenal capsules, by a peculiar  discoloration of the
skin and  of certain  mucous  membranes, and by  the development of pro-
gressive and fatal asthenia.   This  disease, in  honor of its  discoverer,  is
called usually Addison's disease.   It has also received  the names  bronzed-
shin disease, melasma suprarenale, and suprarenal capsular  disease.   Since
the  masterly description given by  Addison  little has  been added to  our
knowledge of this disease, which  still remains  one of the  most obscure in
the nosology.   The most important  addition since Addison's memoir is that
the change  in the suprarenal capsules usually  presents certain well-defined
anatomical  characters common  to  the  great  majority of  cases.   It was
thought by  Addison that any disease of the suprarenal capsules was capable
of producing the characteristic group of symptoms;  it is now  known that,
as a rule,  the morbid  process  in the capsules is a definite one, to which  the
name fibro-caseous metamorphosis is applicable.
   Almost without exception  both  suprarenal capsules  are  involved.   The
change  may be  farther advanced in one than in the other.   The capsules are
usually  found  to be  enlarged, of firm consistence, and with nodulated sur-
faces.   The size may equal that of  a small hen's egg, but it is usually less.
Sometimes the size is  normal or even less than normal.   The latter condition
generally  corresponds to a  late stage of the process.   Upon  section, usually
no trace of  the normal parenchyma or of the distinction between cortex and
medulla can be detected.  The place of the normal  tissue is  occupied by
opaque,  yellow, friable, cheesy masses imbedded in firm, grayish, semi-trans-
parent fibrous tissue.  The proportion between  these two substances varies;
sometimes one predominates and  sometimes the other.   On  close inspection
gradual  transitions from the  grayish fibrous to the  yellow cheesy  material
can often  be seen.  The  caseous substance may become  dry and calcified, or
it may soften and form collections of  thick, creamy fluid resembling abscesses.
The whole interior of the  organ may be converted  into a hard, cretaceous
mass, or into a  cavity containing creamy fluid.   In this case the organ  may
be much diminished in size.  In some cases small grayish granulations resem-
bling miliary tubercles can  be seen  around the cheesy material and in  the
fibrous  stroma.   The  microscopical examination  of the gray  fibrous  material
shows a  fibrillated, sometimes a reticulated, stroma containing fusiform cells,
lymphoid  cells, and not infrequently  giant-cells.   The caseous substance con-
  1 The Constitutional and Local Effects of Diseases of the Suprarenal  Capsules, London,
1S55. 
390
ADDISON'S DISEASE.
sists of a granular detritus of albuminous and some fatty particles with rem-
nants of cells.   Little nodules composed of lymphoid cells and  giant-cells—
in other words, of tuberculous tissue—have been occasionally observed.   As
to the nature of this change in the suprarenal capsules writers are not agreed.
Some consider it as a chronic inflammation resulting in the formation of con-
nective  tissue and in caseation of the inflammatory products (AVilks).  Others
regard the alteration as tuberculous in character.  This is the most  probable
view.   In  not a few cases undoubted  tuberculous  changes have been found
at the same time in the lungs  and in other parts of the body, but there have
been  many cases in which the alteration was confined to the suprarenal cap-
sules.   In some cases tubercle bacilli have been found  in the lesions of the
suprarenal capsules; in other cases the bacilli  have been  missed.  Further
observations upon  this point are  needed, as well as concerning  the inocula-
bility in animals of the caseous substance in  the capsules.
   The altered capsules are usually found imbedded in a mass  of indurated
fibrous tissue which binds them firmly  to surrounding structures, such as the
liver, pancreas,  kidneys, stomach, vena cava, and diaphragm.   This over-
growth  of  connective tissue  generally  invades the  important  sympathetic
nerves in the neighborhood of the suprarenal capsules—namely, the solar and
suprarenal plexuses and the semilunar ganglia.  Changes have been found,
although not constantly, in these nervous structures.  These consist in hyper-
amia, swelling in consequence of thickening of the nerve-sheaths, fatty degen-
eration  and atrophy of the nerve-fibres and ganglion-cells, and increased pig-
mentation of the ganglion-cells.   Alterations have been described also in the
nerve-plexuses in the stomach  and in the intestine.
   The mesenteric glands, especially those in  the neighborhood of the supra-
renal capsules, are often enlarged and  sometimes cheesy.  It  is  not unusual
to find  enlargement of the  solitary and agminated follicles of the  intestine.
In some cases the spleen has been found enlarged and softened.  Tuberculous
deposits in various parts of the  body are frequent.  Indurated  and  caseous
nodules in the apices of the lungs seem to be the  rule.   General pulmonary
tuberculosis is less frequent.   Caseous nodules  have been found in the testi-
cles, brain  (solitary tubercles), and lymphatic glands.  The carious condition
of the vertebra, which has  been found several  times as  a complication with
and without lumbar abscesses, probably belongs to the category of tuberculous
changes.  Acute miliary tuberculosis  may  result  from  the  invasion of the
suprarenal veins by the tuberculous material.
   The discoloration of the skin and of  certain mucous membranes  is due to
the deposit of brown or yellowish-brown pigment-granules in the lowest lay-
ers of the epithelium.   In  the skin it  is found  chiefly in the  epithelial cells
composing the  two or three lowest layers of the rete Malpighii, and is most
abundant in the layer next to the corium. Similar pigment-granules are found
in the connective-tissue cells beneath the epithelium and  about the blood-ves-
sels.  The deposition of pigment is in the same anatomical elements as in the
negro.
   In some, but not the majority, of eases fatty degeneration of the heart has
been noted, and also parenchymatous degeneration of  the heart, liver, and
kidneys.  More  or  less anamia  is usually present, but the anamia  is rarely
intense, and it  may  be absent.  Anamia is not an essential element of the
disease.
   Before completing the description of the anatomical characters  of Addison's
disease  it is necessary to add that changes in the suprarenal capsules, other
than the fibro-caseous metamorphosis, have  been reported as associated with
bronzing of the skin  and the other symptoms of Addison's disease.   Most of
these changes have  been  due  either to atrophy or to primary or secondary 
ADDISON'S DISEASE.
391
cancer of  the  capsules.  Primary cancer of the suprarenal capsules is very
rare, and  some of the cases so reported seem to have been  in  reality fibro-
caseous metamorphosis.  Secondary cancer is more frequent. In  the' larger
number of cases of carcinoma of the suprarenal capsules no pigmentation of the
skin was observed.   Greenhow, who has analyzed those cases in  which dis-
coloration of the skin was  present, comes to the conclusion that the pigmen-
tation did not present the characters typical of Addison's disease.  Very posi-
tive statements, however, have been made as to the indentity of the pigmen-
tation with that in Addison's  disease.   There are observations which strongly
support the view that a variety of morbid processes in  the suprarenal capsules
may produce the symptoms of Addison's disease.  On the other hand, appa-
rently typical cases of Addison's disease, so far as the  pigmentation and other
symptoms are concerned, have been reported without any disease of the supra-
renal capsules.  In a large number of the cases reported as bronzed-skin dis-
ease without  change in the  suprarenal capsules  the pigmentation did not
present the typical  characters, or it  was due  to  some of the many physio-
logical or  pathological causes of discoloration of the skin which  have nothing
in common with Addison's  disease.   There remains, however, a small number
of cases in which the pigmentation and the constitutional symptoms were the
same as those in Addison's disease, but in which the suprarenal capsules were
found to be normal.

   There has been no explanation  at  all satisfactory  of the relation between
the three  conditions which characterize Addison's disease—namely, the change
in the suprarenal capsules, the pigmentation of the skin, and the constitutional
affection.   It  is not within the scope of this work to enter into a discussion
of the diff'erent theories  which have been  proposed.   A brief  mention  of the
leading views will suffice to bring out the points at issue.  According to one
theory, disease of the suprarenal capsules is primary  and  is the  cause  of the
symptoms.  In opposition  to this theory it is argued that  the symptoms can-
not be  referred to  an abolition of the functions of the suprarenal capsules,
whatever  those functions may be ; for the capsules have been  extirpated in
animals, and  have  been destroyed in man  by cancer and  other processes,
without bronzing of the  skin  or other symptoms of Addison's disease.  Noth-
nagel has succeeded in  producing in animals  caseous inflammation  of the
suprarenal capsules without the sequence of Addison's disease.  Physiological
experiments have shown that these organs  are not  necessary to life.  The
theory that the symptoms of Addison's disease are due to irritation of  sup-
posed secreting cells in  the glands, by which their function is increased and
deleterious substances are introduced into the blood, was advanced by  Klebs,
but is not based on established physiological  facts, and has not met with favor.
Appreciating the difficulty  of referring the symptoms to interference with the
function of the suprarenal  capsules, many, even of those who regard the dis-
ease of the suprarenal capsules as primary, attribute the symptoms to involve-
ment of the adjacent sympathetic nerves and ganglia.  This theory is advo-
cated by  Virchow,  Schmidt,  Greenhow, Jaccoud, Resel,  and many  others.
The objections raised against this theory are that the alterations in these
nervous structures are not  constantly present, that similar changes are found
in a variety of processes without  any of the symptoms of Addison's disease,1
and that the affection of the sympathetic does not make any clearer the expla-
nation of the  characteristic  symptoms.  Rossbach believes  that Addison's
disease  is  a  general neurosis due to functional disturbance of the entire nerv-
  1 Bronzing of the skin has been observed in a few cases of  aneurism of the abdominal
aorta, and of tuberculous or cancerous disease of the retro-peritoneal glands with involve-
ment of the adjacent sympathetic nerves and ganglia. 
392
ADDISON'S DISEASE.
 ous system.   Another theory is that disease of the suprarenal capsules and
 the characteristic symptoms are independent of any causative relation to each
 other, and are  all the result  of some common antecedent condition  which
 Heschl,  Buhl, and others seek  in the blood.   Buhl suggests the entrance of
 some morbific agent from without into the blood;  in other words, he regards
 Addison's disease as infectious in its origin.   Heschl  emphasizes especially
 the tuberculous diathesis.   Pepper ranks Addison's disease with pernicious
 anamia, leucocythamia, and pseudo-leucocythamia among the anamatoses;
 that is, diseases in which the primary change is a profound disturbance  of the
 blood-forming functions.
   The following is a description of the appearances of the skin and  of the
 symptomatology, by Dr. Edward Headlam Greenhow, who has devoted spe-
 cial study to  this disease  and  has analyzed a larger  number of cases than
 has been collected by any  other writer:1
   " The peculiar change of color consists in a gradual darkening of the skin
 of various parts of the body or even of the whole  body.   The aspect of this
 discoloration  gives to the  patient the appearance of belonging to one of the
 dark races of mankind.   Most frequently it has a dusky, smoky, or yellow-
 ish-brown hue,  but sometimes it is  of an olive or green-brown  color, and
 when deepest approaches  in parts to the  tint of negro skin.  The  discolor-
 ation is never uniform over all  parts of the body, but commences earlier and
 becomes deeper  on some or all  of the exposed  parts—the face, neck, dorsum
 of hands and fingers; and on  those parts which  are naturally the seat of
 more pigment than the general surface—the axilla, abdomen, groins, genital
 regions,  nipples, and  especially the areola.  The deep discoloration  of  these
 last may, in  my opinion,  be regarded as one  of the most  decisive  external
 signs of Addison's disease, and the appearance of small, well-defined  black
 specks, like black moles or freckles, on already discolored portions of skin, is
 in my experience another no less certain.   Although sometimes universal, the
 discoloration is  more frequently only distinctly obvious  on certain parts of
 the  body.  Even  in  the  latter cases, however, it  probably affects  in  some
 degree the whole cutaneous surface,  for  on  microscopical  examination of
 parts of  the skin which by contrast with the dark  spots appeared normal, I
 have found deposited also in them, though in  comparatively small quantity,
 the pigment which imparts the abnormal  color to the skin.  The transitions
 from the darker to the  paler  shades of the discoloration  of different  parts
 of the body are never abrupt; the  darkest parts  are never sharply-defined
 patches,  but merge insensibly into the lighter or apparently normal  portions
 of the surface.  There is, however, one marked exception to this rule.  AY hen
 the  skin has  suffered any superficial abrasion or  injury, or when the patient
 has  been blistered at some recent period, the injured parts not only become
 much darker than the surrounding portions of the  surface, but they present
 defined  margins coinciding with  the extent  of the cutaneous injury.   The
 cicatrices of deeper injuries, on the contrary, usually remain pale,  and are
 surrounded by a distinct  border  of more or less dark  pigment,  contrasting
 strongly  with  the  ivory-like hue of the cicatricial tissue.  It does not,  how-
 ever, require  actual abrasion of the skin to  excite a greater deposit of pig-
ment in certain parts; slight local irritation of the surface appears  in  not a
few cases to have produced the same effect.  I have myself seen dark streaks
on  the skin corresponding with the lines of pressure  exerted on particular
parts by petticoat-strings  and garters, and the same circumstance has been
noted by others.   In a case recorded by Mr. Nicholson  in 1872  it is stated
that the  patient, a baker's  lad,  presented on his shoulders dark stripes cor-
  1 Vide "Croonian Lectures on Addison's Disease," The Lancet, 1875; also, a mono-
graph published in 1866. 
SYMPTOMATOLOGY.
393
responding to the bands by which the basket he carried was slung at his back.
The  discoloration in Addison's disease is not  entirely restricted to the skin,
being also frequently found upon the mucous membrane of the lips, cheeks,
and gums, and  also  upon the tongue.  On the lips it takes the form of an
irregular bluish-black  streak, running lengthwise,  near  the junction  of the
mucous membrane and outer skin.   It is seen on the gums and buccal mucous
membrane  in the form of irregular stains and patches, mostly of a brownish
color, with ill-defined margins.  In two of my own cases the stains on the
buccal mucous membrane have certainly corresponded  with seats of irritation
produced  by the pressure of ragged, protruding teeth;  but in other cases I
have been unable to verify any such cause.   The discoloration of the tongue
appears usually in   sharply-defined  stains of a purplish-black or sometimes
inky hue; and  in my cases these stains have always been situated  near the
margins of  the  organ.   On  the  other hand, the  conjunctiva  have always
remained  normal, and  the contrast  between their  pearly whiteness and the
dusky  hue of the discolored  skin  is very striking, and  involuntarily recalls
the similar  contrast in the mulatto or negro  countenance.
  " We see, therefore, that the discoloration  of  the skin  in Addison's disease
usually begins, and  eventually becomes deepest, on  those parts which are nat-
urally the most liable to become pigmented either by exposure to sun and air
or by the excitement of certain physiological  processes; and to these must
be added such  parts as may accidentally be subjected to the excitement of
local irritation.   In  other words, this peculiar  change  of color is, like many
other pathological processes, merely an exaggerated, and therefore a morbid,
development of  a natural physiological process."
  Greenhow describes the constitutional symptoms as follows : " Gradual pro-
gressive asthenia, often originating without  any apparent cause and seldom
dating from any definite period; great languor and indisposition for exertion,
with, in advanced cases, breathlessness and  palpitation, frequent sighing or
yawning, and generally faintness on making any muscular effort, sometimes
even on being raised up in bed.   There are almost  invariably great weakness
of the heart's action and remarkable feebleness of pulse; loss of appetite;
irritability of stomach,  with  nausea; and toward the  close of the illness at
least occasional, and often  persistent, vomiting.  The mind is generally clear
to the last, but so great is the prostration in the latest stages of the disease
that the patient often  lies in a drowsy, apparently  semi-comatose state, from
which, however, he  can be roused  by questions, and  to these  he  generally
gives pertinent, though slow and reluctant, answers.  There are in many cases
pains in the loins, hypochondria, or epigastrium, and, more rarely, dimness of
sight, vertigo, and, near death, a tendency to incoherence or delirium.  Death
takes place  from asthenia, and  often  rather suddenly." . . . . " There is, in
uncomplicated cases, comparatively  little or no emaciation.  The skin is soft
and cool.  The tongue is usually clean and moist until the last day of life."
  The occasional occurrence of convulsions  is mentioned by  Greenhow, and
also by Jaccoud.  The  convulsions  are oftener partial  than  general.  Pye-
Smith  and others have observed cases which terminated with severe cere-
bral  symptoms—namely, delirium, coma, etc.  In a case reported by Noth-
nagel the coma  was associated with  acetonuria.(p. 72).   Attacks of syncope
are not rare, and may  end fatally.
  All writers dwell upon the frequency and prominence  of gastric symptoms—
namely, anorexia, nausea  with more or less vomiting,  eructations, cardialgia,
etc.1  In the early stage of the  disease the bowels  are generally constipated,
but at a later period diarrhoea  is not infrequent.
  1 Merkel, author of the article on this disease in Ziemssen's  Cyclopaedia, in a foot-note
mentions, " as a curiosity," that in the  Phil. Med. and Surg.  Reporter, June, 1871, an 
394
ADDISON'S DISEASE.
   As regards the urine, Thudicum found diminution of uric acid and of color-
ing matter.   Rosenstern ascertained that the excretion of urea is diminished,
and that there is an increase of indican.
   The course of this disease is progressive, but  its progress is not always
continuous.   Greenhow's observations show, in  certain  cases, paroxysms of
progress, exacerbations,  and remissions.   During a remission the  discolora-
tion of the skin is lessened, and there  may  be more or less general improve-
ment.  Exceptionally, the disease runs a rapid course.  In these cases bronzing
of the skin usually precedes for some  time the constitutional symptoms.   In
the vast majority of cases the progress is slow, the duration, however, being
indefinite, extending sometimes over several months  and sometimes over many
years, the average  duration  being a year, or, according to AYilks, a year and
a half.
   The diagnosis  is to  be based on  the  characteristic bronzing of the skin
together with the associated  symptoms.   A discoloration of  the  skin bearing
more  or  less resemblance  to that of Addison's disease may be referable to
pityriasis, chloasma, protracted jaundice, cancerous  and tuberculous disease,
particularly  when seated in the abdomen, the internal use of the nitrate of
silver, the permanent staining which  follows some  syphilitic eruptions, and
that caused by exposure, dirt, and the irritation of vermin, the latter described
by Voght and by  Greenhow under the  name " vagabonds' disease."  The
associated symptoms representing the constitutional affection corroborate the
diagnosis as based on the appearances  of the skin.   It is to be borne in mind
that the bronzing of the skin may precede as well as follow the constitutional
symptoms.  Some  delay under  these  circumstances may be requisite for a
positive diagnosis.   On the other hand, there is no doubt as  to the occasional
occurrence of cases of  Addison's  disease, as proved  by the constitutional
symptoms and  by  the  characteristic  changes  in the  suprarenal  capsules,
without any pigmentation of the  skin.   In  these cases  generally the dura-
tion of the disease  has been brief or it has  been  associated  with grave com-
plications.  Brown patches in the mouth have been observed without bronzing
of the skin.   It is  not very comprehensible that, associated with pyrexia, the
disease should be mistaken for  typhoid fever.   The author of the article in
Ziemssen's Cyclopaedia, however, states that  this mistake was made in  a case
under his observation. Litten, and more recently Krocker, describe pigmenta-
tion of the skin as  a sequence of typhoid  fever.
   Addison's disease resembles the other grave diseases of the hamatopoietic
system in the obscurity of its causation.  It occurs after adult age, in early
or middle life, but very rarely in childhood and in advanced  age.   In a large
majority of  cases patients are of the male  sex, and a majority of these belong
to the so-called working  class.  The character of  the anatomical changes,  and
the not  infrequent  association  with phthisis, justify the conclusion that a
tuberculous diathesis may favor the  development  of the disease.
   AArriters agree that the prognosis in the present state of knowledge is fatal,
but the duration of the disease sometimes extends over many years.   It may
remain non-progressive for an indefinite period, and  in  some cases notable
improvement  takes place.   These are  important facts  to be considered with
reference to  the prognosis and as affording encouragement in  the treatment.
   In the absence of any remedies known to have a special curative efficacy,

attempt is made to " refer the entire complex set of symptoms to degeneration of the
glands of the stomach." If the  attempt to  connect the disease with glandular organs so
vast and important as those which secrete the gastric juice be worthy of being men-
tioned only as a curiosity, how absurd would it have seemed to the author of that arti-
cle to refer the disease to organs comparatively so insignificant as the suprarenal capsules
had he written his article prior to Addison's researches! 
TREA TMENT
395
symptomatic indications  are to be fulfilled, and treatment, medicinal and
hygienic, is to be pursued with reference to the same objects as in treating the
other diseases of the hamatopoietic system.  In a case which came under my
observation the treatment by general  faradization  and  galvanization  of the
sympathetic  nerve in the hands of Dr. A. D. Rockwell  was accompanied by
marked improvement as regards the muscular strength  and  endurance ; the
sexual desire and capability, which had been lost, returned, and the bronzing
became perceptibly  less.   This improvement  continued  for  two years, when
the patient suddenly,  without any apparent cause, failed,  and died  within
twenty-four  hours.1

  1 A'ide Med. and Surg. Electricity, by Drs. Beard  and Rockwell, 2d ed., p. 675.  For
exhaustive articles in relation  to this disease the reader is referred, in addition to the
works by Greenhow, to which  reference  has been already  made,  to  Jaccoud, article
" Uronzee maladie," in Nouveau Diet,  de Mid. et de  Chirurg. pratique, tome xi., 1866;
and to Traite  de pathologie interne, tome ii., einquieme edition, 1877 ; to Averbeck, Die
Addison'sche Erankheit., Erlangen,  1869 ;  to article  by Pepper, in Am. Journ. of Med.
Sciences, April, 1877;  and by Osier, in System of Medicine by American Authors, vol. iii. 
                   SECTION  FOURTH.

DISEASES AFFECTING  THE DIGESTIVE OR CHYLOPOIETIC  SYSTEM,
                         CHAPTER  I.

DISEASES  OF  THE  TONSILS, THE  PHARYNX,  THE (ESOPH-
               AGUS, AND  THE PAROTID  GLANDS.

Introductory Remarks.—Tonsillitis.—Pharyngitis.—Diseases of the (Esophagus.—Paro-
                              tiditis.—Mumps.

   THE important organs composing the digestive system are the mouth, with
    the parotid, submaxillary, and sublingual glands, the fauces, the pharynx
and oesophagus, the stomach and duodenum, the small and the large intestine,
with the mesenteric glands,  and the solid abdominal viscera—namely, the
liver, pancreas, and spleen.  Affections of  the two outlets of the alimentary
canal—namely, the mouth, fauces, pharynx, and oesophagus, with the appended
glands, and the rectum and anus—properly belong to the department of  sur-
gery, being either open to view or accessible by manual exploration, and often
requiring surgical operations.  These affections, for the most part, will not be
considered  in this work.  This section will therefore be devoted mainly to the
diseases affecting the hollow viscera and the solid organs within the abdomen.
The  affections of the digestive system, as of other anatomical systems, con-
sist of—-first, inflammation ;  second, structural lesions ; and  third, functional
disorders.   The diseases of the different  divisions  of the  alimentary canal
will be considered in their natural order, beginning with the affections of the
upper part of this canal.  The diseases of  the mouth and of the tongue, such
as the  different varieties of stomatitis or of glossitis,  belong  to surgery.  Cer-
tain affections of the mouth, prevailing especially in  early life, are considered
in treatises devoted to  diseases of children.


                              Tonsillitis.
   The  most important varieties of tonsillitis are acute simple tonsillitis (often
designated  as catarrhal), follicular tonsillitis, and parenchymatous or suppu-
rative tonsillitis, commonly known as quinsy. When the inflammation involves
especially the lacuna or crypts of  the tonsils, the disease is  called lacunar or
follicular tonsillitis.  Pseudo-membranous tonsillitis is usually present in true
croup and in diphtheria, and is considered in connection with these diseases.
   Acute. Simple Tonsillitis is characterized, anatomically, by redness with mod-
erate swelling of the tonsils and an inflammatory exudation  from  the mucous
membrane,  composed of mucus mingled with  epithelial  cells, pus-cells,  and
serum.  This simple tonsillitis is present in most cases of acute  pharyngitis,
or ordinary sore throat.  The  tonsillitis  contributes its share to the constitu-
tional disturbance, pain, and  other symptoms  which will be described under
       396 
TONSILLITIS                          397
Acute Pharyngitis; but the affection of the tonsils is not  usually so severe
as to require  a separate  consideration.
  Acute Follicular or Lacunar Tonsillitis is of considerable clinical importance.
In this  affection  the  inflammation involves not only the mucous membrane
covering the surface of the  gland, but especially that lining the crypts.  The
tonsils present little  white patches composed of  epithelial  cells, pus-cells,
mucus, and  a  large  number of bacteria.   These white deposits  extend into
the lacunar depressions.  It is important to distinguish  these white  patches
from a  diphtheritic  exudation with which they  are sometimes  confounded.
In distinction from the latter the white masses in follicular  tonsillitis form
a pultaceous deposit, not a membraniform layer like the  deposit of fibrin;
they cannot  be removed in  strips like  the latter;  they  are more easily
removed,  are  more  prominent, are more abruptly  defined,  and disappear
spontaneously more quickly, than  patches of fibrin.  On close inspection the
secretion will  be  seen to dip into the follicular depressions.   The follicular
deposit occurs without any abrasion of  the mucous surface, but it is common
for patients to consider the patches as ulcers.
  Acute follicular tonsillitis is often attended by severe constitutional disturb-
ance.  The symptoms at the onset may be as severe as in diphtheria.  Chilly
sensations, or even a chill, may mark the beginning  of the  affection.  The
temperature rapidly rises, and within twenty-four  or  forty-eight  hours  may
reach 104° or 105°.   There are often headache, anorexia, insomnia, and other
symptoms which usually  attend marked pyrexia.   The  patient complains of
dryness and soreness of  the throat, and  there may be considerable pain on
swallowing.  Usually within three to five days  the fever and other symptoms
subside and recovery is rapid.  During, and sometimes for a considerable time
after, the attack there may  be marked prostration.
   The prognosis  is  always  favorable.   The  severity of the constitutional
symptoms  in  many  cases,  together with the anatomical  appearances,  has
often led to the  diagnosis  of diphtheria from which, as already  stated, it is
important that follicular tonsillitis  should be  carefully  discriminated.
   Parenchymatous Tonsillitis, or inflammation of the  substance of the tonsil,
may terminate in resolution, but usually it  goes on  to  suppuration, consti-
tuting the disease called suppurative tonsillitis or quinsy.   The tonsil of one
side  only or both tonsils may be affected.  The tonsil becomes much enlarged
and the seat of an abscess.   The abscess may open at one or at several points
on the surface of the tonsil.   The inflammation usually extends to surrounding
parts, the soft palate and uvula  especially becoming hyperamic and much
swollen.   The  submaxillary gland is not infrequently  enlarged.
   Suppurative tonsillitis  may attack a previously  healthy tonsil, but  it is
particularly liable to occur in those whose tonsils are  affected  by  chronic
inflammation.   The  causation involves a predisposition  to  the  affection, and
persons predisposed are likely to experience repeated attacks.  The immediate
cause of the  suppuration doubtless is to be found in micro-organisms which
invade the substance  of the tonsil.
  Suppurative tonsillitis is a very distressing affection, in consequence of the
pain and difficulty in deglutition.   There is  elevation of temperature, which
may be considerable.   Increased  frequency  of pulse, loss  of appetite, head-
ache, sleeplessness, pain  in  the limbs, are other  symptoms which mark the
febrile disturbance.   Pain is a prominent symptom, this being most marked
upon attempting  to  swallow.  Sometimes pain is referred  to the ear.  The
throat is at first dry ; and subsequently there is a secretion of viscid  mucus
and of saliva,  often in abundance.   The voice is husky,  and articulation may
be difficult or almost impossible.  Difficulty of breathing occurs when both ton-
sils are greatly swollen.   A rare complication is cedema  of  the glottis, which 
398     DISEASES OF THE TONSILS,  THE PHARYNX,  ETC.

may cause death.  The symptoms increase in severity until the abscess bursts
or is opened, and then there is a notable  and usually rapid  abatement of the
local and constitutional disturbances.   A very exceptional  occurrence is suf-
focation produced by  escape  of the  pus into  the  larynx when the abscess
ruptures during sleep.  Fatal hemorrhage has been known to take place from
ulceration of the abscess into the internal carotid or internal maxillary artery.
These  unfortunate terminations, however, are very  rare, and the prognosis is
to be considered as favorable.
   It is not rare for little yellowish-white concretions to form in the crypts of
the tonsils.   These concretions  consist of desiccated  epithelial and pus-cells
and  low vegetable  organisms.   AYhen  crushed, these  whitish  pellets emit a
very offensive  odor.  These concretions, which may contain lime salts,  are
sometimes mistaken for tubercles.
   In acute  simple  tonsillitis the measures of treatment are those  which will
be mentioned in connection  with Simple Pharyngitis.
   In the follicular variety a solution of alum, borax, or the chlorate of potassa
may be used as a topical application by means of a camel's-hair pencil brush.
Gargles do not bring the solution in contact with the affected parts.  In cases
with marked pyrexia  the  tincture of aconite  in small, frequently  repeated
doses should be given, until  an impression is made on  the pulse.
   The treatment of parenchymatous tonsillitis, or quinsy, consists of poultices
or the  water-dressing to the neck, ohe  inhalation of warm vapor, and anodynes
to lessen discomfort.   Milk is the form of nourishment  best taken.   AVhen
fluctuation is perceived, the abscesses may be opened and the patient will be
relieved sooner than if they had been left to break.


                             Pharyngitis.
   A variety of forms  of pharyngitis  are distinguished, many  of  which can
receive only passing mention within the limits of this work.
   In Acute Simple Pharyngitis the mucous membrane is congested, swollen, and
coated with more or less of a muco-purulent  secretion.  The  inflammation
usually extends to  the  tonsils and soft palate, and it may also involve the
nasal passages.  This variety  of pharyngitis is  one  of the forms of " a cold "
or ordinary  sore throat.  There is usually more or less pain, especially in the
act of  swallowing.  There is at first a sensation  of dryness.   The secretion
of mucus at a later stage provokes efforts at hawking and expuition.  If the
inflammation extend low in the pharynx, coughing  is excited.  The cough is
of a peculiar character, easily recognized and distinguished as a throat-cough,
the forcible  current of expired air being brought  to bear on  the pharynx.
The limitation of the inflammation to  the pharynx or its non-extension into
the larynx is shown by the  absence of huskiness or hoarseness  of the voice.
Febrile disturbance, except sometimes  in children, is slight,   The extent and
intensity of the inflammation are to be ascertained by inspection of the throat.
The involvement of the vault of the  pharynx, the posterior nares, and the
posterior surface of the palate  and the lower part of the pharynx can be
ascertained  by the  use of the laryngoscope and of the  rhinoscope.
  Acute simple pharyngitis sometimes  occurs  as  an epidemic affection, in
which case the  disease  is to be regarded as a form of fever rather than simply
as a local inflammation.  I have analyzed a series of twenty-three cases which
occurred during such an epidemic in the western part  of New  York State in
IS.")!.1   From this analysis the  conclusion was reached that the disease was
an epidemic fever characterized by mild  erythematic inflammation  of the
pharynx and fauces as  the  only constant  local complication.  The febrile
                   1 Buffalo Medical Journal, vol.  xii. p. 718. 
PHARYNGITIS.
399
movement was  in a marked degree out of proportion  to the local  affection.
Its duration was from three to five days.  The epidemic prevailed extensively
for about two months, both sexes and different ages being affected without
notable discrimination.   No proof of contagion existed.   The affection was
not scarlatina, but it resembled influenza, save that the pharyngeal  and not
the bronchial mucous membrane was the seat of inflammation.  It is perhaps
proper to regard the  epidemic disease as a form of influenza.
  Acute pharyngitis is a common  complication in  many acute infectious dis-
eases, especially in the exanthematous fevers.   Reference  will be made here-
after to Exanthematous Pharyngitis in connection with scarlatina, measles, and
smallpox.
  The pharyngitis is designated as erysipelatous when it  complicates erysip-
elas, particularly facial erysipelas.  Usually, the inflammation is of the acute
simple variety,  but it may be gangrenous or  suppurative, and in the latter
case the prognosis is grave.  It is  claimed that  erysipelas may attack the
pharynx primarily.
   Gangrenous Pharyngitis may occur also in connection with diphtheria, and
rarely as a  complication of scarlet fever, smallpox, typhoid fever, or other
acute infectious disease.   The symptoms assume a typhoid character and
and  the termination is usually fatal.
  In  Phlegmonous Pharyngitis  there is an accumulation  of pus in  the sub-
mucous and deeper  tissues of the pharynx, constituting  a retro-pharyngeal
abscess.  This affection may occur traumatically, as by the penetration of a
sharp piece  of bone.   More frequently  it is secondary  to  caries of the cerv-
ical vertebra.
  Pseudo-membranous  or Fibrinous  Pharyngitis constitutes a  part  of the
lesions in croup and in  diphtheria,  with which diseases  it is considered.
   Subacute  Simple Pharyngitis  is a very common  affection, and is generally
treated without the  advice of a physician.  The  lesions  and symptoms are
similar to those in  acute simple pharyngitis, but they are less intense.
   Chronic Pharyngitis is an extremely common affection in this country.  It
is commonly known  as " the catarrh."   It may follow repeated attacks  of
acute pharyngitis, but it is  generally a  subacute affection  at the beginning,
and is developed imperceptibly.   It is customary to distinguish two forms of
chronic pharyngitis—namely, simple chronic pharyngitis, and chronic follicu-
lar or granular  pharyngitis.   In simple  chronic pharyngitis the mucous mem-
brane is inflamed without especial involvement of the lymphatic follicles of
the pharynx.  The membrane is more or less  reddened and thickened.  Fre-
quently small, dilated veins can be seen mapping out irregularly the surface
of the pharynx.  Viscid mucus adheres to the surface of the inflamed mucous
membrane.   In follicular or granular pharyngitis the follicles of the pharynx
are enlarged in  consequence of hyperplasia of their lymphoid cells.   These
enlarged follicles form little nodules studding  the surface  of  the  pharynx.
They are surrounded by congested and inflamed mucous membrane.  In both
forms  of pharyngitis—between which,  in fact, no sharp line  of distinction
can be drawn—the inflammation may extend to adjacent mucous membranes.
AArhen the inflammation  extends to the  Eustachian tubes  or their openings,
deafness is  produced in  greater or less degree.  AA^hen chronic  pharyngitis
has existed  for a long time, portions of the mucous membrane are likely to
become atrophied.
  Chronic pharyngitis in some persons occasions but little inconvenience.  It
is often found when  the  patient makes no complaint  of any trouble in the
throat.  In  other cases it occasions more or less annoyance.  An uncomfort-
able  sensation is felt  in the throat.  The presence  of adhesive mucus excites
efforts of hawking and coughing.   The  proximity  of the inflammation to the 
400     DISEASES  OF  THE TONSILS,  THE PHARYNX', ETC.

larynx may give  rise to  a dry, hacking  cough.   The  voice  becomes hoarse
after considerable use in speaking or reading, and the use of the voice is fol-
lowed by a sense  of fatigue in the vocal  organs.
  The affection is much  more frequent in men than  in women.  It occurs
most  frequently after puberty and in middle life.   The form of the disease
which is sometimes called clergyman s sore throat is usually of the follicular
variety.  This form of the disease occurs in those  who are under the neces-
sity of using the voice a great deal in public speaking, but  it is probable that
in these cases the excessive use of the voice is not the  only cause, for chronic
pharyngitis in general occurs most frequently in persons of sedentary habits
who suffer  from the wear and tear of continued  application without  physical
and mental  relaxation.  The number of persons  is very large in this coun-
try  who overtask the powers of the  system by steady labor in the office, the
counting-house, or the workshop,  continued  without intermission for many
years.   It  is especially among those who  in  this  way violate the  laws  of
health that chronic pharyngitis prevails.   It seldom occurs among the so-called
laboring-classes, and  it is  much more frequent in cities than in the country.
Occurring in persons of sedentary  habits, it is usually accompanied by symp-
toms denoting impairment  of the general health.   The patients complain  of
debility and a want of their accustomed energy ; they are generally depressed
in spirits;  and they  often fancy the  existence of some serious disease, espe-
cially pulmonary  consumption.   Dyspeptic ailments frequently coexist.
  The diagnosis of chronic pharyngitis  is readily  established  by inspection
of the throat.   The  use of the pharyngeal mirror is of service in determin-
ing the extent of the lesion.
  The prognosis  of  chronic  pharyngitis is favorable  so far  as life  is con-
cerned, but it is not favorable as regards  the return  of the mucous membrane
to its healthy state.  The tendency of  the disease is to  long  continuance.
There is no tendency of  chronic  pharyngitis to eventuate in laryngitis  or
bronchitis,  nor is there any tendency to the development of tuberculosis.
  The annoyance  from chronic pharyngitis is often much enhanced by patients
concentrating their attention upon  it.   They sometimes fall into the habit  of
constant hemming or " clearing the  throat," which is not  only fatiguing to
themselves, but extremely disagreeable to others.
  Tuberculous Pharyngitis is characterized by the  growth of tubercles and
the formation of tuberculous ulcers in  the pharnygeal mucous membrane.
Although  simple  pharnygitis is not uncommon in chronic  pulmonary tuber-
culosis, a genuine tuberculous pharyngitis is infrequent.   Sometimes tuber-
cles can be  seen during life in the floor or sides or neighborhood of the ulcers ;
but at other times there is nothing distinctive in the gross  appearance of the
ulcers, although microscopically their tuberculous nature is evident.   Tuber-
culous ulcers  form most  frequently at  the sides of the larynx and on the
palatine folds;  and from  these situations they may extend to the soft palate
and to the  posterior  wall  of the  pharynx.  Portions of the mucous mem-
brane, particularly that of the uvula, often become  irregularly thickened and
of a grayish color.   In tuberculous pharyngitis there is usually marked pain
upon  deglutition.  The lymphatic glands  of  the neck are usually  swollen.
  The diagnosis  is to be  based  upon the recognition of tuberculous disease
elsewhere,  particularly in  the lungs, and by the  detection of tubercle bacilli
in the secretion from the ulcers.
  Tuberculous pharyngitis sometimes runs  an acute  course, and at other
times it is  chronic.
  Syphilitic Pharyngitis may occur during any stage of syphilis, either con-
genital or acquired.   The  manifestations of syphilis begin more frequently
upon  the tonsils and palate than upon the pharynx.   Initial syphilitic sores 
PHARYNGITIS.
401
have been seen upon the tonsils, the palate, the pharynx, and the epiglottis.
An erythematic inflammation of the tonsils and palate, extending to the phar-
ynx, is among the earliest and  most frequent manifestations  of secondary
syphilis.   The inflamed regions are usually symmetrically situated.  Mucous
patches are  common.  These  are  due to thickening and opacity of patches
of epithelium, together with infiltration of the subjacent tissue with lymphoid
cells.   A secretion, sometimes purulent, takes place from these patches.  The
mucous patches are usually of short duration, especially under appropriate
treatment.   Syphilitic ulcers may form  in the secondary, but they  are most
common  in  the  tertiary, stage of syphilis.   Tertiary ulcers may be due  to
the softening and  destruction of gummata, or they may result from suppu-
ration.  Syphilitic ulcers occur most frequently on the soft palate and palatine
folds, but they may extend to the pharynx or may involve the latter primarily.
These  ulcers are irregular in  shape, with undermined edges  and surrounded
by a zone of congestion.   A sequel of syphilitic  ulceration is the formation
of cicatrices, the recognition of  which may aid in the diagnosis of pre-exist-
ing syphilis.  In rare instances these  cicatrices by their extent and contrac-
tion occasion serious distortions and stenoses of the pharynx.
   The symptoms of  syphilitic pharyngitis do not differ materially from those
of simple and ulcerative pharyngitis due to other causes, except that pain is
rarely  a marked symptom, and frequently there is little  or no increased sen-
sibility of the throat.
   The diagnosis is made by means of a syphilitic  history, by the appearances
of the inflammation and  ulceration already described, and especially  by the
readiness with which the lesions usually respond to antisyphilitic treatment,
   The prognosis is good.   Destructive ulcerations with extensive involvement
of the bones are much less frequent now than in former times.
   Thrush, a disease belonging  more appropriately to the affections  of the
mouth, will  receive  only  brief consideration here.  Thrush is  characterized
anatomically by the  appearance of  white  or  brownish-white, curdy patches
upon  the  affected mucous  membrane.  These patches are composed essen-
tially of  the mycelium and  spores  of a fungus which is usually called Oid-
ium albicans, but  the  exact systematic  classification of the fungus has not
been determined.  The mucous  membrane beneath these parasitic patches is
usually congested, but  not ulcerated.
   Thrush is observed  most frequently in the mouth  and  on the palate, but
it may involve the pharynx, and it is not infrequent in the oesophagus.  It
has even  been  seen in the stomach.
   Thrush is a symptomatic affection.  It  occurs  most commonly in nursing
infants, especially  in those fed by bottle in hospitals and asylums where suf-
ficient attention  is not given to cleanliness of the mouth and of the nursing-
bottle.  Thrush, may,  however, occur in adults, and  is then observed in con-
ditions of great  prostration of the vital forces, as in  old people, and toward
the termination  of such exhausting diseases as carcinoma, tuberculosis, dia-
betes,  dysentery, and typhoid fever.
   As regards the  treatment of thrush, the  borate of sodium  is an efficient
remedy.   This remedy is  best applied dissolved in glycerin.  Applications by
means  of a camel's-hair pencil brush may be made three or four times daily.
In addition to these applications the indications for treatment are to be derived
from the pathological conditions with which this local affection is associated.
   Acute  simple pharyngitis, occurring as a sporadic disease or as the anatom-
ical characteristic of an epidemic fever, is usually a mild affection, having  no
tendency to  end  fatally.   Oedema of the glottis  is an accident  which may
occur,  but it is extremely infrequent.  I have met with one example of its
occurrence in a case of sporadic pharyngitis.  The therapeutical measures
       26 
402     DISEASES  OF THE  TONSILS, THE PHARYNX,  ETC.

indicated are mild purgatives, followed by anodyne remedies, quinine, and the
chlorate  of potassa.  Gargles of the chlorate or the nitrate of potassa are
usually prescribed, but the liquid can in this way be brought into contact with
the inflamed membrane  to only a limited extent.  A mucilaginous liquid or
glycerin  taken in small quantity and swallowed will allay the dryness and
irritation of the  throat.  Small pieces  of gum allowed to dissolve  in  the
mouth have the same  effect.  The chlorate of potassa, taken in the form of
troches, is  more efficient than in solution and used as a gargle.  Caustic or
stimulating applications to  the inflamed membrane  are not called for.   A
sinapism externally, liniments containing chloroform, aconite, and laudanum,
and the  water-dressing give relief.
  The treatment of chronic pharyngitis, to be effective, must have reference to
the system.  Topical applications alone  are rarely efficacious.   A fair trial of
them, however, should be made.  The nitrate of silver in strong solution (2U or
30 grs. to the ounce) in  some cases, especially those of the granular variety, is
highly useful. It is to be applied by means of a probang, mop, or large camel's-
hair pencil  brush.  A solution of tannin is often of service. The chloride, iodide,
or sulphite  of zinc and iodoform are recommended.  Inhalations are not appro-
priate ; they carry the medicated application too far.   On  the other hand, gar-
gles are of little use ; they do not carry the application far enough.  Projecting
a spray of  medicated solutions into the  throat is  an efficient mode.   Applica-
tions  to the posterior nares  may be made by means of the nasal douche;  if
made  by injecting from  the fauces, there is danger of the fluid passing into
the Eustachian tubes and causing  otitis media.   The  constitutional  remedies
which exert a curative influence in certain cases  are the iodide of potassium,
the bromides, the chlorate  of potassa,  and the hydrochlorate  of ammonia.
Alteration  of the habits of life is first in importance.   Relaxation, recreation,
and out-of-door life are far more efficacious than medicines, and the latter are
of little  use without the former.  AAThen circumstances permit,  relinquish-
ment of business for a time  for  travel or rural occupations is of signal ben-
efit.   Tonic remedies  may  often  be advantageously conjoined with proper
hygienic  management.   Tonics, to  be  efficacious, should be continued for a
long period, and the form  of tonic changed  from time  to  time.   The diet
should be  nutritious.   The  object of treatment, in short, is to restore the
general health.
  For syphilitic pharyngitis local and general antisyphilitic measures of treat-
ment are. indicated. (For these the reader is referred to works which treat of
syphilis.)

                   Diseases of the (Esophagus.

  Inflammation of the oesophagus (oesophagitis), acute, subacute, or chronic,
is extremely rare.   As  an idiopathic, non-traumatic affection it may be said
almost never to occur.   It  may be produced by the  ingestion of corrosive
poisons, by the irritation of  foreign bodies, and by an extension of inflamma-
tion from adjacent parts.  In some  parts of  this  country, especially in the
Southern States, inflammation and stricture are frequently caused by drink-
ing accidentally a caustic preparation used for washing and scouring purposes
known as " concentrated lye."1   In cases of diphtheria the diphtheritic affec-
tion sometimes extends into the oesophagus, and ribbon-like  pseudo-mem-
branes may be expelled. The  eruption  of smallpox  occasionally occurs  in
this situation.
  The diagnostic symptoms of  inflammation are pain  and soreness  localized
  1 Vide article by Henry F. Campbell, M. D., in leans. American Surgical Society, vol.
i., 1883. 
PAROTIDITIS—MUMPS.
403
in this situation, and especially manifest in acts of deglutition.   The passage
of an oesophageal  sound occasions pain, and on its withdrawal mucus or pus
may be adherent to it.  The latter are evidence of oesophagitis only when
carcinoma of the cardiac orifice of the stomach  is excluded  by the absence
of obstruction.
  The rational indications for treatment are  the nourishment of the patient
by a bland liquid diet, of which milk should be the basis, and, if this occasion
pain, rectal alimentation  may be substituted therefor.
  Stenosis, caused by morbid growths, cicatrized ulcers, etc., is ascertained
by exploration with the sound, in conjunction with the evidence of obstruction
to the ingestion of  food.  Primary carcinoma occurs in the oesophagus.  The
consideration of these  affections belongs to surgery.  In this category belong
foreign bodies, the presence of vegetable and animal parasites, dilatations, and
diverticula.   Rupture  of the oesophagus is an occasional accident.1
  Obstruction may depend on compression by an aneurism  or a tumor  of
some kind.  The obstructing cause in  these cases is generally apparent.  The
fact of obstruction in a person over forty years of age should always suggest
exploration for the signs  of  an aneurismal tumor.  Rupture  of aneurisms
sometimes takes place  into the oesophagus.  Ulcers having the characteristics
of gastric ulcer may occur in the lower end of the oesophagus.2
  Perforation from the presence of a foreign body may establish a communi-
cation with the pericardial or the pleural cavity, and it may cause subcuta-
neous emphysema of the neck and the escape of swallowed fluids  into the
areolar  tissue.   Cases have been  reported of softening and perforation  of
the lower portion of the oesophagus  by the  gastric juice.
  Paralysis of the  muscular coat, in connection  with that of the pharyngeal
muscles, may occur after diphtheria, in connection with bulbar paralysis, and
in some cases of general paralysis and of cerebro-spinal multiple  sclerosis.
  Spasm of the oesophagus (cesophagismus) of  transient  duration is one of
the hysterical manifestations.  Irrespective of that  connection it may cause
obstruction for hours and days.   In a case reported by Dr. J. J. Henna, which
I saw in consultation, complete obstruction from spasm had existed for eight
days, and was instantly and permanently removed by a single introduction of
a sound.3
  (For a full account of the diseases of the oesophagus the reader is referred
to Cohen's treatise on the Diseases of the Throat, and to his  articles in  Pep-
per's  System of Medicine, by American Authois, vol. ii.)


                        Parotiditis—Mumps.
  The affection commonly known as mumps may be appropriately noticed in
this connection as seated in an organ  accessory  to the  buccal  cavity.  The
disease  is  infectious and contagious.   It therefore involves a special  cause
which, reasoning from  analogy, is a parasitic organism.  The existence of this
contagium  vivum has not  as yet been demonstrated.  Mumps often prevail as
an epidemic.   The most  marked local affection in this disease is inflammatory
swelling of the parotid gland and surrounding connective tissue.   As the dis-
ease rarely terminates fatally,  little is positively known of the anatomical
changes in the gland.  The interstitial tissue of  the gland is  believed to  be
infiltrated  with serum  and to contain  a few emigrant white blood-corpuscles.
The epithelium of the  acini and ducts  of the gland may be supposed to swell

  1 Vide case reported by Prof. Fitz, Am. Jmirn. of Med. Sciences, Jan., 1877.
  2 Aide Quincke, " Ulcus  (Esophagi ex Digestione,"  Deulsches Archiv fiir klinische
Mcdicni, 1879. Bd. 24, S. 72.
  3 A'ide New York Hospital Gazette, Oct. 18, 1879. 
 404      DISEASES  OF  THE  TONSILS, THE PHARYNX,  ETC.

 up and undergo  parenchymatous degeneration.  An inflammatory oedema of
 the connective tissue about the gland exists  in  most cases.   More serious
 structural changes  than those described  are not  supposed to  exist, as  the
 restitution of the gland and of the surrounding tissues to their normal condi-
 tion occurs with such ease and rapidity.   A irchow teaches that the inflamma-
 tion has its point of departure  in the  ducts, and is propagated from simple
 inflammation of  the  buccal mucous membrane (stomatitis).  According to
 this view, the infectious agent gains access to the  gland  from the mouth by
 Steno's  duct.  A similar  coincident  inflammation of the submaxillary  and
 sublingual  glands is  not infrequent.  Cases have been  described in which
 these glands were involved and  the  parotid escaped.   Erythematous inflam-
 mation of the  mouth and pharynx is frequently present in cases of epidemic
 parotiditis.
   The period of incubation  varies from ten to eighteen days.   The disease is
 frequently ushered in  by a slight chill or by chilly sensations, and in its prog-
 ress it may  be accompanied with  moderate  febrile movement, diminished appe-
 tite, pain in the head,  and  general malaise.   A  certain degree  of febrile dis-
 turbance usually precedes for  a short time the enlargement of the  parotid
 gland, and generally subsides before the swelling fully disappears.  The swell-
 ing usually begins in one gland,  but with few exceptions both glands  become
 involved, although the one first affected suffers  more.  The amount of swell-
 ing in the site  of the parotid gland varies  in different cases.   If considerable
 or  great, it causes a notable  change  in the  physiognomy.  The skin gener-
 ally is not discolored, but there may be an  inflammatory blush.   The  mucous
 membranes  of the mouth, pharynx, and  conjunctiva  are often moderately
 inflamed. Pain upon moving the jaws  and difficulty in swallowing are experi-
 enced.   The disease continues for from four or five days to two weeks.  The
 swelling, pain,  and soreness gradually subside and disappear.  The inflamma-
 tion has  no tendency to suppuration  or to  continue in a  chronic form.    An
 abundant perspiration sometimes takes place at the time of convalescence.
   In males, after the age of puberty,  one, rarely both, of the  testicles  may
 become  inflamed.   This orchitis  is usually  called metastatic.  AYhen  it
 appears  the swelling  in the parotid  sometimes subsides.   This so-called
 metastatic orchitis is  not  very frequent.  It  seems to be more frequent in
 some epidemics than  in others.   Most of the  statistics  bearing on  its fre-
 quency have been derived from military  practice.   The  largest compilation
 from  this source  has  been made by Granier.1   In 495  cases  of  parotiditis
 in  soldiers,  orchitis  occurred in 115;  that is, in 24 per  cent,  of  the cases.
 Atrophy of the affected testicle often follows this  inflammation.  According
 to Granier, atrophy occurs  in -14 per cent,  of the cases of orchitis, and in H)k
 per cent, of the cases of parotiditis.  The shorter  the duration of the orchi-
 tis, the  less probability is there of atrophy of the testicle.   In  females a
 similar  inflammatory swelling of the mammary gland and of the ovary has
 been observed  as an exceptional occurrence.   AArhen parts other than  the
 parotid are  involved,  this is not,  strictly speaking, from a metastasis, but
 from  the operation of the same internal  morbid condition which occasions
 the inflammation  of the parotid.
  In very rare instances epidemic parotiditis is of  an unusually severe  cha-
 racter.   The fever and constitutional disturbance may be exceptionally high.
 Maniacal delirium and other  severe cerebral  symptoms have been observed.

  1 Lyon med., No. 26, 1879.
  In Laveran's collection of 432 cases in soldiers, orchitis occurred 156 times. In 32
cases of orchitis observed by Laurens (out of 118 of parotiditis), one testicle alone was
affected in 26 cases, and both testicles in 6 cases.  In 16 of these cases Laurens observed
distinct atrophy within two  months. 
ACUTE  GASTRITIS.
405
The patient has been known to sink into a typhoid state.  Convulsions some-
times occur in children ; but  facial spasm is less  infrequent.  The gland has
been known to suppurate in this disease.  These occurrences, however, are so
rare as to be regarded more as curiosities than of practical importance.
  The communicability of  this disease is generally admitted, but it has been
denied by some writers of high authority ;  for example, by Aralleix.  Persons
between  twenty and thirty years of age are most  susceptible to the con-
tagium,  but it occurs not infrequently under puberty.   Males are more sus-
ceptible than  females.  It is one of the diseases which affect the same person
but once.
  The prognosis is generally  favorable, the complications and accidents which
have been mentioned being exceptional. Except that it occasions considerable
discomfort, the disease in most cases  is trivial.   In  the  way of treatment  it
claims only soothing embrocations and the application of flannel, cotton bat-
ting, or wool  to  the  neck, with  some anodyne  remedy  if the pain  be con-
siderable.   Bloodletting, purgation,  or other of  the  so-called  antiphlogistic
measures are not indicated.  The popular apprehension of danger from " taking
cold " in this  disease is based on the idea that if the aff'ection of the parotid
be arrested a  metastasis is likely to take place. There is little ground for this
idea, but a patient probably passes through the disease more comfortably by
avoiding exertion and exposure.

  Parotiditis  occurs as an occasional complication  of typhus  and  typhoid
fever, pyamia, and pneumonic fever.  Under these circumstances it is a widely
different aff'ection  from mumps.  Suppuration takes place in the great majority
of cases, the abscesses evacuating either externally or into the meatus audi-
torius, and frequently there  is considerable sloughing of the areolar tissue.
As a  complication of fever it is attended with much suffering and danger.

  Acute suppurative  inflammation of the connective tissue around the sub-
maxillary gland is called by German writers angina Lndorici.  There is pres-
ent in the suprahyoid  region  diffuse cellulitis, combined  often with gangrene
and sloughing of  the tissues.   The inflammation may extend to surrounding
parts.  The affection is a grave one.   The most favorable termination  is  in
abscess.   Death  occurs from oedema glottidis, secondary pneumonia, or sep-
ticamia.   The treatment is  mainly  surgical.
                        CHAPTER   II.

INFLAMMATORY  DISEASES OF  THE  STOMACH  AND OF THE
                             DUODENUM.

  Acute Gastritis.—Subacute Gastritis.—Chronic Gastritis.—Phlegmonous Gastritis-
          Chronic Interstitial Gastritis.—Gastro-duodenitis.—Duodenitis.

                          Acute  Gastritis.
rpHE term acute has been applied to inflammation of the stomach by differ-
 I  ent authors with a widely different scope of signification.   In the cases
of gastritis to which  heretofore, by many authors,  the term acute has been 
406     INFLAMMATORY DISEASES OF THE STOMACH,  ETC.

restricted, the disease  is attended with extreme danger to life, ending  fatally
as a rule.  In these cases almost invariably the disease is caused by  toxical
agents—namely, the corrosive  or  acrid poisons.   Acute gastritis was con-
sidered as thus restricted in the  previous editions  of this work.   On  the
other hand, some  authors  include  under the name acute gastritis  or acute
gastric catarrh gastric inflammation of every grade of intensity, and also cer-
tain affections generally regarded as functional.   It is in accordance with the
application of the term acute to other diseases to extend its scope, as applied
to gastritis, so  as  to embrace all cases in  which  the  inflammation  has con-
siderable severity, obliging patients  generally to  keep the bed.  Acute gas-
tritis will be  considered in this sense in the present edition  of this  work.
Cases in which the intensity of  the inflammation is not sufficient to entitle it
to be called an acute disease will be included  under  the heading Subacute
Gastritis.  Cases of chronic gastritis  are those in  which subacute inflamma-
tion is more or less persistent.
   Adopting the more comprehensive scope of the term  acute  gastritis, the
disease, exclusive of toxical cases, is not of  very frequent occurrence—a fact
which would  not  a, priori be supposed, considering  the quantity of ingesta
received into  the  stomach daily, the various stimulating and irritating sub-
stances which  often enter into  these, the great functional  activity of the
organ, the  amount of blood which it claims during digestion, and the ex-
tensive glandular  apparatus which it contains.

   Anatomical Characters.—More knowledge and caution are requisite in
determining the existence of inflammation of the stomach than  of any other
organ.  The stomach often presents after death various appearances simulat-
ing disease, but which are independent of any morbid process.   These  decep-
tive appearances are dependent  chiefly upon two factors—namely, the vary-
ing amount of blood in the organ within physiological limits, and the rapid
post-mortem softening of the mucous membrane  in  consequence chiefly of
self-digestion.   These changes, which are most  intense in the fundus of the
stomach, will be mentioned subsequently under the head of  Softening  of the
Stomach.
   It is very difficult to discriminate the  milder  grades of gastric  inflam-
mation  from post-mortem changes.   Hence, the observations  of Beaumont
upon Alexis St. Martin, who had a fistulous opening into  his  stomach, are
of special value, and are  usually cited as descriptive of  the mild forms of
acute inflammation of the stomach.   These  morbid appearances were noticed
after  indiscretion in  eating or following the abuse of ardent spirits, and were
accompanied with corresponding local and  constitutional symptoms.   They
rapidly disappeared under  proper medication and  attention  to  diet.   Beau-
mont noticed during these attacks  of mild gastric inflammation a livid, ery-
thematous  redness distributed in irregular, small  patches.   Sometimes the
mucous membrane was pale.  Ecchymoses and oozing of grumous blood from
certain  red  spots of the gastric  mucous membrane were also observed.  The
secretion of gastric juice was deficient, and was  replaced by a considerable
quantity of ropy, alkaline mucus which became yellowish or muco-purulent
when the inflammation was  unusually severe.   Slightly elevated discolored
spots, resembling deposits of false  membrane and called apthous by  Beau-
mont, were  also described.
  In  cases of more severe  gastritis  the mucous membrane usually presents
irregularly scattered spots  of congestion.  Occasionally the  redness is more
diffused, and it may happen that the  inner  surface of the stomach presents
a pale rather than  a congested appearance.   Ecchymoses, especially upon the
summits of the gastric ruga, may be  present in  large number.   The mucous 
ACUTE  GASTRITIS.
407
membrane is thickened, softened, and more opaque than normal.  Its surface
is  coated  with a thick layer of tenacious mucus or  muco-pus.  The swell-
ing may extend  to  the  submucous tissue.   The changes are most  marked
usually in the pyloric portion of the stomach, and  are more distinctive of
inflammation when in this situation than when in the fundus.  Hemorrhagic
erosions, which  consist of round or oval  superficial abrasions of the  mucous
membrane upon a hemorrhagic base, are not infrequent.1  Upon microscopical
examination  hyperamia of the capillaries of the mucous membrane, partic-
ularly of  those about the summits of the gastric tubules, and extravasations
of blood,  are detected.   The intertubular tissue is thickened by the presence
of serum  and of extravasated red and white corpuscles.   The accumulation
of white corpuscles or pus-cells is  most evident about the muscularis mucosa.
They may also be present in the submucous tissue. The epithelial cells of the
gastric  tubules  may either remain  unchanged or they may undergo cloudy
swelling;  that is, become enlarged by the accumulation of albuminous gran-
ules (p. 53).  In some  cases  this  may  be  followed  by  fatty degeneration.
Sometimes the tubules appear to be filled with a granular matter containing
nuclei, but without distinct cell-boundaries.   This parenchymatous degenera-
tion in the glands of the stomach  often occurs in fevers, particularly in infec-
tious diseases, and  sometimes  in  phosphorus-poisoning, without  evidence of
inflammation, but with symptoms of disturbed digestion during life.2  The
cylindrical epithelial cells lining  the  inner surface of  the  stomach and  the
mouths of the gastric tubules become swollen with a secretion of mucus which
escapes from their free ends.   These cells are found in the mucus coating the
mucous membrane, but to what extent they desquamate during  life is a mat-
ter of uncertainty. The solitary follicles of the stomach (or lenticular glands, as
they are also called), when present, are often swollen.  They sometimes seem
to be increased in number in inflammatory conditions of  the stomach.  AYilson
Fox describes the development of follicular ulcers from these structures.
   It is not intended to describe here the manifold morbid appearances belong-
ing to toxic gastritis ;  that is, gastritis produced by swallowing irritant pois-
ons.  These are in some cases  characteristic of the action of special poisons,
and are described in works on special  pathological anatomy  and on forensic
medicine.   The corrosive  poisons, such  as strong mineral acids and alkalies,
cause  necrosis and sloughing of the mucous  membrane to a greater or less
extent, and may  produce such destruction of the coats of the stomach as to
lead to perforation of its wall during life, with the escape of its contents into
the peritoneal cavity.  Some of these poisons cause the formation of a diph-
theritic exudation in the  gastric  mucous membrane.   They  may be accom-
panied by characteristic changes in the color of the mucous membrane and of
the contents of the stomach.  \A7hen corrosive poisons are swallowed, more or
less  inflammation, and perhaps sphacelation, may  be present in  the  mouth,
pharynx, and oesophagus, but these signs are sometimes wanting.  The inflam-
mation in  cases of acute gastritis may extend into the duodenum.

  1 Brinton describes a special and severe form of gastritis characterized by the pres-
ence of a large number  of hemorrhagic erosions. The contents of the stomach are stained
with blood.  He calls the affection hemorrhagic erosion of the stomach  or ulcerative
gastritis.  Hemorrhagic erosions, however, are frequently found in the stomach under
a great variety of conditions, and it is not probable that they possess much pathological
significance.
  '-' A'irchow, in conformity with  his views of inflammation, describes this parenchy-
matous cliange as inflammatory, and designates the process in this situation as glandular
gastritis or  gastradenitis; but Cornil and Ranvier justly remark that the inflammatory
nature of this lesion is very doubtful.  Ebstein finds, in cases of poisoning by phosphorus
or  by alcohol, the parenchymatous degeneration most marked in the chief, or adelo-
morphous cells of the  gastric tubules ( Virchow's  Archiv, 1872, Bd. 55, S. 469). 
408    INFLAMMATORY  DISEASES OF THE STOMACH,  ETC.

   Clinical History.—Acute gastritis gives rise to pain more or less intense.
referred to  the epigastrium, together  with a  painful  sense  of constriction.
The pressure of the diaphragm upon the stomach in inspiration sometimes
increases the pain, so  that the breathing may be costal and the number of
respirations per minute is increased.   Nausea  and vomiting are prominent
symptoms.  In some cases the  stomach is intolerant of water or the blandest
liquids, even in very small quantities.   The vomited  matter is muco-serous,
of a greenish color, the presence of bile being  evident from  the  bitter taste,
and not infrequently it is sanguinolent.  The acts of vomiting occasion  suf-
fering.  The thirst is  frequently, but not always, intense.   The desire for
cold water is sometimes so irresistible that the  patient is  not deterred from
drinking it by  the  painful acts of vomiting which it provokes.  Tenderness
on pressure over the epigastrium is often marked.   The pulse is more or less
frequent and small.  The temperature of  the skin is moderately, and some-
times considerably, raised.   The thermometer, however, as a rule, shows but
a moderate fever-heat, rarely exceeding  101° or 102° F.  The bowels are con-
stipated except in cases of poisoning.   Dysphagia  and aphonia are occasional
symptoms.   The tongue presents no special morbid appearances.  The buccal
fluids are diminished and frequently have an acid reaction.  The patient suf-
fers  from  cephalalgia.   The mind is depressed  and the expression is anxious
and  haggard.   If  life be not speedily destroyed and  the disease run on to a
fatal termination, vomiting of black, grumous, coffee-ground matter may occur,
especially in cases  of toxical gastritis.   Toward the close of life the contents
of the stomach are ejected by acts of regurgitation rather than by  vomiting.
The prostration in  fatal cases becomes extreme.   Hiccough occurs.  The pulse
becomes very frequent  and thready.  Coldness of the surface is marked. The
mode of dying  is by asthenia.  If the disease  end in recovery, improvement
in all  the  symptoms takes place  slowly ;  convalescence is gradual, and the
inflammation may persist in a chronic form.  In cases of gastritis produced by
the corrosive poisons, if perforation of  the stomach occur, the symptoms of
peritonitis are added.  Jaundice occurs in some cases, showing that the inflam-
mation extends into the duodenum.   The foregoing sketch of the symptom-
atology applies to cases of marked severity.  In less severe cases the symp-
toms  are essentially the  same,  but with less intensity.

   Pathological  Character.—The stomach, aside from  its  office  as  a
receptacle of the ingesta, is a glandular organ, furnishing daily a large quan-
tity  of an  important secretion—the  gastric juice.  In its reluctance, so to
speak, to  take  on  acute inflammation from the  internal  and inappreciable
causes which give rise to the so-called spontaneous  inflammations  in other
situations, it resembles other glands, such  as the liver, pancreas, and kidneys.
When acute inflammation  is developed in this  situation it does not differ in
pathological character from acute inflammation seated elsewhere in  a mucous
structure.   The gravity of the disease depends on the physiological relations
of the stomach.   Acute gastritis  produced traumatically by the  action of
caustic or irritant  poisons  is developed like inflammation from the  action of
the same local  causes  in  other situations.

   Causation.—Exclusive of the acrid or corrosive poisons, the most frequent
cause in this country is spirit-drinking.  I have known the disease to directly
follow a debauch, and to prove rapidly fatal.  A person with chronic gastritis
induced and kept up by habitual spirit-drinking is liable to the acute affection
after  an unusually excessive indulgence.  Exposure to cold may act as  an
auxiliary cause.  In a  case under my observation,  the patient being an habit-
ual drinker, the disease followed sleeping  in a cold cellar.  Over-repletion of 
ACUTE  GASTRITIS.
409
 the stomach with stimulating and indigestible food  may sometimes »ive rise
 to acute gastritis.   This so-called crapulous gastritis  is generally subacute.
 It is a traditional error to consider  as exciting causes drinking  cold water
 when the body is perspiring, intense  mental emotions, and contusions of the
 abdomen.

   Diagnosis.—The  symptoms of  acute gastritis  are strongly  diagnostic.
 There is greater  probability of the disease being incorrectly supposed  to exist
 than  of its  being mistaken,  when  existing, for  other diseases.  A'omiting,
 however frequent and persistent, is never alone sufficient evidence of gastritis!
 I have known a  case of chronic  meningitis with persistent  vomiting to be
 treated for acute gastritis, the error not being discovered prior to the autopsy.
 Peritonitis,  if accompanied  with  vomiting, may  assume  an appearance  of
 gastritis, but the  diffusion of tenderness over the  abdomen, the  tympanitic
 distension, and  the rigidity of the  abdominal  muscles generally suffice for
 this differential diagnosis.  Gastritis  has  been mistaken for pneumonitis, but
 physical exploration of the chest should enable the physician to detect or
 exclude  the  latter affection.
   Gastralgia was formerly confounded with gastritis.  The paroxysmal recur-
 rence of pain or its occurrence in marked exacerbations, the absence of febrile
 movement,  of vomiting, as  a  rule, and  of tenderness  on  pressure, and the
 ability to take food, sometimes with relief of the pain, sufficiently characterize
 the affection as neuralgic.
   AVith a view to appropriate antidotal treatment, and  also in a medico-legal
 point of view in  certain cases, it is desirable to determine from the symptoms
 whether acute gastritis be attributable to poison.   This is always to be sus-
 pected in severe  cases if other causes be  not evident.   Burning in the throat
 is complained of  if a caustic or corrosive poison have been taken, and the
 local  action  of the poison may be seen in the mouth  and  fauces.   The mat-
 ters vomited are  likely to contain blood.  Diarrhoea is likely to occur.   If
 caused by a poison the disease  is  developed  suddenly, and inquiry is to  be
 made to ascertain if the sudden development were not immediately preceded
 by a meal or the ingestion of something in the way  of food or drink.

   Prognosis.—Cases of acute  gastritis,  in the restricted sense in which the
 term acute was formerly used, were, in the great majority of cases, fatal.   In
 the more comprehensive scope of  the term the disease ends in recovery, as a
 rule, if toxical cases be excluded.   Death sometimes takes place within a few
 hours, patients  falling quickly into  a condition  of collapse.  These cases,
 however, are exceptional.   The mode of dying  is  by slow asthenia.
  AVhen the  disease  is due  to  the action of a corrosive poison  the  danger
 will  depend,  other things being equal, on the  amount of  local'injury.

  Treatment.—The  indications  for bloodletting  are not present  in this
 disease.  Bearing in mind that  the danger is from  asthenia  and that life is
 sometimes quickly destroyed, the abstraction of blood is not admissible. The
 first and most important object in the  treatment is to secure for  the inflamed
 organ absolute rest,   AVith reference  to this object the less of anything intro-
 duced into the organ the  better.   To  allay intense  thirst small pieces of ice
 may be swallowed, or  iced water taken often in a  very small quantity at  a
 time.   The physieian should resist the temptation  to  try in  succession  the
 host of remedies  to  allay vomiting, all of which will  be likely to aggravate
this distressing symptom.  It is desirable to administer opiates  in order to
quiet the stomach and render the system more  tolerant of the disease.   A
salt of morphia placed  dry upon the  tongue  may be tried, and if vomiting 
410    INFLAMMATORY DISEASES OF  THE STOMACH, ETC.

be provoked by this mode  of administration it should be  administered hypo-
dermically or some form  of opiate  given per enema.   Fomentations or a
blister may be applied over  the  epigastrium.   Cathartics are inadmissible.
The bowels may be moved by stimulating enemas.   Mercury, either in large
or small  doses, is  not indicated.   The importunities of  the  patient for an
emetic are to  be resisted.   There may be a feeling as if the stomach were
distended or as if  there was an accumulation aggravating  the distress.  This
feeling arises from the inflamed state of  the membrane, as tenesmus is inci-
dent to inflammation  of the rectum, and it may be called  gastric tenesmus.
   Alimentation is not less  important than  in other diseases, and in proportion
as the symptoms denote danger in the direction of asthenia supporting meas-
ures of treatment are indicated. The stomach will not tolerate alcoholics and
food; moreover, their introduction into the stomach  conflicts with the most
important object of treatment—namely, absolute rest of  the inflamed organ.
The rectum is to be substituted for the stomach as regards  the reception of
ingesta.   This is  a disease in which rectal  alimentation is of  invaluable
service.   Alimentary support may be adequately provided thereby during a
period as  long as may be required; that  is,  until the acute  symptoms have
subsided and the stomach  will tolerate bland nourishment.   From three to
four ounces of defibrinated blood, Leube's  pancreatic meat emulsion or his
"meat solution," or milk  with the addition of egg  (the  election of any of
these articles  being made  after experimental trials, and perhaps the different
articles employed  in  alternation), may be  injected every  four or  six hours.
If alcoholic support  be indicated, spirit  may be  added  to  the  rectal food
according to the urgency  of the  indication, or the latter may be adminis-
tered hypodermically.  The addition of a little laudanum to each injection
is generally advisable.   Thirst may be relieved  by  the  injection of water
from  time to  time and frequent  sponging of the body.  The danger  from
the disease is much  lessened and the duration shortened by pursuing  this
course.1
   Milk with the  addition   of lime-water  will be likely  at  first  to be best
borne by the stomach, given  in small  quantities  at short intervals.   Other
forms of food are  to be gradually  added.   After the inflammation has ceased
the stomach is left in an atonic condition, and remedies of a tonic character
are indicated during convalescence.   If the acute end in the  chronic form of
inflammation,  the treatment due to chronic gastritis is to be employed.
   Acute gastritis  caused  by the acrid or corrosive poisons  is  to be  treated
after the plan  just stated, with the addition  of measures having reference to
the evacuation and neutralization of the  poisonous substance.   Emetics  are
to be promptly given, and  if they fail  to act efficiently the stomach-pump is
to be resorted to, provided the poison be one which can be ejected.  Arsenic,
corrosive   sublimate, alcohol, antimony,  cantharides,  copper,  phosphorus,
together with  a great number of vegetable irritants, such as capsicum, gam-
boge, croton oil, etc., may  be  expelled from  the stomach; but if any of  the
corrosive  acids  have been taken, reliance must be  placed  on the  prompt
administration of antidotes.  Antidotes are also to be given after the employ-
ment of emetics or the stomach-pump to  effect the removal  of acrid poisons.

  1 The pancreatic meat emulsion is prepared as follows : To 5 ounces of finely scraped
meat add 1£ ounces of finely chopped pancreas and 3 ounces of warm water. The mix-
ture should have the consistence of thick soup.  Leube's meat solution is prepared by
adding hydrochloric acid with water, and employing heat by rmans of a Pepin's
digester. (Vide  " Ueber die Therapie der Magenkrankheiten," von AV. O. Leube, Samm-
bmg klinischer Vnrtrage von Volkmann, No 62,  Leipzig, 1873.)  The  bowels should be
thoroughly washed out by a large enema both before beginning rectal alimentation  and
afterward from time to time.   Laudanum added to the injections promotes their reten-
tion, and probably their absorption. 
SUBACUTE GASTRITIS.                     411
(For details respecting  the  management of cases of poisoning  the reader is
referred to works which treat of toxicology.1)  I shall simply subjoin, for the
convenience of the practitioner, an enumeration of the antidotes for the more
important of the poisons which act locally upon the  stomach.
  Arsenical Preparations: The  hydrated sesquioxide of iron is the special
antidote.  It should be  recently prepared  and given  in large quantity.  If
this preparation be not immediately available, the  sesquioxide or common red
oxide of iron (crocus martis) may be given in its stead.  Bouchardat advises
to combine magnesia with the preparation  of iron,  in order to  promote the
passage of the iron from the stomach into the  intestines.
  Corrosive Sublimate  and  other  Salts  of Mercury:  The most  reliable
antidote  is albumen, and the white of eggs is the  best and most available
article.
  Salts of C>pper:  Albumen is an antidote.  Iron reduced by hydrogen and
the hydrated persulphate of iron are said by Bouchardat to be antidotal both
to the salts of mercury and of copper.
   Tartar Emetic: Substances containing tannin in abundance and magnesia.
  Nitrate of Silrer : Chloride of sodium.
  Mineral Acids:  Magnesia  or  chalk  mixed with water or milk; the alka-
line carbonates or soap.
   Oxalic Acid: Magnesia, chalk.  Whiting or plaster scraped  from the wall
of an apartment may be given, mixed with water.   Alkalies  are  not to be
given.
  Ammonia :  Vinegar or any of the vegetable acids.
  Potassa and Soda : The same.


                         Subacute Gastritis.
  Subacute gastritis, not becoming chronic, but of transient duration, occurs
not infrequently.  It is not easy to say with positiveness how  frequently it
occurs, because practically it is  difficult to  draw the line of demarcation be-
tween slight inflammation and merely functional disturbance in this situation.
Subacute gastritis doubtless enters  into certain cases of the affection which
will  be noticed  in connection with functional disorder of the stomach under
the name of Acute  Dyspepsia.    Subacute inflammation of the stomach  is
much more frequent in  infants and young children  than in the after periods
of life.   As here considered, reference will be  had chiefly to  the  affection
occurring at a time subsequent to the period of infancy.
  The degree  of inflammation in different cases of subacute gastritis  varies,
being either  slight or  moderate as evidenced by the local and general symp-
toms.  The local and  general symptoms are marked according  to the degree
of the inflammation.  The ingestion of food is followed by uneasiness or dis-
tress  referred  to the epigastrium, and  by symptoms denoting  indigestion—
namely, flatulence,  eructations,  etc.  Thirst is a symptom  usually more or
less  prominent.   Tenderness over the  epigastrium  and a  furred or coated
tongue are other symptoms.  The urine is high-colored and loaded with the
urates.   In some cases there is constipation, and  in other cases diarrhoea, the
latter heing due to intestinal indigestion.  Pain in the head  is a  frequent and
sometimes a  prominent  symptom.  There  may be slight pyrexia, but  it  is
frequently or generally wanting, except after the  ingestion  of food  or stim-
ulants.   AVhen transient febrile  movement is not  thus produced, the  pulse is
usually feeble and the  extremities are cold.  There is more or less general
debility, but the sense of weakness exceeds  the actual reduction of strength.
  1 Tat/lor on Poisons may  be consulted for this purpose; also, article "Poisons" in
Dunglison's Medical Dictionary. 
412    INFLAMMATORY DISEASES OF THE STOMACH  ETC.

The spirits are depressed, and the suffering may be considerable from malaise
without any definite location of pain or distress.
  This is a sketch of a class of cases which the practitioner meets with fre-
quently, and which, together  with  cases  of the affection to be  considered in
another chapter under the name of Acute Dyspepsia, is properly known as
a " bilious  attack."
  If the gastric inflammation be greater,  approximating in intensity to acute
gastritis, the local  and general symptoms are more marked.  There is suffer-
ing from gastric distress, and sometimes from a dull, obtuse pain in the region
of the stomach.  The epigastric tenderness is often considerable.   Anorexia
is complete, with loathing of food  and nausea.   A^omiting is  often a prom-
inent symptom.  Mucus is vomited  in abundance, and if the efforts of vom-
iting be  prolonged bile  is rejected.  The patient experiences  a  temporary
sense of relief  after vomiting.   The  feeling  is as  if the stomach  were dis-
tended,  and acts of vomiting  are provoked  and  aided  by voluntary efforts
with the idea that  if the contents of the stomach were eff'ectually discharged
the relief would be permanent.  This feeling  arises from the  inflamed con-
dition of the membrane, and is analogous to  the  sensation connected with
tenesmus in dysentery.   It may be called gastric tenesmus.   Thirst is gener-
ally urgent and cold drinks are craved.   The tongue is coated at first, but in
the course of the affection it may become clean and reddened.  Either con-
stipation or diarrhoea  may exist,  There  is more or less febrile movement,
with evening exacerbations, as shown by the pulse and axillary temperature;
the latter, however, rarely  exceeds 100° F.  Chilly sensations and rigors are
common, continuing for a few seconds and recurring irregularly.   Cephalal-
gia  is generally marked, and in some cases is accompanied by a  sense of ten-
sion or a feeling as if the head would break.   There is often a sense of pros-
tration, with depression of spirits and sometimes a notable degree of mental
apathy.   In cases of  maximum severity subacute  gastritis so closely approx-
imates to acute gastritis that there is scarcely a well-marked line of division
between the two forms of the disease.
  In cases of  gastritis with considerable pyrexia the disease is  sometimes
called " gastric  fever."  This  name  implies  that the disease is primarily  or
essentially a fever, whereas the fever is purely symptomatic and secondary to
the gastric inflammation.
  Subacute  gastritis,  if the inflammation be slight or moderate,  is usually of
short duration, convalescence taking  place in a few days.   If the inflamma-
tion have considerable intensity the duration of the disease is from a week  to
three weeks.   If the  inflammation  persist much beyond the latter date it is
to be considered as chronic.
  Subacute  gastritis  in  some  cases  is  evidently  of  dietetic origin.   It  is
sometimes attributable to the  decomposition of ingested aliment, owing to a
deficiency of gastric juice or to the  quantity of food ingested  being  out  of
proportion to the digestive capability of the stomach, and to the ingestion of
food either difficult of digestion or in which putrefaction had begun prior to
its ingestion.  Persons who are habitually addicted to  over-indulgence in eat-
ing, or to highly seasoned  dishes and the free  use of  condiments, are doubt-
less more liable to  this affection than others as a consequence of a gluttonous
meal or when  from any  cause gastric  digestion is arrested.   The affection
sometimes follows a  prolonged  debauch.   The habitual free use of  spirits
begets a liability to it.   It occurs especially among drunkards.  It  may be
caused by any of the acrid or irritant poisons, not taken in sufficient quantity
to produce acute gastritis.   The so-called  uramic gastritis  is caused  by the
irritant effects of the carbonate of ammonia, formed by the  decomposition of
urea, upon the gastric mucous membrane; and it is not improbable, as some 
CHRONIC GASTRITIS.
413
authors have maintained (Garrod, Charcot), that in some cases of gout, uric
acid is eliminated by the stomach, and by a similar irritant effect causes gas-
tritis.  In  a  certain proportion  of cases the causes, both remote and prox-
imate, are  not  apparent.
  An affection  to which subacute gastritis is closely affiliated is that  to be
considered under the name of Acute Dyspepsia. Gastric inflammation doubtless
enters into certain cases of the latter aft'ection, but the functional  disturbance
is disproportionately great as compared with the  amount  of inflammation,
and is not to be accounted  for  by the latter;  hence  the propriety of  con-
sidering it as a  functional affection of the stomach.  The diff'erential diagnosis
of these  affections  is  not, practically,  of great importance.   The symptoms
of gastritis are  present in certain  cases of  remittent fever, and perhaps they
proceed actually from subacute  inflammation of  the stomach  in  these cases.
The  symptomatic  phenomena of  remittent fever,  however, are sufficiently
distinctive to render its discrimination  from simple gastritis easy.  Cases of
ephemeral  fever, or febricula, are  to be discriminated by the want of propor-
tion  between the  febrile phenomena and  the  gastric  symptoms.  Cases of
continued fever, typhus, and typhoid  very rarely present symptoms of gas-
tritis  with  sufficient prominence for the differential diagnosis to  be a matter
of question.  In  general, the diagnosis of  subacute gastritis is not difficult,
  In  the treatment of subacute gastritis rest of the inflamed  organ  is of
primary importance.  If the inflammation be but slight or  moderate, it will
suffice to place  the patient on a diet reduced in quantity, consisting of milk
with lime-water and farinaceous  articles.   In cases of greater severity com-
plete  abstinence for two, three, or four days may be advisable.  The vomiting
and loathing for food will be  likely to secure this end without any injunctions
on the part of the physician.   In the mean time, if  the symptoms denote
exhaustion the patient  may be  supported by rectal  alimentation.    The
abstraction of  blood  either  locally  or by  venesection is  never  indicated.
Benefit may  be derived from  sinapisms  or  a  blister over  the epigastrium.
Emetics  and purgatives are  contraindicated.   The sensations of the patient
may lead  to a desire for both, especially the former, but they do  not effect
any desirable object, and their local action upon the inflamed organ will do
harm. If the bowels be constipated simple enemas may be  employed.   Mer-
cury  is not indicated, any  more than in cases of inflammation affecting the
mucous membrane or other portions of the digestive system.  On the  other
hand, remedies  to soothe the inflamed membrane and  to allay vomiting are
indicated—namely, bismuth, hydrocyanic  acid, hyoscyamus,  and  especially
the salts of morphia.   Small pieces of ice may be swallowed, or iced water
given in a small quantity at a time and often repeated,  if found  to be  grate-
ful  to the patient.  Carbonated  water is  not  only taken with comfort, but
appears to be useful.
  It  is important not to continue  the abstinence from  food  or a  great reduc-
tion of diet too long.   As  soon  as nutritious articles of food are well tole-
rated by  the stomach  they are admissible.   The  improvement of diet should
be made  gradually and  tentatively.   During convalescence the mineral acids
are useful as tonics, and  after the inflammation has ceased other tonics may
be appropriate.   Patients who are spirit-drinkers should be  told of the con-
nection of the disease with their habits.


                         Chronic Gastritis.
  Chronic  gastritis is  not infrequent, although it is not as common  an  affec-
tion as was supposed some  years ago.  Chronic functional disorders were for-
merly considered as inflammatory.   It is not always easy to discriminate clin- 
414     INFLAMMATORY DISEASES OF THE STOMACH, ETC.

ically between chronic inflammation and the functional affections  embraced
under the  name of dyspepsia.   The  diff'erential  points involved in this dis-
crimination will  suffice for the clinical history and diagnosis of the aff'ection.
The  affection  occurs oftener in middle  and advanced  life  than  in children
and  young persons.   It  occurs in  men oftener than in women.

  The anatomical changes in chronic gastritis are  most frequently pres-
ent and most marked  in the  pyloric  region of  the stomach.   This local-
ization applies also  to the majority of morbid  processes  in the stomach.
The  color  of the mucous  membrane varies  in diff'erent cases.   It may be
red,  brown, ash-gray,  slate-colored, or  whitish.   A bluish-red  color, either
diffuse or in spots, is usually present  in  the  chronic inflammation  attendant
upon prolonged passive  congestion of  the  stomach,  such as  accompanies
cirrhosis  of the  liver, emphysema of the lungs, and heart  disease.   Ecchy-
moses and  hemorrhagic erosions are frequently present.  The mucous mem-
brane, as a rule, is more or less pigmented, and this  gives  rise to brown,
ashy, and slate colors.  The pigment generally appears as little dots scattered
over the mucous membrane.  The  same pigmentation  often coexists in the
intestinal  tract.   It is most frequent where there is mechanical congestion
of the stomach in consequence of portal obstruction.  It is referred to alter-
ations in the hamoglobin of extravasated red blood-corpuscles  (Part I. p. 57),
and  is therefore  regarded as a sign of preceding congestion and  hemorrhage.
The  pigment exists in the form of dark granules, either free  or in cells, in the
intertubular tissue, and  sometimes in cells within the tubules.   The inner
surface of  the stomach is coated with a thick layer of viscid mucus or muco-
pus.   The consistence of the  mucous  membrane is  sometimes peculiarly
firm and  tough;  at other times  the membrane  is more or less  softened.
The  thickness of the  mucous membrane varies in different  cases and in dif-
ferent parts of the stomach in  the same case.  Chronic inflammation  leads
both to thickening and  to thinning of the mucous membrane.  The latter result
is often, although not invariably, consecutive  to  the former.  The mucous
membrane  is usually thickened, but not infrequently it is atrophied in cer-
tain  places, and exceptionally the whole membrane may be  abnormally thin.
Both in  healthy and diseased stomachs the mucous membrane of the pyloric
region not infrequently  presents little rounded elevations separated by slight
furrows.    This condition, compared sometimes  to granulations upon wounds,
is called mammillation  or Vetat mamelonue of Louis. AVhen present in healthy
(and often in diseased)  stomachs it is due to  contraction of  the muscularis
mucosa (Briicke's muscle).  In chronic gastritis, however, it  may also be
referable to irregular  thickening of  the mucous  membrane.   The furrows
may correspond  to atrophic spots.   Exceptionally, polypoid growths, due to
localized increase of connective tissue  and enlargement and proliferation of
the  gastric tubules, are  present, even in considerable number  (gastritis  poly-
posa).  Little cysts about a millimetre in  diameter  are frequently observed
in the mucous membrane.   They are the result of distension of parts of the
gastric tubules with a clear mucoid secretion.  Sometimes the cysts attain a
much larger size.  The  submucous tissue  is frequently thicker and denser
than normal.  There  may also  be  some hypertrophy of the  muscular  coat.
Upon microscopical examination the  interstitial  tissue  of the mucous mem-
brane is usually found to be increased in amount.   The gastric tubules may
be enlarged in consequence of swelling and parenchymatous or fatty degene-
ration of their epithelial cells.   Usually the tubules are affected in  groups,
some remaining unchanged.  The degenerative change  may lead to complete
destruction of the epithelial cells.  The tubes  are then partly or completely
filled with  albuminous and fatty detritus.   Finally, the tubules may become 
CHRONIC GASTRITIS.
415
atrophied, and in some places even obliterated.  According to AAT. Fox, fatty
degeneration may occur in the connective tissue  as  well  as  in  the glands.
The cystic transformation  to which reference has been  made  is  attributable
to partial occlusion of the tubules in consequence of the new growth of inter-
stitial  tissue.   A  change which occasionally occurs is  proliferation  or  ade-
nomatous growth of the tubules.  In the neighborhood of the pylorus little
villous projections of vascularized connective tissue  are often met with  in
chronic gastritis.  In the  atrophied portions of mucous membrane  the  tub-
ules  are  shorter and narrower than normal.  Such  places have usually a
smooth surface  and are pigmented.

   Symptoms denoting  indigestion or difficult digestion  are present in cases
of chronic gastritis, but these alone are not diagnostic, since they alike exist
in cases of dyspepsia.  Pain may not be present, and if  present it is not dis-
tinctive.   A burning sensation or a feeling  of  heat in the gastric region is
somewhat  diagnostic.   Tenderness over the  epigastrium is somewhat diag-
nostic, provided it  be limited  to that region  and constant; that  is, not pres-
ent merely during the process of digestion or when the stomach is distended.
Thirst is diagnostic if habitual; that is, present not only during  the process
of digestion, but at other  times.  The appetite  is  much  oftener  impaired  in
connection with  chronic gastritis  than in cases of dyspepsia,  the appetite
being generally  preserved,  and often craving, in the latter.  The nutrition is
oftener defective in cases of chronic gastritis.  Dyspeptics often preserve their
weight undiminished.   In  chronic gastritis stimulating articles of food, such
as meat and condiments, are not as well borne as bland aliments, the reverse
being oftener the case in dyspepsia.  Alcoholic and other stimulants produce
gastric distress  in cases of chronic gastritis, whereas they often relieve dis-
tress  incident to merely functional disorder.   Nausea and  vomiting are more
likely to occur in connection with chronic gastritis, excluding cases of so-called
acute dyspepsia and certain cases of functional disorder characterized by vom-
iting.  In ordinary cases of dyspepsia nausea and  vomiting are not common.  A
slight grade of  febrile  movement is sometimes observed in chronic gastritis,
and very rarely  in a purely functional disorder.

   The diagnosis is to be  based on the  combination of  more or less  of the
foregoing  differential  points.   In making the  diagnosis  certain structural
affections of the stomach  are to be excluded—namely, carcinoma and ulcer.
The diagnostic symptoms of these affections will  be considered  in Chapter III.
   Chronic gastritis may follow an acute or subacute inflammation of the stom-
ach developed spontaneously or produced by the  acrid or corrosive poisons.  It
may proceed from  excesses in eating or spirit-drinking, and on  the other hand
it is stated that long fasting  or too rigid dieting may  give  rise to it.  In
dogs destroyed by starvation Andral found  the  stomach inflamed and ulcer-
ated ; but similar experiments  made by Collard de Martigny were negative as
regards appearances of  inflammation in this organ.1  Stark, who fell a victim
to experiments in dietetics  in 1869, had  symptoms  of gastritis  developed dur-
ing prolonged abstinence.  Arsenic introduced into the system by absorption
from an external wound gives rise to gastritis, as was ascertained by Brodie
and verified by the observations of others.   Chronic gastritis also frequently
results from long-continued venous congestion of the stomach  in consequence
of obstacles to the circulation in the liver,  lungs, and  heart,   This chronic
congestion is most intense, cseteris paribus, when the obstacle  is in the  liver.
Emphysema of the lungs, chronic pleurisy, valvular lesions of the heart, and
especially cirrhosis  of the  liver, are often accompanied  by chronic  gastritis.
                  1 Magendie, Journal de Physiologie, tome viii. 
416     INFLAMMATORY DISEASES  OF THE STOMACH, ETC.

It occurs also in connection with gout and with pulmonary phthisis.  Chronic
gastritis occurs in certain cases of renal disease involving uramia;  the expla-
nation being that already given—namely, that the carbonate of ammonia
which is formed from the decomposition of the urea eliminated by the gas-
tric mucous  membrane acts  as a  local irritant.

   The first point in the treatment is the removal of dietetic causes which may
have originated, or which may tend  to perpetuate, the affection.  The patient
is  to be placed on a bland and  easily-digested diet, consisting of milk,  eggs,
stale bread, soft-boiled rice, and other farinaceous articles—articles  digested
in the small intestine.   Meat and  stimulants are to be interdicted.  For a
short time it may be advisable to reduce  the  quantity of food  below the
amount which the wants of the system  require.  Food  should be taken in
small quantities and at shorter intervals  than in  health.   Moderate  counter-
irritation over  the epigastrium is useful.   The remedies to be administered
are few.  Solicitations for emetics and cathartics are  to be resisted.   Patients
often declare that  they are "bilious"  or  that there  exists  "foulness  of
the stomach," and hence that  they need  evacuant medicines; but  in place
of medicines which  from their irritant action will tend  to increase  or pro-
long the inflammation, remedies to soothe the inflamed membrane are  indi-
cated—namely, small doses  of morphia or  codeia, hyoscyamus, hydrocyanic
acid, bismuth, etc.   After the inflammation  has  ceased functional debility or
atony remains.   Tonics and improved  diet  are  then required.  It is a point
of delicacy to determine when to make this change  in the  treatment.  It is
like  resorting to passive  motion in cases of fracture  or  dislocation.  The
change is to be begun  tentatively, and  to be continued or  not according to
the effect.   The symptoms of functional disturbance and the indications for
treatment which may be present after the inflammation ceases will be consid-
ered in connection with Dyspepsia.  (Vide Chapter IV.)


                      Phlegmonous Gastritis.

   By phlegmonous  gastritis is understood  suppurative inflammation of the
walls of the  stomach.   This  disease is very rare.  The submucous  tissue is
primarily involved, but the  inflammation may extend to the  other coats  of
the stomach.  Synonyms for this disease are gastritis submucosa (Dittrich),
suppurative linitis (Brinton), and interstitial suppurative gastritis (Auvray).
The  affection appears either as a circumscribed collection of pus in the walls
of the stomach or as a diffuse purulent infiltration of the ventricular coats.
The  former condition, which is the  more frequent, is also  called abscess  of
the stomach, which  may be single  or  multiple.  It may attain the  size  of
the fist.  The purulent collection is in the submucous coat,  and it frequently
invades the muscular layer.   The mucous and  serous layers may be intact.
There is usually, however, a localized peritonitis over the seat of the abscess.
The abscess may rupture through the mucous membrane into the cavity of
the stomach, or less frequently through  the serous  coat into the  peritoneal
cavity.  In rare instances recovery may take place  after the escape of the
pus into the cavity  of the  stomach.  A cicatrix then results, and  this may
lead  to stenosis of the stomach.
   Purulent infiltration of the  submucous coat  usually involves only a part
of the stomach ;  it may, however, affect its whole extent.   The suppurative
process may also extend into the lower part of  the  oesophagus and into the
duodenum.  The wall of the affected portion of the stomach  is thickened; and
it  may be  six or eight times thicker than normal.  The mucous membrane is
usually swollen  and spongy in texture.  It generally presents a number of 
PHLEGMONO US GASTRITIS.
417
little  round openings, through which  pus can be  pressed out.  Sometimes
larger irregular ulcers are present.   Upon  cutting  through  the wall of the
stomach  the  accumulation of pus is found to be greatest in the  submucous
coat, whence purulent septa often extend between the bundles of fibres in the
muscular coat.   The subserous tissue  also frequently contains pus.  In fact,
while the lax submucous and subserous tissues suffer the most, microscopical
examination usually shows the presence of large  numbers of pus-cells in the
firmer mucous and muscular coats of the stomach.  Purulent infiltration may
be accompanied by the presence of circumscribed  abscesses.  The suppurative
inflammation exceptionally may not have advanced  to the breaking down of
tissue, so that the infiltration with pus-corpuscles is evident only upon micro-
scopical  examination.  Upon  microscopical examination, in addition to large
quantities  of pus-cells, are found many micrococci, which, at  least in some
cases, are streptococci.   Circumscribed inflammation of the  serous  covering
of the stomach (perigastritis) is often present, and not  infrequently there is
general peritonitis.  Infectious thrombi may form in the veins of the stomach.
and  by the separation of emboli may lead to secondary abscesses in the liver
and  lungs.  Phlegmonous gastritis is one of the  causes of suppurative pyle-
phlebitis.  In a  number of cases there have been evidences  of a  previous
chronic  gastritis, with fibrous thickening of the submucosa,
   Etiologically, phlegmonous gastritis may be divided into  two varieties—a
primary, idiopathic; and  a secondary, metastatic.   Metastatic phlegmonous
gastritis, which is usually in the form of circumscribed  abscess, is  secondary
to severe infectious diseases, such as pyamia and puerperal fever.   The pri-
mary variety has been observed most frequently in  drunkards.  Other causes
which have been assigned, the efficiency of which is doubtful, are injuries in
the  region of the stomach, errors in diet, and ulcer  of the stomach.   In most
cases of  the primary variety it is impossible to assign an efficient cause.  Males
are  more frequently attacked than females.  It  has usually  occurred in  the
 middle period  of life.
   The symptoms of the metastatic variety are usually obscured by those of
 the  primary disease.   The idiopathic  form generally runs an acute course,
 terminating  in  from one  to  three weeks.  Its  progress, however,  may  be
 chronic  and insidious.   As  a rule, the  disease begins with  a chill  and  may
 be attended by repeated  chills.   The temperature is elevated, often consider-
 ably. The pulse is  rapid and feeble.  The patient suffers  from thirst  and
 anorexia.  There are usually severe  pain  and tenderness in  the  epigastric
 region,  but these  may be absent.   Vomiting  and  retching are prominent
 symptoms.   The stomach  is generally more or less distended  with gas.   In
 some cases there has been  constipation, and in others diarrhoea.  Prostration
 sets  in early.   Brinton observed icterus in  some cases.  Toward the end the
 patient becomes delirious.   Death  is usually preceded by a state of collapse.
 The fatal  termination is  sometimes sudden.  These symptoms may be com-
 plicated by those of  acute peritonitis.  As a rule, no pus has been detected
 with the naked eye in the vomited material.  Sometimes, however, when an
 abscess has burst into the stomach a large quantity of pus has been vomited.
 Occasionally an  abscess  in the wall of the  stomach is of sufficient size to be
 felt during life as a tumor.   The duration of the disease is usually from two
 to ten days, but it may  be longer.
   There are no diagnostic  symptoms of phlegmonous gastritis.  Its recogni-
 tion  during life is  usually impossible.   It may,  however, sometimes be  sus-
 pected by  excluding other conditions,  especially general  peritonitis.   In some
 cases its presence has been rendered probable by the detection of  a swelling
 connected  with the stomach, the disappearance of which was followed by the
 vomiting of  a quantity of  pus.   But even in this case it would be  difficult to
        27 
 418     INFLAMMATORY DISEASES OF THE STOMACH,  ETC.

 exclude the rupture of an  abscess which had taken its origin outside of the
 stomach ; for instance, a circumscribed collection of pus in the peritoneal cavity.
   The termination of phlegmonous gastritis is usually fatal.  There is reason,
 however, to believe that abscess of the stomach may end in recovery.
   The treatment indicated in phlegmonous gastritis has for its objects com-
 plete rest of  the affected  organ  and the relief of pain.   The first of these
 objects is secured by rectal alimentation and opiates.  The relief of pain is
 effected by the latter in  conjunction with emollient and soothing applications
 over the epigastrium.

   Croupous  and diphtheritic inflammations of the stomach  have been  de-
 scribed, but they are little understood and are w*ithout clinical interest, being
 unattended by distinctive symptoms.  Pseudo-membranous gastritis is usually
 secondary to some other  disease, such as croup and diphtheria, typhoid fever,
 pyamia, or puerperal fever. It may be produced by swallowing acrid poisons.


 Chronic Interstitial Gastritis—Cirrhosis  of the  Stomach—
             Hypertrophic Stenosis of the  Pylorus.

   The  disease  known  under these names is characterized  by thickening
 of the  walls  of the stomach in  consequence of new growth of connective
 tissue.   The  affection was  clearly described by Brinton,  who proposed for
 it the names plastic  linitis and cirrhosis of the  stomach.   It has also  been
 called  fibroid degeneration or infiltration, induration, sclerosis,  and hyper-
 trophy  of the stomach.   The  name  chronic  interstitial  gastritis  implies
 that the  morbid process is a chronic  inflammation of the interstitial tis-
 sue of  the stomach, analogous to that of the  liver in cirrhosis.   The affec-
 tion is referred to  by  most German  writers under  the name of chronic
 catarrhal  gastritis,  with  which,  although  often  associated,  it  should  not
 be confounded.  The disease, although  rare,  has been observed in  several
 typical  cases.   In  such  cases the stomach is small and increased in weight
 and density.   The diminution in  its  capacity may be extreme.  Its cavity
 may not  be  larger  than a medium-sized  pear.   In  certain instances  the
 stomach has been described as normal in size or even dilated.  The thickness
 and increased  density of  the ventricular walls may be such that upon incision
 the organ does not collapse.  The stomach-wall may measure an inch or more
 in thickness.  The  organ may be uniformly affected or the change may be
 greatest in the pyloric region.  AVhen the pyloric region is alone affected the
 remainder of the stomach is dilated instead of contracted.   Upon examining
 a section  through the wall  of the stomach the coats are found to present
 an unnatural  uniformity.   Their consistence is firm, almost cartilaginous.
 The  new  growth of connective tissue, to which the change is  mainly due,
 involves usually all of the coats of the stomach, but especially the submucous,
 which appears as a dense, white layer.   The muscularis, especially the trans-
 verse layer, is frequently much hypertrophied, and presents a grayish, trans-
 lucent appearance.   It is usually invaded by the  new growth of fibrous tissue.
 The subserous tissue is also thickened and fibrous.  The  serous coat is of a
 peculiar opaque, pearly-white  color.  The mucous membrane may be intact,
 but it is generally involved  in the morbid change.   Its interstitial  tissue is
 thickened, the tubules are atrophied, and they  may  even disappear  over a
 considerable extent of the  stomach.1   In some cases no changes  in the gas-
tric glands have been noticed.

  1 In a case reported by Nothnagel,  and examined  microscopically by AV.  Midler,
glands were found only in  the pyloric region (Deutsches Archiv f. klin. Med., 1879, Bd.
24, S. 353). 
              CHRONIC INTERSTITIAL  GASTRITIS,  ETC.          419

  The thickening is sometimes confined to the neighborhood of the pylorus.
This condition has  been  called fibroid degeneration  of the  pylorus (Haber-
shon) and hypertrophic stenosis of the pylorus (Lebert).  In works devoted
specially to diseases of the stomach it appropriately receives separate consid-
eration.  The thickening here also is due to formation of new fibrous tissue
and to hypertrophy of the muscular coat.   This lesion induces stricture of
the pylorus,  which  may amount almost to complete closure of the orifice.
In consequence of pyloric obstruction, the  stomach becomes dilated and its
muscular coat is hypertrophied.  In a case of hypertrophic stenosis  of the
pylorus, related by Nauwerk,1 the stomach occupied two-thirds of the abdom-
inal cavity.   This  lesion has been confounded with  scirrhous cancer  of the
pylorus, from which it is to be distinguished  only by microscopical examina-
tion.   In some cases of hard cancer of the stomach the cancerous alveoli are
fewln number and  separated by a large  quantity of fibrous tissue.
  The symptoms of cirrhotic  contraction of the stomach  are not sufficiently
distinctive to admit of a positive diagnosis.   The affection is  a grave one, and
usually terminates  fatally.  Sometimes, like  other severe affections  of the
stomach, it is unattended  by symptoms.   Usually the  symptoms at first are
those of simple chronic gastritis, such as indigestion, loss of appetite, vomiting,
and feeling of oppression in the epigastrium;  but  these symptoms are incon-
stant and possess nothing characteristic.  As  the disease progresses a more
severe affection  is  suspected, usually cancer  of the stomach.   The  patient
loses flesh and strength.   In an interesting case reported by Nothnagel the
patient presented all of the essential  symptoms of pernicious anamia, includ-
ing hemorrhages in  the retina and elsewhere.  To a certain degree character-
istic of cirrhotic  contraction  are the inability to take more, than a small quan-
tity of food or drink at a time and  the sense of fulness which follows the
ingestion of this small quantity.  The  patient  thus suffers from inanition,
both in consequence of the small  capacity  of the stomach and from the
disturbance  of its digestive functions.  Sometimes,  but  not always, a hard
mass presenting  the contracted  contours of the stomach  can be felt through
the abdominal wall.   In a few cases the vomiting of coffee-ground material
has been noted, but this occurrence  is  exceptional.   Pain is not usually a
prominent symptom.  Constipation has been the rule.
  In a case  under my observation, in which the walls of the stomach were
found to be from half an inch  to an  inch in thickness everywhere except at
the pyloric third, the  patient up to  a few weeks before death supposed that
he was simply dyspeptic, his ailments not leading him to seek medical advice.
In this case the organ formed a resisting, movable  tumor felt  through the
abdominal walls, and the  disease w*as supposed to be carcinoma.
  AVhen the fibroid  metamorphosis is confined to the pylorus the symptoms
are  those of stenosis of the pyloric  orifice, combined with dilatation of the
stomach.  Prominent among these symptoms are vomiting of  accumulated
ingesta  and  obstinate constipation.    The symptoms are  explicable  by the
obstacle to the entrance of substances from the stomach into the intestine.
The symptoms and signs of dilatation of the stomach will  be considered here-
after.   Nauwerk, in the report of the case of  hypertrophic stenosis to which
reference has been made, gives an'interesting example of the length of time
during which ingesta may  remain in the  stomach.  He found in the stomach,
at the  autopsy, cherry-stones which  had been  swallowed  three  months pre-
viously, and which had remained, although the stomach had been washed out
and the patient had vomited repeatedly.  Sometimes the thickened  pyloric
part of the stomach can be felt during life as a small, hard, movable tumor.
  The diagnosis of cirrhotic contraction of the stomach and of hypertrophic
             1 Deutsches Archiv f. klin. Med., 1878,  Bd. 21, S. 578. 
420    INFLAMMATORY DISEASES  OF  THE STOMACH, ETC.

stenosis of the pyloric valve cannot usually be made with any degree  of cer-
tainty.  The disease is most likely to be confounded with cancer of the stom-
ach. The following points are to be considered in attempting to reach  a prob-
able diagnosis: Cirrhosis of the stomach is often of much longer duration than
cancer; it may attack persons much younger than those usually affected with
cancer; pain in the region of the stomach and vomiting of blood are less fre-
quent and prominent  symptoms in cirrhosis than in cancer; the inability to
take more than a small quantity into the  stomach is a more marked symptom
in cirrhosis than in cancer.  Upon no single one of these points, however, can
much positive value be placed in a differential diagnosis; nor is too much  weight
to be placed upon the detection of a hard tumor simulating the contours of
the stomach.   Such an occurrence is  rare  and would not suffice  to exclude
cancer.   It has been proposed to determine the size of the stomach by caus-
ing the  evolution of carbonic  acid gas in its cavity, according  to the method
first proposed by Frerichs (vide Dilatation of the Stomach, Chapter III.), but
this procedure has not yet been employed in contraction of the stomach, and
it could not well serve as a basis of a positive diagnosis.   The diagnosis of cir-
rhosis of the stomach, then, may in certain cases be rendered  probable by a
combination of favorable circumstances, but it can hardly become a certainty.
   The etiology of chronic interstitial  gastritis  is  obscure.  Most  writers
concur in regarding spirit-drinking as one of the causes.  It is most frequent
in men and after forty years of age.  It has, however, been met with in tem-
perate  persons  of either sex and  in  early life.  It is often  preceded and
accompanied by the symptoms of chronic  simple gastritis, but that there is
no essential connection between these processes  is proven by the infrequency
of cirrhosis of the stomach compared with the frequent occurrence of  simple
chronic gastritis.   The prognosis is grave.   The disease  usually runs a chronic
course and terminates by asthenia.
   The treatment embraces  remedies to palliate  irritation of the stomach,
abstinence from spirits and other  stimulants,  careful regulation of diet, and,
if there be pyloric obstruction, the means indicated in  cases of dilatation of
the stomach.


                  Gastro-Duodenitis—Duodenitis.
   In acute gastritis the inflammation, as  already stated, may extend into the
duodenum.  This is also true  of subacute and chronic gastritis ; but it would
appear from the  symptoms that subacute duodenitis may occur as a separate
affection, not connected on  the one hand with gastritis, or on the other hand
with inflammation of the lower portion  of the small intestine.   The symp-
toms are—obscure pain, uneasiness or distress occurring some hours after the
ingestion of food—that is, after it passes from the stomach into the duode-
num—and tenderness below the epigastrium and over the site of the affected
organ.   Duodenitis, occurring either  separately  or in  connection  with gas-
tritis and enteritis, is interesting  and important as  standing  in a causative
relation to jaundice.   The jaundice  is to be explained  by obstruction  either
from swelling of the mucous  membrane of the duodenum at the opening of
the ductus choledochus or  from an extension of the  inflammation into the
duct.   A plug of mucus  is  frequently found in the ductus communis near its
opening into the duodenum.  The treatment is the same as that of subacute
gastritis.  The affection will again be  referred to in the consideration  of
Jaundice.
   It is a curious  fact, first ascertained by Curling  and confirmed by other
observers, that a sloughing ulcer  sometimes forms at the upper part  of the
duodenum within a few days after the  occurrence  of a severe burn  of the 
SOFTENING OF THE STOMACH.
421
skin.  Perforation may occur under these  circumstances.  Ulceration of the
duodenum, however, is by no means a constant effect of  an extensive burn.
                        CHAPTER  III.

          STRUCTURAL DISEASES  OF THE  STOMACH.

Softening.—Gastric Ulcer.—Carcinoma of the Stomach.—Dilatation of the Stomach.—
     Degeneration of the Gastric Tubes.—Waxy Degeneration of the Stomach.

          Softening of the  Stomach—Gastromalacia.
QOFTENING of the mucous tunic of the stomach has been already men-
kj  tioned as one of the anatomical characters of gastritis.  The importance
of not considering mere softening as an evidence of inflammation was then
dwelt upon.   At autopsies softening of the mucous membrane of the fundus
is very often found.  Softening may, however, be much more extensive.  Not
only may it involve the entire inner surface of the stomach, but it may extend
in depth  so as to affect the remaining coats of the stomach, and it may even
lead to perforation  of the  stomach and the escape of its contents.  Nor does
the process  always  stop there.   The adjoining  organs  may be attacked and
undergo  a similar  softening.   Thus  the liver may be partially destroyed, or
the diaphragm may be perforated and the contents of the stomach be found
in one of the pleural cavities.  There has been much  controversy as to the
nature of this softening, but it is now admitted that it is a post-mortem occur-
rence due to self-digestion.  It has been rendered probable by the experiments
of Pavy that the stomach is  protected during life from self-digestion  by the
alkalinity of the blood  circulating  in its walls. The  alkaline blood, which
flows in an especially rich network of capillaries in  the superficial layers of
the mucous  membrane, neutralizes the acid of any of the gastric juice which
may penetrate the mucous membrane.  AA'ith death the neutralizing influence
of the circulating blood ceases.  If the stomach  now  contain a  sufficient quan-
tity of gastric juice, and if the temperature be suitable, there is nothing to
prevent the  digestion of this organ and the extension of the digestive process
to surrounding parts.   Inasmuch as softening of  the stomach, in the tra-
ditional acceptation of this term, is purely a post-mortem process, it  cannot
claim consideration in works the purpose of which is chiefly clinical.   Fuller
descriptions of this process are to be sought in books on pathological anatomy
and on physiology.

                            Gastric Ulcer.

  The form of ulcer to be here considered constitutes one of the most fre-
quent and dangerous of the diseases of the stomach.   It is to be distinguished
from certain ulcerations which sometimes occur  in connection  with inflamma-
tion  of the stomach—namely, the so-called catarrhal ulcers, follicular ulcers,
and superficial hemorrhagic erosions.  To these conditions, as well as to ulcer-
ations produced bv corrosive poisons,  reference  has  already  been made.
Genuine  tuberculous ulcers occur in the stomach, but they are very rare and
require no further mention. 
422         STRUCTURAL  DISEASES  OF  THE STOMACH
   To the form of ulcer now under consideration various designations  have
been applied, such as simple (in distinction from cancerous), chronic (a term
not always applicable), round, perforating, eroding, and digestive (ulcus ven-
triculi simplex, chronicum,  rotundum, perforans, corrosivum, ex digestione).
Simple ulcer of the stomach presents certain anatomical characters which
are met with elsewhere only in a similar form of ulcer in the lower part of the
oesophagus and in the upper part of the small intestine.1 The most marked of
these peculiarities is that in its early stages the ulcer presents no evidences of
inflammation in its base or its edges.  The shape of the ulcer is round or oval,
and sometimes, but rarely, irregular from the coalescence of two or more ulcers.
The floor of the ulcer usually lies deeper than the mucous coat.  From its
tendency to extend in depth the ulcer is called perforating.  The floor is not
infrequently the muscular tunic ; but it may be the serous  coat, or, if the ulcer
have perforated the walls of the stomach and  adhesions  have formed, the base
of the ulcer may be  occupied by some of the adjacent viscera, such  as the
pancreas  or liver.  As  the ulcer extends in  depth each  successive tunic of
the  stomach is invaded  in  less  extent than  the preceding.   The ulcer thus
acquires a characteristic funnel-shape, the large opening being  in the mucous
membrane and the apex directed  toward the peritoneum.  The  successive
layers can sometimes be recognized as strata or steps in the wall of the ulcer.
This funnel-shaped appearance  is  not always present.  The edges are some-
times abrupt instead of sloping.   If the ulcer be recent, its edges are smooth
and  clean-cut like  those of a hole punched  out of the mucous membrane.
They may be infiltrated with blood, but they are not swollen by inflammatory
exudation.  The base may be smooth or soft and pulpy, and it  may also have
a hemorrhagic  aspect.   More frequently, old  ulcers are found in which  the
edges are somewhat thickened and  indurated by the growth of  fibrous  tissue.
The floor in old ulcers is usually  smooth, pale, and hard.  Chronic gastritis
is not infrequently present.  The  size of the ulcer varies  much  in different
cases.   The average size is perhaps that of a silver dime or quarter of a dol-
lar.   The ulcer may be very minute.  In two cases reported  by  Murchison
pore-like holes  from one to two lines in diameter were found, which had pene-
trated one of the gastric arteries and produced fatal hemorrhage.   A  similar
case has  been  reported by Reid.2   On  the other hand, the ulcer may be as
large as the palm  of the hand, and  may extend along the lesser curvature
from the pyloric to  the cardiac orifice.3  As  a rule, only a  single ulcer is
found, but it is  not  a great rarity to find two or more ulcers (according to
Brinton, in  21  per cent, of the cases).   Still less  infrequent  is it to meet
with the cicatrices of  old ulcers.   Sometimes ulcers are found opposite each
other on  corresponding  parts of the  stomach.  The most frequent seat of
gastric ulcer is in the pyloric region on the posterior surface  and in the im-
mediate neighborhood of the lesser curvature.4  Ulcers of the anterior surface
are much rarer, but are more dangerous, as will be explained presently.  The
microscopic examination of ulcers still progressing  shows  in their base and
edges a granular  substance which is the result of molecular disintegration of
the surrounding tissue.   It is by a process  of molecular necrosis that the

  1 This is true, unless the rare variety of ulcer described by Clarke and  bv Klebs as
ulcus corrodens uteri—corroding ulcer of the cervix uteri—be "included in this category.
(Consult Klebs, Handbuch der Pathologischcn Anatomie, Bd. 1, S. 873.)
  2 Buffalo Medical Journal, 1846, vob ii. p. 641.
  3 Cruveilhier has described an ulcer 6£ inches long and 3J wide; Law, one measur-
ing 6 by 3 inches.
  4 Of "793 ulcers, in 288 the ulcer occupied the lesser curvature; in 235. the posterior
wall; in 95, the pylorus; in 69, the anterior wall; in 50, the cardia; in 29, the fundus;
in 27, the greater curvature (article by Welch on "Gastric Ulcer," in Peppers System
of Practical Medicine, by American Authors, vol. ii.). 
GASTRIC  ULCER.
423
ulcer extends.   In rare  instances granulation-tissue  may be  present in the
wall of the ulcer.   In the ulcers with hard, thickened edges, these as well as
the base are occupied by fibrous tissue containing fusiform and  round cells ;
the blood-vessels in this tissue present thickened  walls and  diminished cal-
ibre ; and they may contain  thrombi.   Newly-formed connective tissue may
extend for some distance into the surrounding mucous  membrane and  com-
press the tubules, which may  be  thereby distorted and even  obliterated.
Simple ulcer may be complicated by cancer of the stomach.   In fact, some
writers believe that ulcer may even predispose to the  development of cancer.
   Ulcer of the stomach not infrequently heals by cicatrization ;  in fact, cica-
trices are found oftener than open ulcers.  The resulting cicatrix is usually a
whitish stellate  scar, attended  with puckering of the adjacent mucous mem-
brane.  If the ulcer be large and deep, cicatrization may cause considerable,
and even extreme, deformity of the  stomach.  Thus the stomach may be con-
stricted so as to  present an hour-glass shape.  Stricture of the pylorus, with
consequent dilatation  of the stomach, may be caused by cicatrization of an
rlcer; but instead of  cicatrizing the ulcer may penetrate all of the  coats of
the stomach.  AVhen  the ulcer is  situated on the posterior surface of the
stomach, as  is usually the case, a localized peritonitis  over the  seat of the
ulcer generally leads to the formation of adhesions  with surrounding organs,
so that when perforation is effected the floor of the ulcer is formed  by some
part adjacent to the stomach.   Sometimes, however, the development and the
progress of the ulcer are so rapid that  time is not  allowed for the formation
of  adhesions,  and  the contents of the  stomach escape into  the peritoneal
cavity.  It is a noteworthy fact that ulcers on the  anterior surface, although
the least  frequent, are the  most liable to perforate without protective adhe-
sions.   The explanation of this peculiar danger  lies in the active movements
of  this part  of the stomach and  its unfavorable  relations to  surrounding
parts.   The pancreas  most  frequently forms  the floor of ulcers  situated on
the posterior surface, but the stomach may also  become agglutinated to the
liver, the spleen, the diaphragm, lymph-glands, etc.   The ulcer may  continue
to extend into the surrounding organs which form its base.   The  pancreas
usually offers  considerable resistance to  the  progress of the  ulcer, but the
liver is not infrequently invaded.   The funnel-shaped appearance is not pre-
served in the organs secondarily involved.  On the other hand, cavities  of
considerable size may be formed which communicate by a small opening with
the stomach.   The reactive inflammation  in organs invaded by  gastric ulcer
leads to the formation of fibrous tissue, and sometimes, particularly in the
liver, to abscesses.  Fistulous communications of the stomach with  adjacent
parts may be formed.  Thus the ulcer  may open into  the colon, the duode-
num  or some  other part of the intestine, the pleural  cavity, the lungs, or
the gall-bladder.  Gastro-cutaneous fistula may be produced, but  they are
very  rare.  The most frequent are gastro-colic fistula*.  If the ulcer  open
into the peritoneal cavity—and this accident may take place even after adhe-
sions  are formed—peritonitis ensues if immediate death  do not  follow. Death
sometimes occurs suddenly from perforation of the stomach, and is attributed
to paralysis of the heart from shock.  The peritonitis  following perforation is
usually general.   It is sometimes, however, localized, in consequence either
of the slow escape of the gaseous and fluid contents of  the stomach  through
a small opening or of the formation of  previous adhesions.   On p.  145 ref-
erence has been made to subphrenic  abscesses containing air  and simulating
pneumo-pyothorax.  The external  opening in the  stomach is  usually round,
and its edges are sharp and well defined in cases of  perforation.
  The hemorrhages which constitute  one of the chief dangers to life in gas-
tric ulcer may proceed from capillaries and small vessels in the walls or base 
424         STRUCTURAL  DISEASES  OF  THE STOMACH
 of the ulcer, or they may come from  erosion of a  large artery or vein.   In
 cases of profuse fatal hamatemesis an eroded artery will generally be found
 in the floor of the ulcer.   The ulcerated  artery may be  either one of  the
 arteries of the stomach or an  adjacent vessel, as the splenic.  Gastric ulcer
 has been known to perforate the portal vein, and in more than one  instance a
 simple or a suppurative pylephlebitis has been produced by this disease.   In
 several cases small aneurisms have been found in the floor of the ulcer.
   The pathogenesis of simple ulcer of the stomach has been a subject of much
 experimentation and discussion.  The absence of inflammation, and the fact
 that this variety of ulcer is met with only in the lower part of the oesophagus,
 the stomach, and  the upper part of the small intestine, early suggested  the
 view that it is produced by the solvent action of the gastric juice ; and this is
 the opinion now generally entertained.   Hence the names peptic ulcer, diges-
 tive ulcer, and ulcus ex digestione are sometimes employed.  In the  preceding
 article was  stated  Pavy's view, which  is widely accepted, that self-digestion
 of the stomach is  prevented during life by the constant flow of alkaline blood
 in the rich capillary network of the gastric  mucous  membrane.   If this view
 be adopted, it must be  assumed that the  primary  cause  of  simple gastric
 ulcer is to be found in some local disturbance of the circulation in the gastric
 mucous membrane.  As to  this also  most writers are agreed.  As to the
 nature, however,  of the  change thus  interfering with the  circulation there
 is the  widest diversity of opinion.  An absolute basis of fact  is lacking  for
 nearly all the theories propounded to explain the diminished resistance of the
 mucous membrane to the action of  the gastric juice.  The anatomical investi-
 gation of the ulcer as a  rule  furnishes little or no clue to its primary cause.
 The following conditions have been assigned as causes of  gastric  ulcer  by
 interfering with the circulation  and consequently diminishing the alkalinity
 of circumscribed portions of  the wall of  the stomach: Embolism and throm-
 bosis of branches of the gastric arteries ; thrombosis  of the  corresponding
 veins ;  diseases of the coats  of  the same vessels, especially atheroma, fatty
 degeneration,  and amyloid  degeneration ;  spasm  of the  arteries, causing
 anamia  of  the districts  they supply; spasm of the muscular coat  of  the
 stomach, compressing the veins and leading  to hemorrhages; obstructions  in
 the portal circulation, inducing chronic congestion and hemorrhages from the
 gastric veins; hemorrhages into the  wall of the  stomach  from rupture  of
 the vessels  incident to  injuries, vomiting, ingestion of corrosive substances,
 increased blood-pressure, and aneurismal and varicose dilatations; inflamma-
 tory infiltration compressing  the blood-vessels.   Disturbed nervous  influence
 has  also been  adduced as a cause.1  Bbttcher's view, that  gastric ulcer is  of
 mycotic origin and produced by the  action of  micrococci, has met with  no
 confirmation.   Finally, increased acidity of the gastric juice has been thought
 to be an element in the causation of digestive ulcer.  It would lead too far
 to attempt  a criticism  of  these different theories.   The  embolic  origin is
 naturally suggested by the funnel  shape of the  ulcer  corresponding  to  the
 wedge-shaped  area of distribution  of  branches of the gastric  arteries, but
 this theory is almost wholly devoid  of anatomical support.    No embolus in a
 gastric artery is found in ulcer of the  stomach,  and in the majority of cases
 there is no source  for an embolus.2  Gastric  ulcer is  by no means a frequent
  1 In support of this view have been cited  the experiment of Frerichs, who found an
ulcer of the stomach in a cat after division of the  splanchnic nerves  and of the coeliac
axis, and the experiments of Ebstein, who by injuries to the brain and cord in animals
produced ulcers upon a hemorrhagic base.  A not very appropriate comparison has also
been made between gastric ulcer and ulcer of the cornea after section of the trigeminus.
  2 In a case presented by Janeway to  the New  York Pathological Society in 1871 a
fibrinous plug was found in a branch of the gastro-epiploic artery leading to an ulcer.
No source for an embolus  could be found. 
GASTRIC  ULCER.
425
occurrence in disease attended by embolism in various parts of the body.  If
a thrombus be found  in a vessel near a gastric ulcer, it is  as proper to con-
sider it the effect as the cause of the  ulcer.  The most plausible view, and
the one  which has the  greatest number of  supporters,  is that a considerable
number of ulcers of the stomach are produced by  hemorrhagic infiltration of
a circumscribed  portion of the wall of the  stomach.   It is to  be  noted, as
pointed  out especially by Axel Key, that the hemorrhage must involve more
than the superficial layer of  the  mucous membrane—must  extend  probably
to the deeper and less vascular tissues.  Superficial hemorrhages are followed
by superficial  erosions, the extension  of which in depth is arrested by the
great vascularity of the mucous membrane.  The mode of production  of
hemorrhagic erosion is  thus  similar to that of simple ulcer.  The causes of
these deeper hemorrhages are doubtless various, and they include many of the
causes of ulcer which have been enumerated.   Perhaps spasm of the muscu-
lar fibres of the stomach attendant upon cardialgia and vomiting should be
specially mentioned ; but, while considering  hemorrhage in the  coats of the
stomach as a probable, and perhaps frequent, cause of  ulcer, it  is not neces-
sary to  consider it the only cause, or to deny the efficacy of other causes
which have been cited, the importance of which, with our present knowledge,
is less evident.  It is interesting that  ulcers which may be  produced  in vari-
ous ways artificially in the stomachs of animals readily  heal.  Anamia, how-
ever, has been proven  experimentally to be an  obstacle to the process  of
repair.   From this point of view the problem  is quite as  much to  explain
why ulcer of the stomach does not heal as it is to  explain how it is produced.
It is probable that various constitutional conditions, and also diseases of the
blood-vessels in the walls of  the ulcer, impede the process of repair.

   Gastric ulcer is not an infrequent affection.  Open gastric ulcer is found in
from 1 to 2 per  cent, of persons dying from all causes.   Cicatrices are found
about three times as frequently as open ulcers.   Statistics appear to show a
considerable  variation in its  frequency  in  different geographical situations.
In this country gastric ulcer, although not rare, is less frequent than in  many
parts of Europe.
   The clinical history embraces as the most prominent symptoms pain, ten-
derness on pressure, vomiting, and hemorrhage from the stomach.  These  are
the important symptoms in  a diagnostic point of view.   Pain is rarely  want-
ing.  It is burning or gnawing in character, coming on directly  or soon after
the ingestion of food, and continuing until the contents of  the stomach have
either passed into the duodenum or been ejected by vomiting. The quickness
with which the pain follows the ingestion of food is a diagnostic point.  If pain
be due to simple indigestion or neuralgia, it generally occurs after a greater
or less interval  from the time of taking food.   It is situated at or near  the
epigastrium, and is generally confined to a small  space.  A similar gnawing
pain in the back, between the  shoulders, is not  uncommon.  The probable
cause of the pain is irritation of the ulcerated  space by the contact of  the
ingesta  and the gastric juice.   The pain from this cause is especially  marked
after the ingestion of stimulating-  articles of food or drink, and when, from
indigestion, the  contents of  the  stomach undergo chemical changes.  Pain
may be caused also by circumscribed peritonitis and by the traction of adhe-
sions which have resulted from peritoneal inflammation.   The latter causes
may account for the exceptional occurrence  of pain irrespective  of the inges-
tion of food.   The  pain caused by the  action of the gastric  juice  is felt
directly after eating, because the secretion of the juice  is excited by the pres-
ence of food  in  the stomach.  The pain is sometimes absent for several con-
secutive days. It is affected by the position of the body, being in some cases 
426         STRUCTURAL DISEASES  OF THE STOMACH

increased  by lying on  the  back and relieved by bending forward;  in  other
cases the reverse is observed.   The explanation is  aff'orded by the  situation
of the ulcer on the posterior or the anterior wall of the stomach.   As in the
majority of cases the ulcer is on the posterior wall, relief is oftener obtained
by bending forward  than by recumbency  on the  back.  Tenderness on pres-
sure over the epigastrium is almost invariably present, confined, like  the pain,
within a small area, and varying  considerably in degree in different cases.
Vomiting  is a very frequent but not a constant symptom, occurring after a
period from the time of taking food varying in different cases, the act of vom-
iting usually not violent but  complete, and the  ejection of the  contents of
the stomach followed by notable relief of pain and  distress.  Mucus may be
expelled in more or less abundance with  the ingesta.  As respects vomiting,
much will  depend  on the quantity and kind of food ingested.   Indigestible
and stimulating articles are  more likely to provoke  it,  as well  as  to increase
pain, than those which are bland and easy of digestion.  Hot substances are
not as  well borne as  cold.  Hemorrhage, as shown by the vomiting of blood in
greater or less quantity, is a symptom of frequent occurrence.  The  vomiting
of blood generally occurs after a  meal.   The hemorrhage  is  sometimes so
abundant that life  is lost from this cause.  Cases have been reported in which
life was lost from  hemorrhage, although no  blood was vomited, the stomach
being found, after death, filled with clots.   The blood  vomited is dark or
grumous from the  cliange of  hamoglobin to hamatin by the action of the
gastric  juice, provided the vomiting do not immediately follow  the hemor-
rhage.  If vomiting quickly  follow a profuse hemorrhage, the blood  may
retain its alkaline reaction and its arterial  color.  As a rule,  simple inspection
of the vomited matter suffices to  determine the presence or the absence of
blood.   In cases of doubt resort may be had to microscopic or spectroscopic
examination.  Blood-corpuscles, usually much shrivelled, can generally be
recognized by the microscope.   Sometimes, however, they are so disorganized
by the action of the gastric juice that their  detection by this  instrument is
difficult or impossible.  In this case the spectroscope will usually afford the
desired information.  The  stools also should be examined with reference to
the gross and microscopical  appearances of blood, since hemorrhage may take
place  without vomiting, the blood passing into the intestinal canal.
  The bowels in cases of gastric ulcer are generally constipated, a symptom
easily understood in the cases in  which vomiting is  a prominent symptom.
Amenorrhoea is  common.   There  is, however, little foundation for  the  idea
that hemorrhage from the ulcer occurs vicariously  in the place of menstrua-
tion, but the latter ceases or is deficient, as in cases of anamia produced by
hemorrhages elsewhere or from other causes.
  The perforating ulcer  occurs oftenest in  young girls, and  particularly in
young maid-servants.  Statistics show that  females are more liable to ulcer,
the proportion being 2 males to 3 females.   In  females the ulcer  most fre-
quently develops between  twenty and thirty, and  in males between  thirty
and forty,  years of  age.   Clinical  observation fails to show any dependence
on particular habits of diet or  other causes, nor has  it any known  relation-
ship with other affections.   It may be  stated, however, that  persons  of feeble
or impaired constitution are more liable to it than the robust.
  The diagnosis of gastric  ulcer may be made with much certainty, provided
the diagnostic symptoms be present—namely, pain of a burning or gnawing
character  limited to a circumscribed  space in the  epigastrium, with tender-
ness, also circumscribed, the pain felt directly after  the ingestion of food, and
especially after certain kinds of food, vomiting occurring during the process
of stomach digestion,  and  followed by relief, and,  finally,  gastrorrhagia or
hamatemesis.  Analogous symptoms, it is true, may be present  in  cases of 
GASTRIC  ULCER.
427
cancer of the  stomach, but  there  are points of contrast involved in this dif-
ferential diagnosis  which will be  noticed  presently in considering cancer.
Moreover, the absence of a tumor  appreciable through  the  abdominal walls
goes far toward the  exclusion of cancer.   Chronic gastritis and ulcer have
symptoms to  some extent in common;  but in chronic  gastritis  pain is less
prominent, vomiting does not occur so frequently, and hemorrhage is want-
ing.   In cases of gastralgia the pain might suggest the idea of ulcer; but
the pain in gastralgia is not aggravated, and, on the contrary,  is often relieved,
by the ingestion of food ;  tenderness over the epigastrium is not  present, but
the pain is  often relieved by pressure;  vomiting  is an occasional symptom
only ; hamatemesis does not occur.  Attacks of gastralgia and gastric ulcer
are, however,  sometimes associated.  In cases of  merely functional disorder
pain, vomiting, and hamatemesis  are all wanting.   Hamatemesis, it is to be
borne in mind, is not alone evidence of ulcer.   It occurs, irrespective of dis-
ease of the stomach, in certain cases of cirrhosis of the liver.   It  is the union
of the  several symptoms just named that renders the diagnosis complete.
These  diagnostic symptoms, however, are  not united in all cases of gastric
ulcer.   Hemorrhage  is not  invariably present;  vomiting  is  not always a
prominent symptom,  and  may be wanting; pain  and tenderness are  not in
all  cases  marked:  {lie  affection, in short, is  sometimes latent, more or less
difficulty  or disturbance of digestion  only being manifested.   Under  these
circumstances a positive diagnosis  cannot  be made.  A strong suspicion of
the existence  of the  affection  may in some cases  be reasonably entertained
when the symptoms  do not warrant a positive diagnosis.
  Gastric ulcer proves fatal in different modes.   One of these is by perfora-
tion, diffuse peritonitis  being induced by  the escape of the contents of the
stomach.  Perforation into  the general  peritoneal cavity occurs in about G£
per cent, of all cases of gastric ulcer.  In  the great majority of cases diffuse
peritonitis caused  by perforation  of the stomach proves fatal.    Recovery,
however, is within the range of possibility.   This  accident would take place
oftener than it does were  it not for the adhesion of the stomach to the adja-
cent organs as a result of circumscribed peritonitis.  Perforation is most likely
to occur when the  ulcer is situated on the  anterior surface  of the stomach.
The perforation  generally takes place after the ingestion of a meal, or in the
act of  straining or sneezing, or in some sudden and forcible movement of the
body.   In some cases peritonitis, following perforation, occurs without having
been preceded by any symptoms pointing to the existence of ulceration of the
stomach.  The following  case is illustrative of  the statement just made: A
well-nourished woman of about  thirty-five  years of age had  complained  only
of indigestion, when suddenly there occurred severe abdominal pain, followed
by speedy collapse and death.  Poisoning was suspected, and  the autopsy was
made by direction of the coroner.   A round, funnel-shaped ulcer of the size of
a quarter of a  dollar was found on the anterior wall of the stomach.  Perfora-
tion had taken place and given rise to acute peritonitis.  As  has  been stated,
peritoneal adhesions having  previously taken place, perforation  may open a
communication with the transverse colon.   The evidence of this is stercora-
ceous vomiting.
  Another mode in which it proves  fatal  is  by hemorrhage.  Life  may be
slowly  destroyed by the continued escape of blood or by repeated attacks of
hemorrhage, or the loss of blood may be so rapid as to destroy life quickly.
Death from hemorrhage occurs in from 3 to 5 per  cent,  of all cases of gastric
ulcer.
  Another mode in  which it proves fatal is by inanition.  Death  takes place
by slow asthenia when the  stomach is so intolerant of ingesta that  aliment
sufficient for the support of life is  not retained.  In other words, patients are 
428         STRUCTURAL DISEASES  OF  THE STOMACH.

gradually starved to death, provided life be not cut off by some other disease
which  the system  may be rendered unable to resist in consequence of the
debility incident  to the  stomach affection.
  The duration is very variable.  Death sometimes takes place from perfora-
tion  or hemorrhage within a few weeks, or even a few days, after the time
when the symptoms first denoted gastric trouble ;  or, as already stated, per-
foration and hemorrhage may occur when previous symptoms denoting gas-
tric ulcer  were wanting.   But if these  accidents do not  prove the immediate
cause of death, life is usually prolonged for many months, and it may be for
many years.   Brinton states that he has notes of one case in which probably
a continuous open ulcer existed for thirty-five years, and of two cases in which
the duration was  thirty years, together with three or four of twenty, four or
five  of fifteen, and  several of ten, seven, five, and  four  years' duration.  It
is not  uncommon for the symptoms from time to time to subside or to dis-
appear, and subsequently to return.  These  remissions  are  probably due to
healing of the ulcer, which afterward again opens; in other words, relapses
are liable to occur.
  Gastric ulcer, although a serious affection, is by no means  incurable.   The
mortality  is estimated by Welch  as about 15 per cent. In consequence of the
various disturbances resulting from  cicatricial contraction of  an ulcer, gastric
symptoms may remain after the ulcer has healed in the anatomical sense.
  The treatment  of gastric ulcer embraces the following objects: First, and
most important, securing for the stomach absolute rest; and second, the arrest
of hemorrhage and the palliation of pain.  Rest of the stomach  is secured
most effectually by  resorting to rectal alimentation.   This is  advisable when-
ever symptoms render the diagnosis of gastric ulcer probable.   It  is  now
well established that not only  life, but complete satisfaction of the sense of
hunger and fair nutrition, may be maintained indefinitely by  the introduction
of food into the rectum.   Indeed, an increase of weight under an  exclusively
rectal diet has been observed.   I can bear testimony to the prompt success
of this method of  treatment.   The  kinds of  food  to be employed  and the
practical rules to  be observed are the same as  in the treatment of  acute  gas-
tritis.  (Vide p. 410.)  AVhen the stomach tolerates food—that is, when pain
and  vomiting are no longer caused by ingesta per os—the  diet should con-
sist  for a time of milk, other articles being cautiously added  or substituted.
Considering the frequency of relapses, care to  adjust the  diet to the digestive
power is advisable for a considerable period.
  Hemorrhage is to be arrested  by small pieces of  ice swallowed, and by the
application of cold  to the epigastrium  if the loss of blood  be considerable.
The fluid extract of ergot may be given per enema.  Pain may require the'
use  of opiates, the  form  being  selected which  is found on trial to be the
least objectionable.   They may be  administered  either by the  rectum or
hypodermically.  Pain and vomiting cease  generally to  be prominent symp-
toms if complete rest of  the stomach be secured  by rectal  alimentation, so
that the  laudanum  added to the nutritive injections suffices.
  It is doubtful  whether any  remedies exert a direct effect  to promote cica-
trization.   The nitrate of silver and other remedies have been  given with
the expectation that they will  exert a  topical  effect  upon the ulcer.   Clin-
ical  observation  appears  not to furnish  evidence of their utility in this way.
Cicatrization is promoted indirectly by remedies which  arrest the peristaltic
movements of the stomach and quiet the irritability of  the  organ ; in other
words,  remedies  which  have  reference to  the first object  of treatment—
namely, securing rest. 
CARCINOMA OF THE STOMACH.
429
                   Carcinoma of  the Stomach.

  Most of the tumors met with in other parts of the body may also occur in
the wall of the stomach—fibroma, lipoma, sarcoma, myoma, gumma, tubercle,
papilloma, adenoma, and carcinoma.   Of these, only carcinoma possesses clin-
ical importance.  (For general considerations concerning the origin and struc-
ture of cancer, the reader is referred to Part I. p. 45.)
  Next to the  uterus, the stomach is the most frequent seat  of primary
carcinoma.1   Secondary cancer  has also been met with  in this organ, but
it is rare.   The  forms of carcinoma of the stomach are scirrhous  (fibrous),
medullary (encephaloid), colloid (alveolar),  and cylindrical-celled epithelioma.
Of  these, colloid is by far  the  least frequent.  As  the distinction  between
scirrhous  and medullary cancer is based  upon the difference in  consistence,
the former being hard  and the latter soft, and as all degrees of combina-
tion and of transition exist between the  two, statistics as to the frequency
of the one or of the other are only of  limited value.   Combinations of hard
and of soft cancer and tumors of medium consistence are more  frequent than
either the very hard or the very soft varieties. Cylindrical-celled epithelioma
is a common form of  gastric carcinoma—according to some authors, the most
common.   The most frequent seat of cancer is the pyloric region.  The pos-
terior surface and the lesser curvature are more  frequently affected than the
opposite regions.   The cardia  is affected in  about 8 per cent, of all  cases.2
Scirrhous cancer is characterized by the large  amount  of fibrous  stroma and
comparatively small development of cancerous alveoli.   In the great majority
of cases it is situated near the pylorus, where it sometimes appears as a par-
tial or complete ring  constricting the pyloric orifice.   Scirrhus  may appear
either infiltrated or in the form of distinct nodules.   In medullary cancer the
spaces filled with cancer-cells predominate over  the stroma, which is usually
richly  infiltrated with round cells.   This variety grows more rapidly and is
more likely to be attended by metastases than the preceding. It forms a soft
tumor, readily ulcerating, and sometimes presenting fungous or villous excres-
cences upon its surface  (so-called  villous cancer).  Colloid cancer is rare.
It may be combined  in  a nodular  form with  one of the other varieties, or it
may appear as  a diffuse thickening of the walls of the  stomach, involving
apparently its deeper coats.  In  the latter  case  the  peritoneum,  as a rule, is
extensively affected by the same  process.   This species of  cancer is readily
recognized by the clear, gelatinous  substance found in its large  alveoli.   In
cylindrical-celled epithelioma the  alveolar structure conforms more closely
than in the other varieties  of cancer to the  type of the normal  gastric tub-
ules.   The cells contained in the alveoli, more particularly those which line
the walls  of the alveoli, are cylindrical in shape.   In consistence this variety
resembles medullary cancer.
  The opinion was formerly held  that cancer of the  stomach develops pri-
marily in  the submucous tissue and invades  secondarily the other coats  of
the stomach.   Since  AValdeyer's view  as  to  the epithelial  origin of cancer-
cells has  been so widely accepted, it has  been the teaching of many writers
that carcinoma develops primarily in the  mucous membrane.  The process,
as described by AAraldeyer,  is briefly as  follows: A group of  tubules (from
ten to twenty)  enlarge, lengthen,  and give  off offshoots.   They  are filled
  1 Of 31,482 primary cases of cancers collected by AA'elch, the stomach was the seat of
the  cancer in 21.4 per cent., and the  uterus, in 29.5 per cent.  {Pepper's  System of Prac-
tical Medicine, by American Authors, vol. ii. p. 533).
  2 AVelch's analysis of  1300 cases of cancer of the stomach gives—pyloric region, 60.8
per cent.;  lesser curvature, 11.4; cardia, 8; posterior  wall, 5.2; the whole or  greater
part of stomach, 4.7 ; multiple tumors, 3.5;  greater curvature, 2.6; anterior wall, 2.3;
and fundus, 1.5 per cent. 
430         STRUCTURAL  DISEASES OF  THE STOMACH

with cells resembling usually the  adelomorphous variety, but more granular
and more deeply staining.   The growth of  the tubules with  their branching
offshoots is downward  through the  muscularis mucosa.  AVhen the lax sub-
mucosa is  reached the progress is  more rapid.  Groups of  cancer-cells now
push  their way in all directions, chiefly in the lymphatic vessels and  spaces.
Cancerous masses  penetrate between the bundles of smooth muscular tissue,
and often extend to the subserous and serous coats.  The growth  may  be so
much more extensive in the submucous coat that the tumor  appears to orig-
inate  there,  but according to AValdeyer careful microscopical examination
will always disclose some band of  connection with the tubules of the mucous
membrane.   The  growth,  however, may from the first involve chiefly  the
mucous coat, and  in any case this  is, as a rule, sooner or later extensively
invaded.
  It has already been mentioned that cancer of the  stomach  may appear in
a diffuse or in  a nodular form, also as  a ring, especially about the pylorus.
Ulceration  is a frequent occurrence.   This is the rule with medullary and
cylindrical  epithelial, and is not'infrequent with scirrhous  cancer.  There is
less tendency to  ulceration  in  colloid  cancer  than  in the  other  varieties.
Ulceration  is not  always to be regarded as  an  unfavorable  occurrence.   The
soft cancers especially may be much reduced in size by this destructive  pro-
cess.  This reduction may relieve an existing stenosis of the pyloric or cardiac
orifice.   The shape of the ulcer, particularly when the cancer is medullary,
has been often compared to that of  a crater—a peripheral  wall of cancerous
tissue  surrounding a central  loss of substance.  Exceptionally, in cases of
scirrhus the  ulcer may bear much resemblance  to  simple  or round  ulcer
with indurated walls ;  arid  this fact is to be considered in weighing the state-
ments of those who report many cases of cancer developing from round ulcer.1
Scirrhous cancer often contains considerable cicatricial tissue, but there  is no
positive reason to  believe that it ever heals.  The muscular  coat in the neigh-
borhood of cancerous growths is almost always hypertrophied.  If the tumor
produce stenosis of the pylorus, the rest of the  organ is dilated ; if the cardiac
orifice be constricted, the  stomach is reduced in size.   Chronic gastritis  is a
frequent attendant upon cancer.   Chronic circumscribed peritonitis, with the
formation of adhesions, is  common in the neighborhood of the cancer.   The
wall of the stomach may  be perforated by cancerous ulceration leading to
invasion of the  surrounding organs, to  perforative peritonitis, or to fistulous
communications.   Peritonitis from perforation  is less frequent with cancerous
than with simple ulcer.2  The erosion of large vessels is also less frequent in
cancer than in ulcer.   General peritonitis may occur without perforation.
  Carcinoma may  extend by continuous growths into surrounding parts.  It
may also lead to  metastases  or secondary  deposits.   The  lymphatic glands
near the stomach,  also the  liver, the peritoneum, the pancreas, and the lungs,
are affected in frequency in the order named.  Secondary deposits in the liver
are those most  frequently detected during  life.3  Metastases  occur  most fre-
quently through the lymph-vessels, but they may also occur through the blood-
current.  An actual growth of carcinoma into  the rootlets and main trunk of
the portal vein has been observed.  The secondary  deposits  generally conform
in structure with the primary growth.   It  is worthy of note that large and
abundant secondary deposits may attend small  and  insignificant tumors of the
  1 Thus Lebert states that in  9 per cent, of the cases cancer develops from simple ulcer
(Deutsches Archiv fur klinische  Medicin, 1877,  Bd. 19, S. 545).
  2 Perforation into  the peritoneal cavity occurs, according to Brinton, in a little  more
than 4 per cent, of the cases;  according to Lange, in a little more than 5 per cent.
  3 In Welch's statistics (1574 cases) the lymphatic glands were the seat of metastases
in 35 per cent., the liver in 30, the peritoneum or intestine in 23, the pancreas in  8, the
pleura and lung in 6, and the  spleen in 2 per cent, of the cases. 
CARCINOMA  OF THE STOMACH.
431
stomach which during life may have produced no symptoms, and after death
may be overlooked on superficial examination.  The blood in cases of cancer
of the stomach may present the same alterations  as in pernicious anamia.
  The symptoms which make up the clinical history of this affection are as
follows : Impaired appetite, or anorexia, is generally more or less marked, but
in some cases  the desire for food is preserved.  Pain  maybe  more or'less
prominent, and the character of the pain may be lancinating.  In many cases,
however, the lancinating pain which attends cancer in other situations is either
slight  or wanting.  A circumscribed gnawing  pain may  be  incident to the
ulcer occurring as secondary to the cancer.   Tenderness over  the epigastrium
may or may not exist.  Vomiting is a frequent symptom, but  it occurs less
frequently than in cases of simple  ulcer, and  at  a  later period after taking-
food.  The vomiting, if the cancer be at the pylorus, may be due chiefly to
obstruction at  this orifice and consequent  accumulation of gastric contents.
Yeast-fungi, sarcina, and torula may be found in the vomited matters when
these have undergone fermentation within the  stomach.  Blood is not infre-
quently found in  the vomited  matters, generally in small quantity and having
the coffee-grounds appearance.  With these symptoms  referable to the stom-
ach are associated progressive  loss of weight'and strength, anamia, usually
constipation, but  occasionally diarrhoea, and in some cases jaundice.  The last-
named symptom points to the probable occurrence of secondary cancer affect-
ing the liver.
  Certain general considerations pertaining to the causation of tumors have
been alluded to in Part I. p. 41.   As to the primary cause of cancer, we are
without any positive information.   It is probable that the cachexia is second-
ary to  the  development of the cancer. The cachexia may be explained partly
by certain facts pertaining to cancer in general, and in part by the local injury
which  the growth inflicts upon an  organ of such vital importance as the stom-
ach.  The general  considerations  are—the  rapid growth of  the tumor ; its
withdrawal in  a short time from the circulation of a large quantity of nutri-
ment employed only for  its  own  noxious growth and for no useful  purpose ;
its  destruction of healthy and useful tissues; the production of metastases,
which  for their nutrition and growth, from  their number and  size, make even
greater claims  upon the organism than the primary tumor; and often  the
occurrence of  exhausting hemorrhages.  The local effects of cancer of the
stomach—loss of appetite,  pain,  vomiting, mechanical disturbance  of  the
digestive functions, and chemical alterations in  the gastric fluids—are often
in themselves  sufficient to explain an extreme degree  of cachexia.  "While
these general and local effects suffice to explain the  cachexia in most cases of
carcinoma of the  stomach, there are a small number of cases in wdiich they
do not seem to be operative, and in which it seems necessary to assume  the
entrance into  the blood  of some virus  produced in the tumor.
  The  liability to cancer of the stomach  is  slight before the  age of forty.
Three-fourths of  all cases occur between forty and seventy years of age ;  the
largest number being between fifty and sixty.   Men are somewhat more fre-
quently affected than women,  but  the disproportion is not great.1  Heredity
is a well-established element in the causation of cancer  of the stomach as of
cancer  elsewhere.
  Cancer of the  stomach is to be  discriminated from merely functional dis-
order or dyspepsia, chronic gastritis, and gastric ulcer.   In merely functional
disorder, pain and vomiting are s}*mptoms rarely as prominent  as they are gen-
erally in cancer.  The ailments in dyspepsia are seldom so protracted ; they do
not lead to the same amount of emaciation, feebleness, and pallor ; hamatemesis
is wanting.  The  same is true of chronic gastritis.   Persistent disturbance
  1 In 2214 cases of  gastric cancer there was a ratio of 5 males to 4 females (AVelch). 
432         STRUCTURAL DISEASES OF THE STOMACH

of digestion, especially if accompanied by pain and vomiting, leading to con-
siderable loss in weight, diminution of strength, and anamia in a person be-
tween  forty and seventy, should always excite suspicion of cancer.   Cases
of gastralgia lack all the diagnostic features of cancer except pain.   Gastric
ulcer is liable to be confounded with cancer, and in  view of the great differ-
ence as regards prognosis it is desirable to discriminate between these affec-
tions.  They present certain points in  contrast as regards  the symptoms.  In
cancer the appetite  is  more impaired  than in  ulcer.  Vomiting is more uni-
formly present  in ulcer; it occurs earlier after  the ingestion of food, and in
general is evidently due to the irritation caused by  the presence of food.  In
cancer it is present in only a certain  proportion of cases; it does not follow
so soon after taking food, and is frequently due  to  the mechanical distension
of the stomach owing to the  pyloric obstruction.  Hemorrhage is more con-
stant and more  profuse in ulcer.   If the patient be a young girl, the chances
are much in favor of ulcer.  The duration of the local symptoms is of import-
ance in this  differential diagnosis.  If  the symptoms have existed for a long
period, the chances  are in favor of ulcer rather than of cancer.  Age  is  to be
considered in the  diagnosis,  cancer occuring  rarely before forty.  Enlarge-
ment of lymphatic  glands above the  clavicles accompanies  cancer  in  some
cases and has  some weight in the diagnosis.
   Considerable importance has  been attached to the complexion which has
been supposed to denote the cancerous cachexia—namely, pallor with a faint
tint of yellow or green, the conjunctiva remaining  unaffected.  It has been
called a waxy complexion.  This is sometimes  well marked in cases of cancer,
but it is by no means always present, nor is it pathognomonic when marked.
If members of the family have had cancer, this fact is entitled to some weight
in the diagnosis.  So also is  the  coexistence of cancer in some other situa-
tion.
   Considerable interest attaches  to the discovery by Von den Velden  that
hydrochloric acid is habitually absent  from the stomach in cases of gastric
dilatation due to cancer.   This diagnostic point will  be considered in  the fol-
lowing article.
   In some cases of cancer there are few or no symptoms denoting  any serious
affection up  to a short time before death.  Like gastric ulcer, it is sometimes
remarkably latent, the  patient seeming to suffer only from moderate or slight
dyspeptic ailments,  the  appetite remaining unimpaired, the strength not fail-
ing,  and the aspect indicating health.    Several cases illustrative of this fact
have fallen under my observation.  In  these latent cases,  and also when the
differential diagnosis relates to ulcer and chronic  gastritis, great importance
belongs to the discovery or otherwise  of an abdominal tumor in the  site of
the stomach.  Exclusive of the cases  in which the cardiac orifice is the seat
of the cancer, a tumor is discoverable by physical examination in the majority
of cases.  According to Brinton, it exists in 80 per  cent, of all cases  of can-
cer.   The tumor is  situated generally between the false ribs and the umbil-
icus, a little to  the  right of the median line.   It may be movable or fixed;
much more  frequently the latter.  If movable, it will be likely to  change
its situation  accordingly as the  stomach is  distended or empty.  The tumor
varies in size from a pigeon's egg to the size of the closed hand.  The weight
of the tumor may  cause it to fall below the epigastrium, and it may descend
nearly to the symphysis  pubis.  It is usually  resisting  and the surface is
irregular or  nodulated.
   The presence of a tumor, if ascertained to he seated in the stomach, renders
the  diagnosis almost positive; but it  is not always  easy to decide positively
that the tumor is seated in the stomach.   A cancerous tumor may simulate
aneurism of the abdominal aorta.  The characters of an aneurismal tumor are 
CARCINOMA  OF THE STOMACH.
433
expansile pulsation, thrill, and murmur.  A cancerous tumor may present, in a
more or less marked degree, the same characters.  It may present not only a
single but a double murmur.  How are the two to be distinguished from each
other?  An aneurismal tumor has usually a smooth outline and may be dimin-
ished by pressure ; the pulsation is felt laterally as well as on its anterior sur-
face ; by a change of position of the patient, as placing him on his hands and
knees, the pulsation is not  materially affected,  whereas  if the tumor be not
aneurismal its pressure on the  artery is taken  off and the pulsation may be
found to cease.  But aneurismal tumors do not always pulsate, and both  thrill
and murmur may be wanting.  Under these circumstances in this diff'erential
diagnosis reliance must be  had upon the  diagnostic points  relating to the
history and  symptoms.   These  are, of course, always to be carefully consid-
ered.   Other tumors, from  their  situation, are liable to be confounded with
cancer  of  the  stomach—namely, tumors  connected with the left lobe of the
liver and with the pancreas, fecal tumors,  etc.   The  distinctive characters of
these will be considered in other connections.   A point of distinction, as con-
trasted with tumors seated in the liver, is that the latter are depressed  in an
act of deep  inspiration, whereas the descent of the diaphragm does not affect
the situation if the tumor be seated in the stomach.   Moreover, percussion
over an enlargement of the left lobe of the  liver gives flatness, whereas a
tympanitic resonance is elicited  usually over  a gastric  tumor.  There  is a
liability to mistake the normal  pancreas for a. tumor; and owing to different
degrees of distension of the stomach the tumor may be felt at  some times
and not  at  other  times.
   Cancerous affection of the cardiac  orifice, leading to stenosis, gives rise to
symptoms quite  different from those which accompany cancer of the stomach
elsewhere situated. Food accumulates in the lower part of the oesophagus and
is regurgitated directly  after deglutition.   The obstruction, if considerable,
interferes with vomiting as  well as with the ingestion of food.   The food is
regurgitated without change, and is devoid of the taste and odor of the gastric
fluids.   The patient is unable  to take solid food, and is compelled to  take
liquids slowly and in small  mouthfuls.   In these cases a tumor  is not dis-
coverable.   The symptoms are  the same as  in  cases of stricture at the lower
portion of the oesophagus from other than  cancerous disease, and the differ-
ential diagnosis cannot always  be  made with positiveness.  Spasmodic  stric-
ture of the oesophagus  may simulate contraction from either cancer or  some
other organic  affection.  The  passage of a probang into the  stomach will
enable the practitioner to exclude the latter.   Adhering to the probang or
sound passed into the cardiac orifice, may be cancerous particles, which estab-
lish the diagnosis.
   A microscopical examination of the matters vomited in cases of  suspected
cancer may  lead to the discovery of cancer elements.  This  test is available
only at an advanced period of the disease, and then only in a very small pro-
portion of cases.
   The  prognosis in cases of cancer of the stomach  is as unfavorable as pos-
sible.   If a  cure be within  the range of possibility, the probabilities are so
vastly against it that we are not warranted in  entertaining the  least expecta-
tion of such a result in any  individual case.   A fatal termination is merely a
question of  time.   Statistics show the average duration to be  about a year
from the date of the first gastric symptoms.  The maximum duration is about
three years,  and  the shortest period is a month.  Death occurs by slow asthe-
nia, except in rare instances when it follows profuse hemorrhage or perfora-
tion of the stomach.  Oedema  of the lower limbs and ascites occur in  some
cases.  The former may be caused by thrombosis of the femoral veins; the
latter may be produced by pressure upon  the portal  vein  of a cancerous
       28 
434        STRUCTURAL DISEASES  OF  THE STOMACH.

nodule connected with the liver or the formation of  a  thrombus within the
vein.
  The treatment has reference only to the prolongation of life and the pal-
liation of symptoms.   A diet bland and nutritious, consisting of the articles
of food which  experimental trials in each case show to be best borne, taken in
quantities and at intervals to be determined also by trial ; remedies  to relieve
pain and quiet the  irritability of the stomach ; avoidance of cathartics and
any measures  which impair the vital powers,—these are the points to be kept
in view in the management of this distressing and hopeless  affection.   Nour-
ishment by means of  rectal  alimentation in cancer of the stomach  involving
pyloric obstruction prevents pain and vomiting resulting from the accumu-
lation  of ingesta and the chemical changes incidental  thereto.  It may be
resorted to as supplementary to  a limited quantity of food  taken into the
stomach.  AVithdrawal from time to time of the accumulated contents of
the stomach by means of the pump or siphon, in the  manner to be  described
in connection with Dilatation of the Stomach, has been found to afford marked
relief.   In cases of  cancer causing obstruction of the cardiac  orifice the sen-
sation  of hunger is removed and life prolonged by resorting to rectal alimen-
tation.  These desirable results were manifested in a  case under my observa-
tion.   Buttermilk is sometimes better tolerated  in cases of cancer  than  any
other article of  diet.   Cases have been reported in  which the condurango
appeared to have a beneficial effect.
  Since the preceding edition  of this  work there have been  more than 40
published resections of cancer of the pylorus.   Of these, about 30 have died
from  the immediate effects of the  operation.   In no case does life seem to
have  been prolonged  more than two years after the operation.  Only a very
small proportion of the cases of gastric cancer can be considered as suitable
for  operation.   The possibility of successful surgical interference renders it
very important to make an  early diagnosis.  In  the  hands of a skilful  sur-
geon  an  exploratory laparotomy is  attended with little or  no danger.


           Dilatation of the  Stomach—Gastrectasia.

  Since Kussmaul's publication,1 in 1809, concerning  the treatment  of dilata-
tion of the stomach by means of the stomach-pump  increased attention has
been devoted to the etiology, symptomatology, and treatment of this affection.
As  the normal dimensions of the stomach vary in different individuals within
wide  limits, it is manifestly impossible to give  an exact anatomical defini-
tion of this disease.   AVhile well-marked  examples  cannot be mistaken in
post-mortem  examination, it  is  often  impossible to  recognize the  lesser
grades of this disease.  During life certain  characteristic disturbances of
the  physiological functions of the  stomach  are of  great  importance in
reaching a diagnosis—sometimes  of greater  importance  than the anatom-
ical  investigation.
  AVhen dilatation  of the stomach is  excessive the  organ may occupy the
greater part of the  abdominal  cavity, and may even  descend  into the pelvis.
In less extreme cases  the lowest part of the stomach  lies somewhere between
the  umbilicus and  the symphysis pubis.   By increased weight the  whole
organ  is generally dragged downward,  especially the  pyloric portion when it
is movable, so that  the position of the  stomach is more nearly vertical than
normal.  AVhen  dilatation is  due to stenosis of the pylorus  the  muscular
coat is almost invariably hypertrophied.  In the so-called  atonic dilatation to
be described presently the muscularis may be  of normal or of reduced thick-
ness.  In one case fatty and colloid degeneration of the muscular fibres was
                  1 Deutsches Archiv f. klin. Med., Bd. 6, p. 455. 
DILATATION OF THE STOMACH
435
found (Kussmaul and Maier). The mucous membrane is sometimes thickened
and sometimes thinned.  It is readily understood that neighboring organs may
be more or less displaced by  a widely-distended stomach.
  It is important to know that the stomach may be situated  abnormally low
in the abdomen without being dilated. Thus if, during life, the lower part of
the stomach be found a hand's breadth below the umbilicus, it does not neces-
sarily follow that it is dilated.  The so-called vertical position (situs verticalis)
of the stomach is a not infrequent malposition which simulates dilatation.  In
this condition the pyloric orifice is lower than normal, and it may be in nearly
a vertical line with the cardia. The position may be a preservation of the fatal
state, or it may be  acquired  as  a result of pressure (in women especially by
tight lacing).   As  pointed  out by  Kussmaul,  the greater  curvature  may
occupy an  abnormally low position in consequence of the so-called loop shape
(Schlingen-form) of the stomach.  In  this state the pylorus is  nearer the
cardia than normal, and the lesser curvature is abnormally sharp.
  Kussmaul  distinguishes two forms of  dilatation of the stomach, the hyper-
trophic  and the atonic.1  In the former the muscular coat is hypertrophied,
and  the  cause  in the great majority of cases is obstruction at or near the
pyloric  orifice.   In the atonic form the muscular  coat is relaxed, and  after
death it is  found but little if at all hypertrophied, and  it may be atrophied.
Hypertrophic dilatation he compares, not inappropriately, to  eccentric hyper-
trophy of  the heart.
  The causes of dilatation relate, in the first place, to mechanical obstacles
to the passage of the contents of the stomach into the intestine.  The obsta-
cles may be various.  They may be seated in the upper part of the duodenum
as well as  in  the stomach.    The most frequent and important are cancer and
the cicatrices resulting from old ulcers.   Other causes of organic stenosis of
the  pylorus  are—tumors of neighboring organs, causing  external pressure,
particularly cancer of the liver and of the pancreas;  the contraction of cica-
tricial tissue resulting from perigastritis and  the inflammation of  connective
tissue near the stomach;  hypertrophic stenosis (see p. 41S) ; the pressure
upon the  duodenum  of a wandering right kidney ; and, as rarities, fibroma,
lipoma, glandular and cystic polypi of the pylorus.   A very  rare condition is
congenital  stenosis of the pylorus.2  Dilatation has been referred  to traction
upon the  stomach  produced by large  scrotal  hernias.   According to Kuss-
maul, it may be referable to  spastic stenosis of the pylorus.   The sphincter
pylori ma)* be thrown into  spasmodic contraction by  painful  erosions, ulcers,
and inflammations in its neighborhood.  Destruction of a part of the muscular
coat near the pylorus is evidently an obstacle to the propulsion of food through
this orifice, and so may lead to dilatation.  In this way ulcers and cancers which
destroy the muscularis may produce dilatation even when they do not obstruct
the lumen  of the stomach.   It has already been mentioned that cirrhosis of
the  stomach, which is usually  attended  by contraction, may  exceptionally be
accompanied by dilatation.
   Atonic  dilatation may be due to weakness of the muscular tone of the
stomach from imperfect nutrition in  cases of anamia, chlorosis, exhausting
acute and  chronic  diseases,  or amyloid  degeneration  of  the  gastric arteries.
Important  causes of dilatation of  the stomach are chronic gastritis and dys-
pepsia, especially when attended  by stagnation and fermentation of the gastric
contents.   Individuals of sedentary habits who eat and drink a great deal are
liable to dilatation.  The polyphagia which attends diabetes  thus  becomes a
cause of dilatation.  The  dilatation which results  from organic  stenosis of
  1 Kussmaul,  " Die peristaltische Unruhe des Magens," Volkmann's Sammlung klinische/r
 Vortrdge, Leipzig, 1880.
  2 Landerer, Ueber angeborene Stenose des Pylorus, Tubingen, 1879. 
 436         STRUCTURAL DISEASES OF TEE STOMACH.

 the pylorus  reaches a more  extreme degree than that from other causes, and
 is accompanied by a greater hypertrophy of the muscular tunic.

   Aromiting occurs almost without exception when dilatation is due to pyloric
 obstruction ; and  in other cases it is a frequent but not a constant symptom.
 The  characteristic features  as  regards  this symptom are the occurrence of
 the vomiting  after periods  varying  from a  day to  several  days, the  large
 quantity of the matters vomited, amounting sometimes to several quarts, and
 the presence of undigested aliment which had been taken the previous day or
 several days previously.  The  matters  vomited are almost  invariably  acid,
 and frequently they are in a condition of fermentation, as indicated  by  a
 froth  containing  gas,  sometimes  inflammable,  in  the upper layers.  Sarci-
 na, the yeast-fungus,  bacteria,  and crystals  of fatty acids are often found.
 Acetic, lactic,  butyric,  and other organic acids  are usually present.  Von
 den A elden has discovered an interesting fact in regard to  the  presence of
 hydrochloric acid, the normal  acid of the  gastric juice.  He failed  to find
 this acid  in any case of dilatation due to cancer of the  stomach.  In dilata-
 tion from other causes it was often, but not invariably, present.  According
 to this author, if  hydrochloric acid be repeatedly detected in  the contents of
 the stomach obtained by means of the stomach-pump, obstruction from can-
 cer may be excluded.   If this  acid be persistently absent, no positive  con-
 clusions  can be drawn.1   Bile is  not often found in  the matters vomited or
 withdrawn by the stomach-pump if the  dilatation  be due to  stenosis of the
 pyloric orifice.
   The feature  pertaining to the contents of the stomach which  appears to
 be most diagnostic of dilatation is  their retention for a day or for several  days
 within this organ.  This may be ascertained by washing out the stomach in
 the morning before food has been taken.  In  healthy persons  the stomach
 does  not contain  in the  morning  any of the ingesta of the  preceding  day.
 The ingesta may remain overnight in cases of temporary indigestion, but if
 they are habitually present in the morning, it is certain that the power of the
 stomach to propel  its contents into the duodenum is wanting.  This condition
 leads  to dilatation.  It is called by Rosenbach  insufficiency of the stomach,
 and of course  it may  exist  for a  time  before dilatation ensues.
   Dilatation  of the stomach may  occasion an abnormal prominence  of the
 abdomen, especially marked at the epigastrium and extending more or less
 below the umbilicus.   The projecting tumor yields at the upper part a tym-
 panitic resonance  on percussion  having the characteristic gastric quality of
 sound.  At the lower  portion, if the stomach contain ingesta, there is  flat-
 ness on percussion, and the relative situation of the  flatness  and tympanitic
 resonance changes when the  position of the patient is changed from the ver-
 tical to the recumbent.  On succussion a splashing sound is produced analogous
 to that in pneumo-hydrothorax.  AVith the ear or stethoscope placed over the
 stomach, metallic  tinkling may be  heard when the patient swallows  liquid.
 Sometimes a  sizzling sound is produced  by bubbles of gas generated by fer-
 mentation.   These auscultatory signs, however, are not  distinctive of dilata-
 tion.  They may be caused by the presence of air and liquid in a stomach more
 or less distended, but not dilated.   If the abdominal walls be thin, the form
 of the stomach may  be apparent and  its  undulatory  movements  visible.
 According  to Kussmaul, these  peristaltic undulations  are  characterized by
 their  intensity, their long duration, and  by coming on speedily after meals.
 They  may give rise to  disagreeable sensations, whereas in health persons are
unconscious of  the peristole of the stomach.   The enlargement of the stom-
  1 The methods of testing for free  hydrochloric  acid in the gastric contents are
described in Pepper's System of Practical Medicine, vol. ii. p. 544. 
DILATATION OF THE STOMACH
437
ach varies  at  different  times according to the variations in the quantity of
ingesta and gas.  A sense of fluctuation may be perceived by the touch when
the stomach  contains  considerable liquid.
   AVith the object of ascertaining the amount of dilatation by the eye and by
percussion the method of generating gas within the stomach, as first proposed
by Frerichs, may be resorted to.  The quantity of effervescing powder required
to bring  out  distinctly the contour of the organ varies  in different persons
according to  its capacity, the tension  of the walls of both the stomach  and
the abdomen, the reflex susceptibility to vomiting, etc.  From _!0 to 30 grains
of bicarbonate of soda and from  15 to 20 grains of tartaric acid may be at
first introduced.  The  soda is to be given  in a little lukewarm water and fol-
lowed  by the  acid.   Some persons with relaxed, dilated  stomachs require 2
or 2} drachms of soda and a corresponding  quantity of  acid.1  The amount
of dilatation  may also be demonstrated by means  of  a  stomach-sound,  the
length which  is introduced being ascertained, and  the extremity can some-
times  be felt  by the  hand applied over the abdomen.
   It is important to know that a  person may be found to have an unusually
capacious stomach, but if it do its work well—that is, if it be sufficient in the
sense in which this  term is used by Rosenbach—and is  empty in the morning,
there is no propriety in considering the large size of the organ as a  morbid
condition, any more than a similar condition  of  the bladder.   On  the other
hand, the signs may not denote much enlargement; but if the organ be insuf-
ficient, its muscular power being inadequate to propel the  contents during the
night into the intestine, either dilatation exists or a condition leading thereto.
Since attention has  been directed to dilatation of the stomach more than here-
tofore, it has probably not  infrequently been diagnosticated  on  insufficient
grounds.   No organ in the  body varies in volume more widely  within  the
range of health than the stomach, and an unusually large  volume is not to
be considered  as dilatation unless the symptoms denote  habitual undue deten-
tion of the ingesta.
   In  cases of dilatation the quantity  of  urine  is often diminished and  its
reaction  is alkaline.  The bowels are  constipated.   The body wastes from
innutrition.  The symptoms of cancer of the stomach when  the  pylorus is
obstructed are referable in a great part to the dilatation  which ensues.
   Paracentesis has been practised in a case  of enormously dilated stomach
under  the  belief that the affection was hydro-peritoneum.  Physical  exami-
nation of the  abdomen, in addition to the  symptoms characteristic of dilata-
tion, should enable the  practitioner to avoid this error.  In hydro-peritoneum
the enlargement is not uniform, but is  greatest at the lower  part of the abdo-
men, the reverse being true of dilatation of the stomach.  In hydro-perito-
neum the enlargement  is proportionate anteriorly and laterally ; in dilatation
of the stomach the  anterior projection  is greater than the lateral.   In hydro-
peritoneum flatness  on percussion exists at the lower part  of  the  abdomen ;
in dilatation of the  stomach intestinal tympanitic resonance will be likely to
be found below the  space which yields flatness—namely, in the hypogastric
and iliac regions.  The variation in the  enlargement and  its disappearance after
complete vomiting or the use of the stomach-pump suffice for the  diagnosis.
   If not dependent on pyloric  stenosis a considerable degree of dilatation
may not  give  rise to notable  inconvenience;  but if the  dilatation be great,
nutrition suffers in consequence of the non-absorption of  the accumulated

  1 Fbstein has described under the name insufficiency of the pyloric valve (inconti-
nentia pylori) a condition  in which the gas  thus generated is not retained  in the stom-
ach, but rapidly escapes into the  intestines through the  pyloric  orifice. (Vide  " Uelv r
die Nichtschlussfiihigkeit des  Pylorus," Volkmann's Sammlung klinischer Vortraqe,  No.
155, 1878.) 
438         STRUCTURAL DISEASES  OF THE STOMACH.
ingesta.   Rupture may occur if the walls be attenuated.   A fatal termina-
tion,  however, irrespective  of carcinoma  or  other  diseases which occasion
obstruction, is rare.

   Regulation  of the ingesta as regards  quantity and  quality, together with
tonic remedies, constitutes appropriate treatment.  Indigestible food and articles
which from decomposition develop gas  in abundance should be interdicted.
The diet should consist of meat, milk, soups, and eggs.  Saccharine and amy-
laceous articles are  to be avoided, in  consequence of their tendency to fer-
mentation.  Strychnia or nux vomica may be given with a view to increase
the muscular tone of the stomach.  Artificial  digestion may in a measure be
effected by pepsin and  hydrochloric acid.   Food artificially digested before it
is ingested (peptones) is appropriate.  Kussmaul recommends the withdrawal
of the contents of the stomach  by means of the  stomach-pump whenever
there is evidence  of  undue detention, and  claims that a cure may be some-
times effected  by  this method of treatment.  The advantages of this method
as a means of  obtaining relief are obvious ;  but it is preferable, if practicable,
to adjust the  diet so  that undue detention will not take place.  Inasmuch,
however, as this  is  not always  practicable, if there be pyloric  stenosis  the
use of the stomach-pump is a valuable resource.   AVhen the obstruction is so
great that the system fails to receive  sufficient  alimentary supplies  by the
stomach, supplementary  rectal alimentation becomes an important measure
of treatment.   In some cases it may  be advisable to nourish for a time
wholly by the rectum.  Giving the stomach  nothing to  do in the way of
digestion  is preferable to the  introduction into  it  of ingesta  to  be with-
drawn.   There is, moreover, risk of injury  from the  suction force  of  the
stomach-pump.  Portions of the mucous membrane of considerable size have
been  repeatedly torn away and  withdrawn by the pump.   As yet, however,
no instance of serious injury from this cause has been reported.  The siphon
may be used  instead of  the pump, and is unattended by risk of injury,  but
it is ineffectual for  the  removal of solid  contents.   Kussmaul recommends
washing  out  the stomach  every  alternate  morning  before  taking  food.
Patients  may  learn  to wash out their  own stomachs.1


Degeneration  of the  Gastric   Tubules—Atrophy  of  the
                               Stomach.
   Together with the liver, kidneys, and heart, the stomach is a frequent seat
of parenchymatous degeneration  or cloudy  swelling.  (See Part I. p. 53.)   In
this condition  the mucous membrane is somewhat swollen, and may be either
congested or pale.  The  microscope  shows the glandular cells to be swollen
and filled with albuminous granules, which, at least in great part, dissolve in
acetic acid.  The contours of the cells  may be so obscured that  the tubules
seem to be filled with a granular mass.   This change, when  of much intens-
ity, frequently leads  to fatty degeneration.   The cells now contain fatty mole-
cules  which refract the light more than the albuminous granules, and are  not
soluble in acetic acid.  In extreme degrees of this degeneration, such as may
occur in  phosphorus-poisoning, the cells are  more or less disintegrated and
their places occupied by a fatty and albuminous detritus.  The most frequent
and important causes  of parenchymatous degeneration are the febrile and
infectious diseases, of  which may be specially  mentioned typhus and typhoid
fevers, smallpox, septicamia, puerperal fever, and yellow fever.  Phosphorus-
  1 For further  details, vide article by Leube in Ziemssen's Cyclopaedia, vol. vii.; also,
article by Prof. Welch in the System of Practical Medicine, by American Authors, vol. ii.
p. 503. 
           DEGENERATION OF THE GASTRIC  TUBULES.        439

poisoning has been mentioned as a cause of the more extreme grades leading
to fatty degeneration.   Poisoning by arsenic, mercury, or the mineral acids
is said to produce  similar changes.   It cannot  be doubted that these altera-
tions in the peptic cells impair the secretion of the gastric juice.   It  is rea-
sonable to refer to them many of the disturbances in digestion which charac-
terize the conditions named.   Parenchymatous degeneration in the stomach.
as elsewhere, is a condition from which recovery readily takes place when its
causes are removed.
  AVhile treating  of the different forms of gastritis, reference was made to
changes of the tubules, mostly of a degenerative character,  which occur in'
inflammatory states.   Parenchymatous and fatty degenerations and  atrophy
of the tubules  were  the most important of these alterations.  An interesting
comparison is often drawn  between the changes in the gastric mucous mem-
brane  in  chronic  inflammation  and those  in  the kidney in  chronic  diffuse
nephritis.   In  both  there  are increase of the  interstitial tissue, fatty degen-
eration of the  glandular epithelium in certain places, atrophy of the tub-
ules, with constriction of the tubules at certain  points and cystic dilatation
at others.
  There is reason  to believe  that degenerative  changes  in the gastric mucous
membrane occur  independently of chronic  inflammation and of the various
causes of  parenchymatous degeneration.  Atrophy of the stomach,  atrophy or
degeneration  of the  gastric mucous  membrane  or of the gastric tubules, are
names which have been employed to designate  these changes.  Alterations in
the gastric glands have been studied  especially by Handfield Jones, AA'ilson
Fox, Habershon,  Fenwick, and  Henry and Osier.  It is generally recognized
that atrophic changes occur in the  mucous membrane of the stomach, as in
other organs, in chronic wasting diseases and in old age ;  but  it is maintained
by Fenwick and others that atrophy of the stomach occurs also as a primary
morbid condition attended by grave symptoms; in  other words, that it con-
stitutes a disease by itself.   So  long ago as in 1860, in a published lecture on
anamia, I ventured  the  opinion that degeneration of the gastric  tubules is
the anatomical characteristic in certain cases  now included under the name
of pernicious anamia.  (See p. 384 et seq.)}   In the third edition of this work
(18G8) I  predicted that future investigations  would disclose important facts
pertaining to morbid conditions seated in the  gastric tubules.  In an essay
published in 1871,2  I  endeavored to  still further substantiate these views.
My conclusions were based partly on deduction and  partly on the anatomical
studies of Jones, Fox, and Fenwick.   My object was to show, from a clinical
point of view,  first,  the existence of a well-defined class of cases  character-
ized by anorexia, impaired digestion, progressive debility, anamia, and death
from inanition ; and second,  in view of these clinical  characteristics, together
with the  absence  of adequate lesions  elsewhere, the  probability that  the
essential disease is  seated in the secretory glands of  the  alimentary canal.
It is gratifying to  be able  to add that recent  years  have furnished several
contributions to our  knowledge  of this still  obscure  subject.   Fenwick, in a
lecture on atrophy of the stomach in 1877,3 published four cases with autop-
sies showing atrophy of the gastric tubules without  thickening of the walls
and without diminution of the lumen of the stomach.  The symptoms resem-
bled closely those which have been described  in the  article  on  Pernicious
Anamia.   Quincke,  in  an  essay on  pernicious  anamia,4 mentions a case in

  1 American Med. Times,  1860.
  2 "The Pathological  Relations of the Gastric and Intestinal Tubules," by Austin
Flint, M. I)., New York Med.  Journal, March, 1871.
  - The Lancet, 1877, July 7 et seq.
  4 Volkmann's Sammlung klinischer Vortrage, No. 100 (Case  6). 
440        STRUCTURAL DISEASES OF THE STOMACH

which  the gastric  symptoms were even  more marked than is usual in  per-
nicious anamia, and in which after death the gastric  mucous  membrane was
found to be thin and pale, the glands being few and  far apart.  He suggests
that the atrophy of the gastric mucous membrane may have been  the start-
ing-point of  the  disease.   Brabazon  in 18781 reported a case of  general
atrophy  of the stomach with  absence of organic disease.    The symptoms
during life were anorexia and extreme  anamia.  The walls of the stomach
were found to be atrophied,  but, unfortunately, no microscopical examination
was made.   In 1879, Nothnagel2 published a case of cirrhotic contraction of
the stomach  attended by disappearance of  the  gastric glands in all parts
except the pyloric region.   The microscopical  examination was made by AV.
Midler.  The clinical history of this case was in all  respects that of perni-
cious anamia, and this was the diagnosis during life.  Nothnagel does not
hesitate to refer these symptoms to the atrophy of the gastric tubules.  As
he remarks, atrophy of  the gastric glands appears under  two conditions, the
one with and the other without thickening of the walls of the  stomach.   The
former condition corresponds to cirrhosis of the stomach, the latter to simple
atrophy.  It  is the  latter form to which  Fenwick has called especial atten-
tion.  In some of  the reported cases an  increase of the interstitial tissue of
the mucous membrane has been observed, but  whether it be primary or second-
ary is uncertain.   Even  if the interstitial change prove to be primary, there
is  no propriety, as Nothnagel justly says, in considering the process as an
ordinary chronic catarrhal  gastritis.   A case of fatal  atrophy, the  history
being that of pernicious anamia, has been recently reported by Thorowgood,
and  a  similar case has  been  carefully studied  and reported  by Henry and
Osler.3
   The symptoms which have been observed in cases of atrophy of the gastric
tubules are those of severe anamia. The digestive symptoms are—loss of appe-
tite, vomiting (usually but not always), distress after  eating, and eructations.
These are symptoms in cases of pernicious anamia.  It is desirable, as Noth-
nagel suggests, to pay special  attention  to the condition  of the  stomach in
death from pernicious anamia.   The pathological conditions are probably not
the same in all cases of this grave form of anamia.   That a  certain propor-
tion of the cases are referable  to atrophy of  the gastric tubules may reason-
ably be inferred from cases already published.  From a clinical standpoint it
is  important to take cognizance also of atrophy of the glands of the stomach
as a secondary change in various affections of this organ, especially in chronic
inflammation and in cancer.   It is to be expected that in the future greater
attention will be directed to the condition of these important glands in  dis-
ease, and that valuable  contributions will thereby be made to our knowledge
of this recently-opened  field of research.

   Waxy degeneration of the walls of the stomach is not a very infrequent
condition in cases in which this degeneration  is widely extended.   As a rule,
the metamorphosis is more marked in  the small  and  large intestine than in
the stomach.   All the coats of the stomach  may be  involved, but  generally
the change is greatest in the muscularis mucosa and  the  mucous membrane.
Here, as elsewhere, the  waxy material appears first in the walls of the small
arteries and about the capillaries, and it may be confined to these structures.
The change may, however, extend to the  surrounding tissues.  In the majority
of cases the epithelial cells of the tubules do  not undergo the waxy metamor-

  1 British Med. Journal, July 27,  1878.
  2 Deutsches Archiv fur klin. Med., Bd. 24, p. 353.
  3 Thorowgood, Med. Times, Feb. 5,1881; Henry and Osier, Amer. Journ. Med. Sciences,
April, 1886. 
DYSPEPSIA.
441
phosis.  According to Kyber,  amyloid degeneration of the  stomach is gen-
erally  accompanied  by  chronic inflammatory  changes  and  pigmentation.
Extensive amyloid degeneration may so impair the nutrition of the gastric
mucous membrane as to  favor  the  development of round  ulcer.   Although,
according  to Kiihne, the amyloid material outside of the  body is extremely
resistant to the action of the gastric juice (see p. 55), it would appear from
the studies of Kyber that this  substance in the  living body may be digested
by the gastric juice.   Amyloid degeneration  is  generally an accompaniment
of severe wasting disease (p.  56).  That the  functions of the stomach  are
impaired by this metamorphosis is in the highest degree probable, but we  are
without positive information on this point.
                       CHAPTER   IV.

          FUNCTIONAL  DISEASES OF  THE STOMACH.

Dyspepsia and Indigestion.—Polyphagia, etc.—Gastrorrhagia.—Inanition.—Gastralgia.

                              Dyspepsia.

   OF the functional disorders of the stomach and intestine, a large  proportion
     relate  to digestion ; that  is, to  the processes  involved  in  the  changes
which the ingesta undergo in the alimentary canal.  The processes of diges-
tion  take place within the stomach and small intestine.  Certain of the func-
tional disorders of digestion are commonly embraced  under the name dyspxpsia.
This name signifies  simply difficulty of digestion,  but conventionally it  is
applied  to  cases in which  the  digestive processes  are  disturbed  in  various
ways, as well as to the cases in which their performance appears  only to be
difficult.   It is, however, convenient to make a  distinction between simply
difficult digestion—that is. dyspepsia in the literal sense  of the  term—and
disordered digestion.   The latter may be distinguished as indigestion.  Gen-
erally, dyspepsia denotes ailments which are sufficiently persisting to be con-
sidered as chronic.  The term acute dyspepsia, however, is applied to a disorder
of the  digestive organs attended with  comparatively violent  symptoms and
having a short duration.   The  disorder so called  claims  a brief  notice.
  The  term acute  dyspepsia denotes an affection called by French writers
embarras gastrique, and popularly known with us as a bilious attack.  AVhen
accompanied with more or less  febrile movement it is sometimes called gas-
tric fever.   The latter term is objectionable, because it implies that the affec-
tion  is essentially a fever, whereas the febrile movement  is symptomatic. The
term bilious attack is also objectionable, because it  is by no means clear that
the pathology of the affection  involves special disturbance of the  liver.  In
the absence of precise  knowledge of  the pathological character  of the affec-
tion  the term  acute dyspepsia is to be preferred, inasmuch as,  pathological-
ly, it expresses no more than a functional disorder pertaining  to digestion.
The  term, in fact,  is applied to cases embracing probably different morbid
conditions.
  In certain cases of acute dyspepsia the  disorder  is caused either  by over-
repletion of the stomach, the ingestion  of  indigestible articles of food, or an 
442         FUNCTIONAL DISEASES OF THE  STOMACH

arrest of digestion by strong emotions, fatigue, or other causes.  It is  mani-
fested  by a sense of weight, fulness, or  pain in the  epigastrium ; nausea and
perhaps vomiting may occur, or after a time looseness of the  bowels ensues;
some febrile movement may be induced,  with pain in the head and general
malaise.   Succeeding these symptoms are  loss of  appetite,  coating of the
tongue, an unpleasant taste, with more  or  less uneasiness referable to the
digestive organs for several days.   Such cases are common.  In the way of
treatment they claim only a mild evacuant remedy and regulated  diet  for a
few days,  with  perhaps  some  tonic remedy.
  The practitioner meets often  with cases which differ from the preceding in
the disorder not being distinctly referable to indigestion.  There is impair-
ment  or total loss of appetite  ; nausea  and slight vomiting may occur, but
oftener a liquid containing bile is regurgitated ; uneasiness or undefined dis-
tress is felt in the neighborhood of the stomach;  the bowels are  sometimes
constipated and sometimes loose; the patient complains of a bitter taste, and
the breath is frequently offensive ; the tongue becomes furred or coated ; pain
in the frontal region of the head is a frequent symptom, which if accompanied
by nausea goes by the name sick headache; the urine deposits an abundance
of urates ;  in some cases there is moderate febrile movement; and the counte-
nance frequently presents a sallow appearance.  Patients imagine  that  their
malady is very clearly defined when they declare that they are bilious.  It is
frequently, if  not generally, difficult to trace the aff'ection to  any cause.  It
occurs undoubtedly oftener in  the  spring than in other seasons of the  year.
It continues a few days, and  gradually the normal condition of the stomach
and system is  regained.   It  is  probable  that  in many, if not most, cases of
acute dyspepsia there is subacute gastritis.  In certain cases  the affection is
that called by some authors catarrh of the  stomach, to which  reference has
been already  made.
  Patients with acute dyspepsia are likely to desire active treatment.   They
fancy they need cleansing remedies, and in this light they regard emetics and
cathartics,  or they solicit  medicines to act upon the  liver.   Readjustment of
digestion, etc.  takes place without medication, but  a mercurial cathartic  often
appears to afford prompt relief.   A few grains of calomel or blue mass, fol-
lowed  by a saline purgative, and afterward a mild tonic, such as a  grain
or two of quinia two or three times daily, with regulated diet, are appropri-
ate  measures  of treatment.

  The term dyspepsia, without  the prefix acute, is applied to a more persist-
ent aff'ection than that just considered.  As  the name of a functional  affec-
tion it is not correctly used when applied to disorders of digestion connected
with inflammation or structural  lesions  of the digestive organs, or to disor-
ders incident  to fever and other general diseases.  The term is much less
frequently used now  than formerly.  One  reason for this is, that formerly
the term had a wider latitude than now, embracing affections which  progress
in pathological knowledge has placed nosologically elsewhere; but the  affec-
tion is undoubtedly less prevalent in this country  than it was half a century
ago.
  The source  of chronic  dyspeptic ailments and  indigestion  may  be either
the stomach or the small intestine; hence the names gastric and  intestinal
dyspepsia and indigestion are appropriate.  These two forms of disorder can
generally be differentiated.   A\rithout treating of these forms separately, I
shall  indicate  the symptoms on which  the differentiation is  to be based.
  The symptoms of dyspepsia  are, in  the first place, local—that is, referable
directly either to the stomach or to the small intestine, and in the second place,
manifested elsewhere—in other words, sympathetic or consecutive.  The local 
DYSPEPSIA.
443
symptoms, which  will be first noticed,  are  varied in character,  and mi»ht
serve as a basis  for  the  subdivision of dyspepsia into  several varieties."
  These symptoms  are  conveniently classed  as follows:  First, symptoms
denoting labored or difficult digestion—that  is, dyspepsia in the literal sense
of the term ; and  second, symptoms proceeding from  imperfect or disturbed
digestion—that is, indigestion.
  In certain cases the processes of  digestion  appear to be fully accomplished,
but they are accompanied with uncomfortable sensations.  In healthy persons,
as is well known, a good digestion is conducive to a sense of comfort.   It is
quite the reverse  in  some dyspeptics.   They are often  miserable while the
digestive processes are going on ; they complain  of uneasiness in the  stom-
ach or intestine, of a sense of distension, and of a general  sense of discomfort ;
and these  symptoms  may afford  the only evidence  of disorder.   The  food
appears to  be digested and the body may be  well nourished, whereas in other
cases  these symptoms are associated with those denoting imperfection or dis-
turbance of the digestive processes.  On the other  hand, when digestion is
incomplete or disturbed various symptoms arise in  diff'erent cases, and with
these there is sometimes comparatively little  suffering.  It is a curious appa-
rent inconsistency that some persons manifest habitually more or less derange-
ment  of digestion without much annoyance, while other persons appear  to
digest perfectly, but pass a wretched existence.   In  cases of  dyspepsia with-
out evidence of indigestion the disorder has been distinguished  as  nervous
dyspepsia.  Leube  has  demonstrated, by  withdrawing the  contents of the
stomach at diff'erent periods after the ingestion of food, that labored digestion,
or the so-called nervous dyspepsia, is not incompatible with the complete per-
formance of the digestive process within the  stomach.
  The more prominent of the local  symptoms in  cases characterized by gas-
tric indigestion may be arranged under the following  heads : Regurgitations
(including pyrosis), cardialgia, tympanites, and vomiting.
  Certain cases are characterized by regurgitations from the stomach.   The
liquid regurgitated is sometimes intensely sour from  the presence of lactic,
butyric,  acetic, or other organic  acid.   If the regurgitations occur, as is
usual, during the progress of stomach digestion, the acidity is due to chemi-
cal  changes in the ingesta; but occurring, as  is sometimes the case, after long
lasting, when  the  stomach contains no  food, it may come  from the gastric
glands.   The presence of hydrochloric acid  in the stomach may prevent the
chemical changes  in the ingesta, and hence  this acid  is sometimes a remedy
in cases  characterized by acidity of eructations.  The regurgitated liquid is
sometimes  acrid, seeming to scald the throat; or it may be greasy or nauseous,
having  the odor  and taste  of rotten eggs, the latter denoting putrefactive
changes.   Some persons possess or  acquire the faculty of voluntary regurgi-
tation, and are able to expel  at will  the  contents of the stomach—a faculty
analogous  to that of rumination in herbivorous animals.
  The regurgitation of a considerable  quantity of a  liquid which is either
insipid or  saltish  or  brackish, and  is sometimes acid, when  the  stomach is
empty of food, and usually in the  morning,  is called  pyrosis or water-brash.
  Cardialgia signifies pain at the cardiac orifice of the stomach of a burning
character, and shooting into the chest and  up the  oesophagus into the throat.
It is vulgarly called heartburn.  Every one has occasionally  experienced this
symptom.  It characterizes  certain  cases of indigestion, and it is evidently
dependent  on  the presence of an acid in the stomach, as it is quickly and
completely relieved for a time by  an alkaline remedy.
  A painful sense of  fulness after eating is common without any abdominal
distension,  but more or  less distension  from  air or gas is a prominent symp-
tom in  certain cases, constituting  tympanites.   In   most  cases  the  gas is 
 444         FUNCTIONAL  DISEASES OF THE STOMACH.

 derived  from  putrefactive or fermentative changes  in  the ingesta.   The
 nature of the gas will depend on  the  kind  of food ingested.  In  the decom-
 position  of albuminoid substances  sulphuretted hydrogen is produced, and
 the  gas  expelled  from the stomach has a  characteristic fetor;  the butyric
 fermentation furnishes hydrogen and carbonic acid gas, and  the latter is also
 furnished by the acetic fermentation.   The formation of lactic acid is unat-
 tended  by  the production of gas.  The accumulation  of  gas  within the
 stomach, if considerable, occasions painful distension,  embarasses  respiration
 by interference with the descent of the diaphragm, disturbs the action  of the
 heart, and interferes with the gastric peristaltic movements.  The formation
 of gas resulting from over-repletion  of  the stomach may distend the stomach
 to such  an extent as  to  cause  sudden death.  Two  instances of this kind
 have fallen under my  observation.1
   A source of  flatulent distension of the small intestine is from gas secreted
 or evolved  in some way independently of chemical changes in the ingesta.
 Some persons suffer from  an habitual tympanites.   Females are more  liable
 to it than males.   Cases are occasionally met with in which  the rapid devel-
 opment of tympanites occasions great suffering, the abdomen becoming enor-
 mously distended, the respiration embarrassed by interference with the descent
 of the diaphragm, and in  females the  suffering being  increased by pressure
 upon the uterus and bladder.  In  a case under my observation paroxysms of
 intestinal tympanites, occasioning intense distress, had occurred daily for sev-
 eral  successive months, an inodorous  gas sometimes passing off by the rectum,
 and  sometimes  the tympanites disappearing without any escape of gas.  A
 host of remedies had been employed  in  this case unsuccessfully, and at length
 improvement took place under simple palliative treatment.   In a case of this
 description  the appearance  of the abdomen  during an attack of tympanites
 was  extraordinary.  The  convolutions   of the small intestine and  their peri-
 staltic movements  were distinctly visible through  the distended  abdominal
 walls.   So far as my observation goes,  such  cases occur only among females,
 and  the  tympanites is associated with more or less  neuropathic disorder.
 Hysterical phenomena  are  sometimes  associated  with it.
   There is another source of flatulent  distension, the seat of the  tympanites
 being the stomach—namely, the ingestion of air.   More or less air is habit-
 ually commingled  with food and drink, but the quantity received in this way
 is  never sufficient  to distend the stomach.   A  habit of swallowing  air is
 sometimes acquired, resembling crib-biting or wind-sucking in horses.  Some
 writers refer to this habit  as not  uncommon, but the  effort  required in the
 deglutition of air is such that the  act could  not escape detection ;  and, judg-
 ing from my own experience, cases are  by no means frequent in this country.
 In a case which came under my observation  the patient was about  fifty years
 of age and had suffered from a disorder of  the digestive  organs for twenty-
 five years.   In  order to show  how he  performed  the act of swallowing air,
 he drank  a quantity of water precipitately, and  appeared to make violent
 efforts to force  it downward.  During these efforts the face became flushed
 and the eyes watery.   Shortly the efforts were discontinued, and at the  same
 moment a loud  gurgling sonnd was beard in the region of the  stomach.  It
 appeared as if there were  some obstruction in the  oesophagus, but a probang
 was readily passed into the  stomach.  The patient  stated  that the habit had
existed for twenty-five years.  He was  led to it gradually in order to prevent
regurgitation, which he stated always occurred if he failed  to ingest  air in
conjunction  with his food  and  drink.   He was accustomed to belch air fre-
quently.   Percussion over  the stomach showed  considerable  gastric  tym-
panites.
           1 Reported in Boston Med. and Surg.  Journal, March  10,  1841. 
DYSPEPSIA.
445
  An habitual tympanites  of the  stomach  occasions in some persons, after
the ingestion of  liquid, a succussion sound in walking resembling the sound
frequently heard in horses.   This  is a source of much annoyance and morti-
fication, especially to women.   It may be avoided by taking into the stomach
only very small  quantities of liquid at a time.  This symptom alone is  not
proof of dilatation of the  stomach
  A'omiting is not common in cases  of chronic dyspepsia.   It is more fre-
quent  in occasional fits of indigestion.  It is, however, characteristic of a
form of chronic  dyspepsia occasionally met with, occurring generally in young
girls.   In this variety of disorder  vomiting almost constantly follows the in-
gestion of food or  drink ; and the  stomach seems to be intolerant of all forms
of nourishment, although taken in small  quantities.  The vomiting occurs
directly or  soon after food is taken, and in  some cases it  is  surprising that
there  is  not more evidence of inanition,  since everything  taken into  the
stomach appears to be ejected ; yet, although the disorder may continue for a
long time, the patient does  not become greatly emaciated or notably enfeebled.
The disorder often resists all the usual remedies to relieve irritability of  the
stomach, such  as  bismuth,  creasote,  opiates,  hydrocyanic acid, oxalate  of
cerium, etc.  It is usually accompanied with mental  depression, hypenws-
thesia  of the surface, and marked tenderness over the spinal column.  In
determining that  the affection is  purely functional, gastritis, gastric ulcer,
subacute meningitis (especially in children), pregnancy, and disease of  the
kidneys are  to be  excluded.   Restricting the patient to milk  or some  other
article of diet, in very small  quantities and repeated at very short intervals,
will sometimes  succeed ; but the  plan of treatment which in my experience
has proved  most  successful  consists in change of scene and  living as much
as possible  out  of doors.  I have known a sea-voyage to prove  efficacious.
  The local symptoms just noticed are  not  peculiar to dyspepsia or  indiges-
tion as a functional affection.   They may occur in  connection with subacute
gastritis and structural lesions of the stomach.  In arriving at the diagnosis—
that is, determining that only a functional affection exists—inflammation and
the lesions which have been considered are to be excluded.   They are to be
excluded by the  absence of their diagnostic symptoms, and for these the reader
is referred to the preceding chapters.
  Of symptoms other than those  referable  directly to  the digestive organs
mental  disorder is one of the most noticeable.   During the processes of
digestion dyspeptics often experience an uncomfortable  heaviness or dulness,
rendering it  difficult to  concentrate  the attention  upon  any  subject.   The
following extract from  Chambers's work gives a graphic representation of  the
condition in many  cases : " There is great languor and incapacity for exertion,
coming on generally about an hour after food, and accompanied in some cases
by  an almost irresistible drowsiness  which lasts for several hours.  This
symptom is  particularly  marked in the afternoon if  the patients dine in  the
middle of the day and endeavor  to  continue their employment afterward.
Yielding to the drowsiness  and taking a siesta seem to make matters worse,
for  there is usually felt after such  an  indulgence an intense headache or gid-
diness, which continues longer  than the symptoms would have done  had  the
inclination to sleep been resisted.   The depression of spirits is not so  remark-
able as the  feeling of utter helplessness, both of mind and body, accompanied
in persons naturally active  with a sense of shame at their unwonted apathy."1
This condition may be connected with  the process of digestion in the  small
intestine, and may be unaccompanied by  symptoms denoting  disorder  of
stomach digestion.
  In most cases  of dyspepsia patients suffer more or less from mental depres-
                1 Digestion and its Derangements, Am. ed., p. 367. 
 446          FUNCTIONAL DISEASES OF THE  STOMACH.

 sion.   They are devoid of buoyancy, gloomy, and disposed to look always on
 the dark  side.  Frequently, this  depression  is increased  by anxiety respect-
 ing health.   They are apprehensive of  the existence of some grave disease,
 such  as consumption or an affection of  the heart.   Their attention becomes
 concentrated upon themselves.  They are constantly watching the sensations
 connected with digestion, and fall into the habit of counting the pulse, feeling
 the hearts beat,  examining the  abdomen, urine, etc.   This mental disorder,
 carried beyond a certain point, eventuates in melancholia and hypochondriasis.
   In  addition to these symptoms of mental disorder, various symptomatic phe-
 nomena belong to the clinical history of dyspepsia.   Irregular action of the
 heart or palpitation is not uncommon.   Constipation generally exists, some-
 times alternating  with diarrhoea.  The  skin is frequently  dry and  rough, and
 the extremities  are often cold,  showing  deficient activity of the circulation.
 The tongue is usually furred or more or less  coated.   The urine deposits the
 lateritious sediment, and on microscopic examination crystals of  oxalate of
 lime  may be found in abundance : the  latter, being  incident to various mor-
 bid conditions and not  uncommon  in  connection with trivial  disorders, are
 incorrectly considered as denoting a  special affection called oxaluria.  Vigil-
 ance is a frequent source of complaint, and the sleep  obtained is often incom-
 plete  and disturbed by dreams, the patient arising in the morning unrefreshed
 and miserable.1   The appetite in the morning is often poor, becoming perhaps
 during the day morbidly craving.   A dry hacking cough  is reckoned among
 the sympathetic phenomena, but this is rare.   The existence of cough should
 always excite suspicion of pulmonary disease or of chronic pharyngitis.
   AVith reference to the pathology of dyspepsia and  indigestion, it  is to .be
 considered that digestion is not  a simple process.  Including  under this term
 all the changes which take place in the ingesta within the alimentary canal, there
 are certain changes in the stomach from admixture  with  the salivary fluids
 and the gastric juice, others in the duodenum from the addition of the bile and
 pancreatic secretion, and others in the small intestine  below the  duodenum
 from  the action of the intestinal juice.   For the proper activity of  the organs
 and for the secreted liquids, the latter being vastly more  abundant than was
 formerly supposed, a large supply of blood is  required.  The movements due
 to the muscular coat of  the stomach and intestine are important.   A certain
 influence derived from the nervous system is requisite for the secretion of the
 liquids and  for the peristaltic movements.   An analysis of the symptomatic
 phenomena in diff'erent cases of  dyspepsia shows  that the different elements
 which enter into the function of digestion may be affected either  separately
 or with different degrees of predominance.  Thus, vomiting and regurgitation
 show  irritation and spasmodic  action ; pain  or distress, morbid sensibility;
 prolonged digestion, with chemical changes, deficiency in the digestive liquids,
 etc.   It is of  importance to take cognizance of these several elements in the
 management.
   As  regards the differentiation  of gastric and intestinal dyspepsia and indi-
 gestion, the period which elapses after eating  before the inconvenience is felt,
 and the absence of symptoms of disorder referable to the  stomach, show the
 affection  to be intestinal rather than gastric.   In  cases of intestinal disorder
 from two to four hours  elapse after  the ingestion of  food before the manifes-
 tation of the local and general symptoms.  Diarrhoea is a frequent symptom
 of intestinal  indigestion.   This  is the  source, in most cases, of  functional
diarrhoea.

  1 The poet Cowper, who  appears  to have suffered from intense mental depression in
connection with dyspepsia, describes his feeling in the morning in the following forci-
ble language: " I awake like a  toad out of Acheron, covered with the ooze and slime
of melancholy." 
DYSPEPSIA.
447
  The causation  involves  agencies  affecting the digestive  processes  either
directly or indirectly.  Excesses in  eating and drinking act as direct causes.
The digestive powers may be overtasked by the quantity or over-excited by
the quality of food.  Under these circumstances dyspepsia has been  called
" the remorse of a guilty stomach."   The habit of spirit-drinking  engenders
dyspepsia.  Drunkards after a time becomes dyspeptics.  Dyspepsia may fol-
low subacute gastritis or enteritis produced by dietetic  error or other causes;
inflammation leaving the organs in a weakened state.  These direct causes,
however, are not so largely operative as is generally  supposed.
  The indirect more than the direct agencies are involved in  the  causation.
These are various.   Anamia is one of the indirect causes.   It  gives rise to
dyspepsia by diminishing  the  functional activity  of the gastric and  intes-
tinal glands, the digestive liquids being  lessened, or  affected as regards their
quality.   Clinical  observation shows that in cases of  anamia  the digestive
power  is  generally  more or less weakened.   On the  other hand, impaired
digestion may stand in a causative relation to anamia.   A notable  change in
habits as regards physical exercise is not infrequently  causative.   The vigor
of the digestive organs  is  in a  measure commensurate with the demand for
nutritive  material, and the  latter is dependent on the waste of the  tissues.
Now, certain dietetic habits are formed in accordance  with occupations involv-
ing physical activity and a proportionate amount of disassimilation.  Persist-
ence in these dietetic habits after a change from an active to a sedentary life
is likely to induce  disorder.  This is, in part  at least,  an explanation  of its
occurrence among those who exchange the farm or workshop for the desk or
study, and among  those who retire from  business to enjoy leisure.
  In a large proportion of cases dyspepsia originates and is perpetuated by
mental causes.   It is induced and kept  up by anxiety  and depression.   Dis-
order is often, in the first place, produced by mental causes, and then it  reacts
upon  the mind, increasing its morbid condition.   An  examination into  the
previous history of cases  will  frequently show the  affection  to have been
preceded  by mental disquietude  of some kind.  Persons  of a certain mental
constitution are especially prone to dyspepsia—namely, those so constituted
as to  be constantly anxious  about something, such  as acquiring success in
life, getting out of  debt, securing an  independent position, or about  imag-
inary troubles.   The period of life when persons are  most liable to  dyspepsia
is that in which anxieties are likely to be greatest—namely, between adult age
and middle life.  After the latter period the events  of life  are  taken  more
calmly and  there are fewer  sources of intense anxiety.  Persons who have
been dyspeptics for many years  are often free  from  this affection after hav-
ing entered  upon middle  life.   It may be doubted if  the affection be often
produced  by overtasking the intellect.  When it  occurs in those who  are
devoted to intellectual pursuits,  it arises generally from the  sedentary habits
connected with these pursuits or from mental anxiety  ; and, on the other hand,
deficient exercise of the intellectual and moral faculties frequently leads to it.
Conditions in life involving ennui and dissatisfaction  predispose to it.  Under
these  circumstances the attention tends to become  concentrated on the func-
tions of the body,  which go on best without close surveillance.  These  views
are sustained by observing the classes of persons who suffer  from dyspepsia.
Fpicures and gormandizers by no means of necessity  become  dyspeptics;  and
they often escape  this affection,  when their  indulgences  lead to other conse-
quences, such as gout, etc.   The laboring-classes are not prone to dyspepsia,
notwithstanding the use frequently of  the  coarsest and most  indigestible
kinds of food, prepared without  regard to the art of  cookery ; but  cases  are
met with especially among retired rich persons without occupation  or mental
resources, among those who have no useful or proper  aims in life, and among 
448         FUNCTIONAL  DISEASES  OF  THE STOMACH.

those who are debarred from the interests of domestic life.   In these several
classes  it may be developed irrespective  of any dietetic  errors.1

   Treatment.—In the management of dyspepsia and indigestion, as of other
affections, the first point is to remove or obviate causes, as far as this is prac-
ticable.  The practitioner may be able to control causes  relating to dietetic
errors, but he may not be able to reach those connected with the mind, and
hence  there is difficulty in effecting a cure.  Measures  of treatment may be
arranged in three divisions—namely, 1st, those relating to diet and  regimen;
2d, measures addressed  to  the mind;  and 3d, medicinal  remedies.
   1. If the aff'ection have been induced by dietetic excesses it is sometimes
useful to give the digestive organs a short period of rest, and with this view
to reduce the diet for a time below the  wants of the system.   This,  however,
should be but temporary.   A cure is not  to be effected by persisting in this
course.  Not  only  the system is reduced, but the digestive  functions are
impaired  by too  great or too  protracted  abstemiousness.  Dyspepsia is, in
fact, perpetuated, and  may  be  produced, by attempts  to live on  as little and
as coarse food as possible. Persons who think it vulgar, unrefined, or worldly-
minded to eat well are likely to be subjects of dyspepsia as well as  of other
affections.  This  is  true  also  of those  who fancy that most maladies  arise
from  over-eating, and that the great  problem  of  health-preservation  is to
learn  to eat  sparingly.  The object  of treatment is  to bring the digestive
powers up to such a point of improvement that particular care in diet is not
requisite.
   As regards the diet for dyspeptics, there are no rules  suited to all cases.
Individual experience  in each  case is not to be altogether ignored, but there
is a liability to error in regard to this experience.   Unusual difficulty of
digestion, or  indigestion, after  a meal is often imputed to certain articles of
food when it  is due to some  other incidental circumstance.  Idiosyncrasies
in relation to particular articles of food are far less common  than the state-
ments  of  patients would lead one to suppose.   In general, articles which are
wholesome to most  persons  are not unwholesome to any.   It  is rarely true
that " what is one  man's meat is another's poison."   As  a  rule,  when  a
patient says that he  cannot  take such and such  articles which  general expe-
rience  shows to be digestible and  nutritious, it is fair to presume self-decep-
tion ;  and of  this the patient may  generally be convinced if persuaded to per-
sist in  their use.  At first, the expectation  that  an  article will prove hurtful
contributes to render it so; but after a  time the idea is overcome.  It is often
an object in the treatment of dyspepsia  to do away with these fallacious ideas
respecting various kinds of  food.  Some persons are fond  of encouraging the
notion  that their digestive organs are endowed  with peculiar  susceptibilities
which prevent them  from conforming to general rules of diet.  Their egotism
is gratified by the thought  that they differ in this  regard from the  common
herd.   In most cases  animal  food is best  digested, especially old and tender
meats plainly but well cooked ; but in some cases a  milk and farinaceous diet
is found to agree best.   An  obvious  reason why so  many persons  imagine
they do not digest milk well is that it  is  often  taken as a beverage after or
with solids, the fact that it is, in effect, a solid article  of food not being
appreciated.  Bread, to  be  readily digestible,  should not be  new, nor  is it
desirable  that it should be stale.   AVell-boiled rice, corn-meal mush, and
other  analogous farinaceous preparations are easy of  digestion.   Crude veg-
etables  are digested with more difficulty, but they are not to be interdicted
as a matter of course.   Some dyspeptics find  even the much-abused cucum-
  1 For a fuller exposition of these views of  the causation of dyspepsia, vide  article by
the author in the Am. Journ. of Med. Sciences, Jan., 1841. 
DYSPEPSIA.
449
her grateful to the stomach as well as to the palate.   Pastries, rich pud-
dings, and sweetmeats are generally to be eaten sparingly or to be discarded.
Ripe fruits  in proper moderation are useful.   It is never advisable  for  the
patient to adopt a restricted range or any particular system of diet.   On  the
contrary, it  is  important to persevere in attempting to digest all the varied
forms of wholesome food, not being restricted to meat  or a vegetable diet,
but aiming to eat like persons  in health, without the need of particular care
in the selection.
   Diff'erent  kinds of food are suited to different cases according as the func-
tional disorder is chiefly gastric or  intestinal.  If gastric, farinaceous arti-
cles will be  likely to be best suited, as these are digested mainly in the small
intestine.   Fatty articles may be well digested in these cases.  On the other
hand, if the disorder be intestinal, farinaceous and  fatty  articles of food will
be likely to  be difficult of digestion, and albuminoid substances or an animal
diet will be  found to occasion less inconvenience.
   Restriction to a few meals a day is not an uncommon error.   If a patient
have no appetite for breakfast, an early lunch should be taken.  If the dinner
be near the  middle of the day and  an early tea be taken, some light  food in
the evening is advisable.  Long intervals between the periods of taking food
tend to weaken the  powers of digestion.   Food  should be eaten  slowly.
Deliberate mastication prepares the food for the  action of the gastric juice.
Moreover, slowness in eating gives the stomach a chance to  express  satiety,
and  is therefore a protection against over-eating.  Errors, however, in this
respect  are  likely  to  be  over-estimated.
   AVith regard to the use  of wine or spirits, the danger of intemperance is
always to be considered, especially as  dyspepsia not infrequently leads to a
morbid  desire for stimulants, and in view of the fact that the mental state is
favorable for the formation of intemperate habits. Yet an alcoholic stimulant
taken with  meals is often useful until  the normal powers of the digestive
organs are restored.  Stimulants should never be taken when the stomach is
empty.
   It may be  well to  remind  the  practitioner  that it is unphilosophical to
judge  concerning his patients from the  conclusions derived from  his own
personal  experience.   The  physician who has his  notions of what kinds of
food agree with  himself best is often inclined to apply  these notions indis-
criminately  to his patients.
   To consider fully the subject of dietetics would be incompatible with  the
scope of this  work ; but, practically, this is less desirable than  many might
suppose.  My  experience has led  me  to  adopt a plan of dietetic treatment
which has  the merit of great simplicity, and which I have found to  be very
successful.  I am accustomed to say to patients that if they expect to acquire
a  good digestion they must  not pay particular attention  to  diet—that they
must follow the dictates of  instinct rather than any precise rules  as  respects
the articles  of food, the quantity to be  taken, and  the time  of taking it.  I
have never  known a dyspeptic  to recover vigorous health who undertook to
live  after a  strictly regulated diet, and  I  have never  known of  an  instance
of a healthy person living according to a  strict dietetic system who  did  not
become  a dyspeptic.   On  the other hand, in  a  great number of  cases  in
which persons had been  sufferers  for years on a regulated  diet, health  has
been speedily regained by  eating  simply in accordance  with appetite.
   The clothing of dyspeptics should be such  as will secure uniformity of
temperature and maintain the  functions of the skin,  without  over-accumu-
lation of heat  or exciting  perspiration.   A sense of comfort is the crite-
rion  in this regard.   Exercise is of importance, but to be useful   it must
be taken with a  motive and end aside from the sanitary object.  Exercise
       29 
 450          FUNCTIONAL DISEASES OF THE STOMACH.

 taken simply as exercise tends to keep  the mind  of the  patient on his  dis-
 order, and it will not be likely to be persisted in.   There is a risk  of resort-
 ing  at  once to over-exercise, a too violent change  of habits in this regard
 proving hurtful and discouraging the  patient.  The  exercise should be in the
 open air.  A change of business  from one requiring sedentary habits to one
 involving out-of-door occupation is often advisable.   Travelling, especially in
 foreign countries, where the attention is diverted with a succession of novel
 scenes, is  highly useful.   Sir  James  Johnston  said that no  case  of purely
 functional dyspepsia could resist a pedestrian tour over the  Alps.
   2.  The moral treatment consists first in establishing confidence by atten-
 tion and sympathy.   Inattention to the details into which dyspeptic patients
 are fond of entering, and ridicule  of hypochondriacal fears, prevent the phy-
 sician from being of  service to this unhappy  class of patients, and  lead them
 to seek  for aid  from quacks and  secret remedies.   If the  confidence  of  the
 patient be secured, the assurances of the physician will often remove needless
 apprehensions, and afford  an encouragement which  in itself will  contribute
 not  a  little toward  improvement.    If  the patient be convinced that  his
 mental  state is in a  measure due to a disordered condition of the  body, he
 derives  consolation  and encouragement  from  this  belief.   The  treatment
 relating to  the mind will  embrace, as far as possible, measures having ref-
 erence to the  removal  of mental causes which may have produced or which
 perpetuate the affection.  It is important to incite to occupations which divert
 the attention from the bodily functions, especially during the process of diges-
 tion.   It is desirable that the  mind  should be pleasantly occupied.   It is
 often observed by dyspeptics that if they dine alone, and  are left by them-
 selves to watch  the  sensations connected  with digestion,  they are sure to
 suffer, whereas  they  experience no inconvenience  from a greater amount of
 indulgence  in  eating if they be in agreeable company during and  after din-
 ner.   Popular  works on indigestion do harm by directing to the  subject the
 attention of those prone  to  dyspepsia.   The benefit of travel  is, in a great
 measure, moral,  involving recreation  as  well as exercise, and  keeping the
 mind occupied with  extrinsic subjects.
   3.  The division of the  treatment which relates to  medicinal remedies is
 relatively least important, but it is by no means unimportant.   If the symp-
 toms denote morbid sensibility of the stomach, counter-irritation on the epigas-
 trium is often  useful.  Small  blisters, the strong aqua ammonia, or the croton
 oil may be used  for this  purpose.   The  benefit is probably in part due to a
 moral effect.   The nitrate of silver may be given in these cases, care being
 taken not to continue it too long.   If anamia be associated, the chalybeate
 tonics are indicated, of which in cases of dyspepsia the tincture of the chloride
 of iron is one of the best.   The addition of an equal part of dilute phosphoric
 acid  and of the syrup of ginger or orange makes this an agreeable remedy.
 The  citrate of iron and  quinia is an excellent form of tonic in dyspepsia asso-
 ciated with anamia.  The powder of iron reduced  by hydrogen is another
 eligible form.  If there be constipation, the  bowels  are to be  regulated  by
 appropriate measures, but  purgation is to be avoided.  Constipation  will be
 considered  as a distinct  functional  affection.   There  are no special indications
for mercurial remedies except as an occasional cathartic or laxative.   In gen-
eral, the various vegetable tonics are  useful, the tonic remedy being varied
from time to time.  A grain  or two of quinia twice or thrice daily, continued
steadily for several weeks,  appears to be often useful.  A few drops  of hydro-
chloric acid after eating may frequently be prescribed with advantage.  The
benefit of the tincture of the chloride of iron is probably in part due to the
hydrochloric acid.  Pepsin, in doses of five or ten grains after  each meal,
appears  often to be of service.   The principle  on  which  it is  employed— 
DYSPEPSIA.
451
namely, to supply a deficient element in the gastric juice—entitles it to be
considered only a palliative, not a curative remedy.  A convenient and eligible
form in which pepsin may  be given is the  preparation commonly known as
rennet wane.   This  is  prepared by putting  a fresh rennet, cut up into small
pieces, into a pint of  sherry wine, which after  maceration for two weeks is
to be strained, and it is then ready for use.  Of this preparation from half a
teaspoonful to a teaspoonful is to be given shortly after taking food.  I have
used for several years past, with great satisfaction, as a stomach tonic, salicin
in ten-grain doses, dissolved in a wine-glass of water and taken just before
each meal.  The benefit derived from this remedy is often remarkable.  It is
useful  especially when fermentation  and flatulence result from indigestion.
The salicin in these cases acts as an antiseptic  as well  as a  tonic remedy.
   Symptoms  characterizing certain cases of dyspepsia claim particular reme-
dies.   Pyrosis is generally relieved by bismuth in doses of a scruple or half
a drachm  combined with a carminative, such as powdered cinnamon, in con-
junction with measures relating  to diet, hygiene, etc.,  and followed by tonic
remedies.   Cardialgia  calls for alkaline remedies—namely, lime-water, liquor
potassa, bicarbonate of soda,  and magnesia, the two latter especially if there
be constipation. Flatulence  and tympanites are relieved by carminative stim-
ulants, the tincture of the essential oils, the aromatic  powder, and charcoal
powder, the  latter being useful on account of its power of absorbing gases.
All these  remedies, however, are merely palliatives.  The conditions on which
depend the several  symptoms just named  are, if possible, to  be removed by
tonic remedies, such as salicin,  quinia, and the mineral acids. Intestinal tympa-
nites occurring in paroxysms from the secretion of gas is  an extremely obsti-
nate form of disorder.  Purgatives are not useful.  Opiates  to relieve pres-
ent suffering  are required.   Carminatives and alcoholic stimulants will some-
times afford relief.  Asafoetida given  by the mouth or rectum is highly use-
ful, especially when hysterical symptoms  are  associated.  In  the  intervals
between the  paroxysms measures, medicinal and hygienic, to  invigorate  the
system are indicated,  together with the use of antispasmodic remedies, such
as  belladonna,  valerianate of  zinc, etc.   Small doses of strychnia, or of nux
vomica in the form of tincture or extract, are useful in these cases.
   The management in certain cases of dyspepsia characterized  by persistent
vomiting  after taking food  has  been already alluded  to. Change of scene
and out-of-door life are the most efficient measures.  A sea-voyage will be
likely to prove effectual;  but various remedies may be employed in succes-
sion, each of which will sometimes be found useful if not successful.   The
salts of morphia or codeia  may  succeed if the patient be not unpleasantly
affected by opiates  of any kind.   The hydrocyanic acid  in some cases is an
efficient remedy.  Creasote  sometimes acts efficiently given  in doses of  one
or two minims repeated after  each  act of vomiting.  In  young children this
remedy, given in doses of one-eighth or one-sixth  of a drop,  frequently acts
like a  charm  in arresting vomiting.  Bismuth  in large  doses  is a valuable
remedy in some cases.  Strychnia or  the nux vomica has been found useful.
The oxalate  of cerium, from  two to  five grains  at a dose, is  another useful
remedy.   Counter-irritation  on the epigastrium by means of blisters or  dry
cupping is frequently followed by relief.   Milk, with lime-water added, is
sometimes retained when other  articles of food are rejected.   Vomiting is
symptomatic  of a  great variety  of affections,  exclusive  of inflammation or
structural lesions of the stomach.  Occurring  as a form  of functional disor-
der of the stomach, it is sometimes considered  as an individual affection,  but
it may with propriety be included among the symptoms of dyspepsia.
   There is a  variety of vomiting  which  claims  a  brief  separate notice.  Ref-
erence is had to cases in which a  liquid is thrown from  the stomach in greater 
452         FUNCTIONAL DISEASES OF THE STOMACH.

or less abundance, emitting an  odor of fermenting wort, and, after  standing
a few hours, becoming covered with a  mass of brownish  froth resembling
yeast.  Goodsir in 1842 discovered in this liquid in great abundance a vege-
table organism which is now commonly known as the Sarcina ventriculi, called
by Robin Merismopcedia ventriculi.  The  sarcina  are distinguished  by their
oblong or square form  and by their being divided by lines into four equal
squares, so that they resemble a package tied with a cord, as  the name sarcina
denotes.  The sarcina are now classed with the bacteria or schizomycetes.  The
vomited liquid containing sarcina may also contain the yeast-fungus in abun-
dance.  The  liquid is  sour, according to  Budd, from the presence of acetic
acid, and the vegetable productions are incidental to a process of fermentation
attended with the formation of this acid, together with  the  evolution of  car-
bonic acid.  There does not appear to be ground for the belief that the pres-
ence of the vegetable productions is the source of disorder.   Their production
within the stomach appears to be owing to an undue retention of its contents
from  pyloric obstruction  or other  causes.  The treatment,  therefore, relates
not alone to the  circumstances immediately involved in  their production, but
to the morbid conditions giving rise to these circumstances.   Remedies, how-
ever, designed to arrest  the fermentative  process are indicated; and of these
one of the most efficient is the bisulphite of soda.   These remedies are valu-
able as palliatives whenever, from defective power of digestion, fermentative
processes in  the ingesta  take place.   Small doses of carbolic acid,  salicin,
salicylic acid, and gaultheria are  other efficient remedies.  The value of these
remedies in cases of  dyspepsia depends on their power in arresting fermenta-
tion.   AArashing  out the stomach by the siphon process is especially useful in
cases characterized by fermentation of the gastric ingesta.
  Dyspeptics  frequently  derive advantage from  the use of mineral-spring
waters, especially if connected with a  sojourn under agreeable circumstances
at a pleasant  watering-place.  Much  of  the  advantage, doubtless, is  due to
change of habits and relief from care, together with the moral influence of
the expectation of improvement.   Of the various mineral waters, those from
the gaseous and chalybeate springs  are best suited to cases of dyspepsia.
Cold  sea-bathing and  the invigorating  influence of a  bracing  sea-air  are
frequently  useful.   The  hygienic discipline  of the hydropathic  system is
undoubtedly useful  in  some cases, the benefit being due probably in part to
a physical, but  more to a moral,  effect.   There is  perhaps no affection in
which the  anticipation of  improvement  from the  employment  of  certain
measures contributes to their efficacy more  than in dyspepsia.


Polyphagia, Malacia and  Pica, Polydipsia, and Dipsomania.

  These  names  express morbid  conditions which  relate to  the ingestion of
solids  or liquids—conditions which  severally  do not constitute  individual
affections, but which may be the most prominent, or perhaps the chief, ail-
ments.
  Polyphagia—or, as it is more commonly called, bulimia—denotes a craving
for food beyond the wants of the system.  As thus defined, these terms are
not correctly applied to the greatly augmented appetite felt frequently during
convalescence from  fevers and other acute diseases, or when from any cause
the system for a time has been deprived of alimentary supplies adequate to
its needs.  The  inordinate desire for food under  these circumstances is an
expression of the requirements of  the system, and the  ability to  digest food
may be proportionately augmented—a  fact  which illustrates in a  striking
manner the connection  existing between nutrition  and the function of diges-
tion.   True bulimia does not  exemplify this  physiological connection, the 
POLYPHAGIA, ETC.
453
amount of food craved far exceeding the requirements for nutrition.  Bulimia
may be another name for gluttony.   The love of eating may be cultivated to
such an extent that little else is thought of, and persons who fall into this
habit may be said to live to eat, rather than to eat to live.   The observation of
every one will furnish examples of this kind.  Habits of gluttony may lead
to dyspepsia, which, by interrupting further indulgence,  proves conservative,
or, if the digestive function continue active, they may lead  to obesity, fatty
degeneration of the heart or  other organs, and to various affections.  Vora-
cious eating characterizes  certain cases of mental derangement.  It may be a
symptom of disease attended with progressive waste ; as, for example, diabetes.
In a more marked and  rare form the craving for food  greatly exceeds  that
under the circumstances just named.   Curious instances  have been reported
in which the morbid appetite appeared to be insatiable, all kinds of food—raw
meat, candles, etc.—being eaten in some cases with avidity and in enormous
quantity.   It  is difficult  to explain the morbid  appetite in these  instances.
Recovery from this  condition is to be  expected.   The indications are to regu-
late  the diet as far as  possible, to establish the general  health by hygienic
measures, to correct any disorder of digestion which may  exist, and to palliate
the excessive craving for food by opium, or sometimes by nauseant remedies.
Swallowing  pieces of ice has been found effective as a palliative measure.
  Malacia and pica are terms applied to perversions of  appetite; that is, to
a morbid craving for particular substances.   The terms are commonly used
as synonyms, but strictly  they denote different kinds of  perversion.  Malacia
denotes a morbid craving  for certain articles of food or articles which are not
devoid of  nutrition, whereas pica denotes a desire for innutritious substances.
The craving for strange kinds of food sometimes  attending pregnancy, and
commonly known as " longings," is  sufficiently familiar.   Similar  eccentrici-
ties of the appetite  are  sometimes observed in connection with hysteria, and
they may be due in some  cases to that desire to  become objects of wonder or
interest which weak-minded hysterical women sometimes present.  Unnatural
and disgusting perversions of  the appetite are among the symptoms occasion-
ally met with  in  cases  of insanity.   Perversions falling under the head of
pica are sufficiently common.   Innutritious  substances frequently  craved are
charcoal, chalk, slate, and certain kinds of earth.  The habit of eating these
substances is  sometimes carried to a great  extent.  In the  case of a young
woman seized shortly after marriage with epidemic  dysentery, which proved
fatal, the dejections  contained an enormous amount of a black substance which
on investigation was found to  be from a species of slate-stone which she was
accustomed  to eat  daily in excessive quantity.  In some cases of pica  the
articles are at first taken  with  the idea of improving the complexion, and in
this way the habit is formed;  but in other cases a morbid uneasiness in the
stomach leads to their use.  The appetite is chiefly confined to females, espe-
cially young girls, and is generally associated with anamia or chlorosis.  The
measures  of treatment  are  to be addressed to  the associated disorders, the
continued indulgence of the perverted appetite  being  interdicted.
  Dirt-eating, as it is vulgarly called (chthonophagia), is a morbid habit which
heretofore prevailed to a considerable extent among the plantation  negroes
of the Southern  States.  It  was described  by  John  Hunter as  prevailing
among the negroes of the AVest Indies.  The kind of earth selected is a loam
or clay.  Duncan gives the following account of this form of pica : " A very
common disease among negroes  on  plantations  in  this  part of the country
(Louisiana) is a state of anaemia very often  attributed,  and perhaps  justly,
to the  pernicious habit of dirt-eating.   On examining negroes on a plantation
a medical  man is surprised  to  meet with so many of these cases.   Almost
every large  plantation has three or four, and sometimes more of them..... 
 454          FUNCTIONAL DISEASES  OF THE STOMACH.

 With many, no doubt, dirt-eating is a symptom only of a diseased condition
 of the digestive organs and of the system generally.   AVith them dirt-eating
 proceeds  from the same propensity which  leads white females  to  resort to
 chalk, magnesia, etc. in  order  to relieve a disordered .acrid condition  of  the
 stomach.   This condition of system is often, in  my opinion, produced by a
 deficiency of suitable nutriment."1
   Polydipsia is a term used  to denote a condition characterized by an excess-
 ive craving for liquids.   AVater is  drunk in a very large  or enormous quan-
 tity, amounting sometimes  to  several  gallons in the twenty-four hours.  In
 some cases the patient  experiences  constant or  frequently recurring  thirst,
 associated with dryness of the tongue and  fauces.  There is inability to sleep,
 except  for  short periods, in consequence of the urgency of  the desire  for
 drink.  The quantity of urine is proportionately great, so that  this condition
 is also denoted by a term expressing the latter fact—namely,  diabetes insipi-
 dus.  The urine voided is of low specific gravity, presenting a clear, limpid
 appearance like pure water,  and containing  neither sugar  nor  any abnormal
 constituent.   In  other respects the  health  may not  be notably disordered.
 The appetite and digestion  may be  unimpaired, the functions  generally are
 well performed, and the body does  not waste.  This  condition at first sug-
 gests to the physician the  probable existence of diabetes mellitus, but  an
 examination of the urine leads to the exclusion of the latter  disease.  The
 condition  may  occur  in early life  or become developed at any age.  It has
 been observed  to occur as an intermittent malady, but in general it continues
 for an indefinite period or during life.  It does not appear to lead to any dis-
 ease, and  is serious in itself only on account of the annoyance and debility
 which it occasions.   Its pathological character, with  our present  knowledge,
 cannot be  satisfactorily explained.   Existing to the extent just described, it
 is so rare  as to belong among the curiosities of  clinical experience.  In our
 ignorance of the  pathology there  are no  rational indications for treatment,
 and experience has not furnished any reliable means of cure.   Opium,  vale-
 rian, camphor, and other antispasmodics have  been  found to  diminish the
 thirst temporarily, and some benefit  has been derived from the use of various
 tonic remedies.
   Dipsomania, is a term sometimes used to  denote  the  peculiar delirium
 arising from the abuse of alcohol, but it is  commonly applied to  an uncontrol-
 lable desire for alcoholic  drinks.  A craving for  this class of  stimulants is
 sometimes developed  in cases of dyspepsia, and may prove a source of intem-
 perate habits.  This fact  has been already referred to.  It is  not to be lost
 sight of in judging of the propriety of prescribing or  sanctioning the use  of
 alcoholic  stimulants in dyspeptic cases.   A morbid  craving  for  alcohol  in
 some form is an element of intemperate habits whatever may have been their
 source.    The  habitual drunkard feels a desire for  continued indulgence,
 which, with an impaired power of self-control and lessened self-respect result-
 ing from intemperance, he is after a  time wholly unable to resist.   It is use-
 less under these circumstances to attempt to reason him into temperance ;  he
 may appreciate the force of  all  the  arguments which  are presented, but  he
 lacks moral strength enough to govern an acquired appetite which represents
 a morbid condition as  much  as the delusions of insanity.  Reason and per-
 suasion, however, may be effective  before this  condition  of dipsomania  is
 reached; that  is, they may prevent this condition by  leading  to  abstinence
from alcoholic stimulants.  Dipsomania  is to be  treated as a disease of body
and mind.   The cure is to be effected by withdrawing the patient  from the
use of alcohol in any  form, and by the employment of medicinal and hygienic
measures  to  invigorate the  physical and  mental faculties. The  treatment
                   1 Fenner's Southern Medical  Reports, vol. i. 
GASTRORRHAGIA.
455
must be continued long enough  for the cessation of the morbid craving for
stimulants and for the  development of moral strength sufficient to enable the
patient to adhere  to a course of total abstinence, in which  alone  consists
safpty.  It is evident that successful management is rarely practicable, except
by means of  institutions in which the patient is under the same restrictions
as in insane  asylums.   In fact, dipsomania is to be treated as a form  of men-
tal derangement.
  There  is a species of dipsomania which is constitutional and  congenital.
The desire for stimulants is paroxysmal, and an  irresistible craving is devel-
oped by any indulgence, however small.   Persons with this idiosyncrasy lose
their power of self-control as soon as they feel the influence of alcohol.  The
only protection in such cases is in rigid abstinence.
  Connected with the  subject  of dipsomania are questions pertaining to the
causes of intemperance and the means of its prevention which  are of the
utmost importance to the welfare of mankind, but which do not properly fall
within the scope of this work.    The morbid  effects of alcohol upon  the sys-
tem, aside from  the development of dipsomania, will be referred to in con-
nection with different individual diseases, especially those affecting the nerv-
ous system.


                           Gastrorrhagia.
  Hemorrhage into the stomach and vomiting of blood  are denoted by the
term hsematemesis.  The term gastrorrhagia is in uniformity with the rule of
nomenclature by which a hemorrhage and its situation are expressed, and is
therefore to  be  preferred.   Moreover, the term  gastrorrhagia applies to all
cases of gastric hemorrhage, whether vomiting take  place or  not,  the blood
sometimes not being expelled  by the mouth, but passing into the intestinal
canal and being evacuated from the bowels.  In the great majority of the
cases in which hemorrhage takes place into the stomach, blood is vomited,
and, more or less blood also passing into  the intestinal  canal,  the stools pre-
sent appearances to be described under the head of Enterorrhagia.
  AVhen  blood is expelled from the mouth the first point is to ascertain  the
source of the hemorrhage.   It may be from the mouth or posterior nares.
Coming directly  from either of these sources, it  is traced without difficulty ;
but if blood  be  swallowed and vomiting occur, it may sometimes be a ques-
tion whether gastric hemorrhage exist or not.   In cases of bronchorrhagia
blood may be swallowed and  vomited.   In  a child too young to expecto-
rate bronchial hemorrhage  might thus be supposed to be gastric.   Although
instances both of bronchorrhagia and of gastrorrhagia in  young children have
been recorded, such an  occurrence is very  rare.   The rupture of an aneurism
into the pharynx or oesophagus is another  source of  hemorrhage which  may
appear to be gastric ; but in general the question is whether the blood come
directly  from the  stomach or the air-passages.   The points involved in this
differential diagnosis have been  already  presented in treating of  bronchor-
rhagia.1   Blood which has been vomited  in most cases presents  a dark,
grumous  appearance.   Exceptionally it is  florid,  like arterial blood.   It then
comes from  an artery, and is vomited as soon as it accumulates within  the
stomach.
  Gastric hemorrhage in the vast majority  of cases has no claim to be regarded
as an individual affection.  It may be a symptom  of carcinoma of the stomach
or of gastric ulcer, and as such has been  already considered.  It is an effect
of portal congestion in  cases of cirrhosis of the liver and  of obstruction of the
vena porta from a thrombus or the  pressure of a tumor.  It may  be caused
                              1 Vide p. 261. 
456          FUNCTIONAL DISEASES OF THE STOMACH
 by aneurisms or by varices of the  gastric blood-vessels.   It coexists with
 hemorrhage in other  situations in cases of purpura hamorrhagica  and scor-
 butus.   It occurs in cases of acute gastritis, in acute yellow atrophy of  the
 liver, and in relapsing fever.  It is a prominent event in the natural history
 of yellow fever, the so-called black vomit in this disease denoting neither more
 nor  less than gastrorrhagia.   It may occur in  profound anamias and in
 malaria.  It may occur in place of the  menses in cases of amenorrhoea.
 Instances in which  gastrorrhagia is vicarious  are  by no means common ; in
 the majority of the cases in which it follows suppression of the menses it pro-
 ceeds from  disease of the stomach ;  yet that  it  may take the place of  the
 menses must be  admitted.  The cessation of habitual  hemorrhage in  some
 other situation, the arrest of purulent discharges of  long  standing, and  the
 healing of old ulcers have been supposed to stand occasionally in a causative
 relation to gastrorrhagia, but this  supposition does not rest on adequate clin-
 ical  proof.   Hemorrhage  sometimes occurs from  the stomach, as from  the
 bronchial tubes,  the  Schneiderian membrane, and other situations, without
 any  apparent pathological connections, neither following nor preceding any
 appreciable  morbid  conditions.  It is then to be considered as idiopathic or as
 constituting an individual  affection. Several cases have come under my obser-
 vation, one of which, with the hemorrhage extremely profuse, I have reported
 in another work.1 Examinations after death have shown the absence of ulcer-
 ation, erosions, or of any appreciable  solution of continuity, and  the hemor-
 rhage is then to be  attributed to diapedesis.  Hemorrhage from the  stomach
 is an occasional  event in pregnancy.  It  may be  caused by a contusion
 received on  the epigastrium.  Irrespective of its occurrence as a symptom  of
 gastritis, yellow fever, acute yellow atrophy of the  liver, purpura hamor-
 rhagica,  and scorbutus, gastrorrhagia occurs oftener in women than  in  men.
 It is a rare event in new-born children, occurring a few hours after birth, the
 blood being  vomited and  also passed from the bowels (melana neonatorum).
 It proves fatal in some of these cases.
   The prognosis in cases of gastrorrhagia will depend upon its pathological
 import.   The prognosis is of course unfavorable if it be associated with gastric
 carcinoma or yellow atrophy or cirrhosis  of the liver, although under these
 circumstances death is rarely an  immediate effect of  the loss of  blood.   If,
 however, the hemorrhage  be vicarious or not connected with any  appreciable
 morbid conditions, the prognosis, as a rule, is favorable.   The loss of blood in
 proportion as it is  considerable or large  induces debility, anamia, and may
 prove the direct cause of death.  The amount and rapidity of the hemorrhage
 may be such as to induce sudden death from syncope.  On the other hand,
 a vicarious hemorrhage if  moderate is not only without danger, but may con-
 duce to  the welfare  of the system so long as the  menstrual discharge remains
 suppressed.   In  determining the amount of hemorrhage it is to be borne  in
 mind that the quantity of blood vomited is  not always a criterion.   The blood
 may accumulate and  coagulate within the stomach without  being vomited.
 The hemorrhage may be sufficient to destroy life, although the quantity vom-
ited be not large.  Death may take place in such cases  as in cases of concealed
uterine hemorrhage after  labor.   Evidence of hemorrhage  being  out of pro-
portion to the amount of blood vomited is  afforded by dulness on percussion
over the distended  stomach and symptoms denoting  loss of blood—namely,
feebleness of  the pulse, coldness of the  surface, pallor, faintness, etc.  The
blood thus accumulating within the stomach if not vomited passes into the
intestines and is discharged by stool (melana).   Hemorrhage  into the stom-
ach has  been known to occur and death to take place from the loss of blood
 without  any vomiting.
                       1 Vide Clinical Medicine, p. 253. 
GASTR ORRHA GIA.
457
  The treatment of gastrorrhagia has been already referred to in connection
with gastric ulcer.  The general principles of  treatment, having reference to
the arrest of hemorrhage and the prevention of  its recurrence, are the same
under  whatever circumstances  it  occurs.   AVith reference  to these  objects
perfect rest of body and mind is important.   If the  hemorrhage be profuse
or if it recur, rest of the stomach should be secured by withholding from this
organ all nutriment and nourishing the patient exclusively by rectal alimen-
tation.  Alcoholics  if indicated are to be given hypodermically or per enema.
Opium is useful by quieting the peristaltic movements of the stomach.   It
should be given hypodermically.   The direct refrigerant effect of iced water
taken  in small quantities  at a time, or of swallowing small pieces of ice, is
useful.  In urgent cases, as a means of arresting the hemorrhage, ice may be
applied to the epigastrium.  In less urgent cases revulsive measures may be
relied upon—namely,  sinapisms  and  dry cups applied in different situations
over the abdomen.  Hot, stimulating foot-baths are useful  by way of revul-
sion.   Hamostatic  remedies, such as ergot, the acetate  of lead, tannic acid,
etc., if introduced into the stomach, are liable to excite vomiting and thereby
do  harm.   Ergotin  may be given  by hypodermic injection.   Purgatives  are
contraindicated.
  Experience has shown that transfusion  is likely to  cause  renewed  hemor-
rhage, so that this procedure should be resorted to in gastrorrhagia only when
there is imminent danger of a fatal termination  from the loss of blood; and
then only a small quantity should be  transfused.  The  infusion of physio-
logical salt solution is  safer than the transfusion  of blood, and is about as
effective.
  These measures are to be employed in individual  cases according to  the
urgency with which the arrest or the prevention of hemorrhage is indicated.
If there be ground for regarding the hemorrhage as vicarious, interference will
be  required only to keep  it within proper limits.  This statement will also
apply  to hemorrhage occurring in pregnancy.
  The treatment in most  cases of gastrorrhagia of  course embraces other
measures  than those  having reference to the arrest  and the prevention of
the hemorrhage—namely,  measures addressed to the  morbid conditions with
which  the  hemorrhage  is associated.   The latter are  considered under other
heads.  So  also  measures called for after the occurrence of  gastric  hemor-
rhage, having reference to debility and  anamia dependent on the  loss of
blood,  need not  be  here considered.   After a considerable  hemorrhage  the
stomach,  assuming  the  non-existence of  cancer  or ulcer, is  enfeebled, and
the liability to a recurrence of the hemorrhage is to be kept in view.   Care-
ful  regulation of the diet, quietude  of the body, and the avoidance of all
disturbing  agencies  are important during convalescence.   Although  profuse
or repeated hemorrhages  involve  more or  less immediate danger, patients
may recover  even when the loss of  blood occasions prolonged syncope and
extreme anamia.  Striking illustrations  of this  fact have come under my
observation.
  Gastric hemorrhage is sometimes simulated by hysterical females and by
malingerers among  soldiers and prisoners.   Blood obtained  from  animals,
and even human blood, may be  taken into the  stomach, and vomiting excited
by various  means.   This deception may be suspected in the case of a young
woman who manifests a morbid disposition to  impose on the credulity of
those around her as regards her ailments, when the symptoms do not denote
loss of blood, when  there  are no grounds, aside from hemorrhage, to suspect
gastric ulcer, and when the menses are  not suppressed.  Among soldiers and
prisoners it is to be suspected when the usual  effects of hemorrhage  are  not
apparent, and when  the  morbid conditions with which gastric  hemorrhage is 
458         FUNCTIONAL DISEASES OF THE STOMACH

usually associated are wanting.   The microscope may be of use in the detec-
tion of this kind of deception.   Bennett cites a case in  which a specimen of
blood which  it was pretended had been vomited was found to present the
characteristic  red  corpuscles of the blood  of a  bird.
  Leube mentions, as an occasional sequel of gastrorrhagia, double and per-
manent amaurosis, pallor of the papilla  and attenuation of the retinal  arte-
ries being  the only appearances revealed by the ophthalmoscope.   That the
amaurosis  is  simply an  effect  of anamia is disproved by the fact  that it
persists after  the anamic condition disappears.    He  therefore  infers the
existence of some  connection between  the  nerves and vessels  of the stomach
and certain parts of the brain—an inference sustained by the occurrence of
gastric hemorrhage after injuries to certain parts of the  brain.
                               Inanition.

   In connection with the functional affections of the stomach, I shall offer a
few remarks on a pathological condition which is not perhaps entitled to rank
in the nosological catalogue as an individual disease, but which is an element
of all diseases compromising alimentation and digestion.   The  pathological
condition referred to is inanition.   The importance  of a due appreciation of
this  condition in medical  practice  renders it  desirable to  devote to it some
attention, and it may with propriety be noticed in connection with the func-
tional affections of the alimentary canal.
   Health requires  the assimilation of nutriment adequate in quantity  and
kind  to  the wants of nutrition.  Every one is familiar with the mental  and
physical exhaustion  felt when  abstinence  is protracted for only a few hours
after the sense of hunger indicates  the need of food.  Every one knows that
the deprivation  of aliment for a period varying according to circumstances
proves  fatal.  During the progress of starvation the  body loses rapidly in
weight, the fat disappears, the muscles diminish in size, exhaustion progress-
ively increases, the heat of the body is lowered, vomiting and diarrhoea  not
infrequently occur, the mental  powers are weakened, listlessness and hebe-
tude  are sometimes followed by delirium  and coma, and, according to Chos-
sat, if the  deprivation of aliment be complete death takes place when one-
fourth of the  weight of the body at the time aliment was withheld has been
lost.   The mode of  dying is a type of slow asthenia.  It is worthy of note
that   during the progress  of starvation hunger is  not usually a prominent
symptom.  If felt for a time it is liable to disappear, and it may be followed
by a loathing of food.
  Inanition is a pathological condition entering into all diseases which inter-
fere with the  ingestion or the  assimilation of aliment.   The phenomena of
inanition in cases of these diseases are combined with the symptoms belong-
ing to the particular  disease which exists.   The inability of the system to
support, resist, and overcome disease  proceeds, in a greater or  less degree,
from  this element.   The immediate cause of death  in many cases of disease
proving fatal by slow asthenia is inanition ; that is to say, starvation.  These
are facts of great practical importance, and they are not sufficiently appre-
ciated by many practitioners of medicine.
  An important practical bearing of these  facts relates to alimentation in  the
management  of  diseases.   Until recently  for  many years not only was  the
importance of alimentation not fully recognized in  medical practice, but  the
dietetic treatment of most diseases contributed to  inanition.  The writings
of (rraves led to the employment of alimentation in fevers.  It is not less
important  in  all  other  diseases which tend  to destroy life by asthenia. 
INANITION.
459
Patients may be starved to death  in  other diseases as well as in fevers.   As
a practical rule, it is an object in any disease in which the danger lies in the
direction of asthenia to meet, as far as practicable by alimentary supplies,
the wants of nutrition.   Harm  may arise from the ingestion of food beyond
the powers of digestion, but no harm can arise from  an undue assimilation
of food; on the  contrary, the greater  the assimilation the less the danger
from  inanition superadded to the disease.   Let it be borne in  mind  that  in
all  diseases tending to destroy life by asthenia there  is  danger from  inan-
ition, but never from hypernutrition!   In the language of Chossat, "Inan-
ition  is a cause of death which marches silently  in front with  every disease
in which  alimentation  falls below the normal  standard.  It reaches its  natu-
ral termination sometimes sooner and sometimes later  than the  disease which
it covertly accompanies, and it may supersede  the disease of which at first it
was merely an incidental element."
   Alimentation is important in diseases not attended with immediate danger.
In proportion  as the assimilation of food can be  made to approximate to the
normal standard, the phenomena of inanition are  forestalled, the vital powers
are better enabled to tolerate and overcome the  disease, the duration of the
disease may be shortened, convalescence is hastened, and the recovery is more
likely to be complete.   As regards the  selection of food and the modes of its
preparation in different diseases, in addition  to dietetic rules based on general
experience, our knowledge of  alimentary  principles, etc.,  reliance may be
placed upon the desires and tastes of the patient;  but the absence of appetite
is not to be a guide as  regards alimentation.   Loss of appetite  is  one of the
symptoms of  inanition.  The wants of the  system are  not in  disease,  as  in
health, always expressed by hunger.   The  state  of the  mind  dependent on
the morbid  condition of the nervous system, the  coatings on the tongue, etc.
interfere with the desire for food and the sense of taste.   The  practitioner is
to exercise his judgment and tact in securing, as far as practicable, the assimi-
lation of an adequate amount of nutriment, either with or without the co-opera-
tion of desire and taste on the part of the patient, and it is often  better to incur
risk of exceeding rather than falling below the  quantity of food which the
wants of the  system seem to require.   It  may  be laid down  as a principle
applicable to the management of most acute diseases that the assimilation of
food to the  fullest practicable extent is important; and it is a maxim of con-
servative medicine that under all circumstances  a chronic affection is les,s
likely to be prolonged, serious lesions of structure  are less liable to take place,
and a fatal  termination is postponed, in proportion as  the vital powers are
maintained  by a nutritious diet.1
   Innutrition is not infrequently involved in the  causation of diseases.   The
connection between scarcity of  food and the prevalence of typhus has  been
repeatedly observed in  epidemics in  Ireland.   The same connection in  indi-
vidual cases and families is observed frequently  everywhere.   Scorbutus is
caused by  a  deficiency of certain  alimentary principles  or the  want  of a
sufficient variety in food. Insufficient nourishment, which is sometimes invol-
untary and  sometimes  voluntary, is  supposed  to favor the development of
phthisis in persons having the tuberculous predisposition.   This cause  may
co-operate with other causes in giving  rise to  various diseases, whether epi-
demic or sporadic ;  and the ability of the system to bear up under disease is
impaired in proportion as the powers of life are enfeebled by previous defec-
tive alimentation.

  1 A'ide " Kssavs on  Conservative  Medicine," by the author,  American Journal of the
Medical Sciences, January  and  October, 1863.  Vide, also, essay on "Alimentation in
Diseases," New  York Med. Journal,  1867, and the work  entitled Essays on Conservative
Medicine and Kindred Topics. 
460         FUNCTIONAL DISEASES OF THE STOMACH.

  AYant  of success in the  treatment of diseases in hospitals, and often in
private practice,  especially  among the poorer classes,  is  attributable in  no
small measure  to the want of adequate alimentation.
                               Gastralgia.

   Gastralgia, called frequently gastrodynia,  is a neuralgic affection charac-
 terized by pain, more or less intense, referred to  the region of the  stomach.
 Pain is a symptom of  gastritis, carcinoma of  the  stomach, and gastric ulcer;
 it also enters into the clinical history  of dyspepsia, especially  the variety
 called acute dyspepsia, and a peculiar character of pain constitutes the dys-
 peptic symptom called cardialgia or heartburn.  But, considered as character-
 izing a distinct functional  affection, the  pain  is not  necessarily incidental to
 inflammation or any appreciable lesion, nor is it always, although frequently,
 associated with dyspeptic disorder; in short,  gastralgia exists when pain and
 other circumstances denote an  affection of the same pathological character as
 neuralgia in other situations.
   Gastralgia is presented in  practice in two forms: in one  form a  severe
 attack of pain occurs,  and if not relieved by remedies it continues for several
 hours or even days.  The  pain is often  excruciating, subduing the strongest
 resolution.  The patient writhes and groans with intense suffering.   A sense
 of constriction frequently accompanies  the pain.   Vomiting may occur, but
 this is rare.  Generally,  tenderness over  the  epigastrium is  wanting, and
 some relief may be afforded  by pressure.    The paroxysm is not attended
 with pyrexia,  and the  skin may be bathed  in perspiration from the intensity
 of pain.  These attacks are generally attributed to  spasm or cramp, and the
 affection has been called colic of the stomach.  It is difficult to say how much
 of the suffering is due to spasmodic contraction and  how much to neuralgic
 pain.  Practically, it is not important to  make this discrimination.  This form
 of gastralgia may be distinguished as acute.
   Such attacks in some  persons are  produced by certain ingesta.   Straw-
 berries, for example, have  been known to prove in this way poisonous, and  I
 have met with a patient who had  always an attack after eating honey.  He
 came under my observation when  suffering from an attack  thus produced.
 These,  like other  idiosyncrasies,  are  inexplicable.   Attacks appear  to be
 sometimes attributable to exposure to cold and to fatigue from over-exertion.
   This form of gastralgia  is readily discriminated from acute gastritis.  The
 pain may be much more intense than  in cases of the latter disease.   As a
 rule,  the  tenderness over  the  epigastrium which belongs  to the history of
 gastritis is  wanting.   Vomiting  may  be wanting, and  if present is not  as
 prominent a symptom as in gastritis.   The absence of pyrexia is  an import-
 ant point  in the exclusion of gastritis.  The passage  of gall-stones, or hepatic
 colic, offers many symptoms in common,  and the discrimination is  not at once
 readily made.   The points involved in the differential diagnosis will be con-
 sidered presently in treating of the passage of gall-stones.   In the diagnosis
 of gastralgia attacks of angina pectoris are to be excluded. (Vide p. 360.)
   Although, as  a  rule, acute  gastralgia  occurs irrespective of inflammation
 or any appreciable lesion, it is sometimes  associated with either gastric  or
 duodenal  ulcer.   The  existence of ulceration is  liable to  be overlooked  if
 the diagnostic symptoms  be not marked.  This statement is, especially true
 of duodenal ulcer.  In several cases which have come under my observation
profuse hemorrhage has followed attacks of gastralgia.
  Attacks of severe gastralgia, recurring after interruptions of variable dura-
tion and accompanied by vomiting, are described by Charcot, under the name 
GASTRALGIA.
461
gastric crises, as associated with  locomotor ataxia.  They may be associated
with other affections of the spinal cord.1
  This form of gastralgia is to be treated by opiates carried to the extent of
procuring relief.   A quarter or a half of a grain of a salt of morphia may be
sprinkled on the tongue, and this dose repeated, if necessary, after the  lapse
of from half an hour to an  hour,  until  the pain is  relieved ; or the  same
course may be pursued with  other forms of opiate.  If the  opiate be rejected
from the stomach, it  may  be given per enema.   The  hypodermic  mode  of
administration is well suited to this affection, as to all  affections in which it is
desired to  produce quickly and efficiently an anodyne  effect.   This  plan  of
treatment is not to be deferred for the operation of a cathartic or an emetic
even if the attack be attributable to dietetic cause. A sinapism and fomenta-
tions to the epigastrium are useful as auxiliary measures. An alcoholic  stim-
ulant may be  added with advantage if not contraindicated by vomiting,  espe-
cially if  the pulse be feeble and  the surface cold.  Rest, regulated diet, and
a mild cathartic or laxative, provided  the  bowels do not act  spontaneously,
will  constitute the subsequent treatment.
  Although the  suffering  is as great as in any other affection, there is  little
or no  danger.   It may be doubted whether this affection  alone  ever prove
fatal ;  and the practitioner may  count with confidence on  procuring  speedy
relief by means of the plan of treatment just stated.   The affection, there-
fore, is one of those which exemplify in  a striking manner the resources of
medicine.
   Chronic gastralgia is another form of  the  affection.  The pain is either
limited to paroxysms which recur more or  less frequently,  or it  is habitual,
with exacerbations at variable intervals.   The pain varies  much in different
cases as regards intensity, and also in different paroxysms  or exacerbations
in the  same case.   It may have  so little intensity as to occasion only annoy-
ance, or it may be  so severe as to give rise to extreme suffering.  The cha-
racter of the pain is described by patients as burning, lancinating,  or gnawing.
Frequently the  pain  extends from the epigastrium in different directions—
namely, to the back, into the chest, and laterally into  the right and the left
hypochondrium.
  With the affection in some cases are associated  dyspeptic ailments, and in
other cases there is no disorder of digestion.   Paroxysms or exacerbations
sometimes  appear to be provoked by the ingestion of  food, but as a rule
relief of pain is  felt after eating.   The desire for food  is oftener increased
than diminished.   Generally, tenderness   over the epigastrium  is wanting,
and pressure  frequently affords relief.  The decubitus during the suffering
from  pain  is  sometimes upon  the  belly.    Constipation exists  much  oftener
than looseness of the bowels.   Flatulent distension of the stomach or intes-
tine is sometimes  associated.   The pulse  preserves its normal frequency and
the temperature  of the body is  not increased.  Patients who  have suffered
from  the malady for some time are likely to  become melancholic and hypo-
chondriacal.   I have known it  to be  associated with a tendency to suicide.
  Gastralgia rarely if ever occurs before the age of puberty or in old age.
It is generally considered that women, much more than  men, are liable to it,
but of 39 cases  analyzed by Aralleix only 20 were females.  It affects those
of good  constitution and the robust as well as the feeble and delicate.  Per-
sons of sedentary habits are more likely to be  affected than those engaged in
active  pursuits.   Prolonged  mental depression has been supposed to favor
its occurrence.  It appears in some cases to depend on  the  gouty diathesis.
Like neuralgia in other situations, it may be an effect of malaria;  and attacks
  1 Aride article on " Gastric Ulcer" by Prof. AYelch in the System of Practical  Medicine,
by American Authors, vol. ii. p. 517. 
462         FUNCTIONAL  DISEASES OF THE STOMACH.
of gastralgia may recur with the regularity of the paroxysms of intermittent
fever.   I have known gastralgia to take the place  of the  cold stage  of  the
paroxysm, being followed by the hot and the sweating stage.  Finally, causes
which  induce anamia or lead to debility may be  more or less  involved in its
production.
  The diagnosis of the  chronic form of gastralgia is to be based on certain
distinctive characters—namely, the occurrence of pain, either in paroxysms
or marked exacerbations ; the  relief frequently afforded by pressure and  the
ingestion of food;  the persistence of appetite in  many cases; and not  infre-
quently the absence of disorder  of digestion and of pyrexia.   These  points
in the  history are involved especially in  the discrimination of gastralgia from
subacute or chronic gastritis.  The  diagnosis involves the exclusion of gastric
ulcer and cancer.1  These  affections are to be excluded by the absence of their
diagnostic symptoms, irrespective of pain.   In some cases of intercostal neur-
algia pain is referred to the epigastrium.  This affection is excluded by the
absence of its diagnostic criterion—namely, tenderness on pressure over three
points, posteriorly,  laterally, and anteriorly.2
  Chronic gastralgia is likely to be persisting.  Its duration in different cases
is extremely variable.  In this  respect it resembles other neuralgic affections.
It may continue for many months,  and it sometimes persists for many years.
As regards  prognosis, the  worst to be  apprehended is the persistence  of
the  aff'ection.  It does not tend  to  destroy life either directly or by eventu-
ating in some other  more serious disease.   It is not prudent for the practi-
tioner  to predict that the affection will  end speedily  or within  any definite
period, yet not infrequently it does not continue.   In  certain cases  it is one
of the affections most rebellious to  therapeutical measures,  but in other cases
it is readily amenable to treatment.
  In the treatment of gastralgia clinical experience has abundantly shown
certain measures formerly in vogue to be not only ineffectual, but prejudicial.
This remark has reference to general and local bloodletting, emetics, mercu-
rials, purgative remedies,  and perhaps also vesication or other modes of active
counter-irritation.  Anodyne remedies are frequently called for to relieve pain.
If the pain be severe, opium  can  hardly be dispensed  with; but in this, as
in other painful  affections which are likely to be persisting, the liability to
the  formation of  a  habit of using opium is to be  considered.  Moreover, the
use of opium, aside from the palliation of pain,  is objectionable  on account
of its interference with the appetite and digestion, and  in  this  way it may
contribute to perpetuate the  affection.   Opium is therefore  to be used with
circumspection, and when practicable other palliative measures are to be sub-
stituted, such as  belladonna, hyoscyamus, etc.  Fomentations and  embroca-
tions containing  opium, chloroform,  aconite, etc. will sometimes succeed in
affording relief.  Cold applied to the epigastrium has been found  effectual.
Certain remedies appear  in some cases  to  exert  a curative influence.  Bis-
muth is one  of  these.   I have known large doses of this  remedy to  be
promptly curative.   Monneret  advises  it to  be given  to the  extent of one,
two, or three  ounces  daily.  These enormous does are not required.  AVhat-
ever curative power the remedy has will  be exerted in doses  of from  a scruple
to a drachm three or four times daily. Alum has  been recommended in doses
of from  ten to twenty grains three or four  times  daily.   Strychnia and nux
vomica have been found useful, especially if the  affection be associated with
the formation of gas.  A quarter of a grain of the extract of nux vomica may
be given three or four times  daily.   Other remedies which may be employed
  1 For the points involved in the differentiation from gastric ulcer, vide System of Prac-
tical  Medicine, by American Authors, vol. ii. p. 516.
  2 Vide p. 183. 
A C UTE  D YSENTER Y.
463
with a view to a curative effect are the nitrate of silver and the subcarbonate
of iron (precipitated carbonate or sesquioxide), given in drachm  doses, and
the iodide of potassium, as in  other neuralgic affections.   Another remedy is
the purified oxide of manganese in doses of from five grains to half a drachm
three times daily.   Of curative remedies, in my experience, quinia in full doses
is most likely to prove successful.  The doses should be  sufficient to produce
cinchonism, which should be steadily maintained for about two weeks.   If at
the end of this time a curative effect be  not exerted, it is useless to continue
the remedy longer.   Although  it often  succeeds,  it not infrequently fails.
After quinia,  arsenic, given in small doses and continued  without increase
of dose, has been, in my experience, the most successful remedy.   Salicin, a
drachm or more given daily, is sometimes curative.   In the  hands  of Leube,
Beard and Rockwell, and others electricity has proved efficacious.   The  con-
stant current is the form to be employed.
   Measures of treatment other than the employment of direct curative rem-
edies are of importance.  Change of habits from those of sedentary to active
life is of the first importance in certain cases. The moral influence of recrea-
tion, change of scene, etc. is often of more service than medicines.   The diet
should be nutritious.  It should not be  restricted.   Alcoholic  stimulants  in
moderation  with  meals may be advised  for a  time, exercising that reserve
dictated  by the danger of  patients becoming addicted to their habitual use.
Tonic remedies in most cases,  continued  steadily for a long period  and varied
from time to time, are advisable.   The valerianate of zinc may be mentioned
as a tonic remedy likely to prove useful.  Preparations of iron are especially
indicated if anamia be present.   Dyspeptic  ailments which may or may not
be associated are  to  receive appropriate treatment.  In short, the object, aside
from the  employment of palliative  and  curative remedies, is to endeavor to
place the digestive organs  and the system in the best possible condition, and
for this  end hygienic and medicinal measures  are to be adapted  to the  cir-
cumstances peculiar to individual cases.
                        CHAPTER  V.

       INFLAMMATORY  DISEASES  OF  THE INTESTINE.

Anatomical Characters of  Acute Dysentery.—Sporadic Dysentery.—Epidemic Dysen-
  tery.—Chronic Dysentery.—Inflammation and  Perforation of the  Caecum.—Fecal
  Abscess.—Inflammation  and Perforation of  the A'ermiform  Appendix—Colitis.—
  Proctitis.—Acute Enteritis.—Subacute and Chronic Enteritis.

                         Acute  Dysentery.
   THE term  dysentery  has long been in use to designate an  inflammatory
    disease of the large intestine characterized by mucous and bloody dejec-
tions and by tenesmus.  As a name for the disease it is not very distinctive,
its etymology simply expressing intestinal difficulty ;  but it  is not easy to
substitute a term  conformable to  the nomenclature of inflammatory-affec-
tions, as there is no anatomical name for the large intestine as a whole.  The
term dysentery has the advantage of not  expressing anything erroneous or 
464      INFLAMMATORY DISEASES OF THE INTESTINE.

doubtful in regard to the pathological character of the disease.   Acute and
chronic dysentery claim  separate consideration.  Acute dysentery occurs as
a sporadic and as an epidemic disease.   This is a distinction of much clinical
importance.   After having considered the anatomical  characters of sporadic
and  epidemic dysentery, these two forms of the disease will be treated of
separately as regards clinical history, pathological character, etc.

  Anatomical Characters.—After death from acute dysentery the mucous
membrane of the large intestine is in a condition either of simple muco-puru-
lent  or of diphtheritic inflammation.  Anatomically, therefore, the disease is
distinguished as simple inflammatory—or, as it is also called in accordance with
German  nomenclature, catarrhal  dysentery—and as diphtheritic  dysentery.
Most of the cases of sporadic dysentery are of the simple inflammatory variety,
which is the milder of the two varieties.  The largest number of cases of diph-
theritic dysentery belong to the epidemic form  of the  disease.  The anatom-
ical, however, cannot be used interchangeably with the clinical  terms.  Diph-
theritic dysentery may  occur sporadically, and  epidemic dysentery usually
includes a large number of cases of the simple  inflammatory variety.   There
are, moreover, all grades  of transition between the mildest cases of simple in-
flammatory dysentery and the most malignant cases  of diphtheritic dysentery.
It is not always possible during life to distinguish between simple and diph-
theritic inflammation of the large intestine.  For these and  other reasons it
is most convenient to  treat of the clinical history of acute  dysentery under
the headings  Sporadic and Epidemic Dysentery, but to describe the anatom-
ical appearances first of  simple and  then of diphtheritic inflammation of the
large intestine.
  Dysentery  in the acute simple (catarrhal) variety is  a simple inflammation
of the inner coats of the large intestine.  The inflammatory process is usually
more intense  in certain situations  than in others.  The parts most involved
are the cacum, the hepatic and the splenic flexures of  the colon, the sigmoid
flexure and the rectum.   These are  the parts where the contents of the large
intestine remain longest in contact with the mucous membrane.  The inflam-
mation often, although not invariably, increases in  degree  toward the lower
end of the large intestine.   The  lower part of the ileum is also frequently
involved in the inflammatory process.
  The mucous membrane is reddened, softened, and swollen.  The redness is
usually in patches, and is most intense  in the  situations named.   The color
varies  from   light  pink  to  dark,  livid red.   The redness  is due chiefly to
hyperamia, as is evident from the arborescent appearance, especially marked
when the intestine is examined by transmitted light.   In addition  to conges-
tion, however, there are  usually extravasations  of blood in the mucous  and
submucous tissues  in the form either of  punctate  or  of diffuse ecchymoses.
It may happen that a congested  appearance is not evident  after  death, as
may be the case in inflammation of other mucous membranes.   The surface
of the mucous membrane is covered with  a layer of tenacious  mucus, either
colorless or of a yellowish or brownish-red  hue from admixture  of bile  and
blood.   Sometimes the admixture of pus  is sufficient to give  an opaque,  yel-
lowish color  to the mucus.   The mucus  contains, microscopically, pus-cells,
red blood-corpuscles, and desquamated epithelial cells.  Both the mucous mem-
brane and the  submucous tissue are swollen, the latter often in  the greater
degree.   This swelling is due to  congestion, together with the exudation of
serum and of pus-cells.   The  solitary follicles  are usually swollen, and they
appear as grayish-white projections about the size of a  pin's head, surrounded
by a zone of  congestion.   They may become as large as a small pea.   Some-
times the inflammation seems to be chiefly  in the follicles. The disease is then 
ACUTE  DYSENTERY.
465
sometimes called follicular dysentery.   If there  have been repeated  attacks
of acute dysentery, or if the acute passes into a chronic stage, the mucous
membrane becomes more or less pigmented.   Points of dark pigment appear
in the centre of the solitary  and of the agminated follicles.   In Peyer's
patches this pigmentation gives rise to the so-called shaven-beard appearance.
The pigment is chiefly in the form of brown  granules in the lymphoid  cells.
Diffuse patches and streaks  of slate-colored  or  brownish pigmentation may
appear outside of  the follicles in the mucous  membrane, especially in the
large intestine.  Small follicular  ulcers, due  to softening and breaking  down
of the follicles, are often observed  in acute dysentery, especially in the fol-
licular variety. The peritoneum over the parts most inflamed may be normal
or it may be  coated with a layer of fibrin.
   Microscopical examination  shows the small  veins and capillaries of the
mucous membrane and of  the  submucous tissue,  particularly  of  its upper
layers, distended with blood.  In some places there may be only hyperamia,
but as a rule there is distinct evidence of inflammation.   This is afforded by
the presence  of pus-cells.  The pus-cells are  particularly abundant near the
muscularis mucosa (Briicke's muscle), just below the glands of Lieberkiihn,
where there  is normally a  rich network of blood-vessels.   The pus-cells are
frequently  observed in  swarms around the small veins.   There  are also pus-
cells in the mucous membrane between the glands of Lieberkiihn ; but as the
connective  tissue in this situation is of the variety called adenoid, which nor-
mally is densely infiltrated with lymphoid cells, it is difficult to determine
here the presence of a moderate number of  pus-cells, as these  anatomically
resemble the lymphoid cells.  If the pus-cells accumulate in large number,
they press  apart and distort the glands of Lieberkiihn.  The enlargement of
the solitary follicles is  due to an increase in the  number of lymphoid ele-
ments.  These infiltrate the surrounding submucous  tissue.   In addition to
the emigration of  white corpuscles more or less  red corpuscles escape by dia-
pedesis.  The larger hemorrhages are the result  of rupture of the vessel-
walls (rhexis).  The spaces between the fibres of the submucous  tissue are
distended  by the  presence  of serum (adenia).   As  already said,  the  accu-
mulation of lymphoid cells may be sufficient to compress the  tubules  of Lie-
berkiihn.   In this way the tubules may be obstructed in  certain  parts.   They
may undergo cystic dilatation below the seat  of obstruction. Most of the epi-
thelial cells  lining the tubules are distended  with mucus, and they  appear as
so-called goblet or caliciform  cells—forms which are  normally very frequent
in the large intestine. The fate of the columnar epithelium covering the inner
surface of the mucous membrane is uncertain.  As under normal circumstances
this epithelium soon desquamates after death, its absence from its normal place
in inflammation cannot be considered evidence of its separation during life. It
is not probable that extensive desquamation of the epithelium occurs during
life.
   The description  which has been given of the histological changes in  acute
simple inflammation  of the intestine in dysentery is applicable to the same
variety of  inflammation in other conditions, as in acute enteritis.  It is espe-
cially the involvement of the lower part of the  large intestine in the inflam-
matory process which characterizes acute dysentery.  As is evident from the
description, there  are no changes in acute simple dysentery which may not
undergo resolution, with the exception  of the  follicular ulcerations, which
are by no means always present, and which  may readily cicatrize.   More or
less  pigmentation  and  atrophy of the mucous  membrane usually remains
after  an attack of dysentery.
   Some writers describe a more severe form  of purulent inflammation than
that to which the name  simple inflammatory dysentery has been given.  In
       30 
466      INFLAMMATORY DISEASES  OF THE INTESTINE.

this, excessive suppuration occurs and ulcers are formed by destruction of the
superficial layers of the mucous membrane.   Follicular ulcers are present at
the same time.
  Dysentery with diphtheritic or pseudo-membranous exudation is a much
graver disease than  the simple inflammatory variety.  It is  called diphthe-
ritic, not on account of any connection with diphtheria of the pharynx, but in
consequence of the resemblance between its lesions and those  of diphtheritic
inflammation of the throat.   It is also called fibrinous (croupous) dysentery,
and corresponds in its more severe manifestations to the putrid and gangren-
ous dysentery  of  the old writers.   Diphtheritic inflammation of  the large
intestine is  characterized  by the presence of an exudation containing  fibrin,
blood, and  pus-cells upon the surface and in the substance of the mucous
membrane, combined with sloughing and consequent loss of substance of the
mucous membrane.  A large number of cases of epidemic dysentery are of
this  type, but it may also occur sporadically.
  According to Arirchow, diphtheritic dysentery is always preceded by simple
inflammation of the  large intestine.  Others  believe  that the inflammation
may be  diphtheritic from  the onset.   However this may be,  diphtheritic
inflammation is very  frequently combined with  simple  inflammation.  The
morbid changes are usually, as  in  simple inflammation, most  marked in the
cacum, the flexures, and the rectum, and they affect by preference the project-
ing folds of the mucous membrane.  The inflammation is often most intense
in the sigmoid flexure and the rectum, and it may be confined  to these  parts.
Sometimes the rectum escapes.   In other cases the  inflammation is uninter-
rupted from the beginning to the end of the large  intestine.  In the lower part
of the ileum  simple inflammation is frequently  present,  but  there is rarely
diphtheritic inflammation.  In the early stages of the diphtheritic process the
inner surface of the large intestine presents here and there patches of gray-
ish-red, yellow,  or variously discolored material, of  varying  thickness and
extent, usually soft, but  sometimes firm.  This  pseudo-membranous deposit
consists of an exudation of fibrin, pus, and blood involving the upper layers
of the mucous membrane.  It extends in depth and destroys  the vitality of
the invaded tissue.  The mucous  membrane and often the subjacent tissues
slough.  In this way the so-called  diphtheritic  ulcers are produced, which
may extend only in part through the mucous membrane, or they may expose
the submucous tissue and even the muscular coat of the intestine.   By fur-
ther extension of the sloughing process the wall of the intestine  may be per-
forated and a fatal peritonitis induced.  This occurrence is infrequent.  The
diphtheritic ulcers  are irregular in shape, their walls being bevelled or abrupt,
in some cases overhanging.  Sometimes little openings appear in the bed of
the ulcer, which lead into dilated tubules of Lieberkiihn.  The ulcers may be
so extensive that the undestroyed  mucous membrane  appears  in  the form of
scattered islands rising from the surrounding depressions.  The mucous mem-
brane may slough away in little shreds or in larger coherent masses, sometimes
several inches in extent.  In advanced cases the inner surface of the intestine
—with the ulcerations, the pseudo-membranous deposits, the ridges of mucous
membrane, the partially detached sloughs, all of various colors and consistence
—presents a peculiarly variegated appearance.   Enlargement  of the follicles
and  follicular ulcerations may likewise be present.   The submucous tissue,
where preserved, is usually much swollen and infiltrated with blood  and pus.
Submucous abscesses may form and undermine the mucous membrane.  The
peritoneal covering of the inflamed portion of the intestine is congested and
is frequently coated with fibrin.   Thus, circumscribed and sometimes general
peritonitis  may occur, agglutinating the coils of intestine.
  The microscopical examination shows sometimes distinctly fibrillated fibrin, 
SPORADIC DYSENTERY.                    467
enclosing  red  blood-corpuscles, pus, and epithelial cells, as a firm layer upon
the surface of the mucous membrane, extending into the glands of Lieberkuhn
and infiltrating the substance of the  mucous membrane.  Frequently, how-
ever, the pultaceous deposits on  the inner surface of the intestine present lit-
tle evidence of structure, but consist of a mass of granular material, low vege-
table organisms, and decomposed blood.  In the sloughs of mucous membrane
careful  inspection may reveal traces of the  glands of  Lieberkuhn.  These
glands,  when  preserved, often  present  constrictions  and cystic  dilatations.
These cysts may invade the solitary follicles.  In the submucous layer a net-
work of fibrin  appears in the dilated interstices of the connective tissue, espe-
cially in the lymphatic vessels.  Hemorrhages  and pus-cells are  abundant.
Bacteria are frequently  observed in  the coats  of the intestine and in  the
pseudo-membranous deposits.  It is difficult to assign  to these and the other
forms of low organisms observed here any pathological significance, as they
are normally  present in large number  in  the  feces,  and as decomposition
rapidly  attacks  the sloughy masses  in  dysentery.  Coagulation necrosis is
probably an essential element in the  pathology of diphtheritic  dysentery, as
of fibrinous inflammations of mucous membranes in  general.
   AVhen the sloughing process involves the mucous membrane of most of the
large intestine death is almost inevitable.  Less extensive diphtheritic ulcer-
ations may cicatrize.   Granulation-tissue  develops from the surface  of the
ulcer.  (For the repair of ulcers, see Part  I. p. 39.)   The  cicatrix is com-
posed of dense fibrous tissue, covered with epithelium but without glandular
elements.  The cicatrix is usually puckered, and  it causes some contraction of
the surrounding tissue.  Sometimes, but not frequently, stricture of the intes-
tine, followed  by grave and even fatal symptoms, is produced by the contrac-
tion of  these cicatrices.  The healing of these ulcers  is  slow and is attended
by the  symptoms of chronic dysentery.
   Of changes  in other organs of the body occasionally observed in diphtheritic
dysentery, abscess of the liver deserves especial  mention.  This is a frequent
complication in  tropical  climates.  It is not frequent in this climate, but it
seems to be oftener observed here than in Great Britain  and  on  the continent
of Europe. The abscesses are usually multiple.  They are explained by the
transportation of infectious  emboli  derived from thrombi in the mesenteric
veins proceeding from  the diseased  intestine.   The  mesenteric glands are
usually swollen, and they may suppurate.  Pulmonary complications,  such
as pneumonitis and oedema, are  frequent.   Parenchymatous  degeneration of
the kidney and occasionally acute diffuse  nephritis  occur.1

   The foregoing account of the  anatomical characters  is of course descriptive
of appearances observed  in fatal cases of sporadic and epidemic dysentery.  It
is to be added that in either form the disease is not infrequently so mild as to
involve no danger, and hence in mild cases the opportunity of inspecting the
parts after death is not offered.   There  are  but few diseases in the nosology
which offer a wider contrast than the mildest cases of sporadic and the gravest
cases of epidemic dysentery.

                        Sporadic Dysentery.

   Clinical History.—Dysentery is generally preceded by simple diarrhaa ;
that is, more  or  less  frequent and loose dejections of  a feculent character.

  1 An exhaustive consideration of the pathology and of other subjects pertaining to the
natural history of diarrhoea and dysentery is given by  Woodward in the second medical
volume of the Medical and Surgical History  of the War of the Rebellion, AVashington,
1879. 
 468       INFLAMMATORY DISEASES  OF THE  INTESTINE.

 Of 33 recorded cases which I have analyzed with reference to this point, these
 dejections preceded the characteristic dysenteric evacuations in 30.   The lat-
 ter appeared after the former had  existed for  a  period varying from twenty-
 four  hours to seven days.1   AVith this  prodromic diarrhoea there are  colic
 pains, the appetite is impaired, and there is a  general feeling of malaise.  A
 pronounced chill rarely occurs, and even  chilly sensations are not common.
   The various ingredients which may enter into the composition of dysenteric
 stools are—feculent matter, mucus, blood, pus, serum, pseudo-membranes, necro-
 tic tissue, bacteria together with  other low organisms, and undigested aliment.
 According to the preponderance  of one or more of these substances  the stools
 are described as mucous, muco-purulent, muco-sanguineous, sero-sanguineous,
 sanguineo-purulent, gangrenous, bloody, or purulent. The presence of pseudo-
 membranes and of necrotic portions of the intestinal coats is characteristic of
 the diphtheritic form of inflammation.  The other ingredients are common to
 both  varieties of inflammation. The development of the disease is denoted by
 characteristic evacuations  consisting of mucus, with which more or less blood
 is usually commingled.    The quantity passed at each  act  of defecation is
 generally small, but the act is repeated at short  intervals, slight evacuations
 often  taking place every hour or  two, and sometimes a few moments only
 intervening.   The mucus is discharged in the form  of clumps of a  yellowish
 or reddish glairy material, sometimes  without feces  and sometimes around
 balls  of feces.   The quantity of  mucus expelled  in some cases is abundant,
 and forms a jelly-like mass not unlike a collection of the rusty sputa of pneu-
 monitis.   Microscopical  examination of the mucous  discharges shows cells
 resembling the white blood-corpuscles (called often, in this situation, mucous
 corpuscles, but in no  way differing from pus-cells), red blood-corpuscles, bac-
 teria, and  sometimes  cylindrical  and flattened epithelial cells.  The  mucus
 itself is characterized by its viscid nature, and  by its precipitation with  acetic
 acid in the form of threads and flakes of  mucin insoluble in  an excess of the
 acid.   AAlien the mucous or  pus-corpuscles are present in large  number the
 substance  acquires an opaque whitish or yellow appearance, and  is called
 muco-pus.  The  blood  may give a diffuse or a streaky red color  to the  dis-
 charges.   After the characteristic dysenteric stools appear, feculent matters
 are usually entirely absent.  These may, however, appear, at intervals, espe-
 cially in the form of hard  balls of  feces called scybala.   AVhen improvement
 begins feculent matters appear in  the  stools.  In mild cases the discharges
 may remain mucous throughout  the whole  course of the disease.   In severe
 cases  of sporadic (and frequently in epidemic) dysentery the discharge of a
 sero-sanguinolent liquid occurs.   The serous fluid is very rich in albumen, of
 which large  quantities may be  precipitated, after  filtration, by nitric acid.
 The amount of albumen is much greater  than  can  be accounted  for by the
admixture of blood.   It is  the result of exudation of the  blood-plasma.   The
characteristic stools of diphtheritic  inflammation of the large intestine consist
of a sero-sanguineous fluid containing small morsels of pseudo-membranous and
necrotic tissue.  These morsels have been compared to raw minced meat, and
the yellowish-red fluid containing them was called by the older writers lotura
carnium.    The microscopical  examination of these  shreds and particles  fre-
quently shows only a mass of decomposing granular matter and bacteria min-
gled with  blood-corpuscles  and perhaps indistinctly fibrillated fibrin.  In other
specimens the fibrin  may be  more distinct.  The examination of a  sufficient
number of specimens will usually bring to view some  in which fragments of
the tubules of Lieberkuhn can be recognized, and thus  is demonstrated the
origin  of these particles from necrosed  intestinal mucous membrane.  These
stools  emit a peculiarly offensive,  cadaveric odor.  Less frequent  than  the
  1 Clinical Report on Dysentery, based on an analysis of 49  cases, by the author, 1853. 
SPORADIC DYSENTERY.
4G9
presence of these small shreds is the discharge of large fragments of necrosed
mucous membrane.  These may be several inches in length.  The stools con-
taining them are dark in color, have a putrid odor, and are called gangrenous.
The tubular pseudo-membranous casts which  have been described by  some
writers  are  composed of inspissated mucus.  They are very rarely observed
in dysentery, but are present in a rare form  of enteritis called membranous
enteritis, muco-colitis, or tubular diarrhoea.   Bacteria are present in dysenteric
stools in enormous number.   Fungus-spores and  infusoria  are  also observed.
The stools may consist almost wholly of  blood or  they may be  chiefly pur-
ulent.   Little transparent clumps resembling granules of boiled sago or frogs'
spawn have been seen in dysenteric stools.   According to many writers, they
consist of masses of mucus moulded into a round form in follicular ulcers.
According to A:irchow, they are colored blue with iodine, and are, in  reality,
undigested granules of starch.  AVoodward also considers  them to be of a
starchy nature.   Dysenteric  stools are usually alkaline in  reaction, and are
said to  contain  carbonate of ammonia.
   The inflammation of the rectum occasions a sensation as if this portion of
the bowel were filled, and leads to the freq-Uent desire to defecate, with as much
straining as the  soreness of the parts will  allow.  This disposition to strain
ineffectually is called tenesmus.  Sometimes the straining efforts produce pro-
lapsus of the intestine.   The evacuations  are frequently preceded by griping
or colic pains which are called  tormina.  The tormina and tenesmus are not
proportionate to the gravity of the disease.  They  are sometimes wanting in
fatal cases, and are prominent symptoms in some mild cases.  They are, how-
ever, the chief sources of suffering.  Tenderness on pressure is in some cases
more  or less marked over the descending colon and  sometimes over the whole
tract of the large intestine.  It is rarely great, and not infrequently is wanting.
Meteorism or tympanitic distension is rarely present.  The abdomen is usually
depressed.   Strangury and retention  of urine are occasional symptoms, and
in the female leucorrhaa may be produced.  Redness and excoriation around
the anus may  be produced  by the irritation of the dejections.   Perineal
abscess is an occasional result of an extension of the inflammation.  Intus-
susception, with the symptoms of ileus, sometimes  occurs in children.
   The pulse  in the majority of cases is but little,  and sometimes not at all,
accelerated.   The body-heat is but moderately or slightly increased.   Excep-
tionally, high febrile  movement  exists.   The  thermometer may show an
increase  of  temperature to  103°  or  104°.  Great frequency  of the  pulse
always denotes gravity and danger, but the converse does not hold good.  In
some fatal cases the  pulse is never much  accelerated.  The tongue may be
frosted or more or less coated, or it may present a natural appearance.  Dur-
ing the course of  the disease the appetite is sometimes more or less diminished
or is  lost.   Thirst is usually present, and  is  sometimes urgent.   Vomiting
occasionally occurs, and may be prominent  as a symptom, the matter vomited
being of a greenish  color.  The intellect  is unaffected, as a rule, delirium
occurring with  great infrequency in cases which end  in recovery, but  occa-
sionally, in cases which prove  fatal, being present  toward  the close of life.
The loss of strength  varies greatly in  different cases according to the inten-
sity and extent of the local affection, depending also on the condition of the
patient when attacked.
  The duration of the disease from the date of the attack to  convalescence
varies from  four to twenty-one days.  These  figures represent the minimum
and maximum duration in thirty  recorded cases.

  Pathological  Character.—Our present knowledge of the pathology of
sporadic dysentery embraces only the intestinal aff'ection, the local and gene- 
470      INFLAMMATORY  DISEASES OF THE INTESTINE.

ral phenomena which make up the clinical history being symptomatic of this
affection.   The pathological character of the intestinal  aff'ection  is the same
in the sporadic as in the epidemic form  of the disease.
  AVriters  have described different varieties of the disease, distinguished as
typhoid, bilious, intermittent and remittent, febrile and non-febrile, etc.  These
terms denote  either variations in the  phenomena of the disease or the coex-
istence  of  other diseases.   Dysentery may occur as  a  complication  of con-
tinued and of periodical fever.   Rheumatism and dysentery are occasionally
associated.   These combinations are important in their practical relations, but
it does not follow  that  the disease under these circumstances is  specifically
different from  its  ordinary form.   Arariations as regards febrile movement,
supposed disorder of the liver, etc. do not affect the special character of the
disease.   Paralysis affecting certain muscles, especially the muscles  of the
lower limbs (paraplegia), has been observed in some cases  to either accom-
pany or follow dysentery ; and different theories have been proposed to  explain
a supposed  pathological connection between the paralytic and the dysenteric
affection.   The truth is, the affections are so rarely connected that their asso-
ciation is probably a mere coincidence.

  Causation.—No  age is  exempt from liability to this disease,  but  in the
majority of cases  the patients  are adults  and less than thirty-five years of
age.  A larger number of males than females are  attacked, but the pre-
ponderance  is not sufficient to  show  that  a marked predisposition relates to
sex.  The  causation  has a very obvious relation to  climate.  The disease is
much more  frequent, in the sporadic as well as in the epidemic form, in trop-
ical than in cold and temperate climates.   The causation has also a striking
relation  to  season.  Of 44 cases  which  I  recorded, all  save 1 case occurred
in July, August,  September,  and October.   The constitution and previous
health were good in  one-half of the cases  which I have analyzed, and in the
remaining  half there was no uniformity in  character  as regards the  antece-
dent affections or disordered health.
  AVriters  have been accustomed to state  that the disease may be produced
by various obvious causes, such as atmospherical changes, excess in  eating
and drinking, indulgence in acid, unripe  fruits, crude vegetables, etc.; but
in the majority of cases its origin cannot be traced to these causes or to any
obvious cause.   This renders it probable that a special cause is involved in
sporadic as well as in epidemic dysentery.   The  limitation of the occurrence
of the disease  to  the summer and autumnal season, and its  more frequent
occurrence in tropical climates, point to this conclusion and to the agency of
a high temperature  in the evolution of the  special cause.   Persons who are
in good  health and  vigorous are as  likely to be affected as those who are
feeble.  Various  circumstances standing in  a causative relation  to the dis-
ease in  an  epidemic  form may  also be involved in its production  when it is
sporadic.   These  causative circumstances will be  noticed  in  treating of
epidemic dysentery.

  Diagnosis.—The diagnosis of dysentery involves no difficulty.  The  charac-
teristic evacuations are  pathognomonic.  It is to be discriminated from  cases
of bloody evacuations and  irritation of the  rectum incident to hemorrhoids.
intestinal hemorrhage or melana, and the  discharge  of pus from  an  abscess
opening into the  intestine.   The points  of  contrast with dysentery  which
these  cases offer are sufficiently  apparent.

  Prognosis.—Sporadic dysentery in temperate  climates tends to recovery.
It is  a  distressing disease, but is attended  with  little danger  to life.  A 
SPORA DIC D YSENTER Y.
471
 fatal result is due either to an unusual intensity and extent of the local affec-
 tion, to an inability of the system to resist the disease from feebleness of con-
 stitution, or to some coexisting affection.   The prognosis in tropical climates
 is less  favorable.  The recovery from the disease in temperate  climates is
 almost  always complete;  that is, it rarely eventuates  in  chronic  dysentery;
 nor  does it predispose  to any  other disease.   In tropical climates abscess of
 the  liver is not an infrequent sequel.   This very rarely follows in temperate
 climates.   So far as my experience goes, immediate relapses are not likely to
 take place, and the occurrence of the disease  diminishes  the  liability to its
 occurrence at a subsequent period.   AVith reference to the latter point, my
 analysis of cases, although the number, was not large, developed an interest-
 ing  result.   Of the cases  recorded during fourteen years, in  not a  single
 instance was  the disease known to  recur;  and  in  16 of these  cases  the
 patients were under observation  after recovery during periods  varying from
 one  year to thirteen years.  This result was the more  striking from the fact
 that the  patients for  several years were within  the sphere of an epidemic
 influence which in some instances affected other members of  the same fam-
 ilies.

   Treatment.—Sporadic dysentery is a self-limited disease, and in the great
 majority of cases would  end in  recovery without medicinal treatment.  In
 order to study its  natural history I allowed the disease in 10 cases to pass
 through its course without any therapeutical interference.  These were spo-
 radic cases of average severity.  They ended  in recovery after an average
 duration of from eight to nine  days.  An analysis of 49 cases  previously
 recorded, in which different methods of treatment were employed, gave about
 the  same duration in the  cases ending in recovery.1  These observations  are
 sufficient to establish the  self-limitation of sporadic dysentery and its intrinsic
 tendency  to recovery—facts  which, so far as I know, had not been  before
 demonstrated  by withholding all medication  in a series of cases; but  there
 is reason to believe that  the  disease is sometimes arrested, that its duration
 may be frequently  abridged, and that  the  distressing symptoms may be
 greatly  relieved  by judicious therapeutical measures.
   It is  desirable that as early  as possible the fecal  contents  of the  large
 intestine should  be effectually removed, in order  to  prevent their continued
 passage over the  inflamed surface, and to secure so far as may be that import-
 ant end in  the treatment of all inflammations—namely, rest of  the inflamed
 part. It  would  seem  that nature endeavors to relieve  the bowels of their
 contents by the diarrhoea  which precedes the dysenteric evacuations.   The
 first  point in  entering on the  treatment  is to ascertain  if the  bowels have
 been spontaneously relieved.  AVith  reference  to  this  point  the size and
 character of the  stools are to be ascertained and the abdomen  examined by
 palpation.   In  general, it is  advisable to render the  effort of nature  more
 complete by giving an effective purgative.  Castor  oil has been in  much
 repute as an appropriate remedy, but, aside from the  objection on the  score
 of the disgust which many persons have  for this remedy, the saline cathar-
 tics  are to  be  preferred.   The sulphate of magnesia or soda,  the Rochelle
 salts, or the citrate of magnesia may be employed.   The saline  selected
 should be given in sufficient doses to promptly produce abundant  dejections,
 and it is then to be discontinued.  It will  sometimes happen that after free
 purgation the dysenteric evacuations do  not  return and  recovery at once
 ensues.   This abortive effect takes place only in some  cases  in which the
  1 A'ide  "A  Contribution toward the Natural History of Acute Dysentery,"  in  the
 Am. Jnurn. of Med.  Sriruces. July, 1S7-"), and a clinical report  based on analyses of 49
cases, in the Buffalo Med.  Jaurn., July, Aug., Sept., and Oct., 1853. 
 472       INFLAMMATORY DISEASES OF THE INTESTINE.

 inflammation is not intense  and is limited in its extent.   Notable diminution
 of the frequency of the dysenteric evacuations and relief of the tormina and
 the  tenesmus not infrequently follow the operation of the saline purgative.
 This treatment may be pursued except in cases in which  it is contraindicated
 by great feebleness of the patient.   In these cases castor oil is the purgative
 to be preferred.
  Another method of effecting the removal of the contents  of the large intes-
 tine deserves  mention—namely, the  employment of large  injections.   More
 than a century ago O'Beirne demonstrated that a flexible tube can be passed
 into the sigmoid flexure, and in this way a large quantity of liquid injected
 into the colon.   He advocated  the  employment of this method in dysentery
 and  other  affections.  Under the name irrigation (Darmeingiessungen) this
 method has been recently revived, and it is recommended  on the basis of clin-
 ical  experience especially by two German writers, Hegar and M osier.1  By
 means of a tube carried into the sigmoid flexure several quarts of liquid may
 be injected. By the writers just named the injection is made through a funnel
 elevated sufficiently for the requisite force from  gravitation.   The  object is
 to remove fecal accumulations and all irritating matters.  By this  method
 also  medicated liquids may be brought into contact with the inflamed surface.
 The  method claims trial sufficient to determine whether it can advantage-
 ously take  the place of saline or other cathartics in the treatment of dysen-
 tery, and also to what extent the topical application of medicated liquids may
 be employed with  advantage.   The injections may be repeated  two or three
 times daily.  They are  made more effectual  if the patient be placed in the
 knee-and-elbow or  the knee-and-shoulder posture, but if the patient be feeble
 the decubitus may be on the back or side.  Davidson's syringe will probably
 answer as well as,  if not better than, the elevated funnel.   In order to intro-
 duce as much water as is practicable  and desirable, it should  be introduced
 slowly, intermitting  the  injection for a  few  moments from time to time.
  After purgation, opium in some form is the remedy most to be relied upon.
 A full dose of opium administered  by enema or  as a suppository will some-
 times succeed in arresting the disease.   It often mitigates  the severity of the
 disease and affords marked relief.  Administered by the rectum, however, it
 is not always retained, and then reliance must be had upon its administration
 per  os or hypodermically.   It  may  be given in full doses repeated every
 four, six, or eight hours, or in smaller doses repeated at shorter intervals.
 As regards the form of opium  selected, I believe this is chiefly important in
 respect to the preference or peculiarity of the patient.  I have seen the opium
 in gum or powder, the various  liquid preparations,  and the salts of  morphia
 equally effectual.   The form found to be preferable is to be continued during
 the progress of the disease, the doses being  regulated by the frequency of
 the  evacuations and the suffering. Experience in each case is to  be the guide
 as to the mode of administration.  Generally,  the administration by the mouth
 and  rectum alternately is advisable.  The opiate remedies  are to be gradu-
 ally  diminished as the dysenteric evacuations become less  frequent and the
 suffering from tormina and tenesmus is less.  After two or three days, if the
 disease continue, the saline purgative may be repeated, if  not contraindicated
 by the feebleness of the patient,  and afterward the use of opium resumed.
  In this  plan of  treatment the  reliance is upon free purgation  and opium.
 The  chief reliance, I believe, should be upon  these measures, but other meas-
ures may be conjoined.  The subnitrate or the  subcarbonate of bismuth in
scruple or half-drachm doses, the acetate of lead, the sulphate of copper, gal-
lic acid, and the various vegetable astringents, such  as rhatania. kino, catechu,
hamatoxylon, etc., are useful  as adjuvants.  These are to be relied upon, to
              1 Deutsches Archiv fur klin. Med., 1875, Bd. 15, p. 233. 
SPORADIC DYSENTERY.
473
the exclusion  of opium, in  those  cases  only in which, from a constitutional
peculiarity, the latter  produces unpleasant effects sufficient to preclude its
employment.  It is  undoubtedly  true  that  some  persons are  affected  so
unpleasantly by opium  that its use is, if possible, to be avoided; but  it is
often the case  that it is well borne in  this and some other diseases, although
it  may not be  in  trivial affections.   Certain  preparations of opium  may be
well borne, although  others occasion unpleasant effects.   An  aqueous solu-
tion or  extract is frequently taken without  difficulty by those  who  cannot
comfortably take other preparations.  Codeia  sometimes answers well  as  a
substitute for the preparations of opium  and morphia.
   Dr. Q. C. Smith of Texas recommends belladonna as an adjunct to  opium,
and as a substitute when the latter remedy is not well borne.  His  recom-
mendation is based on a large personal experience and on  the testimony of
physicians in his neighborhood. He has found belladonna especially useful in
cases  occurring in childhood, in view of the fact that opium  must be given
to  children  with more caution than to adults.
   Ipecacuanha has been considered a valuable remedy in dysentery.  Some
have  attributed to it a special curative influence, and  have advocated its
employment in as large doses as can  be  borne.   Maclean states  that the
system of treating acute dysentery generally followed in  India is as follows:
Thirty drops of the  tincture of opium may be at first given, but this  may
be sometimes omitted  and the ipecacuanha given at once.   If the opiate be
given, in half  an  hour it is to be followed by from  25 to 30  grs. of  ipecac-
uanha.  The latter remedy should be given in as small a  quantity of fluid as
possible, and a little syrup of orange-peel  covers  the taste of the medicine.
The patient after this dose should keep perfectly quiet and abstain from  fluid
for at least three hours.  AVith these precautions nausea and vomiting are
rarely troublesome.    After eight  or  ten hours the ipecacuanha may be
repeated in a  reduced dose, observing the same  precautions.1   If required,
the treatment is to be continued for several days, the remedy being given in
diminished doses, with intervals sufficient to allow mild nourishment to be
taken.  He cites statistics showing the mortality in  India under the use of
ipecacuanha to be 28.87 in 1000, whereas under the old system the mortality
was 88.2  in 1000.  It is to be borne  in mind, however,  that the old  system
of treatment included bloodletting  and the free  use of mercury.    I  have
resorted to this  plan of treatment  in  a  considerable number  of cases  at
Bellevue Hospital, but  without very satisfactory  results.   In a small pro-
portion  of cases  the  disease was either arrested or was  favorably modified
by it, but in the  majority of cases  it had no apparent influence on the dis-
ease.
   Mercury has been  heretofore much  relied  upon  in  the  treatment  of this
disease, given   either  in  large doses, united with opium in order to prevent a
cathartic effect, or in  small doses repeated at short intervals.  The recovery
in  cases treated  with mercury is of course no proof of  its value, inasmuch
as sporadic dysentery tends intrinsically to recovery.  The duration  of the
disease, the relief of the symptoms, the rapidity of convalescence, and the
subsequent condition  of health are the points to be considered in estimating
the influence of remedies in this disease.   AVith  reference to these points  a
fair estimate of the effects of mercury has led to its rejection by most prac-
titioners in this country as a remedy for dysentery.
   During the  early part of the disease the  diet should  be  restricted  to  a
small quantity of the blandest articles of  food.  It  is an object throughout
the disease to keep the patient on a diet which will leave but little residuary
matter to pass into the large intestine: in other words, a diet as purely nutri-
      1 A'ide article on dysentery  in A System of Medicine, edited by Eeynolds. 
474      INFLAMMATORY DISEASES  OF  THE INTESTINE.

tious as possible.   After the first  few days, however, it is important to pro-
vide for proper support of the system by nutritive supplies, and for'this pur-
pose milk and animal broths are best suited.  If the symptoms denote failure
of the vital  powers, alcoholics are to be given, as in all diseases which destroy
life by asthenia.   Tonic remedies  may be given with advantage during con-
valescence.
   Patients should be instructed to refrain as much as possible  from repeated
acts of defecation and straining efforts.   Cold applications to the anus some-
times relieve  the tenesmus.   A piece of ice may be wrapped in cloth and
applied frequently in this situation.   Enemas of cold water are often  grate-
ful.   Relief in some cases is  afforded by injecting astringent  liquids.   The
nitrate of silver,  a solution of  tannin, acetate of lead, or the sulphate of zinc
may be thus used.
   Fomentations  and  mild revulsive  applications over the abdomen are use-
ful as palliatives in  proportion  to the amount of tormina and abdominal
tenderness.

                        Epidemic  Dysentery.

   Epidemic dysentery is essentially the same disease  as sporadic dysentery.
Certain events occur much oftener  in the former than in the latter,  yet there
is nothing pertaining to  the epidemic which is not occasionally seen  in the
sporadic  form of the  disease.  Epidemic dysentery is often very fatal, yet in
the epidemics  attended with the largest fatality cases occur which are as mild
as the mildest sporadic cases, and on the other  hand occasionally in sporadic
cases life is quickly destroyed. Like other diseases which prevail epidemic-
ally, this differs  greatly at different times and places as  regards gravity, and
at certain times  and places it  presents features which it does not present at
other times and  places.   The differences between the epidemics of this dis-
ease are  in  a  measure to be explained by the coexistence of other diseases,
and  by the  conjoint operation of morbific  causes  not standing in  a special
relation to the production of this affection.  In treating of epidemic dysen-
tery the  main object  will be to point out  the  circumstances in  which  it is
likely to differ from  sporadic  dysentery.
   With respect to the anatomical  characters, they are essentially the same
as in cases  of sporadic dysentery.   In fatal cases of either form the varied
appearances which have  been stated  may be found.   Extensive and  disor-
ganizing  changes occur  oftener in  epidemic  dysentery.  As  a rule, in the
latter the inflammation extends over a larger portion of the  large intestine,
and it sometimes  extends into  the  ileum.   Ulcerations and diphtheritic exu-
dation are much more likely  to occur in epidemic dysentery.  Perforation of
the intestine  is  sometimes a result of ulceration, giving rise to peritonitis.
Perforation  of the cacum may take  place in this disease, leading to abscess
in the areolar tissue  beneath  the  peritoneum or fecal  abscess.   Perforation
of the rectum and fecal abscess in that situation have been known to occur.
  The clinical history of epidemic differs from that of sporadic dysentery
according to differences as regards the extent and severity of the local  affec-
tion, and also according  to various morbid conditions  due  to  the action of
accessory causes,  the  latter co-operating oftener in epidemic than in sporadic
cases.  Severe cases  of epidemic  dysentery are characterized  by the occur-
rence of  sero-sanguinolent dejections, the lot lira earuium of the older writers,
containing  usually pseudo-membranous and necrotic particles in more or less
abundance,  and   holding  in  solution a large quantity  of albumen.  Hence
epidemics of dysentery are popularly known  as bloody  flux.   Dejections of
this character  always  denote gravity of disease.  Tormina and tenesmus may 
EPIDEMIC DYSENTERY.
475
 be less prominent as symptoms in severe cases of epidemic than in most cases
 of sporadic dysentery.   In some fatal cases these symptoms  are  entirely
 wanting.  Tenderness over the tract of the colon may or may not be  marked.
 The local symptoms in some cases of epidemic dysentery are comparatively
 slight, and  in general, so far as my observation goes, patients suffer  far  less
 in fatal cases than in  sporadic  cases  wholly devoid  of  danger.   Nausea  and
 vomiting occur oftener in the epidemic than in the sporadic disease.   In  epi-
 demic dysentery albumen and casts in the urine are occasionally observed.
   The differences, as regards the general symptoms, in diff'erent epidemics  and
 in different cases are marked.  Severe  cases are characterized by prostration,
 feebleness of the circulation, coldness of the surface—in short, by symptoms
 denoting adynamia.   The pulse may become frequent,  small, soft, and vibra-
 tory but compressible, or it may be small,  weak, and thready, with but little,
 and sometimes not any, increase of frequency.  These characters of the pulse,
 denoting feebleness of the action of the heart together with other adynamic
 symptoms, are developed in some cases early in the  disease, without  having
 been preceded by active  febrile movement; but in other cases the pulse for a
 time is full and strong, the  skin hot, the adynamia succeeding these symptoms
 of high fever.   In fatal  cases a condition analogous to the stage of  collapse
 in epidemic cholera may precede, for a variable period,  the termination of the
 disease.   In this  condition the pulse is scarcely appreciable or it is extinct;
 the surface is cold, and either  dry or  bathed  in perspiration ;  the teeth  are
 sometimes covered with sordes; the quantity of urine is greatly diminished ;
 cramps of the muscles of the  lower  extremities sometimes  occur; and this
 collapsed condition may  exist for one, two, or three days before death.  The
 mode of dying  is by  slow asthenia.
   The intellect  generally either  remains intact or slight  mental aberration
 occurs only in the  latter part of life;  but some cases are characterized by
 delirium.  The  patient talks incoherently  under  the influence  of transient
 delusions; he may attempt to get out of bed, and requires to be restrained.
 In a case which came under my observation the delirium was of a boisterous,
 mirthful character, the patient singing snatches of humorous songs, shouting,
 and attempting to get  out of bed, after the pulse had become extinct  and  the
 surface of the body was  cold like that of  a cadaver.  In this case the mani-
 festations of delirium were so painfully incongruous that the patient was kept
 under the influence of  chloroform for several hours before  his death.
   The delirium and other  symptoms  in some cases are analogous to those
 belonging to typhus and  typhoid fever.  The typhoid state  may exist in cases
 of this  disease as in various other affections.   But  it is to be borne in mind
 that dysentery sometimes occurs as a local complication of typhus and  typhoid
 fever.   Certain epidemics of these fevers are characterized by the occurrence
 of this complication.   The distinction  between dysentery with typhoid symp-
 toms, or typhoid dysentery, and typhus or typhoid  fever  with  a dysenteric
 affection developed secondarily, is the  same as between  typhoid pneumonitis
 and typhus or typhoid fever complicated with pneumonitis.  The symptoms
 of scorbutus are associated with those of dysentery when, as is sometimes
 the case, the latter prevails among persons who are suffering from scorbutic
 deterioration of  the blood.   So in  districts where periodical  fevers  prevail,
 epidemics of dysentery may be  characterized by periodicity as regards febrile
 movement, etc., due to  the union of dysentery with intermittent or remittent
fever or the conjoined operation of the special  cause  producing the latter.
   The  duration  of  the disease  in cases of epidemic dysentery is very vari-
able.  In malignant epidemics  the  disease  sometimes runs very rapidly to a
iatal is.sue, the collapsed  condition  occurring perhaps in the course of a few
hours.   On the other hand, cases may be protracted to  the third and fourth 
 476       INFLAMMATORY DISEASES  OF  THE INTESTINE.

 week before either convalescence or death takes place.   As  already stated,
 epidemics  differ widely as regards the severity of the disease.   In some epi-
 demics  the majority of cases are mild and the rate of mortality is very small,
 while in other epidemics the proportion of deaths is very large.   The latter are
 justly  distinguished as malignant.   There  are few  epidemics more  to be
 dreaded than those of malignant dysentery.   They occur much  oftener in
 tropical than in temperate climates,  but there is no part of the world exempt
 from their occasional occurrence.  Epidemic dysentery is one of the scourges
 of camps  in time  of war, especially  if to causes operating particularly on
 armies  tropical  influences be added.   It prevailed to a very great extent in
 the  late civil war in this  country among  the  national  and  the insurgent
 forces,  especially in the Southern States, and it was  often associated with
 phenomena referable to malaria.1
   Epidemic dysentery is an infectious disease.  The special cause is the same
 in epidemic and in sporadic dysentery.  Reasoning  analogically, this  special
 cause is a specific micro-organism.   The various agencies which appear to
 give rise to the  disease, such as exposure to atmospheric  vicissitudes, fatigue
 and  hardships incident to army life, insufficiency of diet, overcrowding, mala-
 ria, etc., probably act as co-operating causes,  rendering the system more sus-
 ceptible to the  dysenteric poison and  giving rise to other morbid phenom-
 ena  than those which  the  special cause would alone produce.  Epidemics
 would  perhaps not often occur were  it not  for the operation of accessory
 causes; hence  the rationale of their occurrence in camps, in prisons, and in
 situations where numbers are exposed to hygienic influences conducive to the
 development of  any disease.  With respect to the source of the special  cause
 of dysentery or the conditions under which  it is  generated and diffused we
 have at present no positive knowledge.   The contagiousness of epidemic dys-
 entery  has been a much-mooted  question.  Without entering into any  dis-
 cussion of this question I shall content myself with saying that the evidence
 of cominunicability rests mainly on the  successive  occurrence of a greater
 or less  number of cases  among members  of one household,  or in  persons
 who from  proximity of residence  are brought into contact with each other;
 and  the diffusion of the disease under  these  circumstances may perhaps be
 satisfactorily accounted for by the fact that the persons  attacked are alike
 exposed to the special cause together with the same co-operating causes.   It
 is, however, proper to state that some distinguished authors suppose that the
 intestinal excreta contain a virus by means of which the disease may be com-
 municated.   That the virus is a contagium vivum has not as yet been proved
 by the discovery of a special micro-organism  and the production of the  dis-
 ease by inoculation.  Whether the disease be communicable or not, there are
 instances which seem to afford  evidence that the special cause may be trans-
 ported by means of clothing, etc.
  The opinions of different  writers and  practitioners concerning the treat-
 ment of dysentery, especially as an epidemic, show great diversity, and there
 is abundant testimony of the success of measures quite opposite in  charac-
 ter.  The fact just stated shows  either that the recoveries were due mainly
 to  an intrinsic tendency of the disease, or  that the disease is presented at
 different times and places under different  pathological  phases, and  the meas-
 ures of  treatment  require to be correspondingly varied.   Both explanations
 are doubtless measurably applicable.   Sporadic dysentery  as a rule, and epi-
demic dysentery in a certain  proportion  of  cases, tend  intrinsically to recov-
ery.  Recovery under these circumstances takes place, whatever be the  treat-
ment, provided it be not destructive.  On the other hand, in a certain pro-
  1 Aide  AVoodward, second medical volume of Med.  and  Surg. History of the War of
the Rebellion, AVashington, 1879. 
EPIDEMIC DYSENTERY.
477
portion of cases of epidemic dysentery the disease  must, of necessity, end
fatally.  The extent of mucous surface affected, the loss of fluids by hemor-
rhage  and transudation, and the destructive lesions which take place preclude
recovery under  any treatment;  but it is also true  that the diff'erent  features
which the disease assumes in  different epidemics, and the  various  morbid
conditions  with which it  may  be associated, must more or less influence
therapeutical measures.
   Purgatives, especially of the saline  class, may  be as appropriate  in  epi-
demic as in sporadic dysentery;  but they should be given  cautiously or omit-
ted if sero-sanguinolent dejections occur  or if the  symptoms denote much
tendency  to  adynamia.  Theoretically,  it  would seem that the removal of
the fecal  contents of the  intestine  would  be more  safely effected by large
injections (irrigation) than by  saline  purgatives.    It  is  very desirable to
arrest or moderate the dejections just named, for these  doubtless conduce to
the condition of collapse into  which patients are liable to fall.   For this pur-
pose  opium  is to be  given  in  as large doses  as are required or as are well
borne, in  conjunction  with astringent  remedies, such as gallic  acid, acetate
of lead, the  persulphate or pernitrate  of iron, rhatany, etc.  I believe the
main reliance should  be  placed on opium in some form in these cases, other
remedies being considered as auxiliary.   The latter, therefore, are not to be
employed as substitutes for opium  except  in cases in which, from a consti-
tutional peculiarity, this remedy in any form produces such distressing effects
as to contraindicate its use.  It  should  not be decided that opium  cannot be
tolerated on  the assertion of the patient, but  only  after a fair trial.
   In this disease,  as in some others, there is frequently a wonderful tolerance
of opium—a tolerance not to be  explained by the antagonizing influence of
pain, since it is manifested in cases in which pain is not a prominent symp-
tom.   Christison,  in stating this fact, adds that he has known from 24 to 30
grains of the gum of opium to be taken in the course of twenty-four hours.
I have given 2  grains hourly in the case of a female  affected  with dysen-
tery characterized by abundant sero-sanguinolent  dejections, for  the space
of a week, without at any time symptoms  denoting narcotism.   I  have  met
with a case  exemplifying  a still  greater  tolerance of this remedy.   In  this
case, the patient not being habituated to the use of opium before his  illness,
the quantity of the sulphate of morphia given hourly was gradually increased
to one grain, making 24 grains in the twenty-four hours, and this quantity
was  given  for several consecutive days without any narcotism.  Opium is
not to  be given as a matter of course in doses approaching these, but it is to
be given with a  view to the desired  end—namely, the arrest of the sero-san-
guinolent dejections; and if this  effect  be not obtained the doses are to be
increased to the amount which will be borne without narcotism, be the amount
never so large.   It is hardly necessary to say that in increasing  the dose the
condition of  the patient is to be carefully  watched; and. attention is to be
directed to the pupils  and  to  the number of respirations, as well  as to  the
soporific state, in  order to avoid a cumulation which may result  unexpect-
edly in narcotism.   The quantity of opium which may with prudence  and
propriety be  given in  dysentery will vary greatly  according  to  the  varying
tolerance in  different cases.
  In proportion as the symptoms denote a  tendency to death by asthenia, the
powers of life are  to be supported by alcoholics and nourishment.  The gen-
eral principles which should govern the employment  of supporting measures
are the same  as in  other affections which in like manner tend  to destroy life
by exhaustion.   Alcoholics  are sometimes tolerated in  large  quantity in
severe  cases of this disease.  I have  known over 40 ounces of brandy to be
taken in  twenty-four hours by  a  patient who in health was not accustomed 
478      INFLAMMATORY DISEASES OF THE INTESTINE.

to the use of ardent spirits, and  this large quantity produced no excitation
of the circulation or nervous  system.  This patient was  saved apparently
by the persevering use of alcohol with large doses of the sulphate of mor-
phia.   I have  repeatedly seen patients  recover  under the vigorous employ-
ment  of supporting measures, conjoined with opium in large doses,  when,
as judged by the symptoms, the  condition appeared  to  be truly desperate;
yet of the cases  properly distinguished as malignant many must die, despite
the faithful  employment of the measures on which the chief reliance is to be
placed.
  Dysentery associated with phenomena denoting the operation of the special
cause of periodical fever calls for  treatment having reference to the latter, in
addition  to  the measures addressed  to the dysenteric affection.   Quinia is a
highly important remedy  in these  cases.   Associated  with  scorbutus, the
dietetic and  remedial  measures appropriate  to this condition  are indicated.
Occurring as a complication of the continued fevers, it furnishes an additional
indication for the supporting measures which  these fevers claim irrespective
of the dysenteric complication.   Coexisting rheumatism calls for the addition
of the remedies appropriate for this disease.


                        Chronic Dysentery.

  The anatomical basis of chronic dysentery  is chronic  inflammation of the
large  intestine, with or without ulceration.   The  term, however, is sometimes
applied to  cases of functional diarrhoea, and on the other hand the term
chronic diarrhoea is often applied to cases of chronic dysentery.   The distinc-
tion between chronic diarrhoea  and chronic dysentery is usually based  upon
the character of the stools.  It is impossible, however, to draw a sharp bound-
ary-line between the two processes.   AYoodward even takes the ground that
no distinction is admissible.  He says :*  " The results of any attempt to sub-
divide these cases into chronic diarrhoea  and chronic dysentery in accordance
with  the presence  or absence of  tenesmus or of mucus, muco-pus, pus, or
blood  in the stools, or any other clinical evidence with which I am acquainted,
would not be found to correspond with any anatomical classification."  He
therefore includes  under the name  chronic  diarrhaa all the  chronic alvine
fluxes with  the exception of those  resulting from tuberculous ulceration
of the intestine; but,  as in many other processes  which cannot be sharply
separated from  each  other, it is here convenient  to  retain the old names,
although the assignment of certain cases to one class or to the other may be
more  or  less arbitrary.   Typical  cases of chronic diarrhaa, however,  are
sufficiently distinguishable from typical cases of  chronic dysentery.
  Chronic dysentery very  rarely occurs  in this climate, save as a sequel of
acute  dysentery.  Recovery from  the latter  does not take place, but the in-
flammation becomes chronic, or more commonly  ulcerations which take place
during the  acute affection do  not cicatrize,  but continue for an indefinite
period.   Acute exacerbations often occur in the  course of chronic dysentery.
Acute dysentery, however,  very rarely eventuates in  the  chronic form of the
disease in temperate climates, and hence chronic  dysentery is rare in  these
climates.  It is otherwise in warm climates.   Here the chronic often follows
the acute affection.  Chronic dysentery in tropical climates may also  begin
insidiously without an  acute attack.   Chronic dysentery thus prevails chiefly
in tropical countries or among those who have contracted dysentery in these
countries.  In the Northern States of the Union the cases observed are, for
the most part, imported from the South.  Of the soldiers who returned from
  1  AVoodward, second medical vol. of the Med. and  Surg. History of the War of the
Rebellion, AVashington, 1879, p. 483. 
                         CHRONIC DYSENTERY.                     470

the war in Mexico, large  numbers were affected with this disease, and during
the late civil war cases were abundant among the soldiers sent to the Northern
military hospitals from different points in the Southern States.
  The lesions observed in chronic dysentery are the result of inflammation of
the mucous and submucous coats of the large intestine, with or without ulcer-
ation.   Chronic inflammation without ulceration  presents  an appearance in
many respects similar to that already described for acute simple inflammation
of the large intestine.  Instead of bright red, the color of  the mucous mem-
brane  is more frequently bluish-red, or some  hue due to the deposit of dark
pigment, as brown, slate-color, or ash-color.   The  pigmentation may be both
in the follicles  and in the  mucous  membrane outside  of the folliclevS.   The
mucous and submucous  tissues are thickened,  usually more in  some places
than  in others.  The wall of  the  intestine  often  feels stiff and  hard.   Its
calibre may be diminished.   The mucous membrane may present many small
elevations lying close to each other and producing the so-called mammillated
appearance.  In rare cases  large polyp-like excrescences, consisting of hyper-
plastic connective tissue containing  glands and covered with columnar epithe-
lium, are produced, and may be present in large number (enteritis polyposa).
Sometimes  little projecting cysts, varying in  size from a pin's head to a pea
and containing clear mucus, are observed  beneath the  mucous  membrane.
These are formed by the dilatation  and coalescence of the tubules of Lieber-
kiihn.  They generally occupy the  site of the solitary  follicles.   As pointed
out by Cornil, and  especially by Kelsch,1 the solitary follicles in  dysentery,
particularly in cases with follicular  enlargement and ulceration, are not infre-
quently invaded by distension  and  new growth of the adjoining tubules of
Lieberkuhn.  The thickening of the mucous and submucous coats in chronic
dysentery is due partly to infiltration with  new cells and partly to  new for-
mation of connective tissue.    There is, however,  less tendency  toward the
development of new fibrillated connective tissue  in chronic  dysentery than
in the chronic  inflammation of most mucous membranes.   Hence, complete
recovery is  possible  after  long duration of the disease.   In some cases of
chronic dysentery enlargement and ulceration of  the solitary  follicles  are
very  prominent, and constitute  almost  the  sole  lesions.    Such  cases  are
called follicular inflammation  or  follicular  dysentery.  In  many of these
cases the  growth of the glands of Lieberkuhn into the follicles  has  been
observed by Kelsch and  by AVoodward.   Swelling and ulceration of the fol-
licles, however,  frequently occur without any such growth.2
  The ulcers which may occur in  dysentery are of three  kinds:  first, follic-
ular;  second, non-follicular or simple  (catarrhal); and  third,  diphtheritic.
These varieties are often combined.  The follicular ulcerations are the result
of softening and breaking down of the swollen solitary follicles, either in their
centres or at their apices. The ulcer at first presents a little, round, constricted
opening, as  if punched out, leading into an irregular cavity in the mucous or
submucous  tissue.   It extends peripherally more rapidly in  the  submucous

  1 Archives de Phys. norm, el path.,  1873, pp. 406 and 573.
  2 Kelsch  (loc. cii.) describes a form of dysentery prevalent  in tropical  countries in
which embryonic or granulation-tissue develops in the mucous membrane and obliter-
ates most of the  glands of Lieberkuhn.  Portions of these glands undergo cystic dis-
tension and  invade the solitary follicles.  Embryonic cells collect in especially large
number about Briicke's muscle and infiltrate also the submucosa.  The disease begins
insidiously, and, unless acute attacks occur, no ulceration takes place  If there be an
acute attack, the  accumulation of  pus-cells about the  vascular plexus  beneath  the
mucous membrane becomes so great as to shut off the nutritive supply to the  tissue
above, and gives rise to sloughing of the mucous membrane. Kelsch denies that a fibrin-
ous or diphtheritic exudation ever occurs in dysentery;  but his  observations are based
upon an insufficient number of cases. 
480      INFLAMMATORY DISEASES OF THE INTESTINE.
than in the mucous  coat, and hence often presents overhanging edges, even
when of considerable size.   By extension and coalescence of these follicular
ulcers  large losses of substance in the inner coats of the intestine  are pro-
duced,  ulcers unconnected with the follicles are formed by  dense infiltration
of the mucous membrane with pus-cells.  By softening and molecular disin-
tegration  of the  intercellular  substance, first in the upper  layers,  superficial
ulcers are produced.  These extend in depth  and in superficies by continuance
of the purulent  infiltration  and by  liquefaction  of the basement-substance.
These ulcers  possess no  very distinctive characters.   They resemble closely
those produced by diphtheritic sloughing. The method  of formation of diph-
theritic ulcers has already been sufficiently described under the head of Acute
Dysentery.   AVhen the fibrinous exudation and the sloughing process disap-
pear, these ulcers extend by the same process of suppuration as the preced-
ing. 'They usually present abrupt or  sloping edges, but may have undermined
walls.  In fact, when dysenteric ulcers  attain to a large size, it is generally
impossible to tell in what  way they have originated.  Any of these ulcers
may extend in deieth so  far as to perforate the intestinal wall,  but this is a
rare  occurrence.  " Recovery from dysentery  with  ulceration is effected  by
cicatrization  of  the  ulcers.   Some  ulcers  may  cicatrize while  others  are
extending.    There   is  nothing  characteristic   regarding  these  cicatrices
except in the case  of those resulting  from small follicular  ulcers.  The
cicatrices of  these small follicular ulcers are stellate in shape.   The radiat-
ing ridges extend into the substance of  the surrounding mucous membrane,
and enclose  between them mucous membrane somewhat modified,  but con-
taining the glands of  Lieberkuhn (AA'oodward).   Allusion  has  already been
 made to the occasional occurrence of stricture of the intestine from contrac-
 tion of the cicatrices resulting from dysenteric ulcers.  AVaxy degeneration
 of the intestinal mucous membrane has been occasionally observed in cases
 of dysentery.  Acute  diphtheritic inflammation  may occur at any time dur-
 ing the course of chronic dysentery, and may lead to a fatal  issue.  Of  the
 diseases which may complicate chronic dysentery, peritonitis, hepatic abscess,
 and pneumonitis should be mentioned  especially.  Abscess of  the  liver  is a
 frequent complication  in tropical, but is rare in temperate, climates.  It is
 generally in  the form of small multiple abscesses.
    In  chronic dysentery  the evacuations vary in  character.   They contain at
 times thin or pultaceous feces, and  occasionally scybala.  Their most charac-
 teristic ingredients are  mucus, pus, and  blood; mucus, however,  may be
 absent.  Flakes of pseudo-membrane and of necrosed tissue are present only
 when an acute diphtheritic inflammation  supervenes.  Undigested particles of
 food  are often present, especially when  substances difficult of  digestion  are
 taken.  AVoodward applies the term yeasty to frothy stools containing bub-
 bles of carbonic acid and the yeast-fungus.  These may be observed when the
 digestion is greatly impaired and amylaceous  articles of food are taken.   The
 stools are  usually  accompanied with griping pains.   Tenesmus  is  less  fre-
 quent than  in  acute  dysentery.  In  some cases the  evacuations are unat-
 tended with  any feeling of distress.  The  stools vary  from three  or four to
 twenty or more in the twenty-four hours.   There may be intervals in which
 constipation  takes  the place of the frequent discharges.  The  accumulation
 of gas in the intestines and the escape of flatus  may be annoying symptoms.
 In severe cases  the stools are always loose  and thin and contain mucus,  pus,
 and blood.   In  these cases it is to be inferred that the inflammation extends
 over the  whole  or the  greater part of the large  intestine.  In  other cases
 dysenteric discharges  occur more or less frequently in alternation with fecal
 dejections.   In these cases the inflammation is  less diffused.   If the evacu-
  ations be generally or frequently solid or moulded, the dysenteric evacuations 
                        CHRONIC  DYSENTERY.                     481

being superadded, the inflammation or lesions  are circumscribed and situated
near the anus.  In these cases ulcerations may sometimes be seen if examina-
tion be made with  the speculum.  There is generally more or less tenderness
along the line of the colon.
  Chronic dysentery is one of the most intractable and hopeless of diseases.
For a time, if the  evacuations  be held  in  check by palliative measures, the
appetite and digestion  not  being greatly impaired, the general aspect and
strength  may not  show much deterioration, but at  length  the appetite and
digestion fail, and the continued  irritation and loss of fluids induce progressive
emaciation and debility.  The duration of the disease extends usually over sev-
eral months, and sometimes years.  If not destroyed by some intercurrent affec-
tion, the patient becomes extremely emaciated  and is reduced almost to a skel-
eton ; the surface is usually dry, cool, or  cold ; the pulse becomes more and
more feeble;  the mental faculties are  weakened, delirium  rarely occurring,
but the mind  in certain  cases falls into an apathetic state, the patient being
indifferent to, and taking but little notice of, persons and  things around him.
Anorexia becomes complete, and vomiting in some cases is a prominent symp-
tom ; oedema of the lower limbs sometimes occurs; ulceration of the cornea
is an occasional event, and I have known the cornea to  be perforated, with
loss  of the  humors  of both  eyes.   The  mode in which a  fatal termination
takes place  is generally typical of dying by slow asthenia.   The immediate
cause of death is sometimes general  peritonitis from perforation of the intes-
tine.  Parenchymatous nephritis is not an infrequent complication, but uramic
coma and convulsions are rare.  AVoodward states  that " sudden death was
a not infrequent  occurrence,  and attracted  considerable  attention  during
the  war." 1
   The diagnosis of chronic  dysentery is not always easy.   The disease is
to be discriminated from functional   diarrhaa, and  this is not always readily
done.  The  presence of  pus, mucus, and of blood at times, if not frequently
or constantly, is the important point in the differential  diagnosis.  It is also
to be discriminated from ulceration of the large intestine due to tuberculosis,
carcinoma, or other cause.   Tuberculosis may be excluded if the lungs be
free from the deposit  of tubercle.   In  carcinomatous disease frequently  a
tumor is to  be felt through the  abdominal walls, or if seated in the rectum it
is accessible to examination by means of  the touch and speculum.   The fact
that in the  great  majority of cases  chronic is preceded by acute  dysentery
is highly important in the diagnosis.   AVe may conclude at  once that the dis-
ease is chronic dysentery if  it have followed the acute disease ; and the latter
fact may generally be ascertained without difficulty, owing to the well-marked
diagnostic symptoms of acute dysentery.  In temperate climates the affections
with which  chronic  dysentery is liable to be confounded  are most likely to
exist in  cases of doubt, owing to the  infrequency  of the  latter.
   The treatment  of chronic  dysentery relates first to  the local affection.
Remedies to  allay  irritation  and to  promote  the healing  of ulcerations are
indicated; but, unhappily, in  the great majority of cases  there is very little
probability that a cure will  be  effected, and all that can  be hoped for from
judicious treatment  are palliation  of  symptoms and prolongation of life.
   Certain remedies have been  employed with a view to their direct  action
upon the affected portions of the intestines.  The  nitrate of silver is one of
these; but it is absurd to suppose that this remedy, given  as largely as pru-
dence will allow, passes through the stomach and small intestines unchanged.
AVhatever benefit may be derived from  it, therefore,  is not to be explained on
the  ground of its topical application to the diseased surface.  The balsamic
medicines—particularly the balsam of copaiba—have been given for the same
                                 1  Op. cil.
        31 
 482       INFLAMMATORY DISEASES  OF  TEE INTESTINE.

 purpose, and with more reason ;  but clinical observation shows not much bene-
 fit to be derived from them.   The subnitrate or the subcarbonate of bismuth
 may be  included  among  the remedies  supposed to act by coming in contact
 with  the affected parts.  This  remedy is often beneficial as a palliative, the
 dejections becoming less frequent, with relief of pain, etc., under its use.  It
 should  be given in doses of from 20 to 30 grains three  or four times  daily.
 Some have recommended much  larger doses, and,  given almost without limit,
 it produces no deleterious effects;  but probably all the benefit  to be derived
 from  it is secured by the  doses just indicated.   Its administration in enemas
 has been advocated in  this  disease.  The various astringent  remedies  are to
 be tried in succession.  Of  those most likely to be useful the following may
 be  mentioned: tannic or gallic  acid, alumen, rbatany, rubus villosus (black-
 berry-root), and  the persulphate or pernitrate of  iron.   The oxide of zinc is
 considered by many as a useful remedy.
   In so far as the dejections are controllable by the foregoing remedies, they
 should  be relied upon to  the exclusion of opium,  because they  will interfere
 less with  appetite and digestion.  Opiates, however, will be required to a
 greater or less extent in conjunction with other remedies.   So  far  as practi-
 cable, they should be administered  by the rectum, either in enemas (a salt of
 morphia  or some liquid  preparation contained  in an ounce  of mucilage or
 thin starch-water) or in suppositories.  The lower part of the rectum should
 be examined with the speculum, and appropriate topical applications made if
 ulcers in this situation be  discovered.   Dr. Maury and  Prof. T. G. Thomas
 have reported cases in  which remarkable benefit followed the application of
 nitric acid to ulcerations within the rectum;  and they call  attention to the
 fact that by means of a speculum  the  interior of the bowel may be brought
 into view as  far  as the sigmoid flexure.1  The removal of fecal collections
 and of other irritating material, by means of large injections given  through a
 flexible tube introduced into the sigmoid flexure, deserves trial in  chronic as
 in acute dysentery.   Prudence, however, dictates caution  in the introduction
 of the tube and  as regards  the  quantity  of water introduced, lest rupture at
 an ulcerated spot may be produced.
   The treatment relates,  secondly, to the  system.   In relative importance the
 general  take  precedence of the local  measures.   The surface of the body
 should  be well protected against atmospheric changes.   The diet  should be
 nutritious but bland, articles of food being selected which do not leave much
 indigestible matter to pass  into the large intestine.   Milk, eggs, and farina-
 ceous food are generally best suited, but in some cases animal  food is found
 to agree.  The plan of diet is to be governed by  experimental trials.  Tonic
 remedies and alcoholic stimulants are indicated by defective  appetite and
 digestion. Of tonic remedies, quinia, the  chalybeate preparations, the mineral
 acids, and the bitter infusions are to be employed in succession.  The use of
 alcoholic stimulants is to be regulated  by their effects  in individual  cases.
 Moderate out-of-door exercise and mental recreation are important.   Change
'of climate is sometimes effectual when other measures prove unavailing.  The
 experience of the late war showed  the happiest effect of transferring soldiers
 from the South to Northern hospitals in salubrious rural  situations.


     Inflammation  and Perforation of the Caecum—Fecal
                                Abscess.
   Inflammation of the cacum, the inflammation limited  to  this portion of
 the large intestine, constitutes an affection called  typhlitis, typhlo-enteritis, or
  1 Vide New  York Med.  Journ., Jan.,  1876, and the  author's Clinical Medicine, p. 292
 et seq. 
 INFLAMMATION AND PERFORATION OF THE CACUM,  ETC.   483

csecitis.  Acute inflammation confined to the cacum is not of frequent occur-
rence.  The symptoms are—pain and tenderness within a circumscribed space
corresponding to  the  situation of the cacum, with vomiting, sometimes  con-
stipation and sometimes  diarrhaa, and  febrile movement.   It is liable to be
confounded with  phlegmonous inflammation  connected with  disease of the
vertebra,  renal calculus, circumscribed peritonitis from perforation  of the
vermiform appendix, and inflammation of the right ovary.  Peritoneal inflam-
mation, limited to the portion of peritoneum covering the cacum, may accom-
pany the affection.  The pain and tenderness are then more marked, and the
cacum is  distended by an accumulation of gas, the peritoneal inflammation
producing paralysis of the muscular tunic.  The distension sometimes is  so
great that a circumscribed  prominence corresponding to the  area  occupied
by this portion of the large intestine is manifest to the eye and  may  be felt
through the abdominal walls.  Extension of the limbs may occasion pain,  as
in cases of general peritonitis.  The cases which I have seen have terminated
in recovery.  I have not  met with perforation  followed by either general  peri-
tonitis or  fecal abscess in a  case of acute inflammation of  the cacum.  The
probable  explanation  is  that in these  acute  cases circumscribed peritonitis
gives rise to an agglutination of  peritoneal surfaces, which is protective
against perforation.   Subacute inflammation gives rise to symptoms less dis-
tinctive.  It may occur, and recovery  take  place, without  the development
of symptoms denoting an  affection of importance;  but it becomes a  very
important affection when it  leads to ulceration and  perforation of the intes-
tinal coats.
   If the  perforation  take place in  that portion of  the cacum not invested
with the peritoneum,  the gaseous and other contents of the intestine, escaping
into the areolar tissue, give  rise to inflammation which may  be either diffused
or circumscribed, in the latter case  forming an abscess called a fecal abscess.
If diffused, the inflammation may  extend more or less over the abdominal
walls, which become swelled, pitting on pressure as in oedema, with a feeling
of crepitation due to the  permeation of intestinal gas.   If an  incision  be made,
a dark, sanious liquid escapes  with gas emitting  an intestinal odor.  Under
these circumstances a fatal result is inevitable.  If, however, the  perforation
lead to a circumscribed abscess which opens externally, gas and fecal matter,
with pus,  escape ; a fistulous communication with the intestine is  established;
and this  may remain  permanently, or  it  may gradually close and  recovery
take place.
   Perforation at  a point where the intestine is covered with the peritoneum
may give  rise to diffuse peritonitis, which  in most cases, if  not invariably, is
fatal.  Often, however, the  escape  of the intestinal  contents  into  the  peri-
toneal  cavity is prevented by a prior circumscribed peritonitis  resulting  in
protective adhesion of the peritoneal surfaces.  Under these circumstances a
perityphlitic abscess follows, and this is liable to rupture into the peritoneal
cavity if  timely  surgical interference be not resorted to.
   The causes of inflammation of the cacum, whether it be acute  or subacute,
are probably the  detention in this situation of the feces, and the presence of
irritating  matters either received with  the ingesta or arising from  chemical
changes within the intestine.  Over-exercise and exposure to cold may be
auxiliary  causes.
   Complete rest is an essential  part of the  treatment.  This should be  rigidly
enforced when the inflammation is  subacute not less than when it  is acute.
The importance of this part of the treatment relates to the prevention  of per-
foration.  It is desirable to  effect the removal of the contents of the cacum,
but active purgatives  are fraught with danger.  Mild laxatives only are admis-
sible, such as castor oil or small doses of Epsom salts.  It  is perhaps safest 
 484       INFLAMMATORY DISEASES  OF THE  INTESTINE.

 to rely upon enemata given through a long  flexible  tube carried  upward
 to the sigmoid flexure.   These may be repeated at short intervals; that is,
 three or four times daily.  A warm poultice or the water-dressing should be
 applied over the site of the cacum.  Blisters and other  counter-irritant appli-
 cations are of doubtful utility.  The ingesta should be restricted to animal
 broths  and milk with the addition of lime-water.  Opiates should be given
 in doses  sufficient to relieve pain.  After  the disappearance  of the symp-
 toms denoting  inflammation, the  diet for  some time  should be regulated
 with reference  to  a  small quantity of fecal residue.   Constipation should
 be avoided by  means of mild laxatives,  and physical exercise should be
 interdicted.
   Perforation of the cacum from an ulcerative process may take place without
 having been preceded by local symptoms  denoting any important affection.
 It occurs perhaps when  patients are engaged in  their usual avocations.   A
 localized sharp pain is usually felt  at the time of the perforation,  followed by
 circumscribed tenderness.  These symptoms should at once  excite suspicion.
 A\rithin the area of the pain and tenderness, situated  in  the right iliac fossa,
 a sense of resistance is shortly felt  by the touch, the boundaries of which may
 not  be  sharply  defined.   On  percussion  there  may be either  flatness  or a
 tympanitic resonance, the. latter, if limited to  the  area of tenderness, being
 due  to  gas escaping through  the perforation.  In  the  course of a few days
 fluctuation is appreciable.
  As regards diagnosis, fecal or perityphlitic abscesses are to be discriminated
 from psoas abscess in Pott's disease, abscess with caries of pelvic bones, cellu-
 litis, abscess  originating in the abdominal wall, perinephritic abscess, and dis-
 ease of the hip-joint.  Tympanitic  resonance on percussion and crepitation
 from the  presence of intestinal  gas are diagnostic  points.1  The tympanitic
 resonance, if ascertained not to be transmitted from  the cacum, distinguishes
 this  abscess from phlegmonous suppuration, which  is primarily extra-cacal;
 that is, not  secondary to perforation.   An  abscess, however, originating in
 either the connective tissue behind the cacum or in the abdominal wall  may
 lead to perforation  of the intestine.  In the latter case, if the abscess do not
 discharge its contents into the intestine and  a fluctuating  tumor  remain, the
 differential diagnosis is not important practically, since the treatment indicated
 is the same as if the perforation preceded the abscess.
  An abscess connected  with perforation of the cacum  if treated only by
 rest, fomentations, and anodyne remedies  may open  externally, as already
 stated, and recovery follow.   The  recovery may be rapid, as in an instance
 which I have reported.1 The discharge may take place into the  intestine, and
 recovery may follow closure of the perforation.  An opening may take place
 into  the bladder and fecal matter be passed  with the urine.   I have met with
 an instance of this kind.   There is, however, danger of  the discharge of  pus
 into  the peritoneal cavity, and consequent fatal  peritonitis.  The pus is rarely
 absorbed.  It may migrate in different directions for a considerable distance.
 In a case  which I saw with Dr. Damainville  of New  York, it  made its way
 above the diaphragm into the bronchial tubes, and was discharged by expec-
toration.  The case ended in recovery.
  The treatment which has proved  successful in the hands  of many sur-
geons in this country is that  inaugurated by Prof.  AATillard  Parker in 1867.
It  consists in removing  the pus, either by aspiration or  by a  free opening,
as  soon as fluctuation is felt and  the presence of pus demonstrated by an
exploratory puncture.  This method is a highly important improvement in
 1 Vide an analysis of 32 cases, by Prof. Roberts Bartholow, in the Amer. Journ. of
Med.  Sciences, Oct., 1866.
 2 Vide Clinical Medicine. 
     INFLAMMATION,  ETC.  OF  THE VERMIFORM APPENDIX.   485

the treatment of perityphlitic  or fecal  abscess. (Further  details  belong to
surgery.1)
  Absolute rest is to be enjoined until recovery; cathartics are to be avoided,
and the patient should be restricted to a purely nutritious diet.


Inflammation and Perforation of the  Vermiform Appendix.

  The  appendix is, in fact, a part of the cacum, but inflammation and per-
foration here  may occur independently of any affection of the cacum proper.
The term typhlitis is applied to inflammation of the vermiform appendix as
well as to eacitis.   Perforation of the cacum  is much more infrequent than
of the  appendix.
  Inflammation of the appendix is caused either by the entrance of irritating
substances within its cavity or by distension  from fecal matter.  The commu-
nication of its cavity with that of the cacum may become closed, and dilata-
tion may result from the accumulation of inflammatory products.   It may be
dilated so as to form a tumor of considerable size.  My colleague, Prof. Jane-
way, has seen a  case in which it formed a tumor as large  as a child's  head,
and another case in which it was as large as  a Bologna sausage.2   AVhenever
moderately enlarged it may be felt as a tumor through  the abdominal  walls.
The tumor in cases  reported by James Jackson, in his Letters to a Young Phy-
sician, under the  title "A Painful Tumor near the Cacum," was doubtless an
enlarged appendix.   I have met with a case in which  five previous attacks
had occurred.  In  this case the tumor and all the symptoms disappeared
after the discharge of  pus from the bowels.   At the meeting of  the  Inter-
national  Medical Congress in  Copenhagen  in  1884  the late  Dr.  Mahomed
related a case in which, after  repeated attacks, an  abdominal incision was
made  and a calculus removed from the  appendix, the patient recovering and
no subsequent attacks taking place.
  Perityphlitis and fecal abscess  may arise from inflammation and perfor-
ation of the appendix.  Indeed, these  affections are  more  likely to  be con-
nected  with inflammation and perforation of  the appendix to the cacum than
with diseases  of  the latter.  The treatment is that already considered in con-
nection with  inflammation and perforation  of  the cacum.
  An important question  is, whether in cases of intestinal perforation lapa-
rotomy be not admissible  with a view to closure of the opening into the intes-
tine and the  removal of the irritating  matter  within the  peritoneal cavity.
In the light  of  the knowledge recently acquired respecting  abdominal sec-
tions this operation appears not only warrantable, but advisable as  a  possible
life-saving procedure under circumstances which without it render the prog-
nosis almost of necessity  fatal.
  Perforation of the appendix, followed by diffuse  peritonitis, is often  not
preceded by symptoms denoting acute inflammation.  In cases which have
come under  my  observation  the  patients generally  had had  uncomfortable
sensations in  the iliac region for  two or three days, and in  many instances
had taken some cathartic medicine, thinking that they were  " bilious" or
needed " clearing out."   Suddenly a sharp, lancinating pain was followed by
the symptoms of diffuse peritonitis, which  proved  fatal.  At the autopsy,
generally within  the appendix hard bodies are found to which it is  customary
to attribute the  perforation.   These bodies are usually of small  size  (from
a pea to a date-stone), and consist  of hard  feces, a  calcareous material, the

  1 For  a table of  60  cases, with operations  and  results, collected by Dr. AVilliam C.
AVev, vide Trans, of Med. Soc. of the State of Xew York, 1880.
  2'N. Y. Med.  Record, April 12, 1884. 
 486       INFLAMMATORY DISEASES OF THE  INTESTINE.

 seeds  or  stones of fruit, etc.  If nothing be found,  the  supposition is that
 the bodies have escaped through the perforation.
   Perforation of intestine in cases of diffuse peritonitis is  referable, as a rule,
 to the appendix, if not preceded by notable intestinal  or gastric symptoms.
 The evidence for  and against the occurrence  of perforation  as  the cause of
 diffuse peritonitis  will be considered in connection with the latter affection.
   In the  exceptional instances of recovery when diffuse peritonitis has been
 thus induced the  appendix quickly becomes adherent to  adjacent parts, and
 the perforation  is in this way closed.  I have met with fatal cases in which
 the appearances after death showed more  or less progress  toward this result.
 In the examination of bodies dead with other diseases old adhesions are not
 infrequently found.   They are probably results of circumscribed peritonitis
 secondary to disease of the appendix.  Adhesion, taking place before perfor-
 ation occurs, protects against diffuse peritonitis; but fecal abscess may follow,
 as in  cases of perforation of the cacum.   I have seen  a  specimen in which
 the appendix was attached to the bladder  and  perforation had taken place,
 oausing a vesico-intestinal fistula.   The first evidence  of this was the appear-
 ance of a  lumbricoid worm at the end of the penis, the  patient  then being
 eight  years of age.   Subsequently, other  worms were  discharged with the
 urine, and repeatedly the seeds of fruit.   Most of the urine  was  discharged
 by the bowels.  The fistula for many years  gave  but little  inconvenience.
 The patient served as a soldier in the late civil war.  He  was operated  upon
 for stone in the bladder, and died five  days  after the  operation, the fistulous
 communication of the bladder  with  the appendix having existed for  twenty
 years.
  Pain or uneasiness referred to the right iliac fossa, without other symptoms
 of disease, should always excite apprehension  in the  mind of the physician.
 Rest  should be enjoined and  cathartics avoided.   By these precautions, if
 patients seek  advice prior to perforation, its occurrence may perhaps be pre-
 vented.

                          Colitis—Proctitis.

  Inflammation of the colon  (colitis) and  of the rectum (proctitis) furnishes
 the anatomical characters of dysentery. But  in the latter the inflammation
 involves a special cause;  hence dysentery  is with propriety included  among
 the infectious diseases, using the term  infectious in the sense now generally
 adopted. (Vide  p. 84.)  The  terms colitis and proctitis may be  applied to
 inflammation in the colon and in the rectum when it occurs irrespective of a
 special causation.  These terms will then  correspond to the ordinary catar-
 rhal  inflammation  of many authors.
  Colitis, in this scope of the  term, is  rarely acute, hut as a subacute affec-
 tion it is not rare in the adult,  and is common in infancy.   It enters into the
 disease known as cholera infantum or the  ileo-colitis  of childhood.  It may
 or may not be  associated with inflammation  seated  in the  small intestine
 (enteritis).  In the cases among soldiers  grouped by AAroodward  under the
 name  of Acute Diarrhaa, inflammation affected especially the large intestine.
 The local  symptoms are colicky pains, diarrhaa, the dejections being loose or
 watery and containing  gelatinous mucus  in greater  or less quantity,  with
 absence of tenesmus.  Tenderness may be present,  either  limited  to or most
marked in  the situation of the  colon.   The diagnosis is to be based on these
 symptoms.  Fever, anorexia, and  general  debility  are associated with  these
 symptoms, and are proportionate to the degree and extent of inflammation.
  The causes  are the  accumulation of feces, and especially the presence of
undigested irritating matters  received from the small intestine.  General 
ACUTE  ENTERITIS.                       4-S7
  causes,  such as  over-fatigue, exposure to  cold, insufficient  alimentation,
  intemperance, etc., co-operate  with the local causes, increasing the suscepti-
  bility to the  latter  and impairing tolerance.   Hence the greater frequency
  and the greater severity of the disease in  military campaigns than  in civil
  life.
    The general principles of the treatment are essentially the same as in cases
  of sporadic dysentery.
    There is no practical  advantage in endeavoring  to  distinguish chronic co-
  litis  from chronic dysentery,  although the  distinction may be admissible on
  anatomical and  pathological grounds.
    Proctitis occurs from the action of local causes, and it may simulate dysen-
  tery  as regards the  presence of mucus  and blood in the  dejections, together
  with  tenesmus.   Diarrhaa is wanting, and  the  clinical  history in other
  respects lacks the  features of a  truly  dysenteric disease.   Perforation of
  the rectum  sometimes  gives  rise to periproctitis and fecal  abscess.   These
  purely local  affections  of  the rectum  are  properly surgical.

    Reference  may be made  here  to  the occasional expulsion, per rectum, of
  niembranifonn casts of the intestinal tube.  These have been observed a foot
  and more  in length.   They have  been supposed to be the mucous membrane
  it>elf exfoliated, but oftener they have  been mistaken for  fibrinous exudation.
  They consist of inspissated  mucus, and usually do not contain fibrin or coagu-
  lable  lymph.   In a  case which came under  my observation a number of casts
  were  expelled, one of which was fifteen inches in length, one and a half inches
  in breadth, and from one-fourth to one-eighth of an inch in  thickness.  This
  specimen, examined by  Professor AATm.  H. AVelch, was found  to contain fibril-
  lated fibrin,  a large number  of pus-cells, mucous  corpuscles, with bacteria.
  red blood-corpuscles, and  a few cylindrical epithelial cells.   Their  expulsion
  is preceded  and accompanied by colicky pains and diarrhaa, the dejections
  containing blood and  muco-pus.  In most instances  the  casts are expelled
'  repeatedly after variable intervals.   The patients  are generally  women  who
  manifest  hysterical  phenomena,  and uterine  troubles are often  associated.
    The casts are probably  formed in the large  intestine, and in connection
  with other symptoms they denote inflammation.   The affection  is therefore
  a variety  of  colitis.   It has received a variety of names.  DaCosta, who  has
  reported a number of cases,1 calls it membranous enteritis.   The name tubular
  diarrhoea  was proposed by John Mason Good, and to this  name AAToodward
  gives the preference, as implying no theory.   (The reader is referred to the
  Medical History of the War of the Rebellion, p. 363, for a  full reference to the
  literature  of  this curious intestinal affection.)

                             Acute  Enteritis.

    The term enteritis signifies, literally,  intestinal inflammation.   A^arious  sig-
  nifications have been attached to it  by diff'erent writers.   The  older writers
  described  under this name  inflammation  of the  serous coat of the intestine,
  but modern  authors, almost without exception, apply the term  to  inflamma-
  tion of only  the mucous and  submucous layers.   Many pathologists  under-
  stand by enteritis inflammation of any part of the intestinal tract, and con-
  sider as*subdivisions of enteritis  duodenitis, jejunitis, ileitis,  typhlitis, colitis,
  and proctitis.  There are clinical  grounds for distinguishing as separate affec-
  tions  duodenitis (usually in conjunction with gastritis), typhlitis, and proctitis,
  but it is  impossible to distinguish, clinically, jejunitis  and ileitis.   It  has
  already been remarked  that diffuse inflammation of the large intestine is lia-
                  1 American Journal of Medical Sciences, Oct., 1871. 
 488       INFLAMMATORY DISEASES OF THE INTESTINE.

 ble to involve the lower part of the ileum ;  and it is likewise true that inflam-
 mation of the small intestine frequently extends into the large intestine.  As
 we already have in the words dysentery and colitis names for inflammation of
 the large intestine, it has become a conventional usage in this country, and to
 an extent elsewhere, to apply the  term  enteritis particularly to  inflammation
 of the small intestine.  The  fact, however, is recognized that as in dysentery
 the inflammation often involves  the  ileum, so in enteritis, with even greater
 frequency, the inflammation  extends to  the upper part of the  large intestine.
 It will be found that in  most of the ca.ses here described as enteritis the
 inflammation is most intense  in the ileum, the cacum, and the  upper parts of
 the colon.  The  inflammation may be,  however, nearly or quite confined to
 the small  intestine.

   Anatomical Characters.—As the disease in  itself rarely proves fatal,
 the opportunity of  inspecting the appearances after death is not often offered.
 The changes  are essentially the  same  as  those described for acute simple
 inflammation of the large  intestine (p. 464).  The mucous membrane presents
 an arborescent redness, either diffuse  or in  patches.   Ecchymoses within and
 beneath this membrane may  be observed.   Its  surface is coated with mucus
 and muco-pus.   An increased transudation  of serum  occurs, which, combined
 with rapid peristole, causes fluid stools.   The mucous and submucous tissues
 are swollen in consequence of adema, congestion, and cell-infiltration.  The
 enlargement of the villi gives a  plush-like appearance to the  surface of the
 mucous membrane.  The solitary and agminated follicles usually are swollen
 and appear as  grayish-white elevations surrounded by a red, congested zone.
 Microscopical  examination  shows a  variable  number of emigrated white
 blood-corpuscles in  the submucous and mucous  coats.  The same remarks are
 applicable  to the desquamation  of the  epithelium here  as in  acute simple
 inflammation of the large  intestine.

   Clinical History.—The local symptoms in cases of acute enteritis are
 pain, tenderness on pressure over the abdomen,  especially over  the lower part
 of the  ileum and the cacum, and  frequently diarrhaa, with nausea and vomit-
 ing.   The pain is not intense, and is of a dull, aching character, with exacer-
 bations, in which it resembles the pain of colic.  The pain  is referred to the
 umbilical region.  The tenderness is not great.  Slight pressure is well borne,
 but deep, firm pressure occasions more or less suffering.  Diarrhaa  is often,
 but not always, present. If present, the dejections are more or less frequent,
 loose, watery, and gelatinous.  Tenesmus and the characteristic dejections of
 dysentery are wanting.  I have met with  fatal cases in which diarrhaa had
 not occurred, the inflammation having been limited to the small  intestine, as
 shown by the  autopsy.  If diarrhaa be a  prominent symptom, it probably
 denotes an extension of the inflammation into the cacum and colon.  Aromit-
 ing is  generally more or less prominent as a symptom.   It may be excited
 sympathetically, or it may denote an extension of the inflammation  to  the
 duodenum  and stomach.  If  jaundice occur it denotes duodenitis.  The  gen-
 eral symptoms vary considerably in  different  cases,  the variations probably
 corresponding to the extent as well as the  degree of  the inflammation.  The
febrile temperature  is in most cases moderate or slight, and the prostration is
not great.  The intellect is unaffected, except in severe cases, when delirium
may occur, together with tympanites,  hiccough, and symptoms denoting  ady-
namia.  The duration in favorable cases is brief, convalescence being declared
in from a week to ten days.

  Pathological Character.—Excluding enteritis occurring in connection 
ACUTE  ENTERITIS.
489
 with typhoid fever, tuberculosis, and the diseases of infancy, the disease has
 no special pathological character.   It  is a simple inflammation of a mucous
 membrane (intestinal catarrh).  It occurs only as a sporadic disease, in this
 respect differing from dysentery.  It differs also from dysentery in not  lead-
 ing to  destructive lesions of the affected membrane, like those which occur
 especially  in the  epidemic form of that disease.

   Causation.—The  susceptibility  of  the  mucous membrane  of the small
 intestine to acute  inflammation after infancy is  slight.   It  may be produced
 by dietetic excesses, the use of  stimulating food and alcoholic drinks, poison-
 ing with acrid substances, and the use of drastic purgatives. It is sometimes
 attributable to the action of cold upon  the body when heated and perspiring,
 local causes being conjoined therewith.   Fatigue and debility may co-operate
 with these causes.

   Diagnosis.—Acute  enteritis is to be discriminated  from dysentery, gas-
 tritis, colic, peritonitis, and typhoid fever.  Assuming that the local symp-
 toms  are  sufficient to denote inflammation somewhere within  the abdomen,
 the absence of the characteristic dysenteric evacuations, of tenesmus, and of
 tenderness in the tract of the colon suffices to exclude dysentery.  The micro-
 scopical examination  of the  stools  may aid in determining the  seat of the
 inflammation,  as  has been shown by Nothnagel.  Under normal conditions
 Gmelin's reaction  for  bile-pigment with nitroso-nitric acid cannot be obtained
 in the feces or in the  contents of the large intestine.  If yellowish balls and
 clumps of mucus, or  yellowish  cylindrical  epithelial cells which  respond to
 Gmelin's  test,  be found  in  the  feces,  it is evidence of increased peristole,
 and often of inflammation in the small intestine.  The presence of much
 undigested food,  such as  abundant starch-granules, in the feces is also  evi-
 dence  of  increased peristole  in the small intestine.
   Nausea and vomiting, if unusually prominent, may suggest acute gastritis.
 But the symptoms of acute  gastritis point distinctly to the stomach as the
 seat of disease.   This disease may generally be excluded  without difficulty.
 The two  diseases, however, may be  combined.  The inflammation  in some
 cases perhaps extends from the small intestine  to the stomach ; and  in  cases
 of poisoning with acrid substances the local effects of the  latter may be pro-
 duced within the  small intestine as well as in the stomach.
   Colic is a functional affection characterized  by intense paroxysmal pain,
 without tenderness or febrile movement, and is oftener accompanied by con-
 stipation than by diarrhaa.  These  points are sufficient  for its  exclusion.
   As regards the local symptoms, acute enteritis approximates to acute peri-
 tonitis more closely than  to  any other affection; but as a rule there is a
 marked disparity  in the intensity of the  symptoms in these two affections.
 The pain, tenderness,  and  tympanites  common to both  are, in the  great
 majority of cases, notably greater  in  peritonitis.  Diarrhaa, which  is  the
 rule in enteritis, occurs exceptionally in peritonitis.   Rigidity of the  abdom-
 inal muscles, which is one of the diagnostic symptoms of peritonitis, is want-
 ing in enteritis.   Moreover, the constitutional disturbance, as denoted by  fre-
 quency of the pulse, prostration, etc., is much greater in peritonitis. Attention
 to these points renders the differential diagnosis easy in most cases.
  The abdominal  symptoms in typhoid fever may lead the  physician to sup-
 pose that  disease  to be  simply enteritis, and  on the other hand a primary
 enteritis may  be  supposed  to be typhoid fever.   Typhoid fever is to  be
excluded by the absence of the diagnostic symptoms which  attend its develop-
ment and  progress—namely, the characteristic rise of temperature, together
with cephalalgia, epistaxis, bronchitis, the rose eruption, and delirium.  More- 
490       INFLAMMATORY DISEASES  OF  TEE INTESTINE.

over, the adynamic symptoms in typhoid fever  are generally greater than in
simple acute enteritis, while the enteric  symptoms are less marked.

   Prognosis.—:Acute enteritis after infancy in the majority of eases is not a
disease of  great gravity.   If it be  not  associated with any other important
aft'ection, and the patient have not a feeble  constitution, a favorable prognosis
may generally be entertained.  The  disease, however, sometimes ends fatally.
This  is to be apprehended when the pulse becomes feeble and frequent, the
prostration marked, and delirium is developed, the local symptoms persisting.
The mode  of dying is by asthenia, as in cases of dysentery.

   Treatment.—The indications for treatment may be embraced in  a few
words.  An  efficient  but non-irritating  purgative is generally at first  advis-
able.   Afterward opium in  some form  is to be given  sufficiently to relieve
pain and diarrhaa.   It  may be administered by either the mouth or rectum,
or alternately in both modes, or by hypodermic  injection.  It is to be  given
in doses proportionate to the urgency of the symptoms,  and graduated accord-
ing to its effects.  Fomentations over the  abdomen by means of poultices,
the water-dressing, or spongio-piline are  useful.  Moderate stimulation of the
surface of  the abdomen by sinapisms or  liniments is appropriate.  General or
local  depletion by bloodletting is very rarely if  ever called  for.  Mercury as
an alterative remedy,  or given to " improve the secretions," is not to be recom-
mended.   The supporting treatment  is indicated in proportion to the duration
of the disease and the tendency to failure of the vital powers.  The diet at
first should be restricted and bland, but alimentation is of course  important
if supporting measures be  indicated.  The question  of irrigation does not
enter into  the consideration of the treatment of enteritis, inasmuch as the
injected liquid does not readily  ascend beyond the  ileo-cacal valve.


                 Subacute and  Chronic  Enteritis.
   Subacute enteritis  is of frequent occurrence, arising either  from  dietetic
errors or an arrest of digestion by exposure to cold, over-exertion, etc.   It is
not easy to distinguish, practically, cases of transient subacute enteritis from
cases of functional diarrhaa ; nor is it of much practical consequence to make
this discrimination, since the indications for treatment in either case do not
materially  differ, embracing mild purgation, followed  by anodyne remedies
and regulation of the ingesta.
   Enteritis, acute, subacute, and chronic, is described by some authors  under
the name of intestinal catarrh.  Here, as in other connections, the term catarrh
is not adopted in  this work.  Authors who treat at length of intestinal catarrh
embrace under this head  cases which I describe in connection with diarrhaa
and intestinal dyspepsia.
   Chronic  enteritis is  usually referable to some prior morbid condition. It very
rarely follows acute enteritis.  Chronic passive congestion in the portal circula-
tion is a cause of chronic enteritis.   It may in this way attend diseases of the
liver (such as cirrhosis), of the lungs (such as emphysema, chronic pleuritis),
and of the heart (valvular lesions.) All of these affections lead to chronic intes-
tinal inflammation by obstructing the flow of blood through the portal system.
The pathological condition is at first chronic passive  congestion of the  intes-
tines.  Bright's disease may be accompanied by chronic enteritis.  It is  a fre-
quent attendant of tuberculous ulcerations  of the intestine, and it may  occur
in chronic  tuberculosis  without the  presence of  intestinal  ulcers.  Chronic
enteritis occurs also  as a circumscribed  inflammation  about other forms of
intestinal ulcer, about new growths  in the intestine, and above strictures of 
INTESTINAL  ULCERS.
491.
the gut.   The intestinal mucous membrane in chronic enteritis is coated with
mucus, and is usually of a slate or ash color from the deposition of pigment.
The follicles are often enlarged and pigmented, and they may be the seat of
ulcers.
  The symptoms are the  same as those in acute enteritis, hut they are less
marked.   Constipation may alternate with diarrhaa.  As regards treatment
the cause should be, as  far as  possible,  removed.   This involves in  many
cases  the treatment of a prior  morbid state.
                         CHAPTER   VI.

          STRUCTURAL DISEASES  OF  THE  INTESTINE.

 Intestinal Ulcers.—Duodenal Ulcer.—Embolism of the Superior Mesenteric Artery.—
   Carcinoma of  the Intestines.—Waxy Degeneration of  the  Intestines.—Structural
   Lesions causing Intestinal Obstruction.—Intussusception.—Strangulated Hernia with-
   in the Abdomen.—Kotation or Twisting of Intestine.—Compression and Stricture of
   the Intestine.—Obstruction from Impaction of Feces, Enteroliths, and Foreign Bodies.
   —Functional Obstruction.

                           Intestinal Ulcers.

    THE important forms of intestinal ulcers are the following:  simple inflam-
     matory (including follicular), digestive, dysenteric, typhoid, tuberculous,
 and syphilitic.  Certain rare varieties, as the embolic, the amyloid, the corro-
 sive  (from swallowing corrosive  poisons), the variolous, and the mycotic
 (especially  in malignant pustule),  will receive  no further attention.
   Ulcers may occupy any part of the intestinal  tract.   In general it may  be
 said that their favorite seats are the ileum, the  cacum,  the sigmoid flexure,
 and the  rectum.   Simple  inflammatory  ulcers, also  called  catarrhal, have
 been treated  of in connection  with dysentery  and  with enteritis.  They
 include follicular and  non-follicular forms.  Ulcers produced by pressure  of
 impacted feces are sometimes called stercoral.   Similar ulcers  may be caused
 by foreign  bodies.  These ulcers  from pressure  are  most frequent  in the
 cacum, vermiform  appendix, and sigmoid  flexure.   They have been consid-
 ered in connection with typhlitis (see p. 482 et seq.).  Digestive ulcers occur
 only in  the upper part of the intestine.   They are  of the same  nature  as
 digestive or simple gastric ulcer, and will  he considered  in the next article,
 under the head of Duodenal  Ulcer.  Dysenteric  ulcers  have already been
 described.   The so-called  uramic  ulcers  which occur in Bright's disease,
 and which are sometimes attributed to the irritation of carbonate of ammonia
 produced from urea in the  intestinal tract, are in some cases the result of a
 dysenteric process.   Dickinson  has  observed  small ulcers  in  the lower part
 of the ileum  in connection with small contracted kidney.  Typhoid  ulcers
 will  be  described subsequently in connection with  Typhoid  Fever.
   Tuberculous intestinal ulcers are  very frequently present in cases of pul-
monary   tuberculosis.    They  very  rarely,  if  ever,  occur independently  of
tuberculous processes in the lungs.  The hypothesis that the intestinal  ulcers
of phthisical patients are caused by swallowing tuberculous sputa is probable, 
492       STRUCTURAL DISEASES  OF THE INTESTINE.
in view of the fact that these ulcers have been produced  by feeding animals
with tuberculous substances.  Tuberculous ulceration affects by preference
the lower part of  the small intestine.  The solitary follicles  and Peyer's
patches are usually first involved, but  tubercles may develop independently
of these structures.  The  process often  extends to the remainder of the small
intestine and to the large intestine.  The vermiform appendix is very often the
seat of tuberculous ulceration.   The solitary follicles and the individual folli-
cles of Peyer's patches become swollen, and they undergo, first in their centre,
cheesy degeneration.   The cheesy mass softens and a little ulcer is produced.
This ulcer extends partly by an inflammatory process, but chiefly by the devel-
opment of tubercles in its edges and base.  These tubercles undergo cheesy
metamorphosis and  softening.   The shape of the  ulcer may correspond at
first to that of a Peyer's  patch, but its tendency is to extend transversely in
the course of the lymphatics and blood-vessels.  This direction is explained
by the fact that the tubercles, to whose development the ulcer owes its progress,
form chiefly in the walls of these vessels.   The appearance of a fully-formed
tuberculous ulcer is characteristic.   Its long axis is transverse to the axis of
the intestine ; but this rule is not without exceptions.   The ulcer may nearly
encircle the lumen of  the intestine.  Tuberculous ulcers constitute the most
frequent and important of the so-called annular or girdle ulcers.  The edges of
the ulcer are thickened and sinuous, and present an appearance often described
as worm-eaten, from the presence of little excavations due to softened tuber-
cles.   Tuberculous granulations are usually recognized without difficulty both
in the edges and in the base of the ulcer.  Tubercles are developed in the
vicinity of the ulcers.   Patches of little white tuberculous nodules seated in
the subserous tissue can generally be seen on  the peritoneal surface covering
the site of the tubercle.   These peritoneal tubercles are of great assistance in
the recognition of both the position and the nature of the ulcer.  Upon micro-
scopical examination tubercles are found in the neighborhood of the ulcer in
the muscular and other coats of the intestine.   They are formed chiefly in the
outer sheaths of the arteries and in the lymphatic vessels.   As a rule, they
present the typical  giant-celled structure  (p. 48).   AA"oodward describes a
transverse puckering of the mucous membrane in the neighborhood of tuber-
culous ulcers,  due to a  tendency in the ulcer to longitudinal contraction.   Par-
tial cicatrization of tuberculous ulcers,  resulting even in stenosis, has been
observed in several instances.  That the tuberculous  ulcers  ever completely
cicatrize is improbable.  These ulcers do not often lead to perforation of the
intestine,  and  very rarely indeed to general peritonitis from perforation.  Cir-
cumscribed  peritonitis over the seat of the ulcer is common.  Tuberculous
ulcers  are usually  accompanied  by more  or less inflammation of the sur-
rounding  mucous membrane.  The mesenteric  glands are frequently swollen
and tuberculous.
  Syphilitic intestinal  ulcers are infrequent.   In only a small  number of cases
has their origin from gummata been demonstrated.   Syphilitic ulcers of the
intestine are either round or transverse.  They may form annular or girdle
ulcers.   Their edges are generally grayish-white, indurated, and fibrous;  the
base is also indurated and usually without much purulent secretion;  and the
serous coat over the ulcer is often  thickened, and may present cicatricial tis-
sue containing little fibrous nodules.  In the thickened walls  and base cheesy
nodules, which are doubtless gummata, are occasionally detected.  The hard
fibrous  tissue forming the floor and edges  of the ulcer is generally densely
infiltrated with small round cells.  These ulcers may he found in both the large
and the small intestine. Their cicatrization leads to more or less contraction of
the calibre of the intestine.  Submucous gummata have been found with and
without ulceration of the intestine, but they are extremely rare.  They appear 
DUODENAL  ULCER.
493
to be more frequent in congenital than in acquired syphilis.   Syphilitic ulcers
and  strictures of the rectum are considered fully in works devoted  to vene-
real diseases.  According to Fournier,1 syphilitic stricture of the rectum may-
be due not only  to the cicatrization of ulcers, but also to a  diffuse hyperplas-
tic infiltration of the  mucous and  submucous coats.  To this  syphilitic infil-
tration he  gives the  name of ano-rectal syphiloma.  Birch-Hirschfeld2 has
described as an occasional lesion of congenital syphilis diffuse sclerosis of the
intestinal mucous membrane, which was  found thickened by an infiltration of
fusiform cells.
  The symptoms of intestinal ulceration cannot well be considered apart from
the morbid conditions on which the ulcers depend.  In general, the symptoms
are not characteristic of ulceration.   There may be tenderness on pressure if
the ulceration be extensive, especially if it  be seated in the large intestine.
The nutrition of the patient is usually impaired.   The character  of the stools
is often abnormal.  There may be diarrhaa, with liquid and often bloody evac-
uations.  On the other hand, constipation may be present, particularly if the
ulcers  be high up in the bowels.  Symptoms  are often referable to a coinci-
dent enteritis.   The hemorrhage from intestinal ulcers  may be so profuse or
persistent as to prove the immediate cause of  a fatal termination, but instances
of this are  rare.  Tubercle bacilli are  frequently present in the fecal  dis-
charges in cases  of tuberculous ulceration of the intestines.   In rare instances
tuberculous ulcers  of the rectum are situated so that they can be explored
during life.   Ulcers may give rise to perforation and fatal peritonitis.  They
may cause fistulous communications.   If cicatrization take  place, constriction
of the intestinal canal may be thereby produced, and  this  stenosis  may be
the cause of  death.   Syphilitic  ulcers are particularly likely  to cause stric-
ture of the intestine, but the same result may follow dysenteric, simple inflam-
matory, and  even in  rare instances  tuberculous ulcers.  Typhoid ulcers do
not lead to stenosis.   Not very infrequently ulcers are found unexpectedly
in post-mortem  examinations, there having  been no symptoms  referable to
them during life.  The prognosis depends upon the primary morbid condition.
The treatment also has reference to this state.  In general, the  treatment indi-
cated in  chronic  dysentery is applicable.   Ulcers and strictures seated in the
lower part of the rectum arc open to inspection, and are to be treated by local
applications and surgical procedures.


                          Duodenal  Ulcer.

  Chronic ulcer  has the same anatomical characters in the duodenum as in the
stomach, and is probably, like the latter, caused  by the  solvent action of the
gastric juice.  It is far less frequent  than gastric ulcer,  the proportion being
as 1 to 30 of the latter.  The situation is usually near the pyloric opening.
In contrast  with gastric ulcer  the ages of patients are generally between
thirty  and  forty, and  duodenal ulcer occurs much oftener in men  than in
women.  These  are  points to be  taken  into account in the diagnosis.  The
fact of its occurrence in some  cases  after severe burns  of the skin is also to
be borne in mind.
  The  local symptoms by which it is to be  differentiated from gastric ulcer
are as  follows: Vomiting is often wanting, and when it occurs the intervals
between  its  occurrence and  the ingestion of  food are longer.  The ingestion
of food does  not occasion the same degree of gastric disturbance and conse-
quent distress.   Paroxysms of pain  often occur having  the severity and cha-
racter of gastralgia.   The pain, as in gastralgia,  is sometimes relieved by the
                   1 Lecons redigees par Ch. Porak, Paris, 1875.
                   2 Wiener Med. Presse, 1878, No. 41. 
494       STRUCTURAL DISEASES  OF  THE INTESTINE.

taking of food.  The pain  is referred to the right hypochondrium.  Jaundice
sometimes, but rarely, is associated with duodenal ulcer.   From the occur-
rence of this  symptom either duodenitis  or  the  situation  of the ulcer  near
the opening of the ductus communis is to be inferred.   Hemorrhage is  as
liable to  occur as in  cases of gastric ulcer.   Blood may be vomited, but it is
passed in larger  quantity  by the  bowels.  These points  relating to hemor-
rhage are significant as regards the diagnosis.   Cancer is excluded by the
absence of tumor, of the gastric symptoms usually connected with that affec-
tion, and of the appearance characteristic of  the cancerous cachexia.   More-
over, cancer usually occurs at a later period of life—namely, between forty
and sixty years of age.
  Duodenal ulcers may cicatrize, giving rise  to stenosis and consequent dila-
tation of the stomach ; but cicatrization is rare.   Perforation may take place
and give  rise  to  fatal peritonitis.    This result is sometimes  prevented by
adhesions of the  duodenum over the site of the  ulcer prior to the perfora-
tion.  These adhesions may take place and rupture afterward occur, as in a
case which  was under  my observation.  Duodenal  like  gastric ulcer may
remain latent  until perforation occurs.
  The treatment is essentially the same as  in cases  of gastric ulcer.
        Embolism  of the Superior Mesenteric Artery.

   Embolism of the superior  mesenteric artery is  followed by hemorrhagic
infarction of the small intestine.   Although this  artery anastomoses freely
with  the pancreatico-duodenal and with the inferior mesenteric, it has been
shown by the  experiments of Litten1 that  its branches are  so little toler-
ant of an insufficient supply of blood that their coats  undergo a  molecular
alteration which suffices for the production of a hemorrhagic infarction before
a  complete  collateral circulation can be established.   The wide  extent of
territory over which this vessel  is distributed is an impediment to  the rapid
development of a sufficient collateral circulation, which, even in arteries more
favorably situated,  often requires  considerable time.   About thirty cases of
embolism of the  main trunk or of the branches of the superior mesenteric
artery have  been recorded.   The embolus  itself  can  usually be detected
post-mortem without difficulty.  The parts affected  by embolism of the main
trunk  are the greater portion of the small  intestine and the upper part of
the large intestine.   The extent of intestine involved  of course  depends upon
the size of the branch obstructed.   The wall  of the affected portion of intes-
tine  is swollen, adematous, and more or less infiltrated with  blood.   There
may be in addition large and small circumscribed  hemorrhages in  the intes-
tinal coats.   The mucous membrane especially  is swollen, soft, and infiltrated
with blood.   Its  surface is coated with a layer of blood or of blood-stained
mucus.  In  certain places there  may be loss of substance from necrosis of the
mucosa.  The solitary follicles,  Peyer's patches, and the mesenteric glands
are frequently swollen.  AVhen the main trunk of the artery is occluded there
are hemorrhages  also in the  mesentery.   At  first circumscribed  peritonitis
and subsequently general  peritonitis result.    If the artery become slowly
obstructed, as by pressure, no effects  follow.
   The symptoms have been studied chiefly by Gerhardt and by Kussmaul.2
Those  to which they attribute diagnostic importance are  the following: 1. A
source for an embolus (organic disease of the heart was  usually present). 2.
Abundant intestinal hemorrhages, which cannot he explained by an inde-
                 1  Virchow's Archiv, 1875, Bd. 63, S. 289.
                 2  Wiirzburger medic. Zeitschrift,  1864, Bd.  4 u. 5. 
CARCINOMA  OF THE  INTESTINE.
495
pendent disease of the intestine or by portal  obstruction.   3.  Rapid fall of
temperature.    4.  Pain in the  abdomen, often resembling colic  and often
violent.   5.  After a time development of tympanites, and perhaps of a recog-
nizable exudation in the peritoneal cavity.   6. The evidence of embolism of
other arteries of the body.  7. In rare  instances the detection by palpation
of sacs containing blood between the folds of the mesentery.   Vomiting was
present in many of the cases reported.   The bloody stools often  had a fetid
odor.  The blood was sometimes of a tarry  consistence, and at  other times it
was fluid or in clots.   Occasionally no hemorrhage occurred.   In  that case
the diagnosis is impossible.  The symptoms  develop suddenly, and death usu-
ally soon follows, preceded by collapse. It does not seem to be absolutely fatal.
In a case reported by Moos which recovered  the diagnosis of this affection was
rendered very probable.  The diagnosis in the favorable  cases of Lereboullet
was not so well established.
  The objects of treatment, as stated by Gerhardt, are  to check the hemor-
rhage, to  prevent necrotic processes in the intestine,  to repair the loss of
blood, and to favor the re-establishment of a collateral  circulation.   He says:
" In what way these indications are to be best fulfilled future experience must
decide."   Moos treated his case which  recovered by rest, lukewarm nourish-
ing broths, small doses of wine, and by the internal and  external application
of ice.   A certain degree of doubt necessarily attaches to  the diagnosis of this
case.
  Embolism  of the  inferior  mesenteric artery is  sometimes unattended  by
symptoms; at other times  symptoms similar to those described were present.
Only about eight cases have been recorded.
                    Carcinoma  of the Intestine.

   Cancer of the intestine presents  the same varieties as when seated in the
stomach.  The most frequent situation by far is the rectum.  Here it is open
to discovery and examination by the touch  and vision.   Next to the rectum,
it is most frequently situated at the sigmoid flexure of the colon ; and next in
the transverse  colon.  It is situated in the  duodenum or jejunum, the lower
portion of the ileum, the descending colon, the ascending colon, and the mid-
dle of the  ileum, as regards relative frequency in the  order in which these
parts  are now  enumerated.  In these different  situations it often produces
obstruction by compression and  stricture.
   The cancerous growth, when  it  has reached  a certain extent, if situated
above the rectum, forms a  tumor which may be felt through the  abdominal
walls.  The problem is then whether or not the  tumor  be carcinoma.   The
diagnosis is to be based on  the existence of radiating, lancinating pains, the
age of the  patient (over forty years), the frequently nodulated  character of
the tumor, the occurrence of bloody stools,  the evidence of hereditary predis-
position,  and the symptoms which denote the cancerous cachexia.  Fecal
tumors, enteroliths, and foreign bodies are to be excluded ; also, sarcomas
and the benign neoplastic growths—namely, fibromas, myomas, lipomas, cysts,
and adenomas.   These as well as cancerous  growths may produce obstruction
at different situations in the intestinal canal.  They cannot in cases of obstruc-
tion be excluded with certainty unless they  be situated in the rectum.  They
cannot he differentiated from each  other during life, and hence they are of
pathological rather than of  clinical interest.  This brief reference to them,
therefore, is all  that is called for.  Duodenal cancer is not easily differentiated
from cancer of the stomach.  The differentiation is not practically  of  import-
ance.   The association of jaundice points to the former. 
496        STRUCTURAL DISEASES  OF THE INTESTINE.


              Waxy Degeneration of the Intestine.

  The character of the  lesion known as waxy, lardaceous, and amyloid  has
been  considered in the first part of  this work. (Aride p. 55).   The intestine
as well as the stomach is not infrequently the seat of this structural change.
The alteration is generally present throughout both the large and the small
intestine, but it  is  usually most intense in the lower part of the ileum.  The
mucous membrane may be the coat  chiefly affected, or in addition the other
coats  may be involved.   Usually the solitary follicles and Peyer's  patches
escape or  are but slightly affected.   In certain  cases, however, the waxy
change  is  most  marked in these structures (Hayem).   Neumann observed
cases  in  which  the muscularis mucosa  was predominantly affected.   AVaxy
degeneration is  not to be  positively recognized post-mortem  without  the
application of iodine or other appropriate reagents.   Simple  inflammation
of the mucosa is  generally present  in  cases of waxy degeneration.   Kyber
denies that there  is any tendency in this alteration to the production of
ulcers.  Tuberculous ulcerations are often present when the waxy metamor-
phosis is secondary to phthisis.
  AVaxy degeneration  may be inferred when diarrhaa  is  a prominent and
persistent  symptom  in  connection  with waxy  degeneration  of the  liver,
spleen, or kidneys, these organs being affected either singly or collectively,
the latter being  often the case.  The lesion  is rarely confined to the aliment-
ary canal, and if so confined the diagnosis is impossible.
  The lesion is a permanent one, and admits of only palliative treatment.


  Certain  structural  affections of the  intestine  are important as  causing
mechanical obstruction to the passage  of  the  intestinal contents.   Hence,
we may consider obstruction of the bowels or  obstipation  as caused, first, by
structural  affections; and  second, as dependent on causes other than  lesions
of structure—namely, on the impaction of feces, the formation of concretions
called enteroliths,  the  introduction of foreign  bodies, and  on merely func-
tional disorder.  The term  ileus or iliac passion and  other  names have been
applied to cases  of obstipation with the ejection from the mouth of the intes-
tinal contents, or so-called stercoraceous vomiting.   As  the latter symptom
occurs in connection with obstruction from various causes, the  names based upon
it have no special pathological significance, and they tend to produce confusion.
  Obstruction from  structural affections  is not of very frequent occurrence.
The  statistical researches  by  Brinton,  the whole number of  promiscuous
necropsies being 12,000, showed obstructions from various  causes, exclusive
of hernia,  in  the  proportion  of 1 in 280  deaths.1    The  lesions  involving
obstruction  are  the  following:  Intussusception or invagination ;  strangula-
tion  from  hernia  within the  abdomen ;  rotation of a  portion of intestine
upon  its own axis or upon the mesentery, and twisting of a portion of intes-
tine around another coil of intestine; compression of one portion of intestine
by another portion or by a tumor situated exterior to the canal;  and stric-
ture produced by morbid growths within the canal or by the contraction fol-
lowing the cicatrization of ulcers.  In these several  affections obstipation is
a common feature; but they differ in an important point—namely, certain of
them  causing only mechanical obstruction,  and others involving in addition
strangulation.   This point of difference is to  be taken into  account with
reference  to  diagnosis, prognosis, and treatment.   The  structural affections
giving rise to both obstruction and strangulation will he first considered, and
afterward obstruction by causes which do not occasion strangulation.
           1 British and Foreign Medico-Chirurg. Review, October,  1857. 
INTUSSUSCEPTION.
497
                          Intussusception.

  Intussusception, or intestinal invagination, is the reception of one portion
of the intestine into  another portion.   Generally, the invagination is  from
above downward, but in rare instances the lower portion  is received into the
upper.   The latter, called retrograde  invagination, according to  Leichten-
stern, never  becomes  incarcerated  and  strangulated.   It is certain  that
invagination  may occur  transiently, giving rise  to  no symptoms.  In  post-
mortem examinations, especially in children, innocuous invaginations of the
small intestine  are not infrequently found;  the invaginated portion  is  re-
stored without  difficulty, and, aside from the displacement, there are no mor-
bid appearances.   I counted  as many  as fifteen such invaginations in the
body of a child dead with typhoid  fever.  They have been observed  espe-
cially after  death from  cerebral diseases, and they are supposed to  occur
during the last moments of life.   It is  only when the  invaginated portion
becomes  incarcerated, giving rise  to  congestion,  inflammation,  etc.,  that
obstruction and the symptoms of strangulation are  produced.  The lesion is
<hen one of  very great gravity, in the great majority of cases ending fatally.
This is  the most frequent of the lesions causing fatal obstruction.  Of 169
cases of  obstruction from  various  lesions collected by Phillips, 03 were of
this class.  An analysis of GOO cases by Brinton showed in 43 per cent, the
obstruction to  be from intussusception; and  of 1541 cases of obstruction
from  all causes  analyzed by Leichtenstern, 442  were  due to this  cause.1
The  greater  relative  frequency of the  affection, however, relates to  child-
hood.  In adults it is less frequent than other causes  of obstruction.
  Intussusception brings into apposition three layers of intestine—namely,
an entering, a returning, and a receiving layer.   The receiving layer is called
the intussuscipiens, and the middle and inner layer  the intussusceptum.  In
the relation of the returning and receiving layers mucous surfaces are in con-
tact, and these do not become adherent; but  serous surfaces are in contact
in the relation of the entering and returning layers, and inflammation, excited
at the point of entrance, leads to adhesion of  these surfaces extending  more
or less beyond this point.  In this way the invagination becomes incarcerated.
The  vessels of the portion of  the mesentery connected  with the invaginated
intestine are obstructed by tension.  Congestion  and swelling of the invagi-
nated intestine ensue;  it  is dark-colored and ecchymotic, and at length it
becomes  gangrenous and sloughs away if life he  sufficiently prolonged.  The
obstruction is due  to  the swelling  from congestion  and  the exudation  of
inflammatory products.  Usually, the  obstruction is complete, but in rare
cases the intestinal passage remains pervious although  much contracted.  In
these cases the intussusception is usually in the large  intestine.   Peritonitis
may extend more or less around the seat  of the invagination, leading to mor-
bid attachment to the adjacent parts.
  The invagination may occur at any point in  the intestinal tract.  Its most
frequent seat is at the junction of the ileum and the cacum.  This is shown
in cases of children by the statistical researches of J. Lewis Smith.2  Smith's
account of the  mode in which  it generally occurs is as follows : " The intus-
susception not  infrequently begins in the prolapse of the ileum through the
ileo-cacal valve, in the same  way that prolapse of the rectum occurs through
the sphincter ani.  If death  take place early, only a small portion of the
ileum may have passed the valve.   If  the case  be  protracted,  the tenesmus

  1 \Tide Ziemssen's Cyclopaedia, Am. ed., vol. vii.
  2 "Statistical Researches relative to the Seat, Symptoms, Pathological Anatomy, etc.
of Intussusception in  Children,"  Am. Journ. of Med. Sciences, Jan., 1862.  A'ide also
Smith on the Diseases  of Chddren.
32 
498        STRUCTURAL  DISEASES  OF  THE INTESTINE.
brings down more and  more of the ileum with its accompanying mesentery.
The constriction of the valve, which acts  as a ligature, prevents the further
descent of the ileum, and, the tenesmus continuing, the next step is the inver-
sion of the caput coli, which is drawn into the colon  by the descending mass,
and unless the case terminate by sloughing or death  the ascending and trans-
verse  portions of the colon are successively invaginated.  Not infrequently
the cacum  is the part primarily inverted and invaginated, and, descending
along the colon, it draws after it the ileum, which  sustains its natural relation
to the ileo-cacal valve.   These two forms of invagination—that in which the
ileum, passing through the ileo-cacal  valve, successively inverts and draws
after it the caput coli and the divisions of the colon, and that in which the
caput coli is primarily invaginated, and, descending along the large  intestine,
inverts the latter and draws  after it the ileum—constitute the vast  majority
of cases of this disease in childhood."   The invaginated portion may descend
so low as to be felt and seen at the anus, and it may even protrude  from the
body.  The invagination, however, may occur at any  point in either the large
or the small intestine.   Of the cases analyzed by Brinton, the intussusception
was ileo-cacal  in  50 per cent., iliac in 28 per cent., jejunal  in  4 per cent.,
and in the colon in 12 per cent.   Leichtenstern's statistics of 479 cases gave
52 per cent, of ileo-cacal  and  ileo-colic, 30 per cent, of iliac, and 18 per cent.
of colic invaginations.
  The probable causation in the majority of cases is formularized in the fol-
lowing quotation  from  Leichtenstern :  " Paresis  of a limited  portion of the
intestine,  associated  with  vigorous peristaltic action excited by any cause
whatever, offers suitable  conditions for invagination."  In  adults the most
frequent cause is a tumor of the intestine, particularly a polyp-shaped tumor,
projecting within the intestinal  canal.   Such  a  tumor by its  weight drags
down  a portion of the intestine and thus mechanically causes intussusception.
  Intussusception causing obstruction  and strangulation, as already stated,
proves fatal in the great majority of cases ; yet the affection is by no means
absolutely hopeless.  The manner in which recovery usually takes place is of
importance in its  bearing on the  treatment.  The  invaginated portion of
intestine sloughs  away and is evacuated, the  entering and receiving portion
at the point of entrance remaining adherent and the perviousness of the canal
being restored.   Cases have been reported in which  a large portion of invag-
inated intestine  was thrown off, and recovery followed.  Prof. Aan Buren
reported a case to the New York  Pathological Society in which five feet of
intestine were passed per  anum. the patient recovering.  Prof. Peaslee exhib-
ited at a meeting of  the 'Sew  York Academy of Medicine, in  1805, five feet
of intestine which had been passed per  anum four months before the death of
the patient.  He also exhibited the intestines removed from the body of this
patient after death.  The small intestine was  only sixteen feet  in length, the
length of the large intestine  being five feet and ten inches.   The invagina-
tion and sloughing had  taken place in the small intestine at a distance of six
feet from  the  duodenum.  A stricture existed at this point; the  intestine
above was much  dilated,  and that below was  greatly reduced  in size.  The
patient died from inanition dependent on the stricture of the intestine.1  Dr.
AVilliam Thompson of Edinburgh collected 43 cases ending in recovery.2  Of
Dr. Haven's 59 cases, in 12 the invaginated portion was passed per anum, and
of these 12 cases 10 ended in recovery.  This is the  mode of recovery which
is to be hoped for after incarceration and  strangulation of the invaginated
intestine have  taken place.
  1 Aide Bulletin of the Nnr  York Academy of Medicine, vol. ii. Xos. 2o-29.
  2 Aide article on " Internal Strangulated Intestine," by Elisha Harris, M. D., in Nv:
York Journal of Medicine, 1853. 
INTUSSUSCEPTION.                       499
  The prominent local symptoms which enter into the clinical history of intus-
susception  are  the  following : Pain is more or less prominent, at first  parox-
ysmal as in colic, and after a time becoming constant, with  frequent exacer-
bations.  The pain, if the  patient  be old  enough to describe it, appears to
emanate from a certain fixed point,   Tenderness  at first may not be marked,
but  becomes developed, being  either  limited to  or  greatest at the  point
whence  the pain emanates.  The tenderness and constant  pain denote the
occurrence  of peritonitis at the  seat of the invagination.   Vomiting soon
becomes a prominent and persistent symptom, with very few  exceptions.  The
vomited matter after a time may have the odor of feces, and is then said  to
be stercoraceous.  The accumulation  of ingesta  and gas above the obstruc-
tion occasions more or less abdominal distension, provided  the  invagination
be not situated  in the upper portion of the small  intestine.   Frequently, the
accumulation of intestinal contents at the seat of the invagination gives rise
to a tumor  appreciable by the eye and touch, and to dulness on percussion.
The  tumor is elongated, •'sausage-shaped,'' corresponding  to the  size and
direction of the dilated intestine above  the  seat of the obstruction.  After
the contents  of  the intestinal canal below  the seat of the  obstruction have
been evacuated there is persisting obstipation, save in a few exceptional cases.
Previously  there is usually diarrhaa, followed by the discharge of bloody
mucus, and if the invaginated  portion  of  intestine descend to the rectum,
tenesmus is felt and the patient is led to  make straining efferts.  Under these
circumstances the affection  is liable to be mistaken for  dysentery.
  The general symptoms at first may  not be marked, but soon they  denote a
grave aff'ection.   The pulse becomes  accelerated,  its frequency progressively
increases, and it is  proportionally feeble or compressible.   Progressive pros-
tration, hiccough, coolness or coldness of the surface, and an anxious or hag-
gard expression, denote the progress  toward a fatal termination.  The mode
of dying is by asthenia, the pain and tenderness frequently diminishing  or
ceasing  for  some time before death.
  A favorable progress is denoted by  the occurrence of free  evacuations from
the bowels, the discharge  of  the invaginated portion of intestine,  together
with improvement in the  local  and  in the general symptoms.
  Invagination  is to be distinguished  from functional colic,  acute peritonitis,
and obstruction from other causes.  The symptoms at  first may denote noth-
ing more than colic.  The persistency of the pain, the development of tender-
ness, the acceleration of the pulse, the vomiting,  etc., however, soon point to
an affection of greater gravity  than  colic.  Acute  peritonitis  is to be excluded
by the  gradual development of the  local  and  general  symptoms:  by the
absence of  diffused tenderness  over the  abdomen and  of rigidity of the
abdominal  muscles;  by the localization of pain and tenderness within a cir-
cumscribed space; by stercoraceous vomiting;  and by  the presence of a cha-
racteristic tumor.  Acute peritonitis sometimes supervenes in cases of  invag-
ination from rupture of the intestine  above  the obstruction.   From  obstruc-
tion caused by hernia within the abdomen or by  rotation and twisting  of the
intestine the discrimination is more  difficult, and, indeed, cannot be made with
positiveness.  The age of the patient  has a bearing on  the diagnosis.  Invag-
ination occurs most frequently in infancy.  According to Smith's statistics, it
is most liable to occur between the  second and  third months of infantile life.
Of 47 cases, only 18 occurred  between the ages of one year and twelve years.
In Haven's  cases the mean age  was  eighteen  years;  the youngest age was
three months, and the oldest  sixty-five years.  In Leichtenstern's  statistics
half of the whole number of cases (473) occurred  during the first ten years of
life;  and one-fourth  occurred  after three months  and within the first year of
life.   3Iale children are somewhat more  liable to it than female, the relative 
500        STRUCTURAL DISEASES  OF  THE INTESTINE.

proportion in Smith's cases  being 32 to 22, and in  Haven's 59 cases 34 were
males.  On the other hand, hernial  obstruction occurs oftener after infancy
and childhood, and  cases occur oftener in females than  in  males.
   A point in diagnosis is to determine the probable seat of the invagination.
The chances are that it is seated at the junction of the large  and small intes-
tine,  especially in childhood.   The probability  of this  being  the  seat is
increased if the pain, tenderness, and swelling are situated in  the neighbor-
hood of the right iliac  fossa.   Tenesmus, with the discharge of blood  and
mucus, shows that the large intestine is  involved.  The invaginated portion
may sometimes be felt and seen within the rectum.   If seated  in the small
intestine, the constitutional  disturbance is greater, and if the point of obstruc-
tion be toward the upper portion of  the small intestine, there will be little or
no abdominal distension.  Indican is found in abnormal quantity in the urine
in case of intestinal obstruction from intussusception and other causes, but
also in other  affections of the alimentary  canal.1
   The prognosis  is extremely unfavorable.  The usual mode of recovery in
the exceptional  cases in which the  affection  does  not end fatally has been
stated—namely, by sloughing away of the invaginated  portion of intestine,
the adhesions at the point of entrance being permanent.   Possibly the invag-
inated portion is spontaneously restored in  some cases after symptoms denot-
ing the affection are developed, but  such  instances  must  be  rare; and it is
also rare for the invaginated portion of intestine to remain, the canal becom-
ing or  continuing pervious.  Of the  50  cases analyzed  by  Dr. Smith, in 7
recovery  took  place, in  each  case by sloughing.   In all  these 7 cases  the
ages were between five and  twelve years, Dr. Smith's researches being limited
to cases occurring in childhood.   The constitutional powers in infancy do  not
seem to be adequate to  support the affection for a sufficient period for  the
sloughing  process to be  completed.  The separation of the invaginated  por-
tion of intestine takes place, according to Leichtenstern, in the majority of
cases between the  eleventh and the twenty-first day.  In fatal  cases the dura-
tion rarely extends beyond eight days.  Death may take place within twenty-
four hours, the symptoms denoting " shock."  In the majority of  cases life is
not prolonged beyond the third day.   In rare instances, the obstruction being
incomplete and the  invaginated intestine  not strangulated,   the  affection is
tolerated for many weeks and months.  There are cases, therefore, of chronic
intussusception.   Death  sometimes is hastened by peritonitis  caused by rup-
ture of the intestine above the seat of the obstruction.   In  young children
the duration is sometimes shortened  by the occurrence of convulsions.  Gen-
erally, the mode of dying is by slow asthenia.
   If  the  existence of invagination  could  be  ascertained  prior to the devel-
opment of  symptoms  denoting incarceration, it is probable that measures
for restoration  might be successfully employed; but  generally a day or two
elapses before the  character of the affection is even  suspected.   In the mean
time cathartics are likely to increase the invagination and  diminish the prac-
ticability  of restoration.  The liability  to the existence of this affection,
especially in children, should be borne in mind in cases of apparent colic, and
should  dictate  reserve in  the employment of  cathartics.  As  soon as  the
character of the affection is rendered probable by the symptoms measures to
effect restoration may be tried.  These measures are the injection of water or
of air in considerable quantity into the rectum.  If practicable, the injection
should be made through  a long flexible tube carried into  the  intestine as far
as it can be made  to pass without  undue  force.  The  object  is to effect  the
restoration by the upward pressure  of the air or water.   The injections are
not to be pushed beyond the limit  at which  they are borne without much
     1 Aide article by Heineman, Archives of Medicine, New York, August, 1880. 
INTUSS USCEPTION.
501
suffering,  and if they do not  succeed after a  fair trial they are not to be
persisted in.   They will very  rarely succeed after the invaginated  portion
of intestine has  become swollen by congestion and the peritoneal surfaces in
contact have become adherent.   If  pushed too far, rupture of the intestine
below the seat of the obstruction may be produced.   I have known rupture
to result  from the injection successively of an  alkaline carbonate  and an
acid, giving rise to the  evolution of gas within the intestine.  This method
of employing pressure is highly objectionable, because the amount of pressure
cannot be regulated.  Cases  have been repeatedly reported in which  the injec-
tion of air or water has apparently effected restoration in cases of supposed
invagination  even after  obstruction had  existed  for several  days;  but it is
probable that in  a certain proportion of these cases invagination did not really
exist.  These measures for reduction are of no avail if the seat of the invagina-
tion be above the ileo-cacal valve.
   Exclusive of measures for reduction, the objects of treatment are to secure
as much quietude of  the intestinal canal as possible, to palliate suffering, and
to support the powers of life, under the hope that sloughing and recovery may
take place.   The  avoidance of cathartics is essential.  The  practitioner is
not to be tempted to employ them with the hope of overcoming the obstruc-
tion.   They interfere with the  objects just named, and are destructive.   Not
only the active cathartics, but even mild purgatives and laxatives, are contra-
indicated.  To quiet  the peristaltic  movements  opium  is to be given in  suf-
ficient  doses to secure relief of  pain without inducing narcotism.  Fomenta-
tions over the abdomen  are useful.  The strength of the patient is to be
supported by concentrated and  purely nutritious food given  in small quan-
tities at a time, together with alcohol.  It is to be borne in mind that recovery
will depend on life being sufficiently prolonged for the sloughing away of the
invaginated portion of intestine.  Bloodletting, counter-irritation, or any meas-
ures which tend to impair the vital  forces are never indicated, and  they can-
not fail to do harm.  After sloughing has taken  place and  the  obstruction
has been removed, purgatives are not to be employed, lest by exciting  unduly
peristaltic  movements the adhesions at the point of the invagination may be
broken up and peritonitis ensue from the  escape of the contents of  the intes-
tine into the peritoneal sac.
   Important practical questions relate to  the operation of abdominal section,
or laparotomy, in cases of invagination.   Heretofore this operation has been
resorted to as a  last resource, and for this reason its  merits were not fairly
represented by its results.   The first object of the operation is to restore the
parts if practicable, and, if  this be not practicable, a second object  is to  per-
form enterotomy and establish  an artificial anus. The chances for restoration
are greater in proportion as  the operation  is resorted to early.  After strangu-
lation has existed for some time it would not be advisable to restore the in-
vaginated intestine, even were  this practicable.  After the  time  has elapsed
for the practicability  or safety  of the restoration, the chances of recovery by
sloughing away  of the  invaginated  intestine are  lessened by the operation,
and it would have been better to have trusted to  Nature's method.   Taking
into  view this consideration, together with  more or less uncertainty as  re-
gards the diagnosis, surgeons have not been disposed to regard  the  operation
with favor, and in the early editions of this work  doubts concerning  its  pro-
priety were expressed.   AVithin  the past  few years, however, experience  has
shown  that laying open  the  peritoneal cavity is  not attended with the danger
formerly attributed thereto, and a number of  cases have been reported in
which the operation for invagination has been resorted to with success.  Pro-
fessor Sands, in 1*77, operated successfully in the case of an infant six months
old, eighteen hours after the occurrence of symptoms  denoting invagination. 
502        STRUCTURAL DISEASES  OF THE INTESTINE.

In  connection with  his report of this  case  he gives an analysis  of 2D cases
collected from different sources, in 7 of which the operation was  succes.-ful.1
The important points for decision respecting the operation in individual cases
are the correctness of the diagnosis and the probability or otherwise that the
invaginated intestine has not become gangrenous.   The probable seat of the
invagination is of importance with reference to enterotomy.
   As a palliative measure, if the distension  of the abdomen from tympanites
become excessive, interfering with  respiration, it has been recommended to
pass an aspirating needle  into the intestine and remove the gas.   This pro-
cedure  is not devoid of danger.  Prof. AYelch has met with  an  instance in
w*hich  fatal peritonitis was thereby induced, fecal gas and thin feces escaping
into the peritoneal cavity.
   Reference has been already made to cases in which  invagination may not
involve complete obstruction and is  tolerated for several months.   These are,
of course, cases of invagination without strangulation.  A remarkable instance
has been reported by Dr. C. A. Leale.  The patient was a woman seventy-nine
years of age.  An attack of severe abdominal  pain was followed by jaundice,
bloody  stools, tenesmus, complete fecal obstruction,  and from time to time
vomiting of intestinal contents.   Five weeks afterward, on exploration of the
rectum, an invaginated portion of intestine was felt.   The finger, after con-
siderable effort, was passed into the latter, and  two quarts of pasty feces were
subsequently voided.  Eleven days afterward a solid body was felt at the open-
ing of the invaginated bowel. This  was broken into two pieces, and with con-
siderable difficulty it was removed.   It proved to be an enterolith four and a
quarter inches in circumference and two and a half inches in length,  formed
by concentric layers  of stercoraceous matter around a biliary  calculus three
and a half inches  in circumference.   Restoration of the bowel was speedily
effected by the injection of carbonic-acid  water in large quantity.   This
patient  was seen by me in  consultation.2  Jonathan  Hutchinson  relates the
ca>e of a  child  in  whom  the  invaginated  bowel extended  several  inches
beyond the anus.   The case  had  heen treated  as  one  of  prolapsus ani.
Abdominal  section was made and the  bowel was restored with ease.  Rapid
recovery took place.  The invagination  in  this case began  at the cacum.


   Strangulated Hernia within  the  Abdomen—Rotation or
                       Twisting  of Intestine.
   Several abnormal conditions lead  to hernia within the abdomen.  Fissures
sometimes exist in the mesentery, meso-colon, omentum, and diaphragm, into
which a portion  of intestine passes  and is liable to become incarcerated and
strangulated.  The vermiform appendix  of the cacum sometimes becomes
adherent to  an adjacent part, leaving a loop through which intestine  may pass
and  become ligated.   The same may happen  in connection with  diverticula
of the intestinal tube, which are not very infrequent.  The  most frequent
and important of these is that known as Meckel's diverticulum.   This repre-
sents a portion  of the unobliterated omphalo-mesenteric canal, by which  in
the embryo the umbilical  vesicle  communicates  with the intestine.   It  is
connected with  the  ileum  usually from a foot to three  feet above  the ileo-
cacal valve.   From its extremity a solid cord containing the remains of the
  1 Aide New York Mediad Journal, June, 1877; vide also article by Dr. John Ash-
hurst, Jr., in the Amer. Journ. Med. Sciences,  July, 1874 ; also article by Jonathan
Hutchinson, in the Loudon Med. Times and  GazeUe,So. 29, 1873, and in the New York
Med. Record, January 15, 1874.  Peyrot  has collected 23 cases, of which 9 recovered:
De I' Intervention chimrgicule dans I'Obstruction intestinale, Paris, 1880.  This work con-
tains an analysis of 12o laparotomies for intestinal obstruction.
  2 For the report of Dr. Leale's case, vide New York Med. Record, November 22, 1S79. 
     STRANGULATED  HERNIA  WITHIN  THE ABDOMEN, ETC.   503

omphalo-mescnteric vessels may pass to the umbilicus.   Bands of adventitious
membrane, resulting from peritonitis, may leave spaces for hernial protrusions.
A'arious other forms of internal hernias have been described, some of which,
being very rare, are to be regarded as curiosities rather than of practical im-
portance.  Much has been written concerning the so-called duodeno-jejunal
hernia, of wdiich between fifty and sixty  cases have  been reported.  In this
form of hernia, first accurately described  by Treitz. the small intestine makes
its way into the duodeno-jejunal fossa,  which normally is a small pouch situ-
ated in front of the vertebra at the beginning of the  mesentery.  A crescent-
shaped fold of peritoneum, passing over the duodeno-jejunal flexure, bounds
the free  opening of this fossa, which is directed upward.  All of the small
intestine has been known to push its way into this fossa, which  then becomes
enormously  distended.   The intestine lies behind the peritoneum in this form
of hernia.  A very rare form  of internal hernia is produced by the passage of
portions of  the small intestine through the foramen of AVinslow into the cav-
ity of the lesser omentum.  Diaphragmatic hernia is more frequent on the left
than on the right side.   The intestines pass more frequently through the mus-
cular than through the  tendinous part of the diaphragm, and oftener through
the posterior than the anterior part.  The organs usually involved in diaphrag-
matic hernia are. in the order of frequency, the stomach, the transverse colon,
the omentum, and the small intestine.   The hernia may be due to a congenital
defect in the diaphragm.   Acquired diaphragmatic hernia is most frequently
referable to traumatism, as to a stab or gunshot wound.  Rare forms of her-
nia which are not, strictly  speaking, internal, but which are often difficult to
detect by external  examination, are the ischiatic, the obturator, the perineal,
the  lumbar.  As regards the frequency of the different varieties of internal
hernia, of Leiohtenstern's  1541  cases,  embracing obstruction from all  causes.
the  strangulation was  caused by false  ligaments in 111,  by the omentum in
58.  by diverticula in  GG,  b}* the  appendix vermiformis in 34, by the  dia-
phragm in  215,  and  in other ways in GO.   The cases  collectively amount
to 544.
   AVhatever be the mode in  which the strangulation is produced, the  symp-
toms are the same.  They are, in fact, identical with the symptoms of ordi-
nary strangulated hernia occurring at  the femoral or the  inguinal outlet, and
they are for the most part the same as in cases of intussusception.  The exist-
ence of tenesmus with bloody and mucous evacuations in certain cases of the
latter constitute the chief  point of distinction.  Irrespective of  the symptoms
 just named, the  differential  diagnosis  can hardly be made with positiveness.
but  the chances are that in the young child invagination  exists, whereas in
after-life  obstruction from other causes is more liable to occur.   The small
intestine is  far more likely to be the seat of hernia within the abdomen than
the large intestine.  Sloughing of the strangulated portion of the intestine is
destructive, whereas in  cases of invagination it is the mode of cure.   The
only hope of recovery  is  in  the spontaneous or operative reduction  of the
hernia before gangrene takes place.   Distending the large intestine with air
or water  will probably  be useless if the seat of the hernia be  in the small
intestine.   Cathartics do harm.   Opiates to palliate pain, fomentations to the
abdomen, and supporting measures are indicated.
   Rotation, or twisting  of a portion of intestine (volvulus), so as to induce
strangulation, is most liable to occur at the sigmoid flexure of the colon.  An
unusually small root of  the sigmoid meso-colon favors torsion of this portion
of the intestine.  The root  of the  meso-colon  may be contracted by cicatri-
cial  tissue from an old peritonitis.  Similar contractions may occur elsewhere.
Torsion may occur at the cacum, this portion of the large intestine being
exceptionally mobile.    Twisting of a portion of intestine around' an  axis 
 504         STRUCTURAL. DISEASES OF THE INTESTINE.

 formed of mesentery or around another coil of intestine  occurs in the small
 intestine, or a coil of intestine  may become looped around the sigmoid  flex-
 ure, and  vice versa.   These accidents are infrequent.  Their symptoms are
 those  of  strangulation, and it is impossible to discriminate them from hernia
 within the abdomen.  In  the analysis of 600 fatal cases of obstruction from
 various causes exclusive of hernia, rotation or  twisting of intestine occurred
 in 8 per cent.   In Leichtenstern's 1541 cases, 54 were in this category.  In
 cases of obstruction and strangulation exclusive of invagination the propriety
 of resorting to  laparotomy is to be considered.  Ashhurst (op. cit.) collected
 57 cases in which this operation was performed.  Of these cases, 18 terminated
 successfully, giving  a mortality of a little over 68 per cent.  It is in favor of
 resorting to the operation  in these cases  that the  prospect of recovery with-
 out it is much less  than in cases of intussusception.   Ashhurst's  conclusion
 embodies a proper rule of  practice in these cases.   It is as follows:  " In cases
 of acute intestinal obstruction from other causes than intussusception, should
 milder measures  fail  to give relief in the course of three, or at most four,
 days, laparotomy should be unhesitatingly recommended, and may under such
 circumstances be  resorted  to with a reasonable hope of success."
   A highly important injunction is to be added to the consideration of obstruc-
 tion dependent on the foregoing structural  affections: It  is, that the practi-
 tioner in  all  cases which  present the symptoms of these affections examine
 carefully  for inguinal or femoral hernia.  The hernial tumor may be so small
 as not to  excite the  attention of the patient, and in females motives of delicacy
 may  prevent the patient  from suggesting  an examination  even  when the
 presence of a tumor is known to her.  Instances have repeatedly occurred of
 patients dying with a strangulated femoral or inguinal hernia which was over-
 looked, the symptoms being attributed to some inaccessible lesion or even to
 functional disorder.


             Compression and Stricture of Intestine.
   Obstruction due to  closure or diminished  calibre of the intestinal tube by
 morbid growths within the tube, the pressure of tumors situated exterior to
 the tube, or  constriction  following the  cicatrization of ulcers,  differs from
 obstruction  caused  by the  structural affections  already considered in  not
 involving strangulation.  The obstruction under these circumstances is devel-
 oped  gradually, having been preceded by progressively increasing constipa-
 tion.   Above the seat of  the  obstruction the intestine is dilated  and filled
 with accumulated fecal matter.   The muscular coat is hypertrophied.  Below
 the obstruction  the  intestine is small, collapsed,  and often atrophied.  The
 obstruction  is rarely complete.   The  local and constitutional symptoms inci-
 dent to inflammation, sphacelation, and  sloughing  of  the  intestine  are want-
 ing.   The symptoms are those  arising from  the gradual accumulation of the
 contents of the intestine above the point of obstruction.  The affection pro-
 gresses more slowly  toward a fatal termination after the obstruction becomes
 nearly or  quite complete than the affections which  involve strangulation.
  Cases of obstruction falling under this head form a considerable proportion
 of the  cases of obstruction from all causes.   Stricture of the intestine may be
 due to cicatrization of dysenteric, of syphilitic, of digestive, and of simple in-
 flammatory ulcers, and in rare instances to partial  cicatrization of tuberculous
ulcers, to  cicatrization of  ulcers produced by irritant poisons, and of ulcers
caused by sloughing of an invaginated  portion of intestine.   In exceptional
cases cicatrization of unusually extensive and deep-seated typhoid ulcers may
be followed  by stenosis.   The contraction of  newly-formed connective  tissue
resulting from circumscribed or from general peritonitis may  cause constric- 
           COMPRESSION AND STRICTURE  OF INTESTINE.       505

 tion of the intestine.   Both benign and malignant tumors may produce intes-
 tinal stenosis, either by pressure or by invading in their growth the calibre of
 the intestine.  The consideration of  syphilitic  and other strictures of  the
 rectum belongs to surgery.   In the majority of  cases stricture is due to can-
 cer of the intestines.   According to the  statistics  of Coupland and  Morris
 (1 *7*), in three-fourths of the cases of stricture  the seat is in either  the
 rectum or the sigmoid flexure. The transverse and descending colon  are more
 frequently affected than the ascending colon and the cacum.
   The discrimination of the  cases of obstruction caused by compression or
 stricture from the cases involving strangulation can generally be made clin-
 ically  by means  of the differential  points which have just  been stated.
   The fact of the obstruction  being seated in the lower part of the large intes-
 tine can  generally be ascertained.   If seated in the  rectum, it is accessible to
 direct  exploration.   If seated at the sigmoid flexure, the  fact is shown by the
 evidence, afforded by manual  exploration, of distension of the transverse and
 ascending colon and by the inability to inject liquid beyond the rectum.  Per
 contra, the situation at the upper part of the large intestine or in the small
 intestine  is shown by the absence  of distension of the  large  intestine with
 intestinal contents, and by the ability to fill the colon with  injected  liquid.
 The obstruction may be complete, but in general a certain quantity of lique-
 fied fecal matter passes the point of obstruction and is evacuated.  The injec-
 tion of liquids as a means of determining the seat of stricture is open to falla-
 cies.   Not only may the obstacle be clue to other causes, such as a fecal col-
 lection, but liquids  may pass beyond a  stricture from  below, although the
 occlusion be complete as regards the passage downward of intestinal contents.
 Simon's method of exploration by the passage of the hand into the bowel may
 be resorted to, giving due consideration to  the care to be  exercised in the ope-
 ration  and the possible danger of producing rupture of the intestine.
   The distension from accumulation of the intestinal contents may lead to rup-
 ture of the intestine.   The distension may gradually go on and lead to this
 accident without  pain or other symptoms sufficient to direct attention to the
 existence of any  serious  obstruction.  This fact was illustrated by  a case
 under  my observation at Bellevue Hospital, in which nothing more than ordi-
 nary constipation had been suspected, when peritonitis suddenly became devel-
 oped, ending fatally in a short time.   Obstruction was produced in this case
 by a  cancerous tumor at  the sigmoid flexure;  the colon and  cacum were
 enormously distended with feces, and the peritonitis  was due to rupture of the
 cacum.   This case illustrates the ability of  the ileo-cacal valve to resist an
 amount of pressure  sufficient to lead to rupture of the cacal walls.
   In the treatment of obstruction from compression or stricture active pur-
 gatives are  to  be avoided, but saline laxatives  in  small doses,  in  order to
 liquefy the intestinal contents, are indicated.   Colic pains are to be relieved
 by opiates.  The diet should be nutritious and concentrated, in order to leave
 as little fecal residue as possible.   If the obstruction be situated at the lower
 part of the large  intestine, careful efforts to pass a  flexible tube beyond the
 constricted portion may be employed, and if successful liquid  maybe injected
 above the obstruction.
   In cases of  obstruction  from compression or stricture at the lower part of
 the large intestine, colotomy with a view to the establishment of an  artificial
 anus is warrantable, provided  other measures to free the intestine from an
amount of accumulation likely to lead to  rupture be not successful.  Cases
have been reported in which  life has been  prolonged and comfortable health
obtained  by means of surgical interference.   Casar Hawkins reported the
results of the operation for artificial anus  in 44  cases.  In 10 of these pases
death took place within forty-eight hours,  in 21 within five weeks, and in 13 
506        STRUCTURAL  DISEASES OF THE INTESTINE.

the operation was successful.  Of these 13 cases.  6 died in six months, and 7
survived more  than  a year.  Professor Erskine  Mason, in connection with
G eases in which he had performed this operation, collected and tabulated  so
cases, exclusive of the 44 cases reported by Hawkins.   The reader is referred
to Mason's article for a full consideration of the claims of colotomy.1


Obstruction from Impaction of Feces, Gall-Stones, Entero-
                    liths, and  Foreign Bodies.

   Obstipation may be produced by the  causes named in the above  heading,
but in general they induce only more  or less constipation, and in treating  of
the latter affection they will again be referred to.  An accumulation of a
mass or of masses of hardened feces  sufficient to produce obstruction may
take  place in different parts of the large intestine.  The rectum  in aged per-
sons  not infrequently is  the seat of such  an accumulation.  It is to be sus-
pected when  enemas cannot be given  and perhaps the pipe of the syringe
is found to penetrate a fecal mass.  Examination shows the seat and the cha-
racter of the obstruction.   It  may be  necessary to  break down  and remove
the accumulation by a scoop or the handle of a spoon.   The accumulation
may  be at the sigmoid flexure, and then resistance  to the passage of  liquid
injected and to  the introduction of a flexible tube is found to be at that point.
The accumulation  may  be  at any point above the  sigmoid flexure, but  is
oftenest  in the cacum  or  ascending  colon.
   Masses of  feces above the sigmoid  flexure may give rise  to a tumor or  to
tumors  appreciable  by manual exploration  through  the  abdominal  walls.
These fecal tumors are liable  to be mistaken  for others of a different cha-
racter.   A woman in the country presented an  abdominal tumor of the cha-
racter of which her attending physician was not satisfied, and an eminent pro-
fessor of anatomy, now deceased, was  requested to see the case.  He was led
to regard the tumor as malignant, and of course to form a very unfavorable
prognosis.   Shortly  after  the consultation a profuse  diarrhaa  set  in, and,
much to the astonishment of the  patient  and  her physician, the tumor sud-
denly disappeared.   It was a fecal tumor.  I could cite other instances of a
similar  error.   In view of the liability to error  of diagnosis, and  in order
that  appropriate measures of treatment may be pursued, the distinctive fea-
tures of the tumors are  to  be borne in mind.   One point in the diagnosis  is
their situation in  the tract  of  the colon.  Generally, they are not tender  on
pressure, but may be handled freely without giving pain ;  but  to this rule
there are some  exceptions.   By firm and continued pressure they may some-
times be moved backward or forward in the direction of the colon.  By firm
and continued pressure also  the form of the tumor may be altered.
   The absence  of pain, tenderness, vomiting, and  of the constitutional symp-
toms accompanying invagination, internal hernia, and twisting of the intestine
suffices  to exclude these affections, but it cannot  be at once determined that
the obstruction is not due to compression or stricture.  The effect of measures
of treatment will be likely to settle  the diagnosis.   The  measures  to  be
employed are mild purgatives in  small  doses,  repeated after short intervals,
conjoined with large  enemas given through a stomach-tube carried upward  to
the sigmoid flexure.  Active cathartics do not accomplish the object, and are
liable to do harm.   The object is  to  soften  the harder collections, at the
same  time gently increasing  the  peristaltic  movements.  An emulsion of
castor oil and a solution of the sulphate of magnesia or of soda are eligible
  1 Aide Am. Journ. of Med. Sciences, October, 1873.  A considerable number of cases
has been  reported in different  medical journals since  the date of Professor Mason's
article. 
         OBSTRUCTION FROM IMPACTION OF FECES,  ETC.      507

purgative remedies.  The bitter waters (Friedrichsliall, Pulna, and Hunyadi
Janos) may be found effective.   The injections should consist of lukewarm
water, to which syrup or mucilage  should be added to obviate rapid absorp-
tion  by the bowels.   Some  attach  importance to  the  addition of ox-gall  to
the enemas.   These measures,  judiciously employed, will generally prove
successful without much delay in relieving  the obstipation and  causin<r the
fecal tumors to disappear.   Mild purgatives may be required  for some  time
after the obstruction is removed; and  the treatment  then will resolve itself
into  that adapted to habitual  constipation.
   Obstruction may be  due to the  presence  of large gall-stones  or of intes-
tinal calculi or enteroliths.   Gall-stones of sufficient size  to produce obstruc-
tion usually escape into the intestine after fistulous communications have  been
formed  between the gall-bladder and some part  of the  intestinal canal,  as
the duodenum.  Large gall-stones  may, however, pass through the greatly-
distended ducts into the  duodenum.  Obstruction produced by gall-stones is
rare, and is  almost  invariably  situated in the small intestine.1  Intestinal
concretions or enteroliths rarely  exceed  in  man the size  of a hazelnut.  In
the horse and other herbivorous animals they  are more  common, and  may
attain an enormous  size, weighing  sometimes twenty pounds.  These intes-
tinal calculi in animals constitute a variety of the so-called bezoars, to which
were formerly attributed remarkable medicinal virtues.  The nucleus of these
concretions in man is often formed by a gall-stone, by a hard mass of feces, or
some foreign body, as fruit-seeds, eggs of ascarides, indigestible aliment, etc.
The concretions frequently  present concentric layers. They are composed
for the most part of phosphate of lime and of magnesia, mixed with carbonate
of lime,  biliary coloring matter, and intestinal mucus.  Concretions occasion-
ally form in  the  intestine  in consequence  of the prolonged  use of certain
mineral drugs.  In this way  have been formed concretions composed of cal-
cium  carbonate, of magnesium  carbonate, of magnesia,  and  of  iron.   Indi-
gestible constituents of the food, especially the fibres and husks of vegetables,
may form a conglomerate mass  of  sufficient size to give  rise  to  obstipation.
All these varieties of concretions are  most frequently formed in the cacum
and large intestine.  They rarely attain sufficient size  to produce any consid-
erable  obstruction.  They  may,  however, prove serious  obstacles in  case a
stricture of the intestine already exists.   These obstructing  bodies may be
situated  within the cacum, at the sigmoid flexure, or  in  the  rectum.   They
may sometimes  be  felt  through the abdominal walls.   They may lead  to
ulceration and perforation of the intestine, or, if  not  discharged and if the
obstruction be complete, vomiting  of so-called stercoraceous  matter  ensues,
and death may take  place from exhaustion.   An intestinal concretion, cuboid
in form,  the vertical and  transverse diameter one and a half inches, its weight
fifteen drachms, was sent to me by  Dr. 0. T. Jameson, which was found  after
death in  the ileum just above the cacum.   It was distinctly felt  through the
abdominal  walls during  life, and had existed for more  than twenty years.
The patient was a shoemaker, and he experienced notable  inconvenience  from
the concretion only  at times  after  overwork or after  violent  muscular  exer-
tion.  He died of pneumonia at the  age of forty-seven.
   Finally, foreign bodies—that is, by way of distinction, bodies not contained
in the aliment or derived from the body—may pass into  the  intestinal canal
from the stomach or be introduced into the rectum.   In  the latter case their
presence is readily ascertained by exploration, and they are removed by appro-
priate surgical measures.   AArhen introduced into the stomach  they have  been
swallowed either deliberately, as is done by jugglers, or inadvertently.   Prof.
  1 Aide case reported by Dr. Draper, in New  York Med. Journal, July, 1882, and case
reported by Dr. Johnson, in Medical News, June 27, 1885. 
508         STRUCTURAL DISEASES OF THE INTESTINE.
 Gross cites the case of a man who swallowed a bar of lead weighing a pound.
 which was removed from the stomach by an opening made through the abdom-
 inal  walls,  and the patient recovered.  The  same author refers to another
 case in which a large teaspoon was  swallowed in a fit  of delirium, and this
 was  extracted from  the ileum by the  operation of enterotomy.

   Foreign bodies, not  sufficient in number or not large enough to occasion
 obstruction,  are often swallowed, especially by children.  The practitioner is
 frequently summoned in haste, and great anxiety is felt when bodies such as
 pins, coins, portions of glass, etc. are known to have been swallowed.   They
 may give rise to more or less  irritation  of  the mucous  membrane,  and they
 may even occasion ulceration  and perforation of the stomach or intestines.  In
 general, however, they pass through  the alimentary canal without any appre-
 ciable inconvenience, and the physician  is warranted in giving assurances of
 the  absence  of danger.   It is not judicious in such cases to give cathartics
 or laxatives.   The mucous membrane is best protected against  injury if a
 sharp-pointed  or irritating  body  be  contained in  the  solid contents  of the
 bowels.   Moreover, the  increased  peristaltic  movements caused by a purga-
 tive  increase the  risk of injury.   The desire to have anxiety  relieved as
 quickly as possible, by ascertaining that the foreign body has passed, is an
 inducement  to resort  to purgation, which is to be  resisted.


                      Functional Obstruction.
   Persisting obstipation, accompanied with vomiting of  so-called  stercora-
 ceous matter,  colic pains, etc., may  occur  as a purely functional  disorder,
 constituting  an affection which has been  called idiopathic ileus.  A person is
 seized with  abdominal  pain,  increased  paroxysmally ;  vomiting  soon  takes
 place, and after a time  the  matter vomited has the odor of  feces ; measures
 to procure evacuations from the  bowels are  ineffectual; the  pulse becomes
 frequent, and there is more  or less prostration.  After the  lapse of a week or
 more these  symptoms subside, free evacuations from the  bowels  ensue, and
 the patient recovers.   These  are  the prominent  features of a case which I
 reported many years ago.1
   Cases  of functional obstruction may  simulate  those  of obstruction from
 the structural affections which have been considered, and there is ground for
 the belief that in a certain proportion of the reported cases of  the successful
 treatment of invagination2 or of  strangulated hernia within the abdomen the
 affection was purely functional.   The regurgitation  of the  contents of the
 small intestine, which have a stercoraceous odor from  the  diffusion of the
 gases contained in the large intestine, in these as in other cases of obstruc-
 tion, has been  attributed to an inversion of the peristaltic movement.   Ex-
 periments on animals do not  favor this  explanation.   Brinton explains the
 regurgitation by supposing that in the centre of the intestinal tube a retro-
 grade current is produced by the normal  peristaltic movements if there be an
 obstruction.  The obstruction,  when  functional, may be caused by spasmodic
 contraction of  the  tube, or  it  may be due  to paralysis of a portion of the
 tube, and consequent failure  of this portion to  propel  its contents.
   The clinical discrimination of functional obstipation from obstruction caused
 by structural affections cannot always be made at once with confidence.   The
absence of tumor and of pain  and tenderness localized  at a particular  point
tends to  the  exclusion of the latter.   The functional character of the  affec-
tion may be surmised if the patient be a female  subject to hysteria and suf-
                  1 Buffalo Med. Journal, 1851, vol. vii. p. 530.
                  2 Ibid., 1852, vol. vii. p.  383. 
DIARRHCEA.                          5Q9
feting from the nervous symptoms  associated with so-called  spinal irritation.
The probability of the aff'ection being functional is increased in proportion as
the obstipation, with vomiting, etc., continues, without the supervention of the
symptoms which occur after sphacelation of intestine has taken place—name-
ly, frequency and feebleness of the pulse, coldness of the surface, extreme
prostration, and great tympanites ; in short, the symptoms denoting impend-
ing death by asthenia.
  In the treatment of functional obstipation opium and other measures to
relieve pain and allay spasmodic action  are indicated.  Cathartics may  be
cautiously tried, but if ineffectual they  should  not be persisted  in.   Ene-
mas administered by means  of a long flexible tube are to be employed.
  The importance of examining for the evidence of femoral and inguinal her-
nia is to be enjoined in connection with the subject of functional obstipation.
                       CHAPTER   VII.

          FUNCTIONAL  DISEASES  OF THE INTESTINE.

 Diarrhoea.—Enterorrhagia.—Constipation.—Intestinal Colic.—Enteralgia.—Lead Colic-
                   Colic from Copper.—Passage of Gall-Stones.

                               Diarrhoea.

    THE term diarrhaa is used to denote morbid frequency of intestinal dejec-
     tions which  are  also liquid or morbidly soft, and  often otherwise altered
 in character.   Diarrhaa is a symptom of inflammation of the large and the
 small  intestine and of certain  structural lesions, such as those incident to
 tuberculosis of the intestine and to typhoid fever.   It is a functional affec-
 tion when not dependent  on inflammation or on any appreciable lesion  of
 structure.   It  is an element of other functional  affections—namely, sporadic
 cholera, intestinal indigestion,  and certain cases of colic.   As a functional
 affection it  may  be either  transient or chronic.
   AAHters have described several varieties of diarrhaa, based on diversities as
 regards the  dejections.  It  is sufficient to enumerate the  more important of
 these diversities without considering each as constituting a separate variety
 of the affection.  The following enumeration answers all practical purposes :
   A diarrhaa  is said to  be fecal, feculent, stercoraceous, or  simple when  the
 dejections consist of the feces not changed in character, but simply  morbidly
 soft  or liquid.   This form  of diarrhaa is represented by the operation  of
 cathartics, which increase the peristaltic  movements and  give rise  to a cer-
 tain  amount of transudation.   The dejections in  this form of  diarrhaa have
 the normal  fecal odor.  They are called  bilious  when, from their  yellow or
 green  color, bile  is supposed to be present in larger  quantity than usual.
 The  green color  which has been  considered  as  characteristic of the action
 of mercury upon the liver, according to Thudichum is due to the presence  of
 subsulphide  of  mercury.1   Robin states that the microscope shows the color-
ing matter to be biliverdin.2  Diarrhaa is  serous  or watery when there is  an
abundant discharge of liquid; that is, when  there is copious transudation or
  1 The Lancet, Oct., 1860.                                  2 Sur les Humeurs. 
510        FUNCTIONAL  DISEASES  OF  THE INTESTINE.
enterorrhaa.  This is represented by the operation of hydragogue cathartics,
such  as  elaterium, jalap, and  the  bitartrate of  potassa.  The dejections arc
called lienteric when they contain undigested  aliment.   This form  of  diar-
rhaa  is  met with especially in children.  A diarrhaa is mucous or dysenteric
when  mucus is apparent in the dejections.   An  abnormal amount of mucus
may be secreted from irritation alone without inflammation, but if the mucus
be abundant it denotes an inflammatory condition.  This form of diarrhaa is
represented by the operation of drastic  cathartics, such as  croton oil.  Finally,
in a rare form, called adipose or fatty  diarrhaa, free  fat  or oil in greater or
less abundance is found in the evacuations.   This last form  claims  distinct
consideration.
   In  cases  of  adipose  or fatty diarrhaa the fat is generally liquid when
passed,  resembling melted butter or grease, having when  cold the  consist-
ence of butter, beef tallow, or wax.  In some cases it is passed in the form
of globular concretions  of a waxy consistency,  varying in size, which  melt
with heat and burn like  tallow.   The fat is often passed by  itself, and it may
be passed  involuntarily in a small quantity at a  time.   AVhen passed  with
the feces  it separates   and  collects on the surface.    It has  usually an
extremely  offensive  odor.   The quantity passed per diem in cases which
have been reported varies from  two or three ounces to half  a pound or more.
   Assuming all the fat passed  from the bowels to have been ingested as fat,
the rationale involves simply the non-digestion of this alimentary  substance;
but in some reported cases it  is stated that the quantity of fat passed was
not affected by the amount of fatty food.   In a case  reported by Wells the
patient abstained for several weeks from fatty food, and as  far as convenient
from  articles convertible into fat, without any diminution in the quantity of
fat passed, nor was the latter affected by indulging freely  in fatty food.1  In
two cases reported by Bright no change was produced by  excluding as far
as possible  fatty articles from the diet.  That the non-digestion of fat is in
a great measure involved in the pathological explanation  is, however, not to
be doubted.  Physiological  researches  have  shown that the pancreatic secre-
tion, the bile, and the intestinal juice  effect the  digestion of fat,  and hence
we are to look to the sources of these fluids in tracing the causation of fatty
diarrhaa.  It is  an interesting fact that Bright, long before  the  discovery
of the particular function of the pancreas by Bernard, was led by an analy-
sis of three cases which came under his observation  to consider  fatty diar-
rhaa  as a symptom of  disease of the pancreas.  In  these three  cases the
only lesions found after death  which  were  common to all  were of the  pan-
creas, duodenum, and liver.   He excluded the lesions in  the two latter  situ-
ations because they occur in  these organs so often without fatty diarrhaa;
but he admits that disease of the pancreas is not always accompanied by this
symptom.2  The  pancreas has been found diseased in a large majority of the
reported fatal cases  in  which  this organ was examined after  death.   Of -0
cases  tabulated by Griscom,3 in 10 the  bodies were examined after death; of
these  10 cases, in 8 the pancreas was  diseased, and in the remaining 2 cases
the absence of disease  of the  pancreas  is  not  stated.  Yet  fatty diarrhaa
occurs in only a small  proportion of  the cases of disease  of the  pancreas.
Thus, it  was observed in only  3 of 37 cases of  cancer affecting this organ
tabulated by DaCosta.4  Hence it is to be inferred that there are  generally
  1 New  York Medical Times, February, 1854.
  2 " Cases and Observations connected  with the Diseases of the Pancreas and  Duo-
denum,']  by Kichard Bright, M. D.,  Medico-Chirurg.  Transactions, vol. xviii.  Aide
review in British and  Foreign  Medieo-Chirurgical Review, July,  1853.
  3 Transactions of the, American Medical Association for 1863.
  4 " On the Morbid Anatomy and Symptoms of Cancer of the Pancreas," extracted from
the Proceedings of the Pathological Society of Philadelphia, 1858. 
DIARRHOEA.
511
involved morbid  conditions which influence the digestion of fat, irrespective
of the pancreatic secretion.  Of the fatal cases among those tabulated by
Griscom in which the morbid appearances were observed, the liver in several
was either diseased or its ducts engorged ; but in some of the cases this organ
appeared to be healthy.  The fact of complete recovery taking- place in a cer-
tain proportion  of cases goes to show that the non-digestion of fat may occur
as a functional  disorder.
   A  larger number of  cases than  now available is required in  order to
establish the clinical history, as well as the causation and pathological rela-
tions, of this form of diarrhaa.   Jaundice was noted in several (six) of Gris-
com's cases.  Diabetes mellitus  coexisted in two cases.   Hemorrhage from
the bowels, vomiting, and pains  in the abdomen sometimes  resembling  those
caused by the passage of gall-stones, are among the symptoms noted in these
cases.   The duration of  the aff'ection varies much in difierent cases.  In one
case it had existed at frequent intervals for six years, in another case for two
years, and  in one case it disappeared after a few7 weeks.  It is  evident that
the prognosis is to be based on circumstances other than the discharge of fat
—namely,  enlargement of the pancreas and liver, persisting jaundice, pro-
gressive emaciation,  etc.; in other words, the danger depends on  the lesions
or morbid conditions on which the discharge  of fat may be dependent or with
which it is associated.  Of the 25  cases  collected  by Griscom,  14 died, 8
recovered,  and  in 3  the termination was not noted.
   The treatment must have reference more to the circumstances connected
with  the fatty diarrhaa than to the  latter.  AVith our  present  knowledge,
palliative measures according to the symptoms in individual cases, together
with measures to improve  digestion  and invigorate the general health, com-
prise the treatment.   In one of Griscom's cases  recovery  took place under
the use of  olive oil in  large quantity, and AVatson states that a case was suc-
cessfully treated by  Elliotson in the same way.  In a case observed by Gris-
com at the New  York Hospital the  discharge of fat invariably  ceased when-
ever the patient took from six to eight ounces of whiskey per diem.  In the
case reported by AVells, the patient, having  had a daily discharge of three
gills of fat for  two  years or more, recovered in a few weeks after giving up
the occupation of a carpenter and  adopting the  life  of a farmer.
   Exclusive of the form just considered, diarrhaa involves different patho-
logical elements—namely, increased peristaltic movements, increased transuda-
tion, increased secretion from the mucous follicles, and perhaps increased flow
of bile.   If the diarrhaa be purely functional, of course there is  no inflamma-
tion  of the mucous membrane.   Practically, it is not always easy to determine
whether diarrhaa be purely functional or dependent on  subacute inflamma-
tion ; but with  reference to the treatment to determine this point is not of
great importance.   It is not improbable that, of the cases considered as func-
tional in a  certain proportion there is a slight grade of  inflammation, such as
exists in coryza or a mild bronchitis.  In making the diagnosis,  acute inflam-
mation  is  to be excluded by the absence of diagnostic symptoms—namely,
pain, tenderness, febrile movement, and anorexia. Lesions of the mucous mem-
brane are also to  be  excluded.  In cases of chronic diarrhaa this  is not always
easy.  Lesions  are to be suspected if the diarrhaa follow*  an attack of dysen-
tery or enteritis, if  it  persist in  spite of judicious management, if  blood be
sometimes  present in the dejections, and if tubercles exist in the lungs.  In
the latter case tuberculosis of the intestine is  to be suspected; and on the other
hand persistent or frequently recurring diarrhaa, conjoined with cough.be the
latter never so  slight, should excite suspicion of pulmonary phthisis.
   Transient diarrhaa due to arrested or defective  intestinal digestion is of
frequent occurrence.  AVith the diarrhaa which  follows over-indulgence  at 
512         FUNCTIONAL DISEASES OF THE INTESTINE.

the table or the ingestion of certain articles of food every one is practically
familiar.  This is the diarrhoea crapulosa of the old writers.  It may proceed
from excesses in quantity or from particular kinds of food, the indigestibility
of the latter perhaps showing an idiosyncrasy of the  person  affected ;  thus,
ices, salads, shellfish, etc.  in  some persons  always,  and occasionally in all,
give rise  to  transient diarrhaa.  The undigested aliment, passing into the
large intestine, having  undergone chemical  changes which the  processes of
digestion  in  health  prevent,  produces irritation  and  acts like a cathartic.
Frequently the diarrhaa is preceded  and accompanied by griping pains, and
it may be under these circumstances an element of another functional  affec-
tion—namely, colic.   These attacks of diarrhaa  cease spontaneously, as a
rule,  after the expulsion of  the undigested  contents of  the intestine, and
they are rarely considered of  sufficient importance to require medical advice.
  An  arrest of intestinal digestion  may take  place from  causes other  than
errors of diet and give rise to diarrhaa.   A strong mental emotion may have
this effect.  I was present at  an  operation for hernia when the surgeon, from
the mental anxiety incident to his sense of responsibility, was obliged to relin-
quish the scalpel and precipitately retire to  evacuate the bowels.  A gentle-
man in business, receiving suddenly unexpected information which led him to
know that he was a bankrupt, was immediately seized with  diarrhaa.  In like
manner, diarrhaa may arise from an  arrest of digestion from an exposure to
cold  or from over-exertion.  In these  cases the mechanism is the same as when
the diarrhaa depends on dietetic errors, the undigested aliment in the large
intestine acting like  a  cathartic.
  Diarrhaa  not transient, but  continuing more or less,  perhaps becoming
chronic or recurring at short intervals, also proceeds in a large proportion of
cases from indigestion.  Habitual or frequent indigestion leads to diarrhaa in
the same way as when it is transient—namely, the undigested  aliment under-
goes chemical changes and causes irritation of the large intestine. The dejec-
tions, as in transient diarrhaa, may he feculent, bilious, mucous, lienteric, or,
more rarely, serous.   The diarrhaa in these cases is an element  or symptom
of indigestion, but  not  infrequently, the disorder of  digestion being confined
to the small intestine, gastric ailments are not present.   The indigestion thus
giving rise to diarrhaa may be produced and kept up by various causes  inde-
pendent  of excess or errors of diet.
  It has been customary to attribute diarrhaa in certain cases to an excess or
to a  vitiated quality of  bile.   This causation is inferred when the dejections
are notably bilious.  This view is not improbable, although  not based on posi-
tive knowledge.  The bile may  not be reabsorbed from the alimentary canal
as in health, and hence it  accumulates in excess  without  a morbid increase
in the  secretion ; or it  may be  secreted in undue quantity or it may have a
morbidly  irritating property.
  Diarrhaa is most liable to occur during the summer  season.  This may be
explained, in part, by the  larger proportion  of fruit and  vegetables  in the
ingesta during this season  and by the effect of heat in weakening digestion.
It may also  in part be  due to  a more abundant secretion or to a lessened
absorption of bile.   It is a  much more frequent affection in tropical  than
in cold or temperate climates.    It occurs in travelling, especially  in the
summer season.  Its occurrence  is generally attributed to the drinking-water,
but it is  more rational to refer it  to  indigestion caused  by  dietetic  errors,
over-exertion, and disturbance  of the  regular habits  of life.  Children are
far more subject to diarrhaa than adults, especially during dentition ;  and in
children the dejections are often  manifestly lienteric, showing  its dependence
on indigestion.  It is the most  prominent feature of the  affection known as
cholera infantum, or popularly, in this country, summer complaint. Among sol- 
DIARRHCEA.
513
diers, especially in campaigns during the summer season or in warm climates,
diarrhaa is extremely common, and is attributable to irregular habits as regards
diet, conjoined with the exposure, excitement, and fatigue incident to active
service.  Diarrhaa occurs in  persons  exhausted from "the  want  of  food  or
from other  deprivations, and in females enfeebled and anamic from protracted
lactation, due in these cases to intestinal indigestion.  The same explanation
probably applies to the diarrhaa which occurs  at a  late period in  cases of
pulmonary  phthisis and other chronic affections when not dependent on intes-
tinal lesions.   Cnder  these circumstances it  has  been  called  colliquative
diarrhoea.
  The  accumulation of urinary principles in  the  blood as a consequence of
renal disease occasions diarrhoea.   The diarrhaa and vomiting which occur
under  these circumstances  appear to be for the purpose of eliminating urea
vicariously, and they are  therefore conservative.  They occur when the kid-
neys are removed in inferior animals,  and, as shown by the experiments of
Bernard  and Barreswill,  the liquid transudation  into the alimentary canal
contains either urea or the carbonate of ammonia.   The dejections in  uramic
diarrhaa are serous or watery.
  Another  pathological condition occasionally giving rise to diarrhaa is con-
gestion of  the portal vessels when  the circulation in this portion of the  vas-
cular system is obstructed by hepatic disease.   It thus is a symptom  in some
cases of cirrhosis of the liver, and it sometimes  appears to limit the dropsical
effusion into the peritoneal sac  which  belongs to the history of that  disease.
The diarrhaa under these circumstances is serous, transudation taking place
from the pressure of the blood within the congested veins.
  Crapulous diarrhaa, or transient diarrhaa  due to indigestion,  in  general
calls for little or no treatment.   If the  contents of the large intestine be not
spontaneously expelled, an  evacuant remedy  may be given.   A saline  pur-
gative  is best adapted to this  end.   The  propriety of this measure  is to be
determined by ascertaining the quantity and character of the dejections which
have occurred.   If these  have been abundant and feculent, a cathartic is not
required.   If, after the bowels  have been freely evacuated, diarrhaa,  pain,
or uneasiness continue, the irritation may be quieted by a mild anodyne ; for
example, a drachm or two of the camphorated tincture of opium for an adult
in chalk mixture ; a grain of opium ; a sixth or a quarter of a grain of a salt
of morphia in mint-water; or five  grains of Dover's powder combined  with
two  or three grains of aromatic powder.  The remedy chosen  is to be repeated
after six or eight hours,  if required.   The diet for a day or two should be
simple and somewhat  restricted.   Subsequently a laxative may be required
if the  bowels do not act spontaneously.  The treatment of cases of diarrhaa
tending to  continuance or frequently recurring and dependent on  indigestion
embraces,  in the first  place, remedies  to  relieve  the irritation of the  large
intestine.   Opium in some form  may  be used  for  this purpose, but  only
temporarily, because its continued  use  tends still  more  to impair digestion.
A mild purgative may often be  prescribed with advantage, for frequent and
loose dejections are not  incompatible with retention of hardened feces—in
fact, with constipation.  The subcarbonate or the subnitrate of bismuth is an
excellent remedy to relieve intestinal irritation.   It  is often  effective, and  is
not open to the objections of opium.   It  should be given in doses of from a
scruple to  half a drachm  to adult patients.   If not effective alone, a small
quantity of a salt of morphia may be added to it.  Of a variety of remedies
tried in cases of chronic diarrhaa  among soldiers returning from the cam-
paigns  in Alrginia in the summers of 1802 and  1863, bismuth, in my hands,
proved the  most effective, and this, I believe, was the result of the experience
of others.   Opiates are sometimes most  effective and least objectionable when 
 514         FUNCTIONAL DISEASES OF THE  INTESTINE.

 given per enema.   Pepsin or the rennet wine is sometimes useful  temporarily
 as  a  means of artificial digestion, given as already recommended in cases of
 dyspepsia.
   This part of the treatment, however, is  merely palliative.  The curative
 treatment embraces regulation of diet and measures to render digestion com-
 plete.  The diet in quantity and quality should be adapted  to the digestive
 powers.   Chickens, eggs, and tender meats plainly cooked  are  most likely
 to be digested, but in some cases a milk and farinaceous diet is  found to be
 preferable.   Experience  in individual cases is to be the guide.  Crude vege-
 tables are to be interdicted, but ripe fruits in moderation may frequently be
 taken without inconvenience and with  advantage.  A  moderate quantity of
 food  taken at short intervals is  generally advisable, rather than a  full meal
 once  or  twice daily.   A sea-voyage, a visit, removal from  the  city to the
 country, or the change of  a warm, variable, humid, relaxing climate for an
 atmosphere cool, uniform,  dry, and  bracing, will be likely to prove highly
 beneficial, if not curative, in cases which resist dietetic and medicinal treat-
 ment.  The efficacy of these measures is strikingly illustrated in cases of the
 so-called summer complaint in  children.
   The remedies, other  than those merely palliative, which are useful in the
 cases of diarrhaa under consideration belong among the tonics and the astrin-
 gents ; and the latter may be both palliative and curative.  Of the various vege-
 table astringents,  krameria, hamatoxylon, kino, catechu, and rubus villosus
 are eligible articles.  The tannic acid, if well borne by the stomach, is some-
 times efficient.  As purely tonic remedies, quinia or the non-officinal prepara-
 tions of  calisaya-bark so much in vogue, and other bitter infusions,  are often
 useful. Salicin, in  doses of from ten to twenty grains three times daily, is an
 excellent tonic remedy.   Preparations of iron are especially useful when the
 patient is anamic,  as in cases  of  diarrhaa occurring in females during lacta-
 tion.   The tincture of the chloride of iron  is  one of the best of the chalyb-
 eates.  The  persulphate  or pernitrate  of iron  is sometimes efficacious as an
 astringent, as well  as  a tonic  remedy.  . Of  mineral tonics and astringents,
 the acetate of lead, nitrate of  silver, and the  sulphate of copper have  been
 found useful.  The subcarbonate or the  subnitrate of bismuth  is of great
 value in chronic diarrhaa, not  only as a palliative, but as a curative remedy,
 given in large doses—namely, from a scruple to a drachm three or four times
 daily,  sometimes in combination  with small  doses of a salt  of morphia, as
 recommended above  in connection with palliative  measures of treatment.
 The mineral acids  are efficacious in some cases.   The preparation known as
 Hope's mixture has been  much in use.  This mixture is composed of four
 drops of nitric acid and from forty to sixty drops of laudanum in four ounces
 of  camphor-water, a tablespoonful to  be taken every two, three, or  four
 hours.  In rebellious cases of chronic  diarrhaa the various  remedies which
 have been  named are to be given in succession and in different combinations.
 The curative and palliative remedies are to be  combined to meet  the  indica-
 tions in individual cases.
  Diarrhaa dependent on uramia and on cirrhosis of the liver does not admit
 of curative treatment, and, being conservative, is only to be kept within cer-
 tain limits by palliative remedies.


                            Enterorrhagia.
  Hemorrhage into the intestinal  canal is properly called enterorrhagia.  The
term melsena has been used to denote dark-colored or black dejections consist-
ing of blood which has passed from the stomach into the intestinal canal.
Partial digestion of the blood  or  the action  upon it of the  gastric and  intes- 
ENTERORRHAGIA.
515
tinal secretions renders it tarry or pitch-like in appearance and generally very
offensive to the smell.   Dejections of this character often follow gastror-
rhagia.   The term melana has been also applied to cases of gastrorrhagia in
which the vomited blood presents a similar appearance.   Moreover, the term
has been loosely applied  to denote dark-colored or black evacuations not con-
sisting of  blood.  The  term is  one of those  which it  is  desirable should
become  obsolete.  Cases in which blood evacuated  from the bowels  comes
from the stomach or from any of the abdominal viscera other than  the intes-
tinal canal  are not cases of enterorrhagia ;  and cases of hemorrhoidal or other
hemorrhages occurring  near the anus are not properly embraced under this
head. The source of the hemorrhage must be the mucous membrane between
the stomach and rectum.  The tarry or pitch-like appearance of  blood  in the
stools is evidence of its source  in the  stomach or upper part of the  intes-
tine ;  but this  appearance is not positive proof that the matter  evacuated is
blood, as a dark color may be imparted to  the stools by the administration of
iron or of bismuth.  It probably  is blood if the stools have been preceded  by
the vomiting of blood ;  but in some cases  of gastrorrhagia vomiting does not
take place, all the blood passing  into the intestinal canal.   In doubtful cases
dilution in  water of some of the  matter evacuated  renders the appearance of
blood more evident, or recourse may be had to the  microscope or to the spec-
troscope.   When the source  of hemorrhage is the rectum, the blood is fresh
in appearance, and is passed alone, in  greater or less abundance, either after
a fecal  evacuation or with straining efforts to procure a stool.  Examination
with the eye or touch will generally show the existence of hemorrhoids, but
in  some  cases  it reveals other  local affections, such  as  ulcers,  carcinoma, a
polypus, or intussusception.
   In cases of enterorrhagia the hemorrhage takes place in different situations
along the tract of the small  and  large intestine.   The blood is less  changed
in appearance the nearer its source is to the rectum and the  more quickly it
is evacuated.   If the hemorrhage be at the upper  part of the intestinal tube
and if the  blood pass slowly along the tube,  it becomes dark or blackish, its
appearance  resembling that of the melanic stools  in  cases of gastrorrhagia,
and there  may be a similar  difficulty  in determining whether the appearance
be  due to the presence of blood.   The quantity of blood passed varies  in dif-
ferent cases of enterorrhagia. It is frequently large, amounting in some cases
to several pints and even quarts.  Evacuations may consist wholly of blood
or  the blood may be mixed with fecal matter.  The blood  may be entirely
liquid or the evacuations  may contain clots in greater  or  less abundance.
   Intestinal  like gastric hemorrhage  has  rarely any claim to be regarded as
an  individual affection.   Like gastric hemorrhage, it is incident to a variety
of  morbid conditions.  It is  an important  occasional  event in typhoid  fever,
and will be referred to in treating of that  disease.   It enters into the charac-
teristic dejections  of dysentery.   It is an effect also  of thrombosis of the
portal vein  and of the  mesenteric vein.1   It is  one of the symptoms  of
embolism of the superior  mesenteric  artery.   It  occurs in cases  of carci-
noma of the bowels.  It is  a rare occurrence in  tuberculous ulceration  of
the small or large intestine.   It  belongs to the natural history of scorbutus,
purpura  hamorrhagica, and  yellow fever.   Like gastric hemorrhage, it may
be vicarious of menstruation.  It is not  an  uncommon  effect of  the  portal
congestion  occasioned  by cirrhosis of the liver.   It  occurs, however, when

  1  Sir AVilliam Gull has reported a case of probable thrombosis of the superior mesen-
teric vein  and the renal veins, recovery taking place. (Aide Guy's Hospital Reports, vol.
xlii.)  Profuse intestinal hemorrhage was associated with severe  pain, albuminuria,
and a condition of nearly complete collapse.  He cites a fatal case reported by Dr. Hil-
ton  Fagge. 
516         FUNCTIONAL DISEASES  OF  THE INTESTINE.

not connected with  these  or any other discoverable  morbid conditions.  I
have met with several examples of enterorrhagia not connected with any of
the several causative conditions which exist in the larger proportion of cases.
AVhile, therefore, the  chances are that  some of these conditions exist, the
occurrence of hemorrhage is not proof of the  existence of any of them.
Symptoms attributable to the loss of blood, and marked in proportion to the
amount of hemorrhage, are debility, pallor, feebleness  of the pulse, perspira-
tion, sense of  faintness, etc.   The loss of blood may be sufficiently great and
rapid to occasion sudden death, but this is rare.  The repetitions of the hemor-
rhage may lead to a degree of exhaustion  and anamia from which recovery
is  difficult, and  a fatal result may take place  by slow  asthenia.   In  general,
however, if the  hemorrhage  be not connected with morbid conditions which
involve danger, the prognosis is favorable.  Hemorrhage sufficient to  occasion
fatal syncope may take place  and no  blood  be discharged by stool. In such a
case the diagnosis of enterorrhagia is impracticable.
   The treatment of the different affections or morbid conditions with which
intestinal hemorrhage is usually connected  need not be here repeated.  It will
suffice to refer to measures having reference to the hemorrhage.  These are
essentially the same as in cases  of gastric  hemorrhage.  Rest in the recum-
bent position  and quietude of mind are important.   The peristaltic move-
ments  are to be  quieted by opium.   Cold applications to the abdomen should
be made  if the  arrest of the hemorrhage  be  urgently indicated.  The most
effective mode of applying cold is by means of the ice-bag.  In cases in which
this indication is less urgent, dry cupping, sinapisms, and warm stimulating
pediluvia will suffice  without the  application  of cold.   Food and  drinks
should be taken cold.   The  diet should  be  restricted and  bland.   Purga-
tives are contraindicated.  The mineral acids are generally thought to be
useful in  cases of intestinal as well as in gastric hemorrhage.  The sulphuric-
acid lemonade has the advantage of being  a grateful beverage.   The various
hamostatic remedies given in cases of gastrorrhagia—namely,  tannic acid,
gallic  acid, acetate of lead, ergot, the astringent preparations of iron, etc.—
are  to be  resorted  to in proportion to  the importance of arresting the
hemorrhage.

                             Constipation.

   The  terms  constipation and costiveness are  commonly used  as synonyms,
denoting insufficiency of evacuations from  the bowels.   The latter of  the two
terms  is  sometimes  used to  denote  a less degree of insufficiency than the
former, the number of dejections being normal, but  the quantity  deficient
and the act of  defecation labored.   The  term  obstipation has  been  already
defined to denote a greater  amount of  difficulty than constipation;  that is,
obstruction of the bowels, either as a functional disorder or dependent on the
various  lesions  which have been considered in a preceding chapter.   Consti-
pation  exists  as a functional  disorder and it is incident to various affections.
As a functional disorder it is extremely frequent, and, although not aserious
affection, it claims attention  on  account  of the inconvenience which  it occa-
sions,  its importance as leading to other ailments, and the difficulty often of
its removal.
   The affection is seated in the large  intestine.  The anatomical  arrange-
ments of this portion  of the alimentary  canal show it  to be intended  to serve
as a temporary  depot for fecal matter, thus providing against  the need of fre-
quent acts of defecation.   The contents  of the alimentary canal are propelled
more slowly in the large than in the  small intestine—first, because the circum-
ference of the former is larger in proportion to  its muscular power; second, 
CONSTIPATION.
517
in the ascending part of the colon and of the sigmoid  flexure the  contents
are  propelled  in opposition to  gravitation ; and  third, the liquid portion of
the contents is absorbed in their passage through the small intestine.   Expe-
rience shows that one free evacuation from the bowels daily is  the rule in
health;  but this rule is not without exceptions.   Some persons have, habit-
ually, two or three evacuations daily, and on the  other hand some have an
evacuation regularly every second  or third day without any of the  inconve-
niences  of constipation  ; in fact, persons of the  latter habit usually experi-
ence discomfort if temporarily  evacuations take place daily.  In determining,
then, the  existence of  this aff'ection, the  habit in health  is of course to be-
taken into account.  In some cases the  act of defecation is delayed for one,
two, or  three days after the period when it should have taken place, but the
evacuation when it occurs is ample.  In other cases the act occurs daily, but
it is incomplete, and in these cases the  act is  usually labored and painful,
the feces being dry, compact,  and  hard.   The affection  may be occasional
and transient or it may  be habitual.
  Constipation gives rise  to various local morbid effects, such as a feeling of
pressure or weight in the  perineum, a sense of abdominal distension or uneasi-
ness, flatulency, diarrhaa,  and colic  pains.  Plemorrhoids are  often  attrib-
utable to this aff'ection.   It gives rise also to pain in the head, dulness of the
mind, flushing of  the  face, palpitation, and general malaise.  If the  act of
defecation require violent straining efforts, these  sometimes occasion hemor-
rhage into the brain if  the cerebral arteries be diseased, and hernial protru-
sions.   The contractility  of the muscular tunic of the  large intestine may be
permanently impaired  by long-continued distension, so that the affection is
necessarily permanent.
   Occasional  constipation is not generally considered of sufficient importance
to require medical advice, and persons resort of their own accord to a  purga-
tive or an enema.  It is  when the affection  has become habitual or chronic that
cases come  under the  cognizance  of  the physician ; and, in order  to  under-
stand the pathological  character of the affection in these  cases and its causa-
tion, certain points pertaining  to the function of defecation in health are to
be  borne in mind.   In  its normal  condition the rectum is  empty, as  shown
by  the researches of O'Beirne.1  This portion of the large intestine is endowed
with a peculiar sensibility which  in health gives  notice  of the  presence of
feces and occasions the desire  to  defecate.  The ability to perform the act
involves a certain contractile power in  the large  intestine, and  also  in  the
abdominal and other muscles which co-operate in the performance of the act.
In  habitual constipation the contractile power of the intestine is impaired by
distension.  The muscular tunic is more or less paralyzed from  the accumu-
lation  of the intestinal contents, in the  same  way as  the bladder becomes
paralyzed from over-distension.  The  accumulation giving rise  to the  disten-
sion may be owing to the  large quantity of excrement, but it is generally a
result of habitual neglect of the calls of nature.   The desire  to defecate is
resisted, or, the mind  being preoccupied, is  unheeded, and the act is post-
poned, until at length the sensibility no  longer gives notice of fecal accumu-
lation ;  hence  the accumulation goes on, the rectum and other portions of the
large intestine become distended, and paresis follows.   This is the manner in
which constipation as a chronic affection is produced  in a large  majority of
cases.   The hurried performance  of  the act of defecation, the evacuation
being in consequence  incomplete, has  measurably the same result  as  the
neglect  of the calls  of nature.   Instead of receiving  adequate attention  as
important to  health, defecation  is considered an  annoyance to be escaped
from as quickly as possible.   The uncomfortable provisions for defecation,
          1 Nw Views of Defecation, etc., by James O'Beirne,  Am. ed., 1834. 
518        FUNCTIONAL  DISEASES  OF  THE INTESTINE.

especially in the  country, contribute to constipation by rendering it disagree-
able to devote to the act more time than  seems absolutely necessary.
  Various circumstances may contribute to this affection.  The abdominal
muscles  play  an important  part in  the  act of defecation.  These  muscles
become weakened by obesity, and in females as a result of pregnancy.   The
muscular tunic of the intestine and the auxiliary voluntary muscles concerned
in defecation lose more  or less of their  contractile  power, in  common with
the whole muscular  system, in anamia and in other enfeebling conditions.
Deficiency of  bile and of the intestinal secretions may enter into the causa-
tion in some cases, but probably the importance  of this  source of constipa-
tion has been over-estimated.  Constipation  is not always present when no
bile enters  the  alimentary canal in  certain cases of jaundice.   Inadequate
alimentation, and especially the  ingestion of purely nutritious food,  leaving
but little  excrementitious residue, contribute  to constipation.   Sedentary
habits are supposed to favor the affection, but it is probable that other causes
are  generally more operative, and especially inattention to the calls of nature.
On  the other hand, active exercise  induces constipation  by rendering assimi-
lation  more active, the  liquid contents of the small  intestine being more
fully absorbed.   Loss of fluids by abundant perspiration  or by diuresis is
another cause.   The  change of habits, with, generally, an  increased assimila-
tion, incident to a sea-voyage, as is well known, induces in most cases consti-
pation.
  Occasional constipation, if slight, is relieved by  a laxative pill, repeated if
necessary, or by a small  quantity of P]psom or  Rochelle  salts dissolved in a
tumbler of simple or carbonated water and taken upon  an empty stomach.
The Congress  or the Kissingen water and  the stronger bitter waters—namely,
the Friedrichsliall, Pullna, or  Hunyadi-Janos—in small doses may be taken
in lieu of the  salts  just  named.  A preferable method, which will generally
suffice, is to excite the action  of the large intestine by a simple enema  of cold
water.  By means of Davidson's syringe  the patient can resort to this meas-
ure  without any difficulty.   If the constipation be more than  slight, a  few
grains of blue mass  or a purgative pill  may be taken at bedtime, followed,
if necessary, by a saline  draught or an enema in the morning.  Persons often
have recourse to purgatives without  consulting physicians, under an impres-
sion that such remedies are always  harmless and generally useful aside from
the relief of constipation.  Hence it is common to take active purgatives for
slight constipation,  and often  when nothing is required.  If the constipation
give rise to little or  no  inconvenience, it is  better to wait for  spontaneous
relief,  and a little delay will  often  show that medicinal interference would
have been unnecessary.
  The management of habitual constipation often requires much care and per-
severance on the part of the  physician and patient.  The object is to secure
regularity and sufficiency in the  evacuations.   The means  which may  be
employed are various.   They may be arranged into dietetical, medicinal,
and mechanical.  The dietetical means consist in using  freely articles which
leave, after digestion, a bulky residuum—namely, cabbage, lettuce, the vari-
ous vegetables known in the country as greens; articles  having a laxative
property, such as molasses,  prunes,  figs,  etc.;  or articles with indigestible
constituents which stimulate  the alimentary canal—namely, bran bread, corn
meal, groats, or  cracked wheat.  A diet  consisting in part of the foregoing
articles will sometimes succeed in  relieving habitual  constipation;  but with
regard to the  choice  of  this  class of means  the following practical rule is to
be adopted: They are not to  be preferred if  they disorder digestion or occa-
sion more disturbance than medicines.   More harm sometimes  results from
overloading the digestive organs with articles of diet difficult of digestion or 
CONSTIPATION.
519
subjecting the canal to the  irritation of unbolted flour than  the continuance
of constipation would occasion.  A tumbler of simple  water or of carbonated
water taken in the morning before  breakfast is not infrequently efficacious;
if  not, a teaspoonful of table-salt added will often render it sufficient.
   The medicinal means are laxative remedies.  AVith regard to these, a general
rule is that the remedy chosen  should be mild and  the quantity as small as
will suffice for the object.  Purgation is to be avoided.  Some patients fall into
the custom of allowing the constipation to continue for several days, and then
resorting to a free purgative.   The constipation is of  course relieved for the
time,  but the  constipated habit becomes more and more fixed by this course.
Another general rule may be stated :  If more than one small dose of laxative
be required, the remedy is to be given in small doses repeated twice  or thrice
daily, rather than in a  single, larger dose.   In this way the object is effected
with a less amount of medicinal impression, and there is less risk of purgation.
   As regards  the  particular remedy, aloes is specially suited  to the desired
object.  It may generally with advantage be combined in a pill with a tonic,
either the sulphate  of quinia or a preparation of iron, and a small  quantity
of hyoscyamus or belladonna may be added.  A very small  proportion of
aloes, a small fraction of a grain in each  pill, will often suffice.   The  old
preparation  known as the elixir proprietatis (tincture  of aloes  and myrrh) is
well suited to the object, a drachm given at bedtime, and repeated, if necessary,
once or twice during the day.   This preparation  loses its disagreeable bitter-
ness with age, and it is not generally  repulsive when given with a little water
and an abundance of sugar.   The extract of nux vomica combined  with bel-
ladonna or hyoscyamus  sometimes answers well.  A small piece of rhubarb
taken repeatedly during the day sometimes  effects  the object satisfactorily,
and this remedy to many persons  is not disagreeable.  I have known a few
drops of the tincture of colchicum, repeated shortly after each meal, to answer
admirably.   The syrup of buckthorn, the extract of butternut, and  the com-
pound licorice powder  are good laxative remedies.   There are  various modes
of rendering the daily  use of a laxative remedy not unpleasant to  the taste.
Prunes stewed in an infusion  of senna answer well,  and  are  not unpalatable.
The confection of senna  and medicated figs are also  suited to persons  who
take a pill  or potion with repugnance.  Trousseau  claimed  for his favorite
medicine, belladonna, that it acts as an efficient laxative in cases of habitual
constipation.   It has failed to  secure this action in my experience, and I have
frequently made trial of it.  Here, as in other instances, experience in individual
cases is to be the guide.   In the majority of cases in which medicinal means
are relied upon, some form of the so-called dinner-pills, or, as they have been
appropriately termed, " peristaltic persuaders," will be found  most convenient
and satisfactory ; and for the fastidious they may be silvered or sugar-coated.
The white  mustard-seed was formerly a popular remedy much in vogue, but
this is objectionable on account of a liability  to  accumulate and  become im-
pacted within  the intestine.   Laxative remedies are  not to be continued for a
longer period than  is required  to secure an habitual action of the bowels.   A
minute dose of strychnia or nux vomica added to a  laxative renders the ope-
ration of the latter more successful.
   The mechanical  means consist in the use of enemas and suppositories.  The
regular use of an enema of cold  water at the same hour  daily is a simple
and sometimes an effective measure.   This measure, however, is better suited
to occasional  than  to  habitual constipation.   Habitually resorted  to,  it is
likely to fail after  a  time; and the rectum becoming accustomed, as it were,
to the stimulus of distension, it ceases to  excite the peristaltic movements. In
some  cases  a suppository of  soap answers the purpose  of provoking a regular
and sufficient evacuation.  The cocoanut butter may be used for this purpose. 
520        FUNCTIONAL  DISEASES OF THE INTESTINE.

Common molasses candy answers equally  well, an oval mass of the size of a
pigeon's egg being introduced within  the  rectum.  This, however, is only a
temporary  expedient, ceasing usually to  be effective after a time.
  The most important part of the management in cases  of habitual constipa-
tion is not embraced in  the foregoing measures.  It is the adoption of a rule
to solicit an evacuation at the same hour daily.   The importance of this rule
is to be enjoined, but of course  its  success will depend on the perseverance
of the patient.  The time of the day  most convenient for the act of  defeca-
tion is to be selected, and in  general the most favorable time is in the morn-
ing after  breakfast.  At  the time fixed  upon  the patient should devote a
reasonable period to the function of  defecation,  but without persisting in vio-
lent fruitless efforts.   This should be considered in the  light of  a duty, not
to be  omitted a single day  except from necessity.   It may be long before the
desired object is  accomplished, but  sooner or later, with the aid of some  of
the means which  have been indicated,  the  desire will  be felt at the appointed
hour, and the ability to defecate at that time  will be acquired in the great
majority of cases.  It is  impossible to secure  regularity and sufficiency  of
the evacuations without perseverance in this part of the management.  The
management also  includes a rule not less important—namely, never to neglect
or postpone the call to defecate when it occurs  either after or before the time
for  the habitual performance of the act of defecation.  The importance of wait-
ing for a certain  period after the contents  of the rectum have been expelled
is to be enjoined.  Often  the expulsion of the contents of the rectum is im-
mediately followed by the passage of fecal matter from the colon into the
rectum, which, remaining,  blunts the sensibility of the  bowel and renders it
accustomed  to distension.   The  objects of  the  management are to be  under-
stood and kept in view—namely, 1st, To preserve or restore the normal ani-
mal sensibility of the  rectum by which the  presence of fecal matter is felt;
and 2d, to prevent paresis from distension,  and to restore the muscular power
which has been lost from this cause.
  If this plan were  early inculcated and carried out in health, habitual con-
stipation would be as  rare as it is now frequent.  The prevention  is not
less sure than simple.  This fact should be generally understood, especially
in the training of  girls, most of  whom become  affected with habitual  consti-
pation and  suffer  from it ail their lives.  Unfortunately, the existence  of the
function of  defecation is too often ignored  from  notions of false delicacy, and
the affection becomes established because parents and teachers  are  either
themselves  ignorant of this simple method of prevention  or  consider the
subject as  belonging exclusively to the physician.
  Cases in which the intervals between fecal evacuations are many weeks and
even  many  months, the accumulation  of intestinal contents being  tolerated
with more  or less inconvenience during these  long  periods,  are  among the
curiosities  of  medical  experience.   Of the cases in medical literature, the
one in which the  longest interval occurred, with a single exception, was com-
municated for the American Journal  of Medi<<d  Sciences in  1874, and the
autopsy, in 1876, by Dr. Thomas D. Strong of  AVestfield, N. Y.  In this case
eight months and sixteen days elapsed without an evacuation from the bowels.1


                           Intestinal Colic.
  The term colic, in its etymology, relates  to the colon, hut it is often applied
to paroxysmal, spasmodic  pain in other parts.   Thus, the phrase hepatic colic
is used to denote  the pain  caused by the passage of gall-stones, and renal colic
the pain caused by the  passage of renal  calculi along the ureter.   A painful
    1 For synopsis of this case, vide Clinical Medicine, by the author, 1S79, p. 354. 
INTESTINAL  COLIC.
521
affection  of the uterus is  sometimes called uterine  colic.    In  the present
nomenclature  of diseases there is  no suffix or prefix which, joined  to  the
nana of a part, expresses a painful spasmodic  affection  of that part.  The
affection  of the alimentary canal known  as colic may not be seated exclu-
sively in  the colon.   It is probable  that  the small as well as the large intes-
tine is affected in certain cases of  intestinal colic.   As applied to the intes-
tine, colic denotes pain occurring in paroxysms or in marked exacerbations,
the pain  being of a character supposed to indicate spasm; that  is, twisting,
constricting, or griping. Colic pains are symptomatic of different inflammatory
affections—namely, dysentery, enteritis, peritonitis—and of the various lesions
which give rise to intestinal obstruction.   They  also enter into the functional
affection  called sporadic cholera or cholera morbus.   As constituting an indi-
vidual malady, colic of course is independent of inflammation or  structural
lesions and is  disconnected from any other functional  aff'ection.
   An attack of colic is characterized by paroxysms or exacerbations of pain
varying much  in its  severity in different cases. The pain is usually seated in the
region of the  umbilicus.   It is frequently extremely  severe ;  and the patient
bends the body forward with  the  thighs  flexed, writhes, and tries  a variety
of positions, groaning  or crying aloud from the intensity of suffering.  This
severe pain continues for a few moments, and then it either ceases completely
or abates, to return again with  the same severity after an interval usually of
brief duration. If left to continue without measures for relief, an attack may
embrace  a few paroxysms only or it may last for several  hours.  An attack
lasting for a short time and ending  in one or more free evacuations  from  the
bowels is so common as to  be familiar to every one.
   The abdomen in attacks of colic  is frequently retracted, but in some cases
it is more or less  tympanitic.   Generally, there  is absence of  tenderness,  and
firm pressure  with  the hands or lying upon the belly affords relief;  but in
some cases there is more or less soreness  and  tenderness on pressure, espe-
cially over the site of the cacum.   During the paroxysms of pain the abdom-
inal  muscles are sometimes  spasmodically affected, especially the rectus mus-
cle, the  sections of  which are felt as hard bunches.   Usually there is consti-
pation.   Nausea is  sometimes present, and occasionally vomiting.   The pulse
is but little or not at all accelerated, and absence of fever is shown  by the
thermometer.   The  skin is  cool, and during the severity of pain frequently
bathed in  perspiration.
   In a case presenting the characters just  described  it is important to deter-
mine, as  soon  as  practicable, the existence simply of a functional  affection ;
that is, to differentiate colic from affections in which  pains like those of colic
occur. The diagnosis is to  be made by excluding these affections.  Dysentery
and enteritis are to  be excluded by  the absence  of diarrhaa and of symptoms
denoting  inflammation.  The pain in these  two affections is rarely as violent
as in most cases of colic; but in cases of acute peritonitis the exacerbations
of pain  may equal in violence those of a severe attack of colic, and the error
of confounding these two affections has been committed in not a few instances.
The exclusion of peritonitis is to be based on the  absence of  notable  tender-
ness over the abdomen, of increase  of temperature, of frequency of the pulse,
and of other general symptoms denoting a much graver affection than colic.
Invagination, internal hernia, and other obstructive lesions with strangulation
cannot always be at once excluded.   As a rule, the paroxysmal pain occurring
in connection with these lesions at the outset, and, indeed, during a considerable
time, is less violent than in colic, and after  a time the existence of something
more than colic is shown by persisting pain, tenderness, vomiting of so-called
stercoraceous matter, sometimes tenesmus, frequency of the pulse, prostration,
etc.   The absence of these  symptoms warrants  the  exclusion of obstructive 
 522        FUNCTIONAL DISEASES  OF THE  INTESTINE.

lesions.  The possibility that some obstructive  lesion may exist is not to be
lost sight of in cases which at first have the appearance of simple colic.  The
possibility of inguinal or femoral hernia is also to be borne in mind, and a care-
ful examination with reference to this point is not to be omitted. The resem-
blance of labor-pains to  those  of colic is to be recollected.   Pregnancy is
sometimes concealed, and it has  happened that  the physician, supposing his
patient to be suffering from colic, has been taken by surprise by the cry  of a
newly-born  infant  under the bedclothes.   The passage of a urinary calculus
from the kidney to  the bladder may give rise to pains (renal colic) resembling
that of enteralgia.  This affection is to be excluded by the absence of its diag-
nostic  features.
   The several varieties of colic which writers have generally recognized do not
require separate consideration. Some of these varieties rest on an insufficient
basis of classification.   The colic has been called crapulous when it proceeds
from indigestion. Every one is familiar with the  attacks which sometimes fol-
low over-indulgence at the table,  ending frequently in  crapulous diarrhaa.  A
colic is called flatulent when it is accompanied with tympanites or by the expul-
sion of gas with relief.  This variety occurs especially in  infancy.  The term
bilious colic has been used when the affection is supposed to depend on hepatic
derangement.   This dependence  is  merely conjectural, and there is no more
reason for continuing to append the word bilious to this affection than to vari-
ous others in  which the coexistence of disorder of the liver is equally hypo-
thetical.   Colic has been called stercoraceous when  attributable to the reten-
tion of feces,  but the latter is perhaps oftener an effect than a cause of colic.
In another variety,  called verminous, the colic is supposed to depend on the
presence of worms ; but it may fairly be doubted whether colic ever proceeds
from this source.   The variety called saturnine or lead colic is properly a dis-
tinct affection, and  will be considered as such.
   The morbid condition in  colic is supposed to  be  spasm.  Its seat is there-
fore  the  muscular  tunic of the  intestine.   That this is the pathological cha-
racter  of the affection is rendered probable by the kind of pain, the constipa-
tion, together  with  the local symptoms, and the therapeutical measures which
are found to be successful.   It is not  improbable, as supposed  by Abercrom-
bie, that in certain  cases the spasm may be preceded by paralysis of a section
of the intestinal tube, and  consequent obstruction  to the passage of  its con-
tents.  Like other  spasmodic affections, it may be produced by causes which
act either  directly  upon  the part affected or indirectly through its nervous
communications.
   Attacks of  colic  are  frequently, if not generally, attributable to the local
action  of the  ingesta.  They may  arise from indigestion caused by either
excess in quantity or the indigestible quality of food.   They not infrequently
follow  exposure to  cold or fatiguing exertions, but  these causes probably act
by occasioning indigestion.   Certain articles of  diet—for example,  shellfish
in some persons—give rise to attacks of  colic in consequence  of an  idiosyn-
crasy which is inexplicable.   The muscular tunic of the intestine is especially
susceptible to  spasm in infancy, and  colic  occurs much oftener in early than
in middle and advanced life.  A susceptibility to intestinal spasm belongs to
some  persons, constituting a predisposition to this affection.   In the practice
of every physician  there are those who are subject to attacks of colic more
or less frequently.   This predisposition may continue for a certain number
of years, and then disappear.  Persons with this predisposition often have an
uncomfortable sensation of  weight, coldness, or numbness in  the abdomen,
with general  languor and  irritability, preceding the  development of colic,
and by means of these premonitions they are able  to predict  an impending
attack. 
INTESTINAL COLIC.
523
  Although attended  with  great  and,  if not  efficiently  treated, often  pro-
tracted  suff'ering, colic is not  a  dangerous affection.  It  may  be doubted
if alone it ever prove fatal.  It is one of those violent functional affections
from which recovery takes  place rapidly.  It has no tendency to eventuate
in inflammation or in any other disease, but in proportion  to its duration  it is
followed by fatigue or weakness,  and more or  less abdominal  soreness may
remain for some  time.
  The object of treatment is the relief of spasm as indicated by the cessation
of pain.   Measures are to be directed to this object without  reference to the
cause of the attack or the existence of constipation.   If, as is generally the
case, an attack have been induced by the presence  of  irritating  ingesta, meas-
ures directed to the spasm should take precedence  of  evacuants ;  and if, as is
frequently the case, the bowels were constipated at the time of the attack, the
removal of this condition  is a secondary object.  So  long as pain continues
there is a  resistance to the action  of cathartics, and to defer measures for the
relief of the pain until the  bowels have been  evacuated is to needlessly  pro-
long the sufferings of the patient.
  In mild attacks warmth to the  abdomen and extremities, a little spirit not
largely diluted with hot water, some aromatic stimulant, such as anise, ginger,
cloves,  mint, etc., or a  few drops of chloroform, will suffice to procure relief.
Twenty drops  of chloroform, repeated, if necessary,  at short  intervals, will
sometimes afford  prompt  relief in severe cases; if not, opium  in some form
is to be given to the extent  of procuring freedom from pain.  Administration
per  enema is to be preferred.   A drachm of laudanum, with the same quan-
tity of the tincture of asafatida  in a small quantity of mucilage or starch,
may be injected, with  injunctions to  the  patient to resist the desire to expel
it;  and usually in a short time this  desire passes  off.   If complete relief do
not follow in the space of an hour, the enema may be repeated.   If the suf-
fering  be  extremely intense, double this  quantity of laudanum  in the case
of an adult may be given in the first or second enema, or  a solution of a salt
of morphia may be injected hypodermically.   If necessary,  the enema or the
hypodermic injection may be repeated a second  or  third time.  A similar
plan is  to be  pursued as regards the doses and repetitions if the opiate be
given by  the mouth.  If hypodermic injections be  given,  caution  is to be
exercised  in their repetition.   Fatal narcotism has been induced by want of
caution in this regard.  Hot fomentations or dry  heat should  be applied  to
the abdomen.   Speedy success may be counted upon by  pursuing this plan
of treatment.
  The  subsequent treatment is to be determined by circumstances relating  to
the abdomen.  If no inconvenience be felt, measures to effect a movement of
the bowels need not be employed  for twenty-four  or  even forty-eight hours.
Not infrequently, if the physician be not in haste to  give a cathartic, a suf-
ficient  evacuation  occurs  spontaneously.  If  measures to effect a movement
be required, a large simple enema may suffice;  if not, a mild saline purgative
may be given  in  divided doses, or castor  oil  if this  remedy be not offensive
to the  patient.   The diet for a day or two should be simple and restricted.
  The  certainty with which colic yields to an efficient opiate treatment ren-
ders it  one of the affections which exemplify  very palpably the resources of
medicine.   Some patients, however, suffer considerably from  the  after-effects
of the  opium  given, and  this  in a measure  compromises the  mutual satis-
faction of' the physician and patient  in the success of the  treatment.  Per-
sons who  are  unfortunately affected  unpleasantly by most forms of opium
are sometimes able to  take certain preparations with less  inconvenience than
others.  The experience of  the patient on this point should  be consulted. 
524        FUNCTIONAL DISEASES OF THE INTESTINE.


                              Enteralgia.

  The term enteralgia denotes a neuralgic affection referable to the intestine.
It has to the latter the same relation as gastralgia to the stomach.  Gastralgia
and enteralgia may be associated (gastro-enteralgia). Enteralgia and colic are
not infrequently confounded;  and it is not  always easy to distinguish, clin-
ically, the one from the other. Enteralgia is  characterized by pain within the
abdomen, with intermissions or remissions, the pain having more or less inten-
sity, but lacking the twisting or griping character of the pain in colic.   It may
be so severe as to lead to contortions and  oral  expressions of suffering.  In
females enteralgia is an element of attacks of tympanites  due to the formation
of gas, and is often associated with hysterical phenomena.
  The diagnosis involves the exclusion of the  various affections from which
colic  is to be discriminated, and the exclusion of the latter affection.  (Vide
p. 520.)   The so-called rheumatism of the abdominal walls (myalgia) is also
to be excluded.   Lumbo-abdominal neuralgia is to be discriminated  by the
existence of tenderness in front at the umbilical  or hypogastric region, and
also at the points in the lumbar and lateral portions of the body, whereas in
enteralgia, tenderness on pressure is generally wanting.   Moreover, this affec-
tion, as well as myalgia, is generally unilateral.
  The treatment involves the  same principles as the treatment of gastralgia
and other neuralgic affections. (Aide p. 462.)


               Lead Colic—Enteralgia from Lead.
  The affection now commonly known as saturnine  or lead colic has been
described by writers at different times and places under a variety of  names.
Painter's colic, plumber's  colic,  colic of Poitou, colica pictonum, Devonshire
colic, colic of  Madrid, rachialgia,  dry bellyache, and  other  names  which
might be added, all relate to the same affection, which  is one of the varied
forms under which lead-poisoning is  manifested.  The affection differs from
ordinary colic as regards not only its causation and clinical history, but its
pathological character.  It is not a spasmodic, but a neuralgic affection ; that
is, a variety of enteralgia,
  It is developed usually  in a gradual manner,  and is preceded by prodromic
phenomena which are the general effects of lead-poisoning—namely, pallor
due  to anamia, and frequently  an icterode hue of the skin, a peculiar fetor
of the breath,  and a  metallic taste in the mouth, loss of appetite, constipation,
pain in the limbs, more or less emaciation, and muscular debility.  Pain in
the abdomen, at first comparatively slight, progressively increases, becoming
at length the chief  ailment.  The pain is  oftenest referred to the region of
the umbilicus, sometimes, however, to the epigastrium or hypogastrium. and
it may be  limited to other situations or it  may  extend over the whole abdo-
men, but it is  usually confined  within  a small  space.   The pain  frequently
shoots into the back, the genital organs, and in other directions.   It is some-
times dull  or aching, and at other  times acute and lancinating.  It varies in
diff'erent cases  within  wide limits  as regards intensity.   In a mild form it
merely occasions annoyance, like the pain  in certain  cases of gastralgia, but
in a severe form the suff'ering is extreme, causing the  patient to  assume a
variety of  unnatural and fantastic positions,  and to utter loud groans or cries
as in severe cases of  gastralgia and ordinary colic.   The  abdomen may be
more or less meteori/.ed or  tympanitic, but it is oftener depressed and resist-
ing to pressure.   The resistance to  pressure  is caused by tonic contraction
of the abdominal muscles, and this  in some  cases is a marked feature  of the
affection.   Pressure  on the abdomen, if made gradually and over a consider- 
LEAD COLIC.
525
able space,  is generally well  borne,  and often affords relief.   Patients are
inclined to lie upon the belly with a folded  pillow or some other substance,
and  sometimes the closed hand, placed under them over the  seat of pain.
Pressure, however, with the ends of the fingers or percussion of the abdomen
may not be well borne.   The bowels are constipated, the exceptions to this
rule being infrequent, and  the  dejections frequently consist of small  hard
lumps, or scybala.   More or less nausea occurs  in a majority  of  cases, and
not infrequently vomiting.  Hiccough and eructations of gas are not uncom-
mon. The appetite is lost.  The urine is scanty and micturition is sometimes
difficult and painful.  Circumscribed projections or tumors, changing their
situation, and due,  evidently, to an  accumulation of gas in  a portion of the
intestinal tube, have been observed.  The pain may be exclusively in parox-
ysms, the patient in the intermissions being entirely free from  it, but much
oftener  more or less constant  pain  is experienced, with exacerbations.  The
paroxysms or exacerbations vary much in different cases in duration as well
as severity.  They may last for a few moments only or continue for several
hours.  The intermissions or remissions also  vary in  duration from a few
moments to  hours  and even  days.
   In conjunction with the foregoing local symptoms there is no fever unless
there be some accidental complication.  The  pulse  is abnormally slow and
frequently irregular.   It is  generally fuller and harder than  in  health.  The
skin is cool.  The mind is anxious and depressed.  The strength fails in pro-
portion  to the severity of the pain  and the duration of the affection.  The
affection may be complicated with other manifestations  of  lead-poisoning—
namely, paralysis affecting  certain of the voluntary muscles, especially the
extensors of the forearm, amaurosis, neuralgia  in different situations, occa-
sionally epileptiform convulsions, delirium, and coma.  The  latter have  been
embraced by Tanquerel and other writers under  the name of lead encephal-
opathy.
   The affection has no definite duration, in this  respect resembling neuralgic
affections in general.   AVhen left to itself it may end in a few  days  or  after
the lapse of  weeks, and if the patient  continue to be exposed to the cause  it
may persist for an indefinite period.   In itself it involves little or no danger to
life, nor is there ground to believe that it leads to any serious abdominal dis-
ease ; but other effects of lead-poisoning which may complicate  or follow this
aff'ection, especially the effects embraced under the name  of lead encephalop-
athy, are liable to  end fatally.   The affection frequently pursues an  irreg-
ular course, varying in severity much at different periods ; and  relapses, after
all the  symptoms have ceased for days or weeks, without any fresh introduc-
tion of  lead, are not uncommon.
   R, Maier found in rabbits  poisoned  with  small doses of lead degeneration
and atrophy of the  ganglion-cells in the intestinal wall and increase of connec-
tive tissue in the ganglia.   He and Kussmaul  had previously found in a case
of lead-poisoning in a human being  a  sclerosis of the caliac ganglia.   It  is
probable that lead acts directly upon  the sympathetic ganglia in  the intestinal
wall, causing sclerosis and partial necrosis of these structures.
   The introduction of lead  into  the system in  sufficient quantity to give rise
to  its morbid effects  may  take  place  through the lungs,  the  stomach, the
mucous membrane  in other parts, and the skin.   Certain occupations involve
the inhalation of lead.   Persons employed in the manufacture of lead paints
are most exposed, and of those who suffer from  lead-poisoning the largest pro-
portion  are of this occupation.   Next to this class, painters are most exposed.
Alore or less exposure by inhalation belongs to a great number of occupa-
tions, such as paper-staining, grinding of colors, glazing cards, manufacturing
earthen  pottery, plumbing,  shot-making, etc.  Lead-poisoning has repeatedly 
526         FUNCTIONAL DISEASES OF THE INTESTINE.
occurred  from sleeping in  newly-painted rooms.   Lead may be  introduced
through the stomach in  various  articles  of  food  and drink.  The colic of
Poitou  was due to wine, and  that  of  Devonshire to cider adulterated with
lead in  order to give  it sweetness.   This kind of adulteration has  been  prac-
tised since the occurrence of the affection  in the places just named, and it is
perhaps still sometimes resorted to.  Liquid  and solid articles of diet, espe-
cially if they contain a free  acid, become impregnated  with lead by being
in leaden vessels or earthen vessels glazed  with lead.  Some years ago a large
number of persons within a limited district in Ohio were affected  with a dis-
ease which for some  time was regarded as a  novel epidemic, and  was called
dry cholera.   It was found to have the  diagnostic characters of lead colic, and
was  traced to the common use of  a  cheap  kind of  earthenware made  in that
vicinity, into the glazing of which lead entered.   An epidemic colic in New
Orleans was traced to lead contained in soda-water; and Prof. Doremus some
years ago demonstrated the presence of lead in considerable quantity in soda-
water drawn from fountains in this  city (New York).  AVater distributed in
lead pipes is  not infrequently the vehicle of its introduction into the system.1
Lead sometimes enters into  the substances used to  color confectionery, condi-
ments, and other articles in  sufficient quantity to give rise to poisonous effects.
Articles enclosed in lead-foil may become contaminated.   Authentic instances
of poisoning by the use of  tobacco thus enclosed have been reported, and in
France  enclosing tobacco in lead is prohibited by law.   The habit of chewing
shot and pieces of the lining of tea-boxes has  been  known to give rise to vari-
ous manifestations of lead-poisoning lasting for years before the  cause of dis-
ease was discovered.2   During the spring of 1866 two hundred and thirteen
cases of lead-poisoning occurred in the AValkill Valley, Orange Co., New York.
After considerable research  it was ascertained that lead was contained in the
flour and meal  used in that  part of the country.   The source of the lead was
ascertained to be the  stones used for grinding  the meal and  flour.  The stones
were old, constantly needing repair,  large cavities frequently occurring, which
instead  of being filled  up with cement were  filled with common lead.  The
attrition of the grinding detached minute particles of lead,  and the lead thus
becoming mixed with the flour and  meal was transformed  into the carbonate
by the process  of fermentation and  baking.3  Children may be  poisoned  by
sucking leaden toys, glazed writing-cards, painted artificial nipples, etc.  These
are only a few  of the diverse modes in  which  lead finds its  way into the ali-
mentary canal.  The use of  lead as a remedy has given rise  to colic and other
morbid  effects.   It may be  introduced  through the skin, although doubtless
with difficulty.  Lead-poisoning  is  sometimes attributable to the  long-con-
tinued application, to  the hands and face,  of  a  cosmetic  containing lead.   I
have known a case in which phenomena denoting lead-poisoning were attrib-
utable to the use for  a long period  of a dressing for the  hair containing the
acetate  of lead.  Finally, instances of lead-poisoning by means of collyria and
vaginal  injections have  been reported.
  The  diagnosis of lead colic in most cases  is not difficult.  If the occupa-
tion  of the patient involve obvious exposure to lead, a suspicion of the nature
of the  affection is  of  course at once  aroused; but  this and other  manifesta-
tions of lead-poisoning  not infrequently occur in  persons who are  not aware
of any  such exposure, and it may require no small pains to  discover the mode

  1 Vide appendix to translation of Tanqnerel's  treatise, and  report of Horatio Adams,
M. D., in IVansactions of American Medical Association, vol. v.
  2 Aide case in  Western Lancet, Cincinnati,  communicated by Dr.  Edward  Murphy of
Indiana.
  3 Philadelphia Medical News and Library, July, 1866. 
LEAD COLIC.
527
in which the poisoning has taken place after the character of the affection has
been ascertained.  The diagnostic characters of lead colic as compared with
those of ordinary colic offer points of difference which enable the physician to
discriminate it from the latter.  The gradual development, the occurrence of
remissions  much more  frequently than intermissions, the persistency of the
affection, the concurrence of  pain in the  back, limbs, and sometimes in the
chest, the occurrence  of nausea and vomiting, the obstinacy of the constipa-
tion, and frequently dysuria, characterize this affection when contrasted with
ordinary colic.   Coexisting paralysis in some  cases, especially if limited to
the extensor muscles of the forearm, confirms  the  diagnosis.  Enteritis and
peritonitis are excluded by the  absence of symptoms denoting inflammation.
Enteralgia, exclusive  of its occurrence in  connection with hysteria, is so rare,
except when produced  by lead, that its existence is  strong  presumptive evi-
dence of this causation.   A  valuable sign is a  blue discoloration of the gums
at their junction with the teeth.  The blue line  on the gums may be apparent
on the upper or lower jaw or on both.   It is wanting in sections where teeth
have been  lost.   It is most  marked in proportion as the teeth are encrusted
with tartar and in persons who neglect cleanliness in this situation.  The dis-
coloration is attributed to the formation of the sulphide of lead, sulphuretted
hydrogen being evolved from the decomposition of'  particles of food remain-
ing between the teeth and beneath the margin of the gums.  The lead may
be introduced through the mouth either with the inspired  air or in food or
drink, or sufficient lead may  be eliminated in this situation to account for the
sign.   The  sign  is not  present  in  all  cases.   Its absence, therefore, is not
proof that lead  colic  does not exist.   Clinical  observation, however, shows
that the sign is  present in a large majority of  cases.   It is found frequently
to precede the development of colic and  other  affections dependent on  lead-
poisoning.   It is  not a transient sign, but is likely to persist, not only during
the continuance of the affection, but for some time afterward.  In a diagnostic
point of view it is highly important, and the gums  should be examined with
reference to it whenever lead-poisoning is  suspected.  A chemical  analysis of
the urine may show the presence of lead in this fluid.  In a case in which the
lead was introduced  by the use of a cosmetic  called " the bloom  of youth,"
lead was obtained from the urine in sufficient quantity  to form distinct parti-
cles of the  metal.1  Edes states that if  the iodide of potassium be  given  for a
few days before an examination of the urine, and the metal be not then found,
it is safe to exclude plumbism from the diagnosis.2
   The treatment of lead colic embraces palliative and curative measures.
The  pain is to be palliated by anodynes given  by the mouth or rectum, con-
joined with  soothing applications  to the abdomen,  as  in cases  of ordinary
colic.  Chloroform given by  the mouth and applied  over the abdomen  some-
times acts promptly and efficiently in relieving the pain.  If this  prove inef-
fectual, opium in  some form is required, the doses and  their repetitions to be
graduated by the intensity and  persistence  of the  pain.  Relief is afforded
by free purgation, and for this  end saline  or  such other  cathartics as the
stomach will best tolerate may be given, and their operation aided by large
purgative enemata.   The obstinacy of  the constipation often renders it diffi-
cult to procure free evacuations from the bowels, and active  cathartics  may
be required.  The employment of cathartics may be useful in removing lead
contained  in  the  contents of the alimentary canal.   Aside  from  this object
and the relief of inconvenience from constipation, cathartics are not indicated.
Croton oil and other drastic cathartics,  heretofore entering into the treatment
  1 For the method of testing the urine for the  presence of  lead  employed by Prof.
Doremus, vide my work  on Clinical Medicine, 1879.
  2 Aide Therapeutic Handbook. 
528         FUNCTIONAL DISEASES  OF THE INTESTINE.

of this affection, are contraindicated.  The warm bath is useful as a pallia-
tive, soothing measure.
   Several  remedies have  been supposed  to have a curative efficacy in this
affection.  Alum is one of these.  Brachet, in a prize essay on the subject
of lead  colic, stated that he had treated 150 patients  with this remedy more
successfully  than by opium  and purgatives.   From one  to two drachms of
alum were administered during the day in a ptisan to which  40 or 50 drops
of laudanum were  added,  a mild aperient given on the third day, and the
alum continued for two or three days after the symptoms  of the affection
had disappeared.  Other observers  have not met with a similar success with
the alum treatment.  Sulphuric acid has been advocated on the basis of suc-
cess in a large number of cases.   A drachm of dilute  sulphuric  acid in a
quart of sweetened water  forms a pleasant  drink resembling lemonade, and
this  may be  taken in the twenty-four hours.   Tanquerel denied the  efficacy
of this remedy, giving as the basis of his denial the results of its trial in 5!5
cases.   The  prophylactic efficacy of the sulphuric-acid lemonade appears to
have  been satisfactorily proven in the lead-works at Birmingham,  England.1
Strychnia or nux vomica has been recommended as a curative remedy. Bella-
donna and nitrite of amyl have been used with some benefit in lead colic.  Their
use is  based  upon the view that the  colic is due to spasm of smooth muscular
fibres, either of the intestine or of blood-vessels.
   The remedy now regarded as possessing the most efficacy is  the iodide  of
potassium.   Its use in the treatment of lead diseases,  and also in those  due
to the presence of mercury in the system, dates from the publication in 1S49
of a paper  by Melsens.2  Assuming that the  local  manifestations  of lead-
poisoning are due to the  presence of an insoluble compound of lead in the
tissues of the  affected parts, Melsens claims for the iodide of potassium the
power of effecting  the liberation of the lead and its elimination  from  the
system.  The iodide  is supposed to combine  with  the lead in the tissues,
forming the soluble iodide  of lead, which passes out of the body in the urine.
Chemical examination of the intestine, the paralyzed voluntary muscles, and
other organs in cases of lead-poisoning has shown the presence of lead in
larger  quantity than is to  be accounted for on  the supposition that it may
exist  in the  body in health.   The  examination of the  urine  in  cases of
lead-poisoning  under treatment with the iodide of potassium has shown the
presence of  lead, its absence in this liquid having been ascertained prior to
the treatment.3  Finally, clinical observation appears  to  afford proof of the
efficacy of this treatment.   AVith reference to the therapeutics  of this affec-
tion, knowledge of its natural history as regards termination when left to its
own course is important.   Tanquerel in his valuable treatise gave the results
in 31  cases in which no treatment was  pursued for twelve days after admis-
sion into hospital, the aff'ection having existed for one or more days before
admission.   Of 8 of these cases in which the colic was violent, in  3 a spon-
taneous cure took place within the twelve days—namely, on the third, eighth,
and eleventh clay.   Of 13  cases in which the colic was of moderate severity,
in 5 a spontaneous cure took place on the fourth, seventh, eighth, ninth, elev-
enth day, and in 1 on the thirteenth day.  Of 10 cases in which the  colic was
light,  in  6 a spontaneous cure took place within the twelve days.
  In the treatment  of lead-poisoning  by the iodide  of potassium  Melsens

  1 Appendix  to Tanquerel's Treatise, by Dana.
  2 Auu/des de Chimic et de Physique, 1849; also,  British and Foreign Medico-Chirurg.
Review, 1853.
  3 For facts verifying this statement, see  a report of the results of treatment with
the iodide of potassium in 23 cases in the IS'ew York  Hospital  by H. S. Swift, M. D.,
New York Medical Times, February,  1854. 
COLIC FROM COPPER.
529
enjoins to begin with moderate doses and to increase the doses gradually.  He
supposes that disturbance may arise from dissolving the lead out of the tissues
rapidly.  Five grains may be given three times daily at first, and the quantity
increased to a drachm per diem if the remedy occasion no inconvenience.
  The utility  of the warm bath as a palliative measure has been already
referred to.  It may be useful in promoting the elimination of lead through
the skin.  It is useful by removing from the skin lead which conies into con-
tact with, and adheres  to, the surface in  persons engaged in certain occupa-
tions.  The sulphur bath  may be employed for the latter  object.   This is
made by adding four ounces of the sulphide of potassium  to thirty  gallons
of water in a wooden bathing-vessel.  The use of  this bath renders the pres-
ence of lead on the skin apparent by the production of  a dark  discoloration
which is readily removed by a brush.  The blackness is marked in various
parts of the body in painters and workmen  employed in the manufacture of
the preparations  of lead used as paints, especially  if they have neglected
cleanliness; but it  may be due to the presence of lead  eliminated from the
body and remaining adherent to the surface.   The  bath renders the lead
which may be in contact with the skin inert, and it is useful as affording evi-
dence that the surface of the body is entirely free from lead, whether derived
from  without or eliminated.
   Prevention of  the continued introduction of lead into the system is an
essential part of the management.   The  occupation  is to be suspended if it
involve exposure;  and if the affection be renewed or there be other mani-
festations of poisoning  on  resuming the  occupation, it should be exchanged
for some other.  If the source of the poisoning be  not  apparent, it is to be
sought for until  found.  This  poison is one  which gives  no  notice of its
entrance into the body,  and no manifestations of its presence until a certain
amount of  accumulation has taken place.  The affection under consideration
is but one,  although the most frequent, of the forms of  disease  to which the
poison gives rise.  There is reason to think that obscure  and indefinite ail-
ments are not infrequently  produced by it in cases in which suspicion of the
cause is not awakened ;  and the liability  to these as well as the more marked
effects from the  use of water conducted in  lead pipes and various other
sources, some of which have been enumerated, is  one of the important sub-
jects pertaining to public health.
   The protection of those necessarily exposed to an atmosphere more or less
charged with lead or to contact with it is also  an  important subject.   Much
may be done to prevent its introduction by  attention  to ventilation, clothing,
baths, washing the mouth, and the occasional use   of purgatives.   Special
means of protection, such  as the application of moist sponges to  the mouth
and  nostrils  or the use  of  masks,  under  certain  circumstances  may be
important.
   After recovery from the colic an anamic condition, with general debility,
will  often claim  appropriate medicinal and  hygienic  measures of  treatment.


                        Colic  from  Copper.
   AVriters have  described  a form  of colic supposed  to be  produced by the
introduction and accumulation of copper in  the system, and the  term metallic
colic has been used  to embrace not only the colic due to lead, but  abdominal
pains with other symptoms attributed to  copper, mercury, and arsenic.   The
diagnostic features of so-called copper colic, as contrasted with lead  colic,
have been considered to be as  follows : Limitation of pain to the abdomen,
increase of pain by pressure, enlargement more frequently than  retraction of
the abdomen, and diarrhaa with greenish  stools.   These symptoms denote
       34 
530        FUNCTIONAL  DISEASES OF  THE INTESTINE.

not merely functional disorder, but gastro-enteric inflammation.  An extended
and careful examination of a number of establishments in which the workmen
were exposed to emanations from, and contact with, copper in various modes,
conducted  by Chevallier and Boys de  Loury in Paris, led to the conclusion
that such an affection as colic from copper does  not exist.1  This conclusion,
however, is by no means inconsistent  with  the fact that copper within the
system  exerts  a  deleterious effect.   Arsenic and preparations  of mercury,
taken in quantities sufficient to produce  the phenomena of a local acrid or
irritant  poison, give rise to pains which may resemble those of colic.  Accu-
mulating within the system, these minerals  occasion  certain  toxical effects;
but  they  do not  under these circumstances lead  to abdominal  symptoms
which may with propriety be  considered as an individual  affection under the
name of colic.

            Passage of  Gall-Stones—Hepatic Colic.

  The passage of  biliary calculi along  the cystic and common bile-duct may
give rise to symptoms resembling those of acute gastralgia.  The discrimina-
tion at once is not always easy.  Moreover, a paroxysm of pain from the pas-
sage of a gall-stone, or hepatic  colic, is to  be discriminated  from affections
other than gastralgia—namely, peritonitis, ordinary colic, colic with intestinal
obstruction, acute gastritis, and the passage of calculi  from the kidney to the
bladder.  Biliary calculi usually form in the gall-bladder, but they have been
found in the  hepatic duct and  its branches within the liver.  They vary in
size from that of a pin's head to that  of a hen's egg.  They are frequently
found in the  gall-bladder after death,  sometimes in great number.  A col-
lection  of  several hundred is not uncommon.    Bennett  relates  a case  in
which the number amounted to two  thousand, and  cases have been reported
in which the number was still greater.  They are usually of soft  consistence
and of low specific gravity.   They are sometimes white, but oftener either of
a yellow,  brown, or greenish color from the  imbibition of bile.   On section
they are often found to consist of successive layers which differ in consistence
and  color.   In general they are composed chiefly  of cholesterin, but they
frequently contain the salts of lime.  Remaining  within the gall-bladder,
they may occasion no  inconvenience; but if many or large, they may give
trouble  by distending the gall-bladder, and they may lead  to  ulceration and
perforation.  If the perforation be into the peritoneal  sac, diffuse peritonitis
follows, and  will  be  likely  to  prove fatal.  If the  distended  gall-bladder
become  adherent to the abdominal walls, the perforation may lead to circum-
scribed abscess which opens externally, and a number of calculi  may be dis-
charged through the fistulous opening.2  They are oftener discharged by an
ulcerated  opening into the intestinal canal.  The opening may  take  place
into the duodenum  or colon.   It has been  known to take  place into  the
stomach, the portal  vein, and the pelvis of the kidney,   (rail-stones some-
times occasion a noise like that produced  by the collision of nuts or marbles
in a bag when shaken if forcible pressure or  strong percussion be made over
the distended  gall-bladder; but in general their existence is  not suspected
until, having entered  the cystic  or common duct, they occasion, by their pas-
sage toward the intestine, paroxysms of so-called hepatic  or gall-stone colic.
It is evident that the  time occupied in  the passage  of a gall-stone, as well
as the  suffering, will  depend, other  things being equal, on its size and  the
irregularity of its shape.
  1 Vide Nysten's Dictionnaire de Medecine, etc., 1858; also ATalleix, op. cil., torn. v.
  2 For an account of reported cases, and  also cases of cholecystotomy, vide article by
Dr. G. W. H. Kemper, in  Transactions of the Indiana State Medical Society, 1879. 
                     PASSAGE OF GALL-STONES.                  531

  The pain occasioned by the passage of a gall-stone is frequently abruptly
developed without any obvious cause, but in some cases it is preceded  bv a
sense of uneasiness referred to the right hypochondrium.  In the majority of
cases the attack occurs three or four  hours after a meal.   The sufferino- is
often extreme, causing the patient to writhe and assume a variety of positions
with  the hope  of obtaining relief.   The pain is referred to the  epigastrium
or the right hypochondrium.  It may radiate thence throughout the abdomen,
often extending into the chest  and  to  the right shoulder.   Usually, there is
more or less tenderness over the seat of the pain, but in some cases pressure
affords a certain measure of relief.  Aromiting speedily occurs in the majority
of cases, and is repeated more  or less  frequently during the continuance  of
the pain.   The  bowels are  constipated.  The pulse, as a  rule, is not accel-
erated, and it may be retarded.   Not infrequently it becomes small and weak.
The retardation of the pulse  is sometimes notably great.  I have known  it to
fall to 30 and to 20 beats per minute.   Pallor of the face and  coldness of the
surface  are  marked  in some  cases.  Chilly sensations, with rigor,  are not
uncommon.  The duration of the paroxysm is variable.  It  may last for a few
moments only or for many hours or days, depending of course on the period
occupied by the passage of the stone either onward into the intestine or back-
ward into the gall-bladder. At length  the pain and other symptoms suddenly
cease, and nothing remains but more  or less soreness  and  the fatigue  occa-
sioned by the suffering.   If  the paroxysm have been of considerable dura-
tion,  the urine may show the presence of bile, and jaundice is frequently
produced.  These symptoms disappear after the  paroxysm is  ended.   The
dejections may show deficiency or  absence of bile.  The  absorption of bile
and its absence in the  stools show that the gall-stone is impacted in the  com-
mon (not the cystic) duct, and that its form and  size are sufficient to cause
obstruction more or less complete.  Under these circumstances the bile  may
accumulate within the gall-bladder, and distend it so that it can be perceived
by  the touch below the lower margin of the  liver.  Finally, after the  par-
oxysm is ended one or more  gall-stones may be discovered  in the dejections
if these be carefully examined for several successive days.  In  some cases,
however, careful examinations  of the feces fail to show the presence of a cal-
culus or of calculi.  The failure to discover them is not proof that an attack
is not one of hepatic colic.   The gall-stones in these  cases, after remaining
for a time in  the cystic duct,  may have passed backward into the gall-bladder,
notwithstanding the valvular folds of the lining membrane.   Another explana-
tion is that the cause of the  obstruction is inspissated bile, and not properly
gall-stones.1
  After an  attack of  hepatic  colic recurrences are to be  expected, but as
regards the intervals cases differ greatly.  Successive attacks may occur  after
days, weeks, months, or years.   Not infrequently  a greater or less  number
of attacks follow in quick succession—several perhaps occurring  on  the  same
day and for several  days in succession.  This is  probably owing to a  tem-
porary dilatation of the cystic  and common duct produced  by the passage of
calculi of  considerable size, in  consequence of  which other stones within the
gall-bladder more readily escape.  The  patient under these circumstances may
be consoled by  the reflection  that the more  frequent  the  passage of calculi
the less the number that remains to give rise to subsequent attacks.  The fre-
quent repetition of attacks, if severe, may occasion considerable disturbance
of the digestive system and general prostration.   A single instance of death
during a paroxysm  has come  under  my observation.
  The differential diagnosis of  the passage of gall-stones from acute gastral-
  1 The presence of inspissated bile in the dejections may be ascertained by chemical
tests.  (Aide Bartholow in System of Medicine, by American Authors, vol. ii. p. 1073.) 
532        FUNCTIONAL  DISEASES OF TEE INTESTINE.

gia is to be based on the following points :  The occurrence of pain not excited
by any obvious dietetic or other cause ; the prominence of  vomiting as a
symptom; the presence generally of more  or less tenderness; the existence
of bile in the urine, and of icterus or an icterode hue of the conjunctiva and
skin ; retardation  of  the pulse;  the  persistence  of pain notwithstanding
opiates are given in full  doses;  the sudden relief  occurring  irrespective of
remedies;  and  after  the attack  the  discovery of  biliary   calculi  in the
evacuations.
   The examination of the evacuations for gall-stones not only serves to estab-
lish the diagnosis, but on the appearance of the  stone or stones may be pred-
icated an  opinion that the gall-bladder  either does or does not contain calculi
which have not escaped.  If only a  single round or oval stone be discovered, it
is probable that this was  a  solitary calculus in  the  gall-bladder, and  other
attacks  need  not be  expected ; but  if several  stones be discovered, polyhe-
dral in  form, with smooth or  polished  facets, which may be plane, convex,
or  concave,  it  is  highly  probable  that the  gall-bladder contains  others,
and the  patient cannot count on being exempt from repetitions of the par-
oxysms produced by  their  passage.  The  only  effectual mode  of examin-
ing  for the  presence  of stones is  to  dilute the feces  and  strain through
a  sieve.
   Acute  diffuse peritonitis may be accompanied by pain resembling in inten-
sity that of hepatic colic ;  but in determining the existence of the latter, peri-
tonitis is  excluded by the absence  of tenderness  diffused  over the  abdomen,
of  rigidity of the  abdominal walls, of tympanitic enlargement, of notable
acceleration of the pulse  and pyrexia, together with the general prostration
which belongs to the clinical  history of peritoneal inflammation.  In  cases
of intestinal  colic  the  pain  is more paroxysmal, with intervals of complete
relief.  Intussusception and internal strangulation  of the intestine are to be
excluded  by  the absence of a tumor  caused by the accumulation of the intes-
tinal  contents at the point of obstruction, by the absence of intestinal obstruc-
tion and of acceleration of the pulse, together with the greater gravity of the
general symptoms  in those affections.   In acute  gastritis vomiting is a more
prominent symptom than in hepatic colic, and the greater gravity of the affec-
tion is shown by the pulse and by the general  symptoms.  In some cases of
hepatic colic  the pain extends downward in the direction of the right ureter, so
that the passage of a calculus along this duct may be suspected.  The absence
of certain symptoms belonging to the history of so-called renal colic—namely,
retraction of the testicles, deficiency of  the urine, hamaturia,  etc.—will serve
to exclude this affection.   Knowledge of the occurrence of one or more prior
attacks which have been ascertained to be  due to the passage of gall-stones
will aid  in determining the diagnosis.  The age of  the  patient is of some
account in the  diagnosis.  Gall-stones  may form at any age, but they are
most likely to form in middle or advanced  life, and in females oftener than
in males.
   In the  great  majority of cases gall-stones  escaping from the gall-bladder
find their way into the intestine, giving rise to  no evil results  beyond the
pain, etc. which their  passage  occasions; but  occasionally a  stone becomes
impacted  in the biliary canal, and if situated in the common  or hepatic duct
retention  of  bile  ensues,  giving rise to persisting jaundice  and  structural
changes  within the liver from  the distension  of  the  bile-ducts.   Charcot
has  described paroxysms  resembling   those  of malarial fever,  sometimes
recurring regularly and presenting  the quotidian, tertian, or quartan type
of an intermittent, and sometimes  recurring without regular periodicity.  To
these paroxysms this author has applied the name hepatic intermittent fever.
They differ from intermittent  paroxysms due to malaria in the time of their 
PASSAGE OF GALL-STONES.
533
occurrence, this being usually in the afternoon or evening, whereas malarial par-
oxysms generally occur before midday.   They are probably caused by septic
infection incident to suppurative inflammation of the duct at the  seat of the
impaction.   The prognosis is unfavorable, death taking place sometimes sud-
denly in a paroxysm.  Recovery may follow the passage of the stone, either
through the  common duct into the duodenum or by ulcerative  perforation
into  the intestine.1
  Stenosis of the colon or duodenum  may result from the projection of the
ulcerated opening into those portions of the intestine.  Intestinal hemorrhage
is an occasional effect of ulcerative perforation, and death may take place from
the loss of blood.   Permanent obliteration of the  canal of the cystic or com-
mon duct may result from the inflammation and  ulceration caused  by the
presence of the  stone.   The formation of a stone within the liver is  one  of
the causes of hepatic abscess.
  The rationale of  the formation of gall-stones is not well understood.  Prob-
ably the deposit in a solid form of certain of the constituents  of bile takes
place in consequence of the presence in  the biliary passages or call-bladder
of mucus, collections of which serve as the nuclei for  the  formation  of cal-
culi.   Hence gall-stones  may be the  result of  inflammation of  the gall-
bladder.  It has been  conjectured that cholesterin may  be  deposited  in
consequence  of the  bile  losing  the  faculty  of holding  this principle  in
solution from a diminution  of the taurocholic acid.  It  is not  improbable
that an excess of  the  salts of  lime  or of bile-pigment  may lead  to the
production of  calculi.   Undue accumulation  and retention of bile  in the
gall-bladder,  and an  unduly large proportion of solid  constituents, may  be
considered as entering into the causation.
  The treatment  of a paroxysm of hepatic colic consists of palliative meas-
ures.  Opiates are  called  for in doses proportionate to the intensity of the
pain, either administered by the mouth or rectum or hypodermically.   If the
suff'ering be  great,  the inhalation of chloroform or ether should  be resorted
to.   AA'arm  anodyne  fomentations may be applied to the seat of  pain.  The
hot bath may aid in procuring  relief.   The local application of cold  by means
of a bladder filled  with pounded ice has  been  found to be  useful  as a pallia-
tive measure.   Remedies to palliate vomiting may be indicated.  Effervescing
draughts and the hydrocyanic acid may be employed for this purpose.  An
alkaline remedy may be found  useful if, as is frequently the case,  the matters
vomited show notable acidity of the stomach.
  Emetics and cathartics  have been advocated under the notion that they aid
in the  passage of the stone.   It is irrational to suppose that they have this
effect,  and clinical observation does not furnish evidence of their value. The
passage of the stone is due to the accumulation of bile behind it after it enters
the common duct, and to contraction of the gall-bladder, which contains mus-
cular fibres.  These are wanting in the cystic and  common ducts.  Exciting
the movements of the stomach and intestine by emetics and cathartics, if any
effect be exerted, is as likely to retard  as  to favor the onward passage of the
stone.   Opium and anasthetics probably promote its  passage.   If the dis-
tended gall-bladder form a tumor which is appreciable by the touch, an effort
may be made, by  pressure with the fingers, to propel the bile in the ducts and
thus aid in the removal of the  obstruction.
  It is desirable, if possible, to effect the solution of gall-stones  within the
gall-bladder.   The  alkaline carbonates are given for  this purpose.  A treat-
ment for this end.  known in France  as  Durande's method, consists in the
administration of sulphuric ether and the spirits of turpentine (3 parts of the
  1 Aide cases reported by Prof. AAllliam Osier, in Medical Times and Gazette (London),
July 30, 1881. 
534        FUNCTIONAL DISEASES OF THE INTESTINE.

former to 2 parts of the latter).  Buckler1 has proposed the use of chloroform
in view of the solvency of cholesterin in this liquid.  He has reported a case
in which an indurated tumor felt through the walls of the  abdomen, directly
over the  inferior margin of the liver, disappeared in five days under the use
of chloroform given in teaspoonful doses after each meal.   It  was concluded
that the tumor was the gali-bladder distended with calculi, but there is room
for doubt as to the correctness of this diagnosis.   It seems hardly probable
that any remedies  can  be introduced  into the system so as to enter into the
composition of the bile largely enough to dissolve  the  cholesterin  of  which
mainly  biliary calculi  are  composed.   Bartholow proposes to puncture the
gall-bladder with a fine exploring trochar and to inject through the canula a
suitable  solvent.
   The occurrence of gall-stones  cannot he anticipated, but, being known, it
is of course desirable to prevent the formation of others.  It is to be remarked
that clinical experience is not to be relied on as  affording evidence of preven-
tion, inasmuch as the success of preventive  measures  cannot be proven.  It
would seem that sedentary habits predispose to the formation of gall-stones.
A change in  this respect  is therefore advisable.   Harley and Bartholow
attach much importance to restriction of  diet as regards  fatty, starchy, and
saccharine articles of food.  Buckler suggests the hydrated succinate of the
peroxide of iron  in cases in which gall-stones are known to  have been passed,
the object being to prevent  their  further formation, this remedy, as he sup-
poses, controlling the fatty or cholesteric diathesis.2   The alkaline mineral
waters of Carlsbad, Vichy, and Marienbad  are  held in much  repute as pre-
venting the formation  of  gall-stones.   The  soda  salts are considered  to be
most  effective  by Harley  and Bartholow.   The sulphate  of soda is recom-
mended  by Harley, and. the phosphate by  Bartholow.   The  latter recom-
mends a drachm  of the phosphate of soda three times daily.  He attributes
the usefulness  of this  remedy in part to a cholagogue effect.   Alonzo Clark
considers the bicarbonate  of soda an  effective  remedy, provided it be con-
tinued for a sufficiently long period.   This  remedy can be  taken in consider-
able doses for a  very long period  without  any apparent ill effects.   A med-
ical friend of the author has taken from a quarter to half  an ounce daily for
the last  thirty years.
   Gall-stones  of sufficient  size to  occasion intestinal obstruction  are  some-
times lodged in  the alimentary canal.   These escape  from the  gall-bladder,
not through the biliary passages, but  by  ulceration, the  walls of the gall-
bladder becoming  adherent to the duodenum or to some other  portion of the
intestine,
   Olive oil, taken largely, is a popular  remedy for gall-stones.   This remedy
sometimes causes the discharge of small, hard bodies supposed to be biliary
calculi.   These  are composed of a concrete .form  of fatty matter, like the
bodies passed  in some  of the  cases  of fatty diarrhaa  which have  been
reported.   A case is quoted by  Dunglison  in which  olive oil, taken  abun-
dantly for the relief of pains attributed to gall-stones, caused a discharge of
fatty matters of  a globular form, varying in size from  that of  a small pea to
that of a grape, and of sufficient  consistence to be cut with a knife, like  soft
wax.3
  1 American Journal of the Medical Sciences, July, 1867, p. 51.
  2 This remedy is given by Dr. Buckler as follows: Hydrated succinate of the  perox-
ide of iron, J iss ;  water, f 3 viss:  a teaspoonful after each meal, continued for several
months, and  resumed at intervals afterward.
  3 Dunglison's Practice of  Medicine, 1842, vol. i. p. 135.
  The reader is  referred  to .-1  Treatise on  Gall-Slones. by J. L. AT. Thudicum,  M. D.,
London, 1863, for a full consideration of their chemistry, pathology, and treatment.
Aide also Murchison's Clinical Lectures on Diseases of the Liver, etc. 
SPORADIC CHOLERA,
535
                      CHAPTER  VIII.

   SPORADIC  CHOLERA.—CHOLERA  INFANTUM.—ASIATIC
                              CHOLERA.

Sporadic Cholera : Clinical History ; Pathological Character; Causation; Diagnosis; Prog-
  nosis; Treatment.—Cholera Infantum.—Epidemic Cholera: Anatomical Characters;
  Clinical History; Pathological Character; Causation; Diagnosis; Prognosis; Preven-
  tion ; Treatment.

  SPORADIC CHOLERA may be considered as a functional affection of the
    stomach and intestine.  Epidemic or Asiatic cholera belongs more properly
among infectious diseases ;  but inasmuch as the symptoms  and lesions are in
great part referable to the intestine in this affection,  it is placed in this chap-
ter for convenience of reference.  Moreover,  the symptoms in some cases of
sporadic cholera simulate  closely those  of epidemic cholera,  and this  is a
reason  for placing the two  affections in juxtaposition.   Cholera infantum,
belonging  among the diseases of children, does not come within the scope of
this work.  I shall, however,  notice it briefly,  referring the reader for a fuller
consideration of it to works devoted to the diseases of children.


                         Sporadic Cholera.
  The affection called cholera in its ordinary form is commonly known as chol-
era morbus.   Aside from the  incongruity of associating  these two words, the
one of  Greek and the other of Latin derivation, there is no good reason for
appending the word morbus, which expresses  no  more than  is implied in the
name of any affection—namely, the existence of disease.   The etymology of
the  term cholera is somewhat doubtful, but it  is supposed to signify a flow of
bile.  The term is of ancient date, and was introduced when various liquids
were embraced  under the name of bile.  Not only is the term sanctioned by
long usage, but it would be  difficult, with  our present knowledge, to substi-
tute  a better name for the affection  under consideration.   The term sporadic
serves to  distinguish  this  from another affection  known  as  cholera which
prevails as an epidemic.  To  distinguish it from the latter, which emanated
from India, it is sometimes called by French writers European, and by Brit-
ish writers English cholera.   AA'riters on this side of  the Atlantic might  with
equal propriety call it American cholera, since it is sufficiently common as
an indigenous affection in America.  It is called by German writers cholera
nostras.

  Clinical History.—An attack of sporadic cholera is  often abrupt, but in
some cases it is preceded, for  a period usually brief and  rarely longer than a
few hours, by a sense of  weight or uneasiness referred to the epigastrium or
extending  more or less over the abdomen, with nausea, occasional colic pains,
etc.   The  attack occurs much oftener in the  night  than in the daytime.   It
is ushered in by vomiting, which is speedily followed by purging.   Aromit-
ing  and purging, occurring in quick succession and recurring either simul-
taneously  or in close  alternation, constitute  the prominent and distinctive
symptomatic features of this affection.
  The evacuations from the stomach and bowels are  generally  abundant,  and
at first consist  of the  alimentary  and fecal  contents.  Afterward  liquid is 
 536     SPORADIC  CHOLERA,  CHOLERA INFANTUM,  ETC.

 vomited, sometimes in large quantity, often having the appearance and taste
 of bile, sometimes acid, and sometimes so acrid as to  occasion a scalding sen-
 sation in the throat.   In like manner, the dejections become liquid and occa-
 sion frequently a burning sensation at the anus.  The acts of vomiting and
 purging occur suddenly with but little premonition.   They are often violent,
 the contents of the stomach and  bowels  being ejected with force.  The  acts
 of purging are preceded  and accompanied by colic  pains, often extremely
 severe, which  are  temporarily relieved by a free evacuation.   Severe pains,
 like those of spasm or cramp, often attend the acts of  vomiting.  In the inter-
 val between the acts of vomiting the  patient usually  suffers from dryness of
 the mouth  and fauces  with urgent  thirst.  The abdomen may be  at  first
 voluminous, but after repeated acts of vomiting and purging it becomes  con-
 tracted.  Tenderness over the abdomen is  either wanting or slight.  Spasm
 of the abdominal muscles sometimes occurs, causing hard  bunches or knots, as
 in some cases of colic.   Hiccough is an occasional symptom.
   AVith the foregoing local symptoms are associated anxiety, restlessness, and
 a sense of exhaustion proportionate to  the violence and duration of the attack.
 The pulse is more or less accelerated, small, and feeble.  The  skin is cool or
 even cold, and  is frequently bathed in clammy sweat.  The voice  is feeble,
 sometimes altered  in  quality, and occasionally there  is aphonia.  In some
 severe cases cramps occur  in the feet,  the calves of the legs, and in other sit-
 uations.  These add greatly to the suffering of the patient.
   The affection runs a rapid course.   After continuing for several hours the
 acts of purging and vomiting become less severe and occur at longer intervals;
 the pains, etc. progressively diminish,  until at length  all  the  symptoms  dis-
 appear, leaving an  amount of fatigue  proportionate to the violence and dura-
 tion of the  attack.  The patient  usually recovers rapidly.   It is remarkable
 that an affection involving so much disorder should  leave the affected organs
 in a condition to resume so speedily the exercise of their functions.  This is
 the rule as  regards the  progress and termination of the affection, even if its
 course be not arrested by remedial interference.   Exceptionally, the vomiting
 and purging continue, the evacuations from the bowels occur involuntarily,
 the pulse becomes more and more feeble, coldness of the surface is more and
 more marked, and contraction of the features takes place;  in short, the patient
 falls into a state of collapse, and  dies within  a few hours  from the onset of
 the attack.  This unfavorable course  is extremely rare.   I cannot  recall an
 example that has fallen under my observation exclusive of cases occurring in
 infancy.

   Pathological Character.—Sporadic cholera  appears to combine morbid
 conditions belonging  to  other functional affections  of  the alimentary canal.
 In  a certain proportion of the cases considered as cases of cholera the symp-
 toms are  attributable simply to indigestion.  Amounting and purging denote
 in these cases  the coincidence of acute dyspepsia and crapulous  diarrhaa.
 Such cases  are  usually comparatively mild, and the  vomiting and purging
 cease as soon as the offending contents of the stomach and bowels are expelled.
 In other cases something more than indigestion is involved in the pathology.
 The evacuation of liquid, often  in great abundance, shows hypersecretion or
morbid  transudation  into  the stomach and intestines.  The affection then
combines gastrorrhaa and  enterorrhaa.  In some cases the secretion of bile
seems to  be increased, but it is  difficult to  estimate, from the color and
the bitter taste of the vomited liquid, the relative proportion  of bile.   It has
been common to suppose that in this,  as in various  other affections, disorder
of the liver  is in some way involved.   There  is no solid foundation for such
a supposition;  it rests on conjecture alone.  It is only in a certain propor- 
SPORADIC CHOLERA.                      537
tion of cases that  the  bile appears to be secreted in morbid quantity.  The
limit of our present knowledge of the pathological character of the affection
is reached when the different morbid conditions into which it is resolvable are
enumerated.   These morbid conditions or elements of the affection  are  indi-
gestion, irritation,  spasm of the muscular coat of the stomach and intestines,
enteralgia, morbid  gastric and intestinal transudation, and perhaps in some
cases hypersecretion of bile.   By German  authors the affection is considered
as a variety of gastro-intestinal catarrh.  It is  impossible to  distinguish, by
means  of post-mortem  appearances, sporadic from epidemic  cholera.

   Causation.—Sporadic cholera is not  peculiar to any  country, but it is of
more frequent occurrence in warm than cold climates.  In cold and temperate
latitudes it occurs very rarely except during the summer and autumnal months.
An elevated temperature is thus involved in its causation, either by contribut-
ing to the development of causes or by rendering the system more  liable  to
be affected by them.   The  affection occurs oftener in childhood, youth, and
middle age than in advanced  life, and oftener  in  males  than  females.   Fre-
quently an  attack  seems to be attributable to the ingestion of particular arti-
cles of food or drink.   Uncooked vegetables, fruits, ices, etc. are often  sup-
posed to stand in a causative relation to it.   An attack may follow the arrest
of digestion from various causes.   In some  cases, as already stated, the affec-
tion is  apparently  due  to indigestion alone.   It is  probable that exclusive of
these cases the affection involves a special cause, the nature and  source of
which are unknown.  In several  cases of sporadic cholera Finkler and Prior
have found in the  dejecta comma-shaped bacilli which  bear some resemblance
to the bacilli of Asiatic cholera, but which can be distinguished from the lat-
ter by cultivation  in different media.  Although Finkler and Prior consider
their bacilli as the cause of sporadic cholera, other observers have failed to
find comma-shaped bacteria  in this disease.

   Diagnosis.—The diagnostic features of an attack of  sporadic cholera are
so strongly  marked that little need be said under this head; yet there is
some liability to errors of diagnosis.  I have known a case of acute  peri-
tonitis, accompanied by vomiting and purging, to be considered as a case of
cholera, the nature of  the disease not being discovered until the autopsy was
made.  It is extremely rare for vomiting and purging to have sufficient promi-
nence early in peritonitis to lead to this error.  The diagnostic marks of peri-
tonitis, however—which will be considered in another chapter—should always
be sought after in  cases of apparent cholera.  The chief liability to error  in
diagnosis relates to cases of poisoning from the ingestion of acrid or  corrosive
substances.   It  is  important to discriminate these cases  from  cholera with  a
view to antidotal treatment, prognosis, and medico-legal  considerations.  The
following are the differential points: The acrid or corrosive poisons occasion
vomiting, which continues for some  time before diarrhaa occurs, whereas  in
cholera the  purging is simultaneous with  or follows quickly the vomiting.
Moreover, the vomiting in cases of poisoning is out of proportion to the  diar-
rhaa.  The symptoms in  cases  of  poisoning denote  a  condition of greater
gravity;  the  pulse is more frequent and smaller, the expression is more  hag-
gard, etc., than in  the majority of cases of cholera.  Redness or charring of
the mouth  and  throat  distinguishes certain cases  of poisoning.   There  is
marked tenderness over the  stomach in cases of poisoning, and more  constant,
excruciating pain in this situation in the intervals between the acts of vomit-
ing;  in short, the  symptoms of gastritis are present.   The matter vomited is
frequently bloody.   Finally, in cases of poisoning the symptoms are developed
soon after a meal or the ingestion of something containing the poison. 
538      SPORADIC CHOLERA, CHOLERA  INFANTUM, ETC.

   During the prevalence of epidemic cholera it  is not always easy to distin-
guish  cholera  nostras from  Asiatic cholera.  In doubtful  cases the recog-
nition  of the cholera bacilli of Koch and their cultivation suffice to establish
the diagnosis.

   Prognosis.—As  already stated under the head of the Clinical History,
this affection in the  vast majority of cases intrinsically tends to recovery.  A
fatal termination is a rare exception to the rule;  yet the fact that the termi-
nation is  sometimes  fatal is to be borne in mind, and should enforce prompt
and effective measures of treatment.  Occurring in  persons already affected
with some important disease, the prognosis is of course not so  favorable as
when healthy  subjects are  attacked.

   Treatment.—In the treatment of sporadic  cholera  the  first point is to
ascertain whether the matters vomited have contained ingesta in more or less
abundance.  If not, and if there be reason to suppose that the stomach contains
undigested aliment, a mild  emetic may be  given.   Almost  invariably, how-
ever, the contents of the stomach are  expelled with  the first  acts of vomit-
ing, and as an emetic is  indicated for  no  other object it is very  rarely called
for.  In my own experience I have not prescribed an emetic in this affection
for the last thirty or more years.  The next object is to arrest  the  vomiting
and purging, together with  the pain, etc., by the employment of some form
of  opiate  in  doses  sufficient to effect  this object.   In the vast majority of
cases this object may be speedily effected.  The form  of opiate should be
chosen with reference to promptness of action and its retention.  Laudanum,
the  black drop, and  an  aqueous  solution of opium  are well  suited to  the
management of this  affection, but Magendie's solution, or a salt of morphia
placed dry upon  the tongue, is in general  the  best  form.  A full dose—a
quarter or half a grain of a  salt of morphia or an  equivalent dose of any
other preparation to an adult—should be given directly after an act of vom-
iting.  The  first dose will  perhaps be immediately rejected; if so, a second
should be at once given.  If a second and third dose be instantly or quickly
rejected, the  administration by the  mouth  should be abandoned,  and from
one to two drachms of laudanum or an equivalent dose of some other prepa-
ration  may be given in a little thin starch  or mucilage per enema. The enema
should be given directly after  an evacuation, and  the  patient should be in-
structed to resist as  long as possible the  inclination to expel it.  If the  first
enema be quickly rejected, a second and a  third maybe given. If the attempt
to administer the opiate by the mouth and rectum fail, the hypodermic injec-
tion may be resorted to.  In  whatever way the remedy be  introduced,  it is
to be repeated  after an interval  of from  half an hour to an hour  until  the
vomiting and purging are arrested, the effects of each dose being  carefully
watched and the intervals being sufficiently long to avoid any risk of indu-
cing narcotism.
  An  important part of the treatment is the withholding of liquids.   The
intense thirst leads  the patient to drink largely between the acts of vomiting,
and this tends to prolong the affection.   The drink should be  restricted to a
tablespoonful of ice-water at  short intervals, or, what is better,  small pieces
of ice may be taken frequently and allowed to dissolve in the mouth.  Strict
compliance with  injunctions on the score  of  drink is  essential to the prompt
success of the treatment.   If there be  great  prostration a little spirit  and
water may be  taken, if retained, at short  intervals.
  In my experience this method  of treating sporadic cholera has proved  uni-
formly successful, and complete  relief may generally be expected within an
hour.  No  apprehension need be  entertained with  respect to the sudden ces- 
CHOLERA INFANTUM.
539
.   sation of the vomiting and purging; and the more quickly the arrest is made
   the better after a free evacuation of the stomach and bowels.   Mercury is, to
   say the least, superfluous.   The success  of treatment without it is  all that
   could be desired.
     Care as regards diet is alone required  in most cases after  the  affection is
   arrested.
     I do not deem  it necessary to consider other methods of treatment, since
   the success of  the plan just stated is, as far as my experience goes,  uniform
   and immediate.  The only objection to  the plan  is that some persons  are
   unpleasantly affected by opium, and after the affection  is arrested the effects
   of the remedy may be more or less annoying for a time.   This objection  has
   not much weight,  since the after-effects of opiates, however distressing, occa-
   sion  far less suff'ering  than the  continuance of cholera; but they who  fre-
   quently experience annoyance after the use of opium, under  certain  circum-
   stances take it without inconvenience, and I have been led to observe that
   the  after-effects are  likely to be slight or wanting when opium is given in
   this affection  to patients who usually suffer  from these effects.


                           Cholera  Infantum.
     The name cholera infantum, or the more popular phrase summer complaint,
   is supposed by some to denote an affection peculiar to  this country.  The
   morbid phenomena, however, considered by American writers as belonging
   to this aff'ection are described in  European  works under other names.  Cru-
   veilhier  enumerates many of the symptoms as occurring in  cases in which
   gelatiniform softening of the stomach due to the post-mortem action of  the
   gastric juice is found  after  death.  British writers on diseases of  children
   generally describe the symptomatic phenomena under the head of diarrhaa.
   AVeaning brash, watery gripes, and choleric  fever  of children  are names
   under which  these phenomena were  described  by Cheyne, Armstrong,  and
   Copland.   By  some French writers they have been described as belonging
   to colo-enteritis, follicular  enteritis,  choleriform diarrhaa  of children,  and
   gastro-intestinal catarrh.   German authors consider  the affection as gastro-
   intestinal catarrh.
     As commonly used in this country, the term cholera infantum, or  summer
   complaint, embraces different pathological conditions—in  fact, distinct affec-
   tions occurring in  children under two  years of age.  These different condi-
   tions, however, may be developed  at  different  periods in  the same case.   In
   certain cases  the  symptoms  closely resemble  those  of the sporadic  cholera
   of adults.   A  child is  seized with  vomiting and purging, the latter usually
   occurring first; the acts of vomiting and purging are violent  and frequently
   repeated ;  after the  contents of the stomach  and bowels  are expelled  the
   evacuations consist of secreted or transuded liquid in  more or  less abundance.
   The attack may cease or be arrested and recovery speedily ensue, as  in cases
   of the sporadic cholera of adults; but  this favorable course  does not obtain
   so generally in children as in  adults.   If the course be unfavorable the vom-
   iting and purging continue; the child  is tormented with thirst, but every-
   thing is rejected from  the stomach;  great prostration ensues; collapse  fol-
   lows, and death takes place in one, two, or three days.  The fatal result may
   be preceded by convulsions and coma.   In some cases the violent symptoms
   of cholera cease, and the attack eventuates in a chronic affection accompanied
   by diarrhaa and occasional vomiting.
     In  other cases  the affection is  gastro-intestinal indigestion.  These  are
   characterized by diarrhaa, the dejections being lienteric and  watery.  Arom-
   iting  occurs either occasionally and is an accidental  symptom, or it may  not 
540      SPORADIC CHOLERA, CHOLERA INFANTUM, ETC.

occur.  The diarrhaa is more or less  persisting, the discharges  being  often  •
green  in  color—an appearance  which Golding Bird, and more  recently J.
Lewis Smith, have shown not to depend on  vitiated bile;1 the appetite  is
impaired or lost; colic  pains  are often troublesome; the child progressively
wastes, and death may take place from inanition.   In another class of  cases
the  affection  is either  enteritis  or  entero-colitis.   The dejections  in  these
cases contain gelatinous  or stringy mucus, and are not infrequently tinged
or streaked with blood.   Febrile movement, with remissions, occurs  in  these
cases.   There is more or  less  abdominal tenderness and pain.  Aromiting may
be prominent as a symptom or it occurs only  occasionally.  Progressive ema-
ciation and debility mark the unfavorable  progress of this  affection.  Head
symptoms are often  developed in its course.  The  child becomes dull and
somnolent and  lies with the  eyelids partially closed, frequently rolling the
head from side to side.   Convulsions and coma  may  occur.  After death an
examination reveals the evidences of inflammation  of the mucous membrane
of the small, and perhaps also of the large intestine, the follicles  being  espe-
cially involved.   Enteritis or  entero-colitis  is  liable to become developed in
the cases  which at first appear to be cases of  diarrhaa dependent merely on
indigestion.  In  still another class of cases the symptoms  and the appearances
after death denote the existence and limitation  of inflammation to the large
intestine.
  Under the name of cholera infantum, then, are commonly embraced cases of
sporadic cholera, diarrhaa from  indigestion, enteritis, colo-enteritis, and dys-
entery.   The  head symptoms  which are likely to be developed in unfavorable
cases of each of these affections in the young  child were formerly incorrectly
attributed to  inflammation  of the meninges  of  the  brain.  They constitute
the  hydrencephaloid  affection of Marshall Hall.
  The affections embraced under the  name  of cholera infantum are not, as
already stated, peculiar to America, but  they doubtless  prevail  to  a much
greater extent in certain  parts of this  country than in Europe, owing, prob-
ably, in a great  measure, to the  greater heat in the  summer months.   The
causation  has relation to a high temperature, the affections prevailing almost
exclusively during the months of June, July,  August, and September. Some-
thing more than temperature, however, is concerned in their production, for
they are almost limited to cities and large towns,  and are more prevalent in
the Northern and Middle  than in the Southern States.  Children of the poorer
classes, in insalubrious situations and living in  crowded dwellings, are more lia-
ble  to be affected, but the children of those in easy circumstances and of the
wealthy by no means escape.   The irritation  of  dentition and the change of
diet  after  weaning doubtless  render the system more vulnerable.   Infants
brought up by hand are  especially subject to these  affections.   The diet of
the child  after weaning  has much to do, if not  with  the causation of  these
affections, at least with the ability of the system to resist and overcome them.
Restriction to insufficient  articles of nourishment, such as arrowroot and gel-
atin, is one  source of innutrition in infancy ;  but there is reason to believe
that infant  mortality in cities  is attributable  in no small measure to the use
of diluted, sophisticated,  and artificial  milk.   The  importance of undiluted
milk from a pure source  to the welfare of children is far from being gener-
ally appreciated.  The quality of milk is  of comparatively little consequence
after  childhood, because it then  usually enters but little into the diet, but as
the  chief  reliance is  upon  milk  in infancy its purity is  then of the utmost
importance.
  The general principles  which should  govern the management of the  same
affections  after the period of  early childhood are applicable to the different
                     1 Vide Smith on Diseases of Children. 
CHOLERA INFANTUM.
541
forms of disease embraced under the name of cholera infantum, with certain
modifications which will be here referred to very briefly.  The treatment, in
the first place, has reference to the  form of cholera infantum which is pre-
sented.   In  the acute form, resembling  the  cholera of adults, in which  there
is a liability to a rapidly fatal termination by exhaustion from loss of fluids.
the patient  falling into a state  of collapse, the indications  are to'arrest  the
vomiting and purging, to restore warmth to  the surface  by the application of
dry heat, mustard-water, and the warm hath, and to sustain the powers of the
system by stimulants and nourishment.   For the arrest of the vomiting and
purging opiates are to be relied upon, as in the cholera of adults, but they
are to be given with much circumspection in order to avoid risk of narcotism.
Exclusive of this form, the affections do not occur with a sudden and violent
attack, but as a rule they are developed gradually and tend to become chronic.
Measures for the relief of vomiting are—a sinapism to the epigastrium ;  crea-
sote, which in doses of a sixth  or an eighth of a drop  in mucilage, repeated
after each act of  vomiting, sometimes  acts like a charm ; the subcarbonate
of bismuth in doses of from ten to thirty grains; small  doses of calomel with
chalk, chloroform,  and hydrocyanic acid.   AVith reference to this symptom a
careful regulation  of the ingesta is requisite, and milk with lime-water,  given
in small quantity  at a time, will  often be  retained when other articles of
nutriment are rejected.
   AVith reference  to the  diarrhaa, occasionally  a laxative is useful, and a
few grains of calomel or  blue  mass, followed  by the syrup of rhubarb, are
well adapted for this purpose.   There are no indications for mercury except
as a remedy for vomiting and an occasional  laxative remedy, the convenience
of  its  administration being  perhaps its chief recommendation in cases of
young children.   Opium  in  some form  with  due  circumspection is  to be
employed.   It is most efficient when given by enema, provided it be admin-
istered with proper care and retained.   If  given  by the mouth, the Dover's
powder is an eligible preparation.  Hypodermic injections of morphia should
not be given.   If  the dejections denote acidity, chalk in powder or mixture,
or  lime-water, is  indicated.   The  mineral and vegetable astringents  are
highly important.   Of the mineral astringents, the most efficient are bismuth,
lead,  and the persulphate or  pernitrate of iron.  The  nitrate  of silver is
highly  recommended by some  authors.  Of the  vegetable  astringents, kra-
nieria, tannic acid, kino, catechu, hamatoxylon. geranium, and rubus villosus
are articles  from which a selection  may be made or which may be tried in
succession.   Dr. AV. Byford Ryan claims remarkably good results from bel-
ladonna conjoined  with nux vomica and arsenic.1
   Attention  to diet and regimen  is  of prime importance.   Many children,
there is reason to  believe, die with these affections from an insufficiency of
nutriment.  Pure  milk  is the most  appropriate article of food.   It may be
rendered more nutritious by the addition of boiled flour, powdered biscuit, or
other farinaceous preparations.   Gelatin and arrowroot  or other amylaceous
substances alone are inadequately nutritious.  The essence of meat and strong
broths are often taken with  avidity by very young children, and  the  desire
for them should be indulged  and encouraged.   This remark is also applicable
to broiled tender meats taken  in a solid  form.   AVithin  the past few  years
the use of raw meat has been recommended as a form of diet adapted  to the
affections under consideration, and it is  frequently taken with relish.  Tender
beef is to be preferred, but mutton  and chicken  are sometimes more accept-
able to  the patient.  The  meat is  to  be finely hashed,  and may be given in
this way, or it may he made  into a kind of puree by being reduced to a pulp
in a mortar  and pressed through a fine sieve, so as to separate the  vessels and
                      1 American Practitioner, June, 1885. 
542     SPORADIC CHOLERA,  CHOLERA INFANTUM,  ETC.

areolar tissue.  If the child manifest an  aversion to it as  thus prepared, the
hashed meat or pulp may be rendered palatable by the addition  of salt, sugar,
or some  kind of preserve, or it may be added to a  broth made with sago or
tapioca.   Cooked tender meats, however, are  generally  more  acceptable,
equally digestible, and not less nutritious.  The liability to tania as a result
of eating uncooked meat renders its use of doubtful propriety.
  As regards the administration of  different kinds of food, the quantity given
at a time is to be graduated by the ability of the  stomach to retain and digest
it;  and this is the only rule of limitation.  It is of vast importance for the
physician not to  deem it too  trivial to enter into full and minute  directions
with respect to  the  details  of nourishment.  He should bear  in mind  that
children  often die from innutrition through the  apprehensions and ignorance
of nurses and mothers.
  In  conjunction with diet, alcoholic stimulants  are highly useful.  A few
drops of  brandy or some  kind of spirit may be given at short intervals  with
advantage.   The preparation known as calisaya cordial or elixir is well suited
to children,  combining a  tonic and stimulant in a form agreeable to the taste.
The need of a stimulant is shown frequently by  the avidity with which  chil-
dren  take it in  these affections.
  Finally, removal from  the city, either to a situation on  the seaboard or to
a salubrious  point inland, is the  most efficient of all curative  means.   This
measure, if  not  deferred  too  long, rarely fails.   If other  measures be  not
speedily  successful, this, whenever practicable, should be resorted to without
delay.  If it be not practicable, the child should  be in the open air as much
as possible, and  should be carried daily as far from  home  as  convenient, in
order in  this way to secure  a change of air.
  The head symptoms referred  to  in  the clinical  history claim sustaining
measures, stimulants, and nourishment, conjoined with mild  revulsives.
  In  these  affections hope of recovery need not be relinquished under an
assemblage of symptoms which may seem to render  the prognosis as unfavor-
able as possible.   Patients sometimes recover  after lingering for a long  time
on the verge of the grave. The reason is  that the affections, when they prove
fatal, do not  necessarily  involve incurable lesions  of structure, but a fatal
result is due to  protracted irritation, exhaustion, and innutrition.


                         Epidemic  Cholera.
  The term epidemic cholera  is selected as the one most frequently used and
the most convenient to designate a disease which has received a great variety
of names,  such as Indian, Oriental,  and Asiatic cholera,  cholera asphyxia,
spasmodic  cholera, malignant, pestilential cholera, etc. etc.  The etymology
of the word cholera, it is true, is singularly inappropriate, accepting the  deri-
vation which signifies a flow of bile ; but our present knowledge does not war-
rant a name  expressive of the pathological character of the disease.  More-
over, it  is to be presumed that the disease  is  not essentially the  same as
sporadic  cholera.  The two are not  merely different varieties of one disease,
but they are  distinct individual affections, having  certain  prominent symp-
toms in common, but differing in essential  points relating to clinical history,
pathological character, causation, and prognosis.
   For an account of the prevalence of this remarkable epidemic in different
countries and at different times the reader is referred to other works.  Suffice it
to say that the disease appears to be indigenous  in India, and to have existed
there, both  as a sporadic and an epidemic affection, for a long period.   In
other  parts of the world it has made  brief visitations  solely as an  epidemic.
In  1817  it  began its march  from  Bengal, and  during  the following fifteen 
EPIDEMIC CHOLERA.
543
years it traversed nearly the whole of the known world.   It prevailed in dif-
ferent parts of the American continent for the first time  in 1832, and again
in ls:il.   It  began its  march a second time from India  in 1847, and again
traversed the greater portion of the globe, prevailing  in the United States in
1849, '50, '51, and '52.  Beginning again its inarch  over the globe in 1804,
it reached  this country in  1866, and during this and the following year  it
prevailed in many of the large towns in the different States of the Union.  It
may be proper to add that my opportunities for observing the disease in  1849
and 1S52 were ample.   During the*se years I treated, in hospitals and in pri-
vate practice, about 200 cases, recording at the bedside the histories in about
90 cases.  A few cases came under my observation in 1866 and 1867.  The dis-
ease prevailed in different  parts of this  country in 1873.1  In 1883 cholera
appeared in Egypt, and since  then it has  prevailed  in  Italy, Spain, and the
southern part of France.

  Anatomical  Characters.—With the exception of the presence in the in-
testines of specific organisms, there is nothing in the pathological anatomy of
Asiatic cholera which, so far as at present known, can be considered as pathog-
nomonic of the disease.  The same changes may be met with in severe  cases
of sporadic cholera.  The  anatomical appearances vary  according as death
takes place during the algid stage or during  the stage of reaction.   The
changes of the algid or asphyctic stage will be first described.  Post-mortem
rigidity is  marked; it comes  on soon after  death and  continues for a long
time.  In  some  cases  shortly after  death visible twitchings of the muscles
occur, and occasionally considerable movements of the limbs.   The heat of
the body is preserved for a long  period after death, and  there may be  even
a post-mortem elevation of the temperature.   The surface of the body has a
cyanotic hue, especially in the dependent parts and in the extremities.   The
serous surface of the small intestine has a rosy color.  The  intestine is not
distended with gas, but in typical cases it contains a large (sometimes an  enor-
mous) quantity of yellowish-white  fluid,  holding in suspension  small white
flakes, and hence presents a heavy, flabby, sodden appearance.   The mucous
surface of the small  intestine  is swollen, adematous, moderately congested,
and may contain  ecchymoses.   The congestion and the extravasations are most
marked in  the lower part of the ileum, and usually are  not present in either
the large intestine or the stomach.  The  solitary follicles and Peyer's patches
are, as a rule, considerably swollen, and are frequently surrounded by a zone
of congestion.   The mesenteric glands are  moderately  enlarged.  The sur-
face of the mucous membrane  is coated with tenacious  mucus.  There are
marked inflammatory  changes in the intestinal coats,  indicated by an in-
creased number of lymphoid cells in the mucous and submucous coats.  After
death the epithelial cells lining the mucous membrane are extensively desqua-
mated, and may  be found in the intestinal  contents.   The view has prevailed
that this desquamation  occurs during life and  constitutes a lesion character-
istic of cholera.   Competent  observers have  failed to find intestinal epithe-
lium in any considerable quantity in the  discharges during life.   There is no
ground for assuming that during  life an  extensive desquamation of the epi-
thelium takes place.
   In  the   intestinal contents  and  in  the walls  of  the intestine are found
comma-shaped bacilli,  which were discovered  by Koch, and which will be
considered  fully  under the  head of  Causation.  The comma bacilli are usu-
ally abundant in the  intestinal  contents.  They are found in  the glands of
  1 For an account of the cholera epidemic in 1873, vide Reports prepared under the
Direction of the, Surgeon-General of the Army,  1875, published by the Government of
the United  States. 
 544      SPORADIC CHOLERA, CHOLERA  INFANTUM, ETC.

 Lieberkiihn, between the epithelium  of these glands and the membrana pro-
 pria, and to some extent in the tissue outside of the glands.   They are  not
 present in the blood or in other organs of the body.
   Changes  in  other  parts of the body are in great part explicable  by  the
 enormous transudation  of  fluid from  the blood into the intestines.   The
 blood  is dark,  and from loss of water is  so  thick  and viscid  that it circu-
 lates  with  difficulty  during life.   It  is  accumulated  chiefly in the large
 veins  and in the right  cavities of the heart, where it may  be  fluid, or it
 may contain soft,  dark, or in some cases  decolorized  clots.   The  heart,
 especially its left ventricle, is generally firmly contracted.   By way of com-
 pensation for its loss of serum, the blood  absorbs fluid from the tissues,
 and hence  these  are found abnormally  dry.  The muscles  are  firm, dry,
 and dark-red in  color.   In  consequence of  the  concentration of the fluid
 in  the serous  cavities,  the  pleura, pericardium, and peritoneum are often
 covered  with a thin  layer  of stick)* substance which  has  been sometimes
 mistaken  for an inflammatory  exudation.    The meningeal vessels  of  the
 brain and cord  are often congested.   The cerebro-spinal fluid  is diminished,
 and the substance of  the brain and cord is firm and dry.  The  lungs collapse
 to an unusual degree in consequence of the empty and dry state of the bron-
 chi.  The upper portion of the lungs  is usually dry and light colored, and  the
 lower portion is frequently engorged with blood.  There are sometimes hem-
 orrhages in  the lungs. Small ecchymoses  are usually present in the tissue of
 the pleural  and of the  pericardial membranes.  The spleen may be small,
 flabby, and  dark red,  or it may be swollen.   There  is nothing noticeable in
 the liver.   The kidneys in  this  stage are not usually  swollen.  The veins
 may be  somewhat distended, and ecchymoses are often found.  Yellowish-
 white  patches  in the cortex of the kidney, indicating fatty degeneration of
 the epithelium, appear in the asphyctic stage, but they are more abundant
 later.  The  mucous  membrane  of the  pelvis and calyces is hyperamic and
 ecchymosed.  The bladder  is contracted  and nearly  or quite  empty.
   The composition of the blood  in  cholera patients  has  been studied with
 great care by C. Schmidt.  He found that the degree of concentration of the
 blood generally reached its maximum in thirty-six hours after  the onset  of
 the choleraic discharges, at which time the relative proportion of solid con-
 stituents may be nearly one and a half times greater than  normal.  This
 increase pertains mainly  to the organic matters in the blood.   As it is chiefly
 the chloride of sodium that escapes in the transudation, the relative quantity
 of phosphates  and of potash salts in the blood  is increased.   The functions
 of the kidneys being suspended,  there is an accumulation  of urea and  of
 extractive matters in  the blood.   The percentage of red and white corpuscles
 in a given quantity of blood is increased.   The red corpuscles are shrunken.
 The white corpuscles  are often found  in clumps in the blood after death.
   In the stage  of reaction, or typhoid stage, the morbid changes are notably
 different.  The tissues no longer are abnormally dry.  The intestinal contents
 do not present the rice-water character, but are stained with bile and some-
 times with blood.  They  usually have a pasty  consistence.  The solitary folli-
 cles and Peyer's patches  may be pigmented.  The congestion  may have disap-
 peared, or in its place there may have developed a more intense inflammation
 than was present  in  the first  stage.  Follicular ulcers are  not infrequent.
 Changes similar to those in dysentery, with diphtheritic inflammation and
 necrosis, occasionally  make their appearance in this stage in  the large intes-
 tine.   In  the brain and  cord there are often congestion and increase of the
 cerebro-spinal fluid.   The lungs not infrequently are adematous and hyper-
amic.   Pneumonia may  develop  in this stage.   The  spleen  may be normal
in size or swollen.   The  most important changes relate to the kidneys.  Fol- 
EPIDEMIC CHOLERA.
545
lowing the anamia of the first stage, parenchymatous and fatty degenerations
of the renal  epithelium ensue. Sometimes an acute diffuse nephritis develops.
The kidneys are congested and swollen, especially in the cortical portion.  Yel-
lowish streaks,  indicating fatty degeneration, appear in  the swollen cortex, in
which the normal markings are obscured.  The dark-red color of the pyramids
contrasts with the yellowish-white aspect of the  cortex.  The epithelium of
the tubes in many places is desquamated and has undergone parenchymatous
and fatty degeneration.  Hyaline, granular, and fatty  casts are found in the
tubes.   Parenchymatous degeneration of the liver and of other  organs  may
be present in this stage.

  Clinical  History.—In  the great majority of cases the  disease is pre-
ceded by simple  diarrhaa, the dejections  being  greater  or less in number,
copious, and painless.   The  duration of this preliminary diarrhaa varies  in
diff'erent cases  from  a few hours to several  days.   AVith  this  diarrhaa  in
some cases occasional vomiting occurs.  Aside from these symptoms, nothing
denotes a tendency to the disease.  The  system otherwise is but little or not
at all  disturbed, and  it is often difficult to persuade the  patient that the  intes-
tinal disorder is of any special importance.  Of 45  cases in which the  exist-
ence or otherwise of premonitory diarrhaa was  noted in the  histories which
I have recorded, it existed in 34 cases and was wanting in ll.1   Statistics on
a larger scale show a much smaller proportion of cases in which  the premon-
itory diarrhaa  is wanting.   Thus the report of the General Board of Health
of London for  1848-49 contains  the statement by Dr. MacLoughlin, one of
the sanitary inspectors, that of 3902 cases the premonitory diarrhaa was not
wanting in a single case.  Of 142 cases treated in hospital in Paris by Michel
Levy, the premonitory diarrhaa was wanting in only 6.   Of 274 cholera cases
treated in the different  Parisian hospitals  in  1853, the existence of premon-
itory diarrhaa  was ascertained in 140, in the remainder of the cases it  being
absent or its existence  not ascertained.   By some the period during which
the premonitory diarrhaa exists is reckoned as a stage  of the disease.   This
is obviously improper, as there is nothing then distinctive of epidemic cholera,
and during the prevalence of  the epidemic very many have the same kind of
diarrhaa without the  development of cholera.  The simple diarrhaa which
prevails  extensively during  the  prevalence of cholera  is called, in  France,
cholerine—a  term adopted  to a considerable extent  in  other  countries.   By
German  writers, however, this  term  is used to  designate a mild form of
cholera.   In a practical  view, the importance  of taking cognizance of the
premonitory  diarrhaa is very great, as will presently appear.
  The development of cholera is generally first denoted  by characters relating
to the  intestinal  evacuations.  If diarrhaa  have existed, the discharges are
suddenly increased in quantity, or sudden and copious liquid discharges with-
out previous diarrhaa mark  the  onset of the disease.   This  constitutes the
attack, and in the majority of cases it occurs during  the night.  The cha-
racteristic stools consist of a  thin liquid  generally known as the rice-water or
choleraic discharge.  The liquid is generally yellowish-white and slightly opal-
escent.   It contains  in greater or less abundance small, white, solid particles,
like grains of rice in rice water or flakes of curd  in  whey.   It is devoid of
bile, but may be somewhat blood-stained.  There is no distinctive odor.  The
reaction of the fluid  is neutral or slightly alkaline.  It contains a remarkably
small quantity of solid constituents.  These do not usually exceed 1 to 2 per
cent.   The specific gravity varies between 1006 and 1013.    The chief  solid
  1 In  connection with the history of a cholera epidemic in Buffalo in 1849, by the
author, was published a tabular abstract of the histories of 33  not fatal and of 34 fatal
cases. (Aide Buffalo Medical Journal, 1850, vol. v.)
       35 
546      SPORADIC CHOLERA, CHOLERA  INFANTUM, ETC.

ingredient is chloride of sodium.   There is  also present some  carbonate of
ammonium, which gives the alkaline  reaction,  and a very small quantity of
albumen.   The  particles resembling rice-grains are composed of mucus with
granular matter and some pus-cells. Occasionally a few cylindrical epithelial
cells may be found, but they are not abundant.  Various low  vegetable organ-
isms are present in large number.   Of these the only ones of importance are
the comma bacilli already mentioned, which,  as will be shown under the head
of Causation, are  doubtless the  specific cause  of the  disease.    The quan-
tity expelled at each act or in  the aggregate  is very variable.  A large quan-
tity, enough to  nearly fill an  ordinary chamber-pot, sometimes  escapes  at a
single dejection, or the quantity with each  act may be small.  The  quantity
is not always in  proportion to other symptoms denoting gravity.   The dejec-
tions are not accompanied by pain, but by a sensation of relief.   There is no
smarting at the  anus.   The patient is suddenly impelled  by a sense of dis-
tension to evacuate the bowels, and when the quantity is large it escapes very
rapidly.  In some cases the evacuations, after several have occurred, cease; and
in other cases after a time the liquid flows away constantly, the patient being
unable to prevent it.   The  characteristic dejections are sometimes  wanting.
The  disease has been  called cholera sicca when death  takes place without
choleraic discharges.  The  name, however, is inappropriate.  In the so-called
cholera sicca the rice-water-like liquid is present in the alimentary canal, and
the quantity found after death may be  unusually large.  It is  conjectured
that in  these cases the peristaltic movements of the intestine are paralyzed,
so that the intestinal contents are not expelled. These cases terminate fatally
with great rapidity.
  Vomiting usually occurs.   In a diagnostic  and pathological view it is less
important as a symptom than the characteristic diarrhaal  discharges.  In
some cases it is a prominent and  persistent symptom, everything taken  into
the stomach being rejected; but  in other cases it occurs occasionally, and
sometimes it occurs at the onset and ceases.  The matter vomited is  a watery
liquid, frequently consisting chiefly of water which has been drunk, but some-
times it is evidently a transuded liquid.  The quantity may exceed that of the
liquids ingested.  The vomited liquid is  usually neutral, but it  is sometimes
acid.  The vomiting is not preceded or accompanied  by much nausea.   The
act of vomiting occurs suddenly, and appears to arise simply from distension
of the stomach.
  These symptoms, conjoined with a sense of prostration, more or less feeble-
ness, and  generally  frequency of the pulse, coolness  of the skin, or  perspira-
tion, with, in some cases, cramps of the muscles of the limbs, may constitute
the clinical history of the  disease.  In  other words, the disease  may either
end spontaneously or be arrested without symptoms other  than those  just
described.   The vomiting  and purging  cease,  improvement as  regards the
other symptoms follows, convalescence is  at once declared,  and recovery is
rapid.  The duration of the disease in these cases is brief—a few hours only.
In a large proportion of cases, however, the  disease  does not pursue such a
favorable  course.  A group  of striking symptoms becomes developed, and the
disease passes into what has been called the  algid or cyanosed stage, or more
commonly the stage of collapse.   It  remains to sketch  the  further clinical
history  in these cases.
  Important symptoms pertain to the  circulation.  The pulse is usually fre-
quent and proportionately  feeble, beating 120,  130, or 140  per  minute, but
in some cases it  becomes more and more feeble without acceleration.  I have
observed it to fall below the normal frequency.   AVhen the  state of collapse
is fully  developed  the pulse at the wrist is  extinct.   Feebleness or absence
of the apex-beat of the heart and of the heart-sounds also shows greatly 
EPIDEMIC CHOLERA.
547
diminished power of this organ.   The  blood  stagnates in the  veins, giving
rise to lividity at the roots of the nails and a dusky hue of the prolabia, face,
and surface of the body generally.   Hence the significance  of cholera  cya-
nosis and cholera asphyxia  as names of this stage of the  disease.   If vene-
section be practised, the blood trickles from  the aperture, not flowing  in a
projected  or  continuous stream.   Leech-bites do not  bleed  as usual.  The
blood is  manifestly thicker than  in health.
  The respiratory  system presents striking symptoms.  The number of res-
pirations is usually increased, but is sometimes diminished. Dyspnaa is occa-
sionally complained of, and sometimes  exists  in a distressing degree, owing
to the feeble  circulation, from the thickened  state of the blood.  The respi-
ration  is frequently suspirious or sighing, and  irregular  in  rhythm.   The
expired air, when the collapse is complete, is low in temperature as compared
with health (76° or 80° F.), giving to  the hand a sensation of  coolness.   It
contains more oxygen and less carbonic acid than in health, showing a notable
deficiency of the changes incident to the function of respiration.   The voice
undergoes a marked change, becoming feeble,  raised in pitch,  husky, and not
infrequently  extinct, attributable in part  to muscular debility, but chiefly to
dryness and stiffness of the vocal cords.  In the moribund state the tracheal
rales which so often precede death from other diseases are wanting.
  Arery  little pain  is  experienced except from muscular   contractions  or
cramps.   As regards the  nervous system, the  disease  is characterized by
mental indifference or apathy.  The  patient  has no apprehensions, although
prior to the attack there may have been  intense dread of the disease.   In
some cases there is great restlessness and jactitation, and in  other cases the
patient lies quietly, save  when disturbed  by  evacuations and cramps.  The
latter give rise to most of  the suffering.  Cramps are usually but not invari-
ably present.  They are seated especially in the feet, calves, and  abdominal
walls, the muscles of the upper extremities and even of the face being some-
what affected.   The prominence of this symptom renders the name spasmodic
cholera significant.  The muscular strength in some cases is retained in an
extraordinary degree.   Patients if not prevented will  sometimes  get up and
walk  about even  a few moments before  death.
  The functions of most of the secretory organs are nearly or quite suspended.
No bile is contained in the matter vomited or  in the dejections, and the urine
is suppressed.   Patients do not weep.   It is a remarkable fact, however, that
in nursing women  the lacteal secretion  may continue.  The disease also does
not prevent the occurrence of menstruation,  but the menstrual discharge is
diminished.  The  skin, in addition to  its cyanosed appearance, is cold  and
often covered with a copious, viscid perspiration ; but in other cases it is cold
and dry.  The coldness of the surface is like that of a cadaver.  Of this, how-
ever, the patient is not conscious; on the contrary, there  is generally a sense
of heat and a desire to be uncovered.  The heat of the  body is  diminished,
as shown  by  the thermometer in the rectum or vagina. The axilla in this dis-
ease does not give a  fair representation  of the internal  temperature.  The
diminution ranges generally from two  to four  degrees below  98°, but it may
fall to 9(1°, and even considerably lower, and it has  been known to fall to
73°.  The skin is frequently shrivelled and wrinkled like the arms of washer-
women.   Its elasticity is diminished,  as shown by its subsiding very slowly
after being pinched up.  The tongue gives to the touch  a sensation of cold-
ness.   Thirst is a prominent symptom.   The patient  craves  constantly cold
drinks, and iced water or ice is taken with  great avidity.
  The general aspect in the collapsed state is highly characteristic.  The
features  are  contracted, the eyes sunken ; the  whole body is diminished in
bulk;  the patient  appears  to have suddenly grown old, and the countenance 
548     SPORADIC CHOLERA,  CHOLERA  INFANTUM,  ETC.

is often so much changed that the person is scarcely recognizable by familiar
friends.
  Of the. foregoing symptoms, most are present in all-cases in which the dis-
ease is not  speedily  arrested.   Differences  relate chiefly to the degree of
severity of the disease.   In  stating the condition of patients it is customary
to say before or after collapse, and to express different degrees of the  collapsed
state  by saying semi-collapsed  or completely collapsed.  Collapse is  complete
when the pulse at the wrist is extinct, the surface cold, etc.   The collapse
may ensue with more or less rapidity—from an  hour to  six  or eight  hours
after  choleraic dejections occur.  It occurs almost invariably in fatal  cases,
the mode of dying being of  course by asthenia ; but I have known cases to
end fatally without the stage of collapse, the patient becoming comatose and
dying by apnaa.
  The patient after emerging from  the state of collapse does not, in general,
pass at once into convalescence, but there follows a period of the disease com-
monly called the stage of reaction.  In  this stage there is usually fever, the
temperature rising more or less above the maximum of health.   Diarrhaa not
infrequently continues, the dejections becoming green and gelatinous.   Dys-
entery is sometimes a sequel.  In some cases constipation more or less  obsti-
nate follows.   Vomiting in some cases is a troublesome symptom in this  stage,
the vomited matter being either green or yellow.   Capillary congestion  of the
surface, especially of the face, is frequently marked, as in cases of typhus.
The renal secretion returns, and the  urine is albuminous,  brownish-red in
color, and it contains epithelial, fatty, and hyaline casts, together with degen-
erated renal cells, and usually also red and white blood-corpuscles. This stage
is not devoid of considerable  danger.  The patient may be worn out  with con-
tinued vomiting or diarrhaa; somnolency and  coma become  developed in a
certain proportion  of  cases, dependent  probably on uramia;  and delirium of
a passive  kind is  not  uncommon, together  with  subsultus, sordes, and  other
symptoms of the typhoid state.  Pneumonia is  sometimes developed. A fatal
termination occurs in a pretty large proportion of the cases in which  the stage
of reaction takes place ;  and  in the  cases which recover the powers of the sys-
tem are generally  impaired for  a long period.  Exceptionally, patients emerge
from  the collapsed state and pass  either gradually or quickly into  convales-
cence without febrile movement or  other symptoms belonging to the stage of
reaction.
  Epidemic cholera has a brief duration.   After the  occurrence of the cha-
racteristic choleraic dejections death sometimes  takes place within two or three
hours, the patient  dying as if from  profuse hemorrhage.  The duration  rarely
extends beyond ten or twelve hours.  If life continue longer and either  death
or recovery ensue, the disease has run its  course, and the symptoms denote
its  sequels or  effects.   Assuming the  disease to  be parasitic, the local con-
ditions for the multiplication of the parasites  continue only  for  the limited
period of the duration of the disease  proper.

  Pathological  Character.—Most  of the striking phenomena of the dis-
ease are plainly attributable to  the blood-lesions resulting from the loss  of the
constituents found in  the choleraic dejections.   The blood  circulates with
difficulty, and the changes  incident to respiration take place  imperfectly;
hence  the feebleness  and extinction of  the  pulse, the  cyanosis, loss of tem-
perature, thirst, mental apathy, spasm, unchanged expired air, defective  secre-
tion, etc. etc.  The retention  of excrementitious principles in the blood doubt-
less plays an important  part in the production of morbid phenomena.    The
coma which occurs in some cases may be due to uramia.  Cholesteramia may
occur, since the function of the liver is  suspended. 
EPIDEMIC CHOLERA.
549
  The transudation, however, which is first in the catenation of appreciable
events involves an underlying pathological condition.  That this condition is
due to the invasion and growth of the cholera bacilli to be presently described
is very probable.  Koch is of the opinion that these  bacilli produce some
poison which is absorbed into the system and causes the severe constitutional
symptoms and the lesions of organs other than the intestine.

  Causation.—Since the  preceding edition of this work an important addi-
tion to our knowledge of epidemic cholera has been made by the discovery
by Robert Koch of a form of bacterium peculiar to this  disease and to be •
regarded as its specific cause.   Koch  was sent by the German government as
the head of  a commission to investigate  epidemic cholera in Egypt, and  sub-
sequently in the East  Indies.   He discovered  the cholera  bacillus in Egypt
in 1883,  and  in  the latter  part of that  year and in the early part of 1884
he continued his studies of this organism in India.
  The cholera  bacillus is  shorter, but  somewhat thicker, than the tubercle
bacillus.   It  is  more or less curved, and from its resemblance in  shape  to  a
comma it is called by its discoverer comma bacillus.  The curve is not always
that of a comma, nor  is one end usually  thickened, like the upper end  of  a
comma.  Sometimes, especially in cultures, the organism presents a spiral or
corkscrew shape.   These spirals represent either a series  of comma bacilli
joined together or  a spiral  growth of a  single organism.  From this appear-
ance it is claimed that the organism  should be called a  spirillum or a vibrio,
and not a bacillus; but there  is some doubt as to the  interpretation of the
spiral  mode of growth.  The  cholera bacilli multiply by transverse  fission.
  Although, to a trained bacteriologist, the morphological appearances of the
cholera bacillus are quite  characteristic, nevertheless, for certainty in diag-
nosis,  it  is necessary  to resort to artificial cultures of the organism.  The
cholera  bacillus  grows readily in  a great variety  of  media,  of which  the
most important are bouillon, nutrient gelatin, agar-agar, blood-serum, potato,
and milk. It grows best at a temperature of between 30° and 40° C. (86°-104°
F.).   It  can be cultivated  at 17° C.  (62J° F.), but its growth nearly ceases
below  16° C.  The most useful agent for the study of the diagnostic  charac-
ters of the growth  of  the cholera bacillus is nutrient gelatin in plate and in
test-tube cultures.   These characters are  manifest within twenty-four hours
after  inoculating the  gelatin  and cultivating  at a temperature of about 21°
C. (70° F.).  In the gelatin cultures on plates a typical  colony of the  cholera
bacillus appears as  a small  glistening, round particle, which, when examined
with a low magnifying power, presents a granular, grayish appearance with well-
defined but slightly irregular borders. Each colony is surrounded by a narrow
clear  ring caused by liquefaction of the gelatin.   In test-tube  cultures the
growth of the colony gradually extends from the surface down and along the
line produced by sticking the platinum wire into the gelatin when inoculating
the tube.  Corresponding to the top of this line, the gelatin appears to be occu-
pied by a round or  conical air-bubble, from which the tapering colony extends
in the line of inoculation.  There is a  moderate liquefaction of the  gelatin
around the colony.   Upon  sterilized  steamed potato at ordinary temperatures
the cholera  bacillus grows  very imperfectly, but  between 30° and 40°  C. it
grows  very rapidly.   AAThen cultivated and examined in  a drop of bouillon the
cholera bacilli are found to be endowed with  the power  of rapid movement.
  The form and the development of  the cholera  bacillus, together  with  the
characters and the  conditions of  its growth in various culture  media, suffice
to distinguish this organism from all other forms of bacteria with which we
are acquainted.  Many other comma-shaped  bacteria are known to exist, but
all of them, such as the comma bacteria of Finkler and Prior (p. 537), those 
 550      SPORADIC CHOLERA, CHOLERA INFANTUM, ETC.

 found sometimes in the saliva, those discovered in cheese, in foul water, etc.,
 can be positively distinguished from the cholera  bacilli.  The cholera bacilli
 are peculiar to epidemic cholera, and hitherto they have been found only in the
 intestines and the dejecta of patients affected with  this disease.1   Moreover,
 the cholera bacilli are invariably present in the intestinal contents and evacua-
 tions of cholera patients, except in a late stage of  the disease when the patient
 is suffering from'the sequels rather than from the  immediate effects of cholera.
 It is certain, therefore, that the cholera bacilli and  the disease cholera bear a
 close relation to each other, and it is difficult to conceive that this relation can
 be any other than that the bacilli are the cause of Asiatic cholera.  Inoculation
 of the cholera bacilli in animals has not given clear and  satisfactory results,
 as animals under normal conditions do not  seem  to be  susceptible to Asiatic
 cholera.  Still, it has been found possible, after neutralizing the acidity of the
 gastric juice  and after paralyzing  intestinal peristole by opium, to obtain in
 animals, by the injection of cultures of cholera bacilli into the stomach, lesions
 of the intestine similar to those in cholera.  The intestines are congested and
 filled with fluid or semifluid contents, which contain cholera bacilli in  enor-
 mous  numbers.  Satisfactory inoculation experiments on animals, welcome as
 they  would  be, are  hardly necessary  to prove the causative  agency of  the
 cholera bacilli, as the observations on human beings can hardly admit of any
 other  interpretation than that  which has been given.  In every case where it
 has been possible to fulfil all the conditions of a strict proof it has been found
 that peculiar organisms, whenever constantly associated with the lesions of a
 given  disease,  are the specific cause of that disease; and  in  no instance has
 support  been found for the hypothesis that organisms not found  elsewhere
 and constantly associated with  a disease are present simply because the dis-
 ease makes a  favorable soil for their growth.    If, then, the cholera  bacilli
 are  the specific cause of  epidemic  cholera,  it  is  important to know  all
 the conditions which are favorable, as well as those  which  are  hostile, to
 the growth and development  of these organisms.  Our knowledge of these
 conditions is as yet  imperfect.   It has already been mentioned that growth
 of  the cholera bacilli  is checked  by a  temperature much  below 16° C.
 (61°  F.).  The bacilli, however,  are  not  destroyed  by  a  temperature  far
 below  the freezing-point.   They  do  not  form  spores,2  and  are therefore
 much  less resistant  to  injurious influences than the  spore-forming bacilli,
 such  as those of anthrax.  Cholera bacilli in the moist condition, however,
 may preserve  their vitality for five or six months, and after  special modes
 of cultivation  for even a year  or more.  AVhen  completely dried the cholera
 bacilli die within a short time.  They are very susceptible to  the  action of
 most  acids, which  even in very dilute solution destroy the bacilli or  check
 their growth.   They  are destroyed by carbolic acid in one-half  of  1 per cent.
 solution.   This agent is recommended by  Koch as the most suitable for the
 disinfection of cholera  stools  and linen.   The  cholera  bacilli grow rapidly
 upon  linen soiled with cholera dejecta, so that after twenty-four  hours  this
 linen  seems to present  a pure  culture of these organisms.  After a day or
 two the bacteria of putrefaction predominate and  displace the comma bacilli.
 The cholera  bacilli  do  not  develop in very foul  and  putrefying  substances.
 The cholera  bacilli  preserve their  vitality for a considerable  time in water,

  1 Koch found  cholera bacilli in the water of a tank in India which was used for
drinking  purposes, and which  was contaminated with  the  dejecta and tho linen of
cholera patients.
  'l Hiippe and others describe a fragmentation of cholera bacilli into little round bod-
ies, which they claim are more resistant than the bacilli and are capable of developing
into bacilli. These round bodies they therefore regard as spores (arthrospores). 
EPIDEMIC CHOLERA.
551
but they do not develop in water unless this contain a certain (not too small)
proportion  of nutritive material.
  The question now arises, How far is it  possible to reconcile the doctrine of
a special contagium in cholera stools and the known facts concerning this con-
tagium with the views derived from  a careful study of epidemics of Asiatic
cholera?  The epidemiological study of cholera has led to a wide  although
not universal  acceptance of the view that Asiatic cholera is not directly con-
tagious.  The following are the main considerations upon which  is  based
the opposition to the  doctrine of contagion :
  1. Of those who are brought into contact with or close proximity to cholera
patients the  proportion who become  affected is not larger than that of those
who are not thus exposed.   It is a notorious fact that physicians and nurses
in attendance upon cholera patients  do  not contract the disease more fre-
quently than  others living  in  the same locality.  In this respect there is a
marked contrast between the development of cholera and of typhus fever in
hospitals.
   '1. Although there is no ground for the  assumption that an epidemic of
cholera can ever originate  in  a place in which the cholera germs  have not
been introduced either by persons or by clothing or other substances derived
frr)m a cholera locality, nevertheless, imported cases of cholera in situations
where the disease had  not previously existed very frequently, and perhaps as
a rule, do not lead to its  diffusion.
   3. The epidemic  breaks  out in a place almost  simultaneously in different
situations,  without  any communication  of  the cases with each other.
   4. It is diffused too rapidly to be propagated by contagion.   If contagious,
it must be most highly so to account for the rapidity with which it extends;
and the latter assumption is not consistent with other facts.
   5. There are  certain places which possess temporary or permanent immu-
nity against  the invasion of Asiatic cholera.   Lyons  in  France is  such  a
place.   From its well-known immunity Lyons has become a refuge for per-
sons  fleeing from  cholera-infected localities.   Although such  persons are
readily admitted  into  the city, there has never  been an epidemic of cholera
in this place  except in a very limited district.  Many places in which there
is immunity  from  cholera  are known to exist.
   These considerations lead to the conclusion that the spread of cholera is not
due to its being directly communicated from those affected with the disease. To
explain the epidemiological  facts concerning cholera the hypothesis  has been
advanced, and has met with wide acceptance,  that the stools of cholera patients
contain a virus which is not capable  of  producing cholera at once, but must
first undergo, outside  of  the body and probably in the soil, certain unknown
modifications  or metamorphoses.  Cholera has therefore been classified among
the miasmatic contagious diseases.   The conditions of the soil  favorable for
the development of epidemic cholera have been investigated most carefully
by Pettenkofer.   These conditions are—first, a certain degree of porosity of
the ground;  second, a certain amount of moisture in the superficial layers of
the ground, and this amount must be neither too great nor too small,  and  in
most  places is indicated by a sinking of the ground-water; and third, a cer-
tain amount of organic matter suitable  for the growth of the cholera  germs
in the soil.   Such matter is present  particularly in soil contaminated by filth
or  imperfect  drainage.  It  is apparent that these conditions of  soil  may  in
certain regions be  permanently absent, and  in other regions be  temporarily
absent.  Hence is explained the permanent and the temporary immunity of
certain places against the  invasion   of cholera.
   The facts which  have been  mentioned in  opposition to the contagion doc-
trine of cholera and in support of the essential  influence of local conditions 
 552      SPORADIC  CHOLERA,  CHOLERA  INFANTUM, ETC.

 in the development of  the  disease have  led  Pettenkofer and his followers to
 reject the view that the comma bacilli found in cholera stools are the sjiecial
 cause of the disease.   This view, they say, cannot be reconciled with epidem-
 iological facts.
   In reply it may be said that the constant presence of cholera bacilli in the
 intestinal contents of cholera patients is an established fact, and requires an
 explanation.  No satisfactory explanation has  been offered or seems possible
 other than that the bacilli are the cause of the disease.   In other words, the
 dejecta of cholera patients do contain a special poison capable  of causing
 cholera without undergoing any special metamorphosis in the soil.  Positive
 facts speak  for the  existence of this contagium in  the  stools, such  as  the
 repeated instances in which washerwomen have contracted  cholera  by wash-
 ing clothing or bed-linen  which has been soiled by the dejecta of  cholera pa-
 tients.  Macnamara  relates the  following well-authenticated case in his own
 experience in the East Indies:1 "  A small quantity of a fresh rice-water stool
 passed by a patient suffering from cholera was  accidentally mixed with some
 four  or five gallons  of water, and the mixture  exposed to  the rays  of  the
 tropical sun for twelve hours.  Pearly the following morning nineteen people
 each  swallowed about an ounce  of this contaminated water: they only par-
 took  of it once, but  within thirty-six  hours five of these  nineteen persons
 were  seized with cholera.  In this instance the choleraic  evacuation did  not
 touch the soil; as it was passed, so was it swallowed."  Cholera was not pre-
 vailing to  any considerable  extent in the locality at the time.  AVhile, then,
 these and other observations support the view that the cholera stools contain
 the special agent of infection of  the disease, it is to be noted that this infec-
 tious agent must  be  received into the alimentary canal in order to produce
 cholera.  Under ordinary  circumstances it is apparent  that portions of cholera
 stools could gain  access to the digestive tract only through great carelessness.
 AVe  know  that bacteria are not conveyed into  the air from moist  surfaces.
 and,  as has  already  been  mentioned,  the  cholera bacilli are destroyed  by
 being completely dried.  The exhalations and  the urine of cholera patients
 do not contain cholera bacilli.   These are  present  only in  the  discharges
 from  the  intestinal canal, and very exceptionally in  the vomit.   It is expli-
 cable, therefore, that  with  ordinary  care those who  are in  close proximity
 to cholera patients are not likely to contract the  disease merely from such
 proximity.
   AVe come, therefore, to the conclusion that an epidemic of Asiatic cholera
 is due to  an infection  of the  soil or  of the drinking-water  of the locality
 by cholera bacilli  derived directly or  indirectly from the dejecta  of cholera
 patients.  That the contamination of the drinking-water with cholera  germs
 may cause an outbreak of epidemic cholera seems certain; but it is  not proven
 that this is a frequent mode of infection.   Probably  a common source of in-
 fection is direct contact with objects which  contain  cholera bacilli, such as
 might come  from  eating  uncooked fruit, salads, etc.   As to the exact mode
 of infection we are in most cases ignorant;  but from  what has been  said it is
 apparent that the known  facts concerning the origin and development of epi-
 demics of cholera  are not opposed to the acceptance  of Koch's  discovery of
 the cholera bacilli and of their causative relation to the disease.
  Great importance is to be attached to the auxiliary or predisposing  causes
 of Asiatic cholera, as  it is within  our power to prevent many  of  these.
 Unfavorable  hygienic conditions,  especially such as affect the purity  of the
drinking-water  and of the soil, are most potent  factors in aiding the develop-
ment  of cholera.   By improvement in sanitary conditions places  have been
rendered nearly or  quite exempt  from the invasion  of cholera, even in India,
               1 Quain's Dictionary of Medicine, article "Cholera." 
EPIDEMIC CHOLERA.
553
 the home of the disease.   Individual predisposition  also plays an  important
 role.   The  cholera bacilli are destroyed  by acids, even by the  acid  gastric
 juice.  Disorders of digestion, therefore,  which  reduce  the  acidity  of the
 gastric juice, facilitate  the entrance and  development of the cholera bacilli
 in  the intestine.  Hence deprivations, intemperance,  depressing  emotions,
 over-exertion, fear of the disease,  are  auxiliary  causes in certain cases.
   Cholera has prevailed  in all climates and at all seasons.   In  temperate
 climates it has prevailed  most frequently in late summer and  in the autumn.
 Feeble persons  are  more apt to be  attacked  than the robust.   As regards
 age, no period of life is exempt, but the largest proportion of fatal cases is
 among persons  advanced in  life.   Excluding old persons, the mortality is
 largest after  adult  age,  next in early infancy, and last in  childhood and
 youth.   A  certain degree of immunity, at least for a few years, is afforded
 by having  experienced an attack  of cholera.

   Diagnosis.—During the prevalence of cholera there is  no difficulty  in
 recognizing the  disease  when fully developed ; that is, when symptoms denot-
 ing existing or impending collapse are present.  There is scarcely  any other
 disease in which the diagnostic  features are  so strongly marked; but  it is
 exceedingly important to recognize it before  it has advanced sufficiently  to
 manifest  its most obvious striking  characters.  The diagnosis is then to  be
 based mainly on the characteristic intestinal evacuations.  As soon  as the
 so-called  rice-water or choleraic stools are  apparent the  patient is to be con-
 sidered as attacked with  cholera.  In a very small proportion of cases these
 evacuations do  not occur at all, or not until other symptoms characteristic
 of the disease become developed.  The diagnosis in these cases must be based
 upon the  latter.
   It is important to recognize cases of cholera which appear in places where
 no epidemic prevails.   Prophylactic measures to be effectual must be applied
 to the first  cases of cholera which  appear in a community.   Hitherto it has
 been  by no  means easy to distinguish the first  cases of  cholera, especially  if
 they do not terminate fatally, from sporadic cholera or cholera nostras.  A\a
 possess, however, in  the  recognition  of Koch's  comma bacillus a  means of
 certain diagnosis.  In general, from twenty-four to forty-eight hours will suf-
 fice to establish the diagnosis.  If it happen that the cholera bacilli  are found
 in almost pure cultures upon the surface  of the cholera dejecta or upon the
 linen soiled  thereby, the diagnosis is established.   Usually it is necessary not
 only to make  stained microscopical preparations from the stools, but also  to
 prepare cultures ; which  is clone by first making a plate culture in nutrient
 gelatin.   From the characteristic  colonies which develop in the gelatin  pure
 cultures may be  made in test-tubes  containing  nutrient gelatin, and  specimens
 can be examined in a drop of bouillon in order to study the properties of the
 living bacilli.  At present, undoubtedly few practising physicians possess the
 knowledge requisite for the preparation of such cultures.   This knowledge,
 however, is  not  difficult to acquire, and at least  in every large  community
 some  one should be found who is capable of making the diagnostic tests which
 have been mentioned.
   Cholera is to  be discriminated from the simple diarrhaa which  generally
 precedes it,  and  which during the continuance of  an epidemic affects a large
 number of persons without eventuating in cholera.  It is probable that this
 premonitory diarrhaa proceeds from the epidemic cause, but cases  are not  to
 be considered as cases of cholera when neither the choleraic  discharges nor
other characteristic symptoms occur.   This discrimination is  important with
reference to  determining the rate of mortality and  the value of therapeutical
measures.   The apparent  success attending the practice of some physicians  or 
554      SPORADIC CHOLERA, CHOLERA INFANTUM,  ETC.

following the employment of certain  methods of treatment  may  depend on
cases of simple diarrhaa being  reckoned as  cases  of cholera.
  This disease is one of the most insidious in its approaches.  Aside from a
mild diarrhaa it gives no warning of the attack.  So  little are patients con-
scious of danger that they often apologize for giving the physician the trou-
ble  of visiting them, when a glance suffices to show that they are on the verge
of collapse.   It behooves the physician in all  cases of simple diarrhaa during
an epidemic of cholera to carefully watch the evacuations with reference to
the  diagnosis.  On the  other hand, during  an epidemic physicians are  not
infrequently  called to see  persons who  under nervous excitement imagine
that they are about to  be  attacked, when  no symptoms  of  the disease are
present.   These have  been  appropriately called  cases  of  cholera-phobia.

  Prognosis.—Of those attacked with  cholera,  a large proportion die.  The
average rate of mortality i;i hospitals varies from  one-half to one-third. A\Then
developed in hospital  wards among patients admitted for other diseases, it
proves fatal in the great majority of cases.   In private practice, especially
among the better  classes of society, the mortality  is  considerably less.  In
individual cases the prognosis is widely different according to the period of
the  disease at which the  patient  is first seen.   If the patient be seen imme-
diately after the attack, before serious blood-lesions  have occurred, the pros-
pect of an arrest of the disease is good ; but if the disease have advanced to
the  stage of collapse the prognosis is always exceedingly unfavorable.  After
reaction  from the  collapsed  state the danger  is still great, but  the  cases in
which  recovery takes place  preponderate.    The  statistical  researches of
Duchesne show the rate of mortality at different periods  of  life in  the epi-
demic at Paris in  1849.l  The proportion in 1000 in subjects less than five
years of age  was 14S ; from five to fifteen  years, 50 ;  from fifteen to thirty
years, 177;  from  thirty to forty-five years,  254;  from forty-five to sixty
years, 206;  and from  sixty to eighty-five years, 102.   The  mode of dying
is in general  typical of  asthenia.  Accumulation of liquid in the air-tubes
very rarely takes  place.

  Prevention of Cholera.—The prophylaxis of cholera claims considera-
tion under a distinct heading, and I give it precedence  over the therapeutical
management, in view of  its  greater  relative importance.   In  addition to  the
removal, as far as  possible, of all the  auxiliary causes  of  disease which con-
tribute to render the special cause of cholera efficient, the prevention involves
prompt  attention to the diarrhaa which in the  great majority of  cases pre-
cedes the attack.   This premonitory diarrhaa is amenable to simple measures
of treatment, and if effectually treated there is  reason to believe the superven-
tion of  cholera is prevented.   All physicians who have had  much practical
acquaintance with this disease will bear testimony—first, to the fact that an
attack of cholera  is generally preceded  by diarrhaa;   and second, to the fact
that an  attack very rarely  occurs when this diarrhaa receives appropriate
attention.  Giving results  of my own experience with respect  to the facts
just stated, in 1849 for the  space of three  months I prescribed  for as many
private  patients with  the premonitory diarrhaa as my physical  endurance
would  permit, my practice  being chiefly among the prudent classes, and I
had  during that  epidemic  but 10 cases  of cholera  in private practice.  In
only one of these  10 cases  did I prescribe for any premonitions, and in  the
single case  the prescription was for a slight  nausea  only.   In  each of  the
10 cases either the premonitory diarrhaa did not exist or it was  neglected.
During another epidemic in 1852, I had about the same number of  cases of
                             1 A'alleix, op. cit. 
EPIDEMIC CHOLERA.
555
cholera in private practice.  In not a single case had I been called upon to pre-
scribe for premonitory  diarrhaa,  and I prescribed  for hundreds  of persons
with simple diarrhaa, not one of whom had an attack of cholera.  The expe-
rience of others would doubtless furnish in like manner evidence of the above
stated facts, and  from these facts the following conclusion may be drawn :
Except  the very  small proportion of cases  in which cholera is not  preceded
by diarrhaa it may with almost absolute certainty be prevented.  It needs but
a little reflection to see the immense practical importance of this conclusion.
  The treatment of diarrhaa during a cholera epidemic  is simple.  An opiate
conjoined with an astringent remedy, regulated diet,  rest, and recumbency
suffice.   A few drops of laudanum with camphor, or the camphorated tincture
of opium in  conjunction  with  the tincture  of kino, catechu, or krameria, a
salt  of morphia or opium with either tannic acid or the acetate  of lead  or
bismuth  and capsicum, may be given in  doses sufficient to arrest  the diar-
rhaa at once, and repeated  often  enough  to prevent  its  recurrence.   Inas-
much as the bacilli enter the body probably by  way of  the digestive system,
the free use of the mineral  acids  may be  useful as a prophylactic  measure,
these being found to be destructive to the parasite out of  the  body.
  The great difficulty as regards the prophylaxis is in the prompt  application
of simple but effectual treatment in all cases of diarrhaa during the epidemic.
Aery many pay no attention to  the premonitory diarrhaa through ignorance,
and not a few of  those  better informed neglect  it either from recklessness or
because they cannot appreciate the fact that a disorder so slight and ordinary
can be a precursor of a malady of  such gravity as cholera.   Public announce-
ments by handbills, articles in newspapers, etc. of the importance of promptly
resorting to treatment for diarrhaa  fail in  accomplishing the  object.  The
only effectual  plan is to organize a sanitary police,  and to provide for one or
two domiciliary visits daily at every house within the limits of the epidemic,
the purpose of the visits being to inquire if any one be affected with diarrhaa,
to impress the importance of immediate attention  to it,  and  when circum-
stances  render it  necessary  to  supply appropriate  remedies at once.  This
plan, faithfully carried out,  demonstrates that cholera  is in a great  measure
preventable.   The prevention  is  effected by arresting at once diarrhaa  as
often and as  soon as it occurs.   Abundant proof of the successful operation
of the system of  the house-to-house visitation was furnished by its  practical
results in  London  and other towns in  Great  Britain  during the  epidemic
of 1S49.
  Another mode of escaping the disease is to remove without the range of
its prevalence.  Persons not compelled to remain by necessity or by a sense
of duty should go beyond the limits of the epidemic ; and the removal of
persons  in districts where, owing to the activity of auxiliary causes, the dis-
ease is especially  rife, should be enforced as a sanitary measure by municipal
authority.
  The foregoing remarks relate  to the prevention of cases of cholera  during
an epidemic.  To prevent the epidemic is an object of still greater importance.
This is to be done by thorough sanitary measures in regard to the removal of
filth, attention to  sewers, cesspools, and privies,  also to wells or other sources
of water-supply, together with proper protection against causes of disease from
waste-pipes in houses, by providing against overcrowding of tenements, etc.,
and by efficient quarantine regulations.  Ships, merchandise, luggage, etc. com-
ing by sea or land from  a  cholera region  should  be eff'ectually disinfected.
The clothing of persons  from an infected place should be disinfected, but only
those need be detained  in quarantine who are suffering from cholera or diar-
rhaa.   It is of the utmost importance to disinfect thoroughly the stools, the
linen, and the bed-clothing of cholera patients—in fact, everything  with which 
556      SPORADIC CHOLERA,  CHOLERA INFANTUM,  ETC.

by any chance the discharges of the patient can come in contact.   The most
useful agent for disinfecting the stools is carbolic acid, which may be employed
in a 5 per cent, solution.  Sulphate  of iron is not an effective disinfectant for
the stools.  By these means the introduction, or at least the spread, of cholera
germs may be prevented.  If these means do not prove protective, it is because
they are not, and perhaps cannot be, employed with sufficient completeness;
for with our present views of the causation of the disease it may be affirmed
that if the cholera bacilli can be completely excluded cases of cholera cannot
occur.
   AVhen the introduction of the disease is not prevented, the prevention of
its diffusion is  practicable by the  prompt  and effective disinfection of every
house in which it occurs.  In this way an epidemic is " stamped out."  That
this is practicable  was demonstrated  in the city of New  York in 1866.  A
thousand cases occurred in  that year in different  situations widely  separated
from  each other.  Cases occurred in 362 houses, all of which were instantly
disinfected and all local  appreciable causes of disease were removed.   In no
instance did the disease extend beyond  the house  in which a case occurred.
These facts are of momentous importance.1

   Treatment.—To consider the host of remedies and of therapeutical meas-
ures which have been advocated as more  or less efficacious in the treatment of
this disease would  require not a little space.   There are  but few articles in
the materia medica which have not  been tried, even including antimony and
drastic purgatives.  Much injury has doubtless been done by over-medication
under the idea that the treatment, as regards activity, must be proportionate
to the  amount of danger from a disease.  On the  other  hand, many of the
remedies which have been employed exert little or no effect  either for  good
or  harm.   It would be unprofitable to  devote space to the consideration of
the great variety of practice which the literature of cholera affords.  Accept-
ing the parasitic doctrine, a specific  remedy must be a parasiticide, capable of
securing by its toxical effect upon the parasite its destruction within the intes-
tinal canal.  As yet no such remedy is known ;  but there is reason to believe
that the disease is frequently controlled by efficient treatment, and when not
arrested the recovery may depend on the judicious employment  of  measures
for that end.   In the present state of  our knowledge the objects of treatment
are the prevention of the  immediate  serious consequences of the action of
the parasite, and  to  obviate the  tendency to death.  I  shall limit myself
to a brief statement of the principles of treatment which my  own experience
and  reflections have  led me to regard as most consistent with  our present
knowledge.
   The treatment is to  be considered as  applicable to the diff'erent  stages—
namely, before collapse, during the collapsed stage, and after reaction.  Prior
to collapse the  paramount object is the arrest of the intestinal effusion.  This
effusion is the first appreciable  link in the chain of morbid sequences, and, if
it  be  promptly arrested  before  it has proceeded so far as to  affect  seriously
the blood and circulation, the patient is usually safe.  The remedy on which
most dependence is to be placed in effecting this object is opium.   Some form
of opiate is to be given promptly in doses sufficient to effect the object.  The
form of opiate  is to be chosen with reference to promptness of action and the
probability of its being retained. Opium in substance is unsuitable, from the
comparative slowness of its action.  Laudanum or the acetated tincture or an
aqueous preparation is to be preferred; but the article which I have been led
to regard as the most eligible is a  salt of morphia, administered by placing
  1 For further details and for the processes of disinfection, vide Report of the Metropol-
itan Board  of Health,  New York, 1867. 
EPIDEMIC CHOLERA.
557
it dry upon the tongue.  In  the  endeavor to effect the object of treatment
in this  stage  moments are precious, for there is always  danger that if the
object be not promptly effected the patient will  fall into  the collapsed state.
The opiate  should therefore be given at once in a full dose.  A grain of a
salt of morphia is rarely if ever too large a dose for an adult.  A physiciaa
should  if possible remain with the  patient.  If the first dose be  quickly
rejected, a second should be instantly given.   The  remedy is to be repeated
at intervals of from one-half  to three-fourths of an hour until the dejections
cease.  If, owing  to  the  occurrence  of vomiting, the administration  by the
mouth be ineffectual, it should be  given  by the rectum, and in cases in which
the symptoms are urgent both modes of administration should be resorted to.
The system, even in this stage of the disease, is not readily affected by opiates
thus  given.   In  view of the  importance of the object, if it  be necessary in
order to effect it some risk of inducing narcotism is justifiable;  but if the
administration be  in the hands of  the physician, and the effects of the doses
watched with care, danger from this source may be avoided.  The practical
point is to employ the remedy promptly so as to effect the object, bearing in
mind that the delay of half an hour or an hour  is often fatal.  Relying upon
the opiate, it  is best not to add other  remedies, lest by increasing the bulk
of the doses they be rejected.  A full  dose is preferable to  small doses fre-
quently repeated,  because the effect within a short  space  of  time is greater
and the remedy is more likely to be retained.   Aside from  the rejection of
the remedy, vomiting is, if  possible, to be prevented in view of its perturba-
tory effects.   The patient in  this stage should be restricted to a very small
quantity of water or spirit and water  given  at short intervals, or to  small
pieces of ice.   Perfect quiet is important.  He should not  be  permitted to
get up to go to stool, and he should  be urged  to  resist  as much as possible
the desire to evacuate the bowels.   Frictions, the warm bath, sinapisms, etc.
in this  stage  are  useless and hurtful.
   I  have repeatedly succeeded in arresting the  disease by this plan of treat-
ment, and when it has been  arrested before the stage of collapse the recovery
is usually speedy.  Regulated diet, rest, with  perhaps a tonic remedy, suffice
for the cure.  The bowels should be allowed to remain constipated for several
days, and then if movements do not spontaneously occur  simple enemas will
probably be sufficient.  If not, a little  rhubarb  or some  other mild laxative
may be  given.  I believe no other plan of treatment promises more than this,
but it is not to be expected that it will always prove  successful.  It will fail—
or rather it is  not available—when, owing to the persistent vomiting and fre-
quent purging, the remedy is not retained sufficiently long to exert its effect;
and it is not available when, owing to the great  rapidity of the transudation,
the state of collapse occurs so quickly that there is not time enough to obtain
a remedial  effect.   These difficulties are equally in the way of success from
any remedies.
   The foregoing remarks on the treatment prior  to the phenomena of collapse
were written  before the hypodermic method  of administering opiates and
other remedies had come into vogue, and the  inquiry has arisen whether by
means of this method the opiate  plan  of treatment of cholera in  the  first
stage  may not be  carried out more  efficiently than  by giving opiates by the
mouth or rectum.   Considering the great importance  of the promptness of the
effect of opiates, and the uncertainty attending their  administration by the
mouth or rectum,  owing to  their rejection by vomiting or purging, and the
difficulty of absorption if  they be retained in the alimentary canal, the hypo-
dermic method seems  to offer a great advantage as regards  speediness and
reliability of effect.   The hypodermic  injection of  Magendie's solution of
morphia was employed  in a large proportion of  the cases  which came under 
558     SPORADIC CHOLERA,  CHOLERA INFANTUM,  ETC.

my observation in 1866.  The vomiting, purging, and cramps were generally
arrested  promptly by this measure ; recovery,  however, followed in  a very
small proportion  of cases.   So far  as my experience goes, it affords evidence
of the efficiency of  the measure  with regard  to the immediate objects—
namely,  the arrest of the  vomiting, purging, and cramps—-but it  does not
afford proof of its curative efficacy. AVith regard to the latter, the character
of the patients is to  be borne in mind, nearly all who were seen in the first
stage being inmates of the  hospitals, and many being affected, when attacked
with cholera, with some serious  chronic  disease, such as phthisis, Bright's
disease, etc.   The hypodermic injection of a solution  of morphia in this dis-
ease is to be employed with circumspection.  Narcotism is sometimes induced
by an amount much below  that which might be given by the mouth without
risk.  I have known a little less than a grain, given in two injections with an
interval  of two hours, to produce deep  narcotism.  The tolerance of opiates
in large  doses by the stomach or rectum is not a criterion of the quantity to
be injected beneath the skin in epidemic cholera.
  Rectal injections of brandy and  a strong tea-infusion were used  consider-
ably, with apparent efficacy, in arresting the evacuations  and preventing col-
lapse.  The proportions used  were  half an ounce of brandy and two ounces
of the tea-infusion, the injections being repeated every half hour, every hour,
or after longer intervals according to circumstances.

  In the stage  of collapse the plan  of treatment  indicated prior to this stage
may prove not only ineffectual, but hurtful.  It is still an object to  arrest
intestinal transudation  if it continue, but to  employ opiates  largely for this
object is  not judicious with reference to the recuperative efforts of the system.
The symptoms in this stage are due mainly to the damage which the blood
has sustained in the loss of its constituents from the  transudation which has
already taken  place.  Opiates may be given, and, owing to the remarkable
degree of tolerance  under these circumstances, they  may be given in con-
siderable doses; but much  care should be observed not to induce narcotism.
They should be given by either the mouth or the rectum ; but never, in this
stage, by the hypodermic method.  Astringent remedies, if the stomach will
retain them, may be added, such  as tannic acid, the acetate of lead,  bismuth,
etc.   If,  however, these or other remedies provoke  vomiting,  they will do
more harm than  good.  Remedies  to allay vomiting may be tried—namely,
the  hydrocyanic  acid, creasote, chloroform, etc.
  In a large proportion of  cases  after collapse has taken place little can be
done with much  hope of success.  Even if the  vomiting and purging cease
recovery may not follow.   The blood may have been damaged  irremediably.
Under these circumstances  it is plain that active treatment can effect nothing.
Recovery, however, in a certain proportion of cases takes place and under a
great variety of treatment.   It may take  place when no treatment is  pursued.
My first  case of cholera in 1849 illustrated the fact just stated.   The patient
was brought into hospital completely collapsed.  I remained with him several
hours and resorted to various therapeutical measures.   At length all measures
were discontinued.  He was allowed to drink abundantly of cold water, under
the  impression that  the case  was utterly hopeless, and therefore the indulg-
ence could do no harm.  Much  to my surprise, after an absence of several
hours I found the vomiting and purging had ceased and reaction was coming
on.  He recovered rapidly.   I have been  led to  doubt whether any active
treatment is of use in the collapsed stage, and I cannot doubt that it is often
prejudicial.   The object of treatment in  this stage, aside from  the arrest of
vomiting and purging, is to excite  and  aid  the  efforts of nature in restoring
the circulation, together with the  functions dependent thereon.  The measures 
INTESTINAL  WORMS.
559
to be employed for  this object  are external warmth, stimulating applications
to the  surface, diffusible  and other stimulants, and alimentation.
  The  application of heat may  be made by means of warm blankets or bottles
of hot  water placed near the body.   The more active modes of applying heat
are  of  doubtful propriety.  I have  never seen benefit from the warm bath or
the application of steam or hot  air.   It is not desirable to excite perspiration,
and if perspiration occur it  should be  wiped away with warm, dry cloths.
Alolent friction does more harm than  good.   The surface  may  be gently
stimulated with sinapisms or  the tincture of capsicum.   Diffusible stimulants
in the  form of spirits and water should be given as freely as the condition of
the stomach will permit, always recollecting the risk and the evils of inducing
vomiting.  They will be most likely to be retained if given in small quantities
at a time  and  often  repeated.   If vomiting be provoked by either drinks,
remedies, or aliment, more or less injury is done.  The ethers, stimulants such
as capsicum, the essential oils,  cardamom, ginger, etc., are appropriate if they
be grateful to the stomach and  retained.  Concentrated nourishment—essence
of meat, chicken-broth, and milk—is to be given in small quantities at a time,
provided  the stomach will retain it.  It is doubtless desirable to introduce
liquid  into the system  as far  as possible.  The  only  objection to  the  free
ingestion of  water is the risk  of provoking vomiting.   Small lumps of ice
should be freely allowed.
   If the patient emerge from the collapsed state, the indications are to support
the system by the moderate use of  stimulants and by alimentation ; to restore
the function of the kidneys by diuretic  remedies and  mucilaginous drinks.
bearing in mind that uramia is one of the dangers of this stage; to restrain
diarrhaa, if it occur, by anodynes and astringents ; to strengthen by tonics ; and
to palliate by  appropriate remedies  the various symptoms which may arise.
   The disinfection of the intestinal excreta in cases of cholera, as has already
been mentioned, is  important in view of  the fact that  they contain  cholera
germs ; and during the prevalence of an epidemic this precautionary measure
should be resorted to in all cases of diarrhaa.
                      CHAPTER   IX,

                        INTESTINAL AAX)RMS.

Ascaris lumbricoides.—Oxyuris vermicularis.— Tricocephalus dispar.—Ascaris mystax.—
              Taeniae.—Trichina spiralis.—Anchylostoma duodenale.

   OF the  various  Entozoa which  dwell  within the  human body, the largest
     number  is  found in  the intestines.   They give rise  to  more or less
disturbance, and are properly enough considered in connection with the func-
tional disorders  of the alimentary canal.  I shall treat of intestinal worms
only in so far as concerns the practical duties of  the  physician.  The  study
of these and of other parasites, as  belonging to comparative  anatomy and
physiology and as  a branch of zoology, is highly  interesting and has led  to
valuable practical  results, but other points  than  those which relate  directly
to them as involving  morbid conditions would be  here out of place.
  The intestinal worms  of frequent occurrence are  the Ascaris lumbricoides, 
560
INTESTINAL  WORMS.
lumbricoid or round worm, and the Oxyuris vermicularis, thread or seat-worm.
The worm known as Tricocephalus dispar is sufficiently common, but is of little
or no  practical importance.  The diff'erent  species of Taenia, or tape-worm, are
of rare occurrence in this country, but their presence constitutes an important
affection.   These different worms will be  noticed under distinct heads.  The
worm called Anchylostoma  duodenale will  be  noticed in connection with the
cylindrical  worms.   As appropriately classed  among the intestinal  worms,
because received and  developed within  the alimentary canal, the  Trichina
spiralis  will be considered in this connection.
                       Ascaris lumbricoides.

  With this  worm every young physician soon becomes  familiar.   It resem-
bles  the  common earth-worm.  It is the most  common of all  the  intestinal
worms.   It is of a whitish or yellowish color;  and the body is round, fusi-
form, and marked by a number of fine  transverse rings.  The  mouth is sur-
rounded  by three tubercles.   The sexes are  distinct.   The  males usually
measure from four to six inches in length and  the females from ten to four-
teen  inches.
  The common lumbricoid  worm inhabits the  small intestine.   It  rarely
exists in early infancy, and is most common  between the ages  of three and
ten.   It  is not very uncommon in adults, but is  extremely rare in old age.
This species  of worm is not usually  solitary.   In different cases the number
of lumbrici varies  greatly.  Sometimes the number is very  great,  and  in
autopsical examinations they are occasionally coiled together so  as to  form
balls or masses of considerable size.  Cruveilhier cites a case in which more
than a thousand were found after death.   They are not infrequently brought
into the stomach by acts of  vomiting, and are ejected from the mouth.  They
may  find their way into the nares, and they have been known to pass into the
Eustachian tube, frontal sinuses, and larynx.  They may migrate  from the
intestine into the biliary  ducts and gall-bladder.  In  a subject dead with
lumbar abscess connected with caries of the vertebra I found a  great number
within the hepatic ducts, some  extending along the ducts and  others  coiled
up.  They may possibly give rise  to hepatic abscess.   They may  penetrate
into  the  pancreatic duct.   They have been  found in the peritoneal cavity
and  in abscesses within the abdominal  walls.   In these cases they escape
through  intestinal perforations caused  by ulceration or  sloughing incident
to other  morbid  conditions.  It is not probable  that the worms  ever per-
forate the  intestines, as was formerly supposed.   They have been observed
to escape  from the  body through fistula  communicating with  the  intes-
tinal canal.
  The symptoms denoting the presence of these or other worms within the
intestinal canal are obscure.  A host of symptoms having little or no signifi-
cance have been enumerated by writers.   Nothing is more common than the
passage of  lumbrici from the stomach  or bowels,  when there  have been no
symptoms of  disorder.   The morbid  effects have heretofore  been greatly
exaggerated.   These  worms, it is probable,  very rarely give rise to serious
results except  when  they migrate into the  biliary or pancreatic  ducts, the
Eustachian tube, or  the larynx ; and these migrations are exceedingly infre-
quent.  There  is no  foundation for  the belief  that they give rise to a form
of fever, as implied by the term worm fever.   They are not infrequently,  in
cases of fever, passed from the  bowels and found  in the intestine after death,
but their  presence  is merely a coincidence.   That they may give  rise  to
sonvulsions, epileptic paroxysms,  chorea, and other affections of the ner- 
ASCARIS LUMBRICOIDES.
561
vous system, as is  generally supposed, must be  considered as by no means
established.
  Symptoms generally regarded as denoting these worms are—colic pains,
tumefaction of  the abdomen, impaired appetite,  excessive flow  of saliva,
diarrhaa, itching of  the  nose,  swelling of the  face, offensive odor of  the
breath, disturbed, dreamy sleep, and grinding of the teeth during  sleep.   It
is  never prudent for a physician to declare  positively that a  child between
three and  ten years of age has not worms, for he is liable to be convicted
of error by the operation of a vermifuge given without his sanction ;  but the
only readily available  diagnostic proof is the presence of  one  or more in the
stools.  AVhen more or fewer of the above-named symptoms are present a brisk
purgative may be given, the stools being examined with reference to diagnosis.
If one or  more worms be passed,  it is proper to act as if there were others
remaining.  According to Davaine,1 a microscopical examination of the feces
will show the characteristic ova if lumbrici be present.  He states that their
ova are readily recognized, and hence the diagnosis may be made positive in
this  way.  Practitioners in general, however, will be satisfied to base  the
diagnosis  upon  other  facts.
  The lumbricoid worm is propagated  by ova.   The  body of  a female lum-
bricus  contains  a vast number of eggs, estimated by Eschricht to be sixty-
four millions.   These  ova  are discharged with the  feces.   The observations
of Davaine and others show  that their vitality is retained for  many  months.
Their ingress  into the  alimentary canal is probably by means  of  water  con-
taining  them, and,  finding favorable conditions  in the  small  intestines,  the
production of the worms takes  place.   That special conditions are required
may be inferred from the fact that these worms are so common  in certain
periods  of life  and so  infrequent at other periods.  As regards  the nature
of the conditions, we  have no positive  knowledge; but mucus in abundance
is  supposed to  be  a favorable  nidus for  their production.
  The expulsion of lumbricoid worms is generally effected without difficulty.
Beginning with a brisk purgative, which  alone is sometimes sufficient, an anthel-
mintic remedy  is to be given for  several successive days.  Of the various
anthelmintics, those best suited for the  destruction of these worms are cheno-
podium  or wormseed,  santonin, and spigelia or pinkroot.   Santonin  is most
easily administered, and is perhaps as effective as the other articles. The dose
is  from 3 to 6 grains, repeated three or four times daily, given either mixed
with sugar or made into dragees or troches.  AVormseed is taken most conve-
niently in the form of the oil. From 5 to 10 drops may be given three times daily
mixed with sugar or in an  emulsion.  The pinkroot has long been relied upon
as an efficacious remedy.  The infusion may be used, but the fluid extract of
spigelia and senna is the most eligible form, the dose being from 1 to 4 drachms
three times daily. Tanacetum or tansy and absinthium or wormwood are doubt-
less efficacious remedies. All these remedies act toxically; that is, by poison-
ing the worms.   After two or three days a brisk purgative should be given.
If with  this treatment no  worms be discharged, their non-existence  may  be
inferred.   If worms be brought away by  this treatment, it need  not be  con-
tinued or repeated  unless, from the continuance or recurrence of  symptoms
denoting disorder, it be inferred  that their expulsion  is not complete.   The
absence  of the ova in the stools, according to Davaine, may he  relied upon
as  proof positive of the absence of the worms.

 1 Trade des Entozoaires  et des Maladies verminenses de VHomme et des  Animaux domes-
t'upies, 1860.  The reader  is referred to this work as treating of entozoa minutely and
comprehensively.  See, also, Heller, in Ziemssen's Cyclopaedia, vol. vii., Am. ed.; Leuck-
art, Die menschlichen Parasiten, Leipzic, 1863-76; and Cobbold's  Treatise on Parasites,
London, 1879.
36 
562
INTESTINAL  WORMS.
  AVith a view to  prevent the ingestion of the ova  of lumbrici  attention
should be directed  to  the purity of the water used as drink.   AVater from
shallow wells in the neighborhood of dwellings and from small rivulets should
be avoided.   Filtration would probably prove effectual  in the way of prophy-
laxis.  Davaine states that it is not common in Paris for  children and others
to be affected with  this worm—a fact which he attributes to the custom of
using filtered water.

                       Oxyuris  vermicularis.

  This worm, called also Ascaris vermicularis, and  commonly known  as the
thread-, pin-, seat-, or maw-worm, inhabits the  large intestine, especially the
rectum. The size is  small, as indicated by certain of the names in common use,
and the length varies between two and five lines.  The vermicular oxyurides
frequently exist in immense numbers, and they are sometimes voided in large
masses or balls agglomerated by mucus.  They occur especially in  young
children, but they are not  extremely uncommon at any period of life.  I have
met with several examples of their occurrence in aged persons.
  These worms occasion pain in the rectum, tenesmus, and more especially
pruritus at the anus.  The latter symptom, which is often due to an herpetic
eruption in this situation, should always excite suspicion  of  the  presence of
these parasites.  The itching often  occurs in paroxysms, and is  particularly
troublesome at night. Excitation of  the sexual organs frequently occurs, with
seminal emissions, and  it is stated  that the habit of  masturbation  in either
sex may originate from this source.   In girls  the worms sometimes migrate
into  the vagina and occasion pruritus with  leucorrhaa.  The diagnosis is
made without difficulty.  On examination  of the stools the worms are seen,
in greater or less  number, adhering to  the feces, and on an ocular inspec-
tion of the anus they may generally be discovered.   It  is doubtful if they
ever lead  to any serious disorders,  but  owing  to the irritation  which they
occasion and the loss of sleep, the general health may  become more or less
impaired.
  The  treatment  is  simple and efficacious,  hut it may require a certain
amount of perseverance.  The same  anthelmintics may be  employed as for the
destruction of the lumbricoid worms, given in the same way.  Purgative reme-
dies  are to be given from time  to time.   In addition, enemas of either cold
water,  salt and water, or soap and water are to be administered once or twice
daily.  These are to be continued for a fortnight or  longer, until  all  the local
symptoms disappear.  The treatment by enemas  alone will frequently prove
effectual.  Various  remedies in  enemas have been advised, such as wormwood,
vinegar, empyreumatic  oil, asafatida, camphor, sulphide  of potassium, etc.
Injections containing a  small percentage of carbolic acid are efficacious. Infu-
sion of quassia and  decoction of aloes are also useful in enemas.   The irrita-
tion or slight  inflammation about the anus which is  sometimes caused by the
presence  of these worms may be relieved by the application of  a  soothing
unguent or the daily injection of a little almond or olive oil.  Extreme clean-
liness is essential in the treatment.  Zenker and Heller have found the eggs
of this parasite beneath the nails.   The  danger of auto-infection from this
source  should  be guarded against.


                      Tricocephalus dispar.
  This worm, as the name tricocephalus denotes, is characterized by the hair-
like appearance of the  cephalic  extremity.  It  is from  an inch and a half to
two inches in length.  The filiform cephalic  portion forms about two-thirds 
TJENLE,  OR  TAPEWORMS.
563
 of  its length.  As in  the ascaris lumbricoides and the oxyuris vermicularis
 the two sexes are distinct.   The posterior or caudal  extremity of the male
 is curved ; that of the female is straight and bluntly pointed.  It inhabits the
 cacum especially, but is sometimes found in the colon, and very rarely in the
 small intestine.   The propagation is by ova, which, according to Davaine, are
 readily recognized by means of the microscope in the dejections.  The parasite
 is found frequently, when  sought after, in the bodies of  subjects  of all ages
 dead with different diseases.  Some years ago, when  engaged in  examining
 bodies dead with typhoid fever, I was  led to examine the  cacum for it, and I
 rarely failed to find one or more.   It is not positively known that its presence
 gives rise to disorder.   Barth of Paris reported a case in which  death  took
 place with the symptoms of meningitis, and after death no lesions  were found
 within the head, but the intestines contained an enormous quantity of worms
 of  this species.

   The  foregoing  species of intestinal worms belong in the class styled by
 helminthologists  Xematoda,  or  cylindrical  worms.    (See  Part  I.  p.  94.)
 Another worm belonging to this class was described by Bellingham under the
 name of Ascaris (data.   It is the  same parasite as the ascaris mystax, which
 infests the dog and cat.   According to Cobbold, about seven instances of its
 occurrence  in  man have been noted.   This parasite,  as regards its practical
 importance, is  in  the  same category with  the tricocephalus dispar.


                       Taeniae, or Tapeworms.
   On the natural history of tania, constituting the class Cestoda in helminth-
 ology, and commonly known as tapeworms, much light has been shed  by the
 researches of Kuchenmeister, Xon Siebold, Leuckart,  and others.   Referring
 the reader to other works for a full account of these researches, suffice it to
 say that different varieties of tania have been  shown to be the  cystic entozoa
 known as cysticerci and echinococci in a state of maturity or complete develop-
 ment.  A C3*sticercus  is an immature or  undeveloped tapeworm.   Different
 varieties of cysticerci  are found in  the solid  parts of different animals, and
 each variety, received  into the alimentary canal of another animal, and, there
 finding favorable conditions, becomes a perfect worm  or tania, each kind of
 cysticercus  becoming a particular kind of tania.   A cysticercus, on the other
 hand, is the product of the  ovum of a  tania.   The eggs of the tania, passing
 out of the body, finding their way into the bodies of men and  other animals,
 and probably entering  into the circulation, are transported to and fixed in solid
 parts, where they become  cysticerci.   The later, as long as they remain in
 solid parts, reach only a certain stage of development; if, however, the parts
 containing the cysticerci be eaten by another  animal, they attain  their com-
 plete development in the alimentary canal of the latter.   Thus a particular
 cysticercus found within the liver of the rat. if eaten by the cat, is developed
 into the kind of tapeworm frequently found in the intestine of the latter; and
 the ova from this tapeworm received into the body of  the rat give rise to the
 kind of cysticercus found in  the liver of this animal.  The ovum from  the
 tania of the dog, received into the body of  the sheep,  becomes the cystic
' entozoon  called Cfcnurus cerebralis, found in the brain  of the latter, which, if
 eaten by the dog, becomes  the  tania  found in the intestine of this animal.
 These highly interesting, and in a practical view important, facts  have been
 substantiated by observation and experiment.
   The  tania or  tapeworm  is distinguished, as  these names indicate, by its
 ribbon-like form.   It  is composed of  a great  number of segments  or joints
 called proglottides, each one of which, after it attains to  its full maturity, is 
564                      INTESTINAL  WORMS.
provided  with  male and female generative organs.   Several  varieties have
been found in man, but as regards medical  practice the discrimination is not
of much  importance, the same  measures of treatment being alike applicable
to all.   In the vast majority of ca.ses the tania developed in the human intes-
tine  is  one of  three kinds;  and it will suffice to notice  these.
   In  this country, of the  three  kinds of tania, the one  which has been
supposed  to be  most common is  the  Taenia solium, or  solitary tania,  so
called  because it is  supposed  always to  exist singly.   This is  true as a
rule, with some  exceptions.   Two or more tania have  been observed  to-
gether,  but such instances are rare.    The  tania solium  varies in  length
between four or five and thirty-five feet, the number of segments or joints
numbering from 800 to 1000.  Toward the  head it becomes attenuated, form-
ing a thread-like  neck of considerable length, and in this portion there are
transverse markings  or  ruga, but no visible joints.   The joints succeed-
ing the neck are about as  long as they are broad, but lower  the  length
is twice or thrice the breadth.   From the resemblance  of these joints to
the seeds  of  a gourd  the worm  has  been called  Vermis cucurbitinus, or
gourd-worm.  The generative  foramina are placed near the middle of one
of the margins of each joint, and are generally alternate.   The head is about
the size of a pin-head, hemispherical  or  triangular in form, and under the
microscope with a low power it is found to present four projections or suckers
and a coronet of  twenty-six alternating short and long booklets surmounting
a projection  called the  rostellum.  The joints of  the inferior part are con-
stantly  thrown  off, and  are passed almost  daily by stool.   These  exfoliated
joints contain an immense number of ova.   Bennett  quotes an  estimate of
the number of  ova in the tapeworm of a cat to be 12,500,000.   It is  fortu-
nate that  worms are  not developed  from the ova  within the  alimentary
canal!
   The  second  variety,  called  Taenia   mediocanellata   (Taenia saginata), has
not until  late years been  generally recognized as distinct  from the  tania
solium,  and the relative  frequency of  its occurrence  in  this country has not
as yet been ascertained.  It is  probable that here, as in England and Ger-
many, it is more common than the tania solium.   The  generative foramina
are situated alike in both varieties, but the joints are longer and thicker, and
the head has four suckers, without hooklets or rostellum.
  The  third variety is known as the Taenia lata, or broad tapeworm, reckoned
by some helminthologists as a species distinct from the true tania, and named
Bothriocephalus latus.   This worm is distinguished  from the tania solium by
the breadth of the joints, which are broader than they are long, by the situa-
tion of  the genital orifices, which are in the middle of the  joints, and by the
different conformation of the head.  The head is unprovided with hooklets,
and hence this and the second variety are distinguished as the unarmed tania,
while the  tania solium is said to be armed.  The form of the head is elongated,
and instead of  suckers it has two lateral longitudinal depressions or fossa;
hence the  name  bothriocephalus, from  poOpiov, a small pit.   This worm may
attain to even a greater length than the tania solium.  Like the latter, it is
usually solitary.  A tania called Bothriocephalus cordatus, distinguished by
the form  of the  head,  is only known to  infest  the inhabitants  of  North
Greenland.
  Of these varieties of tapeworm, tania mediocanellata and tania solium are
those commonly met with  not  only in this country,  but in most countries.
As already remarked, tania mediocanellata seems  to  be the most common.
Bothriocephalus latus has been observed chiefly in Russia, Switzerland, Ire-
land, and Japan.  It is observed  that this variety is likely to affect inhabitants
living on  the coasts of  seas, lakes, and rivers, whence it  has  been inferred 
                      TJENLE,  OR TAPEWORMS.                   565

that  it proceeds from a cystic entozoon existing in  fish.1  The opinion, how-
ever, is also entertained that the embryos of this worm may be taken  into
the system in drinking-water, and may be developed in the intestine without
the intermediate stage of  cystic development in  the solid parts.   The tania
solium is attributable to  the ingestion of the Cysticercus cellulosae, which  is
common  in the flesh of swine.  It is the presence of this entozoon  in  large
numbers which renders pork "measly."  Pork, eaten raw or partially cooked,
is the source of this form  of tapeworm.  Thorough  cooking destroys the cys-
ticercus, and  the development into  the  tapeworm does not then take  place.
It is a matter of observation that butchers and cooks are often affected with
tapeworm,  and it  is  stated that in Abyssinia, where  the custom of  eating
uncooked meat prevails, nearly all persons of different ages become affected
with tania.   The production of tania in children by the use of raw meat  as
food in cases  of so-called cholera infantum has been already referred  to.  The
tania mediocanellata is derived from a  cysticercus found in beef.    Tania
solium is the pork-tapeworm, and tania mediocanellata is the beef-tapeworm.
The  frequency of one or of the other of these species in a given district bears
a strict relation to the amount of underdone measly pork or beef consumed by
the inhabitants.
   The habitat of a tapeworm is the  small intestine.  AAThen it attains a great
length it extends  into the large intestine, and it  has been found  to reach
nearly to the anus.   No  age  is exempt  from  the  liability to its occurrence,
but  in  the majority of cases the ages are between twenty and  forty years.
It occurs oftener in  females than in males.  Professor Armor has reported a
case in which  an infant five days old passed segments of tania.  Two months
after the birth of the  child the  mother was treated for tania.2  The frequency
of its occurrence varies much in different countries and in  different sections
of the same  country.  The  report  of the military surgeons  of the French
army from  1840  to  1848 showed only  7 cases  among 250,000  soldiers.
During a practice of forty-three years I  have not met with more than  thirty
or forty cases.
   The existence of  a tapeworm is  not  indicated by well-marked diagnostic
symptoms.  The symptoms attributed to it are vertigo, tinnitus aurium, dis-
turbance of vision sometimes amounting to temporary amaurosis, pruritus at
the nose and anus, salivation, disordered  appetite and digestion, colic or neur-
algic pains in  the  abdomen, and emaciation.    These are  symptoms  which
may be due to other  morbid conditions,  nor are  these symptoms uniformly,
if generally,  marked  in cases of tapeworm.   The  existence of  the  worm is
often discovered accidentally, and in persons who prior to the discovery con-
sidered themselves perfectly well.   In the case of a young female affected
with sciatic neuralgia I was led to prescribe a full dose of turpentine, and
the result was the expulsion of a large  quantity of tapeworm, the existence
of which had not been suspected.  After the existence of the worm is  known
disorders of all kinds are likely to be referred to it,  and often the imagination
creates  various  morbid sensations.   Convulsions,  epilepsy,  and chorea  are
supposed to be occasional effects, but clinical observation supplies but little
data for this  supposition.  The pathological effects of the presence of this
worm  have doubtless been  greatly exaggerated.   Tapeworms are  almost
invariably found in  the intestines  of dogs destroyed  for experimental pur-
poses, apparently in  perfect  health.
   The diagnosis  must rest  on the  discovery of  detached joints or segments
of the worm in the evacuations.  This mode of diagnosis is always available.
Segments are generally passed at short  intervals, and  hence it is usually not
    1 Kiichenmeister surmises that infection occurs from eating uncooked salmon.
    2 Detroit Review of Medicine, Jan., 1872. 
566                      INTESTINAL  WORMS.

long before  its existence is ascertained.  If there he reason to suspect its
existence  before segments  have been  seen, a brisk purgative may be given,
and  this will be likely to be followed by the expulsion of a greater or less
quantity.    If an  examination of the stools for some time, and  especially
after the  administration of purgatives, fail to discover  any portions  of the
worm, the  physician may be  satisfied of  its  non-existence.   Persons not
infrequently fancy they have a tapeworm.   This is one of the notions likely
to be seized upon by hypochondriacs, and in some  cases it becomes a fixed
belief of which the mind cannot be dispossessed, becoming,  in fact, an insane
delusion.  Several  instances of this kind have  fallen under my observation.
A few instances  are on record in which  portions of the  worm  have been
vomited.
   AAlth reference to treatment a point of importance is the natural duration
of the life of this  parasite.  It is undoubtedly long-lived.  It  is not uncom-
mon for fragments to  be passed  at short intervals for  many years.  Cases
have been reported  in which this was observed for twelve, twenty-five, and
even thirty-five years.   If an  interval of several months elapse without any
segments  having  been discharged, and  if  subsequently they make  their
appearance,  it is probable that a second worm has become developed. Sooner
or later, the worm dies a natural death and a cure  takes place spontaneously.
If successive  remedies  have been  used in  such a case, the last  remedy of
course gets the credit of having effected a cure.   For a  cure to  be effected
with certainty the head must be expelled.  The frequent exfoliation of seg-
ments is natural, and if, as an effect of a remedy or  from any cause, a large
portion or even all  the body be  expelled, reproduction by  growth may take
place as long as  the head remains.  It is, however, a matter of observation
that  the parasite  is likely to  die when the separation takes place  near the
head.  As positive evidence of a  cure the head is to be sought for;  but it  is
not  found in  the  larger proportion of the cases in which a cure  is effected.
   Of the remedies to be employed for the destruction of the tapeworm, one of
the  oldest, and certainly in many cases an effective remedy, is the oil of tur-
pentine.  It  is most likely to be effective if given in large doses.  A half ounce
may be given  in emulsion, with the addition of some aromatic tincture to pre-
vent nausea, this dose being repeated every half hour until two or three ounces
have been taken, or sometimes  the whole amount taken at once is well borne.
Strangury is an occasional result, but this is less  likely to  occur  than when
the remedy  is given in small doses.  After a large dose the patient feels as if
slightly inebriated.  This remedy, thus given,  may be repeated if necessary
after intervals of  several days.  Given  in  the  quantity  just stated, it  gen-
erally acts as a purgative.  Chabert's empyreumatic oil, which has  been much
in vogue as a  remedy for tania, is probably efficacious chiefly from the tur-
pentine which enters  into its  composition, and is  much more disagreeable
than the turpentine alone.   It  is stated  by Bellingham and others that tur-
pentine, given in moderate doses and repeated  for several successive days, is
frequently successful.
   The male fern (filix mas) is a taniafuge, the efficacy of which  rests upon
the  testimony of many observers  of large experience.  In my own experience
it has proved  promptly efficacious.  It may be administered in powder, from
half a drachm to a drachm being  given in  divided  doses in the course of a
few hours, but the  oil and ethereal extract are  more eligible preparations.
The  oil may be given in doses of a drachm either  in mucilage or in gelatin
capsules.   The dose of the extract  is from 20 to 30 grains.  Dr. Alexander
Fleming advises a drachm of the oil,  with mucilage, to be given in an ounce
and a half of  sweet milk at bedtime, the dinner and evening meal of the day
having been omitted.  This mode of administration  is advised on the  sup- 
TJENIJE,  OR  TAPEWORMS.
567
position that milk being a favorite food of the worm, it is more effectually
poisoned by imbibing  the  remedy  in this vehicle.
  Another effective taniafuge is the kousso (Brayera anthelmintica), the dried
flowers of a tree in Abyssinia, where tapeworm  is  exceedingly common.  This
remedy is said to be relied upon in that country.   AYithin the past few years
it has been used with much success in Europe and in this country.  Half  an
ounce of the powdered  flowers mixed with water may be given in a dose, both
the liquid and sediment being taken.
  Another remedy is an emulsion  of pumpkin-seeds (Cucurbitapepo).  The
emulsion is prepared by pounding  two  ounces  of  the seeds in a mortar with
half a pint of water and straining through  cloth.  This quantity will con-
stitute a dose which may be repeated  for several days.  This remedy has
proved  successful  in the hands of a number of physicians  in  this country.
It has the advantage of producing no unpleasant effects, being, aside from  its
action as a vermifuge,  innocuous.
  The bark of the  pomegranate-root (Punica granatum) is another anthelmin-
tic remedy which has been found destructive to the tapeworm.   A decoction
made by boiling two and a half ounces of fresh bark in a pint and a half  of
water until this quantity is reduced one-half is the form in which this remedy
is to be administered.  The whole of the quantity just named may be given
in the course of a  few  hours.   It generally produces purging, and  not infre-
quently vomiting.    Kameela,  the  powder and hairs from  the capsules  of
Rottlera tinctoria, is a powerful anthelmintic which has been found promptly
efficacious  in cases of  tania.   The dose is from one to two drachms given in
honey or thick gruel.   It  acts efficiently as a  purgative.   The remedy has
been given with great  success in combination with the ethereal extract of the
male fern.   Carbolic acid  in doses of half a grain or a grain given hourly,
if well tolerated, throughout the day, followed by a cathartic, has been found
efficacious.
  These are the most valuable of the  anthelmintics which experience has
shown to be capable  of destroying the  tapeworm  toxically.  The powder  of
tin  (pvlvis sfanni), given in doses of a  scruple  or more, mixed  with  honey,
has in some cases proved efficacious,  probably destroying  the worm by  its
mechanical action.   It is far  less  reliable than the  toxical remedies.   Active
cathartics,  such as calomel and jalap,  scammony, gamboge, and croton oil,
occasionally succeed,  their action  probably being  mechanical.   They will
generally bring  away greater or  less portions  of  the worm, but alone  they
are not to be relied upon for  effecting a cure;  that is, for destroying the
worm.  In  conjunction with the toxical  anthelmintics  they are generally
useful.
  The success of the treatment will depend much upon  accessory measures.
The worm  is nourished, not  by nutriment sucked from the intestinal walls,
but from  the alimentary contents of the  intestine, which enter the body  of
the parasite by endosmosis.  An  important part of the treatment, therefore,
is to weaken the parasite by starvation.   The patient, by way of preparation
for the administration of the  taniafuge, should  abstain from those articles of
food which are  digested in  the small intestine for at least a day or two.  Beef-
tea or chicken-soup may be allowed freely.  The treatment  should be begun
with a mild purgative, and the administration of the anthelmintic remedy
should be  followed after a few hours by a pretty active purgative.  If the
treatment prove unsuccessful, the strength of the  patient  should be restored
by  a  return to a  full diet  and  tonic  remedies,  and the same plan again
repeated, employing  the same  remedy or selecting another.  The treatment
is to  be repeated,  allowing sufficient intervals for  recruiting  the  strength,
until a cure is effected.  It is to be borne in mind  that if the greater part of 
568
INTESTINAL  WORMS.
the worm he expelled, although the head may not be found, the death of the
worm is likely to follow, and the treatment therefore  need not be repeated
until the discharge of fragments is again observed.
   The prophylaxis involves  care  never to eat meat not thoroughly cooked.
In meat much underdone the cysticerci which  may be contained in it are
perhaps  not destroyed.   Purity  of the water  used as a drink may be an
important measure of prevention.   The use  of filtered water is to be recom-
mended.  The meat contained in  the Bologna sausages  is liable to  contain
living  cysticerci.   In  view  of  the danger  of acquiring a tapeworm  it is
doubtful if  it be  ever  judicious to advise raw beef or pork as an article of
diet.                                             «


                          Trichina spiralis.

   From the discovery of the Trichina spiralis  by Paget, and its description
by Owen in 1835, to  a recent date, this parasite had been  observed  occa-
sionally in the muscles of subjects in  the dissecting-room, but  in a patho-
logical view it was not considered to have any importance.  Facts, however,
accumulated within the past few years have shown that the introduction and
multiplication of trichina within  the body of man  may give rise to morbid
effects of great gravity which often prove fatal.   Much information has been
obtained respecting the natural  history  of  the  parasite, the  circumstances
under which the  human body becomes  infested by it,  and the morbid phe-
nomena which characterize the disease.   This  information has added to the
nosological  catalogue  a new and  highly important affection known as the
trichina! or trichinatous disease, trichinosis or trichiuiasis.
   The trichina spiralis belongs  in the class Nematoda.  As  found in the
muscles it is coiled up  in a cyst containing a granular  substance at first, and
afterward calcareous  matter.  AVhen expelled from the cyst  the  parasites
are seen  to be round worms -fa of  an inch long and -g-1^ of an  inch in thick-
ness.  So long as they remain  in the muscular tissue the worms are quiescent;
when, however, they are taken into the  stomach and  set free  by the action
of the gastric liquids upon the  muscular  tissue and the cyst, they pass from
the stomach into  the intestinal canal, and immediately begin to grow rapidly,
attaining to three or four times their former size ; they acquire fully-developed
generative organs, copulate, and,  at the end of a week the female parasites
contain living young in great abundance.  According  to Virchow, each tri-
china gives  birth to two  hundred young; Gerlach  says four  hundred, and
Leuckart, one thousand.  The young trichina shortly after birth penetrate
the mucous membrane, and find  their way rapidly to the  different muscles
throughout the body.  They  appear to select the voluntary muscles for their
permanent dwelling-place.  It is stated that they have not been found in the
muscular walls of the  heart.   In other than muscular organs they are rarely
found.
   Trichina  are found especially in the muscles of swine, but they have been
found also in the  muscles of various other animals—namely, eels, cats, rats
and  mice, dogs, badgers, hedgehogs, and moles.   They find their way  into
the bodies of swine from these animals feeding upon the flesh and excrement
of other animals infested with the  parasites, especially rats and mice.  Hence,
to prevent trichiniasis  in  swine and  in other animals which serve as food for
man, it is highly important to cut off all the sources of the disease in the diet
of these animals.  They  find their way into the  alimentary  canal of man
chiefly from the eating of trichinous pork not subjected to processes of cook-
ing sufficient to destroy the parasites.  They are not destroyed by salting or
smoking, and they may retain their vitality in roasted  or broiled meat much 
TRICHINA  SPIRALIS.
569
underdone.  To effectually secure their destruction every portion of meat
which is eaten should have been subjected  to thorough cooking.   The cus-
tom which prevails among the Germans of eating sausages and smoked hams
uncooked involves a liability to the disease.  It has been traced to eating pork
chops which were underdone in the centre, although sufficiently cooked on the
outside.  Meat abounding in trichina may present no evidence of the fact as
regards  the  gross appearance,  especially if a calcareous deposit have  not
taken place in the cysts which contain them ; hence,  trichinous meat may be
sold and bought without any  suspicion  of its being unwholesome.  The only
reliable  evidence of the presence of trichina  in the meat procured for food
is afforded by microscopical examination.  The trouble, however, of  such an
examination precludes  its being generally resorted  to  as a means  of  protec-
tion.  Moreover, a microscopical examination of a few specimens is not ade-
quate to determine that trichina are not present.  They may not be found
in the few specimens examined, although present in  other portions.   Hence,
this test is  reliable only  in  a positive not  in a  negative point of view.
  After becoming encysted in the muscles the trichina retain their vitality
for an indefinite time.   In one case  trichina were found encysted and alive
in portions of muscle attached to a cancerous tumor  removed from a patient.
The previous history of this  case  showed conclusively that the patient was
affected with trichiniasis twenty-four years before the  operation.1  The flesh
of animals,  therefore,  which have been affected with  trichiniasis will  ever
afterward be likely to contain living trichina.  Moreover, the flesh of a single
trichinous animal may produce trichiniasis in a very large number of persons,
so that the disease in its prevalence may present the character of an epidemic.
Muscular trichina, however, may after a time become completely calcified, in
which case they are innocuous.
  The clinical history of the disease caused by trichina is highly important
with reference to an early diagnosis.  The  primary  symptoms relate to  the
alimentary canal, and are due chiefly to the perforation of the mucous mem-
brane by the newly-produced worms.  Abdominal pains, vomiting, and diar-
rhaa  characterize the  first  stage  of  the disease.   These symptoms occur
within ten days after the ingestion  of  trichinous meat; that is, as  soon as
the young worms have  been  produced and become developed  so as to begin
to migrate toward the  muscles.   It is  not  difficult  to understand that  the
aggregated punctures of the mucous  membrane by these parasites  should
occasion  notable  disturbance when it is considered  that the  trichina which
have been found  to be  contained in  a half pound of meat may be sufficient
to give birth in  a few days to a brood  numbering 30,000,000.  It is stated
that peritonitis may be produced by  the passage of worms into the peritoneal
cavity.
  The secondary symptoms relate  to the muscles.   Pains  resembling those
of myalgia are  occasioned by the  entrance of the trichina into the muscles.
Certain  of the muscles  become contracted in some cases, and  their extension
occasions  great  suffering.  Constitutional disturbance  more  or less  marked
accompanies both the  primary and the secondary symptoms.  The general
symptoms are not unlike those of typhoid fever, for which the disease is likely
to be mistaken.   The temperature in  the axilla varies  between 101° and 106°.
(Edema of the  face or  lower extremities often occurs, and sometimes there
is anasarca.   Sweating  is generally  prominent as a symptom.  Death takes
place  in a certain proportion of cases after a protracted  period  of suffer-
ing  and  exhaustion, being often preceded by coma.  It is stated that life in
some cases is destroyed by the  impairment  of the respiratory muscles from
the presence of the  parasites.  Aphonia is a symptom which  exists  in some
              1 Medical News and Library, Philadelphia, May, 1866. 
570
INTESTINAL  WORMS.
 cases, attributable to the presence of trichina in the muscles of phonation.
 Deafness may be caused by trichina in the stapedius muscle.  The danger,
 catteris paribus, is proportionate  to the abundance of  trichina  generated
 within the alimentary canal.  If the number be not sufficient to cause death
 from the amount of local and constitutional disturbance which they occasion,
 recovery takes place very slowly, the illness lasting for  several weeks or even
 months.   The trichina become encysted in the muscles, thereafter remaining
 quiescent.
   Diarrliaa and abdominal pains, followed  by muscular pains, together with
 more or less constitutional disturbance, should excite  suspicion of this dis-
 ease.  Inquiries respecting food should  be instituted, and if any portion of
 the  suspected  meat  remain,  it should  be examined microscopically.   The
 diagnosis may be made still more  complete by harpooning some one or more
 of the painful muscles and  obtaining portions sufficient for examination with
 the microscope.  Davaine suggests that the presence of  trichina in  the  stools
 may  be  ascertained,  and the diagnosis  in  this way rendered positive.  If
 clinical observation should establish the availability of the  latter method of
 arriving  at a diagnosis, it would have this  advantage—namely, the existence
 of  the disease may  be  positively ascertained before the trichina migrate
 from the alimentary  canal.  The  practical  importance  of making  the  diag-
 nosis thus early is sufficiently obvious.
   It  is  evident that the treatment of this disease  to  be effective  must be
 employed while  the worms  are in the alimentary canal.   Hence, the import-
 ance of an early diagnosis.   It remains to be ascertained whether treatment
 can be effectively employed in this stage, and to determine the measures most
 likely to prove effective.   The object is either the destruction of the worms
 or their expulsion from the  intestines.   Cathartics are indicated for the latter
 object, but clinical experience has yet to show  what  toxical anthelmintics
 are best  suited to destroy this parasite.  Benzine  has been found  by Mosler
 to destroy the trichina in the  intestinal canal, when given in  doses which are
 well borne by the patient.   Mosler's method of treatment  with this remedy is
 to have a mixture  consisting of two drachms of benzine, an ounce of licorice-
 juice  and mucilage of gum-arabic, and four ounces of peppermint-water.
 Of this mixture a  tablespoonful is to be given every one or two hours.   This
 remedy,  however, has  not proved  efficacious; but it is to be considered that
 the diagnosis is rarely made prior to the emigration of the parasites from the
 alimentary canal.  The carbolic acid is a remedy which should be tried with
 a view to the destruction of the  worms in the intestinal canal.  After the
 trichina  have left the intestines the opportunity for destroying  or  expelling
 them has  passed.   Recovery  now depends  on the ability of the system to
 endure them  until they  become  encysted.   Measures  to palliate  pain, to
 restore disordered functions, and to support the powers of life are indicated,
 and  the  success of the treatment  will depend on the judicious employment
 of measures  for these ends.
  The prevention  of this disease  is the great  practical benefit to be derived
from its  discovery.   The mode of prevention is sufficiently simple—namely,
abstaining from meat, especially the flesh of swine,  not  thoroughly cooked.
The process  of smoking, pickling, or salting cannot  be relied upon for the
destruction of this worm.   Uncooked  sausages cannot be eaten without dan-
ger.   Heller states that the  parasite is destroyed by a temperature of 155° F.


                    Anchylostoma  duodenale.
  This worm was discovered by Dubini in  Milan  in 1838.  Its relation to a
severe form of anamia which prevails in Egypt  was first made known by 
ANCHYLOSTOMA  DUODENALE.
571
 Griesinger in 1851.  The  disease to which this  parasite bears  a causative
 relation has received various names, of which the following are the most im-
 portant: Egyptian  chlorosis, anchylostoma disease, anchylostomiasis, tropical
 chlorosis, the anamia of the workers in tunnels, etc.   The anchylostoma dis-
 ease is common in Egypt, in Brazil, and in some other tropical countries.  It
 has also been observed in Italy, and was not uncommon among the workmen
 engaged in building the St. Gothard tunnel.  It has recently been observed
 among workmen in coal-mines and in brickyards in Belgium, also in the neigh-
 borhood of Cologne, and occasionally in other parts of Germany.  It has been
 thought that the  parasites  are brought to  these places by Italian workmen.
 This parasite has  been found also in certain cases of geophagia.  No cases of
 the disease have been described as occurring in this country.
   The anchylostoma duodenale belongs to the family Strongylida of the order
 of nematoid worms.   It is also called strongylus or dochmius duodenalis.  It
 is found in the upper part  of the small intestine  in man.   The body of the
 worm is round and thread-like.  The length  of the female is from 0 to 18 mm.,
 that of the male from 6 to 10 mm.  There is an average of about three females
 to one male present.  The  conical pointed  head is bent backward, and pre-
 sents a mouth surrounded by a horny capsule, and possessing  on the ventral
 side four hook-like teeth and on the dorsal side two vertical teeth.   The eggs
 of anchylostoma are oval in shape, from 44  to 07 /* long and from 23 to 40 ;x
 broad.  They undergo the  first  segmentation within  the intestine.  Outside
 of the body, in muddy water and under artificial cultivation at a temperature
 of from 25° to 30° O, embryos  develop and escape from the eggs, and then
 become encysted as larva in a clear chitinous  layer. These larva or embryos
 when taken  into the  human intestine develop  into the mature worms.  The
 anchylostoma worms do not multiply within the intestine, so that the number
 there present corresponds to the number of embryos which have  been swal-
 lowed.
   The anchylostoma  duodenale  bites with  its claw-like hooks or teeth the
 intestinal mucous membrane, and  may  penetrate to  the  submucous  coat.
 Here it sucks the blood from the intestinal vessels.  The female worms are
 those found most gorged with blood.   Sometimes  the  living worm is  found
 rolled  up in the substance  of  the mucous or  the  submucous coat in a little
 cavity filled with  blood.  The parasite leaves  behind an ecchymosis of the
 size of a pea with a white spot in the centre, presenting a  little hole through
 which blood can ooze.
   The anchylostoma  duodenale proves dangerous both by causing digestive
 disturbances and  by withdrawing blood from the body.  The leading symp-
 tom of the  anchylostoma disease  is anamia, which may become as profound
 as pernicious anamia, and in fact  has  often  been mistaken for pernicious
 anamia. AVhen a large number of  anchylostoma embryos are introduced at
 once or rapidly  into  the intestine, the anamia develops acutely ; and  when
 they are introduced more  slowly the  anamia is  chronic in its development.
 Other  symptoms  are  colicky pains in the abdomen,  nausea,  vomiting, con-
 stipation alternating with diarrhaa, and  abnormalities of the  appetite.   The
 stools may or may not contain  blood.
  The diagnosis  is based upon finding the  eggs or the mature worms in the
 feces.  These are  present after the administration of  a  brisk cathartic.   The
 number of eggs found gives a clue as  to the number of worms present.   The
 degree of anamia is not always proportionate to the number of worms present.
  The dttration  of the anchylostoma disease varies between a few months
 and several  years.
  The prognosis  depends upon the degree of the anamia and the obstinacy
of the diarrhaa and other digestive disturbances.  A  fatal termination  is not 
572
DISEASES  OF THE PERITONEUM.
uncommon when the disease is left to pursue its own course.   Nevertheless,
the disease may cease spontaneously by the passage or death of the parasites.
The anchylostoma eggs are sometimes found in the feces of those who pre-
sent no symptoms of disease.
   The treatment consists in the administration of anthelmintics and of iron.
An anthelmintic of great repute  in Brazil against this parasite is doliarina, a
preparation made from the juice of the tree  Ficus doliaria, and  mixed with
aromatics and some form of iron.   About a drachm of this is given three times
daily.   The ethereal extract of male fern  in large doses has also been found
useful in  expelling  the parasites.  Thymol in  form of powder has likewise
been  recommended.

   Animals not  entozoic,  such as snakes,  slugs, and  lizards,  are not infre-
quently exhibited to physicians as having  passed from the  alimentary canal.
It is  a  popular notion that they may live and  grow indefinitely within the
stomach and intestine and give rise  to  a  variety of morbid symptoms.  In
the great majority of cases the statements with respect to the passage of these
animals are simply falsehoods, proceeding generally from a morbid exaggera-
tion of that craving  to become objects of curiosity and interest which enters
largely into the mental constitution of many persons.  In some  cases, how-
ever, the statements are honestly made, persons being deceived. Prof. Dalton
performed a series of experiments to ascertain the duration of life of the com-
mon garden slug  (Limax agrestis) and the water-lizard (Triton millepnnc-
tatus) after having been introduced within the stomach of a dog.  The former
were found completely dead at the end of  nine  and a half minutes,  and no
traces of them were discoverable  when the dog was killed an hour after their
introduction.  The lizards ware found perfectly dead  and about  to undergo
the digestive  process at the end of fifteen minutes.1   It  is safe to set down    •
most of the cases  referred to as cases of either  self-deception  or  imposition.
Maggots, however, have been known to be discharged from the nasal cavitv,
the mouth, and the rectum.  They may be  developed in the nasal cavity from
ova inhaled.
                        CHAPTER  X.

                 DISEASES  OF  THE  PERITONEUM.

Acute Diffuse Peritonitis: Anatomical Characters; Clinical History; Pathological Cha-
   racter ; Causation ; Diagnosis ; Prognosis ; Treatment.—Circumscribed Peritonitis.—
   Chronic Peritonitis.—Hydro-peritoneum.

   THE  peritoneal  cavity, like other  serous  cavities,  has been  generally
    regarded as a large lymph-sac lined with a single layer of flat,  polygonal
cells called endothelium.   (For a different conception of the nature of this
cavity the reader is referred to  p. 115.)  It communicates by means of minute
openings, called stomata, between the endothelial cells with the  lymph-spaces
in the  subserous connective tissue.  Liquids  and small particles are readily
absorbed from the peritoneal sac by the adjoining lymphatic canals.   By this
               1 American Journal of Medical Sciences, April, 1865. 
ACUTE DIFFUSE PERITONITIS.
573
free communication with the lymphatic system the peritoneum readily receives
infectious and  otherwise  deleterious  substances which  may  be present in
adjoining  organs.  This  disposition favors the  propagation of inflammation
from these organs  to the peritoneum.  Peritonitis may be acute or chronic,
diffuse or circumscribed.   It will  be  convenient to consider separately acute
diffuse or  general peritonitis, circumscribed or partial peritonitis, and  chronic
peritonitis. Some writers divide the disease into  several varieties according to
its different causes or to the circumstances under which  it is  developed.  It
will suffice to notice these diversities under the head of Causation.  Puerperal
peritonitis is an important variety presenting certain peculiarities, but it does
not fall within  the scope of this work to consider this form fully or sepa-
rately.  It is treated of at length in works on obstetrics  and on the diseases
of women.


                    Acute  Diffuse Peritonitis.

  Anatomical Characters.—The pathological changes are essentially the
same as in inflammation of other serous membranes.  The intestine, as a rule,
is distended with  gas.   The inflammation usually begins at one  spot,  and
extends with more or less rapidity  over the entire membrane.  The inflamma-
tory changes are usually most marked at the starting-point, and are  elsewhere
more intense in certain places than in others.  At first there is redness due to
congestion and  ecchymoses.  The  serous  surface loses its normal lustre, and
soon it is  coated with a thin, grayish layer of  fibrillated  fibrin, which at  first
contains few cells, but  afterward becomes  richly infiltrated with pus-cells, and
then assumes a greenish-yellow color.  The exuded fibrin causes the coils of
intestine to become agglutinated to each other, to neighboring viscera, and to
the abdominal walls.   Together with  the  exudation of fibrin there is an effu-
sion into  the peritoneal  cavity of more or less serum containing flocculi of
fibrin and some pus-cells.   The subserous tisssue is swollen and adematous,
and contains  pus-cells, usually  in swarms about the  veins.   The other coats
of the intestine may be  somewhat altered.   The muscularis is  usually ade-
matous, and, especially in cases of puerperal peritonitis, there  may be inflam-
mation of the mucous membrane.  While  the chief source of pus-cells is from
the blood, there is sufficient evidence that the endothelial cells  lining the
peritoneum likewise  take an active part in the inflammatory process.  They
become swollen, granular, multinucleated, and by their proliferation produce
young cells.
  Different cases of  peritonitis vary greatly as to the quantity and character
of the inflammatory products.   These products are  fibrin, serum, and pus-
cells, mixed with  a  certain number of red blood-corpuscles.   According to
differences in  causation  and in individuals,  sometimes  one  and  sometimes
another of these  products  preponderates.  In  some cases  the  exudation is
chiefly fibrinous, in others chiefly serous,  and  in others purulent. Again, the
exudation may  he  described as sero-fibrinous, sero-purulent, fibrino-purulent,
etc.  Peritonitis with fibrinous exudation and with but little fluid is sometimes
called dry or adhesive.  In some cases the peritoneal cavity is distended by
a large quantity of serum.   Such cases are generally secondary to ascites.  In
the majority of cases the  exudation may  he described as sero-fibrinous; that
is, the  peritoneal  surfaces are  coated with fibrin, and the cavity contains a
moderate  amount  of serum rendered somewhat turbid by admixture with
fibrin and pus-cells.  Purulent effusions are  also frequently met with.  All
grades of transition occur between the moderately turbid  serum just described
and thick  creamy pus.   Peritonitis  due to perforation, to traumatism, and to
puerperal  fever and other infectious processes is generally purulent.  In  sep- 
574
DISEASES  OF THE PERITONEUM
 tic peritonitis the exudation  may  be foul-smelling and  ichorous.  In very
 rare cases it  has a colloid consistence.  Not infrequently it has a reddish or
 brownish tint from admixture with  blood, but a truly hemorrhagic exudation
 belongs to certain forms of chronic rather than to acute peritonitis.   It is  not
 rare to find collections of serum or of pus encysted in different parts of  the
 peritoneal cavity by means of fibrinous or of old organized adhesions.  In
 connection with these collections of pus there have been observed suppuration
 and ulceration of portions of intestine with which the pus is in contact, and
 even perforation  from without inward (ulcerative peritonitis).
   If peritonitis  terminate  in recovery the serum is absorbed, and the fibrin,
 having undergone molecular disintegration, is likewise absorbed.  Large  col-
 lections of pus cannot be absorbed, but the pus may lose its watery constit-
 uents,  become inspissated, and be converted  into a kind  of cheesy  mass in
 which  lime-salts may be deposited.   New  connective  tissue in the  form  of
 adhesions and of thickening of the serous membrane is a result of peritonitis.
 The method of formation of this new tissue resembles that already described
 for inflammation of the pleura (p. 117). There may be adhesions of  the coils
 of intestine to each other, to the solid viscera, and of the opposing  parietal
 and visceral layers of the membrane.  These adhesions may be innocuous, but
 they may also be  the cause of serious and even fatal consequences.   In the
 spaces or loops formed by bridles of newly-formed tissue portions of intestine
 are liable to become strangulated.  The contraction of the new fibrous tissue
 may lead to constriction of the intestine.  Coils of intestine may be so bound
 together by adhesions  that their peristole  is greatly impaired.  In  cases  in
 which the cause  of the peritonitis  is not evident it  is always necessary to
 search  carefully for some  lesion to which the inflammation  can be referred.
 The presumption is  in any  given  case against a primary  peritonitis.   A
 causative lesion will be found in most cases  in some organ or part within
 the  abdominal cavity, such as perforation of a hollow viscus, hernia, typh-
 litis, perityphlitis, and inflammation  of other parts  adjoining  the peritoneum,
 especially the female generative organs.

  Clinical History.—Acute peritonitis is sometimes developed gradually.
 Abdominal pain and soreness, progressively increasing, may be felt one, two,
 or three days before the local and general symptoms are  sufficient to show
 the existence of the disease; but in most cases the attack  is  abrupt  and the
 disease is quickly declared.  The disease is often in these cases ushered  in
 by a chill.  Pain is usually a marked  symptom.   Beginning at a  particu-
 lar  point, it extends over  the whole abdomen.  It is burning or lancinating
 in character.  It  is  increased  at times so as to constitute  marked  exacerba-
 tions, and not infrequently in these  exacerbations  the character of the pain
 is that of spasm or colic.  Acute pain is produced by a deep inspiration.  The
 respirations are usually shortened,  and by  way of compensation  increased
 in frequency.  The movements of the diaphragm are restrained, and those of
 the ribs proportionately increased; the  breathing, in other words,  is costal.
 Acts of coughing and  sneezing  occasion  intense pain.  Movements of the
 body are painful.  The degree of suffering from pain varies in different cases.
 It is generally great, often extreme, occasionally moderate or slight; and this
 symptom  may be wanting.   Tenderness on pressure  over the abdomen  is
 usually marked.   This  symptom is very rarely wanting.   The tenderness  is
often such that the slightest pressure is painful, but the degree of tenderness
varies considerably in different cases.  The pain and tenderness are frequently
most marked in a particular circumscribed portion  of the abdomen.   These
 symptoms continue during the course  of the disease.   Owing to these symp-
toms the patient often lies  upon the  back, with  the  knees and thighs raised, 
ACUTE DIFFUSE PERITONITIS.
575
in  order  to lessen the tension of the  abdominal muscles and to relieve the
abdomen of the waight of the bedclothes.  This decubitus, however, is by no
means  constant.   The patient may lie on the side with the knees and thighs
flexed, or even on the back with the lower  limbs  extended.   More  or less
tympanites is generally present, due to paralysis of  the muscular coat of the
intestine.   The abdomen is often greatly distended  and tense ;  and this con-
dition persists during the course of  the disease.  The abdominal distension
offers a  mechanical obstacle  to the descent of the diaphragm, and  thus
increases the dyspnaa, which if great is accompanied by cyanosis.  The dis-
tension may be sufficient to displace the heart and to push  the  liver upward.
If the tympanites be not great, the abdominal  muscles, especially the rectus
muscle on either side, are usually notably rigid and  resisting.  The bowels, as
a rule, are constipated, but the exceptions to this rule are not very infrequent.
Constipation  sometimes exists at first, diarrhaa subsequently occurring, and
occasionally diarrhaa exists at the  outset.  The latter symptom is most fre-
quent in  cases of puerperal peritonitis, in consequence of the coexistence of
inflammation  of the intestinal mucous membrane.   A'omiting is  a frequent,
and in some  cases a prominent symptom.  The vomited matter  consists  of
mucus and the contents of the stomach, and afterward of bile, which  often
has a notably green color.  This grass-green or  spinach color is, however, not
characteristic of peritonitis.  The  acts  of  vomiting occasion  great pain.  In
the latter part of the course of the disease the contents of the  stomach are
ejected by regurgitation rather than  by vomiting.   Thirst  is  usually  urgent.
Obstinate and painful singultus is a not infrequent  symptom.
   The temperature of the body is more or less raised, but there is much vari-
ation in different cases as regards the degree of pyrexia.  In some cases  there
is  but a moderate increase of temperature ;  and in other cases there is hyper-
pyrexia.   There may be considerable variation  in the same case during the
course of the disease.  The temperature sometimes  falls to  nearly the  normal
shortly before death. The pulse is  more or  less  accelerated. It often becomes
quite frequent, numbering 120 or 130 per minute; but in some cases the accel-
eration is moderate.  It is generally small, and sometimes hard or wiry.  The
sense of  prostration is considerable or great.  Perspiration  is liable to occur.
The countenance denotes the gravity of the disease, and  the expression is
haggard, pinched, and anxious.   In  some cases  the  upper lip is elevated
and drawn tightly over  the  teeth.   This  appearance is  characteristic, and
when present it  points  to the disease, but it is  by no  means uniformly
present.
   Difficulty in micturition is a frequent symptom, due in part to paralysis
of the muscular  tunic of the bladder in consequence of inflammation of its
investing membrane, and partly to  loss of power over the abdominal muscles
in consequence of the abdominal distension.  Moreover, the  pain  occasioned
by the effort to micturate leads the patient to postpone it as long as possible.
Retention of urine, requiring  the use of the catheter, is not uncommon.  The
urine is high-colored, and throws down a lateritious deposit of urates.  Pain
in the penis is a symptom in certain cases of peritonitis.   This pain is some-
times extremely intense.   In some cases there is priapism with intense  vene-
real desire.
   The  intellect  in cases  of  acute  peritonitis is   generally  not disordered.
Slight  delirium sometimes  occurs, especially in fatal cases, toward the  close
of the  disease.

   Pathological  Character.—Acute  peritonitis, as  regards pathological
character, does  not differ essentially  from  other acute  inflammations  of
serous  membranes. 
576
DISEASES  OF THE PERITONEUM.
   Causation.—Acute  diffuse inflammation of  the peritoneum, exclusive of
 puerperal peritonitis, is not a frequent disease.  The liability  of the peri-
 toneum to become inflamed is  very much  less than that of the pleura or
 the pericardium—a fact not easily explained. In the great majority of cases
 peritonitis  is incidental to some  other  affection of the  abdominal viscera.
 The most frequent cause, exclusive of its  occurrence in childbed and of the
 cases  in which  it  is produced by traumatism, is  perforation of  the  aliment-
 ary canal.  Perforation  of the ileum is incident to  the intestinal  lesions of
 typhoid fever, and  peritonitis thus produced is one  of  the occasional events
 pertaining to the clinical history of that form of fever.  The intestinal ulcera-
 tions which occur in certain cases of phthisis sometimes, although very rarely,
 lead to perforation, and  also other  ulcers situated in  either the small or large
 intestine.   Perforation from ulceration  or  sphacelation of the extremity of
 the  appendix vermiformis of the  cacum  is not of very rare  occurrence.
 (Aide p. 485.)   Perforation of the stomach and of the  duodenum is  an
 occasional event in cases of gastric and duodenal ulcer.   AVhatever  be  the
 seat of the perforation, the gaseous and  other  contents  of the  alimentary
 canal  escaping into the peritoneal  sac, peritonitis becomes  at once developed.
 The escape of bile from rupture  of the gall-bladder or of the cystic, hepatic,
 or common duct gives rise to peritonitis.   Other causes are the discharge of
 pus  into the peritoneal cavity from hepatic, ovarian,  or other abscesses, rup-
 ture of the urinary bladder or ureter, and  the  evacuation of hydatid cysts.
 Inflammation, at first local, may  become general, as in certain cases of intus-
 susception and strangulation of intestine, of typhlitis, and  perityphlitis with-
 out perforation.   Injections into the cavity of the uterus  have been known
 to give rise to  the disease, the  liquid  injected passing into the peritoneal
 cavity through the Fallopian tubes.  In certain cases of puerperal peritonitis
 the inflammation begins in the uterus and  is propagated to  the peritoneum.
 The disease may be produced traumatically by accidental wounds of the
 abdominal walls and violent contusions.   It may be  caused by surgical ope-
 rations which involve  opening of the peritoneal cavity in cases of ovari-
 otomy, of laparotomy in  cases  of obstruction, etc.   It sometimes  follows
 paracentesis, very rarely, however,  except in cases in which the kidneys are
 diseased.   It occurs in  intra-uterine life—a fact which Sir James Simpson
 was  the first to observe.   The extension of inflammation from  the  umbili-
 cal vessels to the peritoneum explains the  occurrence in some instances of
 infantile peritonitis.
   Acute peritonitis is one of the local affections incident to the morbid con-
 ditions of the kidneys collectively called Bright's disease. In two  cases under
 my observation  it was developed in connection with  acute  articular rheuma-
 tism, the patient recovering in  each case after a short duration of the disease.
 Exposure to cold  may give  rise to it.  I  have  known its occurrence to  be
 attributable to this cause.   It has been observed to occur not infrequently in
 the Northern States among laborers  employed  in the  winter and spring to
 repair  water-wheels damaged by  ice, this occupation requiring them to work
 standing in water.
   Occurring as an epidemic  affection in childbed, it  doubtless proceeds from
 a special  cause.   During  the  prevalence of puerperal  peritonitis, epidemic
 erysipelas has been  observed to prevail, showing some pathological relation-
 ship between the two affections.

  Diagnosis.—The diagnosis  of acute  diffuse peritonitis  is  not difficult in
cases in which its characteristic features  are well marked,  as they are in the
majority of cases.   These features are sometimes obscure  or wanting, and it
is  then liable to be overlooked  or to be  confounded with other affections. 
                    ACUTE DIFFUSE PERITONITIS.                577

 From  acute  enteritis it is  distinguished generally by a  greater degree of
 pain, greater frequency of the pulse, more tenderness on  pressure over  the
 abdomen, more tympanites, rigidity of  the abdominal muscles,  and the evi-
 dence  on  all sides  of a  graver malady.
   It is sometimes mistaken  for functional colic.   The pains in some  cases
 of peritonitis are like those of colic;  but colic lacks  the continuous  pain,
 the abdominal tenderness, the muscular rigidity, the tympanites, the pyrexia,
 the  frequency of the pulse, prostration,  etc. of  acute  peritonitis.   These
 symptoms, however, may not be immediately developed in peritonitis, and a
 little delay may therefore sometimes be necessary in arriving  at a positive
 diagnosis.
   Myalgia (muscular rheumatism)  affecting the  abdominal  muscles may
 give rise to certain  of the  local symptoms  of acute  peritonitis.  Instances,
 however, of myalgia limited to these muscles are rare.  The diagnostic points
 are as  follows: In peritonitis movements of  the  body occasion pain over the
 whole  abdomen, whereas in  myalgia  the pain is limited  to certain muscles,
 and perhaps  confined to one  side  of the  abdomen.   The  same is true  of
 tenderness on pressure.   Moreover, in  peritonitis the pain from pressure is
 proportionate to the amount of pressure, but  in  myalgia  deep, firm pressure
 may be made without  augmenting the pain.  These are  diagnostic points
 pertaining to the local symptoms, but the general symptoms present in acute
 peritonitis are wanting in the so-called muscular rheumatism.
   Lumbo-abdominal neuralgia  with hyperasthesia of the abdominal walls or
 integument sometimes simulates closely peritonitis as  regards  certain  local
 symptoms.   The pain may be severe, the tenderness  great, the  decubitus on
 the back  with the  thighs and  knees flexed, and not infrequently there is
 more or less  tympanites.  Cases presenting these symptoms are not uncom-
 mon.  The patients are generally women, and they manifest more or  less of
 hysterical phenomena.   The general symptoms of acute peritonitis, frequency
 of pulse, prostration, etc., are wanting in these cases ;  but attention to  certain
 points  connected with the local symptoms will suffice for the differential  diag-
 nosis.  The  tenderness in the neuralgic affection  is more  superficial; the
 patient shrinks from the slightest  touch, but  firm, prolonged pressure with
 the open palm is often well borne, and may even afford  relief, whereas in
 peritonitis the pain  is always proportionate to the amount of pressure.  The
 muscular rigidity of peritonitis is wanting.
   I have known acute peritonitis  to  be mistaken for sporadic  cholera in a
 case in which vomiting and  purging  occurred  early  and were  prominent
 sjmiptoms. In the exceptional  cases in  which these symptoms are sufficiently
 prominent to suggest that affection, the  error of diagnosis is to be avoided  by
 finding, associated with the vomiting and purging, the  local  symptoms of peri-
 tonitis—namely, pain, tenderness, tympanites, and muscular rigidity, together
 with general  symptoms denoting an  inflammatory  affection—symptoms not
 belonging to  the  history of sporadic cholera.
  Acute peritonitis  is sometimes remarkably  latent, the local symptoms, usu-
 ally so  strongly marked, being obscure or wanting.  Pain and tenderness may
 be slight or even absent.  Muscular rigidity in such cases may be a very valua-
 ble diagnostic symptom.  As regards occasional latency, this disease resembles
 other inflammations of serous membranes—namely, pleuritis and pericarditis.
 Pain and tenderness may be obscure in consequence of the coexistence  of
other affections which occasion delirium or  blunt the perceptions  of the
patient, and  from the absence  of these local symptoms peritonitis may  be
overlooked.   In some cases of peritonitis  produced  by perforation—in the
course  of typhoid fever, for example—the manifestations of pain and tender-
ness may not be sufficient to direct attention to the  abdomen.  In such cases
       87 
 578               DISEASES OF THE PERITONEUM.

 other local in conjunction with general symptoms must be  relied upon in the
 diagnosis.  Certain physical signs may enter into the diagnosis of peritonitis.
 There is  not  infrequently liquid effusion sufficient to be recognized by per-
 cussion and palpation. (Vide Diagnosis of Hydro-peritoneum.)  A peritoneal
 friction sound may be heard by auscultation over the liver.
   It is desirable in cases of peritonitis  to  determine whether the disease be
 idiopathic or dependent on some one of the various local circumstances which
 in the majority of cases stand in  a causative relation to it.   In consequence
 of  the relative infrequency of idiopathic peritonitis the probabilities in any
 case  are  in favor of the existence of some one of  these  causative circum-
 stances.  Developed in the  course  of typhoid  fever, it  generally, but  not
 invariably, proceeds from perforation of the intestine.  If developed in a case
 of  pulmonary tuberculosis accompanied by  diarrhaa,  chronic peritonitis not
 preceding its development,  perforation  connected  with intestinal  ulceration
 is the probable cause.   Perforation  of the  stomach  is probable if the peri-
 tonitis  occur suddenly  in a case presenting  the symptoms  of gastric ulcer.
 Perforation of  the intestine, connected with  latent ulceration, is  to be very
 strongly suspected whenever the affection is developed  suddenly, without any
 appreciable cause,  in a person apparently in  health ;  and if  the pain and ten-
 derness first occur in the neighborhood of  the cacum, and  continue  most
 marked in this  region, the  seat of the perforation  is probably the appendix
 vermiformis.   In cases of perforation gas usually escapes into the peritoneal
 cavity.   Its presence  here gives rise  to intense tympanitic  resonance on  per-
 cussion, extending over the  liver  and taking  the  place  of hepatic flatness.
 Tympanitic resonance over the liver, however, cannot be considered as proof
 of  the presence of gas in the  peritoneal cavity, inasmuch  as this resonance
 is found not infrequently when the transverse colon  is much  distended with
 gas or when this portion of the intestine is pushed upward above  the lower
 margin  of the liver;  but persistent  hepatic  flatness is proof almost absolute
 against perforation.  Clinical observations, in my experience, substantiate  this
 statement.  In  a cadaver in  which the intestines are  nearly free  from gas,
 and even when the muscular  walls of the  abdomen  are notably stiff from
 cadaveric rigidity, the injection of a small quantity  of air into the perito-
 neal cavity suffices to  render the resonance over the liver tympanitic.   This
 experiment I have repeatedly performed.1  Perforation of the ureter may be
 strongly suspected if the sudden development of the disease have  been pre-
 ceded by  symptoms denoting obstruction from calculus or some other cause.
 In like manner, perforation of the  ductus communis choledochus is the prob-
 able cause if symptoms denoting the impaction of gall-stone in this duct have
 preceded.  The disease is attributable to intussusception or internal strangu-
 lation of the intestine  when preceded and accompanied by symptoms denoting
 these causes of obstruction of the  bowels.   Its connection with renal disease
 is to be determined by an examination of the urine for albumen and tubular
 casts.  Finally, if  evidence of  the existence  of any of the causative circum-
 stances referred to  be  wanting,  and the disease be fairly attributable to expo-
 sure to cold, it is to be considered as idiopathic.

  Prognosis.—Acute  general peritonitis is always a grave  disease, involv-
ing danger to life.   In the majority of cases  the danger is greatly enhanced

  •Vide paper by the author in Transactions of the Medical Society of the State of New York,
entitled " On the Physical Diagnosis of Peritonitis with and without Perforation of the
Alimentary Canal," 1882; also article  by the author, entitled "On the Persistence of
Flatness  on Percussion  over the Liver, as Proof that Acute Diffuse Peritonitis is not
associated with  Perforation of the Stomach or Intestine," in the Medical News, Jan.
17, 1885. 
ACUTE DIFFUSE PERITONITIS.
579
either by the circumstances on which the development of the disease depends,
as, for example,  intestinal perforation, or by  coexisting affections, such as
renal  disease.   AVe have  no data for determining  the  amount of intrinsic
tendency to death belonging to simple idiopathic peritonitis.  There is reason
to believe that the rate of fatality in all cases depends much on the mode of
management.  Judiciously treated  in  uncomplicated cases,  the  prospect of
recovery is good.   In complicated cases—including  under this head cases in
which the disease is connected with gastric  or intestinal  ulceration, Bright's
disease, etc.—the prognosis is always very unfavorable.  Under certain circum-
stances  the disease runs rapidly to a fatal is.sue.  It may destroy life within
a few hours if developed as a result of perforation.  Recovery, however, is
not impossible in  cases of perforation, provided the  opening be not large  and
if closure be quickly effected by adhesions around it.  The average duration
in fatal cases  is  from five to six days.
  The mode of dying is by either rapid or slow  asthenia.   An unfavorable
progress of the disease is denoted by a progressive increase  of the  feeble-
ness and frequency of the  pulse, progressively increasing prostration, coldness
of the extremities, cyanosis, hiccough, regurgitation, etc.  On the other hand,
a favorable progress may be inferred  from improvement as regards the gen-
eral symptoms just  referred to, together with diminution of the tympanites
and muscular rigidity of the abdomen.   Convalescence is generally slow,
more or less tenderness and colic pains persisting during the progress  toward
recovery.

  Treatment.—The treatment of this disease, as  inculcated  and generally
adopted of late years in this country, is in striking contrast with that formerly
pursued.  The change consists—first, in the disuse of bloodletting and  cathar-
tics ; and second, in  relying mainly on the  use of opium.   Governed  by the
general principles which should  regulate the employment of bloodletting in
acute inflammations, the indications  for this measure  are not present in
peritonitis, a disease which  tends to destroy life, sometimes very quickly, by
asthenia.   Bloodletting has been much employed in  the treatment of this  dis-
ease, and clinical  observation has abundantly shown  that  it is not, to say the
least, a  curative measure.   It  is a measure which  must do either good or
harm in a disease  like this, involving always not  a  little danger to life ;  and
if it do harm  instead of good, the  amount of harm, even if not large, may
bear heavily on the result.  Cathartics also have been much employed in the
treatment of this disease.   Not only are they devoid of curative efficacy,  but
they are pernicious.  An important point in the treatment of an acute  inflam-
mation of any  part is to secure for the part  as  complete rest as  possible.  The
friction  incident to the peristaltic movements tends  to  prolong and increase
the inflammation in peritonitis.   An object of treatment is the arrest of these
movements, thus  securing rest for the  inflamed membrane.   Cathartics not
only conflict with the means for effecting this object, but they aggravate the
inflammation by  increasing the peristaltic  movements.   Moreover, they are
objectionable on  the  same  score  as  bloodletting and other  depletory  and
depressing measures.  Clinical  observation  furnishes no evidence of the use-
fulness of  cathartics in the treatment of  acute  peritonitis.   On  the other
hand,  it has occurred to me, as to others, to see the intensity  of the  inflam-
mation reproduced by the too  early administration  of a  cathartic  when  the
disease appeared  to  be  progressing  favorably, the  patient's life apparently
being lost in consequence.  Cathartics, then, should  not enter  into the treat-
ment of this disease.  The bowels should be allowed to remain  constipated,
if evacuations  do  not spontaneously occur,  during the  career of the disease,
even if this period be a week or more.   In pursuing this course the physician 
580
DISEASES  OF THE PERITONEUM.
 must expect in some cases to encounter the importunities of the patient or
 friends  for  medicine to open  the  bowels.    If  the patient  suffer from  an
 accumulation  of feces within the  rectum,  its contents may be  cautiously
 removed by repeated simple injections.   Much relief, if tympanites be great,
 is sometimes obtained by the introduction into the rectum of a flexible tube,
 which allows the escape of gas.
   An important object effected by the use of opiates is the arrest of the peri-
 staltic movements;  and this is a special object in this disease, but opiates are
 also useful, as in other inflammations, by rendering the system more tolerant
 of the local affection.  The latter is also an object in  the treatment.   AVith
 reference to both these  objects opiates are to be given in doses sufficient  to
 produce certain effects.   Relief of abdominal pain is evidence that the first
 object is effected.  The doses, therefore, should be sufficient to produce this
 effect.   The pain is  to  be  relieved as quickly as possible, and the return of
 pain  prevented  by  repeating  the  required  doses at proper intervals.  The
 success  of  the  treatment  will depend  much  on its  being  begun early  in
 the disease.  Time should not be wasted by  delay for any preliminary meas-
 ures.  The treatment should  begin  with a full dose, the  amount  being reg-
 ulated by the  intensity of  the pain.  For  an  adult a quarter or a half of a
 grain of a salt  of morphia or an equivalent dose of some other form of opiate
 may be given at once.   In  two or three hours the effect of the first dose can
 be appreciated.  If  the patient be not then free from pain, another dose is to
 be given, the dose being increased or diminished  according to the  degree of
 pain.  And  during  the course  of the disease the opiate is to  be repeated, if
 required, at intervals, in doses sufficient to prevent return of pain.  Narcotism
 is to be avoided. In  order to avoid this the physician is to observe the  effects
 of the doses as regard  somnolency, contraction of the  pupil, and diminished
 number  of respirations.  Judgment  and careful watching are  important, lest
 narcotism be produced.   The somnolency  from  the  opiates  should  never
 become so great that the patient  cannot be easily aroused.  The respirations
 should not be reduced below twelve per minute.  If, as not infrequently hap-
 pens, they are found below this number or irregular, the intervals between
 the doses are  to be  lengthened or the  doses diminished.   In carrying out
 this method of treatment it is desirable that  the physician should see the
 patient frequently.    If this be  impracticable, as it often is in country prac-
 tice, the administration of the  doses  must be entrusted with minute instruc-
 tions  to an  intelligent and  faithful  assistant or nurse.   The doses are to be
 gradually diminished in proportion as the local and general symptoms denote
 improvement.
   The extent to  which  opiates  are to be  given in  order to secure the objects
 of the treatment will  vary much in different cases.   Other things  being
 equal, the doses required will   depend on the degree of pain  ; but the sus-
 ceptibility of different persons  to opium varies greatly, and in  peritonitis, as
 in some other diseases, there is sometimes an extraordinary tolerance of this
 remedy.   Thus,  in one of  the cases treated successfully by  Prof. Alonzo
 Clark the patient took  within  the first twenty-six hours, of opium and the
 sulphate of  morphia, a  quantity equivalent to  106 grains of opium; in the
 second twenty-four hours she took 472 grains; on the third day, 236 grains ;
 on the fourth day, 120 grains;   on the fifth day, 54 grains; on the sixth day,
 22  grains; and on the  seventh day,  8 grains, after which the  treatment was
 suspended.   This patient. Prof. Clark had reason to believe, was not accus-
tomed to the use of  opium in health, and was not intemperate.  As regards
the amount  of  opium required, this  case is exceptional, the patient having
an enormously  increased tolerance of this drug.   Rarely is more than half  a
 grain  of a salt of morphia every two, three, or four hours needed.   Often 
ACUTE DIFFUSE PERITONITIS.
581
the requisite effects are produced by smaller doses.   If there be  irritability
of the stomach, the opiate should be given by hypodermic injections.  Vom-
iting conflicts  with the great object for  which opiates are given—namely,
rest of the inflamed part, and  therefore everything is  to  be  avoided which
will be  likely to excite it.
  In  the  treatment of this disease the  main reliance is  upon opiates ; but
other  measures are important.  Quietude of the body is to be enjoined, and
the bladder is to be relieved by the timely  use of the catheter if there be reten-
tion of urine.  Rubefacients, sinapisms, or turpentine stupes  may be applied
over the abdomen.  Blisters are contraindicated.   All the good to be done in
the way of revulsion will be effected by  rubefacients, and counter-irritation
beyond  this does harm by increasing constitutional disturbance  and contrib-
uting  to depress  the powers of  life.  Warm fomentations to the abdomen, if
grateful to the patient, are useful; poultices are uncomfortable  from  their
weight, and the water-dressing or the spongio-piline is to be preferred.  I can-
not speak  of the utility of cold applications from much observation, but  it is
safe to trust to the feelings of the patient in deciding between cold and warm
applications.  Cold may be applied  by means of compresses dipped in ice-water
and renewed at intervals of a few minutes,  or the ice-bag.  Sustaining measures
are indicated in proportion as the symptoms denote failure of the vital powers.
Alcoholic  stimulants and concentrated nourishment constitute the  supporting
measures which are not less appropriate to this disease than to other diseases
tending  to destroy life by asthenia.   I have seen cases in which life apparent-
ly was saved by  the free  and persevering use of  alcoholic stimulants in  con-
junction with the use of  opiates.  The  employment  of  cathartics in  con-
valescence calls  for  great  circumspection ;  and they may not  be required,
the bowels  acting spontaneously.   The liberal  use of  opiates continued
throughout  the  disease does not  appear  to  conduce to constipation, and it
does not prevent the occurrence of diarrhaa in a certain proportion  of cases.
Quinia in full  doses as an antipyretic remedy is indicated  if there be hyper-
pyrexia.

  As  an addendum to the treatment of this disease may be offered a sugges-
tion relating to  measures which doubtless  are  too bold to commend them-
selves without having been carefully considered.   These measures are, mak-
ing an opening through the abdominal wall, washing out the peritoneal cavity
by injecting a  tepid disinfecting liquid, and maintaining the opening so as to
secure effectual drainage.   These  measures of course are applicable only to
cases  in which the  presence of septic,  infective  morbid products may  be
inferred.   In many instances these  products probably constitute the chief
source of danger.  Modern experience in  ovariotomy and in the operation  of
laparotomy in  cases of intestinal obstruction has shown the admirable results
which follow cleansing of the  peritoneal surfaces, and the absence of the great
danger formerly attributed to laying open the abdominal cavity.  The time
may come when paracentesis  abdominalis for the  purposes just  stated  will
have  been proved to be as  applicable to certain cases of peritonitis as  are
thoracentesis, injections into  the pleural  cavity, and a permanent opening in
the chest  to cases of suppurative pleurisy.
  The foregoing  paragraph was contained in the last  edition of  this work,
published  in  1881.  Since  that  date several  cases  have  been reported  in
which the abdomen was opened, the purulent contents washed out, and anti-
septic injections  employed.   Dr. Z.  B. Adams reported a case for the Boston
Medical  and Surgical Journal, Nov. 20. 1884, in which  this practice  was suc-
cessfully pursued.   A successful case has been reported to me in a letter by
Dr. Eug. A. Crouse of Iowa.   Leyden and others  in Germany advocate the 
582
DISEASES  OF THE  PERITONEUM.
 treatment of suppurative peritonitis after the manner of empyema, and illus-
 trative cases are cited.1


                     Circumscribed Peritonitis.

   Inflammation limited to a circumscribed portion of the peritoneum is almost
 invariably a complication  of a  prior aff'ection of the parts covered by  the
 inflamed  portion of the membrane.  Circumscribed  peritonitis may be acute
 or  chronic, but these varieties cannot be sharply separated from each other.
 AArhen inflammation reaches the surface of  an organ covered by peritoneum
 the latter always becomes inflamed.   Hence, a local peritonitis is frequent in
 various lesions of the  stomach, intestine, liver, gall-bladder, spleen,  urinary
 bladder, and the uterus and its appendages.   Ulceration of the stomach leads
 to a peritonitis limited to the site of the ulcer.  Cirrhosis of the liver in  the
 great majority of cases is accompanied by inflammation of the serous invest-
 ment of this organ.  This  inflammation  is called  perihepatitis.  It  leads  to
 thickening of the hepatic capsule and to the formation of adhesions with the
 diaphragm and other  adjoining parts.   A similar  perihepatitis often  accom-
 panies abscess, cancer, and some other affections of  the  liver.   Perisplenitis
 signifies a local peritonitis about the spleen and is not infrequently found at
 post-mortem examinations.   Among the most  frequent and important forms
 of  circumscribed peritonitis  is  inflammation of  the  pelvic  peritoneum in
 females—pelvic  peritonitis, perimetritis, peri-oophoritis.   Intestinal  ulcers
 and typhlitis often lead to circumscribed  peritonitis.   In consequence  of
 adhesions a perforation of the  intestinal  canal may give rise  to only partial
 peritonitis.   Encysted collections of pus may be  present in the peritoneal
 cavity, without diffuse peritonitis.   Diaphragmatic  pleuritis may be  accom-
 panied by inflammation of the adjacent peritoneum.
  The inflammatory products in circumscribed peritonitis are the same as in
 the diffuse form.  The exudation in many instances is chiefly fibrinous.   In
 some chronic cases resulting in formation of new connective tissue it is prob-
 able that from the onset there is simply a new growth of connective tissue
 without any free exudation.   The  perihepatitis accompanying cirrhosis  of
 the liver  is usually of this simple proliferative form.  The peritoneal thick-
 ening and fibrous adhesions which result from circumscribed peritonitis may
 cause displacements and deformities of  the viscera.  Displacements  of  the
 uterus and of  the ovaries thus induced  are frequently met with in gynaco-
 logical practice.  Circumscribed hemorrhagic peritonitis will be considered in
 the following article.
  The symptoms of circumscribed peritonitis are pain and tenderness within
 a space corresponding to the extent of the inflammation, accompanied perhaps
 by more or less febrile movement.  These symptoms are marked in propor-
 tion to  the acuteness  of the inflammation,  but circumscribed peritonitis is
 oftener subacute or chronic than acute.   Physical exploration  in some cases
 furnishes  diagnostic evidence.  The presence of fibrin may occasion a friction
 sound or a tactile sensation  of rubbing due to the attrition of opposed surfaces
 by the diaphragmatic respiratory movements.  This sign is most likely to be
 obtained when the peritonitis is situated over the liver and  spleen.  It is
 obtained in cases of circumscribed oftener than of diffuse peritonitis, and is
 of comparatively less importance in the latter, because the symptoms gen-
erally suffice for the diagnosis  if the inflammation  be diffuse.
  It must be difficult, if not impossible, to determine the existence of circum-
scribed peritonitis not connected with an affection of the parts covered by  the
  1 ATide Verhandlungen des Vereins fur innere Medicin zu Berlin, 1884; also, Am. Journ.
of Med. Sciences, April, 1885, p. 573. 
CHRONIC PERITONITIS.
583
 inflamed portion of peritoneum.   Cases, however, are so  rare that, the exist-
 ence of circumscribed peritonitis being ascertained, an affection of  the parts
 covered  by the inflamed membrane is  to be  inferred.
   The prognosis in  cases of circumscribed peritonitis  will depend  on  the
 nature and extent of the affection of which the  peritonitis is a complication.
 The adhesions resulting from the inflammation may be either conservative or
 deleterious.
   So far as the  peritonitis is concerned, palliative treatment is alone called
 for.


                         Chronic Peritonitis.

   Chronic peritonitis  may.be of the following varieties: 1, with exudation
 of serum, fibrin, and pus, as in acute peritonitis ;  2, chronic serous peritonitis ;
 3, peritonitis with predominant  production of connective tissue; 4,  hemor-
 rhagic; 5, tuberculous ;  6, cancerous.
   Chronic peritonitis with exudation of serum, fibrin, and pus may follow an
 acute peritonitis or may develop  slowly and insidiously.   It  is more frequent
 as the sequel of an acute peritonitis than in a latent form, but it is in either
 case a rare variety of the disease.  There is sometimes, but not always, coin-
 cident disease of some of the abdominal viscera.   In consequence of the  for-
 mation of membranous adhesions the fluid part of the exudation often becomes
 sacculated.   Sometimes  the  exudation consists  almost wholly of  fibrin, by
 which the intestines and other viscera may be agglutinated to each other  and
 to the parietal peritoneum.  The intestinal walls are softened and easily torn.
 Chronic  peritonitis  with an exudation   almost  wholly purulent sometimes
 develops insidiously.   AVhen acute peritonitis  passes into a chronic  state  the
 pain,  tenderness, and tympanites diminish, but they do not wholly disappear.
 There are  usually recurring febrile paroxysms  with intervals of apyrexia.
 Gastric and intestinal disorders are present.  The patient is troubled more or
 less by vomiting. The bowels are irregular, constipation alternating with diar-
 rhaa.  The patient emaciates and becomes anamic.  Sometimes irregularities
 due to encysted collections of fluid in the peritoneal cavity may be made  out
 by inspection, palpation, and percussion.  AVhen the disease begins insidiously
 it is usually not susceptible of diagnosis.  The prognosis is unfavorable,  but
 recovery may take place by absorption and by the formation of adhesions.  Col-
 lections of pus may ulcerate and escape into the  bowels or externally.
   Chronic serous peritonitis is usually secondary to  ascites.  Together with
 the accumulation of a large amount of serous fluid in the peritoneal cavity
 there  are evidences of inflammation.   The serous fluid maybe rendered some-
 what turbid by the admixture of pus-cells.   In some  cases there is  fibrinous
 exudation upon the peritoneal surface ;  and in others the chronic inflammation
 is manifested by fibrous thickening of the peritoneum, either diffuse or in  the
 form of nodules.   The nodules may resemble tubercles in their gross appear-
 ance.  These various appearances may be combined.   Peritonitis is not a  fre-
 cpient complication of ascites.  It is more  likely to develop after repeated tap-
 pings  than when paracentesis has not been performed.  In very rare instances
 chronic  serous peritonitis is  an  idiopathic  affection.  Cases  of this  nature
 were formerly described as idiopathic dropsy of the peritoneum, but it is prob-
 ably more .correct to regard them as inflammatory in origin.   A serous fluid
 accumulates, as in ascites; but none of the recognized causes of ascites  are
present, such as obstruction of the circulation in the liver, in the lungs, or in
the heart, or as Bright's disease, hydramia, tuberculosis, or cancer.   In most
cases there is either a free inflammatory exudation or a formation of new con-
nective tissue  in the peritoneum ; but there is sometimes no more sign of 
584
DISEASES  OF THE  PERITONEUM.
inflammation than  in  an ordinary case of ascites.'   Peritonitis  complicating
ascites may be  suspected when the  symptoms of the former disease, which
have been described, develop;  but it rarely happens  that these symptoms are
manifested with sufficient  intensity to  be diagnostic.  It is very difficult to
distinguish  idiopathic  chronic serous peritonitis, on the  one hand,  from
ascites, and, on the other hand, from tuberculous peritonitis.   This difficulty
is increased by the  rarity of the disease, which in a given case raises a strong
presumption against its existence.   A probable diagnosis can be  reached only
by excluding the symptoms and causes of the two diseases in question.   In
ascites due to that large group of causes occasioning  obstruction  to the circu-
lation  the  spleen is almost invariably enlarged, while in the disease under
consideration this organ is not  affected.   Serous peritonitis  may  occur in
chronic alcoholism, as  pointed out by Leudet,2
  Peritonitis with predominant production of connective tissue may be called
proliferatioe peritonitis.  The new connective tissue  is in the form either of
adhesions or of thickening of the peritoneum.   The two alterations  may be
combined.   This form  of  chronic peritonitis may develop without any  pro-
duction of fibrin or of pus, or  a moderate amount of these products  may be
present.   Proliferative peritonitis with adhesions as the chief lesion is gener-
ally circumscribed.   This has been mentioned in the  preceding article.  Peri-
tonitis with fibrous  thickening of the peritoneum  is  sometimes  observed in
connection with  cirrhosis of the stomach.  The serous covering of the stomach
and intestine, the omentum, the mesentery, and the mesocolon are sometimes
enormously thickened  by the production of fibrous  connective tissue.   The
peritoneum in other situations may also be thickened.  The omentum, mesen-
tery, and mesocolon are usually  retracted.   The coils of  intestine may be
inextricably united  to each other  by the new growth of tissue.  Not only is
the cavity of the stomach encroached upon, but the lumen of the  intestine
may also be diminished.  There is usually serous or  sero-purulent  liquid in
the peritoneal cavity, and there may be fibrin upon the thickened peritoneum.
Chronic  inflammation of the gastro-intestinal  mucous membrane is generally
present.   This form of  peritonitis is comparable to  the chronic interstitial
inflammation of parenchymatous organs.  The symptoms point to some severe
abdominal trouble.  The symptoms of chronic gastro-enteric inflammation are
often present.   Vomiting,  diarrhaa, dull pain,  and emaciation may be men-
tioned as frequent symptoms.  The  distinction often  cannot  be made from
tuberculous peritonitis or  from  cancer of some of  the abdominal  organs.
The  same  induration of the peritoneum and of the abdominal organs which
may be  felt through  the  abdominal walls  is often   present in  tuberculous
peritonitis.
  Hemorrhagic peritonitis may be  either diffuse  or circumscribed.  Reference
is not had in this connection to a simple staining of the inflammatory products
with blood, such as often  occurs in cancerous and  tuberculous peritonitis,
but to a special form of inflammation characterized by the development, upon
the peritoneum, of  successive  thin  layers of connective tissue,  rich in wide
capillaries with thin walls, which  readily rupture and give rise  to large  and
small hemorrhages.   The new membrane  is reddish  or brown in color, from
infiltration  with  blood.  Extensive extravasations of blood form hamatomata.
This peculiar form of peritonitis  is analogous to chronic  hemorrhagic pachy-
meningitis, which will be described in the  next section of this work.  Fried-

  1 In ascites the peritoneum is often thickened, and even when no changes are visible
to the naked eye it is  not perfectly normal.  The endothelial cells are changed in size
and in shape, and  present evidences of proliferation (Delafield).  Similar changes exist
in the pleura in hydrothorax and in the tunica vaginalis testis in hydrocele.
  2 " Des  Lesions du Peritoine chez les Alcoolises," Gaz. hebdom., 1879, No. 49. 
                        CHRONIC PERITONITIS.                    585

reich has observed two cases of diffuse hemorrhagic peritonitis in patients with
ascites who  had been  repeatedly tapped.   The  circumscribed  form was first
described  by Virchow.   It is  met with especially in  the  recto-uterine fossa,
where it causes bloody tumors known as retro-uterine or pelvic hamatoceles.
A similar  hamatoma may occur in the recto-vesical fossa  in males.   The
prognosis  in pelvic hamatocele is good, the blood being often  absorbed with
astonishing  rapidity.   The consideration of this form  of disease belongs  to
works on gynacology.   There are no symptoms diagnostic of  diffuse hemor-
rhagic peritonitis.  Cornil and Ranvier mention the occurrence both of diffuse
and of circumscribed  hemorrhagic peritonitis in  hypertrophic cirrhosis,  in
articular rheumatism,  in tuberculosis, and in  Bright's  disease.  It is a rare
form  of inflammation.
   Tuberculous peritonitis, of all the forms of chronic diffuse peritonitis, is the
most common and of the greatest clinical importance.  In acute miliary tuber-
culosis the peritoneum, especially the omentum and the serous covering of the
liver and  of the spleen, is studded with small, gray miliary tubercles.  This
acute tuberculosis of the peritoneum  is accompanied usually  by little or no
serous effusion.  It  is not attended  by recognizable  symptoms, and is not
included under the heading of tuberculous peritonitis.  So, too, the eruption
of miliary tubercles, combined often with  local  inflammation, on  the perito-
neum, covering the  site of tuberculous ulcers  of  the  intestine, is of patho-
logical  rather than of clinical interest.
   The  most frequent  form of  tuberculous  peritonitis is characterized by
abundant  production  of firm  connective  tissue.   This  new  tissue  causes
thickening  of  the serous  membrane  and intimate adhesion of  coils of
intestine and other  abdominal organs to  each  other and to the abdominal
walls.   The intestinal  coils are inextricably matted together.   The omentum
is drawn up into  a thick, hard mass which can  sometimes be felt during life
as a transverse band above the  umbilicus.   The mesentery  and mesocolon
are likewise  thickened and retracted.   Tubercles are present  everywhere  in
the thickened peritoneum and in  the adhesions.   They  appear  as translucent
miliary granulations, as yellow caseous deposits,  and as fibroid nodules. Some
fibrinous  exudation  is present.   Cases differ much  as to the quantity and
the character of  the  effused liquid.   The quantity may  be  small, but more
frequently it is abundant, so that during life  hydro-peritoneum is simulated.
In the majority of cases the  liquid consists  of turbid, blood-stained serum.
A hemorrhagic effusion is  common in  tuberculous inflammation of all serous
membranes.  Fresh  ecchymoses  and old pigment-stains are  often present  in
the fibrous tissue, especially near the tubercles.  The fluid part of the exuda-
tion is frequently shut into separate cavities by  means of the extensive adhe-
sions.   Encapsulated  collections of pus  are  found  not very  infrequently.
These, as  well as softened tubercles, may  lead  to ulcerations into the intes-
tinal canal from without.  The adherent coils of intestine may also ulcerate
into each other.   Even fecal fistula, opening through the abdominal parietes,
may be formed.
   Li another form of  tuberculous peritonitis  there are few or no adhesions;
there  is an abundant collection of somewhat turbid, and often bloody, serum ;
and the peritoneum, which may be thickened,  is  studded with a large number
of tubercles  which may coalesce into the form of nodules and plaques as much
as an  inch in diameter.   This form has been called  tuberculous ascites.
  Still less frequent  is a third  form described by Wilks  and  Moxon under
the name of latent  peritoneal tubercle.   The  peritoneum is studded with
tubercles  in  the  midst of a soft, gelatinous,  fibrinous exudation by which
its surfaces  adhere to each other.
  Tuberculous  peritonitis  in extremely rare  instances  may  be a local affec- 
586
DISEASES  OF  THE PERITONEUM.
tion.  It is  usually accompanied by tubercles  in  other  parts  of the  body.
As a rule, there is pulmonary tuberculosis, but cases are  not very infrequent
in which the pulmonary lesions  are  comparatively trifling, and  there may be
no pulmonary tuberculosis  whatever.  Tuberculous pleurisy is a  very fre-
quent accompaniment of tuberculous peritonitis.  Primary tuberculosis of
the genito-urinary organs—in females of the uterus and Fallopian tubes, in
males of the epididymis  and testicle, also  of the  bladder, ureters, and kid-
neys—lias been  repeatedly followed  by tuberculous peritonitis.   The mesen-
teric glands, the spleen, and the liver often  contain tubercles in all  forms of
this disease.  There may  be intestinal ulcers and waxy degeneration of vari-
ous organs.   Cirrhosis of the liver  has been repeatedly  observed associated
with chronic tuberculous peritonitis.  Tuberculous peritonitis  may occur at
any age.  It is  rarer before the fourth and after  the fortieth year of age
than at other periods.
  As regards clinical history and  diagnosis, tuberculous  peritonitis  is an
obscure disease.   It may begin acutely or  may be attended by  acute exacer-
bations, but as  a rule it is insidious  in its  onset and slowly progressive in
its course.   There is usually moderate fever,  with  more  or less acceleration
of the pulse.  Aromiting and  other  digestive disturbances are  more or less
prominent.  Diarrhaa alternates with constipation.   Other general symptoms
are—night-sweats, hectic paroxysms, progressive emaciation, anamia, and gen-
eral  debility.   As regards  local symptoms, abdominal pain and tenderness
may be wanting, and  they rarely are prominent  symptoms.  Increasing dis-
tension  of the abdomen by fluid and by meteorism may be the first symptom
to attract attention.  It  may be possible  to  make  out  encysted collections
of fluid in the abdomen  and tumors formed  by agglutinated coils  of intes-
tine.  The detection  of the thickened and retracted omentum is a significant
sign.
  The diagnosis of tuberculous peritonitis is not easy. AArhen there  is a large
accumulation of fluid the differentiation from ascites is difficult. In the diagno-
sis the following points are in favor of tuberculous  peritonitis:  the presence
of tubercles in the lungs  and in other organs; the  simultaneous occurrence
of pleurisy ;  no notable decrease in the size of the liver ; no enlargement of
the spleen ;  the  presence of some fever and abdominal tenderness ; no history
of intemperance ; no  marked  collateral dilatation of the  abdominal veins;  a
large quantity of albumen in the fluid; and the recognition of some of the
local  signs mentioned, such as the contracted omentum.  The distinction of
tuberculous from simple chronic peritonitis is all the more difficult from the
fact that both may occur  in connection with  chronic pulmonary tuberculosis.
In suspected cases the fluid withdrawn by tapping may be  examined for tuber-
cle bacilli, but failure to find these would not exclude tuberculous peritonitis.
  The* termination of tuberculous peritonitis is always fatal, either from the
disease  itself or  from  tuberculosis of the lungs or other organs.  The duration
is from one or two months to  a year or more.
   Of the tumors of the peritoneum, carcinoma is the only one which demands
clinical consideration.  The occasional occurrence  of echinococcus cysts in
the peritoneum  may  be simply mentioned.   Carcinoma of the peritoneum  is
almost  always  secondary.  Colloid  cancer  is probably the only form which
develops primarily in this situation.  It occurs as a diffuse growth, involv-
ing the omentum and other parts of the peritoneum.  Colloid cancer has its
seat by preference in  the peritoneum, and it attains sometimes an enormous
size,  a  growth  weighing one hundred and fourteen pounds  having been
reported.   Peritoneal cancer may  develop  as  secondary to cancer of the
ovary, uterus, testicle, retro-peritoneal glands, rectum and other parts of the
intestine, stomach, liver, pancreas, etc.   It may appear  in the  form of one 
HYDR 0-PERITONE UM—A SCITES.
587
or more  large tumors in the serous membrane, or there may he countless
little cancerous nodules studding the peritoneum.   The latter  distribution is
called  miliary carcinosis of the  peritoneum.  By the  aid of the  microscope
it  is readily distinguished from tuberculosis, which it  resembles in gross
appearance.  Peritoneal carcinoma  is not necessarily accompanied by  inflam-
mation.  Usually, however, there is considerable accumulation of brownish
serum  which may contain fibrin.   The brown color  conies from admixture
with blood.   A new growth of connective tissue, with agglutination of intes-
tinal coils, may accompany cancer as well as tubercle of the peritoneum.  In
cancerous peritonitis the local symptoms do not differ materially  from those
in tuberculous peritonitis.  Febrile movement is  less constant and marked in
the former, and perspiration is not so liable  to occur.   The age of  the  patient
is greater than in the  majority of  cases of the  latter.   A\rhen the primary
cancer is recognized, the diagnosis of cancerous peritonitis does  not usually
involve much difficulty.  AArhen, however,  the primary growth is latent  the
diagnosis is not easy.   The recognition  of  tumors seated in the  peritoneum
is  of assistance in diagnosis.   The examination of the  fluid  withdrawn by
tapping may also be of assistance.   It has been  pointed out  by Foulis and
by Thornton1 that in cancer of the peritoneum or in cancer of  the  ovary, with
ascites, the fluid in the  peritoneal cavity often contains large cells in  groups
(budding cells, group-cells).   The prognosis is fatal.

   As regards the treatment of the different varieties of chronic peritonitis,
the objects are, to palliate the local  symptoms, and by tonic remedies, nutri-
tious diet,  and hygienic influences  to enable the system to tolerate the  dis-
ease as long as possible.


                   Hydro-peritoneum—Ascites.
   The  term hydro-peritoneum or ascites denotes peritoneal dropsy. The fluid
accumulated in the peritoneal cavity  consists of clear serum  with the prop-
erties described in Part I. (p.  33) as belonging to transudations.   Like other
dropsies, hydro-peritoneum  is a symptom or an effect of  disease, not  strictly
a disease in  itself.   It  is, however, convenient and proper to give separate
consideration to ascites, as the accumulation of liquid in the peritoneal cavity
may be the first and chief manifestation of  disease, and as it occasions incon-
venience and danger, to which therapeutical measures are specially directed.
Hydro-peritoneum may occur either as a  local dropsy or  as part of a general
dropsy ; that is, in conjunction  with anasarca and with  dropsical accumula-
tions in  other serous sacs.
   AVith very few exceptions, ascites, occurring as a local  dropsy, is the result
either of disease of the  peritoneum  or of obstruction in the main trunk of the
portal vein or in the branches of this vessel within the liver.   In  most if not
all cases in which  the ascites  is attributable to disease of the  peritoneum the
fluid accumulation is to be regarded as an  inflammatory  effusion  rather than
as a transudation.   This is proven  by the  presence  of a certain degree of
inflammation in these cases, and by  the fact that the fluid, in  the amount of
albumen which it contains, is, as a rule, more closely allied to exudations than
to transudations.   The  inflammation is often no more than a chronic thicken-
ing of the peritoneum, either  diffuse or in the form of nodules, and it may not
be attended  by the exudation of fibrin.  This  form of peritonitis has been
described  in  the  preceding  article  as chronic serous peritonitis.   Tubercles
and cancer  of the peritoneum  may also be causes  of  ascites,  even when
marked inflammatory changes are  absent;  but  here, too, the serous accu-
                         1 British Med. Journ., 1878. 
588
DISEASES  OF THE PERITONEUM.
mulation is to be attributed to inflammatory alterations, which careful exam-
ination will usually reveal.   It is a rule that slight inflammatory changes in
the vascular walls are attended by an effusion chiefly serous.  Obstruction of
the main trunk of the portal vein, as a result of thrombosis or pylephlebitis,
in most cases is followed by ascites.  Cirrhosis is the most common morbid
condition, seated in  the liver, which causes ascites.  Syphilitic hepatitis is
also a cause of ascites.   Echinococcus, abscess, cancer, and other tumors of
the liver may  cause  ascites by compressing the portal vein  or its  principal
branches.   Atrophy of the liver induced by external pressure or by growths
in its substance may likewise be a cause.   Advanced  amyloid degeneration
of the liver is  accompanied by ascites as a rule.   These various diseases of
the liver will  be considered in the  following chapters.   A\rith the possible
exception  of amyloid liver, they all cause ascites by  interfering  with the
portal  circulation through  this organ.
   The causes  of hydro-peritoneum in conjunction with general  dropsy are
obstruction  to  the  circulation in the lungs and through the heart and a
hydramic state of the blood.   The most important of  the pulmonary causes
are emphysema and fibroid induration  and  contraction  of  the lungs, such as
may follow chronic  pleurisy.  Uncompensated valvular  lesions and  other
organic diseases of  the heart are frequent causes of ascites  with general
dropsy.  Bright's disease is by far the most important cause of ascites refer-
able to hydramia ; but  other cachexia, as the tuberculous, the cancerous, the
syphilitic, and  the malarial, may also cause hydramic  dropsy.  The connec-
tion between hydramia and dropsy has been  discussed in Part I. (p.  63 et
seq.).  From the foregoing  it is evident  that dropsy of  the peritoneum, as of
other parts, may be  divided into mechanical dropsy and cachectic dropsy
(p. 33).  Ascites due to  mechanical causes (obstructions to the circulation
in the liver, lungs, or heart) reaches a  higher degree  than  that due to hy-
dramia.
   Ascitic  fluid consists, as a rule, of  yellowish serum. In cachectic peritoneal
dropsy it  is clear and watery in  appearance.   In  cirrhosis of the  liver it is
darker in color.  It may be  stained  with  blood, especially  in tuberculosis
and in cancer of the  peritoneum.  The  specific gravity is rarely below  1004
and seldom exceeds  1020.   The percentage of albumen is less than in exu-
dations.   In dropsical accumulations in the peritoneal cavity the quantity of
albumen is usually less than 2? per cent., whereas in  inflammatory exuda-
tions  in the  same situations the quantity generally exceeds  4  per cent.   In
cachectic  ascites the  amount of albumen rarely exceeds 1 per cent., whereas
in ascites due  to tuberculosis of the peritoneum  the  quantity is,  as a rule,
greater than 2J per cent.   Chemical examination of fluid removed by tap-
ping may  thus  be of assistance in diagnosis.  Ascitic fluid contains fibrinogen,
and (as explained on p. 34) it often coagulates spontaneously when with-
drawn from the body.   At autopsies ascitic fluid is by no means always found
devoid of coagulated fibrin.   Since Schmidt's investigations as to the coagu-
lation of fibrin it has not been found possible  to draw as sharp a distinction
between fluids free from fibrin and those  containing this substance  as was
formerly done.
   The transudation  may present a milky appearance from  an admixture of
chyle in consequence of compression or of rupture of the thoracic duct or
large chyle-vessels.   This condition  is called chylous ascites  (hydrops chylo-
sus.)  A similar appearance may be due to the presence of a large number of
fat-granules and of cells containing molecules of fat. This constitutes hydrops
adiposus.   It has been  observed in connection with cancer and with tubercle
of the peritoneum.   In one case of  chylous ascites which followed  residence
in  a tropical climate AVinckel found in the fluid countless parasites  resem- 
HYDRO-PERITONEUM—ASCITES.
589
bling the Fiiaria sanguinis detected by Lewis in the blood of those suffering
from chyluria.1

  In the account of the clinical history of ascites reference is not had  to
slighter transudations, such as occur in cachectic states, and which, as a rule,
neither give rise to symptoms nor call for therapeutical interference.
  The  effusion of liquid and its accumulation take place without  pain, ten-
derness, or  any local subjective symptoms.  The enlargement  first directs
attention to the abdomen.  In the majority of cases it goes on with rapidity,
and the abdomen  soon becomes considerably or greatly distended.   The symp-
toms referable directly  to the  dropsy proceed from the mechanical  pressure
of the liquid and are in proportion to the quantity of the effusion.   The dis-
tension of the abdominal walls by the liquid and its weight occasion  more or
less inconvenience.  The functions of the abdominal organs (stomach, liver,
kidneys) are impaired by compression.   Pressure on  the veins within  the
abdomen gives rise to adenia in the lower  extremities.   The movements  of
the diaphragm are restrained or arrested, breathing being carried on by the
costal  muscles, and if the accumulation be very large the capacity of the
chest is  diminished by  the  upward pressure.   The  appetite is usually  im-
paired.   A  sense of fulness  is frequently felt  after taking food  in moderate
quantity.   Vomiting and diarrhaa are occasional  symptoms.2
   Enlargement of the superficial veins on the anterior aspect of the  trunk is
a consequence of  the passage of a portion of the  blood  from the portal vein
into the systemic venous system through anastomosing branches.  The super-
ficial  veins  of the abdomen  in  some cases, of the chest in other cases, and
sometimes in both situations, become more or less dilated, presenting a vari-
cose appearance.   Hernial protrusions at the umbilicus and in other situations
are occasionally produced.
   AVhen the fluid accumulation is considerable, adema of the lowar extremi-
ties is a pretty constant  symptom, the  amount of adenia varying  much in
different cases.  The limbs, scrotum, and penis sometimes become enormously
swollen.   Some adema  of the  lower limbs preceded an  enlargement of the
abdomen sufficient to attract the  attention of  the patient in one-half of the
cases (21)  among those analyzed by me, the  histories of  which contained
information on this point.   (Edema of  the face and upper extremities does
not belong  to the clinical history of local  hydro-peritoneum.   If present, it
usually denotes coexisting renal or cardiac disease.  In the progress of the
affection emaciation  and pallor become  marked.   The  attenuation of  the
upper part  of the body, the distended  abdomen, and  the adematous lower
extremities combine to  render the appearance highly  characteristic of the
affection.   Cholaunia or icterus is occasionally present.  It occurred in 7 of
the 46 cases which  I have  analyzed.
   Fever does not attend the progress of this  affection.   The pulse may be
more or less increased in frequency and  proportionately feeble,  or it is more
or less enfeebled  without acceleration.   The urine is frequently scanty.  The
mind is usually intact, but in a certain  proportion of cases, toward the close
of life, delirium, convulsions, and coma  occur.   These  symptoms may be due
to uramia or to  retention in the blood of the excrementitious principles of
the bile (cholesteramia).
   The mode of dying in the great majority of  cases is by slow asthenia.  A
rapid and large  accumulation of liquid may destroy life by interference with
respiration ;  and  apnaa and asthenia are  combined when coma precedes  death.
   1 AVinckel, Deutsches Archiv fur klin. Med., 1876, Bd. 17, p. 303.
   2 A'ide paper by the author, entitled " Clinical Report on Hydro-peritoneum, based
on an Analysis of Forty-six Cases," American Journal of Medical Sciences, April, 1863. 
590
DISEASES  OF  THE PERITONEUM.
  The prognosis in most cases is unfavorable.  The cases in which a perma-
nent recovery takes place are few.   The morbid conditions on  which the
affection is dependent  are  generally incurable, and lead to  its return, sooner
or later, in most of the cases in  which the dropsy disappears or is removed.
The duration of the affection is variable.   In the fatal cases of those which I
have analyzed, the  duration varied between six weeks and seventeen months,
the average duration being more  than five  months.  Cases in which the affec-
tion is attributable  to obstruction of the portal vein by non-infecting emboli
or by thrombi may end in  recovery, changes in the  obstructing  thrombus or
embolus taking place  which permit  return  of circulation  through  the ob-
structed vessel.    Instances  apparently exemplifying  this fact have  come
under  my  observation.

  The diagnosis of hydro-peritoneum is  generally made without difficulty,
yet there is a liability to  errors which  may lead  to serious results.   A dis-
tended  bladder has been  punctured, the case  being supposed to be one of
peritoneal dropsy.   There  is a tradition that John Hunter made this mis-
take.   On careful  examination the tumor  formed by the distended bladder
may generally be felt through the abdominal walls, but the introduction of
the catheter is the diagnostic test.   The sacculated bladder may cause a notable
anterior projection  of the abdomen.  The contents of the saccular appendage
may generally be removed by the  catheter combined with suction  by means of
an india-rubber bag.  Pregnancy, the liquor amnii being unusually abundant,
has been mistaken  for dropsy and the uterus  has been punctured.  Careful
examination  through the abdominal  walls and per vagiuam, together with
auscultation  of the abdomen, should prevent this error.  Great corpulence
has led to error and to the operation of paracentesis, as in the  famous case
of "dry tapping"  related in the  lectures of Sir Astley Cooper.   Finally,
tympanites, large abdominal tumors, and ovarian cysts are to be discriminated
from peritoneal dropsy.
  The enlargement of the abdomen  from  dropsy begins at the lower part;
and if the abdomen be not  largely distended it is more marked below than
above when the patient stands or sits.  The enlargement  on both  sides is
equal, and the abdomen is symmetrical.  If the patient lie upon  either side,
the weight of the liquid causes the depending side to sag. Percussion on one
side, the open palm being placed on the  opposite side, frequently causes  a
characteristic  shock, called the sense  of fluctuation.   Sometimes this  sensa-
tion is more appreciable when the palm is placed near the point at which the
percussion  is  made.  The former method of percussion gives rise to what is
called  diametrical, and the latter to  peripheral fluctuation; but a more sat-
isfactory application of percussion is to compare the results  when the patient
is placed  in  different positions.    Percussing  first in the  sitting or standing
posture, tympanitic resonance, from intestinal  gas contained in the intestine
floating upon  the liquid, is usually found at the upper part of the abdomen,
extending below for a  greater or  less  distance, and  flatness from this point
to the pubis.   Placing the patient on the back,  the change in  the relative
situation of the liquid  and  the intestine is  shown by the greater extension of
the tympanitic resonance toward the pubis.  Similar proof of  the presence
of liquid is obtained by percussing upon either side of the abdomen  success-
ively, the body being inclined first to one  side, and then to the  other.  The
exceptional cases in which this test afforded by percussion is not available are
those  in which the intestinal coils are fixed  by morbid adhesions.   This is
rare  in  cases  of a  purely  dropsical affection.
  The  several affections  simulating dropsy  which have been  named may
generally  be excluded by  the application  of  percussion as just described. 
HYDRO-PERITONEUM—ASCITES.
591
Ovarian cysts of sufficient size to distend the whole  abdomen are the most
likely to be  confounded with hydro-peritoneum.   These are generally, how-
ever, distinguishable by the appreciation  of the form of the cyst through the
abdominal walls, the existence of a tumor on one side before it extended to the
whole of the abdomen, the absence  of symmetry in the enlargement  of the
two sides, together with the  want of evidence of the presence of liquid  in
the peritoneal sac,  afforded by percussion when the body is placed in differ-
ent positions.  The chemical and the microscopical examination of the fluid
removed by  puncture often assists in this differential  diagnosis.   AVhen the
fluid is thick and viscid it is ovarian.  The thin ovarian fluids present more
difficulty in  diagnosis.   The presence of a large quantity of a modified form
of albumen, called  paralbumen, is diagnostic of ovarian cysts.   80, too, the
recognition  of a  large  number of granular  corpuscles devoid of  nuclei,  in
which  the granules are insoluble in acetic acid and  in ether, is diagnostic.
These  bodies  are known as the ovarian corpuscles of  Drysdale.  The  detec-
tion of a few of these corpuscles and the  presence of a small quantity of
paralbumen  are  not sufficient for the diagnosis.  Ovarian  fluids  very  rarely
coagulate spontaneously.   If cylindrical epithelial cells be found, the fluid
conies  from  an ovarian cyst, but these cells are rarely discovered.  The spe-
cific gravity of ovarian fluids is generally higher than  that of ascitic.

   The treatment  of hydro-peritoneum relates—first, to  the dropsical effu-
sion;  and second,  to  the morbid  conditions on  which the  effusion depends.
As regards  the dropsical effusion, the object is to effect its removal or dimi-
nution.  For this object, medicinal and  surgical measures may be employed.
The medicinal means consist of  remedies to eliminate water  from the blood
and thereby induce absorption of the effused  liquid.  The elimination of
water  from  the  blood  is to  be accomplished  by diuretics and  hydragogue
cathartics.   Diuretics  in most cases  effect but little.  It is generally not easy
to obtain much  diuretic effect from any of the  remedies  of this class, the
difficulty arising from  the slowness with which the remedies enter the general
circulation,  owing to the fact that the morbid conditions giving rise  to the
dropsy  usually involve obstruction  to the  portal circulation.  Of 13 cases
treated with diuretic  remedies, in 8 no effect upon the dropsy was produced:
in 5 more or less diminution of the dropsy followed; but in only 2 cases was
the improvement marked  and progressive.   Little  dependence, therefore, is
to be  placed  on  diuretics, but inasmuch as, if properly prescribed, they do
not cause much  disorder or prostration, they should be  fairly  tried.  The
saline  and vegetable diuretics may  be  given  in  succession, and  a diuretic
effect is more  likely to be produced  if several  be employed in combination.
   Hydragogue cathartics  act more  efficiently than  diuretics, but  clinical
observation  does not furnish much evidence  of success from their use.  Of
the different hydragogues,  elaterium  is the most reliable.   I am  accustomed
to prescribe  this remedy in doses of a quarter of a grain repeated at short
intervals until abundant liquid  evacuations  are  produced.  Afterward the
doses may be repeated according to circumstances.   Owing  to the disturb-
ance and prostration caused  by the  prolonged use of hydragogues, they are
liable to do  harm  and should not enter largely  into the  treatment,
   The apocynum  cannabinum, or the Indian hemp indigenous in this coun-
try, is  considered by some  as an efficient hydragogue in this form of dropsy.
From some  trial of this remedy  in  Bellevue  Hospital I have been  led  to
think it is less  reliable than the elaterium.   The decoction of the root  or
the extract  may be employed.
   It is important to bear in mind that in order to secure the desired effect of
diuretics or  hydragogue cathartics upon the dropsy the ingestion  of  liquids 
592
DISEASES  OF  THE PERITONEUM.
is to be restricted, the patient drinking no more than the wants of the body
require.
   The  surgical  method  of effecting the removal  of the  liquid  is tapping.
With respect to  this operation the views  heretofore  held are that it is to be
resorted to only when the abdominal  distension occasions  great  distress or
danger, and not  until the  indirect  means have been thoroughly  tried;  that
the dropsy generally increases more rapidly after the  operation ; and that the
operation involves danger  if the system  be  much prostrated.  These views
are erroneous.   Tapping effects promptly, without perturbation and without
impairing the vital powers, the object for which diuretics and cathartics  are
employed, the latter being generally ineffectual, disturbing the digestive func-
tions, and enfeebling  the powers of life.  The operation is a trivial one, involv-
ing little risk  of  accidents or of peritoneal inflammation.  A patient under my
observation had repeatedly tapped himself, using as a  trocar a blade of a pair
of scissors, and a piece of an ordinary clay pipe-stem as a canula,  There is
no  danger from  increased  rapidity of effusion directly  after the operation.
The patient is spared not only the inconvenience and  distress, but  the perma-
nent injury caused by the prolonged pressure of the  liquid  upon the abdom-
inal and thoracic viscera, and he is in a condition more  favorable for the action
of remedies other than those which have special  reference to the  removal or
diminution of the dropsy.   Clinical experience  shows  that in some cases,
even when the dropsy is dependent on cirrhosis, the liquid does  not accumu-
late for  weeks, months, and years afterward.   In another work  I  have cited
several instances  in which, after a great number of tappings, the dropsy ceased
to return and recovery seemed to be complete.1  It is judicious to resort to
tapping as soon as the accumulation of liquid is  sufficient to occasion much
inconvenience, adopting this  direct  method in lieu  of  the  indirect  means,
provided the  latter do not prove immediately efficacious, and repeating the
operation whenever the abdomen becomes again distended.  These  views were
enunciated by me in a paper published in  1863, and  were based  on  the
results of tapping in 20  cases under my observation, the operation in these
cases being performed but once in  11 cases, and in  the remaining 9 cases
being repeated from three to thirty times.   The conclusions drawn from the
facts contained in the histories of these cases are the following:  1. Tapping
may be resorted to as a palliative measure when the condition of the  patient
is such that only temporary relief is to be expected.  2.  In  a certain propor-
tion of cases the  dropsy returns more or less quickly, and it may be necessary
to repeat the operation many times.   The repetitions, however, are  innocuous.
This was illustrated in one case in which it was performed thirty times within
eighteen months.  3. In some cases the dropsy does  not return  for a consid-
erable or even a long period, and in some cases it never returns.  That it  will
prove a  curative measure is not to be expected in  the majority of cases.
Since the publication of  that paper the correctness of these  conclusions has
been substantiated by a large number of cases under  my observation.  If it
be deemed advisable to avoid a rapid withdrawal  of the liquid,  it  may be
removed by aspiration.  An aspirating needle, however, should  not be used.
My adaptation of Davidson's  syringe  is the  most convenient aspirator.2
  The dropsical  collection is sometimes discharged spontaneously, the walls
of the abdomen becoming attenuated by distension and rupture taking place.
The perforation in these  cases is most likely to occur at the umbilicus or at
some point at  the median line.  In a case at  Bellevue Hospital a protrusion

  1 \Tide Clinical Medicine.
  2 Vide paper entitled " Early Tapping in Cases of Ascites," by the author, read at a
meeting of the British Medical Association, in August, 1883,  and" published in the Brit-
ish Med. Journal, and in the Journal of the Am. Med. Association, Sept. 15, 1883. 
SUPPURATIVE HEPATITIS.
593
of a cyst-like tumor  took place  at  the umbilicus, which, after attaining a
large  size, burst, and the contents  of the  peritoneal  sac were discharged
through  the  opening.   Four months  after the spontaneous discharge took
place  the dropsical effusion had  not returned.
  The treatment relating to  the morbid conditions on which the dropsy
depends embraces, in the  first place, measures to prevent an increase of the
incurable lesion which exists in the majority of cases—namely, cirrhosis of
the liver.  It will be  seen, when we come to consider this lesion, that it  is
caused by spirit-drinking.  Change of habits as regards  the use of  spirits is
therefore  the  most important of  the measures coming under this head.  In
the second place, certain  accessory or co-operative causative conditions may
be removed—causes which act by impoverishing the blood and impairing the
forces which  carry on the circulation.   This part of the  treatment  embraces
tonic medication with  nutritious diet and other measures to strengthen and
invigorate  the system.   AVell-directed treatment for this end, although not
curative, will often do much to prolong life  and to secure as much improve-
ment of health as is compatible with existing structural lesions.
   Mechanical compression  of  the  abdomen  after tapping, by means  of a
swathe or a laced supporter, is  a  measure of importance, as not only afford-
ing comfort,  but tending to prevent  a renewal of the  dropsical effusion.
                        CHAPTER   XI.

                    DISEASES  OF  THE  LIVER.

Suppurative Hepatitis.—Chronic Interstitial Hepatitis (Cirrhosis).—Syphilitic Hepa-
                  titis.—Acute Yellow Atrophy of the Liver.

    OF diseases affecting the solid abdominal viscera, the greater number and
     the  more important are seated  in  the liver.  These will be  first con-
sidered, and afterward diseases  of the  spleen and  pancreas.  Acute diffuse
hepatitis, considered as a disease distinct from  acute  yellow  atrophy of the
liver, has so  little practical interest, except in certain tropical climates, that
it is not considered in the present edition of this work. Suppurative hepatitis
or hepatic abscess, chronic interstitial hepatitis, syphilitic hepatitis,  and acute
yellow atrophy of the liver will be treated of in this chapter, and the next
chapter will embrace the different structural together with functional affec-
tions.

        Suppurative Hepatitis—Abscess of the Liver.

  Anatomical Characters.—Suppurative hepatitis is always circumscribed
and leads to the formation  of abscess.  There may be  only one abscess, which
may attain a very large size, so  as to occupy the greater  part of  the liver.
Such large solitary abscesses are found especially when the disease is  of trau-
matic origin or when it occurs in tropical climates.  They are sometimes called
tropical abscesses.  There  may be multiple abscesses, varying in  number be-
tween three and forty or more.  AAThen very many the individual abscesses are
usually of small size. In a case under the author's observation  five and a half
       38 
594
DISEASES  OF THE LIVER.
 quarts of pus were at once evacuated by an opening made through the thoracic
 walls.  The patient recovered.   An abscess has been  found to contain after
 death eighteen pints of pus, the  entire organ except the left lobe  being trans-
 formed into a mere sac.   The  abscess may be situated  at  any part  of the
 gland.  It is oftener seated in  the right than  in  the  left lobe, and oftenest
 at  the  posterior and  superior portion of the  right lobe.
   AVe may assume that abscesses in the liver, as well as abscesses elsewhere,
 are caused by the invasion of micro-organisms, such as have been considered
 as the cause of  suppuration in  Part I. p. 81.   In most cases, and probably
 by proper methods in all, it is possible to demonstrate the presence of bac-
 teria in hepatic abscess.   In the majority of cases,  at  least in temperate
 climates,  the bacteria enter the liver by the  blood-current, either through
 the  portal vein or the hepatic  artery.   They  lodge  within the capillaries
 of the  liver, where  they usually form zooglaa  filling up a certain number
 of capillaries.   The hepatic cells adjacent to these capillaries become cloudy,
 lose their nuclei, and disintegrate.  In this way necrotic foci  are produced
 which appear to the naked eye as grayish  or yellowish-gray spots embracing
 one  or  more  hepatic lobules.  Around these  areas  of necrosis there is an
 emigration of white blood-corpuscles,  which appear first  in the interlobular
 connective tissue, rarely in the centre of the lobules.   This  accumulation
 of pus-cells  is accompanied by  the breaking  down  and liquefaction  of the
 necrotic tissue.   The  result is the formation  of  an  abscess-cavity.   Small
 abscess-cavities  so produced may coalesce and  make larger  cavities.   As  a
 rule, the longer  the  duration of the disease the  smaller the number and  the
 larger the size of the abscesses.
   The purulent matter  from an hepatic abscess often does  not  differ from
 ordinary pus, but it may  contain liver-cells and shreds of necrotic tissue.  It
 is not infrequently reddish or brownish in  color from extravasated blood, or
 it may  be stained with bile when the abscess communicates with one of  the
 bile-ducts.  Sometimes the abscess contains few or no recognizable pus-cells,
 but  instead debris composed of fatty and albuminous granules, pigment-par-
 ticles, bacteria, and perhaps shreds of dead tissue.   The walls of  the abscess
 at first  consist of  exposed hepatic tissue more or less discolored, ragged, and
 infiltrated with  pus-cells;  but after a time a  wall  of connective tissue is
 formed  which increases in thickness  and firmness  with age.  Sometimes the
 abscess-wall  becomes gangrenous, especially when  air  enters the  abscess or
 when the abscess is secondary to gangrene in some part of the body.  An
 instance of this is reported in the  author's Clinical Medicine.
  If the contents of an abscess be discharged, its walls may cease to secrete
 pus  and cicatrization may ensue.   The pus in small abscesses may become
 thick and dry and remain  innocuous, or  an abscess may  become  enveloped
 with  extremely  firm fibrous tissue and cease to grow  ; but as a rule, if life
 continue, the  pus makes its way, as in other abscesses, in the direction in
 which the pressure is least, and is at length discharged  in some cavity, canal,
 or outlet.
  AA'hen the abscess reaches the  surface of the liver a  circumscribed inflam-
mation of its serous covering takes place.   This, as a rule, leads to adhesion
between the surface of the liver and  the  diaphragm, the  abdominal wall, or
some neighboring viscus.
  In the larger proportion of cases the evacuation  is through the thoracic or
the abdominal parietes.   AVhen  it takes this  direction a  fluctuating  tumor
after a time makes its appearance, caused by  the accumulation of the pus
beneath the  integument.   The  tumor, if left  to  itself, increases, becomes
pointed, the skin becomes reddened, and finally the discharge is effected  by
ulceration.   The most frequent situation of  the tumor  is below the ensiform 
SUPPURATIVE HEPATITIS.
595
cartilage, but it may appear at any point  over the site of the liver.  Some-
times the pus  burrows beneath the integument, and the tumor is situated at
a greater or less distance from the liver.  It has been observed as high as the
axilla, and below on the inner side of the  thigh.  In the latter case it is liable
to be mistaken  for bumbar abscess.  Of course partial peritonitis and adhesion
over  the circumscribed space  occupied by the abscess are essential in order
that the pus may be discharged externally.  This conservative provision does
not always precede the opening of the abscess, and then the contents are dis-
charged into the peritoneal cavity ;  peritonitis is at once developed, and under
these circumstances death speedily follows.  The direction next in frequency
which the pus  takes is through the diaphragm into the  chest.  Partial  peri-
tonitis precedes the perforation of the diaphragm, and partial pleuritis ensues,
frequently limited to a small space, preventing  evacuation  into the pleural
cavity.    Occasionally,  however, the latter  conservative  provision  does not
take  place, and the pus, discharged into the pleural cavity, at once causes
general  pleuritis.   If this be  prevented by adhesion around the  opening
through the diaphragm, the lung becomes perforated, and the evacuation is
into the bronchial  tubes, the pus being  discharged by expectoration.  The
abscess is sometimes evacuated  into the pleural cavity, and afterward per-
foration of the lung takes place and the pus is expectorated.  Other less fre-
quent directions in which  the pus is discharged are the following:  Into the
stomach or intestine, the pus being then discharged by vomiting or stool;
into the pericardium,  causing pyo-pericarditis, or if the  quantity of pus be
large speedy death; into  the pelvis of the right  kidney, the pus being dis-
charged with the urine; into an hepatic vein or the vena cava, giving rise to
purulent infection  of  the  blood; into  the gall-bladder or biliary ducts, and
thus, if there be no obstruction, the pus finds its  way into the duodenum.'* In*
a case which came  under my observation an abscess pointed externally and
was opened; subsequently perforation of the stomach  took place  and liq-
uids ingested escaped  through the external  opening^ the patient dying  from
inanition.

   Clinical  History.—The  clinical history of hepatic  abscess is  obscure.
The symptoms rarely point  distinctly  to this affection.  Pain  exists if the
hepatitis be  near the  surface  of the liver and  whenever partial peritonitis
ensues;  but  even then pain  is not  always a prominent symptom, and if the
inflammation be deep-seated  there may be no pain.   Pain is felt in the right
shoulder in a small number of cases.   Rigidity of the abdominal walls over
the liver or of the right rectus muscle is a sign to which much importance is
attached by several observers.   Febrile movement is rarely marked,  and may
be wanting.  Chills usually  occur during the  suppurative  process.  These
sometimes occur regularly, simulating  intermittent fever, but generally  they
are irregular.   Jaundice is rare.  The appetite and digestion may be more or
less disturbed or they may be unaffected.   The nutrition may he but little or
not at all affected.  Reference is now had to  symptoms prior to the discharge
of the pus or its appearance  beneath the integument.  The affection is not
infrequently completely latent.  It is  not uncommon in tropical climates to
find an abscess  in the liver in bodies dead with various diseases when hepatic
disease  had  not been suspected  during life; and the first intimation of the
existence of this affection  during life in  certain  cases may be the discharge
of pus from  the stomach,  bowels, or air-passages.
  The clinical  history  after the discharge takes place will of course depend
upon  the direction  in which  the abscess  is evacuated.  In certain  cases the
phenomena of the affections caused by the presence of pus are superadded—
namely, of peritonitis, pleuritis, pyamia, etc.  If the evacuation take  place 
596
DISEASES OF THE  LIVER.
 either externally or into the alimentary canal or through the bronchial tubes,
 symptoms are produced analogous to those connected with purulent discharges
 in other situations—namely, anamia, debility, emaciation, and, in cases which
 pursue an unfavorable course, hectic fever, colliquative diarrhaa, and exhaus-
 tion, death taking place by asthenia.

   Causation.—Abscess of the liver  may be produced by wounds of this
 organ.   It sometimes, though rarely, follows injury over  the  region of  the
 liver without wound of the latter or even of the integuments.   Suppurative
 inflammation may invade the liver  by extension  of  suppuration  from adjoin-
 ing  parts.   An abscess may be caused by perforation of a  gastric ulcer.
   Usually,  however,  the  special  agent  which causes  suppuration,  and
 which probably consists of bacteria, is brought to the liver by the blood-cur-
 rent in the form of  septic emboli, or it enters the organ from the  intestine
 through the bile-ducts.   In one group  of cases the septic material is derived
 from some affection  involving the rootlets of the  portal vein in the  stomach,
 the  intestine, or the  spleen.  Ulcerative and necrotic processes in these parts,
 particularly  dysenteric ulcers, are likely to give rise to secondary abscesses of
 the  liver.   As will  be described in a  subsequent article,  suppurative pyle-
 phlebitis is usually accompanied with multiple abscesses of the liver. In another
 group of cases  the  primary focus of infection is in parts of the body other
 than those from which the portal vein derives its blood. Injuries and  suppura-
 tions of the head, of the extremities, and of other parts may cause the entrance
 of the bacteria of suppuration into  the blood, and these wherever they lodge
 and  develop give  rise to pyamic abscesses.  It  is an  interesting  fact that
 although these bacteria must pass the  pulmonary circulation before  they are
 carried to the liver,  nevertheless they not infrequently leave the lungs intact,
 although giving rise to hepatic abscesses.   An  explanation of the relatively
 frequent involvement of the liver  by  pyamic  abscesses  is probably to  be
 found in the slowness  of  the circulation  in this  organ in consequence of the
 diminished vis a tergo, so that bacteria more readily lodge in the hepatic than
 in the pulmonary capillaries.
   Abscesses starting from the  bile-ducts are rare, except in  connection with
 the  formation  of biliary  calculi within the hepatic  ducts.
   The  causation of the large,  single  abscesses  not   uncommon  in  tropical
 countries is  not understood.   Such abscesses without evident causation are
 not  uncommon in those countries.  Cases  apparently identical with tropical
 hepatic abscess sometimes occur in New York in those who  have never visited
 a tropical country.   There has been much discussion as to the relation between
 these abscesses and  dysentery.  In  some cases tropical abscess appears to  be
 secondary to dysentery; in other  cases the dysentery follows the abscess, or
 both may  develop simultaneously,  as  if dependent  upon  a  common cause.
 Again, tropical hepatic abscess may  develop without the appearance of dysen-
 tery  at any time during the history of the case.   A plausible supposition is
 that  the bacteria of  suppuration in these cases enter  the liver from the intes-
 tine  through the bile-ducts.
  Abscess of the liver is called primary or  idiopathic when not referable  to
 some antecedent affection.  The so-called  tropical abscesses of the  liver, at
 least many of them,  in the present state of  our knowledge are to be classified
 as primary.  Hepatic abscesses resulting  from pyamia, pylephlebitis, and
 affections involving the rootlets of the portal vein are called secondary, pya-
 mic,  or metastatic abscesses.  Pyamic abscesses are generally small and mul-
tiple ; primary  abscesses are usually of large size, and are either single or few
in number.   It is probable that the  large abscesses are due  to coalescence  oi
 small abscesses. 
SUPPURATIVE HEPATITIS.
597
  Pyamic  abscesses of the liver are  not uncommon in infants as a result of
inflammation of the umbilical vein.
  Primary  abscess of the liver is more common in males than in females, and
is rare in children.

  Diagnosis.—AVhen abscess of the  liver is considered clinically as an indi-
vidual affection, reference is had not to the small, multiple pyamic abscesses,
which are not susceptible of diagnosis, but to cases in which the patient's life
is sufficiently prolonged for the abscess to attain a certain  size.
  The diagnosis by means of symptoms cannot be made with any degree of pos-'
itiveness prior to the discovery of the abscess by manual exploration or the dis-
charge of pus into the alimentary canal or the bronchial tubes.  The symptoms
which have been named as belonging  to its clinical history should suggest its
existence as possible or perhaps  probable, especially  in a warm climate, but
they are not sufficiently distinctive to render the diagnosis positive.  Not in-
frequently  grounds of even a suspicion of its existence are wanting.  AA'hen a
fluctuating  enlargement or tumor is perceived over the site  or  in the  neigh-
borhood of  the liver, it is  to be discriminated from  a subcutaneous,  phleg-
monous inflammation, carcinoma of the  liver, a hyatid formation, and  a dis-
tended gall-bladder.   The first of these is distinguished by pain, hardness, and
redness of  the integument, preceding the  sense  of fluctuation.  Carcinoma
offers a resemblance  only when  the medullary variety exists.  The duration
of the tumor and the nodulated condition of the liver  as felt through the
abdominal  walls will serve for the recognition of this affection.  A hydatid
cyst is of slower development, and is  not attended with the pain, tenderness,
chills, and  febrile movement which usually accompany an abscess.  A hydatid
cyst, however, may be the seat of suppuration, becoming converted into an
abscess, and then the discrimination is impossible.   A distended gall-bladder,
which is the tumor most likely to be confounded with an abscess, is to be dis-
tinguished  by its situation, the pear-shaped form, and by the fact that in con-
sequence of peritoneal adhesions rarely taking place it has a mobility which
an hepatic  abscess has not.  The antecedent history is of course always to be
taken into  account.  Enlargement of  the liver frequently, but not invariably,
exists in cases of hepatic abscess, and the  enlargement may be found to be
limited to a particular direction, not  affecting the whole  organ—a point of
some importance in  the diagnosis.   Exploration  by means of a fine hollow
needle attached to a hypodermic syringe is admissible whenever there  is rea-
son to suspect the existence of abscess, and by this method the differentiation
of abscess from the other affections just named can be made demonstratively.
There is no risk of injury in resorting to this procedure, and it should there-
fore not be  omitted.
  If the abscess discharge  through the  bronchial tubes the diagnosis is gen-
erally made without difficulty.  The  sudden  expectoration of  pus in  large
quantity without evidence of  antecedent and coexisting empyema or pulmo-
nary abscess, and the  expectoration coming  from  the bronchial tubes of the
right lung,  render the diagnosis altogether probable.   The presence of bile or
disintegrated hepatic tissue affords demonstrative  proof of the source of the
purulent expectoration, but these are rarely present.  A reddish or  brown
color of the expectorated pus is of diagnostic import.   If the abscess discharge
into the pleural cavity, the diagnosis is established by symptoms of hepatitis
and suppuration having preceded the sudden development  of  pyothorax.
  The discharge of the abscess into the stomach  or  intestine  is followed  by
the vomiting of  pus  or its appearance in the stools.  The diagnosis is to be
based on these events, together with  antecedent symptoms  pointing to the
existence of suppurative hepatitis.  The discharge into the peritoneal cavity, 
598
DISEASES  OF  THE LIVER.
pericardium, and vena cava gives rise to no phenomena  distinctive of hepatic
abscess.  Its existence  may have been foreshadowed by the symptoms pre-
ceding the discharge, but the  proof can  only be afforded  by an autopsical
examination.  The discharge into the pelvis of the  kidney gives rise to
pyuria,  but it  may be  difficult or impossible to determine that  the pus
comes from the liver and not  from the kidney  or  some other source.

  Prognosis.—The prognosis, even in the cases in which the abscess is evac-
uated in the most favorable  directions, is  unfavorable.   AVhen it discharges
into  the peritoneum, pericardium, or vena cava death  speedily follows.  If
it discharge into the pleural cavity the  termination is usually  fatal.   The
cases which offer a fair prospect of recovery are those in which the discharge
takes place through the integument, the bronchial tubes, or into the aliment-
ary canal.
  The prospect of recovery is of course less when two or three abscesses exist
than when  there is a single abscess.
  Statistics show the duration in fatal cases to be longest when the discharge
takes place through the bronchial tubes.   The average duration in fatal cases
is between  three and four months. In cases which recover statistics show the
longest  duration to be when the discharge is  through the integument.   The
average duration in cases which recover is between four and five months.

  Treatment.—From what has been said respecting the clinical history and
diagnosis, it follows that there is seldom an opportunity  to employ therapeutic
measures with a view to prevent suppuration.   Even  if the existence of cir-
cumscribed hepatitis were early ascertained, it is  doubtful  if the formation
of an abscess could be prevented.   Cases  only in which the abscess is appre-
ciable by palpation or  an exploratory puncture, and  those in which the con-
tents are discharged into the bronchial tubes and alimentary canal, admit of
treatment with  a positive knowledge of the  existence of the affection.  In a
case in which the  abscess is ascertained to  be making  its way through the
abdominal  or thoracic  parietes  an early  opening should be  made  and the
pus evacuated.   If a free opening be made  before the pus has made its way
beneath the integument exterior to the abdominal or thoracic walls, there is
danger of the pus escaping  into the peritoneal cavity in consequence of the
absence of peritoneal adhesions over the abscess.  Under these circumstances,
in order to  avoid this danger, an incision may  be made  through the skin and
muscles down to the peritoneum without opening the abscess,  and the wound
filled with  lint.  This procedure induces  firm adhesions around the wound,
and in three days the abscess may be opened with safety if a spontaneous
opening do not  in the mean  time occur.   If, however, the walls  of the abdo-
men or chest have been  perforated by ulceration, a free opening may  be made
at once  without hesitation.   Prof. Janeway directs attention to the following
methods of determining whether or not adhesions have taken place  between
the  liver and abdominal wall: Hepatic friction  murmur shows the absence
of adhesions, but renders probable their speedy formation.   Adhesions exist
if the liver do not descend with inspiration.   If a long  needle be introduced
into  the liver, the part  projecting will  move  upward as the  liver descends,
and downward as the liver  ascends, if no adhesions  exist.  He  advises the
application  of a bandage to promote  adhesions by preventing movements of
the  liver.1
  It is advisable to resort to aspiration as soon as the existence of an abscess
is demonstrated by an exploratory puncture.  The withdrawal of the pus by
means  of a hollow needle or trocar of  small size,  attached to Davidson's
      1 A'ide paper in Transactions of the New  York State Med.  Association, vol. i. 
CHRONIC  INTERSTITIAL HEPATITIS.
599
syringe or some  one of the different  instruments  for aspiration  now in use,
need not  be delayed on account of any doubt respecting peritoneal adhesions.
If these have not taken place, there is no risk of the escape of pus into the
peritoneal cavity.   By promptly aspirating, the  danger of rupture of the
abscess from  delay is avoided, and also whatever harm may result from the
entrance  of air.  The pus should be removed as soon as it is discovered.  The
aspiration should be repeated if there be a reaccumulation of pus.  By pur-
suing this plan a free  opening  may perhaps not be required.   If, however,
there be reaccumulations of pus, an opening should be made and the abscess
treated here as in other situations.  The details of  the  treatment belong to
surgery.   Aside from the local  treatment, tonic and  supporting measures are
indicated.  Good diet and out-of-door life, in so far  as the patient's  strength
will permit, are far more important than medication.
   AA'hen  the abscess evacuates through the bronchial tubes or the alimentary
canal,  palliative remedies are called  for to relieve  undue irritation of the
bowels and air-passages.  In addition  to these, measures hygienic and medi-
cinal, which tend to support, strengthen, and invigorate  the system, are indi-
cated, as  when the discharge is through the integument.


   Chronic  Interstitial Hepatitis—Cirrhosis  of the  Liver.
   An attempt has been made to distinguish various forms of cirrhosis of the
liver, but concerning  some  of  these  forms there  is much controversy.  It
seems proper to  recognize at least three forms of hepatic cirrhosis—namely,
the cirrhosis of  Laennec, biliary or hypertrophic cirrhosis,  and  syphilitic cir-
rhosis ; and these will  receive separate consideration.  The present article is
devoted to a description of  the  cirrhosis  of  Laennec, which is the form  long-
est recognized and the one  generally understood when the term  cirrhosis of
the liver  is used.

   Anatomical  Characters.—The  name  cirrhosis, signifying  a tawny or
orange color, was applied  by Laennec to  the affection  under consideration
on account of the  yellowish color of the  nodules which  the  liver  usually
presents in this  disease.  These nodules, now known to  be parts of the pre-
existing  liver-substance, were  supposed  by  Laennec  to  be  new  growths
replacing the original  parenchyma.   As the essential change, however, was
found to  consist in the development of fibrous tissue, the term cirrhosis  came
to be applied  not only to  the liver, but also to  the  fibroid induration  of
other organs, especially of  the  lungs  and kidneys, although this application
is etymologically incorrect.   The term sclerosis,  signifying induration, is
more appropriate.   The  customary division of the  pathological  changes of
cirrhosis  of the  liver into two stages, in one of which  the liver is enlarged
and smooth or slightly granular, and in the other small,  firm, and nodular, is
wholly schematic and is not based upon pathological  observation.  A cirrhotic
liver is usually small,  but it may be of normal size or enlarged, even in  cases
of long duration, and there is no proof that the large cirrhotic livers are to
be regarded as early stages of the contracted form.  The left lobe  is often dis-
proportionately reduced in size, so as to appear as a  mere membranous append-
age of the right. The surface is nodular; but in exceptional  cases it may
be smooth.  The nodules vary  in  size from a pin's  head to a pea, and may
be larger.  Some livers are coarsely nodular, others finely granular, although
the size of the nodules or granules varies much in the same liver.  The nodules
are usually of a  yellowish or greenish color, and consist of one or more hepatic
lobules in which the liver-cells are  bile-stained and  usually contain oil-glob-
ules.   The nodules are separated from each  other by grayish-white bands of 
600
DISEASES  OF THE LIVER.
newly-formed connective tissue.  This nodulated aspect has given rise to the
term hob-nailed as  applied to some  examples  of cirrhosed liver.  The  con-
sistence of the liver is firm, sometimes almost cartilaginous.  The cut surface
is dry and  anamic.
  The microscopic examination  shows that the most important change is an
increase of the connective  tissue which accompanies, under  the name of the
capsule of  Glisson, the medium-sized and  small branches  of the portal vein.
This increase of the interlobular tissue is not  uniform, but is in the form of
bands  or masses which surround usually a  number  of lobules.  The  new
growth of  connective tissue  is not always confined to that surrounding the
ramifications of  the portal vein; but it often invades the lobules, and  also
appears around  the central vein, so that  the  lobules  may be  split  up into
larger  or  smaller portions  by bands of fibrous tissue.   The new tissue is
usually rich in lymphoid and spindle  cells, and with  age it generally has a
tendency to become fibrous.   It invades the walls  of  the  interlobular veins,
so that they lose their elasticity and many  of  them become obliterated.   The
most important  symptoms are referable to this destruction of a number of
branches of the portal  vein.  The new  tissue,  however, is not poor in  vessels,
many  of which are probably newly formed  and  derived from  the  hepatic
artery.  The branches of the  hepatic artery and the bile-ducts suffer much
less  from  the  compression of the new tissue  than the  thin-walled portal
vessels.
  This development of connective tissue is  attended  by atrophy of  hepatic
lobules and destruction of a large number of liver-cells.  The atrophy of  the
hepatic parenchyma has usually been  attributed to the compression of  the
liver-cells by the fibrous tissue, but an equally important factor is the lack
of nutrition consequent upon the obliteration of the interlobular veins.   The
remaining hepatic cells usually contain oil-globules and are stained  with bile-
pigment.
  There is  much plausibility in the view first  advanced by AVeigert, and now
adopted by several authors, that the primary change in cirrhosis is  degenera-
tion and necrosis of a certain number of liver-cells.  This view is based upon
investigations which show that in similar chronic interstitial inflammations in
the kidney  and elsewhere the primary change is degeneration of the epithelium
or parenchymatous cells, and the new growth of connective  tissue  is  second-
ary to this.
  In many cases of cirrhosis of the liver a number of branching, narrow chan-
nels, containing  a single or double row of cubical epithelial cells and resem-
bling the interlobular bile-ducts, are met with in the connective tissue. They
are too many to consist of  only pre-existing interlobular ducts, and there has
been much discussion as to their origin.  Three theories have been advanced:
one,  that they are offshoots by new growths from the old bile-ducts ; a second,
that they are intralobular bile-capillaries which have  acquired an  epithelial
lining; and a third, which  is perhaps the most probable, that they are rows
of liver-cells altered in shape and arrangement by the growth of connective
tissue  into the  lobule.
  The capsule of the liver is thickened, and often presents little villous  pro-
jections  of vascularized connective tissue, which develop into the  fibrous
adhesions so frequently connecting the  liver with the diaphragm and  abdom-
inal wall.
  Cirrhosis may be  combined  with extensive  fatty  infiltration  and with
amyloid degeneration  of the  liver.  Especially in the latter case the liver
may be of very large  size.
  The changes in other organs are chiefly referable to the portal obstruction
and consequent  damming back of blood upon the rootlets  of the portal vein. 
CHRONIC INTERSTITIAL HEPATITIS.
601
The effects of this obstruction are only imperfectly relieved by the establish-
ment  of collateral channels.  The spleen  in  the  great majority of cases is
enlarged and  firm.   This enlargement is due to  congestion, and  sometimes
also to hyperplasia of its  stroma—a condition which may be referable to  the
same  cause as the cirrhosis.  The size of the  organ is  not usually more than
twice  or thrice the normal.  The increase cannot always be made  out during
life.  The mucous membrane of the stomach  and intestine  is usually thick-
ened,  pigmented, and coated with more or less muco-pus; in other words, in
the condition of chronic inflammation.  Ascites and, in the  later stages, gen-
eral adema are present.   Hemorrhages into the stomach and  intestine, and
in other parts of  the body, as in the retina, may be found  after death.
   The small  kidney  and other forms of chronic  diffuse nephritis occasionally
complicating cirrhosis  of  the  liver are  probably  effects of the same  cause.
   Cirrhosis  is to be regarded as a chronic inflammatory affection  involving
the interstitial tissue of the liver.

   Clinical History.—Cirrhosis, as a rule, gives  rise  to few or no symptoms
which point  to the  liver  as the seat of disease prior to the occurrence of
hydro-peritoneum.  Preceding this event  and afterward, pain  in  the region
of the liver exists in only a small proportion of cases.  Dropsical effusion is
usually the  first  symptom to  suggest the existence  of the affection.  The
dropsy may  occur when the patient  supposes  himself  to be in  his habitual
state of health, or it may be preceded and accompanied by indefinite ailments.
The dropsical accumulation increases, usually with  considerable or great
rapidity. It is rare for the quantity of liquid to remain at a  moderate amount
for a considerable period.   (Edema of the lower limbs in a  moderate degree
is observed in a considerable number of cases before the patient's attention has
been directed to enlargement of  the  abdomen.   It is, however, probable that
an amount of dropsical effusion not sufficient to attract attention always pre-
cedes  the adema  of the lower  limbs.  After considerable abdominal enlarge-
ment  has taken  place the adema increases.   The  limbs  often are largely
swollen, and the genitalia  may become more or less adematous.  The adema
in these situations is attributable to  pressure of the peritoneal  effusion upon
the iliac veins.  (Edema of the  face and upper extremities does  not occur
except in cases in which cardiac or renal disease  coexists.   Oedema of the
lower limbs does not occur in all cases.
  Jaundice is present in a small proportion of cases, and is rarely great. The
lesion does not necessarily occasion obstruction of  the biliary ducts, although
it must diminish the  secretion of bile.  Pallor  of the prolabia and skin  exists
in the majority of cases.   In general, the anamic aspect is marked in propor-
tion as other symptoms show the condition of the patient to be unfavorable.
Febrile movement does not accompany the  disease in its progress.  The pulse
may be not increased in frequency, or it may be more or less accelerated.   It
is generally soft and feeble.  AVhen the pulse is frequent, the other  characters
denote diminution of the  vital forces, or asthenia.
  The obstruction of the  portal  circulation is compensated,  in a measure,  by
new channels of  communication  between the  portal and the systemic  veins.
The most important of these are anastomosing branches which pass to  the
liver between the  folds of the falciform ligament and in  the ligamentum teres,
communicating with the veins of the abdominal parietes through the epigas-
tric and the  internal mammary veins.  The course of the blood in the anas-
tomosing branches in cases of cirrhosis is the reverse of that in health, being
in the latter in a direction  toward, and in the former from the liver.   Owing
to this, the abdominal veins become dilated, and those superficially situated in
some cases are seen to be more or less enlarged.  A collateral  circulation, in 
602
DISEASES  OF THE LIVER.
a measure, is also established  through communications between the inferior
mesenteric and the hypogastric veins  in  the  hemorrhoidal plexus;  by anas-
tomosing branches between the vena porta and the veins of the serous cover-
in"- of the liver;  between the coronaria ventriculi and the oesophageal veins;
and  by newly-formed vessels  in the tissue by which the liver  adheres to the
diaphragm.  The size of the  superficial  abdominal veins on  either side of
the median line is  sometimes enormous.   The  dilated network of  radiating
veins around  the umbilicus  gives rise to the appearance called the caput
Medusa.   The conservative  effect  of compensatory development  of veins
communicating with the two circulations is shown by the fact  that examples
of great  enlargement of the vessels  upon the  abdomen may be  observed
in patients who  are  free from dropsy,  notwithstanding  a  notable  amount
of cirrhosis.
   Hemorrhage from  the stomach and bowels is an occasional event.  Gas-
trorrhagia  occurred in  6 of about 40 cases which I have analyzed, the his-
tories not being complete in all the cases.   It  preceded the hydro-peritoneum
in 3  cases.  Hamatemesis may proceed from varices at the lower end of the
asophagus.   Enterorrhagia  coexisted  with  gastrorrhagia in  2  cases,  and
occurred without it in  2 cases.  Aromiting is occasionally a prominent symp-
tom, and  diarrhaa  is prominent in  a small proportion  of cases.
   At an advanced period of the disease hemorrhage is liable to occur  from the
nostrils, sometimes from the gums, and also into the retina.  In these situations
the hemorrhage is attributable, not to the portal congestion, but to an altered
state of the  blood.   The appetite is  usually impaired.   A sense of fulness
after taking food is generally complained of  if  the  dropsy be sufficient to
distend the abdomen.   Progressive  emaciation  attends the  progress  of the
disease, and in an advanced stage the attenuation of the upper  portion of the
body, the  distended abdomen,  and  the lower limbs enlarged by  adenia render
the general aspect highly characteristic.
   Albuminuria is rare in cases of  cirrhosis.  Of 28 cases in which the condi-
tion  of the urine in this respect was noted, in only 1 case was albumen present.
The  urine is generally scanty, but in some  cases it is abundant.  The color-
ing  matter of the urine  is abnormally abundant—a fact attributable  to the
deficient secretion of  bile; and the blood-pigment which serves for  the  pro-
duction of the bilirubin, not being expended in the liver, is eliminated in the
kidneys.  The abundance of the coloring matter may be  such as to give to
the urine  the appearance of being bloody.  The urates are usually deposited
in great quantity, and are notably  red from the abundance of pigment.
   In the great majority of cases there are no important symptoms pertaining
to the nervous system.   The mode of dying is usually by slow  asthenia.  If,
however, the abdomen be greatly distended  or if the dropsical  accumulation
take place  very rapidly, death  may be due in  part to  the extent to which the
respiratory function is compromised.   The mental faculties are  generally pre-
served up  to the last moments  of life.   To this rule, however, there are excep-
tions.  In 3 cases I  have noted the occurrence of delirium several days before
death; in 1 case the delirium  was  hilarious ;  in 1 case the patient appeared
bewildered; and in  1  case the patient lapsed  from childlishness into imbecil-
ity.  These cases ended in coma. In 3 other cases the patients died comatose.
In 1 case convulsions occurred, followed by coma.1  The symptoms of icterus
gravis may appear in the last stage.

   Causation.—Cirrhosis in the vast majority of cases is due to spirit-drink-
  1 This account of the symptomatology is  based on an analysis of 46  cases  of hydro-
peritoneum, cirrhosis existing in nearly all the cases.  (Vide Clinical Report, already
referred to.) 
CHRONIC INTERSTITIAL HEPATITIS.
603
ing.   Hence the significance of the term gin or whiskey liver applied by British
writers to this aff'ection.   In most cases an inquiry into the mode of drinking
will show that the habit has been to take raw spirits at different  periods of
the day,  before breakfast and  at  other times, on an empty stomach, a little
water being generally  drunk  after the spirits.   In this mode the  greatest
amount of effect from a given  quantity of alcohol is obtained.  Occasionally
patients  declare that they have been accustomed to drink only wine or beer.
If the use of alcohol in any form be denied,  it may perhaps be  said, in con-
nection  with the disease, that etiological laws  are more  trustworthy than
human testimony.   In  a considerable number  of cases the  statements  of
patients  in  regard to the quantity  of spirits taken are not reliable.
  The disease is sometimes  attributed to  other causes than alcohol—namely,
to malarial poisoning, syphilis,  chronic peritonitis, chronic phosphorus-poison-
ing, and  occlusion of the  common bile-duct.   The efficiency of these causes
is open to doubt.  At all  events, if the diagnosis of cirrhosis of the liver be
made, the inference of spirit-drinking is always warrantable.  As to the action
of alcohol in producing this aft'ection, the explanation is that, passing readily
into  the  portal blood from  the stomach and  carried at once to  the liver, it
excites by contact inflammation of low grade in  the  interlobular  spaces, and
hence the production of adventitious tissue ;  or,  according to AA eigert's  view,
it causes primarily death  of a certain number of hepatic cells.  So far as my
observations go, they furnish  no evidence of the agency  of  disease of the
heart in the causation of  this aff'ection.
   Cirrhosis very  rarely occurs  at less than thirty years of age,  and in the
majority of cases the age  exceeds fifty years.   Still, cases of typical cirrhosis
have been observed in young children.  The affection is generally a result of
the habitual abuse of alcohol continued for a  long period.  Males are affected
much oftener than females—a fact readily explained by the dependence of the
affection on the use of spirits in the manner stated.

   Diagnosis.—The  diagnosis  in most cases of cirrhosis after dropsy has
occurred is  made without difficulty.   Hydro-peritoneum, occurring as a local
dropsy—that is, irrespective of general dropsy—in a person addicted to spirit-
drinking warrants an inference that  this aff'ection exists.  Additional proof is
afforded  by the diminished  size of the  liver.   This is ascertained by percus-
sion.  The upper margin  of the liver is accurately determined by finding the
line of hepatic flatness ; and the lower border  is determined not so accurately,
but approximately, by the  line of demarcation between  hepatic flatness and
the tympanitic resonance due  to gas in the transverse colon.   The  latter is
not exact, because tympanitic  resonance  is conducted for a certain  distance
above the lower margin of the liver, and, moreover, a  distended colon may
rise above the lower margin of the liver.   The vertical diameter of the liver
in health, on the linea mammillaris,  is about four inches.  Directly after the
operation of tapping, while the abdominal walls are relaxed, the  lower bor-
der of the  liver may frequently be grasped  by  the fingers pressed upward
beneath  the false ribs, and its  indurated,  nodulated condition appreciated by
palpation.   It is to be remembered  that  a normal  or even  increased  size of
the liver  would not  exclude the  diagnosis of cirrhosis.
  The physician is rarely called upon to make  the diagnosis prior to the occur-
rence of  dropsy.  It may  be practicable in some cases to determine, by palpa-
tion, induration  and  a nodulated  condition of the  lower part of  the  organ
before dropsy has taken place ;  and, this information obtained, the diagnosis
is highly probable if the patient be addicted to spirit-drinking.  Hemorrhage
from the  stomach  sometimes precedes the occurrence of dropsy, and  in a spirit-
drinker this renders the existence of cirrhosis probable.  Hydro-peritoneum, it 
604                  DISEASES  OF  THE  LIVER.
is to he borne in mind, occurs in other pathological connections, as well as in
cirrhosis of the liver. (Aride p. 587.)  AVhen it occurs as a result of occlusion
of the portal vein by thrombosis, the peritoneal  dropsy occurs rapidly, the
spleen may become greatly enlarged, and the liver  is undiminished in size.
A number of cases of gastrorrhagia from cirrhosis without dropsy have come
under my observation.   I have known most  profuse  hemorrhage, proceeding
from cirrhosis without dropsy, to be followed by the recovery of a fair condi-
tion of health.   On the other hand, I have known it to cause sudden death.

  Prognosis.—Cirrhosis is to be regarded as an' incurable  lesion.   After it
has led to dropsy, in  the majority of cases  its course is  progressively toward
a fatal  termination.   The  duration  in sixteen  fatal  cases,  dating  from the
occurrence of dropsy, varied between  six weeks and  seventeen months, the
average  duration being about  five months; but doubtless  in all cases the
disease has existed for a considerable period before dropsy occurs.   In a cer-
tain  proportion  of cases, the dropsy being removed, the patient may regain
comfortable or even good health, and remain  free from any manifestations of
the disease for months and  years ; but sooner or later, as a rule to which there
are very few exceptions, the dropsy returns,  and unless  life be destroyed by
some  intercurrent  affection the disease ends fatally.  Circumstances  which
preclude much expectation of  improvement are—the coexistence of cardiac,
renal, or any other important  disease, considerable emaciation,  sufficient
debility to keep  the patient in bed, greatly impaired  appetite  and  digestion,
speedy reaccumulation of liquid after tapping, and the occurrence of jaundice.

  Treatment.—As  regards treatment in cases of cirrhosis and in the  great
majority of  the cases  of hydro-peritoneum, the  indications  are the  same.
The reader is therefore referred to the Treatment of  Hydro-peritoneum, con-
sidered  in the preceding chapter.


              Hypertrophic Cirrhosis of the Liver.

  It  has already  been  mentioned that exceptionally in ordinary  alcoholic
cirrhosis the liver may be  large throughout the whole course  of the disease,
presenting the  same microscopical appearances and  giving rise to  the same
symptoms as the more usual contracted liver.  French writers1 were the first
to call attention, under the name hypertrophic cirrhosis with severe icterus, to a
disease  which they consider to possess distinctive pathological and clinical
characteristics.   The  liver, as  a rule, is considerably enlarged, its surface
smooth  or finely granular, and its consistence firm.   Its  free and cut surfaces
present little yellowish islands of liver-parenchyma, between which  are  gray-
ish bands and masses of connective tissue.   The lobular markings are  indis-
tinct or obliterated.  The new connective tissue is more uniformly distributed
than in  ordinary cirrhosis.   It surrounds and penetrates the individual lob-
ules2 rather  than  surrounding  groups of lobules, and is particularly rich in
so-called newly-formed bile-ducts.  It is maintained by Charcot and Gombault
that this form of cirrhosis  begins as an inflammation of  the interlobular bile-
ducts, and extends to the surrounding  connective tissue.3  This opinion, how-
  1 P. Olivier, Hayem, and especially Hanot, Etude sur une Forme de Cirrhose,  hyper-
trophiqve du Foie,  Paris, 1876,  and Charcot et Gombault, Arch, de Physiologie, 1876.
  2 For this reason it is called by Charcot insular or monolobular cirrhosis, in distinc-
tion from annular or multilobular cirrhosis, which is the ordinary form.
  3 Hence this form of cirrhosis has also received the name of biliary cirrhosis.   There
is another form of biliary cirrhosis which is chiefly of pathological interest.  This latter
form is due to obstruction of the main bile-ducts, usually by a gall-stone. The retained
bile causes the death of some liver-cells, and a resulting increase of interstitial  tissue. 
SYPHILITIC HEPA TITIS.
605
ever, is hypothetical.   The spleen is constantly enlarged, usually to a greater
extent than in ordinary cirrhosis.
  As a characteristic feature of this  form of cirrhosis,  marked icterus is
present throughout the greater part of  the disease.  Ascites is  less marked
than in ordinary cirrhosis, and it appears later or may be absent.  Symptoms
referable to the  digestive tract  are  present, as in ordinary cirrhosis.  In the
later stages marked cerebral symptoms—coma, convulsions, and delirium—are
frequent.   Here, too, the only well-established cause is the abuse of alcoholic
liquors.  The duration of the disease is  usually more than  a year, and may be
five or six years.  The chief points in the diagnosis  are the  enlargement of the
liver, the presence of icterus, the enlargement of the spleen, and the absence
of marked ascites.   The even surface  and uniform enlargement of the liver
distinguish hypertrophic cirrhosis from enlargement due to echinococcus, car-
cinoma, and other  new growths.  The  causation is also to be considered in
making a diagnosis.  In some cases of  otherwise typical hypertrophic cirrho-
sis with icterus, ascites has been a marked feature.


                        Syphilitic  Hepatitis.
  There  are several  forms of syphilitic disease of the liver.  Diffuse  syphi-
litic hepatitis  is observed as a frequent manifestation of  congenital syphilis,
but very rarely  if ever in the adult.   In  this condition the  liver is enlarged,
smooth, firm, and anamic.  The lobular markings are obscured.  Upon micro-
scopical examination there are  found  an  increase of the connective tissue,
both  within and without  the lobules,  and a quite uniform  infiltration with
small round cells.
  A second form of  syphilitic hepatic disease is characterized  by the pres-
ence of gummata  in the liver.   These sometimes appear in  new-born chil-
dren  as very abundant, yellowish, miliary nodules scattered throughout the
substance of the liver.   In the adult, gummata generally  appear in the liver
as scattered nodules varying in  size  from a pea to a hen's egg, with a dry,
yellowish,  caseous  centre, surrounded  by a grayish  zone of fibrous  tissue
which encroaches upon the hepatic parenchyma.
  One of the most characteristic forms of syphilitic disease of the liver, the
one often  called the syphilitic liver, is  that in which the liver  is greatly dis-
torted in  size and  shape by coarse bands  of fibrous tissue, which pass from
the  thickened capsule  into the substance of the organ  and cause deep cica-
trix-like depressions.  In this condition the surface of the  liver is coarsely
lobulated,  and  presents  an  absolutely characteristic appearance.   In the
fibrous bands gummata may be present, and it is held by the  majority of
writers that the fibrous tissue is developed only around gummata or as cica-
tricial tissue in their  place.  Not infrequently, however, gummata are absent
in these livers, and ATirchow,  denying that the caseous products  of a gumma
can  ever be wholly absorbed, regards  this disease of the liver as a chronic
interstitial  hepatitis developed in a circumscribed form, either with or  with-
out the presence of gummata.
  Finally,  amyloid degeneration of the liver, either occurring independently
or complicating one  of the previously described  conditions, is one  of the
manifestations of the syphilitic  taint.
  Syphilitic disease of  the liver, as is the case with all forms of visceral
syphilis, appears chiefly in the tertiary stage.   Although  in itself not com-
mon, it is  one of the most frequent forms of visceral syphilis.
  Syphilitic disease of the liver, especially the gummatous form, may give
rise  to no evident symptoms.   The lobulated syphilitic  liver  may  remain
latent, so far as symptoms are concerned, but it usually is accompanied with 
606
DISEASES  OF  THE LIVER.
some  or all of the  symptoms of  ordinary cirrhosis, from  which it is to be
distinguished  by the syphilitic history of the  patient and the characteristic
feel of the  liver.   The coarse nodules which can be  felt on  these livers
resemble very much those present in carcinoma of the liver, and the distinc-
tion between them  is  not always  easy.  The umbilication, which can some-
times be felt on the cancerous nodules, may be of assistance in the diagnosis.
The spleen is usually enlarged in syphilitic liver, and is not enlarged in cancer
of the liver.   The history  of the patient is, however, the capital  point in the
diagnosis, as bearing upon  the presence or absence of cancer or of syphilitic
disease in other  parts of the body.

              Acute Yellow Atrophy of the  Liver.

  This affection is characterized, as  the name  denotes, by a rapid reduction
in the size of  the liver.  Its anatomical characters were  first recognized  by
Rokitansky  in 1842.  The same  disease has been known under the names
malignant or fatal jaundice, hemorrhagic icterus, and diffuse parenchymatous
hepatitis (Frerichs).  It is a comparatively rare  disease.

  Anatomical Characters.—In typical cases the liver is much diminished
in size in all directions, but especially as regards its thickness.   The volume
and likewise the weight may be reduced one-half  or even two-thirds.  Occa-
sionally the  size of the liver is not below the normal. This happens especially
when the disease attacks a liver previously enlarged or when  the  affection is
of unusually short duration.  The consistence is soft and  flabby, so that the
organ when  resting on its concave  surface is flattened, or when supported on
its edge it folds up from its own weight.   The capsule is wrinkled in conse-
quence of diminution in bulk of the liver-substance.  In the living body the
shrunken liver may  sink back  toward the vertebral column, so that coils of
intestine  find  place  over its anterior surface.
  Upon its  cut surface the liver appears  intensely jaundiced.   The  color
may be yellow throughout, but the prevailing yellow color is usually mingled
with some reddish-brown patches.   The reddish color may preponderate over
the yellow.   Great  variety exists in  the relative proportion and the  distribu-
tion of the yellow and the red  substance.  The yellow substance  is soft and
friable.  Its color is due to. bile-staining and the  presence of fat.  The red
substance is of lax  texture, but of tough  consistence, and on section it is
seen  somewhat depressed  below the level of the yellow.   It  appears homo-
geneous, without any trace of the hepatic  lobules, or at  the most presents
the faint outlines of very small  lobules.  In the yellow substance  the out-
lines of the  lobules  are very much obscured.   If seen at all, the lobules are
found to be  larger than in the red substance,  but as a rule they are smaller
than normal.  The  disease is often farther advanced in the left lobe than in
the right.  The former may be almost  uniformly red, while the latter is yel-
low mottled with some  red spots.
  The microscope shows that the  atrophy is due to an actual destruction of
the hepatic cells by the process of fatty degeneration.  Different stages of the
process can  usually be found in the same liver.  At first the hepatic cells are
swollen, cloudy, and bile-stained;  but later their outlines are obscured and
their  substance is occupied by fat in the form  either of  granules or of  large
and small globules.  There is reason to believe  that the fat is formed directly
from  the albuminous material of the cell.  Finally, there is left no trace of
the liver-cells, but  in  their stead we  find a mass of granular detritus and
drops of fat, with crystallized and amorphous bile-pigment.  All  these condi-
tions  may be  observed in different parts of the yellow substance, the degree 
            ACUTE  YELLOW ATROPHY  OF  THE LIVER.         607

of destruction of liver-parenchyma varying much in different cases.  In some
instances the detritus resulting from the disintegration of the cells seems to
be more albuminous  than fatty.
   The red substance is usually regarded as representing a later stage of devel-
opment of the yellow portion.  Its color was  formerly  supposed to be due to
blood-extravasations which may be present in the liver of acute yellow atro-
phy.   Upon  microscopical examination, however, the red  substance is found
generally to be composed chiefly of connective tissue, blood-vessels, and prob-
ably newly-formed bile-ducts.  Some granules and small drops of fat, together
with  bilirubin crystals, may still be found in the connective tissue, but the
greater part of the disintegrated  liver-cells  has  been absorbed.   Cells which
can be recognized as hepatic cells are entirely absent or are present in small
number.  Leucocytes, sometimes in abundance, are found in the connective
tissue.  The  increase in connective tissue is partly apparent, in consequence of
disappearance of the liver-cells and  of their fatty detritus, and partly real, by
means of a new growth of the interlobular tissue.   In  this red substance are
often found narrow, branching channels filled with a single or double  row of
small polyhedral cells.  These epithelial canals resemble the small interlob-
ular bile-ducts;  but they are too many  to consist  only of pre-existing ducts.
They  are considered by  Waldeyer, Zenker, and others as offshoots by new
growth from these bile-ducts, and intended  for the regeneration  of  the
destroyed liver-parenchyma.   Klebs and Perls, however, regard the cells in
these canals  as row's of pre-existing liver-cells altered in shape.  Attempts at
artificial injection of the  blood-vessels of the liver after death fail in conse-
quence of the escape of injecting  material between the  liver-cells.
   The larger bile-ducts are usually empty.   They may be inflamed and con-
tain  a secretion of muco-pus, or they  may contain bile-stained  fluid.  The
gall-bladder  contains a mucous fluid either colorless or  bile-stained.  It may
contain apparently normal bile.   Leucin and tyrosin crystals often form in
the.substance of the liver after  death.   Rod-shaped bacteria and micrococci
have been found by Klebs and others in the bile-ducts and in the atrophied
liver-tissue.   Their accumulation in large numbers  in the bile-ducts has  led
to the belief that they have made their way  there from the  intestine, but
whether before or after  death is a matter of uncertainty.
   The changes in other  organs are similar  to those found in  certain acute
infectious diseases.   The tissues are jaundiced.   The blood is fluid or loosely
coagulated and contains leucin  and tyrosin.   The  cardiac muscle  and  the
renal  epithelium  usually show decided fatty degeneration, not approaching,
however, in degree that of the liver.  The stomach  and  intestine frequently
show evidences  of inflammation.  The  epithelial cells  of  the gastric  tubules
undergo parenchymatous degeneration.  The  spleen is found swollen and soft,
unless its size have been  reduced by hemorrhage from  some of the rootlets of
the portal vein.   Multiple hemorrhages occur in the majority of cases.  These
occur especially from vessels of the portal  system.  Blood is often found
in the contents of the stomach and intestine, also  in the mucous membrane of
the bladder, pelvis of the  kidneys, beneath the serous membranes, in the lungs,
etc.   Hemorrhages very  rarely take place in  the brain.

   Clinical  History.—The affection is either  developed abruptly or is pre-
ceded by a prodromic stage.   The  premonitions are symptoms denoting gas-
 tro-duodenitis and are not significant of the affection.  AVithout  or with pre-
monitions lasting usually from three to five days, but sometimes much longer,
  jaundice occurs.   This is an almost constant symptom, but it may be absent.
 It is  usually marked, but not intense, and does not differ, as regards  the  col-
oration of the skin, from ordinary jaundice.  Intense cephalalgia and delirium, 
608
DISEASES  OF  THE LIVER.
occurring either  simultaneously with  the jaundice or after a period varying
between two and twenty-one days, become  prominent  symptoms.  The delir-
ium is often  active, patients crying out and sometimes requiring restraint;
but  in  some cases the delirium manifests itself only  in  quiet wandering.
In  a third of the cases convulsions occur.   These in  some cases are epi-
leptiform, in some cases  they consist of general tremor  or  rigor, and in
some cases  they are  limited to a  few muscles.   Trismus has occasionally
been observed.   To  the delirium  and convulsions stupor is added, eventu-
ating in profound coma.   The  pupils are  sometimes  contracted, but are
usually dilated, and in some cases  they are  unaffected, responding readily
to light.   AVhen the jaundice first appears the pulse is slow, but  when
delirium occurs the  pulse is more or less frequent.   During  the  progress
of the disease  the pulse  fluctuates remarkably  as  regards frequency.  At
one  time it may  rise to  120,  at  another  time  falling  to  80 or 90.   The
pulse varies  also as  regards other characters.   In  the latter part of the
disease  it becomes persistingly rapid,  increasing progressively in frequency
and  becoming more and  more  attenuated  and feeble.   There is generally
a moderate  rise  of temperature  in the early stage,  but at a later period
fever may be absent, except that  sometimes shortly before death a consid-
erable rise (104°  or 105°) occurs.   Hemorrhages take place in  various situa-
tions, generally into the stomach and intestines, in females from the uterus,
and  occasionally there is hamaturia. Extravasations are not uncommon, giv-
ing rise to petechia and to ecchymoses found after death in various situations.
Pains in the epigastrium are common, extending to the right hypochondrium.
Tenderness on pressure exists in these regions.  The bowels are generally con-
stipated. The stools are sometimes  clay-colored, sometimes green and bilious,
and  sometimes  dark  from blood.   The breathing is likely to be early accom-
panied by sighing, and after coma  occurs  the respirations  are irregular and
stertorous.   The  urine has  been found to contain biliary salts  by a number
of observers.  The small quantity present and the difficulty in the detection
of these salts may explain  some of the negative  results of other observers.
The amount of urea is notably diminished, especially in the  latter part of the
disease, when it may entirely disappear. Leucin  and tyrosin are found in the
great majority of cases. Leucin in the  form of globules somewhat resembling
fat is found  only  after evaporating the  urine.   Tyrosin in the form of needles
appears as a spontaneous sediment.   Albumen is  found in a moderate quan-
tity.  Coolness and dryness  of the surface exist, except under the excitement
of delirium and convulsions, when the heat of the skin is sometimes increased.
Enlargement of the spleen in a greater or less degree exists in most  cases of
this  disease.
  The duration of the affection is usually short.  In  28 cases, a fatal termi-
nation took place in 13 within a week,  in 6 during the second week, in 5 dur-
ing the third week, and in 4 during the fourth week.
  The termination in  the great  majority of cases  is fatal.

  Pathological Character.—As regards  the  anatomical changes in the
liver, according to many authors they denote a diffuse parenchymatous inflam-
mation.   As  opposed  to this view, the alterations formerly regarded as evi-
dence of parenchymatous inflammation, are now attributed to degenerative
processes.  The theory, based upon the presence of leucocytes in the intersti-
tial tissue, that the inflammation is  interstitial, is not satisfactory.  The wan-
dering cells are most abundant in the red substance, and  their presence may
therefore be regarded as a secondary change.   The greater number of pathol-
ogists at the present time regard the changes in the liver  as primarily regress-
ive  and  produced by an acute fatty  degeneration. 
ACUTE  YELLOW ATROPHY OF THE LIVER.         609
  As to the pathological  character of  the  disease,  there have been many
speculations, most of which possess only historical interest, such as that  the
changes in the hepatic cells are due to an over-production of bile, to paralysis
of the bile-ducts, to disturbances in the innervation of the liver, etc.   The
hypothesis now most strongly advocated is that acute yellow atrophy of  the
liver is an infectious disease.  The changes  in the liver may be regarded as
local manifestations of a general  infection, or the  infectious principle may be
considered to act primarily upon the liver and secondarily upon the blood  and
other organs.  According to the latter view,  the special poison makes its way
into the system  through the liver, perhaps  by means of the  ingress of  the
infectious material (bacteria?) from the intestine into the bile-ducts.
  The symptomatic  phenomena which form the clinical history of the disease
are in a greater  or less degree effects of the action of the infectious principle,
the existence of which may be assumed.  Certain of the grave phenomena,
however, are attributable to the non-elimination of excrementitious principles
which it is a function of the liver to excrete.  The retention of these in the
blood is denoted  by the  term  acholia.   The  physiological discovery that the
cholesterin in bile is an excretory product derived  chiefly from the destructive
metamorphosis of nerve-tissue is  sustained by, and affords a rational explana-
tion of, the phenomena in this  disease which are  referable to acholia.  That
these are effects of cholesteramia is evidenced by clinical observations show-
ing in this disease a notable accumulation in the blood of cholesterin, and by
experiments showing the production of phenomena analogous to those of  this
disease  in animals by the injection of cholesterin into the blood.1  Uramia is
doubtless in many cases  a pathological element, but the clinical history shows
clearly  toxical  effects other than those referable  to that element.

   Causation.—Of 143 cases analyzed by  Thierfelder, 88 were women  and
55  were men.  Of the 88  women, 30 were attacked during pregnancy and 3
were in  childbed.   Of the 143  cases, 93 were between the ages of twenty
and of thirty-nine;  2 were less  than one year of age, and 5 were more than
fifty.  Aside from the influence of age, sex, and the condition of pregnancy,
as shown by the above statistics, we have no  knowledge of causative agencies.
If,  as held by many, the  disease be specific or infectious, it involves, of course,
a special cause.

   Diagnosis.—The  symptoms  are not diagnostic of this  disease prior to
the occurrence of the grave toxamic phenomena—namely,  delirium, hemor-
rhages, etc.—in connection with jaundice.  The  fevers—typhus or typhoid,
remittent,  pyamia, yellow  fever—are excluded by the absence of  the diag-
nostic 'features   which  belong  to  them severally,  and  sometimes by  the
absence of a febrile temperature.  Diminution of the size of the liver while
the case is under observation, in connection  with  the clinical history, renders
the  diagnosis positive;  but this effect  does not  always  take place.  More-
over, it is sometimes difficult to determine  accurately the vertical diameter
of  the liver by  percussion, owing to the fact that the tympanitic resonance
from the colon  may be  conducted upward, so as  sometimes even  to meet the
pulmonary vesicular resonance when the size of  the liver is normal.  There
is, therefore, a  liability to  error in  deciding  that the liver is reduced in  size.
This difficulty applies to  cases in  which the transverse colon is distended with
gas;  but  generally it  may be correctly ascertained whether the  size of the
liver has diminished.   The presence of leucin and tyrosin in the urine is
  1 A'ide "Experimental Kesearches into a New Excretory Function of the Liver," by
A.  Flint, Jr., Am. Journ,.  of Med. Sciences,  1862 ; also, Flint's textbook of  Human
Physiology.
        39 
610                   DISEASES OF THE  LIVER.
diagnostic.   The  sex  of the patient  and the existence of pregnancy  have
some weight in the diagnosis, as well as the gravity of the disease, as denoted
by the symptoms and the rapid progress toward a fatal termination.

  Prognosis.—It is questionable whether this disease ever ends in recovery.
Cases of recovery have been reported, but there  is perhaps more probability
that in these cases there was an error in diagnosis than that the disease really
existed  and terminated  favorably.
  Thierfelder gives the following statistics in regard to the duration after the
development of grave symptoms, based on an  analysis of 118 cases:  twenty-
four hours or less  in 10; from twelve to forty-eight hours in 40;  from two
and a half to three days in  20;  from three and a half to four days in 17;
from five to seven days in 15; nine days in 2; and  ten and  fourteen days,
of each  1  case.

  Treatment.—A few words will embrace all that is to be said with refer-
ence to treatment.  AVith our present knowledge nothing is to be expected,
beyond  palliation, from  remedies.  Drastic purgatives and emetics have  been
advised, but the propriety of these or of other perturbatory measures is  very
doubtful.  Symptoms which  furnish indications  for  palliative remedies are
vomiting and hemorrhages.   For  the vomiting and gastrorrhagia ice in small
pieces, bismuth,  and anodynes may be  prescribed.   The mineral  acids are
appropriate.  The symptoms referable to the  circulation—namely, the fre-
quency  and feebleness  of the pulse, with coolness of the  surface—indicate
tonics and stimulants.   Inasmuch as  the convulsions and coma may be due
to uramia, it would be desirable, if possible, to excite  the action of the  kid-
neys ; and if this be not practicable  the hot-air bath  and perhaps hydra-
gogues  suggest themselves as means of effecting the vicarious elimination of
urea.   Hemorrhage from the bowels is to be controlled by cold  applications
and opiate  enemas.  Revulsive  applications over the  site of the liver by
means of fomentations and  stimulating embrocations or rubefacients may be
of some service.  Quinia in full doses  deserves further trial.
                      CHAPTER   XII.

              DISEASES OF  THE LLVER  (Continued).

Fatty Liver.—Parenchymatous Degeneration of the Liver.—Waxy Liver.—Cancer of the
   Liver.—Other New Growths in the Liver.—Hydatid Tumors  of the Liver.—Multi-
   loeulax Echinococcus.—Other Parasites in the Liver.—Pigmentary Deposits in the
   Liver.—Hypertrophy and Atrophy of the Liver.—Changes in the Position and in the
   Shape of  the Liver.—Congestion of the Liver.—Portal Thrombosis.—Adhesive and
   Suppurative Pylephlebitis.

    HAArING considered inflammatory affections  of  the  liver, I shall take up,
     next in order, structural affections  of  this  organ.  The more important
of these are incident to an abnormal accumulation of fat,  to the waxy or lar-
daceous alteration, to carcinoma, and  to hydatid  tumors.  These will be con-
sidered in  this chapter. 
FATTY  LIVER.
611
                             Fatty Liver.

  The liver is one of the normal  situations for the  deposition of fat.  In
well-nourished, healthy  individuals,  the liver-cells in the periphery  of the
lobules contain  some  oil-drops.  As there is great  variation in the  quantity
of fat contained in the livers of healthy persons, it is by no means easy to
determine  the amount which is to  be  regarded as abnormal.
  It is customary to distinguish  between  fattty infiltration and fatty degen-
eration of the liver.   The reader is referred to Part I. p. 54 et seq. for the
grounds upon which this distinction,  as  adopted in  this work, is based.  The
distinction may be here repeated: In  fatty infiltration or fatty growth  the
protoplasm is displaced by the fat, but does not  suffer materially in its integ-
rity, except by a slow  process of atrophy from  compression.  If the fat be
derived from the albuminous constituents of  the cell, these are,  in great part
at least, renewed.  In fatty  degeneration  or fatty atrophy the cell-substance
is directly converted  into fat, and is  not at all or is  insufficiently regenerated.
There are  important exceptions  to the rule that in fatty infiltration  of the
liver the fat is present in the form  of large drops, whereas in fatty degen-
eration it  appears as small  drops or molecules.  The most  typical example
of fatty degeneration of the liver is acute yellow atrophy of this  organ, to
which no further reference will  be made in  this connection, as  it has  been
already considered.   Some writers regard all the other  forms of fatty liver
as examples  of  fatty infiltration.   It  is true  that, as  a rule,  they present
the  gross  and microscopical appearances which have been considered cha-
racteristic of infiltration ;  but,  as explained in Part I., these  morphologi-
cal  appearances do  not suffice  for  the  diagnosis between infiltration and
degeneration.
   A fatty liver is usually more or less enlarged, its margins rounded, and its
surface smooth.   The consistence is less than in health.   The specific gravity
in extreme cases is so light that the  organ floats in  water.   The weight, how-
ever, owing to increase  in volume, is usually greater than  in  health.  The
color is yellowish, and the lobular markings are often obscured.   Drops of oil
adhere to the knife in making a section.   The  organ is  anamic.  While the
amount of fat which can be extracted by ether  from a normal liver  is esti-
mated at  from 3 to  5 per cent., that present in extremely fatty livers may
rise as high  as  40 or 45 per cent.
   In  the physiological  accumulation of fat in the livers  of women during
lactation the fat is present chiefly in  the central cells of the lobules.   In most
other cases of fatty infiltration the fat appears primarily in the hepatic cells
in  the periphery  of the lobule,  and  extends,  as the  fatty  accumulation
increases,  to  the cells in  the centre.  The fat  appears  first  as small drops,
which increase in size and coalesce, until finally one  large drop occupies nearly
the  whole of the space within the cell-contour.   An hepatic cell thus altered
is spherical in shape, its nucleus is pushed to one side, its protoplasm forms a
narrow ring around  the oil-drop,  and the whole cell resembles an  adipose-
tissue cell.  The fat may also exist  between the hepatic cells, either free or
in stellate cells in the intercellular  spaces.1
   The essential condition for the development of fatty metamorphosis of the
liver is that more fat be either introduced or produced than can be oxidized.
This failure  of oxidation may depend either upon an excessive introduction
or production of fat  in the organ,  or upon a diminution  in the oxidizing pro-
cesses due usually to a deficient supply of oxygen to the cells.  AAa thus find
fatty livers in conditions apparently  the most opposite—namely, in  cases of
  1 Perls, Lehrbuch der allgemeinen Pathologie, Bd. 1, p. 177; Platen, Virchow's Archiv,
Bd.  74, p. 2US. 
612
DISEASES  OF THE  LIVER.
great obesity and in cases of extreme emaciation.  The causes of fatty liver
may be summarized as follows :
   1.  Lactation. The accumulation of fat in the centre  of the lobules before
and during lactation is to be regarded  as physiological  rather than  patho-
logical.   2.  Obesity.  Persons  who  take little muscular  exercise,  whose
food  contains an  excess  of hvdrocarbonaceous  substances, and who have a
predisposition, either hereditary or acquired,  to the deposition of  fat, may
develop very  large fatty  livers  as well as an  excessive  panniculus adiposus.
3. Continued and excessive indulgence in alcoholic stimulants.   This leads
often, but not constantly, to fatty infiltration  of the liver as well as  to cir-
rhosis.  4. Pulmonary phthisis, and less frequently other cachectic  conditions,
such  as cancer, chronic dysentery, profound anamias, etc.   The largest fatty
livers met with are those  developed  during chronic  pulmonary tuberculosis,
especially in  females.   5.  Phosphorus-poisoning. Although the  liver here
presents the appearance  usually considered as characteristic  of fatty infiltra-
tion, it is probable that poisoning by phosphorus leads to fatty degeneration
of the liver, as well as of the kidneys, muscles, etc.   Arsenic and some other
poisons also occasion fatty metamorphosis of the liver.   6.  The acute fatty
degeneration of the new-born described by Hecker and Buhl.1 The  liver takes
part with other organs  in the general  fatty degeneration.   7. Yellow fever.
The fat is present in large drops, but the  process  is fatty degeneration.  The
hepatic cells usually contain  fat in cirrhosis and in  chronic passive conges-
tion of the liver.  The cause here is local and referable to the  interference
with  the  circulation.
   Our present knowledge is not sufficient to enable  us to  determine  the
pathological importance of fatty liver.   The pressure of the fat appears to be
sufficient to render the organ anamic, but not to  occasion obstruction enough
to give rise  to peritoneal  dropsy.  If the latter coexist with fatty liver, cir-
rhosis is combined, or there exists some  other cause for the hydro-perito-
neum.  The spleen does not become enlarged.   There may be some  obstruc-
tion to the passage of bile in the minute hepatic ducts, but this is not sufficient
to occasion jaundice.   The function of the secreting cells must be  more or
less impaired when these  are filled with  fat, but  we  are unable  to refer any
symptoms to  this condition.
   The diagnosis of fatty liver can be made only when the organ is enlarged.
There are no subjective local symptoms  other than  those dependent on the
increase  of  size.   The  enlargement may be determined by  percussion and
by manual exploration  below the false ribs.   The  blunt or rounded  lower
margin  may sometimes be ascertained.   The  smoothness of the  surface is
appreciable, and sometimes also the diminished consistence ;  or, at  all events,
the absence  of induration may be ascertained.  An enlarged liver presenting
these  characters, occurring in a patient affected with pulmonary phthisis,  an
intemperate person,  or  a  person of luxurious, indolent habits, may be con-
sidered  as probably fatty.   The probability  is  greater in females  than  in
males.  Simple enlargement, in this pathological  connection, is not sufficient
for the  diagnosis of fatty  liver, inasmuch as waxy liver is not infrequently
associated with pulmonary phthisis; and  it is  not always easy to  determine
the physical characters which distinguish these  two forms  of enlargement
from  each other.
  Fatty liver occurring in cases of pulmonary  phthisis does  not  claim  treat-
ment.  In fact, the  treatment of phthisis, which in certain  cases is highly
useful—namely, with cod-liver oil and alcoholics—may be  supposed to  favor
the deposit of fat in  the  liver.   Nor, as  a general remark, with our present
knowledge,  does  it claim  treatment  when associated with  other  important
                      1 Klinik der Geburtskunde, 1, 1861. 
WAXY LIVER.
613
 affections.   Occurring in persons addicted to the use of alcohol  and to over-
 feeding, especially as  regards fatty articles of diet, it is  to  be  treated by a
 reformation of the habits  of living—namely, by temperance or total absti-
 nence in respect to the use of alcoholic beverages, by restricting  the  diet in
 a great measure  to articles not abounding in fat, and,  if the strength will
 permit, by increased muscular exercise.  The remedies indicated  are those
 which will tend to strengthen and invigorate the system.   Fatty liver com-
 bined  with chronic alcoholic  gastritis offers  a  bad prognosis.


         Parenchymatous Degeneration of the Liver.

   By the terms parenchymatous degeneration  and cloudy swelling of the liver
 is designated a condition of the organ often met with after death from fevers,
 diseases involving severe blood-poisoning, and affections accompanied with a
 high temperature.  The liver is sometimes  enlarged and  the outlines of the
 lobules are indistinct.   The liver-cells are swollen and filled with granules
 which are  coarser and more abundant than normal.  These  granules at first
 are albuminous, and they disappear on the addition of acetic acid. They may,
 however, give place to fatty granules and drops.  Some regard parenchymatous
 degeneration as an essential stage  in the process of fatty degeneration.  The
 clinical importance of parenchymatous degeneration of the liver is not well
 understood.

                            Waxy Liver.
   The liver is one of the  organs frequently attacked by waxy degeneration.
 This degeneration, called waxy, amyloid, lardaceous, or albuminoid, consists in
 the deposition of an albuminous substance, the characters of which have been
 considered in Part I. of this work  (p. 55).  It may be repeated here that this
 substance  strikes  with a  solution  of iodine a reddish-brown or mahogany-
 brown color; with iodine and  sulphuric acid,  a blue color ; and with methyl-
 violet, a red color.  The reaction with iodine alone suffices as  a test.
   In  cases of advanced waxy degeneration of the liver the  organ is  much
 enlarged.   The enlargement is in some cases enormous.   The weight may be
 twelve or fourteen pounds, and is not infrequently double the normal weight.
 The form of the organ is not materially altered.   The surface is smooth, and
 the edges are usually, but not always, blunted  or rounded. The consistence is
 notably stiff and board-like, so that thin slices are easily taken off.  Notwith-
 standing its firm  consistence, the  organ  cuts easily, like uncooked  bacon.
 The interior of the liver  is dry and anamic.   The  cut surface, especially
 when examined in thin slices held  to the light, presents a characteristic  trans-
 lucent appearance  compared to uncooked bacon, wax,  smoked  salmon, and
 tissues soaked in  glycerin.   The lobular markings are obscured, but even in
 extreme cases opaque yellowish-white lines can be seen usually about the
 periphery and in the centre of the  lobules.   The amyloid or waxy  change is
 not, as a rule,  uniformly distributed, but some lobules are more affected than
 others ;  and with  the naked eye, even in advanced degrees of the degenera-
 tion, lobules and  parts of  lobules,  usually  of a yellowish color from fatty
 metamorphosis, can be seen without the characteristic translucence.  In the
 lesser degrees of  the waxy change the organ is not at all  or but slightly
 enlarged, and the affected parts can  be distinguished  only by the  chemical
tests mentioned.   The earliest stages are to  be recognized  only by  micro-
scopical examination of sections stained with  iodine or with  iodine and sul-
phuric acid or methyl-violet.
  Under the microscope the amyloid material appears as  a white, structure- 
614
DISEASES  OF THE  LIVER.
 less, translucent, refracting substance.  The amyloid degeneration begins first
 in the terminal branches of the hepatic artery and  in  the walls of the capil-
 laries within the lobule.  If we imagine the lobule to be divided into three
 concentric zones, the amyloid deposit appears first chiefly in the middle zone,
 and then gradually extends to  the centre of the  lobule, while the peripheral
 part remains longest unaffected. The peripheral hepatic cells usually contain
 oil-drops, and  the central cells are  often stained  with bile-pigment.   The
 hepatic vein and its branches and the interlobular branches of  the  portal  vein
 may become waxy.   In the arteries and veins the waxy material first replaces
 the muscular fibres of the middle  tunic, and may then extend  to the other
 coats.   In the  interior of the  lobules  the waxy material is deposited along
 the capillaries between their endothelium and the liver-cells.   The capillaries
 appear to be changed  into canals with  very  narrow  and  finally  obliterated
 lumen  and thick refracting walls, between which the  liver-cells  are  com-
 pressed and finally disappear.   It is uncertain whether the waxy material be
 ever deposited within the hepatic cells.   A large  number of liver-cells are
 destroyed by pressure when the whole  lobule becomes  waxy.   Usually, when
 the  liver is  the seat of this morbid  change other organs are also  affected,
 especially the spleen and kidneys, then the intestine, lymphatic glands, heart,
 large arteries, etc.   Sometimes, even  in comparatively slight degrees of the
 degeneration, the waxy substance is deposited  in  the liver as a homogeneous
 nodule, of the  size of a walnut or even larger, and more like a tumor than a
 centre of infiltration or degeneration.
   The affection is rare in infancy and in old age.  Of  116 cases analyzed by
 Frerichs  and E. AVagner, 24 occurred  at between ten  and twenty years of
 age ; 37 between twenty and thirty years ; 31 between  thirty and fifty years ;
 16 after the age of fifty;  and 8 prior to the age of ten years.  It is met with
 in cachectic patients  who have suffered from caries or necrosis of  bones.  It
 is incident to prolonged suppuration, especially of  bone, as in hip-joint disease,
 Pott's  disease, etc.; also to cachexia from tumors,  slowly-growing cancers, and
 other causes. It occurs in persons affected with syphilis. It has been observed
 to follow malarial fever.  It accompanies pulmonary phthisis, especially when
 there are suppurating  cavities.  In all these connections it is a secondary
 affection.  In a small proportion of cases it is not preceded by any other  dis-
 ease.   Cohnheim has demonstrated that three or four months suffice for the
 change to be brought  about.   It occurs in the male sex oftener than in the
 female.
   The pathological importance of waxy liver and  its clinical history are to be
 based on the study of cases in which the affection  is not associated with other
 serious affections.  Such cases are not  easily collected, for if the affection be
 not secondary,  the kidneys, spleen, and other parts are liable to be similarly
 affected.  It is  undoubtedly an important affection.   The functions of  the
 liver must be compromised in  proportion to the  amount of the deposit.   It
 may impede the  portal circulation through the liver sufficiently to give  rise
 to peritoneal dropsy.  Jaundice very  rarely occurs.   Pain referable to  the
 liver is wanting.   If the kidneys be  affected, general  dropsy is  likely to
 occur.
   The  diagnosis of this affection is to he based on  the existence of  enlarge-
ment and the exclusion of other affections of the liver involving increase of
size.  From fatty liver it is to be distinguished by the greater resistance on
palpation  and by the  margins being in a less degree blunt or rounded.  The
existence of peritoneal  dropsy  in some cases aids in the exclusion of fatty
liver.   From cancer of the liver it is distinguished  by  the absence of tumor
and the  smoothness of  the surface.  The absence of subjective local symp-
toms, especially pain, aids  in  the exclusion of cancer.  Cirrhosis generally 
CANCER  OF  THE LIVER.
615
leads  to  contraction of the  organ ; hut  this  affection is excluded  by the
smoothness of the surface when it can be felt, and by either the absence of
peritoneal dropsy or the  existence of only a small amount of effusion.   The
coexistence of enlarged spleen,  and the evidence of disease  of the kidneys
afforded  by albuminuria, general dropsy, and  perhaps uramic symptoms,
strengthen the diagnosis.  A capital point in  the  diagnosis  is the coexist-
ence of affections to which,  as  clinical observation  shows, this  affection  is
secondary—namely, prolonged suppuration, necrosis of bones, syphilis, etc.
   The prognosis is unfavorable.  The lesion  must be regarded as, in most
cases, incurable.   There  seem to  be some data for believing, especially  in
cases  of  cured hip-joint  disease, that patients  may regain good health after
waxy  degeneration  of  the liver  has been established, but it is doubtful
whether  the  waxy material be absorbed.   Frerichs,  Graves, and Budd, how-
ever, have observed diminution of the size of the liver in cases in which this
affection  was  supposed to exist.   Generally, the fatal  termination  is to a
greater or less extent  due to the diseases with which the  affection is asso-
ciated.
   The treatment must have reference to the morbid  conditions under which
the affection is developed.  The  iodide of potassium and the iodide of iron are
considered by Frerichs as sometimes successful in cases in which syphilis is
involved.  In scrofulous or  tuberculous  patients the therapeutic measures
should be directed  especially to the  cachexia which  is to be considered  as
standing in a causative relation  to the  affection.   Budd recommends the
muriate  of ammonia, from five to  ten grains  three  times  daily.   Frerichs
attaches  importance to mild alkaline remedies and the use of the sulphurous
mineral waters.   Dietetic and other hygienic measures are of the first import-
ance.  The body should be well nourished, the surface properly protected
against vicissitudes, and as much  out-of-door life as the strength will  permit   .
is advisable.  Disorders of any of the functions are  to  receive appropriate
attention.  Diarrhaa occurs not infrequently, and this will claim astringent
remedies and perhaps opium  in small doses. Albuminuria and general  dropsy
furnish indications the same as when these symptoms occur in connection with
any of the renal changes which, collectively, are called Bright's disease.


                        Cancer of the Liver.
   Of  the various forms of tumor which may occur in the liver, cancer is the
one of greatest importance.  AVhile primary cancer of the liver is a very rare
disease, the liver is one of the most frequent seats of  secondary cancer. The
statistics of Leichtenstern show 74 cases  in which  the cancer was  primary,
and 358 in which it was  secondary.   Primary hepatic cancer may develop
either from the  epithelium of  the bile-ducts or from  the liver-cells.   In sec-
ondary cancer of the liver the primary tumor may be seated in various organs
of the body, but it will be found most frequently in the stomach,1 and then, in
order of frequency, in the intestine, including the rectum, and the uterus.  It
has been demonstrated  that  the  secondary cancerous nodules may be devel-
oped from emboli of cancer-cells transmitted from the primary growth along
the portal vessels or the lymphatics into the liver, and it is believed that this
is the most frequent mode of propagation.  A cancer in an adjoining organ,
especially the stomach, may  invade  the liver by continuous growth.
   Primary carcinoma of the liver usually presents itself in the form of a single
large tumor, more or less distinctly circumscribed, and often surrounded with
several smaller  cancerous nodules.   Primary  cancer of the liver may also
   1 Of 1 o74 cases of cancer of the stomach analyzed by AArelch, the liver was the seat
of secondary cancer in 475 (30.2 per cent.). 
616                   DISEASES  OF  THE LIVER.
occur in an infiltrated form, and in this case the liver  sometimes bears con-
siderable resemblance to a large cirrhotic liver, but  the parts corresponding
to the lobules are larger and of a yellowish-white color, and they present the
microscopical  appearances of  cancer.  Secondary carcinoma of  the liver  is
almost invariably presented in the form of multiple circumscribed nodules of
varying size and number.   These are usually many, but the whole organ may
be studded with them, while sometimes only a few nodules are present.   The
cancerous nodules have  generally a whitish color, with scattered  yellowish
dots and lines.   Extravasations of blood into the cancerous mass are occa-
sionally observed.  The consistence is  sometimes that of scirrhous,  but  more
frequently that of medullary carcinoma.   The tumors are present as well on
the surface as in the interior of the organ.   A quite characteristic appearance
of those nodules which reach the  surface  is the presence  of a cup-shaped
depression in the centre.  This so-called umbilication is due to  degenerative
and wasting changes in the central or oldest part of the tumor.   Partial peri-
tonitis, causing adhesions, is generally developed when the tumors  project
beyond  the  surface,  and in some  cases the  peritonitis becomes  general.
   The type of the secondary cancer conforms generally to that of the primary
growth.  As a rule,  the cancerous  alveoli are large and close together, and
contain  irregularly-shaped, polygonal cells.   The  cells may, however, be of
the cylindrical  epithelial type.   So-called melanotic carcinoma of the liver is
secondary, usually, to similar primary tumors of the choroid coat of the eye
or of the skin.   They are usually melano-sarcomata.
   The cancerous affection usually gives rise to more or less enlargement of
the liver.  The increase  in size and  weight is  sometimes enormous.   The
weight  has  been known  to reach twenty-five pounds.  Primary as well as
secondary cancer of  the gall-bladder and larger  bile-ducts has been repeat-
edly observed.
   Cancer here, as in other situations, rarely occurs in early life.  Of 472
cases analyzed by Leichtenstern, the ages  in 37  were between  twenty and
thirty years; in 61,  between thirty and  forty years; in 250, between  forty
and sixty years ;  and in 33, more than sixty years.   Of  756  cases, 334 were
men and 422 were  women.1
   It is  a singular fact that  cancer in this situation is more infrequent in
tropical than in temperate climates.
   Cancer of the liver being generally secondary, the symptoms in most cases
are combined with those referable to other affected organs.  It is much oftener
secondary to an affection  of other abdominal viscera than to a primary can-
cer of a part not connected with the portal  circulation ;  and when developed
secondarily under these  circumstances the  hepatic  affection is liable to be
overlooked.
   The general manifestations of the cancerous cachexia—namely, waxy pallor,
progressive emaciation, and debility—are usually present sooner or later ; but
in this as in other situations the affection sometimes makes considerable  prog-
ress before cachectic  phenomena are apparent.  The  affection in some  cases
remains for a longer  or shorter period  quite latent.  The general symptoms
may be manifest without  local phenomena  pointing  to the seat  of  the  affec-
tion ;  but in the majority of cases the affection  speedily gives  rise to both
general  and  local symptoms.   Pain is usually more or  less  prominent, refer-
able to the liver and  shooting in  different directions.   Tenderness on pressure
is a frequent symptom.   Jaundice occurred in 67 of 140 cases analyzed by
Leichtenstern.   In the  cases  in which it occurs the jaundice persists  until
death.   Peritoneal effusion occurs in about the same proportion of cases—
namely, 78 of 154 cases.   This may be due to peritonitis excited by the can-
                         1 Vide Ziemssen's Handbuch. 
              OTHER  NEW GROWTHS IN  THE LIVER.           617

cerous tumors or to  pressure upon the portal vein.   In the latter case the
effused liquid is serum without lymph ; in the  former, more or less lymph is
exuded.  Occasionally blood, extravasated into the cancer, escapes into the
peritoneal cavity.  The  accumulation of liquid  may be so great as to call for
tapping.   The appetite and digestion are early impaired, and at a later period
diarrhaa not infrequently occurs.  03denia of the lower extremities is liable
to occur in the latter part of the disease.   Emaciation and loss in weight are
progressive, and death takes place  by slow asthenia if the patient be not car-
ried off by some intercurrent disease.  A fatal termination may be hastened
by peritonitis  induced by the  local  affection, by abundant hemorrhage, by
coexisting cancerous affections elsewhere,  and by various accidental complica-
tions.  Aside from these circumstances the progress of the affection is some-
times rapid and sometimes slow.  The duration varies from a few weeks to a
year, rarely, if  ever, exceeding  the latter.  The  average duration is twenty
weeks.
  In most cases the diagnosis is made without difficulty.  The enlargement
of the organ, the presence of one  or more nodules or tumors appreciable by
the touch, with pain and tenderness, and frequently  the  knowledge of the
existence of cancer in some  other situation, render the nature of the affection
sufficiently clear.  The  hepatic affections to be excluded are—abscess of the
liver, cirrhosis, waxy liver, hydatids, and syphilitic growths.  For their diag-
nostic characters the reader is referred to  the articles treating of  these affec-
tions.   Tumors situated  near  the liver  are  to  be discriminated—namely,
aneurism, cancer of the stomach,  peritoneal  or omental cancer, a distended
gall-bladder, and fecal  masses in  the ascending  or transverse colon.  The
antecedent and coexisting symptoms, taken in connection with the local signs,
are in most cases sufficient for the differential diagnosis.   Progressive loss in
weight and the  appearances which denote the  cancerous cachexia point to a
malignant  disease.
   The diagnosis is difficult when no evidence is  obtained  by palpation.  If
the cancerous growth be confined  within  the liver, and the organ be simply
enlarged—still  more, if  the  size be normal or below the size in health—the
existence of the affection can only be conjectured in view of more or less pain
and  tenderness over the liver, conjoined  with a cachectic  condition  and the
existence of cancer elsewhere.   The diagnosis is  impossible in the few  cases
in which there are no physical signs and when the affection  is latent as regards
local symptoms.
   The age of the patient, peritoneal effusion, persisting jaundice, and heredi-
tary predisposition are to be taken into account in the diagnosis.
   The treatment lias  reference only to the palliation of  symptoms and the
prolongation of life.  Pain will often require the habitual use of opium.  An
advantage of an early diagnosis consists in the avoidance  of injurious medi-
cation.  Every debilitating measure  will tend to shorten life.  The system is
to be supported, as far as practicable, by  tonic remedies, nutritious diet, and
other hygienic  measures.   The  object in  this,  as  in other chronic  incurable
affections, is to  endeavor to aid the system in resisting as long as possible the
fatal termination.

                Other New  Growths in the Liver.

   A brief enumeration of the more common of  the other tumors found in the
liver must suffice, since  they generally possess no  clinical interest.  Primary
sarcoma is not known to occur in the liver. Secondary melanotic sarcoma has
been mentioned under  the  head of Cancer.   Spindle-celled sarcomata and
lympho-sarcomata have been observed as secondary growths in the  liver. 
618
DISEASES  OF  THE LIVER.
Tubercle appears in the liver in the form of countless miliary nodules of small,
often microscopic, size in the course of general  tuberculosis  and in chronic
pulmonary tuberculosis.   Large, solitary, cheesy  tubercles may occur in the
liver, as  in the brain and spleen, but  they are pathological curiosities in this
situation.  Lymphomata are present  in  many cases of leucocythamia and
pseudo-leucocythamia.  Little nodular accumulations of lymphoid cells in the
portal canals, so-called miliary lymphomata, are  often observed after death
from  typhoid fever, and in cases of diphtheria, smallpox, and  scarlatina.
Adenoma presents itself  in two forms—either as a nodular  hyperplasia of
liver-substance or as an  atypical growth  of bile-ducts  in  a  nodular form.
Cysts of retention developed from bile-ducts, and cysts  apparently of new
formation, are not infrequent, combined sometimes with cystic disease of the
kidney.  These  cysts are sometimes  lined with  ciliated epithelium.  Little
nodules of cavernous tissue are  often observed in the liver.  Gummata  have
been mentioned under the head of Syphilitic Hepatitis.


       Echinococcus  or Hydatid Tumors of the Liver.

  The echinococcus represents the larval stage of tania echinococcus, a tape-
worm about one-sixth of  an inch in length, which infests the  small intestine
of the dog.   The embryos developed from the eggs of  the tania which have
been introduced into the  human  alimentary canal make their way through the
blood-vessels  and lymphatics into the various organs of the body, where they
undergo further development.  It is held that these embryos  may enter the
liver also by way of  the bile-ducts.  An hydatid tumor or echinococcus cyst
consists of a membranous bladder, varying in size from that of a pin-head to a
child's head,  enclosed in a fibrous capsule developed from the  surrounding
tissue.  The hydatid vesicle is not adherent to the surrounding sac.   Its wall
is composed of an outer cuticular layer, which appears,  under the microscope,
clear and translucent, with exceedingly characteristic parallel lines, indicating
a lamellated structure, and an inner granular, germinal layer  provided  with
cilia.   In simple  echinococcus cysts minute whitish particles, called brood-
capsules, which contain  several  scolices or tapeworm heads, project as out-
growths from the inner germinative layer into the cavity of the sac, which is
filled  with fluid.  A scolex has in front four suckers and a double row of from
thirty to forty hooklets.   It is capable of invaginating the  anterior portion
of the head, so that the hooklets may appear to  be  in the dilated posterior
part.   This scolex undergoes no  further development  in man, but, finding
its way into  the alimentary canal of  certain animals, especially the dog, it
becomes  a fully-developed  tapeworm.  Simple echinococcus  cysts  are  not
common  in man.  Usually there is an endogenous proliferation of so-called
daughter-vesicles, so that the main or mother-cyst contains floating globular
or ovoid cysts varying in size from that of a  pea to a hen's egg, and in num-
ber from a few to several thousand.   The daughter- (and sometimes grand-
daughter-) cysts produce from their inner  germinal layer brood-capsules con-
taining scolices, in the manner described for the mother-cyst.  Very rarely in
man, but frequently in the ruminants, there is an  exogenous  instead of an
endogenous growth of daughter-vesicles, which then appear as small sacs out-
side  of the mother-cyst.  The fluid contained  in an echinococcus cyst, free
from  regressive or inflammatory changes, is clear, somewhat opalescent, neu-
tral or slightly alkaline, and with a specific gravity between  1007 and 1015.
It is devoid of albumen or has only a trace, is rich in chloride of sodium, and
it frequently contains grape-sugar, inosite, succinic acid and succinates, and
some  less important ingredients.  (For a description  of the modifications,
some  of  a rather complex nature,  which  may  occur  in the  structure  of 
      ECHINOCOCCUS  OR HYDATID  TUMORS OF THE LIVER.   619

echinococcus cysts,  the  reader is referred  to works  treating  specially of
entozoa.1)  Brief reference,  however, must be made to the regressive changes
and to the multilocular echinococcus.   The fluid may be absorbed or thick-
ened,  the vesicles  and scolices may undergo fatty and calcareous  metamor-
phoses, and  the fibrous capsule may shrink so  that nothing is left hut a fatty
calcareous  nodule, usually  containing cholesterin  and hamatoidin crystals.
The booklets are preserved among the debris  and  aid  in  the diagnosis.  In
this way spontaneous cure may ensue.  It is maintained  that the destruction
of echinococci is  sometimes due to the entrance of bile into the mother-cyst,
Inflammation, resulting  in  suppuration,  of  an echinococcus cyst may fake
place.  Sometimes no scolices  are developed.   Such  cysts, with or without
daughter-vesicles, are called acephalocysts.
  Echinococci occur  in the liver oftener  than in  all other parts collectively.
They  may be present in any organ  of the body.  Usually there exists a sin-
gle  tumor, but there may be a dozen or  more.   Similar tumors  sometimes
coexist in other  organs, especially in the lungs and  spleen.   Oftener found
in the right than in the left lobe, they may exist  in  any part of the organ.
The growth of the echinococcus is very slow,  extending  usually over years;
but it is sometimes  continuous, or  it may become arrested at any stage by
the death and consequent  regressive changes of the parasite.
  The echinococcus  disease is less frequent  in the  United States than in
Europe and some other  countries.  It is said to be particularly common in
Iceland, where the inhabitants  live in close community with dogs.   Osier has
collected 01 cases occurring in this country.  Of  these, fully one-third, and
probably more, were in foreigners.   Echinococci are said to be not infrequent
in hogs and cattle in this country.2
  The clinical history offers nothing which points to  this or any affection of
the liver until the tumor attains  a sufficient size  to occasion inconvenience
by pressing on the adjacent parts.    As long as the tumor is contained within
the gland it is usually completely latent.  It  gives rise to neither pain nor
tenderness, and the hepatic  functions are not  appreciably disturbed.  Hyda-
tids of  considerable  size are  not infrequently discovered unexpectedly in
autopsical examinations.    If,  however, the cyst  be situated near the  per-
iphery and project considerably beyond the organ, it is likely to give  rise to
local  symptoms  directing attention to the part.   Usually, under these cir-
cumstances  pain  is  slight or wanting, but  there  is a sense of fulness and
uneasiness in the neighborhood of the liver.   AVhen pain is present it is due
mainly to inflammation  developed by the pressure of  the tumor.   The pres-
sure upon adjacent parts gives  rise to symptoms which  differ according to the
direction in  which the tumor extends.   Extending into the thoracic space, it
gives  rise to dyspnaa on exertion, cough, and palpitation.   Pressure on the
stomach and intestine is  liable  to produce vomiting and constipation.  If the
vena  cava  be compressed,  adema  of the lower  extremities  follows.   The
growth of the tumor is  attended  by little or no  constitutional disturbance.
There is no febrile movement, and  the  nutrition of the  body may be unim-
paired.
  Important local and general symptoms, however, are incident to the burst-
ing of the cyst or the discharge of its contents by ulceration.   These symp-
toms will depend on  the  direction in  which the  opening occurs.   Pleuritis,
pericarditis, and  peritonitis  are results of the rupture respectively into the
pleural, pericardial, and peritoneal cavities, and the two latter  affections thus

  1 The following works may be consulted : Davaine, Traite des Entozoaires, 2me edition,
Paris, 1877 ; Leuckart, Die menschlichen Parasiten, i., Leipzig, 1863; Heller, in Ziemssen's
Cyclopaedia of the. Practice of Medicine, vol. iii.;  Cobbold's  Treatise on Parasites.
  2 Osier, Am. Journ. of the Med. Sciences, Oct., 1882. 
620                  DISEASES OF THE LIVER.
induced are uniformly fatal.   The first of these three affections is very likely
to prove  fatal.   Opening  into the vena cava, it  gives rise to the symptoms
of obstruction of the pulmonary circulation from  embolism.   If the lung be
perforated without general pleuritis, cough and expectoration are prominent
symptoms, and  in the latter  are  contained, from  time to time,  hydatids,
together with bile in some cases.  If perforation of the  lung ensue after the
evacuation into the pleural  sac, the phenomena of pneumo-hydrothorax are
developed.  Perforation of the  stomach or colon is usually attended by severe
pain, and is  followed by the discharge, either by  vomiting or stool,  of hyda-
tids.   The discharge of the  hydatids  into the biliary passages gives rise to
jaundice.  Jaundice, irrespective of this cause, is rare  in  cases of hydatid
tumor.  Dropsy of the peritoneum does not belong to the clinical history
of the affection.   Both jaundice and  hydro-peritoneum, however,  are  occa-
sional effects of the pressure of the  tumor on the biliary passages without
the  liver and on  the  vena porta.
   A diagnosis is impracticable so long as the growth does not extend beyond
the gland. The affection can be recognized only when either the tumor is dis-
coverable by physical examination or hydatids are discharged through some
outlet,  A tumor extending from  the anterior surface or from  the inner or
lower  margin of  the liver, after it has attained a  certain size is appreciable
by the touch.   The  diagnosis  now involves  its  discrimination  from other
tumors.   AVhen situated over the liver it is to be  discriminated  from cancer
and  hepatic  abscess.   This discrimination may generally be made without
much difficulty.   From cancer  it is distinguished by its smooth and  globular
form, its elasticity and the sense of fluctuation, the freedom from  pain, and
the  absence of the cancerous cachexia.   From hepatic  abscess it  is distin-
guished by the slowness of its growth, absence of pain  and tenderness, and
by its being unattended by the  constitutional symptoms to which suppuration
generally  gives  rise—-namely,  chills,  fever, etc.   Extending from  the left
border, it is  to be discriminated from cancer of the stomach or of the pan-
creas, and from an aneurismal  tumor.  The connection of the hydatid tumor
with the liver, and the disconnection of other tumors, may generally be ascer-
tained by palpation and percussion.  Cancer of the stomach or of the pan-
creas is usually accompanied by pain, and in the former situation by notable
gastric symptoms.   The  cancerous cachexia  may be apparent,   A cancer-
ous tumor is generally irregular or lobulated.   An a'neurismal tumor is  dis-
tinguished by its anterior  and  lateral  pulsation, the frequent occurrence of
murmur,  and generally by persistent  gnawing  pain referable to the back.
   A physical sign sometimes  obtained  by percussion is highly distinctive
of a hydatid tumor.  If percussion be made upon the tumor, the fingers  of
the left hand or the whole hand being placed over the  tumor, the  collision
of the floating hydatids with each other causes a characteristic tactile vibra-
tion  known as  the hydatid fremitus.   The sensation is compared to that
felt  when percussion  is made  upon the hand  resting  on a mass  of jelly.
By placing the stethoscope over the tumor  and practising percussion, a pecu-
liar  sound is elicited, which  in some cases  has a musical intonation  like the
sound from a violoncello.   These signs are  obtained in only a certain number
of cases.
  An hydatid tumor encroaching more or less upon the  thoracic  space gives
rise  to flatness on percussion and absence of respiratory murmur from the
base of the chest upward in proportion  to the height to which the tumor
extends, with perhaps  more  or less displacement of the heart.  The signs
are those  of pleuritis with effusion.   Attention to the  following point will
suffice for the discrimination in many if not in most cases: In pleuritis the
level of the liquid effusion when the patient is sitting or standing is denoted 
      ECHINOCOCCUS  OR  HYDATID TUMORS  OF  THE LIVER.   621

 by flatness extending upward on the anterior aspect of  the affected side of
 the  chest to about a  uniform  height;  but  the  flatness due  to  a  tumor
 extending into  the thoracic  space generally  has  an irregular limit;  that
 is, the  flatness  extends higher  at  some than at other points.   Moreover,
 the  test of the presence of liquid effusion  afforded by the  results of per-
 cussion when the  position  of the body is changed  from the  vertical to the
 recumbent is not available in the case of a tumor.
   The  diagnosis in cases  in which the tumor opens  externally or its  con-
 tents are  discharged by expectoration, vomiting, or stool,  is established by the
 discovery of hydatids, either entire or the remains left after their destruction.
 If entire, they are easily recognized with the naked eye.  If not entire, the
 microscope is tp be employed to discover shreds of the  characteristic mem-
 brane and hooklets of echinococci.
   The most certain means of arriving at a positive diagnosis in cases in which
 the  contents  of  the tumor  are not discharged through some outlet externally
 is by withdrawing a portion of the liquid by means of an exploring canula.
 If the  fluid withdrawn be clear,  free from albumen, and rich in chloride of
 sodium, there can  scarcely be room for doubt as to the nature of the tumor.
 The presence of succinic  acid or of glucose is evidence in favor of echino-
 coccus.   If  the contents  have  become mixed with blood or inflammatory
 products, the chemical  examination is  not conclusive.   If scolices  or  their
 hooklets,  or portions of the finely-striated  but otherwise homogeneous  echi-
 nococcus  membrane, be  found in the fluid, the diagnosis  is  established.
   Hydatid tumors are not in themselves serious, but they do harm by pressure
 upon adjacent parts.  They prove  serious  also by opening into certain situa-
 tions in which  grave or fatal  diseases  are induced  by their presence.   The
 prognosis in these cases has been already stated.   If the opening occur into
 a  situation from which  the contents are discharged from the body—namely,
 through the  integument into  the bronchi or into  the  alimentary canal—
 recovery  may be  hoped for  or expected according  to the circumstances in
 individual cases.   If recovery do not  take place, the  fatal  termination is
 preceded  by  protracted irritation and progressive exhaustion, due generally
 to suppuration  within the sac.
   In the treatment of hydatid  tumors of the liver there are two objects to
 which measures may be directed.   One object is the evacuation of the tumor,
 and the other is to arrest its growth and promote absorption of  its  contents.
 Medicinal means are applicable to the last-named object only; and the  first
 object is  of course to be  effected  exclusively by surgical interference.
   Several internal remedies have been proposed as capable of  destroying the
 hydatids.   On the death of the parasite the tumor ceases to grow, and, grad-
 ually diminishing in size, it may finally disappear.   This is the  mode in which
 a  spontaneous cure not infrequently takes place.  Calomel, common salt, and
 the  iodide of potassium have been thought to have the power of effecting
 the destruction  of the hydatids, these remedies acting by being absorbed and
 exerting a poisonous effect  upon the parasites.  Their efficacy, however, does
 not appear to have been established by clinical observation.
   An effectual  surgical measure  in certain cases is to make an incision  into
 the tumor sufficiently large to remove both the liquid and the hydatids which
 it  may  contain.   This  operation  is  warrantable when the tumor extends in
 an outward direction, provided adhesions have taken place  around a space in
 which the opening is made, so that there is no danger of the escape of the
 contents into the peritoneal sac.   A method of determining  whether  adhe-
 sions exist or not is to ascertain if the  tumor or  the liver be depressed by
 a  forced inspiration or  remain fixed in the  same  position.   This point is
readily ascertained by marking on the chest or abdomen the situation of the 
622
DISEASES  OF  THE LIVER.
tumor, or the lower margin of the liver, or its upper margin, successively at
the end of an expiratory and an inspiratory act. After evacuating the tumor
cicatrization  may be expected to follow, but this result may be preceded  by
suppuration within  the  sac, which may be continued so as to involve danger
from  constitutional irritation  and exhaustion.
   A simple method of treatment which often  suffices for the cure is to with-
draw  a portion  of  the  liquid by aspiration, puncturing  the sac with a  fine
hollow needle or trocar.  The destruction  of the parasite may be in this way
effected, and the risk of the escape of the liquid into the peritoneal cavity is
extremely small.   The injection of medicated liquids into the sac is unneces-
sary,  and increases  the liability to suppuration.  If suppuration occur, a free
opening may be required.  In order to avoid danger from a free opening,
Simon recommends the following procedure :  " The tumor is punctured with
a fine trocar and the canula allowed to remain ;  in twenty-four hours perito-
neal union will have taken place.   Eight days afterward a second trocar is
thrust in at some distance from the former, and the canula again allowed to
remain.   After  about twenty-two hours the two punctured wounds  may be
united  by an incision."1   For the destruction of  the  parasite  electricity,
transmitted through needles introduced into  the tumor, has been effective.
   The  prophylaxis of hydatids in the liver and elsewhere is to be based on
the source—namely, the  ova of  the  tania echinococcus developed  in the
intestine  of the dog.   Hence it  is  important,  as far  as  practicable, to
avoid  the possibility  of the introduction  of  ova from  the excreta  of  this
animal into  the human intestine.
                   Multilocular Echinococcus.

  The echinococcus multilocularis represents  a peculiar  form of develop-
ment  of  this parasite.   AA'ith very few  exceptions it has been found only
in the liver.  It forms  a hard, smooth tumor, often of very large size,  which
takes  the place of the liver-parenchyma.  Upon section this  tumor bears  a
striking resemblance to a colloid  cancer, with  which it was  formerly con-
founded.   In the  meshes of a firm, fibrous  stroma are small cavities con-
taining a gelatinous material in which are present the characteristic echino-
coccus membranes, rarely in the form of  vesicles.  Fully-formed scolices are
rarely found, but their hooklets are more frequently observed.  The  tumor
has a  tendency  to form in its central part ulcerative cavities sometimes filled
with pus. Virchow, who  first recognized the nature of the disease,  holds that
the echinococcus multilocularis develops in the lymph-vessels; and Friedreich,
that it grows in the blood-vessels and bile-ducts.
  The disease has been observed almost exclusively in South Germany and
Switzerland.  Prudden describes a case occurring in a German who had been
in this country  five years.1   The symptoms are usually more pronounced and
graver than those of ordinary echinococcus.  They  are—jaundice,  often
intense and rarely absent, gastric irritation, enlargement of the spleen, some-
times pain and  tenderness in the region of the  liver, progressive emaciation,
and, at the last, often  hemorrhage from  different mucous membranes.   The
prognosis is very grave.  The enlarged liver presents  usually  a smooth, hard
surface, and not the nodular swellings of ordinary echinococcus and cancer.
The duration, too, is longer  than that of  cancer, which is  not  usually accom-
panied with enlarged spleen or such intense jaundice.   There  is no effectual
treatment.
     1 ATide Heller,  in Ziems-en's Cyclopaedia, Am. ed., vol. iii.
     1 Delafield and Prudden's Handbook of Path. Anat., New York, 1885,  p. 354. 
         HYPERTROPHY AND ATROPHY OF THE LIVER      623

  The other parasites which  are  found in the  liver are of  little clinical
importance,  at least in this climate, on account either of their infrequency
or their innocuousness.   The  cysticercus cellulosa is a rare parasite  in the
liver.  A'arious species of distoma, of which the most  common in this climate
are  distoma hepaticum, or liver-fluke, and distoma lanceolatum, produce serious
disturbances in dogs, sheep, and some other animals, but they are infrequent
in man.  They are found in the gall-ducts and in the gall-bladder.   In  India,
and especially in China, certain species of distoma, known as distoma crassum
and  distoma spathulatum, or  sinense, are said to be common  and to  cause
serious  hepatic disorders.  The distoma hematobium, found  by Bilharz in
Egypt,  occurs  in the portal veins, but causes no  lesion of the liver.
  The pentastoma  denticulatum, the larval stage  of pentastoma  tanioides,
infesting the nasal cavities of  dogs, horses, and some other animals, has been
frequently found, especially in parts of Germany, in  the human liver,  where
it usually occurs in small calcareous cysts.  The pentastoma constrictum has
been observed, especially in Africa.   A specimen of this parasite, which had
been expectorated by a patient under his care, was sent to me by Dr.  M. M.
Campbell of Missouri.   From seventy-five to one hundred of these parasites
had already been expectorated.   The liver was much  enlarged, and the pri-
mary habitat of the parasites  was probably in this organ.1  The pentastomes
are not known to interfere with the hepatic functions.
  The ascaris lumbricoides sometimes enters the common bile-duct from the
intestine.  It may  cause  obstruction of the  ducts  and jaundice, but this
occurrence is very rare.   The psorosperms which are so common in the rab-
bit's liver have been occasionally found in the human liver, where they gen-
erally prove harmless.


             Pigmentary Deposits  within  the Liver.
   A deposit of dark-brown granules in  the liver, giving  to the organ a steel-
gray, chocolate, or bronzed  appearance, is  observed not infrequently after
death  from malarial fevers.  A similar deposit generally  coexists in the
spleen, and may be  found in other organs.  It is found in the blood, especially
within  the  portal vessels.  The  source of the pigmentary matter, together
with its pathological relations and  effects, cannot  be considered as settled.
(Aride Part I.  p. 78.)   AATith  our present knowledge, the pigment-liver  is
hardly entitled to be reckoned in  the list of hepatic  affections.  It will be
referred to hereafter as  entering  into the anatomical characters of the peri-
odical fevers.
   A certain  amount  of  bile-pigment is  often  present in normal  livers, and
this amount is increased in diseases causing  obstruction to the flow of bile.
   In severe anamia, particularly in pernicious anamia, the  liver contains a
large number of colorless granules  which are stained  greenish-black by treat-
ment with sulphide of ammonium,  and  which therefore contain iron.  These
ferruginous particles are probably  the result of an extensive destruction of
red  blood-corpuscles.

            Hypertrophy  and  Atrophy of the Liver.

   Hypertrophy of  the  liver was supposed to be not infrequent  before  the
several degenerative  affections to  which this organ is  liable were as well
understood  as  now.  AVhile the liver  may be greatly increased  in size by
tumors, abscesses, fatty  and  amyloid degenerations, congestion, and certain
  1 ATide N Y. Med. Record, Jan. 13, 1877; also Aitken's Science and Practice of Medi-
cine. 
624
DISEASES  OF  THE LIVER.
forms of cirrhosis, there is no evidence that a  simple  hypertrophy of the
liver with preservation of its  normal structure occurs as a pathological con-
dition.  The size  of the liver varies considerably within normal limits.
  It has been proven by experiments that the liver possesses  to a moderate
degree the  power of regeneration  of its tissue when this is destroyed to a lim-
ited extent. AVe may assume that this regenerative power is active after such
degenerations of  liver-cells  as  sometimes occur in  phosphorus-poisoning,
typhoid fever, cholera, and certain  other  diseases.
  Simple atrophy of the liver occurs  as  a senile change and  in  diseases
accompanied with  prolonged  marasmus.   The liver  is uniformly diminished
in size, and the liver-cells  often  contain a considerable  amount  of reddish-
brown pigment (brown atrophy).


  Changes  in the  Position and  in the Shape of the Liver.
  Aside  from  congenital malformations,  which  are  of  no  special clinical
interest, the liver may undergo changes of position which it is important to
understand  for diagnostic purposes.
  The liver is readily displaced  downward by  pressure  from  above, as  by
large  pleuritic effusions, and  is displaced  upward by fluid accumulations in
the peritoneal cavity, by abdominal tumors, and by tympanitic  distension  of
the intestines.  It possesses a certain degree of  mobility upon  its transverse
axis, and, in consequence of  this, pressure from  below, as by  the distended
colon, may  cause the liver to rotate, so that its anterior surface becomes supe-
rior, and the normal liver-flatness in front almost  or wholly disappears.  Its
mobility  may be abnormally  increased by  relaxation of its ligaments, and
sometimes,  especially in women with flabby abdominal walls who have borne
many children, it  is considerably  dislocated  and is  very movable  (hepar
mobile).  Sometimes  coils of  intestine, particularly  the  transverse colon,
may pass between the liver and  the anterior abdominal walls, so as to sub-
stitute a tympanitic resonance for the normal  hepatic  flatness.
  The liver may be variously distorted by pressure.  The most important of
these distortions is that  produced by tight-lacing.  In consequence of con-
striction  of the lower part of the chest it is compressed from side to side, and
a circular furrow or depression is produced which may be  so deep as to almost
divide the  organ, especially the  right lobe, transversely into  two  parts,  of
which the lower may even be tilted up over the upper division.   Correspond-
ing to the tight-lace furrow the liver-substance is atrophied and the capsule
is thickened and opaque.
  The liver may be dislocated downward by the traction of peritoneal adhe-
sions below the organ.  In an  instance observed  at Bellevue  Hospital the
lower margin was a little above the  crest  of the ileum.   In a  case reported
to the New York  Medical and Surgical Society by Willard Parker the dislo-
cation was an  effect of a fatal  injury.  Dr. Alex. Y. P. Garnett has reported
a case in which dislocation followed a violent muscular exertion, a spontane-
ous return of the organ to its normal situation taking place within three days.1
  Bestoration in cases of dislocation—or, as it  has  been termed, wandering
liver—is to be effected, if practicable, by pressure from below, and the  organ
should be retained in place, by a properly-adapted abdominal supporter.


                     Congestion of the Liver.
  Congestion of the liver may be either active  or passive.  Active conges-
tion is caused  by an increased flow of blood to the liver through the hepatic
                 1 Vide Am. Journ. of Med. Sciences, Jan., 1881. 
                     CONGESTION OF THE LIVER.                 625

 artery or the portal vein.  Passive  congestion is the result of some obstruc-
 tion to the  outflow of blood  from the hepatic  veins.
   A physiological  active  congestion  of  the liver occurs during  digestion, and
 it is believed  by  many  writers that this  form  of congestion  may  become
 abnormal in degree or in  persistence in those who indulge excessively in the
 pleasures of the table and  who lead  sedentary  lives.  It is held also  that
 highly-spiced food and  immoderate use of alcohol tend to produce active
 hyperamia of  the  liver.   Active congestion is  said to be more common  in
 tropical than in  temperate climates, and is attributed to  the  use of highly-
 seasoned  food, to  telluric influences, and to malarial infection.
   Congestion of the liver formerly  played a more important role in patholog-
 ical speculations than  at the present time.  It entered into the conception of
 so-called  abdominal plethora,  and  in connection  with an  abnormal secretion
 of bile it was regarded as an important  cause of the so-called bilious disorders.
 A sense of  weight in the right hypochondrium, impaired  appetite and diges-
 tion, sometimes nausea and vomiting, a bitter  taste in the mouth, pain in the
 head, a coated tongue, and a sallow complexion, are symptoms often attributed
 to hepatic congestion.   It is by no  means certain that this  pathological con-
 dition is represented by the  foregoing  symptoms.  Active congestion doubt-
 less occurs,  but the agencies producing it and  its  morbid effects  are not
 understood.  The  diagnosis  with  our present knowledge  is  not practicable,
 and the physician, therefore,  in treating it  acts upon the  suspicion of its
 existence.
   Chronic passive  congestion, on the other  hand, is  a well-defined condition,
 the causation of which is understood.   Anything  which obstructs the current
 of blood through the hepatic veins, through the inferior vena cava above the
 entrance of the hepatic veins,  through  the lungs, or through the heart causes
 passive congestion.  The obstruction is usually seated either  in the heart or
 in the lungs.  The various forms  of uncompensated valvular  lesions of the
 heart, particularly  mitral  and tricuspid  lesions, insufficiency of the power of
 the heart's action due to  myocarditis and obstructions in  the pulmonary cir-
 culation, such as those resulting from  emphysema, chronic pleurisy, fibroid
 phthisis, or  tumors of the mediastinum, are the  most frequent causes of
 chronic passive congestion.
   In consequence  of  the  damming back  of blood upon  the hepatic  veins,
 first the central veins  of  the lobules, and next the lobular capillaries imme-
 diately  surrounding these veins, become over-distended with  blood.  Thus
 the centre of the lobule presents a dark-red  color, increased usually by the
 presence of  brownish pigment-granules  in the central hepatic cells.  In con-
 trast with this the periphery of the lobule  is pale and yellowish from  the
 comparative  anamia in  that situation  and  from the presence of oil-drops
 in the peripheral  liver-cells.   A liver  presenting the appearance described
 is called a nutmeg-liver.   It is usually more or less enlarged,  and  is firm
 in consistence.
   AY hen the congestion is long continued and severe, the tissue at the centre
 of the lobule consists of little else than dilated  blood-vessels, between which
 the liver-cells have  become atrophied from compression.  AVhole lobules may
 be reduced to this  cavernous tissue, which appears on section dark red and
 depressed.   This  change is called red or cyanotic atrophy of the liver.  It is
 thus a late stage of the nutmeg-liver.    The organ is diminished  in size, the
 consistence is firm, and  the capsule is usually thickened and opaque. Cyanotic
 atrophy is often associated with more or less increase of the interlobular con-
nective tissue.
  AVhen the  condition  of  chronic passive congestion is well  marked during
life, it is possible  by means of palpation and percussion to  make  out enlarge-
       40 
626
DISEASES  OF THE LIVER.
ment of the liver.   It may extend a hand's breadth below the free border of
the ribs.   There may be  considerable variation from  time  to time  in size,
corresponding to variations in the amount of obstruction  to the circulation.
  The  symptoms  referable to the nutmeg-liver are not well defined.  There
may be a feeling  of weight,  but  rarely of actual  pain, in the right hypo-
chondrium.   A slight icteroid hue  of the conjunctiva and of the skin may
be present, and this, combined with the cyanotic color, gives a characteristic
aspect  to many cases of heart disease and of emphysema.  The obstruction
to the  flow of blood through  the  liver leads to  congestion in the  rootlets of
the portal vein, causing passive congestion of the spleen, of the stomach and
intestine, and  of the peritoneum.   In this way digestive disturbances and a
certain amount of ascites  are produced.  These effects, however, belong to
the general venous congestion which is present in most cases of nutmeg-liver,
and only  exceptionally  are they  out of proportion to other  symptoms of
general venous congestion.   In the atrophic stage of  the nutmeg-liver the
symptoms of  portal congestion become more  marked.
  The  treatment in  cases  of chronic passive congestion  of the  liver  is
directed not to the  condition  of this organ, but to the causes which obstruct
the circulation; that is, to heart  disease, emphysema, or some  of the other
causes  already mentioned.  Saline laxatives are useful in relieving tempo-
rarily  the portal  congestion.

  Portal Thrombosis—Pylethrombosis—Adhesive and  Sup-
                      purative Pylephlebitis.

  Thrombosis of the main trunk of the portal vein or of its larger branches
may be due to pressure  from without, caused by enlarged glands, abscesses,
tumors, impacted gall-stones, fibrous bands resulting from localized or general
peritonitis or  from a chronic inflammation  of the surrounding  connective
tissue (portal phlebitis).  It may be caused by foreign bodies within the vein
or calcific plates resulting  from chronic endophlebitis.   It  may be secondary
to cirrhosis.   A blow upon the abdomen  has  been known  to  cause portal
thrombosis.   In rare instances the thrombus is due to general  weakness of
the circulation in  consequence of marasmus.
  In recent cases the thrombus is grayish-red or yellowish in color  and more
or less  adherent to the inner  coat of the vessel.  It either partially or com-
pletely occludes the vessel.  In the so-called adhesive pylephlebitis the pres-
ence of the  thrombus leads to  secondary changes  in the wall  of the vessel,
resulting  in what is regarded  as an  organization of the thrombus. (Aide
Part I. p. 29.)  The thrombosed vessel is converted into a fibrous cord, either
solid or canalized.  In the  latter case the circulation may be partially or com-
pletely re-established, and recovery takes  place.  If the main trunk of the
portal  vein be occluded, life is not prolonged sufficiently for the  organizing
process to take place.
  The  symptoms of adhesive pylethrombosis or pylephlebitis are referable to
the mechanical obstruction of  the portal circulation.  If the  occlusion be
complete or nearly so, it gives rise to peritoneal dropsy.  The rationale is the
same as in dropsy caused by cirrhosis  of the liver.   From the latter it is dis-
tinguished by a more rapid accumulation of liquid, and by its occurrence in
persons not  addicted to spirit-drinking, this being the cause, par excellence, of
cirrhosis.  Hemorrhage from the stomach or intestine may occur, as in cases of
cirrhosis, and sometimes this  precedes  the occurrence of dropsy.  The spleen
is more or less enlarged.  The superficial abdominal  veins may become dilated.
Anorexia  and  loss  of digestive power  are symptoms occurring without much
delay.   Diarrhaa  occurs  frequently.   The lower limbs and  genitals become 
          PORTAL THROMBOSIS,  PYLETHROMBOSIS, ETC.       627

greatly adematous.  There is progressive loss of strength without fever, and
death may take place within a few waeks by asthenia.  Bapidly fatal asthenia
may follow a profuse hemorrhage. Jaundice is often present.  Its occurrence
may be explained  by the  diminished  pressure in the  branches of the portal
vein, or in some cases by a coincident obstruction of the bile-ducts from the
same causes which induce thrombosis of the veins.  In general, however, the
substance and  the functions  of  the  liver are little  disturbed by a  simple
portal thrombosis.   This is due to the fact that, as has  been shown  by the
experiments of Cohnheim and Litten, the blood  carried by the hepatic artery
is sufficient for the nourishment of the liver and for the secretion of bile.
  The treatment embraces, as an important palliative measure, paracentesis
abdominis, repeated as often as the dropsical accumulation  recurs.  Measures
to arrest  hemorrhage are indicated when  this occurs.   Additional  measures
are  those to meet other symptomatic  indications and  to support the powers
of life.
  Recovery has taken place  in several cases under my observation, in which
ascites and intestinal hemorrhage were referable to portal thrombosis.1

  In  pylethrombosis, as just described, or adhesive pylephlebitis, inflamma-
tion is limited to  the  site of the thrombus.   The phenomena of the disease
are referable to occlusion of the portal vein.   Supjmra/ire pylephlebitis, on
the other hand, involves  the presence of emboli or thrombi, which act, not
only mechanically, but by the agency of a noxious principle.  Owing  to this
principle they give rise to multiple hepatic abscesses.   The clinical history 'is
that of pyamia, often  without symptoms pointing directly  to the liver. Pain
and tenderness in the right hypochondrium, jaundice, and enlargement of the
liver may be present.  To these symptoms are added  those of obstruction if,
as may or may not be the case, the portal vein  or its  principal branches be
occluded.
  The most frequent causes  of suppurative pylephlebitis relate to ulcerative
and suppurative processes within the district of the  portal circulation.  In
this category belong  abscesses of the  spleen,  typhlitis  and perityphlitis,
ulceration of the gall-bladder, stomach, and intestinal  tract, particularly dys-
enteric and sloughing  ulcers, abscesses and ulcers of the rectum, such as
sometimes follow surgical operations in that neighborhood, and inflammation
of the umbilical vein in the newly-born infant,  A foreign  body in the portal
vein may give rise to suppurative pylephlebitis.   In an autopsy at Bellevue
Hospital  by Dr. Janeway a fish-bone two inches  long  was  found, one half in
the superior mesenteric and the other half in the portal vein.  The portal vein
contained puriform matter and the liver multiple abscesses.   Another similar
case has  been reported.  A thrombus in the portal vein is sometimes a direct
continuation  of  a thrombus primarily formed in some of the rootlets  of the
vein at the diseased part.   Sometimes the thrombosis follows the  lodgment
of an embolus broken off from a thrombus situated in some of the afferent
branches of the portal vein.
  In  suppurative  pylephlebitis the  thrombus  breaks  down into a puriform
mass from which emboli are  detached, the vascular walls  become infiltrated
with pus-cells, and the suppurative process extends to the  surrounding  con-
nective tissue and  the  hepatic parenchyma, the  result being  the production
of abscesses  in  which  the presence  of bacteria can be  demonstrated.  The
abscesses are usually not of large size, but they are  many, and their distri-
bution can  sometimes  be  seen"to follow  the  course  of the portal vessels
within the  liver.
  The diagnosis  of suppurative pylephlebitis  is to  be based  on the local
   1 ATide paper entitled "Early Tapping in Cases of Ascites."  (See note, p. 592.) 
628        DISEASES OF THE BILIARY PASSAGES, ETC.

symptoms already stated, in conjunction with the symptoms of pyamia and the
antecedent existence of some one of the causative conditions which have been
named.  Certain of the latter are not discoverable before death, and there are
ca.ses  in which  the post-mortem examination sheds no light on the etiology.
The affection is then said  to be idiopathic.
  There is no ground for  encouragement in the way of prognosis, and the
treatment has relation solely to symptomatic indications and to support.
                     CHAPTER  XIII.

     DISEASES OF  THE  BILIARY PASSAGES.—JAUNDICE.

Inflammation of the Biliary Passages.—Dilatation of the Gall-bladder:  Cancer of the
      Gall-bladder.—Jaundice, or Icterus.—Functional Affections of the Liver.

             Inflammation of the Biliary Passages.

   THE  most frequent form of inflammation of the biliary passages is simple
    inflammation, or, as it is often called, catarrhal  inflammation.   The seat
of the  inflammation is usually the lower  part  of the ductus  communis
choledochus,  particularly the part  contained in the wall of the duodenum.
The  inflammation is in the great majority of cases simply a continuation of
a similar inflammation affecting the stomach  and the duodenum.
  The anatomical changes in simple inflammation of the common bile-duct
consist  in hyperamia and swelling of the mucous membrane and increased
secretion of mucus.   As  in  similar inflammations elsewhere, these  changes
may not be well marked after death, the  congestion and  swelling  especially
being often absent  upon post-mortem examination.
  The importance of acute simple inflammation of the common bile-duct con-
sists in  the obstruction  which is offered to the flow of bile by the swelling of
the mucous membrane and  the accumulation of mucus. Inasmuch as the
force  which propels the bile through the biliary passages  is slight,  being
chiefly due to the continued secretion of bile by the liver-cells and the move-
ments of the diaphragm, even an insignificant  obstruction suffices  to impede
its flow.  The obstruction  offered to the passage of bile causes an  accumula-
tion of  bile in the ducts within the liver and an absorption of  accumulated
bile by  the lymphatics.  The bile thus  absorbed  enters the  blood-current by
way of  the thoracic duct and causes jaundice.
  The jaundice which  is produced by simple inflammation  of the intestinal
part of  the common bile-duct is usually called simple jaundice or catarrhal
jaundice.  Simple jaundice, caused in  this way, is a very common affection.
Being secondary to  simple gastro-duodenitis, simple jaundice is usually pre-
ceded for a few days by moderate disorder of the gastric functions,  such as
anorexia, had taste in the mouth, belching of gas, lassitude,  and  occasionally
by vomiting.  These symptoms continue for a time  after the appearance of
jaundice.   The  bowels  are usually constipated.
  The diagnosis is based chiefly upon the exclusion of other causes  of jaun-
dice, particularly the impaction of gall-stones, and severe structural affections 
DILATATION OF THE  GALL-BLADDER.            629
of the liver, such as cirrhosis, acute yellow atrophy, tumors, etc.   In general,
the diagnosis is easily established.
  The duration  of  an attack of simple jaundice  is  generally from about
three to  six  waeks.   Constitutional symptoms disappear,  as  a  rule, a con-
siderable time before the jaundiced color is lost.
  The causation is  that of gastro-duodenitis.   In some  cases there is evi-
dence  of some specific  or  infectious cause.   This, at least, is the probable
explanation  of the occasional accumulation  of cases of simple jaundice at
certain times and  in  certain places, giving to the affection an epidemic or
an  endemic  character.
  Simple jaundice, if uncomplicated,  is not a serious  affection,  and nearly
always terminates favorably.  It is  to be  remembered, however,  that  some
cases of acute yellow atrophy of the liver begin  with the  symptoms  of sim-
ple jaundice.
  As the natural  tendency  of simple jaundice is to recovery, active medical
interference  is not indicated.  The  patient's diet should be regulated, fats
especially being  excluded.   As  the  bowels are usually  constipated, a cathar-
tic  may be occasionally  administered, for which purpose some of the laxative
saline waters, such as Carlsbad, may be employed.   A  time-honored  remedy
is calomel or blue mass, given at night and followed by  a dose of salts in the
morning.  Devices for the displacement of the assumed plug of mucus from
the bile-duct are of doubtful efficacy.   Such devices are,  pressure upon the
gall-bladder,  faradization over the  gall-bladder,  and  the injection of  large
enemata of cold or lukewarm water  with the intention of arousing intestinal
peristole.
  Nothing is known  of simple inflammation of the bile-ducts within the liver
as an independent affection.
  Purulent inflammation of  the  biliary passages  may be caused  by the pres-
ence of gall-stones or of parasites, and  is sometimes, though rarely, a com-
plication of infectious diseases, such as pyamia,  typhoid fever,  and cholera.
Sometimes  the inflammation is secondary to suppuration or  necrosis of the
tissues in the neighborhood of the ducts.   Purulent inflammation of the
bile-ducts outside of  the liver may lead  to ulceration and  perforation of the
affected portion, with consequent peritonitis.  Purulent inflammation of the
ducts  within the  liver  leads to the formation of abscesses  containing bile
and usually  biliary  concretions.
   Croupous  and  diphtheritic inflammations of the biliary ducts have  been
described, but they  are rare and only of pathological interest.
  The various forms of inflammation which have been  described may attack
the gall-bladder, with or without coincident disease of the bile-ducts.  Inflam-
mations of the gall-bladder, except those caused by the  presence of gall-
stones, which have already been described  (p. 530), do  not call  for consider-
ation in  works the  purpose of which is  mainly clinical.   Ulceration and
perforation of the gall-bladder may occur  independently of the presence of
calculi.  I have  met with a  case in which  an abscess within the walls of the
gall-bladder led to perforation and fatal peritonitis.


 Dilatation of the  Gall-bladder (Hydrops Cystidis Fellese).

  The two most  common  causes of obstruction of  the biliary passages—
namely, gall-stones and mucus-plugs—have already been described.   Further
reference will be  made to these, as well as to other causes  of obstruction to
the flow of bile, in the article on Jaundice.   Closure of the  common bile-duct
causes, in addition to  jaundice,  an  accumulation of bile  within the  gall-blad-
der, but this accumulation is not generally sufficient to produce marked symp- 
 630        DISEASES OF THE  BILIARY PASSAGES,  ETC.

 toms.   Exceptionally, however, under  these  circumstances the gall-bladder
 becomes enormously distended with bile, as in a case related by Van Swie'ten
 in which the gall-bladder contained eight pounds of thick bile.
   Some consideration is clue to obstructions of the cystic duct.   These do not
 lead to jaundice, but manifest their effects upon the gall-bladder.  By far the
 most common cause of occlusion of the  cystic  duct is the impaction of one or
 more gall-stones.  Other causes are stenosis from cicatrized  ulcers, accumula-
 tion of inflammatory products, and pressure from without,  as by tumors and
 peritoneal bands.   Congenital stenosis is a rare condition.
   As  a result of occlusion of  the  cystic duct the gall-bladder  becomes dis-
 tended with  a clear, usually somewhat viscid fluid, which  is free from bile.
 This condition is called hydrops cystidis fellea, although the fluid is not of
 dropsical origin, but is a secretion from the  glands  and mucous membrane of
 the gall-bladder.   The  gall-bladder, thus distended, forms  a tumor, usually
 about  the  size of the fist, but  sometimes as large  as a man's head  or even
 larger.  In the latter case the  tumor extends to the  pelvis and occupies the
 greater part of the abdominal cavity.1   The shape of the tumor produced by
 hydrops cystidis fellea is globular or pyriform.
   There are usually no symptoms, other  than the presence of  a tumor, and
 this in ordinary cases is not so  large as  to cause much inconvenience.
   The diagnosis is based upon the situation and the characters of the tumor.
 The normal  situation of  the fundus of the gall-bladder corresponds to the
 median extremity of the ninth or  tenth right costal cartilage.  It can usually
 be ascertained by palpation and by  percussion  that the tumor projects in this
 situation from the lower margin of  the  liver.   The tumor is generally mov-
 able, although it  may be fixed by  adhesions.   It usually follows the respi-
 ratory movements of the diaphragm.  Unless  the tumor be  greatly distended
 a sense of fluctuation can be appreciated.   In  exceptional cases there may be
 considerable difficulty in diagnosis,  as when  the colon makes its way between
 the upper  part of the tumor and  the  abdominal wall, so that a tympanitic
 resonance may be found between the liver and  the tumor.  Cases are  recorded
 in which the tumor has been  so constricted as to resemble the kidney in shape,
 and, in fact, it has  been  mistaken for a  wandering kidney.   It suffices to call
 attention also to the possibility of  mistaking a distended  gall-bladder for an
 echinococcus cyst, a cancer, a hydro-nephrosis, or an  ovarian cyst; but such
 errors  are not likely to  occur.   An  exploration of the tumor by a hypodermic
 syringe may be of assistance in diagnosis.
   The treatment must have reference to the circumstances in individual
 cases.   In  many cases no treatment is required.   Aspiration of the gall-blad-
 der may be employed if the degree  of dilatation warrant this procedure.  The
 fluid, however, is almost certain to be renewed.  If it be decided to make a
 free opening into the gall-bladder, the same precautions are to be adopted with
 reference to the formation of peritoneal  adhesions and the avoidance  of septic
 inflammation as in making similar  openings into abscesses and hydatid cysts
 of the liver.
  Sometimes, instead of a clear, bland fluid, pus accumulates in the gall-blad-
 der (empyama cystidis fellea).  The affection is  then, of  course, of a very
 grave  nature, and  is likely  to terminate fatally.   If the  diagnosis can  be
 made, the evacuation of the pus by a  free incision is indicated.
  Primary cancer of the gallPladder occurs, but in its symptoms and course
it cannot be discriminated with any certainty from cancer  of the liver, and it
therefore does not require separate  clinical consideration.
  1 In a case described by Frdmann the amount of fluid is said to have been from sixty
to eighty pounds. 
JAUNDICE,  OR ICTERUS.
631
   The parasites which are sometimes found  in  the  biliary passages have
 already been considered (p. 550).


                         Jaundice,  or Icterus.
   The presence of bile-pigment in the blood and lymph in sufficient quantity
 to give to the conjunctiva and to the  skin a yellow color, greater or  less in
 degree, constitutes the morbid condition known as  icterus, or jaundice.   The
 term cholaemia denotes the presence of bile in the blood, and under this head,
 in treating of the morbid conditions of the blood in  Part L, was embraced the
 general pathology of the affection to be now considered (p. 77).  The terms
 icterus and jaundice, of which  the latter is the more commonly used, relate to
 yellowness of the surface from the presence of bile-pigment, whereas cholamia
 implies the presence  of all of the bile-constituents in the blood.
   Jaundice is strictly never an individual disease.  It is merely an effect or
 a symptom of disease ;  but as it is an  obvious and  striking morbid  condition
 dependent on various affections, and occurring sometimes when its  causation
 is not evident, it is convenient to give it separate consideration.  This removes
 the necessity of much repetition in treating of the manifold affections of which
 jaundice is a symptom.
   The presence of bile in the blood, or cholamia,  is a result  of the entrance
 into the blood of bile after its secretion.  The  bile-pigment and  the  biliary
 salts  (the glycocholate and the taurocholate of soda) are formed within  the
 liver, and do not pre-exist in the blood.  The bile, however, contains at least
 one excrementitious  principle—namely, cholesterin.  The latter  constituent
 of bile accumulates in the blood if the secretion  of the liver be from any cause
 suspended.
   AVhether the bile-pigment be ever formed in the  circulating blood is a mat-
 ter of uncertainty.   Hamatoidin, a pigment identical with bilirubin, is often
 formed in old blood-extravasation ; and  this fact, together with other facts,
 has given rise to the  supposition that  in certain cases of jaundice  the bile-
 pigment is formed outside of the liver, probably in  the circulating blood.
 Jaundice thus produced is called hamatogenous jaundice, in distinction from
 that  caused  by  the  absorption  of bile, or hepatogenous  jaundice.   The
 hypothesis of a hamatogenous jaundice is advanced to explain certain cases
 of jaundice in which  none of the recognized causes of  the absorption of bile
 from  the liver have been found.  A hamatogenous  origin has been  urged es-
 pecially for the jaundice occasionally occurring in certain infectious diseases,
 such  as septicamia, pyamia, remittent fever, and certain cases of poisoning,
 as by phosphorus and  the mineral  acids, in which destruction of red blood-
 corpuscles doubtless occurs.   It  must  be admitted, however, that there  are
 serious objections to the acceptance of the theory of a hamatogenous jaundice,
 and that  this theory  has of late lost, rather  than  gained support.   Hamo-
 globin, which is set free by destruction of red blood-corpuscles in the circulat-
 ing blood, is eliminated by the kidneys  in the form of  meth-hamoglobin, and
 there  is no proof that it is ever converted within the blood into bile-pigment,
 although dissolved hamoglobin increases the formation of bile-pigment within
 the liver.   There is a tendency to refer many cases which some writers have
 regarded as hamatogenous jaundice—for instance, the jaundice of many acute
 infectious diseases—to a mild inflammation  of the  large bile-ducts ; but  the
 anatomical proof of this view is  deficient for a considerable  number  of  the
 cases.   Nor is the theory that the  absorption of bile  in these cases  is  the
result of lowered blood-pressure in the liver to be regarded as established.   It
must be admitted, therefore, that while a certain number of the cases of jaun-
dice formerly considered as hamatogenous are in reality of hepatogenous ori- 
632        DISEASES  OF  THE BILIARY PASSAGES, ETC.

gin, we possess no satisfactory explanation of the cause of the jaundice in the
remaining cases.
   In all cases in which we possess an adequate explanation of the causation
the cause is to be found in some obstruction to the flow of bile in its passage
from the liver to the intestine.   The  causes of such obstruction  are various,
and they may be classified—-first, as abnormalities in the interior of the  bile-
ducts ; second, as alterations in the walls of the ducts; and  third, as lesions
causing pressure  upon the bile-ducts from without.
   The most frequent of the first of these causes are plugs of mucus resulting
from simple inflammation of  the  common  bile-duct  secondary to gastro-duo-
denitis (simple or catarrhal jaundice) and gall-stones, including concretions of
inspissated bile.  Lodgment of parasites in the bile-ducts is a  rare cause of
jaundice. These parasites are lumbricoid worms, the various forms of distoma
and echinococcus.   Pus,  blood, and fibrin may block up the bile-ducts in rare
instances.
   Of the changes in the  walls of the  bile-ducts which may encroach on the
lumen  of these tubes, the  most important are inflammatory swelling, either
that of acute or of  chronic inflammation, cicatricial  thickening, and contrac-
tion following ulceration and new growths.   Congenital  stenosis of the bile-
ducts is a  rare condition.
   The  most  important of the causes which produce jaundice by external pres-
sure on the bile-ducts are tumors  and  inflammatory products.  Cancers of the
liver, of the gall-bladder, of the lymphatic glands in the porta of the liver, of
the pylorus, of the duodenum, and of  the head of the pancreas, may all cause
jaundice by compression of the common bile-ducts.   Less frequently cancer
in other situations  and other forms of tumor produce jaundice  in  a similar
way.  Hepatic abscesses  and  echinococcus cysts may compress the main bile-
ducts.   The pressure of the gravid uterus and of fecal accumulations  in the
transverse colon belongs in this group of causes.  Obstruction  may also be
due to peritoneal adhesions, which cause traction on the peritoneal fold which
contains the common bile-duct.   The  compression of a large number of intra-
hepatic ducts in cirrhosis of the liver  leads to a certain amount  of jaundice.
   The quantity of smooth muscular tissue  in the walls of the bile-ducts
appears to be too slight to support the theory of jaundice produced by  spasm
of the  ducts. Although it is possible,  it cannot be considered proven, that bile
may be absorbed, and that jaundice be  thus caused by diminution of the blood-
pressure in the liver.  This, however,  is the usual explanation of the jaundice
occurring in cases of portal thrombosis.  As has already been mentioned, bile
is not absorbed in cases of jaundice directly by the blood-vessels, but it is first
taken up by the lymphatics in  the liver, is carried to the thoracic duct, and
thence enters the blood.  Another supposed agency in producing jaundice in
certain cases is enfeebled respiration.  This  is based upon the  idea  that the
movements of the diaphragm aid  in the  propulsion of the bile, so that when
these are weakened there  may be a sufficient stasis of bile in the bile-ducts
for the production  of jaundice.
   The  jaundice wdiich frequently  occurs in from two to four days after birth,
and is  called icterus neonatorum,  has  not received any explanation which has
met with general  acceptance.   This jaundice is peculiar in the  fact that the
urine is generally free from bile-pigment, and that the blood after  death, as
well as the papilla of the kidneys,  and sometimes  other organs,  contain a
large quantity of crystalline pigment.
   Yellowness of the conjunctiva and  skin takes place after a certain amount
of bile has entered  the circulation.  Prior to the appearance of jaundice the
bile-pigment may be found in the blood, the urine, and the  liquid of  serous
cavities.   The coloration of the surface  depends on  the presence of  the bile- 
JAUNDICE,  OR ICTERUS.
633
pigment in the transuded liquid which infiltrates the tissues.   Other thin as
being equal, the intensity of the yellow color is proportionate  to the degree
of the  cholamia.    The presence of the  bile-pigment in the serum of the
blood is shown by the yellow color of the liquid beneath the epidermis if a
blister be applied.
  The urine in cases of jaundice contains bile-pigment  in  abundance, very
often hyaline casts and sometimes epithelial casts.   Not infrequently a small
quantity of albumen is present in the urine.  The presence of the pigment is
apparent to the eye, and  it gives to linen a yellow stain.  The perspiration
contains it, and the body-linen may also be stained yellow, especially from
the abundant cutaneous secretion in the  axilla.   Bile-pigment is rarely, if
ever,  contained in  the saliva, nor, as a rule, is it found in mucus, but it may
be found in  the sputa of  pneumonitis developed in a person  affected with
jaundice.  The milk of nursing women rarely contains it, although its pres-
ence  in this secretion has  been observed.  The humors of the eye do not
contain it, except  in some cases in which the jaundice is unusually intense.
The "jaundiced eye" (xanthopsia) is so rare an event that  the phrase is to
be regarded  as a  poetical  license.
  The tissues in the interior of the  body are  more or less colored.  The col-
oration  is seen especially in the areolar tissue, the serous membranes, and the
muscles.  The  substance of  the brain escapes, except in  cases in which it is
unusually infiltrated with  serum, that  is, adematous.
  Bile in the blood acts as a sedative on the circulation and nervous system.
The heart's action is usually diminished in frequency.  The  pulse frequently
falls to  50, 40,  or even lower, in cases in which the jaundice  is not associated
with acute inflammation or fever, and if thus associated the frequency of the
pulse is less than if jaundice did not coexist.   The effect is attributed to the
presence in  the blood,  not of  the pigment, but of the  biliary salts.  The
temperature of the  body may be lowered.  The respirations diminish in  fre-
quency in proportion to the  effect on the  circulation.  The  mental faculties
are dull and there is a disposition to somnolency.   Pruritus of the surface,
especially in  the axilla  and the inguinal region, troublesome particularly at
night, is an  occasional symptom.  It is sometimes a source  of great annoy-
ance.   An occasional complication  is urticaria, denoted by the  characteristic
elevations on the skin, or wheals, which present a deeper yellowness than the
surrounding integument and  occasion intense  pruritus.
  The symptoms  referable to the digestive system  are frequently due to co-
existing duodenitis  or gastro-duodenitis.  Anorexia, nausea, and sometimes
vomiting, thirst, more or less pain in the neighborhood of the  epigastrium, and
tenderness in that situation, are symptoms denoting subacute inflammation of
the gastro-duodenal  membrane.   In  cases of jaundice  disconnected from this
affection the appetite may be  but  little or not at all  impaired, and certain
articles of food are apparently digested  without difficulty.   Fatty food is
imperfectly digested, and chemical  examination of the evacuations from the
bowels shows fat in more or less abundance.   Patients have an antipathy to
fatty  articles of diet.  The nutrition for a time  may be  but  little affected,
but sooner or later, loss in weight takes  place;  and  this is progressive if the
jaundice continue.
  The appearance  of the dejections is important, as  affording evidence of the
completeness or otherwise of obstruction to the passage of bile into the intes-
tine.   If complete occlusion exist, the stools are ashy or clay-colored, owing
to the presence of fat.  On the other hand, they have more or  less of the
yellowish or brownish color of health if the obstruction be only partial.  The
feces, when  the intestines  are  devoid  of bile,  emit  an odor of putrescence,
and the  formation of gas  is  frequently  troublesome,  bile in the intestinal 
63-1        DISEASES  OF  THE BILIARY PASSAGES, ETC.

canal being an antiseptic as regards the fecal contents.  Generally, the bow-
els  are constipated, but this is  by no  means always the case, even  when
complete occlusion exists.
  Jaundice may exist for a greater or less period without giving rise to nota-
ble  disturbance.   The system sometimes tolerates the accumulation of bile
for  a long time.  Not infrequently, patients are able to be up and about as in
health, experiencing but  little inconvenience.   The symptoms and the gravity
will depend in a great measure on the pathological conditions with which  the
jaundice is associated.   If the jaundice depend on obstruction in connection
with subacute  gastro-duodenitis,  the  prognosis is  always favorable.  Simple
gastro-duodenal jaundice usually  continues for from three to six weeks.  If it
depend on the impaction  of a gall-stone  in  the  common hepatic duct,  the
recovery will depend  on  the  passage  of the stone into the intestine or  back-
ward into the  gall-bladder.   Permanent obstruction from a gall-stone or  the
pressure of a tumor involves of  course  persistence of the jaundice.  Under
these circumstances serious results may not take  place for a considerable  or
even a  long period.  Cases  have been  under my observation in which  the
nutrition of the body was  not  greatly impaired for  one, two, and even four
years.   In one case under my observation the jaundice had persisted for eight
years.   Life has continued for a  much  longer period.  Sooner  or later, how-
ever, the body wastes, the  patient becomes anamic and cachectic, the vital
powers gradually fail, and  the termination is fatal, irrespective of either  the
morbid condition  giving  rise  to the jaundice or of intercurrent affections  of
other organs than  the liver.  The color of the skin  becomes dark  or almost
black in some cases of long-persisting jaundice.  In  the majority of cases of
jaundice from  permanent obstruction, however, the  duration of life does  not
extend beyond several months.
  AVhen life is destroyed purely  in consequence of the retention of bile,  the
liver takes  on  important lesions.  The bile-ducts within  the  liver become
dilated; the gall-bladder may or  may not become distended with  bile;  the
liver is at first increased  in volume from the accumulation of bile, but subse-
quently its volume is  diminished  and  it becomes flabby and wrinkled.  There
is often a new growth of interstitial  tissue, constituting one of the forms of
biliary cirrhosis of French  writers.  The persisting distension of the hepatic
bile-ducts at length leads to an arrest of the secretion of bile.   In proportion
as the  secretion of bile is  arrested the jaundice diminishes, and  the patient
suffers from the retention in  the  blood of the excrementitious portion of  the
bile—namely, cholesterin.  In  some cases death is  preceded by  convulsions
and coma.   In these cases  cholesteracmia may be supposed to exist, but  these
phenomena in a certain proportion of cases are due to uraemia.  Post-mortem
examinations show an accumulation  of granules  of bile-pigment in the uri-
niferous  tubes when  jaundice has existed for a considerable or long period ;
and the uramia proceeds from the morbid condition of the kidneys.  Hydro-
peritoneum may occur in  the  latter period of the affection, and general dropsy
is sometimes a result of  the superinduced renal affection.
  The  diagnosis of jaundice is readily made if the examination of the patient
be made in the daytime,  but the yellowness may not be apparent by artificial
light.  The yellow  tint of the surface seen in some cases of cancer, intermittent
fever,  and chlorosis  is  readily  discriminated from slight jaundice by the
absence of yellowness of the conjunctiva, the latter  being  always  present  in
jaundice;  but to determine the causative pathological  conditions in indi-
vidual  cases is not always easy or in  all cases practicable.  The dependence
on duodenitis  or  gastro-duodenitis is to  be  inferred from the symptoms of
these affections preceding and accompanying the jaundice—namely, anorexia,
nausea, vomiting, and tenderness over or in the neighborhood of the epigas- 
JAUNDICE,  OR ICTERUS.
635
triuni.   The presence of  a  gall-stone may be inferred from the pre-existence
and coexistence of the symptoms of hepatic colic.  A tumor which presses
upon the  common duct may be discoverable by manual  exploration.   From
the character of the tumor and the coexisting symptoms its cancerous nature
may sometimes be inferred.   Occlusion  as  a result of inflammation of the
ducts exclusive of duodenitis, from  lumbricoid worms in the common duct,
and from other causes, cannot be determined during life.  The existence only
of obstruction is determinable in such cases.   Not infrequently the distended
gall-bladder may be  felt,  and this  is positive evidence that the jaundice
involves obstruction of the common  duct.
   In  the treatment of  jaundice  it has   been the custom to  prescribe
active cathartics and  emetics under  an idea of removing the obstruction by
their operation.^  If, however, the jaundice  be connected with duodenitis or
gastro-duodenitis, not only are these measures ineffectual, but  they can hardly
fail to do harm. If the obstruction be caused by  a gall-stone, its passage will
not be  hastened by these measures; and they will weaken the patient with-
out doing good if the jaundice depend on a tumor pressing on the common or
hepatic  duct.   As remedies, then, addressed  to the obstruction giving rise to
the jaundice, cathartics and emetics  are contraindicated.
   The treatment of jaundice in the majority of cases is to be addressed to a
subacute inflammation of the stomach and duodenum.  Laxatives or cathar-
tics are  required only for the relief  of constipation, and when required the
mildest  forms  are to be preferred.   There is no ground for the supposition
that mercury exerts  any special efficacy, but  a  few grains  of  calomel and
blue mass frequently  prove as mild and effective  as any form of cathartic or
laxative, followed, if  necessary, by a saline  draught.  The latter alone will
often suffice.   The saline mineral waters, such as the Congress or Kissingen
water, will frequently secure  an adequate laxative effect.  Bemedies to soothe
the inflamed mucous membranes are  useful,  such  as small doses of morphia or
some of the succedanea of  opium—namely,  belladonna, hyoscyamus, conium,
etc.   Conium has been  considered  as a remedy having special efficacy in
jaundice.   Its apparent efficacy may be  accounted for, in part by its useful-
ness as a soothing remedy and partly by  its supplanting active cathartics
and  emetics,  which are injurious.   The  diet should be bland  and  digestible.
Fatty articles of food should be excluded, and to these the patient  generally
has  an  antipathy.  A blister over the epigastrium has  seemed to me to be
useful.   Accidental  symptoms will  of  course  claim  appropriate  palliative
measures.   If a distended  gall-bladder can be  felt, pressure upon it will
sometimes  remove the obstruction, the tumor disappearing  under this pro-
cedure.   This fact I  have verified.   Pressure, however, should not be made
with such force as to  incur risk of rupture.   Gerhardt has found the induced
current of  electricity to be useful by exciting spasmodic contractions of the
muscular  coat  of the gall-bladder.1   A  bubbling sound, caused by the pas-
sage of  the bile into  the duodenum, may sometimes be heard occurring with
the disappearance of  the tumor.
   In cases of jaundice connected with the passage of gall-stones the palliation
of pain  is the chief object of  treatment.  The occurrence  of jaundice does not
add  indications to those which have  been already considered  as pertaining to
the passage of  gall-stones or  hepatic colic. (A'ide p. 533.)
   Jaundice dependent on  irremediable causes, such  as  permanent occlusion
of the biliary ducts or the pressure of a tumor, does  not admit of cure, and
the existence of an irremediable cause is to be inferred when the jaundice
persists  for several months or years.   Yet I have repeatedly met with eases
in which, after the  persistence of jaundice for  many  months, recovery at
          1 Ueber Icterus gastro-duodenalis, von C. Gerhardt, Leipzig, 1871. 
636        DISEASES OF THE BILIARY PASSAGES,  ETC.

length took place, and I have known recovery to take place  after a persist-
ent jaundice for several years.   A fecal tumor in the  transverse colon and a
movable right kidney have  been known to give rise to jaundice by pressing
on the common duct.  A fecal tumor may be removed, but, in general, tumors
so situated as to produce obstruction are persisting.  In cases not admitting
of cure the objects of treatment, as regards the jaundice, are the elimination
of bile by the renal and  cutaneous emunctories and the support of the powers
of life in order to postpone as long as possible the fatal termination.  AVith a
view to the elimination of bile, the action of the kidneys may be excited by
the vegetable diuretic remedies, and the functions of the skin maintained by
the use of the warm bath and by guarding against vicissitudes of tempera-
ture.   The  powers of life are to be supported by a nutritious diet,  together
with  all the hygienic means, moral and physical, of invigorating the system.
  In cases of jaundice ending in recovery it is to be borne in  mind  that the
yellowness of the skin continues  for some time  after  the absorption of bile
has ceased.  The coloring matter, being outside of the  vessels, remains when
the cholamia no longer  exists.   Of the continuance of  the cholamia  or of
the condition  which occasioned  the jaundice  the  urine  affords the  most
reliable evidence.  The  affection  is to  be considered as  having ended  when
the coloring matter  ceases to be  apparent in the urine.  I have known  yel-
lowness of the skin to persist for several months  after the disappearance of
bile-pigment from the urine.   In the  case in which this was observed the
jaundice  had  existed for a  year.  The absorption is  probably slow in pro-
portion as the jaundice has been of long duration.

              Functional Affections of the Liver.
   Functional affections  of the liver have hitherto held a prominent  place in
pathological speculations,  and they are  still often  mentioned by physicians in
conversing with each other and  with their patients; but in a  clinical  point
of view, with our present knowledge, the importance of the functional  affec-
tions  of the liver is in striking contrast with the frequency with which  this
organ is referred to as the source of morbid phenomena.
   It  is customary with many to  refer a certain group  of symptoms to con-
gestion of the liver.  The nature of these symptoms  and the propriety of
considering them as dependent upon hepatic congestion have already been
discussed  in the article on  Congestion of the  Liver (p. G25).
   Physiology teaches us that the liver  is endowed with various functions, of
which the most important are the secretion of bile, the production and  per-
haps  the  transformation of  glj'cogen, and the metamorphosis of the albumi-
nous and  other constituents of the products of  digestion which are absorbed
by the portal vein.
   The action of the liver upon the products of digestion which are absorbed
by the rootlets of the portal vein, although not well understood, is probably
an important one.  The liver seems to be an important, although not  the sole,
seat of the formation of urea.  It may be believed, therefore, that structural
and functional disorders of  the liver interfere with the alterations which the
absorbed  products of digestion normally undergo in the  liver, but our  know-
ledge of this subject is  too imperfect to admit of more than profitless specu-
lation.
   The views concerning abnormalities in the glycogenic function  of  the liver
have  already been considered in Part I. (p. 70).   There  remain, therefore, to
be considered only the functional disturbances in  the secretion of bile.
   Functional disorders of the biliary secretion are a morbid excess, a morbid
deficiency, and a vitiation of the  bile.   A morbid excess of bile is supposed 
DISEASES  OF  THE SPLEEN.
637
to enter  into the etiology of diarrhaa, colic, and sporadic cholera in certain
cases.  Deficiency of bile is often treated as  a functional affection under the
name of torpor of the liver, remedies being given to increase the biliary secre-
tion.  A whitish or ashy color of the stools probably is evidence  of  deficient
secretion, although this appearance may arise from undue  absorption of bile
from the intestinal canal.  Every practitioner is familiar with this appearance
of the stools in young children and after the administration of opium.   The
production of the so-called bilious stools by the use of mercury is well known.
Torpor of  the liver  is a  phrase often applied to cases  in which  the morbid
condition is obscure.  It affords an acceptable explanation  to patients, owing
to the popular notion that the liver plays an important part in the  ailments
referable to digestion and to the nervous system ; and, whatever  may be the
rationale, a mercurial cathartic or laxative often  affords relief of the  symp-
toms, which are vaguely  called bilious.   A  deficiency of precise  knowledge
respecting  excess and deficiency of the secretion of bile  as  functional dis-
orders must  be confessed, but  as regards vitiation of bile the deficiency of
knowledge is still greater.  Acrid bile is supposed to be sometimes secreted,
and  the  greenish color of the stools, often observed, especially in children,
has been regarded as denoting a morbid quality of bile.   It is not improbable
that a vitiated bile may be secreted, but it is impossible to determine whether
morbid changes be  due to a faulty secretion or to causes  acting  within the
alimentary canal; and nothing can be more  vague than to regard a vitiated
secretion of bile as a functional disorder furnishing therapeutical  indications.
                      CHAPTER   XIV.

DISEASES  OF  THE  SPLEEN.—DISEASES OF  THE PANCREAS.

                      Diseases of the Spleen.
    MOST  of the  diseases  of the  spleen are secondary to  other  diseases,
     and  they are therewith  considered.  It is desirable, however, to bring
together the various affections of the spleen, although few of them require
detailed  consideration as independent diseases.   The spleen bears to the
blood-current much the  same  relation that the  lymph-glands  do to the
lymphatic current.  This explains the frequency with which the spleen  is
involved in the various blood  diseases, particularly in  those characterized by
the presence  of infectious substances.
  Acute congestion of the spleen is one of the morbid elements in the produc-
tion of acute splenic tumor, to be presently considered.
   Chronic passive congestion of the spleen is caused by mechanical  interference
with the portal circulation.  The most important of its causes are pylephlebitis,
cirrhosis of the liver, compression of the portal vein by tumors, cardiac disease,
emphysema of the lungs, large effusions in the pleural cavity, and intrathoracic
tumors. The spleen is enlarged, dark red in color, firm in  consistence, and its
capsule is usually thickened.  The enlargement can usually be determined by
physical examination, and this is often of considerable assistance in diagnosis.
There may be complaint of a feeling of weight and tension in the left hypo-
chondrium, but in general no definite symptoms are referable to chronic pass-
ive congestion of the spleen. 
638         DISEASES  OF  THE SPLEEN AND PANCREAS.

  The spleen, next to the kidneys, is the most frequent seat of embolic infarc-
tions.  The emboli are usually derived from the left side of the heart, but they
may come from any part of the aorta above the origin of the splenic artery.
The branches of the splenic artery do not anastomose  with each other, so
that the mechanical effect of an embolus in this organ is the production of
an infarction.  Splenic infarctions are wedge-shaped, with the apex directed
toward  the  hilum of the spleen.  Splenic infarctions may be hemorrhagic,
white, or  mixed infarctions.   Most  frequently the centre  is white and the
periphery is hemorrhagic.   They are  on the average  of  larger  size than
renal  infarctions.  It is said that sometimes the  lodgment of an embolus in
the spleen is attended by a sensation of pain, but this is not proven;  nor in
fact  are we  able to refer any  symptoms to  the bland infarctions of  this
oro-an.  If life  be sufficiently prolonged, an embolic infarction terminates in
the formation of a  fibrous cicatrix which  may  contain blood-pigment  and
lime salts.
  If  the  embolus contain infectious substances, generally in the form of
micro-organisms, it produces, in addition to its  mechanical effects, suppura-
tion  leading to  the formation of an abscess.  In rare instances a gangrenous
focus is produced by an infectious  embolus.
  Embolic  abscesses are produced in many cases of acute ulcerative endo-
carditis and in  pyamia.   Such abscesses  are generally of small size  and
do not  admit of positive diagnosis.   The  symptoms are  those of the  dis-
eases  named.   These diseases are usually attended  by more or less enlarge-
ment  of the spleen, whether  abscesses  be present in  this  organ or  not.
Embolic abscesses may, however, attain a large size, especially by the coales-
cence of a number of abscesses.  Splenic abscess may be produced independ-
ently of emboli. It may be caused by wounds of the  spleen.   It rarely follows
severe injuries  without wounds which involve this  organ.   It occurs  some-
times as a complication of various infectious diseases, such as relapsing fever,
typhoid fever, and intermittent fever, where an embolic origin cannot be demon-
strated.   Abscess may be caused  by perforation  of  a gastric ulcer into  this
organ  or  by extension of suppuration from adjoining parts.  Sometimes no
cause  can be determined for an  abscess in the  spleen.  The  size  of the
abscess may be enormous.  Sometimes all of  the splenic tissue is destroyed
and only the capsule remains.  The  abscess may  burst in different directions,
as into the peritoneal cavity,  the stomach, the  intestine, the chest, and  exter-
nally.   Except when the abscess presents itself as a  fluctuating tumor a
positive diagnosis from symptoms and signs  is  impracticable.  An exploratory
puncture  may  aid in the diagnosis  by demonstrating the presence of  pus.
The prognosis  and treatment in cases of splenic abscess are essentially the
same  as in  abscess  of  the liver.  (See p. 598.)
  Acute splenic tumor is one  of  the  most important  pathological  changes of
the spleen.   By this name is designated the enlargement of the spleen  which
forms one of the most frequent and essential lesions  of many acute infectious
diseases.  Nearly every acute infectious disease may at times be accompanied
by  splenic  enlargement, but there  are  certain of  these diseases in  which
swelling of  the spleen is more constant than in others.   Acute  splenic  tumor
is nearly always present in relapsing fever, typhoid  fever, typhus fever, and
intermittent and remittent fevers.   It is usually or frequently present in
pyamia and septicamia, including puerperal fever, in epidemic cerebro-spinal
meningitis, erysipelas, acute lobar pneumonitis, diphtheria, acute  yellow atro-
phy of  the liver, acute miliary tuberculosis, the acute exanthematous fevers,
etc.   It has  been observed during the primary and the  secondary periods of
syphilis.
  The spleen is enlarged, often twice or thrice its normal size; its consistence " 
DISEASES  OF  THE SPLEEN.                  639
is soft, its color dark red or bluish-red; and upon section the pulp swells above
the surface.  The Malpighian bodies are generally invisible, but they may be
distinct or even enlarged.  The enlargement is due to active congestion and to
an increase in the number of cells in the spleen, some of which, at least, are
produced by proliferation of the pre-existing cells.   The lesion, therefore, in
acute splenic tumor is  an acute hyperplastic splenitis.   In splenic swellings
of short duration probably the change does not pass beyond active congestion.
   The acute splenic tumor of infectious  diseases is believed to be due to the
accumulation in the spleen of noxious  substances present in the blood, these
substances acting as an irritant and causing congestion and  inflammation.
That these substances,  in many cases at least, are micro-organisms seems cer-
tain.  The accumulation of these organisms, as well as of fine particles in gen-
eral, is  explained  by the peculiarities of  the  circulation in the  spleen, which
render  this  organ a kind of filter for the blood, as the lymphatic glands are
for the lymph.
   Clinically, the chief importance of acute splenic tumor is the aid which its
recognition affords in diagnosis.   In rare instances the swelling of the spleen
has  led to rupture  of  the  organ and fatal  hemorrhage into the peritoneal
cavity.  This is an accident which has occurred in typhoid fever, intermittent
fever, and other acute infectious diseases.
   Under the name of  chronic splenic tumor are included enlargements which
occur in a variety of chronic diseases, of which the most important are mala-
rial fever, leucocythamia, and pseudo-leucocythamia. A similar enlargement
is met with in  some cases of syphilis.  The enlargement  is due to a chronic
hyperplastic splenitis, but the morbid appearances vary in different diseases ;
in some cases the hyperplasia affecting especially the trabecular tissue, and in
others affecting uniformly the cells  and the trabecules.   These differences are
considered in connection with the different diseases in which chronic splenic
tumor  occurs.
   Chronic interstitial  splenitis occurs   sometimes without apparent cause,
although in most cases it is referable  either to malaria  or to syphilis.
   Enlargement of the  spleen, acute or  chronic, is not  attended  with much
pain  or with tenderness on  pressure.   If not greatly enlarged, there may be
no local symptoms directing attention to  an affection of the organ.   If much
enlarged, its weight  occasions a sense of uneasiness and tension in the left
hypochondrium.   Disconnected  from  the pathological  associations under
which  it is  generally  presented, it may  exist without any  notable general
symptoms.
   Splenic  enlargement  is generally ascertained without difficulty, by palpa-
tion  and percussion.  In some cases the enlarged organ extends upward,
pushing up  the diaphragm, and causing an evident projection of the false
ribs of  the  left side of the  chest.  Its  upper border is accurately indicated
by the  line of  demarcation between pulmonary resonance and flatness on per-
cussion, and the lower border  is determined, approximately, by finding the
upper limits of tympanitic  resonance.  In other cases the organ  is dragged
downward by its weight, and it may descend  as low as the  brim of the pelvis.
Under  these circumstances,  if the abdominal walls be thin and  relaxed, the
organ may be  grasped by the hand and restored to its normal position.  The
form will serve  to  distinguish  it from  the  other  abdominal tumors.   The
notches on the anterior border may sometimes be felt through the abdominal
walls.  An enlarged spleen is depressed by the act of inspiration and recedes
in the  act of expiration.  Its normal limits  in  the left  infra-axillary region
are the ninth  and eleventh ribs.   AVhen  enlarged, its lower border  extends
downward and anteriorly.  Pulsation  of an enlarged spleen,  in connection
•with  aortic  regurgitation, has  been observed. 
6-40'       DISEASES OF THE SPLEEN AND PANCREAS.
  The treatment of acute enlargement involves the indications belonging to
the infectious diseases with which it is associated.   Associated with malarial
fever, experience shows  a special influence  of  large doses of quinia, salicin,
and other antiperiodic remedies upon  the  spleen.  These remedies are also
indicated in chronic malarial enlargement.   There  is ground for attributing
to quinia, given  in full doses, an  effect upon the  enlargement in  other  infec-
tious diseases than malarial fever.  The treatment in chronic enlargement not
due to malaria has reference to the associated diseases—namely,  cirrhosis of
the liver, leucocythamia, etc.   There is no  special course of medication  to be
pursued.  Generally,  chalybeate  tonics, continued steadily for a long  time,
are useful.  They are  indicated  in  proportion as the  symptoms and  signs
denote anamia.   Changing the form  of the chalybeate tonic from  time  to
time is important.  DaCosta has reported a case of splenic  leucocythamia
in which an apparent cure was  effected by the hypodermic injection of ergot.1
  Extravasation  of blood sometimes occurs in connection with vascular engorge-
ment of the spleen, and the hemorrhage may lead to rupture of the capsule and
the escape of blood into the peritoneal cavity. This has been observed in  cases
of intermittent fever, of typhoid fever,  and  during an epileptic paroxysm.   It
also occurs in connection with pregnancy, both before and after labor.  Death
may take place immediately from the loss of blood, and  in most of the  cases
which  have been observed  the duration of life  after  the rupture has not
exceeded  twenty-four hours.   The symptoms  resemble those which follow
intestinal  perforation, and  the differential  diagnosis cannot  be  made  with
positiveness.  AArere it practicable to  recognize  the accident  by the symp-
toms, the treatment would  be the  same as  in cases  of perforation—namely,
opium in full doses, with perfect quietude  of  body.   It would be proper  to
apply  cold over the abdomen.  Nothing is to be  expected  from  treatment
beyond palliation.
   The different  structural affections which  have been considered  as seated  in
the liver  are sometimes found in the spleen—namely, waxy degeneration,
syphilitic growths,  tuberculosis, cancer, and hydatids.  These may  involve
the whole or only a portion of the  organ.   They  occasion enlargement,  in
some instances  giving rise  to  splenic  tumors, properly so called, of greater
or less size.
   Waxy degeneration  of the spleen  rarely exists except in connection with
a similar affection in other  situations,  as in the liver, kidneys, and  intestinal
canal.   There are two forms of waxy spleen—namely, the sago spleen and the
diffuse waxy spleen.  In the former  the Malpighian  corpuscles are chiefly
affected, in  the  latter the splenic pulp.  The enlargement of the organ, as a
whole  or in part, is sometimes very great.   The diagnosis is to be  based on
the affection of  other organs and the causative  conditions—namely, suppura-
tive disease  of  bones or cachexia, especially  syphilis.
   Tuberculous disease may be manifested anatomically either by miliary  gran-
ulations or by cheesy collections called solitary  tubercles.   The former are
almost invariably present in the acute miliary tuberculosis of adults and in
tuberculous disease affecting children.   The spleen is very rarely the seat of
a  primary tuberculous affection.   The organ becomes in some  cases mode-
rately enlarged. Pain  and tenderness are rarely  present, and the enlarge-
ment is generally the only evidence that this organ  participates in  the tuber-
culous disease.
   Cancer of the spleen  is  never  primary,  and its occurrence is infrequent.
It is always  secondary to cancer of the liver or of some other of the abdom-
inal organs.  Cancer  is to be inferred from the development of splenic
enlargement or  tumors  in  the course of cancer seated elsewhere.
                1 Vide Am. Journ. of Med. Sciences, January, 1875. 
AFFECTIONS  OF  THE PANCREAS.              641
  Syphilitic affections of the spleen in the form of gummata, causing enlarge-
ment  or appreciable  tumors, are to  be diagnosticated by taking into account
other  antecedent or coexisting evidences  of syphilis, and  by excluding waxy
degeneration.  As stated by  Mosler, syphilitic affections in this organ " are
more frequently the object of anatomical than of clinical observation."
  Hydatid tumors in the spleen are rare.  Their history and  the  means  of
diagnosis  are the  same as when they are seated in the liver.  (Aide p. 61S.)
  AVith reference  to the  anatomical characters, pathology, prognosis, and
treatment of the foregoing structural  affections of the spleen, it  suffices to
say that in these regards they are the analogues of the corresponding hepatic
affections.
  Our present knowledge does not enable us to understand fully  the  conse-
quences o*f the impairment or loss of the functions of  the spleen.   It is well
known that this organ  may  be removed from inferior animals without the
destruction  of life or serious injury to health.  This  fact goes to show that
whatever may be its functions, they are adequately performed by other organs
in its absence.   There is reason to believe  that this statement  is applicable
to man as well as  to inferior animals.   A case was communicated to  me in
1861  by Dr. John L. Alston of Texas, in  which,  after an  abdominal wound
by a musket-ball, a portion of the spleen protruded three  and a half  inches
in length  and two and a half inches in width.  The protruding portion was
ligated and  it dropped  off on the fourth  day.   Recovery took place rapidly,
and  the patient was in a short time  discharged from the  hospital entirely
well.   Cases have been reported  in which the entire  spleen,  having escaped
through a wound,  was removed, recovery taking place  and the health remain-
ing good for years afterward.   There have been several cases recorded of con-
genital absence of the spleen without apparent detriment to health.   Within
the last twenty-five  years several surgeons have ventured upon the removal
of this organ for great enlargement.  In the  majority of  instances patients
have died from the immediate  effects of the operation.  In view of the dan-
ger the operation is not  warrantable.
   The spleen  is sometimes dislocated downward as an effect of tight-lacing
or other causes not always apparent (wandering spleen).   The organ may or
may not be enlarged.  It is  important to distinguish  between the dislocated
organ and simple enlargement.  If dislocated, the organ is to be restored by
pressure with the  hand and retained in its normal situation by an appropriate
mechanical  supporter.

                    Affections of the  Pancreas.

   Owing to their infrequency and to their obscurity as  regards diagnosis, affec-
tions of the pancreas require in  this work  but a brief notice.   This gland
may  be the seat  of inflammation,  acute or  chronic.  Of all the glandular
organs—liver, ovaries, testes, kidneys, etc.—the pancreas is perhaps the least
 liable to become  inflamed.   Acute pancreatitis has been found, on examina-
tion after death, to  occur in  cases  of continued fever, of puerperal fever, of
pyamia,  and apparently  as  a result  of the  employment  of mercury.  The
morbid appearances denoting  acute  inflammation are hyperamia, softening,
 enlargement, and  suppuration.  Gangrene  has been  observed,  and even the
 discharge of necrosed portions of  the pancreas by the rectum.   The symp-
 toms which have  been observed are, pain  referable to the epigastrium, vom-
 iting, diarrhaa, chills, and  more or  less  febrile  movement.   The data for
 determining the clinical history of the affection are insufficient,  A discharge,
 by vomiting and stool, of a liquid resembling saliva, supposed to  be the pan-
 creatic secretion, has  been thought to be a diagnostic symptom, but there  is
41 
642        DISEASES  OF THE  SPLEEN AND PANCREAS.

no reliable evidence of the  correctness of this opinion.   The  presence of fat
in the stools has been supposed to be a diagnostic symptom.  The diagnosis,
with our  present knowledge, is impracticable.  An abscess of the pancreas
has been  known to open into the  stomach.   Chronic pancreatitis is, if pos-
sible, even more obscure, as regards diagnostic symptoms, than  the  acute
form of the disease.  In a case observed by AVilks death followed extreme
emaciation without any symptoms pointing to the seat of the disease.1   From
what has been stated with regard to the  diagnosis, it follows that it is impos-
sible to  form an opinion  as to the proportion of cases in which either acute
or chronic pancreatitis ends in recovery.
  The pancreas may be the  seat of either primary or secondary cancer.2   Pri-
mary cancer most  frequently  begins at the  head of the  pancreas.   It is
usually  of the scirrhous variety.  Medullary cancer, colloid cancer, and cylin-
drical-celled epithelioma  also occur  in this situation.  Enlargement of the
head of the pancreas from chronic inflammation, cancerous disease, or the
formation  of cysts may  constitute a tumor discoverable  by manual explora-
tion.  The diagnosis involves its discrimination from  other tumors in the
same  situation.  It is  most likely to be confounded with aneurism of the
aorta and  cancer of the  pylorus.   A pulsation  may be  communicated to the
tumor from  the aorta, and this  is suggestive of aneurism.  The diagnostic
symptoms and signs of aneurism of the abdominal aorta are to be sought for,
and this affection may be excluded by their absence.  A positive discrimina-
tion between cancer of the pancreas and cancer of the pylorus can scarcely be
made.  The main points which weigh in favor of cancer of the pancreas are, less
prominence of gastric symptoms than in  cancer of the stomach (vide p.  431),
the presence of jaundice,  fatty stools, and sugar in the urine.  The  connection
between structural disease of the pancreas  and fatty diarrhaa has been con-
sidered  in  treating of the latter. (Aride p. 510.)   The presence of free fat in
the alvine  dejections, taken  in connection with  a tumor supposed to be an
enlarged pancreas, is undoubtedly a point of much weight in the diagnosis.
The absence of fatty dejections, under these circumstances, is not proof against,
but their  existence is strong evidence for,  the supposition  that the tumor is
pancreatic.  Glycosuria  has been observed in several cases of cancer of the
pancreas.
  Enlargement of the head of the  pancreas may give rise to serious results
from pressure upon adjacent parts.   The duct  leading from  the  pancreas is
sometimes compressed, and dilatation of its branches within the organs ensues.
Pressure upon the ductus communis choledochus, involving obstruction to the
flow of  bile, is followed by the retention of this secretion,  causing persistent
jaundice,  dilatation of the  bile-ducts, and at length disorganization of the
liver.    An  enlarged  pancreas  may cause obstruction of the  pylorus or
duodenum, and this renders it difficult to  differentiate the affection from cancer
of the pylorus. Pressure upon the portal vein may exist to such an extent as
to give  rise to hydro-peritoneum.
  Disease of the pancreas,  particularly  atrophy, has been  found associated
with glycosuria sufficiently often to render not improbable a pathological con-
nection  with the latter disease in some although not in all cases.
  An abnormal deposit of fat occurs in  the  pancreas in two forms: first, as
fatty degeneration of the glandular  cells of the pancreas;  and  second, as
lipomatosis, or development of adipose tissue between  the acini, which may be
thereby obliterated.  AVe know no  symptoms referable to  lipomatosis of  the
pancreas.
  1 Pathological Anatomy.
  2 For an analysis of 37 cases by DaCosta, vide Proceedings of the Pathological Society
of Philadelphia, 1858. 
AFFECTIONS OF THE PANCREAS.
643
  Zenker1 and Klebs have described cases of sudden death in which the only
important lesion found was hemorrhage within  and around the pancreas, com-
bined with fatty degeneration.  Similar  cases  have been reported under the
name of acute hemorrhagic pancreatitis, in which the interstitial tissue of the
gland was infiltrated with  lymphoid cells.   Necrosis of adipose  tissue in and
about the pancreas has also been observed in several cases.  Sudden  death has
also  been known  to  attend carcinoma  of the  pancreas.2  The  symptoms in
some of these cases have been severe epigastric or abdominal pain, sometimes
icterus, vomiting,  subnormal  temperature, and  collapse.   The explanation
offered by Zenker for the sudden  death  is the occurrence of a reflex paralysis
of the heart from a coincident  affection, by pressure or otherwise, of the caliac
plexus and semilunar ganglion.
  Finally, calculi sometimes form within the pancreatic ducts, varying in size
from that of  a pea to  an  almond.   These have  been found in considerable
number.   In their journey along the excretory passage to the duodenum they
may occasion  severe pain  resembling that caused by biliary calculi.   Parox-
ysms of pain due to the passage of pancreatic calculi or attacks of pancreatic
colic are  doubtless  sometimes  attributed to gall-stones, and  it is not practica-
ble, with our present knowledge, to make the differential  diagnosis.   The dif-
ferential  diagnosis is not, practically, very important, since the indications for
treatment are the  same in  either case.  Clinical  observation with reference
to' the presence of free fat  in the dejections may  show this symptom  to  be
present in  cases  in which, without special attention, it is overlooked; and it
may be found that this symptom  is of much value in the diagnosis of affec-
tions of  the pancreas.3
  A cystic tumor of the pancreas may attain to a large size.  Dr. N. Senn has
reported  a case in which occlusion  of the common  duct  led to the  formation
of a  tumor containing three quarts of liquid. Laparotomy and  the removal of
the contents of the cyst were  followed by complete recovery.4

  1 Tageblatt d.  1ftten Versammlung Deutscher Naturforscher.
  2 Haber, Deutsches Archivf. klin. Med., Bd. 15, p. 455.
  3 For a full consideration of affections of the pancreas, the article by Friedreich, in
Ziemssen's Cyclopaedia, Amer. ed., vol. iii., and the article  by Humbert Moliere, in the
Nouveau Dictionvaire de Medecine el de Chirnrgi.e  (1873), may  be referred  to; also,
Chvostek, " Klinische PjeitrLige zu den Krankheiten des Pancreas,"  Wiener med. Blatter,
1879, No. 33  et  seq.   A'ide, also, an elaborate article on "Calculus and Other Affections
of the Pancreatic Ducts," by George Woodruff Johnson, M. D., in the Am. Journ. of Med.
Sciences, Oct., 1883.
  4 A'ide article in the Journal of the Am. Med. Association, Oct. 3, 1885.  Six additional
cases, being all to be found in medical literature, are reported in this article. 
         SECTION"  FIFTH.

DISEASES AFFECTING THE  NERVOUS SYSTEM.
                         CHAPTER   I.

DISEASES RELATING  TO THE  CEREBRAL  AND  THE SPINAL
                            CIRCULATION.

Cerebral Hyperaemia.—Cerebral Anaemia.—Cerebral Embolism and Thrombosis.—Cerebral
   Hemorrhage.—Localization of Cerebral Diseases.—Meningeal Hemorrhage.—Insola-
   tion, or Sunstroke.—Hyperaemia and Anaemia of the Spinal Cord and its Meninges.—
   Spinal  Hemorrhage.

    OF the diseases affecting the nervous system, the greater number relate to
     the  nervous centres—the  brain  and spinal cord.   Important affections,
however, are seated in the nervous trunks or their branches; that is, in  the
peripheral portion of the cerebro-spinal system.  I shall consider first those
diseases  of the brain and the spinal cord, together with their meninges, which,
as regards pathological character, are common to all the anatomical systems—
namely,  hyperamia, hemorrhage, embolism  and thrombosis, inflammation, and
various structural lesions—taking up afterward  the  diseases peculiar to  the
nervous  system,  or the neuroses.   This chapter will embrace  hyperamia,
anamia,  embolism and  thrombosis, hemorrhage, and  insolation, or sunstroke,
these diseases forming a group in which are involved morbid  conditions per-
taining especially to the circulation within the  skull and the spinal canal.


                       Cerebral Hypersemia.

   From  the assumption that the contents of the cranium are incompressible
by any amount of force which the  heart  can exert through the arteries, and
from the fact that they are enclosed in an  air-tight case, Monroe, in the last
century,  drew the conclusion that the quantity of blood  within the skull can
never vary.  The  incorrectness of  this conclusion, however, has been abun-
dantly established, particularly by Magendie on rational grounds, and  by  the
direct observations of  Donders.  Magendie demonstrated that the cerebro-
spinal fluid is an important regulator of the cerebral  circulation, inasmuch as
it  recedes from the cranial cavity when the blood-vessels become distended,
and is increased  when the quantity  of blood in the intracranial vessels is
diminished.  It has since been shown  that a similar and  an equally important
role  is played by the  lymph in  the  perivascular  lymph-spaces,  Donders
adopted the ingenious device of observing in animals  the degree of fulness of
intracranial vessels through a  glass plate accurately adjusted and hermetically
sealed, in an opening made through the skull  by trephining.   He and after-
ward other observers were able to prove conclusively by this method that  the
amount of blood in the intracranial vessels  under various influences increases
and  diminishes.   AVhile  the  possibility of cerebral  hyperamia  is now uni-
       644 
CEREBRAL  HYPEREMIA.
645
 versally admitted, there is not the same unanimity as to its frequency, import-
 ance, and etiology.  AVithin the last few years there has been a decided tend-
 ency, especially among neurologists, to deny the clinical importance of this
 affection; but while it is  to be admitted that in former  times  the diagnosis
 of cerebral congestion was made  too frequently and upon  insufficient evi-
 dence, and while our knowledge of its pathogeny and symptomatology is still
 imperfect, there remains  sufficient evidence of its occurrence and importance
 to justify its careful consideration.
   The morbid appearances of congestion of the brain are  to be sought chiefly
 in the brain-substance, and not in the meninges.  The mistake is too  often
 made of deciding upon the existence of  cerebral congestion merely from ful-
 ness of the meningeal veins.  Distension of these vessels with blood  is no
 index of cerebral hyperamia during life, being  dependent  upon the position
 of the body after death,  the length of time during which the blood remains
 fluid, the manner of dying, and whether the head or the trunk be opened first
 at the post-mortem examination.   It is probable that transient hyperamia of
 the brain, as of  other  organs,  may leave no trace of its existence after death.
 AVhen,  however, the  congestion is intense and  has  lasted some  time, there
 are found flattening of the convolutions from turgescence of the brain, a rosy
 color mixed with the  gray of the cortical substance,  and red points (puncta
 vasculosa) disseminated over the  cut surface of the white matter.   The ves-
 sels of the  meninges, especially the  smaller vessels, are  also injected.   The
 perivascular spaces are diminished in size or they disappear.   Cerebral hyper-
 ieniia, especially of the passive or  venous variety, may be followed  by transu-
 dation of serum  into the meshes of the pia mater, the choroid  plexuses, and
 the ventricles.  The presence of a large amount of reddish-brown amorphous
 pigment in the walls of the vessels and in the perivascular spaces has been
 held as an evidence of long-standing congestion.  The presence of a certain
 amount  of  this  pigment  is physiological rather  than pathological.
   Congestion  of the brain, as of other  parts, may be active or passive.  In
 active  congestion an increased amount of blood  is brought to the cerebrum
 by the  arteries;  in passive congestion the blood  accumulates in the brain in
 consequence of  some  obstacle to  its return by  the  veins.
   It is thought that a full or plethoric habit predisposes to active determina-
 tion of  blood  to the brain.  Increased force of the heart's  action, especially
 when resulting  from  simple  hypertrophy of  the left ventricle, may cause
 active cerebral congestion.  Hypertrophy of the  left ventricle is, in the great
 majority of cases, developed in compensation of  some obstruction to the cir-
 culation, and  has no  tendency  to produce cerebral  congestion ; but in the
 hypertrophy accompanying certain forms of chronic  Bright's disease, and in
 the rare cases of so-called idiopathic cardiac hypertrophy,  active  cerebral
 congestion is  sometimes  developed.
   Paralysis  of the vaso-motor nerves supplying the cerebral arteries and irri-
 tation of vaso-dilator nerves are to be reckoned  among the causes of  active
 cerebral  hyperamia.   It has been experimentally demonstrated that division
 of the sympathetic in  the neck causes hyperamia of the intracranial  vessels.1
 It may be suspected that  strong  mental  emotion may cause hyperamia by
 an affection of the vaso-motor nerves.   Nitrite  of amyl produces  cerebral
 congestion in this way.  There are reasons for believing that  one form of
 migraine or  hemicrania is the result of unilateral vaso-motor  paralysis caus-
ing cerebral congestion.2
   Collateral fluxion of the cerebral vessels, resulting  from  some obstruction
to the flow of  blood from the aorta into  other branches, has been considered
                 1 Ackermann, Virch. Arch., 1858, Bd. 15, p. 431.
                2 Mollendorfl; ibid., Bd. 41; Berger, ibid., Bd. 59. 
646  DISEASES OF THE CEREBRAL  AND  SPINAL  CIRCULATION.

as giving rise to cerebral  hyperamia.   As causes of this  collateral fluxion,
have been regarded  stenosis of the aorta at the point of entrance of the
ductus Botalli, compression of the  abdominal aorta and its branches by dis-
tended intestine, tumors and exudations,  and obstruction  to the  cutaneous
circulation by the action of cold.   The adequateness of these causes, how-
ever, is doubtful.  Excessive mental or emotional activity and alcoholic stim-
ulation are efficient causes.   Cerebral hyperamia is an element, but jtrobably
not the most important one, in insolation.

   Rapidly-induced  active congestion of great  intensity  may produce sudden
coma which  may disappear after a few hours or  may prove speedily fatal.
This is the pathological explanation of apoplectic attacks in the cases which
have been distinguished as  cases  of  congestive apoplexy.    An  instance of
sudden death from active  congestion  incident to simple hypertrophy of the
heart has fallen under my  observation.   AVhen  the  encephalic  functions
are thus  suspended, this effect is attributable to  intracranial pressure.  The
coma is produced by  the pressure of the blood within the vessels, as it is by
the extra-vascular pressure in cases of meningeal  hemorrhage.  The pressure
of the blood  in the  large vessels  interrupts the circulation  in the brain-sub-
stance ;  and hence the suspension of the cerebral  functions.   It is apparently
a paradox that an over-accumulation of blood within the skull should cause
coma, and perhaps  destroy life by depriving the  mass  of the brain of a clue
supply of arterial blood, yet the fact  is sufficiently intelligible.  Apoplexy
attributable to active  hyperamia is a rare  event,  but of its  occurrence there
can  be no doubt.
   The symptoms of active hyperamia of  more or less intensity, but falling
short of a degree sufficient to produce coma, are as follows:  Pain in the head
varying in degree, sometimes intense, with  a sense of heat, fulness, bursting,
or weight. The  pain is not limited to one side or to any particular part of the
head.  There is inability to sleep, or if sleep be obtained it is incomplete and
unrefreshing.  Delirium sometimes occurs, and if present it is active.  This
symptom  occurs especially when the congestion is due to excessive alcoholic
stimulation.  Convulsions occasionally occur in the adult.  They are less infre-
quent in  infancy, but active congestion as a primary affection is not frequent
in infantile life.   The countenance is usually but not invariably flushed, the
eyes are suffused or injected, with intolerance  of light and sometimes scintil-
lations.   The head  is hot; the carotids and the  temporal arteries  pulsate
strongly; and the patient is conscious  of a throbbing sensation in  the head.
Inability to control  mental  operations, mental  confusion,  and momentary loss
of consciousness are occasional symptoms,  and also vertigo,  tinnitus aurium,
and  some embarrassment in speech.  The symptoms are more or less marked
in proportion as  the hyperamia is greater or less in degree.
   Simple hyperamia  is merely a functional affection.   It involves no lesion ;
and if the congestion be removed without much delay the structures  are left
intact.  In a slight  or moderate degree it involves no immediate danger.   As
already stated, however, it may be developed rapidly in a sufficient degree to
produce apoplectic coma, which sometimes  proves speedily fatal.  Congestion
may prove an exciting cause of cerebral hemorrhage if  the minute  arteries
of the brain  be the  seat of  miliary aneurisms  or other lesions.  AVithout
morbid changes in  the coats of the  vessels  cerebral hyperamia, however
intense, is very  rarely causative of hemorrhage.
   The diagnosis of congestive  apoplexy  involves the  discrimination from
sudden coma  caused by cerebral or meningeal hemorrhage, cerebral embolism,
alcoholic  intoxication, and uramia.   The differential points cannot be stated
without anticipating  the clinical histories of these affections.   Suffice it to 
•  CEREBRAL HYPEREMIA.
647
 say here that apoplexy from cerebral hemorrhage and embolism is excluded
 by the absence of hemiplegic paralysis, and  that  the  svnn.toms pointing to
 congestive  apoplexy are those which denote a determination  of blood to&the
 head, such as  a  flushed countenance, strong pulsation  of the  carotids,  etc.
 Circumstances  causative of active hyperamia are  also to be considered, such
 as simple hypertrophy of  the left ventricle,  alcoholic  excess, mental excite-
 ment, etc.
   Intense active hyperamia calls for bloodletting.  Relief is obtained most
 promptly by  this measure.   If the symptoms do not denote a degree of con-
 gestion sufficient to call for bloodletting, relief may be obtained "by the cold
 douche, ice to  the  head, stimulating hot  pediluvia, dry cups  applied to  the
 neck, and an active purgative.   The bromide of  potassium  and  the other
 bromides are  potential remedies, the rationale of their operation being  that
 they diminish  the  amount of  blood  within the  cranium.   They may be*
 employed  when the degree of  congestion does not  indicate  either  blood-
 letting or active purgation.  Faradization of  the cervical sympathetic nerve
 and ergot relieve active congestion by inducing contraction of the intracranial
 arteries.  Antimony relieves by its  sedative effect upon the heart, but it
 should not be given in  doses which  produce  vomiting.   Sinapisms  and other
 excitants of the skin relieve by revulsion.
   These measures are  for  the removal or diminution of existing congestion.
 The  treatment, in  addition, should  embrace, if possible, the removal of  the
 causes, and if the patient be of a full habit, regulation  of diet and occasional
 saline laxatives are advisable.

   Passive congestion differs  from  the  form just considered.  Intracranial pres-
 sure  from over-distended  vessels exists alike in both, but in active conges-
 tion  there is  an overplus of arterial blood, and in passive congestion there
 is an excess of  venous blood.  This difference accounts for disparity in  the
 symptoms.
   In a degree  to constitute a morbid  condition passive  congestion may be
 produced by  any mechanical impediment  to  the return  of blood  from the
 head.   This may be due to pressure on the jugular veins in cases  of goitre,
 or of enlargement of the lymphatic  glands of the  neck, and by the pressure
 of an aortic aneurism or other tumors on  the vena cava.   Prolonged efforts
 of expiration, as in  some forms of spasmodic cough  and in playing on wind
 instruments, have this effect.  Diseases of  the lungs occasioning interference
 with  the pulmonary circulation, such as  pleuritis with  large  effusion  and
 emphysema, give  rise to passive congestion by leading to an overloading  of
 the right cavities of the heart.   It is incident to certain diseases  of the heart,
 especially to obstruction at  the  right side  of  the heart from valvular lesions
 on that side, but more frequently from dilatation of the  right ventricle  and
 auricle, together with  tricuspid  insufficiency  as a  result of  mitral lesions.
 Obstruction or obliteration of the cerebral sinuses  by coagula induces pass-
 ive congestion in the communicating  veins.   Diminished force  of the arterial
 circulation—that is, weakness of  the vis a  tergo—is also a cause.
  The symptoms denoting passive  congestion are somnolency, dulness  of
 mind, blunted  perceptions, and sometimes in children convulsions. Throbbing
 of the carotids  and temporal arteries, active delirium, increased  heat, and
 other symptoms denoting active congestion are wanting.  The  veins of the
 head  are turgid, and the face not infrequently is cyanosed.  The symptoms
 are due  in part to intracranial pressure, and  in part to the excess of venous
or the deficiency of arterial blood.
  Passive congestion of the brain is to be considered as not an individual
aff'ection, but  a morbid element entering into various  affections.  AVhen 
 648   DISEASES  OF THE  CEREBRAL AND SPINAL CIRCULATION.

 dependent on a mechanical impediment to the return of blood from the head,
 caused by cardiac lesions, tumor of the neck, etc., the object of  treatment is,
 if possible, to diminish the obstruction.   It  can do no good to  diminish the
 mass of blood by bloodletting.   It  is doubtful  if aught is to be effected  by
 revulsive measures.   Anything  which weakens  the force of the circulation
 tends to increase the congestion.  If dependent  on feebleness of the circula-
 tion,  the  therapeutical indications are to remove, if possible, the causes  of
 exhaustion, and to increase the force of the circulation by digitalis and other
 cardiac tonics, stimulants, and nutritious diet.   The degree of toleration of
 great venous  congestion in  some instances—for example, in  dilatation of the
 right side of  the heart or when an aneurismal tumor presses on  the descend-
 ing vena  cava—is worthy of  note, as showing  that symptoms are probably
 often incorrectly attributed to this cerebral  condition.

   In  the  foregoing account of cerebral hyperamia reference has been had to
 this condition as general;  that is, affecting the entire encephalon, and not lim-
 ited to certain portions of the brain.  Hyperamia more or less circumscribed
 occurs in connection with tumors which  may produce obstruction of vessels
 or cause a determination of blood within a limited area.   Of these two modes,
 the former gives rise to passive, the latter to active congestion.  Passive con-
 gestion, limited more or less in extent, is  a result of thrombosis of veins and
 also of  both thrombosis and embolism of  arteries.


                          Cerebral Anaemia.

   In  cerebral  anamia the brain  is pale.   The puncta vasculosa in the white
 substance are  few or absent. The contrast in color between the gray and white
 substance is less marked than normal.   The perivascular spaces  are  dilated.
 Cerebral anamia is often accompanied by increase in the amount of cerebro-
 spinal fluid in the  subarachnoid  space and by serous transudation into the
 ventricles.  This adematous condition of  the  brain is often found in persons
 who have died of wasting  diseases and who may not have presented any cere-
 bral symptoms during life.  A wet brain,  as it is  called, is often found as the
 chief  pathological lesion in individuals who  have  died of acute  or  chronic
 alcoholism, and who may have been comatose during the  last hours of life.
   The quantity of blood sent to the brain is diminished whenever the mass
 of blood in the body undergoes diminution, as after hemorrhages, and in all
 diseases in which the constituents of the  blood  are expended without a pro-
 portionate renewal  by means  of  alimentation.    An  over-accumulation  of
 blood in other organs than the brain has the same effect.  Mitral obstruction
 or regurgitation also occasions a defective supply of blood  to the brain.  An
 increase of the subarachnoidian liquid and adema of the  brain, which may
 be effects  of venous congestion, must diminish the amount of arterial blood
 by pressure  on the cerebral arteries.  An  obstacle to the passage of blood in
 the distributing arteries may arise  from  their spasmodic contraction excited
 by influences  exerted through the  vaso-motor  nerves; and  certain mental
 emotions which are accompanied by notable pallor of the face and a tendency
 to syncope produce this effect.  Anamia from vaso-motor spasm exists in the
 first stage of an epileptic paroxysm.
  A deficiency of arterial blood in either the whole or a part of  the brain is
 an important pathological  element in certain affections of the nervous system
 which are to be presently  considered, the  deficiency arising from plugging of
a cerebral artery (embolism and thrombosis), the pressure of a  clot, oAhe
products of inflammation  (fibrin,  serum, and pus), and of tumors of dif-
ferent kinds.   Inasmuch  as the red globules are the chief constituents of 
CEREBRAL  ANEMIA.
649
the blood on which  depends the normal condition of the nervous centres, a
paucity of these as regards  morbid effects is equivalent to a diminished sup-
ply of arterial  blood  to  the brain.  Cerebral anamia, therefore, is  incident
to impoverishment of the blood.   Thus produced, it is an important element
in many affections.  Cephalalgia, mental  depression,  hysteria,  and the phe-
nomena referable  to nervous asthenia  are often attributable  to a deficient
supply of fully oxygenated  blood to the brain in consequence of its impover-
ishment, or, in other words,  a morbid  deficiency of  the carriers of oxygen—
namely, the red globules.   Impoverishment of the blood, together with fee-
bleness of the circulation, resulting from intestinal  transudation, occasions in
children that condition of semi-coma described by  Marshall Hall  under  the
name " hydrencephaloid affection"—a condition involving, with deficiency of
arterial blood or of red globules, venous congestion.
   The immediate  effect of  a sudden and considerable  diminution  of  arterial
blood in the brain is  syncope.   Consciousness is  lost, the face  presents a
death-like pallor, and  convulsions  may occur.  Syncope  occurs in cases of
abundant hemorrhage or after a  copious venesection, and it may  be pro-
duced by feebleness of the  heart's action  without any loss of blood.  The
phenomena of syncope are due to a certain deficiency of arterial blood in  the
brain.  It is especially liable to occur when the mass of blood  in the  body is
deficient; and  impoverishment of the blood also predisposes to it, inasmuch
as the efficiency of blood in maintaining the functions of  the nervous system
depends chiefly on a  normal quantity  of  the  red  globules.   Epileptiform
convulsions  were  produced  by Kussmaul  and Tenner  in  rabbits by tying
the arteries  which supply the brain. Convulsions are not infrequently symp-
tomatic of the anamia induced by severe  post-partum  hemorrhage.   Coma
and paralysis in cases  of cerebral hemorrhage, embolism, etc. are attributable
to an interruption  of the free circulation of arterial  blood  in the substance of
the brain.  Notable diminution of the arterial blood sent to  the brain  may be
tolerated in  a remarkable degree.   This fact was exemplified in a case which
came under my observation in which were absence of arterial pulsation in
both  upper  extremities and an  extremely feeble pulsation  in  both carotids,
the autopsy  showing  complete  embolic occlusion of the innominate artery,
with  complete  occlusion of the left subclavian artery, and the left  carotid
artery so nearly occluded  as to admit of the passage only of a fine probe.
There were  aortic lesions  and the heart  was found  enlarged.   The  patient
suffered from  frequent attacks  of  vertigo and blindness, and was incapable
of taking any active  exercise.   Pressure  on the carotids produced syncope.
There were no other noteworthy cerebral symptoms, and death  was due to an
attack of  pneumonia.
   The treatment of syncope  embraces  measures to increase the quantity
of oxygenated  blood  sent to the  head.   Recumbency,  with  the head  low
to  secure the  effect  of gravitation,  is important.   Internal  stimulants to
increase the force of  the heart's  action are indicated.   Dashing cold water
upon  the face is an efficient  measure which acts  by causing deep inspiratory
efforts.  The application of the  vapor  of ammonia to the nostrils has  the
same  effect.  These  measures generally are promptly successful, unless  the
syncope be  caused by an  excessive  hemorrhage  or the loss  of blood con-
tinue.   If not  successful, another  efficient  measure consists in compressing
the abdominal aorta and the arteries of the upper limbs.   In this way, advan-
tage is taken of collateral fluxion.
   Cerebral anamia, as incident to  impoverishment of the blood, calls for  the
remedies  and  hygienic  measures  which  have  been  already  considered in
treating  of  anamia  as one of the diseases  of the  hamatopoietic  system
(p. 3(ii>).  The importance of recognizing this condition, with  reference  not 
 650  DISEASES OF THE CEREBRAL  AND SPINAL  CIRCULATION.

 only to  a correct interpretation  of pathological phenomena pertaining to the
 brain, but to disorders in other organs, and to its morbid agency when it is an
 element of nervous affections, cannot be too strongly enjoined.
   It is  to be noted that a deficiency of arterial or  oxygenated blood may
 coexist  with  venous congestion within  the skull.   The former  may lead to
 the latter in consequence  of the contents of the skull being free from atmo-
 spherical  pressure ; and  on the other hand congestion of the cerebral veins
 due to some  impediment to the return  of blood  from the head may be  an
 impediment to freedom of circulation in the distributing  arteries, and thus
 occasion a deficiency of arterial blood.


              Cerebral Embolism and Thrombosis.

   The fact  has been pointed out in Part I. of this  work (p. 30) that the
 presence of  an embolus or a thrombus  in  an artery, the  branches of which
 freely anastomose with each other—as, for  example, in an artery of  a volun-
 tary muscle—produces, as  a rule, no  appreciable  disturbance  of the circula-
 tion ; while the occlusion by embolus or thrombus of an artery  belonging to
 the terminal  arterial system—that is, of one whose  branches do  not inoscu-
 late—is followed by an infarction, either hemorrhagic or  simply necrotic, in
 the district supplied by the occluded vessel.  It has  been demonstrated by
 Heubner and by Duret that the arteries supplying the so-called basal district
 of the brain—that is, the region occupied  chiefly by the  nucleus caudatus,
 internal capsule, nucleus lenticularis, optic thalamus, and adjoining  cerebral
 substance—are terminal arteries, and  that those supplying  the cortex cerebri
 freely anastomose with each other in the pia matter, in which they become
 much reduced in  size  before they enter the gray matter.   AVe are thus able
 to explain why an embolus lodging in one  of the cortical arteries in the pia
 mater (whither, however, it rarely finds its way)  produces, as a rule, little
 permanent disturbance, while  an embolus or thrombus occluding one of the
 basal arteries beyond the circle of Willis is followed  by destructive  changes
 in the region from which  the blood-supply has been cut off.
   The source of the emboli conveyed into the  cerebral arteries  in the great
 majority of cases is the left ventricle  of the heart.   They consist usually of
 masses of fibrin which have been deposited on the aortic  or mitral valves in
 consequence of acute or chronic endocarditis, and which are washed away by
 the blood-current into the circulation.  Thrombi formed in the  heart from
 any other cause may also give origin to emboli.  Cerebral emboli may also
 be derived from the pulmonary veins, the first part of the  aorta, the carotid
 and  the vertebral arteries.   Next to disease  of the left ventricle,  aortic
 aneurism and atheroma of the  aorta form the most frequent source of emboli.
 The emboli usually consist of portions of a thrombus, but they may be cal-
 careous  concretions, fragments of connective tissue,  bits of new growth, bac-
 teria, other vegetable parasites, fat, etc.  (Aride p. 30.)
  An embolus may lodge in any artery  of  the brain, but in the  majority of
cases it  occludes the middle cerebral  artery not far from its origin.   Next in
order of frequency comes embolism of the internal carotid, and  then embolism
of the basilar  artery.   The statistics compiled  by Gelpke1  showed that out
of 100 cerebral emboli more than 90 affected the arteries  which  supply the
basal ganglia.   An  embolus enters the left middle  cerebral artery more fre-
quently  than the right.  The explanation of this is afforded by the difference
in angle at which the left common  carotid and the innominate come off  from
the aorta; but the predominance in  frequency of embolism of the left cere-
bral  arteries  over that of  the right  has been  exaggerated.  According  to
                      1 Arch.  d. Heilkunde, 1875, p. 501.  ' 
             CEREBRAL EMBOLISM AND  THROMBOSIS.          651

Gelpke, of 131 emboli of the carotid artery or  of its branches, the left side
was affected  64 times, the right side  54 times, and  both sides  13 times.
  An embolus usually leads to the formation of a thrombus about it.   The
cause of spontaneous thrombosis  of the  cerebral arteries is to be sought in
some cliange  in the walls of the affected vessels.  The most frequent cliange
is atheroma of  the arteries of the  brain, but other forms of chronic arteritis.
especially syphilitic endarteritis, may also occasion thrombosis.   Other and
rarer  causes  are—simple  fatty and calcareous  degenerations of the arteries,
compression of the arteries as by a tumor, extension of a thrombus primarily
formed in one of  the carotid  arteries, and possibly mere slowing of the circu-
lation from weakened heart's action.
  Cerebral thrombosis occurs chiefly in old age, because the arterial changes
to which it usually owes its  origin are most frequent at this period of life.
When it  is present in  the earlier periods  of  life, it is due usually, but  not
necessarily, to  chronic alcoholism or to  syphilis.  Embolism, on  the  other
hand, may occur at any  age.
  The effect  of the occlusion by an embolus or a thrombus of an artery of the
brain belonging to the terminal system  is softening of the portion of brain the
blood-supply  of which has been cut off'.   For reasons which have ahead)* been
given, embolic softening in the vast majority of cases is situated in the caudate
nucleus, the internal capsule, the lenticular nucleus, the optic thalamus, or the
island of Reil.  According to the size of the artery occluded, a  greater or less
portion  of this region of the brain  will be affected. It is  especially to involve-
ment of the internal capsule  in the softening that we attribute the hemiplegia
which attends embolism of the middle cerebral artery; for in this narrow band
of white  matter, situated between the  lenticular nucleus  externally and  the
caudate  nucleus  and optic thalamus internally, are compacted together  the
motor-fibres  which supply the opposite half of the  body.  Embolism  of a
cortical artery of the brain  may  do no permanent damage, or it may be fol-
lowed by  softening of the district supplied by the artery.   Many  of  the
depressed, soft yellowish  patches  (plaijues jaunes) found in the cerebral cor-
tex are of embolic or of thrombic origin.
  The first effect of  embolism of a cerebral artery is anamia  of the district
supplied by  that vessel.   If a sufficient collateral circulation be established,
this anamia passes off without permanent damage ; but  if the branches of
the artery do not anastomose, the anamia is followed by a gradually progress-
ive necrobiosis or death of the  part, which may or  may not be accompanied
by hemorrhage.  A true hemorrhagic  infarction, like that which follows em-
bolism of one of the branches of the pulmonary artery or of the splenic  artery,
does not occur in the brain, but a  certain  amount of extravasation of blood in
a punctate form is not infrequently present in the anamic district,  It is not
quite clear why in some cases embolic softening is accompanied by so much
blood-extravasation as to  resemble a primary cerebral  hemorrhage, while in
other cases no blood is extravasated.   It is  probable that increase of pressure
in the veins  coming from the anamic  spot  favors a regurgitant current with
hemorrhagic  softening, and  that  low venous pressure  opposes it.  AVhen  a
spot of embolic softening is stained with extravasated  blood, the process  is
called red softening ;  if there be simply anamic necrosis without hemorrhage,
it is spoken  of as yellow  softening by some  and  white  softening by other
writers.   It  may be mentioned here  that  the  term cerebral  softening  has
ceased to have any exact  significance as a pathological process, and that each
of the varieties—red, yellow, and white  softening—may occur from various
causes and indicate various pathological conditions.
  In the early stages of embolic softening (and what is said in this  connection
of embolic applies equally to thrombic softening) the volume of the affected 
652  DISEASES OF THE CEREBRAL AND SPINAL CIRCULATION.

portion of brain is  somewhat increased ; its consistence is  diminished ;  its
boundaries are not distinctly marked off from the surrounding healthy tissue ;
and its color is  red or yellow or whitish-yellow.  At a later  period the soft-
ened spot is  diminished  in  volume and its consistence may  be  nearly fluid.
The final stage of the process is not  always the  same.  Frequently  a cyst
with fluid contents remains.   If  the first stage  have been red softening, the
cyst-wall and the fluid contents are stained with blood-pigment,  and the cyst
cannot be distinguished  from one following a primary cerebral  hemorrhage.
If hemorrhage have not attended the  process of softening, the cyst-wall and
its contents are  unstained and the embolic origin of the cyst is evident.  Some-
times, instead of a cyst  there is  left a reticulum  of connective-tissue fibres
and blood-vessels  enclosing  in their meshes fluid or semifluid contents, fre-
quently of a white color.  This is called the cellular infiltration of Durand-
Fardel.  Other  terminations  are in a  cicatrix  and in a dry caseous mass.
Finally, the  affected  tissue  may remain indefinitely as  a spot   of yellow or
white softening.   In the sequence of changes a  spot of primary red softening
becomes one of  yellow softening  in consequence of pigmentary alterations in
the extravasated blood.
  The microscopic examination  reveals, as the most characteristic element
throughout the  stages of softening, the  so-called  granular  corpuscles, formerly
called the inflammatory corpuscles of Gliige.  These are large, usually spher-
ical cells, so  densely filled with fat-globules as to appear dark by transmitted
and white  by reflected light.   They are usually present in  large numbers.
They probably have different origins.   They consist of emigrant  white blood-
corpuscles  which have taken up the fatty matter  resulting  from the disinte-
gration of nerve-elements, or they may represent neuroglia-cells, ganglion-cells,
adventitious  cells of the blood-vessels, or endothelial cells distended with fatty
globules.   Similar granular cells are found in pathological processes accom-
panied with fatty degeneration in various other parts of the body, as in ova-
rian cysts,  pneumonia, etc.  In the  early stages the disintegrated nerve-ele-
ments can be recognized  in the shape of broken nerve-fibres, drops of myelin,
and fatty ganglion-cells.   These gradually disappear.  Corpora amylacea and
red blood-corpuscles, and later amorphous and crystalline hamatoidin and
crystals of the  fatty acids, may be detected.
  Certain secondary degenerations in the spinal cord which may follow soft-
ening of the  internal capsule and some other  parts will be noticed  under
the head of  Cerebral Hemorrhage.
  The preceding description of the  anatomical  changes resulting from cere-
bral embolism has been  based on the assumption  that the embolus is bland
in its nature, which is usually true.  If, however, the embolus be infectious,
it leads to the formation of an abscess here as  in other situations;  or if an
embolus  come from a gangrenous focus, such  as may be present  in the lung,
gangrene of  the affected portion of the brain  or necrosis accompanied  by
decomposition follows.

  Clinical History.—Cerebral embolism is one of the several  pathological
conditions which are causative of sudden coma or apoplexy.   This effect does
not occur as a rule, but  it is not infrequent.   The apoplectic attack is not
preceded by  premonitions.  If antecedent cerebral symptoms have existed,
they had  no connection with the  occurrence  of the  embolism, the latter
depending  entirely on the  dislodgment of the  embolus  at  its  source, and
being wholly independent of any previous affection within  the  brain.
  The apoplectic coma  may be complete or the patient  may be aroused  to
consciousness by more or less effort.   There may be stertor,  infrequency of
the  pulse, vomiting,  and immobility or inequality of the pupils; but these 
             CEREBRAL EMBOLISM AND  THROMBOSIS.         653

symptoms are rare in embolic  apoplexy  as compared with  apoplexy from
cerebral hemorrhage.   Convulsive movements occasionally occur.
  Hemiplegic paralysis almost always is an effect of embolism of the middle
cerebral artery, and this effect is coincident with the apoplexy if the latter
occur.
  The duration of the coma varies between a few moments and  many hours.
A fatal  termination, the coma existing until death, is rare.   The hemiplegia,
with few exceptions, persists for  a longer or  shorter period after the  coma
has disappeared.   It  may be permanent.   It may or may not include the
muscles of the face. It affects the side opposite to the hemisphere in which the
embolism  is seated.  It is chiefly or exclusively motor.   Owing to  the fact
that the embolus is seated oftener in the left than in the right hemisphere, the
hemiplegia in the majority of cases affects the right side.
  It is  not easy  to give  a satisfactory pathological  explanation of embolic
apoplexy.    The localized anamia, limited  to the district  supplied  by the
occluded artery, and the increased pressure  by the arteries dilated in conse-
quence of arterial fluxion,  seem a priori inadequate to account for the sudden
coma, and other causes are not apparent.
  In a  considerable, perhaps the  larger, proportion of cases embolic hemi-
plegia is not preceded by an apoplectic attack.   The hemiplegia occurs sud-
denly without premonitions.  The paralytic, like the apoplectic, stroke  takes
place unexpectedly, the patient being free from any cerebral symptoms up to
the instant of its occurrence.
  Cerebral thrombosis very rarely causes apoplectic coma.  Coma, if it occur,
is developed gradually, and is due to an extension of  the thrombus by  fresh
deposits, thus enlarging the district from which the arterial supply is cut off.
Hemiplegia takes  place, not by a sudden stroke, but by degrees, not infre-
quently becoming greater by successive  steps  instead of by a continuous
increase.  Moreover, the occurrence of coma or of hemiplegia is preceded by
premonitions, such as vertigo, impairment of mental faculties,  difficulty in
speech, etc.   These premonitions may in some instances be due to embolism,
which causes a  partial obstruction, the occlusion being rendered complete by
a thrombus  added  to the embolus.  The so-called softening of the brain of old
people, which is accompanied by increasing dementia, is usually the result of
thrombosis.
  Disturbances of speech often  occur in cases of  cerebral embolism and
thrombosis.   Loss of speech, not from any affection of the organs concerned
in phonation or from  mental imbecility, is expressed by the term aphasia.
The terms aphcmia and alalia have the  same significance, but  are not gen-
erally used.  Aphasia is  to  be  distinguished from aphonia, a term denoting
inability to speak in consequence of either laryngeal disease or  paralysis of
the laryngeal muscles.  Aphonia is the loss of  voice, and aphasia is the loss
of speech ; the former relating exclusively to the vocal organs, the latter pro-
ceeding  from a  cerebral affection.   In aphasia the patient is mute from an
inability to  use words expressive of the ideas which  are in  the  mind.  The
loss of speech may be complete or partial, and the patient in some instances
is absolutely dumb.   Sometimes a single word can be spoken, such as " yes "
or "no," and this is uttered whenever the attempt to speak is made ;  in  other
instances the vocabulary is larger, but limited to a few words; and in differ-
ent cases there is  every degree of incompleteness  in the aphasic condition.
A difficulty  of speech  may consist in  an inability to use the  proper w*ords to
express  the  mental ideas.   Things  are not called by their right names, and
the language in sentences  either  spoken or written is incongruous and  unin-
telligible.   This difficulty  is sometimes distinguished as paraphasia.
  An important  distinction is  denoted by the  terms amnesic and ataxic 
654  DISEASES OF THE  CEREBRAL  AND  SPINAL  CIRCULATION.

aphasia.   In ataxic aphasia the mind recognizes the  proper signification of
words, and  the difficulty consists  in  an inability to  give utterance to the
words.  The name ataxic implies  that this inability proceeds from a lack of
power to co-ordinate the muscles concerned in speech.   Something more than
simple ataxia, however, seems to be involved.  A lack of co-ordinating power
would be manifested  by movements responding to, but not governed by, the
will, and the result would be inarticulate phonetic sounds.   This evidence of
ataxia is sometimes manifested, but generally the patient will  not make  any
effort to speak—that is, if the aphasia be complete—and if a few words be
uttered, these may be spoken with distinctness.   In amnesic aphasia there is
inability to recollect  words as the symbols  of ideas.  Language is lost to the
memory.
  If the aphasia be  purely ataxic, the ability to use  language correctly in
writing is not lost, and may not be impaired, provided the intellectual faculties
be intact.   The ability to read is retained,  and  language spoken by others is
comprehended. So far as can be judged, in some cases of ataxic aphasia abso-
lute mutism is not incompatible  with undiminished intelligence.  Frequently,
however, the cerebral affection which causes the aphasia impairs, in a greater
or less degree, the mental faculties.  In  amnesic  aphasia, on the other hand,
the loss of  speech  is  accompanied by inability  to  use written  language
(agraphia).   The loss of the memory of words does not  necessarily carry with
it  inability to understand their  meaning when  they are heard or seen.   The
patient may understand both spoken and written language.  Inability in these
respects involves, in a greater or less degree, mental imbecility.
  In  ataxic aphasia the ability to interpret signs or  gestures  is preserved.
If this be lost in either ataxic  or amnesic aphasia, there is imbecility in a
greater  or less degree.   Patients affected with ataxic  aphasia, even when it
is  evident that the intelligence is well  retained, cannot repeat words after
dictation.   Patients  with purely amnesic  aphasia  are  able  to  do  this, pro-
vided the intelligence is  not too  much  impaired.   The inability  to repeat
words is evidence either that the aphasia is not purely amnesic or that there
is imbecility.
  The ataxic and amnesic forms of aphasia may be combined.   The patient
can then express ideas neither by spoken nor written language, and is unable
to repeat words after dictation.   In  a form of aphasia which has been called
word-blindness  the ability to  read  and write is lost, although  speech is  not
affected.   I  have met with two instances in which the aphasia was exclusively
of this character, recovery taking  place in each  instance.  Hemiplegia was
wanting in  both  these  instances.
  In cases of either  ataxic or amnesic aphasia  it is not an easy problem to
determine whether or not, or to what extent, the mental powers are impaired.
This problem is sometimes presented to physicians in medico-legal cases.
The instances must be rare in which persistent aphasia, associated with hem-
iplegia, does not involve more or less  impairment of mind.  Ataxic  aphasia
as an isolated  affection may exist with the intellect  apparently unaffected.
It is doubtful if this can be said of amnesic aphasia.   Words are the instru-
ments of thought as well as the  expression of ideas; and it is difficult to
believe  that  the inability to  recollect words is possible without deterioration
of the reasoning faculties.   The inability to understand spoken or written
language and signs  is proof of impaired intellect.
  A large accumulation of clinical observations within the last few years has
established the connection of aphasia, in the vast majority of cases, with lesions
localized in  a  particular part of the brain—namely, the island of Reil, and
especially the posterior part of  the third frontal  convolution.  These lesions
are not alone those incident to embolism and thrombosis, but those caused by 
             CEREBRAL EMBOLISM AND THROMBOSIS.          655

cerebral hemorrhage, morbid growths, abscess of the brain, etc.   Aphasia is
therefore a symptom belonging also to the clinical history of diseases which are
to be hereafter considered.  In a small number of cases lesions have been found
in the similar parts of  the right hemisphere, or the  aphasia has  been associ-
ated with left-sided hemiplegia.   In a certain  proportion of the latter cases it
was ascertained that the patients were left-handed.   It may be doubted if in
any case  of well-marked persistent aphasia an autopsy has shown conclusively
absence of any lesion affecting the island of Reil or proximate parts  in  one
or the other hemisphere.  (For statistical facts on which these statements are
based the reader is referred to other works.1)
  The theory which, with our present knowledge, furnishes the  most satis-
factory  explanation of these facts assumes  the  following postulates: The
third convolution and the island of Reil are in a direct physiological relation
to language.  This is true of the  left, and  not of  the right, hemisphere in
most persons, owing to the habitual use of the  left instead of the right
hemisphere in the exercise of the function of language.  As exceptions to
the rule  some persons habitually use the right instead of the left hemisphere
in the exercise of  the  function of language, and these persons are generally
left-handed.  Injury of the parts in the left hemisphere which  are in relation
to language do not in these persons cause aphasia, but this  result  follows
injury of the parts in  the  right hemisphere.2 The parts in the right hemi-
sphere which are in a physiological relation to language, although their func-
tional activity has been in abeyance owing to non-use, may assume in some
instances activity  after the parts of the left hemisphere  have  been incapaci-
tated by lesions;  hence,  improvement or recovery from aphasia may some-
times take place,  the lesions in the  left hemisphere remaining  unchanged.
  Aphasia attributable to  embolism  occurs  without  apoplexy or paralysis.
The following case is an example :  A young man having ridden all day in an
open wagon, the weather  being cold,  after eating a hearty supper  was sud-
denly unable to utter a word.   He went to bed, hoping that the  ability to
speak would return in the morning.   He slept perfectly well, but on awaken-
ing he was still unable to speak.   In the course of the day he began to use
some words, often using wrong words, but  in the course of  a  few days he
recovered his speech, although ever since he has had some difficulty in select-
ing right words.   He saw me a year after this occurrence.  Meanwhile, noth-
ing had  occurred to denote  any cerebral disease, except that he was  conscious
of an uneasy sensation in the left side of the head.   He had an aortic  regurg-
itant and a mitral  direct murmur, with considerable  enlargement  of the
heart.   It can hardly  be  doubted  that in this case the temporary  aphasia
was 'due  to embolism of one of the branches of the middle cerebral artery.
   Cases have been reported of the occlusion, after an interval, of the middle
cerebral artery on the two  sides,  giving rise to  double hemiplegia.   These
cases have furnished  examples of left hemiplegia without aphasia, followed
by  right hemiplegia  with aphasia.

  Diagnosis.—The  diagnosis in most cases of embolic apoplexy requires
the exclusion of apoplexy from cerebral hemorrhage.  The latter is presently
to be considered.   If the  apoplexy be due to  occlusion of the middle cerebral
artery, it is accompanied by hemiplegia.  This is true also of apoplexy due
to cerebral hemorrhage in the situations where it is most likely to take place.
As  a rule, the other pathological conditions which stand in a  causative rela-
tion to apoplectic  coma do not give  rise to hemiplegia.   The  differentiation,
  1 A'ide the very comprehensive article on Aphasia, by Kussmaul, in  Ziemssen's Cyclo-
paedia, vol. xiv.
  2 ATide cases reported in Trans. London Clinical Society, vol. xiv. 
656   DISEASES  OF  THE CEREBRAL AND SPINAL CIRCULATION.

therefore, in the great majority of cases is between embolism and hemorrhage
in cases  of apoplexy with hemiplegia.   The following are  the differential
points :
  Embolism may occur at any period of life, and it is as frequent in early as
in middle or advanced age.   Cerebral hemorrhage is rare before the middle
period  of life.   An apoplectic  seizure, the  patient not having  reached  the
latter period, is therefore more likely to be due to embolism than to  hemor-
rhage.   The occurrence of hemiplegia on the right side weighs somewhat in
favor of  embolism.  The  existence of endocarditis or of valvular  lesions in
the left side of the heart renders  embolism probable.  The absence of symp-
toms denoting  cerebral congestion which often, but  by no means uniformly,
precede cerebral hemorrhage, has  some weight in the diagnosis.  The absence
of cerebral prodromes, which applies to all cases of  embolism, is not as con-
stantly applicable  to cases of hemorrhage.  A'omiting,  an  infrequent pulse,
stertor, changes in the  pupils, and convulsions are more frequent and more
marked in cases of apoplexy due  to hemorrhage.  The diagnosis  of embolism
is strengthened by the occurrence of symptoms denoting embolism of  the
spleen  and  kidneys.  Unilateral  amaurosis from embolism  of  the  central
artery of the retina, preceding or  accompanying the attacks, is diagnostic of
embolic apoplexy.
  These  diff'erential points suffice  often for a highly probable diagnosis.  They
do not warrant a positive  diagnosis.   The physician  who ventures upon  the
latter incurs a risk of being convicted of an  error  at the autopsy.   If, how-
ever, the  patient speedily emerge from the apoplectic condition, rapid improve-
ment as regards the paralysis subsequently taking place and ending  in com-
plete recovery,  the diagnosis of embolism is very probable.
  Embolic hemiplegia is  to be differentiated  from hemiplegia  due  to cere-
bral  hemorrhage and to other conditions—namely, morbid growths,  abscess,
etc.  The difficulty in  the diagnosis, however, is chiefly in excluding hemor-
rhage.   The other conditions generally involve antecedent symptoms  of cere-
bral  disease, whereas  the  paralysis caused by embolism is devoid of these;
and this  is often true of hemorrhage.  Both embolism  and hemorrhage may
give  rise  to sudden hemiplegia without apoplexy, but in much the larger pro-
portion of cases this  is true of  embolism.   In sudden hemiplegia  without
apoplexy, therefore, the chances  are that it  is  embolic.  Other differential
points are embraced in the list of those which relate  to the differentiation of
apoplexy from embolism and hemorrhage.  Rapid improvement is much more
likely to  take place in paralysis from embolism, and complete recovery, which
is not infrequent in embolic hemiplegia, is rare in paralysis from  hemorrhage.
Increase  of the  body-heat two  or three days after an apoplectic or paralytic
stroke  has been regarded as denoting the presence of a cerebral clot,  but
observations have shown that an  equal increase sometimes follows when  the
apoplexy and paralysis  are due to embolism.
  For the differentiation of  embolism  from  thrombosis the most important
point has been  stated—namely, the effects of arterial occlusion occur by  the
former suddenly, and by the latter more or  less gradually.   This point of
distinction, however, cannot always be relied upon.  A thrombus may excep-
tionally form so rapidly as  to  simulate embolism in the  abruptness of its
effects. An attack  of hemiplegia,  either with or without apoplexy, may occur
during sleep, and under these circumstances this differential point may not be
available.  Again,  as already stated,  an  embolus may cause only a partial
obstruction, complete occlusion afterward being  produced by  a  thrombus
formed at the  seat of the embolus.
  Other differential points are as follows : The conditions for thrombus belong
to middle or advanced age.   The youth of the patient is therefore a  point in 
             CEREBRAL EMBOLISM  AND  THROMBOSIS.         657

evidence for embolism.  The existence of endocarditis or valvular lesions of
the heart points to embolism, and their absence to thrombosis.   Calcification
of the radial arteries is a ground for inferring that the cerebral arteries have
undergone  the  same change, this  being the most frequent of the conditions
which are  causative of thrombus.
  Embolism and thrombosis of the basilar artery may produce  coma, either
suddenly or more or less  slowly, without hemiplegia.   Death takes place in
some cases  within a few hours. In other cases patients recover, although the
artery remains occluded.  These statements have been verified by cases under
my observation.

  Prognosis.—An  apoplectic attack caused  by embolism of the middle
cerebral artery is less likely to prove immediately fatal  than .apoplexy from
cerebral hemorrhage ;  hence the probable diagnosis has a  bearing on the
prognosis.   In  most cases, after a few hours the coma disappears, hemiplegia
remaining.
  The persistence  of  hemiplegia,  whether  preceded  or not by apoplexy,
depends on the occurrence of softening  from necrosis and  extravasation of
blood as effects of the arterial  obstruction.   If the circulation within the
district  in  which the blood-supply was furnished by the occluded  artery be
restored within two or three days, so as to prevent the changes incident to
defective nutrition, rapid  improvement takes place  and is followed by com-
plete  recovery.  These changes are to be inferred  from the persistence of
the paralysis.   There  may be more or less  improvement, which  will be in
proportion  to the favorable course of the local process  as described  in con-
nection  with the Anatomical  Characters.  Complete  recovery from the paral-
ysis is not  to be expected.  If the local  process be not favorable, more or
less impairment of  the mental faculties is added to  the  persistent paralysis.
The duration of life is indefinite.   Death  is  generally caused by antecedent
or intercurrent disease.
  The prognosis if hemiplegia he caused by thrombosis is less favorable than
if it be  due to embolism, as the patients  are more enfeebled.   The prognosis
is extremely unfavorable if coma supervene upon hemiplegia.
  The prognosis as  regards the continuance of aphasia  is a matter of much
interest to patients and their friends.   The restoration of. speech may accom-
pany recovery from  the paralysis, but it may  be otherwise.  In  a hospital
case under  my observation the hemiplegia entirely  disappeared, the  general
health was  excellent, and the mental faculties were apparently not in the
least affected,  but complete mutism persisted.  The patient made no attempt
to speak ; and when asked why he was silent he placed his finger on his lips
and shook his head.   He was discharged in this  condition.  If,  owing to the
pathological changes in the  affected district  of the  brain, the paralysis per-
sist, aphasia generally continues.   There may, however,  be more or less
improvement,   There are no  means of judging  beforehand  what degree of
improvement will take place.  Adopting the views  stated in regard to the
duality of the parts which stand in a physiological  relation  to  language, if
the injury  destroy the functional  capacity in the hemisphere to  which the
exercise of the function  has been limited  (usually the  left hemisphere), the
recovery of speech or the degree of improvement will depend on the ability
to develop functional activity of the corresponding  parts in the other hemi-
sphere, which  had previously been in abeyance.  The probability^ success
is greater in proportion to the youth of the patient,   if the aphasia  continue
without improvement for several months, none is to be expected.
  The prognosis is favorable when  aphasia  occurs without apoplexy, hemi-
plegia, or  other evidence of cerebral disease.
       42 
658   DISEASES  OF  THE CEREBRAL AND SPINAL CIRCULATION.

  Treatment.—The object of treatment in the  early stage of  embolism
and thrombosis  is the re-establishment of the circulation within  the  district
deprived of blood-supply, in order to prevent the changes incident to defect-
ive nutrition.   Bloodletting, cathartics, and  any measures which weaken the
heart's action contravene this object, and  are therefore contraindicated.  On
the contrary, it  is often important to  increase the strength of the  heart's
action by tonic remedies, a nutritious alimentation,  and alcoholics.  If there
be feebleness and irregularity of the heart's action  in connection  with valvu-
lar lesions  and dilatation, digitalis is  indicated.   All forms of counter-irrita-
tion are contraindicated.   Cold applications  to the  heart are inappropriate.
AVarm applications may  be useful.
  This plan of treatment is to be pursued for  several days until it be deter-
mined whether or not the patient can escape the local changes which ensue
if the circulation be not  re-established  in the affected  district of the brain.
If softening take place, the objects of treatment relate to the general condi-
tion of  the system and  to the  hemiplegia.
  The first of these objects embraces measures for improving and  maintain-
ing the nutrition of the body—namely, tonic remedies, a good diet, and an
invigorating regimen.  In  cases of  embolism diseases of the  heart will often
furnish indications for treatment.
  Hemiplegia incident to the  brain lesions resulting from  embolism and
thrombosis claims  the  same treatment  as when it is  due to a blood-clot in
the brain. (Vide Cerebral  Hemorrhage.)  It consists of passive movements,
together with rubbing and kneading  the paralyzed limbs, the employment of
electricity,  and  as  much voluntary exercise of the muscles as  practicable.
These measures  are important  in order to prevent degenerative changes in
the muscles and nerves  of the  paralyzed limbs, to promote the circulation
and nutrition  in these parts, and to develop as far as possible  their func-
tional capacity.
  The treatment which has special reference to aphasia consists in persistent
efforts  to regain the memory of words and their  vocal  utterance.  If the
mutism  be  not complete,  perseverance in exercises  for these ends may some-
times  accomplish much, and their importance is to be enjoined.


              Thrombosis of the  Cerebral  Sinuses.

  Thrombosis of the  cerebral  sinuses, especially  of  the longitudinal and
lateral sinuses, may be the result of slowing of the circulation from  weak-
ened heart's action in patients, particularly  children who are greatly enfee-
bled  by  some wasting disease.   This  form is  called marantic  thrombosis.
Of a similar nature is the thrombosis sometimes observed in  acute infectious
diseases, particularly typhoid fever.
  Thrombosis may also be occasioned by inflammation of the walls of the
sinus  or phlebitis of the sinus, secondary, as a rule, to disease of the cranial
bones.   Thrombi thus formed are usually infectious or purulent.   Caries of
the petrous portion of  the  temporal bone  following  inflammation  of the
middle ear or of the mastoid cells may be taken as  one of the most frequent
and typical causes of this variety of sinus-thrombosis.   The lateral, petrosal,
and in a less degree the  cavernous, sinuses are most frequently the  seat of
purulent thrombi.  Large carbuncles and severe erysipelatous inflammation
about the head and  neck may lead  to sinus-thrombosis.  Thrombosis of the
cerebral  sinuses may be  accompanied by no very  characteristic changes in
the meninges and  brain.   Venous congestion, with punctate hemorrhages in
the membranes and in the  cortex cerebri, is often observed.  Sometimes more
extensive hemorrhages follow.   The purulent thrombi are often accompanied 
CEREBRA L  HEM ORRHA GE.
659
with meningitis, and not infrequently abscess of the brain.  They may lead
also to the formation of embolic abscesses in the lungs and in other parts of
the body.

  Thrombosis of the cerebral sinuses can  rarely be diagnosticated  with any
approach to certainty.  The marantic variety in young children gives rise to
symptoms analogous to those attributed to anamia in the so-called hydren-
cephaloid affection of Marshall  Hall—namely,  somnolence and coma, with
general  and  progressive prostration.   The symptoms which, added to these,
render thrombosis probable are tonic contraction of the muscles of the neck
and back, strabismus, and ptosis.  In adults  indefinite cerebral disturbance
gradually eventuates  in  coma.  Turgidity of the  external veins limited to
certain  situations on  the cranium  is  a diagnostic  feature in  some cases.
Thrombosis of the lateral sinus sometimes occasions venous congestion and
adema behind the ear.  In a few recorded cases the thrombus has extended
into the internal jugular, causing pain and swelling of that side of the  neck.
Thrombosis of the cavernous sinus has been observed to give rise to conges-
tion of the intraorbicular veins, with prominence of the eyeballs, swelling of
the eyelids, and congestion of the retina, with choked disc.
  Prominent encephalic  symptoms accompanying pyamia, if  preceded  by
caries of the  bones  about the ear, by  carbuncles  or erysipelas  of the face,
head,  or neck, may  be  referable  to purulent thrombosis of  the cerebral
sinuses.


     Capillary Embolism  and Thrombosis of the Brain.

  Our knowledge of embolism and thrombosis of the  cerebral capillaries is
too limited for a determination of their pathological effects, symptomatology,
and diagnosis.  Pigment embolism is incident to malarial fevers, especially in
their  pernicious forms.   Emboli or thrombi  may  consist  of leucocytes, fat-
drops, or the salts of lime.  Future observations may establish an  import-
ance which  does not at  present belong to occlusion of the cerebral  capil-
laries regarded from  the  standpoint of practical medicine.


                      Cerebral Hemorrhage.
  Anatomical  Appearances.—Intracranial hemorrhage may be conveni-
ently  divided into cerebral hemorrhage and meningeal hemorrhage.  In cere-
bral hemorrhage, which will be first considered, the extravasation of blood is
into the substance  of the  brain.   Hemorrhages, usually punctate  in cha-
racter, are frequently found in and about  tumors, around  abscesses, and in
foci of embolic softening, but only the so-called spontaneous cerebral hemor-
rhages will  be  considered  in  this  article.
  The ultimate cause of  spontaneous cerebral  hemorrhage is, probably with-
out exception, disease of the cerebral arteries.   Since the publication in 1868
of the investigations of Charcot and Bouchard the bursting of miliary aneur-
isms has been recognized as the predominant cause  of spontaneous cerebral
hemorrhage.  These aneurisms are for the most part visible with the naked
eye as little  nodules of the size of  a millet-seed or of the head of a pin ; but
they may exceed these dimensions, or, on the other hand, may be microscopic
in size.  In the majority of cases the whole circumference of the artery takes
part in the  aneurismal dilatation.  The aneurisms are usually  fusiform, but
they may be round, and they are sometimes sacculated.  The aneurisms  are
the result of pre-existing  disease of the  arterial coats.  The most  frequent
form of  this disease  is  chronic deforming endarteritis or atheroma.   The 
660  DISEASES OF THE CEREBRAL AND SPINAL  CIRCULATION

aneurisms  may also be caused by obliterating endarteritis and  by a hyaline
degeneration of the middle coat of the artery.
  Aneurisms  cannot be found in  all cases of spontaneous  cerebral hemor-
rhage.  Atheroma, fatty  degeneration, obliterating endarteritis, hyaline degen-
eration, mesarteritis and periarteritis, may so weaken the vascular walls as to
prove  efficient causes of  hemorrhage  without  the development of miliary
aneurisms.
  In cases of cerebral hemorrhage occurring in  the so-called hemorrhagic
diathesis, as in scurvy, purpura, leucocythamia, etc., it is  not always pos>ible
to demonstrate any alteration in  the vascular walls.
  All circumstances which occasion increased  arterial  tension  may serve as
exciting causes of cerebral hemorrhage, but they never lead  to cerebral hem-
orrhage unless there be  disease of the arteries.   Such  circumstances will be
mentioned  under  the head of Causation.  Here may be mentioned, as an
important exciting cause of cerebral  hemorrhage, cardiac hypertrophy asso-
ciated with  elevated  blood-pressure, particularly  the cardiac hypertrophy
associated  with chronic  Bright's disease.
  Cerebral hemorrhage occurs by far most frequently in and about the basal
ganglia  of the  brain; that is, in  the  nucleus caudatus, internal  capsule,
nucleus  lenticularis, optic thalamus, and  the adjacent  part  of the centrum
semi-ovale.   Much less  frequent are  hemorrhages in other parts of the cen-
trum semi-ovale, in the pons, cerebellum, crura cerebri, medulla oblongata,  and
cerebral convolutions.   The explanation of the frequency  of hemorrhages in
the opto-striate  bodies (corpus striatum  and  optic  thalamus)  and in their
neighborhood is found in the fact that the arteries which  supply these parts
are given off from the  anterior, middle, and posterior cerebral arteries near
their origin, and penetrate directly, as comparatively large vessels,  the  brain-
substance,  where they divide  as  terminal  arteries.   These  arteries  are sub-
jected, therefore, to a relatively  high  pressure;  whereas  the arteries  which
supply the cortex  cerebri become almost  capillary in  size  before they dip
down  from the pia mater into  the gray  substance, and  are therefore  less
exposed to the direct effects of increased blood-pressure.   In the majority of
cases the hemorrhage  is  due to rupture of some of the branches  of the middle
cerebral artery, which are destined  for  the supply of the  lenticular nucleus,
the greater part of the  internal  capsule and of the caudate nucleus, and a
part of  the optic thalamus.1  Of special importance is involvement of the
internal capsule ;  as lesions of most parts of the internal capsule are followed
by  permanent hemiplegia, whereas the hemiplegia  which immediately follows
hemorrhages confined  to the lenticular nucleus or caudate nucleus  is usually
temporary, or at least is capable  of  great  improvement.
   Cerebral hemorrhage  occurs in the form of capillary extravasations and in
that of so-called apopletic  foci in which the extravasated blood is collected
into a mass.   The  capillary hemorrhages are of the lesser importance.  They
appear as  isolated  small  red  points, either scattered through the brain or
collected together  in  a  small  space.   The  capillary hemorrhages  may unite
to make apoplectic foci.   They are  often found  around the  large  extravasa-
tions ; they are present  around  tumors, abscesses, centres of softening;  and
they  may result  from  active congestion of  the brain  and from diseases
  1 According to Duret, the localization of hemorrhage in the region of the basal  gan-
glia depends upon whether the rupture be in the region of the lenticulo-striate arteries,
which supply the anterior part of  the corpus striatum, or in that  of the lenticulo-optic
arteries, which supply the  posterior part of the corpus striatum and  a part of the optic
thalamus. Among these arteries, which are branches of the arteria corporis striati, there
is one particularly well developed, which supplies the region of the lenticular and the
caudate nucleus. This artery, according to Charcot, is so liable to rupture that he desig-
nates it as " the artery of cerebral hemorrhage." 
CEREBRAL  HEMORRHAGE.
661
attended with severe blood-changes.   An apoplectic focus or clot is  usually
about the size of a hazelnut or of a pigeon's egg, but it  may be no larger
than a pea, or it  may occupy nearly the whole  of one cerebral hemisphere.
If the extravasation take place  in the vicinity of one of the  lateral ventricles,
the blood not infrequently finds its  way into the latter.   The blood  may
reach the outer surface of the brain  either  by breaking directly through the
peripheral  cerebral  substance  or by penetrating the third and thence  the
fourth ventricle, from which  it  can reach the exterior.  Usually only  a single
hemorrhagic  focus is present, but there may be several foci.  It is not  very
uncommon to find remains  of a previous hemorrhage.
   If the hemorrhage in the interior of the brain be of considerable size, the cor-
responding hemisphere is swollen, the convolutions are flattened, and the  dura
mater is tense.  If the hemorrhage be recent, the apoplectic focus consists of
a dark-red  clot of blood  mingled with the debris of cerebral tissue, and con-
tained in a cavity  the wall of which is composed of lacerated nerve-tissue
surrounded by adematous cerebral  substance.   Frequently, in proximity to
the clot a number of capillary  extravasations  are present.   If  the extravasa-
tion be large, the  substance of the  corresponding  hemisphere is anamic.
Careful examination by  proper methods  will usually reveal miliary aneur-
isms in  or around  the focus.   Care must be exercised not to mistake for
these aneurisms  hemorrhages  into the perivascular sheaths, the so-called
dissecting aneurisms which  are usually to be found about  cerebral extrava-
sations.  If life be prolonged, retrograde metamorphoses  occur in the extrava-
sated blood.   The color changes from dark red to brownish or yellow in con-
sequence of  the  formation of blood-pigment in the form of granular  and of
crystalline hamatoidin  out  of the  red  blood-corpuscles.   From dissolved
coloring matter the surrounding  brain-substance  becomes  stained diffusely
yellow or brown.  The fibrin and the lacerated nerve-elements undergo  dis-
integration and are absorbed,  granular corpuscles making  their appearance.
While these  regressive changes are  going  on, a connective-tissue capsule is
formed  by reactive  inflammation around the  focus.  The final result is the
production of a  so-called  apoplectic cyst.   This cyst consists of a fibrous
capsule  enclosing  a brownish or  yellowish  (rarely  a clear)  fluid.   The
cyst-wall and the  fluid are  stained  by  blood-pigment.   Usually  delicate
threads  of connective tissue  traverse the cavity  between the  cyst-walls.
Sometimes the  walls of the cyst come together and  only  a pigmented  cica-
trix is  left.   It is probable that a cicatrix  may also be formed without the
intervention  of a cyst.   It rarely happens that  the inflammation around the
extravasated  blood  is sufficient to cause  extensive  softening, and  abscess
seems never to follow.  AVhen the hemorrhage is situated in the periphery
of the  convolutions, the changes  are essentially  the same, except that  here
the pia  mater forms the outer covering of the focus.
   The  lungs  of  those dying in the early stages  of  cerebral hemorrhage are
usually congested and adematous, often  containing  extravasations of blood,
particularly  in the  lower  lobes.
   The  secondary degenerations which follow after a certain time (from six
weeks to several  months) hemorrhagic  foci  situated in certain regions of the
brain deserve a  brief mention here.   These secondary degenerations, first
studied exhaustively by Tiirck, follow not only hemorrhage, but softening and
other destructive lesions  cutting across the group of motor-fibres which, begin-
ning in  the anterior and posterior central convolutions, pass through the corona
radiata, the internal capsule,  the pes pedunculi, the pons, and the anterior pyr-
amids of the medulla oblongata to the crossing of the pyramids, where the
greater  portion cross over and descend in the posterior part of the lateral
column  of the opposite side, a  small  portion continuing  in  the median region 
662  DISEASES OF THE  CEREBRAL ANI) SPINAL CIRCULATION.

of the anterior column of the same side.  Destructive lesions of the internal
capsule especially, and also of the central convolutions, lower portion of the
corona radiata and of the pes pedunculi, are followed by atrophy of the motor-
fibres below the  seat of lesion.  The secondary degeneration not  only con-
sists in atrophy of the nerve-fibres, but is  accompanied by increase of the
connective tissue  between the fibres.   It  is at first characterized by the
appearance of large numbers of  granular cells.   The  atrophied bundles are
visible on fresh specimens as gray bands following the course which has just
been described as that of the  motor—or, as they are called, pyramidal—fibres.
Upon making a cross-section of the spinal cord in a case of secondary descend-
ing degeneration a triangular  gray patch will be observed in the posterior part
of the lateral column on the side opposite the lesion in the brain, and a narrow
gray band, not always visible to the naked  eye, in the anterior column  near
the median fissure on the side of the lesion.   The contrast  in color between
the healthy and  the degenerated  parts  becomes more distinct in  specimens
hardened in chromic acid.  Lesions confined to the nucleus  caudatus, lentic-
ular nucleus, or to regions  of the brain  other than those  named  are not fol-
lowed by  these secondary degenerations.  The degeneration does  not affect
the peripheral motor nerves.

   Clinical History.—Of the several  pathological  conditions  which occa-
sion sudden coma or apoplexy, cerebral hemorrhage  is the  most frequent in
its occurrence.   Some writers limit the term  apoplexy  to sudden coma caused
by extravasation of blood.  In a large majority of cases the  apoplectic attack
is without  premonition.  It is, however,  sometimes preceded by certain cere-
bral symptoms, such as a sense of weight or  fulness, vertigo, tinnitus aurium,
and flushing of the face.   These symptoms, however,  are not sufficiently
significant  to warrant a prediction of impending apoplexy,  especially if the
patient  have never  had  an  attack.   It  is  not uncommon  for an  attack  to
occur at a time when the person attacked feels  unusually well.
   In an apoplectic attack the  loss  of consciousness may be so abrupt that the
patient, if standing or walking, falls to  the  ground as if felled  by a blow;
but in most instances the coma is developed, not instantaneously, but during
a period ranging from a few moments to  half an hour or even longer.  It has
happened  to me to witness  an attack which occurred when I was  interrogat-
ing a patient who had just stated that he had felt on that day unusually well.
I noticed  suddenly a change in his appearance, as  if he were mentally agi-
tated ;  his  expression changed  and he winked with his left eye only.   He
made an effort to rise and fell from the chair.  The right side was paralyzed.
He did not at  once become  unconscious, but was irrational, attempting  to
speak,  being unable to articulate, and  frequently making  efforts to get up
from the  sofa on which he had been placed.   The respiration  soon became
heavy, with slight stertor and puffing of the lips.  He vomited freely.   He
became  profoundly comatose in about half an hour.  He  remained in the
comatose state and died  within twenty-four hours.
  The coma in different cases is more  or less profound.  AArhen complete, the
patient cannot be roused in  any degree by efforts to awaken consciousness; but
in many cases there is not this total loss of mental faculties.  Aroluntary move-
ments in some cases are entirely wanting; and except  that the movements of
respiration continue, the  body is  as motionless as a cadaver.  In the major-
ity of cases, however, the patient  exerts the will, although all manifestations
of intelligence may be wanting. In this way the existence of unilateral paral-
ysis becomes apparent.  The movements are  limited to the  upper and lower
extremity  of one side, and  it is evident  that hemiplegia is added to the  apo-
plexy.  The paralysis is generally at first  complete, and  the paralyzed limbs are 
CEREBRAL  HEMORRHAGE.
663
motionless as regards volition.  The respirations are slow, the rhythm is some-
times irregular, and the inspirations are stertorous or snoring.  If' the coma be
profound, the  buccinator muscles and the lips are flaccid and are puffed out
in expiration.   The pulse is usually  diminished in frequency, full, and hard,
the artery striking  against the finger like a metal rod.  Exceptionally the
pulse is small and feeble.  The face  is frequently flushed, and, if respiration
be much embarrassed, more or less  livid, but  it is sometimes pallid.  The
surface in most cases is warm, but sometimes it is cool.  At first the temper-
ature of  the body, as determined by  the thermometer, is lowered from one to
two and a half degrees, but after twenty-four hours there is usually a  consid-
erable increase of the body-heat.  The pupil may be contracted or dilated, or,
without either contraction or dilatation, immovable, and some disparity between
the two pupils  is not uncommon.   The muscles are generally flaccid,  but in
some cases rigid.  Rigidity of the muscles is the rule in intraventricular hem-
orrhages.  Convulsive movements are infrequent, but they sometimes occur,
especially when the hemorrhage  involves the motor cortical  region.  These
are usually limited  to one side, and to the side not paralyzed.  To this rule
there are exceptions.   The limbs  are sometimes rigid on the  non-paralyzed
side.  Aromiting is usual at or shortly after the attack.
   These  are the prominent symptoms which characterize the apoplectic state.
Its duration varies.  It may  last for a few moments only, the patient gradu-
ally emerging from it, or unconsciousness slowly disappears after the lapse
of a few hours, or the  state may continue for days and then pass off.  As a
rule, if the coma persist without any improvement for eight or ten hours, and
especially if during this period the  coma become more and more profound,
improvement is not to  be expected, and the attack will  prove fatal.   On the
other hand, the attack may prove fatal in a few moments, the mode of dying
being by apnaa ; or death takes place after several hours ; or, again, the apo-
plectic state continues, and proves fatal after the lapse of several days, in the
latter case the mode of dying being by asthenia and apnaa combined.
   Patients emerging from the coma appear as if awakened from sleep, and they
rarely evince surprise or ask what has happened to them.  A noticeable appear-
ance, lasting  for several days,  is a lateral deviation  of the eyes, and some-
times there is rotation of the head in a direction opposite to the paralyzed side.
AVith more or  less increase of the body-heat pain is referred  to the head.
Sometimes there is delirium, and spasmodic movements or contractions of the
paralyzed muscles may occur.   These symptoms denote circumscribed  inflam-
mation of the  brain surrounding  the blood-clot.  As a rule, they disappear
after a  few  days.
   The symptoms in apoplexy dependent on  cerebral  hemorrhage are essen-
tially the same  as when coma  from compression of the brain follows an injury
to the head.   The extravasation of blood produces a shock or stunning effect
upon the brain proportionate  to the  rapidity and  the  amount of the  hemor-
rhage, and the pressure  affects the  circulation in the whole mass  of brain.
The pressure impedes the circulation in  the substance of the brain, and the
apoplectic phenomena are measurably due to the want of a proper supply of
blood therein.  The production of apoplexy depends on the suddenness of
extravasation.  If it take place gradually, apoplexy is not induced, and if  it
be not sufficient to destroy  life  within  a brief period, the circulation  may
become  restored sufficiently for the restoration of consciousness.
  The symptoms which  remain after the  disappearance of the coma depend
upon the situation  of the clot,   In the next article will be considered symp-
toms  referable to hemorrhage and other lesions occupying different parts of
the encephalon.  In the present article  the  hemorrhages in the usual  situ-
ation—namely, in the basal ganglia and their neighborhood—will be taken as 
6G4  DISEASES OF THE CEREBRAL AND SPINAL CIRCULATION

the basis of description.  It is important to distinguish between symptoms
due to the destruction of a  certain part of the  brain by the hemorrhage and
symptoms dependent upon pressure, adenia, and other disturbances of nutri-
tion in parts adjacent to the clot.  Evidently, the first set of symptoms are
permanent, while the second set of symptoms may be, and usually are, recov-
ered from.1
  Hemiplegia is a constant  effect of cerebral hemorrhage when  the extrava-
sation  takes place in the situations in which it occurs in the great majority
of cases.  After the apoplectic state disappears the hemiplegia remains ; but
in a small proportion of cases the hemiplegia occurs without loss of conscious-
ness, this proportion being much smaller than  in cases of cerebral embolism.
The attack of hemiplegia without apoplexy is often sudden, but the paralysis
is sometimes  developed gradually.   The difference as regards  this point
probably depends on whether the extravasation  take place quickly or slowly.
The hemiplegia, however, may  be at first complete, although unaccompanied
by any impairment of consciousness.   The following account of the hemiple-
gia dependent on cerebral hemorrhage is applicable to  cases with or without
an apoplectic attack.
  The paralysis may embrace both motion and sensation, or it may be limited
to motion.   In the great majority of cases, if sensation be  at first lost, it is
shortly regained, the motor paralysis continuing.  The paralysis may be com-
plete or incomplete, and if incomplete it may be of every gradation  as regards
degree.  The  paralysis may be complete in one and incomplete  in the other
extremity.   If incomplete in both extremities, the degree of paralysis is gen-
erally greater  in one than in the other extremity, and in the vast majority of
cases the greater degree is in the upper extremity.
  In  cases of complete  motor  paralysis movements may frequently be pro-
duced by pricking the integument, tickling the sole of the foot, or applying
a heated iron  to the surface.   These movements take place  without volition,
and much  to  the  surprise  of the  patient if the  mental faculties  be intact.
They are purely reflex.  They are produced in the lower, but rarely in the
upper, extremity.   In most cases of cerebral hemiplegia the tendon reflexes
are increased on the paralyzed side, and to a less extent on the healthy side;
whereas the skin reflexes, including the cremaster reflex, are diminished on the
paralyzed side.  Direct  mechanical irritation of the paralyzed muscles will
often  cause  marked  contractions  which are possibly of  a  reflex nature.
There  is a  notable difference in different cases as regards the condition of
the muscles of the paralyzed limbs.  They are in  some cases soft and flaccid,
offering  no resistance to the movement of the limbs in different directions;
but in other cases they are hard and rigid, resembling sometimes muscles in
tetanic contraction, and  offering much resistance to movements of  the limbs.
  The paralysis generally involves the muscles of  the face, the side affected,
as a rule, corresponding  to the paralyzed limbs.   Exceptionally, the limbs on
one side  and the face on the opposite side are affected.  This is called crossed
paralysis (paralysie alterne).  Only the muscles of the lower facial district—
namely, the muscles  of the mouth, cheek, and nose—are affected.   On the
paralyzed side of the face  the expression is abolished, and when the facial
muscles  are excited to action, as in speaking or smiling, the mouth is drawn
to the opposite side. Aoluntary power over the frontal muscle and the orbic-
  1 It is possible that symptoms due to destruction of brain-suhstanee may disappear by
other parts of the brain—for instance, corresponding parts of the opposite  hemisphere—
taking on vicariously the functions of the destroyed  district.  This supposition, how-
ever, cannot be  considered as  proven.   There is no way of distinguishing between
symptoms resulting  from destruction of brain-substance and  those dependent on dis-
turbed  nutrition of brain-substance, except  that the latter  disappear  more or less
rapidly. 
CEREBRAL  HEMORRHAGE.
665
ular muscle of the eye  is rarely lost.   The patient is generally able to close
the eye on the  affected side, but he cannot, as a rule, close the eye on the
affected side while the other eye remains open.  The power over the orbicular
muscle  in  a  certain proportion of cases is very  obviously impaired.   The
patient  usually  winks  on the affected  side.
  If the patient protrude the tongue, the extremity frequently points to the
paralyzed side of the face.   In  the  instances  in which the tongue has been
thought to point to the  opposite side there was probably an error of observa-
tion.  The tongue may appear  to be thus  deflected,  owing to the different
situations of the upper lip and angle of the  mouth  on the paralyzed side.
If the mouth on this  side be drawn by the  finger laterally, so as to be  in
symmetry  with  the opposite side,  the  tongue, which  had appeared to be
deflected,  may be seen  to be protruded in  a direct  line or to point to the
paralyzed side.   The loss of certain teeth may cause  the tongue to protrude
in an abnormal direction.   The deflection  of the tongue  to  the  paralyzed
side  may  be explained by the action of the stylo-hyoid muscles and of the
posterior belly of the digastric, which effect the protrusion of  the tongue by
elevating  the base  attached  to the hyoid bone.  AAHien only the muscles of
one side act, the base  is elevated upon this  side only, and the tip of the
tongue  is protruded to the  opposite or paralyzed side ; or the deviation of
the tongue may  be the  result of paralysis of the hypoglossal nerve  supplying
the genio-glossus muscle.   The velum  pendulum palati on the side of the
paralyzed limbs is  sometimes involved  in the paralysis.   This is  shown by
an abnormal flaccidity  of the velum on one side, which remains motionless
when the muscles  of  the  other side are seen to  contract on depressing the
tongue  with  a spatula.  The uvula in  these cases is deflected to  the  unaf-
fected side;  but this alone is not evidence  of paralysis, as deflection of the
uvula to  one side is frequently observed in  healthy  persons.   Occasionally
there are ptosis, diverging strabismus, and dilatation  of  the pupil, sometimes
on the same  side, but in the  great majority of cases on the side opposite to
that of the paralyzed  limbs.  These symptoms show that the third cranial
nerve is involved.   The other nerves distributed to  the  eye are very rarely
involved.   The  fifth nerve usually escapes.   The  eighth nerve  is unaffected,
save in certain  cases  of hemiplegia with coma about to terminate fatally.
The  nerves of special  sense almost always escape.   The muscles of respira-
tion  are not usually involved in the paralysis, the respiratory movements  on
the two sides being equal.   Sometimes, however, the respiratory muscles  on
the hemiplegic  side are paretic, as is  made  evident by a slower and less
complete  expansion of that  side of the chest than of  the  opposite  side.
This  lessened expansion  may explain  a tendency  of pulmonary complica-
tions, which  are common in cerebral hemorrhage, to  affect the lung on the
side  opposite to the hemorrhage.   The  muscles  of the neck  and trunk  in
general remain  unaffected.   It is a law that muscles  which usually act  co-or-
dinately or consensually, such as the muscles  of the  eye and the respiratory
muscles, escape  in hemiplegia.  The  trapezius  muscle on the paralyzed side is
usually paretic,  causing a sinking of the corresponding shoulder.
   The clinical history of hemiplegia from cerebral hemorrhage  presents  much
diversity in different cases.   It is impossible to  judge at first of the prospect
as regards the amount of improvement which will  take  place.  More or less
improvement takes place in  the majority of  cases.  The improvement is usu-
ally  gradual.  The  sensibility, if this have been lost, is first restored, and
it may  become  abnormally  increased on the  affected side.  The  paralyzed
condition  of the face  may diminish or  disappear in a short time.  Improve-
ment, as a rule,  begins  sooner and progresses  more rapidly in the lower than
in the upper extremity.   Frequently  the  patient is able to  walk without 
666  DISEASES OF THE CEREBRAL  AND  SPINAL CIRCULATION.

much difficulty, while the upper extremity remains almost completely para-
lyzed.   The  manner  of walking varies in different cases.  If the  rotating
muscles of the thigh be relatively but little affected, the limb is thrown for-
ward so as to describe the arc of a circle; but frequently the body is inclined
to the opposite  side  and the limb is dragged after its fellow.  Sometimes it
is  brought forward with a jerking movement.   Tremulousness of  the  limb
in walking is sometimes observed.   The patient often experiences  difficulty
in walking, from  a  depression of the toes  which renders him  liable to  trip.
   A remote effect upon the paralyzed parts is deficiency of volume or wast-
ing, this effect being proportionate to the degree  of permanent  paralysis.
Atrophy of the paralyzed muscles, however, occurs later, and is much less in
degree, than in cases  of paralysis from affections of nerves or of the spinal
cord.   The atrophy  which takes place is due  to disuse of the  muscles.
Paralyses  dependent on cerebral lesions are distinguished by the absence of a
trophic disturbance of the affected muscles. The  paralyzed  muscles  also, as a
rule, respond to the excitation of electricity; that is, their electro-contractility
is  preserved.  The temperature in hemiplegia becomes less on the paralyzed
than on the opposite side;  the pulse has less amplitude ; and the veins some-
times  show congestion.  There may  be adema on  the paralyzed side.   Remote
effects relate  to the contraction of certain muscles.  Permanent contraction of
the flexor muscles, especially of the forearm, is frequently observed.  It  is in
some  cases due to a contraction sufficient to overcome antagonizing  muscles,
and in other cases to a greater degree of paralysis of the extensor  muscles,
the flexors contracting  simply  because they are not  antagonized.   In  the
latter case the flexed  parts are restored with a little force; and in the former
the contracted muscles  offer  resistance  to efforts for extension.  It is  cus-
tomary to distinguish a primary and a secondary contracture.  The  primary
contracture  appears a few days  after the attack,  and is attributed to reactive
inflammation.  It generally disappears.  The secondary contracture appears
several months after the attack, and is permanent.   It is attributed  by many
to secondary degeneration of  the spinal cord.  It is  a  bad prognostic sign.
AAreir  Mitchell has observed that the growth of the nails on the limbs of the
affected side is arrested, and that a resumption of their growth is a forerun-
ner of a return of power over the paralyzed muscles.  There is a tendency to
the formation of  bed-sores, particularly on the nates and over the trochanter
of the paralyzed side.
   The mental condition  in different cases of hemiplegia from cerebral hemor-
rhage presents great variation.   The faculties of the mind are generally, if
not invariably, more or less impaired.   Patients  are moved  to tears  or laugh-
ter by trivial circumstances.   A marked  change in character is frequently
observed.   Patients are  liable to become impatient and  irritable.  They  lose
self-reliance,  and  are easily influenced by those around them. This fact some-
times has important  medico-legal bearings.  The tendency is to progressive
impairment of the  mental faculties,  ending at last in imbecility.   Cases
differ much  as  regards the rapidity of progress toward  this  result.   The
mental  deterioration  doubtless  often depends in no small measure on the
deficiency  of  the  exercise  of  the mental  faculties  after  paralysis  has
occurred.
   Aphasia has been  already considered as incident to cerebral embolism and
thrombosis.  (Vide p. 653.)  It occurs in a certain proportion of the cases of
hemiplegia caused by cerebral hemorrhage.  There may be either  total  loss
or more or less impairment of speech, and the aphasia may be  either ataxic
or amnesic,  As  regards the dependence of this  symptom on the situation of
the clot, the facts  stated in connection with Cerebral Embolism  and Throm-
bosis are applicable.   Recovery from the  aphasia is less likely to take place 
CEREERAL  HEMORRHAGE.
667
when dependent on the presence of a clot than when it depends on occlusion
of an artery.  Aphasia is  to  be distinguished from the difficulty in articu-
lation  arising from paralysis  of the  tongue and lips.

  Causation.—The dependence of cerebral hemorrhage on conditions pertain-
ing to  the vessels within the brain has been considered in connection with the
anatomical characters, and  also its relation to disease of the heart.   The local
conditions are rarely present prior to the middle period of life; hence, apoplexy
and hemiplegia,  caused by  cerebral hemorrhage, seldom occur in persons less
than forty years of age.  In the majority of cases the age is more than sixty.
Cerebral hemorrhage is  somewhat more frequent in males  than in females.
The various causes of arterio-sclerosis are  remote causes of cerebral hemor-
rhage.   Such causes are—alcoholism,  syphilis, gout, and hereditary predisposi-
tion.   As already stated, simple hypertrophy of the left ventricle of the heart
may have a causative relation to cerebral hemorrhage  by  increasing arterial
tension, assuming the existence of the lesions of the arteries of the brain which
have been described.   Hypertrophy associated with mitral stenosis or insuffi-
ciency or with aortic lesions has no causative agency.  It is doubtful if venous
congestion, incident to dilatation of the right side of the heart or other causes,
ever has much agency in determining the occurrence of hemorrhage.  Active
congestion from  causes other than simple hypertrophy of the heart may have
this effect.   Persons have  been  attacked when  under mental excitement, as in
public speaking  or  in a fit of  anger.   In two cases under  my observation an
apoplectic attack took place during sexual intercourse.  Straining  at stool,
violent muscular exercise, the throes of labor, and drunkenness have in some
cases appeared to produce an  attack.   All these are exciting causes.  In the
larger  proportion of  cases the hemorrhage takes place without any obvious
exciting cause.  In  a considerable proportion of cases it occurs during sleep.
I have known  it to  occur in a patient considerably reduced by prolonged
menorrhagia, and to  follow much  loss of blood from  hemorrhoids.
  Formerly, much importance was attributed to a so-called  apoplectic consti-
tution,  consisting of shortness of the  neck, with considerable embonpoint and
what is known as a full habit,  An analysis of a considerable number of cases
shows  that no reliance is to be placed on these or any other  external charac-
ters as denoting a predisposition to cerebral hemorrhage.

  Diagnosis—Apoplexy  from  cerebral  hemorrhage maybe confounded with
several morbid conditions which involve coma more or  less complete.  There
is little risk of confounding apoplexy  and syncope except for  a  short time, for
syncope is of brief duration.   It  is characterized by death-like pallor, cold-
ness, catching of the breath, and great feebleness or extinction  of the pulse—
symptoms which do not belong to the clinical history of cerebral hemorrhage.
The coma which sometimes follows an epileptic  paroxysm bears a resemblance
to apoplexy.   Knowledge of the fact that the  comatose state  has been  pre-
ceded by violent convulsions, with difficult  and noisy respiration from laryn-
geal  spasm, will at once settle  the character  of the  attack.  AVithout this
knowledge the foam or blood  on the  lips and the wounded tongue show that
epileptic convulsions  have  occurred.   The doubt can only arise when the
patient is a stranger found in an unconscious state.   The physician generally
is aware or is able to ascertain that  the patient is  subject  to epileptic fits.
A paroxysm of epileps}* may act as an exciting cause of apoplexy.   Hysteri-
cal coma is another condition which may suggest the existence of apoplexy.
This is to be discriminated by the characteristic  phenomena  of hysteria having
preceded the comatose  state ; by convulsive movements  in  some cases, into
which  volition enters more or less;  and by the absence of stertor, the mobility 
668   DISEASES  OF  THE CEREBRAL AND SPINAL CIRCULATION.

of the iris, and the restoration of consciousness on resorting to the cold douche.
The  coexistence generally, in  uramic coma, of epileptiform convulsions if
dropsy do not coexist,  suggests the probable existence of renal disease, and
the urine is  found to  contain  either albumen  or casts, or both.         .
   Profound alcoholic intoxication may be mistaken for apoplectic coma.  The
following are the differential points :  The odor of spirits or of wine in matters
vomited and in the breath of the patient;  absence of hemiplegia; the pulse
usually feeble or soft and increased in frequency, not diminished in frequency
and  hard as it is usually in  apoplexy; the  pupils dilated.  The patient can
generally be  roused sufficiently to exhibit some  of  the manifestations  of
drunkenness in the manner of  speaking.  Pouring cold water upon the  head
from a considerable height is a ready mode  of partially arousing the  patient.
It is important to make  this discrimination.  To call apoplexy drunkenness
would  be an unfortunate error, and the reverse would be annoying to the
practitioner.
   In deep  narcotism due to opium-poisoning  the  patient by vigorous efforts
can generally be roused for  an  instant.  The respirations are notably dimin-
ished in frequency, but there is  no stertor.  The pupils are contracted. There
is no hemiplegia.
   Apoplectic coma caused by active  hyperamia (congestive apoplexy) and
by meningeal hemorrhage is  excluded  by the coexistence  of hemiplegia.
Hemiplegia may generally be ascertained during  the  apoplectic state.  The
patient moves the  extremities of one side, while those of the other side remain
motionless.   He may manifest sensibility only  when the  integument of one
side  is pinched or pricked.   The face may be drawn to one side, especially if
manifestations of pain can be produced.  The paralyzed members, when raised
and allowed to drop, fall as if inanimate.  The absence of the cremaster reflex
on the paralyzed side, and its presence on the other side, may assist in deter-
mining the hemiplegic  side during coma.  On the other hand, meningeal  hem-
orrhage  and  cerebral hyperamia do' not, as a rule, give rise to hemiplegia.
The  existence or otherwise of hemiplegia is of course readily ascertained  after
the patient emerges from the apoplectic state.   The exclusion of embolism as
the cause is more difficult and is not always practicable.  For the differential
points  the reader  is referred to the diagnosis of embolic  apoplexy (p. 0f)">).
Hemiplegia without apoplexy may be caused by cerebral affections other  than
hemorrhage,  embolism, and  thrombosis—namely, by tumors and abscess  of
the brain.  These affections give rise to cerebral  symptoms prior to the occur-
rence of hemiplegia, and not infrequently to paralysis limited to one or  more
of the  cranial nerves.   If the hemiplegia be not preceded by symptoms point-
ing to  tumor or abscess, and if  functional hemiplegia be excluded, the differ-
ential diagnosis lies between hemorrhage, embolism, and thrombosis.   If the
hemiplegia have occurred suddenly, thrombosis  may be excluded.  The points
involved in discriminating embolic hemiplegia have  been stated.   The  oc-
currence of spinal hemiplegia  in rare instances is to be remembered in the
diagnosis.
   The importance of a careful  examination of  the  head for the evidence of
injury in cases of coma when nothing is known of the history may be  here
alluded to.   A patient  admitted into hospital in a comatose condition,  with-
out  this precaution may be supposed to  have apoplexy, when  subsequently,
perhaps  at the autopsy, fracture  of the skull  with  meningeal hemorrhage
may be  found.

   Prognosis.—An attack of apoplexy from cerebral hemorrhage may prove
fatal within a very short period, sometimes within a few moments.   AA'hen it
proves suddenly fatal, the coma is at once profound and  accompanied by  great 
CEREBRAL  HEMORRHAGE.
669
 disturbance of respiration  and loss  of deglutition,  death taking place by
 apnaa.  A fatal  termination frequently takes place after  the  lapse of from
 twelve to twenty-four hours. The  coma in these cases continues, and becomes
 more profound ; the respiration is more  and more embarrassed ;  tracheal rales
 occur; deglutition is gradually lost;  the  urine is retained or flows  away
 involuntarily ; involuntary dejections occur ; and the mode of dying is chiefly
 by apnaa.  If no improvement take place within ten  or  twelve 'hours the
 coma  remaining  or  becoming  complete,  disturbance of the respiration'and
 deglutition being more marked, there  is little  room for the expectation of
 amendment, and the case will probably  end fatally within a short period.  In
 other cases life is prolonged for several days, the patient not emerging from
 the apoplectic state,  but more or less  improvement, as regards consciousness,
 taking place in some cases.   The  mode of dying in these cases is by apnaa
 and asthenia combined.
   On  the other hand, the apoplectic attack may pass off in a few moments or
 a few  hours, hemiplegia remaining.  The paralysis at first is generally com-
 plete,  and  the sensibility on the affected side, as wall as the power of motion,
 is often  lost.  The latter usually returns more  or less speedily ; and  more
 gradually there is improvement as regards  the power  of  motion.  In  most
 cases this improvement goes on progressively until a certain point is reached,
 and at this point, which varies much in diff'erent cases, the improvement stops.
 More or less of the paralysis remains permanently as a rule.  It is impossible
 to judge beforehand of the degree of improvement which may be expected
 as regards  the  paralysis.   The completeness of the paralysis at first is  prob-
 ably due to the shock or contusion of the parts of the  brain in proximity to
 the extravasated blood.  After recovery from this the amount of paralysis
 will depend on the extent of damage  which the brain-substance has received.
   The occurrence of cerebral hemorrhage involves liability to its recurrence.
 Of those who recover  from a primary attack, a considerable proportion are
 again attacked  after  intervals  of varying duration in different  cases.   As a
 rule, the hemorrhage in successive attacks is greater, rendering them  more
 severe or dangerous.   It is, however, to  be borne in mind that recurrences
 do not always occur.   Patients with hemiplegia  resulting from a clot in the
 brain  sometimes  live for twenty  years or longer, a second hemorrhage not
 taking place.  In a recurrent  attack the hemorrhage  may be on the  same
 side or in the other hemisphere, more frequently the former.  Instances have
 occurred in which a hemorrhage occurred simultaneously in  both hemispheres,
 causing double hemiplegia.   The  mental condition after the occurrence of
 hemorrhage has been already  referred  to.

  Treatment.—-To bleed or not to bleed is  the first question which  arises
 in the treatment  of an  attack of apoplexy from  cerebral hemorrhage.   The
 answer is neither  affirmative nor negative as regards cases collectively, but it
 may be either according to the  symptoms in individual cases.
  If the apoplectic attack be accompanied by  symptoms denoting determina-
 tion of blood to the head and increased  arterial tension—a flushed face and
 strong pulsation  of  the carotids—venesection  is indicated, especially if the
 patient be robust or  full-blooded and the action of the  heart be abnormally
 strong.  Under these circumstances it is fair to infer that the giving way of
 the cerebral artery was due in  a measure to the hyperamia or to the arterial
 tension as an accessory or exciting cause.  Bleeding will not undo the mis-
chief  which has already taken  place, but it may prevent an increase  or a
renewal of the hemorrhage.  In a certain proportion of cases the symptoms
are essentially different. The  face may be pallid, the  carotids  do not beat
strongly, and the  pulse may be small and weak.  Venesection  under these 
670  DISEASES OF THE  CEREBRAL AND SPINAL  CIRCULATION.

circumstances is  contraindicated.   If the abstraction  of  blood be  decided
upon, it should be by venesection.   It is important that the effect of  the
bleeding be produced promptly, and for this reason cups or leeches do not as
well meet the indication.  The amount of blood abstracted should be deter-
mined by  the effect.   A large bleeding is  rarely indicated.
  Generally,  it is advisable  to administer  an active cathartic.  Croton  oil,
from the facility with which it is administered, its  efficiency and its quickness
of operation, is to be preferred to  any other cathartic.   Three or four drops
may be given at once and repeated in three or four hours if free purgation be
not produced.  Its operation may be promoted by large, stimulating enemas.
An active cathartic should not be  given if the pulse be  notably small or
feeble.
  The patient should be  placed in a cool, airy apartment; the head should
be moderately raised ; cold or  evaporating lotions  should  be applied  to  the
head, or, if the head  be hot  and flushed, the ice-cap ;  stimulating pediluvia
may be employed if  the extremities be cool; and everything constricting  the
neck and chest should be removed.  Attention is to be directed to the bladder,
and if required the use of the  catheter is  not to be delayed.
  These are the measures to be pursued until it is decided whether the patient
is to emerge  from the apoplectic state.  If  after the lapse of several hours
the symptoms denote a hopeless condition, the  physician must content him-
self with  measures which  appear to contribute to the comfort of  the patient,
for he is,  in fact,  unconscious of suffering.  Purgatives and  other perturbat-
ing remedies under  these circumstances will only tend to hasten  the fatal
termination.  If,  on  the other hand, the  attack pass off, the measures indi-
cated are  simply quietude and an unstimulating diet until  symptoms denote
inflammation around the clot,   These do not call  for active treatment.  Cool
applications to the head, a sinapism to the neck, saline laxatives, and  perfect
quietude are  sufficient.  The vital powers should not be impaired by active
treatment.  The recovery is effected by the disintegration and absorption of
the clot, and  this  requires many weeks or months.   The processes of  disinte-
gration and absorption are not promoted directly by any medicines.  There is
no ground for supposing that mercury, iodine, or other drugs have any direct
influence  over these processes.   Blisters or other modes of counter-irritation
are of no  utility.   Electricity applied to the  brain is a doubtful measure, and
is not without hazard of  injury.  As regards the clot, nothing can be done
except  by nourishing the  patient well, avoiding stimulants, preventing as far
as possible everything which disturbs  body  or mind, and meeting any symp-
tomatic indications.   The case is  now one  of hemiplegia  dependent on  the
presence  of the clot and the  damage which it has occasioned.
   A tendency to  the formation of  bed-sores is counteracted by observance of
strict cleanliness  and by not allowing continued pressure on susceptible parts.
   Active  treatment directed to the paralyzed muscles is contraindicated while
the symptoms denote inflammation or irritation at the situation of the hemor-
rhage.  Gentle rubbing of the paralyzed  limbs and passive movements, how-
ever, may be resorted to with but  little delay.   More energetic measures are
indicated  after two  or three months.   The objects of treatment are the pro-
motion of the circulation  and  nutrition in  the paralyzed  muscles, together
with the increase, as far as possible, of their functional capacity. The means
are massage or kneading,  rubbing with stimulating liniments, passive move-
ments, electricity, and volitional exercise.  Kneading,  rubbing,  and  passive
movements should be systematically and perseveringly employed.  If  they do
not occasion  fatigue, they cannot be too much employed.  It is to be borne in
mind that paralyzed muscles do not of themselves resume at once  their normal
functional capacity, even  after the  conditions causative of the paralysis are 
CEREBRAL  HEMORRHAGE.
671
removed ; and  having been  for a considerable period paralyzed, they  may
remain  so  indefinitely if appropriate measures  be not  made for  their res-
toration.
  Electricity is a potential agent in promoting the objects stated,  especially
when the paralyzed muscles  respond not at all or feebly  to  the will.  It pro-
motes circulation, nutrition,  and is a substitute  for the will  as  regards the
functional exercise of the muscles.   AVith respect to the choice  between the
two currents, the methods to be adopted, etc., the reader is referred to treatises
on the  practical use of electricity  or to works devoted  to  nervous diseases.
This agent is apt to be inefficiently  employed.  It may be injudiciously used,
and it is potential for harm as well  as good.  AA'hen practicable, therefore, its
employment  should  be under the direction of an experienced physician who
has given  special attention to electro-therapeutics.
  When the  paralysis is not  complete, the most efficient measure  for securing
as much improvement as is compatible with the amount of damage  which the
brain has received is voluntary exercise of the paralyzed muscles.  A patient
who has been for some time a paralytic  is in a condition not unlike that of
the infant  who has not learned to  use the muscles.  Persistent exercise  in
the one case, as in the other, is the means by which development and power
are to be acquired.  There is reason to believe that in not  a few* cases paral-
ysis continues  until it becomes fixed at a  certain point, when  persevering
exercise in conjunction with other measures might have led  to  more or less
improvement.  It is often  difficult  to enforce this  measure on account of its
simplicity.
  The liability to the recurrence of cerebral  hemorrhage renders  it  important
to observe  all  possible precautions  by way of prophylaxis.   Placing the sys-
tem in the  best possible condition by means of a  well-regulated diet and  regi-
men,  and avoiding exciting causes,  will afford  all the security which can be
obtained.   It is not probable that any protection is afforded by reducing the
powers  of the system, and injury may thereby be produced.  It is injudicious
to adopt a  diet which is insufficient for the wants of the system, or to resort
to repeated bloodlettings, cathartics, or other lowering measures.  In striving
to avoid excesses and imprudences of all kinds care must be taken not to err
in the opposite  extreme.  Mental occupation within certain limits  is  advisable.
  A liability to hemorrhage if an attack have never occurred cannot be esti-
mated with any degree of certainty.  Apoplexy and paralysis are  affections
which many persons  apprehend, and if certain cerebral  symptoms  be experi-
enced, especially  vertigo, the apprehension is  often the source of  much tin-
happiness.   The  suggestion  by the physician that there  is danger of these
affections is  an indiscretion  which  I  have known to prove most calamitous.
When apprehension is felt,  the physician is warranted in  giving assurances
that vertigo  and other cerebral  symptoms are sufficiently common without
being followed by apoplexy or paralysis,  and that these affections  are rarely
preceded by  obvious  premonitions.   Needless uneasiness  may oftentimes be
removed by  these assurances.
  The treatment  of hemiplegia from cerebral hemorrhage is the same whether
it occur with or without the  occurrence of apoplexy.

  In  connection with the subject of cerebral hemorrhage the  question arises,
Can the particular situation of the extravasated blood be  ascertained by means
of the symptoms?  This question arises in respect to the particular situation
of softening from embolism and thrombosis, and also with  reference to the local-
ization of circumscribed inflammation or abscess of the brain, cerebral tumors,
and atrophy.   In  order to avoid repetitions, the facts at present known con- 
672  DISEASES OF THE  CEREBRAL AND SPINAL  CIRCULATION.

cerning the localization of cerebral  diseases are  concisely stated under a
separate  heading.


            Topical Diagnosis of Cerebral Diseases.

  In  the  present article will be considered the diagnosis of cerebral diseases
according to the situation of  the lesion.  The possibility of the topical diag-
nosis  of cerebral diseases  is based upon  the fact  that  certain parts of the
brain  are endowed with  special  functions, the excitation or the abolition of
which gives rise to  characteristic symptoms.  Our knowledge of  the  local-
ization of these functions is due  partly to physiological, but  chiefly, so far
as man is concerned, to clinical  and pathological observations.  This know-
ledge  is  still very imperfect.  In  the  present article only such facts will be
considered as  are reasonably certain.
  The diseases of the brain are conveniently  classified as focal or  local dis-
eases, in  which the lesion is confined to a circumscribed part of the brain,
and diffused or general diseases, in  which a large part of the brain is affected.
Examples of  focal cerebral diseases  are — circumscribed  hemorrhages, foci
of softening either embolic or thrombic, localized  encephalitis, abscess, and
tumors.   Examples of diffuse diseases of the brain are—anamia and hyper-
amia, diffuse  encephalitis, and the conditions produced by concussion and
compression of  the  brain.  It is  of course  only  the local diseases of the
brain  which admit of a topical diagnosis.
  The symptoms which  may be  produced  by local  diseases of  the  brain
are  either direct or  indirect.  The direct  symptoms are those due  to irri-
tation or  to destruction of the  part  of the  brain  which is the  seat of the
lesion.  The indirect symptoms  are those referable to the influence exerted
by the lesion upon  neighboring  or remote parts of the brain.  Direct symp-
toms  caused by destruction of brain-substance are  permanent, except, so far
as some other part of the brain may  be capable of assuming vicariously the
functions of the destroyed part.  Indirect symptoms  are to a great extent vari-
able and  inconstant, and in the case of many local lesions they disappear after
an indefinite period, leaving only direct symptoms.   Although  certain symp-
toms,  such as  coma, and  in most instances headache, delirium,  and  vomiting,
can be recognized as  indirect symptoms, yet it is in general impossible from
their  nature  alone to distinguish the  indirect from  the  direct symptoms.
This distinction, however, can often be made  in the course of time by noting
that certain symptoms disappear, and are therefore probably indirect, whereas
other  symptoms  remain permanently and are considered to be direct.   For
instance,  a fresh  hemorrhage in that part  of the internal capsule  occupied
by the motor tracts  may give rise, in addition to hemiplegia, to anasthesia,
aphasia, and strabismus, the last three symptoms being indirect,  as they are
referable not,  like the hemiplegia, to destruction of the  part named, hut to
an influence exerted upon other  parts by pressure,  inflammatory adema, etc.
After a time anasthesia and the other secondary or indirect symptoms dis-
appear, and  the  hemiplegia remains as the direct symptom of the lesion.  It
is evident that the fewer the indirect, and  the more pronounced the direct
symptoms, the greater the probability of making  an  accurate diagnosis of
the  seat  of  the  lesion.  Hence  it follows  that a topical diagnosis is  often
impossible in  the early stage of cerebral hemorrhage or softening, but can
frequently he made at a later stage, when  the indirect symptoms  have dis-
appeared.
  For various reasons mistakes are especially  liable to be made in the topical
diagnosis of tumors.   Not only  do tumors  often grow in parts of  the brain
the  function of  which is  very imperfectly  understood, but they give rise to 
           TOPICAL DIAGNOSIS OF CEREBRAL DISEASES       673

many diffuse and indirect  symptoms,  and by  their slow development they
frequently  displace nerve-eleilients without destroying them.
  Hughlings-Jackson has graphically  designated as discharging lesions those
which  irritate nerve-elements, and as  destroying lesions those  which annul
their function.   A  discharging  lesion in a motor  tract produces  spasm—a
destroying  lesion, paralysis.
  After these few remarks by way of introduction, the lesions situated in the
different parts of the brain will be briefly considered with reference to their
topical diagnosis-
  1. Cerebellum.—Hemorrhage in the cerebellum occurs much less frequent-
ly than in  the  cerebrum.  The  proportion is variously estimated as  from 1
to 12 to 1 to 35.  Embolism of  the cerebellar  arteries is even more unusual.
Other local diseases of the cerebellum  are abscesses, encephalitis, tumors, and
atrophy.
  Lesions,  often extensive,  of the cerebellum may remain  entirely latent
during life.   This is believed to  be the case only when^he lesion is localized
in one  cerebellar hemisphere, and when its influence does not extend beyond
the seat of disease.   In a remarkable case reported by Ebstein,1 nearly the
whole left hemisphere of the cerebellum was occupied by an  osteoma which
did not encroach upon surrounding parts.  The patient died  of a pulmonary
affection, having  manifested  no  symptom referable to the  nervous  system.
Characteristic,  although not pathognomonic of lesions of the cerebellum,
are disturbances  of co-ordination  designated as cerebellar ataxia and dizzi-
ness.   These symptoms are  believed to be  the result of an affection of the
vermiform  process or middle lobe  of the cerebellum, either directly  when it
is the seat  of disease or  indirectly by an encroaching lesion.  The  gait  in
cerebellar ataxia, which affects  chiefly the lower extremities, resembles  that
of a drunken man, and  not that of  a  patient affected with  locomotor ataxia
or posterior spinal sclerosis.  The symptoms in the great class of  cerebellar
lesions, such as fresh hemorrhages and tumors which act  upon  adjoining
parts, particularly upon  the pons and medulla oblongata, are various, but they
can sometimes be utilized in  making the  diagnosis.   Of symptoms produced
by cerebellar disease, but not directly referable  to disturbances of function of
the cerebellum  itself, may be mentioned vomiting, amblyopia, and amaurosis;
headache, most frequently in the  occipital region; hemiplegia, either corre-
sponding to the side of  the lesion or to the opposite side; less  often epilepti-
form convulsions and spasm; and sometimes  irregular and infrequent action
of the heart.
  2. Crura Cerebelli.—No characteristic symptoms  of lesions of the superior
or of the inferior peduncles  of  the cerebellum have  as yet been discovered.
On  the other hand, lesions  of the middle  peduncles, the  crura ad pontem,
have repeatedly been observed  to be attended by so-called forced or com-
pelled  movements.   These peculiar  movements appear, according  to Noth-
nagel, when the lesion acts as an irritant and does not completely sever the
connection  of the affected  crus with the cerebellum.   Recognized forms of
these compelled movements  are  rotary movements of the  body around its
long axis;  the  assumption of a compelled position upon one  side, to which
the patient instantly returns when moved;  the tendency to fall to one side,
accompanied with dizziness ;  and the deviation of the head and of the eyes,
most characteristic when one eye is turned upward and the other downward.
These  movements may  occur during coma, but they are more characteristic
of disease of the crura cerebelli  when present in the waking state.  AVith the
exception  of the rotary or " circus" movements  and the peculiar deviation
of the  eyes, similar  compelled movements  have been  observed in diseases
                       1 Virchow's Archiv, Bd. 49, p. 145.
     43 
674  DISEASES OF THE CEREBRAL  AND  SPINAL  CIRCULATION

situated in other parts of the brain.  The movements may be toward the side
of the lesion or toward the opposite side.
  3. Pons Varolii.—Hemorrhages  occur in  the  pons with  about the same
frequency as in the  cerebellum.   Emboli  rarely lodge  in  the  basilar artery,
because its size exceeds that of either vertebral artery, and because the latter
is unfxvorably placed for the reception of an embolus.  On the other hand,
thrombosis of the basilar artery in consequence of atheromatous degenera-
tion, followed by  softening in the pons, has been repeatedly observed.  It is
important to keep distinct from each other  tumors of  the pons and tumors
exterior to  the pons and situated at the  base  of the  brain, although they
may have  many  symptoms in common.
  Fresh hemorrhages in the pons can be diagnosticated  almost  with certainty
when alternating or crossed paralysis  (that  is, facial paralysis on the side of
the lesion and paralysis of the extremities  on the opposite  side) can be made
out; but  in  many cases, perhaps  the majority, of fresh hemorrhage in the
pons there are no characteristic symptoms present and the topical diagnosis
is impossible.   Often the symptoms are those of an ordinary apoplexy, such
as follows hemorrhage in the internal capsule.   AVhen it is considered that
through the pons pass the bundles of motor and of sensory fibres which con-
nect the cerebrum with the spinal cord, that here  are situated the  roots of
origin  of  the trigeminus, abducens,  facial, and  acoustic  nerves, and taking
into view  the close relation of the  pons to the medulla oblongata, it cannot
occasion surprise to find  that the symptoms of stationary lesions, such as of
old  hemorrhages and foci of softening, and  particularly of  slowly-progressive
tumors, may present a variety and complexity somewhat diagnostic of affec-
tions of this part.   It would be beyond the limits and scope of the present
summary to enumerate the possible, or even  many  of the frequent, combina-
tions of symptoms which may attend diseases of the pons.   The most cha-
racteristic, and when occurring suddenly probably a pathognomonic, symptom
is crossed paralysis  (paralysie alterne).  When this variety of  paralysis  is
due to a stationary, non-encroaching lesion, this  lesion will  almost always be
found in the lower half of the pons.  In crossed paralysis, while the  extrem-
ities are always paralyzed upon the side opposite to the  lesion,  there is paral-
ysis of the facial, abducens, or hypoglossus  nerves upon the side of the lesion.
The facial paralysis of crossed hemiplegia  resembles peripheral facial palsy;
that is, all of the muscles supplied by the facial nerve (including the occipito-
frontalis, corrugator  supercilii, and orbicularis palpebrarum) are involved and
the  reaction of degeneration appears.   Crossed  hemianasthesia may like-
wise occur, but less frequently than crossed hemiplegia.1  It must not be
inferred that the facial paralysis is necessarily on the side of the lesion in affec-
tions of the pons.  It is  sometimes on the same side as the body paralysis,  in
which case the hemiplegia is in no way characteristic of disease of the pons.
In a remarkable case of  tumor of the posterior portion  of  the  pons, reported
by AVernicke,2 there  existed  paralysis only of cranial nerves, and not at all
of the extremities.   AAfhen crossed paralysis  fails, it is from the grouping of
the symptoms and by a careful  analysis  of individual  symptoms that the
diagnosis of a pons lesion is to be made, rather than by the presence of any
one characteristic symptom.   Bilateral  paralysis is rare—in fact, much less
frequently met with  than was formerly assumed or would  seem probable on
theoretical grounds, if we except those extensive hemorrhages which lead  to
death during the stage of apoplectic coma.
  4. Medulla Oblongata.—Hemorrhage into the  medulla oblongata is not fre-
  1 The manifold variations under which crossed paralyses of motion and of  sensation
may appear have been tabulated by Sigerson, Dublin Med. Journ., Feb., 1878.
  1 Arch.f. Psych., Bd. 7, p. 513. 
           TOPICAL DIAGNOSIS OF CEREBRAL DISEASES.       675

quent.  It leads almost invariably to death, either instantaneously or within
a few hours, in consequence of injury to the centres of respiration and  of
circulation.   Tumors occur in this  situation,  but they are rare, and their
symptomatology is  very imperfectly understood.   The most interesting and
carefully studied of the  local diseases of  the  medulla oblongata is bulbar
paralysis, the  acute form of  which is  generally due to ischamic softening
or to inflammation, rarely to hemorrhage.   Both  the acute and the chronic
forms of bulbar paralysis will be subsequently considered.
  The nerves which originate in the medulla oblongata are the hypoglossal, the
vagus, the spinal accessory,  and the glosso-pharyngeal.  The symptoms which
are  most characteristic of lesions of the medulla  oblongata are  difficulty  of
articulation, called dysarthria and anarthria,  and difficulty  in swallowing.
Disturbances in the rhythm of respiration and of circulation  are frequent.
Lesions of the medulla oblongata are the only central lesions which can cause
aphonia.  Diabetes mellitus and  diabetes insipidus  have  been  occasionally
observed to attend lesions (tumors) affecting the floor of the fourth ventricle.
Lesions of  the medulla can  of course cause  extensive paralysis of motion and
of sensation, which  may be either unilateral or bilateral according to the situa-
tion of the lesion, and which  may exist without the coincidence of characteristic
symptoms.
  5. Pedunculus Cerebri.—Lesions confined to one of the peduncles are rare.
Nevertheless, localized  hemorrhages,  foci of softening, and tumors,  particu-
larly tuberculous tumors, have been  observed in  this  situation.  It  is, as a
rule, only when the affections are situated in the basal portion of the pedun-
cle near the pons that  their  effects are limited to this structure.  The pedun-
cles  are  composed  essentially of  centripetal and  of  centrifugal nerve-fibres
connecting the cerebrum with the spinal cord.  The motor  fibres, constituting
the  so-called pyramidal tracts, occupy the middle third of the pes pedunculi;
and the sensory fibres are situated in the tegmentum.   The intimate  relation
between the inner border of the crus and the oculo-motor nerve is to be borne
in mind.  Characteristic of localized lesions of  the crus cerebri are paralysis
of motion and often of sensation of the side  of the body opposite to the lesion,
and paralysis of the third or oculo-motor nerve on the same side as the lesion ;
in other words, a variety of crossed paralysis.  The symptoms  of paralysis
of the third nerve are ptosis, external strabismus, and dilatation of the pupil,
often combined with double vision.  It is only when  the ocular paralysis and
the  crossed facial or body paralysis  develop at the same time that  it is safe
to diagnosticate an  affection of the crus.   Lesions of the  crus may  produce
simply hemiplegia or hemianasthesia without ocular paralysis, in which case
the  topical  diagnosis would be impossible.
  6.  Corpora  Quadrigemina.—Of the anatomical facts bearing upon the func-
tions of these bodies, the  most important is the termination of a part of the
fibres of the optic  tracts in the anterior pair or the  nates.  Furthermore, is
to be considered the close relation between the  terminations of the third and
fourth cranial nerves  and the corpora quadrigemina.  Arery little is known
concerning  symptoms referable to disease of the corpora quadrigemina.  Le-
sions of the anterior pair lead to diminution of vision or to blindness.  If the
lesion be confined to one of  the anterior pair, it  is  probable that  hemianopsia
is produced.  Paralysis of the oculo-motorius, reflex immobility of the pupil,
nystagmus, and disturbances of  co-ordination  resembling cerebellar ataxia
have also been observed in  lesions, particularly of the posterior  pair and  of
the  superior  cerebellar peduncles.  None  of  these  symptoms, however, is
characteristic of disease of  the corpora quadrigemina, which, with our pres-
ent knowledge, does not admit of  positive diagnosis.
  7. Thalamus Opticus.—Although the optic thalamus is very often involved 
676   DISEASES OF  THE  CEREBRAL AND SPINAL  CIRCULATION.
Fig
in hemorrhage, softening, and other affections of the internal capsule and the
basal ganglia, it is rare that a lesion  is confined  exclusively to this body.
Contrary  to former views,  it is now believed that lesions situated in the
optic thalamus, their influence not extending beyond the seat of disease, do
not produce paralysis either of motion or of sensation.   The posterior part of
the optic thalamus—namely, the pulvinar and the external geniculate body—
receive fibres derived from the optic nerves, so that lesions of this part pro-
duce loss of  vision, probably in the  form  of hemianopsia — a disturbance
which, however, is not  peculiar  to lesions in this  situation.   Post-hemiplegic
hemichorea has been repeatedly observed with lesions of the optic  thalamus,
but whether as a direct or an indirect  symptom is uncertain.   No  symptoms
which can  render certain the topical  diagnosis are  as  yet known  to attend
localized lesions  of the optic thalamus.
   8.  Corpus  Striatum  (nucleus caudatus,  nucleus  lenticularis,  and capsula
interna).—This region  is the  most  frequent  seat  of hemorrhage and  of
softening.   It is  important to be familiar with  the  anatomical  relations
                                of the parts here situated.   The anatomy
                                of this region is shown  in Fig.  1, which
                                represents a horizontal section  through the
                                right cerebral hemisphere.  The corpus stri-
                                atum  is composed of the caudate nucleus
                                 (N C in Fig. 1) or intraventricular nucleus,
                                the lenticular nucleus (XL)  or  extraven-
                                tricular nucleus, and  the anterior division
                                of the internal capsule1 (CI a).   The cau-
                                date and the lenticular nuclei are  masses of
                                gray matter.  The internal  capsule is com-
                                posed of  white  matter.   The  internal cap-
                                 sule is made up of  an anterior division,
                                 situated between  the  caudate nucleus and
                                the  lenticular  nucleus,  and   a   posterior
                                 division,  between the  optic thalamus and
                                 the lenticular nucleus.   The  two divisions
                                meet  at   a  bend  called the  knee  of the
                                 internal capsule.   The  destination  of the
                                fibres  composing  the anterior division  of
                                the internal  capsule is  not  thoroughly un-
                                 derstood.   In the posterior division are sit-
                                 uated  the motor and  the sensory tracts of
                                 nerve-fibres  supplying  the opposite  half
                                 of the body.   The  motor tract forms a
Horizontal  Section through  the  Right compact   mass  of nerve-fibres  called the
   Cerebral Hemisphere (from Strumpell):     r ..         ✓ r»\   •      i  •   1    • i ii
   nv, nucleus  caudatus;  nL, nucleus pyramidal tract (P), situated  in the middle
   lenticularis;  T/i,  thalamus opticus; th;rr|  „f t\.a  nnatpr;nr rlivwinn nf  tbp irttpr-
   Cla, anterior division of the capsula tnira  0T tne  posterior aiMSlOn 01  tile lnter-
   intema; cip, posterior division of the nal capsule.2  The fibres  belonging to the
   capsula interna; Fa, fibres  belonging n  • -,               i  i i   •.  1i  •   o
   to the facial nerve; p, pyramidal tract facial  nerve are probably situated in  front
   (motor); .v, sensory tract; o. occipital 0f the pyramidal  tract, nearer the knee of
   lobe; k, frontal lobe.                        »            '
                                 the capsule.   The  sensory tract occupies
the  posterior third of the  posterior division  of  the  internal capsule.   The
sensory tract  includes  both the nerves of  ordinary sensation and the nerves
of special sense.

   1 Some authors include only the caudate nucleus in the corpus striatum.
   2 The exact situation of the pyramidal tracts in the internal  capsule varies somewhat
with the level of the section, these tracts being nearer the knee in the superior part and
nearer the posterior extremity in the inferior part of the internal capsule.
 
           TOPICAL DIAGNOSIS  OF CEREBRAL  DISEASES.       677

  The further course of the pyramidal tract is as follows: The tract is com-
posed of motor fibres which originate in the motor cortical area—namely, the
central convolutions and the paracentral lobule. (See Figs. 2 and 3, pp. 678,679.)
These fibres descend through the centrum ovale in the corona radiata, and are
collected together into a compact mass in the middle third of the posterior divis-
ion  of the internal capsule. From the  internal capsule the pyramidal tract is
continued into the middle third of the pes pedunculi,1 thence  into the anterior
half of  the  pons, where  the fibres are scattered among the longitudinal bun-
dles of the pons, and thence into the medulla oblongata, where  they form the
anterior pyramids.   At the crossing of the pyramids a part of  the  pyramidal
fibres usually remains uncrossed, and descends in  the anterior columns of the
spinal cord, while the larger part crosses and descends in the lateral columns
of the cord.2 (See Fig. 5, p. 729.) Here the pyramidal tracts  terminate in the
ganglion-cells of the anterior horns, whence the anterior nerve-roots originate.
The pyramidal tracts, therefore, transmit voluntary motor impulses directly
from the motor cortical area to the motor ganglion-cells in the  anterior horns
of  the spinal cord.   In  the pyramidal tracts of the brain are also included
fibres belonging  to the  motor cranial nerves.
  Destruction of the pyramidal tract  of one half of the brain  causes hemi-
plegia of  the other half of the  body.   It is  evident that the lesion must be
very large to destroy all  of the pyramidal fibres in the centrum  ovale, whereas
a small lesion in the  posterior division of the internal capsule will  cut across
the entire tract.   For reasons which have been previously stated, the internal
capsule and the adjacent ganglia are the most frequent seats of hemorrhage
and of softening.  Hence the  symptoms which attend  these lesions  in this sit-
uation are usually taken as the  basis of  the clinical history of cerebral hem-
orrhage and of cerebral embolism.
  AVhen the lesion involves the anterior two-thirds of the posterior division
of  the  internal capsule, there is ordinary hemiplegia; that  is, paralysis of
motion of the opposite extremities and paralysis of the lower branches of the
opposite facial nerve.   The hypoglossal nerve  is paretic.  Secondary  con-
tracture of the  paralyzed muscles in most cases ensues when life is sufficiently
prolonged.  The muscles  undergo only  slight atrophy from  disuse, and  pre-
serve their normal  electrical reactions.
  Lesions involving the posterior third of the posterior division of the inter-
nal capsule are much less common.   They cause  hemianasthcsia or paralysis
of  sensation of the opposite half of the body.  This hemianasthcsia is often
complete, including  not only ordinary sensation, but the special  senses of
sight, hearing,  smell, and taste.    The special senses may be  only partially or
not at all involved.   The affection of sight  is probably in the form of hemi-
anopsia.   Post-hemiplegic hemichorea (which was first described by AVeir
Mitchell) and  athetosis  have been observed especially  with lesions in  this
situation.
  No symptoms have been referred directly to lesions confined to the anterior
division of  the internal  capsule, to the caudate nucleus, or to  the lenticular
nucleus.  Lesions of these parts, however, are almost invariably accompanied
by  hemiplegia, but this  is referable to involvement by pressure or otherwise
of  the  neighboring pyramidal tracts of the posterior division of the internal
  1  Here, too, the situation varies somewhat with the  height of the section, the  tracts
occupying the third quarter (reckoned from within outward) in the upper  or anterior
part of the peduncle.                                                       .
  2  Sometimes all of the pvramidal fibres  cross to the opposite lateral column.   It is
believed that verv rarelv the pvramidal fibres do not decussate at  tbe crossing of the
pvramids, but descend in that half of the spinal cord which corresponds to the hemi-
sphere in which  they originate.  In the latter case it has been claimed that a lesion in
the  brain would  produce hemiplegia on the same side as the lesion. 
678   DISEASES  OF  THE  CEREBRAL  AND  SPINAL CIRCULATION.

capsule.  If the pyramidal tracts be not directly involved, the hemiplegia  is
often temporary, disappearing when  the effects  of pressure or of  collateral
adema have  been removed.   The hemiplegia caused  by destruction of the
pyramidal tracts is permanent,   The  partial  facial  paralysis, however, seems
to be an exception to  this rule, as it is probable that  one hemisphere may
innervate the facial  muscles of both sides.
(   9.  Centrum Ovale.—AVe know of no  symptoms diagnostic of lesions situ-
ated in the centrum ovale of the cerebral hemispheres.   Lesions involving the
fibres of the corona radiata, which connect centres in the cortex with periph-
eral parts, cause the  same symptoms as lesions of the cortical  centres them-
selves.  Hence  lesions  affecting the fibres descending from the motor cortical
area, if extensive, cause hemiplegia ; if of small extent, monoplegia  of the
opposite side.  Lesions  of fibres of the corona radiata coming from the visual
area of the occipital lobe cause hemiopia.   Lesions of fibres from  the third
frontal  convolution or  from the first temporal  convolution of the  left side
produce aphasia.   Lesions in the  frontal  lobe,  and less frequently  in  the
white substance of the other cerebral lobes, may give  rise to no appreciable
symptoms.
   10.  Cortex  Cerebri.—Since  the publication  by Fritsch and Hitzig, in 1870,
of their discovery of motor-centres in  the cortex of the brain, much attention
has been  directed,  and  with fruitful result, to  the  clinical  and pathological
study of  localized  lesions  of the cerebral  cortex.
   A.  Motor Area, of the C>>rf"x.—In confirmation of physiological experiment,
pathological observations have demonstrated  that lesions of a certain  region
of the cerebral cortex are followed by motor disturbances. This region, desig-

                                  Fig. 2.
Diagram showing Position of Motor-centres in the Cortex (after Eichhorst).
nated as the motor cortical area, embraces the anterior central and  the  pos-
terior central convolutions (also called respectively the ascending frontal and
the ascending parietal convolutions) and the paracentral lobule.   The results 
           TOPICAL DIAGNOSIS  OF CEREBRAL DISEASES.       679

of experiment, as well as the symptoms following small circumscribed lesions
in the motor area, justify the recognition of  separate  motor centres  in this
part, the locations of which are represented in the accompanying diagrams
(Figs. 2 and 3).
   The centre for the movements of  the lower  facial muscles (those supplied
by the buccal,  oral, and nasal branches of the facial nerve) of the opposite

                                  Fio. 3.
Diagram of the Median Surface of the Cerebral Hemisphere, showing the Paracentral Lobule (Lbl.
   ParuceiUrl.) (modified from Kcker).  Abbreviations: G, gyrus; F, fissure; C, corpus callosum; Conv,
   convolution; F. Rol, fissure of Kolando; Hup, superior.
side is situated in the lower third of the central convolutions.   Near this, and
probably  somewhat lower, is  the centre for the movements of the  tongue
(Hypgl, in Fig. 2).  The centre for the movements of the opposite arm occu-
pies the middle third of the anterior central convolution.  The centre  for the
movements of the opposite lower extremity is situated in the upper part of
the  central convolutions, especially in  the paracentral lobule. (See  Figs. 2
and 3.)
  The motor cortical area receives its blood from the middle cerebral artery—
a fact which  explains  the greater frequency of  embolic  and of thrombic
softening  in  this  district  than in other parts  of the  cortex.
  Lesions involving the entire motor area of the cortex are  attended  by the
symptoms  of  an  ordinary  cerebral hemiplegia, and then,  if the  hemiplegia
develop at once, it cannot usually be distinguished  from lesions of the inter-
nal capsule or of the pyramidal tract in  other situations.  Such lesions in the
cortex must be very extensive, and they are rare.
  Less extensive lesions  in the  motor cortical area cause  paralysis of only
certain muscles of the opposite side.  The term monoplegia is used to desig-
nate these  localized paralyses.  The following-forms of monoplegia have been
observed  to  attend  localized  cortical  lesions: 1, oculo-motor  monoplegia
(isolated ptosis) ;  2, facial monoplegia, sometimes combined  with paralysis of
the hypoglossal  nerve ;  3, brachial monoplegia, or  paralysis of the opposite
arm ; 4, crural monoplegia, or  paralysis  of  the opposite leg;  5, brachio-facial
monoplegia, or paralysis  of the arm and face. It is evident, from the situation 
680  DISEASES OF THE CEREBRAL AND SPINAL CIRCULATION.

of the motor-centres, that while  facial  monoplegia and  brachial monoplegia,
and  also brachial monoplegia  and crural monoplegia, may be and  often are
combined, paralysis of the face and of the leg without involvement of the arm
can scarcely be produced by a single cortical lesion, and in fact has never been
observed.  In progressive  cortical lesions a paralysis at first confined to one
arm  or to the face may  advance to total hemiplegia, the cortical  localization
being then characterized by the development of the hemiplegia out  of  suc-
cessive monoplegias.  Secondary contractures  make  their appearance almost
invariably in the paralyzed muscles,  but are of course not distinctive of cor-
tical affections.   As in other forms of cerebral paralysis, the electro-muscular
reactions  are normal or only quantitatively affected—a circumstance which
distinguishes cortical monoplegias from most of those produced by lesions of
the spinal cord and of peripheral nerves.
  Of great value in  the diagnosis of lesions of the  motor cortical area are
spasms  affecting isolated  groups of muscles (mono-spasms), such as  spasms
confined to the muscles  of one side of the face  or to the  muscles of one of the
opposite extremities.  The spasms are both tonic and clonic, and they  are some-
times designated as partial epilepsy of cortical origin.  They may occur with-
out paralysis, they may develop  at the same time with paralysis, they may
precede the paralysis, or they may attack muscles which  have been paralyzed
for a variable length of time.   The latter two forms of development are espe-
cially characteristic of cortical lesions.   Partial epilepsy of  cortical origin  is
sometimes accompanied  or followed by general epileptic  convulsions, in which
case the spasm begins regularly in the  same group of muscles.   In the most
characteristic form of the disease consciousness is not lost at the onset of the
paroxysm.  The patient observes the  progress of the convulsions  from  one
group of muscles to another, and finally loses consciousness when the convul-
sions become general.  AVhen this variety of epilepsy is preceded  by  mono-
plegic  paralysis, it may be considered as almost pathognomonic of  a cortical
lesion.
  In most cases of  cortical paralysis  careful  examination  will show some
sensory disturbances, but  our knowledge of these is imperfect. It is believed
that the nerves of ordinary and of muscular sensation terminate in the cortex
of the motor area and in the cortex of  the parietal lobe, but, thus far, it has
not been possible to definitely fix centres for sensation.
  B.  Cortical Centres for  Speech—These exist in the  left  inferior  frontal
(Broca's) convolution in its  posterior part  (or pars opercularis), and  in the
left superior  temporal convolution.   It is probable, although not  definitely
proven, that the left island of Reil also contains centres for  speech.   AVhen
the individual is left-handed or when the speech-centres of the left hemisphere
are congenitally defective, the centres for speech may occupy the correspond-
ing parts of the right hemisphere.
  Ataxic or  motor aphasia is due to  difficulty in the  co-ordination  of the
muscles used in speaking.  It is caused by lesions of the left inferior  frontal
convolution.  Amnesic aphasia, or loss  of the  memory of words, is  probably
the result of  a  lesion  of the left superior temporal convolution.  The disturb-
ance of speech called by AVernicke sensory aphasia, and by Kussmaul word-
deafness and  word-blindness, has been  observed also to  follow lesions of the
first temporal convolution of the  left  side.   Sensory aphasia  is characterized
by inability to understand  spoken or  written words.  On superficial  observa-
tion the patients  are  thought to be deaf.   The various  forms of aphasia are
often combined with each  other.
  C. Visual Area of the Cortex.—It has been demonstrated that the occipital
convolutions  contain centres for vision.   Although not absolutely proven, the
view is widely accepted, that the fibres  of the  optic nerve which supply the 
MEN INGE A L  HEM ORE HA GE.
681
Fig. 4.
Diagram showing Semidecussation of the
      Optic Nerves (after Landois).
outer or temporal half of the retina do not cross in the optic chiasm, but ter-
minate in  the occipital lobe of the same  side, while the fibres which  supply
the inner or nasal half of the retina cross  in the optic chiasm and terminate in
the occipital lobe of  the  opposite side.
The accompanying diagram (Fig. 4) illus-
trates this view of the semi-decussation
of the optic nerves.
  Thus, the right occipital lobe  contains
the visual centres for  the  temporal half
of the right retina and the nasal half of
the left retina.  Destruction of these cen-
tres in the right  occipital lobe  would
therefore cause blindness of the temporal
half of the right retina and of the nasal
half of the left retina.  In this  case ob-
jects occupying the left half of the visual
field would not be perceived.   With an
affection of the  left occipital lobe of course
the relations would be reversed.  This form of disturbed vision is called hemi-
anopsia or hemiopia (strictly, lateral homonymous hemianopsia).  As is indi-
cated in  the diagram, the hemianopsia is limited by a vertical line passing
through the point of  fixation (macula lutea), and not by a line dividing the
retina into two equal  parts.  It  is thus  evident that the defect of vision in
hemianopsia is  greater in the retina opposite to the lesion.1   Hemianopsia is
likely to  be overlooked unless  a  special examination  of the vision be made.
   Hemianopsia may  be caused also by lesions of one optic tract, of  the pul-
vinar and corpus  geniculatum  externum  of the optic thalamus, of the poste-
rior part of the internal capsule, of the medullary substance of the occipital
lobe, and perhaps  also by  lesions of  one  of  the anterior pair of the corpora
quadrigemina,
   Hemianopsia is the only symptom which  has  been directly  referred to
lesions of the occipital lobe.   In many instances  affections of the occipital
lobe have  given  rise  to no symptoms which  attracted attention.
   D.  Other Parts of the Cortex.—Some physiological experiments render prob-
able the existence of  centres for  hearing in the temporal lobe, but auditory
disturbances other than the peculiar form called sensory aphasia are not posi-
tively known to result from cortical lesions.
   Diseases of  the frontal  lobes are often latent.  No distinctive symptoms
have  been assigned to lesions of the parietal lobes.
                      Meningeal  Hemorrhage.
  One of the most important varieties of meningeal hemorrhage is hamatoma
of the dura mater, due to pachymeningitis hamorrhagica, under which head
it will be subsequently considered.
  The extravasated blood in meningeal hemorrhage may be seated as follows :
1, between the dura, mater and the skull;  2, in the so-called arachnoid cavity;
and 3, in the subarachnoid space or the meshes of the pia mater. AVhen seated
between the dura and the skull the most  frequent cause is traumatism.  In
the  majority of cases of traumatic meningeal hemorrhage, but  not in all,  there
is fracture of' the skull.  The hemorrhage resulting from traumatism may be
in any of  the  three situations mentioned, as well as in the substance of the
  1 Hemianopsia is designated as right-sided or left-sided with reference to the  defect
in the visual  field.  Hence with lesions of the right occipital  lobe, left hemianopsia
occurs. 
682  DISEASES  OF  THE CHREBRAL  AND  SPINAL  CIRCULATION.

brain.  It may be most abundant at the base or on the convexity.  The study
of this important variety of meningeal hemorrhage belongs to the domain of
surgery.  Another cause of meningeal hemorrhage is the rupture of aneurisms
of the arteries of the base, most frequently of the basilar or the middle cere-
bral.  The lodgment of calcareous  emboli in the  cerebral arteries may lead to
aneurism and hemorrhage.  The occasional occurrence of  meningeal hemor-
rhage in consequence of thrombosis of the sinuses, and in  consequence of an
intracerebral  hemorrhage  bursting through the peripheral brain-substance,
has already been mentioned.  In a  case given in a former edition of this work
the hemorrhage was attributable  to wounding of a vessel by needle-shaped
spicula of bone in the  dura mater, without any injury of the skull.  Hemor-
rhages, usually in the form of ecchymoses, are often observed in the meninges
in infectious  diseases.   Larger hemorrhages occur in purpura and other dis-
eases with a hemorrhagic diathesis.  Meningeal hemorrhage has been known
to follow a paroxysm in whooping cough,  to  occur during Bright's disease,
and rarely under other  conditions when no  especial  cause could  be assigned.
Meningeal hemorrhage is  common in new-born infants, in  whom it is some-
times, but not always,  attributable to mechanical causes attending labor.
  Large  meningeal hemorrhages are  always fatal; but small hemorrhages
may be absorbed, leaving only  a  pigmented spot behind.

  Meningeal  hemorrhage, if the extravasation  be considerable and rapid,
gives rise to sudden coma  or apoplexy, which is very rarely accompanied by
hemiplegia.   It may destroy life speedily.   In a case reported in a previous
edition of this work  death took place two  hours after the  apoplectic seizure.
Cases which prove fatal in the condition of coma cannot be differentiated by
means of  the symptomatology from cases of cerebral embolism  or cerebral
hemorrhage.  The diagnosis is rendered  probable by a traumatic causation.
From congestive apoplexy it is distinguished by the absence of the symptoms
which denote determination of blood to the head.
  In the case referred to, in which the hemorrhage was caused by spicula
of bone, epileptiform convulsions occurred.   Symptoms of irritation, such as
convulsions, are more frequent  in meningeal than  in cerebral hemorrhage.  If
the hemorrhage be not large  it may give rise to no symptoms pointing to a
grave affection.   In  the case  of Daniel AVebster the autopsy  showed that
slight meningeal hemorrhage had occurred  some time prior  to his fatal illness.
The hemorrhage was connected with an injury which  had  not incapacitated
him from subsequent intellectual efforts in which was manifested no diminu-
tion of his mental powers.
  It follows, from what has just been stated in  regard to the symptomatology
and diagnosis, that the treatment is  to be governed by symptomatic indications.


                    Insolation, or Sunstroke.
  The terms insolation  and sunstroke are applied to an affection—or perhaps
more  properly different affections—occasioned not exclusively by exposure
to the sun's rays,  as the terms signify, hut by the action of great heat com-
bined generally with other causative circumstances.  The terms denote  a
sudden attack in extremely hot weather after exposure to  the  direct rays of
the sun  or to great heat,  the  attack characterized by loss of consciousness,
followed frequently by stertor and  convulsions, and death taking  place, in a
considerable proportion of cases, within the  space of a few minutes or a few
hours.   Now, in a certain  proportion of these cases the morbid  condition, as
judged by the  symptoms, is  expressed by the term  exhaustion.   The vital
powers are prostrated,  the forces carrying on the circulation give way, and 
INSOLATION,  OR SUNSTROKE.
683
death takes place by syncope.  In another class of cases  the affection appar-
ently is similar to congestive apoplexy.   In still another class of cases  the
symptoms show a combination of apoplexy and  exhaustion.   The cases last
referred to probably constitute the majority of the cases of so-called insola-
tion  or sunstroke.  In other cases the condition is referable to the abnormally
high temperature of the blood.   Other names than insolation  and  sunstroke
have been proposed—namely, solar asphyxia, heat-apoplexy, thermal or heat
fever, etc.
  Morbid appearances  found after death  are as follows: The blood is dark and
imperfectly coagulated, often fluid, and collected in the large veins.  The heart
is usually firmly contracted, and the left  ventricle is empty, the right contain-
ing a small amount of  dark fluid or partly clotted blood.   Ecchymoses, espe-
cially subserous hemorrhages, are, as a rule, present.   Extravasations of blood
into  the sympathetic  ganglia of the  neck, about the vagus in the neck, and
in the connective tissue are sometimes met with.  The lungs are deeply con-
gested ; sometimes they contain hemorrhages, and they are often adematous.
A moderate amount of serous transudation into the pleural and pericardial sacs
and  into the ventricles of the brain is not  uncommon.  The spleen is sometimes
swollen and soft.   Parenchymatous  degeneration or  cloudy swelling of the
kidney, liver, spleen, and heart-muscle has been described as a lesion of inso-
lation.  The larger veins of the pia and dura mater  are  usually distended ;
and  injection of the smaller vessels of the membranes and of the  cerebrum
is occasionally but not constantly found.  The consistence of the  brain  and
cord is sometimes notably soft.
   The premonitions are slight or wanting.   Dr. Swift, in  a  report based on
the  observation  of 60  cases  in the New York Hospital,  gives  the  following
account of the attack  : " The patients are suddenly seized, while in the per-
formance of their labors, with pain in the head and  a sense of fulness  and
oppression in the epigastrium,  occasionally nausea  and vomiting, general
feeling of weakness, especially of the lower extremities, vertigo, dimness of
vision, and insensibility.   Surrounding objects appear of uniform color.   In
a great majority of cases  this was, so far as could  be  ascertained, blue or
purple.  In one instance everything appeared  red, in another green, and in
another white."1  It has been stated that irritability  of the bladder precedes
the  attack.  Pain in the head, although generally present, does not always
precede unconsciousness.  It was wanting in the case of a medical friend of
the  author who had a  severe attack accompanied by violent convulsions.
   The  attack may consist of only a transient  insensibility; but  in severe
cases the patient passes quickly into a comatose  state.  It is in this state that
cases come under medical  observation.  The pupils are in some cases dilated,
in some contracted, and sometimes the size is normal, but the  respondency to
lh*ht is lessened or lost, There may be  contraction and dilatation at different
periods in the same case.  The pulse may be at first  infrequent and full, but
it often becomes frequent  and feeble toward the fatal termination.  I have
observed death to take place purely by apnaa, the pulse  having considerable
force until after the cessation of breathing. The respirations in some cases are
stertorous, and in other cases suspirious  and accompanied by moaning.  They
are  increased in frequency in the majority of  cases.   In most cases the tem-
perature of  the  body is  notably raised.   The maximum  rise in  cases  at
Bellevue Hospital, in  July, 1868. was 109]° F., and the lowest observed was
99£°.   In  a case  observed in July, 1872, the temperature in the axilla was
1101°.   If the thermometer indicate a rise to 107° or  more, a fatal  termi-
nation is to be expected.   In the case, however, just referred to, in  which  the
  1 "Observations on Fxhanstion from the  Effects of Heat," by H. S. Swift, Resident
Physician of the New York Hospital, N. Y. Journal of Medicine,  July, 1854. 
684  DISEASES OF THE CEREBRAL  AND  SPINAL CIRCULATION.

temperature was  IIO50, the patient  recovered.   Convulsions and rigidity of
the muscles  are  of frequent occurrence.   A'omiting frequently occurs, and
toward the close  of life there  are involuntary evacuations from the bowels.
The prognosis is rendered extremely unfavorable by the occurrence of vomit-
in"- and purging.   The  duration varies from a few minutes  to several hours.
The average duration in the fatal cases observed by Swift  w*as four hours.
If the patient emerge from the comatose state, convalescence is usually speedy.
Of 20 cases observed by Pepper, in 3 insanity followed. This sequel did not once
occur in more than 100 cases received at the New York Hospital. Temporary
delirium succeeding the attack is occasionally observed. Paralysis is very rarely
a concomitant or a sequel.  I have, however, known of the occurrence of incom-
plete transient hemiplegia in one case after recovery from the attack,  and in one
case before recovery.  In  the latter case it lasted but a few hours.
   As already stated, the pathological character of the affection in all cases of
insolation is not uniform.   Instances of sudden death from exhaustion or syn-
cope produced by  heat and  over-exertion are reckoned among cases in which
the morbid condition is quite different.  In a certain proportion of cases the
appearances after  death, the character of the attack, and all the  symptoms
denote congestive  apoplexy.  In  other cases, which  probably constitute the
majority, the pathological  character is mixed ;  an apoplectic condition being
combined with exhaustion.   It is highly important to take cognizance of these
differences as regards pathological character in treating the different cases which
are grouped together under the name of insolation.  The notably increased
temperature of the body probably stands in a causative relation to  certain of
the phenomena.   Regarded from this point of view, insolation is in a marked
degree a  febrile disease.  That toxical changes in the blood play an import-
ant part in the pathology is probable.  Vallin  of  Paris has reported a series
of observations upon dogs and rabbits destroyed by insolation.  These ani-
mals,  placed  upon  the back, fastened in this  position, and  exposed  to  the
direct rays of the sun in the months of July and August in the climate  of
Paris, presented phenomena analogous  to insolation in man, and they died gen-
erally after an exposure of from  half an hour to two hours.  Examinations
after death showed hyperamia of the brain and lungs,  the  cavities  of the
heart,  especially  the left  ventricular cavity, being  empty..   These experi-
ments  have been  repeated  by  Prof. Horatio C. AVood.   A'allin is  led to  at-
tribute these conditions and death to coagulation of the liquid of the mus-
cular  tissue (sue  museulaire, myosin) of the heart and  diaphragm.   He does
not, however, apply this explanation to all the cases embraced under the name
of insolation.  In some cases he attributes the death  to toxical changes in the
blood, the action  of the heart  being arrested by  a morbid agency operating
through the pneumogastric nerve.   In the latter cases the heart-cavities may
be filled with blood.1  The observations  of Prof.  Horatio C. AVood lead him
to the conclusion that  the contraction of the ventricles  of  the  heart found
after  death, especially when autopsies are  made within a short time after
death, is  in  most  cases of post-mortem, not of ante-mortem, occurrence.2
   Excessive heat is the chief agency in causing insolation, but other circum-
stances  co-operate in  the  causation.  Muscular  exertion, unduly great or
prolonged, is a powerful  auxiliary cause.  Persons are generally attacked
when engaged  in labor, but there are exceptions  to  this rule.  Dr.  Swift
states that of the  cases which he observed a large proportion were attacked
shortly after dinner.  The  concentration of innervation  upon the processes
of digestion, the  distension of the stomach with  food and liquids, the latter
being frequently  taken in large  quantity,  and perhaps, in some  cases, the
           1 \Tide Archives  de Medeeine, Feb., 1870.
           2 On 'Thermic Fever, or Sunstroke, Boylston Prize Essay, 1872. 
                    INSOLATION, OR SUNSTROKE.                G85

disengagement of gas  from chemical  changes arising from  indigestion, will
account for the  fact stated by Swift.   In most cases persons are attacked
when exposed to the direct rays of the sun,  but there are exceptions to this
rule.   Swift states that eleven patients were attacked on the same morning
in the laundry of one of the largest hotels in  this city, and several cases were
brought to the hospital from a sugar-refinery.  Soldiers  are not infrequently
attacked after they have retired to their tents.
   Cases  are more frequent by far  in  tropical than in cold or temperate lati-
tudes, and in the latter they occur during the heated term of summer,  when
the weather is unusually and continuously hot.  Atmospheric influences  other
than  heat have been supposed to be  involved in the causation—namely, an
unusual  accumulation  of electricity, dryness and rarefaction of the air, but
facts  showing the importance of these influences are wanting.   The number
of cases  in the  same place in different years varies  greatly.  According to
Dickson, more persons  died in Charleston, S.  O,  from sunstroke in 1S24 than
in any twelve other  years; and in  the city of New York in the summer of
1853  there were 260 cases reported, whereas in  no previous year had  there
been more than 36 cases.1
   The attack  generally takes place at  periods when the heat of the day is at
its maximum.   Of the 60 cases observed by Swift, 40 occurred between  11
A. m. and 4 p. si., 17 between 4 and 9  p. m., and 3 between 8 and 11 a. m.
   The diagnosis is, in general, made  without difficulty.  The circumstances
connected with  the  attack  and the symptomatic phenomena are sufficiently
distinctive.  Apoplexy with extravasation of blood is to be distinguished  by
the existence  of hemiplegia.  Persons deeply intoxicated are not infrequently
brought  into  hospitals as cases of  sunstroke, but the characters of alcoholic
coma suffice for its  discrimination.
   Exclusive of mild cases in which there is  transient stupor or insensibility,
the danger in  cases of  insolation is always very great.  The death-rate ranges
from  40  to 50  per  cent.  If, with deep coma,  the breathing be stertorous,
sighing,  or moaning,  the  prognosis is extremely unfavorable.   Great fre-
quency and feebleness of the pulse,  relaxation of the  sphincters, tracheal
rales, and complete immobility are forerunners of a fatal  termination.   Con-
vulsions  are extremely unfavorable, yet I have known recovery to take  place
after violent convulsions.   In accordance with the difference in  pathological
character in different cases, the mode of dying is sometimes by rapid asthenia
or syncope. This mode of dying is  exemplified among the cases in which the
death is notably sudden, taking place in the space of a few moments after the
attack.  The mode of dying in other cases is by apnaa, but in the larger pro-
portion of cases by apnaa and asthenia combined.
   The treatment  is  to be adapted  to  the pathological character  of the
affection,  as represented by  the  symptoms,  in  individual cases.   Pursuing
this course, therapeutical measures, so far from  being the same, will be dia-
metrically opposite in  different cases.   In cases of  nervous exhaustion, the
danger being of death by rapid  asthenia  or  syncope, complete rest is of the
first importance.   The removal of  patients to their homes or to hospitals in
this condition  may contribute in no  small  measure to a fatal result.  Stimu-
lants  are  to be  administered by the mouth  very cautiously in order not to
excite  vomiting.  They may be given  with less  risk by the rectum.   Alco-
holic stimulants  may be administered by enema  or by hypodermic  injection.
The carbonate of ammonia is an effective heart-stimulant administered hypo-
dermically.  The oil of turpentine given per enema is  recommended.   All
restraints of dress are  to be removed.  The patient should be kept  in as cool
and pure an atmosphere as possible.  If the surface be hot and dry, sponging
                      1 Elements of Medicine, 2d ed., 1859. 
686   DISEASES  OF THE  CEREBRAL AND SPINAL  CIRCULATION.

the body with spirit and water should be employed.  These should constitute
measures employed during the attack.   Cathartics, emetics, bloodletting, and
all depressing agencies are pernicious.  The symptoms representing the con-
dition which calls for  the treatment just stated are—frequency and feebleness
of the pulse, weakness of the heart-sounds, with absence of stertor and the
embarrassment of breathing indicative of  cerebral compression.
  In well-marked apoplectic  cases I believe bloodletting  to  be  the  measure
especially indicated.  The  treatment called  for is the same as in  congestive
apoplexy.  The life of the patient may depend on the prompt employment
of bloodletting.   The bowels  should be freely opened with croton oil.  Cold
should be applied to  the head, either by means of the ice-cap or the douche.
The  head should be elevated, and everything constricting the chest or neck
should be removed.  Revulsive  applications should be  made  to the extrem-
ities.   The symptoms  representing the condition calling for these  measures
are—fulness of the pulse, slowness of the respiration, with perhaps  stertor,
heat of the surface, congestion  of the  face, and throbbing  of the carotids
and  of the  temporal  arteries.
  The question as to the propriety of bloodletting in cases of insolation has
given rise to much discussion and difference of opinion.   The doctrine which
I desire to inculcate is, that to abstract blood is vastly important in  some and
is  destructive in other cases.  Never to employ bloodletting or to employ it
in  all cases would be alike injudicious.   It is, of course, for the judgment of
the practitioner to  discriminate  between  the  cases in which bloodletting is
called for and the cases in which it will do harm. I have noted several cases
which  apparently exemplify the  importance of bloodletting.
  In the majority of  the cases  of insolation symptoms denoting congestive
apoplexy are combined  in  variable proportions with those denoting exhaus-
tion.  The importance of bloodletting in these cases is to be measured by the
predominance  of the apoplectic  phenomena, and it is contraindicated if pre-
dominance of  exhaustion be  denoted by the frequency or the feebleness  of
the pulse.  The success of  the treatment will depend on the judgment of the
practitioner in deciding whether bloodletting be called for or otherwise, and if
it be indicated, in determining the amount of blood to be taken.  Discrimination
is  also important in prescribing croton oil.   If  the danger be from exhaus-
tion, an active purgative is not indicated.   Cold to the  head is important in
proportion as  the  symptoms  of  cerebral  congestion  predominate.  On the
other hand, in the  cases  in which the circulation is notably feeble stimulant
remedies by the mouth  or rectum are  called for.  In  all cases quietude is
important.  In the cases in which convulsions  occur  these  may be excited
by movements of the body.   The  most efficient measure having  reference
to  convulsions is the inhalation  of chloroform.
  For  several  years  considerable reliance  in  Bellevue  Hospital  has been
placed on sponging the  body freely with cold  water  in addition  to  ice to
the head.  In  1872 the application of cold  water to the surface was carried
out, under my direction, more efficiently than before, in the following manner:
The  patient was enveloped in a sheet  wet with cold water, and  placed  on
blankets covered  with india-rubber cloth.  AVith a sprinkling-pot the cold
water was applied over the whole body at intervals of a few moments.  This
was  kept  up for a  period ranging from  half  an hour to several  hours, the
continuance being  determined by the  effect on  the temperature,  pulse, and
other symptoms.   The  temperature of the body was reduced more or less,
and  sometimes several degrees.   The measure was repeated  as often as the
temperature again  rose.   If  the pulse were feeble, stimulants were given
more or less freely  during  the application of the water.   The good effect of
this plan of treatment has been marked in some cases.   A patient admitted 
       HYPEREMIA AND ANAEMIA  OF THE  SPINAL  CORD.    687

at 2 P. M., unconscious, pupils contracted, pulse 150, breathing stertorous, the
axillary temperature 110]°, and  the  body cyanosed, was at  once placed in
the  wet sheet and  sprinkled.   At half-past 4 p. m. the  temperature  in  the
axilla had fallen  to 104|°, the  frequency of the pulse and the cyanosis per-
sisting.   He was  taken out of the sheet,  dry cups were applied to the chest,
and at 5 o'clock the wet sheet was again  applied,  and  continued until fifteen
minutes after 7 P. M.   The temperature  then was 101£° and the pulse 120.
At 9.45 P. m. the temperature fell to  lOOf °.  At midnight he became con-
scious.  Progressive improvement followed, ending in recovery.  The  only
additional measures employed up to the restoration  of  consciousness were an
enema containing castor oil with a few drops of croton oil, and the hypodermic
injection  of ten  minims of the tincture of digitalis, the  latter  having refer-
ence to the frequency and feebleness of the action of the heart,
  The employment of cold water in the  manner just  described was resorted
to only in the cases in which there was  a considerable increase  of axillary
temperature—104°  and upward.   AVhen the temperature was less, sponging
the body with cold water was employed.   Observations since 1872 have con-
firmed the efficacy of this plan of treatment in cases characterized by notable
increase of temperature.   The  same  method of applying cold has  also been
found efficient in  other affections in which antipyretic treatment is indicated.
  Dry cups  to the  chest relieve symptoms dependent  on  pulmonary conges-
tion—namely, embarrassed breathing  and cyanosis.   Applied over the  spine,
they are useful  in  relieving convulsions and  muscular  rigidity.
  In some cases treated in Bellevue Hospital the Calabar bean has been given
in doses  of one  grain by  hypodermic injection,  and  repeated  two or three
times after intervals  of  from half an hour to an  hour.   This  remedy  was
tried  with  reference  to  muscular rigidity and convulsive movements.   It
seemed to be  useful, but the observations are too few to warrant  any posi-
tive  conclusions.    Given in the  dose just stated, it produced  no marked
effect upon the  pupils.1


   HyperEemia and Anaemia  of  the  Spinal Cord and  its
                              Meninges.
  As regards hyperamia and  anamia, the spinal cord and  its  meninges
are to be considered together.   These pathological conditions are probably
never limited to either the meninges  or the cord  separately.  In  treating of
spinal  paralysis  occurring without symptoms  which denote either inflamma-
tion  or lesions of structure—that is, functional paralysis—the question  will
arise as to the existence of one or the other of these  conditions.   Exclusive
of this connection, it  is  difficult, with our present knowledge, to form an
opinion as to the importance of these conditions.  It is  customary to refer
certain  symptoms  to  hyperamia or anamia  of the  cord  on  conjectural
grounds.  * Our  present knowledge does  not lead us  far beyond conjecture
as regards the frequency of these  affections, their causation, and their  symp-
tomatic phenomena.   Both conditions are probably not infrequent.  They are
attributable  to various causes,  and it is  not irrational to refer to these cer-
tain  symptoms.
  Hyperamia here, as in other situations, may be  active or passive.  (Aide
p. 2(1.)  Active  hyperamia may  be caused  by prolonged muscular exercise
and sexual abuse or excess.  Collateral fluxion is supposed  to  be  causative
in certain  cases of suppression of the menses, the cessation of bleeding from
  1 For a report of  55 cases  treated in Bellevue Hospital, July and August, 1872, pre-
pared, at my request, by Dr. Katzenbach, at that time house-physician, vide New York
Journal of Medicine, Jan., 1873. 
 688   DISEASES OF THE CEREBRAL  AND SPINAL  CIRCULATION.

 hemorrhoids, and prolonged exposure to cold.  Passive hyperamia is incident
 to stasis of  the systemic venous or the portal system.
   The symptoms referred  to active hyperamia are—lumbar pain and pain in
 the limbs, increased  cutaneous sensibility,  formications, muscular twitchings,
 and paresis  of the muscles.  On the other hand, numbness of the extremities
 and anasthesia point to passive hyperamia.
   The diagnosis requires  absence of fever and of the local symptoms which
 denote either spinal meningitis  or myelitis.   The existence of causative agen-
 cies is to be taken into account.
   The  condition  is without danger, except that  it  may be  a  factor in the
 causation of hemorrhage.
   Cupping over the spine, using dry or hot cups according to the local symp-
 toms  and the general  condition of  the patient, stimulating foot-baths, the
 application of cold to the back, and cathartics, are  the therapeutical measures
 indicated.   Ergot and belladonna are considered to be useful by causing con-
 traction of the arteries.   The  patient should lie as much as possible on the
 side or face, and not on the back.
   Spinal anamia  (ischamia) is an  effect of aortic obstruction above the point
 at which the lumbar arteries are given off (Stenson's experiment).  Temporary
 paraplegia is produced by compression of the aorta above that point.  A few
 cases  of paraplegia due to anamia of the lumbar  part of the spinal cord in
 consequence of embolism or thrombosis of the abdominal aorta have  been
 recorded.  Spasm of the intraspinal arteries has been supposed  to be a cause
 of anamia of the cord, continuing long enough   to lead to  impairment of
 nutrition and giving rise to paraplegia.   Doubtless the cord, like the brain
 and other organs, suffers functionally whenever the blood is  notably impov-
 erished.  This local anamic condition, which is incident to general anamia,
probably has a causative  connection with neuralgia affecting the intercostal
and other nerves,  together with other effects pertaining to the so-called " spi-
nal irritation."   Exclusive of  a conjectured causative connection with func-
tional or so-called reflex paralysis, and of the participation of the spinal cord
in the effects of anamia  as a blood lesion, the diagnosis of spinal anamia is
not warrantable in the present state of knowlege.
                        Spinal Hemorrhage.

  Hemorrhage within the spinal  canal, not dependent on injuries of  the
spine, is an exceedingly rare event.  Its infrequency is in striking contrast to
intracranial  hemorrhage.  Spinal hemorrhage may be meningeal (hamator-
rhachis), or it may be in the substance of the cord (hamato-myelus).   In
cases of meningeal hemorrhage the extravasation may be between the perios-
teum and the dura mater, between the latter and the arachnoid membrane (in
the so-called arachnoid cavity), or in the meshes of the pia mater.  In cases
of intracranial meningeal hemorrhage  the blood  may flow down into  the
spinal canal. ^   Hemorrhage into the  substance of the cord may be either
punctate or in the form of a larger  focus.  It is most frequently situated
in the  gray matter, in which it may extend for  some distance in a longitu-
dinal direction.   The  same  changes occur in the  extravasated  blood  as in
cerebral hemorrhage.   Both medullary and  meningeal hemorrhage may result
from traumatism, such as fractures and dislocations  of the vertebra, blows
upon the back, etc.  Most of the cases formerly considered as  spontaneous
spinal apoplexies are cases of hemorrhage resulting from a previous myelitis,
the vessels sharing in the softening process  (hamato-myelitis); but there are
very rare cases which can hardly be interpreted otherwise than as primary 
SPINA L HEM ORRHA GE.
689
 hemorrhage into the  cord.  Aneurisms of the aorta, after having occasioned
 erosion of the vertebra, sometimes burst into the spinal canal.
   Meningeal  spinal hemorrhage causes paralysis, as a rule, so suddenly that
 the patient falls.   Consciousness is retained.   Severe pain may be felt at or
 near the site  of the hemorrhage.   Pain is also felt in the extremities.  The
 cutaneous sensibility becomes impaired, and abnormal sensations are referred
 to the skin. The paralysis and anasthesia are rarely complete.  If the hemor-
 rhage take place in the lumbar region, the lower limbs are paralyzed, to°-ether
 with the bladder and rectum.  If the hemorrhage be in the upper part of the
 spinal canal,  in addition to paralysis  of  the  lower extremities paralysis and
 anasthesia  are present in the  upper limbs, and these  symptoms may  be
 accompanied  by difficulty in breathing and  swallowing.   Cramps, spasms,
 and tremor often occur in the upper or  lower  extremities according  to  the
 situation  at which the hemorrhage takes place.
   The symptoms are due to excitation of the spinal  cord and the paralyzing
 effect of pressure.  According to the rapidity of the hemorrhage, they occur
 abruptly or are developed more or less slowly.   Their degree  is determined
 by the amount and situation of the hemorrhage.
   If the  symptoms follow an injury of the  spinal column, violent muscular
 exertions, or severe convulsive movements, these  etiological relations  render
 the  diagnosis  probable.  The diagnosis is substantiated  by the exclusion of
 spinal meningitis  and myelitis.  These  diseases are excluded by the  sudden
 or rapid development of the symptoms and by the absence of fever.  Second-
 ary  fever may be  developed after the lapse of several  days.
   If the  hemorrhage  take place at the  upper part  of the  spinal canal, and
 if the amount be considerable, it may cause speedy death by disturbance of
 respiration (apnaa).   A large extravasation in  a lower situation, giving rise
 to complete paraplegia, with cystitis and bed-sores, is often fatal after a dura-
 tion more or less protracted.  Recovery may be expected, except in cases of
 injury of the spinal cord by fracture or dislocation of vertebra.   The removal
 of the coagulated blood by absorption is, however, a slow process, and  recov-
 ery  takes  place  after  a  considerable period,  the improvement being: very
 gradual.
   The treatment at the  time of the attack has for its  object the arrest of
 the  hemorrhage.  Absolute rest and cold applied to the  spine are the most
 important of the measures for this object.   Bloodletting is to be  employed
 under the  conditions which render this  measure advisable in  other connec-
 tions.
   The subsequent treatment  has reference to  the  relief of symptoms, the
 absorption of  the extravasated  blood, the prevention of muscular atrophy,
 and  the restoration of the  functional  activity of the  paralyzed muscles.
 Iodine, mercury, and  electricity are recommended as sorbefacients, but their
 usefulness in this way is open to  scepticism.   The treatment to be addressed
 to the muscles is the same as in cases of paralysis  caused by other  spinal
 affections.

  Hemorrhage into  the substance of  the  cord is  preceded by symptoms
 denoting myelitis in a certain  proportion  of cases.  These are wanting  if the
 hemorrhage be occasioned by injury of the spine or violent muscular exer-
 tions.  In either case there is  sudden paralysis  without loss of consciousness,
 accompanied by a localized pain in the spine.   The  paralysis will involve
 only the lower extremities, or in  addition the upper extremities and muscles
 of the trunk, according to  the seat of the extravasation.   The pain is tem-
porary, and  the symptoms of excitation—spasms, cramps, etc.—which cha-
racterize meningeal hemorrhage are wanting.  Sensory paralysis  below the
       44 
690   INFLAMMATORY DISEASES OF THE MENINGES,  ETC.

seat of the hemorrhage is more or less marked,  and it is often complete, as
regards the sensibility to both tact and  pain.   The paralysis  involves the
bladder and rectum.   Atrophy of the paralyzed muscles takes place rapidly.
Bed-sores are produced speedily.  Death may take place quickly by apnaa
if the hemorrhage be into the upper portion of the cord.  If the seat of the
hemorrhage be in the lumbar region, the termination is generally fatal, after
a shorter or longer duration, in consequence of sloughing of soft parts exposed
to pressure, cystitis, etc.
  A small  clot in a lateral half of the upper part of the cord  gives rise to
spinal hemiplegia characterized by motor paralysis  on the side of the lesion
and sensory paralysis on  the opposite side.   This is very rare.
  The points involved in the  differentiation from meningeal hemorrhage have
been mentioned.  Myelitis with softening gives rise to paralysis  more or less
slowly.   This affection is excluded if the paralysis occur suddenly without
having been preceded by any symptoms of spinal disease.  In hamato-mye-
litis, however, the  paralysis may  develop  with great rapidity;  hut myelitis
generally precedes the hemorrhage if the  latter be not produced traumati-
cally.  Sudden paralysis preceded by symptoms  of myelitis renders hemor-
rhage probable.   The affection generally  known  as the acute spinal  paral-
ysis of children (sometimes occurring in adults) is  excluded by the absence
of fever.
  The objects of the treatment are essentially the same as  in  cases of
meningeal spinal  hemorrhage.
                        CHAPTER  II.

INFLAMMATORY   DISEASES   OF  THE  MENINGES  OF   THE
  BRAIN  AND  OF THE  SPINAL CORD.—HYDROCEPHALUS.—
  HYDRORRHACHIS.

Pachymeningitis and Haematoma of the Dura Mater.—Simple Acute Cerebral Meningi-
  tis :  Anatomical Characters; Clinical  History; Causation ; Diagnosis; Prognosis;
  Treatment.—Chronic  Cerebral Meningitis.—Tuberculous Meningitis.—Acute Spinal
  Meningitis.—Chronic  Spinal Meningitis.—Cervical Hypertrophic Meningitis.—Cere-
  bro-spinal Meningitis: Anatomical Characters; Clinical History; Pathological Charac-
  ter;  Causation; Diagnosis; Prognosis; Treatment.—Hydrocephalus.—Hydrorrhachis.
  —Syringo-myelus.

   THE dura mater, which is composed of fibrous tissue, is the most external
    of the three membranes enveloping the  brain.  It consists of an external
lamella, which serves as the internal periosteum of the  cranium, and an inter-
nal lamella, the inner surface of which is lined with flat, polygonal endothelial
cells.  Most of the recent writers, discarding a parietal layer of the  arachnoid,
confine the name arachnoid membrane to that which was formerly described as
its visceral layer. This is a thin connective-tissue membrane whose outer sur-
face is  smooth and covered with  endothelium.  The pia mater is  the vascular
membrane of the brain, the convolutions of which it follows and to which  it
closely adheres.   It is connected with the  arachnoid by  interlacing bundles
of connective tissue.  The space between the arachnoid and the pia mater  is
known  as the subarachnoid space,  or sometimes  as the  meshes of the pia 
      PACHYMENINGITIS-HEMATOMA  OF  THE DURA  MATER.  691

 mater.   In it is contained the cerebro-spinal fluid.  The space between  the
 dura mater and the arachnoid, which is  usually found empty at autopsies, is
 called the subdural space, or, according to the former nomenclature, the arach-
 noid cavity.  The subdural and the subarachnoid cavities are to be regarded
 as lymph-spaces.
   By the term meningitis is usually understood inflammation of the pia mater
 or of the  pia mater and arachnoid, it being impracticable to distinguish  the
 inflammation of one  of these membranes  from that of  the  other.  In fact
 both are  generally involved in  meningitis.  Sometimes  inflammation of  the
 pia  mater is denominated leptomeningitis, in distinction from  pachymeningitis,
 which is inflammation of  the  dura mater.


      Pachymeningitis—Haematoma of the Dura Mater.
  ^ Pachymeningitis is divided into pachymeningitis externa and pachymenin-
 gitis interna.
   External pachymeningitis may be either acute or chronic.   Acute pachy-
 meningitis is always suppurative, and is chiefly of surgical interest.  It fol-
 lows injury and disease of the cranial bones.   Purulent  inflammation of the
 dura mater follows suppurative disease of the internal or middle ear (otitis
 interna or media), with consecutive  caries  of the petrous portion of the tem-
 poral bone.  It is often combined with purulent thrombosis  of the lateral or
 other sinuses of the dura mater.  The purulent inflammation may extend to
 the  pia mater and to the substance of the brain.
   By chronic external pachymeningitis  is understood the fibrous  thickening
 of the dura mater, often  combined with  the formation of osteophytes, which
 occurs especially in  old age.   The thickened dura becomes adherent to the
 skull.  This form of pachymeningitis is analogous to the ossifying periostitis
 of the long bones.
   Internal  hemorrhagic pachymeningitis  is of greater medical interest.  This
 affection is characterized by the formation of an adventitious  membrane upon
 the  inner surface of  the  dura mater, usually in circumscribed patches  over
 the  convexity, and either  limited to one side or extending to both sides of the
 median line.  At first the membrane is  extremely thin,  delicate, and  hardly
 to be recognized, except as a reddish, yellow, or brown stain.  If one of these
 membranes be stripped off and examined under the microscope, it is found to
 consist chiefly of capillary blood-vessels with wide lumina, often  provided with
 varicosities and with  thin embryonic walls.  Between the vessels  are a few
 round, stellate, or fusiform cells, but there is very little fibrillated connective
 tissue.  A considerable number  of extravasated red blood-corpuscles, which
 have escaped  either by diapedesis or by rupture of the vessel-walls, and a
 greater or less quantity of blood-pigment in the form of  reddish-brown gran-
 ules or of ruby-red crystals of hamatoidin, will also be found in these mem-
 branes.   The newly-formed  blood-vessels are in organic  connection with  the
 pre-existing vessels of the dura mater.  In more advanced cases the new mem-
 brane is thicker and composed of several  layers, of which  the deeper—that is,
 those nearest the dura mater—resemble ordinary fibrillated connective tissue.
 In some cases  extensive extravasations of blood occur from rupture of some
 of the thin-walled, newly-formed vessels,  and then  give rise to the  symptoms
 of meningeal apoplexy.  To the bloody tumors thus formed upon  the inner
 surface of the dura mater the name hamatoma is applied.  Hemorrhages con-
fined to the subdural space, and not of traumatic origin, in the great majority
of cases are due to hemorrhagic pachymeningitis.   This  fact was first estab-
lished by  A'irchow.   Some recent writers advocate the view which prevailed
before A'irchow's investigations—namely, that the first stage in hemorrhagic 
692   INFLAMMATORY DISEASES OF THE MENINGES, ETC.

pachymeningitis is an extravasation of blood  upon the inner  surface of the
dura mater, and that the development of blood-vessels and of new connective
tissue is secondary.  It is, however, admitted that when the extravasation is
abundant (hamatoma, properly speaking), an  organized membrane has in the
majority of cases already been formed.  The more usually accepted view is
that in the majority of cases the  development of new blood-vessels upon  the
inner surface of the dura mater antedates the extravasation.
  The symptomatic  phenomena  embrace those proceeding from the chronic
inflammation of the dura mater and those caused by pressure upon the surface
of the brain.   Cerebral  symptoms denoting  inflammation  are—cephalalgia,
which  is often notably intense, vertigo, tinnitus auriuni, vigilance, and dis-
turbed sleep.   Other symptoms  are sensitiveness to light and, in a  marked
degree, contraction of the pupils.   The hemorrhage may occur either rapidly
or slowly.   If rapid  and considerable, it causes an apoplectic attack, which
may prove speedily fatal, but in  most cases  the patient recovers.   Success-
ive apoplectic  attacks occur  after variable  intervals.   If  the hemorrhage
take place slowly, it causes somnolence which continues  for twenty-four or
thirty  hours,  the mind  on  awaking  being more or less disordered.   Suc-
cessive  periods of somnolence mark repeated, slow, and  small or moderate
hemorrhages.   Contraction of the  pupils persists,  and if the hamatoma be
limited  to  one hemisphere,  the contraction is greater  on that side.   At a
later period, however, the contraction  of the  pupils may cease.   The  pulse
is  slow and irregular, becoming frequent in fatal cases before death.   Paral-
ysis of  the facial muscles and hemiplegia may occur, limited to one side, or
occurring  first on one and afterward on the  other  side.  Muscular contrac-
tions,  twitchings, and  convulsive  movements  more  or  less marked are  liable
to occur on one side or on both sides.   The convulsions sometimes  have an
epileptiform character.   Strabismus and ptosis are wanting.   The mental
faculties are impaired in a greater or  less degree.
  The clinical  history has so  much diversity in respect to the events which
occur, the  order of their  occurrence, their duration, etc. that there are few
reliable typical characteristics.   As regards its course, the affection may be
either acute or chronic.   Moreover,  its phenomena  are  often obscured by
those  of various other diseases with which  it  is often associated.
  If death  take place in a primary attack of apoplectic coma, a diagnostic
guess may  be  based  on the antecedent cerebral symptoms  and certain etio-
logical points.  In the cases which  have not  this termination the diagnostic
points  pertaining to  the  clinical history are the  occurrence  of  successive
attacks  of  coma or sopor, lasting for many hours or even for  days, and the
occurrence of more  or less of the symptoms which have  been mentioned,
these occurring in a way not significant of other cerebral affections.   Diseases
to be excluded are—simple cerebral meningitis,  tuberculous meningitis, cere-
bral hemorrhage, embolism  or thrombosis, and general  cerebral paralysis.
There are  cases in which the affection gives rise  to  no  morbid  symptoms.
The morbid condition is sometimes found after  death when  it  had not been
suspected  during life.
  Points relating to the etiology are of much account in the diagnosis.   The
affection rarely occurs at less than forty years of age, and of the different decades
the largest proportion of cases is  between seventy and eighty.   It is rare in
early life, but the percentage  of cases  is larger prior to ten than from ten to
twenty years of age.1   Men are affected much oftener than women.  Persons
in  health  are  never  affected,  if  traumatism  be excepted.   Of the  various
affections in connection with which  it occurs  intercurrently, those  caused by
alcoholism  take precedence.   Clinical observations  show that it is a disease
             1 A'ide Huguenin, in Ziemssen's Cyc, Am. ed.  vol. xii. 
SIMPLE ACUTE CEREBRAL  MENINGITIS.           693
to which drunkards  are especially liable, whatever may be the pathological
explanation.   It is  incident to  different chronic  lesions of the brain, par-
ticularly to those belonging to  general  cerebral  paralysis.   In  a consider-
able proportion of cases it is referable to injuries from blows, falls, etc.  It
occurs sometimes  in diseases  attended by a hemorrhagic  diathesis, such as
scurvy, purpura, leucocythamia, and pernicious  anamia.   Here  doubtless
the hemorrhage is primary.
   The course of the disease varies from a day to a year or longer.  Huguenin
gives  the following as the results of  an analysis of all the carefully recorded
cases  which he could collect:  The duration was from one day to five days in
34 per cent.;] from five to thirty days in 40 per cent.;  from one month to six
months in 18 per cent.;  from six months to one year in 4 per cent.; and more
than a year in 4 per cent.
   The prognosis will depend on  the  extent of the hemorrhage if hamatoma
form.    Patients have recovered who had presented symptoms supposed  to be
a sufficient warrant for  the diagnosis.  Coexisting diseases often  contribute
to a fatal  ending.
   Recovery is not to  be  expected  as a result of  any special  medication.
Impending danger from hemorrhage may be perhaps averted and death  post-
poned by  therapeutical  measures.    Measures  are  to be addressed to the
inflammatory  condition in  proportion  to  the  symptoms.   Generally, cold
applications to the head, counter-irritation  to the neck, cathartics, and stimu-
lating foot-baths suffice.   A enesection or topical bleeding is rarely indicated.
With reference to the limitation of  hemorrhage, the bromides and ergot may
be prescribed.  It is doubtful  if the  iodide  of potassium or mercury promotes
absorption of  the  effused blood.   Palliative remedies, according to symptom-
atic indications, and the analeptica, form part of the treatment.


               Simple  Acute Cerebral Meningitis.
   The name acute cerebral meningitis denotes, conventionally, inflammation of
the meninges of the brain exclusive  of the dura mater;  that is, inflammation
affecting the .arachnoid membrane and the  pia mater.  It is also called  lepto-
meningitis.  To distinguish  it from  tuberculous  meningitis it is designated as
simple meningitis.   It is sometimes  called  acute meningitis of the convexity
in consequence of its localization by preference  upon this part.

   Anatomical Characters.—Inflammation here, as in other situations, is
preceded and  usually accompanied  by hyperamia.  The inflammatory  prod-
ucts are serum, fibrin,  and pus  in  varying amount and in varying propor-
tions.   These products of inflammation are chiefly in the meshes of the pia
mater (subarachnoid space), but in  severe cases  they may be present, to a
certain  extent, also upon the outer surface  of the arachnoid (subdural space),
and may extend into the cortical substance of the brain.  The inflammation
affects usually in the highest degree the pia mater covering the convexity of
the hemispheres, but it may  extend to the meninges of the base, or in rare
instances be chiefly confined to the base.  AArhen death takes place soon after
the onset of the inflammation, the exudation is found to consist chiefly of
serum rendered somewhat turbid by  the admixture of pus-cells. AVhen  death
occurs later, as it does in the majority of cases, the exudation is  more dis-
tinctly purulent,   The greenish-yellow, opaque  streaks of pus are found in

  1 Of course, in these short durations the affection is not a hemorrhagic pachymenin-
gitis, which is necessarily chronic, but it must  be a simple hemorrhage on the inner
surface of the dura mater, it being Huguenins view that this hemorrhage precedes the
pachymeningitis. 
694    INFLAMMATORY DISEASES OF THE  MENINGES, ETC.

greatest abundance in the furrows between the convolutions, especially in the
track of the large veins of the pia mater.  In severe cases of some duration a
greenish-yellow layer may be found spread nearly uniformly over the convex
surface of the brain.  The exudation, examined microscopically, is  found to
consist of serum, pus-cells, fibrillated fibrin (sometimes in great, sometimes in
small amount), together with a certain number of red blood-corpuscles. The
amount of serum varies  considerably in  different cases.  The pus-cells are
doubtless emigrated white  blood-corpuscles.   Pus-cells are also found, some-
times in sufficient number to  be visible to the naked  eye, in the cortex cere-
bri, especially around the blood-vessels.   Punctate hemorrhages are some-
times found  both  in the pia mater and in the cortex.  The  ventricles may
contain a moderate  quantity of serum, which is usually turbid, or they may
be empty. It is to be borne in mind in examinations after death that increase
in the  amount of serum in the subarachnoid space is  not evidence of inflam-
mation; nor is mere opacity of the arachnoid to.be mistaken for acute inflam-
mation.

   Clinical  History.—Simple acute  meningitis may be abrupt or gradual
in its development.   The premonitions are the symptoms of determination of
blood or active hyperamia.   There  is  a  marked  variation  in symptoms at
diff'erent  periods of the disease—namely,  prior to and after a certain amount
of sero-fibrinous  exudation.   The course is  divisible into two  stages, the
division being based on the  amount of the products of inflammation.  The
first  stage extends  to the period when, owing to the pressure of  these prod-
ucts, a notable change in  the symptoms occurs.
   The first  stage is called  the  stage of excitement.   It is characterized by
pain, usually intense, referred to  the  entire head, sometimes greatest in the
anterior and sometimes in  the posterior portion.  The pain is  the same as in
active  cerebral hyperamia.  Delirium frequently occurs, and the  delirium in
this stage is generally active or maniacal, or in some cases hilarious.   Owing
to the prominence  of the delirium, patients are sometimes carried to insane
institutions, the affection being mistaken for  acute functional mania.   Con-
vulsions  may occur, especially in young  subjects.  The senses,of sight and
hearing are abnormally acute.  Light and sounds occasion distress and increase
the cerebral excitement.   There is photophobia, and  the eyebrows are corru-
gated to  shield the  eyes from the  light.  The pupils are generally contracted.
The  face is flushed.  The carotids and temporal arteries pulsate strongly. The
head is hot.  Vomiting generally  occurs in this stage, and is often prominent
as a symptom.  The bowels are constipated.   The  urine is  diminished in
quantity, and is sometimes albuminous.   The abdominal walls are depressed.
Fever  is  more or less intense  ; the pulse is accelerated, strong, and full; and
the axillary temperature  may rise to or above 104° F.  Exacerbations occur
in which the delirium and cephalalgia are notably increased.   The duration
of this stage is short. It may continue but a few hours, and it rarely extends
beyond two or three days.
   The second stage is called the stage of oppression.   The symptoms distinc-
tive  of this stage are those denoting pressure by the  inflammatory  products.
The  pain in the head is diminished.   The morbid sensitiveness to  light and
sounds is lessened. The  pupils  may  be dilated or  contracted, and their
respondency to light is diminished or lost.  Strabismus  and loss  of vision
may occur.   Drowsiness  succeeds the state of  mental excitation.   There  is
rigidity of  the muscles of the back of the neck.   The pulse is diminished in
frequency, and is often irregular in force and rhythm.  It becomes rapid and
thready a few hours before death.  The respirations are disordered in rhythm
or suspirious.  The Cheyne-Stokes respiration  may  be present.   Paralysis 
              SIMPLE ACUTE CEREBRAL MENINGITIS.           695

 may occur, limited to the face or one extremity or extending over one side
 of the  body.   If the progress  of the disease be  unfavorable, coma is  at
 length induced, and continues until death.  Convulsions may  occur  in the
 second  as well as  the  first stage.

   Causation.—Although acute simple  cerebral meningitis often presents
 itself clinically as  a primary or  idiopathic affection, the evidence of post-
 mortem examination shows that it can very rarely be considered as a primary
 disease.  The majority  of the cases which are not secondary  and which occur
 sporadically are  instances of epidemic cerebro-spinal meningitis.  In these
 cases an examination of the  membranes of the spinal cord will  usually show
 that these are inflamed.  It is in accordance with modern views to suppose
 that in  all cases of purulent meningitis  a special infective agent  has  gained
 access to the inflamed membrane.   This  agent is causative  of most  of the
 cases in which the disease is primary.   A'ery frequently simple cerebral men-
 ingitis is secondary to  some  other  disease.  Secondary  meningitis may be
 caused by infection from some disease  of a part contiguous  to  the cerebral
 membranes, or from  some remote  disease, whence the agent of infection is
 transported to the  brain by the blood  or the  lymph-current, or from some
 blood disease.
   Acute cerebral meningitis may be referable to injuries  of  the head involv-
 ing wounds of the. soft  parts or fracture of the skull.  In not a few instances
 it is secondary to inflammation of the middle ear, with or without caries of
 the petrous portion of the temporal bone.  In these instances an  acute cir-
 cumscribed  pachymeningitis usually, but  not  always, precedes  the aff'ection
 of the pia mater.  Caries  of the  cranium  in any situation may give  rise  to
 meningitis, either circumscribed or more  or less  diffused.  Purulent inflam-
 mations in the upper part of  the nasal  cavities and  in the orbits may  be fol-
 lowed by meningitis.  Abscesses of the brain  which reach  the surface lead
 to purulent meningitis.
   Ararious infectious diseases  form an important group of causes.   A certain
 proportion  of cases of  acute  lobar pneumonia, especially in drunkards, are
 complicated with acute  cerebral meningitis.  To this group of causes  belong
 also acute  ulcerative endocarditis, pyamia, septicamia, erysipelas, the erup-
 tive fevers, typhoid fever, typhus fever,  Bright's disease, purulent pleurisy,
 and acute articular rheumatism.  It is uncertain whether in these cases the
 meningitis  be caused by the  special virus  of the disease or  be  due to some
 secondary infection.  In the  meningitis  complicating lobar  pneumonia the
 same organisms have been found in the exudation in the meninges as  in the
 exudation in  the  lungs, so that here, at least, it  is probable  that  the  special
 cause of the pneumonia is also the cause  of the  meningitis.  The weight of
 evidence is  in favor of the  view that  acute cerebral meningitis may be
 caused by a  variety of micro-organisms, including those of epidemic cerebro-
 spinal meningitis, the bacteria of suppuration, and the specific germs of many
 of the acute infectious  diseases.  The cerebral meninges  are rendered more
 susceptible to  the causes of acute purulent inflammation by the  pre-existence
 of chronic  meningitis,  such  as  is  often  met  with  in drunkards, syphilitic
 patients, insane persons, and idiots.
  Acute cerebral meningitis may occur at any age.   It is more common in
males than in females.

  Diagnosis.—Acute meningitis  may be  confounded with  active cerebral
congestion.  If the inflammation  go off  by delitescence—that is, without
passing  into  the second stage—it  may be impossible  to  say after recovery
whether the affection were meningitis or merely active congestion.   In other 
696   INFLAMMATORY DISEASES OF THE MENINGES,  ETC.

words, more  or less  of the  symptoms belonging  to  the second  stage are
required  for  a positive diagnosis.
  Cases of typhoid fever characterized by early and active delirium have here-
tofore  not infrequently been considered as cases of acute meningitis.   The
points  involved in this differential diagnosis are the following:  The access or
slow development of the fever; the distinctive events belonging to it—namely,
diarrhaa, meteorism or tympanites, tenderness in the  iliac  regions, together
with absence  of morbid acuteness of the senses, and continuance of the delir-
ium without the supervention of the phenomena of the second stage of  men-
ingitis ; also the eruption and the characteristic  rise of temperature during
the first week.  These points show the disease to be a fever, and not menin-
gitis.   In the somnolence of typhoid or typhus fever  patients manifest no
opposition to  being aroused, to having their position changed, etc.; whereas
in meningitis the patient is irritable when disturbed, and resists, perhaps
with violence, efforts to give  nourishment, to  examine  the pupils  by raising
the eyelids, or to interrupt  in any  way the somnolent condition.
  Functional  mania may be erroneously considered as  denoting acute  men-
ingitis.   The  discrimination is to be based on the absence of morbid acute-
ness of the senses, together with the absence of febrile movement, and the
continuance of the mania without the symptoms of compression.
  Other  diseases are more likely to be considered as acute  meningitis than
this is to  be  mistaken for other  affections.  In  view of the infrequency of
primary cerebral meningitis the ability of a practitioner to distinguish it from
other affections may be suspected if he believe that he has met with many
cases of  it.

  Prognosis.—Acute meningitis involves much danger.  It may destroy life
quickly.   Cases have  terminated fatally in thirty-six hours.  As a rule, the
duration  in fatal cases does not extend beyond eight or nine days.  The symp-
toms denoting an unfavorable prognosis are—profound  coma, notable disorder
of respiration, difficulty of deglutition, general immobility and anasthesia,
feebleness of  the  pulse, etc.   Strabismus, hemiplegia, and convulsions may be
present in cases which recover.   A few well-marked cases, presenting these
symptoms, which have fallen under  my observation have ended in recovery.
Data are wanting for determining  the ratio of cases which end fatally, but it
is certain  that the fatal cases greatly preponderate.   The association with
acute articular rheumatism is considered as rendering the prognosis extremely
unfavorable.   I have, however,  observed  a well-marked case, the  symptoms
denoting  spinal as  well as cerebral meningitis, which  ended in recovery.
  In cases which prove rapidly fatal death may be due  chiefly to apnaa, but
if life be  prolonged for several  days the mode of dying is by apnaa and
asthenia  combined.

  Treatment.—The treatment  must have reference to the stage of the dis-
ease.   The objects in the first stage  are to lessen the determination of blood
to the head and  to  limit the amount of exudation.  If the heart act with
abnormal power, bloodletting in  this stage is  to be employed.   As a measure
of  depletion   and  revulsion active  purgation  is indicated.   Cold  is to be
applied to the head, either by  means of the ice-cap,  the  cold douche,  or
constant ablution.   Cutting the  hair close to  the  head renders these appli-
cations more  efficient.
  Bloodletting in this disease is indicated in view of  the promptness of its
operation and the  short duration frequently of the first stage.  Bearing  in
mind that the chief source of danger is from  the  products of inflammation,
it is important that the measures employed with the  hope of limiting these 
CHRONIC CEREBRAL MENINGITIS.
697
should he resorted to more promptly and vigorously than in other acute inflam-
mations—for example, pneumonitis—in which the products of inflammation
generally do not give rise to serious results.   Moreover, there is not the same
necessity for  guarding the vital forces as in  other acute inflammations; for
in this disease there is danger that life may  be quickly destroyed by apnaa
caused by the pressure of effused serum and lymph, whereas in most other
acute inflammations the danger is that they will destroy life by asthenia.   It
is not, however, to be forgotten that asthenia enters into the mode of dying
in cases of meningitis which do not pursue a rapid career, and hence blood-
letting and other measures of depletion may be pushed too far.   These meas-
ures are  indicated only in the first stage of  the  disease.   Perfect  quietude,
exclusion  of light, elevation of  the head, and the avoidance of everything
which may tend to increase cerebral excitement by acting on the senses or the
mind form an important part of the treatment of this stage.  The bromides
are useful for  tranquillizing intense cerebral excitation.   If these do  not
prove effective, codeia may be given or a salt of morphia, the latter adminis-
tered hypodermically.  Sinapisms to the  neck and stimulating pediluvia have
a certain measure of utility.  Vomiting  calls for palliative measures.  The
diet in this stage  should be restricted to  the blandest articles taken  cold.
  In the second stage the great object of treatment is to promote absorption
of the morbid products, serum and lymph.  Depletion is no longer admissible.
Mercurialization  is advised for  this  object,  and  although  the  efficiency of
mercury as a sorbefacient  has doubtless  been much  exaggerated, we are not
warranted  in saying  that it has no effect in that  way.  If it  exert never so
small an  effect, it is indicated in a disease like this, in which the  object to be
effected is of so much importance.   Iodine is another remedy supposed to be
useful as a sorbefacient.   I have witnessed, as I think, the good effect of the
iodide of potassium  in  several cases.  Patients  under my observation  have
recovered under the use of this  remedy, mercury not having been employed.
It may be given  in doses of from five to ten grains four or five times daily,
increasing the  doses, if improvement  do not take place, up to  the limit of
tolerance.   A blister may  be applied over the nucha.   The propriety of blis-
tering the  scalp is questionable.
   Another object of treatment in  the second  stage, if death do not take place
by apnaa, is to support the powers of the system.  Measures for this object
are indicated in proportion as the  tendency to death is by asthenia.
   Attention to the bladder is important in the second stage.

                    Chronic Cerebral Meningitis.

   Simple chronic cerebral meningitis—that is, meningitis  not incident  to  a
tuberculous or any prior  cerebral affection—is infrequent, although it is less
rare  than  the  acute  form of the disease.   The  statement has reference to
periods of life after infancy, but it holds good also with respect  to the latter
period.   In a great majority of  cases it is a subacute affection ab initio.
   The anatomical characters  are thickening and opacity of the pia mater
and arachnoid caused by a new  formation of connective tissue.   The inflam-
mation is usually circumscribed.   The thickened and opaque  membranes are
abnormally adherent  to the brain, and frequently adhesions of fibrous tissue
are formed between the dura mater and the arachnoid.  There  may be con-
siderable  effusion into  the ventricles.   A certain degree  of opacity of the
pia-arachnoid, especially marked along the longitudinal fissure, combined with
increase in the number of Pacchionian  granulations, is to regarded as a nor-
mal condition  in old age.
   This affection may be ranked  among the " insidious diseases."   The symp- 
698   INFLAMMATORY  DISEASES OF THE MENINGES, ETC.

TOMS may not point  to any cerebral affection or they are not distinctive of
this form of disease.   The diagnosis is difficult.  Pain in the head is usually
more or less prominent as a symptom, but this is common to many affections.
There  may be little or no  fever.   A'omiting  may be a prominent  symptom,
but this too occurs in various  pathological connections.   Mental  apathy,
amounting sometimes to  stupidity,  indisposition to either mental  or phys-
ical exertion,  and a notable change in disposition, characterize certain cases.
Paralysis of the face  and hemiplegia  sometimes occur, but they are effects
of  other forms of disease.  This statement also applies to epileptiform  con-
vulsions.
   I have known a case of  chronic meningitis to be considered as a case of
chronic gastritis, vomiting being a prominent and persistent symptom.   The
patient fell into coma before death, but this  was attributed to  exhaustion.
Meningitis was not suspected prior to the autopsy.  In another case in which
an  ante-mortem diagnosis was not made, the  patient dying suddenly with
apoplexy from extravasation, the case had  been considered as one of latent
or irregular intermittent fever, chills occurring from time to time.   A hospital
patient had no symptoms referable to  the head except mental inertia border-
ing on imbecility.   He gradually fell into coma, and after death the case was
ascertained to be one  of chronic meningitis.
   As regards diagnosis, close observation  ought to lead to the conclusion
that there exists a chronic cerebral affection.  Paralysis is less likely to occur
than in cases of tumors within the skull.  The absence of paralysis is there-
fore of some account in the  diagnosis.  This statement will measurably apply
to convulsions.  If cephalagia, impairment of  the mental  faculties, and grad-
ually-developed coma  follow an  injury  of  the head,  chronic meningitis is
probable.  A traumatic cause is  likely  to give  rise to inflammation.  Chronic
meningitis is developed in a small proportion of cases of the affections of the
kidneys embraced  under the name Bright's  disease.  The  existence of renal
disease is therefore of some account in the diagnosis;  but in cases of renal
disease cerebral symptoms referable to  uramia^namely, epileptiform convul-
sions and coma—are not to to  be considered as evidence of meningitis.   The
existence of syphilis  is to  be ascertained,  inasmuch  as  this is  a cause of
chronic meningitis.
   The treatment consists of moderate counter-irritation, the iodide of potas-
sium,  and perhaps mercurialization,  quietude of mind and  body,  and the
hygienic regulations appropriate to  chronic affections generally.


                      Tuberculous Meningitis.

   The distinctive feature  of this variety is the presence of miliary tubercles
in the pia mater in connection  with  meningeal inflammation.  Hence  the
name  tuberculous  or  tubercular meningitis.   As the  inflammation, in  the
majority  of cases, is chiefly at the base  of the brain, it  is  called by some
authors basilar meningitis  ;  but  this name is not to be recommended, inas-
much as  meningitis at the base is not necessarily  tuberculous.  An old-name
for this affection is acute hydrocephalus, as there is usually found a consider-
able fluid accumulation in  the  ventricles.  Tuberculous  meningitis affects
children more  frequently than  adults, and is  treated of fully in works devoted
to infantile diseases.  It is of  rare occurrence  in  the first year of life, occur-
ring especially after two and before seven years of age.   It is not, however,
confined  to childhood.

   Anatomical Characters.—Tuberculous  meningitis  attacks by prefer-
ence the  pia mater covering the fossa  Sylvii,  the optic chiasm, the interpe- 
CHRONIC CEREBRAL MENINGITIS.
699
duncular space, and the under surface of the cerebellum ; but it is by no means
confined to these situations, being often found on the convexity of the brain,
although, as a rule, in a less  degree  than at the base.   Tubercles  may be
present also in the choroid plexuses, and even in the substance of the brain.
The tubercles appear as grayish-wbite or  yellowish granulations in the course
of the small arteries of the  pia mater.   They are usually of about  the  size
of a millet-seed, but nodules the size of  a pea may be formed by the conflu-
ence of many granulations.   Some of the  tubercles are  so small as  to be
recognizable only by the aid of the microscope.  AVhile usually found without
difficulty, they may be present in such a small number as to require careful
search for their detection, and on the other hand their number may amount
to thousands.  A sero-fibrinous or a fibrino-purulent exudation is found,  as a
rule, at the base, and may be present upon the convexity  of the brain.   The
amount of  exudation varies much in different cases.  Although there is reason
to believe  that tubercles precede the inflammatory exudation, there seems to
be no necessary connection between the  number of tubercles and the degree
and extent of inflammation.   Tubercles may be present in  large number with-
out any  apparent inflammation, and, on the other hand, the  inflammatory
exudation may be  abundant without  the coincidence of many tubercles.   It
can serve,  however, no useful  purpose, from a clinical standpoint, to distin-
guish between miliary tuberculosis  of the meninges (without apparent inflam-
mation) and tuberculous meningitis, inasmuch as the former usually produces
the same symptoms as the latter, and, in fact, is accompanied not infrequently
by the microscopical  evidences of  inflammation.  In the majority  of cases
of tuberculous meningitis (in 75 per cent., according to Seitz), the ventricles
are found dilated and  containing a large quantity  of serous effusion, either
clear or moderately turbid from pus-cells.   AVhen the ventricular effusion is
abundant  the surrounding brain-substance  is often  found greatly  softened
and sometimes almost  diffluent.  It is probable that this softening is cadaveric
and without clinical significance.   In proportion to the amount of fluid effu-
sion in the ventricles  the convolutions are flattened and the sulci  shallow.
Minute extravasations of blood are frequently found in  the pia  mater, and
sometimes  in the  substance  of the brain.
   The microscopical  examination of the tubercles shows that they consist
usually of a nodular  accumulation, not  always distinctly circumscribed, of
lymphoid and endothelial cells in the walls  and  perivascular sheaths of the
small arteries of the pia mater, especially where they divide.  The lumen of
the artery  will  often  be found compressed and  thrombosed at  the seat of
tuberculous infiltration.   The  inflammatory products are serum, fibrin, and
pus.
   Tuberculous meningitis is  due to the  invasion of the blood-vessels of the
meninges by tubercle bacilli.   Sometimes, especially in children, the  affection
of the meninges is the sole manifestation of the  tuberculous  infection, but
more frequently,  and almost  without  exception  in adults, the meningeal
tuberculosis is secondary to  tuberculosis  of some  other part of the  body.
In children the  primary tuberculosis is often of the cervical, bronchial, or
mesenteric lymph-glands;  in  adults it  is  usually  of the  lungs;  but the
primary tuberculous focus may be  in any part of  the  body subject to tuber-
culous infection, as in the genito-urinary apparatus, the  serous  membranes,
the vertebra, etc.   Although it is  probable that in these cases the  tubercle
bacilli are  carried from the primary focus by the blood-current, it  is a curious
fact that the meninges are often involved without other evidence  of the inva-
sion  of the blood by tubercle bacilli.  Still, in not a few cases general miliary
tuberculosis is likewise present.  In cases of primary tuberculous meningitis
it is not understood how the  tubercle bacilli reach the meninges.  In a few 
700   INFLAMMATORY DISEASES OF THE MENINGES, ETC.

of the apparently primary cases there will he  found tuberculous disease of
the middle ear.   It has been suggested  that sometimes  the  tubercle bacilli
reach the cerebral meninges through the ethmoidal  foramina  from the upper
nasal passages.
  Tuberculous inflammation of the cerebral meninges is nearly always accom-
panied by a similar affection of the spinal meninges, so that the disease is in
reality a tuberculous  cerebro-spinal meningitis.  The  affection of the spinal
meninges is usually less intense than  that of the  cerebral meninges, but it
may give rise to  characteristic  symptoms.

  Clinical History.—In the progress  of this disease,  as in simple menin-
gitis, the symptoms undergo a marked change due to the pressure of the
exudation and effused liquid ; and  this cliange will  serve as  the basis of a
division into two stages.   The development  of the meningitis may be pre-
ceded  by the  symptoms  and signs of pulmonary  tuberculosis, or,  less  fre-
quently, of tuberculosis in other  situations, as in the lymphatic glands, serous
membranes, and  the genito-urinary apparatus.   The  meningeal affection, even
when it does not distinctly supervene upon tuberculous disease of the lungs,
is usually preceded by pallor, loss of waight, impaired appetite, irritability of
temper, muscular debility, indisposition to  exertion, and  other general symp-
toms for a variable period; but in a certain  proportion  of cases  the symp-
toms denoting the head affection appear suddenly, the previous health having
been apparently  good.   AVhen the  meningitis occurs after a prodromic period
extending, as  it  does in some cases, over  several weeks and even  months,
during which  the general health  becomes considerably impaired, an ante-
cedent tuberculous affection in other organs is to be inferred, or  it may be
that the miliary  granulations within the skull  existed for some time prior to
the development of meningeal inflammation.  The  latter is probable if the
prodromic period have been marked by cerebral symptoms.   On  the other
hand, the meningitis,  when it is developed abruptly—that  is, without a pro-
dromic period, the previous  health having been  apparently good—is usually
incident  to  a  primary tuberculous infection  of the meninges.
  The development of meningitis, as a rule, is denoted by pain in  the head,
referred  generally to the forehead.  Convulsions are  less likely to  occur at
the  onset than  in simple acute meningitis.  Vomiting in  most cases is an
early and sometimes a prominent symptom.  More or  less fever occurs.  The
axillary temperature is raised, but the  rise is less than in simple acute men-
ingitis.   Notable  diurnal remissions are likely  to  occur, the exacerbations
taking place at  night.   These  symptoms continue for  several days.  The
cephalalgia  is frequently severe.   Lancinating pains occur from  time to
time, causing  infants  to  give a sudden, sharp, and  short cry,  which  has
been  known as  the  cephalic cry.   A common exclamation  is,  " Oh  my
head!"   The hands are often carried to the head.   There is increased sensi-
bility to light  and sound.   The  expression is frowning.  In children  raising
the lids and exposing the eyes to the light occasion  crying.  The conjunctiva
is often  suffused.  The pupils in this  stage are frequently contracted.  The
face may be flushed, and in some cases paroxysmal  flushing of the  face is a
notable symptom.  I have observed this to precede convulsions.  During this
stage vigilance is frequently a prominent symptom,  and the sleep  obtained is
disturbed by dreams  causing patients to  awake suddenly in terror.  It is
important to note that vomiting and increased  sensibility to light,  although
generally marked, may be wanting.
  Drowsiness  and somnolence  mark the  supervention of the second stage.
There  is  now less suffering  from cephalalgia, but occasional lancinating
pains may still  occur.   The  pulse may  fall  below the average frequency 
CHRONIC CEREBRAL  MENINGITIS.
701
of health.   It is not  infrequently faltering.  It fluctuates in frequency and
may be irregular in rhythm.   The respirations, which in the first stage may
have  been accompanied by sighing, are  now often irregular in rhythm and
may present the Cheyne-Stokes  phenomena.   In young children masticatory
movements  are  common, and after dentition grinding of the teeth.  Rollin-*
the head or boring the pillow is a symptom in  infants.   The somnolency
increases.  The  patients are  reluctant to be aroused.   If able to speak, they
reply to questions  slowly or in monosyllables, like a person half awakened
from profound sleep.   AVhen aroused they have  an  expression  of stupidity.
Incoherence is common, and  occasionally drowsiness alternates with parox-
ysms of delirium.  The pupils  become dilated,  and not infrequently present
disparity as regards size.  They respond sluggishly to light.  As the somno-
lency deepens the movements of the eyeballs are not in unison, strabismus
frequently occurs, and oscillations  of  the balls  are occasionally observed.
The eyelids are  but  partially closed, the eyeballs being raised so  that the
cornea is partially covered by the upper lid, and in some cases the patients lie
with the lids widely opened. Vision is gradually impaired, and frequently is lost.
Ararious ophthalmoscopic appearances have been described, of which the most
common are neuro-retinitis and a swelling of the optic papilla, called choked
disc.  Subsultus, carphologia, and fumbling with the bed-clothes are  frequent
symptoms.  Convulsions frequently occur, especially in children.  They are
either limited or general, and  they may be either severe or slight.  Paralysis
of one side of the face and incomplete hemiplegia are occasionally observed.
Not infrequently the  muscles of the posterior part of the neck  become rigid,
and the patient lies with the head drawn backward.   Contraction of certain
of the muscles of the  limbs occurs in some cases.   This is sometimes observed
on one  side, while the muscles of the opposite side are relaxed.  Occasional
vomiting  is a symptom of the second stage.   As a rule, there is  complete
anorexia, but in some cases which I have observed food has been taken with
apparent relish.   The teeth and lips often become covered with sordes.  Con-
stipation is the rule.   In young children the dejections are sometimes  greenish
and resemble spinach in appearance.  The abdomen is retracted.  Retention
of urine is not uncommon.
  Sooner or later the patient becomes comatose; but in some  cases before
the  occurrence  of coma remissions occur,  in  which  the improvement as
regards intelligence and in other respects is such as to appear to the friends
to afford ground for much encouragement in hoping for recovery. The occur-
rence of profound coma is  followed by impairment and loss of deglutition,
with more or less embarrassment of respiration.  The pulse becomes  frequent
and feeble, and the mode of dying is by apnaa and asthenia combined.
  The duration  of the  disease is  variable.  It  rarely is less  than  a week.
In  the  majority of cases it does not exceed  two weeks.  It rarely extends
beyond  three  weeks,  but exceptionally it  may be prolonged  considerably
beyond  this period.   The termination is almost invariably fatal.    In  some
of  the  cases of  supposed recovery it is  probable that the  affection  was
simple meningitis.

  Diagnosis.—The  diagnosis involves the discrimination from an  essential
fever.   AA'ith the latter  it is  not infrequently confounded.   In  making  this
differential diagnosis,  meningitis is to be excluded  by the absence of  sensibil-
ity to light, of the characteristic lancinating pains which belong to  the first
stage, and of  the strabismus, affection of the pupils, and other symptoms
belonging to the second stage.   In fever, drowsiness  and  delirium  are not
preceded and accompanied by the symptoms just referred to.  Moreover, in
typhoid fever,  diarrhaa, abdominal tympanites, and iliac tenderness  are 
702   INFLAMMATORY DISEASES OF THE MENINGES, ETC.

likely to he present—symptoms  not belonging  to  the  clinical  history of
tuberculous meningitis.
  It is to be discriminated from the  so-called hydrenccphaloid affection  inci-
dent in children  to  exhaustion from  diarrhaa.   AVith this affection  it was
formerly confounded.  In this  affection the symptoms denoting inflammation
are wanting, and  the drowsiness or stupor is not accompanied by strabismus,
inequality  of  the pupils, embarrassment of respiration,  irregularity  of the
pulse, and  other  symptoms,  exclusive of the  somnolence, which  belong to
the second  stage of  tuberculous  meningitis.
  To discriminate tuberculous from simple meningitis is by no means always
easy.  The gradual development  of the former, the prodromic  symptoms,
the longer  duration  of the first  stage, and the  coexistence of  pulmonary
tuberculosis in a certain proportion of cases  must serve  as  a  basis of this
differential  diagnosis.  The meningitis is probably simple if it can be dis-
tinctly traced  to  a traumatic  origin.  It is, however, to  be  borne in mind
that in  most  cases it is possible  to  recall  some  injury of the head  within
a period  of weeks or months prior to the occurrence  of any disease in child-
hood ; and  it is customary to refer the affection to an  injury often when there
is not  sufficient ground for such an opinion.  Tubercles in the choroid  coat
are sometimes discovered by ophthalmoscopic examination.   Their presence
decides  the differential diagnosis;  but inasmuch as they are not always pres-
ent in cases of tuberculous meningitis, their absence is not sufficient to exclude
this affection.

  Prognosis  and Treatment.—If the diagnosis be  positive, the  encourage-
ment for successful  treatment  is  slight.  It is  difficult, of course, to  decide
upon measures which will be likely to be useful in a disease tending intrinsic-
ally, like this, to a fatal issue, and when in cases of apparent recovery we are
obliged  to  distrust the correctness  of the  diagnosis.  The chief source of
encouragement for successful treatment,  in fact, in a case which  the practi-
tioner supposes to be one of this disease, is the possibility  that the diagnosis
may be incorrect.  With reference to this liability to error in diagnosis the
measures indicated  in simple  meningitis are admissible.   If, however, the
practitioner be thoroughly convinced of the correctness of the diagnosis, he
is hardly justified in resorting to bloodletting  or measures which occasion
suffering, such as blisters and frequent cathartics.  Under these circumstances
measures to palliate  distress and  prolong life are alone  indicated.  In this
country the iodide of potassium is  generally given largely  in the second stage
of the disease.  Cases have been  reported  in which  this  remedy  was  appar-
ently successful;  but there is  room for the supposition that in these cases
either meningitis did not exist or the disease was simple meningitis.    It is
certain that in the immense majority of  cases  the remedy is unsuccessful.
I do not, however, concur in the opinion held  by most writers, that  tubercu-
lous meningitis is necessarily fatal.  At least there seems to me ground for
considering  as probable  recovery in some instances.  I  have reported an
instance of apparent recovery in another work.1  Recovery in no instance can
be demonstrated, since it can  always be said that  the diagnosis may have
been incorrect.  Of course  if  recovery invalidate the diagnosis, the disease
must be considered  as always ending fatally.


                    Acute Spinal Meningitis.
  It is  doubtful  whether acute inflammation  of the spinal  meninges  ever
occur as a  primary or idiopathic  affection.   It  has already been  mentioned
                    1 Vide Clinical Medicine, by the author. 
                     ACUTE SPINAL MENINGITIS.                 703

that tuberculous inflammation of the spinal meninges is usually present in a
greater or less  degree in cases of tuberculous cerebral meningitis.   Acute
spinal meningitis is a prominent lesion in epidemic cerebro-spinal meningitis,
an affection which may occur sporadically and will be subsequently described!
Acute spinal  meningitis, as well  as acute cerebral meningitis, may occur,
although  rarely, as a complication in various infectious diseases, such as
lobar pneumonitis, pyamia, septicamia,  typhoid fever, typhus fever, other
exanthematous fevers, gangrene of the lungs, and purulent pleuritis.  Finally,
acute inflammation of the spinal meninges may be secondary to disease of
neighboring parts, in  which case the inflammation is conducted  to the  mem-
branes by continuity.  Thus, acute  spinal meningitis  may be consecutive to
acute myelitis or  to  diseases and  injuries of the vertebra, such as  cancer,
caries, and fracture, or to inflammations in the neighborhood of the vertebra.
In the latter case the inflammation  may extend to the meninges through the
intervertebral foramina without involving the vertebra.   AVhen the  inflam-
mation is secondary to affections of the vertebra  or adjoining parts, there are
generally both  spinal pachymeningitis  and leptomeningitis.   In the  other
cases the pia-arachnoid  membrane is the part chiefly inflamed.  Although
acute sspinal meningitis has been often attributed to prolonged exposure to
cold, it is doubtful  whether this  be ever an efficient  cause of the  disease.
   The inflammatory products are fibrin, serum,  and pus.  In  the ordinary
form of  the  disease these products are accumulated  in the subarachnoidal
spaces, chiefly upon  the posterior  surface of the spinal  cord. AA'hen the
inflammation  is secondary  to  fractures and  diseases of the vertebra, the
exudation  is  usually both  upon the  outer and  upon  the inner surface of
the  dura  mater.  Sometimes  the  exudation is very abundant  between the
dura mater and the  bone (acute  peripachymeningitis).  AVith  acute spinal
leptomeningitis  there is generally more or less inflammation of the adjacent
parts of the spinal cord  (meningo-myelitis).
   The local  symptoms  of  acute  spinal  meningitis are chiefly referable to
effects manifested through  the spinal  nerves, and  they correspond  to the
functions of the posterior and anterior roots of  these nerves.   More or less
pain is felt in the spine, radiating therefrom to the extremities.   The pain is
increased, not so much by pressure over the spinal column as by movements
of the body.  The sensibility of the  surface is  morbidly increased  (hyper-
asthesia). These effects are manifested through the posterior roots of the spinal
nerves.   Other effects are manifested through  the anterior roots or by reflex
action through the posterior—namely, tonic contraction of the muscles of the
extremities, clonic  contractions in some cases, spasm of the muscles of the back
so as to give rise to opisthotonos, and sometimes rigidity of the thoracic mus-
cles, causing dyspnaa. As regards the muscular contractions or spasms, there
are exacerbations and remissions.  These symptomatic phenomena are attribu-
table to a morbid excitation of the spinal nerves, and they belong to the early
part of the affection.  Subsequently, paralysis occurs as the effect of pressure
upon the cord by  the  products of the inflammation.   The paralysis may be
limited to  the lower extremities (paraplegia)  or  it may be general; that is,
affecting  both  the upper and lower extremities.  The paralysis is rarely com-
plete.  It is usually limited  to motion, and with it, indeed, exaggerated  sensi-
bility or  hyperasthesia may persist, as well as tonic contraction of muscles.
AVith these local symptoms there is more or less fever, together with anorexia
and prostration.  The pulse is sometimes abnormally infrequent, and this may
be found in striking contrast with the temperature of the body as determined
by the thermometer.  In the  course of the disease, however, the pulse becomes
frequent and feeble.  Profuse perspirations often occur.  Reflex and electrical
excitability are generally preserved. 
704    INFLAMMATORY DISEASES OF THE MENINGES,  ETC.

   The diagnostic features  point to the spinal cord as the seat of the disease
and denote  an inflammatory and a grave affection.   Hysterical  opisthotonos
lacks the evidences both of inflammation and of gravity.   Moreover, various
antecedent and  concomitant phenomena betoken the existence of hysteria.
It is to be  differentiated from tetanus, which is a very grave disease.   The
latter, however,  is distinguished by the early occurrence of trismus and tonic
spasms, by the absence of local and general symptoms denoting inflammation,
and by the  traumatic origin of the affection in the majority of cases.   The
diagnostic points  involved  in  discriminating acute spinal  meningitis  from
acute myelitis will  be  noticed in treating of the latter in the next chapter.
It may, however, be remarked  here that acute  spinal meningitis  and acute
myelitis very rarely occur  independently of each other.  The two affections
are generally  associated; but the  inflammation may be primarily seated in
either situation, and it may predominate in one or the  other.
   Acute spinal meningitis often runs a rapid course, its duration not extend-
ing beyond  a week. It  ends fatally in a large  proportion of cases.  Life is
destroyed by apnaa in  some cases in which the respiratory function is notably
compromised by either  spasm or paralysis of the muscles concerned in respira-
tion or by an extension of the inflammation  to the medulla oblongata,  if the
latter occur, dysphagia  is likely to be a symptom.   In  either case death is
preceded by intense dyspnaa, which, on a physical examination of the chest,
is found not to proceed from any adequate pulmonary or cardiac complication.
In other cases asthenia predominates in the mode of dying.
   The danger  is to be estimated by the extent of the diffusion of the inflam-
mation and  the  severity of the symptoms.   The immediate danger depends
on the extension of the inflammation upward so as to interfere with respira-
tion.   In  cases  of a moderate intensity of the disease recovery  may take
place rapidly and completely.  The disease may continue and become chronic,
or recovery may take  place, leaving as  sequela more  or less atrophy  and
paresis of the muscles  which had been  affected.
   The indications for  treatment are essentially the same as in acute cere-
bral meningitis.   Considering the rapid course of the disease in severe cases,
and the danger in the  direction of apnaa,  bloodletting, general or local, or
both, may be  employed if  contraindicating circumstances relating  to  the
pulse, the blood, and the constitutional strength be not present.  Mercurial-
ization is warrantable,  if not desirable.  If employed,  it should be rapidly
induced, and for this end  inunction may be added to  the administration of
calomel at short intervals.   Ergot and belladonna are supposed to diminish
hyperamia by causing  contraction of  the small arteries, and in this way to
be  useful.   AVhen  the  symptoms  denote the presence of  the  products of
inflammation,  the  vesication successively of different sections of  the  spine,
and the iodide of potassium in large doses, are indicated.   Sustaining treat-
ment is of course indicated  in proportion  as the duration of the  disease is
prolonged and the symptoms show  a tendency to death  by asthenia,  Reten-
tion of urine is to be prevented, and cystitis may claim appropriate treatment.


                    Chronic Spinal  Meningitis.
   It is now believed that chronic  spinal meningitis with clinical manifesta-
tions  is a much less frequent  affection than was formerly supposed.   This
view is based upon the  following facts:  The symptoms described as charac-
teristic of chronic  spinal meningitis are also produced by diseases of the
spinal cord and by diseases of peripheral  nerves, and many of these diseases,
being  recognized  only  by careful  microscopical examination, may  readily
escape observation at  post-mortem examinations.   Some of these diseases 
                    CHRONIC SPINAL MENINGITIS.                705

have  been  discovered  only within  a comparatively  few  years.   Airain,
the lesions which have been considered as evidence of chronic spinal men-
ingitis,  such as  thickening and  opacity  of the  pia-arachnoid membrane,
calcareous plates in this  membrane,  and  adhesions between this  membrane
and the spinal cord on the one hand  and the dura mater on tbe other hand,
are extremely common, and are usually present without any evidence during
life of a spinal affection.   Chronic spinal  meningitis is not infrequent  as a
secondary affection.  It may follow epidemic cerebro-spinal meningitis  or it
may accompany chronic diseases of the spinal cord or of the vertebra.   In
these cases, however, there are usually no distinctive symptoms referable to
the affection of the meninges.   But, although  chronic spinal meningitis is
doubtless an affection  of much less  clinical  importance than was formerly
supposed, and although the symptoms formerly referred to a primary chronic
inflammation of the meninges are usually dependent upon  some other affec-
tion, nevertheless, there remain  certain cases which are still to be considered
clinically as instances of chronic spinal meningitis.
   The  lesions of chronic spinal leptomeningitis are, thickening and opacity
of the pia-arachnoid membrane, increased  subarachnoid fluid, and  adhesions
between the pia mater  and the spinal  cord and between the arachnoid  and the
dura mater.  As already mentioned, these  lesions, as well as calcific plates in
the arachnoid  membrane, are common, especially in elderly persons,  without
any  corresponding  symptoms during  life.
   The causes  which have  been assigned  for chronic  spinal meningitis are
injury to the spinal  column, exposure to cold, abuse of the sexual function,
and  chronic  alcoholism.
   The symptoms are similar to  those of acute spinal meningitis, but they are
of longer duration, less intense, and not accompanied by acute febrile reaction.
The symptoms are pain and rigidity of the  neck and back, pain in the  extrem-
ities, hyperasthesia, and muscular spasms.  These symptoms of irritation grad-
ually give place to symptoms of loss of function, such as  anasthesia, paresis of
the extremities, incontinence or  retention of urine, and incontinence of feces.
There may be a sensation of constriction, as of a  tight beltr around the body.
If marked paralysis and anasthesia exist,  it may be assumed that the spinal
cord is  involved.
   The following points are urged in distinguishing the paraplegia of myelitis
from that of meningitis : The former is accompanied by less pain in  the spine,
limbs, and extremities ; the paralysis  is developed more rapidly, and is greater
in degree ; cutaneous anasthesia and analgesia  occur  earlier, and  are more
marked; and the muscles sooner become  atrophied.
   In a considerable proportion of cases of paraplegia dependent upon  chronic
spinal meningitis the termination is unfavorable,  but in  general the  prognosis
is better than in myelitis.
   In the treatment of chronic spinal meningitis the indications for blood-let-
ting, local or general, are rarely present.  Dry cupping, blisters, sinapisms, and
irritating liniments  applied to the back are considered as highly useful while
the inflammation continues.  The application of the hot iron is recommended
as an efficient method of counter-irritation.   During this period the avoidance
of exercise and of  exposure to cold is important.   AVhen there is reason to
think that inflammation no longer continues, it  is an object of treatment to
promote absorption of the inflammatory products.  The iodide of potassium
is supposed to be of use in this way.  Mercury may he tried, with proper pre-
cautions to  avoid  ptyalism.  Nothing should be done to impair the  general
condition, and,  if it be impaired, restorative remedies and hygienic measures
are indicated.   Tepid baths seem to be of use.  The improvement sometimes
derived from mineral  waters, used either  internally or externally, probably
45 
706    INFLAMMATORY DISEASES OF THE  MENINGES, ETC.

does not depend on any special efficacy, but to a greater or less extent on the
hygienic advantages which are associated with their use.
  As regards treatment addressed directly to the paralysis, the measures arc
the same as in all paralytic affections whenever the measures are not contra-
indicated by conditions standing  in a causative relation to the paralysis, the
object being to maintain the nutrition and functional capacity of the affected
muscles.


            Cervical Hypertrophic Pachymeningitis.

  This affection was first described by Charcot in 1871.  It is a rare disease.
It is characterized anatomically by the formation of layers of new connective
tissue from the  inner surface  of  the  dura  mater.  This membrane thus be-
comes greatly thickened, and it is  usually adherent to the pia-arachnoid mem-
brane, which may also  become thickened in a similar way.   The  cord  lies
imbedded in a mass of dense fibrous  tissue, by which it is compressed.   The
cord may be simply anamic, but  frequently it is the seat of a chronic  trans-
verse myelitis.   Below the myelitis the cord presents the lesions of a descend-
ing secondary degeneration.  The nerve-roots which are surrounded by the
new  fibrous tissue  are  likewise compressed and  atrophied.   The  disease is
usually confined to  the cervical  region.
  The causation is not  known.  Exposure to cold and  the abuse of alcohol
have been assigned as causes, but without sufficient proof.
  The compression and irritation of the posterior roots  of the cervical nerves
give rise in an early stage of the disease to severe shooting pains in  the
back of the neck, extending to the occiput and to the  arms.   There is often
complaint of formication and  of  numbness in the arms.   At a subsequent
period the  compression of the anterior roots  of the cervical  nerves causes
paralysis with atrophy of the muscles of the upper extremity, most marked,
as a rule, in the muscles supplied by the ulnar and the median nerves.   The
atrophied  muscles rapidly  lose reaction  to the  faradic current.   The hand
may assume a position of exaggerated extension.  There may now be  anas-
thesia of the upper extremities.   In consequence of the cervical part of the
spinal cord being involved, the motor nerves  going to the lower extremities
may lose their power of conduction ;  and  then  follows a spastic paralysis of
the lower extremities.  If  there be a complete transverse myelitis,  anas-
thesia of  the lower extremities  and paralysis of the bladder  and rectum
follow.  Bed-sores may form.   The paralyzed muscles of the lower  extrem-
ities do not undergo atrophy, as do those of the upper extremities.
  Cervical  hypertrophic pachymeningitis may be confounded with tumors
pressing upon the cervical part of the spinal cord, with caries of the cervical
vertebra and with amyotrophic lateral sclerosis.   The main points in diagno-
sis are the  situation  and the radiation of the pain  and  the characters of the
paralysis in the upper  and in the lower extremities.   Amyotrophic lateral
sclerosis is  distinguished by the absence of sensory disturbances, by the pres-
ervation of the vesical  functions, and by the frequent development of the
symptoms of bulbar paralysis.
  The disease is of long duration.  The usual termination is in death,  either
by apnaa or by asthenia.  The symptoms may, however, be arrested, at least
for a long time, and  cases have been reported  in  which recovery is said to
have  resulted.
  It is not likely that any measures of  treatment directly affect  the lesion.
Iodide of potassium and electricity are the therapeutical agents usually  em-
ployed.   Counter-irritation to the back of the neck by  means of  the hot iron
has been recommended. 
CEREBRO-SPINAL  MENINGITIS.
707
                     Cerebro-spinal Meningitis.

   The name cerebro-spinal  meningitis denotes an  inflammatory affection of
 the  arachnoid  and pia mater of both the  brain  and the spinal cord.  As a
 sporadic and  purely local affection, it is considered rare, but of late  years
 sporadic cases of cerebro-spinal meningitis are  met with in New York  not
 very infrequently.   The name  is generally understood as designating an epi-
 demic disease  characterized by cerebral and  spinal meningeal inflammation.
 In the latter application it denotes an infectious disease in the sense in which
 the term infectious is at present  defined.  (Aride p. 84.)   Epidemic cerebro-
 spinal meningitis is a general not a local disease.   Its appropriate nosological
 place is among the  essential  fevers.   It  is  with  propriety called  by  some
 writers cerebro-spinal fever.  The evidence of its having existed prior to  the
 present century  is not  clearly apparent in  medical  literature.  Since  the
 beginning  of the nineteenth century epidemics have occurred at  diff'erent
 periods in various parts of the Old AVorld  and in this country.  It prevailed
 in New England  between the years 1807 and 1816, and was then known as
 spotted fever.   For a quarter of a century  after that period this country was
 exempt from its  visitations; but within  the  last forty years it has prevailed
 from time to time in different  districts of  the United States and in Canada,
 This article  will have reference to cerebro-spinal  meningitis as an  epidemic
 disease, or to cerebro-spinal fever.

   Anatomical  Characters.—In the majority of cases an exudation  of
 a  purulent  character, similar to that in simple  meningitis, is found in  the
 meshes of the  pia  mater both  of the brain and  cord.   The extent and  the
 abundance of the exudation vary much in  different cases.   The inflammation
 affects the pia-arachnoid  membrane both of the convexity and of the base of
 the brain, but it is  usually most intense at  the base, and it may be limited to
 this situation.  AArithin the spinal canal the inflammatory exudation is limited
 chiefly to the posterior surface  of the cord and to the membranous envelopes
 of the posterior  nerve-roots.  The purulent exudation, however, is  rarely
 distributed uniformly over the  posterior surface,  but is most abundant in the
 lumbar, lower dorsal, and lower cervical regions of  the cord, while it may fail
 in the rest of the cervical region or be present there only in scattered patches.
 The exudation consists predominantly of pus, together with serum and fibrin,
 mixed usually with a considerable  number of extravasated red blood-corpus-
 cles.   In recent cases mucin may  be present in considerable  amount, so as
 to render the exudation gelatinous.  The membranes as well as the substance
 of the brain  and cord are generally hyperamic, and frequently the seat of
 small hemorrhagic extravasations.   The substance of the brain and  cord has
 usually an  abnormally soft consistence,  which may  be particularly marked at
 certain points.  The  sheaths of the blood-vessels which  penetrate the  brain
 and  the spinal cord are infiltrated  with pus-cells, which may accumulate in
 sufficient number to form small abscesses  in the brain or in the cord.  The
 ventricles usually  contain an  increased amount of  fluid,  somewhat turbid
 in appearance or rarely decidedly purulent.   The central canal of the spinal
 cord may be distended with  purulent fluid.
   In cases terminating within  a few hours (fulminant cerebro-spinal menin-
 gitis) the anatomical evidences of the disease may  be slight,   In  such cases
 the exudation is mainly serous, although the  microscope will show that emi-
 gration of  white  blood-corpuscles has  already  actively  begun.   In  these
fulminating cases the brain-substance will be found, as a rule, adematous
and anamic.   In cases of prolonged duration  the ventricles are usually found
greatly distended with serum.   The previously creamy, purulent exudation 
708    INFLAMMATORY DISEASES  OF  TEE MENINGES, ETC.

is  perhaps now desiccated and caseous, or more frequently has nearly disap-
peared.
   The following embrace the most important of the morbid changes existing
in other parts  of  the  body: The skin often presents  herpetic vesicles and
petechia.  The voluntary muscles, especially of the neck and back, are dark-
red in  color and often  the seat of granular degeneration.   As in other infec-
tious  diseases,  parenchymatous degeneration of the heart, liver, and  kidneys
is  usually found.  The lungs present no constant changes, but are frequently
the seat of bronchitis,  atelectasis, lobular pneumonia, and  hypostatic conges-
tion.   The spleen, in the majority of cases,  is  not  much  enlarged, but is of
lax consistence.  Sometimes the spleen  is found greatly swollen  and softened.
A moderate enlargement of Peyer's patches and of the solitary follicles is com-
mon.   Abscesses in the joints and elsewhere  have been occasionally observed.
Endocarditis and inflammation of serous membranes are rarer complications.
Suppurative inflammation of the middle and internal car, choroiditis, and iritis
are to  be mentioned as occasional concomitants  or sequela.

   Clinical History.—The characteristic features of epidemic cerebro-spinal
meningitis are remarkably distinctive.  In many cases the disease begins with
a sudden attack, the patient being at once  stricken down with grave symp-
toms ;  but the access may be more or less gradual, the development occupying
from one to eleven days.  The prodromic symptoms, enumerated in the order
of their relative frequency,  are—cephalalgia, chills without rigor or  chilliness,
nausea and vomiting, pain in the spine and limbs, vertigo, and diarrhaa.  Ce-
phalalgia is usually the most prominent symptom when the disease is devel-
oped.  The pain is intense, lancinating, and accompanied with a  sense of  ten-
sion.  It is referred either to the frontal  region, the occiput, or the whole head.
The pain persists without  intermissions.  It is increased by light,  sounds,
and movements of the body.   Pain referable  to the spine,  or  rachialgia, is
generally added to the cephalalgia.   The pain may extend  over  the whole
of the spine, or it may be referred  to  either the lumbar, dorsal, or cervical
portion.   The  extent  and situation  of  the spinal pain probably correspond
with the extent and  situation of the spinal meningitis.   The  rachialgia is
wanting if the  disease prove fatal  without  inflammation extending  to the
spinal  membrane.  The  spinal pain  is not always increased by pressure over
the vertebral  column,  but notably by movements of the body.  Pain is fre-
quently felt in different parts of the body,  especially  in  the lower extrem-
ities.   The pain in situations  other than the head and spine  is often intense.
Hyperasthesia of the surface of the body is often a marked symptom, ren-
dering the slightest contact a source of suffering.   Not infrequently vomit-
ing accompanies the cephalalgia at  the outset of the  disease.
   Delirium in  some cases  quickly supervenes, but in  other cases it occurs
after a variable period.  Sooner or later it occurs in a large proportion of the
cases which are not quickly fatal.  It varies  much in character and intensity.
At first there is simply difficulty in collecting  ideas, but after a time the patient
either  remains taciturn, making  no  response to questions, or replies  incohe-
rently  or becomes actively delirious, shouting  and struggling against restraint.
The latter form of delirium occurs in paroxysms, with  calm intervals.  The
paroxysms occur especially at night.   They are accompanied by  hallucina-
tions in some cases, and insane delusions.  Occasionally the  delirium is hila-
rious.   The mind is  usually desponding and  apprehensive  if the intelligence
be preserved.   Loquacity and erotic  desires with priapism have been observed.
Repeated seminal emissions occurred in a case which came  under my observa-
tion.   In a certain proportion of cases the patient becomes quickly somnolent
and falls into  coma, which may be of temporary duration or continue until 
CEREBRO-SPINAL  MENINGITIS.
709
the disease ends fatally.  More or less stupor, frequently amounting to coma,
occurs not infrequently on the  first day of the disease.  The vision is rarely
lost;  double vision sometimes occurs ; the pupils  are frequently dilated, but
sometimes Contracted;  the conjunctiva is often injected ;  and temporary deaf-
ness is an occasional symptom.   In  one of the cases of sporadic  cerebro-spinal
meningitis which I have observed lateral and vertical oscillation of the eye-
balls  was a  notable  symptom.   The  coma in some cases is without  stertor,
and resembles that of hysteria.   The patients seem to  be  in a quiet sleep, cry-
ing out if any attempt be made to alter the position of the body.   A patient
in one case  which came under my observation had remained in precisely the '
same position for  forty-eight  hours, and in another case  for three  days.
Mobility of the  iris  may remain, although the patient is in  this comatose or
deeply  somnolent state.
   Important symptoms relate to the muscles.  Tonic  contraction of the mus-
cles of  the  neck and back is of frequent occurrence, giving rise to retraction
of the head and opisthotonos in a greater or less degree.   Trismus sometimes
occurs, and  in  rare instances pleurosthotonos.  Contractions of muscles  of
the extremities are not infrequently  observed.  Pain in the muscles of the
"legs and thighs, the spinal muscles, and  those of the  neck is a  source of suf-
fering if the patient be conscious.   Muscular tremor  is an occasional, and
strabismus  not an infrequent, symptom.   Subsultus and carphologia occur in
cases in which  the disease  is protracted.   Convulsions  are  not of frequent
occurrence.   Paralysis is  also  infrequent.   Hemiplegic paresis and ptosis
have been  observed.
   Nausea and vomiting are more or less prominent throughout the disease in
a minority  of cases.  Constipation is the rule.   The  appetite is generally
lost.   However, a desire for food is  sometimes expressed, although convales-
cence is not near at hand.   The tongue  is frequently  large and flabby, show-
ing indentations made by the pressure of  the teeth.  It becomes coated, and
in the progress  of the disease  dry and dark.  The teeth and lips frequently
present sordes.
   The  respirations are sometimes suspirious.  They are usually increased in
frequency even  when  no pulmonary complication exists, and they are some-
times irregular.   Stertor  is rare.   The pulse in the  early  stages of the
disease is generally not more  frequent, and is often less  frequent,  than in
health.  In the progress of the disease it  becomes  moderately accelerated,
rarely exceeding 100 per minute, until toward a fatal termination, when it is
frequent and small.   Fluctuations in frequency  at  different periods of the
day constitute a striking feature in some cases.  Palpitations are occasionally
observed.   The  quantity of urine may be  greater than in health, and the
urates  are deposited in abundance.   In some cases  there  is slight  albumi-
nuria, and exceptionally glycosuria has been observed.  In a fatal case among
those which I  have observed   there was  hamaturia, the hemorrhage  being
abundant and  not occurring in any other situation.
   The  temperature of the  skin  varies in  diff'erent  cases  and at different
periods in the  progress of  the  disease.   At  the beginning  the temperature
rarely exceeds,  and often falls  below, that of health.   Notable heat of  the
surface is very  rarely observed; the thermometer, however, shows the heat
of the  body to be  more or  less  raised.   Thermometric  examinations in  the
axilla were made by Githens in 44 cases  at 6 A. m.,  at  12 m.,  and at 6 P. M.
daily, with  the  following results:  The  maximum of increase was 105°  F.;
and in only 2 cases was this height reached.  The maximum in 15 cases was
between  104° and  105°;  in 7  cases, between  102° and  103°;  in  6  cases,
between 101° and  102°; and  in 2 cases it was below 100°.   The difference
between the morning and evening  temperature was loss than in most of  the 
 710    INFLAMMATORY DISEASES OF THE  MENINGES,  ETC.

 essential  fevers.  " A  rapid fall  was the sure precursor of collapse." *   As
 regards dryness and moisture, cases vary on different days and  at  different
 periods of the  same day.  Sweating is  rare except  in  some  cases  shortly
 before death.   The face is  often  suffused and  of a  dusky hue."
   Petechial  spots are  frequently  observed, but they are by no  means con-
 stant.  They appear to  be of more frequent occurrence in some epidemics
 than  in  others.   They  vary in size from that  of a pin's  head  to  spaces a
 quarter of an inch in breadth  or even larger.  They are evidently due to an
 extravasation of blood  or of blood-coloring matter, such as occurs in scor-
 butus, purpura, in some cases of continued fever, and  occasionally in other
 affections. They are hardly entitled to be called  an eruption.  A rose-colored
 papular  eruption  resembling that of  typhoid  fever  has been  occasionally
 observed.  Herpes of the face occurs often in some, and rarely in other epi-
 demics.   As herpes occurs very rarely, if ever, in  other forms of meningitis,
 this  symptom may be  of diagnostic importance.   Urticaria, erythema, and
 bulla have been observed, but their occurrence is  evidently accidental; that
 is, they do not belong to the clinical history of the disease.   In some of the
 cases which I have observed sudamina were abundant,
   A  survey of the clinical history  of this affection, exclusive of the cases in
 which death  quickly ensues in  apoplectic  coma, shows a correspondence with
 the symptoms of acute   cerebral meningitis, and the addition of those due to
 inflammation of the meninges  of the spinal  cord.  The  duration of the dis-
 ease  is very variable.   Of fatal  cases, the  minimum  duration is stated by
 Tourdes to be twenty hours.   Ames states the minimum to be fifteen hours.
 The maximum duration  in fatal cases is stated by Tourdes to be one hundred
 days, and by Ames more than forty days.  Of the cases analyzed by x\mes, 16
 terminated fatally on the second or third,  and 19  on the fourth day.2  Of 160
 cases  analyzed by Dr. S. B. Hunt, 12, or 1 in 13, died within the first twenty-
 four hours; 92, or more than half,  died before the close of the fifth day ; 14,
 or 1 in 11, died before the close of the tenth day; 4, or 1  in 40, before the
 close  of the fifteenth day ; and 18 survived for various periods thereafter.3 In
 Upham's  cases the duration varied between thirty-six hours  and six weeks.4
 Thus in the majority of fatal cases the disease runs  a rapid course, ending
 prior  to the fifth day.   In cases which  end in recovery the  convalescence is
 generally  tedious and the patient remains for a long period in feeble health.
 Relapses  have not been observed.
   It is not easy to divide the career of the  disease into well-marked stages,
 and the arrangement of cases  into  different  classes, such  as  inflammatory,
 congestive, malignant,  etc.,  is not attended  by  any practical  advantage.
 Remissions are stated to occur  by different observers.  They vary as regards
 the time of their occurrence, their  duration, and the degree of amelioration
 of the symptoms.   Not infrequently the  improvement for  a few hours, and
 sometimes for a day or so, is so marked as to give encouragement to hope that
 convalescence is about to take place. These remissions are most likely to occur
 on the second or third day.  In a case under my observation the temperature
 and pulse became normal, the intelligence returned, and for twenty hours the
 patient seemed convalescent; the symptoms, however, returned and the case
 ended fatally.

  Pathological  Character.—All at present  known of the pathological

  1 Vide Am. Journ. of Med. Sciences, July, 1867.
  2 Vide New Orleans Med.  and Surg. Journal, 1848.
  3 Article by Dr. Hunt in the medical  volume of the Sanitary Memoirs of the War.
  4 Epidemic Cerebro-spinal  Meningitis in the Camps in and around Newbern  in 1862-G3,
by J. Baxter Upham, M. D., Boston, 1S63. 
CEREBRO-SPINAL  MENINGITIS.
711
character of epidemic cerebro-spinal meningitis is embraced  in the statement
that it is an infectious disease and belongs among the essential fevers.  The
inflammation, of the pia mater of the brain and cord is a local manifestation
or an  effect of an underlying general  morbid  condition.   It  is reasonable to
suppose that the specific infectious agent is a micro-organism, but with the
exception of a few observations  of micrococci in the exudation nothing is
positively known concerning such an  organism.  It must be admitted that
the phenomena of the  disease are largely symptomatic of the cerebro-spinal
inflammation.

   Causation.—The prevalence of the  disease as an epidemic implies the
existence of a special cause.  With respect to  the source of the special cause
and the circumstances  concerned in its production we have no positive know-
ledge. Nearly all who have observed the disease concur in the belief that the
causation does not involve a  contagium.   The disease has prevailed in situa-
tions  in which periodical fevers rarely occur.  It is, however, not improbable
that in malarial districts the  special cause may be combined with that giving
rise to periodical fevers, and  that the phenomena of the latter are sometimes
associated with those of cerebro-spinal meningitis.
   In  France  the disease has been observed to prevail especially  among
soldiers,  and particularly among new recruits.  In this country  it has pre-
vailed among troops stationed at several different points.   It  attacks per-
sons in all conditions and at all periods of life.  Infants are not exempt, but
the liability is increased after seven years of age.   In a series of cases the
larger number are between the ages of twenty and thirty years.  Of the per-
sons attacked, the larger proportion are males.  The difference, however, is
not great.  The statistics of Sanderson, cited by Hunt, show  164 cases among
males, and 154 among females.
   Epidemics occur much oftener in  the winter and  spring than during the
summer  months.  Of the epidemics which have occurred  in this country,
nearly all were in the spring and winter months.  Of 182 epidemics in Europe,
analyzed with reference to this point by Dr. John Simon,  10  were in August
and September;  24 were in October  and November ; 46 were in December
and January; 48 were in  February and  March ; 30 were in April and May;
and 24 were in  June  and  July.  The disease, as stated by Hunt, who cites
the foregoing statistics, " has its favorite habitat in prisons and  barracks."
'• In the four or five years  following 1837 it invaded nearly all the crowded
barracks in France.   It  has appeared  frequently  among the galley-slaves
of Toulon."
   Facts pertaining to the localization of epidemics and  the  occasional occur-
rence of sporadic cases show conclusively that auxiliary causes which  pertain
to overcrowding, defective  ventilation  of dwellings, poisoning of the atmo-
sphere by sewer  emanations, etc. have a potent causative influence in  asso-
ciation with the special cause ; and it is an important fact that these auxiliary
causes are by no  means always confined to the habitations of the poor.

   Diagnosis.—Difficulty  in making  the diagnosis  of cerebro-spinal  menin-
gitis relates chiefly to sporadic cases and to  those in which the disease aborts
or is  unusually mild.  Abortive cases  sometimes occur,  and the  disease  is
sometimes  so mild  that its usual diagnostic  features are not marked.
   The disease need never be confounded with typhoid fever.   The sudden-
ness of the  attack in  many  cases, the intensity of the  cephalalgia, and the
occurrence of symptoms denoting inflammation of the meninges of the  brain
and cord, distinguish it alike from typhoid and typhus fever.  The character-
istic abdominal symptoms of typhoid  fever are wanting—namely, diarrhaa, 
712    INFLAMMATORY DISEASES OF TEE .MENINGES,  ETC.

meteorism, and iliac tenderness.   Absence of the latter symptoms does not
exclude typhus, but other diagnostic points  belonging to  the latter disease
are wanting.  The characteristic eruption of typhus, often copious, appearing
on the third or fourth day after taking to the bed, does not occur  in cerebro-
spinal meningitis.  The  spots of ecchymosis on  which the name spotted fever
is based cannot be confounded with  the eruption of typhus.   Tonic contrac-
tion of the muscles of the neck and back, rachialgia, convulsions, and furious
delirium, which occur in cases of cerebro-meningitis, are very rare  in cases of
either typhoid or typhus fever.
  In the cases  in which the patient falls quickly into  coma and dies after the
lapse of a few hours the affection resembles, in this fact, a  paroxysm of per-
nicious intermittent fever.  In  general, however, the latter does not destroy
life in the first  paroxysm, and the occurrence of  a paroxysm from which the
patient has emerged suffices  to establish the  diagnosis.   It is of course  only
in  districts in  which periodical fevers exist that the  practitioner is called
upon  to  make  this differential diagnosis.
  The occurrence of trismus and opisthotonos may suggest  tetanus; but in
tetanus the cerebral symptoms which belong  to cerebro-spinal meningitis are
wanting.  Moreover, tetanus  in other than tropical  climates is exceedingly
rare  save as a traumatic affection,  and it never  prevails  as an epidemic.

  Prognosis.—There are few  epidemic  diseases  so destructive to life as
cerebro-spinal meningitis.  In  the epidemic  observed  by  Tourdes the  pro-
portion  of deaths was  60 per cent.   Ames gives the  same proportion of
fatal cases in the epidemic which prevailed in Alabama in  1848.  In an epi-
demic  observed by Lefevre four-fifths died at the beginning,  and  two-thirds
toward the end of the epidemic.   Of 3(56 cases analyzed by Dr. S. B. Hunt,
the deaths were 243  and the recoveries 123, making the percentage of fatal
cases 70.   Stille states that ten epidemics between 1838 and 1848 gave an
average mortality of 70 per cent,, and a similar number of epidemics between
1855 and 1805 gave an  average of about 36 per cent.   He cites these statis-
tics as showing  a gradual decline  of  power  in  the epidemic cause.  All
observers agree as regards a large death-rate in cases of this disease.   Mild
cases, however, may occur during the prevalence  of an epidemic, but even in
these cases the physician  should be cautious  in giving a prognosis.   The
prognosis in all  cases  in  which  severe symptoms occur, such  as notable
delirium, coma, convulsions, and muscular contraction, is exceedingly grave.
The  disease is most likely to prove  fatal in infants and in  persons in middle
and advanced life.  It  is stated that the proportion of fatal  cases is greater
among females than among males.  The mode of dying, in the cases in which
coma and death take place speedily, may be by  apnaa, but in the majority of
cases it is chiefly by asthenia.
  Deafness and blindness are not very rare sequels of this disease.  In the
large  majority  of cases  the deafness is bilateral.  The blindness  may be in
both eyes, but oftener  it is  unilateral.   The  blindness is  due to purulent
choroiditis or to optic neuritis, and the  deafness to purulent inflammation of
the labyrinth of the ear.1

  Treatment.—As might he expected in a disease  so severe  and fatal as
this, various  potent  therapeutical agents  have been  employed.   No reliable
abortive  pr curative treatment has as yet been discovered.   Experience has,
however, shown the utility of certain measures in the employment of which
"he physician is to be governed by the rational and symptomatic  indications
present in individual cases.
   1 A'ide article by Dr. H. Knapp in the New  York Medical Record,  Aug. 15, 1872. 
     HYDROCEPHALUS—HYDRORRHACHIS—SYRINGO-MYEL US.  713

  Great severity of symptoms, the patient having been attacked in full health
and the pulse being strong or hard, renders bloodletting appropriate.   AVet
cups may be applied to the neck or leeches behind the ears in lieu of vene-
section when the indications for bloodletting are less  clear.   The abstraction
of blood is  contraindicated if the  cerebro-spinal symptoms be not severe, if
the pulse  be readily compressed, and if the patient  were anamic or feeble
when attacked.
  Quinia  in  large doses has appeared in some cases to he useful.   Its appa-
rent success is perhaps, in a measure, to be accounted for by supposing  that
pernicious intermittent fever may have been mistaken for the disease, and by
the fact that malarial effects  may be associated with  the  latter.  The utility
of this remedy may sometimes be due to its antipyretic  operation.  For  the
reduction  of a high  temperature in this disease  sponging the  body  and
the wet sheet are preferable.  These measures  are  indicated  by intensity
of fever.
  The testimony in behalf of opium in large doses is discrepant.  As regards
its  utility, however, there is very general agreement among physicians of
large experience.  Prof. Stille  recommends one grain of opium  every hour
in grave cases, and every two hours in  cases  of moderate severity.  This
recommendation is based on  the  study of about 120  hospital  cases.   He
has not known any approach to  narcotism in the  cases  thus treated.   The
hypodermic  administration of morphia is to be preferred.  It is important to
avoid narcotism.  The bromides, given in large doses, are regarded with favor
by many physicians with w*hose practice I have become acquainted through
professional  intercourse.
  The utility of cold  applications  to the  head and back is conceded by all
physicians.   The  extent  to  which this measure is  to  be carried  is to be
determined  by  the sensations of the  patient and the effect upon  the symp-
toms.
  The foregoing remarks relate to the treatment when the symptoms denote
cerebro-spinal excitation.   AVhen the symptoms  are those of oppression, the
objects of treatment are the  same as in cases of simple cerebral  and spinal
meningitis—namely,  limitation of morbid products  and their removal by
absorption.   The iodide of potassium, given in doses as large  as  are  well
tolerated,  is indicated.   Mercury, internally,  and  by  inunction, may do
something toward effecting the objects just stated,  and if so  it  is desir-
able to secure  its usefulness, however  small it may be.
  Support by alcoholics and nutritious alimentation is indicated in proportion
as the symptoms denote asthenia.
  AVhenever an epidemic or a sporadic case of this disease occurs, local aux-
iliary causes should be sought and removed.  Removal of residents to places
without the  area of the infected situation, if practicable, is to be recommended.


      Hydrocephalus—Hydrorrhachis—Syringo-myelus.

  By the  term hydrocephalus or hydrocephalus internus is understood an
excessive accumulation of serous fluid in the ventricles of the brain, particu-
larly the lateral ventricles.  The name hydrocephalus externus is sometimes
applied  to great increase  of  fluid  in  the  subarachnoid  space.   The serous
effusion of hydrocephalus may be due to a variety  of  different processes,
such as venous  congestion, atrophy of the brain, changes in  the walls of  the
blood-vessels, and  inflammation of  the  lining membrane  of the ventricles or
of the  pia mater.  In some, especially the congenital, forms of hydrocepha-
lus  we are unable to determine the cause of the disease.   There is but little
tendency to  dropsical effusions within the cranium in  cases of general dropsy. 
 714    INFLAMMATORY DISEASES OF THE MENINGES, ETC.

 Hydrocephalus occurs either as a congenital affection or in early infancy, lead-
 ing in  some cases to an enormous enlargement of the cranium and giving rise
 to a characteristic deformity of the head.   The reader is referred  to works on
 the diseases of children for an account of this affection.
   The name hydrocephalus ex vacuo is given to an effusion of serum into the
 ventricles as a result of wasting or atrophy of the brain-substance, such as
 occurs in old age.   Under  these  circumstances, as the effused  serum simply
 fills an unoccupied  space, the brain  does  not  suffer from compression.  An
 abundant  serous  effusion is an important  element in certain  cases of  tuber-
 culous meningitis (acute hydrocephalus), and sometimes in other forms  of
 meningitis.  The exudation  of fibrin and pus in some cases is very  small,
 and the amount of  effused  serum large; but these are not properly cases of
 hydrocephalus.   It was formerly thought that serous effusion  sometimes
 occurs  suddenly  in sufficient  quantity to occasion  apoplexy (serous apo-
 plexy).  This was the  theory  in  certain cases which are now explained
 by our knowledge  of thrombosis, embolism, and uramia.
   Serous effusion  into the  lateral ventricles may occur in consequence  of
 pressure upon  the veins carrying the  blood from the ventricles into the sinuses
 (vena  Galeni), as from a tumor of the pineal gland, solitary tubercles of the
 cerebellum,  etc.   A  chronic accumulation of serum  in the lateral ventri-
 cles, combined with a granular condition of the ependyma, has been described
 under  the names granular  ependymifis  and chronic ependymitis.   It occurs
 especially in cases of  chronic alcoholismus  and in old age.   A similar serous
 accumulation may be  present in chronic cerebral  meningitis with or without
 a granular ependyma.  The growth and coalescence of the granulations may
 cause obliteration  of portions of the ventricles—for example, the anterior
 horns of the lateral ventricles—or  may lead to the formation of bands  of
 adhesion between  the ventricular walls.
   Extensive serous accumulation within  the  spinal canal is called hydror-
 rhachis. The effusion may  be in the  central canal of the spinal  cord (hydror-
 rhachis interna or hydromyelus) or  in  the subarachnoid or subdural  space
 (hydrorrhachis externa).  These  affections, when congenital, are  often com-
 bined with  deficiency of portions of the vertebral column,  constituting  the
 affection commonly known as spina bifida.   In this affection a tumor consist-
 ing of  the serous accumulation  with its enveloping membranes (hydro-myelo-
 cele) protrudes through  the fissure, most frequently in the sacral  or dorsal
 regions.  The  affection is  treated of in works on  the diseases of children
 and on surgery.  An accumulation of fluid in the central canal of the cord
 attends some  cases of myelitis.
   A peculiar affection of the spinal  cord is designated by the  name syringo-
myelus.  In  this disease a cavity is formed in the gray  matter of the cord.
 This cavity  may run longitudinally throughout the greater part of the cord,
and it is not always easy to distinguish it from a dilated  central canal.   The
 cavity may  be due to the  breaking down of a gliomatous  formation which
 usually originates  near the  central canal.   Another explanation is that  the
tubular cavities of syringo-myelus are  due to congenital  anomalies of  the
central canal.  The symptoms of  syringo-myelus are usually of a complicated
nature, depending upon the part of the cord invaded by the  abnormal canal,
this part being most frequently that occupied by  the posterior horns of gray
matter.  The  diagnosis cannot be made during life. 
              ENCEPHALITIS—ABSCESS OF THE BRAIN.          715





                        CHAPTER  III.

   INFLAMMATORY  AND STRUCTURAL DISEASES  OF THE
                                BRAIN.

 Encephalitis.—Abscess  of the Brain.—Inflammatory Softening of the Brain.—Diffuse
   Sclerosis of the Brain.—Cerebral Paralysis of Children.—Infantile Spastic Hemiplegia.
   —Chronic Bulbar Paralysis.—Acute Bulbar Paralysis.—Intracranial Tumors.—Cere-
   bral Syphilis.

               Encephalitis—Abscess of the  Brain.
   THE terms  encephalitis and cerebritis  denote inflammation of the substance
     of the brain.  It has already been mentioned that in cerebral meningitis
 the inflammation  frequently extends more or less from the pia mater into the
 substance of the  brain.
   Encephalitis may  present  itself—1,  as inflammatory softening;  2, as
 abscess;  3,  as  sclerosis or induration  of the  brain.  In  the  present  article
 abscess of the brain will be  considered, and  afterward the  other forms of
 encephalitis.
   Suppurative encephalitis may occur in any part of the brain.   It is most
 common  in the cerebral  hemispheres and  in the cerebellum.  It is rare in
 other parts of the brain.   Recent abscesses have a shaggy wall of softened
 cerebral tissue.   Old abscesses are usually invested by a fibrous capsule.  In
 the majority of cases the abscess  is  single, but  sometimes there are  several
 distinct abscesses, which are then usually small in size.  Abscesses have been
 described which involve nearly a whole cerebral hemisphere, but in the  major-
 ity of cases  the size varies between  that  of a pigeon's egg and that of a lien's
 egg.   Abscesses may perforate into one  of the ventricles  or may burst upon
 the exterior of the brain.  The pus  is  sometimes fetid, especially when the
 abscess is secondary  to putrid affections of the lungs.  The pus may be gelat-
 inous in consistence, and it is sometimes  acid in reaction.
   The most frequent cause of cerebral abscess is injury to the head attended
 by wound of the  soft parts or fracture of the skull.  Sometimes the abscess
 follows injury without wound or fracture.  Suppurative inflammation  of the
 brain is often secondary to caries of the cranial bones and to disease of the mid-
 dle or internal ear, and  less frequently to disease of the orbit or of the nose.
 It may be secondary to empyema, to gangrene of the lungs, and to bronchi-
 ectases with putrid secretion.  In these cases, as well as in cerebral abscesses
 complicating pyamia and acute ulcerative  endocarditis, the abscess  is prob-
 ably due to  infectious emboli lodging in the cerebral arteries.  Other acute
 infectious diseases, such as typhoid  fever and  the exanthematous fevers, are
 very  rarely followed  by cerebral abscess.
   Cerebrai abscess may occur as an apparently primary or idiopathic disease.
 In a certain number  of these cases it has been suggested that the abscess is
 the result of infection with the special poison of cerebro-spinal meningitis.
   Cerebral abscess is more common in males than in females, and  during the
 period from  twenty to forty years of age  than before or after this time. It is
 very rare after sixty years of age.
   Kven large abscesses of the brain, particularly of the primary variety, may
remain latent for  a long time, and they are sometimes discovered accidentally
at autopsies.   AVhen the abscess is secondary to severe injury to the head or 
716   INFLAMMATORY AND  STRUCTURAL DISEASES OF BRAIN.

to middle-ear disease, it is generally difficult to distinguish the affection from
acute cerebral meningitis, which,  in fact, is often also present.  In these cases
the course of the disease is generally acute.
   Cerebral abscess often pursues  a chronic course, and then more or less cha-
racteristic symptoms are present.   Some of these symptoms are referable  to
the abscess per se ;  others are dependent upon  its  situation.   Of the first
group  of symptoms the most important are—headache, which may be severe
or of a dull character, vertigo, vomiting, rigors, and fever.  These symptoms
are not always  present.  Rigors are not common.   Fever, if present, is usu-
ally not high and is of an irregular  type, with remissions  or intermissions.
The symptoms which  are  dependent upon  the situation of the abscess are
manifold.   If the motor regions be involved, muscular spasms occur, followed
by paralysis (which may be complete or incomplete) in the form of hemiplegia
or of monoplegia. Epileptiform convulsions are often present if the motor cor-
tical zone be affected.  Abscess seated in the occipital lobe may give rise  to
hemianopsia, and seated in the temporal lobe or involving the third frontal con-
volution on the left side, to aphasia.  Disturbances of the pupils and of vision
are common. (For further points which bear upon the localization of cerebral
abscess, the reader is referred to the article on Topical Diagnosis, p.  G72.)
   Abscess of the brain  may give rise to somnolence deepening  into coma.
The coma may  develop suddenly,  so as to give rise to the suspicion of hemor-
rhage or of embolism.
   The duration of  cerebral abscess is variable.   The acute form  may ter-
minate fatally  within  a few days following the onset of the  disease.  The
chronic form generally lasts for  several  months,  and it may be for years.
   The diagnosis involves especially the discrimination from cerebral menin-
gitis, tumor of  the brain, and thrombic softening.  As already mentioned, the
diagnosis of acute cerebral abscess, following  traumatism and disease of the
middle ear, from cerebral  meningitis is difficult and  often  impossible.  The
main  points to  be considered are that in meningitis the cephalalgia, delirium,
and fever  are usually  more intense, whereas in abscess symptoms dependent
upon a local affection  of the brain, such as hemiplegia, monoplegia, hemiopia,
etc., are more common than in meningitis.
   A capital point in the discrimination of abscess from tumor of the brain  is
the causation.   AVhen the symptoms follow injury to the head, ear  disease,
pulmonary disease, and the other causes of abscess which have  been men-
tioned, the probability is in favor of abscess.   The existence of rigors and of
fever is in favor of abscess.  Choked disc is rare in abscess and is common  in
tumor.  When the diagnosis is doubtful, especially when  none of the causes
of abscess can  be determined, the  probabilities are in favor of tumor, inas-
much as tumor is much more frequent than primary abscess.  Cerebral embo-
lism and  thrombosis  can often be excluded by attention to the causation.
Coma resulting from abscess is generally preceded  by marked cerebral symp-
toms, which are absent or less prominent in embolism or thrombosis.
   Cerebral abscess  in nearly all  cases ends fatally after a variable period.
The immediate  cause of death may be general adema of the brain, producing
coma, or  rupture of the abscess either into one of the ventricles or upon the
surface of the brain.   The abscess may become encapsulated, and remain sta-
tionary for an indefinite time.
   The treatment is generally to he directed  to symptoms.  Depletory and
debilitating measures  are to be avoided.  Tonic remedies, a nutritious diet,
repose  of the mental faculties, and stimulants if the patient be in danger from
depression of the vital powers, should  constitute the treatment.
  The  only possibility  of effecting recovery is to trephine  the skull and make
an incision into the abscess.  The  operation is justifiable if the diagnosis be 
DIFFUSE SCLEROSIS OF THE BRAIN.
717
reasonably certain  and if it  be probable that the abscess is in an accessible
situation.  These conditions are not likely to be fulfilled  except when the
abscess is the result of injury or of disease of the bones or of the middle ear.
Surgical works are to be consulted for the operative treatment.   Several suc-
cessful operations have been recorded.


             Inflammatory  Softening of the Brain.

  Formerly, nearly all varieties of cerebral  softening were considered to be
inflammatory in  their origin.   It is now known that the majority of cases of
softening are not inflammatory, but the result of suspended nutrition  (necro-
biosis), attributable either to embolism or to thrombosis.  There remain, how-
ever, rare cases  of primary softening  the cause of  which cannot be found
in changes  in the blood-vessels,  that are  still classified  as inflammatory,
although our  knowledge is very imperfect as to their genesis  and their dis-
tinctive pathological characters.   It is possible that in these cases the soften-
in°- is analogous to that present in many cases of myelitis.  This encephalitic
softening is  generally reddish  in color, and hence  is  called inflammatory red
softening.   The affected part of the brain, which may be either the white or
the gray matter, is softened,  somewhat swollen, of  a diffuse  reddish-yellow
color, and frequently dotted with red points of capillary blood-extravasations.
The region of inflammatory softening  is not distinctly circumscribed, but  is
surrounded  by a zone of adematous  brain-tissue.  The microscopical exami-
nation reveals hyperamia, blood-extravasations,  broken-up  nerve-fibres, fatty
and disintegrating ganglion-cells, pus-cells  in greater or less number, com-
pound granular corpuscles, and sometimes pigment-granules. The histological
characters do  not suffice to distinguish inflammatory from non-inflammatory
softening.   The lesion has nothing to do with abscess, which, in  the brain as
well as  elsewhere, is due to some specific infection.  AVhether  this form of
softening can terminate in resolution or complete restitution of the  normal
structure is unknown, but such  a termination  does not seem  probable.
   The  symptoms resemble those of  thrombic  softening, and of course are
various according to the situation of the  disease.   They do not enable us
to  make a  diagnosis of inflammatory  softening.
   The  cases  which are designated popularly as softening of the brain are
often cases of thrombic softening.  The term "  softening of the brain," how-
ever, is often  used  in a vague sense to designate mental weakness, which may
be dependent upon a variety of morbid conditions.
   As is evident, the treatment of encephalitic softening must be directed
to  symptoms, and it does not differ from  that applicable to softening from
thrombosis.   The general health  of the patient should be maintained so far
as possible.    The  phosphide of  zinc,  chloride of ammonium, and bromide of
potassium  have been  recommended.
   It is  customary to include also under the term encephalitis certain  cases m
which cerebral  symptoms, such as paresis of one or more of  the extremities
or  of the face,  muscular spasms, disturbances  of speech,  appear, and  then
after a  variable  period, usually of some weeks  or months, wholly or  in great
part disappear.   The  pathogeny of these temporary forms of cerebral dis-
order is not  understood,  but they  cannot depend  upon  severe structural
lesions.

                  Diffuse Sclerosis of the Brain.
   Sclerosis  of the brain is characterized by an increase of the neuroglia.
Sclerosis may affect the  whole or the greater  part  of the brain, when it is 
 718   INFLAMMATORY AND STRUCTURAL DISEASES  OF BRAIN

 called diffuse  cerebral sclerosis,  or  it may  occur  in  isolated, disseminated
 patches, and it is then  distinguished as multiple or insular sclerosis.   Mul-
 tiple  cerebral  sclerosis is  generally accompanied by a  similar lesion of the
 spinal cord.   The disease is then called  cerebro-spinal sclerosis, which is a
 well-characterized affection,  and  will receive consideration in a  subsequent
 article.  At  present  only  the  diffuse form of cerebral  sclerosis will be con-
 sidered.
   In diffuse  cerebral  sclerosis  the brain presents an abnormally firm consist-
 ence.  The brain is usually more  or less atrophied, and the ventricles are fre-
 quently dilated.  The microscopical  changes are often less marked  than the
 gross  appearances  would  lead one  to  suspect.  AVhen  these changes are
 marked, the  lesion  is found to be an increase of the neuroglia, usually, but
 not always, with atrophy of the nerve-elements. The centrum ovale is gen-
 erally most affected,  but the cortex  may also be sclerotic.
   Diffuse cerebral sclerosis is most common in the brains of idiots, old epilep-
 tics, and patients affected with  the general paralysis  of the insane.  A certain
 amount of diffuse sclerosis with dilatation of  the ventricles is not uncommon
 in the brains of those dying from chronic alcoholism.    Diffuse cerebral  scle-
 rosis  occurs in  children as  well as in very old persons.
   The symptoms vary according to the extent and the intensity of the lesion.
 There is generally mental impairment which may amount to dementia.   Epi-
 leptic convulsions are common.  Rhythmical muscular spasms  or chorea may
 be present.   There is frequently hemiplegia, and when both hemispheres are
 affected there  may be paresis on  both sides of the  body.  The paralysis is
 often of a spastic nature.  Speech is frequently disordered.   The cutaneous
 sensibility is  usually  but little  or not at all  affected.   Defective vision and
 deafness are  not uncommon.
   The course of the disease  is chronic.   The  duration  is long, extending
 often over many years.
   The treatment relates only to symptomatic indications.


 Spastic Cerebral Paralysis of  Children.—Infantile  Spastic
                             Hemiplegia.
   In  the  present  article will  be  considered  a peculiar form  of hemiplegia
 occurring in children  which resembles in many particulars the so-called spinal
 paralysis of children.  As  the  latter affection is caused by a special form of
 myelitis involving the ganglion-cells of the anterior  horns of the spinal cord,
 so the disease  under consideration is the result of a special form of enceph-
 alitis  involving the motor region of the cerebral cortex.
  No post-mortem examination has as yet been made in an early stage of the
 disease, but the symptoms render it  probable that the lesion is primarily an
 acute encephalitis of  the motor cortex. In cases of  long standing there have
 been  found atrophy and sclerosis  of  the central  convolutions  in whole or in
 part.   The affected convolutions  are  shrunken and are firm in consistence.
 The microscope shows increase  of  neuroglia and atrophy of the  ganglion-cells,
 especially of  the large pyramidal  ganglion-cells.  The disease  may be either
 unilateral or bilateral, but  is generally more marked in one hemisphere than
in the other.   Secondary degenerations are found in the pyramidal  tracts.
  The disease seems to be confined to children and begins usually within the
first four years of life.  The onset is generally acute  and marked by fever,
and often  by  convulsions.  The existence  of paralysis is not usually detected
until after the febrile paroxysm, which is ordinarily of only a few days' dura-
tion, has subsided. The arm  and the leg are paralyzed upon the side opposite
to the lesion.    The  face is  less  frequently affected.  The paralysis may be in 
CHRONIC BULBAR PARALYSIS.
719
the form of a monoplegia.   The  paralysis is accompanied with more or less
muscular  rigidity  and contractures, not,  however, as a rule,  involving the
fingers.    The paralyzed muscles,  although atrophied, do  not present the
reaction  of degeneration to  be  subsequently  described.  Spasms of the
paretic  muscles,  particularly  in  the form of  athetosis  or of chorea, are
common.   The children  may become epileptic.  Sensation  is not affected.
The  tendon reflexes are  usually  increased.  Temporary aphasia is common
with right-sided hemiplegia.
  Infantile spastic  hemiplegia  is distinguished  from the spinal paralysis of
children  by the hemiplegic form of the paralysis, by the  absence "of the
reaction of degeneration, and by the increased tendon reflexes.
  There may be some improvement in the degree and extent of the paralysis
soon after it  first appears.   The paralysis which remains after  this  early
improvement is permanent.  The paralyzed members are less developed than
the others. The mental development may be normal, but it is often defective.
  The treatment at the onset of the disease consists in cold applications to
the head and in the administration of mild purgatives.  For the subsequent
paralysis  electricity  and  massage are of  benefit.   Bromide of potassium is
useful if  epileptic convulsions occur.


      Chronic Bulbar  Paralysis—Glosso-labio-laryngeal
                              Paralysis.
  This form of paralysis was described  first by  Duchenne in 1860 under the
name " progressive muscular paralysis of the tongue, the palate, and the lips."
Since that date a variety of names ha've been proposed, among which may be
mentioned chronic progressive bulbar paralysis, progressive bulbo-nuclear par-
alysis, progressive atrophic bulbar paralysis, and glosso-labio-laryngeal paral-
ysis.  The disease is characterized by progressive paralysis  and atrophy of
the  muscles  of the lips, tongue,  soft  palate,  pharj*nx,  and  larynx.  The
symptoms and the anatomical  lesions are analogous to those of progressive
muscular  atrophy, with which, in  fact, chronic  bulbar paralysis is not infre-
quently combined.  Chronic bulbar  paralysis is  also often associated with
amyotrophic lateral sclerosis.   The anatomical  basis of chronic bulbar paral-
ysis  is to be found in an  atrophy  of ganglion-cells belonging to the nuclei of
origin of certain motor nerves of the medulla oblongata.   "While there is no
doubt that the essential  change is  an atrophy  and disappearance of motor
ganglion-cells, it is not certain  whether  the morbid process consists in a pri-
mary atrophy of these cells or in a primary interstitial myelitis with second-
ary  degeneration  of the nerve-cells.  The mfedulla  oblongata may present
no distinct alterations to  the  naked eye, or perhaps  there may be detected a
few ill-defined gray and atrophic spots near the  floor  of the fourth ventricle.
Microscopical  examination  is required for an accurate localization and study
of the lesions.  Atrophy and  disappearance of  the ganglion-cells have been
found in  the  main  and  accessory  nuclei of the  hypoglossal nerves, in the
motor (anterior) nuclei of the pneumogastric, spinal  accessory, and  glosso-
pharyngeal nerves, in  the nucleus  of the facial, and  in the motor  (mastica-
tory) nucleus  of the trigeminal nerves.  The changes are  bilateral.  Of these
nuclei the main nucleus  of the hypoglossus seems  to  be earliest and most
extensively involved.   Sometimes it  possesses not a single ganglion-cell.
Some of the above-named nuclei may escape—for example, the motor nucleus
of the fifth nerve.  In  the  process  of atrophy  the ganglion-cells become
rounded, devoid of processes, filled  with pigment and diminished in size, and
finally they disappear.   In the nuclei of origin, some increase of the neur-
oglia (interstitial myelitis), corpora  amylacea, and granular corpuscles usually 
720  INFLAMMATORY AND  STRUCTURAL DISEASES OF BRAIN.

attend the degenerative changes in the ganglion-cells.  The degenerated spots
are most readily recognized on microscopical sections stained with carmine by
their red color, which is deeper than  that  of  the normal parts.   The nerve-
fibres in the roots and trunks  of the nerves  whose centres of origin  are
affected undergo,  to  a  greater  or  less  extent, degeneration and  atrophy.
Although the muscular fibres in the tongue are atrophied, the  organ  may
preserve nearly its normal dimensions in consequence of a formation of  fat-
cells in the interstitial tissue—a change  recognized by the yellow color on
section.  The atrophy which  takes place  in the muscular fibres in this affec-
tion is of the same nature as that to be  described for progressive muscular
atrophy.
   Clinically, the  disease is characterized by  progressive diminution  of vol-
untary  power over  the  tongue,  the muscles  of  the  palate, and  the  lips.
The disease  begins insidiously.  The  paralytic effects are bilateral and sym-
metrical.   The  loss  of power, at first slight,  gradually increases.   After
a time  there is  much difficulty  in articulation.  The  patient is unable to
pronounce words  and  the letters of  the  alphabet, especially the consonants
requiring for their enunciation movements of the tongue and lips.    Speech
at length is  impossible, and the  only  means of  communication is  by  signs or
writing.  The paralysis of the orbicularis oris  renders  the lips  immovable
during emotions of grief or mirthfulness.  The  mouth is elongated and gives
to the face an expression as if about to weep.  The saliva is increased and
dribbles over the lips.   Food  collects between the teeth and cheeks, and the
fingers are required to dislodge it.  The ability  to protrude  the tongue or to
curl the tip  upward is  lost.   Fibrillary  contractions of the muscles of  the
tongue and of the lips can usually be 'observed.  AVhen the paralysis of  the
tongue and orbicular muscles  of the mouth has  increased to a certain  extent,
or even from the outset  and before the paralysis has extended to the  lips, the
muscles of the palate are affected.  Deglutition then is more or less difficult,
food and drink being often returned through the  nostrils.   The laryngeal mus-
cles become  paralyzed, causing aphonia, with either diminution or cessation of
the respiratory movements of the glottis.   Paresis of the muscles of respira-
tion may follow.   The acts of respiration are feeble, and the power of coughing
is impaired.
   Portions of food and drink and the salivary fluids are  often  drawn into
the larynx,  and  are with difficulty expelled, owing to  the inability to cough
effectively.  For this reason, if the patient be attacked with bronchitis, there
is danger from the accumulation of mucus in the bronchial  tubes.  Paralysis
may occur in other parts of the body and may extend more or less over  the
voluntary muscles.  The progress of the affection is unattended by fever.
The affection advances steadily, but more or less gradually, toward a fatal ter-
mination.  Death may be caused by apnaa from impaired ability  to carry on
respiration, and from accumulations of foreign material in the bronchial tubes
and air-cells,  causing  bronchitis, aspiration-pneumonia, or  pulmonary gan-
grene ;  or the mode of dying is  by asthenia or  starvation, in consequence of
inability to  ingest an  amount of aliment sufficient to  sustain life.   At an
advanced period the action of the heart may be notably disturbed.   Parox-
ysms of feeble, irregular action, together with cyanosis, sometimes occur, and
death may take  place by syncope.
   The  intelligence remains unaffected.   Although the paralyzed muscular
fibres present the reaction of degeneration, this  is generally difficult to deter-
mine on account of the preservation of a certain  number  of fibres with normal
electrical excitability.   Reflex excitability is generally lost, but in  some in-
stances  it is  retained, and in rare instances is increased.  The paralyzed mus-
cles are atrophied. The general sensibility of the mouth,  tongue, and pharynx 
CHRONIC BULBAR PARALYSIS.
721
is not affected ;  the gustatory sense and the other special senses are preserved;
and the appetite and digestion may be unimpaired.
  The affection is readily distinguished from double facial paralysis (diplegia
facialis) by the fact that the orbicular muscles of the eye and the muscles of
the face, other than the orbicularis oris, are not affected.   In  its progressive
character and the occurrence of paralysis in other situations, it bears a resem-
blance to general cerebral paralysis, in which the muscles concerned in speech
are often the first affected.  It differs from the latter affection in the fact that
the intellect  remains unaffected;  and paralysis of other muscles than those
of the tongue, mouth, pharynx, and larynx occurs incidentally in only a cer-
tain proportion of  cases.  The group of symptoms which characterize bulbar
paralysis may occur in  the  course of progressive muscular atrophy.   In  the
latter  disease, however, the muscles  of the extremities  or  trunk are also
affected.  In other words,  spinal  disease accompanies that  of the  medulla
oblongata.   Chronic bulbar paralysis may be preceded or followed by pro-
gressive muscular atrophy.  In  like manner  the spinal diseases, called amy-
otrophic lateral sclerosis and  disseminated sclerosis of the cord, may involve by
extension the medulla oblongata, and  give  rise  secondarily to the  symptoms
which belong to the history  of bulbar  paralysis.   Embolism or thrombosis
of the vertebral arteries, occluding the branches going to the medulla oblon-
gata,  and hemorrhage limited to  the  latter, have  been  known  to cause  the
group of phenomena which  characterizes bulbar paralysis.  The differential
points pertaining to thrombosis  and  hemorrhage  are, the sudden occurrence
of the  paralysis of the tongue, lips, and  pharynx, and the occurrence simul-
taneously of paralysis either unilateral or bilateral of the limbs.   The name
acute  bulbar paralysis has been  applied to these cases.  (See  next article.)
Tumors in the medulla oblongata, in connection with the symptoms of bulbar
paralysis, give  rise to those denoting cerebral disturbance and to ophthalmo-
scopic appearances  which are  wanting in the latter disease.
   AVith reference to causation, the fairest statement is a confession of igno-
rance.  The  disease very rarely  occurs  before forty years of age, and  the
male  is more liable to it than  the female.  Occupation and station in life have
no causative influence.   Beyond these facts nothing can be positively affirmed
in regard to  the etiology.  It is,  however, reasonable to suppose  that expo-
sure  to cold, excesses of all  kinds, over-exertion,  either  physical  or mental,
and,  perhaps, syphilis, have  more or less agency in  the development  and
progress of the disease.
   In  chronic bulbar paralysis involving  irremediable anatomical changes in
the medulla oblongata, all that can be hoped for is that the disease will cease
to be progressive, or, next to this, if  the  progress  continue,  that  this will be
slow.    The extreme limit of  the  duration of the disease  is five years.  The
prognostics which show the fatal  termination to be not far distant are, com-
plete  dysphagia, great debility from  inanition, embarrassment of respiration,
and disturbances of the  heart's  action  from syncope.
   The objects of treatment are, first, the arrest of the progress of the disease,
and, second, if this object be unattainable, retardation of its  progress.  AVith
reference to these objects, the patient should, as far as possible, be withdrawn
from  every agency which may be supposed to  have a causative operation.  All
unsanitary influences pertaining to body and mind sre to be removed.  The
system should be well nourished, and  measures are to be employed for restora-
tion of the general health if this be in any way impaired.  These injunctions
embody, perhaps, the most  important part of the treatment,  with our present
knowledge.  It is not certain that any remedies  have a special influence on
the disease.  An able  observer (Erb) warns against the administration  of
strvchnia and phosphorus ;  yet the latter is undoubtedly useful  in some cases
        46 
722  INFLAMMATORY AND STRUCTURAL  DISEASES OF BRAIN.

of a similar disease seated in the spinal cord—namely, progressive muscular
atrophy—and also in multiple sclerosis.   It is doubtful if much  benefit be
derived from the nitrate of  silver, the iodide of potassium, ergot,  and bella-
donna, but  it is proper to make trial of these remedies.   There is  very little
ground for expecting benefit from counter-irritation.   Most neurologists attach
importance,par excellence, to electricity, but it does not seem, thus far, to have
effected great results.   Persistent trial of this agent, however, is  not to  be
omitted.
  AVhen deglutition becomes difficult, nourishment should he introduced into
the stomach by means of the asophageal tube, and  rectal alimentation may
be resorted to.  In  order to avoid the danger of foreign  substances entering
the bronchi, it is well not to delay too long before resorting to the use of  the
asophageal tube.

                   Acute Bulbar Paralysis.

  Various  lesions  of the medulla oblongata may give  rise to the group of
symptoms which  has received  the name of apoplectiform  or acute  bulbar
paralysis.   Such lesions are hemorrhage, softening from embolism  or  throm-
bosis of the vertebral and basilar arteries, acutely developed  compression of
the medulla oblongata, and acute inflammation.   In three cases of acute bul-
bar paralysis examined by Leyden there were found in the medulla  oblongata
a number of small foci of inflammatory softening.   These  foci may  be dis-
coverable only upon microscopical examination.   The term  acute bulbar par-
alysis is sometimes  limited to the inflammatory variety, which will be  taken
as the basis of the following description of the symptomatology.
  The symptoms develop acutely, and often  rather  suddenly.  The disease
may be ushered in by pain in the head and back of  the neck, vomiting, and
dizziness.   The characteristic bulbar symptoms soon  appear.   These are dif-
ficulty in swallowing, difficulty in  articulation producing the disturbances of
speech called dysarthria and anarthria, and often irregularity in the rhythm
of respiration and of the pulse, which  is frequent,  small, and  intermittent.
There  is often, but not always, elevation  of temperature.   The extremities
may or may not be paretic.  Not  infrequently there is paralysis of  facial and
of ocular muscles.  Paralysis of the diaphragm has been repeatedly observed.
  The duration of the disease  is  from four days to two  or three  weeks.
The termination appears to be always fatal, and is generally due to paralysis
of respiration.
  No measures of treatment have thus far been  attended with success.
Counter-irritants to the back of the neck may be employed.   The indications
are essentially the same as in acute myelitis.


                  Tumors within the Cranium.

  Most of  the tumors which have been found in other parts of the  body may
also develop within  the brain.   Among  the most frequent and characteristic
of cerebral tumors is glioma.   It develops from  the cerebral substance, and
not from the membranes.  It is met with elsewhere  only in  the spinal cord
and retina.   It is the sarcoma of  the brain, differing  from ordinary  sarcomata
by the presence of that finely-fibrillated and molecular connective substance
called neuroglia.   A peculiarity of glioma is that it  often appears more as a
diffuse infiltration  than as a circumscribed growth.   The  consistence  of  the
tumor may be either hard or soft.   The  hard variety may be  mistaken  for
cerebral sclerosis, and the soft for cerebral softening.  The tumor is  often very
vascular, and may be the seat of hemorrhages.   Sometimes  the hemorrhage 
                  TUMORS WITHIN THE CRANIUM.              723

is  so  great  as to destroy the larger part of the tumor and to present the
appearance  of a primary cerebral hemorrhage.   In  such a case the micro-
scopical examination of the tissue immediately surrounding the hemorrhage
will usually reveal gliomatous structure.  In some cases of glioma there can
be demonstrated large numbers of the  branching  cells, called brush-cells and
spider-cells, which  characterize the normal  neuroglia.  In other cases the
tumor seems to consist chiefly of small round cells imbedded in a finely-fibril-
lated granular matrix.   In the latter cases proper methods of demonstration
will often reveal the characteristic branching cells. Glioma is often combined
with sarcoma, constituting the so-called glio-sarcoma.   All varieties  of sar-
coma  may develop in the brain, either as primary or  as secondary growths.
They  originate more frequently in the membranes  than  in the brain-substance.
Gummata  are among  the most  important of  cerebral tumors.  They take
their origin  almost invariably from the membranes, but not infrequently grow
from the pia mater into the brain-substance.   They  also form in many  cases
diffused growths.   They are  usually  combined  with chronic inflammatory
changes (gummatous meningitis).   They usually  present spots  of cheesy
degeneration.  Solitary tubercles consist of nodules, varying in size from a pea
to an  apple, which present a cheesy centre and  a  periphery of connective tis-
sue rich in  small round  cells.  In  the peripheral zone there are  sometimes
miliary tubercules containing endothelioid cells  and giant-cells.  The tuber-
cle bacilli  have been found  in  solitary tubercles.   Tubercles may  be  present
in other parts of the body.   Solitary tubercles  may  occur in any part of the
brain.  They are found with especial frequency in the cerebellum.  The  brain
and its meninges may be the seat of secondary carcinoma.   Tumors  present-
ing a  structure very similar  to  carcinoma may develop primarily in the mem-
branes.  They probably  take their origin from endothelium in the  perivas-
cular  sheaths (endothelioma).   The tumor called cholesteatoma is misnamed, as
it by no means always contains cholesterin.  The appearance  of cholesterin
is  afforded by the presence  of flat epithelial-like cells,  often arranged in con-
centric masses.  Psammoma derives its name from the presence of little cal-
careous granules resembling particles of sand.  The calcareous masses  often
present a  concentric arrangement.   They appear to be connected with the
blood-vessels.   The last  two varieties  of tumor  grow from the membranes,
especially  from the dura mater.   Of  other intracranial tumors may simply
be mentioned fibroma, myxoma,  lipoma, lymphoma, osteoma,  angioma,  neur-
oma, papilloma, and tumors of the pituitary body.   (The  reader is  referred
to Part I.  p. 42 et seq. for a  brief consideration  of most of the tumors found
in this situation.)   In this  connection may be  mentioned  the  occurrence in
the brain of the parasites cysticercus cellulosa and  echinococcus.  The cere-
bral arteries are occasionally the  seat of aneurism,  aside from those distin-
guished as miliary.   Aneurismal tumors are generally connected with  arteries
at the base of the  brain, the  basilar,  the internal  carotid, the middle  cere-
bral,  and  the circle of AVillis.   Generally the tumors are small, but they
are sometimes of the  size of a pullet's egg.
   The different  tumors produce morbid effects by pressure on  the brain, and
their  effects, thus produced, other  things being  equal, are proportionate to
the size of the tumor and the rapidity of its  growth.  Special  morbid effects
depend on  the situation  of the  tumor.   They  cause additional injury to
the brain, either  by exciting circumscribed cerebritis, and thereby inducing
softening  of the brain-substance surrounding  them, or by interfering with
nutrition,  and thus  leading to non-inflammatory softening;  and as a result of
the softening hemorrhagic  extravasation is  not  uncommon.   These  morbid
effects are produced  alike  by  different tumors ;  that  is to say, the  morbid
effects have no relation to the particular kind of  tumor.  Hence the  kind of 
724   INFLAMMATORY AND  STRUCTURAL DISEASES OF BRAIN.

tumor in any case cannot be determined by the symptoms which it occasions.
For this reason  the  several tumors are  considered collectively, instead of
receiving each a separate consideration.

  Of the symptoms  which accompany tumors within  the  skull, cephalalgia
is usually  prominent.   The pain  is frequently limited to a circumscribed
space which sometimes, but not always, corresponds to the site of the tumor.
Pain  is prominent  as a symptom  in proportion as the tumor gives rise to
circumscribed meningitis or increases the intracranial pressure.   Other cere-
bral symptoms more or less prominent are—vertigo, difficulty in preserving an
equilibrium in walking, momentary loss of consciousness, tinnitus aurium, the
feeling of formication, numbness  in different parts  of the body, and scintilla-
tions ; hyperasthesia  of the surface followed by blunted  sensibility ; mental
irritability, to which  succeed dulness and progressive impairment of the fac-
ulties  of the mind; sometimes active delirium, and frequently  epileptiform
convulsions.   The so-called compelled movements,  either backward, forward,
or rotatory, or in  a  circle (circus movements), are sometimes, although rarely,
observed.  Vomiting may be a prominent symptom, occurring irrespective of
the ingesta and not  accompanied by symptoms denoting  gastritis.  This symp-
tom is likely to be prominent in the cases in which cephalalgia and vertigo are
unusually marked.  The pulse is often slower than normal.  Constipation is the
rule.   Polyuria and glycosuria have been noted, especially in tumors pressing
on the pons or medulla oblongata.
  Paralysis more or less extensive, affecting the special  senses and  voluntary
muscles, occurs sooner or  later.   Hemiplegia, generally incomplete, is a fre-
quent form of the  paralysis.  The hemiplegia is often  developed  from  suc-
cessive monoplegias.   In some cases the  two sides are successively affected,
constituting double hemiplegia.   The hemiplegia may have  been preceded by
facial  paralysis, and if the iatter do not precede it may either accompany or
follow the hemiplegia.  The tumor may be so situated  as to press  upon cer-
tain of the cranial  nerves  exterior to the brain.  The paralysis of the  parts
supplied by these nerves will then be  on  the same side as the tumor and
opposite to the hemiplegia, whereas if the paralysis be due to pressure of the
tumor within the  substance of the brain the cranial nerves  affected are  those
on the same side  as the hemiplegia and the side opposite to the hemisphere
in which  the tumor  is situated.   The paralysis  caused by pressure  upon
nerves beyond their  central connections have the  distinctive characteristics
of a peripheral paralysis.   The  affected  muscles  atrophy  and  speedily lose
electrical excitability.  The paralyses may be limited to  the  seventh or portio
dura nerve, or other cranial nerves may be  involved.  Loss  or impairment of
vision in one or both eyes occurs  when the tumor either involves destruction
of the optic nerve or interrupts its function by pressure.  Neuralgia and paral-
ysis of sensation  on one side of the face result from similar effects upon the
fifth nerve.  The  third and the fourth nerves may be involved, and not infre-
quently the paralysis  affects, separately or collectively, the senses of hearing,
smell,  and taste.
  The differences in different cases, as regards the  parts affected with paral-
ysis, of course  depend on the seat of tumors, their size, and the direction in
which they extend.   With  reference to the differential diagnosis of tumors
and inflammatory softening or other lesions, the extension of the paralysis to
different parts  in succession after variable intervals is a  highly significant
fact.   The paralysis affecting successively parts supplied by different cranial
nerves, the members in some cases becoming affected first  on one side and
then on the other side, and the continued increase of the degree of  the paral-
ysis of different parts, point with significance to tumors, because such a his- 
                  TUMORS  WITHIN THE CRANIUM.               725

tory is in correspondence with their continued growth and  the progressively
increasing  amount of pressure and of destruction  of cerebral  substance.
Aphasia in some  cases is an  effect  of tumors, and this symptom  renders it
probable that they affect the posterior part  of the  inferior convolution of
the  left frontal  lobe.  The  ophthalmoscope is  useful in determining the
existence of intracranial tumors.  31orbid changes in the  optic discs, either
congestive, inflammatory, or atrophic, are found  in  a very large  proportion
of cases, even though vision  be not appreciably  affected.  The ophthalmo-
scope may be, therefore, of much value in  the diagnosis,  even  before  there
are any subjective symptoms referable to  the eye.   Swelling  of the  optic
papilla, producing the appearance called  choked disc, is a  result of intracra-
nial  pressure, and this may occur wherever be the  seat of the tumor.  Choked
disc  is an important aid in  diagnosis.  There  may be descending optic, neur-
itis.   Atrophy of the optic nerve may be either  secondary to the foregoing
or a direct  effect of the pressure of the tumor on the optic tract.   The pupils
are often dilated, and not  infrequently they differ in size and respond feebly
to light.  AVith  reference to the localization of tumors the reader is referred
to the article on the topical diagnosis of cerebral  lesions. (Aride p. 072.)  It
cannot be claimed, on the basis  of clinical experience, that, by means of the
so-called topical  symptoms, tumors  or other lesions can be  always accurately
localized.  Aside from the imperfections of our present  knowledge of the
functions of the  different parts  of the brain, their relations with  each  other
are such that a lesion in a particular  situation  may affect other  situations
more or less remote, and the parts  thus secondarily affected may give rise to
prominent  symptoms.  Nevertheless, experimental physiology and clinical
observations  have furnished  facts which  have led to some  approximation to
accuracy in localization.

   As regards diagnosis, abscess of the brain may present  a series of clinical
events  which  render it difficult thereby  to  differentiate this aff'ection from
tumor.   If the  affection have speedily followed injury of the head, if it be
connected  with  otitis, or if there be caries of the  skull in  any situation, the
affection is probably abscess.  If  these etiological  relations  be  wanting,
tumor is more  probable than abscess.  Cerebral hemorrhage and softening
from thrombosis or embolism  are distinguished by this fact—namely, paraly-
sis with or without an apoplectic seizure occurs suddenly without  prodromes,
whereas paralytic and other marked effects  of tumor occur in succession and
after prodromic  symptoms which have  existed for a longer or shorter period.
In cases of hemiplegia from the affections just named nerves of the special
senses and other cranial nerves are rarely involved, as they  often are in cases
of hemiplegic paralysis from  tumor.  Paralysis of the face on one  side and
of the limbs on  the  other  side (alternate paralysis) is more  likely to  occur
from  tumor than from  hemorrhage or softening.
   With respect to the character of  the tumor in individual cases, carcinoma
is probable if the patient be of middle or advanced age, if  cancer be heredi-
tary,  and if it exist elsewhere.  The evidence afforded by the symptoms of a
rapid growth of the tumor is  in favor of  the  conclusion that it is  carcinoma-
tous.   The tuberculous character of the tumor  is to be  inferred from the
existence of tuberculous disease in the lungs  and  other organs, and from the
youth of the patient.  Tumors of this kind rarely occur after puberty or at
less than three years of age. The syphilitic character of the tumor  is rendered
probable by the fact that the patient has had syphilis and  by the  absence of
evidence of carcinoma and tubercle.  Aneurismal tumors rarely  occur except
in persons  between fifty and sixty years of age.   AVhere no data  exist as to
the variety of tumor, glioma is to be inferred, as being the most common form 
726   INFLAMMATORY AND STRUCTURAL DISEASES  OF BRAIN.

of cerebral tumor not referable to syphilis or to tuberculosis. Cerebral tumors
are more common in males than  in females.
   As regards  digestion, nutrition, and the functions of the body in general,
cases differ.   Patients may  retain their weight and an aspect  of health for a
considerable period  after the occurrence of paralysis and other  symptoms
referable to the brain.  In other cases debility and emaciation occur early.
The  general condition will  be likely to  deteriorate speedily in the  cases in
which the tumor is  either carcinomatous or tuberculous, parts  other than the
brain being the seat of the disease.  It is to be added that the tumors within
the skull  may remain latent, as regards both local and  general symptoms,
until  they  have attained a considerable size.  The slowness of their  growth
favors their latency.   On the other hand, local morbid conditions incident to
the growth of the  tumors—namely, inflammation and softening of the sur-
rounding brain-substance, congestions, circumscribed meningitis, and extrava-
sation of blood—give  rise not only to paralysis affecting different  parts in
succession  and progressively increasing  in degree, but to exacerbations  of
pain  and other cerebral symptoms varying much in frequency and intensity
in diff'erent cases—to somnolency or coma in some cases,  either of transient
duration or lasting for several  days, and occasionally to active delirium.
   The termination  in  most  cases of tumor  within the  skull is,  sooner  or
later, fatal, the duration of life varying much in different cases according
to the nature  of the tumor, the rapidity of its growth,  and  the  incidental
local morbid conditions.  In  some cases death takes place after a few months,
and  in  other  cases  not until after many years.   An exception to this state-
ment is to  be made  in  behalf of syphilitic  tumors.  These are amenable to
curative treatment  if they have not attained to much size and have  not led
to damage  of  the cerebral substance in proximity  to them.  Death may take
place after gradual  exhaustion ;  it may occur suddenly from cerebral hemor-
rhage; epileptiform  convulsions sometimes determine  the fatal termination;
and  patients sometimes die  from  secondary  meningitis.
   Syphilitic tumors offer much encouragement in the  way  of  successful
medicinal  treatment.  Cases in which are presented hemiplegia,  paralysis
of cranial  nerves,  aphasia,  epileptiform convulsions,  and  delirium  are  by
no means  hopeless if the  affection be traced  to syphilis.   I  have met
with  instances successfully  treated in  which these  symptoms  were pres-
ent.   It is very important to resort to  antisyphilitic  treatment in all cases
in which  there is  any ground   for suspecting the previous existence  of
syphilitic  disease.
   The indications  for  the treatment  of non-syphilitic tumors relate to the
palliation of symptoms and the prolongation of life by  analeptic and support-
ing measures.   It  is not certain  that any  known remedies  have  a special
influence upon the  tumors  themselves or the brain lesions which they pro-
duce.  It is, however, claimed that certain remedies—namely, the iodide  of
potassium,  the bichloride of  mercury, and arsenic—do have such an influence
in some cases.  Trial may be made of these remedies,  taking  proper precau-
tions  as regards a deleterious effect upon the general condition  of the patient.
                         Cerebral  Syphilis.

  Although in previous articles mention has  been made of various  syphi-
litic affections of the brain, nevertheless, for the sake of clearness and in view
of the frequency and  importance of these  affections, it  is thought best to
bring them  together in a  separate article.
  Cerebral  syphilis may  be a  manifestation of congenital  or of acquired 
CEREBRAL  SYPHILIS.
727
 syphilis.   In the majority of  cases  it is  one of the late, tertiary  lesions,
 occurring  sometimes ten to twenty years after the primary infection.  Cere-
 bral  syphilis in  the secondary stage  of syphilis is  rare.
   The  two leading  syphilitic lesions  of the brain are gummata and  obliter-
 ating endarteritis.
   Intracranial gummata originate usually either in the dura  mater or in the
 pia mater.   They may develop in the cranial bones.  Gummata originating
 in the substance of  the brain are  very rare.   They then develop primarily in
 the walls of the blood-vessels.   At first a gumma  is composed simply  of
 soft,  grayish granulation-tissue,  but  in a  short time central caseation  and
 fibroid  metamorphosis occur, producing  a mass of firm consistence  and
 opaque yellowish color.   The gumma may develop  as a circumscribed nod-
 ular  tumor or as a diffuse growth.   In either case  there is usually more or
 less diffuse inflammatory  thickening of the adjacent membranes, so that the
 term  syphilitic  or gummatous meningitis appropriately describes the lesion.
 There may be a single gumma or many gummata  in the  membranes.  It is
 important to note that gummata, although almost invariably starting in the
 cerebral membranes, frequently grow into the substance of the brain, which
 they  compress and destroy.
   Obliterating endarteritis of the cerebral  arteries  is a  common syphilitic
 lesion,  but it is not  peculiar to syphilis.   The arteries  at the base of the
 brain are the ones  oftenest affected.   The affected  arteries are hard, of an
 opaque whitish  color, and thickened.   The change  consists in a thickening
 of the  intima due to a new growth  of connective  tissue.  The thickening
 may  affect the circumference of the artery symmetrically or be most marked
 at one point in the circumference.  The artery may  become entirely  obliter-
 ated,  either  by  the continued  growth  of the  new  connective  tissue  or by
 thrombosis.   Small gummata are frequently found in  the  media and  the
 adventitia  of arteries which  are  the seat  of  syphilitic endarteritis.   Small
 aneurisms  may  form as  the result of the arterial disease.  The occlusion of
 the arteries, especially of those of the base which  belong to  the terminal
 arterial system, leads  to softening  of the  region of the  brain supplied by
 the obstructed  vessel.
   Finally, it may be mentioned  that syphilitic disease  of the  arch  of the
 aorta, or  syphilitic  endocarditis or myocarditis attended  by the  formation
 of thrombi, may give rise to embolic  cerebral  softening.   Cases of cerebral
 syphilis without any  coarse lesions in  the brain have been described,  but
 here  it is probable  that  the  small  arteries are  diseased.
  From this description of the syphilitic  lesions of the brain  it is  evident
 that the symptoms are manifold and variable in individual cases, so that it is
 impossible  to give a  clinical description  applicable to all cases.   The  follow-
 ing may be mentioned as some of  the  common types.
  The grouping of symptoms in cases of gumma may be that of other forms
 of cerebral tumor. AVhen the gumma  is seated at the base of the brain, there
 are affections of various cranial nerves, such as facial paralysis, neuralgia and
 paralysis of the  trigeminus, paralysis and twitching of the  eye-muscles; dis-
 orders of vision, such as diplopia,  hemianopsia, amaurosis, irregularity of the
 pupils;  sometimes impairment of hearing, of smell,  or of  taste; and rarely
 paralysis of the  hypoglossal nerve  Involvement of  the crus cerebri  causes
 hemiplegia.   Choked disc is the rule.  A gumma involving the motor cortical
 zone causes monoplegia or hemiplegia, usually accompanied with motor spasms
and frequently with  epileptic  convulsions.   AA^hen the centres for speech are
affected there is aphasia.   (The previous article may be consulted for other
symptoms of syphilitic cerebral tumor.)
  In a second group of cases the symptoms are referable to softening  of  the 
728              DISEASES  OF THE SPINAL  CORD.

brain caused by occlusion of one of the cerebral arteries.  These  symptoms
do not differ from those of ordinary thrombic softening.
  In a large group of cases the symptoms are not those  of  a focal  disease, as
in cases of tumor  and of softening, but belong to some  chronic diffuse  dis-
order of the brain.   Here the  clinical  history may resemble  that of chronic
cerebral  meningitis, of multiple cerebral sclerosis,  of chronic insanity, or, in
women, of hysteria.
  The diagnosis cannot he made from the cerebral symptoms  alone, although
the  transitory nature of many of the symptoms, their rapid  development,  and
amelioration are in a certain  degree  characteristic.    The diagnosis must
be based upon a syphilitic history and  the recognition of  manifestations of
syphilis in other parts of the body.  The  ophthalmoscopic  examination may
aid  in the diagnosis, as, in addition to choked  disc, a syphilitic choroiditis  has
been observed in some cases of cerebral syphilis.
  Cerebral syphilis is often markedly amenable to treatment.  If, however,
parts  of the brain have been seriously impaired in  their  structure  by syphi-
litic lesions, it cannot be  expected  that these parts will be restored, so that in
a considerable number of cases the termination is unfavorable.
  The treatment consists in the use of  mercury and of iodide of potassium,
according to the recognized principles of antisyphilitic therapeutics.
                       CHAPTER  IV.

   INFLAMMATORY  AND STRUCTURAL DISEASES  OF  THE
                            SPINAL  CORD.

General Considerations relating to Inflammatory and Structural Diseases of the Spinal
   Cord.—Myelitis, Acute and Chronic.—Cerebro-spinal Sclerosis.—Locomotor Ataxia, or
   Posterior Spinal  Sclerosis.—Hereditary Ataxia.—Acute  Anterior Poliomyelitis.—
   Acute Anterior Poliomyelitis in the Adult.—Subacute and Chronic Anterior Polio-
   myelitis.—Progressive Muscular Atrophy.—Progressive Unilateral Facial Atrophy.—
   Spastic Spinal Paralysis.—Amyotrophic Lateral Sclerosis.—Compression of the Spinal
   Cord.—Intraspinal Tumors.—Pseudo-hypertrophic (or Myosclerotic) Paralysis.—Scle-
   roderma.—Myxoodema.

General Considerations Relating to Inflammatory and Struc-
                tural Diseases of the Spinal Cord.
  IN order to understand the localization  of certain of the diseases  of the
    spinal cord which are to  be  described in this chapter, it is necessary to
know the  situation of certain  bundles of nerve-fibres entering into the com-
position of the white  columns  of the cord.  The  accompanying diagram
(Fig.  5) represents these bundles upon a  transverse section  of the cord  at
the level  of  the sixth cervical nerve.
  In  the  anterior column of each half of the spinal  cord adjacent  to the
anterior median fissure is a narrow tract of nerve-fibres, marked p. a. in the
diagram, called the  pyramidal fasciculi or pyramidal tracts of the anterior
column.   These bundles  are  called also the  uncrossed or direct pyramidal
tracts and the columns of Tiirck.   They may be absent in normal cords.   In
the posterior part of the lateral  column are situated the pyramidal fasciculi 
                     GENERAL  CONSIDERATIONS.                 729

of the lateral columns or the crossed  pyramidal tracts, marked p. I. in the
diagram.   The pyramidal tracts are composed of motor-fibres which originate
in the central convolutions of the brain, descend through the centrum ovale
to the posterior division of the internal capsule
(see p. <>76), pass thence through the pes pedun-             Fig. 5.
culi, the pons, and the anterior pyramids of the              VM_
medulla oblongata to the  crossing of the pyra-
mids,  where the majority of the motor-fibres
cross over  and descend in the pyramidal tracts
of the lateral columns of the cord,  while  a
smaller but variable portion remains  uncrossed
and descends in the pyramidal tracts of the an-
terior  columns of the spinal cord.  The latter            '^V'^
pyramidal tracts  cross in  their course through          After Eichhorst.
the spinal  cord,  so that  eventually all of the
motor-fibres of the pyramidal  tracts which originate in one cerebral hemi-
sphere cross to the opposite half of  the spinal cord.  The fibres of the pyra-
midal  tracts are  connected with the ganglion-cells of the anterior horns of
the spinal cord.   From these ganglion-cells originate the anterior nerve-roots.
AVhen the pyramidal  tracts are destroyed in any part of their course, as by
a hemorrhage in the  posterior division of the internal capsule, they become
the seat of a descending  degeneration which  can be traced  from the seat of
the lesion  downward to the termination of the tracts.
   Retween the pyramidal tracts of the lateral columns and the periphery of
the cord are seated the direct cerebellar fasciculi, marked d. c.  The remain-
ing parts of the anterior and of the lateral columns are called the fundamental
fasciculi of the antero-lateral column or the anterior root-zone (/. in the dia-
gram).
   Two divisions  are  recognized in  the posterior columns—namely, the  tri-
angular columns on  each side  of the  posterior median fissure, called  the
funiculi graciles, or columns of (roll (G.  in the diagram), and the wedge-
shaped columns  between  these  and the  posterior horns, called the  funiculi
cuneati, or columns of  Burdach (B in the diagram).
   The columns of Goll and the direct cerebellar fasciculi contain centripetal
nerve-fibres, and  are the seat of an ascending degeneration above any lesion
which destroys their continuity.
   The pyramidal tracts diminish  in  size from  above downward, and in  the
lower dorsal region the uncrossed pyramidal tracts disappear.  In  the lumbar
and  the lower dorsal  regions the division of the posterior columns  into the
columns of Goll and  the columns of  Burdach cannot  be made out.  The
direct  cerebellar fibres make their first appearance in the lumbar enlargement,
and increase in size from below upward.
   The divisions  of the  white columns of the cord which have been described
are based chiefly upon the  study of embryonic cords  and  of the secondary
degenerations of  the  cord.  These divisions are of importance, because each
one represents a group  of functionally distinct nerve-fibres, which  may be the
seat of some special disease.

  Two great classes of diseases of the  spinal cord are  recognized—namely,
the systemic diseases or system-diseases, and the unsystemic, mixed, or diffuse
diseases.
  The system-diseases  of the spinal  cord are characterized by the fact that
the pathological lesions are  confined  to certain  definite tracts or parts of  the
cord  which represent distinct physiological  systems or groups of nerve-fibres
or of ganglion-cells.   To the category of system-diseases belong the affection 
730
DISEASES OF THE SPINAL CORD.
of ganglion-cells in the anterior horns, called poliomyelitis anterior; the scle-
rosis of the  posterior columns constituting the essential lesion of locomotor
ataxia; the degeneration of the pyramidal tracts, either alone as in secondary
descending degenerations, or  in combination  with anterior poliomyelitis in
amyotrophic lateral  sclerosis; and the secondary ascending degenerations of
the columns of Goll and of the direct cerebellar fibres. AVe must assume that
in the  system-diseases the special cause of the disease acts primarily upon the
nerve-elements,  and that the interstitial tissue is secondarily involved.
  In contrast with  the system-diseases, the  lesions in the unsystemic or dif-
fuse diseases are  not confined to any definite group of nerve-elements, but
affect irregularly either a large or a small part of  the  spinal cord.  To this
second class  of  diseases  belong hemorrhages, tumors, the transverse, the dif-
fuse, and  the disseminated forms of myelitis, embolic or thrombic softening,
and other affections.

  Before  considering the individual diseases of  the spinal cord  it will save
repetition  and assist in a clearer understanding of these diseases if the  im-
portant symptoms of various affections of the cord be  first considered with
reference  to certain  peculiarities, and especially to their topical diagnosis.
  An important distinction is made  between  two  kinds of paralysis.  In one
variety of  paralysis the  paralyzed  muscles rapidly  undergo  atrophy and
assume the  so-called reaction  of degeneration.  This  variety may be called
atrophic paralysis.   In the second kind of paralysis the paralyzed muscles
waste only after a long period from  disuse, and  they retain their electrical
excitability as long as muscular substance  is  preserved.
  The atrophic form of paralysis, attended with the reaction of degeneration,
is always due either to disease of the  ganglion-cells in the anterior horns of
the spinal cord or to an interruption of the connection between these ganglion-
cells and the muscles ; that  is, to diseases of the peripheral nerves.  If the
paralysis be due to any lesion of the  motor  tracts  from their origin in the
cerebral cortex to their termination in the ganglion-cells of the anterior horns
of the spinal cord, there  will be no rapid atrophy of the paralyzed muscles
and no reaction  of degeneration.  The explanation of this difference is found
in the fact that the ganglion-cells of the anterior horns exert some unex-
plained trophic influence upon  the muscles with which they are in connection.
A peculiarity in cases of paralysis due to  disease  of these ganglion-cells or
to disease of the peripheral  nerves is that the affected nerves from the seat
of lesion and the paralyzed muscles undergo rapid degeneration ;  a degenera-
tion, however, which may be  recovered from if the primary lesion be repaired
before  the  degeneration has advanced too far.
  Another important difference is, whether the paralyzed muscles be relaxed
and flabby or in a rigid, spastic condition.   Sjmstic paralysis is generally
associated with increased  reflex action, and it occurs when certain inhibitory
fibres which  come from the brain and  run  in the  lateral columns are inter-
rupted by some  lesion in their  continuity.   It is assumed by many that  these
inhibitory fibres are identical with those in the  pyramidal tracts of the cord;
but this view is not proven.  For  the production of spastic paralysis it is
necessary also that the  nerve-fibres  and ganglion-cells  which conduct and
originate impulses  for reflex action of the paralyzed  muscles should not be
destroyed.   The conditions for spastic paralysis are present in many cases of
cerebral paralysis, in most cases of transverse  myelitis or compression myelitis
in the upper dorsal and  the  cervical regions, and in sclerosis of  the lateral
columns of the  cord.  Spastic  paralysis does not occur when the centripetal
reflex fibres in the posterior nerve-roots, posterior columns, and  gray matter,
the ganglion-cells of the anterior horns which  transmit  reflex impulses, and 
                      GENERAL  CONSIDERATIONS.                  731

the centrifugal  reflex fibres of the anterior nerve-roots are diseased so as to
arrest  their functions.1
   Loss of sensation is a symptom of spinal  disease when the function of the
sensory fibres in the cord is destroyed or impaired.  The sensory fibres enter
the cord  by the posterior  nerve-roots, from which a part enter directly into
the posterior horns and a part pass into the posterior columns.  The sensory
fibres  of  the  posterior  columns probably also  enter the posterior  horns at
some   point  distant  from  the  entrance  of  the  corresponding  nerve-roots.
Fnlike the  majority of the motor fibres,  the sensory fibres decussate in  the
spinal  cord.   Loss of sensation dependent  upon  spinal  affections, therefore,
points  to  some disease of the posterior columns or of the  posterior horns of
gray matter, more particularly to disease  of the latter.   It is an  interesting
fact that  tactile sensation  may be  lost while the sense of pain  is preserved.
The loss  of sensation to pain is called analgesia.   If  a lesion destroy  only
one-half of the spinal cord—which is a very rare occurrence—the paralysis
of motion will be  on the side of the lesion, and the  paralysis of sensation
(tactile and  for  pain) will be on the opposite side.
   Conditions  affecting reflex action have  already been  mentioned in connec-
tion with spastic  paralysis.   Reflex action  is increased  if the  connection
between the reflex centres and the brain  be interrupted.   The reflex centres
are situated in the gray matter of the cord.   Destruction of the gray matter,
therefore, abolishes the  reflex action  of those muscles which are in nervous
connection with the diseased  part of the gray matter.  A similar effect is pro-
duced  by  disease of centripetal nerve-fibres  which carry impressions from the
periphery to these centres,  as in the case  of disease of the posterior columns
and posterior  horns of gray matter in  locomotor ataxia.  The two most import-
ant forms of reflexes  for diagnostic  consideration are cutaneous reflexes and
tendon reflexes.   Cutaneous reflex is  generally studied by noting the contrac-
tion of the muscles of one  of the lower extremities upon tickling the sole of
the foot.  Other cutaneous  reflexes which may be examined are the contrac-
tion of abdominal muscles upon passing the finger along the skin of the abdo-
men or the contraction of the cremaster muscle upon passing the finger along
the upper part of the inside of the thigh.
   Tendon reflexes are examined  at  the  knee and at  the ankle.   In most
healthy individuals a vigorous contraction  of the quadriceps extensor mus-
cle is produced by striking quickly with  the ulnar side of the hand or  with
a percussion hammer the ligamentum patella when the leg is flexed and the
muscles are relaxed.   This contraction, called the knee-jerk or patellar reflex,2
may be increased or may be  diminished or abolished in certain  diseases of
the spinal cord.  The patellar reflex may  be impaired even when  cutaneous
reflexes are intact.  The centrS for the patellar reflex  is in the gray matter
of the lumbar portion of the  spinal  cord.   Diseases of the gray matter in
this situation, and also disease  of the centripetal nerve-fibres in the posterior
columns of the lumbar enlargement cause the patellar reflex to disappear.  In
the various conditions causing spastic paralysis the patellar reflex is increased.

  1 ft is the rule, therefore, that disease of the posterior columns and of the gray matter
extending  over a considerable longitudinal extent of the spinal cord prevents the occur-
rence of spastic paralvsis.  An apparent exception is amyotrophic lateral sclerosis; but
here it  must be assumed that at the time of spastic paralysis the ganglion-cells of the
anterior horns are not diseased  sufficiently  to prevent the transmission of reflex
impulses.  In  the explanation of spastic  paralysis some writers lay more  stress  upon
the irritation  of certain nerve-fibres and ganglion-cells than upon the abolition of
inhibitory  impulses.  It is probable that both irritative lesions and the withdrawal of
the inhibitory influence of the brain may cause spastic paralysis with increased reflexes.
  2 It is assumed  that the  knee-jerk is a reflex phenomenon,  although this view is not
proven. 
732
DISEASES  OF THE SPINAL  CORD.
   The so-called foot-clonus, ankle-clonus, or foot-phenomenon is produced bv
making passively a vigorous dorsal flexion of the foot, when,  if the clonus
be marked, the foot, upon relaxation of the flexion, will assume a position of
extension in consequence of contraction of the gastrocnemius muscle.  There
may follow repeated movements of flexion and of extension, so that there is
a continuous rapid vibration of the foot from one position to the other.  This
reflex, produced by irritation of the tendo Achillis, is more frequently absent
in health than  the  knee-jerk, but  in spastic paralysis it is often  a marked
phenomenon.
   The use of  electricity has become not only  a valuable therapeutical agent,
but also a most important aid  in the diagnosis and  the prognosis of various
forms of paralysis.  For diagnostic purposes it  is necessary to make use of
both the induced (or faradic) current and the constant (or galvanic) current.
The polar method of  application of the  electric current is the most exact.
In this, one  electrode is placed over the nerve or the muscle to be irritated,
and  the other electrode at some distant part  of  the  body, as the sternum or
the nape of  the  neck.   The galvanic battery  should  be supplied with a  com-
mutator, so that either electrode can be made positive or negative at will.
   In order to  understand the  electrical reactions in disease it is necessary to
be familiar with the so-called law of contraction for motor nerves and muscles
in health.  This law relates to  the responses  to the constant current applied
by the polar method.  This current produces muscular contractions only when
the circuit is opened or is closed.   The occurrence and  the strength of these
contractions depend upon the direction and the strength of the electrical cur-
rent.   If the  constant current  be very weak, no contraction is produced.   If
the- strength  of  the  current   be gradually  increased, the  first contraction
appears upon closing the descending  current; and  this is called the cathodal
closure-contraction (C. C. O), the cathode  or  negative pole being applied to
the nerve or muscle when the  circuit is closed.  If the strength of the cur-
rent be still  further increased, the next contractions appear upon closing and
upon opening  the ascending current, sometimes one and sometimes the other
causing the first response.  These contractions are the anodal closure-contrac-
tion (A. C. C.) and the  anodal opening contraction (A. 0. O), the anode or
positive pole being applied to  the nerve or muscle.   Contraction upon  open-
ing the descending current or cathodal opening contraction (C. 0. C.) appears
last, and not until the current is so strong as to cause  tetanic  cathodal closure-
contractions.   The galvanic current therefore causes contractions in the fol-
lowing order: 1, C.  C.  C.; 2 and 3, A. C. C. and A.  0.  O, sometimes  one
coming first,  and sometimes the other;  4,  C.  0. C.   The main points to
remember are that in health the C. C. C. exceeds the A. C. O, and the A. 0. 0
exceeds the  C. 0.  C.   The contractions occur in the same order whether the
electrode be applied to the nerve or to the muscle.
   The faradic current applied  to nerve or to  muscle in health causes tetanic
spasm  of the  muscle, the intensity of the spasm being in proportion to the
rapidity of the interruptions and the strength of the current.
  The changes in electrical reactions in disease may be quantitative or quali-
tative.  The quantitative changes consist in simple increase or simple diminu-
tion of electrical response.  Simple increased  electrical excitability is common
in the  early stages of various  forms of paralysis;  but when unaccompanied
with qualitative changes in electrical reaction it is not of  much diagnostic
importance.  So, too, diminished electrical response, when of diagnostic import.
is generally, although  not  necessarily, accompanied with qualitative changes
in muscular excitability.
  Far more important  than the simple quantitative changes are the combined
quantitative and qualitative changes in the electrical excitability of nerve and 
GENERAL  CONSIDERATIONS.
>7QO
too
 of muscle  which constitute  the reaction  of degeneration.  This reaction is
 so called because it occurs only when the nerve  or the muscle (or usually
 both) has undergone degeneration.   The  degeneration of the  nerve is indi-
 cated by a  diminution, and finally a disappearance, of its  excitability both to
 the faradic and the galvanic currents.  In cases of  peripheral paralysis  the
 electrical excitability of the  nerve  may be  completely  lost in  from one to
 two weeks, so  that  it is impossible by electrical excitation of the  nerve to
 produce any muscular  contraction.   During this  time  the reaction of  the
 muscle to the direct application of the faradic current also  diminishes, and
 finally disappears.   This is due to degeneration of the intramuscular nerve-
 fibres. _  The reaction of the muscle to the direct polar application of  the
 galvanic current undergoes important alterations, which indicate degeneration
 of the muscle,  going on at the same time as nerve-degeneration.  At an  early
 stage  of  the degeneration  there may be  slight diminution in the  galvanic
 excitability of the muscle, hut this soon  gives place to a decided  and cha-
 racteristic increase  in  the response to the  galvanic current  when directly
 applied to  the muscle.  This increased response is attended by  certain  note-
 worthy peculiarities.  The first peculiarity is, that the anodal closure-contrac-
 tion (A. C. C.) increases, so that after a while it equals, or even exceeds, the
 cathodal closure-contraction (C. C. O), thus reversing the conditions in health.
 The cathodal opening contraction is  also often increased, so that it may equal
 or exceed the  anodal opening contraction.  A second peculiarity is, that the
 muscular contractions,  instead  of being immediate in their appearance and
 short, are sluggish  and prolonged, sometimes continuing during the entire
 duration of the current, instead of only at the opening or the closing of the
 circuit.
   If  the degeneration  go on to complete destruction of the muscular struc-
 ture,  the increased galvanic excitability of the muscle gives place to diminu-
 tion and final disappearance of  all electrical excitability, the last to disappear
 being the anodal closure-contraction.
   If  repair of the degenerated muscular and nervous tissue occur, the exag-
 gerated and altered  galvanic  muscular  reaction gives place to  the normal re-
 action, faradic  excitability of the muscle returns, as well  as the  galvanic and
 the faradic reaction  of the nerve.   The nerve becomes capable of  transmit-
 ting  the  impulses of  the will,  causing  volitional contractions, before the
 normal faradic and galvanic excitability  is  restored.
   Usually,  both  the  nerve and  the muscle simultaneously undergo degenera-
 tion.   If the nerve  be alone degenerated, there will be simple diminution or
 loss of its  faradic and galvanic excitability and  diminution  or loss of the
 firadic muscular excitability, without qualitative change in the galvanic  mus-
 cular excitability.  If the muscle be  alone  degenerated, the faradic and thfe
 galvanic excitability  of the nerve  and the faradic  excitability of the muscle
 will be preserved, while the above-described  characteristic changes following
 direct galvanic excitation of  the muscle are present.   The latter reaction  is
 sometimes called partial reaction of degeneration.
   The reaction of degeneration is present only in paralysis due to disease of
 the peripheral nerves and  in  that due to disease of the ganglion-cells in the
 anterior  horns of  the spinal cord.  It is absent in all forms of cerebral
 paralysis, in all spinal  paralyses due  to disease of the white  matter of the
 cord,  and in functional  paralyses.  If paralysis be due to disease involving a
 segment of  the gray matter of  the spinal  cord,  as in transverse myelitis, the
reaction of  degeneration is present only in  the nerves and  muscles which are
connected with that segment, while it is absent in the  paralyzed  muscles
whose nerves originate  below  the diseased segment.   It is  thus apparent that
the study of the electrical  phenomena  of  nerve  and of muscle in  cases  of 
734
DISEASES  OF THE  SPINAL CORD.
paralysis affords most important information as to the seat of disease.   The
reactions to electricity also indicate the pathological  condition of a nerve or
of a muscle; and  this may prove of great  assistance  in forming a judgment
as to the possibility of recovery.'


                               Myelitis.

   Inflammation of the substance  of the cord is called  myelitis.   Myelitis
appears as an  acute and  as a chronic affection.  These  two  forms, however,
cannot  be  sharply discriminated  in all cases, since acute  myelitis  often
passes into the chronic form.  Other divisions are  based upon  the extent of
the inflammation and the  part of the cord involved.   Thus the inflammatory
changes  may  be  either  circumscribed, diffuse, or disseminated ; the white
matter, the gray matter, or both, may be affected;  or the disease may tend to
extend transversely or  in a  longitudinal direction.   AVhen  both  white and
gray matter of the greater portion of  the  cord are inflamed, the process is
called diffuse myelitis; when the inflammation affects only  or chiefly the gray
matter, the disease is  central myelitis ; and when confined to the anterior horns
of gray  matter, it is anterior poliomyelitis or anterior cornual myelitis.  In
transverse myelitis  the whole thickness of the cord over a circumscribed space
is involved.  Cortical myelitis or meningo-myelitis is the name given to inflam-
mation of the  peripheral  portion of  the cord, the  inflammation being conse-
cutive to spinal meningitis.  AVhen a number of separate foci of inflammation
exist in the cord the change is designated as disseminated myelitis.  Myelitis
extending from below upward is called ascending,  and extending  from above
downward it is called descending.
   As regards  the tissue primarily  affected,  Charcot,  following  Virchow's
classification, distinguishes two varieties of myelitis—namely, interstitial and
parenchymatous myelitis.   In interstitial myelitis the connective tissue or
neuroglia is first inflamed, and the  nerve-elements suffer secondarily ; and in
the parenchymatous  form the ganglion-cells and  nerve-fibres  are primarily
involved, and the  interstitial changes are secondary.   The final result  in both
cases is the  same.
   The gray substance of  the cord, on account of its  greater vascularity and
functional  importance, is  more frequently the seat of primary myelitis  than
is the white matter.   Inflammation of the  gray matter is particularly prone
to extend in the  vertical direction (central myelitis).
   Acute myelitis, in the majority of  cases, appears under the form of softening
of the cord. Chronic  myelitis, on  the other hand, appears as induration or scle-
rosis.  The changes which  characterize acute myelitis will be described first, and
afterward those of the chronic form.  Softening and acute myelitis are not to be
regarded as synonymous, since there exists non-inflammatory as well as inflam-
matory softening of the cord.  Exceptionally, the consistence of  the  acutely
inflamed cord is found to  be normal or even increased.  The color also varies.
It may be  that of the  normal  cord,  in which case, if the consistence be
unchanged,  the existence of  inflammation can be  determined only by micro-
scopical examination.   Most frequently the color is  reddish  or  yellow, but
in cases of prolonged duration  it may be grayish or white.  The red  color
is due to the presence of  blood.  In very acute cases of central myelitis the
softened  part   may contain so much extravasated blood as  to present the
appearance of  a primary  hemorrhage into the cord.   The  name hsemato-mye-
litis is given by Hayem to cases of  acute myelitis attended by extensive  hem-
  1 For further information  on this  subject consult the excellent work of A. Hughes
Bennett, A Practical Treatise on Electro-diagnosis in Diseases of the Nervous System, Lon-
don, 1882. 
MYELITIS.
735
orrhage.  From the  sudden development of the symptoms, it is  also called
apoplectiform myelitis.  The stage of  red  softening gradually gives place to
that of yellow softening.   The yellow color is due to alterations in the blood-
pigment, to fatty degeneration, and to the presence of pus-cells and granular
corpuscles.   The affected  portion  of  the cord is  usually,  but not  always,
swollen.  The pia-arachnoid membrane is. as a rule, involved to some extent
in the inflammatory process.  The dorsal and the lumbar regions of the cord
are the favorite seats of the disease.
   The microscopical examination in cases of acute myelitis reveals dilatation
of the  blood-vessels, extravasated  red blood-corpuscles, granular  corpuscles,
fat-granules, pus-cells, disintegrated nerve-fibres and nerve-cells, swollen and
apparently  proliferating neuroglia-cells, granular material, especially around
the vessels (regarded by Lockhart Clarke as coagulated albuminous  exudation,
and  called  by him  " granular disintegration "), blood-pigment, and  corpora
amylacea.   In the early stage, and  in the neighborhood ofsoftened  foci in the
later stages, the axis-cylinders of some of the nerve-fibres are much swollen,
presenting  the appearance  called varicose  or fusiform  hypertrophy.  The
ganglion-cell.s also  may be  found  swollen, spherical,  pigmented, vacuolated,
and  devoid  of processes.   They finally undergo atrophy and disappear.  The
recognition  of the granular corpuscles  (also called fat-granule bodies or inflam-
matory corpuscles of Gliige) is of great assistance in distinguishing ante-mor-
tem  softening from the softening  so often produced artificially in  removing
the  cord.   These  corpuscles are  usually spherical or oval in shape, vary
greatly in size, and are so  densely  filled with small  fat-globules as  to appear
opaque by  transmitted and bright by reflected light.   They may be formed
from emigrated white blood-corpuscles, from neuroglia-cells, from cells in the
walls of the blood-vessels,  and perhaps in other ways.   They are not distinct-
ive of inflammation, and they may be present in simple degenerative processes.
   If acute  myelitis pass into the chronic stage, the red and the yellow give
place to white softening.   Cysts  filled with a whitish, milky fluid may be
formed as  in cerebral softening.   By absorption of the inflammatory exuda-
tion, by atrophy of the nerve-elements, and  the production of fibrillated con-
nective tissue acute myelitis may terminate  in sclerosis, as has been  demon-
strated by Leyden.   It is  probable that very mild  cases of myelitis  may be
followed by complete restoration to the  normal condition.   Certain observa-
tions tend to show that nerve-fibres in  the cord which have been  destroyed
by the myelitic process may be regenerated.  Suppuration  or  abscess is  an
extremely rare termination of acute myelitis, and  when present  it is either
pyamic or  consecutive to suppurative processes  in  the membranes, verte-
bra,  or surrounding parts.
   Transverse myelitis of sufficient duration  (probably at least a  month")  is
followed by the  secondary degenerations of  Tiirck.   These  degenerations
affect both  centripetal and  centrifugal fibres.  They are therefore  ascending,
and  when the myelitic focus does not  reach the lower extremity of the cord,
descending.  The ascending degeneration occupies the columns of Goll and the
direct cerebellar fasciculi;  and the  descending degeneration follows the course
of the pyramidal fasciculi of the anterior and of the lateral columns.   These
tracts, when degenerated, appear gray and are finally  atrophied, the  process
consisting in a gradual atrophy of the  nerve-fibres combined  with increase
of the neuroglia and the appearance of granular corpuscles.   AA'hen the mye-
litis  occupies the whole thickness of the cord the degenerations are bilateral.
Myelitis confined to one-half of the cord is very rare.
   Chronic myelitis  includes, according to  common  usage, the processes also
called  sclerosis and gray degeneration.   It  is characterized  by proliferation
of the neuroglia-elements, resulting in the production of fibrillated  connective 
736
DISEASES  OF THE  SPINAL CORD.
tissue and the atrophy of nerve-elements.   Granular corpuscles and corpora
amylacea may also be present.  The consistence of the affected part is usually
firm, its size is diminished rather than increased, and its color is gray.   Some-
times there are no morbid changes visible to the naked eye.  As regards their
clinical  history, certain cases of slowly-developing softening of the cord are
to be referred to chronic myelitis, although Leyden  considers all instances of
inflammatory softening of the cord as acute in their origin.
   Chronic  myelitis  embraces affections of  the cord which vary greatly as to
the situation, extent, and nature of the pathological process.  Certain  forms
have an exact localization,  and follow the course of certain definite groups of
nerve-fibres  and of  nerve-cells.   Others are  characterized by irregularity in
distribution and extent.  Of the forms which have more  or  less of an exact
localization may be mentioned posterior spinal sclerosis  or  locomotor ataxia,
amyotrophic  lateral sclerosis, and  anterior  poliomyelitis.   These will each
receive  separate consideration.   The secondary  degenerations  of Tiirck,
although regarded  by many  writers  as the  result of chronic myelitis, are
primarily  degenerative.  The name funicular sclerosis is given to sclerosis
following  certain definite columns of the cord, such as lateral and  posterior
spinal sclerosis.   It is probable  that in these  cases the primary change  is in
the nerve-fibres.   Otherwise it  would be difficult to understand why inflam-
mation  should be  confined to the course of definite  nerve-tracts.   The  most
important examples of  chronic myelitis  with irregular distribution  are-
chronic  transverse  myelitis,  circumscribed sclerosis,  and  disseminated  or
multiple sclerosis.   Multiple sclerosis will be considered  separately,  as it
has a well-defined  clinical history.   Myelitis  resulting from  slow  compres-
sion (angular curvature resulting from Pott's disease, cancer of the vertebra,
or intraspinal tumors) is usually of the ordinary transverse variety and accom-
panied by secondary degenerations.

   The clinical history of acute myelitis presents variations corresponding
to those which belong to the anatomical characters of the disease.  The latter
furnish  the  interpretation of the former, and from the symptoms the seat of
the inflammation, its extent, and the  particular parts of the cord which are
involved may be inferred  with  considerable accuracy.   Certain symptoms
belong alike  to  acute  spinal meningitis  and to acute myelitis.  In many if
not in most  cases  these two affections are  associated.  In meningitis the
inflammation extends from  the  membranes to the cord, and in  myelitis the
membranes  are  likely  to be secondarily involved.  Practically, at  the bed-
side, having diagnosticated  an  acute  intraspinal  inflammation exclusive  of
intracranial  inflammatory diseases, the diagnostic  problem which remains is
to differentiate myelitis from meningitis;  that is, to decide  that the inflam-
mation  has  its origin  in and is predominant  in the  cord.  The symptoms,
therefore, which distinguish myelitis from spinal meningitis especially claim
attention.
   Disorders of sensation are often the first local  symptoms.   These are pain
in the hack, the  sensation of a girdle around the trunk, and  tenderness over
certain  of the vertebra.  Preceding  paralysis the muscles  which are  to be
paralyzed are sometimes affected with tremor or spasms.
   The early occurrence of paralysis  is a  distinguishing  feature.  It occurs
within a day or two, and sometimes within a few  hours, after  the symptoms
have pointed to a spinal affection.  In most instances the form of the  paral-
ysis is paraplegic, showing the seat of the affection to be in the dorsal or in the
lumbar  portion  of the cord.  According to the seat at the outset or the sub-
sequent extension of the inflammation upward (ascending myelitis), the mus-
cles of respiration and  of the upper extremities may be affected.  The speedy 
MYELITIS.
737
occurrence of paralysis is evidence that the cord has been primarily affected.
Sudden and  complete  paralysis denotes that  the  myelitis  is  central  and
accompanied  by hemorrhage  (hamato-myelitis).
  Paralysis affecting the bladder and  rectum  is more constant  and occurs
earlier in myelitis than  in spinal meningitis.   Loss of cutaneous sensibility is
more  frequent in the former than in the latter.  It is rare for sensory paral-
ysis to be wanting.   Its absence shows  that the myelitis does not  involve the
posterior columns or the posterior cornua of the cord.  Sensation  may not be
lost, but is more or less  diminished, and it may be characterized by retarded
transmission  of sensory impressions. Exceptionally, there is cutaneous hyper-
asthesia, this being attributable to complicating meningitis.   Priapism is a
symptom of  not infrequent occurrence.  Symptoms relating-  to reflex  move-
ments are  of significance  as  regards the  localization  and the extent of the
lesions.  The continuance or increase of the reflex  movements shows  either
that disorganizing changes have not taken  place, or that the disorganization
has not extended  to the lower end of the spinal cord.   On  the other hand,
loss of reflex excitability  is an effect  of destruction of the gray matter in
the lower  part of the cord.   This extension  is  shown  by the  loss of reflex
excitability after the occurrence of the motor  paralysis.
  Spasm of  the muscles of the lower  extremities, constituting the so-called
spinal epilepsy of  Brown-Sequard, is a  prominent symptom in some cases of
transverse myelitis not involving the lower lumbar region.
  Notable wasting of the paralyzed muscles  is indicative of destruction of
the gray matter;  and  in this case the reaction of degeneration appears in
the muscles   the  nerves of which originate  in  the diseased  gray matter.
Hence  this  reaction is absent  in  the  muscles of  the  lower extremities in
dorsal and cervical myelitis, and is present in  lumbar myelitis involving the
anterior horns.
  In  myelitis, earlier and in a greater degree than  in spinal meningitis, the
parts  exposed to  pressure—sacrum  and  trochanter—take  on  gangrenous
inflammation.  Not infrequently  this  occurs within a  few days after the
attack.  The urine  is  retained and within  a short period it becomes alka-
line.   The presence  of muco-pus  shows the existence of cystitis.
  Fever in cases of acute myelitis is  rarely high, and  is generally of a low
grade.  The propriety  of the term acute  in  this connection  has reference to
the rapid  development of grave symptoms, rather  than to the elevation of
temperature  and other evidence of constitutional disturbance.   Fever symp-
tomatic of gangrenous inflammation (septic fever) and of cystitis occurs in
the progress of the  disease.
  Acute myelitis may run a rapid course, destroying life in a few  days, or
death may take place  as a result of gangrenous inflammation  or of cystitis
after  the lapse of several  weeks.  Complete recovery is rare.   In a certain
proportion of cases the disease becomes chronic.  It may end in more  or less
complete  atrophy of the cord, and  patients  may live indefinitely with a per-
manent paraplegia, the general health  being good.
  In  the foregoing account of the symptomatology of acute myelitis refer-
ence has been had especially to the parts involved in the differentiation from
acute spinal  meningitis.  These points have been  already referred to  in  the
account given of  the  latter disease.  (Vide p. 702.)   The affection to be
noticed in  connection with the  functional affections of the spinal cord, called
acute ascending paralysis (vide Chapter Y.), closely resembles  acute  ascend-
ing myelitis; but in the latter affection disturbances of  sensation and bladder
and rectal  symptoms are generally not  marked.  The symptoms which relate
to reflex  and electrical excitability, to the paralysis of the bladder  and rec-
tum,  and to  the occurrence of cystitis and of bed-sores at an early period, are
        47 
738
DISEASES  OF THE  SPINAL CORD.
sufficiently characteristic of acute myelitis as contrasted with so-called reflex
and functional paralysis.  Acute myelitis, the inflammation limited to the
anterior horns of the  gray matter of the cord (anterior poliomyelitis), con-
stituting the affection known as infantile paralysis and an analogous affection
in adults,  will be considered separately in this chapter.
   Acute myelitis is a rare disease, especially if cases of traumatic origin be
excluded.   Aside from injuries of the cord from fractures, contusions, pene-
trating wounds, etc., prolonged exposure  to  cold, as in  sleeping upon damp
ground, seems  to be the only cause clearly apparent.  The  adequateness of
other agencies supposed to be  causative, such  as muscular efforts, excessive
venery, and exposure  to a high temperature, is problematical.   Acute mye-
litis is occasionally observed as a sequel of diphtheria and of other infectious
diseases.   The  disease occurs when it cannot  be  traced to  any causative
agenc}*.
   The treatment in the early stage of acute myelitis has for its  objects
diminution of the intensity of inflammation  and the prevention  of disorgan-
ization resulting therefrom.   Dry cupping over the spine, and in full-blooded
subjects the local abstraction of blood by cups or leeches, are indicated.  The
application of the ice-bag to the spine is recommended.  Ergot and belladonna
have been supposed to be useful by causing contraction of the arteries of the
cord.   Mercurialization, by giving calomel and also by  inunction, is to  be
advocated in view of the danger and the frequently rapid  progress  of this
disease, on the ground that the  notions formerly held in regard to the anti-
phlogistic effect of mercury are not without some foundation, and  that  the
evils of the remedy are of little moment, provided it have a favorable influ-
ence upon the  inflammatory process, however  small this influence  may be.
   It will often happen that the acute stage  is too brief to afford much time
for treatment with reference to the objects just stated.  This may be inferred
when complete paralysis has taken place.  Revulsive applications to the spine
may be employed, but, considering the liability to gangrenous inflammation,
they should not be made  in situations exposed to pressure.  To obviate the
effects of pressure is  an  important part of the treatment.    Relieving  the
bladder of an accumulation of  urine is important, as well as proper attention
to the early symptoms of  cystitis.
   Absolute  rest  is an important part of the treatment.   Brown-Sequard
advises recumbency on the abdomen, but the  continuance of this  decubitus
is hardly practicable.   There is no difference  of opinion as to the impropriety
of the employment  of electricity in.acute  myelitis.   Strychnia  is  contra-
indicated.

   Chronic  myelitis, in  the  most comprehensive sense of the term, includes
several distinct affections, among which are sclerosis of the posterior columns
of the cord, multiple cerebro-spinal sclerosis, sclerosis of the lateral  columns,
anterior poliomyelitis, and progressive muscular atrophy.  These will be con-
sidered  in this chapter under separate  headings.   Exclusive of these affec-
tions, the term chronic myelitis denotes an inflammatory affection localized in
a segment, or sometimes in more than one segment, and extending  transversely
more or less throughout the cord (transverse myelitis).   The form of  paraly-
sis resulting therefrom is generally paraplegia ; but if the cervical portion of
the cord be the seat of the affection, general spinal paralysis is the result.   In
cases of the  disease as thus restricted the clinical  problem is similar  to that
in cases of  the acute  form—namely,  to  differentiate chronic  myelitis from
chronic spinal meningitis.   Here, too, it is to be considered  that  in the latter
affection the inflammation extends more or less  from the meninges to the cord,
and that in  the  former affection inflammation of the cord generally involves 
                     CEREBRO-SPINAL  SCLEROSIS.                 739

the meninges.   The antecedent history is to be taken  into account.  Both
chronic myelitis and chronic spinal meningitis may have been preceded by an
acute form of disease, and of  course the chronic  has the same primary "seat
as the acute.   If, therefore, the previous  history show  the acute  disease to
have  been acute myelitis, the existing affection  is chronic myelitis.
   As regards the symptoms, they  point  to myelitis, instead of meningitis, in
proportion as they represent more or less disorganization of the cord.  Hence,
completeness of the paralysis, sensory as  well  as  motor paralysis, paralysis
of the bladder and  rectum, cystitis, wasting of the paralyzed' muscles,  and
a tendency to  gangrenous  ulceration are diagnostic of  myelitis rather than
of spinal  meningitis.
   The practical importance of making  this  discrimination relates chiefly to
the prognosis.   The prospect of improvement  and recovery is far  better in
cases of spinal meningitis  than in cases of  myelitis.   In proportion as  the
symptoms denote  disorganization  of the cord (softening and  secondary atro-
phy)  the prognosis is  unfavorable.   As already stated,  however, destruction
of the cord, causing complete  motor and sensory paralysis of the lower  limbs,
is not incompatible with long  life and good general health.  In the preceding-
editions of this work a case is cited in which complete paraplegia followed a
fall of forty feet, and after death  there was found  atrophy of the cord  below
the twelfth dorsal  vertebra. This patient lived more than fifty years after the
accident, married,  and had six children, amassed a little  fortune by his  indus-
try, and finally died with double  pneumonia.   In  another  case, reported  by
Dr. Purple,1 there was complete loss  of motion  and sensation below  the fifth
dorsal vertebra following  an  injury.   In this  case the patient, finding his
lower limbs burthensome, persuaded a surgeon to amputate them near  the
hip-joint.   The operation  was wholly  without  pain  and the stumps healed
readily.
   The measures of treatment indicated in  cases of chronic myelitis are  rest
as long as the symptoms denote an inflammatory condition, and  moderate
counter-irritation over the  spine.   Remedies  given with a view to promote the
absorption of morbid products—namely, the  iodide of potassium and  mercury
—are not indicated ; and severe counter-irritation—by the moxa, issues, setons,
etc.—is of no use.  Electricity may be useful in  retarding atrophy of the para-
lyzed  muscles.  The application of  water to the spine by sponging and com-
presses is to be recommended, but cold affusions and hydropathic packing are
hurtful.  Experience has shown the hurtfulness of thermal baths.  Attention
to the bladder  is important.   Indications pertaining to the  general  condition
of the patient are to be met.  If the patient be confined to the bed, precau-
tions are  to  be taken  against the effects of pressure.

   Cerebro-spinal Sclerosis—Multiple or Insular Sclerosis.
   Among the  names for this affection  may be mentioned multiple sclerosis,
disseminated sclerosis, insular sclerosis of the brain and spinal cord, sclerose en
plaques disseminees, cerebro-spinal sclerosis, and disseminated chronic intersti-
tial encephalomyelitis. The disease was recognized pathologically by Cruveil-
hier (1835) and'by Tiirck  (1855).  From a  clinical point of view it has been
studied most thoroughly by Charcot  and his  pupils.2   It is characterized ana-
tomically by  the development of  many or of few  nodules of sclerotic tissue
in the central  nervous system.  These  nodules are the result of a dissemi-
nated  chronic  interstitial inflammation.   Charcot distinguishes, according to

  1 New York Medical Journal. 1853.
  2 Charcot, Gaz. des Hopitaux, 1868; Bourneville  et Guerard,  De la Sclerose en Plaques
disseminees, Paris, 1869. 
740              DISEASES OF THE SPINAL CORD.
the situation of the nodules, three types of the disease—namely, the cerebro-
spinal, the cerebral,  and the spinal.   The  cerebro-spinal form  is  the most
common type,  its clinical  history is best understood, and it is the  one most
readily  diagnosticated.   The spinal  form,  with our present  knowledge  as
regards its  symptomatology,  is not readily  distinguished from the ordinary
forms of  chronic myelitis.
  In  the  majority  of cases the spots of sclerosis can be recognized  by the
naked eye.   In  exceptional cases they may be visible  only microscopically.
They are  distributed irregularly throughout  the spinal  cord, medulla oblon-
gata,  pons varolii, cerebrum,  and cerebellum.   The sclerotic  islands  in  the
pons and  medulla are rarely absent, and they give rise to characteristic symp-
toms.   Their number in the cerebrum and cerebellum is greater  in the white
than  in the  cortical  substance.   In the cord  they  occupy, unsymmetrically,
both  white  and  gray matter, more frequently the former.   They may  be
concealed in the interior,  or, reaching- the surface,  they  may be  visible from
the exterior.   It is  rare for the sclerosis  to extend throughout the entire
thickness  of the cord.  The nodules may be scattered at wide intervals  or sev-
eral may  coalesce.   The size of individual nodules  may  vary between  micro-
scopic dimensions and several  inches in length. The  color of the sclerotic spots
is reddish-gray, the  consistence, especially in the brain,  firmer than normal,
the cut surface smooth and somewhat translucent,  and the borders  irregular
and in many cases  well  defined.  The affected parts may be shrunken or  of
normal  or even increased  size.   The membranes,  especially the pia  mater,
may be thickened  and opaque  or they may  be unchanged.
   The microscopical examination of  the gray  sclerotic  nodules reveals,  as
the essential cliange, increase of the interstitial tissue, together with atrophy
of the nerve-fibres and nerve-cells.  The interstitial  tissue appears as a finely-
fibrillated but dense  connective tissue, mingled with finely granular material.
Large stellate  cells, called Deiter's cells or  spider-cells, are  often present.
The walls of the blood-vessels are notably thickened, and are often infiltrated
with  fat-molecules  and lymphoid  cells.   Granular corpuscles  and corpora
amylacea  are usually present,  but not in  large number.  In the  sclerosed
patches most of the nerve-fibres have disappeared,1 those  remaining being,
for the most part, naked axis-cylinders, sometimes much  hypertrophied.    At
the borders  of the  sclerotic  nodules  the neuroglia-reticula are  swollen and
the cells  are apparently in proliferation.  The ganglion-cells, when the gray
substance is involved, become filled with yellow pigment, lose their processes,
and finally disappear by atrophy.  It has been pointed out by Frommann
that  sometimes a considerable quantity of fat in the form of free globules
and in  cells occupies the  sclerotic islands.    This he refers to a  fatty degen-
eration of the  elements  of the  neuroglia.   Similar  gray  translucent spots  of
sclerosis  have  been observed also in  the cerebral nerves and in the roots  of
the  spinal  nerves.   Sclerotic  nodules have  been recognized with especial
frequency in the optic  nerves.

   The  individuality of  this affection has been recognized  only  within a few
years.  Prior  to a  knowledge  of its clinical characteristics, as  pointed  out
by Charcot and others, it was confounded with locomotor  ataxia, general paral-
ysis of the insane,  senile trembling, and especially paralysis agitans.  Typical
cases at the present time are readily discriminated.   This statement will not
apply to the rare instances in which the lesions are  limited to either the brain
or the spinal cord.   I have met with an instance, the diagnostic features being
  1 Later  observations (Erb, Frommann)  do not confirm the  opinion of Charcot that
insular sclerosis, in distinction from other  forms of chronic myelitis, is characterized by
the preservation of many of the nerve-fibres in the sclerotic islands. 
CEREBRO-SPINAL SCLEROSIS.
741
extremely well marked, in which there were no symptoms, other than tremor,
pointing to a cerebral affection, the duration of the  disease extending  over
many years.
  The development of the  disease is usually very gradual, and for a consid-
erable period its peculiar characters may not be declared.  A'arious indefinite
symptoms referable to the brain or spinal cord may have  existed for months,
and even years, before a positive diagnosis is practicable.  Among these symp-
toms  are—cephalalgia, vertigo, mental  disturbance,  apoplectiform attacks,
abnormal sensations in the limbs, muscular feebleness (paresis), lack of co-or-
dinating power (ataxia), etc.   It  is easy to understand  that  different cases.
offer  a  great diversity, as regards not only the initial symptoms,  but those
associated with the diagnostic characters of the disease, when it is considered
how great are the differences as regards the number, size, and situations of the
sclerotic patches.  The interpretation of the diverse symptomatic phenomena
is to be sought after in the pathological relations of the different parts of the
brain, medulla oblongata, and spinal cord in which the lesions are liable to be
seated.   Charcot calls the disease polymorphous, in view of the great variety
of the forms of disorder observed in different cases.   Notwithstanding  these
variations, the diagnostic features, when these are present, render the differen-
tiation from the several diseases just named, not difficult.
  Following incomplete paralysis  of one or both of the lower limbs, and per-
haps  also of the upper limbs, accompanied often by rigidity of the muscles
(spastic paralysis) and increased tendon reflexes, tremor occurs, and the most
diagnostic feature relates to this symptom.  The tremor is excited by volition,
and is wanting  as  long as there is no exercise of the will (volitional tremor).
The muscles are quiet or nearly so if the  patient be entirely at  rest,  but
whenever any action is excited by the will they take  on automatic  spasmodic
movements more or less violent, and the  patient's  will is powerless  for their
arrest.   These  movements may extend from the limbs over the  whole body.
A hospital patient for a long time under my observation while  sitting quietly
was free from tremor, but as soon  as he made any voluntary  effort the motions
of his limbs and  body were so violent and grotesque that  it was difficult to
regard the spectacle  as otherwise than ludicrous.   The tremor  which is  thus
characteristic of this  disease is analogous to that of chorea in so far as it is
automatic, but excited by  the will.  In chorea, however,  automatic move-
ments take place without as well  as with the exercise of the will.   The
tremor  differs from the inco-ordinate movements of ataxia in  that the latter
are not  automatic.   The tremor  in cases of  senile trembling  and  paralysis
agitans differs in being independent of volition, taking place when the patient
is entirely at rest.  Moreover, in both these affections the movements are less
violent, have less  range, and  are  more rhythmical in character.  The  term
shaking tremor  expresses more correctly the movements in  multiple sclerosis
than the word tremor alone.   This symptom is referable  to lesions seated in
the medulla oblongata.
  A peculiar disturbance of speech is diagnostic of this disease. The patient
speaks in a slow, monotonous manner, with intervals between syllables, as in
scanning.  The  peculiarity  is known as the " scanning speech."   The voice
is sometimes reduced to a  -whisper.  Aphonia and  the  feeble, monotonous
voice are referable  to paresis of the  vocal cords.  In some  cases the  lips,
tongue, and  muscles of the  palate become paralyzed, as in cases of bulbar
paralysis.
  Impaired vision (amblyopia) and  double vision (diplopia) occur not  infre-
quently, and oscillation  of the eyeballs (nystagmus) is  so frequent in  this
disease  and so rare in other diseases that it has much  diagnostic significance.
These symptoms represent sclerotic patches affecting the optic tracts or nerves 
742              DISEASES OF THE SPINAL CORD.

and nerves going to the muscles of the eyeballs.  Inequality of the pupils is
a not infrequent symptom.
  Sensory paralysis  is rarely marked, and is  not infrequently wanting.   If,
however, the sclerotic patches  involve the posterior columns  of the cord,
ataxia and  more or less  impairment of  sensibility are associated.   There
mav be little wasting of the muscles, but in some instances  it is otherwise,
the inference in these instances being  that the anterior horns of the gray
matter of the cord are involved.  Cystitis and bed-sores do not usually occur
until late-in the disease, and they are often absent.
  Disturbances  referable  to  the brain  are  rarely,  but sometimes, wanting.
The mental faculties generally  fail.   Patients often alternately weep  and
laugh irrationally, and progressive deterioration of the mind  ends at length
in imbecility.    Apoplectiform attacks are liable to occur, accompanied  by
hemiplegia.  AVith  these  attacks there  may be considerable  fever, showing
an intercurrent acute inflammatory condition.  Patients usually recover from
these attacks, but they sometimes prove fatal.
  The diagnosis is to be  based  chiefly on the  tremor, together with the pecu-
liar disorder of  speech, taken in connection with the varied  motor, sensory,
and  mental disturbances.  The  diagnostic  criteria  probably proceed from
sclerosis of the medulla oblongata and  pons varolii.  If these parts escape,
which probably is  rare, the  clinical  characteristics of the disease may be
wanting.  An important point in the diagnosis is the age of the patient.   In
the great majority of cases the beginning of the disease dates from a period
between twenty and forty years  of life.
  Aside from the influence of age, nothing has  as yet  been definitely ascer-
tained respecting the etiology.
  The disease  is usually progressive, but with a slow march, the duration
sometimes extending over  a period of from ten  to twenty years. Long periods
in which  the  disease appears to be stationary are not uncommon, and also
periods in  which the symptoms give  delusive  hopes of real improvement.
Often the life of the patient is destroyed by some  intercurrent affection.   A
fatal ending may be due to disturbances of  respiration  and deglutition inci-
dent  to the occurrence of bulbar paralysis.  Irrespective of these causes,
death may be the result of exhaustion from cystitis,  bed-sores, and the giv-
ing way of the processes involved in nutrition.  Clinical experience thus far
has  furnished  no  ground for entertaining any hope of recovery from  the
disease.
  The utmost to he hoped for in the way of treatment is that the disease
will remain stationary, or, if it be  progressive, that the  progress may be
retarded.   Ararious  remedies have  seemed  to be of  use  in  isolated  cases.
Among these are the nitrate of silver, arsenic,  the chloride of barium, and the
phosphide of zinc.   The latter  remedy, in a case under my observation,  was
repeatedly followed by  distinct  although  limited improvement.  Electricity
and  hydropathic treatment have appeared to  be beneficial.   More is to be
expected from the removal as far as  possible  of all causes of disorder, from
measures for the improvement of the general health, and from  treatment gov-
erned by symptomatic indications, than  from any remedies  given with a view
to a special influence  upon the disease.


        Locomotor Ataxia—Posterior Spinal Sclerosis.
  This affection was described  by  Duchenne in 1858  and 1S59  under the
name of progressive locomotor ataxia, more fully than  by any previous  writer;
hence Trousseau designated it Duchenne's disease.  The principal symptoms
of the disease, however, had been recognized previously by Romberg, who 
LOCOMOTOR ATANIA.
743
applied to it the old  name tabes dorsalis.  The distinctive  character and the
seat of the affection were clearly  defined also  by the late Dr. Todd prior  to
the researches of Duchenne.   Other names of  the  disease are gray degene-
ration of the posterior columns, sclerosis of the posterior columns, and posterior
chronic leucomy(litis.
  The anatomical characters of locomotor  ataxia consist of sclerosis of the
posterior columns of the spinal  cord, involving frequently a part of the lateral
columns and of  the  gray substance.  The posterior nerve-roots are atrophic
and gray.  The pia mater covering the posterior part of the cord is thickened,
opaque, and is often adherent to the dura mater.  In advanced cases the pos-
terior columns appear shrunken, gray, and somewhat firmer than normal.  The
observations of  Pierret (1872), under Charcot's direction, render it probable
that the primary seat of the  sclerosis is in  two bands, each in  the  outer
part of  the  posterior columns,  and lying close to, and  parallel  with, the
posterior horns of gray matter.   These bands they call the external or lateral
bands.  This view of Pierret and Charcot is  based, on the one hand, on the
fact that sclerosis of the columns  of Goll, although usually present in loco-
motor ataxia, does not cause ataxic symptoms, as shown in cases of ascending
secondary degeneration and of primary sclerosis  of these columns ; and, on the
other hand, on  the  observation of  a case of  locomotor ataxia in which the
sclerosis was confined to the external bands, while the columns of Goll were
normal.   AVhen, as  is usual, the symptoms  are most marked  in  the lower
extremities, the changes in the posterior  columns  are most  extensive and
advanced in  the lower dorsal  and  upper lumbar  regions.  Here  tbe whole
thickness of the posterior columns is involved.  In very rare cases  the symp-
toms  are% chiefly referable to the upper extremities, the sclerosis then being
most  developed in the cervical enlargement.  As a rule, however, while the
dorso-lumbar sclerosis occupies the greater part of the posterior columns, it is
found that in the cervical region the sclerosis is confined either to the columns
of  Goll or to these  together with the external  bands.  The almost constant
involvement of the columns of Goll may be regarded as referable to  an ascend-
ing secondary degeneration.  The sclerosis maybe traced continuously to the
restiform bodies of  the medulla  oblongata, where it ceases.  There is a tend-
ency  in  the disease during the later stages to  extend to the posterior part
of  the  lateral  columns.  The posterior horns  of gray matter are generally
involved.  The nerve-fibres in Clarke's columns are atrophied in  all typical
cases.  Extension to the anterior horns of gray matter is a rare complication,
causing  muscular  atrophy.   Gray degeneration of the optic  nerves,  and
rarelv of the oculo-motor, hypoglossal, and certain other  cranial  nerves, has
been  observed.
   Microscopical examination  of the sclerosed  parts  reveals increase of the
interstitial tissue, which  appears as a dense  but finely-fibrillated  connective
tissue, containing in the early stages  many  nuclei and granular corpuscles,
and in the later stages abundant corpora amylacea.   The walls of  the  blood-
vessels are thickened, and the  perivascular sheaths enclose a large  number of
fat-<ilobules which  have  probably  been  derived from the products of fatty
defeneration of the nerve-elements.  The nerve-fibres lose their medullary
sheaths, undergo atrophy, and for  the most part disappear.  The exact local-
ization of the sclerosis as described above  can  only be determined by micro-
scopical study.   The morbid process is regarded by most writers as beginning
in the nerve-fibres, either as a parenchymatous  inflammation (Arulpian, Char-
cot. Erb) or as  a degeneration  (Leyden), the  chronic interstitial inflammation
being a  secondary change.

   Locomotor ataxia is not a form of paralysis, although it is generally associated 
744
DISEASES  OF THE SPINAL  CORD.
with diminished sensibility, and not infrequently with more or less diminution
of motor power.  The distinctive characteristic  of the affection is impairment
or loss of the ability to combine and  direct voluntary muscular movements.
The patient  may have as much muscular  strength as in health, but  there is
either inability or difficulty in co-ordinating the action of the muscles by the
will.  A natural division  is into the  initial  period or first stage, the ataxic
period or second stage, and the paralytic or third stage.
  Lancinating, shooting  pains, usually at first in  the lower, and later in the
upper limbs, often constitute a prominent symptom.  The patient often com-
pares the pains to those caused by electric shocks.  In consequence  of their
shooting, piercing characters and great intensity they have  been called  ful-
gurating or  lightning pains.    They  are  not positively  characteristic, inas-
much as they occur  in other forms of myelitis, and are not invariably pres-
ent in cases of ataxia.    The  " girdle sensation,"  which is a symptom in
other inflammatory affections of the cord, is  often felt.  Other  events which
may occur  in  the  first stage  are—incontinence of urine, frequent  seminal
emissions, anaphrodisia, or, on  the  other  hand,  a  morbid excitability of the
sexual organs,  urethral and rectal neuralgic  pains, a  sense of fatigue in  the
muscles of the lower  limbs after any exertion, attacks  of vomiting accom-
panied by gastralgia (crises gasfriqucs of Charcot), and paralysis of certain of
the nerves of the eyeball  (the  oculo-motorius, the abducens, and rarely the
trochlearis), giving rise to  strabismus, diplopia, and  ptosis.   These paralytic
symptoms may be transient, and they may disappear  and return, sometimes
remaining permanently.   Impairment of  vision in some cases  occurs early,
and it may end in amaurosis.   The ophthalmoscope shows an opaque, pearly
whiteness of the  optic papilla, characteristic of atrophy of the optic nerve.
Irregularity of the  pupils  is not infrequent.   The  pupil on one side may be
contracted to the size of a  pin's point, showing paralysis of the sympathetic;
and with this symptom are sometimes  associated dilatation of the vessels and
increased heat on the corresponding side of the face. The pupil on one side may
be contracted and on the other side dilated.  Oftener both pupils are contracted.
A symptom which possesses considerable  diagnostic value is the absence of
contraction of the pupil on exposure  to light, while there is normal contrac-
tion in the acts of accommodation (Argyll-Robertson  symptom).   Difficulty
of speech from paralysis of the hypoglossus, and paralysis affecting branches
of the trigeminus and facial nerve, are occasional symptoms.   The acoustic
nerve is rarely involved.   Absence of patellar reflex  is an early and almost
constant symptom of locomotor ataxia. These events are liable to occur in
the first stage—that is, they may precede the development of ataxia—or their
occurrence may be delayed until the second stage.  They may  precede for a
long period, months and even  years, the  ataxic characteristics.   The latter
mark the second stage of the  disease.
  The ataxia is generally first  manifested in the lower extremities.   It may,
however, appear first in the upper extremities. This was true of a case  which I
have observed.  One lower limb  is sometimes affected before the other, and both
limbs on the same side may be  first affected.  AVhen one limb is first affected,
whether it be a lower or an upper extremity, it is on the left  oftener  than on
the  right side.  The defect of co-ordination is apparent  when any combined
movements  are undertaken.  In proportion  as  the  affection is marked  the
patient's gait in walking  is uncertain, irregular, and grotesque.  The lower
limbs are thrown forward  by forcible  jerks,  without  definite direction.   The
body is sometimes swayed  from side to side  in  the  attempt to maintain an
equilibrium, and the arms are thrown out like those of a person balancing on
the  tight rope.  In  cases  less  marked the greatest difficulty is experienced
in beginning to walk, and  after getting under way the patient  is unable to 
LOCOMOTOR ATAXIA.
745
advance  slowly, but walks with precipitation.  The legs are thrown forward
with a quick, jerking movement, and the feet are brought to the  ground on
the heels with force and are liable to strike against each  other.  Notwith-
standing the violence of the exertions, the muscular strength being retained
patients are sometimes able to walk for long distances.  In an extreme degree
of the affection walking, even with the aid of a cane or assistants, is impos-
sible, and the patient is confined to the chair or bed.
   The defect in co-ordinating  power over the upper extremities is  shown by
an inability to  execute acts which require  the  combined movements of the
fingers.  The patient is unable to button or unbutton clothes, and yet the
grasp may have not less  force than in health.   A patient whom I exhibited
at a  clinic  tried in  vain to unbutton  his vest, but his grip  was too strong to
be borne.  In extreme  cases the patient is unable to guide the hand to his
mouth, and requires  to be fed by others.
   In a certain proportion of cases the  affection  progressively extends over
the voluntary muscular system, and  increases in degree more or less slowly.
The  defective co-ordinating power may be much  more marked at some times
than at others.   A  patient for some time under my observation, wTho had suf-
fered from this  affection for five years, habitually walked with a certain amount
of uncertainty and irregularity, and enunciated with  labor and slowly, but dis-
tinctly.  This  patient at times, for the space of an hour or so, walked with
great difficulty, presenting in a marked degree the characteristic gait, and the
embarrassment in speech was  such that he was  with difficulty understood.
These  paroxysms  recurred on some days repeatedly, and he  was sometimes
exempt from them for several successive days.  This patient had occasionally
double vision and night-blindness.
   A symptom,  even when the affection is slight, is inability  to stand with the
eyes closed.  This symptom is not pathognomonic of locomotor ataxia.   The
patient,  with the  feet  in apposition and  the  eyes  closed, soon reels,  and
would fall if not supported.   This has been attributed to the coexistence of
more or  less anasthesia  of the  soles of the feet.   Patients, however, with
notable loss of sensibility of  the  soles,  but who have  not  ataxia, are some-
times able to stand without difficulty when the eyes are closed.1  A moderate
amount of  ataxia occasions want of confidence in the powers of locomotion.
A patient under my care  has  the disease only in a sufficient degree to walk
usually with what seems an  eccentric  gait; but were he  to  cross a street
when it  became necessary to hasten in  order to get out of the way of car-
riages, he  would scarcely be  able to make any headway,  and he carefully
avoids such a  contingency.
   In most if not in all cases the cutaneous sensibility is more or less impaired.
The  amount of sensory paralysis varies in different cases.   Generally both
anasthesia  and analgesia are combined.  There is also diminution of the
sense  of weight and  of temperature.   The so-called muscular  sense  is
impaired.  Retardation in the  transmission of sensory impressions to the
sensorium  is usually marked.  The difficulty in walking is increased by the
impairment of  sensibility.  The patient's eyes  are directed  to  the  feet and
ground in  walking, and  there  may be inability to walk with the eyes closed.
   As already stated, although distinct from motor  paralysis, the latter may
coexist with the ataxia, and  may be either primary or secondary as regards
the former.  In cases of paralysis from different spinal affections, the diffi-
culty in  walking depends often  measurably on defective  power  of co-ordi-
nation.
   Impotence occurs, as a rule, sooner  or later, either before or after the
advancement of the  disease  to the ataxic  stage.
   1 ATide  report  of a case by Dr. Pepper, in Am. Journ. of Med. Sciences, July, 1871. 
746
DISEASES  OF THE SPINAL  CORD.
   Affections of the joints occur in a proportion of cases, small, but sufficient
in number  to  show a pathological connection.   These have been described,
especially by Charcot, under the name  of ataxic arthropathies.  They may
occur  before as well as after the development of the ataxic condition.   Gen-
erally, the  larger,  but sometimes the  smaller,  joints are affected.   Those
attacked by preference are the knee  and the  shoulder.   The joints are
attacked suddenly,  without any traumatic  cause;  they  are swollen  from
intra-articular effusion; pain and fever are wanting; and recovery oftesi takes
place after  several weeks or months.   On the other hand, permanent struc-
tural changes  may be the result, leading sometimes to dislocation1  and the
lesions of deforming arthritis.   The patellar reflex is  wanting.   Percussion
over the ligamentum patella or  over the tendo  Achillis does not occasion
spasmodic  movements  as  in health.   This is a point  of  diagnostic import-
ance.  Cutaneous reflexes are generally normal or nearly  so.  As a rule, for
a long period the nutrition of the muscles is  well maintained.  The electrical
reactions are normal in  uncomplicated  cases.
   In the advanced or paralytic stage notable paralysis is added to the ataxia.
The  muscles waste, the patient falls into a cachectic state, cystitis and bed-
sores occur, and death takes place by exhaustion.   Happily, the disease pro-
gresses to  this stage in  but a small  proportion  of cases.   It is generally
reached, if reached at all, after a long period.  AVhen a certain  amount of
progress has taken  place, sometimes the disease remains without  further
progress  indefinitely or during life.   If the  disease be progressive, its  prog-
ress  may be extremely slow.  Notable improvement takes place in  some  cases.
I have known the ataxia to be so great as to compel patients to keep the bed for
several months, and such a degree of improvement to follow that they were
able  to walk without much difficulty.  Complete recovery is extremely rare, but
if the disease be not far  advanced it is possible.   Hence the name progressive,
applied by Duchenne, is by no means  characteristic of the disease.  In the
great majority  of cases  death is owing to some intercurrent affection.   The
disease may not interfere  with the continuance indefinitely of appetite,  nutri-
tion, and good  general health.
   The diagnosis involves a discrimination from paraplegia, and in  some cases
from general paralysis.  The differential diagnosis may be easily made.   The
ataxia  is not a paralytic affection ; and the difficulty in walking or in using any
of the affected muscles depends not on deficiency of muscular power, but on the
lack  of ability  to combine and  direct the movements of the affected muscles.
The  difference in this respect is strikingly shown by causing two patients, one
affected with paralysis and the other with locomotor ataxia, to walk  side by
side.  The  paralytic walks- with a feeble, tottering, or shuffling gait, while the
patient affected with ataxia throws out his limbs with force, but in an  irreg-
ular, uncertain manner.   The  preservation of  voluntary motor power in
ataxia  is shown  by the resistance which the patient is able to make  when
the physician tries to bend the limbs,  and also by the freedom  and strength
of movement when the patient is recumbent.  If there be paralysis, more
or less in degree, combined with  ataxia, it  is not a difficult problem to  deter-'
mine this fact and to estimate the relative  prominence of either.  The  coex-
istence of mental aberration with general  cerebral paralysis  is a diagnostic
feature of the  latter.   In  that disease the voluntary muscles of the limbs,
face, etc. are simultaneously affected.  In locomotor ataxia different parts of
the voluntary muscular system are successively affected, the aff'ection  being
generally manifested first in  the lower extremities.   General  paralysis of
the insane and  locomotor  ataxia  may occur together, either affection appear-
ing first.
         1 Charcot, Lecons  sur les 3Ialadies du Systbne nerveux, Paris, 1877. 
                         LOCOMOTOR  ATAXIA.                     747

   Affections of the cerebellum giving rise to vertigo may occasion an embar-
 rassment in walking and standing suggestive of ataxia,  the embarrassment is
 due to vertigo, and is analogous to  that caused by drunkenness.  AVith proper
 attention this cannot be confounded with  the ataxic difficulty.   Moreover the
 vertigo  is usually accompanied by other  symptoms  pointing  to cerebellar
 disease.
   Sclerosis of the lateral columns, or spasmodic  spinal paralysis,  presents
 diagnostic characters which, as will be  seen, are  sufficient for the discrimina-
 tion of this aff'ection.   The muscles in  locomotor ataxia are notably relaxed.
   Before the appearance  of ataxia the  diagnosis may be considered  estab-
 lished if lancinating pains, absence of patellar reflex, and the  Argyll-Robert-
 son  pupil are all present as symptoms.
   The etiology of locomotor ataxia relates to age, sex,  over-exertion of the
 muscles, together with  exposure to cold and  sexual excesses.  The disease
 occurs very  rarely prior to adult  life.   In the great  majority of cases the
 ages are between thirty and fifty years.   Men are oftener affected than women.
 The disease has been observed to follow various  affections—namely,  rheuma-
 tism, pellagra, epilepsy, hysteria, etc.—but the diversity of these antecedent
 affections renders it doubtful that the sequence denotes  any etiological connec-
 tions.   The  personal history in many cases gives nothing  definite as regards
 the causation.   Syphilis seems to be an undoubted factor in the causation of
 a  certain proportion of cases  of  locomotor ataxia—a proportion,  however,
 probably not more than 30 or 40 per cent, of the cases.  The analysis of the
 cases shows  antecedent syphilis to have been generally mild, and that the
 ataxia occurs from five to  ten years  after the syphilitic  infection.
   Treatment.—The nitrate  of silver, the  iodide of potassium, arsenic, the
 chloride of barium, and phosphorus are  remedies recommended in this dis-
 ease.  Each  has been found useful by some, and  not  so by other  observers.
 None are entitled  to be considered as specially curative.   Their degree  of
 usefulness is limited in the  cases  in which they appear to be useful.  The
 nitrate  of silver may be given continuously in  doses  of from a third  to  a
 sixth of a grain for  several  weeks, and  it should  then  be suspended for a
 season.  Phosphorus has  seemed  to me to be  useful in  several cases.  It
 may be given in the form of phosphide of zinc or of the oleaginous solution.
   They who  have had large  experience in electro-therapeutics bear testimony
 to the usefulness of electricity. Both the faradic and galvanic forms are use-
 ful, the latter having the more testimony in its favor.
   Thermal baths are generally regarded with disfavor  by those who  have
 observed their effects in  a considerable number of cases.  Sponging the  body
 with  cool or tepid water and  the  hydropathic packing,  the latter employed
 with care and moderation,  are recommended.   The usefulness of these meas-
 ures, as well  as of electricity and the other remedies which  have been named,
 is  to be explained by their general  influence upon the functions of the body,
 this  influence reaching thus indirectly the local disease.
   There is general agreement as to the inutility of  local  depletion and coun-
 ter-irritation.
   The lancinating painSj the  attacks of gastralgia with vomiting,  seminal
 emissions, the affections  of the joints, the retention or  incontinence of urine,
 and  other complications, claim of course  appropriate measures of treatment.
 Stretching the sciatic or other nerves which are  the seat of severe  pain is a
 surgical operation which has aff'orded great relief in some cases, and has  been
 without benefit in other cases.   It  is only a palliative measure.
   Measures  to  improve and maintain  nutrition, to invigorate the  general
health, to remove coexisting disorders, and to palliate symptoms, doubtless
do much  toward preventing  or retarding the progress of the disease. 
748               DISEASES OF THE SPINAL CORD.
  Inasmuch  as  measures of treatment  appear in  not a few cases to prevent
or retard the progress  of  the disease, it is  obvious that an early diagnosis is
highly important.   It is important to recognize the significance of the symp-
toms which precede the ataxic stage, with the hope that  as a result of judi-
cious management the disease may  not  advance to this stage.  There seems
to be no good reason, a priori, why the  disease might not become stationary,
to say the least,  at this as well as at the second stage.

                         Hereditary Ataxia.

  This rare affection was first described by Friedreich in 1803, and is some-
times called  Friedreich's  disease.   Although  several ca.ses of typical loco-
motor  ataxia  sometimes occur in the  same family, in  Friedreich's  disease
there are certain peculiarities in the symptoms and the  pathological lesions
which  distinguish  the  disease from typical locomotor ataxia.
  A number  of members of the same family are  usually affected.   In  an
observation  of Carre  there  were 18 cases  of ataxia in one family, occurring
during three generations.   Dr. AV.  E. Smith has  reported 6 cases of hered-
itary ataxia in one family.1  The female members  of the family seem to be
more  subject to the disease than  the male, although  this has not been
observed in all  instances.  The  first symptoms  generally appear in  child-
hood, often about  the  age of puberty,  but sometimes earlier or later.
  An initial stage  of lancinating pains is wanting.   Ataxia is the first symp-
tom.  Patellar reflex disappears.  In typical cases sensation is intact.   Eye-
symptoms are absent.   There is a peculiar disturbance of speech, due prob-
ably to inco-ordination in the movement of the muscles involved in articulation.
Nystagmus has been repeatedly observed.  Spastic paralysis with contractures,
and often with muscular  atrophy, occurs after the ataxia has  existed some
time.   Spinal  curvature, usually in  the form of scoliosis, is a frequent symp-
tom.  Bladder and rectal disturbances are absent or they occur  only in a late
stage.  The duration of the disease is very long, extending often over thirty
years.
  The  pathological lesion consists  in gray degeneration  or  sclerosis of the
posterior columns,  of the direct cerebellar fibres, and of the pyramidal tracts.
Sometimes  there is degeneration of the ganglion-cells in the anterior horns,
but whether  this be only a complication  or not  is uncertain.
  The  disease, so far as known, is incurable.   The  indications for treatment
are  similar to those in typical locomotor  ataxia.

  In this connection may be mentioned the occasional occurrence of so-called
acute,  ataxia, observed most frequently after  diphtheria, variola, and  rarely
other  infectious  diseases.   The  symptoms resemble those of ordinary loco-
motor  ataxia.   Recovery often  takes  place or  the disease  may become
chronic.  Nothing is  known of the  pathological  lesions of acute ataxia.


Acute Anterior Poliomyelitis—Spinal Paralysis of Children.

  The  primary pathological lesion of infantile spinal paralysis is an acute
circumscribed myelitis of  the anterior horns extending  over a variable por-
tion of the cord.   The few autopsies which have been made in an early stage
of the  affection  reveal undoubted evidences of inflammation of the anterior
cornua in the  presence of leucocytes, proliferating neuroglia-cells, and  hem-
orrhages.  Opportunities  for examining the cord at a late stage of the dis-
  1 \V. Everett  Smith, " Hereditary or  Degenerative Ataxia," Boston Med. and Surg.
Journ., Oct. 1~),  1885. 
ACUTE ANTERIOR POLIOMYELITIS.
749
ease are not rare.   At  this period one or both anterior horns in a situation
corresponding to the  origin of the  nerves supplying  the paralyzed muscles
are shrunken.    Upon microscopical  examination the  ganglion-cells of the
anterior horns in this situation are atrophied, and  may have  entirely disap-
peared.  The surrounding  tissue is sclerotic.  The sclerosis  may extend a
little  beyond the  gray matter  into  the  adjoining antero-lateral  columns.
The essential  lesion, therefore, of infantile  spinal  paralysis is  an  acute
interstitial  myelitis  of  the anterior  cornua  resulting  in  atrophy  of the
motor  ganglion-cells  and  sclerosis  of the neuroglia.   AVhen  the  paralysis
affects  the  lower extremities  the  poliomyelitis  is in  the  lumbar  enlarge-
ment.   AVhen  the  upper  extremity is paralyzed there is  poliomyelitis  of
the cervical enlargement.
   As would naturally be expected (see p. 730), the disease  of the ganglion-
cells of the anterior horns is followed by degeneration of the nerves and
muscles in  connection  with the  cells.  The degeneration of the nerves is
characterized by disintegration of the myeline sheaths, increase in  the nuclei
of the sheath of Schwann and of the endoneurium, atrophy of the axis-cylin-
ders, and eventually new growth of interstitial  connective tissue  within the
nerve-trunk.  The  degeneration of the muscles  is characterized by similar
changes—namely, atrophy of the muscular fibres, increase in the sarcolemma
nuclei  and of the interstitial cells, and a gradual  replacement of muscular
substance by connective tissue, which  may be so  infiltrated  with  fat-cells as
to conceal the  actual atrophy.
  The symptoms of  this disease in children are  strikingly distinctive.  The
initial  history of a typical  case  is  as follows:  A child is suddenly attacked
with fever, perhaps in the night, having been  at  bedtime apparently per-
fectly  well.  The fever has considerable, it may be great,  intensity.   It is
accompanied by cerebral symptoms—namely, vertigo, somnolence, coma, and
sometimes convulsions.  There is also  pain in the  spine and extremities.  The
fever and the concomitant  symptoms subside and disappear after a minimum
duration of a few hours or a maximum duration of a few days.  The patient
may have seemed to have had a febricula.  As a sequel of the fever paralysis
is discovered, generally quite unexpectedly.  The paralysis may be at first
confined to one  extremity, much oftener a lower  than an  upper.   It may
quickly extend  to another  extremity, and it may involve the four  extrem-
ities.   The extension from one part to other parts takes place quickly—that
is, within a  few hours or at most a few days—and  the paralysis  as quickly
becomes complete.  There is no sensory paralysis.  After a few days the lia-
bility to an  extension of the motor paralysis ceases.   As regards the parts
paralyzed cases differ widely.   The paralysis may be confined to one lower
extremity;  but oftener both lower limbs are affected.   Cases occur, but they
are extremely rare, in which either  one or both of the upper limbs are alone
affected.  More or less of the muscles of the trunk may be involved.  Not
infrequently the paralysis does  not affect all  the  muscles of the extremities,
but is  confined to  certain  groups of  muscles.
  There are occasional variations from the foregoing history as regards the
fever and the concomitant  symptoms.  The  fever may  be slight, and in rare
instances wanting.  More or less of the cerebral  symptoms may be absent.
The latter do not represent  any  definite cerebral affection, and  they are prob-
ably incident to the fever.  The fever has been  considered as symptomatic
of acute spinal  inflammation.  The intensity of the fever in some cases, and
the short duration, sometimes lasting  only a few  hours, militate against this
view.   It is more rational to consider the fever as essential or idiopathic.  If
the latter view be accepted, the spinal affection  is  to be regarded as a local
manifestation of a  general  disease, holding  to  the  latter perhaps a relation 
750
DISEASES  OF TEE  SPINAL CORD.
analogous to that of meningeal  inflammation to cerebro-spinal fever or epi-
demic cerebro-spinal meningitis.
   The clinical history after the  development of paralysis  embraces  certain
diagnostic features.
   The susceptibility of the paralyzed muscles to reflex excitation  of the skin
and percussion of the tendons is quickly lost.
   Owing to the degeneration of nerve and  muscle the reaction of degenera-
tion,  as  previously described  (p. 733), rapidly makes its  appearance.   In
seven or eight days the excitability of the nerve to the faradic current  may
be  completely abolished.   In consequence of  the degeneration of the intra-
muscular nerve-filaments the response of the muscle to the  direct  application
of  the faradic current is also lost, but at a somewhat  later period.  The gal-
vanic excitability of the nerve at the same time disappears.  The galvanic
excitability of the muscle, on the other hand,  is increased, this increase  last-
ing often for several months.   The muscular  contractions  are sluggish and
prolonged, and the anodal closure-contraction equals,  and  finally exceeds, the
cathodal  closure-contraction.  After about  three months the increased gal-
vanic excitability is diminished in  consequence of atrophy and destruction
of  the muscular  fibres.  The  qualitative changes  remain.   There may be,
finally,  total disappearance  of  the galvanic muscular excitability.
   If  after two weeks the contractility of the muscle to the induced or faradic
current be not destroyed, there  is  a good chance of restoration of the affected
muscle.   Restoration is also possible after the disappearance of faradic exci-
tability during the period of increased galvanic  excitability.  A oluntary im-
pulses can be transmitted through the nerves  before  the  faradic excitability
returns.
   Speedy and notable wasting of the muscles which  present the reaction of
degeneration is  a diagnostic feature.  This occurs too early and goes  on too
rapidly to be referable simply to disuse; it denotes trophic  disturbance, and
is evidence of a connection of nutrition with the ganglion-cells in the anterior
portion of the gray matter of the cord.   The  atrophy in  some muscles may
proceed to such a degree that all trace of the muscular tissue has disappeared.
The temperature of the surface over the paralyzed parts is lowered, as deter-
mined by the thermometer  as  well as the  touch, and the  skin has a livid
appearance.
   AVithin a few weeks  improvement  begins either in  all or in a certain num-
ber of the  paralyzed  muscles.   In a small minority  of  cases the improve-
ment  in all the muscles goes on to complete recovery.   In the large majority
of  cases  the improvement is limited to muscles incompletely paralyzed and
retaining more or  less  susceptibility to the faradic  current.  The muscles
which, after  the  lapse of several  weeks, are without  any improvement, as a
rule remain  permanently paralyzed.   As regards the  number and the situa-
tion of the muscles so remaining different cases present great diversities.
The permanent paralysis may be confined to one lower limb, to both  lower
limbs, to an upper limb, to an upper  and lower limb,  etc.   It is rare for all
the muscles of a  limb  to remain  paralyzed in an equal  degree   Often the
paralysis  is limited to a certain group of muscles, especially to the peroneal
and anterior tibial, and  sometimes even to  a  single  muscle.
  The permanent paralysis of a greater or  less number of  muscles involves
no disturbance of the general health.   The assimilatory and the nutritive  pro-
cesses (exclusive of those in paralyzed muscles) may go on as completely as
possible.   In all  respects save  the paralysis and its  local consequences the
health may be excellent and the duration  of life is  not shortened.
  The local consequences of the paralysis are, however, by  no means trivial.
A great variety of deformities are results of this disease.  The growth  of the 
ACUTE ANTERIOR POLIOMYELITIS.
751
 bones is arrested.  Owing to a want of a proper antagonism of the muscles,
 distortions of the feet and hands are common.   The joints become loose and
 often admit of ready dislocations.   The  painful spectacles so often met with
 of shortened, flaccid  limbs, club-foot, etc., if  not  congenital, are  generally
 remote consequences  of this disease.
   The diagnosis of this disease, as regards other paralytic affections, after the
 development of paralysis is easy.  The diagnostic points summarized are as
 follows:  The paralysis following an initial  fever  and  affecting muscles in
 rapid  succession  and  in an irregular  manner;  the paralysis  of  a certain
 number of muscles rapidly becoming  complete; the rapid appearance of the
 reaction of degeneration  and the  speedy disappearance of reflex and tendon
 reaction ; early and  progressive atrophy of paralyzed muscles; absence  of
 anasthesia;  coldness and blueness of the skin over the paralyzed limbs ;  no
 tendency to  gangrenous inflammation of parts  exposed  to  pressure; begin-
 ning improvement within a few  weeks in some, and sometimes in all, of the
 paralyzed muscles ;  permanent paralysis of certain of the affected muscles in
 the great majority of cases.  The discrimination from the cerebral paralysis
 of children has  been already considered.
   AA e possess no actual knowledge of the etiology of this disease beyond its
 being  especially incident to childhood.  Children, usually from one to four
 years  of age, are attacked when  apparently  in perfect health  and when
 nothing is  apparent  on  which  suspicion can rest as  causing the  attack.
 These facts render probable a special cause, the nature and source of which
 are unknown.
   The disease involves very little danger to life.  As regards prognosis, the
 danger relates to permanent paralysis with atrophy of a  greater or less num-
 ber of muscles and  the deformities arising therefrom.
   The object of treatment in the early stage of the disease is the prevention
 of these; in other words, the prevention of the changes in the anterior gray
 columns of the cord, on which depend the permanent paralysis and atrophy of
 groups of muscles corresponding to the situation and the  extent of the spinal
 lesions.   For this object the treatment  indicated in acute myelitis is recom-
 mended—namely, active  purgation,  local bloodletting by cups  or leeches,
 the application of cold to  the  spine, dry cupping and vesication, mercurial
 inunctions, the  internal administration  of ergot, belladonna, and the iodide
 of potassium.  The physician must use his discretion in the employment of
 these measures, having due regard to the age  and the  constitution of  the
 patient.   Could  the diagnosis be made in the initial febrile stage, perhaps
 more would be accomplished by  antipyretic treatment than by the  measures
 just enumerated.  Unfortunately, a positive diagnosis is rarely made in this
 stage.
   The treatment after the  occurrence  of paralysis has  for  its object  the
 restoration of motor  power  over the  paralyzed muscles and the prevention
 of atrophy.   For these objects the reliance is chiefly on electrical treatment.
 Neurologists  are generally  agreed upon the superiority of the galvanic cur-
 rent, but faradic  electricity  may  be combined with advantage.  The  electrical
 treatment should be  continued  steadily  for  many months.   Hydropathy
 employed with proper  care,  and  massage, are  useful.  The system should be
 well nourished and  invigorated  by hygienic measures,  together with tonic
remedies whenever these are indicated  by debility, want of  appetite, feeble
digestion,  etc.
  The  treatment of  the deformities which are likely to  follow  this disease
falls within the province of surgery. 
752
DISEASES  OF  THE SPINAL CORD.
          Acute Anterior Poliomyelitis in the  Adult.

  It was for a long time  supposed that the form of acute atrophic spinal
paralysis described in  the preceding article was confined to children.   It is
now known that the sana affection may occur in the adult.  The pathological
lesion is the same as that already described—namely, an acute anterior polio-
myelitis.
  This affection in the  adult is rare.   After childhood the cerebral symptoms
which in  children accompany the initial fever are less marked.   The clinical
characteristics, however, which relate directly to the spinal  affection are the
same.  The development of the paralysis is rapid.   The  distribution of the
paralyzed muscles is  irregular, and, as regards  their number and situation,
different cases present  much diversity.  In more or less of the affected mus-
cles reflex and electrical  excitability is soon greatly lessened or lost.  There
is no impairment of sensation.   The bladder and rectum are  unaffected.  The
sexual function is not involved.   After the lapse of from one to two weeks
improvement in  certain, or it  may be in  all, the paralyzed  muscles begins.
If improvement  begin  in all  and progress, the recovery may be complete
after several weeks or months.  The improvement and  recovery, however,
may be limited to a certain proportion of the paralyzed muscles, a greater
or less number remaining  permanently paralyzed.   These rapidly atrophy,
and as remote consequences distortions  occur, but  in a less degree  than in
childhood.
  The main difficulty in diagnosis is to distinguish  acute anterior  poliomye-
litis in the adult from primary degenerative neuritis involving several nerves.
In both  affections there  is muscular paralysis with rapid atrophy and the
reaction of degeneration, but  in neuritis  there are  usually severe neuralgic
pains, and often other  sensory disturbances  lacking in poliomyelitis.
  The objects of treatment and the measures to be  pursued  are the same as
in the  disease occurring in childhood.

  Subacute and Chronic Anterior Poliomyelitis—Subacute
            and  Chronic Atrophic Spinal  Paralysis.

  Duchenne first described, under the name of subacute anterior general spinal
paralysis, an affection characterized by the gradual  or  by the rapid develop-
ment of paralysis—first, usually, of the lower and then  of the upper extremi-
ties—without marked disturbances of sensation, combined with progressive
atrophy of the paralyzed muscles, and by loss of reflex and  of  faradic excit-
ability.   The recorded post-mortem examinations do not suffice for positive
statements as to the anatomical basis of the disease.  It is believed that the
disease is pathologically  a subacute  or  a chronic  myelitis  of the anterior
horns.
  The clinical characteristics  are analogous  to those of the acute affection,
exclusive of symptoms denoting acuteness.  Fever  is absent.   The develop-
ment of the paralysis, as a rule, is not rapid but gradual, extending over months
or even years.   Groups of muscles of the lower extremities are usually first
affected, and the paralysis sooner or later may extend to groups in the upper
extremities and in the trunk.   The irregular distribution of  the paralyzed
muscles is a feature of this as of the acute  affection.   The paralyzed mus-
cles  present  the  reaction  of  degeneration,  either  complete or partial, and
atropby occurs, evidently from  trophic disturbance.  Reflex excitability of
the paralyzed muscles  is  extinguished.   Sensibility is but little or not at all
impaired.   The bladder and rectum are not involved.
  Complete recovery takes place oftener  than  in the acute affection: but, in 
                 PROGRESSIVE MUSCULAR  ATROPHY.            753

 a certain proportion of cases, the recovery is limited to a greater or less num-
 ber of the paralyzed muscles, the  others remaining permanently paralyzed.
 Distortions follow the disturbance of the normal equilibrium of antagonizing
 muscles.  Death is sometimes caused by an extension of the paralysis upward"
 so that deglutition and respiration become affected.
   This paralytic affection is distinguished from progressive  muscular atrophy
 by  the  fact that paralysis precedes  the atrophic degeneration of muscles,
 whereas  in the latter affection atrophy of the muscles is the primary event,
 of which  the  loss of muscular power is  an effect.  Moreover, in  the  latter
 affection the  atrophy affects parts of the muscles, more or less of  the  fibres
 retaining their susceptibility to reflex  action and electricity.  In chronic ante-
 rior poliomyelitis, on the other hand, the loss of motor power, together with
 that of reflex  and electrical excitability, extends over the whole of the muscles
 affected.   The main difficulty is to distinguish  subacute and chronic anterior
 poliomyelitis from primary multiple neuritis.  It is probable that many cases
 of the latter  affection have been  erroneously referred  to poliomyelitis.  The
 chief  points in diagnosis are mentioned in the preceding article.
   The objects and measures of treatment are the same as in acute  poliomye-
 litis after the acute stage  has passed.   AVith our present knowledge, the
 chief  reliance  is on  the judicious and persistent  employment of electricity,
 especially of  the galvanic current.


                  Progressive  Muscular  Atrophy.
   Progressive  muscular  atrophy was described first under this name by Aran
 in 1850.   In  1855, Cruveilhier also investigated the disease, particularly from
 a pathological point of view.  The affection has  been called by English writers
 wasting or creeping judsy.  There  has been much controversy  as to whether
 the  primary seat of the disease be in the muscles (the  myopathic theory) or
 in  the spinal  cord (the  neuropathic theory).   AVe  are indebted especially to
 Lockhart  Clarke and to  Charcot  and his school  for repeated and  careful
 microscopical  examinations of the spinal  cord in  cases of  progressive  mus-
 cular  atrophy.   These investigators have observed with great uniformity, as
 the  essential lesion,  atrophy of the  ganglion-cells in the anterior horns, com-
 bined  with chronic  interstitial inflammation  about the atrophied cells.  The
 view held by  Friedreich  that  these changes in  the spinal  cord are not pri-
 mary,  but secondary to the muscular atrophy, has  not met with favor, and is
 not  in  harmony with the fact that muscular atrophy, when undoubtedly pri-
 mary,  may exist for a long time without alterations in the cord, and that the
 atrophy  of ganglion-cells which follows amputations is not  to be compared in
 extent and degree with the atrophic changes in progressive muscular atrophy.
 The neuropathic origin of typical cases of progressive muscular atrophy (that
 is, of the  type of Aran and of Duchenne) may be considered, therefore, as
 demonstrated; but it is also certain that there are cases even of widespread
 muscular atrophy which  may  bear  great resemblance to the Aran-Duchenne
 type, and  in which  the  most searching microscopical examination has failed
 to reveal any atrophy of ganglion-cells or other changes in the spinal  cord.
 A case of this  nature of great similarity to typical  progressive  muscular
 atrophy, but differing from it in certain  particulars, has  been reported by
 Lichtheim.1  He failed to discover any diminution in the number or size of
ganglion-cells  in  the cord.   AVe must  therefore admit that there are certain
forms of progressive muscular atrophy which differ more or less widely from
the typical variety,  and which are myopathic in their origin.   Our informa-
tion as to the points of distinction between the myopathic and the neuropathic
                     1 Archiv fur P-ychiatrie, 1878, Bd. 8.
       48 
754
DISEASES  OF THE SPINAL  CORD.
forms of progressive muscular atrophy is as yet so imperfect that it would
not  be  profitable, within the limits of this  work, to attempt to  classify and
describe separately different forms of  the disease.   AVe may hope that in the
future their distinctive characters will be better understood.  In  the  present
article the ordinary  form of progressive muscular atrophy will be described.
This may be considered to be neuropathic in origin.
   Progressive  muscular  atrophy  may be primary or  secondary.    In the
secondary form (deuteropathic of Charcot) the chronic anterior poliomyelitis
is secondary to some other morbid process in  the cord, such as primary lat-
eral sclerosis(?), posterior spinal sclerosis, spinal meningitis, and insular scle-
rosis.   Of the  secondary  form, that  consecutive to  lateral  sclerosis  is the
most important, and is called  amyotrophic lateral sclerosis.  It will  receive
consideration in a separate article.   The intimate connection between chronic
bulbar paralysis and progressive muscular atrophy in symptomatology, devel-
opment, and pathology has already been mentioned in treating of the former
affection.
   The anatomical appearances in the spinal cord in cases of  progressive
muscular atrophy are similar to those met with  in the later stages of infantile
spinal paralysis.  The primary change is, however, best regarded  as a degen-
erative  atrophy of the ganglion-cells, and not as a myelitis. No changes may
be visible to the naked eye, or  a more  or less distinct atrophy of the anterior
horns may be discerned.  The  microscopical  examination shows  the various
stages of pigmentary and sclerotic  atrophy of the motor ganglion-cells  in the
anterior horns, the presence of  a few  granular corpuscles, and  increase with
induration  of the interstitial tissue, especially well marked in the neighbor-
hood of the atrophied cells or cell-groups.  Gray degeneration of the anterior
nerve-roots and of peripheral nerves supplying the  affected muscles is also
present.  The changes in the muscles' are not those of a simple fatty degen-
eration, as was  at one time supposed. They consist in a simple atrophy of the
muscular  fibres, which become smaller  and smaller, but preserve  their stria
until much reduced  in size.  Many of the fibres possess a greatly increased
number of sarcolemma nuclei,  and some may present the characters of fatty
degeneration.  The interstitial tissue is at the same time increased in amount,
and  may contain some fat-cells.  It  is a noteworthy fact that the  affected mus-
cles  do not undergo  atrophy in  their entire volume at once, as is the case in
infantile spinal  paralysis, but that individual fibres or bundles of fibres become
atrophied, while adjoining fibres may remain of normal size.  This peculiarity
of atrophy of individual fibres  or of single bundles in a muscular  mass forms
one of the distinguishing characters of progressive muscular atrophy.

  Progressive muscular atrophy generally begins in one of the upper extrem-
ities, oftener in the right than in the left.  The affection is at first usually lim-
ited  to a certain number of muscles.   In the larger proportion of  cases some
of the muscles  of the hand are primarily affected.  The muscles forming the
ball  of  the thumb and the ball of the little finger and the interosseous mus-
cles  are first atrophied.  Less  frequently the muscles of the shoulder or of
the arm or of the forearm are the first to become  atrophied.  Corresponding
muscles of the other extremity  are likely to become subsequently affected, the
affection thus exemplifying the law of parallelism.  More or less gradually
the affection  extends over the  muscular system.   Not only the muscles of
the extremities, but those  of the trunk, are likely to become atrophied, and
in some cases the latter are first affected.   The intercostal muscles and the
diaphragm  may be involved, and death may be  produced by apnaa.   The
muscles of deglutition  may  become involved, and the  affection  may  prove
fatal by causing inanition.  The affection is limited to the voluntary muscles. 
PROGRESSIVE MUSCULAR ATROPHY.
755
  A marked  degree  of atrophy of external muscles renders the appearance
striking and  characteristic.   In a  case  which came under  my  observation
the atrophy was limited to  the muscles of the left shoulder, arm, and fore-
arm.  The right scapula  was well  covered by its muscles, but  on the left
side this bone was conspicuous, its boundaries distinct, and the spinous ridge
projecting. The whole of the upper limb was attenuated, presenting a remark-*
able contrast with its fellow.   In a case reported by Reade, the patient, a young
man, when stripped to the waist " exhibited the neck, chest, and  arms to the
elbow-joints reduced to the most abject degree of emaciation. The emaciation
was perfectly symmetrical; the greater and lesser pectoral muscles ware little
more  dense than  the  strongest  brown wrapping-paper;  the muscles  of the
neck, anterior and  posterior, proportionately attenuated;  the muscles on the
scapula, particularly  the supra-  and infraspinatus, were so much diminished
as to show the spine  of the bone with distinctness only less  than the dry
bone ; all  prominences from the deltoids were gone, and  the muscles  of the
humeri  were reduced  to the  cellular membrane, the mere  elementary outline
of the muscles, the biceps and triceps especially.   From the elbows the mus-
cles  of  the forearms  and hands displayed  the full development of a robust
and vigorous man of  his stature, with all the concomitant power, sensibility,
and aptitude for  use.  All  the  muscles  outside the pelvis and those  of the
inferior  extremities were full, strong, and well formed."1   A patient in Belle-
vue Hospital presents great attenuation of the arms and thighs, the forearms
and legs  retaining a large muscular development.   In this  case the muscles
of the  back  are affected, so that in walking the spine is curved backward,
and  on  raising the upper extremities  the scapula are thrown outward in a
remarkable manner, forming what has been called the " wing shoulder."  In
another case the atrophy is limited to the feet and about two-thirds  of the
muscles of the calves, the  remaining third of the latter, being unaffected.
The feet  have the  appearances of  bones covered  only  with  integument.
Cases have been reported in which the  affection extended  over  the greater
part of the voluntary muscular system.   The tongue, the  muscles of mas-
tication, the facial  muscles, and the muscles of the larynx  may be included
in the  general atrophy.  In a case cited by Thouvenel the power of mov-
ing the limbs and  body  was lost,  and the patient was able only  to  move
the head  feebly.   The tongue was involved in this case, and deglutition was
difficult.  Trousseau  refers to a case treated by Bretonneau  in which the
power of  speech and  all voluntary movements, except of the head and of the
forefinger of the right hand, were lost.   This patient, a female, held commu-
nications  with her  family by indicating letters, in this way forming words and
sentences.  She dictated in this manner her last will  and testament.   AVhen
the atrophy  is limited to  a few muscles the loss of substance  is rendered
striking by the normal size of  the adjacent muscles.  Atrophy of one class
of muscles—for example, the flexors or extensors of the  limbs—causes dis-
tortion  by the contraction of the muscles which are not affected,  the contrac-
tion arising from  the loss  of  antagonism.   Distortions  of the head, trunk,
and extremities may  be produced by the limitation of the atrophy to certain
muscles, or by the progress  of the atrophy being much greater in some mus-
cles than  in others.  The characteristic appearances belonging to the affection
give to  it a  physiognomy by which it is readily recognized in  well-marked
cases.  Among the frequent deformities may be mentioned the claw-like hand,
or main en griffe.   The first phalanges are extended, the second and third are
flexed.  This'deformity is due to paralysis of the  interosseous  and lumbrical
muscles.  In the early part of its progress the disease may escape recognition
if a close  examination be  not made.
                         1 Dublin Quarterly Journal. 
756
DISEASES  OF THE SPINAL  CORD.
   In general, the first evidence  of trouble is weakness of the  affected  mus-
cles, arising from the  atrophy.   Pain or soreness precedes and accompanies
the  affection  in  a certain proportion of cases.   Generally the pain is not
severe.   It is  referred  to the affected muscles, and is of a neuralgic character.
The affected  parts  are notably  sensitive to  cold, and their temperature  is
•below  that of other  parts.  Defective  capillary circulation  is  sometimes
shown by congestion  of  the surface.   Quivering movements  of  the fibres
of  the  affected  muscles, called  fibrillary contractions, are often observed,
and sometimes subsultus of the tendons and slight twitchings of the  parts
to which the tendons are attached.  These movements occur irrespective of
the  will, occasion no  pain,  and  the patient may not be conscious of them.
The sensibility of the  surface is  unaffected.  The  mental  faculties  remain
intact, and there are  no symptoms pointing to intracranial  disease.   The
appetite, digestion, and nutrition may continue unaffected.  There is no loss
of power over the bladder or rectum, even when the aff'ection is far advanced,
nor does the  heart become  affected.   Constipation may be produced by atro-
phy of the abdominal muscles. The affected muscles lose their electro-contrac-
tility only in  proportion as they become atrophied and degenerated; and the
fibres which are  unaffected respond to the electrical current.   For this reason
it is difficult to make out the reaction of degeneration, which is confined to the
atrophied fibres, but by careful examination it has been detected in  muscles
greatly atrophied.  This apparent preservation of electrical contractility serves
to distinguish the affection from  the wasting of muscles incident to the acute
and chronic forms of anterior poliomyelitis, which  have been considered.
   The progress  of the affection is slow.  More or less  slowly increasing, it
is thus,  as a rule, progressive, as the name implies.   This  rule, however, is
not without many exceptions.  Often it remains stationary after having pro-
gressed  to a  certain extent.  In a few cases recovery may be said to take
place ; that is, the affection ceases without leaving  any permanent deformity
or notable debility.  It may continue, slowly progressing, a great number of
years before tending to a fatal result.  The  prognosis  is extremely unfavor-
able.  The most to be hoped for is that it will cease to progress or that its
progress will be  very  gradual.   Retrogression  is not to be expected  after
much change in the  muscles has taken place.   Life  may be  destroyed by
apnaa if the respiratory muscles become affected, or by  inanition from  atro-
phy of  the muscles concerned  in deglutition.  In  other cases death  takes
place after a  long and tedious confinement to the bed if the patient  be not
carried  off by some intercurrent  disease.
   As regards duration, the following are the results  of the analysis of 105
cases by Roberts: Mean  duration of cases ending in recovery, one year and
two months ;  of cases ending in permanent arrest, two years and  three months ;
of cases ending  fatally,  five years  and two  months.   Of  the cases  which
recovered, the longest duration  was two and a  half years, and the  shortest
 eight months.  Of the cases proving fatal, the longest duration was twenty-
three years, and the  shortest twelve months.  The longest case ending  in
arrest continued active for  seven years, and the shortest for four months.
   The  diagnosis relates  to the exclusion of  other affections  which are
attended by muscular  atrophy, such as diffuse myelitis, anterior poliomyelitis,
primary neuritis, and  primary muscular affections with atrophy.  The  chief
points to be considered are  the typical onset of the disease in the small mus-
cles of the hand ; the development of the atrophy first in individual muscles,
 and even in  individual muscular  fibres, and not in groups of muscles; the
typical  extension of the  atrophy to the muscles of the  shoulder and  other
 parts; the development of bulbar paralysis in some cases; the  apparent pres-
 ervation for a long time of  electric excitability ; the absence of sensory dis- 
          PROGRESSIVE UNILATERAL FACIAL  ATROPHY.       757

turbances; and the existence of paralysis only in proportion to the degree of
atrophy.
  The causation is obscure.   The affection rarely occurs under adult age,
and it is  unusual after middle life.  Males are  much oftener  affected  than
females.   There is no connection with social condition or particular occupa-
tions.  Several members of the same family in repeated  instances have been
affected,  but most cases of hereditary muscular atrophy do not belong to the
Aran-Duchenne type.  It has been  supposed in some cases to proceed  from
undue muscular exertion.  Like most aff'ections, it is sometimes attributed to
the action of cold.
  The great object of treatment is the arrest of the progress of the affec-
tion.  The measures  for this object have reference to the aff'ected muscles
and  the  general  condition.   Undue  exertion of the affected muscles is to be
avoided,  but a  certain amount of exercise is important.   The circulation and
nutrition within the aff'ected muscles are to be  promoted by friction  and
shampooing and the use of stimulating embrocations.  As regards treatment
addressed  directly to  the  affection,  however, the  most  potential measure is
the employment of electricity.   Each of the different forms of electricity is
useful, and they may be employed in alternation.   Measures having reference
to the general  condition  are those which invigorate the powers of the system.
Here, as in  cases of progressive locomotor ataxia,  judicious management,
although it may fail to effect recovery, may do much toward retarding the
progress of the affection and prolonging the life of the patient.  The point in
the progress of the affection  at which the arrest is effected is of great import-
ance to the patient; hence the desirableness of an early diagnosis.
   In one of  the cases at Bellevue  Hospital which has  been referred to, in
which the muscles of the arm, thigh, and back are greatly atrophied, not only
has  there  been no progress of the  disease during nearly ten  years, but the
patient is greatly improved, and although the atrophied muscles remain the
same, he has been able for several years to do active duty as a  hospital nurse
and in other kinds of  labor.

            Progressive  Unilateral Facial Atrophy.
   In this rare  disease the muscles are not primarily  nor chiefly affected, but
the  atrophy  begins at  the  surface and  progresses inwardly,  involving  the
bones as well as the soft parts.  The skin is discolored and thinned.   The
beard, eyebrows, and hair on the affected side become  white  and often fall
out.  The subcutaneous fat disappears.   The muscles are more or less atro-
phied, but in a less  degree than other structures.  The bones and cartilages
are atrophied.   The atrophy may extend  to the tongue on the same side and
also to the palate and uvula.
   The disease  occurs in women much oftener than  in men, and very rarely
after twenty-five years of age.  The left much oftener than the right side of
the face is affected.
   The contrast between the two sides of the face renders the recognition of
the disease easy after it has made considerable progress.  It cannot be con-
founded with facial paralysis, inasmuch as drawing of the mouth to the oppo-
site side is slight or wanting, and  the muscular movements are not lost on
the aff'ected side.
   The disease usually  progresses very  slowly.   In all other respects  the
patient may  be  perfectly well.
   The pathogeny is undetermined.  It is yet to he settled whether the dis-
ease be primarily seated in  the affected  tissues  or whether the  atrophy be
secondary to  a  neurotic  affection.   If  the  neurotic or trophic theory be 
 758               DISEASES OF THE SPINAL CORD.

 adopted, it is not settled to what particular nerve or nerves the disease is to
 be referred.  The trifacial, the facial, and the cervical sympathetic have each
 been supposed to be especially involved.
   The disease thus far has proved intractable to treatment.  An arrest of the
 progress is all  that can be hoped for.  It must be expected that the lesions
 which have taken place will  be permanent.  The progress of the disease docs
 not endanger life, but the conspicuous deformity is not a small calamity.


    Spastic Spinal Paralysis—Primary Lateral Sclerosis.

   In 1875, Erb  described a group of symptoms as a well-defined  disease to
 which he  gave the name spastic spinal jxtralysis.  Charcot, who  had pre-
 viously recognized the main  features of the disease, accepted  Erb's descrip-
 tion, but called the affection spasmodic tabes dorsalis.   The leading symptoms
 are slowly-developing paralysis, rigidity of the affected muscles, contractures,
 and increased tendon  reflexes.   There is absence of sensory  and of trophic
 disturbances in uncomplicated cases.
   It is assumed by Erb and  by Charcot that the anatomical  characteristic of
 the disease is primary  sclerosis of the lateral columns of the  cord.  This view
 is in harmony with the teaching of Charcot,  that  sclerosis  of  the  lateral
 columns, whether primary or secondary,  is attended by  tension of the par-
 alyzed muscles.   The assumption,  however,  that Erb's spasmodic spinal
 paralysis  depends upon primary lateral  sclerosis has not as  yet been con-
 firmed by post-mortem  examinations.  Charcot himself  has  published a case
 in which  he had diagnosticated  this  disease  during life,  and the autopsy
 revealed multiple sclerosis.  A variety of  affections of the spinal cord and of
 the brain may produce the combination of symptoms described by  Erb, such
 as chronic  hydrocephalus, transverse myelitis in the dorsal or cervical region,
 tumors of  the cord, compression of the cord, multiple sclerosis, hydromyelus,
 and combined systemic diseases  of the cord.   In  these  cases the symptoms
 may be for a long time those of pure spastic paralysis, but  eventually other
 symptoms, as a rule, are superadded.  In the  present state of the  question
 it seems proper to recognize  as a distinct symptomatic affection the clinical
 picture  drawn  by  Erb, but it is necessary to await future  investigations
 before we  attempt to localize the anatomical  changes which form its  basis.
   The combination of  locomotor  ataxia with lateral  sclerosis  has been
 described  especially by A\ estphal.  In these cases there  is  an  extension of
 the sclerotic process from  the posterior  to the lateral columns.   Muscular
 rigidity is  added  to the characteristic ataxic symptoms.  Secondary lateral
 sclerosis  has been  repeatedly mentioned  already as forming the descending
 secondary  degeneration of Tiirck.
   The combination of  lateral sclerosis with anterior poliomyelitis constitutes
 the disease called amyotrophic lateral sclerosis, which will be described in the
 next article.

   From a clinical point of view the symptoms described  by Seguin in  1873,
 and called by him  " tetanoid pseudo-paraplegia," subsequently  described  by
 Erb and called  spasmodic spinal  paralysis, and by Charcot  under the  name
of spasmodic dorsal tabes, represent a distinct and  easily-recognized  para-
lytic affection.   Cases presenting its distinctive features, as  delineated  by
these  authors, have fallen  under my observation.
  A synopsis of the clinical history is as  follows:
  Incomplete paralysis (paresis) begins  in  either the  lower  or the upper
extremities—according to Erb, much oftener in the  former.  The paralysis
very slowly increases.   After having reached a certain  degree it is accom- 
SPASTIC SPINAL PARALYSIS.
759
panied by twitchings of the muscles and muscular rigidity.  The twitchings
occur in connection with voluntary movements as well as irrespective of the
will, and especially at night.   The muscular tension or stiffness is at first ex-
cited by motor acts, and, lasting for a few moments only, after a time becomes
persistent, and at length leads to a permanently rigid extension of the limbs.
  Pressure on the toes excites tremor of the foot and sometimes of  the  leg.
Tremor is excited by a rapid flexion of the foot or by pressure with the hand
upon the toes.  This symptom is called ankle-clonus (p.  7o2).  It is not, how-
ever, peculiar to this  affection.  Tremor occurring with a certain  degree of
violence, and sometimes  extending  to  the other limb, has been called by
Brown-Sequard by the inappropriate name " spinal epilepsy."   It may some-
times be  excited by mere  contact of the fingers with the skin.
  The tremor, stiffness,  and  spasmodic  twitchings added  to  the paralysis
increase the difficulty in walking, and give rise to what  is termed by Erb the
" spastic  gait," which he  thus  describes : " The  feet  seem  to  cleave to the
ground;  the tips  of  the  feet find  an obstacle in every irregularity of the
ground;  every step is accompanied by a  peculiar hipping elevation of the
whole  body ; . .  .  . the patient  immediately gets upon his toes, and steps
forward  on  them, showing a  tendency  to  fall forward.  The legs are close
together, held stiffly,  the knees somewhat depressed forward, the upper part
of the body slightly bent forward."   This mode  of walking is distinctive as
contrasted with the purely paralytic  and the ataxic gait.1   The difficulty in
walking is out of proportion to the impairment of muscular power, yet there
is no resemblance  to ataxia.
  Reflex motions are abnormally excited by percussion of the tendons, the
affection  in  this  respect offering a contrast  to  ataxia.   Sensibility remains
intact.  The bladder and rectum are unaffected.  There  is no tendency to
bed-sores.   The sexual functions may be retained.  The muscles for a long
period do not undergo atrophy.  Cerebral symptoms are absent.   The elec-
trical excitability of the muscles is slightly diminished, but there is no reac-
tion of degeneration.
  The duration of  the affection extends over many years.  It may slowly
progress  in degree, and gradually be diffused over all the extremities, or, hav-
ing'reached a certain stage, it may remain stationary for an indefinite period.
Patients  generally die from some  intercurrent  disease.  If, however, it be
otherwise, and the affection continue to be progressive, confinement to  the bed
is at length necessary.  The affection may extend to  the medulla oblongata,
and give rise to the symptoms of bulbar paralysis.  Cystitis and bed-sores do
not occur in typical cases.
  The foregoing account applies to typical cases.  The symptoms may be asso-
ciated with  those of ataxia in different  degrees.  The inference, then, is  that
the sclerosis also  embraces the posterior columns.  The affection may be  uni-
lateral, confined either to one  limb or to the two limbs on one side.  There
may occur  more  or  less speedily muscular  atrophy.   Under these  circum-
stances the affection has been described by  Charcot under the name amyo-
trophic lateral sclerosis.   This form will be noticed under a separate heading.
  The etiology of this affection is not less  obscure than  that of the other
sclerotic  affections of the  spinal cord.   In the great majority of cases the age
of patients  is between thirty and fifty.  Men are oftener aff'ected than women,
and the affection  occurs in persons apparently in  robust health.  In a typical
case which came  under my observation  the patient had suffered much from
syphilis.
 " This form of paralysis admits of a favorable prognosis as regards a fatal
termination.  Erb  states  that recovery may be  said  to have taken  place in
              1 Vide Ziemssen's Cyc. of Med., Am. ed., vol. xiii. p. 97. 
760
DISEASES  OF THE  SPINAL  CORD.
two cases under  his  observation, and notable improvement  in three cases.
The chief source of danger relating to the disease is the liability to the occur-
rence of bulbar paralysis or muscular atrophy.
   The principles of treatment are essentially the same as in the other varie-
ties of sclerotic disease.   Electricity, especially the galvanic current,  is to be
employed, and hydropathic measures may be tried with proper care and  pre-
cautions.  Strychnia is contraindicated.


                  Amyotrophic Lateral Sclerosis.

   Progressive muscular atrophy, as has  already been mentioned, may be a
primary affection  or may  be secondary to other diseases of the spinal cord.
Of the secondary or deuteropathic  forms of progressive muscular atrophy,
that designated  by  Charcot in 1S74 as amyotrophic lateral sclerosis  has
received especial  attention.   In  this disease the symptoms  of progressive
muscular atrophy are preceded by paralysis and accompanied by rigidity.  In
other words, the symptoms of lateral  sclerosis  and of progressive muscular
atrophy  are combined.  Post-mortem examinations  have revealed the lesions
of  progressive muscular atrophy (degeneration and atrophy of the ganglion-
cells of the anterior horns), together with sclerosis of  the pyramidal tracts in
the anterior and the lateral  columns.   The  antero-lateral sclerosis occupies
the same situations as in Tiirck's secondary descending  degeneration ; that  is, a
narrow, wedge-shaped tract on each side of the anterior median fissure, known
as the columns of Tiirck, and a triangular column in the posterior part of each
lateral column, known as the pyramidal tract of these  columns. (See p. 72S.)
Bands of sclerotic tissue connecting the diseased  parts of the anterior horns
with the sclerosed lateral columns  have been observed.   The microscopical
changes are  those which  have already been  described as characterizing pro-
gressive muscular atrophy and gray degeneration of the pyramidal tracts.  In
some instances  the degeneration  of the  pyramidal tracts has  been  traced
throughout their whole extent from their origin in the  cerebral cortex to their
terminations in the spinal cord.   The large pyramidal ganglion-cells  in  the
motor cortical zone have been found atrophied in these ca.ses.   The disease is,
in the majority of cases, accompanied by the symptoms and lesions of chronic
bulbar paralysis.   The primary lesion is to be regarded as degeneration,  and
not  inflammation.
   The paralysis begins  generally  in tbe  upper limbs, and  extends  to  the
lower, but in some instances the reverse is the case.   The spastic symptoms
are usually more marked in the lower extremities, and  the atrophic symptoms
in the upper extremities.  The atrophy  of  muscles generally  begins, as in
progressive muscular atrophy, in the small muscles of the hand.  In distinc-
tion from progressive muscular atrophy the  tendon reflexes of the paralyzed
muscles are increased.  In an advanced stage of the disease contractures occur.
Abnormal  electrical reaction can  be made  out  only  in  muscles which  are
markedly atrophied.  In these the reaction of degeneration is apparent,  but
in most cases this  is the so-called partial reaction  of degeneration, the electric
excitability of the nerves  being normal  or  nearly so  in  consequence of the
preservation of many nerve-fibres.   (See p. 733.)   Sensation is  intact.   There
are no  vesical disturbances.   Finally, if life be  sufficiently  prolonged  the
symptoms  of bulbar paralysis appear.
  The affection, as compared with simple spasmodic  paralysis, runs a rapid
course.   It arrives at an  advanced stage within six  months or a year,  and
death takes place in from two to three years.1
  In no instance  has recovery been known to take place.  The indications
    1 Vide Charcot, Lecons sur les Maladies du Syslcme ntrveux, Paris, 1877, tome ii. 
                COMPRESSION OF THE SPINAL  CORD.            761

 for treatment are those which belong to progressive muscular atrophy and
 to bulbar paralysis.   Irrespective of the muscular atrophy and bulbar paraly-
 sis, the treatment is the same as in cases of  uncomplicated spasmodic spinal
 paralysis.


    Compression of the  Spinal Cord—Intraspinal Tumors.
   Compression of the spinal  cord may be produced suddenly or gradually.
 Fractures and dislocations of the vertebra constitute the most frequent causes
 of sudden compression.   Their consideration belongs to the domain of  sur-
 gery.   Meningeal hemorrhage and the rupture  of aneurisms, abscesses, or
 cysts into the spinal canal may occasion rapid  compression of  the  cord.
   Of greater interest and importance is the  study of the causes  and results
 of slow compression of the  spinal  cord.   The causes are  many and  diverse.
 Of the more important may be enumerated—first, tumors  and  inflammatory
 affections of the vertebra, especially Pott's disease and cancer;  second, extra-
 vertebral tumors, such as aneurism, cancer, or abscess, which make their way
 into the spinal canal either by erosion of the vertebra or through the inter-
 vertebral foramina ; third, tumors and inflammatory thickening of the men-
 inges and of the  perimeningeal tissue ;  and last, tumors  of the  spinal  cord
 itself. ^  Tumors of the cord itself are less frequent than those of the meninges.
 They include solitary tubercle,  gumma,  glioma,  sarcoma,  neuroma, and  sec-
 ondary carcinoma (p. 41 et seq.).   Dilatation of the central canal is called
 hydromyelus, and is generally congenital.   Cavities of variable size and length
 and  more  or less centrally  located maybe  developed in  the spinal cord in
 various ways.  The name syringo-myelus or  syringo-myelia is given  to these
 pathological canals.  (See p. 713.)
   Of the tumors of the meninges and  perimeningeal tissue, may be men-
 tioned—lipoma, sarcoma, myxoma, fibroma, psammoma, gumma, enchondroma,
 secondary cancer, echinococcus, and  cysticercus cysts.   Calcific plates in the
 dura mater, and especially in the arachnoid, are not uncommon in  elderly per-
 sons, and, as a rule, produce no symptoms.  In the list of tumefactions in this
 situation which act as causes of compression  should be included hemorrhage
 and  certain chronic inflammatory processes.   Hemorrhage in the form of a
 tumor (hamatoma) may be  the result of internal hemorrhagic spinal  pachy-
 meningitis.   Of the inflammatory thickenings, that described by Charcot as
 cervical hypertrophic pachymeningitis deserves especial mention.   This affec-
 tion has already been described (p. 706).
  Of the causes of gradual compression of the cord, the  most frequent  and
 best studied is caries of the vertebrae, or Potfs disease.   Is was formerly sup-
 posed that compression of the cord was due  to the narrowing of the spinal
 canal in consequence of the angular curvature of the spine, or kyphosis, so
 frequently produced in this disease.   It is indeed certain that in rare instances
 the cord is  compressed by the displaced vertebra, but that this displacement
 is not necessarily or usually the cause is proven  by the following facts : Ex-
 treme angular curvature may exist without symptoms of compression ; these
 symptoms may be present in Pott's disease without curvature ; and the symp-
 toms  may disappear  while the  kyphosis  remains unchanged.   AVe owe to
 Michaud,1 a pupil of Charcot,  the explanation of  the mechanism of compres-
sion in these cases.   By extension  of the diseased process from the vertebra
to the perimeningeal tissue and the outer  layer of the dura  mater a peripachy-
meningitis and a pachymeningitis externa are  set up, leading to the formation
of new connective tissue and of pus, which undergo in part a caseous meta-
morphosis.  The  caseous purulent mass  thus formed between the bone and
          1 Sur la Meningile et la My elite dans le Mai vertebral, Paris, 1S71. 
762
DISEASES  OF  THE SPINAL CORD.
dura  mater and in the substance of the dura mater is really the agent of
compression.  There  may be  an extension of the inflammation to the inner
layers of the dura and to the other membranes of the cord, but  this is not
necessarily the case.
   Compression renders the cord anamic and flattened, and if protracted leads
to inflammatory changes which  present  the picture of a transverse myelitis
followed by  secondary ascending- and  descending  degenerations.  This  is
known as pressure myelitis.  In a given case  it is not always  easy to deter-
mine  how much of the disturbance  is due to  compression and  how much to
myelitis; but that  compression  often plays an important part is  proven by
the fact that  the symptoms may rapidly disappear  as soon as the cause of
compression is removed.

   It is obvious that the symptomatology in different cases of compression
of the cord must vary very much according to  the cause, the seat, the amount
of pressure, the nature and extent of the induced  changes in  the cord, etc.
Diseases of the vertebra,  as well as fractures and dislocations,  are  deter-
minable causes.  The  existence  of an intraspinal tumor can hardly be deter-
mined with certainty, and, assuming that a tumor  exists,  to  determine  its
character from the symptoms is impracticable.
   The prominent symptom  in cases of  compression  from  different causes is
paralysis, greater or less in degree (paresis) or complete.  The  extent of the
paralysis will of course depend on the seat of  the affection.  If seated  in the
cervical portion of the cord, it may give rise to general spinal paralysis.   In
very rare instances  the paralysis may be paraplegia  of the  upper limbs, the
lower limbs remaining unaffected.  If the compression  be  limited to one-half
of the cord, which  is  extremely rare, the result may be spinal hemiplegia
with  crossed anasthesia, as described by Brown-Sequard.
   Much more frequently the paralysis  has  the  form of paraplegia affecting
the lower limbs. If the spinal aff'ection be above the lumbar region, and if the
latter be not involved, reflex action is not diminished, but is often  increased.
The increase is sometimes  so great  as to occasion  severe contractures and
rigidity.  Reflex action is  diminished or lost if the spinal affection involve
the gray matter of the lumbar region.  Motor paralysis  is  often neither
accompanied by anasthesia  at  the  outset nor  after a considerable period.
The paralysis may or may  not  involve  the bladder or rectum.   Sooner  or
later, if lesions of the cord be progressive, these organs become involved, the
paralysis of motion and sensation becomes complete, and death takes  place,
as when equally destructive lesions  occur independently of tumors or the
various causes of  compression.
   Pain in the spine, in parts of the trunk below the  level  of the spinal affec-
tion, and in the paralyzed  limbs (paraplegia  dolorosa) is especially marked
in cases of cancer of the vertebra  extending to the  cord.  This symptom
may be more or less marked, however, in other forms of disease.   It is pre-
sumptive evidence  of  an  intraspinal  cancerous tumor that prior to the affec-
tion of the cord cancer existed  in some other situation.  That an affection
of the cord is  syphilitic is  to be suspected whenever  the  patient has had
syphilis; and  with  reference to treatment it  is very important to seek for
evidence of syphilis, although the existence of this disease be  denied by the
patient.  It is to be  considered that women  may have been  affected with
syphilis without any  suspicion on their part  of the nature of the disease;
and there are instances in which the physician must derive his  knowledge on
this point wholly from what he is  able to observe  without exciting by his
questions any suspicion  in  the  mind of the patient.
   It is  an  important  practical  fact that the  spinal cord may tolerate com- 
PSEUDOHYPERTROPHIC  PARALYSIS.
763
pression  sufficient to cause paralysis for a long period without  disorganizing
changes.  This is shown  by the  immediate disappearance of paralysis from
displacement of vertebra, in  some cases after it had existed for  years.
  The prognosis, of course, varies in individual cases according to the nature
of the tumor and the different causes of compression ; but  inasmuch as the
nature, of intraspinal tumors is rarely determinable  with anything  like pre-
cision, an opinion in cases of tumor concerning the probable course and  ter-
mination must have another basis.   In general, the  prognosis is unfavorable
in proportion as motor paralysis is progressive, as sensation is impaired, reflex
excitability diminished, and as atrophy of the muscles takes place; in other
words, in proportion as  the symptoms denote destructive lesions of  the cord.

  In  cases of pressure from  displacement of vertebra, recovery from  paral-
ysis or more  or less improvement may be expected from  measures to remove
the cause of  compression.  In another work I have cited a case in which a
patient who had been confined to the bed with  paraplegia  for three  years,
having suffered greatly during this period from pain and reflex  muscular
action, immediately recovered the use of his  limbs  under the  treatment  by
Prof.  Sayre  according to his method of suspension and encasing the body in
a plaster-of-Paris jacket.1  This  method  secures extension of the spine  and
renders the spinal column  immovable—objects of prime importance in cases
of existing displacement and  disease of  the vertebra leading thereto.  As a
means of securing rest it may be found to have a wider  extent  of useful
application than  has  as yet been demonstrated.
  The syphilitic alone, of the different  tumors,  offer encouragement in  the
way  of  medicinal treatment.  Antisyphilitic  medication sometimes  accom-
plishes much, and it should be employed whenever  there is ground for  the
suspicion that  the spinal  affection maybe due  to  syphilis.
  In  other respects the treatment indicated is essentially  the same as in cases
of chronic primary spinal meningitis and myelitis.

      Pseudo-hypertrophic (or Myo-sclerotic) Paralysis.

  The characteristics of this  affection were first pointed out by Meryon in
1858. It was,  however, more fully described and its  nosological individuality
established subsequently by Duchenne.  The affection is peculiar to infancy
and childhood.   It has been known, however, to  occur at the age of twenty-
six years.  In a number  of instances the  disease has affected  several mem-
bers  of  the  same family,  the males oftener than the females.
  The distinctive features are increase of the volume of  certain muscles  and
diminished motor power.   The muscles of the lower limbs are  generally  first
affected, especially the  gastrocnemii or the glutei.  Subsequently  the affec-
tion may extend "to the muscles  of the  trunk  and of the upper extremities.
Corresponding  muscles on  the two sides may be affected,  but there are many
exceptions to this rule of symmetry.   Not infrequently the affected muscles
are irregularly distributed and  the affection  may be limited to portions of
muscles.  The increase of volume may be considerable,  and the enlarged
muscles are  in striking contrast with those not aff'ected.
  The anatomical changes in the  affected muscles  are—hyperplasia of the
areolar tissue, an accumulation of adipose tissue between the muscular fibres,
and atrophy  of the latter.  As regards its pathological  character the disease
belongs in the  category of sclerotic or cirrhotic affections.   The enlargement
of the muscles denotes "false hypertrophy."
  The structural changes involve  diminution of motor power proportionate
                     1 Vide Clinical Medicine, 1879, p. 560. 
764
DISEASES  OF  THE SPINAL  COLD.
to the compression  and consequent  atrophy of the muscular fibres.   Seated
in the muscles of the lower limbs,  the  aff'ection causes a peculiar waddling
gait, the limbs in  walking being widely separated.  If the extensor spinal
muscles be  affected, a lumbo-sacral  anterior curvature  takes place when  the
posture is  upright.   Frequently, the affection  predominating in the flexor
muscles of  the foot,  talipes  equinus is a result of  the greater action of
the extensors,  and with this is  a claw-like deformity of the toes.   After
having  reached a certain degree  and extent, the affection may remain sta-
tionary for several years;  but at  successive epochs it is likely to increase and
to become more and  more  diffused, until  patients  are  reduced to a helpless
condition.   The progress  of the  affection  is unattended  by pain.  There is
neither  hyperasthesia nor  anasthesia.  The functions of the bladder and
rectum are unaffected.  In  an advanced stage the electro-contractility of  the
affected muscles  is notably diminished or  lost, but there is  no reaction of
degeneration.   In a case  reported by Dr. Balthazar Foster, after the lapse
of five  years the volume of the affected muscles became as much reduced as
it had previously been increased.
   It has been a pathological question whether  this disease be a purely myo-
pathic affection or whether it be primarily neuropathic.  In a number of typ-
ical cases no lesion  has been found  in the  spinal cord, so that the weight of
evidence is in  favor of the view that pseudo-hypertrophic muscular paralysis
is due to a primary affection of the muscles of  the nature described.
   As regards the prognosis, a case reported by Benedikt is cited by Jaccoud
in which a  cure was  effected  by galvanism.  Experience, however, thus  far
affords little encouragement to expect a cure from any measure of treatment.
Electricity  should be  faithfully tried.  By measures having  reference to the
general  condition of the patient the  affection may perhaps he prevented from
progressing, and there may  be more  or less improvement.  The disease rarely
destroys life per se, death being due to some intercurrent affection. The dura-
tion  in  13  cases  in which  the termination was  ascertained, out of 85 cases
analyzed by Dr. C. T. Poore, varied between two and  thirty years.1


                     Scleroderma, or  Sclerema.

   The affection called scleroderma or sclerema, also sclerodermia and sclere-
mia, may be here noticed, as it is analogous, in  its pathological character and
in certain of its effects, to the disease just considered. Other terms than those
already  given have been applied to it—to wit, scleremus, scleria, sclerosis, scle-
roma, and sclerymus, all derived from the Greek word avArjpas (hard). Its ana-
tomical characteristic is the production, in the lower portion of and beneath the
skin, of dense fibrous tissue in great abundance.  This renders the integument
notably rigid and resisting  to pressure.   It is closely  adherent  to the mus-
cles.  It cannot be  moved over the muscle  or pinched up in folds.  The mus-
cles are restrained in their movements by the density of the structures above
them, as if  a  firm  bandage were  closely applied.   More  or  less wasting  of
the muscles is caused by the pressure.  Pigmentary matter is in most cases
deposited in the cells of the rete mucosum, producing a  discoloration which is
yellowish, yellowish-gray, or dark-brown, and more marked in some situations
than in  others.  These  changes may be either limited to certain parts or dif-
fused over the whole surface, but they vary in amount in different places.
   The affection is extremely rare.  A case under my observation was reported
by Dr. AValter De F. Day in the American Journal of Medical Sciences. April,
1870.  Dr. Day was able to collect for analysis reports  of only 33 cases, and
the case reported by him was the seventh on record in which there was an
                   1 Nciv York Journal of Medicine, June, 1875. 
MYXCEDEMA.
765
examination after death.   The  affection is not to be confounded with that
called by some  writers acute sclerema, which is peculiar to infants.  The
latter is a variety of adenia.   The aff'ection under consideration occurs gen-
erally in middle  life.  It occurs  much  oftener in  women than in men.  It is
a chronic affection, usually beginning insidiously  and progressing slowly, but
exceptionally it may be developed rapidly with a sudden invasion.  The upper
part of  the body is oftenest first affected, but it may appear primarily in any
part,
  The affection is not necessarily associated with disease of any of the internal
organs,  and if uncomplicated it is not incompatible with good general health.
Existing in a notable degree,  it obstructs muscular movements by mechanical
pressure and restraint, leading at length to more or less impairment of motor
power, by inducing atrophy.  The surface is usually cool or cold, but the heat
at times may be greater than normal.   Sensibility is not impaired, and per-
spiration continues.  The duration is variable.  It may  continue for months
and  years.  A fatal termination is due to some complication or intercurrent
affection.  It continues  in some  cases  indefinitely without  improvement, and
in other cases more or  less improvement takes place without  recovery, but
complete recovery may  be hoped for:   The number of cases  reported is, as
yet,  too  few  to  determine the ratio of recoveries.
  A'arious measures of  treatment were employed in the cases which have
been  reported.   It remains to be ascertained what are the remedies, if there
be any, which exert a  curative effect.  In the  case under my observation
arsenic  was given for some  time, and  it seemed  to be of service, but in this
case there occurred grave complications—namely, pleuritis, pericarditis, and
peritonitis.  An  analeptic course  and tonic medication are rationally indi-
cated, together  with alkaline baths and emollient applications to the skin.


                             Myxcedema.
  This  remarkable  affection, which was  first described in 1873  by Gull,
received the  name myxcedema  from Ord, to whom we owe  the  most com-
plete study of the disease which  has hitherto been  made.  The disease is
characterized by an infiltration  of the connective tissue  of the body with a
gelatinous fluid  containing mucin.
  Nothing is positively  known concerning the causation.   The disease has
been  observed more frequently in women than in men.   It occurs in adult
life, rarely at any other period.  In a certain number of cases it has followed
pregnancy.   Mental distress has been thought by some writers to be an ele-
ment in its  causation.  The disease seems to be  more common in England
and  in  France than elsewhere.  In this  country  only a few cases have been
reported.
  But little is accurately  known of the morbid anatomy.  In the few post-
mortem  examinations which have  been made the connective tissue of the
skin and the  subcutaneous tissue are richly infiltrated with a jelly-like mate-
rial  containing mucin.   According to Ord, the fibrillar and  cellular elements
of connective tissue are increased.   This mucous infiltration and new growth
of connective tissue are not confined to the skin,  but they affect the mucous
membranes, the  glands, the muscles, the nervous  system, and, above all, the
outer coat of the arteries.  The thyroid gland has been found atrophied, a
condition also observed during life in many cases,  but not in all.  In the late
stages of the disease the  cortical substance  of the kidneys is atrophied—a
condition which  may be  secondary  to the changes in  the arterial  walls.
  The peculiar adenia begins generally in the  face, producing a characteristic
physiognomy.   The eyelids, the lips, the ala nasi, the cheeks—in fact, all of 
766
DISEASES  OF  THE SPINAL CORD.
the features—are swollen.  The adema which causes the swelling differs from
ordinary adema in its firmness and resiliency.   It does not pit on pressure
and does not gravitate.  The face acquires a dull, expressionless appearance,
with an absence of all the finer lines of the features.   The  adematous  skin
has an  anamic, alabaster-like appearance, with the exception of the cheeks,
which  present reddish spots or  a more diffuse  dull pinkish hue.
  Next to the  face, the hands are most markedly affected with the  mucous
adenia.  They  become swollen and shapeless, an appearance which has been
described by Gull as " spade-like."
  The  same condition as  that affecting the face and the hands may extend
over the whole  body, so that the skin everywhere is swollen.
  The  skin is usually dry and rough in consequence of the absence  of per-
spiration.
  As already remarked, in a large proportion of  cases the thyroid bodies are
atrophied.  Ord mentions also the  occurrence of tumefaction, with  marked
resilience  of the skin, just  above the  clavicle.
  In the majority of cases there are nervous symptoms no less*characteristic
than the mucous adenia.  For a long time these symptoms  consist only in a
progressive hebetude affecting all mental and physical actions.  The  mental
processes are slow and labored, but they  may be for  a long period  correct.
Speech  is  slow and conducted with a monotonous, and often hoarse, voice.
All muscular movements require a long time in their execution, and they are
often attended  with  a slowness of co-ordination  which may suggest  ataxia.
Sensation  is normal, save  a certain tardiness in perception.
  After a  time  mental aberration is likely to appear, and this  is manifested
in various  forms of insanity attended  with hallucinations.
  Ord  speaks  of the frequent occurrence  of two subjective  symptoms refer-
able to the special  senses—namely, a persistent unpleasant  taste and a per-
sistent  unpleasant smell.   In some cases the occurrence of salivation has
been noted.
  The  hair often falls out,  and  the  teeth frequently decay.   The appetite
may be normal, but after a time it is  generally disturbed.   There is  usually
anamia, which  may be very profound.   Albuminuria is common only in the
later stages of the disease.   The bowels are generally constipated.  There is
not only a subjective  sensation of coldness, but the  temperature of the body
is actually  lowered, ranging from 94° to  98°.  Sometimes there is a  difference
in the surface-temperature of the two sides of  the body.
  The  duration of the disease is long, varying between three and  twenty
years or more.   The prognosis is unfavorable, but instances of  improvement
are not uncommon, and cases of recovery have  been  reported.  Death may
be due to  gradual exhaustion, to uramia, or to  some  complication.  Bulbar
paralysis has been  observed as  a complication.
  There are various theories as to the nature of the disease, but they are all
very hypothetical. A plausible assumption is that myxadema is due to some
trophic nervous  disturbance; but attempts to define  the nature of the  tropho-
neurosis have not been successful.  Some  have  surmised disease of the sym-
pathetic system, others disease of the medulla oblongata.
  Of considerable interest is the possible relation  between  myxadema and
atrophy of the  thyroid gland.  The facts bearing upon this relation are  as
follows: Extirpation of the  entire thyroid gland in human beings for goitre
has in  some cases been followed by a peculiar cachexia, with mental disturb-
ance, and  even  with  firm adema.  This cachexia has been called cachexia
strumipriva.  The extirpation of the  entire thyroid gland in dogs is nearly
always fatal.   Horsley has produced by the extirpation of the thyroid gland
in monkeys profound anamia and an  adema similar to  myxadema.   The 
FUNCTIONAL DISEASES  OF THE BRAIN  AND SPINAL  CORD.  767

affection  known as cretinism bears some resemblance, particularly in the
mental symptoms, to myxadema, and  cretinism seems  to be  in  some way
connected with disease of the thyroid  gland.  Finally, myxadema  is often
associated with atrophy of the thyroid  gland.   These facts lend  some sup-
port to the hypothesis  that there may be some  causative connection  between
myxadema and atrophy of the thyroid gland, but in what this connection
consists we  are  wholly ignorant.
  In the treatment of myxadema the prolonged use of jaborandi has been
found in a few cases to have a favorable  influence over the disease.  From
ten  to sixty minims may be  given  four  times daily.  Arsenic, nitro-glycerin,
and chalybeate preparations are recommended.   Patients should be protected
against cold, and  the diet should be ample and nutritious.  Baths and fric-
tion should enter into the  treatment.
                         CHAPTER   V.

FUNCTIONAL  DISEASES OF  THE  BRAIN AND SPINAL CORD.

Coma.—Saturnine Encephalopathy.—Vertigo and Meniere's Disease.—Paralysis, Remarks
   on.—Treatment  of  Functional Paralysis.—General  Paralysis.—Hemiplegia.—Para-
   plegia.—Acute Ascending Paralysis.—Nervous Asthenia, or Neurasthenia.—Spiual
   Irritation.

   FOLLOAAMNG the inflammatory and structural diseases  of the brain and
     spinal cord, certain functional  affections referable to these central  parts
of the nervous system may be more advantageously considered as forming a
separate group than as included among the neuroses, which will  occupy the
concluding chapter of this  section.   The  group  will  embrace the  following
affections : coma, saturnine  encephalopathy, vertigo, general  paralysis, hemi-
plegia, paraplegia, acute  ascending paralysis, nervous  exhaustion or neuras-
thenia, and spinal irritation.
   It is to be  understood, here and elsewhere, that the term  functional is used
provisionally, in  a conventional  sense, to distinguish diseases without any
established anatomical characters.   In a  literal  sense a  purely  functional
disease  probably  has no existence.   In other words, disturbance of function
always  involves some anatomical change ;  but in the diseases which, for the
sake of convenience, are distinguished as functional either anatomical changes
have not been ascertained or their pathological connection with these diseases
is doubtful.
   Mental disorders are properly embraced among the functional affections of
the brain.  They  do not usually enter into the course of instruction in the
Principles and Practice  of Medicine.   They  are, however,  to  be included
within the range of the studies of the physician.   Lectures and treatises are
devoted specially to these disorders, and  their management constitutes one
of the specialties of medical practice; but all practitioners are called upon to
treat affections of the  mind falling short  of well-marked  insanity.  Melan-
cholia  and hypochondriasis in their lighter grades—that is, not amounting to
insanity—come constantly under  the notice of  the physician in general  prac-
tice.   Want  of energy, lack of buoyancy, mental apathy,  and inertia  often 
768  FUNCTIONAL DISEASES OF THE BRAIN AND SPINAL CORD.

exist without any obvious disease.   The physician should consider  these as
generally denoting corporeal ailment; and this should be impressed upon the
minds of patients, since they are thereby led to reformations and measures of
management  which will  be  likely to afford  relief, and are better enabled to
strive against the depressing influence  of mental disorder.  A vast amount
of unhappiness is due to causes  which under intelligent medical direction
may be  removed, or to  functional morbid  conditions which judicious treat-
ment may  relieve.   It  is a grave error to attribute disorders of the mind
exclusively to mental causes.  These few remarks open up a subject  of great
importance.   Insanity is to be prevented by the general  practitioner.  They
who devote themselves to the treatment of the  insane have not the oppor-
tunity  of preventing the development  of insanity.
  The study  of mental  disorders is  important to the physician as involving
questions of medical jurisprudence.   The existence or otherwise of  insanity
sufficient to require or warrant confinement in institutions for the insane, the
exemption of responsibility for criminal acts, incompetency to perform legal
obligations, to take care or dispose of property, etc., are practical questions
concerning which  physicians  are called upon to  give  testimony ;  but for
information  bearing  on these questions  the student and practitioner  are
referred to works treating of disorders of  the mind and of medical juris-
prudence.

                                 Coma.

  The term coma expresses a state of unconsciousness from which the patient
either cannot be aroused or is aroused with more or less difficulty.  It is cus-
tomary to apply this term to extreme degrees of unconsciousness, more cor-
rectly expressed by the  terms  lethargia  and  carus.  The latter term denotes
a degree in which the patient cannot by any efforts be aroused.   This degree
is generally called profound coma.  Sopor expresses an abnormal degree of
somnolence, or moderate coma.   A patient  in this state is often said  to  be
semi-comatose.  Coma differs from  normal  sleep qualitatively  as  well  as
quantitatively.  Sleep is  a  physiological event  of  essential importance to
the welfare of the  economy.  Coma is a pathological condition from which
the system derives no benefit.   It follows that coma is never a substitute for
sleep.
  Coma is a symptom occurring in most of those  diseases of the brain which
have been considered—namely, hyperamia and anamia of the  brain, throm-
bosis and embolism, cerebral and  meningeal hemorrhage, meningitis, enceph-
alitis, and tumors.  In all these affections, except perhaps active hyperamia,
the rationale of the  coma is a diminution of the supply of oxygenated  blood to
the brain-substance.  Coma may  be an effect of cerebral anamia (ischamia)
due  to  impoverishment  of the  blood and  enfeebled circulation,  as in  the
hydrencephaloid affection first described by Marshall Hall. (Aide  p. 649.)
Coma is a pathological element in certain of the neuroses which remain to be
considered—namely, epilepsy, hysteria, and catalepsy.  It is an incidental event
in various diseases  exclusive of those of the nervous system ; examples of
which are acute  and chronic  affections  of the kidneys, acute yellow  atrophy
of the liver, pernicious intermittent fever, scarlet  fever, smallpox, typhus and
typhoid fever, etc.   It  may be produced by such toxic agents as opium and
other narcotics,  alcohol, ethers, chloroform, etc.  The sudden loss  of con-
sciousness at  the instant of the  attack in  epilepsy is attributed to  cerebral
anamia caused by spasm of  the arteries  within the brain.  Of the other
instances,  the causation of the coma involves  a  toxical agency certainly in
some, and probably in most  if not in all cases.  The nature of these agents 
COMA.
769
 in the general  diseases just  named and their modus operandi are not under-
 stood.
   There are cases of coma not connected with any of the foreo-oin-*- diseases
 and not clearly referable  to any known morbid condition of the brain.  The
 coma is then to be considered and treated as an  individual affection.  It is
 of course, in these as in other cases merely a symptom, but  the pathology!
 and perhaps the etiology, are unknown  or  conjectural.   The coma may^be
 greater or less in degree,  sometimes not exceeding stupor, and sometimes so
 profound as to constitute  carus.   It may occur suddenly,  constituting  a
 veritable  apoplectic attack, or it  may be developed more or less slowly. & It
 may last  for a few hours or  it may continue for several  days.   It may end,
 sooner or later, either in death or recovery.
   In fatal cases morbid conditions may be found  after death which were not
 determinable during life ; examples are—thrombosis of the basilar artery or
 of the  longitudinal sinus and meningeal  hemorrhage.  The  two former of
 these  conditions not  many  years since would have escaped  recognition  as
 causes of the coma; and so further developments in  pathological  anatomy
 may furnish an explanation, post-mortem, of cases in which adequate morbid
 appearances are not now discoverable.  In the progress of etiology, too, toxi-
 cal agents causing  coma may be discovered, of which now nothing is known.
 This is not an unreasonable expectation, in view of  the  fact that urea and
 cholesterin have only  within a few years  been recognized as coma-producing
 principles.
   Coma in some instances seems attributable to cerebral exhaustion ; that is,
 it follows prolonged or excessive mental activity in conjunction with impaired
 nutrition  and general  debility.  It must be confessed  that the term cerebral
 exhaustion does not  embody any clear  idea  of the  pathological condition
 which the coma represents, but it has a practical significance  in relation  to
 the causation  and treatment.   Of course,  in deciding that  coma is to be
 regarded as a functional affection the various diseases  and determinable mor-
 bid conditions with which it  is known to have pathological connections are to
 be excluded.   Recognizable internal toxical agents, e. g. urea, and those which
 are external, e. g. opium, alcohol, etc., are  also to be excluded.   The diagnosis
 involves a careful investigation of  the causation in these different directions.
   Assuming a case in which the pathology and etiology are not determinable,
 the prognosis and treatment must be based upon circumstances pertaining to
 the coma.   Other things being equal, the prognosis is unfavorable in propor-
 tion to the  degree  and duration  of  the  coma.   If  the  patient cannot be
 aroused sufficiently to open  the eyes or  protrude the tongue, the danger is
 great, and it increases  with the continuance of the comatose state. AVhen the
 ability to  swallow is lost a fatal  ending is  to be expected.  Per contra, if the
 coma be moderate in degree the prognosis is favorable.   Absence of paraly-
 sis, the temperature of the body not increased, mobility of the iris, the pupils
 neither contracted nor dilated and equal in size, the ophthalmoscopic appear-
 ances normal, the respirations quiet and of regular rhythm,—these are points
 of importance in the exclusion of grave cerebral diseases and in their bearing
 upon a favorable prognosis.
   The treatment  is to be governed by the symptomatic indications in indi-
 vidual cases.   These  rarely, if ever,  point  to depletion by bloodletting or
 other depressing measures.   The opposite treatment  is  usually indicated by
 feebleness of the circulation  and general  debility.  Supporting treatment is
 especially indicated in  feeble subjects and when cerebral exhaustion is an
etiological factor.  It might prove a serious error, under these circumstances,
to pursue  therapeutical measures on the supposition of the existence of cere-
bral meningitis or hyperamia.
       49 
770  FUNCTIONAL DISEASES OF THE  BRAIN AND  SPINAL  CORD.

  The propriety of counter-irritation is doubtful.  Rest, alimentation, nerve-
tonics, and the judicious employment of wine or other alcoholics are the
measures  which generally meet  the indications present.


                    Saturnine Encephalopathy.

  A rare  form of poisoning by lead is characterized  by cerebral disturbances
of a grave character—namely, coma, convulsions, and delirium.  These three
events are combined in  a considerable  proportion of cases.  An attack  may
occur either  abruptly or after certain  premonitory symptoms.  These are—
headache, vertigo,  ringing in the  ears,  and in  some  instances amaurosis.
Other  manifestations of lead-poisoning—paralysis, arthralgia, colic—may or
may not precede the encephalopathic attack.   The coma is  more or less pro-
found.  In favorable cases it disappears after having continued for one or
two days.  In unfavorable cases  it increases in degree  and continues until
death.   The convulsions are epileptiform in   character (eclampsia vel  epilep-
sia  saturnina).   Paroxysms lasting from five to twenty minutes occur after
variable  intervals.   The delirium is in some cases active and violent, and in
other cases  hilarious.   It is sometimes  characterized by hallucinations of
sight and hearing.  Either of the three events may  be predominant.  Coma
and convulsions in some  instances occur without delirium, and coma between
the paroxysms of convulsions is sometimes wanting.   Amaurosis, if it do not
precede, is likely to accompany, the attack.    The amaurosis  is not caused by
retinal changes, and the ophthalmoscope shows the normal appearances.
  A satisfactory pathological explanation of these effects of  lead-poisoning
cannot be given.   They have been attributed to anamia of the brain from
changes in the minute cerebral arteries, to adema of the brain from increased
arterial pressure, and to  the direct  irritation  caused  by the presence of lead.
Uramia  is probably a  pathological  element in some cases.   The  urine is
diminished in quantity, and has been found to contain albumen.  The effects,
however, are  not  in  all  instances referable to uramia, inasmuch as the evi-
dence of diminished elimination of urea is not always present.  Heubel has
produced  similar  effects in dogs by poisoning them with lead, and this is one
of the recognized causes of the so-called  gouty or small, granular kidney.
  The prognosis is grave in  proportion to the frequency and violence of the
convulsions, together with the degree and  continuance of  the coma.   The
rate of mortality has not been  definitely ascertained, but the  proportion of
fatal cases is large.
  There  is little  to be  said with reference  to the treatment.  Depletory
or debilitating measures are  contraindicated.  If  should be ascertained, by
examinations of the urine, how far uramia  may be a factor in causing the
coma and convulsions.   Hydragogues and sudorific measures are indicated if
there be ground for supposing that there are symptoms of the  accumulation
of urea in the blood.  The inhalation of  chloroform  or the administration of
the chloral hydrate may be resorted to in order to  control  the convulsions.
The iodide of potassium  should  be  given to the  extreme  of toleration.


                    Vertigo—Meniere's Disease.

  Aartigo is a symptom occurring in various  cerebral diseases, and also when
it is to be regarded  as an  individual functional affection.   In this article it is
considered as a functional affection and  as a symptom of Meniere's disease.
It occurs  as a paroxysmal affection.   A  person  seemingly, perhaps, in good
health  suddenly becomes giddy, surrounding objects  appear to be revolving,
or the person seems to  himself  to  be performing movements of  gyration, 
VERTIGO.
771
which, according  to  Charcot, always appear to be from the left to the right.
The sensation is  like that caused by long-continued rotatory movements of
the body.  If the vertigo be moderate or slight, it simply renders the person
unable to walk steadily.   He reels like a drunken man.  In a greater degree
walking  is impossible, and there may be inability to stand  without support.
In some instances the patient falls, but without loss of consciousness and
without  muscular spasm of either the facial or other muscles.   The attack
is  accompanied by a sense of prostration, which, however, is due in no  small
degree to apprehension.  Nausea is a frequent  symptom, and vomiting some-
times occurs.  The paroxysm varies much in duration in different  cases.
It may last for a few moments or the vertigo may continue for hours and
days.
   Successive attacks recur after variable intervals.   Days, weeks, or months
may intervene.  In some cases vertigo for a certain period may be produced
by slight exciting causes, such as any intellectual  effort, sudden  muscular
exertion, looking  upon a  bright light, etc.  A patient may be exempt while in
the recumbent posture, but he may experience vertigo whenever the attempt
is made to sit up  or  stand.   For  this reason patients sometimes keep the bed
for a  long period.
   Attacks of vertigo generally give rise to great apprehension.   The patient
fears  that apoplexy, paralysis, or a fit of some  kind is impending.  If  the
apprehension  be  not removed by  positive  assurances from  the  physician of
the absence  of danger,  it may lead to a  distressing state of despondency.
The patient  is afraid to walk or to he left alone, and all  public assemblages
are avoided, lest  something  may  happen to him to  excite disturbance.  In
a  case  which has been  under my observation the patient, a gentleman in
middle  life,  notwithstanding  assurances of the  absence  of  danger, has  for
many years been  constantly  attended by either a  relative  or a servant,
although a long period has elapsed since an attack occurred and his health
is excellent.   This state of anxiety has repeatedly, in cases under my obser-
vation, continued  for months and  years. The physician is fully warranted in
giving positive assurances  that these attacks of vertigo are devoid of danger.
Of a large number of cases which I have observed,  in no instance  has apo-
plexy, paralysis, epilepsy,  or any  serious affection  followed.   It is an unfor-
tunate error to state, as  is done by some writers, that vertigo  is premonitory
of the cerebral affections just named.   The needless apprehension of patients
is sometimes  encouraged by the fact  that it  is  shared by the physician.   I
have  met with cases  in which danger of apoplexy and paralysis has been
represented to the patient.   Charcot  relates a  case in which the attacks were
confounded with  epilepsy, The patient  having for  a long time been under
treatment for that disease.   Assurances  of the absence  of danger may do
much good,  not  only by removing needless apprehension, but in the way of
effecting a cure;  for the mental anxiety occasioned by the attacks  increases
the liability to their recurrence.
   Of the pathology of vertigo more  cannot be said than that it represents a
functional cerebral condition.  Its etiological relations are better understood.
A French writer, Meniere, in  1861 pointed out the supposed connection of
a  disease characterized by deafness and vertigo with an affection of  the semi-
circular canals of the internal ear.   Subsequent clinical observations^ have
established this  causation in a certain proportion  of cases.   The  vertigo is
not infrequently preceded and accompanied by  tinnitus aurium, sometimes
referred to one ear and sometimes to both  ears.  Sudden deafness  in one ear
or in both ears has  been observed to  be coincident with the attacks of ver-
tigo.   The attacks have been found to cease on the cure of suppurative  otitis,
and even on the  removal of an accumulation  of  wax or a foreign body from 
 772   FUNCTIONAL DISEASES OF THE BRAIN AND SPINAL CORD.

 the meatus.1  The most rational explanation is that a reflex influence exerted
 upon the brain emanates from the aural organs.   The affection in these cases
 is now known as Meniere's disease.
   All cases of functional  vertigo are not cases  of vertigo  ab awe Isesa.  In
 perhaps the larger proportion there is no evidence of aural disturbance.
 Dyspeptic ailments appear to be causative in  some cases, but not constantly
 as contended by Trousseau, who  called the aff'ection stomachal vertigo (ver-
 tigo a stomacho Isesd).   It  is sometimes  fairly attributable to prolonged over-
 tasking of the mental faculties and  anxiety of mind.   Excessive venery, the
 immoderate use of tobacco, and intemperate indulgence  in coffee or tea have
 a causative influence.  It may be incident to the debility which remains after
 convalescence from  a  severe disease; for example, typhoid fever.   DaCosta
 attributes  it in  some  cases to  lithamia (uricamia).2
   The treatment involves, as the first  and most important measure, removal
 of the  supposed cause or causes.  The ears  should be carefully  examined
 with  reference  to removable morbid conditions.   Measures  addressed to
 cerebral congestion—namely, bloodletting,  counter-irritation, purgation,  and
 reduced diet—are  hurtful.   On  the  contrary, tonic remedies, a nutritious
 diet,  and hygienic means  of invigorating  the  general  health  are  generally
 indicated.   The practioner should bear in mind the  importance of assuring the
 patient positively of the  absence of all danger.   This will sometimes do much
 toward  the cure.   A cure is often soon  effected, but in some  cases the dis-
 order persists for a long  time.   Charcot  extols the efficacy, in cases of aural
 vertigo, of quinia given in full doses (20 grains) for several weeks.


                   Paralysis—General Remarks.

   Paralysis is an important symptomatic event in the clinical history of dif-
 ferent cerebral and spinal  diseases which have been  already considered.  It
 is  not always referable to either an  inflammatory or a structural disease, and
 it is then to be distinguished as functional.
   By the term paralysis is understood either the loss or an  abnormal diminu-
 tion of  voluntary power over  muscles.   The term is  also applied to the loss
 or a diminution  of sensibility.  The latter is sensory and  the  former motor
 paralysis.   Sensory paralysis, however, is expressed by the  terms ansesthesia
 and analgesia; the first relating to the sensibility to touch,  and  the second to
 the sensibility to pain.  Analgesia may exist without anasthesia.  A patient,
 for example, partly under  the influence  of  chloroform or ether, may feel the
 cutting of  the knife in  a  surgical operation, but  without  any sensation of
 pain.   On  the  other hand, the loss  of sensibility to touch (anasthesia) car-
 ries with it the loss of sensibility to pain (analgesia).   Cutaneous  analgesia
 is  ascertained, clinically, by pinching or pricking the skin.  Anasthesia is
 ascertained  by measuring  the distance from each other at  which two points
 in contact with the skin  are recognized.   An instrument devised for this pur-
 pose, called the asthesiometer,  may be used, but the common compasses used
 by the draughtsman will answer as well, and, if these  be  not  at hand, two
 pins will suffice.    The farther  the  two points of contact must be removed
from each other  in order that  each may  be  separately felt, the less the sensi-
 bility to touch.  The sensibility is undiminished if the patient be able to feel
two points of contact approximated as closely as they are when appreciable in
 health.   The sensibility  to touch differs  in different parts of the body consid-
 erably in health.   It is most acute on the prolabia, the tip of the tongue, and
  1 Vide "A Clinical Analysis of the Inflammatory Affections  of  the Inner Ear,''by
H. Knapp, in Archives of Ophthalmology, 1871, vol. ii". No. 1.
  2 Vide Am. Journ. of Med. Sciences, Oct., 1881. 
PARALYSES.
773
 the ends of the fingers.  These normal differences are to be taken into account
 in judging of anasthesia, and also variations within normal limits in different
 healthy persons and in corresponding situations on the two sides of the body
 Moderate deviations from the average degree of sensibility, as thus tested  or
 from an exact uniformity of the two sides, are  not to be considered as  abnor-
 mal  without corroborative  evidence of  sensory paralysis.
    Motor paralysis is expressed by the term akinesia or akinesis.  The term
 paralysis, however, is  generally used instead of this term, and  if not desig-
 nated as  either sensory or  motor the latter is understood.   Paralysis may
 affect either the voluntary or the involuntary muscles.   The heart, oesoph-
 agus, stomach, intestines, bladder, and  arteries  may  be the seat of akinesia
 This  pathological  condition  enters into the consideration of  these  organs  in
 other sections of this work.
    Under the name erythromelalgia Dr.  S. Weir Mitchell1 first called attention
 to an  affection characterized by vaso-motor  paralysis of the vessels of the
 extremities.  Males more  than thirty-five  years of  age  are most frequently
 affected.   The  symptoms are burning pain in  the feet, rarely in the hands,
 accompanied by flushing and congestion of the  part,  which may be somewhat
 swollen.  The temperature of the part  is increased.   The sensation is normal
 or it may be sometimes increased.   There are no trophic troubles.   Erythro-
 melalgia is an interesting counterpart to the disease  known as local asphyxia
 or symmetrical gangrene, which is caused by vaso-motor spasm.
    Paralysis is complete when there  is total loss of voluntary power over the
 paralyzed muscles.  It is incomplete when this  power is not "entirely lost, but
 is  more or less diminished.   The term paresis is often used in  a sense equiva-
 lent to that of incomplete  paralysis.   Incomplete paralysis or paresis differs
 in  different cases, between the slightest appreciable impairment of the normal
 motor power and  a degree approaching as closely as possible completeness.
 Paralysis is general when  it embraces the muscles  of the four  extremities,
 either with or without the muscles of the face.  It is partial  when a portion
 of the muscular system is involved, as in hemiplegia and paraplegia.  It  is
 local when  a very few muscles, or perhaps a single muscle only, are paralyzed.
   Paralysis may be neuropathic or  myopathic.  A myopathic paralysis depends
 on a  primary morbid  condition of the muscles paralyzed.   A  neuropathic
 paralysis depends on some cause which  either prevents the action of volition
 upon  the cerebral fibres which are continued into the nerves going to  the
 paralyzed  muscles, or  obstructs the transmission of volition at  some  point
 between the  muscles and the part of  the brain in which  the voluntary act
 originates.   For the performance of voluntary motion there are  three requi-
 sites—namely, the  communication  of the voluntary influence  to certain parts
 of  the brain, the conduction of this  influence from the brain  through motor
 nerves, and the  ability  of muscles to contract  in obedience to  the will.  Par-
 alysis  may depend on causes involving primarily either of these three require-
 ments.
  An  important division of neuropathic paralyses is  into central  and periph-
 eral.   Central paralyses depend on  morbid conditions seated in either  the
 brain or spinal cord, and they may be further divided  into cerebral and spinal.
 Peripheral paralyses depend on morbid conditions affecting nerves at any point
 between their terminations and their central connections with either the  brain
 or the spinal cord.   Paralyses are peripheral when they depend on affections
 of cranial or spinal nerves within the skull or spinal cord.
  There are  certain points of difference in the effects of cerebral, spinal, and
peripheral paralysis, respectively, which  are of practical importance as regards
localization  of causative conditions and differential  diagnosis.   In  cerebral
                     1 Am. Journ. Med. Sciences, July, 1878. 
774  FUNCTIONAL DISEASES OF THE BRAIN AND SPINAL CORD.

paralyses the reflex excitability of the affected muscles is retained and may be
increased.   The electrical excitability is also the same as  in health, or it may
be increased.  The muscles do not speedily become atrophied.  The cutaneous
sensibility is often  undiminished, or it is  not diminished  in proportion to the
motor paralysis, and is regained in a short time, although the loss or impairment
of the voluntary power  over the  muscles remains.   In spinal  paralysis the
paralyzed muscles may or may  not retain  their reflex and electrical excitabil-
ity, the differences  in these respects being dependent on the situation of the
affection of the cord, together with the degree and the extent of lesions.  The
reflex excitability is sometimes notably  increased.  Sensibility may be either
retained, diminished,  or lost.  There may  or may not be trophic disturbances.
These  points  have entered  into the  clinical  history of  the  different spinal
affections which  have been  considered.
   The characteristics of peripheral paralysis will be considered in the next
chapter.  The reaction of degeneration, which is of much value in the diag-
nosis of the different kinds of paralysis, has already been described (p. 733).
   The foregoing remarks relate to  paralysis  dependent on  different pathol-
ogical conditions.  Paralyses which  are dependent on molecular changes not
appreciable,  or on histological lesions  not yet  ascertained,  and  which are
therefore to be considered at present as functional, generally end in recovery.
Their duration is variable.  It may be but a few hours, and even minutes, or,
on the other hand,  days, weeks, and months.  The  paralysis is  in some cases
intermittent.  The  recovery is sometimes abrupt, and sometimes  it takes place
after a more or less gradual improvement.  The paralyzed muscles do not waste,
except as an effect purely of disease.  There may be anasthesia or  the cutaneous
sensibility may remain unaffected.  In functional paralyses the electrical excita-
bility is retained, and the phenomena  of the " reaction  of degeneration " are
wanting.  Reflex excitability is sometimes retained and  sometimes diminished
or lost.  The circumstances under  which the paralyses occur, and their patho-
logical relations,  are of importance in the discrimination. The paralyses which
often follow diphtheria, and  sometimes other acute febrile diseases, are gener-
ally to be considered as functional, although these diseases may be followed by
organic paralyses, usually of spinal or of peripheral origin.  The  so-called hys-
terical paralyses  are examples of typical functional paralysis.  The association
of paralysis with these affections  is often  of significance with regard to diag-
nosis.  Causative circumstances are to be taken  into account.  Functional par-
alyses may be referable to exhaustion from prolonged muscular  exertions and
to the action of cold.  There is no pathological propriety in calling the paralysis
attributed to the latter cause rheumatic; and clinical experience affords no proof
of any relationship  between paralysis a frigore and rheumatism.1  The so-called
reflex paralysis will be presently noticed in  connection with paraplegia.  Finally,
the functional character of paralyses may be inferred from the probable causa-
tion by certain  vegetable poisons, such  as ergot,  tobacco, lathyrus sativus,
absinthe,  camphor, etc.  Saturnine paralyses  may be regarded  as peripheral,
and  these will be considered in the next  chapter.   Other differential points
relate to the particular varieties of functional, cerebral, and spinal paralysis—
namely, general paralysis, hemiplegia, and paraplegia—and will be noticed in
connection with these disorders.

  1 The  usage of German writers in designating as rheumatic all affections supposed to
be produced by exposure to cold has been adopted by some English writers, but it is not
to be recommended.  Under the name ''paralysis from  commotion" German writers
embrace cases in which the affection is due to  injury, but without  appreciable lesions.
(A'ide Eichhorst, Handb. d. Spec. Path, u Therap.) Cases in whieh paralysis occurs after
a variable period dating from railway accidents  have been described, especially by Erich-
sen.  These cases have been considered as important in a medico-legal point of view. 
GENERAL PARALYSIS.
775
               Treatment of Functional  Paralysis.

   In the treatment of functional paralysis a primary object is the removal of
 supposed direct or indirect causative agencies.  Exhaustion from over-exer-
 tion of body or mind is an indication for  rest.  Toxical agents, tobacco, etc.
 should not continue in operation.   Anamia  claims appropriate therapeutic
 and hygienic measures.   Cystitis, phimosis, or other local diseases which may
 be suspected of standing in the relation of causes by means of a reflex influ-
 ence or in other ways should receive proper attention.
   Of remedies having direct reference to the paralysis, electricity holds the
 first rank.  Experience shows the usefulness of  both the faradic and the gal-
 vanic current, individual cases differing as regards the superiority of the one
 over the other.   There need not  be that delay in resorting to electricity
 which is an important precaution in cases of paralysis dependent on disease's
 involving inflammation.  Care, however,  is to be  taken not  to  employ too
 strong currents, or to prolong or  repeat unduly  their applications.    For
 practical details the reader is referred to works which treat specially of elec-
 tricity as a curative agent.   Its curative  efficacy must consist in its effects
 upon the functional activity of the nerves  and muscles involved in the paraly-
 sis, on the  circulation in these parts, and on their nutrition.   Its  action is
 that of an excitant, and it is  evident that if carried too far it may do harm
 rather than good.   The success of electrical treatment in all paralytic affec-
 tions will depend on the exercise of judgment in determining the indications
 in particular cases, and on skill in its employment.  The advantage of expe-
 rience in its  practical application,  together  with  the  time  and appliances
 which it requires, renders  it  desirable that some physicians should give to it
 special attention.   Hitherto,  the employment of electro-therapeutics in this
 country has been  too much  in the hands of uneducated  practitioners who
 know but little of the agent which they employ, and still less  of the human
 organism.
   Friction and massage, or kneading with  deep pressure, are important meas-
 ures of treatment.  Stimulating liniments  facilitate  the rubbing, and are to a
 certain extent in themselves useful.  These measures are serviceable by pro-
 moting the circulation and maintaining nutrition.  They should be systemati-
 cally carried out and persisted in.  If the paralysis be complete, passive move-
 ments are important.  They should  be resorted to daily, and  continued as long
 as they are  tolerated without  fatigue.  If  the paralysis be  incomplete, daily
 exercise of the paralyzed muscles by means of the will is of more importance
 than any remedial measure.   As much exercise of  the  paralyzed muscles as
 can be taken without fatigue is  desirable.   The physician should  impress
 the importance of this measure, the more  because patients are  slow to appre-
 ciate  it.
   Douches of alternately cold and  warm water are useful.  They should not
 be  continued  long enough  to be  followed by uncomfortable sensations; on
 the contrary, it is  desirable  that they should give rise  to agreeable effects.
 Benefit is  also often derived  from the use of the  sponge-bath followed by
 brisk friction.
   Of drugs, strychnia or nux vomica and phosphorus are to be  recommended.
 AVhether or not they have any specially curative effect, clinical experience
 affords evidence of their  utility.

                         General Paralysis.

  The disease  known  as  general  cerebral paralysis, general paresis, or the
paralysis of the insane (dementia  paralytica) is fully considered in works 
776  FUNCTIONAL  DISEASES OF THE BRAIN AND SPINAL CORD.

devoted to the subject of insanity.   Exclusive of this disease, general paral-
ysis referable to  intracranial morbid conditions  is rare.   It may be a result
of two attacks of hemiplegia, the first attack affecting one, and  the second
the other, side.   Hemorrhage in the  central portions of the pons varolii or in
the medulla oblongata may give rise to double hemiplegia, or, in other words,
general paralysis.  Instances of general paralysis involving muscles supplied
by cranial nerves are among the curiosities of clinical experience.  In a case
under the observation of the late Prof. Coventry power was lost over all the
voluntary muscles except the  orbicularis  palpebrarum and the  respiratory
muscles.    Paralysis following diphtheria  has been  known to involve not
only the extremities, together with the neck and trunk, but the muscles of
the face, throat,  and  mouth.   The  intellect in  these cases may be intact;
excito-motory or reflex movements perhaps remaining unaffected, respiration,
deglutition, digestion, and all the functions necessary to existence going on,
but, as regards voluntary manifestations, the patient being in a state of living
death.   General paralysis involving  cranial nerves has also been  known to
occur in connection with hysteria.  In a case for many months under observa-
tion complete paralysis of the four extremities coexisted with incomplete bilat-
eral paralysis of  the face.  The paralysis in this case was attributed to lead.
  In the great majority of cases general paralysis is spinal.  The seat in the
spinal cord is to be inferred whenever cranial  nerves are not involved and
there are no symptoms denoting cerebral disease.  General spinal  paralysis,
as has been seen (vide Chapters II. and IV.), is incident to inflammatory and
structural afl'ections of the spinal cord and its meninges.   These are to be
excluded in arriving at the conclusion that the paralysis is functional.   The
paralysis may be  complete, or there may be a greater or less degree of paresis,
and it may or may not be associated with anasthesia.   It follows diphtheria
in rare instances,  and is sometimes connected with hysteria.  It was produced
by woorara in a case of rabies, to which reference will be made in treating of
that disease.  It  may be caused by exhaustion and  exposure to cold.  This
causation was exemplified in the case of a man  forty-five years of age, who
during a severe snowstorm rode eight miles in  a horse-car, standing on the
rear platform, his back  exposed to the  storm.   After  reaching home  he
became  unconscious for a short time, and on recovering his consciousness
there was complete loss of motion and sensation below the head.  He was dis-
posed to somnolency, but was easily aroused, and his mental faculties were
intact.   I saw him on the fifth day after the date of the attack.   Under a
treatment consisting of stimulants, frictions, and  nutritious food he had, in a
measure, recovered from the paralysis.  This treatment was continued, and
in a short time the recovery was complete.
  In functional  spinal paralysis the paralytic  condition may he developed
rapidly or  more or less  gradually.  The  muscles of  all  the limbs  may be
simultaneously  affected, or the paralysis  may begin  in one limb, the other
limbs becoming successively affected.  The  bladder  and  rectum  are rarely
involved.   The respiratory movements, as a rule, are not affected.  Excep-
tionally there is much  suffering from dyspnaa.   I have known  paralysis of
the diaphragm to occur, as shown by the purely  costal breathing and by ina-
bility to sneeze, although an intense  desire  and  grimaces  were  produced by
the introduction  of snuff into  the nostrils.
  Recovery may  take  place after a few days or  it may be delayed  for many
months.
  Striimpell has  reported a remarkable case of  complete  anasthesia of the
whole surface of the  body, and in  a nearly equal degree  of the  accessible
mucous membranes.   All kinds of sensation were lost.   There  was no sense
of smell or of taste.  There was complete  amaurosis of the left eye and par- 
HEMIPLEGIA.
777
 tial deafness of the right  ear.  The muscular sense was gone.   The patient
 was not conscious of muscular contractions or of fatigue. Some reflex action
 was preserved.  There was  motor paralysis of the  right arm  and leg, but
 none on  the  left side.  The movements  of the  non-paralyzed limbs were
 normal when  controlled by the eye.   If the eye in which the sight was pre-
 served  were closed, the movements were uncertain, although not ataxic.  The
 patient at once fell asleep when the eye and  the ear in which the perceptions
 were preserved were  closed.


                             Hemiplegia.

   Except when due to cerebral affections which have already been  considered—
 namely, hemorrhage,  softening from thrombosis or  embolism, encephalitis, and
 tumors—hemiplegic paralysis is of infrequent occurrence. Examples of func-
 tional hemiplegia are as follows :  Cases  have been reported in which it took
 place suddenly during strong mental excitement,  as in a fit of violent anger,
 recovery  being sometimes  speedy and sometimes slow.  Todd designated the
 affection, in these cases, emotional hemiplegia.  It sometimes follows epilepsy.
 In a case  under my observation in which epileptic paroxysms recurred at short
 intervals  for several days, hemiplegia occurred before the series of paroxysms
 had ceased, the face  as well  as  the limbs on one side being paralyzed.  The
 paralysis disappeared completely after a few days.   Hysterical paralysis is
 sometimes hemiplegic.  The face  and tongue are  not involved, and as a rule
 the left side is paralyzed.  Hemiplegia may follow chorea, the limbs paralyzed
 being those of the side more aff'ected with the choreic  movements. The paral-
 ysis in these   cases docs not extend  to the face  or tongue.  The paralysis
 which follows diphtheria  is sometimes hemiplegic.  I have known  transient
 hemiplegia  to  follow  insolation.
   The following cases, stated as concisely as  possible, will serve  to  illustrate
 hemiplegia  from  either embolism or thrombosis not  giving rise to  softening
 and  hysterical hemiplegia:
   A merchant, aged seventy-five, of active habits, attending daily to business,
 left  his home  in the morning in his usual health.  He was observed  to act
 strangely.  He walked with  difficulty and  had trouble in moving his  left
 hand.   He  was prevailed  upon  to return home  in  a carriage,  although  he
 insisted that  nothing was the matter with him.   In an hour after his return
 I saw him.  He was somnolent, but easily aroused. There was paresis of the
 left upper and lower limbs and of the left side of the face.  The tongue was
 deviated to the left side.  On the following  day there was marked  improve-
 ment.   The improvement continued, and on the sixth day recovery  was com-
 plete, and he  insisted on attending to his business as usual.   There were no
 signs of cardiac  disease.   A little laurel-water  and aconite were the  drugs
 prescribed.  He was allowed at once a nutritious diet.  Six years afterward
 there had been no return of the paralysis and the patient was in  good health.
 Thrombosis was the probable causative condition in this case.
   A man, aged about seventy, after a long walk in the  afternoon retired at
 night feeling  well, and slept soundly  until morning.  On awakening there
 was paresis of the upper and the lower limb on the right side.  The face and
tongue were not  involved, but there was aphasia, the patient being able to
speak but a few words.  Aside from these symptoms he had no ailment. His
appetite was unaffected. The paralysis and aphasia disappeared in the course
of a few days,  no  treatment  being employed.  Three  years afterward he had
had no return  of  paralysis and was in good  health.  The diagnosis in this
case  lies between  thrombosis  and embolism.
  A case  at my hospital clinic exemplified the occurrence, first of embolism, 
778   FUNCTIONAL DISEASES OF TEE  BRAIN AND  SPINAL CORD.

and afterward of thrombosis.  The first attack was sudden, without loss of
consciousness, and the paralysis  was  on the right side.  The paralysis was
complete, but after an  hour it  had  entirely disappeared.    Several  months
afterward hemiplegia  again occurred.   In this attack the paralysis  was
developed gradually,  becoming  nearly complete  in  the course of a week.
In a few weeks  there remained  only a slight diminution  of  motor power.
  Intermittent hemiplegia  of very  brief  duration  was exemplified in the
case  of a clerk, aged  forty  years, who at breakfast, while apparently in per-
fect  health, had a sudden attack of complete hemiplegia of the right side,
without  loss of consciousness or any confusion of ideas.  The  paralysis dis-
appeared completely in the course of an hour.   During the following two
weeks he had ten or twelve  recurrences of the hemiplegia, the paralysis last-
ing for a few moments only, his health otherwise  being  perfectly good.   The
attacks then  eeased to recur, and  I learned several months afterward that he
was  well.  This  patient had had rheumatism, but there were no signs of
cardiac  disease.
  A dressmaker, aged  eighteen, a patient  in  Bellevue  Hospital, exemplified
hysterical hemiplegia.    Three weeks before her admission, having retired
perfectly well the previous night, in  the morning she was  unable  to move
the left  lower limb.   Sensibility was also  lost.   Toward evening she sud-
denly lost sensibility and the power of motion in  the left upper limb.  After
a week she recovered power over the upper limb.   The paralysis of the lower
limb persisted.  In walking with the aid of a crutch she dragged the paralyzed
limb.  There was no facial paralysis and the  tongue was not deflected from a
right line.   There were no symptoms of cerebral  disease. She had retention
of urine, requiring the  catheter,  but after a time she succeeded in urinating,
the physician in  charge refusing to continue the  use of the catheter.   She
was  notably hysterical,  and the globus hystericus  was wall marked.   A
month after her admission  she was much frightened by a thunderstorm, and
had  hysterical convulsions.  The cold douche promptly  arrested the convul-
sions, and on recovering  full consciousness she at once regained, almost com-
pletely, power  over the paralyzed limb.  The next day she walked without
difficulty, and the following day went  out of the  hospital on a permit.  Sud-
denly, after  the  lapse of a week, she  again became hemiplegic on  the  same
side  as before.   She recovered in a short time under the use of the shower-
bath.  She subsequently had paraplegia, with analgesia and  anasthesia.  She
recovered, and was discharged from  the hospital  well.  This case illustrates
the occurrence of hemiansesthesia, which in  this  instance and in the larger
number of cases is of hysterical origin.  Hemianasthesia  may be produced
also  by cerebral  lesions.  (See p. 674.)   The loss of sensation may affect all
forms  of sensation, including the special senses.
   Spinal hemiplegia,  with motor paralysis on one side and,anasthesia on the
opposite side, probably always implies a lesion limited to the half of  the cer-
vical portion of the cord on the side of the akinesia.
   Instances  have been observed of paralysis affecting the upper limb of one
side and the lower limb of the other  side.   This form of paralysis has been
called  hemiplegia cruciata (not to be confounded with alternating  paralysis,
p. 674), and may be produced by lesions situated at the  crossing of the pyra-
mids in the medulla oblongata.
   Malingerers sometimes feign  hemiplegia.   They are likely to pretend that
there is loss of sensation as well as of motion; and this should excite suspicion.
Hughlings-Jackson has  pointed out a method of  discovering this deception.
The malingerer keeps the arm close to the body when asked to stoop forward.
In doing this he exerts a voluntary power over the limb. In hemiplegia when
the patient stoops the palsied arm falls forward. 
PARAPLEGIA.
779
                             Paraplegia.

  Paraplegia is to he considered as functional when  the absence of any ana-
tomical change is to be inferred from the symptoms and course of the" aff'ec-
tion.   As a functional affection  it is much more  frequent  in  its occurrence
than general  paralysis or hemiplegia.  It is the most  frequent form of hys-
terical paralysis.    I have met  with a  case in which  repeated  attacks had
occurred between the ages of seven and ten years, the patient being subject
to other  hysterical manifestations.   It is a not infrequent sequel of diphthe-
ria.  It may be referable to exhaustion and exposure to cold.   The following
case is probably an example of sexual excess as a causative agent: A young
woman admitted into Bellevue Hospital stated  that  she  found both  lower
limbs completely paralyzed on awakening  in the morning.   She was subject
to nocturnal  attacks of epilepsy, and a paroxysm  occurred  during the night
when the  paralysis took  place.   She was a prostitute, and had had sexual
intercourse with  several persons on that night,  There was complete loss of
sensibility.  Slight reflex  movement could be excited.  On the ninth day
after her admission recovery of motion and sensation was complete, and she
was well enough  to be discharged on the thirteenth day, having had no treat-
ment directed specially to the paralysis.
   The subject of reflex paralysis has relation chiefly to paraplegia.  Many
clinical observers within late years have  reported  cases of paraplegia associ-
ated with various affections of different organs—the kidneys, bladder, uterus,
ovaries, intestines, etc.; and a causative  connection  has been  inferred from
the  fact that patients  recover  from the paralysis after recovery from their
local affections.   The latter,  it is supposed,  induce paralysis  by a morbid
influence  transmitted  through the reflex  system  of nerves; and hence the
significance of the name reflex paraplegia.  In order to establish a causative
connection between different  local diseases and paralysis it is  necessary to
show that  the former precede the occurrence of the  latter in a number of
cases too large to be explained by mere coincidence.   That facts sufficient to
show this have  been accumulated may fairly  be doubted;  and when, on the
other hand, it is considered that the various local diseases  supposed to have
a causative connection  are not associated with  paralysis in the vast majority
of cases, such a connection, when the association exists, is conjectural.
   The pathological explanations of reflex paralysis are far from satisfactory.
The theory of Brown-Sequard is that a reflex  influence causes spasm of the
arteries of the spinal cord, and  that the paralysis is due to anamia and defective
nutrition thus induced.  Assuming spasm  of the vessels limited to a  segment
of the cord to be caused by a  reflex influence, that this condition is persistent
enough to  produce the pathological effects attributed to it is highly improb-
able.  Another  explanation is that the  supposed reflex influence has a para-
lyzing effect  exerted through the vaso-motor  nerves  upon the  arteries, and
causes paraplegia by inducing congestion  of the  cord; but paraplegia does
not  take place in connection with diseases which must induce spinal conges-
tion, such as the cold stages of intermittent fever, dilatation of the right side
of the heart, etc.; and it is, to say the least, conjectural to include congestion
of the cord among the causative conditions giving rise to paraplegia.
   In some reported  cases of  supposed reflex paraplegia lesions of the spinal
cord have  been found  after   death.  Leyden,  Dumenil, AVeir Mitchell, and
others think  that the extension of neuritis centripetally sometimes to the
spinal cord will explain the occurrence of paralysis in the  cases in which it
is  supposed to be  due to  a  reflex influence.
   In  view  of  these considerations the theory of reflex paralysis  lacks a solid
foundation. 
780  FUNCTIONAL DISEASES OF THE  BRAIN AND  SPINAL  CORD.

  Paraplegia may be an imagined disease.  I have met with  an  instance in
which this  self-deception was diagnosticated,  the case being analogous to one
reported by J. Russell Reynolds, and called by him paralysis  " dependent on
idea."  These cases are to  be distinguished from ca.ses of simulated para-
plegia.  I  have met with the latter in connection with hysteria.   Kunze
relates the case of a woman who,  having kept the bed  for  a considerable
time under the  conviction that she had paraplegia, on the occasion of the
house taking fire resumed instantly the use  of her  limbs,  and on reaching
the house  of a relative at once became again a paraplegic.  It  is not easy
to discriminate imagined paraplegia, inasmuch as hysterical  paralysis may
instantly be removed by a mental impression.   This is seen  in cases of apho-
nia from laryngeal paralysis.   I have given  the synopsis of a case in which
paraplegia  disappeared  under the influence of fright during a thunderstorm.
Caution is  to  be observed in the diagnosis; and if made the  physician is to
use discretion either in  asserting  that the supposed paralysis  is imagined, or
in employing electricity or some other method of treatment  with reference to
a physical  influence, conjoined  with a confident assurance that the treatment
will be  successful.
                   Acute Ascending  Paralysis.

  Under this  name Landry  in  1859 described a disease characterized by
rapidly-developed paralysis, beginning in the lower extremities and extending
to the upper extremities, and often to muscles supplied by nerves originating
in the medulla oblongata.  Sensation and the functions  of the  bladder and
rectum  generally  remain normal.   No  anatomical  lesions  explaining the
paralysis have been discovered.  The disease is sometimes  called Landry's
paralysis.
  After  prodromic symptoms of an indefinite  character, with slight fever,
lasting for a few days and sometimes for several weeks, paresis of the lower
extremities occurs.  The paresis begins in the  feet, and  in the course  of  a
few days extends over  the  limbs, the paralysis increasing  in degree and
becoming complete.  The paralysis  extends to the trunk, and  thence to
the upper  extremities.   The respiratory muscles are affected, and clyspnaa
becomes  a prominent symptom.   Subsequently the  muscles concerned in
speech,  mastication, and  deglutition are involved.   Death  takes  place by
apnaa and by exhaustion from innutrition.  The duration varies  between  a
few days and  several weeks, the average being  from  eight  to twelve days.
  The intellect remains  intact, and those cranial nerves  only are  implicated
which arise from  the medulla oblongata.  Sensibility of the skin and mus-
cles is but little, if at all, affected.  There is  sometimes hyperasthesia.  The
paralyzed muscles  do not become atrophied; their electrical excitability is
generally unaffected ;  and reflex excitability is not diminished until the latter
part of the disease.  The rectum and the bladder are  not affected.  There is
usually fever,  but not of a high grade.
  In a small proportion of cases the disease ceases its progress before grave
symptoms are manifested, and recovery shortly  takes place.
  The disease affects men oftener than women,  and the majority of cases are
in persons between twenty and forty years  of age.  Beyond these facts noth-
ing is known of the etiology.  The most plausible supposition concerning the
nature'of Landry's paralysis is that the disease is of an acute infectious cha-
racter, with localization  in the motor tracts of the spinal cord, perhaps in some
cases in peripheral nerves.  This view is supported by the occurrence of pro-
dromic constitutional symptoms, by the  existence of fever, the development 
NERVOUS ASTHENIA.
781
of more  or  less enlargement  of the  spleen, and the  frequent  presence of
albuminuria.
  Clinical experience has thus far afforded no evidence of the success of any
particular method  of treatment.  The iodide of potassium, nux vomica, the
wet pack, and  the galvanic  current  are  recommended.  Alcoholics, ammo-
nia, and  stimulating tonics, together  with sustaining nourishment, are  indi-
cated with a view to  obviate the tendency to death.


                Nervous Asthenia—Neurasthenia.
  The term nervous asthenia or nervous exhaustion may be used to denote a
morbid condition common in this country, especially in the  larger cities.  As
the name signifies, debility, prostration, or exhaustion, affecting especially the
nervous  system, constitutes the aff'ection.   It occurs without anamia or any
notable disorder of the vital functions.   It proceeds from undue functional
activity of the nervous system connected with the exercise of the intellectual
and  emotional faculties.   This morbid condition was considered as a distinct
functional affection in the first edition  of  this work  (1866).   So far as  I
know, it  had  not  been so considered prior to  that date.  Under the name
neurasthenia, introduced by Beard, writers in this and in other countries have
accorded to it a place among the functional  disorders of the nervous system.
Popularly, and to some  extent among physicians, it is known by the name
" nervous prostration."
   Physicians  are  often consulted by patients who, although far from being
well,  have  no  well-defined malady.   They complain  of languor, lassitude,
want of  buoyancy, aching of the  limbs,  and mental depression.  They are
wakeful  during the night and enter  upon  their daily  pursuits with a sense
of fatigue.  Under the pressure of mental excitement they may be  able to
exert themselves with their usual energy, but when the  excitement  subsides
they are jaded and worn out.  They become apprehensive that their powers
are giving way, and they  often fancy the existence of some  serious malady.
An investigation of the different organs of  the  body reveals  no  evidence  of
disease.   The lungs, heart, kidneys, etc. are sound.  None of the affections
embraced in the  nosological  catalogue may be  discovered,  yet the morbid
condition is real.   This brief sketch represents a class of  cases with which
every physician is familiar.
   An  inquiry into the habits and circumstances connected  with the daily life
in the cases' now  referred to will show that the mind has been  for a long
period unduly taxed by the cares and responsibilities of business, over-exer-
tion in the pursuit of wealth or  other objects of ambition, long-continued
anxiety or inquietude; in  short, the patient is  suffering from wear and tear
of the nervous system.  The action of mental conditions is  increased by other
causes which tend to diminish the vigor of  the  body, such  as irregular habits
with  respect to diet, the hours devoted to  sleep and  rest, etc.   The causes
which act directly through the mind are especially  operative  in this  country,
owing to the early age at which persons engage in the  active pursuits of life,
the great inducements to excessive exertions, and  the emulation  excited by
the activity of others.   It is not uncommon to meet with persons who have
overtasked  the  nervous  system without any rest or recreation for many con-
secutive years.
   The condition of nervous asthenia is in itself not  a small evil, causing much
discomfort and unhappiness to the  patient,  and rendering him uncomfortable
to others by inducing depression, irritability, or moroseness.  That  this con-
dition favors the development of diseases to which  there may be a predisposi-
tion, or co-operates with the various causes  of disease, is probable.   It often 
782  FUNCTIONAL  DISEASES OF THE BRAIN AND SPINAL CORD.

engenders a desire for  stimulants, and thus leads to intemperance.  It may
eventuate in confirmed melancholia, hypochondriasis, or other forms of mental
derangement.
  An essential part of the treatment relates to the causation.  Frequently
it is desirable to endeavor to procure, temporarily, complete relief from exer-
tion and care.  It is,  however,  extremely injudicious to advise permanent
relinquishment of active occupations.  After  rest and recreation for a season
sufficient for recuperation of the  nervous system a return to accustomed pur-
suits is advisable, with injunctions to observe  proper moderation and to com-
ply with the laws of health as regards a  fair apportionment of time to recrea-
tion and a  proportionate exercise of all  the faculties  of the mind.   It  is of
course desirable that  causes  of  mental  uneasiness and  anxiety should be
removed, but this part of the treatment often  is  not within the range of med-
ical control.   Habits tending to impair bodily vigor are to be corrected, such
as dietetic imprudences, late hours, sexual errors or vices, the immoderate use
of tobacco,  etc.   Hygienic  measures to  invigorate the body are important,
such as nutritious alimentation, out-of-door life, sea-bathing, or  the  sponge-
bath, etc.   Tonic remedies, varied from time to  time and  long continued, are
serviceable both morally and medicinally.
  At the present time  there is perhaps a tendency to exaggerate the pathol-
ogical relations of the neurasthenic morbid condition.   No anatomical system
in  the body tolerates functional activity  better than the nervous system, pro-
vided the organism be  sound and  the requirements of health in  other respects
be observed.  Patients are  sometimes disposed  to  attribute to over-exertion
of the mental faculties what is really due to  other violations of the laws of
health.  The opinion that the symptoms  denote  excessive brain-work is  often
received with satisfaction.   In some  cases, considering the small amount of
intellectual work accomplished and the limited  capabilities of the brain, this
opinion  seems almost  ludicrous.


                          Spinal Irritation.

  The name spinal irritation dates from the publication of a paper by Brown
of Scotland in 1828.   Shortly afterward  the work of Teale on neuralgia and
that of Tate on hysteria  appeared, these  authors referring the  phenomena of
these diseases to irritation of the  spinal  cord.   In 1834 the published obser-
vations of AV. and D. Griffin claimed, in  behalf  of the supposed  morbid con-
dition thus named, a larger scope  of application,  and this condition soon  came
to  be generally recognized  as an individual functional affection.  In an article
contained in the American  Journal of the Medical Sciences for April, 1844, I
gave the results of an analysis of  58 cases which I had observed and recorded.
For several  years I was accustomed, in medical lectures, to  include spinal irri-
tation among the functional diseases  of the nervous system.  I was at length
satisfied that the phenomena grouped under this name had other pathological
connections, and that the claim of spinal irritation to a place in the nosology
was not well grounded.   Others held this opinion, and the name had nearly
passed out of use ; but within the  past few years  it has again come into vogue,
and it is now recognized  by many as denoting a  neuropathic affection.
  In so-called spinal irritation  more  or less  pain is referred to the spine, and
pressure over certain parts of the column, these parts differing  in  different
cases in number and extent, shows greater or less tenderness.   This tender-
ness is also  shown by the  application of ice, a hot  sponge, and electricity.
AVith the spinal  tenderness are  associated, in  different cases, a variety of
symptomatic phenomena, and these, in their situations, are in correspondence
with the relations of the latter to the spinal cord.   Thus, intercostal and cer- 
DISEASES OF THE NERVES.
783
vico-occipital pains, nausea, vomiting, singultus, palpitations, and nervous cough
are associated with tenderness over the cervical and dorsal vertebra-, whereas
pain in the lower parts of the body, tympanites, colic, and dysuria are associ-
ated with lumbar tenderness.  Patients generally are mentally depressed, the
power of physical or mental endurance is diminished, sleeplessness is common,
general hyperasthesia of the surface of the body  is sometimes marked, the
extremities  are cold, and different cases  offer a great variety  of subjective
symptoms.   The great majority  of patients are women.
   That there are  cases which exemplify the clinical history of spinal  irrita-
tion, as described  formerly and at the present time, cannot be denied;  but
that the phenomena are caused by irritation of  the spinal cord, or that they
are attributable to  a morbid condition (either to hyperamia or to ischamia) in
this part of the nervous system,  is by no means certain.   In a large propor-
tion of cases the phenomena are effects of general anamia. In some instances
they  may be due  to  toxical  blood-conditions, and they may be caused by
reflex  influences originating in local disorders  of different  organs.
   Clinical observations show that when there is tenderness over the spine in
connection  with disorders  of various  kinds, soothing applications or  mild
counter-irritants over the tender  portion  or portions are often serviceable  as
palliative measures of  treatment.   Curative measures  must be employed  in
other directions.
   It  is important not  to consider  the pains  and  tenderness referred to the
spine in  cases of so-called spinal irritation as symptoms of inflammation of the
cord  or of its  meninges.  The absence of  fever, the  sex of the  patient, the
existence of anamia  and often of hysteria,  point to a purely functional disor-
der and render the exclusion of spinal meningitis and myelitis easy.
   The name spinal irritation was introduced at a  time when local pain and
tenderness  were regarded  as evidence  of  inflammation,  and,  as the name
denotes a functional  condition, its introduction  had a favorable influence  on
the treatment,  inasmuch as at that  time antiphlogistic  measures—namely,
bleeding, cathartics, mercury, and severe counter-irritation—were considered
indispensable in treating inflammatory affections.
                        CHAPTER  VI.

                    DISEASES OF  THE  NERA^ES.

Neuritis.—Multiple  Neuritis.—Peripheral  Paralysis.—Paralysis of the Third Cranial
   .Nerve.—Paralysis of  the  Fourth Cranial Nerve.—Paralysis of  the Fifth Cranial
   Xerve.—Paralysis of the Sixth Cranial Nerve.—Paralysis of the Motor Portion of
   the Seventh Cranial Nerve.—Paralysis of the Eighth Cranial Nerves.—Paralysis of the
   Ninth Cranial Nerve—Local Paralysis of other  than Cranial Nerves.—Paralysis of
   the Cervical Sympathetic  Nerve.—Paralysis  from Lead.—Paralysis from Arsenic,
   Copper, Mercury, and Phosphorus.—Neuralgia.—Trifacial Neuralgia.—Cervico-occip-
   ital Neuralgia.—Cerviro-hrachial  Neuralgia.—Dorso-intercostal Neuralgia.—Lumbo-
   abdominal Neuralgia.—Crural Neuralgia.—Sciatic Neuralgia.—Dermalgia— Myalgia —
   Cephalalgia.

   THE  diseases  to be  considered in  this  chapter are those affecting either
    nervous trunks, their  branches, or their terminal distributions ;  in other
words,  diseases of the peripheral nervous  system.   In  this division  are 
784
DISEASES  OF THE NERVES.
 embraced  neuritis, paralytic affections, and  neuralgia  referable to nervous
 trunks or branches.  Paralysis from lead will be included among the periph-
 eral paralyses.


                                Neuritis.

   Within recent years  it has  been shown that neuritis is a much more com-
 mon and important affection than was formerly supposed.  The disease known
 as  multiple  neuritis  possesses sufficient clinical peculiarities to merit con-
 sideration  in  a separate article.
   In acute neuritis the affected  nerve is swollen, reddened, and more succu-
 lent than normal.  Microscopical  examination shows hyperamia, and often
 ecchymoses, serum, and emigrated white blood-corpuscles, frequently contain-
 ing oil-globules, in  the interstitial tissue of the nerve-trunk.  The nerve-fibres
 may be little changed, or their medullary sheaths may be broken  up and the
 fibres undergo degenerative atrophy.  Acute neuritis may terminate either in
 resolution with regeneration of the  nerve-fibres or in chronic neuritis.   Sup-
 purative neuritis is rare, and  is due  to some special infection.
   Chronic neuritis is characterized by increase of the interstitial tissue and
 degeneration of the nerve-fibres.  The nerve  is  firmer than normal and of a
 grayish color.   It may  be either increased or  diminished in size.
   Sometimes purely degenerative changes are found in the  nerves.  These
 are identical  with those which follow  section  of  a nerve-trunk, and they are
 often designated, but with  doubtful propriety, as parenchymatous neuritis.
 (See  Multiple Neuritis.)
   Neuritis may affect only a small portion of  a nerve in its course, or it may
 extend from a primary  focus of inflammation  either in a central or a periph-
 eral direction.  AVe thus distinguish  circumscribed neuritis and ascending or
 descending neuritis.   It  is also held that a neuritis may extend  irregularly
 along the course of a nerve, so as to attack certain spots and leave the inter-
 vening portions unaffected.  This variety is called neuritis disseminata, neur-
 itis migrans, or segmental  neuritis. When the  inflammation is confined chiefly
 to the nerve-sheath, it is called perineuritis.
   The most important causes of neuritis are direct injuries to the  nerves, the
 extension of  inflammation  from adjoining  parts, exposure to cold, certain
 poisons (especially  lead),  and the poison of certain infectious diseases. Many
 cases of  so-called reflex paralysis are  referred by Leyden to  an ascending or
 migrating  neuritis  extending from  the region of irritation (for example, an
 inflamed bladder) to the spinal cord, where an acute or chronic myelitis may
 be induced.  The changes which occur in nerves suffering from compression,
 as well as those caused by  indirect  injury, such as  blows, and by severance
 of their  continuity, although often included  under the head of neuritis, are
 in reality degenerative.
   Neuritis is  attended, especially in the early stages, with severe pain, both
 in the region of distribution and in  the course of the affected nerve.  There
 is tenderness on pressure over the inflamed  nerve, the swelling of which can
 occasionally be appreciated  by palpation.  Subsequently there may be anas-
 thesia, either with or without analgesia, but the anasthesia does not usually
 become extreme. Neuritis seated in motor nerves or in those containing motor
 fibres gives rise to paralysis of motion, either partial or complete.  This paral-
 ysis is followed by muscular  atrophy and the reaction of degeneration.  Trophic
 disturbances, particularly herpetic eruption and moderate adema, occasionally
 occur in the region  supplied by the inflamed nerve.
   The onset of  the  disease may  be  acute or the symptoms may  develop
gradually.   As the nerves are  endowed with a remarkable power of regenera- 
MULTIPLE NEURITIS.
785
 tion, recovery may take place  if the cause he removed and the nerve be not
 too  much damaged.   Probably, slight degrees of neuritis  without symptoms
 as severe as those described are not uncommon.   Inflammation of the nerves
 as well as affections of the intervertebral ganglia, has been  repeatedly dis-
 covered in cases  of  herpes zoster intercostalis.
   The  differential  diagnosis  of neuritis from neuralgia is not always
 easy.   In fact, some cases of neuralgia are probably the result of a neur-
 itis.  The main points in the diagnosis  are  the paroxysmal character of  the
 pain in neuralgia, as well as the existence of isolated points of tenderness
 (A'alleix's points), and the  absence  of  paralysis.
   The  treatment  has  reference  especially  to  causative  circumstances.
 Beyond the indications relating  to  causation, revulsive and  soothing local
 applications  are indicated.   Subcutaneous  injections  may be required to
 relieve  the intensity of the pain.   The  employment of electricity is  useful
 in the form of the weak galvanic current, although some  recommend  strong
 currents.   In chronic neuritis cauterization  has been  employed with benefit
 in some cases.


                          Multiple Neuritis.
   The anatomical lesions in multiple neuritis are in many cases degenera-
 tive, resembling those in divided  nerves; but in some, particularly  in  acute,
 cases they are inflammatory.  In the first class of cases the  medullary sheaths
 of the  nerve-fibres are broken up into fragments ;  the cells in the sheath of
 Schwann  are enlarged and  increased in number;  fatty granular corpuscles
 accumulate in the situation of the medullary sheath as well as between the
 nerve-fibres; and the axis-cylinder, which may remain for a long time intact,
 finally disintegrates.   In inflammatory cases an inflammatory exudate, con-
 sisting of serum, pus-cells, and red blood-corpuscles, also accumulates in the
 interstitial tissue of the nerve-trunk.  Microscopical examination is requisite
 to determine the changes, as often no distinct alteration is visible to the naked
 eye.  If  the case  terminate in recovery, the nerve-fibres are  regenerated in
 the  same manner as after section of nerve-trunks.  In chronic cases a new
 growth of connective tissue appears in  the nerve-trunks.
   The  affection involves many, sometimes most, of the spinal nerves.  The
 cranial  nerves  may also be aff'ected,  but less commonly than  are the  spinal
 nerves.   The lesions are not distributed  uniformly over the nerves, but are
 more intense in some places than in others.  Usually, a nerve-trunk is more
 or less  affected  throughout  its entire length.  If the spinal  nerve-roots be
 also involved, there are, usually, slight  atrophic or degenerative changes in
 the ganglion-cells of the anterior horns of the spinal cord.   From the  symp-
 toms it may be inferred that  the motor  nerve-fibres are  by  preference  the
 seat of  the disease.
  The causation of primary multiple neuritis is not known,  but the symp-
 toms support the  usually-accepted  view that  the disease is due  to some
 special infection.  Certain cases of paralysis after acute  infectious  diseases,
 particularly after diphtheria, are referable to a multiple neuritis.1 The affec-
 tion  is most common in early adult life.
  Symptoms.—Multiple neuritis may pursue an acute or a chronic course. The
 acute cases begin generally with fever and constitutional symptoms, often of
 considerable severity.  Swelling of the spleen and albuminuria are sometimes
 present.   These symptoms indicate the infectious  nature of the disease.   At
the onset there is pain,  usually severe, and felt generally in the loins and in
  1 According to Seheube, the disease which is known as beriberi or kak-ke, and which
prevails in Japan  and India, is a multiple neuritis.
        50 
7S6
DISEASES  OF THE NERVES.
the extremities.   Moderate swelling of the joints has  also been  observed.
Paralysis soon makes its appearance, as a rule first in the form of paresis of
the lower  extremities.   The  paralysis increases  in intensity and in extent,
involving the upper extremities, and, it may be,  the muscles  of the  trunk,
especially  the  muscles  of  respiration.   Reflexes,  particularly  the tendon
reflexes, are diminished.   As  may be  inferred from what has been said on
p. 733, the paralyzed muscles rapidly atrophy, and  the  nerves and muscles
soon present the reaction of  degeneration.   In the mean time the pain has
usually lessened, although some  remains, especially upon pressure over the
affected nerves and muscles.   Abnormal sensations, called parasthesia, such
as numbness and formication, are often experienced.   There usually is some
loss of sensation, but marked  anasthesia is  not generally produced.   On the
other hand, in acute  cases there often is pronounced  hyperasthesia.   The
functions of the bladder and of the rectum remain intact.  Herpetic erup-
tions, adema, and less  frequently  other trophic disturbances  may  occur.
There  is often  observed great  frequency of  the pulse,  probably due to
involvement of  the vagus.
   Acute multiple neuritis may terminate within a few  clays or two weeks in
death.   The  most frequent cause  of death is  paralysis of the respiratory
muscles.  In some cases recovery takes place, which  is  usually gradual, as
considerable time is required for the regeneration  of the  nerve-fibres.   In
other cases the  acute  symptoms subside and more or less paralysis remains
permanently, or the disease may pursue a chronic course.
   Multiple neuritis may  begin insidiously, and without  acute symptoms lead
to atrophic paralysis.   In these chronic cases recovery is also possible,  or the
disease may come to a standstill with  more or less  permanent paralysis.
   The main difficulty in  diagnosis is to  distinguish multiple  neuritis from
anterior  poliomyelitis, with  which it has doubtless  often been confounded.
The  main  points in this diagnosis relate to the presence of pain and other
sensory disturbances in  neuritis which  are  absent in uncomplicated anterior
poliomyelitis.  The distinction between  acute ascending paralysis and mul-
tiple neuritis may also occasion some  difficulty, but careful  attention to the
symptoms which have been described will  generally lead to a correct diag-
nosis.
   The prognosis, as is evident from what  has been said, is grave, but not
extremely so.   In distinction from the spinal cord, the peripheral nerves are
capable of  extensive regeneration, so  that recovery may take place after the
paralysis has become complete and has lasted for a number of weeks or even
months.
   In view of the probably infectious nature  of the disease, it is  recommended
at the onset of acute cases to  administer  large doses of salicylic acid.  The
intensity of the  pain  will usually require the use of opium in  some form.
Counter-irritation in the form of stimulating liniments may be applied over
the affected parts.   The systematic  and long-continued use of electricity,
beginning with  not too  strong galvanic currents, is important.  Cutaneous
faradization is  sometimes employed  as  a means of counter-irritation.   In
chronic cases  especially  massage may  be beneficially employed.


                        Peripheral Paralysis.
   In preceding,  articles various causes of peripheral paralysis  have already
been mentioned.   These causes will here be enumerated.  Peripheral  paral-
ysis  may be  caused by  inflammation, degeneration, compression, and  injury
of a nerve.   It  may be  caused by toxic substances, of which  the  most im-
portant is lead, and less common causes are  copper, arsenic,  certain vegetable 
PERIPHERAL  PARALYSIS.
787
 alkaloids, and  some other substances.   Peripheral paralysis is common after
 diphtheria, and is less frequent after other acute infectious diseases, such as
 smallpox, typhoid  fever, measles, etc.   It may be the result of syphilis,  but
 rarely of other chronic infectious diseases.  An important cause of peripheral
 paralysis, particularly of facial paralysis, is exposure to cold.   No satisfactory
 explanation of reflex peripheral paralysis has been given.  Finally, peripheral
 paralysis may occur without known cause.
   Peripheral  paralysis may be the result of some  demonstrable change in
 the nerve, such as inflammation, degeneration, or tumor, or it may be purely
 functional.  As  our knowledge extends, the instances of purely functional
 paralysis become fewer.
   The following are  the main points to be considered in the diagnosis of
 peripheral paralysis:  The paralysis affects a muscle or a group  of muscles
 supplied by a nerve-trunk or  a nerve-branch.   In certain  forms of spinal
 paralysis (anterior poliomyelitis) the paralysis may be confined to a group
 of muscles, but  this is a group of muscles  functionally associated, and  not
 necessarily supplied by a single nerve-trunk.   In  severe peripheral paralysis
 the affected muscles undergo rapid atrophy, and the nerves and muscles take
 on the reaction of degeneration according to  the principles already laid down
 (p. 733).   The  reflexes are  generally  diminished  in peripheral  paralysis.
 Cases vary as to the  existence of sensory disturbances, but a certain  degree
 of these  is not uncommon, and marked anasthesia may accompany the motor
 paralysis.
   The treatment in cases of peripheral paralysis has  relation to local causes
 whenever these can be ascertained and  reached.   Their continued operation
 is, if possible,  to  be prevented.   Lacerations and divisions of  nerves  are
 to receive proper surgical  treatment with reference to the  restoration and
 reunion of separated or injured parts.   Tumors pressing upon nerves are to
 be removed if practicable, abscesses opened, and inflammation treated accord-
 ing to the indications.   It is obvious  that the probability of improvement
 and  recovery  must  depend on  the nature  of the  causes and  the extent to
 which  they can be successfully treated.   Cases in which the  paralysis is due
 to cold or to transient external pressure, and  those in  which  there is no dis-
 coverable causation  or appreciable lesion, generally tend to a favorable termi-
 nation ; and this may  be hastened by therapeutic measures.
   The chief therapeutic agent is electricity.   The employment of this agent
 is to be governed by rules the consideration of which is not embraced within
 the scope of this work.  Local  frictions, the use of stimulating liniments,  the
 cold and  warm douche, the topical application of strychnia, and voluntary
 exercise  of the paralyzed muscles whenever the conduction of volition is  not
 wholly obstructed,  are measures of utility in peripheral  as in  central paral-
 ysis.  In cases of peripheral as in cases of central  paralysis  the probability
 or the possibility of a syphilitic connection is to be considered with reference
 to the treatment.  Antisyphilitic medication  should be employed whenever
 there is  ground  for a suspicion of this connection.

  Paralysis of the nerves of  special  sense—namely, the olfactory, the optic,
 or the auditory nerve—is frequently dependent on abnormal conditions relat-
 ing to the  accessory organs  of smell, sight, and  hearing.   This  remark
 applies  more  especially to the eye  and ear.   Affections  of the  eye and
 ear involving  loss  or  impairment of sight and hearing  belong in the prov-
ince of surgery, and treatises  are devoted  specially  to them.   It is  import-
ant, however,  for the physician to take cognizance  of  paralysis affecting
these  senses, as denoting intracranial disease.   In most cases paralysis  of
the nerves of  special sense, if due to intracranial disease, is associated with 
788
DISEASES  OF  THE NERVES.
paralysis  of other parts.   Paralyses of the other cranial  nerves  severally
claim brief consideration.   It is more correct to say paralysis of the parts to
which the branches of a nerve  are distributed than to apply the term to the
nerve, but the latter is a convenient mode of expression and is sanctioned by
usage.


             Paralysis  of the Third Cranial Nerve.

   Paralysis of this nerve, the motor oculi  communis, gives rise to  dropping
of the upper eyelid or ptosis, diverging strabismus, protrusion of the eyeball,
and dilatation of the pupil.  These effects correspond with the distribution of
the several branches of the third pair of nerves.  The internus rectus muscle
being paralyzed, the eyeball is turned outward by the externus rectus and the
superior oblique muscle ;  and dilatation of the pupil is caused by paralysis of
the circular fibres  of the iris.  The effects are so obvious and characteristic as
at once to be referable to paralysis of this nerve.  Paralysis of this nerve  may
be produced by an injury in the neighborhood of the eye, by the action of
cold, and by over-exertion in occupations which require especially the use of
the eyes.   If produced by cold  or over-use, the paralysis is functional  and
will not be permanent.   Double vision and  imperfect  accommodation accom-
pany  paralysis of this  nerve.  The paralysis is rarely limited to  this nerve
if it  proceed from intracranial  lesions, but it is  associated with paralysis
affecting other nerves or with other marked effects of  cerebral disease.   It is
rare  in cases of hemiplegia.  Occasionally it  is the  first event pointing to
grave  cerebral  lesions.  It may be a forerunner of hemiplegia, 'convulsions,
or coma.   In a case under my observation  paralysis affecting this nerve on
the right side occurred without other central  symptoms three weeks before
an attack of apoplexy and left hemiplegia, the latter proving fatal two hours
after  the  attack.  If ptosis  exist without  strabismus and  dilatation of the
pupil,  it may be inferred  that  the paralysis  is  not  central but peripheral.
The paralysis is then limited to the upper branch of the nerve.   So also, if
the inferior branch be alone affected, causing external strabismus and  dila-
tation  of  the pupil without ptosis, the paralysis is  probably peripheral.


            Paralysis of the Fourth Cranial Nerve.
  Paralysis of this nerve, the patheticus, produces effects less marked than
those  of paralysis of the third nerve.  Movement of the eye at the same time
downward and inward is  impaired. Double vision exists of objects occupying
the lower part of the field of vision, and is therefore manifested especially in
looking downward, as  in going  down  stairs.  Paralysis of this nerve is an
isolated affection in  some  cases of syphilis.


             Paralysis  of the Fifth  Cranial  Nerve.

  The effects of complete paralysis of this  nerve are shown by its  division
within the skull  in  inferior animals.   Loss of  sensibility (anasthesia  and
analgesia)  on one side of  the  face, of  the mucous  membrane within  the
mouth,  the conjunctival membrane  on  that side,  and the  anterior  portion
of the tongue, and paralysis of the masticatory muscles on the  same side,
immediately  follow.    The  intracranial  division of  this nerve  is  followed
within a short time by ulceration of the cornea,  and  sometimes by suppura-
tive inflammation  of the whole  eye.   Complete  paralysis of the trigeminus
from disease is rare.   The motor portion may be  affected either separately or
in conjunction with the sensory  divisions.   Impairment or loss of the power 
           PARALYSIS  OF  THE SINTII  CRANIAL NERVE.        789

of mastication  denotes  paralysis of the motor  or  third division.  Bilateral
paralysis of  the  motor portion occurs rarely  in  cases of bulbar  paralysis.
The different sensory divisions  may be affected separately—namely, the oph-
thalmic, the  superior and  the inferior maxillary.   The loss or impairment of
sensibility  is then confined to the portions  of  skin and  mucous membrane
supplied  by  the  branches of  the paralyzed division.
   Ulceration of the  cornea, absence of reflex conduction, redness and swell-
ing of the face and of the gums, constitute evidence that the paralysis is
peripheral, the local cause  being perhaps  intracranial,  but  extracerebral.
When  the  paralysis is central, it is  accompanied by symptoms denoting
cerebral  disease,  and other cranial nerves are generally  involved.
   Pain is sometimes referred to parts supplied by the branches of the nerve,
notwithstanding anasthesia and analgesia in these parts are complete (anas-
thesia dolorosa).   The  cause  of the  pain  is situated  in  the portion of the
nerve posterior to the seat of the affection which causes the paralysis.  The
explanation is the same as when, after an amputation, pain is felt to be in the
amputated limb (" eccentric projection of perception ").
   Bilateral paralysis of this nerve is sometimes observed.   In a case reported
by Althaus the common  sensibility of the face and scalp was lost, together
with the  sense of temperature and of tact; the mucous membrane of the
eves, nose, and mouth was completely anasthetic ; the  sense of taste was pre-
served, although  the exercise of it seemed less  prompt than in health ; and
the muscles of mastication were completely paralyzed.   The tongue presented
a frightful spectacle, having been bitten and lacerated  in every direction dur-
ing the act of taking  food.   The patient experienced  no  pain when a tooth
was  drawn.  The lips  were covered with froth.  The sense of smell and of
sight were not affected, except that the latter was obstructed by thick leu-
coma of  both cornea.   The patient suffered  much from photophobia.  There
was an abundant  secretion of mucus from the Sehneiderian membrane. Hear-
ing was intact, but the  patient  was greatly annoyed by tinnitus aurium.  The
paralysis  was produced by long exposure of the face to a keen  wind, the
morbid condition being  supposed to be inflammation of the neurilemma at the
point where the nerve emerges from between the transverse fibres of the pons
varolii at  the  base  of  the brain.  The brain was unaffected, and the paral-
ysis was limited strictly to the distributions of the fifth pair.   At the end of
three months, under treatment consisting of  the systematic application of the
continuous galvanic current to the several branches of the affected nerve, the
recovery was nearly complete.1  An  important indication for treatment is to
protect the anasthetic parts, particularly the cornea, from  external injury.


              Paralysis of  the Sixth Cranial  Nerve.
   Paralysis  of this  nerve, the motor externus or abducens, leads to converg-
ing strabismus, the eyeball being turned inward by the action of the internal
rectus  or adductor  muscle, from the loss of the antagonism of the  external
rectus  or abductor  muscle.   The patient is  unable to turn the  eyeball out-
ward, whereas  in ordinary cases of strabismus this can be done  if the other
eye be closed.  Paralysis of this nerve sometimes occurs in cases of  cerebral
meningitis and in connection with lesions giving  rise to hemiplegia.   This
nerve, however, escapes in the majority of  the  cases in which paralysis of
other parts  occurs  from  intracranial affections.   AVhen  the  nerve  is  para-
lyzed,  paralysis  of  the  third  cranial  nerve is frequently associated.  The
effect of  paralysis of  both these nerves is immobility  of  the eyeball  as
regards lateral" movements,  which can be turned neither inward  nor out-
   1 Transactions of the Royal Medical and Chirvrgical Society of London, 1869, vol. lii. 
790
DISEASES  OF  THE NERVES.
ward.   Double vision is likely  to  exist  when  the  paralysis is  limited to
the sixth  nerve.   Functional  paralysis of this nerve is not  uncommon.  It
may be caused by neuritis, and  it is  sometimes attributable to syphilis.


Paralysis  of  the Motor  Portion of the  Seventh  Cranial
          Nerve—Bell's Paralysis—Mimetic  Paralysis.

  Paralysis of this  nerve, the portio  dura,  or the motor facial  nerve par
excellence,  is much less infrequent than paralysis of the  sensitive  portion of
the fifth nerve.  Complete  paralysis of this nerve produces  characteristic
appearances,  by means of which the affection is  at  once recognized.  The
expression of the physiognomy peculiar to  the person  is abolished on the
affected side.   The n'aso-labial fold is flattened on this side.  In speaking or
smiling the mouth and sometimes the extremity of the nose are drawn to the
opposite side.  This appearance is so striking and distinctive that the exist-
ence of the paralysis is immediately apparent.  The power over the  orbicu-
laris palpebrarum being lost, the patient is unable to wink or to close  the eye.
AA^hen  the attempt to close the eye is made, the eyeball is turned upward, so
that the cornea is concealed  by the upper lid.  The upper lid is abnormally
elevated and the lower  lid is depressed, so that the eye appears to project more
than in health.  Owing  to the loss of  power over the orbicular muscle, the
tears are  not diffused  over  the conjunctiva  as in health, and hence results
epiphora.   From the constant exposure of the conjunctiva in sleep  as well
as in waking hours  it becomes inflamed, and opacity of  the cornea  may be
a result of the conjunctivitis.  The eyebrow is lowered, and the  patient is
unable to  frown or to wrinkle the forehead  on the affected side, from loss of
power  over the corrugator supercilii and the anterior portion of the occipito-
frontalis muscle.   The ala nasi ceases  to  dilate, but may contract in inspi-
ration ; and dilatation, if it occur, is in expiration.  Loss of  power over the
orbicularis oris on  the affected side renders  the  patient  unable to whistle;
expuition  is  imperfect, the saliva dribbles from the angle  of the mouth; and
the pronunciation of certain  letters—namely, o, b, p—is difficult.  Loss of
power  over  the  buccinator renders the  cheek flaccid;  it  is liable to be
wounded  in  mastication,  and  the patient  is  annoyed by the accumulation,
between the  cheek and  gums, of food which he is obliged to remove  with
the finger.  The cheek and lips  of the affected side are sometimes puffed
outward by the expired breath, as in the act of expelling tobacco-smoke from
the mouth.   These obvious appearances are readily understood by reference
to the  anatomical distribution of the branches of  this nerve.  They are, of
course, less marked in  proportion as the paralysis is incomplete.   The velum
pendulum  palati  on  the paralyzed side is sometimes  abnormally flaccid, and
tbe uvula is deflected to  the opposite side.   The  auditory sense on the para-
lyzed side is more acute than in health.   After long continuance of  the par-
alysis  contracture of the paralyzed muscles  may develop, causing deviation
of the  features to the affected side.
  Paralysis of  this nerve is not very infrequently an isolated affection, exist-
ing independently of cerebral disease.  The  seat of the affection may be intra-
cranial, but extracerebral; that  is, the seat, although within the skull, is
between the  central connection of the nerve  and its entrance  into the mea-
tus auditorius.   It may be due to the pressure of a tumor on the nerve after
it emerges from the stylo-mastoid foramen.  The nerve may be affected within
the petrous portion of the temporal bone from fracture, or in  connection with
caries of this bone resulting from median or internal otitis.   Facial paralysis
occurs  not infrequently from the  action of cold upon the face.   I  have met
with instances of its occurrence in connection with anamia.  It is  sometimes 
          PARALYSIS OF THE SEVENTH  CRANIAL  NERVE.      791

produced  in new-born children by the  employment of the forceps in labor.
Facial paralysis may proceed from the various intracranial affections which
have  been considered.  In these  cases  it is  frequently associated with paral-
ysis  affecting  other nerves.   It  is sometimes a forerunner of a grave cere-
bral  affection.
  If central, the paralysis is generally preceded or accompanied by symptoms
denoting a cerebral affection.  If the nerve  be affected in a situation involv-
ing the chorda tympani, the sense of taste on the lateral half of the anterior
portion of the tongue corresponding to the  paralyzed side is diminished, as
may be shown by  comparing the sensations produced  by placing successively
on the  two sides of the anterior extremity of the  tongue some bitter  sub-
stance in powder, such as aloes.   The salivary secretion is diminished.  These
effects are due to the involvement of the chorda tympani in the  paralysis.
The  taste and  the salivary secretion are  not aff'ected  if the cause producing
the paralysis act upon the nerve  anterior to  the situation at which the chorda
tympani is given  off.1  Flaccidity of the palatine arch on the  affected  side
and deflection of the uvula to the sound side  denote that  the  cause of the
paralysis acts  upon the nerve either within the aqueductus Fallopii or before
it enters this canal, the branches supplying the levator palati and the azygos
uvula muscles being here given off.   If the paralysis be  central, the electro-
muscular contractility is  preserved ; and if it be peripheral, the  reaction is
rapidly lost.   The paralysis is  peripheral when  the  nerve is affected at any
point beyond  its origin.  Paralysis of the sixth nerve accompanying paralysis
of the facial nerve denotes a central lesion, these nerves arising near each other
in the floor of the fourth ventricle.  The absence of reflex movements is evi-
dence that the paralysis is peripheral.  If winking be not  produced by touch-
ing the eyeball, the  sensibility  of the  latter  being preserved,  the  nerve is
affected after  leaving its central connection ;  and on the other hand, if the eye
be closed  involuntarily, following an impression made on the conjunctiva when
the voluntary power is lost, the paralysis is  central.   Abnormal  acuteness of
hearing is evidence that the nerve is aff'ected  behind the  point  at which the
twig going to  the stapedius  muscle is given off.  The paralysis is much oftener
complete  when it is peripheral than when it  is central.   Accompanying hemi-
plegia, the paralysis is generally incomplete and  the  orbicular muscle of the
eye is but little aff'ected.   It  is rarely wholly unaffected, as stated by Todd.
Evident diseases of the ear or of the  parotid gland  often account for the
paralysis as well as its peripheral character, and they  point  to the  seat of
the affection.
  In  cases of facial paralysis dependent on neuritis caused by cold, or when
it is functional, recovery may be expected  after  the  lapse of several weeks.
If the paralysis continue  without improvement for two or three  months,  it is
probably not functional, but if not dependent on central  lesions it  proceeds
from  either disease of the nerve  or something pressing  upon it and occasion-
ing obstruction.  Under these circumstances it will be likely to remain a per-
manent affection.   The prognosis is also grave in proportion  as the  electro-
muscular  contractility  is diminished.
  Bilateral paralysis (diplegia  facialis)  has been  repeatedly observed,  but
examples  are  extremely rare.2   It may  result from injury or disease of the
two  nerves or from intracranial  lesions.  The expression  is  then  abolished
on both sides of the face.   The  face  remains immovable, the  only changes
which are observed relating to the circulation.  It is as if the face were  cov-

  1 The fibres of the chorda  tympani nerve are probably derived ultimately from the
glosso-pharvngeal nerve, although some assign them to the trigeminus.
  2 For a report of 28 eases of double facial paralysis, see article by Dr. Pierreson in
Archives generates de Malecine, Auut et Septembre, 1807. 
792
DISEASES  OF  THE NERVES.
ered by a  mask.  Relaxation  of the  soft palate may coexist, rendering the
voice unnatural.   Moreover, articulation is  difficult from the immobility of
the lips.  Mastication is difficult from  the  same cause.  The saliva dribbles
from the mouth.   The eyes are constantly open and staring (lagophthalmus).
Aside from the great inconvenience which bilateral  facial paralysis occasions,
the prognosis is serious or otherwise according to the situation and nature of
the morbid conditions on  which the paralysis is dependent.   In a case which
came under my observation with the  double facial paralysis was associated
incomplete general paralysis, and the patient died by apnaa from inability to
expel, by coughing, matter in the  air-passages.  Paralysis affecting the  ala
nasi may lead to an amount of depression w*ith inspiration sufficient to occa-
sion notable obstruction.   The cartilaginous portions of the nostrils  on both
sides are sucked in with the inspired breath to such an extent  as to constitute
a serious obstacle  to respiration.


            Paralysis of the Eighth Cranial Nerves.

  The paralysis affecting the pharynx, which  occurs as a sequel of diphtheria
in certain  cases, and  which is sometimes limited to this situation, is to  be
considered  as a paralysis of that division of the eighth pair called the glosso-
pharyngeal.  This local paralysis will be referred to  in treating of diphtheria.
  Paralysis of this nerve, together with paralysis of the par vagum, occurs in
various  cerebral affections which produce deep coma, giving rise to impairment
and loss of power of deglutition and diminished frequency of the respirations.
This paralysis  precedes a fatal termination.   It may occur from  a small
extravasation of blood into or near the medulla oblongata.  I have met with
an example, the apoplectic attack being'characterized by notable disturbance
of respiration and  inability to swallow, without complete loss of consciousness.
Paralysis of these nerves  occurs also in bulbar paralysis.  The vagus is an
inhibitory nerve of the heart.  Its irritation causes slowing of  the heart-beats,
and if it be intense their cessation in diastole.  Its paralysis causes increased
rapidity of the cardiac pulsations.
  Paralysis of the spinal  accessory nerve, giving rise to aphonia, has been
already  referred to in treating of the  affections of  the larynx.  Incomplete
aphonia may be a result of paralysis of this  nerve from the  pressure of an
aneurismal or other tumor on the recurrent laryngeal  nerve, and it is some-
times produced by the surgeon in operations on the  neck.


             Paralysis  of the  Ninth  Cranial  Nerve.
  Paralysis of this nerve, the hypoglossus, on one side, involves loss of power
over the genio-hyo-glossus and other muscles of the  tongue on that side.  The
effect is a deviation of the tongue from  a right line when protruded, the apex
pointing to the side of the  paralysis.  The direction  in which the apex points
is readily understood  when the action of the muscles which protrude  the
tongue  is considered.  These  muscles extend from the  chin to  the base of the
tongue; and  when from paralysis the protrusion is effected by the muscle on
one side, the base is drawn toward that side, and as a result of the base mov-
ing  in one direction the apex turns  in the opposite direction, the latter being
toward the paralyzed  side.  Paralysis of this nerve rarely  exists as an isolated
affection, and it is generally symptomatic of  intracranial disease.  It  exists
frequently  in  cases of  hemiplegia.
  In determining  the existence of this paralysis it is to be borne in mind
that the tongue may  deviate from a right line in consequence of absence of
teeth on the  side to which the apex is turned or of irregular inward projec- 
     LOCAL  PARALYSIS OF OTHER THAN CRANIAL NERVES.   793

 tion of teeth on the other side.   Dropping of the upper lip on one side  pro-
 duces an appearance as if the tongue  deviated to the opposite side ;  and to
 obviate liability to error on this score the upper lip should be raised with the
 finger while the tongue is protruded.
   Paralysis of the  hypoglossal nerve  on both  sides is  extremely rare, but
 cases are sometimes observed.  In  complete  paralysis of this nerve on'both
 sides there is inability to  protrude the tongue, and  the power of speeeh is lost
 from inability to articulate.   Incomplete paralysis renders protrusion of the
 tongue and articulation  more or less imperfect"   Paralysis of this nerve on
 both sides enters into the paralytic affection which has been considered under
 the head of Bulbar Paralysis.


        Local Paralysis  of Other than  Cranial  Nerves.

   Paralysis may be produced by  injuries or diseases affecting nervous trunks
 in any part of the body.   The loss or impairment of motion or sensation, or
 both, extends over the parts supplied with the nervous filaments given off by
 the nerve below the situation of the injury or disease.  Traumatic  local  par-
 alysis follows division or wounding of nerves  and contusions.   If a contusion
 give rise  to paralysis by simple shock or stunning the nerve, recovery may be
 expected ; but paralysis due to palpable injury of the structure of a nerve is
 likely to be permanent, although reunion, with a restoration of function, may
 take place after the division  of a  nerve of considerable size.  Diseases which
 give rise  to local paralysis by affecting nerves are  tumors or morbid growths
 situated within and without  the neurilemma,  and inflammation of the neuri-
 lemma or of the nerve-substance.  The latter generally occurs either by exten-
 sion of inflammation seated primarily in the structures adjacent to the nerve
 affected or by primary inflammation  of the nerve.  Paralysis due to the pres-
 sure of a tumor may be  recovered from  if the pressure be removed  before
 extensive disorganization  or atrophy has resulted.
   Pressure on a nervous trunk, continued steadily for several hours, may lead
 to temporary  or even permanent paralysis.  Paralysis of an upper extremity
 has repeatedly occurred from remaining  in profound sleep or in  a state  of
 intoxication with  the arm hanging over the back  of a  chair, the  paralysis
 being due to pressure on the brachial plexus.   I have met  with many exam-
 ples of paralysis of the forearm attributable to lying, while intoxicated, with
 the weight of the body upon- the arm.  Paralysis of a  single  muscle  or a small
 group of  muscles, when not traumatic,  is significant of syphilis as the cause.1
 Among the more  common examples of peripheral  paralyses of  spinal  nerves
 from pressure or injury may be mentioned paralysis of the serratus magnus,
 of the deltoid, of  the muscles supplied  by the musculo-spinal nerve, by  the
 ulnar nerve, or by the median nerve, paralysis of the diaphragm, and paralysis
 of muscles supplied by the anterior  crural or by  the sciatic  nerve.
  The following interesting  case  of local sensory paralysis from injury  has
 fallen under my observation.  The injury was  received by  falling from a
 considerable height upon  the deck  of a vessel, and  striking upon the nates
 in a sitting posture.  Permanent  paralysis of the sensibility of the rectum
 and anus followed the contusion.   Excrescences which  at  one  time existed
 around the  anus were removed without  any sensation of pain.  The patient
 has no consciousness of the accumulation of feces in the rectum, and never
 experiences  the desire for defecation.  Hence the bowels are habitually con-
 stipated.   The contraction of  the sphincter, due  to reflex influence, is  intact.
Involuntary evacuations occur only when diarrhaa exists and when  voluntary
power over the muscles is requisite to prevent their occurrence.   There is no
       1 A'ide article by Dr. Keyes in the New York Med. Journal,  Nov., 1870. 
794
DISEASES  OF THE NERVES.
 paraplegia, no difficulty in evacuating the bladder, and  no sexual  deficiency.
 The  accident occurred more than forty  years ago, and in the mean  time the
 person has had  good health.


         Paralysis of the  Cervical  Sympathetic Nerve.

   The experiment of dividing the sympathetic in the neck, repeated by Ber-
 nard in 1851, and  its effects studied more fully than by previous  observers,
 is now made familiar  to medical  students by those  teachers in physiology
 who  employ vivisections.  The reader is  therefore presumed to know that
 the  immediate results of this experiment are congestion of the head on
 the  side  corresponding  to the  section, rise of temperature due to increased
 rapidity of circulation, and contraction of  the pupil on the  same  side.  These
 effects on the circulation  are attributable to paralysis of vaso-motor  nervous
 filaments.   Paralysis of this nerve occurs from pressure by a tumor, and it
 has followed surgical operations and other  wounds.  Contraction  of the pupil
 is one of the symptoms of aortic aneurism when  the  tumor is so situated as
 to press  upon this nerve.   Dr.  S. AVeir Mitchell has reported a case in which
 paralysis of the  right  sympathetic was  caused by a  wound  from  a musket-
 ball.   The right  pupil was contracted, and the eye on that side  was myopic.
 On exercise the right side of the face became flushed, while the left side was
 pale.1  Dr. AVilliam Ogle has reported a  case in which, from the local appear-
 ance and the phenomena, it was inferred that the right sympathetic had been
 destroyed by an abscess in the neck.  In  this case the  right pupil was con-
 tracted and the eyeball was somewhat retracted.   The right side  of the head
 was redder  and warmer than the left, especially after exercise.  A singular
 feature in this case was that  the patient  sweated on the  left side of the face
 only.  This was observed repeatedly after  active exercise and during expos-
 ure to great heat  in  a Turkish bath.  Although this condition  had  existed
 for two years, no  inflammatory process had followed.2   Functional paralysis
 of the sympathetic system in  different  situations has been supposed to  be
 involved in certain cases of paralysis affecting  the upper  and the lower limbs,
 and to enter largely into the pathology of nervous affections accompanied by
 disturbances of circulation, secretion, and nutrition. These views  are founded
 chiefly on the relations of the sympathetic  system to  the vaso-motor nerves,
 as shown by experimental observations on inferior animals.


                        Paralysis from Lead.
  The accumulation of lead within  the system  may give rise to partial and
 even to general paralysis, but as a rule the paralysis due to this cause is local.
 In the great majority of cases the paralysis is limited to the extensor muscles
 of the upper extremities.   The muscles supplied by the musculo-spiral nerve
 are those chiefly affected.  The triceps and  the supinators escape.  The usual
 form  of  lead ^paralysis  is that  commonly known as ivrist-drop.  This name
 expresses the  peculiar appearance of the upper extremities.  The  patient is
 unable to raise the  hand to  a  line with the forearm.   Frequently the first
 series of  the phalangeal bones of the hand cannot be brought on a line with
the  back of the hand, but the second and third series can generally be ex-
tended, as they are acted  upon by the  interossei muscles.   The dropping  of
the hands is characteristic of this affection.  AVhenever  the peculiar appear-
ance  referred to is presented, the physician is  justified in assuming that the
paralysis is from lead.  In lead paralysis of  the lower extremities the peroneal
      1 Vide Injuries of Newes, by S. AATeir Mitchell, M.D., Philadelphia. 1872.
      2 Aide Trans. Royal Med. and Chirwg. Society of London, 1869, vol. Hi. 
                       PARALYSIS FROM LEAD.                   795

muscles are usually first affected, and then the extensors on the leg, the anterior
tibial muscle remaining intact.  The paralysis is shown by inability to raise the
feet with  the  heels resting on the  floor or to raise the  toes.   The feet drop
when the  patient walks, and he therefore steps high to avoid  tripping.   Par-
alysis of the muscles of the lower limbs is not common.   In a case under my
observation the extensors of both  the feet and  hands are paralyzed, and the
patient  is  affected  with dropping at the ankle as well as at the wrist.
  The appearance  is  diagnostic, but other  evidence of lead-poisoning may
almost  always be  obtained.   As  a rule, paralysis  succeeds other charac-
teristic  effects of lead, especially  the  affection known  as lead  colic.  (Aide
p. 524.)   The blue line on the gums referred to  in  treating  of  lead colic is
always to be sought for.   Generally, the occupation  of  the patient suggests
the source of  the  paralysis, but  in  some cases  the mode in which the lead
has been  introduced into  the system is ascertained only after careful investi-
gation.   An examination of the urine for the presence of lead should not be
omitted.
  Lead paralysis belongs among the symmetrical  or  bilateral affections.  It
is very rarely limited  to  one side, and corresponding  muscles  on the two
sides are  usually affected, but in general  differently as regards the  degree
of  paralysis.   The  paralysis may be complete  or incomplete, and  cases
differ much in respect to its degree.  The power over the flexor muscles is
frequently more  or less impaired,  but  in some cases with  almost  complete
loss of power  over the extensors the flexors are but  little if at  all affected.
This fact  was  illustrated in a striking manner in a case under my observation
at Bellevue Hospital.  AVishing to  group several cases of paralysis for a clin-
ical lecture in the hospital amphitheatre, which is situated at the top of the
building,  I desired  to have a patient affected with complete paraplegia car-
ried up from  a ward  on the ground-floor.   Four  flights of stairs were to be
mounted.   One  of the patients, who was to make  part  of the group, was
aff'ected with  lead  paralysis, the extensors of the hand being nearly power-
less.   He was a man of great strength, and  he volunteered  to carry his
fellow-patient to the amphitheatre on his back.  It  was  necessary to assist
him in obtaining  a firm grasp of the patient, but  when  this was obtained  he
performed the feat with ease, and after the lecture brought the patient down
to the ward.
  Lead paralysis belongs to the group of atrophic paralyses.  The peripheral
nerves and muscles rapidly assume  the reaction  of degeneration, but complete
loss of electrical  reaction is not common.  These  facts make  it probable that
lead paralysis is due  either to an aff'ection of the peripheral nerves or to an
affection of the ganglion-cells of the anterior horns of the spinal cord (polio-
myelitis anterior).  The weight of  evidence  seems to favor the view that the
paralysis  is of peripheral origin, but  in  some  instances changes have  been
found  in  the  ganglion-cells of the anterior horn.   Further investigations
upon this point are requisite.  It is an  interesting fact that alterations in the
electrical  reactions have been found before  paralysis appeared, and also in
nerves and muscles which did not become paralyzed.   A'oluntary power over
the muscles is restored before normal response to the faradic current appears.
  It is to be borne in mind that muscles other than those involved in the
common  form of lead paralysis, or  the wrist-drop, may  be paralyzed by this
cause.   The evidence of lead-poisoning is   therefore to be sought  after in
cases of paralysis in  which  other  adequate  causes are  not evident.  Amau-
rosis is one of the occasional effects of  lead-poisoning.   Exceptionally, anas-
thesia and analgesia of the surface have also been  observed, aff'ecting limited
portions of the integument of the body and extremities.   The muscles of the
larynx concerned in  phonation have been known  to become affected, leading 
796
DISEASES  OF  THE NERVES.
to aphonia, as  well as those of the lips  and tongue, rendering  articulation
difficult.
  The duration of lead paralysis is very variable.  It is sometimes of short
duration, but much oftener continues for a considerable period, and improve-
ment, if it take place, is very gradual. If under proper treatment no improve-
ment take place for several weeks, the prognosis  is unfavorable as regards
recovery, and  the paralysis is likely  to be permanent.   If the paralysis con-
tinue long enough to lead to notable atrophy of the aff'ected muscles, and if
they do not react to either the faradic or the galvanic  current, the  condition
as regards  recovery or improvement is  hopeless.   The proportion of  cases
in which this result takes place is  not  small.
  The treatment of  paralysis  from lead involves, in addition to the meas-
ures applicable in general to paralysis, remedies having reference to the elim-
ination of lead from the system.   The  iodide of  potassium is supposed to
form with the lead a soluble compound, and in this way to promote its elim-
ination.  It must be admitted that the clinical proof of this effect  of this
remedy is not  very conclusive.   Warm baths and the hot-air bath are useful.
It is doubtful  whether sulphur baths, which have  been much recommended,
possess any  advantage  derived from  the  action of  sulphur on the body.  As
regards the treatment addressed to the paralysis, the clinical  evidence of the
benefit of strychnia, given internally and applied endermically, is conclusive.
A most important measure of treatment is the employment of electricity, first
in the form of the galvanic  current, and then of the faradic current when
this begins to produce response.  Prophylactic measures are important for
those whose occupation  involves contact with lead.


Paralysis from Arsenic, Copper, Mercury,  and Phosphorus.

  Paralysis is an occasional effect of either acute or chronic arsenical poison-
ing, oftener of the former than of the latter.  The paralysis affects most fre-
quently the muscles of the lower extremities (paraplegia).  General paralysis
is sometimes produced  by this metal.  There are usually, in addition, sensory
disturbances.   Recovery takes  place as  a rule, with  some  exceptions.
  Paralysis from copper  is preceded by the symptoms of gastro-duodenitis.
Instances of paralysis  from this cause  are extremely  rare.
  Mercury sometimes causes paralysis which is always preceded by mercurial
tremor.  The effects of mercury upon the  mouth,  conjoined  with the occur-
rence of tremor, point to  the cause of the paralysis.  The iodide of potassium
is supposed  to promote the elimination of mercury, as well  as of lead, from
the system, and is therefore indicated in cases of mercurial poisoning.
  Paralysis has been observed after  acute and chronic poisoning with phos-
phorus.
  The treatment having direct reference to the nerves and muscles involved
in the paralytic affections caused by these metals is the same  as in cases of
paralysis from other causes.


                              Neuralgia.

  The term  neuralgia is used to distinguish functional  affections of which the
chief characteristic is  pain.  In a purely neuralgic disease  there is neither
inflammation nor any appreciable lesion  in the painful  part.   There is  a con-
dition of morbid sensibility, and this is  all that can he said  of its essential
pathological character.   A'iseeral neuralgias, as they are called—that is, neur-
algias seated in organs  belonging to the respiratory, circulatory, digestive, and
urinary systems—are considered in the several sections devoted to the dis- 
NEURALGIA.
797
eases of these organs.   The neuralgic affections to be here considered relate
to nervous trunks or their branches not connected with the organs composing
the foregoing physiological systems.
   As regards  symptomatology, diagnosis, causation, prognosis, and the gen-
eral principles of treatment, whatever is true of any one of these affections
is mainly true of all of them.  In order to avoid repetitions, therefore, I shall
first  consider  these neuralgic affections  collectively,  or neuralgia  in general,
under the several aspects just named, and shall afterward notice  briefly the
more important  of the affections  individually.
   Neuralgia may occur abruptly, but in  the great majority of cases there are
premonitions.  The  premonitions are—a feeling of weight, a sense  of heat, or
some  uncomfortable sensation in  the seat of  the  affection.   The neuralgic
pain is either chiefly or exclusively in paroxysms, or there  may  be more or
less continued pain, with exacerbations  in which the pain is  much increased.
The continued pain may be dull or contusive, but  during  the paroxysms or
exacerbations the pain is described as darting, tearing, or lancinating, and it is
often excruciating. The paroxysms or exacerbations  are of variable duration,
lasting in some cases  for a few seconds only, and in  other cases  for several
hours  or  even days.   The intermissions or remissions are not less variable
in different cases; and their duration may be only a few seconds or moments,
and they may extend  to days.  The lancinating pain shoots in the direction of
a nervous trunk and its branches;  and patients sometimes delineate the tract
and distribution of the nerve affected in defining the directions in which the
pain extends.  In the great majority of cases neuralgia is unilateral.
   Tenderness on pressure, limited to circumscribed  points,  is an important
diagnostic feature of neuralgia.  Aralleix was the first  to show that, as regards
their relations to the nerves, the tender points are situated  as follows: 1st,
where nervous  trunks or  branches emerge from the skull  or spinal  canal;
2d, over branches which penetrate muscles on their  way to the integument;
3d, at the termination of branches which are  lost  on the surface;  and 4th,
in places  over trunks near the surface.   The situation of the tender points in
intercostal neuralgia has been stated in treating of that affection.  (Vide p.
183.)  The diagnostic evidence to be derived from  this source in  other neur-
algic affections will be stated when these are severally noticed. Pain may not
be produced  by  pressure made with the open palm ; and, indeed, firm pressure
thus  made often  relieves  the pain.   The tenderness is shown  by pressure
made with the ends of the fingers or by percussion.  The pain thus produced
is often  acute, causing the patient to cry out or  to try to  escape from the
exploration.   If, however, the pressure be continued, the tenderness is often
found  to diminish or temporarily to disappear.   The tender points are fre-
quently quite limited, the end of the finger being often^ sufficient to  cover
them.  As a  rule, the pain produced by  pressure  is acute in proportion to the
acuteness of the spontaneous pain.   The  tenderness  is most marked  during
paroxysms or exacerbations of pain.  In the  intervals between  paroxysms,
the patient being  entirely free from pain, the tenderness  on pressure may
disappear. Exclusive of the tender points, there may be either hyperasthesia
or anasthesia of the surface, and the  latter  may follow the former in  the
same  case.
   Paroxysms or exacerbations of pain are excited or increased by sudden or
violent movements of parts in which the affected nerves  are  situated.   A
concussion of the whole body, as in coughing or sneezing, excites  or increases
the pain.  Cold or hot applications to the surface  over the seat of pain in
some  cases are  insupportable.
   Fever  or  any notable constitutional  disturbance  does  not belong to  the
clinical history  of  neuralgia.   The functions of parts to which  the affected 
798
DISEASES  OF THE  NERVES.
nerves  are  distributed may not be notably disturbed.   A neuralgic attack,
however, often induces hyperamia in the site of the pain, as shown by tem-
porary redness of the conjunctiva in cases of neuralgia aff'ecting the ophthal-
mic division  of  the fifth pair.   Involuntary contractions  of muscles  and
cramps sometimes occur.   An increased secretion of tears, saliva, and mucus
may accompany paroxysms of neuralgia aff'ecting the several  divisions of the
fifth pair;  and glandular organs within the body are probably in like manner
excited in the visceral neuralgias.
   Neuralgic affections have  no fixed  duration.   They may end, either spon-
taneously or under  the  influence of treatment, in a few  hours or  days, and
they may continue for years or during life, in spite of all methods of treat-
ment.   The  prognosis is always favorable  as  regards a fatal termination.
Persons who suffer attacks at variable  intervals  for a lifetime  are  at length
carried off by other maladies not developed in consequence of the continuance
of  the neuralgia.
   Neuralgic pain may proceed from a palpable lesion, such as a tumor either
involving or pressing on  the  affected  nerve, the  presence of a foreign body,
the traction  of a cicatrix from  neuritis, etc.  In such cases  the neuralgia is
not, strictly speaking, functional.   As a functional  malady its  causation  dif-
fers in different  cases.  It proceeds in certain cases from malaria.  This is
always to  be suspected in cases occurring in so-called malarious districts.
AVhen due to this cause  the paroxysms sometimes recur with the same regu-
larity as the paroxysms of intermittent fever, but it may proceed from mala-
ria when the paroxysms do not exemplify a law of periodicity.   It is  one
of the effects of  lead-poisoning.   Next to lead colic (and this is, in fact, a
neuralgic affection),  neuralgia is the most frequent form in which the poison-
ous effects of lead are manifested.  Anamia, by whatever cause induced, favors
the occurrence of neuralgia.  A large proportion of those who suffer from
neuralgic affections are anamic.1  Persons are most likely to suffer from neur-
algia between the age of twenty and of fifty.  Prior to ten years of age it is
extremely rare.   AVomen are more subject to it  than men, and of the differ-
ent species of neuralgic  affections, some occur more frequently in  the male
and some in the female sex.  Females, for example, are more  subject to inter-
costal neuralgia, and  males to sciatic neuralgia.   A neuralgic attack is some-
times referable to exposure to cold, particularly to a current of cold  moist air
continued upon the  part which becomes affected.  Cases occur more fre-
quently  in the cold  than in the  warm  seasons  of the year.
  The situation of the pain is not evidence of the seat of the morbid condi-
tion giving rise to neuralgia.   The mind  may refer the pain to the terminal
branches or the parts to which they are distributed when the morbid condi-
tion is seated at any point in the course of a  nervous trunk  or at  the point
of connection of a nerve with the spinal cord.  This is illustrated by the fact
that after  an amputation  the condition  of  the  extremities  of the divided
nerves gives rise  to  pain which the patient  refers to the amputated limb.
Anstie held that,  as a rule, in the neuralgic affections denominated functional
there is some morbid  change at the central connection of  the  nerve or nerves
to which the pain is  referred.   He was also led to think  that in a large pro-
portion of  cases an  hereditary tendency  is involved in  the  causation,  and,
further, that the  development of these  affections is favored by  exhaustion
and debility,  aside from anamia.2  There is ground  for the belief that local
diseases may cause neuralgia of nerves at a  distance by a reflected morbid
influence (reflex or irradiated  neuralgias). AVeir Mitchell has observed cases
  1 AVith regard to the dependence of neuralgia on anremia, Romberg says:  "It seems
as if pain were the prayer of the nerve for bealthy blood."
  'l Neuralgia, and the Diseases that Resemble it, 1872. 
NEURALGIA.
799
 in which injury of a nerve was followed by neuralgia in other and remotely-
 situated  nerves.
  _ The diagnosis of neuralgia is to be based on the character of the pain, its
 situation in the course of a nervous trunk or its branches, and tenderness  in
 certain circumscribed spaces on the surface.  Other diagnostic points are the
 recurrence of pain in paroxysms or marked exacerbations, shifting of the sit-
 uation of the pain  and tenderness, and the difference, as regards pain, between
 pressure  with the ends of the fingers and with  the  open palm.  In the shift-
 ing of pain from one nerve to another, which is a highly diagnostic feature, the
 nervous trunks successively aff'ected do not always have a common origin; and
 thus the  neuralgia may be transferred from a cranial to a spinal nerve.  These
 are the positive diagnostic points.  Negative points are those by which inflam-
 mation and structural lesions are excluded, such as  the absence of fever, etc.
 In determining the affection to be functional, neuritis is to be excluded' and
 it is to be ascertained, if practicable, that the pain is not dependent on a local
 mechanical cause, such as a tumor  pressing on  the nerve at some point in its
 course.   Syphilitic periostitis is also to be excluded.
   The treatment of neuralgia is rational  and  empirical.  The rational treat-
 ment consists, in the first place, in fulfilling indications which relate to morbid
 conditions suspected to stand in a causative relation to the neuralgia.   The
 physician in individual cases is to seek for evidence  of malaria or lead-poison-
 ing, conditions  having diagnostic criteria irrespective of the neuralgic  affec-
 tion.   Appropriate measures of treatment are to be  addressed to these or any
 other associated morbid conditions under the  supposition that they may have
 more or less to do with the existence of the neuralgia.  Diathetic conditions,
 especially the rheumatic and gouty, are to be considered as probably contrib-
 uting to the  neuralgic  affection,  and with reference to the cure of the latter
 these conditions claim appropriate measures of treatment. Attention is always
 to  be  directed  to  the coexistence of anamia.  Symptomatic phenomena,
 together with the venous hum in the  neck, may denote the anamic condition
 when it is not manifested  by pallor of the face  and  the prolabia.   If anamia
 coexist,  preparations of iron should be continued for a long period.  An
 eligible plan is to  give in succession  different  ferruginous preparations for
 weeks or months,  enjoining  upon the patient  not  to expect restoration to
 health  until after  a  long continuance  of the remedies.   This  treatment
 addressed to the anamia  is indicated, provided the  anamic condition con-
 tinue,  notwithstanding  the neuralgia  may cease. The disappearance of the
 venous hum is  evidence that the anamic condition  is removed.
   The relief of pain enters into the rational treatment.   In severe paroxysms
 or exacerbations opiates are called for.  Large  doses are sometimes indicated
 by the intensity of pain.   The most prompt and effective method of affording
 relief is the  hypodermic injection of a solution of  morphia.  In the use of
 opiates for the relief of neuralgic pain the risk of the formation of the habit
 of taking opium  is always to be borne in mind, yet in severe cases which resist
 therapeutical measures this risk must sometimes be incurred.   If the pain be
 not intense, relief may be obtained  by belladonna, hyoscyamus, stramonium,
 conium, the preparation known as  chlorodyne, and the tincture  of aconite.
 Local applications will often  do  much toward the relief of  pain.  Of these
 the most  efficient are liniments  of  the tincture of aconite, chloroform, and
 opium.  Belladonna, stramonium, veratria, and  aconitia, applied in the  foira
 of ointment, are  sometimes efficacious.
  An arrest of the paroxysms of  pain by opiates is sometimes curative; that
is, the  paroxysms or exacerbations do not recur. If the development of the
affection have been  recent, it is not easy to  decide whether a cure be effected
by the  remedy or whether the affection have no intrinsic tendency to continue ; 
800
DISEASES  OF THE  NERVES.
but the paroxysms sometimes cease to recur, after having been once or repeat-
edly arrested, when the affection has existed for a greater or less period, and
in these cases it is fair to attribute a curative efficacy to the arrest.   In order
to arrest a paroxysm a full opiate should be given as soon as the  paroxysm
begins, or, if practicable, the occurrence of the paroxysm may be anticipated
by a full opiate.  Before  abandoning  this plan of treatment  it should  be
employed in  several recurring paroxysms.  The continued employment  of
some form of opiate or of some one of the narcotic extracts, especially bella-
donna, during the intermissions or remissions, in some  cases effects a cure.
Gelsemium and the hydrate of chloral or the croton-chloral are to be included
among the palliative remedies.
  The empirical treatment of  neuralgia consists  in the  use  of  remedies
which experience has shown to be sometimes curative, which are to be tried
without following any particular rational  indications.  These remedies are in
some  cases efficacious and  in other cases devoid of any curative effect; and
often there are no means of determining beforehand which  one  of the reme-
dies will be most likely  to prove successful.  In rebellious cases the different
remedies  are to be  tried  in  succession.    Methodic  counter-irritation  is
undoubtedly  efficacious  in a large proportion of cases.  Of the different modes
of counter-irritation, Valleix preferred the actual cautery, the hot iron being
passed along  the course of the affected nerve, taking care that  cauterization
shall be superficial, so  as not to lead to deep eschars and suppuration.  To
avoid the pain occasioned by the cautery he advised etherization.  He stated
that he had resorted to  the actual cautery in more than 150 cases, and  always
with success  if the neuralgia were functional.  This method may be resorted
to in cases which resist milder  means  of counter-irritation, together with
other empirical remedies.   Milder means should first be tried.   Of the latter,
a succession of small blisters applied over the painful and tender points will
frequently prove successful.  Prof. Alfred Stille advises  blisters of only half
an inch  in diameter, the period of application.to be from one  to two hours
only, the vesicated surfaces to be healed as rapidly as possible, and the blisters
to be repeated in a few  days if the neuralgia continue. He states, as a result
of the employment of this method  of treatment in almost every case which
has come under his observation in public and private practice for many years,
that " in no  single  instance has it failed to mitigate the  symptoms,  and  in
very many it alone has  achieved a cure." *  During the process  of vesication
the neuralgic pain is frequently increased.  AVhen quickness of vesication is
desirable, it may be effected in a few moments  by the strong aqua ammonia,
and still more quickly by means of a hammer heated by hot water.    By the
latter means, or by an  instrument devised for  the operation known  an firing,
a rubefacient effect may be quickly and conveniently produced, and in mild
cases this may suffice without vesication.   Sinapisms are proverbially  useful,
and in certain cases will suffice, in conjunction with internal  remedies.
   Electricity is a therapeutical agent of great power in many cases of neural-
gia.   Both the faradic and the galvanic forms  are useful, but the latter is in
most cases to be preferred.  Applied  in conjunction with acupuncture, it has
been  successfully resorted  to in some rebellious cases.  Duchenne  recom-
mended the  method called cutaneous faradization.  The palliative  effect  of
electricity is  probably due to a temporary blunting of the excitability of the
nerve or nerves to which the  pain  is referred;  their capacity either to orig-
inate or to conduct painful sensations being diminished or annulled bypassing
through them the electrical current.   This measure, however, in many cases
has not  only a palliative but a curative efficacy.  The testimony of those
who have had great experience in its employment  is stronger than that which
                       1 Therapeutics and Materia Medica. 
NEURALGIA.
801
can he cited in behalf of any other remedy.  Strong pressure upon an affected
nervous trunk sometimes has a palliative effect.  The pressure at first may
occasion  great pain, but continued  or repeated at short intervals it is borne
without suffering  and  diminishes for  a  time the excitability of  the  nerve.
   Of the internal  remedies  which experience has shown to be efficacious, the
more important are quinia,  arsenic, the precipitated carbonate of iron, the
preparations  of zinc, strychnia, the  essential  oil  of  turpentine, the iodide of
potassium, and phosphorus.
   Quinia, as  already stated, is  especially  indicated when the neuralgia is
attributable to malaria, and it  will be most likely to prove successful when
paroxysms occur periodically ;  but it is efficacious also in cases in which there
is  no ground  for suspecting a malarious causation and in which there is no
observance of the  law of periodicity.  To be fairly tried, this remedy should
be given  in full doses—from  fifteen to thirty grains daily to an  adult—and
continued for at least  ten  days.  Of the foregoing  list of remedies, this is
entitled to the first rank.   Arsenic may  be tried in cases in which there is an
intolerance of quinia or when the latter  fails to effect a cure.  It is a remedy
of great value in neuralgic affections.  To be fairly tried, it should be carried
to the extent of producing some of  its characteristic toxical effects.
   The precipitated carbonate of iron, advocated some years ago by Hutchinson,
is  sometimes  efficacious.  It is to be given  in large doses—namely,  from one
to two drachms twice or thrice daily.   Ferruginous  remedies are rationally
indicated  by coexisting  anamia, and this condition is present in a very large
proportion of  the cases of  neuralgia.  The  efficacy of the preparation named
is  doubtless, in a measure at least, attributable to the coexistence  of anamia.
The  hydrochlorate, nitrate, and valerianate of ammonium have been found in
some cases notably efficacious.   Bartholow extols as the most successful of
the different methods  of treatment the  injection of  from five to ten minims
of pure chloroform in  the  neighborhood of the  affected nerve.   This treat-
ment is especially useful in neuralgia affecting nerves superficially situated.1
   Of the preparations of zinc, the valerianate is best suited to cases of neur-
algia.  Strychnia  may  be given internally or applied locally upon a blistered
surface.   In the latter mode of administration the benefit may in some cases
be measurably, and perhaps chiefly, due to the counter-irritation.  The oil of
turpentine is  but  little used in neuralgic affections,  but I have known  it to
prove promptly successful  in  doses of  a drachm, combined  with castor oil
given on alternate days, after a variety of remedies had  been employed with-
out success.  The iodide of potassium has been advocated by Graves, AVatson,
and  especially by  Neucort.2  The writer last named advised its use in large
doses.   The coexistence of  the  rheumatic diathesis   is regarded as  specially
indicating this remedy.  The bromide of potassium has been found efficacious
in  certain cases.  According to Anstie, this  remedy is especially useful in
young persons who may be supposed to suffer from the nervous  consequences
of unsatisfied sexual desire.   He thinks its efficacy is rarely secured under a
less quantity per diem than ninety grains.  In some  cases of neuralgia large
doses of phosphorus have been found to be of great  benefit.
   Division of a nerve (neurotomy) and the removal of a section (neurectomy)
are surgical procedures  resorted to chiefly in cases of neuralgia aff'ecting the
fifth  or trifacial  nerve.   They will be noticed in connection with facial neur-
algia.  Stretching of an affected  nerve  is another method of treatment, the
consideration  of which  belongs to  surgery.
  In conclusion, a permanent cure in cases of neuralgia  will often depend on
the correct appreciation and judicious management of associated morbid con-
       1 A'ide Pro et ice of Medecine, p. 630.
       2 " De la Nevralgie lombaire, etc.," Archives generates de Medecine, 1858.
       51 
802
DISEASES OF THE  NERVES.
ditions, together with hygienic measures to invigorate  the  general  health.
Good alimentation is  always indicated,  and it  is desirable  that  fatty arti-
cles  of food  should enter largely into the  diet.  Cod-liver  oil, if well tol-
erated,  is useful.

     Trifacial Neuralgia—Prosopalgia—Tic Douloureux.

  In  this neuralgic affection the pain is seated  in the sensory fibres of the
fifth or trifacial  nerve.   Pain and tendernesss on pressure are either  limited
to, or most marked in, circumscribed  spaces situated as follows:  The point
of exit of the frontal branch above the orbit, the upper eyelid, the  upper and
lateral portion of the nose, the  point of exit of  the  infraorbitar branch, the
lower margin of the malar bone, over the temporal bone,  the point  of  exit of
the inferior maxillary branch, and over the parietal bone.   It  is rare that
pain and tenderness  are  situated in all these spaces,  but  generally  in  at least
one of the spaces within  the range of the three branches of this nerve,  whence
it receives its  name—trifacial.  In different cases  the  pain is either  limited to,
or especially marked in,  different branches of the nerve—namely, the supra-
orbital, infraorbital, and  inframaxillary.  It is rare  for  this affection to be
limited to a single branch, with  the  exception of that portion of the inferior
maxillary which is contained within  the inferior maxillary bone.
  When the first of the  three branches of the nerve  is the seat of the neur-
algia, during the paroxysms of pain there is intolerance of light, with  redness
of the eye on the  aff'ected  side,  and  more or  less  abundant secretion of tears.
In this situation the neuralgic affection has sometimes been called migraine,
hemicrania, and browache, but true migraine differs from neuralgia.  Increased
heat of the nostril and  an abundant  secretion  of mucus are effects of the
neuralgic affection when  seated in the  second of the three divisions, and sali-
vation sometimes  attends  an affection of the third division.   The branches
which accompany the  facial nerve (portio dura) may be the seat of pain-
a fact  which formerly  led  to  the  supposition  that the latter  nerve  was
affected.  Spasmodic contraction of the muscles of  the  face on the affected
side is  an  occasional effect; hence the aff'ection  was formerly called  tic dou-
loureux,  or painful spasm.   The affection in the vast  majority of cases is
limited to the nerve on one side ;  that is, it is unilateral.  The right and the
left side are aff'ected in about an equal proportion of  cases.
  Trifacial neuralgia in point of frequency ranks with intercostal and sciatic
neuralgia.  An  occasional cause is  caries of the teeth.   It  is by no means
frequently referable to this cause, but that it is so occasionally  cannot be
doubted.  Teeth,  however, are  often  needlessly  sacrificed from a supposed
causative connection.  It  is not sufficient to show  such a connection that
there is tenderness on striking one  or more  of the teeth.  If  the neur-
algia proceed  from this  cause,  touching the offending  tooth or  teeth  will
excite a paroxysm of pain extending into more or less of the branches
of the  nerve.
  Trifacial neuralgia is to he discriminated from inflammation  of  the mem-
brane  lining  the supraorbital and the maxillary  antrum  and  from syphilitic
periostitis.   The two former of  these affections  are distinguished by  the dif-
ferent character of the pain, its  fixed  situation, and  the  occurrence of a dis-
charge  into the anterior nares.   The latter affection is recognized  by the
fixed tenderness on pressure, the existence  of swellings or nodes, the aggra-
vation of pain in the night-time, and other evidence of syphilitic disease.
Neuralgia in  this  situation is often dependent on malaria, and the paroxysms
of pain sometimes  exemplify the same laws of periodicity which govern the
recurrence of  the paroxysms of  intermittent  fever. Trifacial neuralgia rarely 
TRIFACIAL NEURALGIA.
803
occurs in infancy.   In the majority of cases the age is between thirty and
fifty years, and it  occurs oftener  in  women than in men.
   This neuralgic affection is curable in the majority of cases.  Exceptionally,
it resists all the therapeutical measures which  have been consideredas appli-
cable to neuralgic  aff'ections in general.   The branches which  are generally
affected in these rebellious cases are  the frontal and the inferior maxillary.
As a last alternative, division or excision of a portion  of the affected branch is
sometimes resorted  to.  The long-continued  and extreme suffering from fre-
quently recurring paroxysms in some cases warrants this procedure after other
measures  have  been faithfully tried.   Mere  division  of a nervous  branch
usually affords only temporary relief.  The affection returns after the divided
extremities have united.  A portion of the nervous branch must be removed
to prevent or delay reunion.  The  removal of a portion of the inferior max-
illary nerve within  the inferior maxillary bone has  sometimes proved success-
ful after the failure of all other measures;  but  in a considerable proportion
of cases the  affection returns sooner or later.  In  a  case under my observa-
tion, in which the patient has suffered from paroxysms of intense pain recur-
ring at intervals of a few moments  for the greater part  of ten years, the
removal  of a portion  of the nerve by  trephining the inferior  maxilla, the
operation being performed by Prof.  Hamilton, procured  relief for  several
months, but the pain subsequently  returned.
   Facial neuralgia, persisting indefinitely, resisting  medication, and  charac-
terized by spasmodic movements of the  muscles of  the face during the par-
oxysms of  pain, is distinguished  by Trousseau  as epileptiform,  neuralgia.
There  are few forms of disease more  distressing than this  or more hopeless
as regards the prospect of effecting a cure.   A  case which came  under my
observation exemplified the persistency of this  form of neuralgia, and also
exemption from  suffering for an unusually  long period  procured by simple
division of the  nerve.   The  patient,  a man aged  about sixty,  had suffered
intensely from neuralgia affecting  the supraorbital branch of  the fifth pair
on the left side for more than two years.  The  paroxysms of  pain recurred
at intervals  of a few minutes, and were  often excruciating beyond descrip-
tion.   After trying a great variety  of remedies  and different systems  of
practice, the nerve was divided by  Aalentine Mott, and the patient was  com-
paratively  free  from suffering for three years.  At the end of this  period,
while under  treatment for enlargement of the heart  and general dropsy, the
neuralgia suddenly returned with  the same  violence as before the operation.
Paroxysms were produced by mastication, by movements of the lips  in pro-
nouncing  words  containing labial  letters, by touching  the face, and  they
occurred without any exciting cause.   The  nerve was  divided a second time
by Prof. J. R. AVood, with immediate  and almost complete relief, which con-
tinued until the patient's death, several weeks  after the operation.
   Carnochan was the first to perform neurectomy beyond the spheno-palatine
ganglion for the relief of persistent neuralgia  of the  superior maxillary branch.
He reported three cases of successful  performance  of this operation in 1857.*
This operation, since that date, has been performed  by James R. AVood and
others  with success.2
   Facial neuralgia, after having persisted for a long period, sometimes occa-
sions disturbance of nutrition on  the affected side  of the face, denoted  by
tumefaction,  an increase of adipose  tissue,  thickness  and  firmness  of  the
beard,  and it sometimes appears to give rise to  pustular or  erythematous

  1 Amer. Journ. of Med. Sciences, vol. xxxv.
  2 For an analysis of 21 cases, and the practical conclusions deduced therefrom, vide
article on " Neurotomy of the Superior Maxillary Branch of the Trigeminus," by Fred-
eric S. Dennis, M. D.,  in the New York Med. Journal, June, 1879. 
SO 1
DISEASES OF THE NERVES.
inflammation.   An  analysis of  128 cases by Notta  showed, as occasional
complications, in addition  to those already mentioned, paralysis, either com-
plete  or incomplete, of the retina, iritis, glaucoma, inflammation and ulcera-
tion of  the  cornea, tumefaction of the tongue on one side, paralysis  of  the
motor oculi, deafness, and  anasthesia of the face on the aff'ected side.1  Cer-
tain  of these complications are  attributable to paralysis of the vaso-motor
nerves.   Anstie, who verified the  correctness of  Notta's observations,  ob-
served,  in addition, grayness of  the  hair on the affected  side and  discolora-
tion  of the skin from the presence  of dark pigment.2


                    Cervico-occipital Neuralgia.

  The pain in this  neuralgic affection is seated in the  posterior branches of
the first four of the cervical  nerves, especially in that branch of the second
cervical nerve  called,  from its size  and distribution,  the occipitalis  major.
The  nerves on  both sides  may  be  affected.
  Painful  and tender points  are situated as follows:  Between  the mastoid
process and the cervical vertebra, over the posterior cervical  plexus, on the
parietal portion  of the head, on the mastoid process, and in the concha auris.
Shooting pains  start from the  cervical vertebra just below the  occiput, and
extend  over the posterior and superior portion  of the cranium. Darting pains
are sometimes referred to the external auditory meatus.  In cases of neuralgia
affecting primarily the cervico-occipital nerves, the pain is likely to  extend to
the branches of  the trifacial distributed to the frontal portion of the  head, and
in like manner in cases of  neuralgia  affecting  primarily the superior division
of the trifacial the pain  often extends to the branches of the cervico-occipital
nerves.
  Cervico-occipital neuralgia is to be discriminated from myalgia affecting the
muscles of the  neck, or  torticollis.   In the latter affection the pain  is limited
to the affected muscles,  the tenderness on pressure is  more diffuse, and it is
not confined to circumscribed points.    The pain is excited  exclusively by
movements of the affected  muscles, and so long as the head remains motion-
less  there  are no painful  paroxysms.


                    Cervico-brachial Neuralgia.
  In  cervico-brachial neuralgia sensory fibres of the four lower cervical  nerves
and of  the first  dorsal  nerve are  affected.  The pain  is frequently referred to
the shoulder, and  it may extend  to the neck.   It shoots downward  along the
arm  to the forearm and hand, following the  course of  one  or  more  of the
nervous trunks  of the upper  extremity. The  pain may be limited  to the
ulnar, radial, median, or  musculo-cutaneous nerve, giving rise to different
varieties of the  affection.   Of  these varieties the most frequent is  neuralgia
affecting the ulnar nerve.   Painful and tender points are situated as follows:
Near the last cervical  vertebra, near the acromial  end of the clavicle, over
the upper  part  of  the deltoid muscle, in the  axilla, at the inner condyle of
the humerus, and near  the lower end of the ulna  and radius.
  Pain referable to the cervico-brachial nerves  is sometimes an effect of injury
of the upper extremity by a wound, a burn, or a contusion.  Functional neur-
algia  is to  be discriminated from the pain incident to neuroma or other mor-
bid growths  affecting the periphery of  these nerves by the failure to discover

  1 Archives generates de Medecin», 1854.  ATide, also, treatise by Anstie.
  2 For a report of cases observed and collected by Prof. Henry D. Noyes,  with refer-
ence particularly  to the effect upon  the eye of paralysis of this nerve,  vide New York
Journal of Medicine, vol. xiv. p. 103. 
SCIATIC NEURALGIA.
805
 a tumor in the course of the nerves.   Pain referred to these nerves may be
 symptomatic of vertebral lesions, and also  of cervical arthritis.  In  cases of
 the latter, movements of  the  head, especially those  of rotation, even in the
 intervals  between the paroxysms, are painful.  Another feature is,  that the
 patient when lying down is obliged to raise the head with a hand on  the occi-
 put to avoid pain.  Myalgia affecting the muscles of the upper extremity is to
 be discriminated by the larger extent of surface which is tender on pressure,
 by the absence of paroxysms of pain except when provoked by movements of
 the aff'ected muscles, and by the  limitation of the pain to the affected  muscles.
  Herpetic vesicles in patches, constituting herpes zoster, sometimes occur in
 the course of the nerves involved in this affection.


                   Dorso-intercostal Neuralgia.
  This affection has been  considered in the section devoted to diseases affect-
 ing the Respiratory System, to which the reader is referred (p. lbo).


                   Lumbo-abdominal Neuralgia.
  Neuralgia having its seat in  the branches of the five lumbar nerves is of
 not infrequent occurrence.  It occurs much oftener in females than in males.
 Pain is often referred to the hypogastrium, and it may resemble that of colic.
 Uterine pain and ovarian pain are incident to this aff'ection. In males the affec-
 tion is sometimes characterized by pain extending along the spermatic cord into
 the scrotum, accompanied by notable tenderness of the testicle.
  Painful and tender points are situated near the upper lumbar vertebra, a
 little above the middle of the crest of the ilium, in  the neighborhood of the
 inguinal ring, in the scrotum,  and in the female on the  labia  majora.  Pains
 are excited by muscular efforts,  the acts of coughing or sneezing, straining at
 stool, and sometimes \>y micturition.
  Myalgia affecting the lumbar muscles, or lumbago, is to be discriminated by
 the existence of pain and  tenderness on both sides, whereas in neuralgia they
 are generally confined to one side ;  by the  tenderness being diffused  over the
 affected muscles,  and not  limited to certain  points; and by the absence of par-
 oxysmal pain except when produced by movements of the affected muscles.
  In the case in which pain extends to the uterus, inflammation of  the organ,
 or metritis, and carcinoma are to be excluded.   In uterine neuralgia the os
 uteri  is tender on  pressure, and the tenderness is either limited to  or most
 marked on one side.  The pains in  these varieties of neuralgia may  simulate
 those caused by  the passage of a calculus along  the ureter, or renal  colic.
 The pains in the latter are more intense and persisting; and they are devel-
 oped suddenly, whereas the development of a neuralgic affection is generally
 gradual.  The absence of symptoms which distinguish renal colic warrants its
 exclusion.
                         Crural Neuralgia.

  This neuralgic affection is rare.   It  is characterized  by shooting  pains in
the  direction of the trunk of the anterior crural nerve and its branches, and
by painful and tender points in the  groin, the inner aspect of the thigh, knee,
and ankle.
                         Sciatic Neuralgia.

  Sciatic neuralgia, or sciatica, in frequency ranks with intercostal  and facial
neuralgia.   It occurs in men oftener than in women, the relative proportion
of cases being as three to two.  It very rarely occurs before the age of twenty 
806
DISEASES  OF THE NERVES.
and rarely after sixty.  It is sometimes symptomatic of pregnancy, of enlarge-
ment of the retro-peritoneal lymphatic glands, of accumulation of feces or for-
eign substances in the  sigmoid flexure of the colon, and of intrapelvic tumors ;
but in the great majority of cases it is a functional affection.
  As in the foregoing neuralgic affections, shooting pains, in  paroxysms  or
exacerbations, extend  along  the trunk and  branches of the affected nerve.
In indicating the course of the pain the patient often delineates with accuracy
the anatomical distribution of the sciatic  nerve.   The character of the  pain
is sometimes described as burning  and  sometimes as a sensation of coldness.
The patient feels as if a current of hot or cold liquid  were flowing  in the
course  of the affected nerve.  A continued  contusive  pain,  more or less
intense, exists in the larger proportion of cases.   This pain, as in the other
varieties of  neuralgia,  is referred to the circumscribed spaces which are ten-
der on pressure.
  Painful and  tender  points in this neuralgic  affection are found  in  certain
of the  following situations:  On the sacrum,  over the  sacro-iliac junction,
about the middle of the  crest of the ilium, at the sciatic notch, between the
trochanter major and  the tuber ischii, on the thigh along the track of the
nerve, in the popliteal space, on the external border of the patella, over the
articulation  of the fibula with the  tibia where  the nerve passes around the
fibula, over the lower and posterior part of the  external malleolus, and on the
dorsum and the  outer portion of the soles of the feet.  The points situated at
the sacro-iliac junction, behind the trochanter major, at the head of the fibula,
and the external  malleolus,  are those  most frequently painful and  tender.
Pressure with the finger upon some-of the foregoing points may not only  be
more or less painful, but excite a paroxysm  or exacerbation of pain extend-
ing  to  other parts in  the course  of the  affected nerve.
  The intensity of the pain,  as in  the other  kinds of neuralgia, varies much
in different cases.  The movements of the affected limb in  some cases occasion
such an amount of suffering that the patient remains in bed, keeping the  limb
as nearly motionless as possible.  In  other cases the patient is able to walk,
but with more or less  difficulty.  Pain  is felt especially when  the weight  of
the body falls upon the affected limb, and  relief is found in the  use of  a cane.
Sometimes difficulty in walking  is felt only in beginning to walk, and  after a
short time the patient  walks  with ease.  The suffering is occasionally relieved
by  exercise.  In severe cases muscular twitchings and cramps accompany the
paroxysms or exacerbations of pain.
  Sciatic neuralgia rarely, as compared  especially with facial neuralgia, exem-
plifies in the recurrence of paroxysms the law of periodicity.  Like other neur-
algic affections, its duration  is  very variable.  As a rule, in favorable cases
it persists  for several weeks, disappearing, as  it is usually  developed, grad-
ually.   In the vast majority  of cases sooner or later it ends in  recovery, but
in some cases it continues indefinitely in  spite  of all remedial measures.   If
it continue for a considerable period so severely as to lead the patient to avoid
as much as possible movements of the affected  limb, the repose of the muscles
may render them for a time incompletely paralyzed.  The muscles under these
circumstances become  flaccid and diminished in volume.
  The diagnosis of sciatic neuralgia involves  its discrimination from  muscu-
lar rheumatism and from the affection  of the  hip-joint  commonly known  as
morbus coxarius.   Muscular rheumatism here, as in other situations, differs
from neuralgia in the  limitation of pain to the affected muscles, in the diffu-
sion of tenderness over a considerable space—namely, a  space corresponding
to the number of muscles affected—and in the fact that paroxysms of pain are
excited exclusively by movements  of the affected muscles.
   Morbus coxarius is  distinguished by the pain in the hip-joint produced  by 
MYALGIA.
807
pressure upon the great trochanter and by flexion and extension of the thigh.
Moreover, febrile movements, general debility, emaciation, etc., in conjunctfon
with  the local  symptoms,  point  to the  existence  of chronic  inflammation
within the joint.
   The term  sciatica, as commonly used, is applied to cases in which pain is
referred  to  sacral  nerves, although the  sciatic nerves may be  unaffected.
Pain  of  a neuralgic character in the nerves  composing the  sacral plexus is
often symptomatic of lesions within the pelvis and  abdomen, such as aneur-
ismal, carcinomatous, or  other  tumors, enlargement of glands, etc. and of
lesions of the sacrum and vertebral column and those occurring within the
spinal canal.  Here, too, as in other  situations, it may be dependent on neur-
itis.   This is to be  inferred from  the speedy occurrence of paralysis and
atrophy  of the  muscles  to which the  nerves are distributed.

 _  The coexistence of two or more of the  foregoing  different' neuralgic affec-
tions or their successive occurrence is frequently observed.  Proximate or
inosculating  nerves may  be simultaneously or  successively affected.  Thus,
trifacial  and cervico-occipital neuralgia are  not infrequently associated, and
this  is true  of  sciatic and crural neuralgia.   A cure or spontaneous cessa-
tion  of neuralgia  in one situation is  likely to  be followed  by the  develop-
ment of the affection in  another situation.    These facts  go  to  show  the
dependence  of neuralgia on constitutional or general morbid  conditions.


                              Dermalgia.
   Neuralgia  is sometimes limited to the skin.  Cases  are occasionally observed
in which pain is felt on the surface of the head, trunk, or extremities, together
with notable  tenderness on pressure, the nervous trunks being free from pain
or tenderness.  This form of neuralgia  has been  called dermalgia.  Under this
heading  may be placed the form of  neuralgia described by AVeir Mitchell as
incident  to injury  of nerves, and called by him causalgia.  This is character-
ized  by a burning  pain in the  soles of the feet  and palms of the hands.  I
have  reported an instance of causalgia affecting the soles of the feet, occur-
ring  without any  injury of a nervous  trunk or any other symptom ;  also, a
case  in which a  paroxysmal  burning pain  was referred to the abdomen and
lower limbs.1


                Myalgia—Muscular  Rheumatism.

   Neuralgia  affecting sensory nerves  in  muscles may be distinguished as
myalgia.  Under this head I shall enumerate certain local  affections which
it has been customary to embrace  under the name muscular rheumatism.  The
term  rheumatism, as applied to these  affections, is  manifestly inappropriate,
and it is  desirable  that the name in this application  should  become  obsolete.
The myalgic  affections were designated  by A'alleix by the suffix  dynia, added
to the name  of the muscle or group of muscles  affected.  This designation,
having the same derivative  meaning as words ending in algia, is appropriate.
   Myalgia is of frequent occurrence as  an  acute and a chronic affection.  The
symptomatic  features of  the acute affection are as follows: The development
is  usually gradual.   A dull pain  is at first  felt in certain muscles, which
increases, and at length becomes more  or less severe.   The pain is compara-
tively slight when  the affected muscles are at rest.   In certain  positions the
patient may  be  nearly or  quite  free from  suffering.  A  constant pain of a
contusive character is often  felt when  the muscles are at rest, and this may
                          1 Aide Clinical Medicine. 
808
DISEASES  OF THE  NERVES.
be aggravated by spasmodic  pains  occurring  from time  to  time.  Tn move-
ments which involve contraction of the affected muscles, the pain is severe,
cramp-like, and sometimes so excruciating that the  patient can hardly repress
loud groans or cries.  A'oluntary movements  which occasion the severe pain
are avoided as much as possible, but as it is  impossible to maintain  rigidly-
fixed positions of the body  as a whole or of  its diff'erent parts, the  affected
muscles are at times  thrown into painful contractions, however much the
patient may desire to avoid them.   Movements occurring during sleep occa-
sion the attacks of pain,  and  hence  the patient is awakened at brief intervals.
In some  cases  the  affection  changes its seat  from  certain muscles to others,
but  oftener it  remains fixed in the muscles  first  affected.
   The aff'ected muscles  are  more  or less  tender on pressure, the tenderness
being diffused over the whole of the space which the muscles occupy, and not
limited to certain points as in ordinary neuralgia.  The tenderness is usually
not great,   Aside from the tenderness, there are no local characters, such as
swelling, heat, or redness.  The local phenomena are not those of inflamma-
tion, as in articular rheumatism.  If the local symptoms denote inflammation
of the muscles, the affection  is not  myalgia.   Uniform firm pressure over the
affected muscles is not only well borne, but it affords relief in cases of muscu-
lar rheumatism.
   There is little or no constitutional disturbance beyond  that occasioned by
the  suffering  and loss of sleep.   The  appetite and  digestion may not  be
impaired, and there is no fever.
   In the subacute or chronic form  of the affection  pain similar to that which
belongs to the acute form may be excited only when the affected muscles are
contracted with unusual force.  The  patient  experiences  suffering when he
makes certain violent  movements.   In  other  cases pain is excited by partic-
ular movements when they are first made after a period of  rest, and the pain
shortly disappears if the movements be continued.   The chronic oftener than
the acute affection is likely to shift its situation, affecting  now certain  muscles
and now those in another part.  If the  chronic affection  remain fixed in par-
ticular  muscles,  they may  become somewhat atrophied in  consequence  of
their being kept as much as possible  in  a state  of inaction.
   The duration of acute  myalgia varies  between a few hours and a week.
Exceptionally the affection continues for several  weeks.   The duration of the
chronic form  is indefinite.   It  is  often a very obstinate affection, persisting
for many months.   The course of  the latter is usually marked by remissions
or intermissions.   In  certain situations—namely, the loins, the walls of the
chest, and muscles of  the scapula—the chronic affection is likely to be long
persisting.
   The following are the principal  situations of myalgia in the acute and the
chronic form :
   1. The Muscles of the Head.—Situated in the occipitofrontal  muscle, the
affection is distinguished from neuralgia affecting  the trifacial and the occip-
ital nerve by the pain being referred to both  sides of the head, by its being
excited by movements of the muscle and comparatively  slight so long  as the
muscle is  at  rest, and by the absence  of tenderness in disseminated points.
The muscles of the eye  are sometimes affected.  Movements of the eye then
occasion more or less severe pain. The temporal and  the masseter muscle
may be  affected, causing pain in  mastication.
   2. The  Muscles of  the Neck.—In this  situation the affection, as it com-
monly occurs, has been  known by  the name rheumatic torticollis.   This name
is applied  to the aff'ection when situated in the muscles of the antero-lateral
aspect of the neck.  The muscles on the posterior  part of the neck are some-
times the seat of the affection.  Aralleix applied to the affection in the latter 
MYALGIA.
809
situation the name cervicodynia.  In  this situation the affection is to be dis-
tinguished  from ordinary occipital neuralgia.
  3. The Muscles of the  Back.—Aralleix called the  affection in this situation
dorsodynia.   Seated in these muscles, the pain is caused  especially by move-
ments which approximate the scapula.
  4. The Muscles of the  Loins.—In  this  situation  the affection is commonly
known as lumbago.   Aralleix designated it lumbodynia.  This is  a  frequent
seat of the affection in a chronic form.  It is to be discriminated from  lum-
bar abscess, lumbo-abdominal neuralgia, and the pains incident to aneurism
of the descending aorta.
  5. The Thoracic Muscles.—Here  the affection goes by  the name  pleuro-
dynia.   In  making  the  diagnosis pleuritis  and intercostal neuralgia are to
be  excluded.   This  may easily be done  by ascertaining  the absence of the
diagnostic characters of  the latter two affections. The pain excited by forced
breathing, coughing, and sneezing is  not unlike that  in pleuritis and inter-
costal neuralgia.  In this situation  the pectoral  and the intercostal  muscles
are affected.
  6. Muscles of the Shoulder.—Aralleix entitled  the  affection here  situated
scapulodynia.   It  is seated especially in the deltoid muscles,  and it  is liable
to be confounded with arthritis situated in the shoulder-joint.
  7. The Muscles of the Extremities.—Seated in  the extremities, the affection
is to be discriminated  from neuralgia  affecting the nervous trunks, and  from
the affection commonly known as syphilitic rheumatism.
  8. The Abdominal Muscles.—The  pain  and soreness caused by the affection
in this situation may  suggest as probable or possible  the  existence of  peri-
tonitis.   This disease is  to be excluded by the absence of the general symp-
toms and by firm pressure with the  palm of the  hand being well borne,  as in
cases of  cutaneous hyperasthesia.
  9. The Visceral Muscular Structures.—The tongue and the  muscles of the
pharynx and asophagus may be the seat of myalgia, giving rise to pain in
speaking and in deglutition.   Examples, however, are extremely rare.  Seated
in the stomach, intestines, and uterus, as it probably may be. to distinguish
the affection from  visceral neuralgias  is impossible ; and in  fact to consider it
as distinct  from the latter is to make a distinction without any essential dif-
ference.  There is reason to believe that the diaphragm may be  the  seat of
myalgia.   It  is perhaps more  reasonable to consider this as the  affection,
rather than  diaphragmatic pleuritis,  in  certain cases characterized  by the
instinctive  arrest of diaphragmatic  movements  in  consequence of pain, and
by  the intense suffering  caused by coughing and sneezing, febrile movement
and pleuritic effusion being wanting.   It may be doubted if the  affection be
ever seated in the muscular walls of the  heart.
  In all  these situations  the most marked diagnostic feature is the connection
of cramp-like pain, more or less severe, with the  movements which bring into
play certain muscles in  the  parts to which the pain is referred, pain, irre-
spective  of contractions  of the affected  muscles, being comparatively slight
and sometimes wanting.   This diagnostic feature distinguishes myalgia from
neuralgic affections  seated in the different  nervous trunks.  Another  diag-
nostic feature  is the diffusion of  soreness over the  affected muscles, whereas
neuralgia seated in nervous  trunks  is characterized by tenderness in circum-
scribed points.  Inflammation affecting muscles is distinguished from myalgia
by the constancy of pain  or  the  absence of the remissions or intermissions
which  belong to the latter affection,  by  the existence of swelling and some-
times redness, by the  greater degree  of  tenderness on pressure,  and by the
presence of more  or less  symptomatic fever.
  The treatment  of the acute  form of the affection consists of sinapisms, 
810
DISEASES  OF THE NERVES
followed by soothing, emollient applications over the affected muscles, rest in
the position most favorable to avoid contractions of the affected muscles, and
the employment of anodynes either internally or  by hypodermic injection.
In  the  chronic form small blisters in succession are useful, but  not  in the
same  degree as in  cases of ordinary neuralgia.   The  employment of the
induced electrical  current I have known to be beneficial  in obstinate cases.
The constant current has also been found highly efficacious.  Friction  or
shampooing, either  dry  or  with  stimulating or anodyne liniments,  affords
relief and  promotes a cure.   "Firing "is  recommended.   The  bromide of
potassium and of ammonium I have found  useful.  The  hydropathic treat-
ment  is said to  prove  successful in   some obstinate  cases, water being
employed locally and generally.   The salts of quinia in full doses are some-
times efficacious, especially when the affection  is intermittent.  Measures  to
invigorate  the  general health  are important in chronic cases.   If  anamia
exist, preparations of iron should be continued for a long time in small doses
or until the venous  hum disappears from the  neck.   Anstie recommends  as
especially useful the muriate of  ammonia in doses of  from twenty to thirty
grains.
  Persons liable to this affection are likely to have an attack after exposure of
a portion of the body to  a current of air, especially during sleep or when the
body is perspiring.   The susceptibility to this cause of disease is to be over-
come by the daily use of the sponge-bath, by avoiding an over-abundance of
clothing, and by becoming habituated to out-of-door exercise in all kinds of
weather.

                      Cephalalgia—Headache.
  Pain  in  the head is  a  symptom  occurring  in  many affections, such  as
active cerebral congestion, cerebral meningitis, cerebritis, the essential fevers,
acute dyspepsia, syphilitic periostitis of the head, intracranial tumors, etc.
etc;  It  is frequently due  to  neuralgia  affecting either  the cervico-occipital
nerves or  the supraorbital division of  the  fifth pair.   Pain limited to one
side of the head, or  hemicrania, may be due to neuralgia affecting the nerves
just named. According to A'alleix, idiopathic cephalalgia  or  headache is  in
all cases resolvable into hemicrania (migraine).  This opinion does not  seem  to
me to be correct.  In certain cases the pain  does not follow the direction of
these nerves, it  is not limited  to  one side of the head,  disseminated  tender
points may not be found, and in its behavior the aff'ection differs from neur-
algia affecting these or other of the nervous trunks and branches.   Hence,
cephalalgia  or headache  may denote a  functional neuropathic affection  dis-
tinct from  hemicrania.   The seat of the aff'ection when  confined to one  side
in certain cases has been  supposed to be the branches of the trifacial nerve
which are distributed to the dura mater.  It has also been  supposed that the
sensory filaments entering into the composition of the cerebral membranes and
of the brain may be the  seat of neuralgia.
  Cephalalgia is extremely common.  It occurs in paroxysms, lasting usually
from twelve to  twenty-four hours, in some cases being of shorter duration,
and occasionally continuing for two  or  three days.  There are few  persons
who do not occasionally experience an  attack after childhood or adult age,
and there are very many who are subject to attacks recurring sometimes  at
regular, but usually at irregular, intervals for many years  or during the  life-
time.   A host  of persons  suffer from  it who either do not consider it of
sufficient importance to resort to medical treatment, or, having found  medical
treatment ineffectual, resign themselves to it as an irremediable malady.
  The pain in  diff'erent cases or  in different attacks in the same case differs 
CEPHALALGIA.
811
much in degree.   An  attack is often not severe enough to prevent habitual
occupation, but in some  instances the intensity of the pain is such that the
patient  is unable to be  about, and  perhaps is obliged to take to  the bed.
The  pain  is sometimes referred to  the  forehead, sometimes to the occiput,
and sometimes to the whole head.  The character of the pain as  described by
patients differs.   It is  sometimes sharp or lancinating, like the pain in neur-
algic paroxysms ; and in other cases it is a dull, heavy pain.   Patients some-
times say that they feel as if the head would burst.  Firm pressure upon the
head, especially over the temples, often affords momentary relief.  Frequently
rubbing or shampooing the scalp with considerable force diminishes the pain.
There is  frequently an abnormal  sensitiveness  to light and  sounds, and in
severe attacks the patient  seeks perfect quietude in a dark room away from
all noise.  The  appetite during the  attack is either impaired or lost.   The
odor of food is often disagreeable.  Nausea and vomiting occur in  a certain
proportion of cases, and  then it  is common to  call the affection megrim or
sick headache.  AVithout nausea or vomiting the affection is commonly known
as nervous headache. The face is in some cases flushed, the eyes are suffused,
and  the temperature of  the head is raised;  and in  other cases, especially if
nausea and vomiting occur, the face is pallid and the head may be cool.  Free
vomiting, although the stomach  may not contain any aliment, is sometimes
followed by relief.
   Accompanying the foregoing local symptoms is more or  less general debil-
ity or prostration.  There is rarely  fever, the.pulse is generally small and
feeble,  and the surface of the  body cool.   Occasional  shiverings are not
uncommon.  Disturbed  action of the  heart, or  palpitation, is not uncommon
during  the attack.
   The  attack gradually passes off,  sometimes  with the occurrence of free
evacuations from  the  bowels or an abundant secretion of urine or a slight
perspiration.   The  attack is often  developed  in  the morning, pain being
experienced on awakening from  sleep, and  it may continue until after sleep
is obtained on the  following night.   Persons  subject to the  affection  are
able sometimes to predict its advent by  a feeling of lassitude, depression of
spirits,  or a sense of indefinite discomfort,  After the  attack has passed off,
there is frequently, for some time, a sense of soreness in the head, with more
or less  general debility.   Often, however, the mental  faculties are  unusually
clear and the spirits are buoyant after recovery from an attack.
   The affection involves a constitutional  predisposition.  Persons are subject
to periodical attacks of  headache, as of asthma  or  epilepsy.  The  predispo-
sition existing,  various  exciting causes  may determine  an attack, such  as
mental  excitement, deprivation of sleep, bodily fatigue, exposure to the sun's
rays, and dietetic imprudences.   Not infrequently attacks occur without any
obvious exciting causes.  AVomen are more  subject to the affection  than men,
and  it  often occurs at the menstrual period.   The predisposition  varies in
degree in different cases, as shown by the frequency or rareness of the attacks.
The predisposition frequently ceases after the age of forty or fifty; and persons
who have experienced attacks more or less  frequently from adult  age up to
the periods of life just named, thereafter are exempt from their recurrence.
This  may be stated as a rule, but, unhappily, there  are not a few exceptions.
   The  affection is neuralgic in its character, but it is difficult to  determine
its precise  seat.   It is  a  reasonable supposition that it  involves  a toxical
agent in  the blood.   Cephalalgia, it is  well known, is produced by diff'erent
toxical  agents—namely, opium,  alcohol,  strychnia,  quinia,  and  the accumu-
lation of urea.   Assuming the correctness of this supposition, the nature and
source of the toxical agent or agencies are unknown. It has been conjectured
that  the  immediate causative condition may be either  spasm or paralysis of 
812
DISEASES  OF  THE NERVES.
the muscular fibres of the arteries within the skull from an influence exerted
through the vaso-motor nerves.  The pallor and coolness of the face and head
in some cases, and the redness and heat in other cases, sometimes bilateral and
sometimes unilateral, afford support to this conjecture; and it is not an incon-
gruity that anamia and congestion alike may give rise to the cephalalgia.  In
accordance with these pathological views, inhalation of the nitrite of amyl has
been suggested as an  appropriate remedy when the appearances denote ana-
mia, and  ergot when there is congestion.  Assuming  the existence of spasm
or paralysis of the arterial muscles, it is reasonable to suppose that the vaso-
motor influence depends on a toxical agent acting on the sympathetic  nerves.
It has been  shown  that a certain number of cases of migraine  are of reflex
origin.  In certain cases, migraine is the result of some aff'ection of the nasal
mucous membrane,  and in obscure cases it  is well to make  an  examination
of this region.   Other  cases of migraine appear to  be of a myalgic  nature,
the occipito-frontalis muscle being chiefly  involved.
  Periodical headache, as regards  successful  treatment, belongs among the
opprobria of medical art, yet in not a few cases much benefit may  be derived
from  treatment.   The treatment embraces  measures  to be employed at the
time of an attack and during  the intervals.
  If patients be not affected unpleasantly by opiates, an attack may be some-
times warded off or  abridged or its severity lessened by a full dose of  opium
in some of its forms, or of its  alkaloids, morphia  or  codeia.   The carbonate
of ammonia is  sometimes successful in affording relief.  A saline  purgative,
taken at the beginning of the attack, is in   some cases an  effectual remedy.
The bromides  given in full  doses are sometimes efficacious.   This statement
will also apply to the hydrate of chloral in doses  of  fifteen  grains, repeated
once or twice  after an hour's  interval  if relief be not obtained.
  Various  palliative measures  may be  resorted  to  with  advantage.   The
inhalation of a little of the vapor of chloroform is sometimes an efficient pal-
liative.  Evaporating lotions to  the head—alcohol, spirits, vinegar,  or ether—
in some cases  afford marked relief.  In some cases a towel or napkin wrung
out  in water as  hot as can be borne, and wound around  the head, is more
efficient  than  cold  applications.   AVarm stimulating pediluvia are  useful.
Strong coffee or  tea affords marked relief in  some  cases.    Electricity has
been  found in  some  cases effective in arresting and preventing the  recurrence
of the paroxysms.   The electrical  treatment should  not be  abandoned until
after a fair trial of  the faradic and  the  galvanic current.  Guarana, given in
the form of powder, infusion, or extract, sometimes is an  efficient palliative
remedy.  This is an uncertain remedy, and generally after a few paroxysms it
fails to afford relief.  In cases of  migraine dependent upon some disease of
the nasal  mucous membrane local  treatment applied  to this part has proved
effective.
  During the intervals remedies which  are  sometimes useful by way  of pro-
phylaxis are—nux vomica  or  strychnia in small doses, arsenic, small  doses
of quinia, belladonna, and the preparations of zinc, especially the valerianate.
These remedies may be tried in succession.  Hygienic  measures are  import-
ant.  In general  terms, the  liability to attacks  is less the  more  closely the
laws  of health are  observed.   Avoidance,  as far as possible, of  everything
which experience shows in individual  cases to act as exciting  causes  is an
important part of the  management. 
CHOREA.
813
                      CHAPTER  VII.

                          THE  NEUROSES.

   Chorea.—Anomalous Muscular Movements.—Local Spasms.—Tremor.—Epilepsy.

   CFRTAIN of the neuroses or functional affections  of the nervous system
    are characterized by  disordered muscular movements.   Chorea is  one
of these affections.  Anomalous movements proceed from disordered volition.
Disorders manifested by involuntary movements are grouped under the names
tremor and local spasms.  In these groups belong senile trembling or paralysis
agitans, writers' cramp, and athetosis.  Epilepsy is an  important functional
affection.  The foregoing  affections  will be considered in  this chapter.


                               Chorea.
  The affection called chorea, chorea sancti Vifi, or St. Yitvs's dance is cha-
racterized by  irregular clonic contractions of  more or less of the voluntary
muscles, giving rise to movements  which are either involuntary or not  under
the guidance  of the will.   The manifestations of the  affection are usually at
first limited to a portion of the body, to one of the upper extremities oftener
than elsewhere, and sometimes they  are confined for a time to the fingers of
one hand.   The movements increase and progressively  extend to both  upper
extremities, the muscles of the face, and frequently to the  lower extremities
and to the trunk.  The appearances consist of frequently-recurring or unceas-
ing movements of the parts affected, producing in the face varied and ludicrous
grimaces, and in the extremities and trunk grotesque contortions and fantastic
gesticulations.
  The spectacle afforded  by the manifestations of this affection is comical,
and it is difficult  to realize  that it is not a performance for the amusement
of observers.  The condition  has been well designated an " insanity of move-
ment."  The condition, however, if the affection be severe, is truly distress-
ing.   The incessant activity of the muscles  induces fatigue.   The patient
may be unable to  perform the voluntary acts  which the wants of the body
require, and is completely dependent upon others.   Speech may be impaired
or lost.  Locomotion  may  be impossible.   The isolation is sometimes more
complete than in cases in  which a  considerable portion  of the body is para-
lyzed  or several senses are abolished.  AVant of ability to direct and harmonize
voluntary movements is a  feature of this affection. Acts of volition give  rise
to the irregular movements,  but movements to a greater or less extent take
place  without the stimulus of volition ; that is, they are involuntary.  In the
latter  respect chorea differs from locomotor ataxia, the  movements in ataxia
being  never wholly involuntary.   The movements in  chorea are usually sus-
pended during sleep, but they sometimes continue, although always more or
less diminished.   They are increased generally when the patient is conscious
of being observed and under any emotional  excitement.   The movements
are frequently more marked on one side of the body, and this  is generally
the left side.   They are sometimes confined to this side, and the affection is
then called hemichorea.   The choreic manifestations are confined to the  vol-
untary muscles.  The sphincters are rarely affected;  and this is true of the
muscles concerned in  respiration, inclusive of the  laryngeal muscles, as also
those  of the  pharynx.  In extreme  cases the disordered movements are so 
814
THE  NEUROSES.
violent as to give rise to contusions  and excoriations unless the patient be
properly  protected.   In consequence  of incessant movements it may be diffi-
cult or impossible to feed the patient.  This severe form  of the  disease is
called chorea major, and  it is  happily very rare.
  The affection is not accompanied by fever.   If this exist it is due to an
intercurrent or coexisting affection. . The  appetite is usually  more or less
impaired and the bowels are constipated.  Anamia often  coexists.   Irrita-
bility of  temper is a notable feature.  The mental faculties are weakened.
The grimaces give  to the physiognomy an appearance of idiocy, and  if the
affection  becomes chronic  patients fall into a condition of apparent imbecility.
The mind fails in these  cases  from the deficiency of exercise of the mental
faculties.  If the speech  be lost,  it  is difficult to estimate the amount of
intelligence which is preserved.  The power of the affected muscles is more
or less diminished, and this  impairment of power or incomplete paralysis  is
more marked on the  side  more affected with the chorea.  Anasthesia  of the
surface on one or both  sides of the body  is sometimes observed; oftener,
however, there  is hyperasthesia, which is especially marked in the tract of
nerves.   Tenderness along the spinal column exists in a large proportion of
cases.  There is an  exaggerated susceptibility to reflex  excitations, and the
electrical excitability of both the muscles and skin  is abnormally increased.
Pressure upon tender points  over nervous trunks excites the choreic  move-
ments.
  Endocardial  murmurs are not infrequently found in cases  of chorea.  If
these be  aortic  or pulmonic, accompanying the first sound of the heart, they
are to be regarded as inorganic or anamic murmurs.  They do not constitute
evidence of endocarditis.   Nor is a  mitral murmur in this affection always
evidence of endocarditis.   I have observed a mitral systolic murmur during
the continuance of chorea, and the  disappearance of the murmur after recov-
ery from the chorea.
  As one of the neuroses, this affection  of course  has  no ascertained ana-
tomical  characters.   In cases  which have proved fatal morbid changes, not
uniform in character  or seat, have been found in the nervous centres. Minute
embolic obstructions in the corpus striatum have been observed by  J. Hugh-
lings Jackson and Bastian in hemichorea.   The opinion is held by many that
there is a pathological connection between it and rheumatism.  The  statistical
researches of See and Henri Roger in France appear to show that in a con-
siderable proportion  of cases chorea either follows or is coincident with rheu-
matism.  The same results have not been obtained by the analysis of cases in
Germany.  Endocarditis  appears to  coexist in a certain proportion of cases
without  other  evidence of rheumatism ;  but it is probable  that in some of
these cases  the existence of endocardial  inflammation  has been incorrectly
inferred  from physical  signs.   It  is certain  that endocardial  inflammation
does not exist  in a  sufficient number of  cases to afford  any ground for the
theory of Kirkes that chorea is caused by the passage into the  blood  of the
inflammatory products of  endocarditis. It is perhaps correct to say that there
is  no essential  pathological connection between rheumatism and chorea, but
that in  children the former predisposes to the latter disease.
  The causation is obscure.  It  is common  to suspect the presence  of
worms in the alimentary canal, but there is little evidence that the affection
is caused by worms.   It is sometimes traced distinctly to fright or  to violent
mental excitement, as a fit of anger.  Its development is favored by anamia,
and in most cases patients are anamic.  There is reason for suspecting sexual
excitation as a  cause in some instances.  It may be produced by unconscious
imitation.  This has been shown repeatedly by its prevalence in schools.  It
occurs occasionally in pregnancy (chorea gravidarum). 
CHOREA.
815
   Chorea occurs especially between ten and fifteen years of age.   It rarely
occurs at less than six years of age.   It  may occur at any period of life.
Henri Roger has reported a case occurring in a  female  aged eighty-four
years.  Graves  observed a  well-marked case in a  male aged  seventy-two
years.  On  the other hand, cases have  been observed in infants shortly after
birth.  Girls  are more liable to it than hoys,  the ratio being as three to one.
   The duration varies from a few weeks  to several months.  The average
duration is  between two and three months.   In the vast  majority of cases
the termination is in recovery.   After a variable duration the affection tends
intrinsically  to  this termination.  In  a very small proportion  of cases it
becomes chronic and is incurable.  Life may be destroyed  by  intercurrent
affections which, in general, do  not  suspend the  choreic  phenomena.   A
fatal  result may take place without any superadded  disease, the patient being
worn  out by prolonged  irritation, loss of sleep, and inanition.  The incessant
movements  sometimes  give  rise to contusions and excoriations which may
lead  to erysipelas and  abscesses, and these may contribute to a  fatal result.
Occurring in pregnancy, it often leads to abortion or premature delivery, and
hence is not without danger.
   Relapses are likely to occur  after intervals varying between a few months
and two or three years.  As a rule, the relapses are shorter than  the primary
attacks.
   A  number of remedies has been advocated as effecting a cure of this dis-
ease.   In general, when different methods of treatment of any disease are
found to be successful, it  is a fair inference that the disease ends favorably
from  an intrinsic tendency.  This is  undoubtedly  true of  chorea.  Of  the
diverse remedies indicated, none  can be relied  upon for promptly arresting
the course of the disease, and it is doubtful if any exert a special curative
agency.  It  by no  means  follows, however, that much benefit may not be
derived  from judicious treatment.   The greater  part  of  the remedies  are
doubtless more or less  useful, and the physician  is  to exercise judgment in
adapting them severally to individual cases, and in employing them succes-
sively in the same  case.
   Rational  indications, in  the first place, are to be sought for in coexisting
disorders or morbid conditions.   If there be symptoms, aside from the chorea,
pointing to  rheumatism, remedies addressed to this condition are called for.
Anamia in a large proportion of cases calls for appropriate  treatment.  Con-
stipation, if present, claims attention.   Purgative remedies are among those
advocated as  efficacious in curing the disease.  Causes  of  peripheral irrita-
tion,  especially  those of sexual  origin,  should be  removed.
   Of remedies,  other than purgatives,  which experience has shown to be
useful, the more important are—arsenic, the carbonate and  prussiate of iron,
zinc,  strychnia, opium, cannabis indica, and various  antispasmodics.  Of the
efficacy of arsenic there  is abundant and strong testimony.   Fowler's solution
is  the most eligible  preparation.  Beginning  with  three or four  drops  three
times  daily,  the  doses should be gradually  increased until the characteristic
effects are observed.  Of the preparations  of iron,  the  carbonate and  prus-
siate have been  supposed to exert a curative effect, aside from  their useful-
ness with reference to coexisting  anamia.   Of the preparations  of zinc, the
oxide  has been especially advocated as curative  in this affection.   Strychnia
was advocated by Trousseau, who preferred the sulphate  dissolved in syrup.
He began the treatment with a  very  small  dose—namely, one-twenty-fifth
of a grain once  daily—and increased the dose very gradually.   Opium was
also advocated by Trousseau as a curative remedy.  He gave  it in a full
dose, producing slight narcotism, which is to be maintained for several days.
He affirmed that this method of treatment is often extraordinarily successful. 
816
THE  NEUROSES.
To the efficacy of cannabis  indica testimony is borne by many.  Cimicifuira
in some  parts  of this country has been a popular remedy, and  its value  is
attested  by many eminent physicians.  Conium pushed to its physiological
action  has been  employed  with  benefit.  Of antispasmodic  remedies, those
which have been  found especially useful are hyoscyamin, valerian, asafatida,
and  camphor.  Keeping the patient daily under the influence of chloroform
for half an hour or more has been found serviceable.  This measure is hardly
to be advised save in cases in which the movements are unusually violent and
constant.   In chorea major  it may be necessary  to anasthetize the patient in
order to introduce the stomach-pump for purposes of alimentation.  The appli-
cation of  ether spray to the spine, for four or five minutes at  a time daily or
on every alternate day, has been found efficacious.   The testimony respecting
the usefulness of electricity is conflicting.  Benedikt  and Jaccoud claim sig-
nal success from galvanization of the spine.  Beard and  Rockwell have found
general faradization  uniformly successful.  The result of galvanization of
the spine in a few cases was unsatisfactory in their hands, and  also in the
experience of Meyer.   This discrepancy may be perhaps  in  a measure ex-
plained by differences as regards  the mode of  employing both  the direct and
induced current, and also by differences as regards the  period of the disease
when the treatment was entered on, bearing in mind that this disease may be
said to have a  self-limited duration.  The bromides, in  my experience, have
failed to  meet the expectations  which  I had been led to  form of their useful-
ness in this affection.
   Hygienic measures are certainly not less important than medicinal remedies.
Alimentation as nutritious as possible is desirable. Daily  exposure and, if prac-
ticable, exercise in the open air are highly important.   The cold sponge-bath
is useful, provided it be not dreaded by the patient and it be followed by brisk
reaction ;  and the shower-bath, with  the  same provisions, is admissible.  On
the other hand, the tepid bath as a palliative measure  is highly useful.  In
the Children's Hospital in Paris for many years much reliance has been placed
on gymnastic exercises for the cure of chorea.  Of course these are practica-
ble only in the cases in which the ability to co-ordinate movements by the will,
although  more or less impaired, is not lost.   The  exercises consist of syste-
matic movements performed under the direction of assistants  and enlivened
by music.1  After the choreic  movements have ceased,  more or less inability
to co-ordinate movements,  together with muscular weakness, remains, and
these effects of the disease are to be removed  by exercise.   The power of
again directing the muscles  is  to be acquired as in infancy, but it is acquired
rapidly.


Anomalous  Muscular Movements—Local  Spasms—Tremor.
   Certain abnormal  muscular movements are considered, incorrectly, as de-
noting  varieties of chorea,  Persons sometimes  without motive or purpose,
impelled  apparently  by  an  irresistible impulse,  perform extraordinary  acts.
One of these is leaping suddenly  and violently, and sometimes jumping upon
chairs or tables.   Such movements have been considered as denoting a variety
called chorea saltatoria.   A patient subject to epilepsy was brought to me
for examination, a young man aged about twenty, who at variable intervals
had  paroxysms of jumping vigorously for a few seconds.  He declared he
was unable to avoid  these movements.  In other cases  there  is a propensity
to run,  and the patient unexpectedly,  when  walking,  rushes forward at  a

  1 For details concerning gymnastic exercises, vide papers by M. See and by M. Blache
in M(-moires de I'Acad, de Medecine, Paris, 1855.  For a summary of these details, vide
Meigs on Diseases of Children. 
ANOMALOUS  MUSCULAR  MOVEMENTS.            817
rapid pace for several minutes.  These movements  have been considered as
denoting another  variety,  called chorea festiuans vel procursiva.   Rotating
and vibrating movements are performed  in  other cases (chorea oscillatoria).
Moving the head  and body alternately backward and forward, constituting
what has been called salaam convulsions, belongs in the same category.   In a
case which came under my observation the patient, a young married woman,
had for several months during her waking  hours constantly pounded some
object  before  her  with both hands.   In another case a young unmarried
woman had  frequently-recurring paroxysms in which for several hours  she
rotated  the head rapidly, and also at times she performed rapid projectile
movements  of the tongue.   This patient  for  three years maintained  the
position of emprosthotonos in sitting, walking,  or standing,  always ceasing
to maintain it when  recumbent.
  These movements, although abnormal,  proceed from the action of the will.
They denote a species of mental aberration.   They are manifestations of a
delirious volition, resembling in this respect certain of the convulsive move-
ments in hysteria.   They are sometimes  connected with cerebral disease, but
in most cases they are purely functional.  In some cases it is undoubtedly
true that patients are unable to resist the impulse which impels to the abnor-
mal  acts, but a morbid  propensity to excite wonder and interest doubtless
enters  into  the rationale in some cases.
  The treatment  embraces remedies and hygienic measures to invigorate the
nervous system, together with efforts to overcome the propensity which gives
rise to the abnormal movements.

  Allied to  the cases just referred to are those in which twitching of certain
parts becomes habitual.  Thus some persons acquire the habit of jerking the
head, raising the shoulders, or making other motions, especially under mental
excitement.  In many, if not most, of these cases the habit may be overcome
by persevering efforts before it  becomes confirmed.   Convulsive movements
of certain  of the  muscles of the face,  producing  sometimes notable  grim-
aces, are involuntary and  closely allied to chorea.  These often become con-
firmed and  irremediable.   Spasm of  the eyelids is  called blepharospasms.
AVhen  the angles  of  the mouth are raised the peculiar expression  is signifi-
cantly stylea risus caninus, or the sardonic grin.  The convulsive movements
or spasms of the muscles of the face, called by Romberg mimic or histrionic,
may be either clonic or tonic.  They are oftener the former.   The involun-
tary grimaces which are sometimes produced occasion much  mortification.
The clonic spasms come  in paroxysms which  generally last but an instant.
They are especially  liable to occur  under  mental excitement.  Sometimes
they interfere with mastication and articulation.  They are almost always uni-
lateral.   Involuntary or  spasmodic movements of the head, with or without
grimaces, characterize some cases.   In a  case at Bellevue  Hospital there  was
violent jerking of the head  from side to side  at intervals of a few seconds, and
with these there were rapid lateral oscillations of the eyeballs.  Aside from
these symptoms there was  no evidence of cerebral disease.  They followed a
debauch.  The patient soon left the hospital, the movements continuing.   In
another case the head was moved spasmodically to the left side at short inter-
vals, with  some contraction of the facial  muscles on that side.   Notable
improvement in this case took place under  the use of the bromide  of  potas-
sium.  Pressure over the branches of the trifacial nerve and at certain points
on the  cervical portion of the spinal column sometimes has an inhibitory effect
upon facial  spasms.   These are  known as " pressure-points."   They may be
found in local spasms situated elsewhere, and the galvanic current applied at
these points not only  has the same  inhibitory  effect as pressure, but it may
       52 
818
THE  NEUROSES.
prove curative.  These pressure-points should be sought after in all cases of
local spasm.  Pressure at certain points is found in some cases to increase the
spasms  instead  of having  an inhibitory effect.  Hypodermic  injections  of
morphia are  sometimes  an  effectual method of treatment if the spasmodic
affection have not  been of long duration.  The injections should be made at
the " pressure-points."  Facial spasms often  continue, and become permanent
in spite  of treatment.   Electricity  and counter-irritation  are  chiefly to  be
relied upon, and should be faithfully tried.

   An affection characterized, by inability to  co-ordinate  the muscles engaged
in the act of writing has  been called  chorea scriptorum, or writers' cramp
(graphospasms).   Whenever the  act  of  writing  is attempted, the  flexor
muscles  especially, but  sometimes the extensors of the thumb and fingers,
either become rigidly contracted or contract  irregularly, and guidance of the
pen is impossible.   Persons who employ certain  muscles constantly in other
acts are sometimes  similarly affected.   Thus,  pianists  and  violinists are
no longer  able  to play, printers cannot compose,  tailors  and seamstresses
lose  the power of guiding the  needle, and turners are  unable  to move the
lathe with the foot.   In all  these  instances other movements, calling into
exercise the same  muscles,  are  performed without  difficulty.   In the treat-
ment of writers' cramp  and  allied  affections  discontinuance of  acts which
occasion the spasm is essential.   The period of rest should extend over sev-
eral months.   If this be resorted to early, recovery may be hoped for.  Gal-
vanic electricity  is  useful. If discontinuance of writing cannot be enforced, as
in cases in which  the livelihood of the patient depends  on writing, the habit
should be acquired of using the pen with the  left hand.  This is sometimes
only a temporary resource, as the affection is liable to occur in  the left hand
after some use.  Changing  the  size of the  pen and adopting contrivances to
change  the action  of muscles which are co-ordinated in writing will  some-
times enable writers to continue their occupation.   The affection consists in
impairment of the  power of co-ordination for the performance of certain acts,
and it is a consequence of the long-continued performance of these  acts.  It
is a fair inference  from these facts that it is a central, not a peripheral, affec-
tion.   If timely and  complete rest  be  not  resorted to, recovery is not to  be
expected.
   Painful contraction of muscles, irrespective of affections of which  this is a
symptom, such  as  tetanus,  epidemic cholera, etc., and not  produced by any
obvious cause, is known  as cramp.   Some persons are liable to suffer much
from cramp of the muscles of  the  leg or feet, occurring especially at night.
A method of treatment proposed by  Bardsley of Manchester, England, is said
to be generally successful.   This consists  of sleeping on  an inclined plane,
the bed being twelve  inches higher at the head than at the foot.

   Under the name essential  or idiopathic spasm of the muscles of the extrem-
ities  (contracture essentielle  ou  idiopathique  des  extremites) French  writers
describe an affection characterized by tonic contraction occurring with either
intermissions or  marked exacerbations.   This affection has also received the
name of intermittent tetany or tetanilla.  It occurs especially in young sub-
jects between the  age of seventeen  and twenty-five and in children between
one year and three years of age.  Females more than males are subject to it.
The puerperal state and  lactation predispose to it.   It is observed as a sequel
of certain diseases, such as  the  continued or eruptive fevers, articular rheu-
matism, and chorea.  In children it appears to be  connected with dentition,
intestinal worms, and gastric disorders.   The spasm or cramp affects first the
muscles of the upper extremities, especially the  flexors of the forearm.  It 
ANOMALOUS MUSCULAR MOVEMENTS.           819
 extends generally to the lower extremities, and here the extensors are the mus-
 cles most liable to be affected.  The hand is often  firmly closed, the  fingers
 concealing the thumb, which is in close apposition to the palm, and the  flexion
 may embrace both the phalanges and the metacarpal bones; or, more  rarely,
 the  fingers are separated and partially flexed, so as to give rise to the claw-
 like appearance.  Sometimes the position of the fingers  is  like that  in  the
 act of writing.   Exceptionally, the  extensors of the wrist are affected.  The
 contractions are powerful.   Generally they are  bilateral,  but they are  some-
 times confined to one side.   In some cases the spasm extends to the muscles
 of the arm, shoulder, thigh, trunk, and neck, together with those of the jaws.
 In these cases the affection simulates tetanus. It has been called intermittent
 tetanus.  In  tetanus the trismus is primary, whereas in this affection it is
 secondary.   Moreover,  in  this  affection  the associated   symptoms  denoting
 gravity of disease are  wanting.  The intermissions sometimes  observe  the
 laws of periodicity governing the different types of  intermittent  fever.  The
 affection belongs among the neuroses; that is, it is a functional affection,  the
 duration varying generally between one week and three weeks.  Relapses
 often occur.  The spasm sometimes leads to paralysis of the muscles which
 are affected.  The affection tends to  a favorable  termination.  Cases, however,
 have been observed in which a fatal result has been due to  paralysis follow-
 ing spasm of the muscles concerned  in respiration and to spasm of the glottis.
 The indications  for treatment relate  to the pathological conditions with which
 it is associated.  Quinia in full doses is  indicated  if the affection be inter-
 mittent.  Belladonna, opium, or the hypodermic  injection of morphia may
 be  resorted to for palliation  of the pain and spasm.1

   A peculiar affection of the voluntary muscles was first  described by  Thom-
 sen in  1876 as occurring in a number of members of his own family.  The
 affection is sometimes called Thomsen's disease.  It has received from Striim-
 pell the name myotonia congenita.   It is a  rare  affection, but a number of
 cases have been reported.   The affection appears to be  congenital, existing
 throughout life.  It affects frequently several members of a  family, and
 apparently with preference  the male members.  The characteristic of  Thom-
 sen's disease  is a peculiar stiffness and tension  of the  voluntary  muscles,
 amounting to a continued tetanic spasm.   This tension is most evident when
 the patient begins to use  the muscles  after a period of  repose.  It lessens
 and  may disappear after the muscles  have been for some time in use.  The
 muscular stiffness is increased  by  psychical excitement.   Rapid muscular
 movements involving precision may be  impossible.  In  most  of the cases
 hitherto observed the muscular development  has been excessive.   Upon elec-
 tric excitation the spasm of the muscles is longer than in health, continuing
 after the  circuit is  opened.  This  indicates some congenital anomaly in the
 muscular structure.   Sensibility is intact, and there are no noteworthy symp-
 toms other than those mentioned.  No benefit has hitherto been derived from
 any therapeutic  measures.

   Tremor—that is, alternate contraction  and relaxation  of  muscles in rapid
 succession—is a symptom of certain  lesions of the nervous centres, especially
 of multiple or disseminated sclerosis of the brain and spinal cord.  It is not
infrequently incident to advanced age, and it is then  observed especially in
the upper  extremities,  but in some cases constant lateral  motions of the
head take place during waking  hours, and they do  not always cease during
sleep.   The senile trembling, as it is called, although not dependent on any
known  lesions, is irremediable.   Tremulousness, especially of the  hands,
                 1 A'ide  Trade de Pathologie interne,  par Jaccoud. 
820
THE  NEUROSES.
occurs in early and middle life as a result of the abuse of alcohol, the habit-
ual use of opium, nicotism, sexual excesses, and other causes which tend to
depress or disorder the nervous system.  Under these circumstances it  may
be purely functional. The trembling sometimes extends to the lower extrem-
ities and to the trunk.
   The  treatment  in  cases  of  tremor from these  several  causes  of course
involves,  as the  first and most important  measure, the withdrawal of the
causes.  Other measures indicated  are  those which have  reference to asso-
ciated disorders and  the general condition of the system.

   The affection known as paralysis agitans,  sometimes called Parkinson's dis-
ease from an English author who described  the affection in 1817 under the
name  shaking  palsy, belongs  in the group  of  affections  characterized by
tremor rather than  among the paralytic affections.   It is to be  included
with the neuroses, inasmuch as it has no ascertained anatomical characters.
Diverse morbid changes have been found after death  in  different cases, but
in some cases no changes have been  discovered.
   It is an affection of middle or advanced life, the age being very rarely less
than  forty years.  Men  much  oftener than  women are affected.   These are
all the facts at present  known respecting  the etiology.
   The tremor consists of feeble, rapidly-recurring, rhythmical movements, at
times, under mental excitement or physical exertion, much increased in range
and  force.  The  movements generally begin  in the  fingers and hands, they
extend gradually over the  upper extremities, and after variable periods the
affection invades the lower limbs, the facial  muscles, the  muscles of  articula-
tion, those of the head, and  sometimes the trunk.  They are in some instances
for a long time or permanently unilateral.   The muscles which are  involved
retain their normal  electrical  excitability.   Paresis  follows the  tremor, the
latter  preceding the former for a considerable or long period.  Stiffness of
certain muscles,  especially  of  the flexors,  is  gradually induced.   The head
and  the trunk  incline forward ; the elbows  stand out  from the chest;  the
forearm  and hands  are  moderately  flexed; the thumb  and forefinger are
sometimes in the position of holding a pen;  and the fingers may be distorted
as in cases of chronic rheumatism.   The lower limbs are often correspond-
ingly affected.  They are  knock-kneed, the feet have the appearance of talipes
equinus, and there is virtually incomplete paraplegia.  Festination, or a tend-
ency to run forward, is  sometimes observed.  The tremor, as a rule, either
ceases or is much diminished  during sleep.
   This affection is to be distinguished from  tremor incident to cerebro-spinal
sclerosis.   The differential  points  are as follows:  In sclerosis, paralysis is
either coincident with or  antecedent  to the tremor; the tremor is excited by
volition; it begins in the lower limbs; and is not very infrequent at less than
forty years of age.  Per contra, in paralysis agitans, paralysis does  not  pre-
cede the tremor or accompany it at an early  period; the tremor is not depend-
ent on volition; it begins  in the upper limbs; and persons  less than forty years
of age are exempt from this affection.
   The independence of volition distinguishes the tremor from chorea.   The
muscular  movements are shorter in paralysis agitans than in  chorea.   The
greater degree of tremor, and  often  the age, serve to distinguish  this affec-
tion  from senile trembling.  The tremulousness  from alcoholism  and other
causes which are  readily ascertained in individual cases is excluded without
difficulty.
  As regards the pathology, it  is to be said, as of other functional affections,
that the existence of morbid changes is logically certain, but their nature and
their seat are yet to be ascertained.    The affection is probably not  myopathic 
ANOMALOUS  MUSCULAR  MOVEMENTS.            821
 or peripheral, but whether the morbid condition  be  seated  in  the  brain or
 spinal  cord, or in both, is an  unsettled question.
   It is also an unsettled question whether recovery ever takes place.  If the
 few reported instances  be not open to distrust, it is certain  that the proba-
 bility of recovery is so  small as to be almost nil in any individual case.  The
 affection, however, is not incompatible with the duration of life and fair gen-
 eral health for an indefinite period.   Patients generally die from intercurrent
 affections.  The affection proves  fatal, per se, by inducing general  paralysis
 after many years' duration,  death  taking  place  by exhaustion.
   The objects of treatment are the prevention of the continued progress of
 the affection  and more  or less amelioration as regards the tremor.   Various
 remedies in the hands of different observers have appeared to be not without
 considerable effect in certain cases.  The  objects  of the  treatment are of
 sufficient importance to render the trial of these  various remedies a duty.
 without abandoning a  case  as  offering no encouragement  in  the  way of
 improvement.   Elliotson claimed to have effected a cure by the carbonate of
 iron ;  Brown-Sequard, by the chloride of barium ;  and Reynolds and Remak,
 by galvanization  of the spine.  Arsenic, administered  hypodermically, has
 been found highly  useful by Eulenburg.   Charcot and  others have given
 hyoscyamus with benefit.   Strychnia was  advocated by  Trousseau.   The
 iodide of potassium  in  large doses  proved beneficial  in a case observed by
 Arillemin.   Other remedies are—opium, belladonna, ergot, the Calabar  bean,
 curare, chloral hydrate,  and the bromides.   None of these can be expected to
 have more  than a palliative effect.  Measures to improve and invigorate the
 general health are perhaps more likely to be of real benefit.  Ampng these, the
 sponge-bath and the  cold pack are to be included.   Bandaging the limbs and
 applying to them  the tincture of aconite, small doses of strychnia being also
 given, diminished the tremor considerably in a case under my observation.

   Mercurial tremor denotes trembling movements of  the limbs, the muscles
 of the face, the tongue, and sometimes the trunk, due to poisoning by mer-
 cury.  The  tremor occurs especially  when the patient makes voluntary move-
 ments, in this respect being  analogous to  chorea.  This  affection, formerly
 not infrequent, of late years is  rarely seen, in consequence of improvements
 in mechanical processes involving the use of mercury and  the better observ-
 ance  of  precautionary measures.   The inhalation of vaporized mercury is
 most likely  to give rise to it, but it has been produced by the  use of mercury
 as a  medicine  and by mercurial  inunctions.  In the only case which has
 fallen under my observation the  gums were swollen,  reddened, and spongy,
 and  the  teeth  had been loosened.   These appearances, together with other
 symptoms of  the  mercurial cachexia, and generally knowledge  of  the  fact
 of exposure to mercurial poisoning as incident  to the  occupation of the
 patient,  will lead  to  the diagnosis.
   Recovery may  be expected  under the  use  of  tonic remedies  with an
 invigorating regimen, provided the  continued introduction of mercury  into
 the system  be prevented.  The iodide of potassium is supposed to effect
 the elimination of mercury from  the body.

   A variety of spasmodic movements was described by Hammond in 1871,
 and designated athetosis  (adtroq, " without fixed position ").   It is character-
 ized by persistent irregular movements of the fingers and toes and inability to
 retain them in  any fixed position.   The movements are  wholly independent
 of volition.   The  patient can rarely arrest them  by an act of the will, even
 for an instant.  In most  instances the affection is confined to one  side (hemi-
athetosis), but in some instances both sides  are affected (bilateral athetosis). 
822
THE  NEUROSES.
It may affect either the fingers or the toes separately, or both conjointly.   In
rare instances  spasmodic movements of either the face, neck, or forearm are
associated.  The movements of the fingers and toes are constant during wak-
ing hours, and sometimes continue, although diminished, during sleep.   If
they cease during sleep, the fingers rest in abnormal relative positions.  The
abnormal movements resemble those of chorea, but differ from them by their
slower  rhythm and greater regularity.   They are also distinguished from
choreic movements by affecting chiefly or exclusively the fingers and toes.
In  many cases more or less anasthesia was present on  the affected sides.
The muscles  of  the forearm involved  in  the  movements  may  become
hypertrophied.
   In  a large  proportion of cases hemiathetosis is a sequel of hemiplegia.
The movements of the fingers and toes are  on the paralyzed side.   Some
writers consider that lesions involving  the posterior third  of the posterior
division of the internal capsule are especially liable to be followed by athe-
tosis.    Others think that the lesion is to be sought  for in the motor cortical
tract of the brain.  Further observations are needed to determine the path-
ology of this affection.   Athetosis may occur as a primary affection without
paralysis.  Although bilateral athetosis is not  associated with well-marked
paralysis on both sides, there is often general muscular weakness.  The affec-
tion in this form occurs in idiots or those who are congenitally feeble-minded.
It doubtless proceeds from a cerebral affection, although  it has been observed
in connection with locomotor ataxia.
   Experience  has furnished few data for a favorable prognosis. Gnauck has
reported a cure effected by the constant  electrical current and the use of
bromide of potassium.  Gowers and Oultmont have found this agent essen-
tially beneficial.1

   The anomalous movements described by S.  AAair Mitchell  under the  name
"post-paralytic chorea,"2 and by Charcot under the name " post-hemiplegic
hemichorea,"3 are  analogous to those of athetosis.   The terms athetosis and
post-hemiplegic chorea have been used to describe the  same,  affection.  As
already remarked, athetosis may occur  independently of hemiplegia.   Char-
cot places  the lesion of  post-hemiplegic chorea in  the posterior part  of the
internal capsule and  the  surrounding  brain-substance.   The  choreic  move-
ments  may, however,  follow lesions of  other parts of the brain.


                               Epilepsy.
  Epilepsy is  a chronic  paroxysmal affection.  The paroxysms are charac-
terized by loss  of consciousness, and in the most characteristic cases by con-
vulsive movements extending  over more or less of the voluntary muscular
system.  Convulsions analogous to those of epilepsy are symptomatic of dif-
ferent cerebral affections, of uramia, of injuries of the head, and they may be
caused  by certain toxical agents; for example, strychnia.   These are  to be
distinguished as epileptiform convulsions.  Epilepsy, as  one  of the neuroses,
is  a functional affection ; that is, it is  not necessarily  connected with any
appreciable lesions.   Related to the affection, sometimes  preceding its  devel-
opment, and sometimes occurring in those who are epileptics, are attacks  in
which  convulsive movements are  slight and  sometimes  wanting.   Epileptic
attacks  in which convulsions are slight or wanting constitute that  form  of
the disease which is  called mild epilepsy, or epilepsia mitior, also by French
        1 A7ide Real-Encyclopadie, AVien und Leipzig, 1880, art. "Athetose."
        2 Am.  Journ. of Med. Sciences, Oct., 1874.
        3 Lecons sur les Maladies du Systhne nerveux, Paris, 1877. 
EPILEPSY.
823
writers le petit mal and epibptic vertigo.  They may he distinguished as cpi-
leptoid  attacks.  In distinction from epilepsia niitior, the common form with
general convulsions is called epilepsia gravior, or le grand mal.   This form is
to be  first considered.
   In the majority  of cases  a  paroxysm  occurs without premonition.   The
loss  of consciousness is as  sudden as if produced by a stunning  blow  upon
the  head.   The  person falls,  and hence the  affection has  been popularly
known  as the " falling sickness."  In  a  minority of cases there  is a brief
warning of the approaching fit.   Generally the  premonition  consists  in a
sensation which the  patient is unable  to describe.  The  sense  of  a "cold
vapor" emanating from some part of the body and mounting to the head has
been called the aura epileptica.  This sensation  was  first described by Galen,
and, as remarked by  Herpin,  " the commentators of Galen  and those who
copied  from  them  handed down the phrase, until the existence of  an  aura
seemed to be accepted as an  ascertained fact,"  It is a traditional error to
consider such a sensation as a frequent warning of an epileptic paroxysm, and
it is certainly extremely rare  for  the  patient  to experience any sensation
emanating from a particular part of the body.  The  onset of the paroxysm is
often marked by a loud, short, and  piercing shriek or cry,  which from  its
intensity and unnatural character is sometimes truly  terrific.  The face at the
time of the seizure becomes notably pale.   The direction in which the fall
takes place is almost always forward on  the face. The face is not infrequently
wounded or bruised by the force of the fall, and severe burns are sometimes
caused  by falling upon  heated  stoves or into the fire.  The convulsive move-
ments  at once begin.   These are at first tonic ; that  is, the muscles are forci-
bly contracted, and the contraction persists for several seconds.   The muscles
of the  face,  neck,  arms, forearms, the  lower extremities, the  abdomen, and
chest are involved,  and have a tetanic rigidity.  In  most cases the  muscles
of one  side of the  body are  more affected than those of  the other side, and
sometimes, although very rarely, the convulsions are  limited to one side.  The
tonic convulsions last for a period varying between a few seconds and half a
minute or somewhat longer.   The convulsions then become clonic ; that is, the
muscles present forcible contractions and relaxations  in rapid succession.  The
face is hideously distorted, the head is moved upon the trunk, the upper and
lower limbs and the body jerk with violence.  The tongue is sometimes caught
between the teeth and is wounded by the tonic contraction of the muscles of
the lower jaw.   This more frequently happens during the clonic convulsions.
Respiration is nearly  suspended by the tonic convulsions and  is irregular and
difficult during the  clonic.  A quackling  noise  accompanies  the respiratory
acts.   The face during the convulsions  becomes deeply congested  and  livid.
Convulsive masticatory movements are accompanied  by the ejection of foamy
saliva, frequently commingled with blood from  the  wounded tongue or  from
a portion of the cheek caught between the  teeth.  The violent clonic  con-
vulsions continue for  a period varying between half  a minute and three  min-
utes.   The period to  the observer seems to  be much longer, but if noted by
the watch it is rarely found  to exceed  three  minutes, and generally it does
not last more than  a minute.   The convulsive  movements now become  less
rapid and violent, the embarrassment of respiration diminishes, the patient
fetches  a deep sigh, and the paroxysm, so far  as the convulsions are  con-
cerned,  is ended.  The paroxysms in  different cases,  and  different paroxysms
in the same case, differ much as regards tbe violence  of the convulsive move-
ments and the extent of the  muscular system involved.  The  convulsions are
sometimes specially marked in the face and upper extremities, and  they  may
be limited to  these  parts. Paroxysms differ  also as regards  duration.   The
violence of the convulsive movements of the muscles of the shoulder  is some- 
824
THE  NEUROSES.
times sufficient to produce  luxation of the humerus.   A case in which this
repeatedly occurred has fallen under my observation. During the convulsions
the urine and feces are sometimes  expelled, and an emission of semen may
take place.  The pupils during the paroxysm  are dilated, and  they do not
contract on exposure to a bright light.   The eyelids, however, close  when the
conjunctiva is touched, showing the preservation of the reflex function.
  After the convulsions have ceased consciousness may be speedily  regained,
and the patient may only experience a  sense of fatigue, with  usually a dispo-
sition to sleep ; but in  most  cases the state of coma continues for a variable
period.  Frequently the  respiration for some time is stertorous and the lips
are puffed out with expiration.  The patient remains in this state for a period
varying between a few minutes and half an hour; the  pupils are still dilated
and do not contract on exposure to light, and  he cannot be roused  from the
comatose state. Gradually he emerges from this state, opens his eyes, appears
confused, and some time elapses before he is able to appreciate his  situation
and reply to questions.   If  he  attempt at once to walk he reels like a person
intoxicated. Occasionally the patient passes from the apoplectiform  state into
one of delirium.  He talks incoherently, manifests  hallucinations, and  some-
times the delirium assumes the form of mania, during which  he may be dan-
gerous to himself or others.   After recovery of the mental faculties there is
complete inability to  recall  anything  which  has occurred  during  the par-
oxysm.
   The paroxysms recur after  intervals which are extremely variable in dif-
ferent cases.   The  intervals may extend  over many months  or  years.  On
the other hand, they recur  in  some cases daily and even many  times daily.
AVhen a paroxysm has  once occurred, other  paroxysms are almost sure to
follow sooner or later.   In most cases the paroxysms at first are more widely
separated  than after  they have repeatedly recurred;  and they become, as a
rule, more  and more frequent, until the affection is confirmed.   In some cases
the recurrence is periodical.   In women sometimes paroxysms occur  regularly
at the menstrual period.  Periodicity,  however, is not  the rule, the intervals
generally  varying considerably in  the same  case ; but  in certain  cases  of
confirmed epilepsy about the same number of  paroxysms take place in suc-
cessive periods of a quarter, .a  half, or the whole of a year.   Exceptionally,
the recurrence of the  paroxysms becomes less frequent after a  time,  and a
patient who for several years has been  subject  to paroxysms after short inter-
vals may afterward have long  intermissions.   Occasionally,  having recurred
more or less frequently for months  or  years, they cease altogether for  a con-
siderable period, and then return with not less,  and perhaps greater, frequency
than before.
   In some cases  paroxysms occur in rapid  succession during a day or dur-
ing several successive days.   This condition  constitutes the so-called status
epilepticus.  As many as one hundred and even a larger number of paroxysms
have  been  known to occur during twenty-four hours.   In a  case under my
observation paroxysms took  place at intervals  of a few moments for fourteen
consecutive days.   The patient recovered, and the paroxysms did not again
recur for several months. AVhen a series of paroxysms thus occurs, the mind
is notably impaired for a time.  The patient is  childish and perhaps idiotic  for
several days, but gradually  recovers the habitual state of the mental facul-
ties.   Hemiplegia  occasionally  follows  a series of paroxysms.   This occurred
in the case just referred to.   The paralysis in such cases is usually of  brief
duration.
   Epileptic paroxysms occur at all hours of the day or night.  They  are likely
to occur during the night.    In some cases for a greater or  less  period they
occur  only at night.  In these cases the affection may have existed long 
EPILEPSY.
825
before the fact is ascertained.  I have known a case in which, the parox-
ysms  never occurring in the daytime, the existence of the affection was for a
long period concealed from the patient.  It is a curious fact that the parox-
ysms  are usually suspended during the course of an acute disease.  A patient,
for example, subject to daily  paroxysms became affected with typhoid fever.
During the career of the fever no paroxysms occurred, and among the events
denoting convalescence was the return of the epilepsy.
   It was  for a long time  believed that the morbid condition giving rise to
epileptic paroxysms was seated in the  medulla oblongata and pons Ararolii.
This view still has its advocates, but there is an increasing tendency to refer
the origin of epileptic paroxysms  to the motor area of the  cerebral cortex,
and it must be admitted that there are weighty  arguments in favor of the
latter  hypothesis.   The  fact that loss of consciousness is a constant  factor
in the epileptic paroxysm, and that  it may occur without convulsions, favors
the cortical  theory  of epilepsy.   It  has been shown experimentally that irri-
tation of the motor cortical area causes paroxysms in no way distinguishable
from  epilepsy in human  beings.   In  experimental epilepsy, as well  as in
many cases of human epilepsy, it has been noted that  the convulsions pro-
ceed  from one group of  muscles to another in an order corresponding to the
relative situation of  the  motor centres in  the cortex.   Thus, if the  spasm
begin  in the  face,  the arm is next affected, and  then the  lower extremity.
Extirpation of a  motor centre in  the cortex prevents the development of epi-
leptic convulsions in  the muscles whose cortical centre is destroyed.  Injury
or disease of the motor cortex is very frequently followed by typical epileptic
paroxysms.   In incomplete epilepsy or petit mal  the  manifestations are  for
the most part psychical.   The facts mentioned  give great plausibility to the
cortical theory of epilepsy.
   As  regards the  immediate cause  of  the epileptic paroxysm we possess no
positive knowledge.   Epileptiform  and true  epileptic paroxysms may be
caused by various  intracranial lesions, such as tumors, syphilitic  affections,
meningitis, and  fracture  of the skull.   A^ ith  the exception of these  cases,
epilepsy is  to be  regarded  as a neurosis  without any known  anatomical
basis.  Except  in  symptomatic epilepsy, post-mortem examination has
failed to reveal any lesion to which the  epilepsy  could reasonably be
attributed.
   It  is very  generally believed  that the  immediately exciting cause  of an
epileptic  paroxysm is  cerebral anamia resulting  from vaso-motor spasm.
This  view is rendered  probable  by the known  effects of  sudden cerebral
anamia from  hemorrhage, from ligation or compression  of the  arteries carry-
ing blood to  the brain, by the notable pallor of the face  at  the  beginning
of an attack of epilepsy, together with the appearance  of the fundus of the
eye as observed by  means  of the  ophthalmoscope.  AVhile the  efficacy of
cerebral anamia as  an  exciting cause of  the epileptic  paroxysm  cannot be
doubted, it is not  certain that it is operative in  all cases of epilepsy.   The
experiments  of Brown-Sequard and others  on  animals show a pathological
connection between peripheral irritations and epileptiform convulsions.  Such
a connection exists in some, but not by any means in all, clinical cases.
   In  a large proportion  of the cases of epilepsy no sources of centric or of
excentric irritation are  apparent.   That under these circumstances the epi-
leptic paroxysms are  due to the action of an  internal and at present unknown
toxical agent  seems to me the most  rational hypothesis.   Epilepsy, according
to this hypothesis, is  a toxamia analogous to uramia, the toxical agent being
produced at  variable intervals, the  quantity and  the  continuance  of its pro-
duction not being sufficient to endanger life ; and  in this respect the contrast
with  uramia being striking.   If this pathological view be correct, knowledge 
826
THE  NEUROSES.
of the nature and source of the toxical agent, which may perhaps be acquired,
will, as we may hope, render this disease controllable.
   Epilepsy is classed among the hereditary diseases.   It has, however, been
customary to consider the existence of other  nervous affections in  parents
or progenitors as evidence of an inherited predisposition.   Heredity, limited
strictly to this disease, does  not often  enter into the causation.  AVhile the
possibility of  the transmission of  the disease  to offspring  should not  be
ignored, it is to be  borne in mind, as a fact which may be of inexpressible
comfort to many persons,  that an  epileptic parentage  by  no means entails
this  or any other disease  on descendants  either proximate  or  remote.   It
would be easy to collect  instances  of families  in  which  the husband or wife
were subject to epilepsy, whose children  and grandchildren  were free from
the disease and in all respects healthy.
   Age is of considerable weight in  the causation.  In  a small proportion of
cases the  disease either  exists from birth  or  is developed in  infancy.   In
nearly one-third of the cases it dates from two  to ten years of age, and  in a
somewhat larger proportion from ten to twenty years.   The number of cases
in which  the development is between twenty and thirty years  is much  less,
and at a later period of life the number is comparatively small.   In the great
majority of cases at  the beginning of the disease the age is between two and
twenty years.
   Of particular causes little  is positively known.  It is certain that intem-
perance as regards the use of alcohol may  give rise to it.  Epileptic parox-
ysms occur not infrequently in drunkards, and  cease  to  recur in  cases  in
which reformation of intemperate  habits  is effected.   It is one of the occa-
sional effects of lead-poisoning.  Aanereal excesses, and especially habits of
masturbation, have been  supposed to be not infrequent  causes.  The suppo-
sition is highly probable, but an accumulation of facts establishing this caus-
ative connection is desirable.   A  female  patient, twenty-three  years of age,
unmarried, who had  been subject to paroxysms occurring almost nightly for
two  years, stated to me, voluntarily, that she  was taught  to masturbate  at
six years  of age, and continued the practice almost daily until she was  four-
teen.  At this  age she became convinced of the  sinfulness of the habit, and
discontinued it.  She was afterward tormented  with sexual desires, and  expe-
rienced the venereal  orgasm almost nightly during sleep.  She was led to dis-
close this  private history by a conviction, at which she had arrived of her own
accord, that it was important with  reference  to the source of the epilepsy.  To
what extent the antecedent history in cases  of  epilepsy would furnish corre-
sponding  facts can only be conjectured.   The number of instances in  which
congenital phimosis exists in epileptics, with cessation of the paroxysms after
removal of the prepuce,  show a  causative connection.   Epilepsy has been
known to  occur in persons  affected with tania, and to cease after the expul-
sion of the worm.
   In persons subject to epilepsy the paroxysms in the great majority of cases
occur without obvious exciting causes.  The causes determining the attack, as
a rule, are intrinsic.  Persons not infrequently are  able to judge, by experience,
from certain  indefinite sensations  that they will ere long  have a paroxysm.
The sensations disappear  after the  paroxysm  has occurred, and it  is  not
uncommon for persons to feel better after recovery from the immediate effects
of a paroxysm  than  for  some time prior to its occurrence.  It has been sup-
posed that the aura which sometimes precedes the paroxysm denotes the exist-
ence of an exciting cause emanating from the part  to which the  aura is referred.
It is more correct to regard the aura as a  peripheral sensation  dependent upon
some central irritation.   A case has fallen under  my observation in which the 
EPILEPSY.
827
 patient, a female, experienced the first paroxysm during the first act of sexual
 congress after marriage.  Subsequently, a paroxysm occurred at each marital
 connection, but after a time paroxysms took place without this exciting cause,
 and the patient became a confirmed epileptic.  It is a remarkable fact that an
 attack may occur from  imitation.   An instance of this has fallen under my
 observation.  A woman subject to epilepsy had a series of paroxysms in quick
 succession.   Her  female attendant while these paroxysms were in  progress
 first manifested hysterical phenomena, and finally she experienced a distinct
 epileptic paroxysm.  She had never before had an attack of epilepsy, nor did
 another  paroxysm take place, the person remaining within  my observation
 for  several years afterward.  It  is  well known  that dogs, cats, and other
 domestic  animals  are liable to epilepsy.  Prof Dalton has related to  me  the
 following interesting illustration of the effect  of imitation in the canine race:
 A dog not previously aff'ected with epilepsy was in company with another dog
 which was subject to this affection.   The 'latter  being seized with an  epilep-
 tic paroxysm, the former immediately afterward  had a similar attack.  This
 occurred  under  Prof.  Dalton's observation.
   The diagnosis of epilepsy in its ordinary form rarely offers much difficulty.
 The disease is, in  general, readily  ascertained  when it has become confirmed.
 In cases in which the practitioner has  not an opportunity of  witnessing  any
 of the paroxysms, he may generally  obtain sufficient information respecting
 the distinctive  features to feel sure of  the diagnosis.  The prominent points
 of inquiry are—the  sudden  seizure, the cry at  the beginning of the paroxysm,
 the loss of consciousness, the tonic and clonic convulsions, embarrassed respi-
 ration, ejection from the mouth of frothy saliva  often mixed with blood, and
 the short duration  of the fits.   An  examination of the tongue, if repeated
 paroxysms have  occurred, in some cases shows cicatrices, resulting from  the
 wounds of this  organ, which are quite diagnostic.
   The aff'ection is to be discriminated from  hysterical convulsions, but these
 present points of  difference which are usually sufficiently marked.  The con-
 vulsive movements are not purely automatic, as in epilepsy, but proceed from
 a delirious volition.  They are of  longer duration than the convulsive move-
 ments in a paroxysm of  epilepsy, and they are developed gradually.   Foam-
 ing at the mouth does not accompany hysterical  convulsions,  and  the  pupils
 are not dilated.   Epilepsy, however, may be developed in persons subject to
 hysteria, and the  two affections may be associated.
   If called to a patient  not  known to be an epileptic, in the  comatose state
 which succeeds  the convulsions, apoplexy might  at first be  suspected;  but
 if the convulsions which precede this state have been observed by any one,
 information respecting  their  occurrence suffices for the diagnosis.    If  the
 convulsions have  not been observed,  the appearance of foam and blood upon
 the lips is diagnostic.  The age of the patient is to be  considered, and  the
 absence of hemiplegia, which often occurs in cases of apoplexy and rarely in
 cases of epilepsy.
   Epileptiform convulsions,  or eclampsia, occurring  in children, in pregnant
 women, or in connection with Bright's disease, are to  be  discriminated  by
 means of  the antecedent and  coexisting symptoms.   Judging from  the con-
 vulsions and associated nervous phenomena, uramia and epilepsy might easily
 be confounded.  Uramic convulsions, however, are rarely of as brief duration
 as an attack of epilepsy.  Examinations of the urine will suffice for this dif-
ferential  diagnosis;  it is, however, to be borne in mind  that  directly after a
 paroxysm of epilepsy the urine contains a trace of albumen.  A paroxysm
of convulsions in an infant or child often with good reason occasions anxiety
lest it may prove  the beginning of epilepsy.   It is not always practicable to
determine this  point at  once.  There is more reason to apprehend  epilepsy 
828
THE  NEUROSES.
in proportion as the convulsions are not otherwise to be accounted for. Their
non-recurrence affords the only positive proof that they are not epileptic.
   It is desirable to determine whether epileptic paroxysms be connected  with
lesions affecting the cerebro-spinal system,  or  whether they be idiopathic.
With reference to  this point, symptoms denoting lesions are to be sought for
in the intervals between the paroxysms.  Persisting  pain in the  head, paral-
ysis, and disturbance of the intellect  greater than the  epileptic  paroxysms
will  account for are symptoms pointing to cerebral lesions.  Lesions are to
be inferred  if the epileptic paroxysm  succeed  an  injury of the  head.
   Epilepsy  is  one of  the  affections  sometimes simulated  by malingerers.
More or less  of the appearances which  are presented in  epileptic parox-
ysms may be  voluntarily  produced,  but  a  malingerer must be very  well
acquainted with the disease to represent  accurately the phenomena in  the
order in which they succeed each other, and certain of the phenomena are
beyond  the  power of the will.  To determine a case of deception, let  it be
observed if  the face become at first pale and afterward deeply congested and
livid, if a cry be uttered, if the fall be forward on the face, if the  convulsions
be at first tonic and afterward clonic, if foamy saliva be  ejected from  the
mouth, and  if the  tongue or cheek be wounded by the teeth.  Let the pupils
be examined, for these cannot be voluntarily dilated and their mobility on the
approach of light  cannot be prevented.  Let the duration of the fit be noted,
and  the convulsions will be likely to be unduly  prolonged.   Let it be ascer-
tained if, accompanying and succeeding the convulsions, there he insensibility
to pricking,  burning, or pinching the  skin.   Let  the  attention be directed to
the time and place in which the paroxysms take place.  Malingerers will not
select the night or a situation in which they will not  be observed.   They
are not likely  to fall in a way  or in a position to receive  injury.  The aspect
of confusion and shame which is manifested on recovering consciousness after
an attack of epilepsy is not easily feigned.
   Epilepsy  may continue for  a long time  before its  existence is ascertained
if the paroxysms  occur only at night.  The disease is to be suspected when
patients complain  of awakening from  time to time with headache, lassitude,
and  a wounded tongue.  Under these circumstances the diagnosis  is to be
settled by  causing the patient to be  watched during  the night.
   Owing to the terrible nature of the malady,  and the apprehension felt by
those in company with an  epileptic lest a paroxysm may occur,  persons are
naturally sensitive with respect to themselves or  their relatives being said to
have epilepsy.  For this reason there  is sometimes a disposition to conceal
the nature of  the paroxysms even from the physician.  To avoid  the depress-
ing effect upon the mind of the patient which a knowledge  of the disease is
likely to produce,  it is sometimes judicious to refrain  from calling it epilepsy.
In the  case of a  lady who was  under my observation  for many years the
nature of the disease was never communicated to her.  The paroxysms, which
were often frequent and severe, were always called nervous  attacks, and she
finally died of an intercurrent affection without knowing that she had  been
an epileptic.  In this case  ignorance  of  her disease enabled her to partici-
pate  in many of the enjoyments of  life from which, owing to her  sensitive
nature,  she  would have shrunk  had  she been  aware that she was  affected
with epilepsy.
   The prognosis in cases of epilepsy, as  regards immediate danger  from
the  paroxysms, is always favorable, and  epilepsy does not give  rise to  any
particular disease  or diseases of a dangerous character.  Epileptics, as a rule,
are  not short-lived, and in  the majority of cases death arises from other dis-
eases, to the  development of which  the  epileptic  paroxysms have not con-
tributed.  In  another  point of view,  however, the prognosis is most unfavor- 
EPILEPSY.
829
able—namely, as regards the persistence of the malady.  In the vast majority
of eases the disease becomes confirmed, and as a rule the intrinsic tendency is
to increasing frequency of the paroxysms.
   In another point of  view the prognosis is unfavorable—namely, as regards
the mental  condition.   To a certain extent the disease tends intrinsically to
impairment or disorder of the faculties of the mind.   Many epileptics, espe-
cially if the paroxysms recur at short  intervals, sooner or later  fall  into
imbecility.  To a greater or less extent this  is due  to  causes other than
the intrinsic tendency of the disease.   If epilepsy occur in early life,  the
mental faculties are not developed by education and those  occupations which
involve their exercise,  and in the cases in which the disease  occurs at a later
period the mental faculties progressively fail from disuse.  The unhappy suf-
ferer  from  this terrible disease is likely  to lose interest in those objects or
pursuits in life which incite to the exercise  of the mental faculties.  This
explanation in part of the apparent effect of epilepsy on  the mind has an
important practical bearing.
   Reference has  been  already made to mild attacks having an  evident rela-
tionship to  ordinary epilepsy, which may be called epileptoid attacks.  It is
important for the practitioner to recognize and appreciate the significance of
these attacks.  They  are  considered  by  French writers as belonging to a
variety of epilepsy which  they  call petit mal, in contradistinction from  the
ordinary form, which they call the grand, or  hunt mal.  These attacks some-
times precede  the  development  of  ordinary epilepsy, and  they sometimes
occur intercurrently in persons who are confirmed epileptics.
   The epileptoid  attacks are multiform.   A  sudden loss of consciousness for
a few seconds occurs in some cases, during which the body may remain fixed,
the person  apparently being lost in deep abstraction, the mental  faculties
resuming their operation as if nothing had  taken place as soon as the attack
passes off.   In a case of confirmed epilepsy under my observation the patient
at one time in the intervals between  the  paroxysms was  subject to frequent
attacks of the  kind just described.  During the attacks  she remained fixed
in the position in which she happened to  be when they occurred.   For exam-
ple, if standing and arranging  her  hair, the hands were  fixed precisely as
they were  at  the instant of the seizure.   On some days these attacks took
place a great number of times, and the patient did not appear to be conscious
of their occurrence.   In  the fixation of the body and limbs these attacks
resemble catalepsy.  In  the case just referred to the  only convulsive move-
ments were of the muscles of  mastication.   Similar  attacks are sometimes
accompanied by  convulsive movements  of other of the facial muscles, of
the muscles of the neck,  and by slight laryngeal spasm.   In some cases the
patient  falls, but recovers  and  rises in a few  seconds.  Loss of conscious-
ness and falling in  some cases are unattended by any convulsive  movements.
Trousseau relates examples of this kind.  Of course in such cases epileptoid
attacks are to be discriminated from syncope.
   In other epileptoid attacks sudden delirium occurs, continues for a few sec-
onds, and passes off, leaving the mind in  the condition in  which it was at the
instant of the seizure.   The delirium is manifested in different ways.  Trous-
seau cites a case  in which the patient  uttered a burst  of laughter, and when
asked why he laughed he looked surprised, having no knowledge of what he
had done.   The same author cites examples of persons  engaged in conver-
sation, debate, or other occupations abruptly, as if struck by a sudden thought,
going into the street bareheaded, and walking until they recovered themselves,
when  they were able to return  and proceed with the  matter in which they
were  engaged as if nothing had happened.1   The following example came
                       1 Aide Clinique medicate, tome ii. 
830                         THE NEUROSES.
under my observation in one of the wards of Bellevue Hospital: A female
patient quietly standing in the ward suddenly uttered a cry, and ran from one
end of the ward to the other.  The urine was at the same time expelled,  leav-
ing on the floor traces of her course.   Having reached  the end of the ward,
she stopped, looked confused, and quietly returned.
  The following example of an  epileptoid attack is interesting from its pre-
senting very distinctly the aura epihptica.   A man thirty years of age had
been for ten months in disordered health, suffering from palpitation and mental
depression.  He described paroxysms of frequent occurrence during the  time
just stated in which he felt a flash, as he termed  it, originating  sometimes
in the chest, sometimes  in the abdomen, and sometimes in one of the lower
extremities, rising upward, giving rise to  a sense of suffocation, and on reach-
ing the head  followed  by  momentary confusion of mind.    He had never
fallen.  In some of these attacks  he had felt stiffness of  the muscles of the
jaws  and of  the forehead.  The  attacks were  irregular, but had recurred
more  or less frequently  every week for the preceding ten months.  On being
questioned, he said that the  " flash " gave the sensation of a stream of air or
gas.  He had  never read or  heard  of the epileptic  aura.   Nine months after-
ward  this patient  had recovered his  former health, and  no  longer had the
paroxysms above described.
  Other  attacks consist  of convulsive movements of certain  muscles without
delirium  or loss of consciousness.  In a case under my observation the patient,
a young man apparently in perfect health, first consulted me for the occasional
occurrence of  convulsive movements of the upper  extremities.   From  time
to time the hands'were violently jerked, and whatever he might happen  to
hold at the time was thrown with great force.  It was unsafe for him to  hold
fragile articles.  A careful  examination in this  case revealed nothing abnor-
mal save these convulsive movements.   They became more  and more frequent,
and shortly they extended to the lower limbs, so that he was repeatedly thrown
down for an instant,  still without loss of  consciousness.  At length, after the
lapse of several weeks, he had a severe paroxysm of epilepsy, and the malady
afterward became established.   In a case under  my observation in 1864 par-
oxysms occurred daily more  or less frequently, in which the head was forcibly
drawn toward  the right  shoulder, and retained there for a  few seconds.   This
affection  had  existed for five  years  without eventuating in epilepsy.  The
paroxysms, however, had increased in frequency and severity, and he appeared
to have loss of consciousness for a few seconds, although he  did not fall.   In
other respects the patient was apparently well.   Being a young  physician,
he  suffered from the anxiety incident to a knowledge of  the fact  that these
attacks might be premonitory of the graver epileptic paroxysms.  Three years
afterward he wrote to me that  the paroxysms were not more frequent, but
more  severe, causing him to fall.  He stated that they were controlled  by
large  doses of the bromide  of potassium.   Subsequently he had  some par-
oxysms of well-marked epilepsy.  In  1879 he reported to  me  that neither
epilepsy  nor  the  epileptoid  attacks had  occurred  for several years.
  In  the case  of a girl aged twelve years the attacks presented the following
features:  Almost daily, often at the breakfast-table, she suddenly manifested
a changed  expression of countenance, appearing as if frightened, sometimes
uttered some exclamation as if surprised, and her  consciousness was lost for
a few seconds.  Sometimes the  face  was distorted.   AVhen consciousness
returned, she almost invariably asked, " AVhat time is it?"  There had never
been any convulsive movements  of the limbs, but they were sometimes rigid.
There was never any spasm  of the glottis.
  Epileptoid  attacks occurring in persons who  have  never had well-marked
epileptic  paroxysms are  to be considered  as denoting a pathological condition 
EPILEPSY.
831
which is essentially that of epilepsy.  Hence the obvious importance of not
overlooking their significance, in order to prevent, if possible, the fully-devel-
oped  malady which is foreshadowed.  Facts showing  how frequently epilep-
toid attacks occur without being followed by the graver form of  the disease
are wanting, but it is certain that the latter by no means invariably follows.
The physician, therefore, should not excite unduly the fears of the patient or
friends by predicting  that these minor forms are necessarily the precursors
of the graver form.

   The treatment of epilepsy relates to the management of the paroxysms
and to measures  for  effecting a cure.  The latter are to be employed in the
intervals.   Curative  treatment, as  in other of the neuroses, may be conveni-
ently considered as rational and empirical.
   The rational treatment  consists  in  deriving, as far as possible, indications
from  an investigation of each case with regard to  the state of the system,
coexisting disorders, and circumstances which may be suspected of standing
in a causative relation to the malady.  If the patient be of a full  habit or
plethoric, dietetic  and other measures addressed  to  this  state are rationally
indicated.   If, on the other  hand,  the  patient be anamic, measures of  an
opposite character are indicated.   Disorders of the digestive system, uterine
affections,  and,  in short,  morbid  disturbances  anywhere  in  the economy,
should receive appropriate treatment, as they may possibly be in  some way
concerned  in the development or perpetuation of the malady.  The presence
or otherwise of tania is to be ascertained.  Inquiries with respect to syphilis
are not to be forgotten.   Phimosis calls  for  appropriate surgical treatment.
Habits of  life with  respect to the  probable or possible causation  are to  be
scrutinized.  Overtasking of mind  or body, undue exposure on the one hand,
and sedentary habits on the other hand, the facts with regard  to mental and
moral influences, the  abuse of alcoholic  stimulants, the  immoderate use  of
tobacco,  and especially over-indulgence in venery or the practice  of mastur-
bation, are to be inquired into.   In brief, an important part of the rational
treatment  consists in enforcing  observance in  all respects of the laws  of
health.  It is  unnecessary to consider the  many and varied  details which
this part of the  treatment involves.
   The empirical treatment consists in the employment of remedies or thera-
peutical  measures which experience  has  shown  to be  sometimes  curative.
The  number of these is  large.   It would require  many pages  simply  to
enumerate  the drugs the  curative efficacy of which,  in certain cases, has
been  attested by honest and  competent observers.  The list is so extensive,
the testimony with  respect to particular remedies is so conflicting, and the
instances of incurable epilepsy are so many, that practitioners are likely to
enter upon the treatment of a case without much expectation of success.  For
the reasons just  stated the disease is not infrequently allowed to continue
without  persevering efforts to effect a cure; and this fact may in a measure
account  for the number of cases in which patients remain hopelessly epilep-
tics.   Of the host of remedies which have been employed, many have doubt-
less proved successful in  a certain proportion  of cases;  but without any
disposition to deceive either  themselves  or others practitioners have  often
been  led to over-estimate  the success of different remedies by not making
allowance for the following facts:  An active remedy  will frequently prevent
recurrence of the  paroxysms  for a considerable period.   Under the use of a
certain remedy a patient passes weeks or months without a paroxysm ; he is
ready to  believe himself cured, and the physician is happy to participate in
the belief.  Now, sooner or later, the paroxysms in most cases return, and the
patient despairs of  benefit from  treatment or- consults another physician. 
832
THE  NEUROSES.
The return of the malady may not be known to the physician, who had sup-
posed that a cure was effected, and in the mean time  he may have reported
the case as one cured by the remedy employed.  Again, the paroxysms cease
in some cases to  recur  for weeks or months or years without  any treatment.
[ have notes of a case in which paroxysms more  or  less in  number every
month, and  sometimes  fifteen or twenty in twenty-four  hours, had occurred
for sixteen  years, a great variety of remedies having been  tried  without
avail; and at length, after all treatment had been discontinued, the paroxysms
ceased to recur for ten or twelve years, when they again returned, but at
long intervals.   Making, however, due allowance for the temporary interrup-
tion of the malady either by the treatment or spontaneously,  there repiain a
certain number of undoubted  cures effected  by different remedies.  In view
of this fact, cases should not be abandoned without the faithful trial of many
remedies.   Of the various remedies which have been considered as curative,
those within  late years and at  the present  time in most repute  are the follow-
ing : The nitrate and  other preparations of  silver, preparations of zinc, digi-
talis, opium,  the narcotic extracts, especially belladonna, and, above  all, the
bromide of potassium.
  The nitrate of silver has long been a remedy for epilepsy, and its occasional
efficacy rests on  abundant testimony.  That it will  not  effect a cure in  the
majority  of  cases is not a sufficient reason for  failing  to make trial of it in
cases which resist other remedies.  Beginning with a fraction of a grain three
times daily,  the  dose  may be gradually  increased to  three or four  grains.
An effect of the  prolonged use of this  remedy in some cases is to be borne
in mind—namely, permanent blueness of the skin.   To avoid  this effect, the
remedy should be suspended for a time  after having been continued for two
or three months.   The oxide of silver is less likely to produce discoloration
of the skin, but is less powerful as a remedy.
  Of the preparations of zinc, the  oxide has been found curative by different
observers, and was advocated especially  by Herpin, who claimed that in  his
hands a cure was effected by this remedy  in  26 of 42 cases.   The mode of
administration advised by Herpin  is to give at first from six to eight grains
daily in divided doses an hour after each meal.  The quantity given daily is
to be increased  by two grains each week until it reaches forty-five  grains,
this  quantity to be continued  for  three months.   The remedy is not to be
discontinued  after the cessation of the fits.
  The prospect of effecting a cure according to Herpin, by this or any remedy,
other things being equal, is proportionate  to the small number of fits which
have occurred.   If there have been more than five  hundred fits, the proba-
bility of a cure is extremely small.   In a  few cases under my  observation in
which the treatment as laid  down  by Herpin was  faithfully carried out  the
remedy proved  unsuccessful.    The cases  reported  by this author, however,
afford indubitable evidence of  a certain amount of  curative power ; and with
reference to any remedy for this disease there is no  known means of determin-
ing beforehand whether it will be likely to prove successful in  any particular
case.  In the cases in which I have tried  this remedy  it has been difficult to
continue  it long  after the  maximum of quantity  is reached, on account of
the strong antipathy to it which the patient acquires.  In a paper published
after his prize essay Herpin advised the lactate in preference to the oxide of
zinc.  Babington advocated the sulphate of zinc, and  carried the quantity
given per diem,, for several  weeks in succession, to thirty-six grains without
producing nausea.  The phosphate and the valerianate of zinc have been
recommended.
  The ammoniated copper has been found  curative.   Of  12 cases  treated
exclusively with  this remedy  by Herpin, 4 were cured.   The dose is half  a 
EPILEPSY.
833
 grain, increased gradually to four or five grains.  The sulphate of copper has
 also been employed successfully.
   Digitalis is said to  have been long a remedy of much repute in Ireland for
 epilepsy, and its efficacy was attested by Sharkey, Cranipton, McCormack, and
 Corrigan.   The infusion  is the preparation to'be preferred.  The quantity
 given daily is to be increased to the amount which is tolerated, and continued
 steadily for several months.
   Opium is among the remedies recommended  as  sometimes curative,  and
 perhaps it deserves a trial more extended than appears  as  yet to have been
 given to it.  The evils of the habitual use of opium  are to be  considered,  but
 with a fair probability of effecting a cure of the epilepsy the physician would
 be warranted in exposing his  patient to this danger.
   Of the different .narcotic extracts, belladonna has the  strongest claims,
 based on the testimony  of different  observers.   Trousseau  was an  ardent
 advocate of this remedy as  capable of effecting a cure in a certain proportion
 of cases, and of frequently ameliorating the condition  of epileptics when it fails
 to prove curative.  Trousseau insists that a fair test of this remedy requires
 its continuance for  a period not limited to months, but embracing several
 years.   His mode of administration was to begin with  a small  dose of  the
 extract (gr. \) once daily, to be continued for a month without increase.   At
 the end of each month the dose is to be doubled, until as large a dose as  can
 be conveniently borne is reached.   The tolerance of the remedy differs in  dif-
 ferent cases.  After the disease is perceptibly modified the doses are  dimin-
 ished in the same manner as they were increased.  Atropine  maybe employed
 in lieu of belladonna, the mode of administration being similar.   With  the
 use of belladonna or atropine  Trousseau frequently combined the employment
 of the nitrate of silver, the sulphate of copper, and  the lactate of zinc.1
   Of all the remedies at the present time known to have any controlling influ-
 ence  over this disease, the bromide of  potassium justly takes the lead.  This
 remedy has not  proved as  successful in effecting permanent cures as was
 anticipated twenty years ago, when it was first employed in  this disease; but
 in a considerable proportion of cases paroxysms do not recur while the remedy
 is in use, and when this result is not obtained the recurrence of the parox-
 ysms is often  rendered less frequent and their severity is diminished.   It has
 effected  permanent cures, making due allowance for occasional spontaneous
 recoveries, but probably the number of instances is not large.  The remedy
 may  be carried  to the extent of  producing distinct bromism.   The doses
 required differ considerably  in different cases owing to difference of tolerance.
 For an adult a scruple of the  salt  may be given, at first twice  or thrice daily.
 These doses are to be increased until the desired effect  upon the disease is
 produced, unless bromism be  induced, even  if forty, fifty, or sixty grains in
 each  dose be  reached.  AVhenever bromism is produced, the  remedy should
 be discontinued for a  few days and then resumed.  If no effect upon the par-
 oxysms be produced within two or three months, it is useless to continue  the
 remedy longer.  Having ascertained the effect produced upon the disease and
 the tolerance of the remedy,  it should not be discontinued, except at intervals,
 for one, two, or more  years ;  that is, provided the paroxysms be prevented or
 rendered infrequent.  It does not seem to be as yet ascertained how far the
 other bromide salts share in  the efficacy of the bromide of potassium.  They
 should be substituted for the  latter if  it be not well tolerated.  The hydro-
 bromic acid appears not to have the same effect as the bromide of potassium,
 and it has even been thought to increase the frequency of the paroxysms.  It
is  of course important not to carry the use of the bromide of potassium to the
extent of causing an alarming degree of bromism; and  the fact  that, given
                             1 Clinique medicale.
       53 
834
THE  NEUROSES.
too largely or continued in large doses too long, it is a dangerous toxical agent,
is not to be  lost sight of.   The following case is of interest as showing the
value of the remedy and the tolerance of large  doses  for a long time: An
epileptic patient came to me about six  years  ago, and was placed upon the
bromide of  potassium, which  was given pretty steadily for two  years, the
quantity per diem being about a drachm.  During this period the paroxysms
were  infrequent and  light.   The  quantity per diem was increased  to  two
drachms, and continued steadily for about two years.  During this period he
had but a few paroxysms, and they were not severe.  Of his own accord, from
some  misapprehension, he increased  the quantity per diem to three drachms,
which he took for about two years.  During this period he was exempt from
paroxysms.  At the end of the two years he came to see me, and I was struck
at once  by his appearance.   His face had a vacant, idiotic expression, and he
walked  with a staggering gait like  that  of a drunken  man.  Recognizing
bromism, I  then ascertained the quantity which he had  been taking for the
past two years.  I directed him at once to suspend the remedy.   He did so
for a  week or two, but on account of inability to sleep he resumed the  dose
of a drachm at night.  Meanwhile, he had a severe paroxysm.   After a few
weeks the bromism had entirely disappeared.   He has continued the remedy
in the dose of a drachm at night, and for two months there has been no recur-
rence of the paroxysms.
   The fact of syphilis having  existed at a period even remote should lead to
the employment of  the antisyphilitic  medication—namely, the  iodide  of
potassium and the  bichloride  of mercury.
   It will  suffice to  mention some other  remedies which are worthy of trial
in the cases in  which the bromides  fail, such as strychnia, or nux vomica,
recommended in small doses, especially by Marshall Hall; cotyledon umbili-
cus, an  ounce of the fresh juice or half a drachm of the  inspissated  juice to
be given twice daily ; indigo, beginning with moderate doses and increasing to
the amount  which the stomach will bear ; valerian in large doses, continued
for a long  period ;  musk, camphor, cimicifuga, and the oil of  turpentine.
   Van der Kolk asserted that counter-irritation over the  nucha by means of
wet cupping, setons, and issues proved successful in his hands.  Others also
have  claimed success for these measures.
   Under the supposition that  the  paroxysm depends upon a morbid agency
springing from some part more or less remote from the nervous centres, and
that the aura indicates the point of departure of this agency, it has been pro-
posed to interrupt  the nervous communications with the part by means of
ligatures,  section of nerves, the actual cautery, and even amputation of an
extremity ;  but  in the  great majority of cases paroxysms are not preceded
by an aura,  and when this exists  there is no ground for  the  conjecture that
it denotes a  causative agency.   It is claimed that in some instances in which
an  aura starts from an extremity, a counter-irritant applied between the start-
ing-point and trunk has succeeded in arresting the paroxysm.
   Surgical measures for the cure of epilepsy, in addition to those just alluded
to, are—ligation of the carotids, tracheotomy, and, after injuries of the head,
trephining.  Ligation  of one or both of the carotids has been repeatedly tried,
but the results do not warrant its being recommended.  The same is  true of
tracheotomy, which was warmly advocated by Marshall  Hall.  Trephining,
when there  is reason  to believe that  the epilepsy may depend on depressed
fracture of  the internal table of the skull, spicula of  bone, or a collection of
blood or pus, is a warrantable operation.  In 35 cases collected and analyzed
by Prof.  Stephen  Smith,  the results  of  this  operation were as  follows:
" Relieved, but not cured, 3.  Immediate relief after operation and no further
note  of result, 2.   Relieved  for  one month  or under  when  last  seen, 3; 
EPILEPSY.
835
    between  one and  six  months,  3;  between six months  and one  year,  6;
    between one and five years, ?>; set down cured, but lapse of time from date of
    operation to time last seen not given,  7." *
      It remains now to consider the treatment called for during the paroxysms.
    These are  rarely witnessed  by the physician  save  when  a  series of parox-
    ysms occur  in rapid succession.   The  duration of a  single  paroxysm is so
    short that if the physician  do not happen to be present it ends'before  he
    reaches  the patient.  The instructions to friends or attendants should  be to
.    place  the patient on a bed if practicable,  and not to attempt to restrain  by
    force  the convulsive movements.  All articles of dress which  constrict  the
    neck or chest should be removed or  loosened.  To prevent wounding of  the
    tongue a roll of linen  or  a piece of  soft wood may be introduced between
    the teeth.   A congregation of spectators  around the patient should be pre-
    vented, and free ventilation should be provided  for.  The patient should be
    kept quiet  after the paroxysm has  ceased, and be soothed by cooling  lotions
    to  the head.
      Epileptics should sleep in  beds  with raised sides to  prevent  injury from
    being thrown upon  the  floor by the  convulsive movements if a  paroxysm
    occur during the night.   They  should be  under observation, as far as prac-
    ticable, during the  night, for death from  suffocation  has  resulted from  the
    face being  pressed into  the  pillow during a paroxysm.
      AVhen a series of  paroxysms occur measures may be employed  to  prevent
    their  recurrence.   Ether, valerian,  belladonna, and opium may  be given  for
    this  object,   The  most effective measure  is  the  inhalation of four or five
    drops of the nitrite  of amyl at the instant of a premonition or of the occur-
    rence of a paroxysm. This drug  arrests the paroxysm by relieving the spasm
    of cerebral  arteries.  Patients may be provided with this remedy for the pur-
    pose of  warding off' a paroxysm.  A paroxysm  may perhaps be postponed,
    but it is doubtful if it be preventable, by any measures resorted  to when pre-
    monitions are experienced.  In a case under my observation a friend  sat  by
    the side of a patient the  whole of  an afternoon, and when  the  premonition
    was  felt dashed a little water  into  the  face.  The paroxysm was  apparently
    prevented for the time, but it occurred as soon as the effort to prevent it was
    discontinued.
      A highly  important point connected w*ith the management  of epileptics
    relates to measures  to prevent deterioration of the mental faculties.   In so
    far  as impairment of mind proceeds  from  disuse of the  mental faculties, it
    may be  obviated or  retarded by  taking pains to secure as much exercise of
    these  faculties as  practicable.   It  conduces greatly to an alleviation of  the
    unhappy condition of epileptics for them to participate, as far as practicable,
    in  the interests and social enjoyments of life ; and if practicable  it is  some-
    times desirable to conceal from them the nature or the extent of the malady
    with which  they are afflicted.   I have known marriage to be advised by  the
    physician in the case of a young woman.  Such advice cannot be too strongly
    censured.   There is no ground  to expect  that the malady will  be favorably
    affected  by  marriage.  With reference to this step, it is the duty of the phy-
    sician to explain fully to the family of the patient, if not to the patient,  the
    nature of the malady.
      The existence of epilepsy is an  important fact in certain medico-legal cases.
    In  the transient delirium which  sometimes succeeds epileptic paroxysms, and
    which may  be incident to epileptoid attacks, violence  to others, and even

     1 A'ide article on the " Surgical Treatment of Epilepsy," etc., New York Journal of
    Medicine, Mareh, 1852.  Prof. Smith in this article gives a summary  of facts with
    respect to setons, issues,  cauterizations and  moxns, operations  on  the sealp. trache-
    otomy, amputation, operations on the nerves, operations on the arteries, and trephining. 
836
THE  NEUROSES.
homicide, may he committed.  The occasional occurrence of delirium, lasting
for hours or days, in connection  with the disease, is to be borne in mind in
giving medical testimony. An epileptic under my observation, a quiet, docile
man, has repeatedly said to me, with an  appearance of  much concern, that
he had fears that he might  kill some one.   He stated that he was conscious
at the  moment of an intense desire to kill any one who irritated him.
   The treatment of cases in which epileptoid  attacks occur, either with or
without the  occurrence  of  epilepsia  gravior, is  essentially the same as in
cases  of the  latter form of the disease.
                      CHAPTER   VIII.

                   THE  NEUROSES  (Continued).

    Hysteria.—Hystero-epilepsy.—Catalepsy.—Ecstasy.—Somuambulism.—Tetanus.

                              Hysteria.
   THE  name hysteria, as commonly used, embraces a multiplicity of morbid
    phenomena.  It is used to denote an  abnormal condition of  the nervous
system  and of the mind, entering largely as a morbid element into a variety
of affections.  The hysterical condition, as regards the mind, involves a mor-
bid susceptibility to  emotions  and a defective power of the will  to restrain
their  manifestations.   A person, whether  male or female, is said  to be hys-
terical who weeps or laughs irrepressibly on  inadequate occasions and when
these  emotional  acts are incongruous.  Frequently these manifestations of
opposite emotions occur in alternation and with  an abrupt transition.   AVeep-
ing and laughter are physiological acts  when they represent emotions which
are natural; that is, excited by adequate  causes and not exceeding the bounds
which observation shows to be consistent with health.   These acts are path-
ological when they do not represent  corresponding emotions or  when they
proceed from  emotions which are unnatural in  view of the circumstances
under which they occur.   The emotions may be real, but morbidly excited
or in  morbid  excess.  On  the other  hand,  the  hysterical  manifestations  in
some  cases simulate  emotions which do not exist.  Patients sometimes weep
violently without experiencing mental anguish, and laugh immoderately with-
out enjoyment.  An  intelligent and estimable lady in  advanced life, who was
under my observation for many years, was subject to spells of uttering loud
explosive  sounds resembling those of  laughter, from  which she  declared
she was unable to  refrain.   They were  called, in the family, her laughing or
screaming fits.   These were the only hysterical  phenomena in the case, and
it was frequently necessary to  administer a full  opiate to arrest them.
  A tendency to exaggerate subjective symptoms of disease often enters into
the hysterical condition, proceeding sometimes from an exaggerated sense of
existing symptoms and sometimes from a morbid desire to excite interest or
sympathy.   It is an important part of  the knowledge and  tact  of the prac-
titioner  to  make  due  allowance for  this  tendency in his  investigation of
symptoms.   In some cases  a morbid perversion of the mind leads patients to
undertake to practise gross frauds as  regards their ailments.  They pretend 
HYSTERLA.
837
to have  extraordinary  disorders,  and  resort to ingenious  and persevering
efforts of deception.  Here, too, the knowledge and tact of the physician are
called into requisition.  He meets  not infrequently  with hysterical malin-
gering as well as hysterical self-deception.  Owing to  the facts just stated,
hysteria  is  associated in the minds of many wTith either imaginary complaints
or imposition ; and hence  many are loath to consider  themselves as affected
with hysteria, and the physician learns reserve in the use of this term in his
intercourse with his  patients.
   Other symptoms of the  hysterical condition are a painful sense of constric-
tion in  the epigastrium and the  sensation of a foreign  body in the throat,
known as the globus hystericus.   To  these a great number and variety of mor-
bid sensations might be added, such  as cephalalgia, tinnitus aurium, eructa-
tions, abdominal tympanites, irregular chills with  yawning  and stretching,
diuresis, twitching of muscles, cramps, etc. etc.   The nervous and mental
disorder which constitutes what is commonly called the  hysterical  condition
may be  associated also with a  host  of aff'ections.   This condition  may enter
more or  less as an element into almost any disease.  There are certain affec-
tions often found associated with symptoms denoting  this condition.  It will
suffice to enumerate the more important of these, as follows:  1. Neuralgia,
especially  supraorbital, cervico-occipital,  and dorso-intercostal.  A form  of
neuralgia almost pathognomonic is that in which the patient describes the pain
as if produced by driving a nail into the head (clavus hystericus).  2. Hyper-
asthesia of the surface, either limited to certain situations or diffused over the
bodv.  Affecting the abdominal walls,  this simulates in some cases peritonitis.
3. Anasthesia,  local  or general.   This is sometimes unilateral (hemianasthe-
sia), and it is generally of the left side.  Not  infrequently the sensibility to
tact remains while  the  sensibility to  pain is  lost (analgesia).  4. Different
varieties of functional  paralysis, especially paraplegia  and nervous  aphonia.
5. The  so-called hysterical cough. (Aride p. 298.)   6.  Hyperasthesia of the
joints simulating grave articular disease.  7.  Pain and tenderness over one
or both of the ovaries, oftener on the  left side.  8. Retention of urine.  9.
Notable  diminution or suppression  of urine (ischuria).
   AVhat I  have  called the hysterical condition embraces the milder manifesta-
tions of  hysteria.  Severer forms of the  affection are hysterical paroxysms
characterized either by convulsive movements or coma more or less complete
or delirium.  In some cases convulsions constitute the  most prominent feature
of the paroxysms, coma in  these cases  usually coexisting.  In other cases coma
occurs without convulsions, but the coma may  precede or follow convulsions,
and in some  cases delirium is the prominent feature.   The  severer forms of
hysteria, therefore, may be considered as  threefold—namely, hysterical con-
vulsions, hysterical  coma, and hysterical  delirium.
   Hysterical convulsions occur in persons subject to the milder manifestations
of  hysteria, and the latter are frequently premonitions of the former.  The
development of the paroxysm  is generally gradual; the  convulsions are pre-
ceded by notable distress,  referred to the  epigastrium, by a sense of choking
or suffocation, and sometimes by a feeling as if a solid body  or ball ascended
from the abdomen to the throat (globus hystericus).  The convulsive move-
ments are often  first  manifested  in  the muscles of the eyelids and  eyeballs.
Other of the  muscles of the face are  rarely affected, and hence movements
more or  less rapid of the  eyes and  constant nictation  are highly distinctive
of an hysterical paroxysm if the movements be limited to these facial muscles.
These muscles  may be alone  affected, but frequently the convulsive  move-
ments extend to the  extremities and trunk.
   A distinctive  feature of the convulsive movements  of the body and limbs
is they are not purely automatic.  Patients throw their  limbs in various direc- 
838
THE  NEUROSES.
tions;  they tumble about the bed with violence, rolling from  the  bed to the
floor, and striking with force against solid substances if not prevented ; they
struG^le  with those who attempt to restrain them, and  sometimes  show a
prodigious  degree of strength.   After making active movements for  several
minutes they remain comparatively quiet for a time, and the convulsions are
then renewed.  At times they grasp the throat as if to remove  an obstruction,
strike the breast, or tear the hair.  These movements are in  great measure
voluntary.   They are directed by a delirious volition, in this respect differing
essentially  from the convulsions of epilepsy or eclampsia, which are  purely
automatic or involuntary.   Automatic movements, however, in certain cases
enter more or less into hysterical convulsions.  Tonic spasm of the posterior
muscles of the trunk, bending the body backward so that the trunk, head, and
lower limbs form the arc of a circle,  constituting what is  known  as  opistho-
tonos, occurs in some cases of hysteria.  The jaws are sometimes firmly closed,
as in trismus.  In  the  intervals between  the active movements the muscles
are often rigid.
   Consciousness  during the  convulsive  movements  and  in  the intervals
appears to  be lost, but generally the patient  has more or  less cognizance of
what is said and done ;  a fact which the practitioner  may  often turn  to good
account in  the management.  The face is  sometimes flushed  and  sometimes
pale.   Respiration  is often notably disturbed, in some cases being extremely
rapid and irregular, in other cases slow and suspirious.  It is  extremely rare
for foamy  saliva to be ejected from the mouth or for the tongue to be bitten.
The spasm of the larynx and muscles of respiration  which characterizes epi-
lepsy is wanting; the nostrils are usually dilated; and nictation  and move-
ments  of the eyes  generally continue.  The pulse is frequently but  little or
not at all  affected.  The heart, howaver, sometimes  acts  with violence and
irregularity.   The  tranquillity of  the circulation in some cases is a striking
feature.  The  duration of the  paroxysm varies much in different cases.  It
very rarely, if ever, is limited to a few moments;  and it may continue for a
period varying from half  an hour to several hours.   The convulsive move-
ments  gradually go off,  and the  disappearance of the paroxysm is frequently
accompanied by cries, groans, sighs, loud  weeping,  or spasmodic laughter.
Copious  diuresis often  occurs  at  the termination of the  paroxysm.
   It is important to discriminate hysterical  convulsions from epileptic parox-
ysms and epileptiform convulsions  or eclampsia.   The foregoing sketch pre-
sents certain points which in general suffice for  the  differential  diagnosis—
namely,  the  evidence of volition in  the  character of  the movements; the
gradual development of the attack ; absence of convulsive movements of the
muscles of the face except those of  the eyes; absence of foamy saliva and
blood upon the lips; the respiration disordered, but  not suspended, by spasm
of the larynx and respiratory muscles;  the long duration of the paroxysms ;
the incomplete loss of consciousness;  and the occurrence of symptoms denot-
ing the hysterical condition prior to and following the paroxysm.  It is a fact,
however, not to be  lost  sight of, that  epilepsy or eclampsia may be  conjoined
with hysterical convulsions.
   Hysterical coma  enters more or less into the paroxysms just described.  It
may precede and follow them.   It is sometimes  accompanied by convulsive
movements limited  to the eyelids or eyes, but it  occurs without any  convul-
sions.  In  a case of simple, ordinary hysterical coma the patient lies appa-
rently  in a  state of profound, tranquil sleep.  The countenance presents a nat-
ural appearance, and the respiration  is quiet, with perhaps occasional  sighs.
The pulse  is regular, and is neither accelerated  nor retarded,  and there  is
frequently  more or less rigidity  of  the  muscles.    Attempts to rouse the
patient from  this  state  are  ineffectual or answers to questions  are obtained 
HYSTERIA,
839
with much difficulty and in  feeble whispers.   The  muscles offer resistance
to efforts  to  separate the jaws.  The quasi-comatose state  continues for a
variable period, often for hours and  sometimes for days, if  not successfully
treated.   Patients in  this state are not completely unconscious.   They are
cognizant  of  what is  said and done.   Sensibility to pain is blunted, but not
abolished; pinching or pricking the skin may be borne without flinching, but
stronger impressions,  such as are  produced by the application of a heated
hammer or the prolonged cold douche, occasion suffering.
   Attacks of this kind occasion great alarm, and the physician will naturally
participate in the apprehensions of  friends if he fail to determine  the nature
of the affection.  It is to be discriminated from apoplexy, and the diagnostic
points are as  follows :  The attacks do  not present the stertor of apoplexy, and
hemiplegia is wanting;  the  pupils respond readily  to light; the patient  is
perhaps known to be subject to hysteria.  The symptoms of  the hysterical
condition  precede the coma,   The age of the patient will  be likely to  be
under the period  when apoplexy is most liable to occur;  and in ordinary hys-
terical coma the nature of the aff'ection is generally speedily  declared by the
efficacy of certain measures of treatment to be presently mentioned.
   Uramic coma  is to be excluded.   Antecedent and coexisting  symptoms
relating to the  urine,  general  dropsy in some  cases, and the absence of hys-
terical premonitions,  will suffice for this differential diagnosis.  Abercrombie
related cases of fatal  coma  occurring in women which are liable  to be mis-
taken for  hysteria, nothing being found after death to account for the coma
except cerebral congestion.   AVilliams described these cases in the following
terms: "A young female becomes anamic,  and after exhibiting various symp-
toms of feeble  general circulation, with headache, drowsiness, and  impaired
sensorial  functions, suddenly becomes worse, passes  into  a  state  of stupor,
with  dilated  pupils, sometimes varied by slight manifestations of delirium,
throbbing of the  carotids and partial heat of the head, and dies comatose.
On opening the head  a small quantity of serum is  found under the arachnoid
and in the  ventricles, sometimes with a little  lymph  (in one case there was
none).  The  vascularity of the membranes  is remarkable,  but  the vessels
most distended are the veins,  and in the larger of  these and in the longitudi-
nal sinus  there is a firm  coagulum." 1  I had met with cases answering to this
description many years  ago, before uramia was as well  understood as now.
The existence of uramia in such cases seems  now to afford a rational inter-
pretation  of  the  phenomena; yet I have  met with a case in which  repeated
careful examinations of the  urine gave no evidence  of renal disease.
   There is a possibility of confounding  the  coma dependent on  meningitis
with  hysterical coma.   Meningitis is to  be  excluded by the fact  that the
coma has not  been preceded by the diagnostic symptoms of that disease—
namelv, pain in  the head, intolerance of light, suffusion of  the eyes, throb-
bing  of the  carotids,  etc.  The thermometer  may aid  in the exclusion of
meningeal or any other acute inflammation.  If an acute inflammation exist,
the heat of the body is more or less raised ; whereas hysteria, existing alone,
does not usually  give rise to  any  increase of heat,   By this also meningitis
may be excluded in  cases of hysterical delirium.   Hysteria may, however,
be attended by rise of temperature, so that the existence of pyrexia in itself
does not positively exclude the existence of hysteria.
   Under the  head of  hysterical coma may  be embraced certain extraordinary
cases in which  the mental faculties, the senses, and sensibility are suspended
more completely  and for a longer period than in ordinary cases.  These cases
are likely  to occasion  much embarrassment in  the mind of the young prac-
titioner.   As an illustration,  in the early editions of this work I have given
                          1 Principles of Medicine. 
840
THE  NEUROSES.
 with considerable detail an account of a hospital case of  which a synopsis is
 as follows: The patient, a man  twenty-five years of age,  was admitted in a
 state of unconsciousness, the previous  history not having  been ascertained.
 For seven days he remained  most of the time in an unconscious  state.  The
 eyes were sometimes open and sometimes closed.  He appeared to take no
 notice.   The  pupils were mobile, and neither contracted  nor dilated.   Flies
 creeping over the face, and even over the conjunctiva, did not disturb him.
 Drinks  introduced  into the  mouth were retained there  for some time, and
 the  greater part escaped.  The respirations were perfectly normal; the pulse
 Ii)  and regular; the skin was natural, and there was  neither distension nor
 tenderness of the abdomen.   He lay motionless, not  changing  his position,
 and giving no manifestation of suffering.
   The treatment consisted of the cold douche (which had  no effect), enemata
 of  turpentine  and asafatida, and fluid nourishment  by the mouth.   The
 urine was withdrawn with the catheter.  On the fourth day there was marked
 improvement.  The eyes were open and  denoted intelligence,  but he did not
 speak or give heed to questions.  He took  nutriment  freely and with appar-
 ent  relish.  On this day he had a paroxysm of violent weeping.
   He relapsed into  the  former condition on the  fifth day.  Castor oil was
 prescribed on this day, no dejection having taken place since his admission.
 He  urinated  voluntarily  while  preparations were making  to introduce the
 catheter.   The bowels were moved freely after four minims of croton oil had
 been given.   He resisted the  administration of the  oil  as  well  as of drink
 and nourishment,  The dejections were not passed in bed,  but  he disposed
 his body so that they were passed upon  the floor.  On the seventh day, there
 being no  material change, "firing" was resorted to by means of a hammer
 heated  by boiling water.  He bore the heated iron for some time without
 manifesting pain, but on continuing the  application  he made vigorous resist-
 ance, and at  length protruded the tongue when  requested, and took brandy
 and water freely.
  On the eighth day the improvement was  marked.  He  took, however, but
 little notice,  and replied  to  questions slowly in a  feeble whisper.   On the
 eleventh day he was dressed,  without any effort  on his part, and  made to sit
 up.   He  remained  sitting in one position, the  eyes fixed in one direction.
 He  protruded  the tongue slowly and partially when requested, but did not
 reply to questions.   On  the  twelfth  day there was a  marked change.  He
 greeted  me with a smile and offered his hand. He walked  of his own accord.
  He relapsed on the fourteenth day into the former state of  unconsciousness,
 and  "firing"  was again resorted  to.  By this measure he was roused suffi-
 ciently to take nutriment.  He continued in this state until  the  seventeenth
 day.  On that day he was made to walk about the ward with assistance, and
 the  experiment was tried of leaving him  unsupported.   After remaining
 motionless for several minutes he dropped down,  but in a way  not to receive
 any  injury.
  On the  eighteenth day he talked and walked about of his  own accord. On
 the nineteenth day he again relapsed  into silence and  unwillingness to take
 food. "Firing" was resumed, and  by means of  this measure he was made
 to walk  into the open air.  On the twentieth day he walked about and talked
 freely.  After this date  he progressively improved, and  he was  discharged
 well at  the end of three  weeks.
  Nothing could be ascertained respecting the  cause of  this attack.   The
patient  stated after his recovery that he recollected what  had occurred dur-
ing  his illness.   I did not discover that the mind was exclusively occupied
by any dominant  idea, as  in  ecstasy.   Consciousness was  not lost, but the
exercise of the faculties dependent  on  the cerebro-spinal system was in  a 
HYSTERIA.
841
 great measure suspended.  A morbid moral  perverseness appeared to be an
 element in the  case, as in most  cases of hysteria, but it  is certain that the
 patient was not  a  malingerer.
    The diagnosis  of hysterical coma in  this case was based on the symptoms
 which have been  stated, together with the absence of fever, as well as of the
 evidence of disease of  the kidneys or of any other organ.  I have met with
 a  few other cases presenting the same characteristic features, and in  two  of-
 these instances the patients were of the male sex.  In one of the cases cata-
 lepsy existed.   In each case the termination  was in recovery.
    Hysterical delirium occurs generally  subsequent to, or  in alternation with,
 the paroxysms of  convulsions or of coma  which have been described, but it
 also occurs alone.   It is preceded  and  followed  by symptoms  characteristic
 of the hysterical condition. The delirium is active,  and is  manifested in some
 cases by wild, excited  talking, the mind passing rapidly from one topic to
 another.   The mind may run on either gay or grave topics, or there may be
 an incongruous union of both.  Patients are sometimes violent,  Occasionally
 they use vulgar  and obscene language.   In some cases the mind  acts under
 the influence of insane  delusions, and these sometimes involve  spectral illu-
 sions.
    Of the pathology of  hysteria  in the severer  forms just  described, all that
 can be said, with  our present knowledge, is, that it involves a functional mor-
 bid condition affecting the nervous system,  especially in its relations with the
 mental faculties.    An  important element of  the  affection is  disorder and
 weakness of the  will;  the affection, however, is by no means purely mental,
 but proceeds from a pathological state of the cerebral organs with which the
 perceptive  and emotional  faculties, together with the will, are  connected.
 The three  forms  of hysteria which have been  described  differ considerably
 as regards  the morbid  manifestations, but that they are  different forms of
 one affection is shown  by their coexistence or occurrence  in alternation, by
 certain symptoms characteristic of the hysterical  condition which  occur alike
 in  connection with  each form, and by  the fact  that what we  know  of the
 causation applies  equally to  the three  forms.
   Hysteria may  occur  at  any period of life, but  in the majority of cases
 patients are between fifteen and twenty years of age.  I have  known it to
 be well marked   in a girl  ten years  old.   It  is of  rare  occurrence  either
 before the  evolution of the sexual instinct or after the period when it may
 be supposed that venereal  desires have ceased ;  but it sometimes continues
 into advanced  age.   The  symptoms which characterize the hysterical  condi-
 tion are not very  uncommon in males.  The name hysteria, therefore; which
 in its etymology refers to the  uterus, is a misnomer.
   The causation appears to require a peculiarity of constitution.   There are
 some persons who are constitutionally prone to  hysteria, and there are  many
 who are incapable of having it.    The  hysterical diathesis often exists in
 members of the same family.   A great  variety of causes  may contribute to
 the  development of the  affection, among the more frequent being anamia,
 overtaxing  of mind and body, mental anxiety  or grief, and the  prostration
 incident to various diseases. The influence of causes pertaining to the  sexual
 system has  doubtless been  much  exaggerated ;  but the agency of excessive
 venereal indulgence or  of masturbation  on the  one hand,  and of  continence
 on the other hand, in certain cases is not to be doubted.  Sudden  disappoint-
 ment, affliction from loss of friends, violent  anger, jealousy, and other  kinds
 of strong mental  excitement, often act  as  exciting causes of an hysterical
 paroxysm.   A desire to  excite in the minds of  friends or  others  anxiety or
 alarm, and  to furnish occasion for interest or sympathy, contributes to that
abandonment or perversion of  the power of the will  which enters into the 
842
THE  NEUROSES.
paroxysms   The hysterical constitution may be developed, and is often fos-
tered  by the absence of wholesome restraint and discipline  in the manage-
ment' of youth, and by  an unfortunate habit to which  women,  more than
men, often become  addicted—namely, of concentrating unduly the attention
on personal sensations and sentiments.
  As re-ards prognosis, hysterical attacks are proverbially devoid of danger.
The practitioner, however, is not to lose sight of the fact that hysteria may be
associated with affections which are serious.   He should  not be too ready to
set down morbid phenomena to the account of hysteria; and it behooves him
to be careful not to confound hysteria with other aff'ections.
   The treatment of hysteria is to  be considered with  reference—-first, to
the hysterical  condition ;  and  second, to  the paroxysms which  have been
described.                               ,.         .    .
   The hysterical condition calls for remedies to  soothe the nervous  system,
but opiates are to be avoided.   Valerian, asafatida, lactucanum, ether, bella-
donna, hyoscyamus, and the valerianate of ammonia are appropriate remedies.
Of these the first two are the most efficient.   The bromide of potassium has
in some  cases a remarkably soothing effect.  Alcoholic stimulants should be
recommended,  if at all, with  great reserve, lest  the  patient take  advantage
of the  sanction of the physician and resort to them more frequently and
freely than prudence warrants.  The  most important part of the treatment
is hyo-ienic.  The object is to invigorate both body and mind.  \\ ith regard
to bodily vi-or, good  diet, abundant  exercise in the open air, and regular
habits as regards sleep are important.  AVith regard to mental vigor, health-
ful occupation  of mind, and avoidance as far as possible of everything calcu-
lated to produce undue development of the sentiments  and passions or to
excite the imagination, are to be enjoined.   The  causes  which may be sus-
pected  in individual cases are to be removed as far as practicable.   lhe
patient should be  encouraged to endeavor to increase the power  of  the will
to  resist a tendency to give  way to  emotional  disturbance.   For this  pur-
 pose the discreditable character of the affection may sometimes  be  referred
 to  with advantage.  The  moral management will involve details suited  to
 individual cases, which  must be left to the discretion, delicacy, and tact of
 the practitioner.   Cases  in which  ailments are exaggerated or simulated
 with a view to  excite attention, curiosity, or commiseration  are unhappily
 not infrequent.  As the determination of the patients in these cases  is not to
 o-et well, the varied measures of treatment which are adopted prove of course
 Tneffectu'al.  These cases  sometimes tax severely the patience and temper of
 the physician.                                                <     .
   In  treating  cases of hysterical  convulsions it is to be  borne in mind that
 if left to pursue their  course, simply preventing the patient from  the self-
 infliction  of wounds  or  bruises, they would  end  spontaneously;  and  it
 would perhaps be as well for the patient if the paroxysm were  allowed to
 exhaust itself;  but the  anxiety and alarm of  friends  generally require a
 resort  to measures to  arrest  the  convulsive movements.   The prolonged
 application of the  cold douche to the head is generally successful.  The
 head  of a patient  is to be held over a tub and cold water  poured upon  it
 continuously  until the  convulsions   cease  and the patient admits being
 relieved and begs that the  measure  may be discontinued.   Remembering
 that consciousness is  not usually abolished, and that the  convulsions depend
 upon a delirious volition, the physician should take  care to  state repeatedly
 that the douche is to be persisted in until  the patient  is able to express relief,
 and is to be repeated if the relief be not permanent.  It is unquestionable that
 the efficiency of this measure depends considerably, if not chiefly, on  its moral
 effect.  The physician should also give to the friends, within  the  hearing of 
HYSTER O-EPILEPS Y.
843
the patient, positive assurances that there is no danger and that the parox-
ysm will certainly be arrested.   After the convulsions cease, if the  patient
be much distressed, an opiate may be given, either by the mouth or by the
hypodermic method, but if valerian, asafatida, or ether will suffice, it is to be
preferred.
  In an ordinary paroxysm of hysterical coma the douche, as just described,
will almost invariably succeed in restoring consciousness.  The same course
is to be pursued, with respect to moral management, as in paroxysms of hys-
terical convulsions.   The treatment after consciousness is restored is the same
as in cases of convulsions after these have  ceased.  In  cases of prolonged
hysterical  coma " firing," repeated from time  to time, is the most  effective
measure.   Nourishment should be given, forcibly if necessary, and as sensi-
bility and consciousness return the exercise of the will in taking food, sitting
up, and performing other voluntary acts should be enforced.
  In  hysterical  delirium, if  mild, the remedies which have been mentioned,
valerian, asafctida,  etc.,  with soothing management, may  suffice.   If the
delirium be violent, the tartrate of antimony and  potassium, carried to the
point of nausea,  will be  likely  to tranquillize the  patient.
  After the paroxysms have  ceased  in each of the  three forms the treatment
resolves itself into that called for by the hysterical condition.
  Among the most remarkable phenomena of hysteria is the influence exerted
upon  anasthetic parts by the application of various metals.   The application
of metals  for this  purpose  is  called metallo-therapy.  The main facts were
discovered long ago  by Burge; but they have been  more fully studied in late
years by Charcot and his  pupils in the Salpetriere in Paris, where most extra-
ordinary and unusual forms  of hysteria are observed.   It is found  that the
application of certain metals to an anasthetic part restores  sensation in this
part and often over a wider  district, and strangely  causes a transfer of the
anasthesia to an  exactly corresponding part of the opposite  side.  The most
efficacious  metals are  iron, gold, silver, zinc, and copper, but others are also
employed.   Not only metals, but  magnets, blocks of wood, mustard plasters,
and  other  agents may produce similar effects.  In a similar way have been
produced restoration  and transference  of  unilateral  loss of  vision,  hearing,
taste, and smell.  An  explanation of these strange phenomena has not been
given, nor  is the  practical application of metallo-therapy of much importance.


                          Hy ster o - epilepsy.

   Hysteria and epilepsy are  distinct  affections, but  they are not antagonistic
to or incompatible  with each other.  A person may be subject to both, and
it may happen that  hysterical phenomena  may precede or follow an  epileptic
paroxysm.  The  term* hystero-epilepsy, as used by Charcot and others, how-
ever,  is applied to cases "in which  hysteria simulates more or less of the phe-
nomena of epilepsy.   In an hystero-epileptic paroxysm hysteria is the primary
and  essential malady, but in addition  there are tonic or clonic convulsions
which are  automatic.  The tongue or cheek may be wounded and foamy saliva
escape from the mouth.   There may be an aura which, according to Charcot,
often has  its source in one of the oVaries.   Pressure over the region of the
ovary sometimes  excites, and methodic compression sometimes averts, a par-
oxysm.   An important point  of distinction  between a  combination of the
two affections and the  simulation of epilepsy is that the latter does not involve
a tendency to the recurrence of epileptic distinct from hysterical paroxysms.
  The prognosis is  more favorable than in cases  of epilepsy existing inde
pendently of this etiological  connection, and the treatment has relation chiefly
to the hysteria. 
844
THE  NEUROSES.
                              Catalepsy.

  The affection called  catalepsy, as this term is now commonly used, is evi-
dently allied to  one of the forms of hysteria—namely, hysterical coma.  In
the cataleptic state the sensory functions, volition, and consciousness are for the
greatest part or entirely suspended.   So far, the state is essentially the same
as in some cases of hysterical coma;  but superadded is a peculiar wax-like
rigidity of the voluntary muscles, retaining  the limbs and trunk in a fixed
position, the different parts  of the body preserving the positions in which
they may be placed by the  hands  of another.  This superadded feature  is
characteristic  of  catalepsy.
  The cataleptic state is  generally  preceded  by symptoms  of the hysterical
condition, but it  is sometimes developed suddenly ;  that is, without premo-
nitions.  The  patient while in this  state  remains immovable, preserving the
position in which the  body happened  to  be  at  the  time of the attack.  In
some cases the rigidity of the muscles is such  that they offer considerable
resistance when efforts are made to alter the position of any part, but in  other
cases the different parts are easily moved.   The trunk or limbs are retained in
positions which in health would require a strong exertion of the will, and for
a longer period than would be possible in  health.  Thus, the limbs are some-
times kept for a long  time extended, or, the  patient  lying  on  the back, the
lower limbs may be raised and the trunk elevated, so that the body rests only
on the sacrum ; and this position, which, voluntarily assumed, would soon be-
come insupportable, is  preserved for a considerable  period.  This remarkable
feature is more or less marked in different cases;  in  other words, the  cata-
lepsy may be complete or incomplete.
  As in cases  of hysterical coma, the vital functions may be but little or not
at all  disturbed.   The circulation may be regular, respiration natural, the
temperature normal, and,  if food be ingested, the processes involved in nutri-
tion may be well performed.
  The affection is paroxysmal, but different cases differ widely as regards the
frequency and the  duration  of the paroxysms.   They are  sometimes short,
lasting but a few moments; not infrequently  they continue  for several days;
and they may extend  to weeks and even  months.   In  the majority of  cases
the duration is three or four hours.   A single paroxysm only may occur, and,
on the other hand, paroxysms have  been known to be repeated  daily for a
long period.  A case is cited by Puel in which twelve hundred paroxysms
occurred within  twenty-eight months.
  Catalepsy in this  country, exclusive of cases of so-called mesmerism or ani-
mal magnetism, must be extremely rare.   AVith pretty large opportunities for
clinical observation for more than forty years, I have met with but 2 well-
marked cases.   The statistical researches of Puel, embracing  results of an
analysis of 148 cases, showed  that the disease is not peculiar to  females.  Of
these 148 cases, 80 were in females and  68  in males.1  In one of the  cases
which  I have  seen  the patient was of the male sex.   A large majority of
cases  are between ten and  thirty years of age.   The affection, however, may
occur at less than ten years and at an advanced period of life.  It appears to
be induced especially by mental causes.  Melancholy, overtaxing the intellect,
and violent excitement of the passions favor its development, and causes fre-
quently determining an attack are hatred, jealousy,  fright, domestic affliction,
reverses of fortune, etc.
  The prognosis is always favorable as regards danger to life.   It has, how-
ever,  been observed to precede the  occurrence of insanity, paralysis, and
epilepsy.
           1 Mem. de PAcad. de Med., Paris, 1S56.  A'ide ATalleix, op. cit. 
TETANUS.
845
  The principles of treatment are essentially the .same as in cases of hys-
terical coma.  The condition of the muscles calls for the use of friction with
stimulating  liniments.   Forcible alimentation may be required if the cata-
leptic paroxysm be prolonged.
  An abnormal state,  analogous  to  that of catalepsy, is  among the curious
phenomena  of  hypnotism, formerly known as mesmerism or animal magnet-
ism.    The  consideration  of these phenomena—which of  late  years have
deservedly received scientific attention—does not come within the  scope of
this  work.
  I shall  content myself with a hare allusion to  certain abnormal conditions
which properly belong  to the domain of psychology.  One of these is the
condition  known as ecstasy.   In  this condition the mind, absorbed in a domi-
nant idea, becomes insensible to surrounding objects.   In some cases during
the ecstatic  state the body remains immovably fixed, as in catalepsy.  Extra-
ordinary visual hallucinations occur in some cases.   The mental condition
differs from that of catalepsy in  this:  the mind is active, and thoughts or
visions which occur are recollected afterward, whereas in catalepsy the action
of the mind is suspended and the period  passed  in the paroxysm is a blank
in the patient's memory.  Another name for the  ecstatic state is trance.   As
in some cases of catalepsy, the respiration  and circulation may become so fee-
ble that without close  examination  life may be supposed to be extinct.   If
the breathing be not readily ascertained and the pulse be inappreciable, auscul-
tation with the binaural stethoscope can hardly fail to reveal the heart-sounds
in such cases.
  Another condition is that called somnambulism.  This condition is incident
to sleep.  It embraces  the mental  and physical performances, sometimes very
extraordinary, which are observed in sleep-walkers.  Similar phenomena are
observed in  the condition known as the mesmeric  or magnetic sleep.


                               Tetanus.
  The term tetanus is applied to an affection  characterized by persisting
rigidity of the muscles of the jaw, and frequently of the greater part of the
voluntary muscular system, with paroxysms  of tonic  spasms, the intelligence
being preserved.  In the great majority of cases this affection follows a wound
or local injury of some kind.  It is  then distinguished as traumatic tetanus,
and  when not traumatic it is distinguished as idiopathic tetanus.  Its symp-
tomatic characters are  essentially the same whether the  disease be traumatic
or idiopathic.   On account of the large preponderance of traumatic cases it
belongs among the surgical affections, and is treated of  at length in compre-
hensive works on surgery.   I shall consider it as an idiopathic affection.
  Idiopathic tetanus is everywhere rare, and in cold or temperate climates it
is one of  the rarest of  affections.   It is less  rare in tropical climates.  It is
one of the affections to which newly-born children are subject, especially in
tropical climates, but occasionally  everywhere.  In adults it seems sometimes
attributable to exposure to cold, and  with this apparent causation it is called
by some writers tetanus a frigore.  It has been  conjectured that the disease
is sometimes a manifestation of rheumatism.
  In  many  cases idiopathic  tetanus is developed abruptly, without premoni-
tions ; but in  a certain proportion of cases  it is preceded by indefinite  ail-
ments, such as chilly  sensations, sense of fatigue, etc.   The muscles  first
affected are those of the  neck and lower jaw.   The affection is sometimes
limited  to these muscles,  and it is then distinguished as  trismus.   The jaws
are firmly shut by the rigid contraction of the muscles, and hence the affec-
tion  is known  as  lockjaw.  The mouth  in some cases cannot be opened by 
846
THE  NEUROSES.
any force which it  would be  prudent to employ, and drink, nourishment, or
remedies can  be  taken only through the spaces between  the  teeth.   The
muscles of the face are frequently involved, giving rise to distortions of the
features which are  sometimes terrific.  The angles of the mouth  are drawn
backward and  upward, giving the  expression called risus sardonicus.   The
tongue is sometimes severely bitten by being caught between the teeth.   The
pharyngeal muscles are not infrequently involved, preventing deglutition.
  If the affection extend to the muscles of the trunk, the abdomen becomes
retracted and rigid and the respiratory movements of the chest are  restrained.
The limbs become rigidly extended. The entire body is sometimes  immovable
and stiff, so that it may be raised by the head or feet as if it were  a statue.
  Rigidity of the  muscles  is persistent, but at intervals spasm is added to
the persisting contraction.   In the paroxysms of spasm  or  convulsions the
body is  frequently bent backward by the  predominant force of the posterior
muscles of the trunk ;  and in extreme cases the body forms  the  arc of a cir-
cle, resting on the  head and  sacrum,  and  sometimes on the  head  and heels.
This is called opisthotonos.  A much less  frequent form of  curvature is pro-
duced by the predominant contraction of the muscles on the anterior portion
of the trunk.   This is called emprosthotonos.  A  lateral curvature, still more
rare, is  called pleuvrosthotonos.  The paroxysms  vary in duration, and  they
occur at intervals which vary much  in different cases.   They are attended
with severe pain.   The paroxysms may be  excited by any mental emotion
and by impressions transmitted from the surface of the body.  In  this respect,
as also  in  the character of the convulsions, they resemble those which  take
place  in  cases  of poisoning by  strychnia.
  As already stated in the enumeration of the characters distinctive  of tetanus,
the intelligence is preserved.  Delirium and coma are wanting.  In general, the
paroxysms are more frequent during the day than during the night.   If deg-
lutition be  prevented by pharyngeal spasm, the patient suffers from thirst and
hunger.  Foamy saliva under these circumstances collects and escapes from
the mouth.  The bowels are  usually constipated,  but in some cases involun-
tary dejections occur.   Retention of urine may occur, or, on  the other hand,
it may be passed involuntarily.   The circulation  may be but little or not at
all disturbed, save as an effect of disturbance of the respiration.  Respiration
is embarrassed  in proportion as  the  respiratory muscles  are  affected.  The
embarrassment is usually great during the paroxysms, and  fatal apnaa may
be induced.  The  temperature of the body  varies much in different cases.
In a certain proportion of cases there  is moderate or slight  fever.   In other
cases there is notable pyrexia, the thermometer in the axilla  sometimes show-
ing a rise to  110° F.   The temperature is measurably  an effect of the mus-
cular  spasms.   The temperature  is always  raised during  exacerbations in
which the  muscular contractions are  increased.   Profuse sweating occurs in
the exacerbations, and  more or less perspiration exists in the intervals.  Con-
traction of the pupil to the size of a pin's point  during the exacerbations is
often observed, the  contraction going off in the intervals.  A frequent symp-
tom is pain at the pit of the stomach, piercing through to the back.
  The disease  sometimes  destroys life within  twenty-four  hours.  On  the
other  hand, in  rare cases  it  continues for several weeks, when it is called
chronic  tetanus.
  In a large proportion of cases the affection ends fatally  after a duration vary-
ing between  twenty-four hours and twenty days, the average duration being
not far  from ten days.  The fatality is somewhat less  from idiopathic than
from traumatic tetanus. The mode of dying may be by apnaa or by asthenia.
The danger of apnaa is in  proportion  to  the  amount  of embarrassment of
respiration.   Death by asthenia  is caused by the exhaustion incident to long 
TETANUS.
847
continuance of the  rigidity and spasms, together with the difficulty in some
cases of alimentation.   It  has  been noticed  that in  some cases rigor  mortis
succeeds the spasms during life without any appreciable interval of muscular
relaxation.
  The distinctive characters of the affection render the diagnosis sufficiently
easy.  It is to  be distinguished from spinal  meningitis and from cerebro-spinal
meningitis by  the absence of local symptoms denoting inflammation, and from
the latter  of these affections by the absence of cephalalgia, delirium, and coma.
Absence of coma distinguishes it from epilepsy.  Moreover, the latter is purely
paroxysmal, the muscles not being contracted in the intervals.   Absence of
characters distinctive of hysteria  sufficiently distinguish  it from  that affec-
tion.  It  is, however,  to  be  recollected that trismus, with or without  con-
vulsions, is an occasional  manifestation of hysteria, and under these circum-
stances  is unattended  with danger.  The phenomena produced by strychnia
in poisonous  doses bear the closest resemblance to those of tetanus,  and  to
discriminate between them is of great importance  in a medico-legal point of
view.  AVithin late years  strychnia has been repeatedly  employed for homi-
cidal and  suicidal purposes.  The  following differential symptoms are  quoted
from Todd:1
  " As regards the  Tetanoid State from Strychnine.—a. The rapid superven-
tion of  tetanoid  convulsions affecting chiefly, and with  most intensity, the
muscles of the trunk and  spine, causing  an active and violent opisthotonos
rarely met with in  tetanus, b.  A rigid and  tetanoid state of the muscles of
the lower extremities,  with somewhat less intensity than  those of the  trunk ;
the limbs  extended and the feet drawn  powerfully inward  by the action of
the tibialis postici muscles. The upper extremities affected also, but in a less
degree, and the hands  generally semiflexed,   c. The trismus existing only
imperfectly, and  the fades tetanica very  slightly  or not  at  all; swallowing
perfect, but the mode  of  deglutition peculiar,  the patient snapping  at the
liquid offered  and gulping  it down with an effort, in a manner very similar to
that in which  hydrophobic patients swallow,   d. The attacks  of opisthotonos
very frequent, seemingly exquisitely painful, and ushered in  by a cry more
or less  loud.
  -- As  regards  Tetanus.—a. The symptoms  coming on  gradually, and the
trismus the earliest, the most  prominent, and  most  important one.   b. The
 fades tetanica a very characteristic symptom,  c. The attacks of opisthotonos
iess frequent,  less extensive, and less severe than in poisoning by strychnine.
d. The extremities the last parts affected, and suffering  much less from the
tonic spasms than other parts,  e.  Deglutition  slow and  difficult, and some-
times impossible, owing to the spasmodic closure  of the mouth."
  To these differential  points it is to be added that a fatal dose of strychnia
kills quickly,  usually within an hour, whereas in fatal cases of tetanus life is
prolonged generally for two or three days.
  Punctate hemorrhages are very  frequently found  in various parts  of the
central nervous system, particularly in the medulla  oblongata and spinal cord,
after death from tetanus;  but these changes are probably secondary, as they
are found after death from other convulsive diseases.  No  morbid changes
have  been discovered  to  which tetanus can be  attributed.   In  the present
state of our  knowledge, therefore, the disease  is to be  considered as functional,
the changes which  may be found after death being  either  secondary or associ-
ated by coincidence. AVith respect to the pathology,  the close analogy of the
symptomatic  phenomena to those  produced by strychnia  is a strong point in
favor of the supposition that  the disease involves  the presence in the blood
of a toxical agent  acting  upon the spinal cord and the  medulla oblongata.
                    1  Clinical Lectures on the Nervous System. 
848
THE  NEUROSES.
The symptoms show an  exaggerated reflex excitability of the medulla and
the cord as a marked pathological  feature of the disease.
  The treatment of tetanus by different  methods has proved unsuccessful
in a large proportion of cases.  Among the measures which have  seemed to
be sometimes successful  are—opium given  in large doses, aconite, alcoholic
stimulants carried to the  extent of producing intoxication, and the  inhalation
of chloroform.  Other remedies advocated as sometimes successful  are  bella-
donna, cannabis indica, and quinia in large  doses.   Bloodletting and counter-
irritation over the spine have been largely tried, but are not to  be recom-
mended.   Ice applied to the spine has been found  useful.   Cold affusion has
been  employed with success.  The  high temperature of  the  body in  some
cases  indicates  antipyretic measures of treatment.
  In addition to the  remedies already named, others more  recently employed
are  the hydrate of chloral, the Calabar  bean, curare, and the nitrite of  amyl.
Cases which have ended favorably under treatment by these remedies  have
been reported; but clinical facts do not, as  yet, warrant positive conclusions
respecting the remedial power which they respectively exert over the disease.
The great number of remedies advocated as possessing curative  efficacy  in
tetanus suggests a reflection which has  been mentioned in other connections:
AVhen cases of a disease  have ended favorably under a host of remedies it
may be reasonably conjectured that  the ending in these cases was  due  more
to an  intrinsic tendency of the disease than to the remedies used.  It remains
to be  determined in  how  large a  proportion of cases  tetanus  would end  in
recovery  without any actual  medicinal  interference.
  In the following case improvement and recovery took  place after all  treat-
ment  had been discontinued: A boy seven  years of age, the son  of a  poor
washerwoman, came  under my observation  about  a fortnight after the be-
ginning of the  disease.    He then  had every few minutes  paroxysms  of
opisthotonic spasms, with rigidity  of the limbs, pronation of the thumbs, erec-
tion of the penis, and firm closure of the jaws.  The paroxysms lasted two  or
three  minutes ;  they were accompanied  by great embarrassment of breathing ;
they occurred spontaneously,  but were brought about whenever the body was
moved.  During the paroxysms the body could be  lifted like a statue by rais-
ing  one leg.   The  angles of the mouth  were depressed and  the features
expressed great distress.  A certain amount  of trismus  was  constant; and the
mouth could not be opened sufficiently for the  patient to take food freely  or
to protrude the tongue.   The pain was severe during the  paroxysms.  The
mind was clear.  He obtained but  little  sleep. The pulse was not accelerated.
The disease could not be referred to any cause.
  The case  had been treated with morphia, quinia, and the valerianate  of
zinc.   The patient was kept  under the influence of chloroform for several
hours.  The effect was to relax the muscles of the jaw and to lessen the fre-
quency of the paroxysms.  Owing to a misapprehension this  patient had no
subsequent treatment.  At the end of ten days he was found to have notably
improved, and he shortly recovered.  After the trial of the chloroform, nothing
was done but to give nutritious  food.   The improvement was very gradual,
slight spasms occurring from time  to time after he had convalesced sufficiently
to be  up and about.
  A highly important part of the treatment relates to  the  quietude of the
patient.  The body should  be moved as little as  possible, and all excitement
of the mind should as far as practicable be  avoided.   Light, currents of air,
and noise should be excluded.  Nutritious  alimentation is  an important part
of the treatment.  If deglutition  be impossible, food should be introduced by
means of a stomach-tube, which may be passed through the nostril. 
RABIES.
849
                       CHAPTER  IX.

                    THE NEUROSES  (Concluded).

      Kabies.—Delirium Tremens—Alcoholism.—Hypochondriasis.—Pathophobia.

    THE affections known as rabies canina, or hydrophobia, and delirium tremens,
     are to be included among the neuroses.  The consideration of these, and
 of  hypochondriasis or pathophobia, will  conclude the section of this work
 devoted to  diseases affecting the nervous system.


                                 Rabies.
   The affection called  rabies canina, and more  commonly known as  Jiydro-
 phobia, is due to  the action of a special poison, a virus derived from the
 mouth of some animal of the canine or  feline race—namely, the dog, wolf,
 fox, or cat.  The virus is communicated  by inoculation ;  that is, by the bite
 of  an animal affected with the disease.    An animal affected with the disease
 in  this way communicates it to  other animals, herbivorous as well as carniv-
 orous.  The former rarely communicate it, because they rarely bite other ani-
 mals or man.   That it  may  be  communicated by herbivorous to carnivorous
 animals appears to be proven.   The virus is contained in the fluids  of the
 mouth, in  the  central nervous  system, perhaps  in  the blood, and  in  other
 organs.   It appears that the  virus enters the  body only by inoculation.
 It  is not absorbed from  the healthy cutaneous  or mucous surface.   It has
 been communicated from man to inferior animals by inoculation.   The dis-
 ease in man is  much oftener derived  from the dog than from any other ani-
 mal; and  hence the name rabies canina.   Owing to the pains taken to confine
 or to destroy animals suspected of having the disease it is rarely seen in man.
 A few cases have  come under my observation.
   The disease does not  make its appearance for some time after  the bite.
 The usual period of incubation is  stated to be  from thirty to forty days.
 There is considerable variation in this period in different cases.  In one of
 the cases  which I have observed the patient was bitten seven weeks, and in
 another case eight weeks, before the  disease appeared. There is ground for
 distrusting the accuracy of statements as regards  cases in which the disease
 is said to  follow* very quickly after the bite, and also when several years have
 been supposed  to elapse.  The error in the first of these cases probably con-
 sists in confounding the disease  with tetanus.  The utmost  possible  duration
 of the period of incubation cannot be stated; and this is a point in the natural
 history of the disease of  no  little consequence with reference to the anxiety
 of persons after having been bitten by an animal  known or suspected to be
 rabid.   It is probable that the period is very rarely if  ever less than eight or
 ten days, and that it very rarely exceeds a year.
  The development of the disease is gradual.  It is stated that certain morbid
 sensations emanating from the cicatrized wound precede other symptoms ; but
 if this be true of some it is certainly not  so of all cases.  There  were  no
 such  premonitions  in the cases  which I  have observed.  The premonitions
 are—notable depression of spirits, so  that this premonitory period has been
called the stadium melancholicum ; change of disposition, restlessness, mental
agitation,  vigilance or disturbed  sleep, cephalalgia, chilly  sensations, loss  of
appetite, a sense of distress referred to the epigastrium, and sometimes nausea
       54 
850
THE  NEUROSES.
and vomiting.  Two or three days elapse before the distinctive characters of
the disease are fully declared.
  AVhen the disease is developed the most prominent feature is laryngeal
spasm  excited by the  effort to swallow water.  The patient has a dread of
water because efforts to swallow it occasion violent paroxysms of suffocation,
and are generally unsuccessful.  The association with these paroxysms gives
rise to  the fear of water, or hydrophobia.   After they have repeatedly been
thus produced the  mere sight of  water may be sufficient to provoke them;
but this is not always the case.  In the cases which I observed  the  patients
did not suffer any inconvenience  from seeing water or hearing the sound of
water.   Patients  are sometimes able to  swallow other liquids.  In one  of
the cases which I have noted  spirit was taken without much inconvenience,
and in  another case at times water was taken from a teaspoon without excit-
ing spasm.   Pieces of ice were  taken  without any inconvenience.   The
paroxysms excited  by attempting  to swallow water  are  extremely  violent.
The patient with  a nervous determination  drinks precipitantly, and instantly
respiration is arrested, the whole  frame is agitated, terror and distress are
depicted on the countenance, and the water is forcibly ejected from the mouth
and nostrils.  In  some  cases paroxysms of laryngismus occur spontaneously.
In one of the cases which I have noted they were repeated  forty or fifty times
in an hour, the patient suddenly and quickly raising himself in bed, the spasm
lasting a few seconds, and in the  intervals the respiration was  hurried and
panting.  In other cases the  patient is free from paroxysms  if he do not
attempt to swallow liquids.   A current of air  may excite laryngeal spasm,
and the patient complains that it takes away his breath.  A bright light, the
reflection  from a  mirror or any polished surface, and any  mental excitement
have the same effect.  The  countenance  expresses excitement, anxiety, and
terror.
  An abundant  secretion of tenacious mucus from the fauces, together with
an increased flow  of saliva, leading  to frequent and sometimes almost constant
cxpuition, is a distinctive feature.   An examination  of the throat shows the
fauces to  be more  or  less  reddened.   At first, the mind is simply  excited,
but in the course of the disease delirium  becomes developed.   The patient
talks wildly and incoherently.   Sometimes the delirium assumes the  form  of
mania; the mind acts under  the  influence of  hallucinations, and  forcible
restraint in some cases becomes necessary.   There is no foundation  for the
vulgar notion that  patients assume  the character of the animal from which
the virus was received and  attempt to bite persons around them.    In some
cases delirium is manifested by excessive tenderness and affection. Satyriasis
has been observed in males, and nymphomania in females.
  Convulsions occur in a large proportion  of  cases.  These are sometimes
clonic, extending  more or less  over the voluntary muscular system, and  they
are sometimes tonic, as in tetanus.   The pulse  becomes frequent and small.
Febrile movement does not  belong  to the history of the disease ; the tempera-
ture of the body being increased  but little or  not at  all.   The surface pre-
sents capillary congestion, and is sometimes covered with clammy perspiration.
The vital  forces  progressively fail: the patient is worn out with continued
vigilance,  the paroxysms of laryngismus, the  convulsions, and innutrition ;
and the mode of dying  is by asthenia.
  Of all the diseases  in the nosology, there is no one in  which the  intrinsic
tendency to death is greater than in this.  The disease runs a brief career,
death usually taking place on  the second or third day, and always within five
days, after it has  become fully developed.
  Small hemorrhages  are often found in the  central nervous  system  after
death from hydrophobia, but these are probably secondary.   Of more import- 
RABIES.
851
ance, however, is the accumulation of small round cells, especially about the
blood-vessels.   These accumulations have been found with  considerable con-
stancy in the posterior half of the medulla oblongata, particularly at or near
the deep origin  of the nerves in this situation.   Similar  but less  marked
changes have been found in the cerebral cortex and elsewhere in  the central
nervous system.  Hyaline metamorphosis of the vascular walls in the nervous
centres has also been observed.
  The diagnostic features of rabies are highly distinctive. It is distinguished
from tetanus by the absence of trismus and the  occurrence  of delirium.  In
some  cases  of tetanus the deglutition  of liquids is impossible ;  but the  diffi-
culty  arises from spasm of the pharyngeal, not involving the laryngeal, mus-
cles, the latter being affected in rabies.  Moreover, convulsions occur at a late
period in rabies, and the convulsions are tetanoid only in a certain proportion
of cases.  The only difficulty of diagnosis relates to  the discrimination of
cases  of true rabies from those in which, to a greater or less extent, hydro-
phobic phenomena are simulated.  Notable repugnance to  liquids, suscepti-
bility to currents of air and to light reflected from a mirror or some polished
surface, frequent sputation, together with delirium and  convulsions, are occa-
sionally incident to various  acute  diseases; but the hydrophobic phenomena
are especially simulated under intense apprehension of rabies after a bite has
been  inflicted by an animal  suspected of being rabid.   Excessive fear  leads
to the belief in  the  mind of the patient  that  the  disease exists, and this
belief  leads to  the  production  of  certain  of  the  phenomena, especially
horror of  liquids, delirium, and sometimes a  fancied  disposition  to bite
others.  Among  the points  to  be considered in this  discrimination is the
time which has  elapsed  after the bite.  If the morbid  phenomena  occur
immediately or  quickly afterward, or, on the other  hand, after a very long
period, the  reality* of the disease is very  doubtful.  If it be evident that
the horror  of liquids  is purely mental  or  dependent entirely  on spasm of
the pharynx, as in some cases  of hysteria—in  other words, if laryngeal
spasm be excluded—the affection is not true rabies.   The continuance of
the hydrophobic phenomena is another point.   If they continue for  many
days  or weeks, the affection is not true rabies, for  the latter affection ends
fatally within  five days.   The opinion which  some have entertained that
rabies may  be  developed in  man  spontaneously probably has no  foundation
other than  the  cases in which hydrophobic  phenomena have  been incidental
to other diseases.
   Of the great number and variety of remedies which have been tried for
the cure of rabies, one only at the present time  claims consideration.   This
remedy is curare.   A few cases have been reported of the successful employ-
ment  of this remedy administered by subcutaneous injection.   There is room
for doubt in these cases concerning  the  diagnosis, and hence other  cases
must  be observed  before it  can be asserted positively that the remedy has
proved in any instance successful.  One of the cases reported as cured by
this remedy came under my observation.  The patient had been  bitten by a
dog undoubtedly rabid.  A servant in the family was bitten by the same dog,
and died with  rabies.  Many of the symptoms in the  case which ended  in
recovery pointed to rabies, but hydrophobia was wanting.1  In  a case reported
by  Dr. Offenberg of AVickrath (Rhein-Preussen) all the diagnostic symptoms,
inclusive of hydrophobia, were apparently well marked.  The patient, a  maid-
servant, had been bitten by  a dog evidently rabid, and a member of  the fam-
ily  in which she lived, having been bitten by the same  dog, died with rabies.
The curare was  given in successive  doses, as follows: two doses  of 0.02
  1 A4de report of this case by Dr. B. A. AVatson in Am. Journ. of Med. Sciences, July,
1S7G. 
852                        THE NEUROSES.

gramme (gr. I) after an interval  of fifteen minutes;  an hour after  the  last
dose 0.03 gramme (gr. T6^, the latter repeated twice after an hour's interval,
once after an interval of two hours and thirty minutes, and again after  two
hours and twenty minutes.   Temporary general paresis was produced by the
remedy.1  This drug is of uncertain strength, and it must therefore  be used
with caution.  Curare has repeatedly failed to exert any curative influence in
hydrophobia.
  ' There  is  no  prophylactic treatment  to be  relied upon save excision or
effectual  cauterization of the wound as quickly as possible after it has been
inflicted.  Amputation  of fingers or toes, and even  of  larger members, is
advisable if the extent or character of the wound  be  such that the excision
and cauterization cannot be effectually employed.
   It is desirable, of course, to know whether an animal  which has inflicted
a wound be really rabid.  Dogs and cats are often supposed to be rabid when
they are  affected  with  epilepsy or some disease  other  than rabies.   It is a
popular  error that dogs  are especially  liable to become rabid during  the
so-called  dog-days; that is, the hot months of summer.   Cases are  quite as
likely to occur at other periods of the year.   AVhen rabies is  suspected  the
animal  should  be confined, and not killed  until the  character of the disease
is fully  declared.  Rabies in the dog is to be suspected  when the animal
manifests a notable change of habits,  becoming  shy and  irritable, eating
straw,  bits  of  paper, etc., and refusing food.  AAThen the disease  becomes
developed the appearance is much changed.  The look is  depressed and hag-
gard, the ears and tail droop, the quality of the bark is altered, the eyes  are
watery, the  fauces are  reddened,  saliva  flows from the mouth, and there is
febrile movement.  Dread of water is no test of the malady in the  dog and
other  animals.   They  frequently lap  water without  difficulty.   Delirium
supervenes,  and  then the  dog snaps at his master as well as others, and at
any animal which comes in his way.   He seldom becomes ferocious, but bites
and runs  away.  He appears sometimes to have hallucinations and snaps at
invisible objects.  Convulsions may  or may not  occur.   Death takes  place
usually within five days.
   Persons bitten by an animal known to  be rabid are by no means invariably
aff'ected with rabies, even  if no  preventive  measures be resorted to.  The
chances of escape are a little more than three to one.   The exemption may
proceed from  an insusceptibility to the poisonous action of the  virus, but
probably often, in those who escape, the  inoculation  does  not take place.  If
the bite be  inflicted through clothing, the virus  will be  likely  to be wiped
away from the teeth before they penetrate  the skin.  The inoculation  is more
likely to take place from the bite of  the wolf than from that of the dog.   Of
250 cases collected by Renault of persons bitten by the wolf, 164, about two-
thirds, became affected by rabies.2
   At the  present time (1886) great interest is aroused in  a method of inocu-
lation which is  claimed by its discoverer, Pasteur, to be preventive of hydro-
phobia, and  which was  reported by  him to the French Academy of  Sciences
in October,  1885.  Pasteur  was led  to the adoption of this method  by  the
following series of experiments on  dogs and rabbits: If a portion of  the
brain-substance  of a mad  dog  be  injected beneath  the dura mater  of a
rabbit, the latter  animal  is  affected  with a disease supposed to be hydro-
phobia  after a period  of incubation of  fifteen  days.   Successive  inocula-
tions in  a series  of rabbits of  portions  of  the spinal  cord from  rabbits
dead of  experimental  hydrophobia cause  a  gradual  diminution  of  the
  1 For a translation of the history of this case, by Dr. S. AV. AVilliams, with full details,
vide New York Med. Record, Aug.* 9, 1879.
  2 Jaccoud, op. cit. 
DELIRIUM  TREMENS.
853
period of incubation,  which  after forty to fifty inoculations becomes only
seven  days,  where  it-seems  to remain  without much further diminution.
The spinal cord  of these rabbits  contains the hydrophobic virus.   Preser-
vation of these cords in dry, warm air  leads to a gradual deterioration  of
the poison, which is finally extinguished.  If dogs be subcutaneously inocu-
lated, first with the weak virus (that is,  with cords preserved for twelve or
fifteen days), and  then  daily with  progressively stronger virus, it is found
that they acquire  immunity against the  strongest virus (that is. fresh cords
from  hydrophobic  rabbits).   Pasteur has had  the opportunity  of applying
this method  of preventive  inoculation to a large number of human beings
who have been bitten by animals supposed to be rabid.   Up to the  present
time (June, 18S6)  of nearly 1000 persons thus inoculated, 8 have died  of
hydrophobia.   Of  the fatal cases, 5 were from  hydrophobia following wolf-
bites  (out of 38 wolf-bitten  persons treated by Pasteur).
   The following considerations  make it  impossible at the present time to
judge of the value of Pasteur's inoculations in  human  beings:   It is  not
known what proportion of the patients treated  by Pasteur were  bitten by
actually  rabid  animals,  and it is probable that the proportion is  not large.
Of those bitten  by rabid animals, in a  considerable 'number of cases  the
wound soon  after  its  reception was treated by excision and by cauterization
and disinfection, and there is  reason to believe that these measures are some-
times protective.  Furthermore, it is established  that of those bitten by rabid
clogs a large  number, probably at least two-thirds, never develop hydrophobia,
even when no preventive  treatment  has been adopted. At  the present writing
the period of time  allowed for incubation  has not elapsed.1


                 Delirium Tremens—Alcoholism.

   This  affection proceeds from the abuse of alcohol.  The various patho-
logical effects of alcohol are considered as incident to a toxical  condition,
called  alcoholismus or alcoholism.   These  effects enter  directly  into  the
causation of many affections,  such  as  cirrhosis  of the liver, fatty liver,
epilepsy, muscular  tremor, gastritis, pyrosis, and various dyspeptic disorders.
Indirectly, alcoholism favors the production of nearly all  diseases by less-
ening  the power  of  resisting their causes,  and it contributes to their
fatality by impairing  the ability  to  tolerate  and overcome them.  Taken
in  sufficiently  large quantity, alcohol  produces  certain  immediate effects
which belong to  the state commonly known as intoxication or drunkenness.
The opportunities  of observing these effects are, unhappily, but too com-
mon.   The coma which  exists when a  person  is profoundly intoxicated—
or, in common  parlance, dead-drunk—is  liable to be mistaken for apoplexy.
The differential points have been  presented in treating of  the latter.  Intox-
ication falling  short of coma sometimes conies under the cognizance of the
physician under  circumstances in which  the nature of the difficulty is  not
suspected by friends,  as  in women and  children.   Knowledge of the cha-
racteristic phenomena  is then  brought into exercise.   The physician in these
cases  is  sometimes  bound by delicacy and prudential considerations to with-
hold an  enunciation of the diagnosis.
   The habitual use of alcohol  beyond certain limits produces a deleterious

  1 There is not a strict analogy between Pasteur's experiments on dogs and his inocu-
lations of  human beings, as in the former the inoculations are made before, and in the
latter after the reception of the strong  hydrophobic virus.  (For a full description of
Pasteur's  methods, vide artiele by H. M."Biggs in the N. Y. Med. Journ.,  March  27,
1886, and  for a critical analysis of these methods and results, the remarks of A. Flint,
Jr., in the same  number of the Journal.) 
854
THE  NEUROSES.
influence on the whole economy.   In cases of chronic alcoholism the diges-
tive powers are weakened, the appetite  is impaired, the  muscular system  is
enfeebled, and  the  generative function decays.   The blood is impoverished
and nutrition is imperfect and disordered, as shown by flabbiness of the skin
and muscles, emaciation, or an abnormal  accumulation of fat.   Pain in the
limbs and back is a symptom of frequent occurrence. AA'ilks and other writers
have called attention to the occasional occurrence of paralysis,-particularly in
the form of paraplegia, in drunkards (alcoholic paraplegia).   The breath and
emanations from  the skin have a  characteristic odor.  The deleterious influ-
ence on the mental is  not  less marked than on  the physical powers. ^ The
perceptions are blunted, the intellectual  and moral faculties progressively
deteriorate, until at length the  confirmed  inebriate, miserably cachectic in
body and  imbruted in mind, has  but one object in life—namely, to gratify
the morbid craving for  alcohol.   He  exemplifies  a variety of the  form of
mental  derangement called  dipsomania, from which recovery is  extremely
rare.
  Delirium tremens,  called also  mania a potu,  is an  affection  incident to
alcoholism.  It has been a mooted question whether the affection ordinarily
known by these  names  be  due  to the sudden  withdrawal of  an  habitual
amount of alcoholic stimulation, or whether it be  a  direct consequence of the
long-continued  action of  alcohol on the brain.  Both explanations are correct.
In a  large proportion of cases  its  development is evidently owing to the use
of alcohol being suspended or much diminished.   Thus, it occurs in persons
who  voluntarily undertake to abandon intemperate habits, who  are unable
to obtain  liquor, or who  are prevented from drinking by the occurrence of
some  disease or accident.  It  is  notoriously common among  inebriates who
are thrown into prison and among those  admitted  into hospitals.   It often
follows paroxysms of intemperance in periodical  drinkers when the  stomach
refuses further alcoholic libations. On the other hand, it is sometimes devel-
oped notwithstanding the continued use of .the habitual amount of alcohol.
  The  symptoms  attending  the access  are anorexia,  insomnia,  muscular
tremor,  especially tremulousness of the  tongue, and notable dejection.  This
state is  known  among  drunkards  as " the  horrors."  The mental  depression
is so  great as not infrequently to lead to suicide.  There is no pain in the
head or febrile  movement.   The pulse  is generally feeble and the surface is
cool.  This stage continues for one, two, or three days.
  The development of the disease is characterized by mental aberration of  a
peculiar character.   The derangement is  characteristic,  although presenting
considerable diversity  in different cases.  The expression becomes wild, and
the eyes are either vacant or staring.  The movements are quick. The patient
is constantly in motion.  He talks incoherently.  His mind wanders from one
subject  to another.   He fancies that he has important business to attend to,
wishes to  go out, and requires to  be constantly watched.  To these manifesta-
tions  of mental disorder are  added  illusions of the senses, phantasms,  and
hallucinations of various kinds.   He sees imaginary objects,  such  as mice,
dogs, cats, lice, snakes, and  ferocious animals.   He hears noises of animals
or men, answers imaginary questions, and often fancies the proximity of per-
sons who  are  bent on insulting  or ridiculing him  or from whom he  appre-
hends personal violence.   Uncouth and unnatural representations appear to
him to be going on.   At first he  may be able to appreciate the unreality of
what he sees, hears, and imagines;  but after a time his morbid perceptions
become delusions, and, however  extraordinary and absurd, they are real to
the sufferer.    They  are  sometimes of a  character to  inspire  the greatest
possible terror.   Thus, patients not  infrequently leap from w*indows and are
dashed  in pieces, believing  that  they are pursued  by wild beasts or by men 
DELIRIUM  TREMENS.
855
who  seek their lives.  A patient who escaped in his night-clothes under a
sense of  personal danger ran barefooted over frozen ground for fifteen miles
before  he was overtaken by men  on horses who followed in  pursuit.  The
degree  of terror must be fearful to lead to such an amount of  physical effort
and  endurance.   In  some cases the delusions are  ludicrous.  Thus, a patient
declared  that  he  should be  able  to sleep, but whenever he fell into a doze
there were persons under his bed who tickled his fundament with straws.
Under  the apprehensions which the delusions excite patients are sometimes
violent and dangerous, but they are usually controlled without much difficulty.
  The  insomnia continues.   The patient gets no  sleep for two, three, or four
days, and sometimes for a still longer period, after  the  development of the
affection.  The delirium is always much worse during the night.  Tremulous-
ness  of the muscles continues,  but this is not  always a marked symptom,
although it enters into the name.  AIgilance being a more constant symptom,
it has been proposed to call the affection delirium vigilans instead of  delirium
tremens.   Anorexia continues, the bowels usually are constipated, the skin is
cool, the pulse is feeble, and, except under mental  excitement, may be  but
little or not at all accelerated; the patient makes  no  complaint of pain in the
head or elsewhere, and generally declares that he is well.
  If the affection end  favorably sleep at length occurs.  If the patient once
become soundly asleep, he will be likely to remain  so for many hours, or if
he awake the speedy  return of sleep  may be counted upon.   After a pro-
tracted sleep, generally the delirium  is found  to have disappeared. Occasion-
ally  it continues, but  is diminished, and disappears  after  renewal of sleep.
Sleep appears to be not  merely a criterion, but a means of  convalescence.
After sleeping much of the  time for one or two days, convalescence is estab-
lished, and the patient recovers more or less slowly or rapidly according to
the duration of the affection and  his physical condition at the  time of the
attack.   If the affection pursue an unfavorable course, the insomnia persists
and  notable prostration  ensues.  The condition is  not  unlike that in  an
advanced stage of typhus;  the  delirium continues, with  efforts to get out of
bed ; subsultus tendinum occurs ;  the pulse becomes more and more  frequent
and  feeble; the skin is sometimes bathed  in  perspiration ;  and death takes
place by asthenia, although the  fatal  termination  is usually  preceded  by
coma.
  The prognosis is generally favorable.  AVhen not associated with other
affections a fatal  termination is  rare.   The affection destroys life per se,
chiefly in cases in which repeated  attacks have occurred and the constitution
is  broken by  a long-existing alcoholic cachexia.  Occurring after wounds,
surgical  operations, or accidents, and associated with other affections—as, for
example, with pneumonitis—it adds much to the  gravity of the prognosis.
  The symptomatic phenomena  show the affection to be cerebral, hut the
nature of the  morbid  condition, as in the other neuroses, is unknown.   It  is
important to bear in  mind  that inflammation is not involved, nor is there
ground to believe that congestion is an essential element.   There is usually
some increase  of  the cerebro-spinal fluid, and the ventricles of the brain may
contain an abnormal quantity of serum.  The substance  of the brain may be
adematous.  This condition* is sometimes called  the wet brain of drunkards.
All that can be said of the pathological character with our present knowledge
is. that the prolonged toxical action of alcohol on  the brain induces a peculiar
morbid condition giving rise to those  manifestations of disorder which are
characteristic  of this affection, especially when the use of alcohol is from any
cause  suspended.   There is reason to believe that the.morbid phenomena
relating to the mind, as well as the progressive impairment of the vital forces,
are to  a considerable extent due to the insomnia.   This is to be inferred from 
856
THE  NEUROSES.
  the fact that the delirium generally ceases after sleep has continued for sev-
  eral hours.   Inability to sleep is an essential feature of the affection and the
  chief obstacle in the way of a favorable termination.
    In general, the diagnosis is not attended with difficulty.  The character-
  istics of  the  delirium  render the aff'ection easily  recognizable when  fully
  developed;  moreover, the known habits of patients generally lead the  prac-
  titioner to  expect it.  Tremulousness of the  tongue and  limbs, with vigil-
  ance, if the patient  be  a drunkard, denotes an impending attack.  If now the
  patient complain of having remarkable visions or  manifest illusions of the
  senses, the development is progressing.  The cases in which  the practitioner
  hesitates in  coming to a diagnosis are those in which the habits are unknown.
  The affection  may be developed  in  secret drinkers  and in persons who are
  supposed  to be perfectly temperate.   I have known a person to be attacked
  who was supposed by his friends never to taste any alcoholic beverage.   As
  the diagnosis implies intemperance, caution  in forming an opinion in some
  cases is advisable, as well as prudence in expressing the opinion when formed.
  Of course it is a breach of medical ethics to reveal the character of the affec-
  tion, save to the patient and, under certain circumstances, to his friends.
    Excesses  in drinking sometimes  occasion a  form  of delirium differing
  pathologically, from  delirium tremens, but liable to be  confounded with it.'
  The delirium now referred to  is an active delirium, characterized sometimes
  by violence  or fury and sometimes by hilarity.   It  is a form of  acute  mania
  due to  active cerebral  congestion,  conjoined with  the  immediate effect of
 alcohol on the brain.   It is occasioned by a protracted paroxysm of drinkino-
 rather than  by the habitual use of alcohol.   This form of delirium has been
 distinguished as delirium ebriosum.   It is accompanied by pain  in  the head,
 increased heat, throbbing of the carotids, and febrile movement; in short, by
 the symptoms  of  active cerebral congestion.  It is of brief duration, ceasing
 when alcoholic stimulants are discontinued.  It thus ceases under the circuit
 stances which  frequently occasion delirium tremens.   It  may be followed by
 delirium tremens.  Aside from the  discontinuance  of stimulants,  it claim's
 the treatment indicated by  active congestion of the brain—namely, blood-
 letting, purgatives, etc., measures not suited to the treatment of delirium
 tremens.
   Finally, with respect  to the  diagnosis of delirium tremens, meningitis is
 excluded by the  absence  of cephalalgia, intolerance of light  and sounds,
 throbbing  of the  carotids,  febrile movement, etc.   Acute gastritis, which
 may present  some of the phenomena of impending  delirium tremens, is to
 be excluded  by the  absence of vomiting, gastric pain, tenderness  over  the
 stomach, etc.   Gastritis, however, is often present  in delirium  tremens.
 Typhoid and typhus  fever are excluded by the absence of the diagnostic
 symptoms  other than delirium  of these diseases.
   The treatment of delirium tremens was formerly by bloodletting and other
 of the so-called antiphlogistic measures, under the belief that it involved either
 inflammation or cerebral congestion.  These measures are now abandoned as
 not only uncalled  for, but  injurious.   Within late years various curative
 methods of treatment have been advocated on the grounds of success; and
 m endeavoring to judge of their respective merits it is to be borne in  mind
 that under favorable   circumstances the intrinsic tendency of this  affection
 is to recovery.  It  may be said of this affection, as of others tending in like
 manner to  recovery, that a large proportion of recoveries cannot be cited in
evidence of the curative  efficacy of anv particular method of treatment, but
that a large proportion of fatal cases  favors the presumption that the treat-
ment was injurious.   Excluding cases in which the  affection occurs in con-
nection with  wounds,  surgical operations, and accidents, or with  other  affec- 
DELIRIUM  TREMENS.
857
tions. and the cases in which  it occurs in persons whose  constitutions  are
shattered  by  intemperance, judicious management  without therapeutical
measures  would,  in the  great  majority of cases, prove successful.   It does
not follow from  this  statement that  remedial measures are not often useful.
  The great object of  treatment  is  to  procure sleep.   Opium  has been
employed largely for  this object.   The statistical researches of  John AVare
showed that the fatality  was greater under the opiate plan of treatment than
when an  expectant or eclectic  plan was adopted, and that the fatality is pro-
portionate to the excessive use  of opium.   Opium used indiscriminate!v and
largely is undoubtedly injurious, but that its moderate employment is  use-
ful  in certain cases is not to be doubted.   The use of opium "as advised by
Stille may be safely adopted.   This author says: " The best mode of exhib-
iting the medicine (opium) is undoubtedly to begin with a quarter of a grain
or its equivalent, and progressively to augment the dose by  small and hourly
additions until sleep is produced or a sufficient degree of tranquillity obtained."
I have not infrequently found a full dose, repeated, if required, after intervals
of several hours, to act very favorably. The remedy  should  never be pushed
to the extent of inducing narcotism, and if on a fair  trial it be not found to
tranquillize, it should be discontinued.
  Ca.ses  have been treated satisfactorily  by  simply continuing the use of
alcoholic  stimulants in moderate quantity.  In  general it  is injudicious to
discontinue entirely the use of  stimulants so long as  the  aff'ection continues.
The time  for breaking off the habitual use is  after sleep has taken place and
the patient  is convalescent.  Stimulants  are  to be given freely in cases in
which the symptoms denote failure  of the vital powers.
  Tartar  emetic in nauseating  doses is useful in certain cases.  This remedy,
if not pushed too far, exerts  a sedative  influence, diminishes delirium, and
disposes to sleep.  It is  suited to  cases in which there  is  considerable con-
stitutional vigor, and it should be very  cautiously given to patients much
enfeebled or in  cases in which there is a tendency to prostration.   Emetics
have  been advocated  as  curative, but the evidence of this is unsatisfactory,
and they are now very rarely employed.   They are objectionable on the
score of perturbation.  Cathartics are objectionable on the same score.  These
evacuant  remedies have been  employed under  the  idea  that they eliminate
the alcohol  from the system ;  but the affection is due  to the toxical effects
of alcohol, not to its  actual presence in the system ;  and, indeed, the attack
often appears to proceed from  a diminution of the amount  of alcohol habit-
ually present.
  Cold  affusions, the cold douche  to the  head, and the shower-bath are use-
ful  in some cases.  They are of doubtful expediency  if employed against the
will of the patient.  He should  be induced to concur in the propriety of mak-
ing trial of them.   They may do harm to feeble subjects  or if the powers of
life be much  depressed.
  Digitalis has been advocated as  a curative remedy.  It was introduced by
Dr. (i. M. Jones  of Jersey,  England, w*ho was  led  to ascertain its  efficacy
by a  patient affected with  delirium  tremens  having taken  an ounce of the
tincture by mistake.  Subsequently he employed it in 70 cases with the loss
of only 1 case.  No practitioner would have ventured to give this remedy in
the closes  which experience has abundantly shown may be given without any
unpleasant consequences in this disease.   The dose advised by Dr. Jones is
half an ounce of the tincture, which  may be repeated, if required, after an
interval of four  hours.   Many cases in  which  this plan of treatment has
apparently proved efficacious have  been  reported.  I have  tried it in a few
ca.ses, in  one of which it appeared  to act like a charm, but in the others no
curative effect was apparent. 
858
THE  NEUROSES.
  The inhalation of  chloroform  in  some cases tranquillizes the  patient and
induces sleep.  This is a remedy to be  employed with great circumspection.
Its effect has been happy in several instances under my observation.  In one
case the effort to employ it excited such a degree of mania that I was led  to
desist,  The  hydrate of chloral  may be  employed.  The use of  this remedy
calls for circumspection.   The  bromide of  potassium, given in  large doses,
is a valuable  remedy in this  disease.   This remedy is chiefly relied upon  in
a laro-e majority of the great number of cases  treated at Bellevue Hospital.
Hyoscyamin  has  lately been  employed with much success as an  hypnotic  in
this disease.
  As  regards the measures  which have been referred  to, and  others, they
are  to be employed  according to circumstances  proper  to individual cases.
Each  of the measures is suited to some cases, and not to other cases.  They
are to be employed tentatively, the practitioner being guided by  the effect  in
deciding whether to  continue or discontinue  them.   Not infrequently they
may be tried  successively in the  same.case.  In short, the appropriate treat-
ment  as  regards these measures is  expectant and eclectic, and they will be
employed judiciously or  otherwise  according to the  judgment  of the practi-
tioner.
  The management  in  other  respects  is  important.   Quietude is to be
enforced.  Arisitors, who are often  actuated by curiosity, are to be excluded.
The circumstances surrounding the  patient should as far as possible be  reg-
ulated with a view of promoting sleep.   Much may be done by the exercise
of tact in soothing the patient, combing the hair, bathing  the face, resorting
to warm pediluvia, etc.  I have  known muscular exercise carried  to the point
of fatigue to be useful.    Alimentation is  highly important.   The patient
should be encouraged as much as possible to take nutritious  and easily-
digested  food.
  It is the duty of the physician, after recovery from this disease, to inform
the  patient of its character, and to  point out  the inevitable consequences of
the habits which have induced it;  and the patient will  be aided in an effort
to emancipate himself from  the slavery of intemperance by  remedies  and
hygienic measures which tend to invigorate the body, thereby  strengthening
the  mental powers.
  A craving for alcoholic  excitation  is  a  result of habit.  It is sometimes
induced by dyspeptic disorders,  mental  depression, or  a  sense  of prostration
incident to various diseases, and  it is sometimes a constitutional idiosyncrasy.
The power to resist it is impaired in proportion as the faculties of the mind
are weakened by indulgence.  It can be overcome only  by sufficiently long-
continued total  abstinence, together with measures to remove  disorders  and
to promote mental occupation and  invigoration of body and mind.   There is
no drug which has a special curative efficacy.   Persuasion, the fear of conse-
quences, and moral considerations are often  unavailing.  The unhappy slaves
of intemperance should be considered as suffering from disease, and should be
treated as patients until the morbid craving  is extinguished by prolonged
abstinence.  In many instances effective treatment is practicable only in insti-
tutions established for this purpose.
  The " opium habit" is to be regarded in the same light.  Generally, instant
and complete withdrawal of every form of opiate is perfectly safe and is the
preferable course.   Under judicious  medical  treatment and encouragement
patients will  be more likely to endure the intense suffering from the sudden
disuse of opium than to  persevere in a gradual diminution of doses during a
period of weeks or  months. 
HYPOCHONDRIASIS
859
                 Hypochondriasis—Pathophobia.
  Although hypochondriasis belongs in the list of disorders of the mind, the
mental aberration is not regarded as amounting to insanity, and patients with
this affection are not proper subjects for treatment at lunatic asylums.  Cases
are not infrequent, and they claim the services of the general practitioner.
In view of these facts, it is appropriate to consider the aff'ection as one of the
neuroses.   The name hypochondriasis—which from its derivation is supposed
to have reference to morbid sensations sometimes felt in  the  hypochondriac
regions—has very little significance as indicating the character and  seat of
the affection.  The  names  pathophobia and nosophobia are much  more
expressive of the malady.
  The characteristic  feature of the affection is a morbid apprehension  of
either the existence of, or a liability to, some  serious disease.   In its mildest
form it consists of a feeling of extreme delicacy of constitution or of a pecu-
liar susceptibility to  the causes of disease.  Existing in this form, it leads to
an anxiety concerning health and over-precautions for its preservation.  In
the severest form of the affection patients suffer from the conviction that they
have  an incurable malady and that life is in imminent  danger.  Different
cases  represent gradations between these extremes.  The mental depression
or despair which  may be produced  by  a knowledge of the fact that a serious
or fatal disease  actually exists  does  not constitute hypochondriasis. The
hypochondriac is  the victim of a delusion with respect to his  condition ; and
the mental suffering arising from this error of belief often exceeds that which
would he  likely to be experienced if the fancied disease really  existed.  Gen-
erally, the hypochondriacal delusion is accompanied by more or less mental
depression, and often by marked  melancholia, but in some cases  patients are
resigned and cheerful.  Fancied  diseases are  sometimes the occasion of pro-
found  religious  sentiment, calling forth  the  manifestations  of  pious resig-
nation.
   The affection is presented to the practitioner in different phases.   In some
cases  the  imagination  becomes  fixed upon  a  particular disease,  and the
patient's belief in the existence of the disease defies all efforts to remove it.
Disease of  the  heart, pulmonary  consumption,  cancer,  syphilis, tapeworm,
softening of the brain, and diabetes are among the diseases which in different
cases  are supposed to exist.  The physician may strive in vain by assurances
and arguments to dispossess  the mind  of his patient of the delusion.  In sup-
port of his  conviction the patient  sometimes not only exaggerates  ailments
which are present, but insists on the  presence of symptoms which are want-
ing.   The pertinacity and ingenuity with which  in  some cases patients hold
to their faith and strive to convince the physician of its truth  are remarkable.
Not infrequently the  conflict  between the physician and patient continues
until  it becomes intolerable, and each is w*ell pleased to break off the  profes-
sional relation.   Hypochondriacs frequently consult  many physicians in suc-
cession, finding for a time greater  attention and apparent interest in a new
medical adviser ;  and, naturally enough in their mental condition, they become
dissatisfied when the patience'of the physician  becomes  exhausted  and they
have given up all expectation of converting him to their belief.  The absurd-
ity of the delusion in some instances is truly  surprising.   I have known two
cases  in which the patients, women of intelligence and good_sense, for a long
time  could not be persuaded that they were  not  affected with cancer of the
breast, although  nothing was to be seen or felt to give color  to the delusion.
It is  a noteworthy  fact that hypochondriasis is not confined  to the  weak-
minded.  Persons of education and strong mental powers are as liable to the
affection as those who are ignorant and of feeble intellectual capacity. 
860
THE  NEUROSES.
   In another phase of the affection there is not a fixed belief in the existence
 of a  particular disease,  but a shifting of the delusion  from  one  disease to
 another.  The physician may succeed in convincing the patient of the non-
 existence of an imagined disease, but no sooner is this done than the patient's
 imagination runs upon  another  disease,  and so divers  diseases are in turn
 imagined, until at length the physician is discouraged and  may give up the
 contest.   Again, patients sometimes keep  the house and take to the bed,
 complaining of ill-health, prostration, and various morbid sensations, without
 selecting any particular disease.  AVith cases of  bedridden patients who have
 no  definite malady, but  a host of subjective symptoms,  all practitioners of
 much experience are familiar.  Such  cases occur much oftener among women
 than  among men, and the phenomena embraced under the name of hysteria
 are generally more or less involved.
   The causes of hypochondriasis are physical  and mental.  Some persons
 are constitutionally liable to morbid apprehensions in this direction.  AVhen-
 ever they are ill with any affection, their mental  constitution leads  to a sense
 of danger and to despondency as regards recovery. Not infrequently this state
 of mind exerts a depressing influence which may interfere seriously with the
 favorable progress of disease.  Persons thus unhappily constituted are  likely
 to exaggerate the permanent consequences of dissipated habits in  early life,
 especially abuses  of  the sexual  function.   Delusions with respect to the
 latter are  fostered by publications and lectures designed  by unprincipled
 persons to produce this effect.  Apprehensions on this score, often with little
 or no foundation, are a source of  nefarious profit to a host of charlatans.  If
 a person with  a  hypochondriacal predisposition either have had or imagine
 that he may have had syphilis, he is liable to fall  into the  belief of supposing
 that his system is irretrievably ruined.   This delusion also is encouraged by
 empirics whose business is to prey upon the fears which they foster and excite.
 There is a class of wretched  hypochondriacs whose minds are absorbed with
 the idea  that they are the hopeless victims of the thoughtless errors of youth,
 and  patients of this class, much  as  they are to be pitied, often tax severely
 the temper of the physician.  It  is to be added that the  practice of mastur-
 bation,  excessive  sexual  indulgence, and the  intemperate use  of alcoholic
 stimulants are  undoubtedly sometimes involved in the causation, not merely
 by an effect upon the imagination, but by contributing to produce a morbid
 condition of the  nervous system.
  The reading of legitimate medical works is to be mentioned among the
 causes of hypochondriasis.   AVant of  mental occupation  contributes  indi-
 rectly to the  affection.    Persons  who  have  relinquished  active  pursuits
 often become hypochondriacs."  Success in the acquisition of wealth, when it
 leads to a determination to forego labor and to enjoy leisure, may thus engen-
 der a far greater evil  than poverty.   On  the other hand,  the loss of fortune
 or want of success in  the pursuits of life, and  severe affliction of  any  kind,
 are sometimes  concerned  in  the causation of this  affection.   These various
 causes may produce the  affection in  those who are not. as well as  in  those
 who are, constitutionally predisposed to it; but of course their efficiency will
 be marked in proportion as the predisposition is strong.
  The morbid physical conditions often existing in  cases of hypochondriasis,
and more or less concerned in its  causation, are various.   Among these may
be mentioned  anaemia, neurasthenia,  and dyspeptic  disorders.   The latter.
there is reason  to believe, are frequently, to a considerable extent,  effects of
the morbid condition of the mind.
 _ The diagnosis of hypochondriasis  must rest on an exclusion of  the  mala-
dies which are apprehended or imagined and  of any serious  disease.  The
different  organs of the body are  to be interrogated  by means  of symptoms 
IIYPOCHONDRIASIS.
861
and signs;  and it is obvious that the accuracy of the diagnosis will depend
on the ability of the physican to exclude the affections to which the diff'erent
organs are subject.  Subjective symptoms  are to be admitted with circum-
spection  and a certain amount of distrust.   The  incongruity of the previous
history and the present condition, as  described by the patient, with the laws
of any definite disease, exclusive of mental disorder, is often at once  signif-
icant  of  the  affection  under consideration,  or the  subjective symptoms  are
incongruous with  the  physical  disorders which may be associated with  the
hypochondriasis.   From want  of sufficient  knowledge  or skill to  reach  the
diagnosis by exclusion practitioners are sometimes misled by the statements
of patients, and thus contribute unwittingly  to  establish more firmly exist-
ing delusions.
  In a certain proportion of the cases in which some serious disease is either
apprehended  or imagined  the positive assurances of the  physician suffice to
dispel the delusion.  In this way the  physician who is confident in his  ability
to interrogate  accurately the different organs  of  the body has the  power of
doing much good.  The fear of the existence  of some grave disease oppresses
especially those who are dependent for the means of living upon a certain
measure  of health ; and a decided opinion, in  which they have confidence, is
a great blessing to patients of this class.
  In  cases of  confirmed  hypochondriasis the first object with reference to
treatment is the removal of any supposed  causes.  Over-exertion, mental or
physical, is to be avoided if possible; and sexual abuses, intemperance, and any
violation of the laws of health are to be inquired into and reformed.  Aside
from  the casual indications, the measures of  treatment relate  to  both body
and mind.   Any coexisting physical disorders are to be remedied as far as
practicable.  Anaemia  and dyspeptic ailments  often claim remedial measures.
In addition to the physical operation of remedies, they undoubtedly  have a
useful moral effect within certain  limits.    Patients often crave remedies,
and it is important not to encourage  this disposition ;  but  it is often  not
judicious to withhold.remedies altogether, even when the medicinal part of
the treatment is comparatively unimportant.  Alcoholic  stimulants and opi-
ates should not be prescribed, or if indicated for a temporary object they
should be  given  with great circumspection.
  The most  important part of the treatment is that which relates  to  the
mind.   Arguments, assurances,  and combined medical opinions may be
brought  to bear  upon  the delusions with  more or less  effect.  It is, how-
ever, not always judicious to act upon a determination  that the patient shall
be at  once  reasoned out of the affection.   It is not wise to  attempt to dispel
the delusions by  ridicule  or indifference.  A  fundamental part of  the moral
management is to divert the patient's attention  from himself.   This is to be
effected by inducing occupation if the patient  have been living a life of indo-
lence, and by well-selected recreations if the patient  be  of industrious  habits.
It is more difficult to  effect this in cases of  hypochondriasis among women
than among men.   Change of scene and new  associations are often effectual,
and, wherever practicable, should be advised.  AVith respect to the particular
plans  to  be pursued in different cases, the habits, intelligence, education, and
social position are to be considered in each case, and the success of the treat-
ment  will depend much on the judgment and tact of the physician. 
862             CONGESTION OF THE KIDNEYS, ETC.




                   SECTION   SIXTH.

       DISEASES  AFFECTING  THE GENITO-URINARY  SYSTEM.
                        CHAPTER  I.

   CONGESTION OF  THE  KIDNEYS.—ACUTE AND  CHRONIC
                        BRIGHT'S DISEASE.

Active Congestion of the Kidneys.—Passive Congestion of the Kidneys.—Parenchymatous
   Degeneration, of the Kidneys.—Fatty Degeneration of the Kidneys.—Acute Bright's
   Disease.—Chronic Bright's Disease.

A LARGE proportion of the affections of the genito-urinary system do
     not fall within  the  scope of this work.  Excluding the aff'ections pecu-
liar to females, diseases of the male generative  organs  and of the bladder
are to be excluded as belonging to surgical rather than to medical practice.
The  diseases which  remain are chiefly those affecting the kidneys.  Abnor-
mal changes in the urine are highly important as  denoting morbid  conditions
relating to the kidneys  and the blood.  These changes constitute important
symptoms in various diseases.   They are not to be considered  as  individual
affections, and in  general it suffices to notice them in connection with other
symptomatic events which make up the clinical history of  different diseases.
In an important disease which, in the  present state of our knowledge, it is
convenient to regard as a urinary affection, it is  certain that the abnormal
change in the urine  expressed  by the name of  the  disease is merely a symp-
tom.  The disease referred  to is glycosuria or diabetes mellitus.   This disease
will  be  included  among the diseases to be considered in this section.  The
same statement may probably be applied to the disease distinguished as dia-
betes insipidus, and also to endemic hsematuria and hsemoglobinuria.


               Active Congestion of the  Kidneys.
   Active  congestion of  the kidneys  may be clue, first, to the  action of irri-
tants, and second, to  vaso-motor paralysis.  These  two forms of active con-
gestion  are widely different from each other.   The former, when of sufficient
intensity to  give clinical evidence of its existence, is almost invariably accom-
panied by inflammatory or  degenerative changes  in the kidneys; the latter
has no tendency to lead to inflammation ; the  former is accompanied by the
excretion of urine similar  to that of certain  forms of acute nephritis, the
urine being  albuminous, bloody, and  usually diminished  in quantity ; in the
latter the urine is abundant in quantity, non-albuminous, and of low specific
gravity.
   In the inflammatory variety of active congestion the kidneys are enlarged,
of a dark-red color, engorged with  blood, and ecchymosed.  Certain  drugs
which exert an irritant effect upon  the kidneys are usually assigned as the
most important causes of this  form  of active congestion.   Such drugs are
cantharides, turpentine, oil of  mustard,  cubebs, copaiba, nitrate  of potash.
chlorate of  potash, and carbolic  acid.  Of these  drugs,  cantharides, taken 
              PASSIVE CONGESTION OF THE KIDNEYS.          863

either internally or applied externally in the form of a blister, provokes the
most marked urinary symptoms.  In cantharides-poisoning the urine is dimin-
ished in quantity and may  be suppressed; it is usually, but not always,
stained with blood;  it is albuminous, and it may contain hyaline  and blood-
casts as well as epithelial cells.   A peculiarity noted in some cases has been
the spontaneous coagulation of the urine.   Gelatinous fibrinous clots, either
pale or red, may form in the bladder and interfere with micturition, or 'similar
coagula may form in the vessel after the urine is voided.  It has been shown
by experiments that a true diffuse nephritis is  produced by cantharides.  It
is probable that an inflammatory condition  likewise exists when similar symp-
toms follow the ingestion of the other drugs named.  The treatment consists
in removal of the cause, rest, and  the administration of  diluent and of
mucilaginous drinks.  Camphor in doses  of two to  five grains  will often
afford relief.
   The existence of vaso-motor nerves of the renal arteries has  been demon-
strated by  physiological experiment.   These   nerves are contained in the
splanchnics.   Paralysis of these nerves causes dilatation of the arteries in the
kidneys and consequent  afflux of  a larger amount of  blood to these organs.
Some also assume the existence  of vaso-dilator nerves  of the kidneys.   It is
fully in harmony with the  results  of physiological experiment that  this
increased flow of blood through  the kidneys'is attended by the excretion  of a
large quantity of pale urine.   AVe may assume that  renal hyperaemia  due to
vaso-motor influence may be produced in man by causes acting upon the per-
ipheral nerves as well as by those acting on the nerve-centres.  AVe possess
little positive knowledge as  to  this variety of renal hyperaemia in man.  It
has been inferred to  exist, from the characters of the urine, in certain diseases
of the  brain.  Hyperaemia of  the  kidneys from  vaso-motor  influence is
assumed to exist in many cases of diabetes insipidus, of hysteria, and of emo-
tional disturbance.


              Passive Congestion of the Kidneys.

   Passive  or venous congestion of the  kidneys  is one of the characteristic
events in the general venous congestion which attends  certain pulmonary and
cardiac diseases.   Passive congestion  of the kidneys may also be  caused by
thrombosis of the vena cava ascendens, but this occurrence is so rare that it
does not demand further consideration here.  Thrombosis of  one of the renal
veins has been observed more  frequently, but in  the cases hitherto recorded
no notable  congestion of the kidney has been observed.   Passive  congestion
of the kidney, therefore, may  be considered as almost invariably accompanied
by general  venous stasis.
   Pulmonary disorders are less  important  than cardiac diseases in the etiol-
ogy.  In advanced emphysema and in  certain cases of fibrous  phthisis there is
chronic congestion of the kidneys.  The various  cardiac diseases which lead to
general venous congestion—valvular  lesions, fatty degeneration, and myocar-
ditis—are the most frequent and important of the causes.  Mitral lesions  may
be especially emphasized in this connection.  It will be remembered that the
symptoms of venous  stasis do  not appear until the stage of non-compensation,
and are intense in  proportion to the failure of heart-power.  It is also import-
ant to bear in mind that  in proportion as the tension in the veins increases the
blood-pressure in the arteries sinks.
  The appearances presented  by the kidneys after prolonged passive conges-
tion are quite characteristic. The condition is sometimes called cyanotic indu-
ration  of the  kidneys.   These organs are  usually somewhat  enlarged, their
consistence is extremely firm,  the  capsule is non-adherent, and the surface is 
 804             CONGESTION OF THE KIDNEYS, ETC.

 smooth.   Upon section both the cortical and the medullary substance present
 a  dark bluish-red color, the pyramids being darker than the cortex.   The
 dark-red color and the firm, almost  stony-hard, consistence of the kidneys are
 the  most distinctive features.   Upon  microscopical examination  the paren-
 chyma and the interstitial tissue are usually unchanged.   Fatty degeneration
 of the epithelium and increase of the interstitial tissue are found  sometimes,
 but  not  as  a rule.
   Chronic passive congestion of the kidneys is accompanied  by the symptoms
 of the primary disease.  There are generally evidences of venous congestion
 in other parts of the body.  OMema of the  lower extremities is usually present.
 The only symptoms which can  be referred, with any certainty, to the condi-
 tion of the kidneys are changes in  the  urine.  The quantity of urine is dimin-
 ished ; its specific gravity is  increased; its color  is darker  than  normal; it
 contains  a moderate quantity of albumen,  and usually some red blood-corpus-
 cles, a few small hyaline  casts, and a  few epithelial cells.  The  urine upon
 standing often throws down an  abundant sediment of the urates.   According
 to Bartels, the  excretion of uric acid is greater than in health.  The amount
 of albumen is not great, rarely reaching two parts in a  thousand.   The quan-
 tity of blood does not generally suffice to color the urine perceptibly.   The
 small quantity of urine may be  referred to the diminished rapidity with which
 the  blood flows through  the glomeruli.   The albuminuria  is attributed, by
 some writers, to increased blood-pressure in the glomeruli;  and  by others to
 changes either in the capillary walls or in  the  epithelium of the glomeruli in
 consequence of an insufficient  supply of arterial  blood.   Passive congestion
 of the kidneys is never a cause of uraemia.   The diminished excretion of urine
 may perhaps increase  the general dropsy.   The treatment is  directed to the
 primary condition, and not immediately to the kidneys.  The indication is to
 strengthen the  force of the heart's action, thereby increasing the arterial ten-
 sion and  relieving the  venous  stasis.   By the administration of digitalis  the
 urinary symptoms are often improved, and they may entirely disappear as the
 power of the heart's action  increases.   The reader  is referred to the article
 on Valvular Diseases of the Heart for a consideration of the treatment appli-
 cable to the disturbances of the circulation which  cause  the  manifestations
 of venous congestion.


  Parenchymatous  Degeneration  of the Kidneys,  Fatty
                  Degeneration of the  Kidneys.
  These  degenerations occur in the different  forms of Diffuse Nephritis, in
 connection with which they will be again mentioned.  Many of the slighter
 grades of so-called  catarrhal  nephritis and  of  parenchymatous  nephritis
 belong, in reality, to the category of these  degenerations.  'The degenerations
 may occur independently of any inflammation of the kidney,  in which  case
 they are  generally without much clinical  importance.  It is desirable not to
 include under the name of Bright's disease these degenerations when unat-
 tended by any inflammation.
  The cortical substance of kidneys in the condition of parenchymatous degen-
 eration or cloudy swelling is  somewhat swollen  and of an opaque grayish
 color.  The surface of the organ is smooth and the capsule is easily detached.
 The  consistence of the kidney is diminished.  Upon microscopical examina-
tion  the epithelial cells of the convoluted  tubes are found swollen and filled
 with albuminous  granules which, in considerable part, dissolve in  acetic acid.
As  these cells are normally very granular, it  is not easy to detect with  the
microscope the slighter grades of  this form  of degeneration.   The macro-
scopical appearances are often more  distinctive than the microscopical. (Vide 
ACUTE BRIGHT'S DISEASE.
865
Part I. p.  53.)   Excluding inflammation of the kidney, tbe most important
causes of  parenchymatous degeneration are infectious and febrile  diseases
and certain mineral poisons.   Of the first group of causes may be mentioned
pyaemia, septicaemia, diphtheria, and the exanthematous and  the continued
fevers; of the second group, phosphorus, arsenic, antimony, and the mineral
acids.  Parenchymatous degeneration  also follows  extensive  burns and irri-
tating applications  to a large surface  of the skin.
  Fatty degeneration is often combined with  parenchymatous degeneration
(granulo-fatty degeneration).  It is a usual sequence when the action of the
causes named is long continued or intense.   In well-marked cases  of fatty
degeneration  the cortical substance  is  more swollen than  in  the preceding-
degeneration.  The enlarged  and pale  cortex presents  yellowish streaks and
patches.   Hemorrhages  are usually present in the fatty degeneration  of phos-
phorus-poisoning.   The microscope shows  in  the epithelial cells of  the con-
voluted tubes an accumulation of fatty molecules larger and more refractive
than  the  albuminous granules of parenchymatous degeneration, from which
they  furthermore differ by  their insolubility  in acetic acid and their solu-
bility in ether after treating the specimen previously with  alcohol.   Both in
parenchymatous and in  fatty degeneration the glomeruli are unchanged.  The
causes of  fatty degeneration, in addition to those of parenchymatous degen-
eration, are anaemic conditions, especially pernicious  anaunia and leucocy-
thicmia;  cachexia), especially chronic pulmonary tuberculosis; chronic alco-
holism ; and, according  to AVilks and  Moxon, diabetes.  In old age  and  in
general obesity a moderate fatty degeneration may  be  met with.  Jaundiced
kidneys are likely to be fatty.  No attempt is  made to discriminate  between
fatty infiltration and fatty degeneration of the kidney.  Many of the causes
of these degenerations are also causes of nephritis.
  Parenchymatous degeneration  of  the kidneys is usually  attended by  a
moderate  albuminuria.   As already remarked,  this condition is held by some
pathologists to be a mild form of acute Bright's disease  or to be the first
stage of some of the varieties of that disease.   This form of degeneration is
generally  transitory, and it readily subsides as its causes disappear.  It is not
certain that the slight albuminuria so often  present in simple parenchyma-
tous  and  fatty  degenerations of the kidney in reality depends upon these
degenerative  changes in  the renal  epithelium.  It is perhaps referable  in
some other way  to the primary condition which causes the degeneration.   It
is certain  that extensive fatty degeneration  of the kidney may exist, as in
some cases of phosphorus-poisoning,  without any albuminuria  or other appre-
ciable urinary symptoms.   These observations justify the separation from
Bright's disease proper of these non-inflammatory degenerative changes.
  In all  forms  of jaundice of sufficient intensity hyaline easts are present
in  the urine, often without any albuminuria.   It is uncertain  whether  the
production of these casts have anything to do with changes in the renal epi-
thelium.

      Acute Bright's Disease—Acute  Diffuse  Nephritis.
  Since the memorable  researches of Richard Bright, published in 1827, dis-
eases of the  kidney characterized by albuminuria and general dropsy have
been  called Bright's disease.  It will be seen  that the renal  changes which
belong to  the different forms of this disease are various, although not so many
as the names which have been proposed for them.  Not  every case of albu-
minuria is to  be  considered as one of Bright's  disease.  AVe  do not include
under this name the renal changes which have already been considered in this
section—namely, simple parenchymatous degeneration,  fatty degeneration,
       55 
866
CONGESTION OF THE  KIDNEYS, ETC.
and hyperaemia of the kidneys—although each of these alterations may form
an important element in Bright's disease.  These changes are attended either
by moderate albuminuria or by none whatever; and if any dropsy be present,
this is not referable, as a rule, to the alteration in the kidneys.  By almost
universal consent Bright's disease is regarded  as  a nephritis; that is, as an
inflammation of the kidneys.  This nephritis affects both organs, and is there-
fore  described as diffuse, in distinction from the  circumscribed  renal  inflam-
mations,  such  as  suppurative nephritis.  The great majority of  cases of
Bright's disease are furthermore appropriately called  diffuse nephritis, on  the
ground that all the constituents of the  kidneys—namely, the interstitial  tis-
sue, the Malpighian tufts, the uriniferous tubes, and the blood-vessels—are
involved  in the inflammatory process.   But the term  " diffuse " must  not
be understood as implying that the  morbid process affects the kidney tissue
uniformly.  Some parts of the kidney are always more diseased than  others.
Bright's "disease is divided into an acute and a chronic form.
  Acute Bright's disease has received various names, such as  parenchyma-
tous nephritis, acute tubal nephritis, acute  desquamative nephritis, catarrhal
nephritis, croupous nephritis.  These  names  are  all  objectionable, as they
imply  theories  concerning the nature of the disease which  are  either  un-
proven or erroneous.   The designation acute Bright's  disease is the sim-
plest, and involves no  doubtful hypotheses.  If it be desired to  employ an
anatomical term, acute diffuse nephritis is  the one least objectionable.

  Anatomical Characters.—The morbid appearances in  acute  Bright's
disease vary considerably in different cases.  The kidneys may present so  lit-
tle variation from their normal aspect that the disease can be recognized only
by microscopical examination.  As a rule, however, these organs are enlarged,
moist,  and somewhat  softened.   The surface  is  smooth,  and  presents  red
patches alternating with opaque grayish or  yellowish-white portions.  The  red
patches correspond to hemorrhages or to spots of congestion,  and the pale por-
tions are either relatively or absolutely anaemic.  Upon section the  swelling is
seen to involve chiefly  the cortex, which  presents the  same mixture of colors.
Red points corresponding to congested Malpighian bodies, or more frequently
to hemorrhages, are observed.  The Malpighian bodies may appear swollen and
abnormally pale.   In some kidneys the hyperaemic and hemorrhagic  portions
predominate, and in others the pale  opaque appearance prevails.  It is thus
possible to distinguish  red kidneys and pale kidneys of acute Bright's disease,
and between these types there is every possible variation.   In the  majority
of cases of acute Bright's disease the kidneys are  hyperaemic.  If the disease
approach  a chronic stage, the hyperaemia usually gives place to a whitish or
yellowish color, but  some hemorrhages usually remain.
  Upon microscopical examination the alterations  are sometimes found to be
astonishingly slight, even when during  life the urine was quite  albuminous
and contained  blood and casts.  In these cases, which are generally mild and
do not terminate fatally from the kidney disease, the  inflammatory alteration
affects  chiefly the capillaries of the glomeruli.  These altered capillaries allow
the escape of an albuminous fluid and the passage of red and white corpus-
cles through their walls.  These  inflammatory products  are  exuded into  the
space between the  glomerulus and Bowman's capsule, whence they pass into
the tubes and escape with the urine.  There may be cloudy swelling of  the
epithelium of the  Malpighian  tufts and of  the convoluted tubes.   The inter-
stitial tissue presents no inflammatory changes.
  AVhen death occurs from the renal affection itself the changes are generally
more marked.   Here, too, the affection of  the  glomeruli is  of great  import-
ance.   To the naked eye the Malpighian bodies often appear swollen and pale. 
ACUTE  BRIGHT'S DISEASE.
867
The capillaries of the glomerulus  frequently contain  desquamated and pro-
liferating endothelial cells mingled with white and some red blood-corpuscles.
Both the epithelium of the glomerulus and that lining  the capsule of Bowman
swells up, proliferates, and, often with an admixture  of white blood-corpus-
cles, forms a crescentic mass of cells filling up the  space  between the  com-
pressed glomerulus and the capsule.  These changes  constitute  the affection
called glomerulo-nephritis, which is an important element in many, and almost
the sole  alteration in some, cases of  acute Bright's  disease.   A similar accu-
mulation of leucocytes and of desquamated endothelium  may occur in the
intertubular capillaries.   The epithelium of the  convoluted tubes is swollen
and filled with an abnormally large number of albuminous, mixed  with some
fatty, granules.   Colloid drops, granular  material, and desquamated  and dis-
integrating epithelial cells are found in some of the  convoluted tubes.  Hya-
line casts are found here and there in the convoluted tubes, and in still larger
number  in the loops of Henle  and  the  collecting  tubes.   Emigrated white
blood-corpuscles are found not only in the tubes and  the Malpighian bodies,
but also  in the interstitial tissue.  In the latter  situation  they are generally
collected in groups, especially around the veins and the Malpighian bodies.
In  most cases of acute  Bright's disease of any severity hemorrhages are
present,  partly in the intertubular tissue, but chiefly within the capsules of
Bowman and within the convoluted tubes.
  It is not possible to draw a sharp line of demarcation between the inflam-
matory and the purely degenerative changes in the kidney.  The same causes
may produce both changes.  As has already been remarked, in most cases of
slight or moderate albuminuria  attending various infectious diseases the sole
change in the kidney is a parenchymatous  or  fatty degeneration of the epi-
thelium.   These cases are  classified by many  writers as parenchymatous
nephritis.  If, however, the  symptoms, especially the  changes in the urine,
are during life sufficiently severe  to warrant the diagnosis of Bright's  disease,
it is believed that in addition to these degenerative changes in the epithelium
actual inflammatory lesions are  present  in the blood-vessels, particularly in
the glomeruli.
  Anasarca and serous accumulations in the pleural,  pericardial, and perito-
neal cavities are usually met with to a greater or less degree in the bodies of
those dead of acute Bright's  disease.  Sero-fibrinous pleuritis and pericarditis
are not infrequent.   Pneumonitis, both in the lobar and in the lobular form,
is one of the recognized complications.   Increase of the cerebro-spinal fluid
with  cerebral oedema, or  even with meningitis, is likewise to  be mentioned
in the enumeration  of complications.

  Clinical  History.—Subcutaneous oedema is a  very frequent but not  a
constant symptom.   It is usually the first symptom  pointing to the existence
of this affection.  The oedema is  generally first observed on the face,  particu-
larly  on  the  eyelids  and around the eyes, but it is  speedily apparent in  the
lower extremities, and sometimes occurs  first in the  latter  situation.  Coinci-
dent with  the appearance of the dropsy is  more or  less  febrile movement,
frequently preceded by  chills or shiverings, together with thirst, anorexia,
pain and tenderness  in  the  loins.   Pain and tenderness over the  kidneys
are,  however, rarely marked and are often wanting.  ATomiting is a fre-
quent symptom at the beginning of the  affection.  The skin  is dry and the
countenance  becomes  pallid.   The  dropsy increases  and becomes general,
varying  considerably in amount  in different  cases.   In  some  cases the  ana-
sarca  is  great, the limbs, scrotum, penis, or external labia becoming enor-
mously  swollen.   In  other  cases  it does  not exceed  a  moderate amount.
More  or less dropsical effusion usually  takes place into the  peritoneal and 
868            CONGESTION OF THE KIDNEYS, ETC.

the pleural  cavity.   Hydrothorax  sometimes occurs to such  an extent as
to occasion  great  suffering from dyspmea  and to endanger  life.
  The examination of the urine is essential for the diagnosis of acute  Bright's
disease.  The quantity is usually  diminished, and it may  be  very  scanty.
Suppression sometimes occurs.   The specific gravity generally exceeds that
of the urine in health.   The total quantity of urea  excreted  in  twenty-
four hours is much diminished.  The urine contains albumen1 in  consider-
able,  and frequently  in  great,  abundance.   The  amount  of albumen is
usually between \ and 1 per cent, by weight, but it may exceed this  propor-
tion.   In some  cases the urine has a reddish-brown, smoky appearance  from
the presence of blood.  A certain number of red blood-corpuscles are  present
in nearly all cases, although not always in sufficient number to color the urine.
It is possible to distinguish two types of urine in acute Bright's disease—the
one bloody, and the other free from blood.  As a rule, in  this disease a consid-
erable sediment forms in the urine. The microscopical examination of this sedi-
ment shows red and white corpuscles in varying proportion ; and the one variety
may be abundant in the absence of the other.  The red corpuscles  may appear
normal or as clear pale rings,  or they may be  shrunken.  Disintegrated red
corpuscles and granules of haematoidin may be observed. Epithelium of the
urinary passages and of  the kidneys may be present.  Granular  matter  and
micrococci are  also  among the frequent constituents of the sediment.  The
most characteristic objects are cylindrical bodies  known  as casts.  These are
formed in the uriniferous tubes of the kidney.  Casts vary between T15\^ and
jj7 of an inch in diameter.  A number of varieties are distinguished.  Those
which belong to acute Bright's disease  are  blood-casts, epithelial casts, and
hyaline casts.   Granular  casts and  fatty casts  indicate  a more advanced
change in the  kidneys than usually belongs to acute Bright's  disease;  but
in some  cases of  the acute disease granular, fatty, and  even waxy casts are
found  in the urine.  Hyaline casts are pale cylinders with delicate contours,
and are so transparent that an inexperienced observer readily overlooks them.
The addition of some coloring agent, such as iodine or eosin, is  of assistance
in searching for them, as they readily stain with most coloring matters. Their
chemical composition is not known.   They are often described as fibrinous,
but they do not conform to the reactions of fibrin.  They are probably of an
albuminous nature.  They vary in size.  Small hyaline casts are those most fre-
quently met with in the acute form of the disease.  Blood-corpuscles, epithelial
cells, and granular material are often attached to  these casts. Epithelial casts
are composed of desquamated epithelial cells of the renal tubes.   Some of the
so-called epithelial casts are composed of white blood-corpuscles.   Blood-
casts are made  up of red blood-corpuscles.  These last two forms  of casts
often possess a hyaline basement-substance to which the cells and corpuscles
are attached.  There may be some oil-globules in the sediment free or attached
to the casts  or contained in cells.   In the  majority of cases there are many
casts, but sometimes they are so scanty as to require careful  search for  their
detection.
  Coma  and convulsions occur in a certain  proportion of cases.  These are
symptoms of uraemia.  Owing to an insufficient  elimination by the  kidneys
of urinary constituents, these may accumulate in the blood to an extent  suffi-
cient for the manifestations of their toxical effects upon  the brain. A'omiting
and purging may precede, or occur without the cerebral symptoms of uraemia,
being  due to  a vicarious elimination of urea through  the gastro-intestinal

  1 Both serum-albumen and globulin are usually present in combination  in albuminu-
ria, the former predominating.  Other forms of albumen (paralbumen, hemialbuminose)
and peptones may be present, but it does not appear that any special diagnostic import-
ance attaches to these latter forms of albumen. 
ACUTE BRIGHT'S DISEASE.
869
mucous membrane.  Epistaxis and pruritus may occur in uraemia.  Impaired
vision and amaurosis are among the effects of uraemia occasionally observed.
Blindness, which may be complete, when it occurs in acute albuminuria is gen-
erally sudden ;  but it is often of temporary duration, and recovery is complete.
The ophthalmoscope, under these circumstances, shows no morbid appearances
within the eye.   The morbid condition is central.  It is otherwise, as will be
seen, in amaurosis occurring sometimes in the acute  affection, but oftener in
cases of chronic Bright's disease. The amaurosis which is not associated with
changes appreciable  with the ophthalmoscope is called uraemic amaurosis.  It
occurs especially in cases of acute  albuminuria developed in connection with.
scarlatina and pregnancy.
   Complications considered as occurring sufficiently often to show not merely
coincidence, hut a pathological connection  with the  affection, are bronchitis
and inflammation of  serous membranes, especially pleuritis and pericarditis.
Pulmonary  oedema is an occasional  complication.
   In the course  of the affection the symptoms may  present  considerable
variation on diff'erent days.  The quantity of urine, the amount of albumen,
etc. vary, and so with  respect to the oedema, the effusion  into  the cavities,
and the  febrile movement.   If uraemic effects and  important complications
do not  occur, the affection continues for  a period  varying between a few
days and  two months, the average duration being about four weeks.  The
approach  of convalescence is denoted by a notable diminution or disappear-
ance of the dropsy, cessation of febrile movement,  return of appetite, and
an abundant secretion  of urine.  Albuminuria usually  continues, but in a
lessened  degree,  after  the  dropsy has  disappeared.  At  length the urine
becomes normal and casts disappear from the sediment.  The  latter some-
times continue to  be found for some time after the albumen has disappeared.
The affection may end in complete recovery or it may eventuate in a chronic
affection.   The latter is rare.   As a rule, if the patient be not  cut off by
uraemic poisoning or the complications which are liable to occur, the recovery
is complete and permanent.

   Pathological Character.—As  both  kidneys are  diffusely inflamed in
acute Bright's disease, it is to be inferred that  the irritant which excites the
inflammation is contained in the circulating blood.   In many cases, as in the
acute Bright's disease secondary to toxic influences  (cantharides, turpentine,
etc.) and  to  infectious diseases, the relation between morbid blood-changes
and the  local affection is clear.   In  other cases, as when the disease follows
exposure to cold, this relation is obscure. The kidneys are peculiarly exposed
to the action of noxious substances, as it is mainly through these organs that
these substances are excreted from the body.  As it is through the glomeruli
that the water and  doubtless many  of  the solid constituents of the urine
are excreted, it is believed that inflammatory  irritants  act  first of all upon
these structures, and in the mildest cases of the disease only upon them and
the  renal epithelium, with which  also irritants contained in the urine must
come into intimate contact.  In more severe cases all of the constituent ele-
ments  of the  kidney  share in  the  inflammatory process.   The diminished
quantity of  urine in acute Bright's disease may be explained by the lessened
blood-pressure and the slow  circulation in  the glomeruli,  these changes in
the vascular system being incident to all acute inflammations.   The red and
white corpuscles found in the kidney and  in the urine are the natural prod-
ucts of inflammation.  The red corpuscles doubtless  escape, at least in  part,
by diapedesis (p. 27).  The albuminuria may be referred partly to inflamma-
tory alterations in the walls of the renal capillaries, and partly to changes in
the epithelium, particularly of that covering the glomeruli.   Changes in the 
870
CONGESTION OF  THE  KIDNEYS,  ETC.
blood-pressure may also be concerned  in  the causation of albuminuria.1   As
to the mode of production of hyaline  casts, there is  discrepancy of opinion.
According to one view, they are formed  from  altered epithelial  cells which
have  coalesced with each other; according to a second, they are produced by
secretion of hyaline  material from the epithelial cells; according to a third,
and the most  probable view, they result from  a coagulation of  albuminous
material which has escaped from the blood-vessels  into the tubes.
   The most important  of the effects produced by the renal disease  upon the
general system are dropsy and uraemia.   The  dropsy is  usually  referred to
the hydraemia which results from the withdrawal of albumen from the blood
and the diminished excretion of water.  The relation between hydraemia and
general dropsy has been discussed in Part I. p. 63.   This explanation of the
dropsy is  not satisfactory in  all cases.   There  is reason to believe that in
some  cases the anasarca is best explained  upon the assumption that some
alteration  exists in the walls of the cutaneous and subcutaneous vessels,
which renders them more permeable  to  the passage of  albuminous fluids.
Cohnheim  assumes this alteration to be of an inflammatory  nature, and to be
produced  often by the  same causes which excite the nephritis.2  The uraemia
is the result of the accumulation of urinary constituents  in the blood.   This
subject has been considered in Part I.  p. 72.

   Causation.—This affection may occur at any period of life, and even young
infants are not exempt from it.  It occurs oftener in males than in females.  As
already stated, in  the majority of cases it is a sequel of  scarlatina.   It may
occur during  the progress of scarlatina  or  follow directly  the  stage of des-
quamation, but it is most likely to occur in the second or third week  after the
date of convalescence.   It is an important question whether this  sequel pro-
ceed  exclusively or chiefly from an  agency pertaining intrinsically to scarla-
tina, or whether  it depend on extrinsic causes, such as  the action of cold.
It occurs  in cases in which the utmost  care  is  taken to place the patient
beyond the agency of  extrinsic causes, but it  is probable that the latter are
frequently involved.   It may be developed in a person much exposed to the
scarlatinous infection without any affection of the throat or an  eruption, the
person having already  experienced an  attack of scarlatina many years previ-
ously. I have notes of  several cases  exemplifying the facts in this statement.
   Exclusive of the cases in which it is a sequel of scarlatina, it occurs in vari-
ous other pathological  connections.   It is an occasional sequel of diphtheria
and of epidemic cholera.  It sometimes occurs during  the development of pul-
monary tuberculosis, in the  course  of articular rheumatism, in syphilis, in

  1 Writers are  far from  being  agreed as to the  causation of albuminuria.  Increased
blood-pressure in the glomeruli has usually  been considered an important cause.  Rune-
berg lias advocated the view that the cause is in  all  cases diminished pressure.   The
truth  seems to be that the blood-pressure is not an important factor in the production
of albuminuria.  Diminished rapidity of the circulation in the glomeruli is considered
by many to be an efficient cause.  The view advocated by Cohnheim is that  the usual
cause  of albuminuria is to be found in changes in the epithelium covering the glom-
eruli.   This view is consistent with the preceding, for slow circulation produces altera-
tions in these cells by depriving them of their proper supply of  nutriment.  The real
difficulty is to explain why albumen is not present normally in  the urine.  All other
capillaries in the body, so far as known, allow an albuminous fluid to transude under
normal circumstances.  The walls of the glomerular capillaries differ  from those of
other  capillary blood-vessels in the fact  that they are not composed of distinct endo-
thelial cells; at least such  cells cannot be demonstrated by staining with nitrate of silver.
Perhaps structural peculiarities in these walls  may explain the absence of albumen in
normal urine.
  2 This view must be considered hypothetical.  It is elaborated by Cohnheim in the
second volume of his Allgemeine Pathologie, Berlin, 1882. 
ACUTE  BRIGHT'S DISEASE.
871
cases of typhoid  and typhus  fever, yellow  fever, erysipelas, relapsing fever,
acute lobar pneumonia, acute yellow atrophy  of the  liver, pyaemia, septi-
caemia, endocarditis, dysentery, carbuncles and  suppurative processes in dif-
ferent  situations, smallpox, and measles.  Albuminuria and general dropsy
occurring in pregnancy depend, in a certain proportion of cases, on this sfl'ec-
tion, but in many of these cases  changes in the kidney are  very slight  or
entirely absent.   As  a primary  aff'ection  it  occurs especially  in  persons
addicted to intemperance.  In these cases it is sometimes difficult to say how
much causative agency is to  be attributed directly  to the action of alcohol
and how  much to  the exposure incident to  intemperance.   It is observed
not infrequently to become developed after lying on the ground in a state of
intoxication.   In a case which came under my observation it followed excess-
ive indulgence in beer without any exposure to  cold.   It is sometimes attrib-
utable to exposure  to  cold irrespective of alcoholic indulgence.  It  may be
caused by extensive burns.   Other causes are cantharides, turpentine, phos-
phorus, carbolic acid, iodoform, the mineral acids, arsenic, the nitrate of silver,
lead, and mercury, taken internally. Finally, it may be mentioned that acute
exacerbations  are not uncommon in chronic Bright's disease.   It is thus seen
that with  regard to etiology most cases may be distributed into three groups :
1st, those in which the disease is caused by toxic agents; 2d, cases in which
it is incident to infectious diseases; and 3d, cases in which it is referable to
causes acting on the  skin, as cold and  burns.

  Diagnosis.—The existence of albuminuria is not, in  itself, adequate proof
of either the affection  under consideration or of the chronic affections of the
kidneys which remain to  be  considered.  Albumen may be  present  in the
urine in a small  or  moderate quantity,  and  for a brief period in the course
of a great number of  diseases.   It is found not infrequently in the urine of
persons who are  apparently in perfect health.   Munn found albuminuria  in
the proportion of 11  per  cent, of persons  applying for life  insurance, this
being the only evidence of any disease.1  In general, the diagnosis is easily
made, being based  on the occurrence of anasarca developed rapidly, accom-
panied with febrile symptoms, and an  examination of the urine generally
showing albumen in abundance.  Dropsy is an early symptom in the great
majority  of cases, but it is sometimes wanting.   The diagnosis is then to be
based on symptoms pertaining to the urine in conjunction with general symp-
toms.  In  addition to the presence of albumen in the urine, the quantity is
usually notably lessened ; it frequently has a smoky or sooty appearance  from
the presence of red blood-corpuscles, and it is sometimes distinctly bloody.
The sediment  of the urine, examined microscopically, is found to contain, in
greater or less abundance, the casts which have been  described.  The  pres-
ence of these, in  conjunction  with other characters  pertaining to the urine
and  the  general  symptoms, render  the  diagnosis positive.  Etiological  con-
nections are also to be taken into account in the diagnosis.  It is to be borne
in mind that acute Bright's disease not infrequently occurs as  an intercurrent
affection in the course  of the chronic form of the disease.

  Prognosis.—The danger in cases of  this affection is from uraemia and the
complications which are liable to occur.   Coma and convulsions always denote
imminent  and  great danger to life, but recovery  may take place notwithstand-
ing these effects of uraemia. Pleuritis, pericarditis, peritonitis, meningitis, and
pneumonitis, developed in the  course of the affection, are likely to prove fatal.
OZdema of the lungs  may prove a cause of death.   Dropsical effusion into
both pleural cavities may take place  to such  an extent as to destroy life
     1 Vide article by Dr. John  Munn in the A. Y. Med. Record, March, 1879. 
872             CONGESTION OF THE  KIDNEYS, ETC.

An instance of death from  this cause has not fallen under my observation,
but I have repeatedly met with cases in which the dyspnoea seemed to denote
imminent danger to life.
  Exclusive of uraemia and serious complications the prognosis  is favorable.
The  affection does not tend  to disorganize the kidneys.   It is a self-limited
affection, seldom continuing  more than two months, and in some cases ending
in from one to two weeks.  It very rarely assumes a chronic form.  Cases of
the chronic affections which  remain to be considered, as a rule, do not orig-
inate in  an acute attack.
  Uraemic poisoning is to be apprehended when the urine is scanty; in other
words, when  the quantity of urea eliminated by  the kidneys is small.   Sup-
pression of urine lasting twenty-four or forty-eight hours places the patient
in imminent  danger, and if  it 'continue is a fatal symptom.  Danger  from
uraemia is not passed, although the albumen may have disappeared from the
urine, if the sediment still contain casts.  I have known fatal uraemic con-
vulsions to occur under these circumstances.

   Treatment.—The treatment embraces  the  following  leading objects:  1.
Diminution of the intensity of the renal  inflammation,  promotion of reso-
lution, and restoration of the excretory function  of the  kidneys.  2.  Dimi-
nution or removal of dropsical effusion.  3. Elimination of urea through the
skin and gastro-intestinal mucous membrane if uraemia exist or be threatened.
   AVith reference to the  first of these objects, warmth and rest of the surface
are important.  The patient should keep the bed  in  order to maintain both
warmth and rest.  Tbe diet should be unstimulating.  AVater and other bland
liquids should be allowed as  freely as the thirst dictates.   Dry cupping over
the  loins is the  best method of revulsion or  counter-irritation, and if the
patient be not feeble or anaemic the scarificator may be employed.  General
bloodletting is advisable  only in cases in which  patients are  full-blooded and
attacked when in good  health.  As  a rule, after scarlatina, in intemperate
persons, and whenever the system is enfeebled  from any  cause,  this measure
is inadmissible.   Fomentations over the region of the  kidneys  by means of
moistened cloths covered with oiled muslin and several thicknesses of flannel
or the  spongio-piline  are useful.  Saline  laxatives  are  useful  by way of
depletion.
   With  reference to the dropsy, either saline  cathartics  or the more  active
hydragogues are indicated in proportion to the amount and situation of the
dropsical effusion.  In  cases  in which suffering and danger are incident  to
hydrothorax, the  fluid  may  be  withdrawn by  aspiration.   Elaterium  is the
most prompt and reliable hydragogue.  I have  repeatedly obtained, by means
of this remedy, effectual relief in a few hours when the pleuritic effusion was
sufficient to occasion alarming dyspnoea.   Gamboge, podophyllin, jalap with
the bitartrate of potassa. and sulphate of magnesia or soda are efficient hydra-
gogues.  Diuretics are not to be relied upon, and the kidneys will not be likely
to respond to them.  Moreover, they are considered by some as inadmissible
because  their action on the kidneys may  increase the inflammation.   They
are, however, recommended as safe and  frequently  useful by others.   A
rational  indication for their use is afforded  by the fact that the renal tubes
are  obstructed;  and a  free  secretion of urine will  be likely to remove the
obstruction by washing away the contents  of the tubes.  So far as my expe-
rience goes, digitalis and the saline diuretics do no harm and are often useful.
   Measures for  the vicarious elimination of urea are indicated whenever the
diminished quantity of urine and its low specific gravity show the elimination
by the kidneys  to be greatly deficient.   By timely meeting this  indication
uraemic  poisoning may be forestalled.   Of course measures for  this object 
CHRONIC BRIGHT'S  DISEASE.
873
 are urgently indicated when symptoms denoting uraemic poisonino- are pres-
 ent.  Hydragogue cathartics are the most efficient, and next to these  the
 hot-air bath.  The pilocarpine, given hypodermically, in some cases produces
 profuse perspiration and is  a  potent  eliminative remedy.   It  may  be con-
 joined with the use of the hot-air bath.  Both hydragogues and  sudorifics are
 to be employed  in alternation if uraemic coma or convulsions have occurred
 If the indication  be  not urgent, salines  and sudorific  remedies mav suffice
 An eligible sudorific remedy is the liquor ammoniae  acetatis in half-ounce
 doses thrice daily.  The statement concerning the use of diuretics with  refer-
 ence to dropsy of course is equally applicable to their use for the elimination
 of urea,  lhey are not  to be relied upon for the elimination of urea  when
 uraemia exists or is threatened.  Under other circumstances diuretics may be
 employed, selecting those which do not act as irritants  of the kidneys.   The
 bitartrate of potassa, the infusion of digitalis, and the decoction  of broom  are
 eligible diuretics.   A\ ith reference to  a diuretic effect pure or distilled  water
 should  be taken  as  a drink as freely as  possible without inconvenience.
 Dickinson says:  "Of  all diuretics, water is the best;"  and my own experi-
 ence has  led me  to think that this statement  is  not  too strong.
  Uraemic coma and convulsions call  for measures of treatment "in addition
 to those which are eliminative in  their operation.   Arenesection  may  be
 employed if not contraindicated by the  condition of the patient exclusive
 of the uraemic symptoms.   For the arrest of convulsions, either  chloroform
 inhalation or the chloral hydrate given by the mouth or rectum is indicated.
 Morphia may be  administered by subcutaneous injection, but  not in  toxic
 doses.   These are  palliative measures to be pursued  until elimination has
 been effected by hydragogues and sudorifics or as long as the coma and con-
 vulsions continue.
  During convalescence care as regards diet, exercise, and exposure  to cold
 is important.  Tonic remedies, and especially preparations of  iron, are gene-
 rally indicated.
  My clinical records furnish  illustrations  of complete recovery from this
 affection when the dropsy was excessive, when life was  threatened by hydro-
thorax and  oedema of the lungs, and also after  the occurrence  of uraemic
coma  and convulsions.
    Chronic Bright's  Disease—Chronic Diffuse  Nephritis.

   It is not easy to make a convenient and correct classification of the differ-
ent forms of chronic Bright's disease.  In different  cases of this  disease  the
kidneys present a  great variety of morbid  appearances as regards size, color,
character of  the surface, etc.   Kidneys aff'ected with chronic Bright's disease
may be small, of  normal  size, or  enlarged;  they may be red.  yellow, white,
or mottled;  their  surface  may be smooth or granular; waxy degeneration
exists in some and not in  other cases.   The  large kidneys usually are pale
in color  and of smooth surface, and  the small  kidneys  are generally red or
mottled and of granular surface ; but the exceptions to these rules are many.
There are three modes of classification which deserve special mention.  There
is. first, the classification of Frerichs, adopted in  its leading features by Grain-
ger Stewart.   This divides Bright's  disease  into three stages: first, a stage
of inflammation ; second, a stage of degeneration ; third, a stage of atrophy.
This classification  is  founded on theory, and is opposed by clinical and patho-
logical observations.   It is certain that in the majority of atrophied kidneys
the disease is chronic from the beginning, and there  is no reason to suppose
that the condition  of these  kidneys is preceded by either of  the other stages; 
874            CONGESTION OF THE KIDNEYS,  ETC.

nor are most cases of the so-called second stage ushered in by an acute attack.
There are cases of Bright's disease which pass through  the  three stages of
Frerichs, but this sequence of events is so rare that it cannot  serve as a basis
of classification.   This  division of  Bright's  disease into  stages  is  generally
abandoned.
  Another classification  is based on a view wholly opposed to the preceding.
Bright's disease, according to this second view, is a general name for a num-
be/of independent diseases.   This doctrine is advocated  by many English
writers, and since  Bartels' work on diseases of the kidney it has been widely
adopted in Germany.  It is without doubt more generally accepted at the pres-
ent time than  any other  classification.   The distinct aff'ections which are thus
recognized as  included under the name Bright's disease are: 1, acute Bright's
disease ; 2, chronic parenchymatous nephritis ; 3, chronic interstitial nephritis ;
4. waxy degeneration of the kidney.   It is admitted that these aff'ections are
often combined  with  each other.   This classification is  in many respects a
convenient one.   It is certainly proper to separate acute from chronic Bright's
disease; but on  pathological as well as on clinical grounds  there are serious
objections  to  the sharp  distinctions  drawn  in  the foregoing  classification
between parenchymatous nephritis, interstitial nephritis, and  waxy degenera-
tion.  In  so-called chronic parenchymatous  nephritis there exist interstitial
changes of the same nature  as those found in chronic interstitial nephritis;
and in the latter  there are also parenchymatous changes.  There is no proof
of the assertion  that the disease begins in one case in the parenchyma and in
the other  in the interstitial tissue of the kidney.  AVaxy degeneration of the
kidney may occur without inflammatory alterations, but in that case the degen-
eration is not  extensive  and is of little clinical importance.  The waxy kid-
ney is, in  the  great  majority of cases, accompanied by a true nephritis.  In
many cases usually described as chronic parenchymatous nephritis there  is
waxy degeneration in  addition to the nephritis.
  A third classification is the one adopted  in this work.   It  embraces all of
the different forms of chronic Bright's disease under the name chronic diffuse
nephritis.   This  classification recognizes the fact that in all of these forms
there are both interstitial and parenchymatous changes.   It does not consider
the preponderance of parenchymatous alterations  in one case and of inter-
stitial alterations in another as a satisfactory reason  for distinguishing a paren-
chymatous from  an interstitial nephritis, especially  as there may exist every
possible degree of combination between these two changes.
  It  has  been  fully demonstrated that certain morbid conditions of the
kidney in chronic diffuse nephritis  are associated with characteristic clinical
phenomena.   These different morbid  conditions are perhaps  best designated
by  indicating the gross appearances of the kidneys in which they are present,
as,  for example, the small granular kidney, the large waxy kidney, etc.  This
method of division has  disadvantages, but  is perhaps as good as any which
our present knowledge enables us to make.   AVhether the varieties of chronic
Bright's disease are to be regarded as distinct affections  or as different mani-
festations of one and the same disease is, in a measure, a matter of individual
judgment.  If chronic diffuse nephritis embraced only typical ca.ses of large
white kidney on the one hand and typical cases of  small granular kidney on
the other hand,  there would be no  impropriety in regarding  these as distinct
diseases ;  but there is  every grade of transition between the large and the
small kidneys. There are large kidneys with the clinical  history of the small,
and vice versa;  and there  are large  kidneys which, except  as  regards size,
may present all  the pathological  changes of the small.   For  these  and other
reasons which might be adduced it is better to regard the types of diseased
kidney which are to be described not  as independent affections,  but as differ- 
                    CHRONIC BRIGHT'S DISEASE.                875

ent manifestations or varieties of the same disease—namely, chronic diffuse
nephritis.
  The two influences of greatest  importance in determining the character or
type of kidney found after death  from chronic  Bright's disease are the dura-
tion of the disease and the presence or absence  of waxy degeneration.  AVhen
the disease has lasted for several years, it is  almost  certain  that the small
granular kidneys will be  found after death.   AVhen the affection terminates
in less than a year from  the onset (a point by no means  easy in all cases to
determine), some form of large kidney will usually be  found  on post-mortem
examination.  The waxy  kidney,  however, even when  of several  years' dura-
tion, is, as  a rule, large  and pale.  It may, however, be small and granular.
It must not be inferred from the fact that the small kidneys run a more pro-
longed course than the large that the former represent a late  stage of the
latter.  In the majority of small kidneys the process of contraction or atrophy
is to be considered as in operation from the onset of the disease.
   The three main forms of chronic diffuse nephritis are: 1. The simple large
kidney (red, mottled, or white) ;  2. The small  granular kidney ; 3. The waxy
kidney.  The waxy kidney is usually enlarged.   It is therefore  convenient
to consider two forms of  large kidney—one with and the other without waxy
degeneration.   Mention will also  be made of the occurrence of waxy degener-
ation in small kidneys.
   I.  The Large  Kidney  without  Waxy Degeneration.—This form  is less fre-
quent than either the large waxy kidney or the small  granular kidney.  It is
the variety met with in  the rare instances in which  acute Bright's disease
passes into the chronic stage.  It is not, however, generally preceded by the
acute disease.  It runs, as a rule, a  more rapid course  than any other variety
of  chronic diffuse nephritis, its duration being rarely more than a year and a
half.  It presents two modifications  according to the color of the  cortical por-
tion of the kidney.   In one the  cortex is red or,  more usually, mottled with
red and white (large red  or mottled  kidney).   In the other the cortex is pale
(large white kidney).  The kidneys are enlarged, less frequently of normal size
(a  normal-sized kidney is reckoned  among the large  in distinction from the
small kidneys).  The surface is smooth.  The  capsule is easily detached.  The
swelling affects chiefly the cortex, which may present  many hemorrhagic and
congested  portions,  with  opaque  whitish  or yellow parts, or  may be almost
uniformly of a pale yellowish-white color, with only here and there a hemor-
rhage or a congested'patch, or even without any hemorrhages.  In not a few
cases the surface of the kidney is granular and the capsule is adherent.
   Upon microscopical examination small hemorrhages  are found in abundance
in  the red or mottled kidneys, and, although diminished in number, they are
usually but not always present in the pale kidneys.   The extravasated blood
may be in the intertubular tissue, but  is more frequently within Bowman's
capsules and in the convoluted tubes.   The changes  in the interstitial tissue
are in the form of  more  or less circumscribed patches scattered  throughout
the cortex.  In these patches the connective tissue between the tubes and
around the Malpighian bodies is increased.  This new tissue  may be rich in
cells and indistinctly fibrillated, or it may be  poor in cells and fibrous.   The
 epithelium lining the tubes surrounded  by the new connective tissue is gen-
erally atrophic, and the diameter  of these tubes is diminished.  In some places
the tubes  may have  entirely disappeared.  The glomeruli may  be shrunken
and  fibrous, and the new tissue may  be developed, especially  around  the
altered glomeruli.   Some of the  glomeruli present the lesions of  a glomerulo-
nephritis as described in the  preceding article (p. 866).  There is often a
crrmvth of new connective tissue  in the walls of the arteries, presenting itself
frequently in the form of an obliterating endarteritis. In addition to this devel- 
 876             CONGESTION  OF THE  KIDNEYS,  ETC.

 opment of new connective tissue combined with atrophy of the tubes, the inter-
 stitial tissue may present here and there  an infiltration  with small round cells
 and with fatty molecules.   Outside of the  patches of new connective  tissue
 the convoluted  tubes, instead of being atrophic, are frequently dilated.   In
 these dilated tubes the epithelium is generally swollen and  contains molecules
 of fat.   In other places no change may be noticeable either in the tubes or in
 the interstitial tissue.   The lumina of the tubes contains also blood-corpuscles,
 hyaline casts,  fatty molecules, and granular matter.
   In the large kidneys, in  distinction from the  small  granular  kidneys, the
 changes in the  epithelial cells (that is, the  parenchymatous and  the fatty
 degenerations) exceed in extent  the  interstitial alterations.  AVhether  or not
 there be a form of chronic Bright's disease  in which the parenchymatous  and
 fatty degenerations constitute  the sole changes is a matter of dispute.  It is
 certain that in the great majority of  cases there are interstitial alterations, as
 described, in addition  to the  changes in the  tubes.  It  is important to observe,
 however, that both the parenchymatous  and the interstitial changes are scat-
 tered in patches throughout the cortical portions of both kidneys, and are not
 uniformly diffused ; also that the most extensive swelling and fatty degenera-
 tion of the  epithelium are found  outside of  the patches of new connective tis-
 sue, in  which, on the  other hand, the epithelial cells  are  usually small  and
 atrophied.  It is evident from  the description that even in large smooth kid-
 neys there  may be (microscopically) atrophied portions resembling  those in
 the small granular kidneys,  but not so abundant.  This atrophy, with increase
 of fibrous tissue, is evident  to the naked eye  in  those large  kidneys which
 present a granular surface with adherent capsule.   These  and other consid-
 erations which will appear in  the course  of this article render it  clear that,
 important as it is to distinguish certain general types or varieties of chronic
 diffuse  nephritis, it is not desirable to separate them from each other by sharp
 boundary-lines.  The  pale  kidneys differ from the red or mottled kidneys
 chiefly  in  a greater amount of anaemia  and  of fatty degeneration.
   A  considerable number of the large, non-waxy kidneys of chronic Bright's
 disease are  accompanied by  hypertrophy of the left ventricle or of the whole
 heart.  Hypertrophy of the  heart does not usually develop in connection with
 the large kidneys when the  renal  disease occurs in patients much enfeebled, as
 by phthisis, syphilis, chronic suppurations, etc.  It is in  connection with such
 wasting diseases that the greatest number of the large white kidneys are  de-
 veloped.  There is reason to believe that  many of the kidneys frequently de-
 scribed as of the large  white  variety are affected by a waxy degeneration which
 has been overlooked, and which therefore places them in  the following variety.
   II. The Large Kidney with Waxy Degeneration.—This variety and the small
 granular kidneys constitute  the most frequent forms of Bright's disease.  This
 form  embraces a large proportion of the  cases developed in connection with
 phthisis, syphilis, chronic suppurations, and  severe  cachexiae.   As already
 mentioned,  a considerable number of the  large white  kidneys belong to this
 variety.1  AVaxy degeneration of  the kidneys  is, with very few  exceptions,

  1 Some writers regard  the large white kidney as characterized  especially by fatty
 degeneration of  the epithelium, as free from waxy degeneration, and as unattended by
 hypertrophy  of the heart.  This constitutes only one variety of large white kidney.   A
 part of the confusion arises from the fact that there are different forms of diffuse nephri-
 tis which may present the appearances of the large white kidneys—namely, 1. The pale
kidney of acute Bright's  disease, especially of scarlatinal nephritis.  2. The large pale
kidney without waxy degeneration and with hypertrophy of the heart.   3. The large
pale kidney of chronic Bright's  disease, without Avaxy degeneration and without hyper-
trophy of the heart.  4.  The large pale kidney with waxy degeneration.   Most of  ihe
large white kidneys of chronic Bright's disease without hypertrophy of the left ventricle
are affected with waxy degeneration. 
                    CHRONIC BRIGHT'S DISEASE.                 877

accompanied by waxy degeneration in other parts, especially the spleen and
the liver.   The kidney is one of the favorite seats of this abnormal deposit.
The waxy cliange in the kidney may be so slight as to be recognizable only
upon microscopical  examination, or it may be so extensive as to give a very
characteristic  aspect to the organ.  In nearly all doubtful cases its presence
or absence  can be determined by means of the simple iodine test.  (See p. 55.)
For microscopical examination  iodine and sulphuric acid and methyl-violet
are to be preferred.  A slight or moderate waxy degeneration may occur without
further parenchymatous or interstitial changes.   This simple waxy degenera-
tion, however, is so rare that its occurrence has even been denied.  AVaxy degen-
eration of the kidney, when of clinical importance, may be considered practi-
cally as associated always with diffuse nephritis.   AVhether the waxy change
be the  cause of the nephritis, or whether both be effects of the same cause, are
undecided questions which at present do not admit of profitable discussion.
   Kidneys affected with waxy degeneration present a variety of gross appear-
ances  according to  the degree of degeneration and the  extent and character
of the parenchymatous and interstitial changes.  The waxy change may be
so slight as not to influence the appearance of the kidney,  which then presents
some one of the forms of chronic diffuse nephritis.  Usually, however, careful
inspection will reveal in the glomeruli, and perhaps elsewhere, the character-
istic translucent appearance of the waxy material.  AVhen a large amount of
the waxy deposit exists, we have the characteristic  appearance of the waxy
kidney.  The organ is then enlarged, pale, and  anaemic.  The consistence  is
firm.   The  surface is smooth and glistening.   The  capsule is  not adherent.
UJpon  section  the cortex is found to be the part chiefly swollen.   It presents
the same pale aspect as  the surface.  The pyramids are  bluish-red, as in
most forms of diffuse nephritis.  The cortical striae are obscured.   The trans-
lucent Malpighian  tufts are visible.   The cortex presents  a combination in
irregular patches or in striae of translucent gray portions with opaque white
or yellow portions.   The latter correspond  to the parts most affected by fatty
degeneration, and the former to the waxy districts.  The more the translucent
gray substance predominates, the greater is the extent of  the waxy degenera-
tion and the more characteristic of the waxy kidney is the appearance.   The
more the yellowish parts predominate, the more  closely does the appearance
approach that of the large white kidney without waxy degeneration.
   By the use of iodine it is evident to the naked eye that the favorite  seats
for the deposit  of the  waxy material are  the glomeruli  and the vasa recta.
Microscopical examination shows  that the capillaries of  the cortex and the
membranae propriae of the tubes, especially of the straight tubes and the loops
of Henle, are also often affected.  The deposit, as a rule, is at first in the mid-
dle coat of the  arterioles and around  the capillary walls  of the glomeruli.
The walls  of the affected vessels  become  swollen  and  homogeneous.   The
lumina of  the vessels is  gradually diminished, and may be obliterated.  In
a similar way the  walls of the tubes may be thickened and homogeneous.
The nephritic changes  are in most respects the same as  those described for
the preceding variety, and need not here be repeated.   It is only necessary
to add that hemorrhages are usually absent in kidneys  affected with waxy
defeneration   Fatty degeneration of the epithelium and  anamna of the kid-
neys are prominent features.   The  waxy glomeruli present a more homo-
geneous appearance, fewer nuclei, and less  shrinkage than  those involved  in
the other forms of  chronic diffuse nephritis.   There is nothing characteristic
of waxy degeneration in the casts found in the tubes.1
  1 These casts often called waxv, rnav stain red with methyl-violet, but  they do not
irive the characteristic reaction with iodine and sulphuric acid    formless  clumps pre-
senting  this reaction have, however, been found in the tubes (Kyber). 
878            CONGESTION OF THE KIDNEYS, ETC.

  AVaxy degeneration is  not confined to  large smooth kidneys.  It is  not
very rare to find  large waxy  kidneys  with irregular surface and  partially
adherent capsule.   Small  granular kidneys may also be waxy.   AVaxy kid-
neys are very rarely accompanied by hypertrophy of the heart.  The coin-
cidence of  waxy spleen and of waxy liver with this form of kidney disease
is an important element in the diagnosis.  There are cases, however, in which
the change in the kidney is well marked, while in  the liver  and in the spleen
it is insignificant.   It may  always be inferred that some degree  of waxy
degeneration of the kidney exists when this change can be recognized in  the
liver and in the spleen.
  III.  The Small  Granular  Kidney.—At  least three varieties of this form
of kidney may be recognized—namely, one representing  an  atrophic stage of
the large kidney without waxy degeneration ; a second representing the same
stage of the large  waxy kidney ;  and a third, being the  genuine contracted
kidney, of  which  no stage of enlargement exists.   The  first  two are called
secondarily-contracted kidneys.   Nothing  could be more erroneous  than  the
view which once prevailed that the  large kidneys  in the  natural order of
events,  if recovery do not take place, necessarily pass  into a stage of con-
traction, and that the majority of atrophied kidneys are  preceded by a stage
of enlargement.   The secondarily-contracted kidneys do  not usually become
as small as the genuine or primarily-contracted  kidneys.  It is not rare to find
small kidneys with  waxy degeneration.  Many  of  the small granular kidneys
occurring in gout are waxy.   It is probable that in  some of these cases the
waxy degeneration  is superadded to a genuine contracted kidney.  Many of
the small waxy kidneys,  however, are better regarded  as representing an
atrophic stage of  the large  waxy  variety.
  While the existence of secondarily-contracted kidneys  is admitted, it is the
primarily-contracted form which is referred to in the remainder of this article
under the  name small granular kidney.   Other names  for this variety  of
chronic diffuse  nephritis are—genuine  contracted kidney, small  red  kidney,
granular atrophy of the  kidney, cirrhosis or sclerosis of the kidney, chronic
interstitial  nephritis, and  chronic desquamative nephritis (Johnson).  There
is no serious objection to  any of  these names except the last.  Of all the
forms of chronic  diffuse  nephritis, this is  the one  which with  most propriety
may be regarded as a distinct disease, and  this is the view now very generally
adopted.  There are authorities who hold  the opinion that renal  cirrhosis is
not only to be separated from other forms of chronic  Bright's  disease, but
that it is only one manifestation of a general disease affecting the arteries  of
the body.   This view will receive consideration subsequently.
  The kidneys in this form  are reduced in volume and  weight.  As in  all
forms of Bright's disease, both organs are involved, and, as a rule, to nearly
an equal extent.  The size may be a third that of  the normal kidney or even
less.  There is usually a compensatory increase of adipose tissue around the
kidneys.  The organs are  abnormally dense and  resisting.  The capsule is
with difficulty detached, and  when removed it brings away portions of the
torn renal substance. The exterior surface presents little irregular elevations
or granulations.   The granulations usually have a yellowish and the depres-
sions  between them  a reddish color.   In many  cases the name small red
kidney is  appropriate.  Sometimes, however, the prevailing color is  whitish
or yellowish.  Upon section it is observed that the cortical portion especially
is diminished.  This is reduced to a narrow  rim over the pyramids.   In
marked cases the  pyramids extend nearly to the external surface, and their
sides are almost in contact.  Little cysts,  varying in size from a pin's head
to a pea or even larger, and  filled with a thin fluid or with  colloid contents,
are  frequently observed  both on  the surface  and  in the  interior.  AVhite 
CHRONIC BRIGHT'S  DISEASE.
879
are
  e
 lines, due to the deposit of urate of soda in the tubes, are not infrequently
 seen in the pyramidal portion.  They are invariably present when the disease
 of the  kidney  is associated with gout.   Small kidneys  with  these  deposits
 were called by Todd gouty kidneys.   The same deposit of urates may occur
 independently of gout.
   The  microscope shows as the  most  essential  change the production in the
 cortex of a large amount of fibrillated connective tissue.  This new tissue is
 not  uniformly distributed, but is in  greater amount  in some  places than in
 others,  and there are usually parts where no  thickening of the interstitial
 tissue exists.  Many of  the Malpighian  tufts are small and  fibrous,  and ar
 often placed abnormally  close to  each other in consequence of atrophy of th
 intervening tubes and retraction  of the new fibrous tissue. The rich develop
 ment of new connective  tissue around the shrunken glomeruli may be espe-
 cially noticeable.  An important change in most cases is the growth of fibrous
 tissue in the walls of the arteries, both in their adventitia (periarteritis) and
 in their intima  (endarteritis).   By the obliteration and partial occlusion  thus
 effected of many small arteries and of capillaries in the glomeruli the circula-
 tion  through the kidneys must be much  impeded ; but the blood-vessels are
 not the only parts that suffer by this new growth of fibrous tissue.  The tubes
 are also compressed, and may be  in part  obliterated.   By this constriction of
 the  tubes in certain places the  flow of  urine  through them  is obstructed,
 and,  being dammed  back, causes cystic  dilatations visible to  the naked eye!
 These  cysts consist of  dilated tubes  and of dilated  capsules  of Bowman.
 In the  latter form  of cyst the glomerulus is compressed or  entirely obliter-
 ated.  Although  interstitial changes decidedly predominate in this form of
 kidney, parenchymatous changes are not  wanting.   Atrophy of  the  epi-
 thelium  is constantly met with in tubes enveloped  in  connective tissue.
 Fatty degeneration  of the epithelium, although less  extended than in the
 large kidneys, will usually be found in some places.   Fat-globules may also
 appear in the interstitial  tissue.   The tubes within the new fibrous tissue are
 small and may be entirely obliterated.   Outside of this they are  frequently
 dilated.   Hyaline and granular casts are often discovered in the tubes, espe-
 cially those of the pyramids.  There may be some increase of the interstitial
 tissue of the pyramids, but the changes  in these  are  trifling in  comparison
 with  the alterations in  the cortex.
   One of the most constant accompaniments of  the small granular kidney is
 hypertrophy of  the left ventricle, unattended usually by valvular lesion.
 There may be hypertrophy of the whole heart.  The hypertrophy is usually
 attended by more or less dilatation, but it may be simple.  Buhl has pointed
 out the  frequent coincidence of fibrous or chronic  interstitial myocarditis in
 connection with this  hypertrophy. Another complication of great frequency
 and of diagnostic value is the form of  retinitis called retinitis albuminuria,
 the ophthalmoscopic appearances of which will be described in connection
 with  the symptoms.  Both the  retinitis  and  the cardiac hypertrophy may
 occur with other forms of chronic Bright's disease, but they are rarely  met
 with  in  conjunction with the large waxy  kidney.   Cerebral hemorrhage  and
 inflammation of serous membranes are also to be mentioned as important com-
 plications. Bartels calls attention  to the frequent occurrence of thickening of
 the skull-cap and adhesion of the dura mater to the bone. Dropsical effusions
 are rather the exception than the  rule in this form  of Bright's disease.
   As  has already been said, many writers  are inclined to  regard  the small
granular kidney  as a  disease entirely distinct from the other forms of chronic
Bright's  disease.   Even  the propriety of considering renal cirrhosis as a
nephritis  is disputed.  Gull and  Sutton  first  advanced  the view that renal
cirrhosis is only one manifestation of  a widespread affection of the whole 
 880             CONGESTION OF THE KIDNEYS, ETC.

 arterial  system,  to  which  affection  they give  the name  arterio-capillary
 fibrosis.   The essential change, according to these authors, is a thickening of
 the outer coat of the arteries.   The disease they  regard as mainly one of old
 age.   The hypertrophy of the heart, they urge,  is to be explained only by
 this general arterial disease.   There are  cases which seem to support Gull
 and Sutton's theory.  Extensive atheroma of the arteries (arterio-sclerosis),
 such as occurs in old age, is usually attended by partial atrophy of the kid-
 ney.   This arterio-sclerotic  atrophy of the kidney  is not,  however, usually
 attended by  any symptoms of  Bright's  disease, and  it is not probable  that
 this is the form of  disease referred  to by Gull and Sutton.  Widespread
 obliterating endarteritis, when  it involves  the renal arteries, leads to atrophy
 of the kidneys, which may give rise to  grave symptoms;  but in many cases,
 probably in the majority, of small granular kidney no arterial changes have
 been  found which can be assigned with  any propriety as the cause of the
 renal disease.  There is not, therefore, sufficient  basis for the doctrine that
 this form of Bright's disease  is in all  cases the result  of primary arterial
 changes.  Moreover,  Gull and  Sutton have overestimated  the  influence of
 old age  in  the causation, and  they seem  to have overlooked the  instances
 of cardiac   hypertrophy  in  connection   with   other  forms of   Bright's
 disease.
   The view is advanced  by AAreigert that the primary change in renal cir-
 rhosis is atrophy or  necrosis of the epithelial cells (therefore  not  inflamma-
 tion),  and  that in accordance  with a pathological law this loss of substance
 is fallowed, by new growth of connective tissue.  The primary atrophy of the
 epithelial cells may be the result of various toxic substances (such as alcohol,
 lead, and uric acid) or the result of insufficient nutrition from defective circu-
 lation  (primary arterial changes).   In most cases, however,  we are ignorant
 of the primary cause.

   Clinical  History.—Chronic Bright's disease sometimes follows the acute
 affection.   This  statement applies chiefly  to the large kidney without waxy
 degeneration ; but as a rule the  disease  is developed imperceptibly and is
 subacute from the first.   In  a large proportion of cases the event which first
 directs attention to the existence of renal  disease is dropsy.  Prior to this
 event  the patient for  some time may have  been sensible of impaired strength,
 and the appearance may have  denoted anaemia ; but  not  infrequently up to
 the time when dropsy is noticed the patient  is not  aware of any deteriora-
 tion of health.   The  first appearance  of dropsy is oedema either around the
 eyes or in  the lower  extremities, or in both situations simultaneously.  As
 regards the amount of dropsy,  and the rapidity with which it increases and is
 diffused, cases differ.  It may be present and remain in so slight a degree that
 its existence  is ascertained only by close examination, and it may escape the
 attention of the patient.  On the other hand, in certain cases anasarca occurs
 either  rapidly or  slowly, the  limbs, body, and especially the  genitals, becom-
 ing enormously swollen, together with more or  less effusion into the serous
 cavities.   A  convenient  place  for determining by pressure with the finger a
 small amount of  oedema is over the sternum.  The different forms of disease
 do not equally give rise to general dropsy.  It occurs most constantly and is
 most marked in connection with the large  kidney.  It is wanting in a certain
 proportion of cases, and in these cases the most  frequent form of disease is
 the small granular kidney.  It is also frequently wanting for  a considerable
 period  during the progress of the waxy form of disease.   Of 89 out of 102
recorded cases of chronic  Bright's disease under my observation, in which
facts respecting dropsy were  noticed, it existed in 74, and w*as absent in 15
cases.  The dropsy was slight or moderate in 21, and considerable in 36 cases. 
CHRONIC BRIGHT'S  DISEASE.
881
In 17 cases the degree and the extent of the dropsy were not noted.1  Of 430
cases collected from different authors and analyzed  by Frerichs, general dropsy
existed  in 376 and was wanting in 34.   As a rule, general dropsy is  marked
in the cases in which  the  albumen in  the  urine  is very abundant, and, per
contra, general dropsy is either slight or wanting  in the cases in which the
urine  contains little or no albumen.
   The examination of the urine is of great  importance as regards diagnosis
in the different forms of chronic Bright's disease.   In the large kidney with-
out waxy degeneration the  quantity of urine excreted  within  twenty-four
hours is diminished unless the arterial tension be elevated by hypertrophy
of the heart,  in which  case  the quantity is normal or even increased.   The
diminution is  rarely as marked as in acute Bright's disease. The specific grav-
ity, as a rule,  is high when the quantity of urine is  scanty, and low under
opposite circumstances.   Generally it does  not vary much  from the  normal
standard.   The urine of this form  of kidney is usually of a yellow color and
turbid.   The  amount  of  albumen is considerable,  and in  some  cases very
large.   The daily excretion of urea is lessened.  There is generally an abun-
dant sediment which contains casts, epithelial cells, red and white blood-cor-
puscles, and granular material.  Urates may be deposited in abundance.  All
varieties of  casts are found, but the most  common are hyaline  casts, either
narrow  or broad, and frequently dotted with  oil-globules and granular casts
which may  also  contain  fatty molecules.   To  both  varieties  of casts fre-
quently adhere red corpuscles, pus-cells, and epithelial cells; and casts com-
posed wholly of epithelium may be observed.  The pus-cells  usually exceed
in number the red corpuscles, but there are exceptions to this  rule.  Cells
filled  with fatty  globules  (so-called granular or  exudation corpuscles) and
free fatty granules  are often present.
   The urine excreted  by kidneys  affected with waxy degeneration presents
great variations in its characters, these variations being influenced  especially
by the  degree and the extent of the  diffuse nephritis which is present and
by the  amount of  waxy deposit.   AVhen the  parenchymatous  changes pre-
dominate the  urine presents  the characters  belonging  to the preceding  form.
In consequence of the  absence of cardiac hypertrophy the quantity  may be
greatly  diminished, although rarely in the degree belonging to acute Bright's
disease.  Bed  blood-corpuscles are absent or few.  In  no  form of Bright's
disease  is a larger percentage of  albumen met with than  in these large waxy
kidneys with  extensive parenchymatous changes.  AVith the typical  waxy
kidneys—that is, those containing a large amount of  waxy deposit and pre-
senting in most parts a pale translucent appearance—the urine usually is
abundant, very pale in color, of low specific gravity, clear, and rich  in albu-
men.   The  specific  gravity  may  fall  as low  as  1005 or even lower.   The
quantity of albumen is usually considerable, but it may be slight.   The daily
excretion of urea is below the normal, but the poor nutrition  of the  patients
will in a great measure explain this.   There is little  or no sediment.  Casts
are not  abundant, and  they are chiefly hyaline and so-called waxy casts.  The
term waxy cast is often employed synonymously with hyaline cast. AVhen used
in a different  sense, it refers  to broad homogeneous casts of a yellowish hue
and more distinct and refracting than the hyaline casts. These waxy casts are
probably similar in structure to the hyaline;  and  they are  not, as the  name
implies, composed  of waxy or amyloid substance.  Exceptionally, however,
casts are found which  give the same reaction with iodine as the waxy mate-
rial.  The so-called waxy casts are not confined to the waxy kidney, but they
  1 A'ide "A  Clinical  Report on an  Analysis of  One Hundred  and  Two  Cases  of
Brio-ht's  Disease," by Austin Flint, M. D., one of the Attending Physicians of Belle-
vue Hospital, etc., published in  the Bellevue and Charity Hospital Reports, 1870, p. 226.
        56 
 882             CONGESTION  OF  THE KIDNEYS,  ETC.

 may be  found in the urine of any form  of chronic  diffuse  nephritis.   It is
 this abundant, clear, albuminous, light urine which is  considered most dis-
 tinctive  of waxy degeneration of the kidney, but, as already mentioned, its
 characters are greatly modified by the intensity and  the extent of coincident
 inflammation  and by  the degree of  waxy cliange.   Litten  and others  have
 reported cases of even extensive waxy degeneration of the  kidneys without
 albuminuria.   In some of these  cases dropsy was present during life.   AVe
 have no satisfactory  explanation of the absence of  albuminuria in these
 cases.
   The small granular kidneys (renal  cirrhosis) sometimes secrete urine which
 in no way  differs from the normal.   It is particularly to be  emphasized that
 albumen and  casts may be absent from this urine.  This is one of the reasons
 why this form of chronic diffuse nephritis so often  escapes  detection.  The
 quantity of urine excreted by the small granular kidneys usually exceeds the
 normal.  The  polyuria may be so great as to lead to the suspicion of diabetes.
 The specific gravity is low.  It averages about 1010, but it may be less.  The
 color is  pale  greenish-yellow.   The  urine  is clear, there being little or  no
 sediment.   The percentage of urea  is lessened, as is likewise in  most cases
 the  quantity  excreted daily.   It is  not, however, very exceptional to find
 this quantity  equal to that in health.   Albumen  is usually present in  small
 amount.   Its quantity is in striking  contrast to that in most  other forms of
 Bright's disease.  It may fail altogether, but this is generally only a tempo-
 rary occurrence.   Bartels, however, mentions a case in which  albumen w*as
 absent  throughout  the  whole course of the  disease.    Exceptionally, the
 quantity of albumen is  abundant.   AVhen a uraemic attack supervenes, the
 amount of albumen is usually increased.  If waxy degeneration  be present,
 there is an increase in the quantity of albumen.   Casts  may  be absent.
 Careful  search will  usually reveal a few  hyaline  casts.   Granular casts are
 much  less frequent.   Toward the end of life it will usually be found  that
,the  quantity  of urine is diminished, the amount of albumen  is  increased,
 and a sediment containing casts appears.   AVith  small  kidneys due to sec-
 ondary atrophy, the urine has qualities similar to those described if hyper-
 trophy of  the heart be  present.
   The characters of the urine belonging to the different varieties of Bright's
 disease are not sufficiently  distinctive to justify a positive diagnosis  of the
 form of  kidney in all cases.   There is no form of cast which is characteristic
 of any one variety of the disease.  In general, it  may be said that hypertro-
 phy of the heart and waxy degeneration tend to increase  the quantity of
 urine, and  that low arterial tension and active inflammatory changes diminish
 the quantity.  An abundant sediment  containing many casts and blood-corpus-
 cles is indicative of  an active inflammatory process, and particularly of that
 associated  with parenchymatous changes.   The smaller in quantity the urine,
 the richer  it is in sediment and in albumen as a rule.   It is of importance to
 estimate the amount of urea excreted daily, for which purpose it is of course
 necessary to determine the percentage of  urea in the total quantity of urine
 passed in  twenty-four hours.  The  specific gravity  affords  an approximate
 idea, although far from an accurate estimate, of the percentage of urea.  The
 specific gravity of  a single  specimen of  urine is manifestly of no value in
 forming an idea as to the  daily excretion  of urea.  It is necessary to take
 into consideration  at the same  time the quantity  of  urine voided  in the
 twenty-four hours.   A low specific gravity may  be compensated  by a large
 daily excretion  of urine.
   Pallor of the countenance, due to anaemia, is generally more or less marked.
 The anaemia  is measurably, if not  chiefly, owing to the loss of albumen,
 and it is most marked in cases in which albuminuria  and general  dropsy are 
CHRONIC BRIGHT'S DISEASE.
883
prominent.  It may be an effect of defective nutrition from anorexia or per-
sistent vomiting.  In cases of cirrhotic kidney in which albuminuria and
dropsy are slight or wanting pallor is not usually a marked symptom.  03denia
and pallor combined give to the face  an appearance highly characteristic of
Bright's  disease.
  Symptoms referable to the  digestive system are more  or less  prominent.
Indigestion  or dyspeptic disorder is common.   Flatulence of the  stomach is
a frequent symptom.   Vomiting is a  prominent and persistent symptom  in
certain cases.   It is referable  to the vicarious elimination of urinary princi-
ples by the gastric mucous membrane.   It may be preceded or accompanied
by other symptoms denoting  uraemia, but  it is  sometimes the chief uraemic
manifestation.  The uraemic vomiting  occurs when  the stomach is  empty, and
often  early in the morning.  The vomited matter or eructated gas sometimes
has an ammoniacal odor.  The acts  of vomiting  often occur suddenly and
violently  without  much previous  nausea.   These  circumstances connected
with vomiting should always  excite suspicion of renal  disease, although no
other symptoms pointing to the kidneys be apparent.   Uraemic vomiting not
associated with general dropsy denotes the small granular kidney.   The vom-
iting  is sometimes  so persistent as to interfere with alimentation and thus
induce alarming prostration.
  Diarrhoea is a less frequent  symptom.  It is, however, a  prominent and
persistent symptom in  some  cases, either with or without vomiting, or, like
vomiting, it may be a uraemic  symptom.  It may proceed from uraemic  intes-
tinal ulceration.  It  is especially frequent in cases of the waxy kidney com-
bined with waxy disease of the intestine.
  Urea is also eliminated vicariously by the  skin.  The perspiration  emits
distinctly the  odor  of urine in some  cases.  An intense  characteristic  odor
is given off  from the  skin by  some  patients who do not pay any attention to
cleanliness.   Crystals of urea are  sometimes found  on the skin.   Bartels
observed a case in which the full beard of a patient had a frosted appear-
ance from an abundant  deposit of these crystals.   An occasional symptom is
an intense itching of  the skin.
  Symptoms referable to the respiratory system may be produced by pleural
effusion or hydrothorax, by pulmonary oedema, and by oedema of the glottis.
Pleuritic  effusion  and  oedema of the lungs  sufficient to occasion notable
embarrassment of respiration occur,  especially when disease of the heart,
involving mitral contraction or regurgitation, or both, coexists with  the renal
disease.   Under these circumstances the pleural cavities may become  nearly
filled  with serum.  GMema of the lungs under these  circumstances is  some-
times the immediate  cause of death.   The occurrence of pulmonary oedema
is sometimes very sudden, and it may prove quickly fatal.   Not infrequently,
however, the oedema  disappears, even when life  has been  placed in imminent
danger.  CEdema of  the glottis is of  rare  occurrence (according  to the  sta-
tistics of Frerichs and of Bosenstein,  in only 4 of  292 cases).   It may occur
when general dropsy is  moderate or slight or wanting.
  Dyspnoea may exist in a marked degree when not referable to any of the
conditions just named, but proceeding apparently  from  a toxical  effect upon
the nervous centre presiding over respiration.   In  these cases the moist rales
incident to pulmonary oedema  and the dry rales of asthma  are wanting.^  Aus-
cultation and percussion give  no signs denoting any pulmonary affection.   I
have  met with several  cases  in which this nervous dyspnoea was  the most
prominent  symptom ;  and I have known it to exist when  no other  symptom
was present to direct attention  to the kidneys as the seat of disease.   The
patients  suffer from  a feeling of apprehension of  " losing the breath," and
are afraid to  sleep on  this  account, an  exertion of the will being required 
884"            CONGESTION OF THE KIDNEYS, ETC.

for respiration.  Disturbance of the rhythm of respiration  characterized by
the frequent  occurrence of a long interval  between the  respiratory acts, fol-
lowed by series of rapid respirations (Cheyne-Stokes respiration), is not infre-
quent, occurring in connection with uraemic stupor and coma.   Enlargement
of the heart with predominant dilatation is another cause of  dyspnoea.   Espe-
cially in cases of contracted kidney dyspnoea from this cause may occur before
other events have directed attention to the kidneys as the seat of disease.
   Symptoms referable to  the nervous  system are among  the most  important
of those belonging to the clinical history of the disease.  Pain  in the back
is  rarely prominent,  and  is  generally wanting.   Cephalalgia is a frequent
symptom.   It may precede  as well as accompany other  symptoms which
point to the existence of renal disease.   Neuralgic pains in other parts of the
body are common ;  and attacks of vertigo are not infrequent.   Insomnia and
disturbed sleep are  frequent  symptoms.   Troubles relating to vision  are in
certain cases important symptoms.  Diplopia or double vision, hemeralopia or
night-blindness, myopia, and presbyopia are  attributed, and perhaps are fairly
attributable, to the disease.  Including these forms of disorder, vision is more
or less affected in a pretty large proportion  of cases; but exclusive of these,
either obscurity or loss of  sight—that is, amaurosis complete or incomplete—
is  not of extremely rare occurrence.  The amaurosis affects both eyes.  AVhen
not complete—and it rarely is so—the  degree varies in different cases and in
different periods of the same case.   In chronic  as in acute Bright's disease
the impairment of vision  may depend on an intracranial morbid  condition,
the ophthalmoscope showing no morbid  appearances within the eye.  This
condition is called uraemic amaurosis.  Under these circumstances  it is tem-
porary, and is liable to recur from time to time.  I have known it to  occur
repeatedly  in  the same case as a precursor of uraemic coma and convulsions.
More frequently, however, it is connected with changes within the eye, which
by means of the ophthalmoscope have been brought under clinical observa-
tion.   In this so-called retinitis albuminuria the optic  papilla is swollen,
clouded, and indistinctly bounded, the retinal veins are  tortuous, and  white
patches appear in different parts of the retina.  The most characteristic appear-
ance, however, is the presence of white dots and streaks in  the periphery of
the macula lutea.   " These fine white  dottings and  radiating lines give the
impression  of having been splashed on  with a feather."   The appearances
are so distinctive  that a practised ophthalmoscopist is led  by them to sus-
pect renal  disease.   It  has happened in  several cases which have  come
under  my observation that disease of the  kidney was  discovered  by means
of ophthalmoscopic appearances, the  patients  having  first  consulted  ocu-
lists for defect of vision.   Amaurosis  dependent on  neuro-retinitis may
diminish, and recovery is  possible;  but it is almost always  persistent, either
progressively increasing or remaining stationary after it has  reached a certain
degree.  The development is usually gradual, whereas  the  so-called  uraemic
amaurosis  occurs suddenly.  The patient describes the defect of vision as
like  that of  a mist before the  eyes.  Deafness, hemiplegia, paraplegia, and
paralysis limited to a single member have been  observed to follow  or accom-
pany uraemic coma and convulsions.  Muscular cramps are sometimes a source
of suffering, and I have known them to constitute  the chief  ailment for some
time before other symptoms directed attention to the kidneys.
   Coma and  convulsions are  the most important of the symptoms referable
to the nervous system.   They occur  in  a  pretty  large proportion of cases
and are often forerunners of a fatal  termination.  In  chronic  Bright's dis-
ease, as in the acute affection, they  proceed  from uraemic poisoning; they are
therefore among  the  ulterior effects of interference with  the  secretory func-
tions of the kidneys.   They are consequently most likely to occur  when the 
CHRONIC BRIGHT'S DISEASE.
885
secretory structure of the organs is extensively destroyed, and hence espe-
cially in connection with the small granular kidney.   In acute Bright's  dis-
ease they always  denote  great danger, but in  chronic  Bright's disease  the
danger is much greater.
  Coma  occurs  in some cases, and death takes place without the occurrence
of  convulsions.    Occasionally  coma  occurs suddenly, but  generally it is
developed gradually,  the  patient having  been more or  less somnolent, dull,
or lethargic  for several days  before  becoming profoundly comatose.  The
coma is sometimes quiet, and in some cases accompanied by stertor.  Marked
dilatation of the pupils is sometimes observed.  The face is congested, some-
times becoming livid, and  death is preceded by  tracheal rales.  The con-
vulsions are epileptiform in character, varying much in degree and extent in
different  cases.  They occur in paroxysms which  may  be repeated at short
intervals,  the patient in  the  intervals being completely comatose, the con-
vulsions  at  length ceasing, and the coma continuing until death ; or after a
paroxysm or  a  series of paroxysms the  patient  recovers intelligence,  and
hours, days, w*eeks, or months elapse before a recurrence takes place.  Con-
vulsions  not  following coma are  generally, but  not always, preceded  by
symptoms referable to the head, such  as  cephalalgia, vertigo, and sometimes
delirium.   Contraction or rigidity of  certain muscles has been observed to
precede convulsions.    Of  70 cases among  those which I  have analyzed,
selecting those only the histories of which embrace either death or recovery,
coma or convulsions were noted in  2G.
  The uraemic phenomena, if neither an  acute  inflammation nor an essential
fever exist,  are not, as a rule, accompanied  by notably increased frequency of
the pulse; the action of the heart is sometimes  diminished in  frequency;  and
I have known the pulse to fall to 32 per minute.   Pyrexia is wanting except
in a certain  proportion of the  cases in which coma and convulsions occur.   In
some instances, in connection with these events, there is a considerable rise of
temperature (105° F.) ; in other instances the temperature is lowered, and it may
fall considerably below the minimum of health. The circumstances which occa-
sion these variations  are not as yet ascertained.   Further study of the temp-
erature in the different varieties of chronic Bright's disease is a desideratum.1
  Delirium, which has just been  mentioned  as sometimes preceding convul-
sions, is occasionally  a prominent feature in cases of uraemic poisoning occur-
ring in connection with both acute and chronic Bright's disease.  It is cha-
racterized in  some cases by remarkable  hallucinations.  The delirium may
be  quiet  or  gay or sad, and it is  sometimes furious  or maniacal.   Uraemic
poisoning, as manifested by delirium, coma, and convulsions,  may occur in
cases of Bright's disease with abundant general dropsy, but it often occurs in
cases in  which dropsy is slight or  wanting.  Of the 2(i cases  above  referred
to in which coma or convulsions occurred, in 11  there was  no dropsy.  It
may follow copious vomiting  and purging, but  it occurs oftener  in cases in
which these symptoms  are slight or wanting.   The  symptoms of uraemic
poisoning are sometimes the  first to direct attention  to the  kidneys as the
seat of disease.
  After  an  attack of uraemic coma and convulsions  there is  sometimes com-
plete absence of  the symptoms of renal  disease, inclusive  of  the  morbid
characters of the  urine, the disease remaining completely latent and another
outbreak occurring after an intermission of a greater or less duration.2

  1  Aide Bourneville, Etudescliniques etthermometriques sur les Maladies du Systeme ner-
renx, 1872 ■ also, article  by MeBride in the Archives of Medicine, New York, Feb., 1880;
also,' Bartels in Ziemssen's Cyclopaedia, vol. xv.
  2  For cases  illustrating the latency of renal disease,  vide Bellevue and Charity Hospital
Reports, 1870, p. 256. 
886             CONGESTION OF THE KIDNEYS, ETC.

  As regards uraemic phenomena, different cases present a striking difference
in the amount of lesions with which their occurrence is connected.  Coma,
convulsions, and death may take place when the kidneys are not greatly dis-
eased, and, per contra, the amount of disease sometimes becomes very great
before any uraemic phenomena are manifested.   So  also there is a great dif-
ference in different cases with respect to the relation between the diminution
of the excretion  of urea and the effects of its accumulation  in the blood.
The  occurrence of uraemic phenomena depends much on  the  rapidity with
which the accumulation of urea in the blood takes place.   Ceteris paribus,
uraemia is quickly induced if the urea accumulate  rapidly.  On the other
hand, if the  accumulation take place slowly, the system acquires a  tolerance
of urea, as of other toxic substances, and hence fatal uraemic effects may be
postponed for a long period.   Another  explanation has reference to the pro-
duction of urea in the system.   This will vary within wide limits according
as the ingestion of nitrogenized food is small or abundant, and also according
to the amount of muscular exercise.   Different cases differ also as regards
the vicarious elimination of urinary  constituents through the  skin and ali-
mentary canal.   It is a  matter of clinical  observation that uraemic  mani-
festations are  less frequent  with than without dropsy.   Bartels  finds  an
explanation of this fact, in a measure, in  the amount of urea  contained in
the dropsical effusions.   The elimination of the urea renders the dropsy to a
certain extent protective against uraemia.
   The complications of the disease form an important part of the clinical his-
tory.   Several affections  included among the symptomatic  events  might be
considered in the light of complications—namely, oedema of the  lungs, oedema
of the glottis, and amaurosis.  Other secondary affections are pericarditis, peri-
tonitis, pleuritis,  and cerebral  meningitis.   Of these, pericarditis and pleuritis
occur oftener than inflammations of other serous membranes.  They are sec-
ondary especially to the small granular kidney.
   Hypertrophy of the left  ventricle  of the  heart is developed especially in
connection with the small kidney.  It may be a secondary affection in cases
of the large kidney, but is rarely so in  cases of the waxy kidney.  If not
associated  with valvular lesions,  hypertrophy  of the left ventricle renders
the existence of renal disease  extremely  probable.   The hypertrophy may
not give rise to any subjective symptoms, and it will therefore be overlooked
if the rule be not adopted of always making a physical examination of the
chest.  AVith hypertrophy of the heart is associated a hard, resistant pulse
and  increased  intensity of the  aortic second sound, indicating  high arterial
tension.   In my  analysis, out of 26 fatal cases  in which the condition of the
heart was noted,  in  11 there  was  more or less enlargement without valvular
lesions.  Cirrhosis of the liver and fatty liver are not infrequently associated
with  Bright's disease,  but they are to be considered as  concomitant, not sec-
ondary, affections.  This statement  is applicable to  waxy liver and  waxy
spleen, which in  a very large proportion  of  cases accompany the waxy form
of disease of the kidneys.   AVaxy disease of the alimentary canal coexists in
a certain proportion of cases.  Cerebral hemorrhage, although not of frequent
occurrence, occurs sufficiently often to show a pathological connection.   It is
a complication of the small granular kidney oftener than of the other  forms
of renal disease.   Hemorrhagic pachymeningitis is an occasional complication.
Epistaxis,.the  frequent recurrence of which in  itself, in a person  in  middle
life, should excite suspicion of  renal  disease, may be explained  by disease of
the blood-vessels  and  hypertrophy of the heart.  A relatively greater weak-
ness of the left than of the right  ventricle is causative of pulmonary oedema.
Pulmonary phthisis is a  complication of the  waxy kidney sufficiently often to
show a pathological connection ; but this does not hold true of the other forms 
CHRONIC BRIGHT'S  DISEASE.
887
of renal disease.   The researches of Fenwick and AVilson Fox show that the
appearances after death often  denote gastritis.   This may be  attributed to
the presence of decomposed urea in the stomach.  Gastritis occurs especially
as a complication in cases of the small granular kidney.   Epistaxis  and
hemorrhages in other situations may  be here mentioned as of not infrequent
occurrence.
   Chronic rheumatism is sometimes associated with chronic Bright's disease.
It may, however, be doubted whether it occur often enough to establish any
pathological connection.  Todd and other British writers have observed the
frequent association of gout and  the small  kidney.  This form of Bright's
disease was called by Todd  the gouty kidney.  Gout in this country is, com-
paratively speaking, a  rare disease,  but the small kidney  is  by no means
extremely rare.   The union of these diseases is not  of frequent occurrence
with us.

   Pathological Character.—With  the  description  of the anatomical
appearances the  grounds for  regarding  chronic  diffuse inflammation of the
kidneys as the basis of all forms of chronic Bright's disease have been given.
   Albuminuria, dropsy, and uraemia  are common to  both acute and chronic
Bright's disease.  Keierenee has  been made  to the mode  of  their production
under  the pathological characters  of the former  disease.   Although a certain
amount of hypertrophy of the heart  may occur  with  acute Bright's disease,
especially in the  scarlatinal form, this symptom  becomes  prominent  only in
cases of chronic Bright's disease.  There are  many theories and much contro-
versy as to the cause of this hypertrophy.  Perhaps the most plausible of these
theories is that which was advocated by Bright, which refers this hypertrophy
to the  accumulation of urinary constituents in the blood, especially urea.   In
some way, it is believed, these constituents increase  the  blood-pressure, but
whether by irritating the vaso-motor  centres, -by acting directly upon the vas-
cular walls, or by  rendering the blood more difficult of  circulation, is uncertain.
In a certain number of cases, particularly of the atrophied  kidneys, the cardiac
hypertrophy may be due to structural changes in the arterial walls.
   However produced, the hypertrophy of the heart is an important  conserva-
tive process.   It  compensates in a remarkable degree for the disturbance of
the renal  functions incident to the small granular kidneys.  The  fact that
notwithstanding the destruction of a  large amount pf  renal parenchyma these
kidneys secrete a normal or even increased amount of water, and not infre-
quently a nearly  normal quantity  of  solids, is explained by the high arterial
tension in the diseased organs ;  and this tension could  not  be maintained with-
out increased  force of the heart.   The  compensation is, however, less  com-
plete for the excretion of the solids than  for that of  the  water of the urine.
The beneficial effects  of this compensatory  hypertrophy are made evident
when from any cause (dilatation  or  fatty degeneration) the cardiac  muscle
becomes insufficient.  Then the quantity of urine becomes small, the excretion
of solids is still further diminished, and the danger of uraemia is great.

   Causation.—In a small  proportion of cases chronic Bright's disease fol-
lows the  acute affection.  The causes  in these  cases are  those which give
rise to the latter.  Exclusive of  these cases the causation is often obscure.
In a considerable  proportion of cases there are no  symptoms denoting impaired
health  prior to the manifestations of the renal disease  ; that is, prior to either
dropsy or  uraemic symptoms.  This was  true in 30 of 53 cases  among those
which  I have analyzed, information on this point being contained in the his-
tories of these 53 cases. In 6 of these 30 cases uraemic coma or convulsions
occurred either when the patients were supposed  to be in good health or when 
888             CONGESTION OF THE KIDNEYS, ETC.

these events were  preceded by other ailments only for a period not longer
than three or four  days.   In the 23  cases in which  ailments  preceded the
manifestations of renal disease, excluding the cases in which other diseases
existed, the  patients had complained of general debility more or less marked
for a period  ranging from a few weeks to several  years.   It is  probable that
in many of the cases in which the manifestations of renal disease occurred in
persons apparently in good health the urine would  have been found for weeks,
months, or even years, to furnish proof that  the  kidneys were not healthy.
The  disease occurs  very rarely  in  infancy and  childhood.  The disease is
also  infrequent  in old  age.  In  the vast majority of cases the patients are
either  young or in middle life.   My analysis  of 102 recorded  cases showed
not a  single case  at less than fourteen or more  than seventy  years of age.
One  patient  only was  seventy years of age.   The mean  age was thirty-four
years.   A difference relating to  age exists between the different forms of
renal disease.   The  large kidney occurs  especially in early life, although it
is extremely rare at less than two years of age.  On the other hand, the small
kidney is  seldom developed in early life.  It is most liable to  occur in the
neighborhood of fifty.  Men are  much oftener affected than women.   Of my
102  cases, 67 were  males and 35 females.  As regards habits of intemper-
ance, of the 102 cases which I have analyzed, in  38 the histories contained
information  on this point,  In nearly all these cases the patients were males.
In 18 cases  the habits, as regards the use of alcoholic stimulants, were good;
in 13 cases the patients were spirit-drinkers and intemperate ; 3  patients were
moderate  drinkers ; 4 drank malt  liquors freely; and in one case  it was simply
noted  that the patient was a " free liver."  So far  as these facts go, they cer-
tainly  do  not show any special causative influence pertaining to the use of
alcoholic stimulants.   It is probable that the abuse of alcoholic  beverages
contributes to the production of the disease, but it is also probable that  their
direct  agency has  been  much  over-estimated.  Clinical observation in this
country certainly does not warrant the name spirit kidney, as applied to the
small kidney by Goodfellow.  The disease is much oftener  observed in hos-
pitals  than  in private practice among the better  classes of society—a fact
going to show that the exposures, hardships, and deprivations incident to the
lives of those who  seek for hospital relief in illness are involved  in  the causa-
tion.   Persons whose occupations involve exposure to cold  and  wet are more
liable to be  affected than tfoose who are protected  against the vicissitudes of
the weather.  Cases are more frequent in humid, marshy climates and on the
sea-coast  than in dry, elevated, and inland situations.  Malaria is supposed
to be a causative agent, but of 78 cases observed in situations in which inter-
mittent fever was  of frequent  occurrence,  this  disease  had  existed ante-
cedently to  the  renal  affection in  only 10.   Dickinson  shows  by statistical
data that  chronic Bright's disease, especially the small granular kidney,  is of
more frequent  occurrence  in temperate than in either cold  or tropical coun-
tries, and  that variableness  as regards temperature and  humidity favors its
production.
   Chronic Bright's disease may he developed  in  the  course of various
other  diseases.  It  is sometimes developed  during the  progress  of pul-
monary tuberculosis, but exclusive of the waxy kidney  the proportion of
the  cases in  which  after   death tubercle  in the  lungs  or  elsewhere is
found  to  be  associated is  perhaps  not greater  than  in fatal cases of
other  diseases.   Of  the  cases  of the  waxy kidney,  pulmonary tubercu-
losis  exists in  a  considerable  proportion, and  it precedes the  renal  dis-
ease sufficiently often  to denote a  causative  influence.   The  waxy kidney
is developed secondarily to syphilis  in  such  a  proportion of cases as to
show that the latter has a causative agency.   Caries and  necrosis of bones. 
CHRONIC BRIGHT'S  DISEASE.
889
ulcers of the intestine and in other situations, and chronic suppuration in any
part, have a relation of causation to this form of renal disease.  Todd, Garrod,
and other British authors have observed the frequent occurrence of the small
kidney in  persons affected  with gout.  That the latter  affection is often
involved in the causation is  doubtless true, but  the  connection  is by no
means  sufficiently constant  to warrant, as a distinctive  title of this form of
renal disease, the name "gouty kidney."   Facts show that the absorption of
lead into the system may lead to the development of the small kidney.
  Chronic  Bright's disease  not infrequently supervenes in protracted cases
of diabetes mellitus.   In these cases  the  latter is probably causative.   In
some of these cases there is  a remarkable tolerance of the  disease of the
kidneys,  but in some cases the renal affection has a rapid course,  life being
speedily  destroyed by  uraemic coma.
  In some instances an hereditary element seems to be involved in the causa-
tion of chronic Bright's disease.  A number of members of the same family
may be affected with the disease.

  Diagnosis.—The diagnosis of  chronic as of acute Bright's disease is to be
based on the evidence afforded by examinations of the urine.   It is  always to
be  borne in mind  that transient albuminuria  is a symptom occurring in the
course  of many diseases.  Albumen in the urine is found in cases of  all the
essential fevers, inclusive of lobar pneumonia, diphtheria, erysipelas, etc. etc.
In these connections it denotes hyperaemia of the kidneys or parenchymatous
degeneration.  Generally the  amount of albumen is small.  On  the other
hand, it is to be borne in mind that albuminuria is not an invariable symptom
in cases of chronic Bright's disease, nor is the presence of a few casts a  sure
sign of Bright's disease.   These may be found in other conditions,  both with
and without albuminuria.  In  general, the  diagnosis is rendered sufficiently
easy and positive  by persistent albuminuria and casts  of  the different kinds
which have been described,  together with dropsy and symptoms  pointing to
uraemia; but  the  occasional latency of the disease, exclusive of symptoms
referable to the urine, is not to be lost sight of.  Not very infrequently albu-
minuria  and casts show disease to exist when dropsy and other diagnostic
symptoms  are wanting.  The disease  is always to  be  suspected in cases of
coma  or convulsions,  of cephalalgia  or  neuralgia  in  other situations, of
repeated attacks  of epistaxis, of cerebral hemorrhage, especially in persons
before  the  middle period of  life, of vertigo and other forms of cerebral disor-
der, of amaurosis and other forms of paralysis, of serous  inflammations, of per-
sistent vomiting or purging, and of anaemia and impaired muscular strength,
whenever the  etiology is not otherwise intelligible.  In short, it is a good rule
in practice to examine the urine in all  cases, whether symptoms point to the
kidneys or not, and repeated examinations should be made whenever there are
any grounds for a suspicion of the existence of renal disease.  To  determine
the coexistence of Bright's  disease or to exclude this disease  in all affections
is of much importance.   Of course the urine is to be examined repeatedly in
order to ascertain the persistency of  albumen or  casts, together with other
morbid  changes.
  AVhen acute diffuse nephritis supervenes  upon chronic Bright's  disease, it
may be difficult to determine the  prior existence of the  chronic affection, and
such cases may lead to the erroneous supposition that the chronic is a sequel
of the  acute disease.
  A difficulty in the way of determining the particular forms of chronic dis-
ease represented  in  individual cases is the fact that the different  forms are
net  infrequently combined.  In typical cases of each form, however, the diag-
nostic points are sufficient for the differential diagnosis, but even  then  mis- 
890            CONGESTION OF THE  KIDNEYS, ETC.

takes in diagnosis cannot always be avoided.   These points, which have been
already presented in the Clinical History and Causation, are as follows:
  1.  The Large Kidney without  Waxy Degeneration.—The  existence of this
form is probable whenever the chronic follows the acute disease.  In trusting
exclusively  to this diagnostic  point, however, there would  be a liability to
error  arising from  the fact that the acute disease  may  occur in  a patient
already affected with either the small or the waxy kidney.   Much or consid-
erable general dropsy, assuming that cardiac lesions are not involved in its
causation, denotes the large kidney.  A scanty secretion of urine, with a large
proportion of albumen, abundant sediment, and the  specific gravity not low,
has the  same significance.   Hypertrophy  of the  left ventricle of the heart
without valvular lesions may occur in this form of Bright's disease when the
affection  is of sufficient duration.   The amount of urine is  then increased.
Uraemic  phenomena—namely, coma and convulsions, cephalalgia, impaired
vision, vomiting, diarrhoea, and inflammation of serous membranes—are  of
less frequent occurrence than in cases of the small kidney; and when they
occur they are preceded  by the symptoms  which are diagnostic of the large
kidney.  Anaemia  is constant, and often exists to  a  marked  degree.  The
youth of the patient is a  point in favor of the  large as contrasted with the
small kidney.   The absence of phthisis and gout is a point of some.weight.
  2.  The Small Granular Kidney.—In this form the disease not infrequently
is  latent as  regards any obvious symptoms  prior to uraemic manifestations.
The minor manifestations—namely, headache, vomiting, impaired vision, etc.
—may be the first to occur, or those of a graver character—namely, coma and
convulsions, pulmonary oedema, and pericarditis—may occur without any ante-
cedent events pointing to renal disease.  Uraemic phenomena are much more
frequent  in  this than in the other forms.   Dropsy is often wanting, and it
rarely exists to much extent.   The urine is usually increased considerably in
quantity  (polyuria) ; its specific gravity is  low ;  albuminuria is often slight,
and at times may be wanting.  The characters of the pulse and increased
intensity of the aortic second sound of the heart, which denote arterial tension
and hypertrophy of the left ventricle, are  so common in this form, and com-
paratively so infrequent in the other forms, that they have much weight in
the differential diagnosis.  The age of the patient has diagnostic weight.   In
the great majority  of cases the age is between forty and sixty.  The coexist-
ence of gout or of lead-poisoning has  a bearing  upon the differential diag-
nosis.
  3. Waxy Kidney.—Important diagnostic points relate to causative and coex-
isting  diseases.  Antecedent  to the renal  affection  are  phthisis, disease  of
bone,  suppurations, ulcers,  or syphilis.  Enlargement of the liver and spleen
from waxy disease is often  associated.  The urine exceeds the normal quan-
tity.   It  is  pale, clear, and of low  specific gravity.   Albuminuria is  rarely
absent, but it is variable as regards its degree, the quantity of albumen being
usually less  than in cases of the simple large kidney, and more than in cases
of the small granular kidney.  Anasarca is more frequent and marked than
in the  small  granular kidney, but less so than in the large kidney.  Hydro-
peritoneum may  be out of proportion to the general dropsy, owing to coexist-
ing disease of the liver.  Diarrha-a is a frequent symptom, pointing to waxy
disease of the intestine.   Hypertrophy of the left ventricle does not occur as
secondary to the renal affection.   Both  the minor and the grave manifesta-
tions of uraemia are less frequent than in cases of large kidney without waxy
degeneration, and much less frequent than  in cases of the small granular kid-
ney.  This form of disease may occur at any age, but it is rare in very early
and in advanced life.   The  diagnostic points  which  have  been mentioned
apply to the  typical waxy kidney.  In cases  in which parenchymatous changes 
•                   CHRONIC BRIGHT'S DISEASE.                891

predominate over the waxy the  urine may be scanty, very albuminous, and
may contain a large number of casts.  Dropsy is then usually very marked.
In  other words, some of the large  kidneys with waxy degeneration  give the
clinical  history usually ascribed to large white kidneys without waxy degen-
eration.

  U"raemic coma, with  or without convulsions, sometimes occurs suddenly in
persons not  known to  be affected with renal disease.   To determine  that the
attack is due to uraemia in these  cases the urine is to  be examined with ref-
erence to albumen, the  presence of casts, the  specific gravity, and the quan-
tity, as  soon as practicable ;  and the catheter should be resorted to, if neces-
sary, in order to obtain a specimen with  as  little delay as  possible.   Apo-
plexy, congestive or from extravasation of blood, meningitis, epilepsy, nar-
cotism,  and alcoholism are the affections to be excluded in cases of uraemic
coma occurring suddenly or when the previous history cannot be ascertained.

  Prognosis.—In a large proportion of cases the different forms of chronic
Bright's disease destroy life sooner or later if the patient be not cut off by
some intercurrent affection.   The duration in fatal  cases varies  greatly in
different cases.   It  is  difficult in many instances to determine the actual
duration, because the  disease is usually  developed  imperceptibly  and has
existed  for  a greater  or less  period before its manifestations are observed.
Dating  from the time when its existence is  declared, the fatal termination
may -take place in a  few hours on the one  hand, and  on  the other  hand
the  disease  may continue many years.  Although recovery does not take
place, not infrequently the progress of the disease is stayed or it  progresses
imperceptibly.  The prominent symptoms may disappear,  and  the patient may
have comfortable health for an indefinite period, albumen  and  casts  sometimes
disappearing from the  urine.  The kidneys, like other important organs, such
as the heart, liver, lungs, etc., may be damaged to a considerable extent and
still be  competent to fulfil their functions sufficiently  for the  continuance of
life and health.
  A fatal termination  is frequently due  to accidents or  secondary affections,
such as pneumonia, pericarditis, oedema of the glottis, cerebral hemorrhage,
etc.   Coexisting disease  of the  heart,  of the liver, or of other  important
organs  often hastens the fatal termination.   The prospects of improvement
will also depend much on the general condition of the system.  As regards
the mode of dying, it is by apnoea in some cases, and in some cases purely
by  asthenia.    In the  former cases unemic  coma, hydrothorax, pulmonary
cedema, or oedema of the glottis  is  the  immediate cause of death.   In the
latter cases long-continued and excessive general  dropsy, persistent vomiting,
or complete loss of appetite and digestion precede  death, symptoms  of uraemic
poisoning being absent,  Of 45 fatal cases among those which I have ana-
lyzed, in 18  the death  was attributable  to uraemic coma or convulsions; in 6
cases the death was due to  exhaustion irrespective of complications; and in
21 cases the cause of  death related, measurably or entirely, to complications
or intercurrent affections.
  Examinations of the urine furnish important prognostics.  If the urine
continue to   be loaded with  albumen,  this,  in conjunction  with  persisting
dropsy and marked anaemia, denotes that the disease will probably not be of
very long duration.   Danger from uraemia is to be apprehended in proportion
to the deficiency of urea in the urine.  A scanty secretion of urine and a low
specific  gravity point to imminent danger in that direction.  Uraemia may, how-
ever, develop When the patient is  passing a fair amount of  urine.
  The prognosis is not the same in the different forms  of chronic  Bright's 
 892            CONGESTION OF THE KIDNEYS,  ETC.               •

 disease.   It is most unfavorable in cases  of  the  small  granular  kidney; yet
 it is  certain  that with the kidneys considerably  damaged from this form life
 may continue with comfortable health for many years.   The  form of disease
 represented by  the large  kidney  without waxy degeneration may exist to a
 greater or less  extent and recovery take place.  Bartels cites cases in which
 there was complete recovery from  the  waxy kidney.   The  changes in the
 small granular  kidney do  not admit of  restoration.  AVhatever  may be the
 form  of disease, it is to be borne in mind that the  kidneys may be damaged
 to an  extent equivalent to the loss  of the whole of one of the organs, and
 yet the remaining  portion be  quite  sufficient for life  and health.
   Of my 102 recorded  cases, in 77 the histories  extended to either death or
 a condition which was considered as denoting recovery,  and of these 77 cases,
 in 22 the latter  termination was noted.   In a few of these cases  the affection
 was  acute, and  in  some,  instead  of a permanent recovery, there  may  have
 been only a temporary suspension  of the  symptomatic  phenomena.   Making
 due allowance for these cases, the result of the analysis affords encouragement
 to hope  for recovery in not an insignificant proportion of cases of chronic
 Bright's disease ; and in many cases the hope may be entertained of an arrest
 of further progress of the disease.

   Treatment.—In certain  cases of  chronic  as well  as  of  acute Bright's
 disease  therapeutical  indications relate to general dropsy and  uraemia.  Gen-
 eral  dropsy, when great or considerable, calls for  the  same measures as  in
 cases of  the acute disease.   In general, hydragogue cathartics constitute the
 most  efficient and  reliable means  of affording prompt relief.  If the  dropsy
 be slight or  moderate, the saline cathartics suffice—namely, the  sulphate of
 magnesia or soda, especially the so-called bitter waters  containing these  salts
 (Friedrichsliall,  Hunyadi Janos, etc.) or the  citrate  of  magnesia; but if the
 dropsical  effusion  be  large more active hydragogues are required—namely,
 elaterium, gamboge, or the bitartrate of potassa with  jalap.  The acrid  or
 drastic cathartics are to be avoided.  The hydragogue may be given in doses
 sufficient to produce free purging, and repeated after intervals  of two or three
 days, or it may be continued  in small  doses  daily,  so as to keep  up a moder-
 ate draining  away  of liquid.  Elaterium is  sometimes well  borne in  doses
 sufficient to produce a few  watery  evacuations daily for  a considerable period.
 When it is important  to obtain  an  efficient hydragogue  effect  as  promptly  as
 possible the elaterium is invaluable.  It may be  prescribed in doses of from
 one-sixteenth to one-fourth  of a grain hourly until the cathartic operation
 begins.   It should then be  at once suspended, in order to avoid  vomiting.
 There  is an  unnecessary apprehension in the  minds of many physicians of
 dangerous prostration from the use of this drug.  I  have been  led by a pretty
 large experience to consider it safe when employed in the manner just stated.
 The sulphate of magnesia in half-ounce doses repeated at intervals of three  or
 four hours is  an efficient hydragogue cathartic, and  is generally well tolerated
 by the patient.
  Diuretics are  much less reliable than hydragogue cathartics.   Frequently
 the kidneys will not respond to them,  but in some  cases they act efficiently.
 Experience shows that they  may be tried without risk of doing  harm.   The
 bitartrate of  potassa  in doses not large  enough to purge,  or  the  acetate of
 potassa, may  be  given in conjunction with infusion of  digitalis,  the infusion
 of broom, or  other  vegetable diuretics.  I have  known the infusion of par-
 sley-root (petroselinum) to be remarkably effective as a  diuretic remedy.  If
the state  of  the stomach and bowels preclude the  internal use  of diuretics,
their external application  may be tried after the plan  proposed by  Christi-
son—namely, an infusion  of digitalis §j, in  water  5xx, applied  to  the abdo- 
CHRONIC BRIGHT'S  DISEASE.
893
  men  by cloths  soaked in it  or  by the spongio-piline.   I have known this
  application  to be followed by copious diuresis  and disappearance  of  the
  general  dropsy.   A liniment of digitalis, iodine, and  squill  rubbed over
  the  abdomen and limbs  will  in  some  instances increase  notably the  quan-
  tity of urine.  If continued,  however, it soon  excites soreness of the skin
  As_ regards digitalis, it  may  be useful in  certain cases not only  as a diu-
  retic, but by  limiting  the production of urea.    Experimental observations
  by Megevaud and Babuteau, under the direction of Bobin of Paris, showed a
  marked diminution  of urea in the urine as  an effect of this  drug, this effect
  being  greater in proportion to the  retardation  of the circulation which the
  drug occasions.   The  inhalation of the vapor of  juniper  has proved useful
  as a  diuretic  in  some cases under my observation when remedies were not
  tolerated  by the stomach.  The vapor may be  produced by dropping thirty
  minims of the oil on a sponge dipped in hot water and squeezed.  The inha-
  lation may be repeated several times daily.   The  fluid extract of convallaria
  is useful  both in strengthening the heart's  action and in increasing the flow
  of urine.
    Sudorifics  must be relied upon if  hydragogue cathartics be not borne and
  if the kidneys do not respond  to diuretics.   The hot-air bath—that is, heated
  air introduced under the bedclothes—is the  most efficient mode of producing
  diaphoresis.    This may be used  in  alternation  with  cathartics  or diuretics.
  Patients often express a sense of marked relief  after perspiring freely under
  the use of the hot-air bath, but in  some  cases it occasions a disagreeable
  heating of the surface without free perspiration, and if  carried too  far or
  repeated too often it produces prostration.   Experience in individual  cases
  must be the guide as to  its utility and  the extent  to which it should  be car-
  ried.  The warm bath, perspiration being kept up for some time afterward by
  covering the patient with an abundance of clothing, may be employed as a sub-
  stitute for the hot-air bath when the latter  cannot be conveniently employed
 or when its operation is unsatisfactory.  Jaborandi or its alkaloid, pilocarpine,
 sometimes acts efficiently as a  diaphoretic remedy, but it is less reliable than
 the sudorific measures which act directly upon the skin.
   In cases of  excessive distension of the integument of  the lower limbs and
 genitals temporary relief may be obtained  by making a  number of  minute
 punctures of the skin with a pin, the punctures  being so superficial as not to
 draw blood.   The amount of water which drains away through  these imper-
 ceptible punctures is  surprising.  This method is  to be preferred to deep punc-
 tures or incisions, which  may lead to erysipelas  and gangrene.   Removal of
 the dropsical effusion in this  way has  the  advantage over measures which
 cause its removal  by absorption, in that the excrementitious principles con-
 tained in the effusion do not re-enter the blood.  Uraemic effects have  repeat-
 edly been observed to follow the rapid absorption of dropsical effusions.
   Hydragogue cathartics, diuretics, and sudorifics  are also the means for the
 elimination of urea in the cases  in  which  symptoms denoting  uraemia are
 present.  If  uraemic  poisoning be manifested by  coma or convulsions, diu-
 retics  are too uncertain to be depended  upon.  Active hydragogues and the
 hot-air bath are indicated.  Impending death is to  be warded off only  by the
 prompt and efficient  action of  these  measures.   AVe have  no knowledge of
 remedies which will neutralize the toxical properties of urea accumulating
 in the blood.   Elimination, so  as  to  reduce  the  quantity below  the amount
 requisite to produce poisoning effects, is  the  only resource.  It is a therapeu-
 tical object to  forestall  the development of uraemia sufficient to give rise to
 poisoning effects in the cases in which an examination of the urine shows a
 notable deficiency of  urea or an examination  of the  blood-serum shows an
excess of  this excrementitious principle.   A moderate  hydragogue  action 
894            CONGESTION OF  THE KIDNEYS,  ETC.

may be maintained for this object, or the hot-air bath may be employed once
or twice daily.  Under these circumstances diuretics may be adequate if the
kidneys respond to them.  It might be supposed that diuretics are objection-
able on the score of their increasing the excretion of albumen in the urine.
Experience shows that they do not produce this effect.  Although the quantity
of urine is augmented, the  amount of albumen is generally not greater than
before, and it may even be diminished.
   An important caution  is not to subject patients  to the effects of sudorifics,
hydragogue cathartics, and diuretics except when these are indicated by urae-
mic manifestations or deficient elimination of excrementitious principles.  The
employment of these measures when these  indications for them are not pres-
ent will tend to disturb the  functions  of the body and thereby diminish
tolerance of the  disease.  Patients may be injured by active treatment in
anticipation of future  consequences.   The  eliminative functions  of the kid-
neys may be adequately  performed although albumen and  casts be present in
the urine in large  quantity.   On the other hand,  eliminative treatment may
be urgently indicated when the urine contains little or  no albumen and few
or no casts.
   Certain  remedies  have been supposed to have a curative  effect—namely,
the tincture of cantharides, nitric acid, and preparations of mercury.   Expe-
rience has failed to establish the efficacy of these or other remedies addressed
directly to the kidneys.  Remedies, however, indicated  by morbid conditions
associated with the renal disease are often of much utility.  Anaemia,  which
is especially associated in cases of the large kidney, calls for chalybeates and
tonics, having reference to improvement of appetite and digestion. Dyspeptic
disorders claim appropriate remedies.   Antecedent and coexisting affections
which may have caused  the renal disease or contributed to its progress fur-
nish therapeutical indications.  This  statement applies particularly to the
waxy kidney, but  measurably to the other forms.  The maxim  that  to im-
prove to  the utmost possible extent the general health of the patient is  to
promote the restoration from, and the tolerance of, a local lesion which may
be irremediable, is important  in its application to chronic Bright's disease.
   Hygienic measures are of the first importance.   Alimentation as abundant
and nutritious as the powers of digestion will admit of, clothing to secure uni-
form warmth and activity of the functions of the skin, and such an amount
of outdoor life as the strength of the patient will bear, constitute the hygienic
management.   In all cases, taking into view the correlation of the cutaneous
and  renal functions, attention to the skin is of special  importance.   Travel-
ling, and  especially long sea-voyages, have  been found  highly useful.   The
fact  that renal disease is infrequent in tropical and also  in cold climates ren-
ders it desirable in certain cases for patients to exchange for these climates
one which  is unfavorable from its variability and humidity.   Experience has
shown the utility of this measure.1  In general, warm climates are to be pre-
ferred.   It  is hardly necessary to add that all causes of debility or disorder
are as far as possible to be removed.  Overtasking the body or mind,  expo-
sure to vicissitudes of weather, the use of alcoholic stimulants (save as  a
means of aiding  appetite and digestion, and  taken for these  objects, if  at
all, very sparingly), venereal  indulgences,  and dietetic imprudences  are  to
be interdicted.
   Symptoms other than  those already referred to  in certain cases call for
treatment.  Cephalalgia  and neuralgic pains  in  different  situations call for
palliative measures.  AVith regard to the use of  opium  to  relieve pain  or
procure rest, some writers have inculcated the importance of great circum-
spection, under the belief that even in moderate  doses this drug is liable to
                          1 Aide Dickinson, op.  cit. 
CHRONIC BRIGHT'S DISEASE.                 895
 produce undue, and  even fatal, narcotism  if the blood be  surcharged with
 urea.   Apprehensions on this score have been greatly exaggerated, if, indeed
 there be any foundation for them.   I have known opiuni°to be taken habit-
 ually m large doses for several  months for vomiting  and diarrhoea, the urine
 being  loaded with'albumen and the dropsy very great, and, so  far from  its
 being injurious, life was apparently prolonged by its  use.  There is reason to
 believe that opium renders  the  nervous  system more  tolerant of the uraemic
 poison.  Opium is indicated by  uraemic dyspnoea.
   Aromiting and purging, if excessive, claim interference, but it is to be recol-
 lected that generally these symptoms denote the vicarious elimination  of urea
 through the alimentary canal.   It would be injudicious to  attempt to arrest
 the ehminatory process in this direction, but as excessive vomiting and purg-
 ing preclude adequate alimentation, palliative measures are to be employed.
 Relief  may be procured indirectly by favoring elimination through the cuta-
 neous surface by means of the hot-air bath.  Direct palliation may be obtained
 by pieces of ice taken into the  stomach, by rubefacients or  dry  cups applied
 to the  abdomen, and by  the internal use  of hydrocyanic acid,  creasote, the
 oxalate of cerium, and  the preparations of bismuth.   The latter are often
 highly  useful.   The  dilute sulphuric  or the hydrochloric acid may be given
 with  a view to neutralize  the  ammonia.
   Astringent remedies have been much used with  a  view to  restrain  the
 excretion of albumen  in cases in  which  the  urine is highly  albuminous.
 Gallic acid,  the acetate of lead,  and  the astringent preparations  of iron have
 been used for this purpose.  I  have repeatedly made trial of gallic acid for
 the end just stated, but with little or no effect.
   It has been claimed that restriction of the diet to  skim milk effects a cure
 in cases of  the large kidney, and that marked  benefit is derived from it in
 the other forms.   These  claims in behalf  of this treatment have  not been
 substantiated, but there is evidence of its utility in certain cases.  It may be
 tried, but if the  symptoms do  not within a short period show its utility, it
 should  not be persisted in.   Milk, however,  may with advantage enter  largely
 into the diet in the different forms of  Bright's disease.  Buttermilk is some-
 times preferred by patients.  Owing  to the loss of the albumen  in the blood
 from its elimination by the kidney, it is important, if the  degree of albumi-
 nuria be great or considerable, to make up this  loss  by a highly albumi-
 nous diet.
   The treatment of complications, such  as  serous inflammations, or of affec-
 tions which  may be accidentally associated  with chronic Bright's  disease, is
 to be modified by the coexistence of the latter.  Active therapeutic measures
 which, under other  circumstances, might be admissible are  contraindicated.
 General or  local bloodletting, mercury, and other depressing measures, as a
 rule, are injudicious.  If there  be exceptions to  this rule,  they are of rare
 occurrence.
   In conclusion, the management, as has been seen, does not embrace  special
 medication, but in  addition  to  remedies for particular  symptoms or effects
 and the treatment  of concomitant affections  it consists, in a great measure, in
 the removal of  morbific causes  and in hygienic regulations.  The object is
 not to effect recovery from damage that has  been done, but to prevent further
 injury  of the diseased organs,  recollecting that the  existence of a certain
 amount of disease is not incompatible with  the  continuance  of life and com-
 fortable health for an indefinite  period.  The advantage  of an early diagnosis
 is very great in this disease.  The same consideration  is  applicable here as in
 cases of pulmonary tuberculosis—namely, inasmuch as the object to be hoped
for is an arrest of the progress of the disease, the earlier its existence is ascer-
tained the less will be the amount of  damage before the disease is stayed. 
896   ACUTE INTERSTITIAL  OR  SUPPURATIVE  NEPHRITIS, ETC.
                        CHAPTER   II.

ACUTE  INTERSTITIAL  OR  SUPPURATIVE  NEPHRITIS—DIS-
  EASES   OF  THE  URINARY  PASSAGES. — PERINEPH1UT1C
  ABSCESS.

Acute Interstitial or Suppurative Nephritis.—Pyelonephritis: Anatomical Characters;
  Clinical History; Causation; Diagnosis; Prognosis;  Treatment.—Pyelitis— Pyo-
  nephrosis.— Hydronephrosis.—Eenal  Colic  and   Nephro-lithiasis.—Perinephritic
  Abscess.

     Acute Interstitial  or Suppurative Nephritis—Pyelo-
                              nephritis.

   THE most common form of suppurative nephritis is that in which a number
    of small abscesses are present in one or both kidneys.  This disease is called
also acute interstitial nephritis and (when there is coincident inflammation of
the renal pelvis) pyelo-nephritis.   Large collections  of pus in the substance
of the kidney,  constituting a single abscess or several abscesses, are rare, and
are generally due to traumatism or to extension of suppurative inflammation
from adjoining parts.
  Suppurative nephritis is  caused by  the presence in the kidney of micro-
organisms capable of  exciting suppuration.   These organisms  usually are
micrococci, and can generally be demonstrated without difficulty.  The  bac-
teria gain access to the kidney either by the blood-vessels or by the urinary
passages.

  Anatomical Characters.—AVhen  the bacteria are brought by the blood
to the kidneys, the abscesses are called  pyaemic or metastatic.  Such abscesses
are embolic  in origin.   In this form of acute  interstitial  nephritis there usu-
ally  are abscesses also in other organs.   Both kidneys are involved.   Small,
yellowish-white elevated spots, often  surrounded by a hemorrhagic zone, are
generally seen upon the surface of the kidney after  removing the  capsule.
Such purulent foci are present, as a rule, in both cortex and pyramids. There
may be present wedge-shaped white infarctions due  to larger emboli.  Upon
microscopical examination are  found foci of pus in which the renal tissue has
been entirely destroyed.  It  is not  always easy to demonstrate microscopically
the presence of bacteria in the fully-formed abscesses.   In an earlier  stage of
the process colonies of micrococci can be found in  the capillaries.   Around
these colonies the tissue may appear  normal or it may be necrotic for a cer-
tain distance.   Around such necrotic spots, containing colonies of micrococci,
a zone of pus-cells  makes its  appearance.  Thus, all  stages in the formation
of the abscesses can  frequently be demonstrated.
  The appearances when the bacteria make their way to the kidney  through
the urinary  passages are somewhat different.   In these cases the pelvis of the
kidney and  the bladder are usually inflamed.   The affection is a pyelo-nephri-
tis.  The abscesses appear as yellowish-white streaks, and they often extend
from the papillae through the pyramidal and  cortical  portions.   The kidneys
are much swollen.  Purulent foci  are generally evident  upon the surface of
the kidney after stripping off the capsule.  Colonies of micrococci are found
in the urinary tubes.   Pus-cells accumulate in the interstitial tissue and in
the tubes, and lead to a destruction  of the  renal  tissue. 
       ACUTE INTERSTITIAL  OR  SUPPURATIVE NEPHRITIS.   897

   In most cases of acute interstitial nephritis the suppurative inflammation
occurs in a large number of more or less circumscribed foci.  In rare instances
there is a diffuse suppurative inflammation of the whole kidney.
   Large renal abscesses are not  common in the form of disease which has
been described.   Many cases which have been described as  renal abscess are
in reality examples of pyonephrosis, an affection which will  be considered in
the next article.  That large collections of pus may, however, in rare instances
be formed primarily in the substance of the kidney cannot be doubted.

   Clinical History.—The miliary abscesses in  the kidneys which occur in
pyaemia give rise to no marked local symptoms.   The urine undergoes no con-
stant distinctive modifications.    It may, however,  contain pus-corpuscles.
Pyaemic renal abscesses are less common  than those  in  the  lungs, liver, and
spleen if  the  pyaemia caused by  acute ulcerative endocarditis be' excluded.
   Acute interstitial nephritis supervening upon  disease of  the  urinary pas-
sages is of grave import.  The  symptoms are those of severe constitutional
disturbance—namely, repeated chills, irregular fever,  delirium, somnolence,
coma, etc.  These  symptoms denote the presence of some toxic agent in the
blood.  They are attributed by some to uraemia, by some  to ammoniaemia,
and  by  some to septicaemia or  pyaemia.  (Aide  p. 75.)  The urine, usually
diminished in quantity, is often  ammoniacal.   It may be albuminous and may
contain casts.  The alterations in the urine, however,  are not  diagnostic of
this  disease.  The symptoms distinctly point to a blood disease.  The nephritic
disease is to be suspected when these symptoms follow  the causes which give
rise  to acute interstitial nephritis.  This disease is developed in many of the
cases in which  death takes place within a few days after an  operation for
stone in the bladder or for stricture of the urethra.  The diagnosis cannot be
made with certainty,  as similar  symptoms and a fatal issue may follow with-
out  the kidneys becoming-  involved.  The prognosis is  grave—as much so as
in cases of pyaemia, with which the condition seems to be identical.  Abscesses
may be present in other parts of  the body, but they are usually confined to
the  kidneys.
   The consideration  of large  renal abscesses,  usually  of traumatic  origin,
belongs to  surgery.  These cases are clearly  distinct from those of acute
interstitial nephritis,  as just described.  These renal  abscesses are sometimes
due  to suppuration in adjacent parts, and they sometimes occur without any
apparent causation ; that is, idiopathically. They are to be distinguished from
P3*onephrosis  and  perinephritic  abscesses, and,  clinically, this is not always
easy.  In renal abscess the  constitutional symptoms may be either  slight or
marked.   An essential  diagnostic point is a  recognizable tumor, sometimes
fluctuating,  referable to the kidney.

   Causation.—Suppurative nephritis caused by infectious emboli occurs in
many cases of pyaemia and in acute ulcerative endocarditis.  It is a rare  com-
plication of dysentery and of other diseases.   Suppurative nephritis has  been
observed in  cases of actino-mycosis.
  As already mentioned, when suppurative nephritis is caused by the entrance
of the infectious agent from the urinary passages  into the uriniferous tubules,
there usually is coincident inflammation of the pelvis of the kidney and of the
bladder.   This pyelo-nephritis occurs  in  connection  with  stricture  of the
urethra, enlarged prostate, gonorrhoea, stone in the bladder, operations on the
genito-urinary tract, and cystitis  from disease of  the spinal cord or from other
causes.
  Abscess of the kidney from traumatism is likely to be associated with  peri-
nephritic abscess.
       57 
 898   ACUTE INTERSTITIAL  OR SUPPURATIVE NEPHRITIS, ETC.

   Finally, renal  abscess may  occur as  an apparently primary or idiopathic
 disease without  evident cause.

   Diagnosis.—Miliary abscesses in the  kidney due to pyaemia give rise to no
 diagnostic symptoms.  Pyelo-nephritis  consecutive to surgical operations  on
 the urinary tract and to cystitis is to be  suspected when the symptoms which
 have been mentioned in the clinical history are present, these symptoms denot-
 ing increased gravity of the disease.   Suppurative nephritis of traumatic ori-
 gin may be diagnosticated by means of unilateral pain and tenderness, together
 with  rigors, more or less fever, and other symptoms of constitutional disturb-
 ance.   The diagnostic evidence of a large renal abscess is  the presence of a
 fluctuating tumor referable to the  kidney.  In  making this diagnosis  pyo-
 nephrosis and perinephritic abscess are to be excluded, which generally is not
 easy.   An exploratory puncture may be employed to reveal  the presence
 of pus.

   Prognosis.—The prognosis  in suppurative nephritis secondary to pyaemia,
 to acute ulcerative endocarditis, and to affections of the urinary passsages is
 fatal.   Idiopathic abscess of the kidney and abscess secondary to traumatism
 may discharge  in various directions, as  into the  renal  pelvis, into the peri-
 toneal or the pleural cavity, into the stomach or the intestine,  or externally.
 Recovery has taken place in some of the cases in which  the abscess opened
 externally, and also when  the opening was into the pelvis of the  kidney  or
 into the intestine.  A certain number of cases  have been cured by appropri-
 ate surgical treatment.   In all  cases, however, the prognosis is grave.

   Treatment.—The treatment in pyaemic  abscesses of the kidney and  in
 suppurative pyelo-nephritis is directed to the general symptoms.  In cases of
 cystitis, or of conditions likely  to occasion cystitis, measures to prevent the
 development of pyelo-nephritis are of great importance. These measures relate
 to the prevention of  the accumulation and of the decomposition of urine  in
 the bladder, to the cleansing of the bladder, and to  the treatment of the cys-
 titis.  Great care  is to be exercised lest infection should occur through the use
 of unclean catheters.  The treatment of traumatic  and of large renal abscesses
 is mainly surgical.   The abscess is  to be opened, and, if necessary, the dis-
 eased kidney to  be extirpated, according to established surgical principles.


                      Pyelitis—Pyonephrosis.
   Inflammation of the mucous membrane of the renal pelvis is called pye-
 litis.  In  the majority of cases pyelitis  is  due either  to a calculus in the
 pelvis of the kidney or to some  disease of the lower urinary passages, par-
 ticularly cystitis.   A moderate  simple pyelitis is not uncommon as a compli-
 cation of various  infectious diseases or as a result of the elimination of toxic
 substances by the kidney, but  in these  cases  the  affection is not of much
 clinical  importance.

  Anatomical Characters.—The slighter grades of simple pyelitis (often
 called catarrhal pyelitis) are characterized by hyperaemia of the mucous mem-
 brane and  the exudation of a  little mucus and  pus.   In more severe cases
the formation of  pus is greater, and  may produce a considerable sediment in
the urine.  In many of these cases  with profuse production of pus there  is
an obstacle to the passage of the urine, and the pus is retained in the  dilated
pelvis, causing the  condition known as pyonephrosis.   In pyonephrosis the
kidney may take  part in the suppurative  process or it may simply undergo 
PYELITIS.
899
atrophy from pressure.  In extreme cases a large sac containing pus is formed,
the walls of the sac consisting of the atrophied renal tissue and the coats of
the renal pelvis.  In the so-called diphtheritic pyelitis discolored sloughs and
ulcers  are  present in  the mucous membrane in connection with  fibrinous
exudation.   The term diphtheritic is used in this  connection in its  anatomical
sense, and not on account of any relation between this disease and  diphtheria.
In chronic  pyelitis the mucous  membrane usually is thickened in  places and
pigmented,  and the  cavity of the  pelvis contains pus.   As  has  been men-
tioned  in the preceding article, pyelitis is often accompanied with suppurative
nephritis, constituting  pyelo-nephritis.   Chronic  pyelitis with obstruction to
the flow of  urine generally causes a genuine chronic interstitial inflammation
of the kidney, with  lesions like those in the atrophied kidneys of chronic
Bright's disease.

   Clinical History.—The  symptoms  of  pyelitis  vary according to the
variety and the cause of the disease.  The simple pyelitis complicating many
infectious diseases does not  generally give  rise  to  any characteristic symp-
toms.   The leading  symptoms of calculous pyelitis are  the  existence or the
history of  attacks of renal colic, pain in one of the loins, and the occurrence
of mucus,  pus, and blood in the urine.   Calculous pyelitis more frequently
than any other form causes haematuria,  which may be more  or less constant
or paroxysmal.   As a calculus may be lodged in the renal pelvis without the
passage of other calculi along the ureter, there may be no history of attacks
of renal colic.  The  lumbar pain, although not a constant symptom, is of
considerable value in  diagnosis.
   When pyelitis is  the result  of  the extension of inflammation from the
lower  urinary  passages, there  is usually  more  or less  pain in  the lumbar
region.  The pain is not  generally  severe, and it may be slight.  There  may
be some tenderness over the region of the kidney. In severe cases, especially
in those complicated with suppurative nephritis  and in  diphtheritic pyelitis,
there is fever,  which may be of a pyaemic type, and  grave constitutional dis-
turbance.   In chronic pyelitis with  secondary  atrophy of the  kidney the
urine is often greatly increased  in  quantity, and the symptoms of the small
granular kidney may  he developed.
   AVhen there is marked pyonephrosis  a fluctuating tumor  may be appre-
ciated  in the region of the kidney.  Exploratory puncture with a hypodermic
needle will reveal the presence of the pus.

   Causation.—It is  doubtful whether  pyelitis  ever occur as a purely  idio-
pathic affection, although in some cases it may not be possible to discover the
cause.   Pyelitis may be  produced by wounds penetrating the pelvis of the
kidney, but rarely, if ever, by contusions.  One  of the most frequent causes
of this' affection "is the  local  action of calculi.  Such calculi may  occupy a
large part of the renal pelvis and send offshoots  into the calices.   Other for-
eign bodies, such as  parasites  (strongylus gigas, distoma haematobium, and
hydatids) are rare causes.  An important cause of pyelitis is obstruction to
the flow of urine, leading to the accumulation and decomposition of the urine
in the renal pelvis.    In these  cases  some inflammatory irritant  is  present.
The obstruction may be in the  ureter,  the bladder,  or the  urethra.  Such
obstructions are furnished by calculi, tumors, enlarged prostate, stricture of
the urethra, phimosis, and paralysis of  the bladder  in  cases of  paraplegia.
An inflammatory irritant may gain access to the bladder, and thence to the
pelvis  of the kidney,  without  any obstruction to the flow  of urine.  Here
belong the cases of pyelitis secondary to gonorrhoea, to  specific vaginitis and
urethritis in females,  and to  surgical operations in the genito-urinary tract. 
900  ACUTE INTERSTITIAL  OR  SUPPURATIVE NEPHRITIS, ETC.

In these cases cystitis is nearly always present.  Sometimes pyelitis is second-
ary to disease  of the  kidney.   The  pyelitis  secondary to smallpox, scarlet
fever, and other infectious diseases, and that  secondary to the elimination of
cantharides and other toxic substances  from the kidney, is of comparatively
little  practical  importance.   Tuberculous and cancerous  pyelitis  will  be
described subsequently.

  Diagnosis.—The diagnosis of pyelitis is to be based on characters pertain-
ing to the urine in conjunction with more or less pain and constitutional dis-
turbance, cystitis being excluded.
  Pus-cells  and (especially  in  calculous  pyelitis) red blood-corpuscles are
found in the  urine.   To determine that these  cells are derived from the renal
pelvis it is necessary to exclude inflammatory  affections of the bladder and
of the urethra. This can sometimes be done by the symptoms and by physical
exploration.   It is not, however, in all cases possible to exclude cystitis.   In
uncomplicated pyelitis the urine is  generally acid, whereas  in cystitis  it is
usually alkaline, but this rule has less diagnostic value than is often assigned
to it.   On the one  hand the urine  may undergo ammoniacal decomposition
in pyelitis, and on  the other hand  the acid reaction does  not of necessity
exclude  cystitis.  Moreover, an uncomplicated pyelitis is  rare.  In many
cases there is coincident inflammation of the bladder.   It is a prevalent  view
that there are characteristic  epithelial cells lining the renal pelvis, and  that
when these cells appear in the  urine the diagnosis of  pyelitis is established.
It is admitted that these cells are not present  in all cases, and that they are
found more  frequently at  the onset than  in  the later stages of the disease.
The cells considered characteristic of pyelitis  are described as oval, pyriform,
fusiform, and caudate cells.  The presence of these  cells in  the urine is not
pathognomonic of pyelitis.   It is generally admitted by histologists that no
essential differences exist between the epithelial  cells of the bladder and those
of the pelvis of the kidney.  Both  belong to the so-called transitional  type
and are characterized by the variety of forms which they present.  The cell-
forms  which are described as  characteristic of pyelitis may also be derived
from  the bladder.
  The occurrence of paroxysms of pain characteristic of the passage  of a
calculus along  the ureter,  and  the expulsion  of calculi or gravel from  the
bladder, are  important  diagnostic events.  The  sudden discharge  of pus in
more or less abundance with the urine shows that  an accumulation  in  the
pelvis of the kidney has escaped through the  ureter into the bladder.  Some-
times the ureter on  the diseased side  becomes obstructed by  the entrance of
a calculus, and in this  case the  urine which is voided, being excreted only by
the healthy kidney, may be clear and normal in appearance.
  Pyelitis caused by calculi will  be likely to be limited to one kidney, hut if
it follow cystitis or retention of urine from an obstruction beyond the ureter,
both  kidneys will be likely to  be affected.  Complete or very great obstruc-
tion, causing an accumulation of urine within the pelves of both kidneys, leads
speedily to uraemia.   Complete obstruction, however, limited to one kidney,
may exist for an indefinite period without leading to uraemia, the other kidney
being sufficient for the excretion of the urine.  The accumulation of pus in the
pelvis of one kidney may be sufficient to occasion a fluctuating tumor which
may be felt  through the abdominal walls.  This tumor  may attain a large
size, and in women it may simulate an ovarian cyst.   It is to be differentiated
from perinephritic abscess.
  An accumulation of purulent  matter within the pelvis  and calices, if the
ureter remain  permanently  obstructed, generally eventuates in  perforation
and the discharge of the pus in  some direction, provided the life of the patient 
HYDR ONEPHR OSIS.
901
be sufficiently prolonged.  The source of the pus is to be determined  by the
antecedent and coexisting symptoms which point to the seat of the affection.
The pus may make its way in an  outward  direction, giving rise to a subcu-
taneous purulent collection.  It may be discharged  into the peritoneal  cavity,
causing a fatal peritonitis.   A case in which these two events occurred  has
fallen under my observation.  Not infrequently the pus has escaped by per-
foration into the intestine.   It has been known to pass into the pleural cavity
and into the bronchial tubes.

  Prognosis.—The gravity of pyelitis depends much on its causes.  If pro-
duced by an extension of inflammation in cystitis, and if there be no permanent
obstruction  to the flow of urine and pus into  the bladder, a favorable termina-
tion may be looked for.  If due to  the presence of  calculi, and if these make
their way into the bladder before destruction of the kidney ensues,  recovery
will be likely to take place.  If from the size of the  calculi their escape be
impossible,  the  inflammation will  probably continue and the prognosis is
unfavorable.  Cases have been observed of pyelitis caused by a large calcu-
lus in which, after having  led to  complete  destruction of the kidneys,  the
inflammation has ceased and the calculus has remained encysted by the renal
capsule, giving rise to little or no inconvenience, the remaining kidney doing
all the work of renal elimination.  Permanent obstruction to the flow of urine
from the pelvis and calices of both kidneys, dependent on cystitis or retention
of urine in the bladder from whatever cause, leads  to destruction of the renal
parenchyma and  death from uraemia.   An accumulation of urine and pus in
the pelvis and  calices of one kidney may prove fatal by perforation into the
peritoneal cavity.  If the discharge take place either into the intestinal canal
or externally, the  patient is likely to be worn out by the prolonged drain and
constitutional disturbance.

  The treatment in cases of pyelitis must have reference to the causation.
If dependent  on retention  of urine from stricture of the urethra,  enlarged
prostate, or paralysis, measures to  relieve the  bladder  are  of prime import-
ance.    If  consecutive to  cystitis,  the latter claims appropriate treatment,
Quietude is to be  enjoined, especially in  cases in which the affection depends
on calculi.   Soothing  applications to the loins and  anodyne remedies  are
indicated in proportion  to the amount  of  pain.   If  the affection become
chronic, the balsam of copaiba  and other balsamic remedies, also boric acid
and benzoic acid, are sometimes useful.    Liquids  should  be taken  freely in
order to dilute the urine.   If the  accumulation of pus (pyonephrosis) form
a tumor which presents itself in an accessible situation, it should be opened
after an exploratory puncture.   Tonic and supporting measures are  required
after the opening of the abscess either externally or into the alimentary canal.
  AVhen a calculus is lodged in the pelvis of one kidney it may be justifiable
to make an  incision and  extract the calculus or even to extirpate the kidney.
Surgical works are to be consulted for the principles guiding the treatment in
such cases.

                           Hydronephrosis.

  Hydronephrosis is the name given to dilatation of the  pelvis and calices of
the kidney  by an  accumulation of  urine in consequence of some obstruction
in the urinary passages.   This dilatation leads to atrophy of the renal tissue.
The obstruction may be seated in the pelvis, ureter, bladder, or urethra, and
consequently the  dilatation  may involve not only  the pelvis, but also other
parts of the urinary passages.  Thus, if the impediment be in the urethra, 
902  ACUTE INTERSTITIAL  OR SUPPURATIVE NEPHRITIS,  ETC.

this canal behind the obstruction, together with the bladder and ureters, will
be distended if hydronephrosis be produced.

  Anatomical Characters.—Hydronephrosis, especially if the distension
be extreme, in the majority of cases is unilateral.  It may, however, be bilat-
eral, and  it then constitutes  a  graver affection.   The degree of distension
varies  extremely.   It may be insignificant, or the dilatation may lead to the
formation of an enormous sac filling most of the abdominal cavity and contain-
ing several gallons of fluid.  From the pressure of the  liquid in the dilated
pelvis  and  calices  the kidney-substance wastes  and gradually disappears.
At  first the papillae are flattened, and afterward the pyramids  are  further
encroached  upon, and  finally disappear.  The cortical substance  also under-
goes atrophy.   This wasting of the kidney is accompanied usually by increase
of its interstitial tissue.  It is very rare to find the hydronephrosis  and the
atrophy of the kidney so extreme that no remnant of the  renal parenchyma
can be found.   Even in large hydronephrotic cysts it is the rule  to  find a
thin border, or at least islands, of renal tissue upon  the  cyst-wall.   A very
large hydronephrotic sac sometimes  consists of a single cavity.  Usually,
however,  a  number of membranous septa  project  from the wall into the
cavity of  the  sac and give to its external  surface a lobulated appearance.
These  septa partially enclose  smaller cavities or sacculi which represent the
dilated calices, and which,  therefore, communicate by wide mouths  with the
main cavity or dilated pelvis.  These  septa may be prominent or may  be
reduced to  narrow  ridges  on  the inner  wall  of the sac.  The walls of a
hydronephrotic sac  consist, in  addition  to atrophic kidney-substance, of dense
vascular fibrous tissue.  The outer surface may be roughened by adhesions to
adjoining parts. According to the seat  of obstruction one or both ureters may
be dilated.  A dilated ureter may reach the  size and present the appearance
of a coil of small intestine.  AVith unilateral hydronephrosis and considerable
atrophy of the kidney the other kidney is often hypertrophied.
  The liquid  contained  within a hydronephrotic cyst varies in  its composi-
tion.  It usually has the appearance  of watery urine.   It is clear  in most
cases, but it may be discolored and rendered somewhat turbid by admixture
with blood,  pus, or epithelium.  The specific  gravity  is low, and the reaction
often slightly alkaline.  The  urinary  constituents  are  usually present, but
urea and uric acid may be in small amount or even  entirely absent.   A small
quantity of albumen is almost invariably found.  In a few cases the contents
have consisted of a gelatinous, colloid  substance.  Paralbumen, the modified
form of albumen present in ovarian cysts, has  also  been  discovered in the
fluid of hydronephrosis.

  Causation.—The causes of hydronephrosis are conveniently divided into
congenital, and  acquired.   Of 52 cases of hydronephrosis collected  by Sir
AArilliam Roberts, 20 were congenital.   Congenital causes are the following:
1, A supernumerary renal  artery  crossing and  compressing  the ureter near
its origin ;  2, narrowing or  obliteration of the  orifices or of the lumen of the
ureter; 3, a valve-like impediment produced  by an oblique insertion of the
ureter  into  the  pelvis; 4, the insertion of the ureter into  the upper instead
of the lower part of the pelvis;  5, certain abnormalities of the bladder or of
the urethra, as vesical diverticula, atresia of the urethra, etc.  Congenital
hydronephrosis is  often  associated with malformations of other organs, as
imperforate anus, hare-lip, etc.
  The causes  of acquired  hydronephrosis may he classified  as  follows: 1.
The impaction of substances  in  the renal pelvis or  in the ureter.   Calculi
impacted in these parts are among the  most frequent  causes of this affection. 
HYDR ONEPHR OSIS.
903
Much less frequently the lumen of the ureter is obstructed by coagula of
blood or by parasites (echinococcus).   2.  Disease of the walls of the ureter,
causing partial or complete  obliteration  of  its lumen.   To this group of
causes belong inflammatory thickening, cicatricial stenosis from  ulcers, and
tumors, especially cancer.  3. Pressure upon the ureter  from without.   The
causes of  pressure include pelvic tumors, inflammation of the pelvic  connect-
ive tissue  or of the pelvic peritoneum, prolapse of the uterus, retroflexion of
the pregnant or of the non-pregnant uterus, and distension of the rectum.  Can-
cer of the cervix  uteri is very frequently complicated by hydronephrosis.  It
is  exceptional for hydronephrosis to be caused by the pressure of an ovarian
cyst,   The newly-formed fibrous tissue resulting from parametritis and  from
pelvic peritonitis  may compress the ureter.   Some of the causes  named pro-
duce  hydronephrosis—not by  pressure,  but by exerting traction upon the
ureter and so causing bends and distortions in its course.  4. Diseases of the
bladder which involve one or both  of the orifices of the ureters.   This  class
of causes comprises hypertrophy of the coats of the bladder, abscess in the
vesical  wall, neoplasms, particularly cancer, and large calculi.  5. Affections
narrowing the calibre of the urethra.   These causes are stricture  and the
so-called  hypertrophy  of the prostate.  In a few cases hydronephrosis has
been  attributed to phimosis.   Hydronephrosis  does not follow these causes
until after the bladder has  become  incapable of overcoming the  urethral
obstacle.   In  cases of  urethral  obstruction, therefore, hydronephrosis is due
to a  secondary affection of the bladder.   6.  In not a few cases no cause of
the  hydronephrosis  has been  found.   AVith  some of  the  largest hydrone-
phrotic sacs the autopsy failed to reveal any impediment to the flow of
urine.  In some  of these cases it  is believed that a calculus, once impacted
in the ureter, has been dissolved or dislodged.  In other cases it is  probable
that some not very obvious  cause  escaped detection.  The largest hydrone-
phrotic cysts are found more  frequently with partial  than  with complete
obstruction in the ureter.

   Clinical  History.—AVith double  congenital hydronephrosis the foetus is
generally not viable.   There are cases, however, in which life has been  con-
tinued in  apparent health for  many  years.  A moderate degree of hydro-
nephrosis, whether unilateral  or  bilateral,  is  unattended by  recognizable
svmptoms.  One kidney may be destroyed by the development of  a hydro-
nephrotic  sac without  any symptoms referable to  this condition.   In this
case the other kidney, which is usually hypertrophied, excretes the normal
quantity of urine.  If, however, the ureter of the remaining  kidney become
permanently obstructed, death ensues within a few days with  symptoms of
uraemia.  In cases of double  hydronephrosis the condition is manifestly grave
if the renal tissue be  sufficiently  impaired  to interfere with  its functions.
Under these  circumstances  the urinary  constituents  are imperfectly elimi-
nated  from the body, and death ultimately ensues, usually with the manifes-
tations of uraemia.  An important diagnostic  sign of hydronephrosis is the
discovery of a tumor  in the lumbar  region.  It  is only when the  hydrone-
phrotic sac is of  considerable size that a tumor can be detected.   The tumor
is fluctuating and presents  in  some  cases a lobulated surface.  It has the
characteristics of a tumor taking its origin  from the kidney, among  the most
important of  which  is  the  existence  of  the  tympanitic resonance of the
colon over its anterior  surface.  This sign, however, may be  wanting, the
colon being pushed to  one side by the tumor.  A symptom of almost  path-
ognomonic value is the  disappearance of the tumor coincident with the dis-
charge of a large quantity of  pale liquid by the  bladder.  This symptom is
not  common.   It is, of course, present  only when the  obstacle, to  the flow 
 904  ACUTE INTERSTITIAL  OR  SUPPURATIVE NEPHRITIS,  ETC.

 of urine is removed or when there is only incomplete obstruction, which latter
 is more frequent.   A hydronephrotic tumor is not painful.  It may give rise
 to symptoms by compression of other parts. Thus obstinate constipation may
 be due  to compression of the colon.  The urine presents no abnormal charac-
 teristics in most cases of hydronephrosis.  As already mentioned, it may be
 suddenly increased in amount by discharge of the contents of  the cyst.   If
 both kidneys be so much involved  that their  function is interfered with, the
 urine is usually diminished in quantity.  Important symptoms may be refer-
 able to  the  conditions  causing hydronephrosis, such as those of renal colic,
 uterine cancer, etc.

   Diagnosis.—If the  accumulation of liquid  in the renal pelvis be small, the
 disease  cannot be diagnosticated. The recognition of one or more of the various
 causes of hydronephrosis which have been mentioned is of great importance in
 the diagnosis.  The presence of a tumor and  its  subsidence or diminution in size,
 coincident with the discharge of a large quantity of urine, are symptoms which
 are sometimes available in making the diagnosis.   Large hydronephrotic sacs
 filling  the  greater part of the abdominal cavity may be mistaken for ascites
 or for ovarian cysts.   Such sacs have repeatedly been mistaken for  ovarian
 cysts, and have been punctured on this supposition.  The attempt has even
 been made  to remove  hydronephrotic cysts by laparotomy under the belief
 that an  ovarian cyst was present.  Some  of the characteristic signs of an
 ovarian cyst have been  mentioned on  p. 591.   It must be admitted  that in
 some  cases  the diagnosis  is very  difficult.  The  presence or absence of urea
 in liquid withdrawn by an exploratory puncture cannot serve as a diagnostic
 point.   Urea may be present in fluid from an ovarian cyst.  It  is frequently
 small in amount, and may be absent  in  hydronephrosis.  The  colon is often
 present over a hydronephrotic cyst,  and it is found very exceptionally in
 front of an  ovarian cyst.  (The reader is referred to the article on Ascites for
 the symptoms and  physical signs of  this condition, p. 587 et,  seq.)    Hydro-
 nephrosis may be confounded with pyonephrosis.   AVith the latter condition
 there  is more constitutional disturbance with  rigors  and hectic fever.  The
 presence of pus in the fluid removed by  exploratory puncture renders  the
 diagnosis of pyonephrosis positive if  other sources of pus can be excluded.
 The diagnosis also involves the  exclusion of hydatid cysts of the  kidney,
 perinephritic abscess, and large renal cysts.

  Prognosis.—The prognosis of  hydronephrosis  depends upon the extent to
 which the  functions of the kidneys are  interfered with and the consequent
 danger of uraemia.  Unilateral  hydronephrosis is unattended with danger so
 long as  the  remaining  kidney does  its work adequately;  but if this  kidney
 become  diseased or if its ureter become obstructed, life is endangered.  Dou-
 ble hydronephrosis  is grave in proportion  to the liability to uraemia.  The
 liability to rupture of a hydronephrotic sac is so slight that it  hardly enters
 into the prognosis.

  Treatment.—An important object in the treatment is the removal of  the
 cause of obstruction.   This cannot often be accomplished.  The measures to
 be pursued  for that object in  individual  cases  are to be determined by  the
 nature  and  seat of  the obstructing cause.  In some instances, by means of
 rubbing  and kneading  over the  sac  or  along the course  of the ureter, an
 obstruction has been overcome  or the urine has been made to pass beyond
the obstructed part.  These manipulations  should not, of course, be so forci-
ble  as to cause pain or  to  incur any risk of rupture.   Removal of the liquid
by  aspiration  has  proved successful.   Using a small aspirating needle or 
              RENAL COLIC AND  NEPHROLITHIASIS.           905

trocar, this measure is attended with little if any danger of the escape of the
liquid into the peritoneal cavity.  For  this reason it is to be preferred to tap-
ping without aspirating.  The treatment in other respects is to be governed
by the local  and general  symptoms in each  case.   Free opening of the sac
and drainage and  the entire removal  of the  tumor are surgical  procedures
which  have thus  far been  attended by favorable  results.


                Renal Colic and  Nephro-lithiasis.
  Urinary concretions or calculi are generally formed within  the  renal cavi-
ties.  Calculi of small size may pass from the kidneys to the bladder, giving
rise  to little or no inconvenience, and, having reached the bladder, thev are
either discharged  with  the  urine, or, remaining in  the bladder, they increase
in size  and may  require  surgical interference for  their removal.  In some
cases calculi within  the renal cavities, increasing  in  size, become too large
to pass along the ureter,  and are consequently retained.  As has been seen,
retention of urine within  the pelvis and calices of the kidney, pyelitis, renal
abscess, and destruction of the renal parenchyma are  sometimes attributable
to the presence of calculi or a calculus.   A  calculus retained in the pelvis
of the kidney may continue to increase in size, and, leading to  atrophy of
the  parenchyma, it may acquire a bulk  nearly as  great as, or perhaps even
greater than, that  of the healthy organ. Calculi not too large to  pass through
the ureter, and not small  enough to pass with facility, occasion during their
passage more or less  pain and constitutional  disturbance.  The amount  and
duration of the pain  caused by the passage of a calculus are in proportion to
its size and the  roughness of its surfaces.   The  pain begins  when the calcu-
lus enters the duct, and ends when it reaches  the bladder.   The paroxysm is
analogous to that occasioned by the passage  of a  gall-stone from the  gall-
bladder to the duodenum.  The latter is  commonly known  as hepatic colic,
and  the  paroxysm of pain  occasioned by the  passage of a renal  calculus is
called renal colic.   In rare  instances attacks  of renal colic are produced by
the passage of coagulated fibrin and of an hydatid vesicle through the ureter.
   A paroxysm  of renal  colic is usually  developed suddenly.  The attack,
however, may be  preceded by  more  or less  pain   or a sense of uneasiness
due  to irritation or perhaps inflammation  caused by the presence of calculi
in the pelvis of the kidney.  The paroxysm quickly attains its maximum
of intensity.  The pain in some  cases  becomes exceedingly intense.  It is
referred  to the  situation  of the kidney on one side;  that is. by the side of
the  last  dorsal  and the first  lumbar vertebrae.  The  pain radiates from  this
point in different directions,  but  especially along  the course of  the  ureter,
extending frequently to the  groin and thigh.   In the male, pain is generally
felt  in  the  testicle, which  is often, but not  always, drawn  upward  by the
contraction  of the cremaster muscle.   Frequently the  pain  is. described as
lancinating  or tearing.  It  is sometimes so excessive as to force  the patient
to groan and cry aloud; he tries a  variety of  positions to obtain relief, walks
about  the chamber, and compresses the  abdomen with the hands  as in intes-
tinal colic.  The pain continues without intermission,  but there occur exacer-
bations and remissions.  The urine in  most cases is notably diminished.   The
patient experiences a frequent or constant desire to micturate, passing only a
few  drops at a time.  The sensation is well expressed by the term tenesmus
of the lladder.  Xot infrequently the urine is bloody.  If it contain pus or
muco-pus, either pyelitis  or cystitis coexists.
   AVith these local symptoms are associated those  denoting more  or less  con-
stitutional disturbance—namely, anorexia, thirst, nausea, and vomiting, cold-
ness of the surface  with sweating, and feebleness of the circulation.   The 
 906  ACUTE INTERSTITIAL  OR SUPPURATIVE NEPHRITIS,  ETC.

 countenance is pallid and expressive of  anguish.   Suddenly, after a duration
 varying considerably in different cases, the paroxysm ends.   The pain abruptly
 ceases.   An  abundant discharge of urine  takes  place.   The calculus has
 reached the bladder, and if care be taken for some  time afterward to examine
 the urine it  may be found  at the bottom of the vessel.   As the passage of
 a calculus  by the urethra, even of one which has  caused  severe  renal  colic,
 may occasion no pain, it is no proof that a calculus is retained in  the bladder
 that its  escape with  the urine  has not been noticed.   The  general symp-
 toms rapidly disappear, and in one or two days the  recovery may be complete.
 In some cases, however, one or more additional paroxysms follow, other calculi
 contained  within the  pelvis of  the kidneys entering the  ureter  in conse-
 quence of  the dilatation  caused  by the calculus which  has just  passed.  A
 person who has experienced one  paroxysm  is liable to recurrences at  periods
 more or less  remote.   Not infrequently,  however, there is  no recurrence of a
 paroxysm.
   The duration of  an  attack of renal colic varies in  different cases, but it is
 usually short.   In  the majority of cases it lasts but a few hours, but in  some
 cases it continues for one, two, or three days.  Although  the suff'ering is often
 extreme, it very rarely proves fatal.   A  persistent  impaction of a calculus in
 the ureter, causing obstruction, is followed  by hydronephrosis, and following
 this pyelitis and pyelo-nephritis may become  developed.  Ulceration may take
 place at the point of the obstruction, and fatal peritonitis may be produced by
 the escape of urine into the peritoneal cavity.  These are  sources of  danger
 happily of rare occurrence.   Simultaneous obstruction of both ureters by cal-
 culi has been known to occur, causing anuria and uraemic poisoning.
   The diagnostic characters of renal colic are—the suddenness of the attack
 and termination, the  situation of the pain  and its  extension to  the groin,
 thigh,  and testicle,  the retraction of the  testicle, the diminution of urine, the
 tenesmus of  the bladder, haematuria in  some cases, and  the discovery of the
 calculus.   The fact of antecedent attacks having  occurred will assist in the
 diagnosis.  The affections to be  excluded are—the form of muscular rheu-
 matism called lumbago, lumbo-abdominal neuralgia,  enteralgia, and hepatic
 colic.  In  lumbago the pain is less  severe,  is provoked especially by move-
 ments  of the body, and is felt on  both  sides.  Lumbo-abdominal neuralgia
 is characterized by tenderness at certain points. (Vide p. 805.)   In enteral-
 gia the seat of the pain is within the abdomen.  This statement also applies to
 hepatic colic.   In  all these  affections  the characteristic features of nephritic
 colic are wanting.
  The  treatment  of  an attack of renal colic consists of palliative measures.
 Complete relief  depends on  the escape of the calculus into the bladder, and
there are  no  means of aiding  directly in effecting its passage.  The propel-
ling force is derived from  the accumulation  of urine  behind the calculus and
from the peristalsis of the muscular coat of the ureter.   The  copious inges-
tion of liquids may, by increasing the urinary secretion, hasten its  progress.
 Fomentations to the loins,  the warm bath,  morphia  given hypodermically,
and. if the suffering be excessive, the  inhalation  of chloroform,  constitute
the measures for palliation.

  The  discharge of urinary concretions from the body, either with or without
the symptoms of  nephritic  colic, constitutes lithiasis or gravel.   The  term
"gravel" is properly applied only to concretions formed  within the body, not
to those which form in the urine after its emission.  Not infrequently concre-
tions varying in size from that of a pin's head to a small  pea pass through
the ureter  without  giving rise  to sufficient  pain to constitute an attack  of
renal colic.   The composition of the concretions varies in different cases.   In 
               RENAL COLIC AND  NEPHROLITHIASIS.           907

 a large majority of cases (five-sixths)  they consist of uric acid.   The  urine
 in  these  cases is always acid.   The concretions may consist of the earthy
 salts—namely, the phosphate  of ammonia and  magnesia, the phosphate of
 lime, and the carbonate of lime.  Concretions of  carbonate  of lime are ex-
 tremely rare in human urine.   Ammonio-magnesian calculi are liable to form
 in  cases of cystitis.   These concretions  are  generally not  renal but vesical.
 The urine in these cases is usually alkaline.   In another variety the concre-
 tions consist of the oxalate of lime.   In frequency these come  next to the
 uric-acid  caFculi.   They are known as mulberry calculi.   In cases of  renal
 colic the composition of the calculi which occasion  the paroxysms may be
 inferred from the knowledge of concretions which  have been already passed
 and from an examination of the sediment which the urine deposits.  If the
 urine contain uric-acid crystals  or abound in  the urates or have an  acid reac-
 tion, the calculus is  probably  composed  of uric  acid; and  the urine will be
 likely  to  contain  the  phosphates in more or less abundance when the cal-
 culi consist of the earthy salts.  Oxalate-of-lime or mulberry calculi will be
 likely  to be preceded  or accompanied  by oxaluria.   Oxaluria is  not, as was
 formerly supposed, attended by any characteristic symptoms.  It may happen,
 however,  that the calculi giving rise to  renal colic are not  of recent forma-
 tion, and  the condition of the  urine giving rise to their formation may not
 exist at the time when the  attack of colic occurs.   A variety of calculus, so
 rare as to be a curiosity, consists of xanthine.  Another  rare variety is the
 cystine calculus.   The  condition of the urine in which the  latter  occurs is
 called cystinuria.   In this  condition the urine contains hexagonal tablets of
 cystine.  This, more than  any other form of lithiasis, has been shown  to be
 hereditary.   Cystinuria may exist without the formation of calculi.  It lasts
 for a  long time, and  sometimes  continues indefinitely.
   The  treatment of nephrolithiasis, irrespective of attacks of renal  colic,
 will depend on  the nature of  the concretions or the character of the urine.
 In cases  of  uric-acid gravel alkaline  remedies  are  indicated.  The liquor
 potassae, in half-drachm doses thrice daily, may be given, but either  the bicar-
 bonate or  the  citrate of potassa, a drachm twice daily, is preferable.  The
 Alchy water and  the waters of other alkaline springs are well suited to this
 variety of gravel.  The phosphate of  soda and  ammonia, introduced by Dr.
 Buckler of Baltimore, is considered as having the power of keeping uric acid
 in solution in the  urine, given in doses  of ten grains thrice daily.   The phos-
 phate of soda in doses of from  a drachm to six drachms is  recommended by
 Heller.  The benzoic acid is another remedy, given in doses of eight or ten
 grains thrice daily.  Lithia in  the form  of the  carbonate and the benzoate
 was introduced by Garrod as a remedy  which promised to he  especially  valu-
 able from its forming with  uric acid a highly soluble  compound.  It may be
 given in doses of  five grains three times daily.   All  these remedies act as
 solvents and as preventing uric-acid concretions.  In addition to these rem-
 edies attention to  the digestive  organs, the skin, and the functions  generally
 constitutes an important part  of the treatment.   Liquids should  be  taken
 freely  between meal-times  in order to dilute the urine.   The  diet should
 consist  mainly of  the  white meats, milk, eggs, and farinaceous articles.
   In cases in which the concretions are composed of the earthy salts the min-
 eral acids are indicated, either the  sulphuric or  hydrochloric.   The  nitro-
hydrochloric  acid  is  especially  indicated in  cases  of  oxalate-of-lime gravel.
Diuretic remedies and  the  ingestion of  pure spring,  river, rain, or distilled
water abundantly  form a highly important part of the treatment in all cases
of gravel.   The Hygeia water may be especially  recommended for its purity.
The phosphatic and oxalate-of-lime concretions often  occur in persons suffer-
ing from nervous asthenia, and the latter condition claims appropriate manage- 
908  ACUTE INTERSTITIAL  OR  SUPPURATIVE NEPHRITIS, ETC.

ment.  Abstinence from articles of diet containing oxalic acid is to be enjoined
if the concretions consist of the oxalate of lime.
   As already  stated, the sedimentary deposits which occur in  urine after its
emission are not properly called gravel.  It is  important, however, to take
cognizance of these as constituting evidence of  disorder and as involving a
liability to the formation of concretions  within the kidney or  bladder.  The
conditions of the urine known as lithuria, oxaluria, and phosphoruria, standing
respectively in relation to the different varieties of gravel just noticed, claim
appropriate treatment, although concretions within the  body have  not  taken
place.   (For further details respecting these and other disordered conditions
of the  urine, the reader is referred to works devoted to urinary affections.1)
                       Perinephritic Abscess.

   Inflammation of the connective tissue surrounding the kidney is called peri-
nephritis.  The tissue involved is the  lax  adipose tissue in which the kidney
is imbedded (the  so-called adipose capsule of the kidney) and the neighboring
retro-peritoneal tissue.  It is possible to distinguish an adhesive and a suppura-
tive variety of perinephritis.  The former is characterized by the development
of new connective tissue.   It accompanies tumors and some other diseases of
the kidney. Adhesive perinephritis has no clinical importance, and will receive
no further consideration in this  article.  Suppurative perinephritis  or  peri-
nephritic abscess  is not a frequent disease, but it is attended by characteristic
symptoms  and merits separate consideration.  On post-mortem examination a
collection of pus is found occupying the situation of the adipose and connect-
ive tissue  around the kidney.   There may be a  number of circumscribed
abscesses, but, as  a rule, there is a single abscess-cavity.  The walls of the
abscess may consist of shreddy necrotic tissue, or in old cases of tough fibrous
tissue. The abscess varies as regards size and the direction in which it extends.
It may be  confined to the tissue immediately surrounding the kidney, but not
infrequently the pus burrows in various directions.   In the majority  of cases
it extends  backward  and  opens externally in the lumbar region.  The  pus
may make its way into the sheath of the psoas  muscle and extend along the
course of  this  muscle to  Poupart's ligament, below  which  it may  be  dis-
charged.   The  abscess may extend in the retro-peritoneal tissue toward the
diaphragm, and may open  by perforation into the  pleural cavity or into the
lung.  The abscess may make its way behind the peritoneum into the pelvis.
The peritoneum  over the  abscess  is usually thickened.  It  is rare  for the
abscess to open into the peritoneal cavity.  More frequently the colon in some
part of its course is  perforated and the pus is discharged into this viscus.
Perinephritic abscess has been known to open also into other parts of the intes-
tine, into the bladder, and into the pelvis of the kidney; and it may discharge
its contents externally in directions other than those named, as in the  gluteal
region and in various parts of the abdominal parietes.   AVhen allowed to dis-
charge its  contents spontaneously, the abscess  most frequently opens exter-
nally in the lumbar region.   The pus in perinephritic abscess often contains
shreds of necrotic tissue.   It may be good and laudable or it may be thin and
ichorous.   The latter is particularly likely to be the case  when  the abscess is
accompanied by infiltration of urine.  In very rare instances the abscess has
a gangrenous character.  AVhen the abscess is secondary to calculous pyelitis
calculi may be found in the abscess-cavity if ulceration of the pelvic walls or
of the kidney have occurred.
  1 Thudichum on the Pathology of the Urine, and Roberts on Urinary and  Renal  Dis-
eases, may be especially mentioned. 
PERINEPHRITIC ABSCESS.
909
   Of 166  cases of perinephritis  collected by Nieden,1 70  per cent, were in
males and 30  per  cent, in females; 26 cases were in children.   From an eti-
ological point  of view it is important to distinguish between primary and sec-
ondary perinephritic abscess.  Secondary perinephritis is much more common
than the primary form.  The causes of primary perinephritis are traumatism
(especially contusions  and wounds in  or about the kidney), muscular strain,
exposure to cold, and severe acute general diseases.  AVounds of the kidney
are by no  means  necessarily followed  by suppurative  inflammation.   Peri-
nephritis has  been known to develop  in  the  course of pyaemia, of smallpox,
and of typhus and of  typhoid fever, but this complication is extremely rare.
Secondary perinephritis is  due to disease of neighboring organs.  The most
important of this second group of causes are affections of the kidney; above
all, suppurative pyelitis and pyelo-nephritis  in consequence of the irritation
of calculi.  Tuberculous inflammation of  the kidney has also  been complicated
in a few cases by  perinephritic abscess.   Tumors of the kidney, the rupture
of renal cysts, and the presence of parasites in the renal pelvis are among the
rare causes of this disease.   Perinephritis has been attributed to the exten-
sion of inflammation from an inflamed bladder.   It has  been  observed more
frequently  to follow  pelvic cellulitis,  especially inflammation of the  connect-
ive tissue  about  the  uterus.  Psoas abscess, which so often accompanies
caries of the vertebrae, may give  rise  to  perinephritis, but in  most cases the
thickened sheath of  the psoas is  an effectual barrier to this extension of the
inflammation.   Perinephritis may follow typhlitis and perityphlitis;  or, in
fact, any suppurative  process involving  the retroperitoneal  tissue.   Finally,
there are cases  of perinephritis  for  which no cause is  discoverable.
   Pain, increased by motion, is one of  the prominent symptoms.  It is referred
to the seat of  the  inflammation, and shoots downward to the lower limb.  It
may extend to the testicle, but there is no retraction of the testicle if the kid-
ney be not  affected.   There is tenderness on deep pressure.   The patient is
confined to the bed and lies  with the limbs flexed.  There is  more or less
increase  of body-heat, with  the  usual  concomitants of fever.  Bigors and
perspirations are likely to occur.  After a variable period a tumor is felt in
or a little below the  lumbar  region.  Fluctuation over the site of the  tumor
may be  felt,  but this for some time is not readily appreciable.  There is
subcutaneous  oedema  over the tumor.  The urine is unaffected unless the
kidney be  involved.    AVith reference to the local symptoms  and the  diag-
nosis the liability of the purulent collection to descend below  Poupart's liga-
ment, to open into  the intestine, the bladder, or the vagina,  and  in  some
instances into the pleural cavity and the bronchial  tubes, is to be  borne in
mind.
   The diagnosis is  to be based on the presence and situation of the tumor, in
conjunction with  the  local and  general symptoms denoting  inflammation.
The symptoms resemble those of suppurative nephritis and pyelitis.   These
affections are to be excluded  by examinations of the  urine.  In suppurative
nephritis the quantity  of urine is  notably diminished, whereas in perinephritic
abscess  there  is no  interference  with the  renal secretion.   The urine in the
latter affection contains neither blood  nor casts, and but little if any albumen.
In pyelitis, with which suppurative  nephritis  is often  associated, the  urine
contains  pus,  and  often blood.
   As soon  as the nature of the affection is ascertained or rendered probable
the tumor should be explored, and in  this way the presence of  pus is demon-
strated.  There  should then be  no delay  in opening the abscess in order to
forestall a spontaneous opening in an unfavorable  direction.   Bowditch has
reported 3 cases in which an  external opening was made, all ending in  recov-
   1 "Ueber Perinephritis," Deutsches Archiv fur klin. Med., Bd. 22, p. 451, 1878. 
910         STRUCTURAL DISEASES  OF  THE KIDNEY.

ery. A considerable hemorrhage followed the opening in 1 of the cases.  In
2 of the cases the kidney was felt by the finger at the  bottom of the-abscess.1
Gibney has  reported  2s" cases of perinephritis in children, suppuration more
or less extensive  occurring  in  16.   In 14  of these  cases  the  abscess was
opened by incision, and in 2 cases the opening was spontaneous. AVith a single
exception, in all of the 16 cases recovery was  complete.   A little lameness
remained in  the  excepted case.  Gibney is  of the opinion  that  in a certain
proportion  of the cases  of reputed  recovery from hip-joint-disease without
lameness or  deformity the aff'ection is  in  reality a perinephritis.'-
                       CHAPTER  III.

STRUCTURAL  DISEASES  OF  THE   KIDNEY.—HEMATURIA.—
  HEMOGLOBINURIA.—DIABETES  INSIPIDUS AND DIABETES
  MELLITUS.—SEXUAL  DISORDERS.

Renal Cysts.—Cystic Degeneration of the Kidneys.—Hydatids of the Kidney.—Renal
  Tuberculosis.—Carcinoma of the Kidney.—Movable Kidney.—Renal Hsematuria.—
  Endemic Haematuria.— Hemoglobinuria.— Malarial  Haematuria.— Chyluria.— Dia-
  betes Insipidus.—Diabetes Mellitus: Clinical  History; Causation; Diagnosis; Prog-
  nosis ;  Treatment.—Involuntary Seminal Emissions.—Spermatorrhoea.—Impotence.

   THE  kidneys are sometimes the  seat of affections involving  structural
    changes other than those already considered.   Carcinoma and the tuber-
culous affection occasionally occur in these organs.   Hydatids and cysts are
additional affections in this category.   Some of the  structural affections of
the kidney  are of greater pathological than clinical  interest.  These  will
receive  only brief consideration.


     Renal Cysts—Cystic Degeneration of the  Kidneys.

  The occurrence of cysts in chronic Bright's disease, especially in the small
granular kidneys, has already been mentioned.  These cysts are rarely larger
than a pea.   They  frequently contain a colloid substance.   They  are devel-
oped chiefly in  the cortical substance.  They are attributable to dilatation of
Bowman's capsules and of portions  of the  uriniferous  tubes.  Similar cysts
are often found in senile atrophy of the kidney.   Cysts may be  formed in
otherwise healthy kidneys.  These are of pathological rather than of clinical
interest.
  Sometimes the  kidney is  converted  into a mass of cysts  between which
little or no renal parenchyma can be discovered.   This is  the cystic kidney
or cj/sfic degeneration of the  kidney.  Sometimes only one,  hut usually both
kidneys  are affected, although not  necessarily in  the same degree.  Cystic
degeneration of the kidney may be  a congenital  or an acquired condition.

  1 Boston Medical, and Surgical Journal, July 9, 1868.
  2 A'ide articles by Dr. AT. B. Gibney in the American Journal of Obstetrics, April, 1876 ;
in the American Journal of the Med iced Sciences, April, 1S77, and Oct., 1878; and in the
Chicago Medical  Journal,  June, 1880.  To the last of these articles  is added a full bib-
liography of  this disease. 
ECHINOCOCCUS  OR HYDATIDS OF THE KIDNEY.
 Cystic  kidneys  developed  during intra-uterine life may attain an enormous
 size, so as to prove a serious mechanical obstacle to the birth of the foetus
 The severe grades of this degeneration render the foetus non-viable, but the
 lighter grades can be tolerated  after birth.  In many cases there is some
 other malformation in the body.   Cystic degeneration of  the kidney is  less
 frequent in adults than in the foetus.   The causes and the symptoms of  this
 condition are not well understood.  An advanced decree of cystic defenera-
 tion is sometimes found at autopsies of persons who had presented no%ymp-
 toms referable to the kidneys during life.   There is no doubt, however,* that
 the functions  of the  kidneys may be  so impaired  by the  cystic formations
 that death may  result therefrom,  usually with uraemic symptoms.  Sometimes
 uraemia develops rapidly.   In the recorded cases the  urine has been rather
 increased than  diminished in quantity.  The specific gravity is low.  Albu-
 minuria is a frequent but not a constant symptom.   The development  of a
 tumor is an important symptom  in some cases.   AVithout  this symptom the
 diagnosis is impossible, and with  it the existence of cystic defeneration is not
 easily determined.  Hypertrophy of the heart has been known to result from
 cystic metamorphosis of the kidneys.  In most  cases in which renal symp-
 toms developed  the affection  had  been considered as Bright's disease prior to
 the autopsy.   No  other mode of  formation of renal cysts than by dilatation
 of  the tubes and of Bowman's capsules has been proven.


           Echinococcus or  Hydatids  of the Kidney.

  Hydatids in the kidney are in all respects similar to those in other organs—
 for example, the liver (vide p. 618 et seq.)—and a description  of them need
 not be here repeated. They occur in the kidney more  frequently than in any
 other organ except the liver and the lungs, but according to  Davaine they
 are twelve times  less frequent in  the kidney than in the liver.   Men  are
 oftener affected  than women.  The disease is rare in this country.  One  kid-
 ney only is affected as a rule to which  there are very  few exceptions.  They
 do  not, therefore, diminish the excretion of urine sufficiently to occasion urae-
 mia.  If they interfere with the  excretory functions of the affected kidney,
 the augmented  functional activity of  its fellow makes up for the deficiency.
 So long as an hydatid cyst remains intact within the renal parenchyma, it gives
 rise to no well-marked symptoms, and it may remain completely latent for an
 indefinite  period.  It has  been found  after death when no renal trouble had
 been manifested during life.  It  may  attain a sufficient size to form a tumor
 perceptible by palpation.  The  symptoms to which it  gives rise depend on
 inflammation, ulceration, and the discharge of echinococci in different direc-
 tions.
  If hydatid cysts open into the pelvis of the kidney, the echinococci pass
 through the ureter into the bladder and are discharged with the urine.   In
 their passage along the ureter they may give rise to the same train of symp-
 toms as the passage of a renal calculus; in other words, to renal colic. They
may also give rise to more or less trouble in their passage through the urethra.
 Owing to their elasticity, echinococci of considerable size may pass  into  the
bladder and through  the urethra without great difficulty and without much
pain.  Cases have been reported in which they were discharged in great num-
bers.  Their passage  may be accompanied by haematuria  and pyuria.   The
latter is due to suppuration of the hydatid cyst or to pyelitis.   The opening
of the cyst is most frequently into the  pelvis of the kidney.  Echinococci may
form the nuclei of  calculi in the pelvis of the kidney or in the bladder.
  The  hydatid cyst sometimes develops in a direction  toward the surface of
the  kidneys and  opens into the circumrenal areolar tissue.  Suppuration takes 
912          STRUCTURAL  DISEASES OF THE KIDNEY.
place and  an abscess forms in the lumbar region, which when opened  or
allowed to  open  spontaneously gives exit to echinococci together with pus  in
greater or  less quantity.   Hydatid cysts in the kidneys have been known  to
open into the stomach, intestinal canal, and even into the  lungs, the echino-
cocci  in  the latter case  being  expectorated.   It is possible that here, as  in
other situations, the parasites sometimes die, and  the  cyst contracts and be-
comes obliterated, or contains a certain amount  of calcareous matter, a sponta-
neous cure in this way taking place.  Instances of this, however, are extremely
rare, and their occurrence has been denied.
   The diagnosis, prior to the discharge of the contents of the hydatid cyst
in some  one of  the situations named, can be made positive only by a micro-
scopical examination  of the liquid  contained in the cyst, obtained by means
of an exploratory puncture and aspiration.  The  diagnostic characters per-
taining to the liquid are the same  as in hydatids of the liver.  (Vide p. 621.)
The hydatid fremitus is a sign rarely available in cases of renal echinococcus.
Hydatids in the kidney are sometimes not readily differentiated from hyda-
tids in the  liver  or the spleen.   Simon recommends an exploration  by means
of  the hand introduced within the large intestine,  in  order  to determine
whether  the hydatid  tumor be  renal or not.1
   The treatment is chiefly surgical.   An attempt should first be made to
destroy the parasite.   For this  simple  aspiration sometimes suffices.  Elec-
trolysis is  sometimes effectual.   The more effective measure is opening the
cyst.   Simon's operation is as follows : He thrusts in two canulae, and allows
them  to remain until adhesions have formed, and then he connects by incision
the two openings made by the canulae.   When the tumor is large enough to
cause projection  of the abdominal parietes it is time to resort to surgical inter-
ference.  Simon advises first to make trial of aspiration and electrolysis.  These
are harmless measures.  If at the end of six months they be found not to have
succeeded,  the cyst should be opened in the manner just described.


              Renal Tuberculosis—Renal  Phthisis.

   Tubercles appear in the kidneys in the following conditions: 1, In acute
miliary tuberculosis;  2, as a secondary event  in pulmonary phthisis;  3, in
primary tuberculosis  of the genito-urinary organs.    Miliary  tubercles are
usually present in the kidneys in acute  miliary tuberculosis.  They give rise
to no symptoms, and therefore do not claim  clinical consideration.  So, too,
the few miliary  tubercles or somewhat larger caseous nodules which are fre-
quently found in the kidneys in  pulmonary phthisis are without clinical sig-
nificance.
   There may be formed in the kidney large and small  cheesy masses, accom-
panied usually by ulcerative destruction of the  affected tissues and by similar
caseous deposits  in the renal pelvis, the ureter,  and other parts of the genito-
urinary apparatus.  This condition is called renal phthisis, nephro-phthisis, or
genito-urinary tuberculosis.  Extensive tuberculous infiltration of the kidneys
and other parts of the genito-urinary system may be secondary  to pulmonary
tuberculosis, to  tuberculosis of bone, or to tuberculosis in other situations,
but it is most frequently a primary disease.   Primary genito-urinary tuber-
culosis is far more common in males than in females.   In females primary
tuberculosis  of the uterus and of  the Fallopian tubes  is more common than
primary tuberculosis of the urinary organs.  The primary tuberculous deposit
in genito-urinary tuberculosis in males  is most frequently in the testicles,
epididymis, seminal vesicles, or prostate.  From these organs the tuberculosis
may extend to the renal pelvis and kidney, involving usually, although not
                1 Die Echinococcuscysien der Nieren, Stuttgart, 1877. 
RENAL  TUBERCULOSIS.
913
always, the bladder and  ureter.  Less frequently the tuberculosis  extends
downward  from the  kidney to the  bladder  and  genital glands.   In rare
instances the  affection  is confined to the Kidney  and  renal pelvis.
  In  renal phthisis caseous masses  usually first involve the  pyramids and
then extend to the cortex.   These cheesy masses generally soften and form
cavities, which usually, but not necessarily, communicate with the renal pel-
vis.   The whole  organ may be destroyed by this process of softening and
of excavation.  Sometimes  only one, but usually both  kidneys, are affected,
although often in  unequal degree.   The diseased, kidney is usually enlarged,
but it may be shrunken.   The mucous membrane of the pelvis  and of the
ureter is usually thickened  from infiltration with fresh  and caseous tubercu-
lous material,  and it presents ulcerations in some places.   As in other  situa-
tions, inflammatory processes are combined with the tuberculous.  The lumen
of the ureter, as a rule, in certain  places is diminished, and as  a consequence
the pelvis  of  the  kidney is dilated, so that pyonephrosis often complicates
the disease.   Tuberculous nodules  and ulcers may be present in the blad-
der.   There  usually are tuberculous nodules  in the  testicles  or in the
prostate.
  The  tubercle bacilli can  generally be  demonstrated  in the  tuberculous
deposits.   In secondary genito-urinary tuberculosis the bacilli may be car-
ried to one of the genito-urinary  organs by the blood.  It  is  probable
that the ordinary mode of  infection in  primary genito-urinary tuberculosis
is by the entrance of the bacilli  through the urethra.
  Acute miliary tuberculosis and pulmonary tuberculosis may be sequences
of primary genito-urinary tuberculosis.

  The  symptoms of renal  phthisis  are generally those  of a severe pyelitis
and cystitis combined.   In most  cases there is pain in the region of one  or
of both kidneys.   The pain is usually dull, but there may be  paroxysms of
severe pain.   Attacks of renal colic may be caused by the passage of blood
or of  caseous  masses along the ureter.  The urine contains pus. and at times
blood.  The haematuria  is generally moderate in degree, but it may be severe.
The reaction of the urine is acid unless a severe  cystitis be developed. Detritus
consisting of cheesy particles and of connective-tissue fibres is occasionally but
not frequently found in the urine.   Of capital  importance in the diagnosis, is
the discovery  of tubercle bacilli in the urine.  By careful search these can be
found in the majority of  cases.  The method for detecting them is similar to
that employed in  examining the sputum (p. 199).  AVhen they  are discov-
ered the diagnosis of tuberculosis  involving  some  part of the genito-uri-
nary tract is established, but the exact location of the tuberculosis  remains
to be determined  by symptoms.   Inoculation  in the anterior chamber of  a
rabbit's eye with  urine from  cases  of genito-urinary tuberculosis produces
tuberculosis in the animal operated upon.  This procedure has been recom-
mended for diagnostic purposes.  Physical examination of the region of the
kidney will sometimes reveal a tumor, but often this examination  yields only
negative results.   It is important to examine  the  testicles  and the prostate
glaiid for tuberculous infiltration.  The lungs and other organs are also to be
examined  for  tuberculous lesions.   Constitutional symptoms develop sooner
or later.  These are—hectic  fever, chills, night-sweats, progressive  emaciation,
and loss of strength.   There may be diarrhoea with or without  tuberculous
intestinal  ulceration..  AVaxy degeneration of  the organs is  an  occasional
result of renal phthisis.  Uraemic symptoms do not usually develop in the
course of renal  tuberculosis.   Bright's disease  may, however, occur  as an
intercurrent affection.
  Renal phthisis terminates fatally in the great majority of cases.   The dura-
        5S 
914         STRUCTURAL DISEASES OF THE KIDNEY.
tion generally is not longer than one or two years.   If the affection be local-
ized in one kidney, recovery may take place.
   The treatment  is directed to the general condition of the patient and to
the palliation of local symptoms.  The general health is to be kept up  and
improved as far as possible.   The treatment of the local symptoms is similar
to that in other  cases of pyelitis and of cystitis.  The general indications for
treatment are similar to those in cases of pulmonary phthisis.


                     Carcinoma of the  Kidney.

   A great variety of tumors form in the kidney, but only cancer and sarcoma
are of much clinical importance.  Sarcoma of the  kidney is infrequent, and
when it gives rise to symptoms it cannot usually be distinguished from  can-
cer.   Cancer may occur in the kidney as a primary or as a secondary growth.
It develops secondarily, either in the form of metastases or as a continuous
growth  from  adjoining parts.   Secondary  renal cancer, although more fre-
quent than  the  primary  form, rarely attains a large size or gives rise  to
symptoms drawing  attention  to  the  kidneys.  It  has much  less  clinical
importance than primary cancer, and the latter is the form to be considered
in this  article.  Primary cancer of the kidneys is a rare disease, although
less  infrequent  than was formerly believed.   It occurs oftener  in the  first
decade of life than in any succeeding decade, and in this it differs from  can-
cer in other  situations.  Rohrer has collected 115 cases  of primary  renal
cancer.   Over one-third of the cases occurred within the  first  ten years of
life.   The next  largest number of cases were those between  fifty and sixty
years.  Notwithstanding  its infrequency, cancer of the kidney is the cancer
oftenest met with in childhood.  Of the cases of renal cancer in  children, by
far the largest number fall within the  first five years of life.1   In very rare
instances it has  been observed  as a congenital  affection.  In the  majority of
cases primary cancer of the kidney is unilateral.  It may, however, develop as
a primary affection in both kidneys.2  Males  are somewhat more frequently
affected than  females.
   Renal cancer, in the great majority of cases, belongs to the soft or medul-
lary variety.   Cancer  in this situation  may, however, present all grades of
transition between  the medullary and the scirrhous forms.   Colloid renal
cancer has also been  described.  The  new  growth may appear  either as a
diffuse infiltration of the  kidney or in a nodular form.   There  may be rem-
nants of  intact  renal tissue  or the entire  parenchyma may be destroyed.
The size of the  tumor is in  many cases enormous, and it is  a remarkable
fact that relatively, and almost absolutely, the  largest tumors are met with in
children.  According to Sir AVilliam Roberts, the average weight in children is
8£ pounds and  in adults 9? pounds.  The maximum weight was 31 pounds,
and this was observed in a child.  In the most frequent form of renal cancer
the consistence is soft.  Not infrequently cavities form containing soft, pulpy,
degenerated cancerous material.   From the fluctuating feel afforded by these

  1 Rohrer, Das primare Nierenrarcinmn, Tnaug. Diss., Zurich, 1874.  Of 107  cases in
which the age of the patient was stated, 37 were less than ten years, 4 were between ten
and twenty, 5 between  twenty and thirty, 10 between thirty and forty, 10 between forty
and fifty, 17 between fifty and sixty, 10 between sixty and seventy, 3 between seventy
and eighty, and 11 were described simply as adults.  Of 29 cases of cancer in children
collected by Hirschsprung (1868), 15 were of the kidney: 82 per cent, of all renal
cancers in  childhood  fall within the first four years of life fRohrer).
  2 Of 114 cases, the cancer  was 52 times on the right side, 50 times on the left, and
12 times bilateral.  In children the left kidney was oftener  affected than the right
(2i : 2).  In adults, the  right oftener than  the  left '5 : 4).  Bilateral cancer was  of
equal  frequency in children and in adults  (Rohrer). 
CARCINOMA  OF THE  KIDNEY.
915
 softened  masses renal cancer has often been punctured during life under the
 supposition that a cyst or an abscess was present.   The coloris not uniform.
 In most cases a section of the tumor presents a whitish  or yellowish appear-
 ance mottled with  red  and brown portions.  The red portions  are  due to
 dilated blood-vessels and to hemorrhages.   AVhen  their number is larae the
 red patches give a hemorrhagic aspect to the tumor, whence it derives the name
 fungus haematodes.   The brown portions result from pigmentary changes in
 blood-extravasations.  Sometimes the tumor is confined within the capsule, and
 at other times it invades surrounding parts.  In some cases the appearance is
 as if the tumor  took its origin in the connective tissue or the lymphatic "-lands
 about the kidney, and secondarily invaded this organ. Those who maintain the
 epithelial origin of cancer are unwilling to admit that it ever develops primarily
 in the perinephritic tissue.   The  tumor usually contracts adhesions to sur-
 rounding parts,  but sometimes a cancerous  kidney is movable.   In nearly all
 cases the colon  lies in front of the  tumor.   Secondary cancerous growths are
 found in other organs in rather less than half the cases of cancer of the kid-
 ney.   It  is a peculiarity of  primary renal cancer,  especially in  children, that
 it  gives rise to  metastases less readily than cancer in other situations.1  The
 secondary deposits are met with most frequently in  the retro-peritoneal glands,
 the lungs, and the liver.  The frequency with w'hich the renal vein is involved
 in the new growth explains the common occurrence of secondary cancerous
 deposits in the  lungs, as by this implication of the veins  cancerous material
 may gain access to  the blood-current.  Metastases are rare in  the lower uri-
 nary passages, but cancer of the  kidney frequently grows continuously into
 the renal pelvis, and it may invade the  ureter.   It is not rare to meet with
 calculi in the pelvis of a  cancerous kidney.  It is exceptional  for renal car-
 cinoma to cause  ulceration of the superjacent integument.   The intestine,
 especially the overlying colon, may be perforated  by the  cancerous growth.
 Intestinal fistulae opening externally have been caused by this disease.  The
 vertebrae in some cases are involved in the malignant growth. Pressure upon
 the inferior vena  cava may cause  oedema of the lower extremities.  Ascites
 is rare.  Displacements and distortions of the abdominal organs are often the
 result of pressure from cancerous tumors of the  kidney.  The diaphragm
 may be pushed  upward  and the lungs compressed.   If the disease  be uni-
 lateral  the  kidney unaffected  by  cancer  is generally hyperaemic.  Amyloid
 degeneration of the kidney, as well as  of other  parts, may  be caused by
 renal cancer.
   Upon microscopical examination the tumor presents the arrangement of
 cells in alveoli with intervening stroma, which was described as characteristic
 of cancer in Part I. p. 44 et seq.   The microscopical appearances as  regards
 the size of the alveoli, the  shape of the cancer-cells, the amount and character
 of the stroma, the degree of vascularity, vary in different cases.  The designa-
 tion of the tumor as medullary or as scirrhous depends upon these variations,
 as has also been explained in the article on  Carcinoma in Part I.  In the soft
 renal cancers, which is the most frequent form, the alveoli are separated by
 a small amount  of stroma and are usually large.   It is a  peculiarity of soft
 cancer of the kidney that the  alveoli  may be separated from  each other in
 some places by  nothing but blood-vessels, the appearance being that blood-
 vessels actually penetrate  the alveoli.   The stroma of these  cancers in its
 scanty amount  of fibrillated connective tissue  resembles  the  normal  inter-
 stitial  tissue of  the  kidney.   The  stroma is not in all places  as  thin as  has
 been  described,  and  it may be abundant.   In some cases the cancer-cells
 resemble the epithelium of  the convoluted tubes, being very  granular and
  1 According to  Kiihn, secondary growths are found in 28 per cent, of the cases in
children, and in 44 per cent, in adults (loc. cit.). 
916          STRUCTURAL  DISEASES OF THE KIDNEY.

indistinctly separated from each other.  They are, however, always irregular
in shape.  Cylindrical-celled epithelioma of the kidney has been described by
Wagner. AValdeyer, Klebs, Pereverseff, and others have described with much
detail the development of cancerous alveoli  from the uriniferous tubes, and
of cancer-cells from the epithelium of these tubes, the tubes becoming dilated
and irregular  in shape, and giving off processes; and within these  dilated
branching tubes the epithelial  cells proliferate.   In the immediate neighbor-
hood of the cancerous growth the interstitial tissue of  the kidney is often
increased in amount, and the tubes are in some places compressed  and  in
others  dilated.   Cancer seems to take its  origin more frequently from the
cortical than from the medullary tubes.

   In a clinical point of view, as already stated, secondary cancer of the kid-
neys has little interest.  It is generally latent  as regards diagnostic symp-
toms.  Both kidneys are affected, as the rule.  The disease does not advance
sufficiently to form appreciable  tumors,  and there may be no symptoms
denoting renal disturbance.  Primary cancer, on  the other hand, is generally
unilateral, and in a large proportion of cases it gives rise  to symptoms which
direct attention to the kidney.   Lumbar pain on the affected side, extending
down the  ureter to  the  thigh, may be a more or less prominent symptom,
but it  is not so except in a certain proportion of cases; and this symptom
for a long  time may be wanting.  There  are loss of appetite, progressive
emaciation, and other symptoms which belong to the cancerous cachexia and
denote an inroad upon the constitution, but they  may be long deferred.  The
diagnosis hinges upon the discovery of a renal tumor.
   The  tumor  is felt between  the ribs and  the  pelvis  latero-anteriorly.   It
varies greatly  in size  and form in different cases.  It may be as large as the
closed  hand or a child's head, and in young subjects it sometimes  attains
enormous dimensions, as  in the  case cited  by Roberts, in which the  weight
of the tumor was 31  pounds.   In the pictorial representation of that case the
enormously enlarged abdomen  contrasts strikingly with the  attenuated chest
and limbs.   The tumor may be smooth or lobulated.  The  aortic  impulses
may cause it to pulsate, resembling in this respect an aneurismal  tumor.   It
may be hard and resisting to the touch or it may give a sense of fluctuation.
It is sometimes hard to the touch in some and  soft in other parts.  The
tumor sometimes retains the shape of the  kidney, although much enlarged,
but oftener  there is so much distortion that the shape is of no value in the
diagnosis.   The  cancerous disease may extend to the neighboring lymphatic
glands, and  these may form a mass which may exceed in size the  enlarged
kidney.
   The  first  point with reference to the  diagnosis is to determine that the
tumor is renal.   It is to be discriminated from enlargement of the liver and
spleen, from an  ovarian and from a fecal tumor.  It is shown not to be con-
nected  with  the liver or the spleen if the fingers can be pressed between the
lower margin of these organs and the tumor.  The evidence afforded by per-
cussion must not be too confidently relied upon.   The renal  tumor is usually
behind the intestine, and therefore a tympanitic resonance  is  often obtained
by percussing  over it; but it is common to find this  resonance over the liver
and the spleen,  owing to its being conducted from the  colon and stomach
upward to a greater or less height.   Hence the resonance over the liver and
over the spleen may be tympanitic, although no part of the intestine is situ-
ated over these organs.   On the other hand, the  portion  of  intestine situated
over a renal tumor  may not at all times contain  gas, and there may then be
flatness on percussion.  Too much reliance on a tympanitic resonance over an
abdominal tumor as a differential point is likely  to lead to error in the diag- 
                    CARCINOMA  OF THE  KIDNEY.                917

npsis.  A cancerous kidney usually becomes closely adherent to adjacent parts.
and it is not, like the liver and spleen, lowered by the descent of the diaphragm
in inspiration.   An ovarian tumor differs in being found at first in the iliac
fossa, and as it increases in size it  extends upward, whereas an  enlarged kid-
ney is at first felt in the hypochondrium, and  as it enlarges it descends.  For
further diagnostic  evidence of ovarian tumors the reader is referred to works
on gynaecology.   Fecal tumors have  their characteristics which have been
considered (p. 506).
  A renal  cancer is to be discriminated from  other affections of the  kidney
—namely, hydronephrosis, pyonephrosis,  renal  abscess, hydatid disease, and
cystic  degeneration.  Relying upon palpable  characters of the tumor this is
by no means easy.  AVith  reference to this  differentiation the antecedent and
concomitant symptoms are to be considered, and, as bearing on  both the seat
and  the character of the tumor,  haematuria is  pre-eminently a  diagnostic
symptom.
   Hematuria and the existence of a tumor  referable to the kidney render
the diagnosis of renal cancer  almost positive.  The analysis, however, of 59
cases by Sir AVilliam Roberts gave  28  in which haematuria did not  occur, and
of the larger collection of cases by Rohrer  this symptom was present  in only
34 per cent.   The absence  of haematuria  therefore  by no means excludes
cancer.  Haematuria, too,  without  tumor is not  evidence of renal cancer.   It
is the conjunction of the haematuria and  the  tumor  which establishes  the
diagnosis,  and a positive diagnosis  is not possible unless these two events be
conjoined.1
   The  haematuria may occur for  the first time early or late in the progress
of the disease.  It often recurs more  or less frequently after irregular inter-
vals. The hemorrhage is sometimes profuse, and sometimes it is small. Clots
formed in the calices or the pelvis  of  the kidney in passing  through the ure-
ter may give rise  to all the symptoms which attend renal colic.   The coagula
in some instances  become moulded in the  ureter, and appear in the urine in
the form  of casts  resembling lumbricoid worms.   Many of these were passed
in a case which came under my observation.   The coagula may obstruct the
ureter and <rive rise to hydronephrosis.  The blood sometimes  coagulates in
the bladder, and the coagula are with  more or less difficulty expelled through
the  urethra.
   The mistake is  often made of supposing that the urine may contain  cells
distinctive of cancer.   It  is perhaps true that  cells from the tumor  may be
contained  in the urine, but these cells have no  characters by which they can
be distinguished as cancer-cells.    The normal epithelial cells lining the urin-
ary bladder present such a great variety of  forms that they are often taken as
the physiological  type or paradigm of cancerous cells.   There  is no instance
of the  diagnosis having been based  upon the  recognition, in  the urine, of
masses of "cancerous tissue of  sufficient  size to enable an alveolar structure
to be  determined.  If blood or pus  be contained  in  the urine, there is  of
course  a  certain amount  of albuminuria ;  but  if these elements be absent
renal cancer may  exist without any trace of  albumen in the urine. The dis-
ease may, however, be attended by changes in the kidney which  give rise to
considerable albuminuria.
   The termination in cases of renal cancer is inevitably in death, sooner or
later.   The duration  of the disease in children is shorter than in adults.  Sir

  1 AATith reference  to these  two diagnostic events—namely, tumor and haematuria—
Rohrer divides  his  115 cases into four classes, as follows:  1, in  36 cases there was
neither tumor nor  haematuria. and the disease was therefore unsuspected;  2, in 12
e.-es there was  hematuria without tumor: 3, in 25 cases there were both tumor and
hematuria; 4, in 42 ca-es there was  tumor without  heefliatuna. 
918          STRUCTURAL  DISEASES OF THE KIDNEY.
 AYilliam Roberts found the  average  duration  in  children to be about seven
 months, the extremes being ten weeks and over a year.  In adults the average
 duration was two and a half  years, and the extremes  five months and seven
 years.  Rohrer from his statistics reaches  similar results.  It is to be observed
 that in the cases embraced in these statistical analyses the latent period of the
 disease  when there were no symptoms present  cannot be taken into account,
 and there is reason to believe that this latent period may be of long duration.
 AVharry mentions a case which proved  to be one  of renal cancer in which a
 tumor,  gradually  increasing in  size, had been  ascertained fourteen years
 before death.1   Dunlop has  reported two cases,  the  duration  having been
 ascertained  to have been in one between ten  and twelve years and  in the
 other sixteen years.2   Rohrer cites  a case which lasted seventeen  years.
 These are, of course, exceptional  cases, but it is a noteworthy fact that can-
 cer in this situation is tolerated in some instances for a very long period, and
 a great  length of  time may elapse without much  constitutional disturbance.
 On the other hand, in  some cases, especially in children, the  tumor grows
 with  astonishing rapidity.
   It is a peculiar feature of primary cancer seated in the kidney that the tend-
 ency is much less here than in other situations to extend to neighboring parts
 or to give rise to metastatic cancerous disease in  situations more or less remote.
 Heredity seems not to be involved in the causation of the disease in this situ-
 ation.   Respecting the causation  nothing  is known.

   The indications for treatment have  reference in  some cases to lumbar
 pain,  to the occurrence of renal  colic, to  urethral obstruction from clots, to
 the removal of coagula from the bladder, to haematuria when the hemorrhage
 is  profuse, and to other  effects, symptoms, or complications which are  liable
 to occur during the progress of the disease.  Aside from meeting these indi-
 cations, the object of treatment is to render the  system  tolerant of the disease
 as completely and as long  as possible.   The measures for  this object are the
 same  as in other diseases in the management of which all that is to be hoped
 for is retardation of their progress and of their inroads upon the constitution.
 These measures embrace tonic remedies, palliatives, nutritious diet, and favor-
 able hygienic influences, moral and physical, in  the place of those which tend
to impair the ability to endure an incurable disease.  The only hope of recov-
 ery is to be sought in extirpation of the tumor.  This operation has been per-
formed a number of times, but thus far not with favorable results.
                          Movable Kidney.

  One of the  kidneys is sometimes loosened so as to form a movable tumor
which  may be felt through the abdominal walls.   This condition is called
movable kidney, floating kidney, wandering kidney, or ectopia renis.   The de-
gree of ^mobility varies much in  different cases.  The kidney is normally held
in position by  the layer of peritoneum which is attached to the anterior sur-
face of its adipose capsule.  In  movable kidney the adipose tissue in which
the_ normal kidney is imbedded  partly or wholly disappears.  The overlying
peritoneum becomes lax and may form a partial or even complete investment
of the  kidney.   In extreme  cases the  mobility of the organ is restrained only
by its vessels and the ureter.   Unusual length of the renal vessels is thought
to be a predisposing cause of displacement of the kidney.  In nearly all cases
the  intestine is interposed between a movable kidney  and the abdominal walls.
In very exceptional cases the organ has been found in front of the intestine.
  1 The Lancet, Feb. 10, 1877.                            2 Ibid., April 21, 1877. 
MOVABLE KIDNEY.
919
A displaced kidney may become fixed in its abnormal position by the forma-
tion of adhesions.
  It is difficult to form  an estimate of the frequency of this abnormality of
the  kidneys, as the condition doubtless often exists without being recognized.
It is probable that abnormal mobility of these organs is not very uncommon.
It is far more  frequent in women than in men.   Of 290  cases collected by
Newman, 252 were in women and 38 in men.1  The right  kidney is movable
oftener than the left.   Both organs  may be affected.  Of  91 cases brought
together by Ebstein, the right kidney was affected 65 times, the left 14 times,
and both kidneys  12  times.2   The affection may be congenital or acquired.
It  is  usually acquired.   In  most of the  cases the abnormality developed
between the twentieth and the forty-fifth year, or, in other words, during the
child-bearing period in women.  The affection may, however, appear at any
age.  Mobility of  the kidney is attributable to relaxation  of the abdominal
walls from  pregnancies, to the use of corsets and tight girdles about the waist,
to violence, to increased weight of the organ from disease, to the pressure of
tumors growing in the neighborhood of the kidney, and to the traction of her-
nias.  The disappearance of the fat from the  adipose capsule of the kidney,
as happens in  wasting  diseases, has  also been assigned as a cause,  but its
efficacy  is  doubtful.  Unusual  laxity of the abdominal  walls from causes
other than pregnancy may be  an element in the causation.  In congenital
floating kidney there  is usually  some abnormality in the development of the
peritoneum covering this organ or in the length, origin, or distribution of the
renal vessels.
  Movable kidney may exist without causing any noticeable svmptoms.  In
several cases it has been discovered accidentally by the physician while mak-
ing a physical examination of the abdomen.  Usually, however, the condition
gives rise to more or less uneasiness.  The patient often experiences a sense
of weight  and dragging pain, especially when walking or standing.  There
may be severe neuralgic pain radiating from the affected side.  If the tumor
be first discovered by the patient, it becomes  often a source of great  mental
anxiety.   In  some cases the movable kidney gives rise  to the paroxysmal
development of symptoms of considerable severity to which the name " symp-
toms of incarceration " was applied by Dietl.  These symptoms are chilliness,
nausea, vomiting, prostration, intense pain, and anxiety.  The affected kidney
and surrounding tissues are swollen and sensitive to pressure.  These symp-
toms  usually  subside within  a few  days under  the  influence  of rest and
opiates.  They are relieved if the  kidney be replaced.   The explanation of
the symptoms of incarceration is not satisfactorily established.   The symp-
toms have been ascribed to twisting of the ureter and to retention of the urine
in the pelvis of the organ from the temporary obstruction thereby occasioned.
In this way it is claimed that acute hydronephrosis and pyelitis may  develop.
Hydronephrosis may  coexist with movable kidney, but this explanation does
not seem to be applicable to all cases.  The symptoms  have  more frequently
been attributed to inflammation  of the peritoneum and connective tissue sur-
rounding the kidney.   Another  possible explanation  is  that the symptoms are
due to partial  strangulation of the kidney from compression or from twisting
of its blood-vessels.   It is claimed that a movable right  kidney pressing  on
the  duodenum may be a cause of dilatation of the stomach.   Constipation may
be a result of  compression of  some  part of the intestine,  most frequently of
the  colon, by a movable kidney.  (Edema of the lower extremities  has  been
described as a result of compression of the inferior vena cava by a displaced

  1 Glasqow Medical Journal, Aug., 1883.                             .
  2 Of 05  cases  collected by Roberts, in 42 the  right alone was movable, in 9 the lett
alone, and in 14 both kidneys. 
920         STRUCTURAL  DISEASES OF THE KIDNEY.

kidney.  According to Roberts, epigastric pulsation is in some cases a promi-
nent phenomenon  in  connection with  movable kidney.  A'arious  symptoms
resembling hysteria have been frequently observed in women  suffering from
this disorder.
  The occurrence  of movable kidney is to be recollected in determining the
nature of  obscure tumors within the  abdomen.   Tbe  recognition of this
variety of tumor is to be based on the following diagnostic points:  It is situ-
ated in the hypochondriac region.  It has the size and the shape of the nor-
mal kidney, and this may he determinable by palpation, which  is most advan-
tageously employed by placing one hand over the lumbar region and the other
in front on the abdominal walls,  and then making counter-pressure from one
hand to the other.   It is generally movable, and in some cases the  organ can
be restored to its proper situation.  Over the normal site  of the organ on the
affected side a depression is sometimes observed, with a tympanitic  resonance
on percussion  derived  from  the  portion of the intestine  wdiich is situated in
the place which the  kidney should have  occupied.  These two latter diag-
nostic  points are available in so  few cases that they are of more theoretical
than practical interest.  Other tumors are to be excluded by the absence of
their diagnostic characters.
  The inconvenience, and sometimes suffering, attending this anomaly may
often be obviated, in  a measure  at least, by mechanical  compression of the
abdomen by means of a bandage or belt or abdominal supporter.  In attacks
of pain the organ should if possible be replaced;  rest and recumbency are to
be enjoined ; emollient applications should be made over the abdomen; and
if these  measures  do not afford relief opiates  are indicated.   It very rarely
happens that the symptoms are so severe as to justify extirpation of a mova-
ble  kidney, although this operation has been repeatedly performed.  An opera-
tion for fixation of the kidney by means of sutures has been devised (nephro-
raphy), but this also is open to many objections.


                         Renal Haematuria.

  Haematuria, or bloody urine, occurs  in  various diseases, as well as after
wounds and other injuries of different parts of the urinary apparatus.  The
blood may come from  the kidney, the pelvis of  the kidney, the ureter, the
bladder, or  the urethra.  AVhen it takes place from the bladder or the urethra,
it comes within the province of surgery; but the means of determining whether
the hemorrhage be either cystic or urethral are of importance to the physician.
Urethral hemorrhage is easily discriminated.  The blood escapes without any
effort of micturition or it immediately precedes the first escape of urine. More-
over, the seat of the disease or injury may be ascertained by surgical explora-
tion.   Vesical hemorrhage is  discriminated by  attention to  the  following
points: The last part of the urine discharged is often more bloody than the
first part;  there usually are blood-clots in  the urine, and  these may prove
an  obstacle to  the free escape of the urine; there can frequently be found
some cause of vesical hemorrhage, such as a calculus, a tumor, or some wound
or injury of the bladder; and ammoniacal decomposition of the urine and other
symptoms of cystitis are often present,
  Hemorrhage from the ureter generally involves the presence of a calculus.
Hemorrhage from the pelvis of the  kidney is  most frequently due either  to
calculus or  to tuberculous pyelitis, and occasionally to infectious diseases with
a hemorrhagic tendency.   Sometimes coagulated blood is moulded in its pas-
sage through  the ureter so as to form  casts of this tube, compared in their
appearance to leeches.
  AVhen the bleeding  is from the kidney the blood is thoroughly mixed with 
                       ENDEMIC HEMATURIA.                    921

the urine, which often presents a smoky or sooty appearance.   Blood derived
from renal hemorrhage is very rarely coagulated.  Of great importance in the
detection of renal hemorrhage is the recognition of changes in the urine indic-
ative of disease of the kidney, especially casts and a much larger proportion
of albumen than can be explained by the quantity of blood present.  The
presence of blood-casts in the urinary sediment is proof that  the hemorrhage
is renal.   The reaction  of the  urine  is  generally acid.   It is  to  be borne
in mind that  blood-corpuscles may not be discoverable in urine which  has
become ammoniacal,  as under  these  circumstances  they may be speedily
destroyed.  In urine of  low specific gravity the  blood-corpuscles  appear
very pale, or  only  the so-called shadows of blood-corpuscles may be pres-
ent.  If, owing to  the absence of blood-corpuscles, there be doubt as to the
presence of blood-coloring matter in the urine, chemical tests1 or the spectro-
scope may be employed.   Bloody urine is always  more or less  albuminous.
   Bloody urine should not he confounded with any of the following condi-
tions:  the high-colored, saturated urine of fevers, the  urine  of jaundice, the
dark urine from carbolic-acid poisoning, and  urine  stained by ingestion  of
rhubarb, senna, logwood, madder, beet-root, the prickly pear,  and fuchsin.
   The causes of renal hemorrhage are injuries to  the kidney,  as from wounds
or from a fall or a  blow; the absorption of various toxic  substances,  such as
cantharides, turpentine, or  oil of mustard;  congestion of the kidney due to
these or other causes ; acute, less frequently chronic, Bright's disease ; rarely
embolism, thrombosis, or aneurism of the renal blood-vessels ;  abscess, echino-
coccus, tuberculosis, and cancer (rarely  other  tumors) of the kidney; occa-
sionally acute  infectious  diseases; and the  hemorrhagic  diathesis, including
purpura and scurvy.  Sometimes haematuria, apparently of renal origin, occurs
without any apparent cause.  The influence of malaria and of parasites in the
production of  haematuria will be considered in the following  articles.
   In cases of renal  haematuria, if the hemorrhage be considerable, the appli-
cation of cold over  the kidneys by means of compresses wet  in cold water or
the ice-bag is indicated.   Internal haemostatics which  may be prescribed are
tannic or gallic acid, ergot, the  muriate and other astringent  preparations of
iron, alum, and acetate of  lead.  Hypodermic  injections  of  ergotin  may be
employed.  Aside from  the treatment  having reference  to  the hemorrhage,
indications are to  be derived from the diseases or morbid  conditions with
which it  is connected as a symptom.

                        Endemic Hematuria.

   This name  is applied to a form of haematuria occurring in Brazil, Egypt,
the Cape of Good Hope, and some other tropical countries.  The  haematuria
is caused  by  the distoma haematobium, a parasite which  is  common in these
countries, and which was discovered by  Bilharz  in  1851.  This parasite,
which is one of the suctorial worms or trematodes,  is about  half  an  inch in
leno-th, and is  found especially in the portal and other abdominal veins.   The
parasite is thought to be  ingested with the drinking-water.   It produce's  a
multitude of  esirs, which are found in  the liver, the intestine, the bladder,
ureter renal  pelvis, kidney, and other  organs.   The lodgment of  these ova
produces  symptoms referable especially to the liver, the intestine, and the

  1 Teichmann's blood-test is convenient.  Some of  the urinary  sediment or a portion
of the dried urine on  a  slide is treated with glacial acetic acid after the addition of  a
few minute crystals of common salt.  The  specimen is covered  with a cover-glass and
heated until it  begins to boil.  After cooling (more glacial acetic  acid can  be added
if necessary) the characteristic brownish rhombic haemin crystals appear if  blood be
present. 
922          STRUCTURAL  DISEASES OF THE KIDNEY.

urinary organs.  The mucous and submucous coats of the bladder, and of the
ureter  and renal pelvis  are thickened, inflamed,  and  ulcerated.  The local
effects  of the  parasite and its ova upon the  urinary organs are manifested in
haematuria, combined generally with  symptoms of cystitis and of pyelitis.
There frequently is diarrhoea, and  there may be pyrexia with symptoms of
typhoid fever or septicaemia.   The ova often form the nucleus of a renal or a
vesical calculus.
  The  diagnosis is based upon  finding  the eggs in the urine.   The eggs are
from yl-g- to Ti7 of an inch in length, and are either sharply  pointed or fur-
nished  with a  projecting spine  near  one end.
  The  disease  is a severe one  and  may terminate fatally.  Recovery, if it
take place, is  slow, generally extending over  several years.
  No remedy has been discovered which will destroy the parasite.   The indi-
cations are to remove the patient from the endemic influence, to support the
strength by tonics  and good hygiene, and to treat the cystitis.   For the latter
purpose the bladder should be cleansed, and such drugs as boric acid, benzoic
acid, bicarbonate of potash, and infusion of  buchu may be employed.
  According to observations in China and in India, haematuria may be caused
by the fiiaria sanguinis hominis.
 " The  strongylus gigas is a long, cylindrical, red  worm found sometimes in the
pelvis of the dog's and of the horse's kidney, but is so extremely rare in human
beings  that it does not require consideration.

                Hemoglobinuria—Hsematinuria.
  If from  any cause the red blood-corpuscles be dissolved in the blood, the
haemoglobin which is thus set free  is excreted by the kidney.   The condition
of blood thus  produced is called  haemoglobinaemia, and that of the urine
haemoglobinuria.   The urine in haemoglobinuria  contains, therefore, dissolved
blood-coloring matter, but usually no red blood-corpuscles.  The urine has a
reddish-brown color, which  in  extreme cases is compared to the color of
porter.
  Haemoglobinaemia and the consequent haemoglobinuria may he  produced
by a variety of causes.   A large number of substances when taken into the
blood cause a dissolution of the red  blood-corpuscles.   Such  substances are
pyrogallic acid, naphthol, arseniuretted hydrogen, glycerin, hydrochloric acid,
sulphuric  acid, chlorate  of potash, and the  biliary salts.   The  ingestion of
certain poisonous fungi has this  effect,  as well as the transfusion of the blood
of one species of animal into  the  blood-vessels  of  another species.  Haemo-
globinuria has been observed in  the course of various infectious diseases, such
as scarlet fever, typhoid  fever, and malaria.  It is also produced by extensive
superficial burns, and in one form of paroxysmal  haemoglobinuria exposure to
cold is an  important cause.
  In all cases of  haemoglobinuria which have  terminated fatally nephritis
has been  found.   This nephritis is to be regarded as secondary.  There are
glomerulo-nephritis, degeneration and  necrosis of the  epithelial cells of the
tubes,  small-celled  infiltration, and  especially characteristic casts in the tubes
composed  of reddish-brown pigment-granules.
  Haemoglobinuria is distinguished from genuine haematuria by microscopical
examination, which shows the absence of red blood-corpuscles.   The presence
of blood-coloring matter  is made evident by spectroscopic or chemical exam-
ination, as  mentioned in the article on  Haematuria.   The urinary sediment
usually contains formless, granular (less frequently crystalline) reddish-brown
pigment, and casts of which  the most  characteristic  are those containing or
composed  of  similar pigment.   The urine is always albuminous.  Of course 
                 PAROXYSMAL HEMOGLOBINURIA.             923

 care must be taken not to mistake for  haemoglobinuria  urine in which  the
 blood-corpuscles have  been dissolved in consequence of ammoniacal decom-
 position.
   Experiments have shown  that fragments of red blood-corpuscles are  not
 only excreted by the kidney, but are also taken up by the spleen, the  liver
 and the marrow of  the bones.  The  spleen becomes thereby swollen, and the
 liver excretes an increased amount  of bile, which may have an abnormally
 thick consistence.   The jaundice  which is a frequent attendant  of haemo-
 globinaemia  is probably to  be regarded  as  haematogenous, although  the
 changes in the liver which have been mentioned  might be adduced in favor
 of  its  hepatogenous origin.
   There is a form of haemoglobinuria which deserves consideration as an inde-
 pendent disease.  This  is the so-called paroxysmal haemoglobinuria.   Some
 of  these cases are  of malarial origin and others are not,  On account of its
 importance  malarial haemoglobinuria will receive  separate consideration.


                  Paroxysmal  Haemoglobinuria.

   Exclusive of its  causation by malaria in certain  regions, this affection is
 not common.  It may occur in persons otherwise apparently healthy. As  the
 name implies, the  disease appears  in paroxysms.  A  typical paroxysm is
 ushered in by pain  in the back, the limbs, and  the head, sometimes by nausea
 and vomiting and a sensation of coldness in the extremities.  Frequent yawn-
 ing has  been noted as a premonitory symptom in several cases.   There is
 usually a distinct chill,  followed by rise of temperature and sweating.   Dur-
 ing this attack, and generally for a few hours afterward, the urine acquires a
 dark reddish-brown, sometimes almost black, color, is generally of acid reac-
 tion, and  is  of rather  low specific gravity.   While the spectroscope reveals
 the absorption-bands of haemoglobin and  of  meth-haemoglobin, the micro-
 scope shows the absence of red blood-corpuscles.  There is generally a choco-
 late-colored sediment containing pigment-granules and hyaline, epithelial, and
 pigment casts.  There  is at the same time albuminuria.  Severe colicky pain
 in  the region of the liver is sometimes experienced during the attack.  A
 more  or  less  distinct icteric hue  of the skin is present.  Urticaria in  some
 cases, and exceptionally purpuric patches, have been  noted.   After the par-
 oxysm the urine gradually becomes clearer, and in from  twelve to twenty-
 four hours it becomes normal.  Meanwhile, the other symptoms diminish and
 disappear, and on the day following  that of the paroxysm, except the weak-
 ness clue to the latter, the usual  health of the patient is restored.
  AVith a light paroxysm  there is  only chilliness, followed  by little  or  no
 fever, and the symptoms may not be sufficient to interrupt the usual occupa-
 tion of the  patient.  Rarely the  haemoglobinuria appears without marked
 premonitory  symptoms.
  The paroxysms may  occur with some  regularity, but more frequently they
 recur irregularly at  variable  intervals.  Two or more daily sometimes occur,
 or the  intervals may be days, weeks, or months.  In proportion as the par-
 oxysms are frequent and  severe patients  present a  pale, cachectic aspect.
  Examination of the blood withdrawn during  the paroxysm by wet cups has
 shown a reddish color of the serum,  indicating solution of the haemoglobin.
 The red blood-corpuscles have been found  sometimes altered in shape and
 size, and  the so-called  shadows  of the corpuscles have been  detected in the
 blood.   The number of red blood-corpuscles  is diminished.   There is less
tendency than normal  in  the red  corpuscles to form  rouleaux.
  In a  large number of cases the causation of the  paroxysm has been attrib-
uted directly to exposure to cold, but of the modus operandi of this cause  we 
924         STRUCTURAL  DISEASES  OF THE KIDNEY.

possess no definite knowledge.   In persons subject to the disease attacks have
been repeatedly produced experimentally by plunging the feet or hands into
cold water.   It is not improbable that the red blood-corpuscles in these indi-
viduals  possess  some peculiarity in  composition which renders them abnor-
mally susceptible to the  action of cold.1  All cases of paroxysmal haemo-
globinuria, however, do not seem to possess this peculiar susceptibility to
cold.  Some  cases are referred to muscular exercise.  The disease is more
common in men than in women.  Most of the paroxysms occur in winter.  A
large proportion  of  the  patients have  had  syphilis.  That malaria  has  an
important influence  in the  causation of periodical  haemoglobinuria  in this
country will  be  made evident  in the following  article.
  Exclusive  of malarial cases,  paroxysmal haemoglobinuria does not involve
danger  to life.   Paroxysms may recur for an indefinite period, but recovery
may be  expected  to take place sooner  or later.
  The treatment during the  paroxysm consists  in placing the patient in
bed, applying heat to the surface, and giving hot drinks internally, with the
addition  of some form of alcoholic stimulant.  After a paroxysm measures
to maintain  warmth of  the surface  are of prime  importance.   A  rough,
changeable climate may be exchanged with advantage for  one which is mild
and  uniform.  Only in a few cases, in which a syphilitic history has existed,
has mercurial treatment been  found  effective.  Even in non-malarial cases
quinine  is often beneficial.  Chalybeates and other tonics, with good alimenta-
tion and the moderate use of wine, are to be prescribed according to the indi-
cations in individual cases.


      Malarial Haematuria—Malarial Haemoglobinuria.
  Both  haematuria and haemoglobinuria may be caused by malarial poisoning.
In the Northern and Middle States of this country only the milder forms  of
malarial haematuria are observed, and these are not common, whereas in parts
of the Southern and South-western States and in tropical countries malignant
malarial haemoglobinuria is not  uncommon.
  In  the milcler cases  the affection  may be either haematuria or  haemo-
globinuria.  The diagnosis is based upon  the history of malaria.  The attacks
of haematuria may occur with the regularity of malarial paroxysms, but more
frequently they  are variable  in the time of their appearance.   In some
instances the haematuria becomes continuous, although fluctuating in intens-
ity.  The ordinary symptoms of intermittent fever may or may not be pres-
ent at the time of the  haematuria.  The paroxysms may resemble those
described in  the preceding article, and they may  likewise be  caused  by
exposure to  cold.
  Malignant  malarial haemoglobinuria is one of the manifestations  of per-
nicious  malarial  fever, and  is a disease of great gravity.   During the last
twenty-five years a large number of cases have been  observed in parts of the
South and South-west of this country.  The  disease  may be preceded by one
or more  paroxysms of intermittent fever, or the haemoglobinuria may be devel-
oped suddenly.  There is always a history of  exposure to malarial influences.
The urine is of a  dark reddish-brown, sometimes almost black, color.   It con-
tains few or no intact red blood-corpuscles, but an abundance of haemoglobin

  1 This view is supported by the experiment of Ehrlich  and of Boas, who, in a case
of paroxysmal haemoglobinuria, after applying an elastic ligature around the root of
one of the fingers, plunged this finger into ice-water for a quarter of an hour.  In blood
withdrawn then from this finger they observed the changes in the serum and red blood-
corpuscles above noted, while blood taken from other parts of the body did not present
these changes. 
CHYLURIA.
925
and meth-haemoglobin, as is shown by the production of haemin crystals or
by  spectroscopic examination.  The sediment contains hyaline and epithelial
casts, granular matter, and granules of blood-pigment, both free and in casts.
The urine is albuminous and generally acid.   At first it is usually excessive
in amount, and later it is diminished.   In addition to  the  haemoglobinuria,
there are other symptoms of gravity. After a few hours the patient becomes
jaundiced.   Usually at the onset of the  attack there are nausea and vomit-
ing, and often black vomit  makes its appearance.  There may be  bleeding
from the nose, from the bowels, from the uterus, from blistered surfaces, etc.
Pain in the back and  in the  epigastric region is often complained of.   The
temperature is elevated, sometimes as high as 106°; the pulse is rapid, small,
and feeble ; and there is great prostration.   There may be delirium, and fre-
quently the  patient passes  into a state of somnolence and coma.  The mind
may, however, remain  unaffected.   Death may occur during the first attack,
or the symptoms may  be relieved, and then recur after  one or  two days,
attended in  all cases with  great  danger to life.
   Malignant  malarial  haemoglobinuria  seems to be more common  in males
than in females.  It is said that  negroes are exempt from this form of the
disease.
   The  prognosis is grave, but  under appropriate treatment recovery may
take place.
   The treatment of  the  malignant form  consists in the administration of
quinine  in  large doses  and hypodermically.  Of  great  importance is  the
administration of stimulants to maintain the vital forces, which are often  at a
low ebb.  Morphine may  be employed to  relieve  the  gastric symptoms.
Physicians in the South consider stimulants and restoratives of equal import-
ance with quinine in the treatment of this affection.
   The milder forms of malarial haematuria are often relieved or cured by qui-
nine. The ordinary  astringent remedies may be employed in conjunction with
quinine.  All severe muscular exertion should be avoided.  For cases which
are rebellious to treatment—and such cases are not very rare—Tyson recom-
mends the use of chalybeate and  alum springs.1  Iron and appropriate hygi-
enic treatment are to be used to counteract the anaemia attending or follow-
ing malarial haematuria.

                               Chyluria.

   This  disease is characterized by the  passage of  urine which  resembles
milk.  The urine has sometimes a rose or pink tinge, due to the presence of
a little blood, and the disease is sometimes  associated distinctly with haema-
turia.  In many instances the urine has the opaque white appearance of milk,
without  any admixture with blood.  After its  passage the urine  generally
forms a jelly-like coagulum  w*hich disintegrates in  a few hours.  The micro-
scope shows the presence of fatty matter in the form of very minute granules.
The fatty matter is dissolved by ether, and  the urine which remains assumes
a normal appearance.  The  urine contains albumen, usually in large amount.
The abnormal chemical constituents of  the urine, therefore, in chyluria are
fat, albumen, and fibrin.  To these blood is frequently added.
  Chyluria  prevails in  certain tropical  and subtropical  countries.  It is
observed in  China, the East and  West Indies, South America, Africa, Aus-
tralia, and some  tropical islands.   In  the cases  which  have fallen  under
observation in temperate climates  the disease, as a rule, has been  contracted
in a hot  climate.   Chyluria, however, has sometimes appeared in persons in
  1 James Tvson, article " Malarial Haematuria and Haemoglobinuria," in Pepper's Sys-
tem of Practical Medicine, by American Authors, Philadelphia, 1886, vol. iv. p. 111. 
926          STRUCTURAL DISEASES  OF  THE KIDNEY.
this  country and  Canada, as well as in England and  Germany, who have
never visited tropical  regions.1
  The milky urine in most cases appears without any premonition or apparent
exciting cause.   All of the urine may be chylous, or it may part of the time
be normal.  Chyluria usually occurs  intermittingly, the intervals in diff'erent
cases varying from  days  to  months  or  years.  There is  no regularity  as
regards either the  duration of the attacks or their recurrence.  In  the  inter-
vals  between the attacks there is no evidence of urinary disease.
  In severe cases there are lumbar pains and symptoms denoting exhaustion.
Dysuria from coagula in the bladder sometimes occurs.   Milder cases are  not
only exempt from grave symptoms, but there may be nothing which points to
any disease, aside from the passage, after irregular intervals, of milky urine.
  Tropical chyluria  is  caused by the presence of the  parasite called florin
sanguinis hominis, first accurately described  by  Timothy Lewis in 1872.  The
adult or parent worms are  cylindrical, thin,  smooth nematode  worms three or
four inches in length.  The sexes are distinct.   The female gives birth to  an
enormous number  of living embryos without sexual distinction.  In the dis-
ease under consideration the parent worms are lodged somewhere in the  body,
probably in the lymphatics.  The embryos  make excursions  into  the  blood
and  lymphatic vessels, where  they are found, sometimes in enormous  num-
bers.2  These embryos are from yy- to  y1^ of an inch long, and  about  as
broad as a red blood-corpuscle.   They are elongated, generally enclosed in a
membranous sheath, and endowed  with the property of a rapid  coiling and
twisting motion.   In a drop of blood they can often be detected with  a low
power of  the microscope by the motion which  their lashing  imparts  to the
red blood-corpuscles.  In chyluria  these  embryonic filariae are found in the
urine and also in the blood.  They have the singular habit of disappearing
from the blood during the daytime, and appearing in  large numbers at night,
the maximum number being usually found  about midnight.   AVhat becomes
of them in  the  daytime is not  known. .  By reversing  the patient's habits—
that is, by making him sleep during the day and eat and move about during
the  night—the  migrations of the parasites become diurnal instead of noc-
turnal.
  In what way chyluria is  produced in general, and what the relations of  the
filariae are to this disease, are problems which  have not been satisfactorily
solved.   The common theory is that chyluria is caused  by some abnormal
communication between the lymph-vessels and  the  urinary passages.   It is
suspected that the  filarial worms  are often lodged in  the thoracic duct  or
abdominal lymphatics, and thus cause a damming back of lymph and conse-
quent distension of the lymphatics.3  Some  think that  the blood contains at
times in chyluria an excess of chyle.
  Chyluria is not the only affection which  may be caused by the fiiaria san-
guinis hominis.   This parasite may be the  cause also of haematuria, chylous
hydrocele, chylous ascites, elephantiasis, milk scrotum, and naevus-like dilata-

  1 Dr. Guiteras has found the fiiaria sanguinis  hominis in two persons in Charleston,
South Carolina.  In one case the patient had always  lived in  Charleston or its neigh-
borhood, and in the other case the patient had always lived in Charleston with the excep-
tion of five years in  Augusta,  Ga.  One was a case of chyluria, the other one of chylo-
cele (John Guiteras, The Medical News,  Apr. 10, 1886).
  2 Stephen Mackenzie estimated  that there were from 36,000,000 to 40,000,000 embryo
filariae in the blood of  a patient whom he  observed.
  3 In Mackenzie's case an enormous dilatation of the lower part of the  thoracic duct
and of the renal  and some other abdominal lymphatic vessels was found after death,
which occurred from pyaemia, the  parent worms having died some  time before  and
not being  found  at  the autopsy.  In the few other reported autopsies no changes have
been found in the urinary organs or lymphatics to explain the chyluria. 
DIABETES INSIPIDUS.                     927
tions of the lymphatics in various  situations, particularly upon the external
surface of the body, from which a chylo-serous fluid may escape.  Abscesses
are sometimes produced in which the parent worms have been found.  These
various aff'ections may be combined with chyluria.
  According to Manson of China, the embryonic filariae are sucked up with
the blood from  patients affected with  the fiiaria  disease  by  mosquitos, in
which the parasite undergoes further development, and, being discharged into
water, is prepared to again enter the human body, where it forms the mature
organism.  Filariae have been found very  frequently in  the blood of healthy
individuals in  China.
  The cause of the non-parasitic form of  chyluria which sometimes develops
in temperate climates is not known.
  The prognosis is generally favorable. So long as the parent  worms remain
alive  in  the human body  complete  recovery from  chyluria  is  not to  be
expected.  The  embryos  are probably  not endowed  with  long vitality.  It
may be  expected that  sooner or later  the parent worms will  die, and  then
recovery takes place.   As  already mentioned, these worms  have been  dis-
charged  from abscesses.  They seem to  suffer in  their vigor by febrile dis-
eases ; at least, it has  been repeatedly noticed  that  the embryos disappear
from  the blood  during attacks of fever.
   The rational indication for treatment is of course the destruction of the
parasite in filarial chyluria, but no drugs  are known which will accomplish
this.  Gallic acid, from one to two drachms given  daily, is  the  remedy which
thus far has proved most useful. Iodide of potassium in large doses has been
beneficial in a few  cases.   Special virtue  has been claimed for  the decoction
of mangrove-bark (Phizophora racemosd) and the picro-nitrate of potash, but
without satisfactory evidence.  Rest, tonic treatment, and  change of climate
meet manifest indications in many cases.


                         Diabetes Insipidus.
   The term " diabetes " signifies simply increased  flow of  urine, or  diuresis.
The term is applied to two affections which differ essentially each from the
other.   In one of these affections notable diuresis exists, a given quantity of
the urine containing a small  proportion  of solid constituents ; that is, the spe-
fic gravity is low, being sometimes but little above that of spring-water.   The
morbid  abundance of urine in this affection is due to an excessive elimination
of  water by the kidneys.   Considered  as a urinary affection, it is called dia-
betes insipidus.  The other affection to which the  term diabetes is applied is
characterized  by the presence of sugar in the urine.  This affection will be
considered in the next article.
   A morbid excess of  water in the  urine, expressed by the terms hydruria
and polyuria, is  a symptom  occurring in  various pathological connections.
It is a frequent  symptom in  cases of the small granular kidney, and is not
infrequent in cases of the waxy kidney.  Polyuria has  been observed also as
a symptom of hydronephrosis with wasting of the  kidneys and in  cases of
enlarged prostate and  some other surgical affections of the urinary organs.
Polyuria occurs  also, in some cases, as a symptom  of  cerebral diseases and
of lesions caused by injuries of the skull.  It is a symptom in cases of hys-
teria, asthma, and other nervous affections.   In all these instances the poly-
uria'is  not properly to be considered as  constituting an individual disease.
Polyuria  and hydruria, therefore, are terms not synonymous  with diabetes
insipidus.   The'latter term, if properly applied, denotes a disease character-
ized by an excess of water in the  urine  when not symptomatic of  the fore-
going diseases. 
928         STRUCTURAL DISEASES OF TEE  KIDNEY.

  In well-marked cases  of  diabetes insipidus  the  quantity of urine  greatly
exceeds that of health.   It may amount to fifteen  and even twenty quarts
per diem.   The specific gravity varies between 1003 and 1007.  There is no
essential change in the composition of the urine except the excess of water.
There  is thirst, which leads the patient to ingest fluids in an amount  propor-
tionate to  their loss by the kidneys.  AVhen deprived  of other liquids patients
have been known to drink their own urine.   The need of drinking often and
the frequent acts of micturition occasion  much annoyance and interfere with
sleep.   The disease may not otherwise interfere with health.   Patients of
either  sex, affected with the disease, have been able  to perform  active labor,
have had  children, and their lives have apparently not been shortened by it.
It is not incompatible with  good appetite, digestion, and nutrition.   It has
been tolerated for  fifty  years.
  The  prognosis  is favorable as  regards the duration of life and the  preser-
vation  of  general  health if  the disease be uncomplicated ;  but it is unfavor-
able as regards recovery from the  disease.  As  remarked by Senator,';  Recov-
ery is rare, but death is still more rare."
  The  etiology is obscure.  The  disease has followed injuries  of the head,
and an  hereditary influence  is involved in some cases.1   In the majority of
instances the disease  cannot be traced to any adequate cause.  It  occurs not
infrequently in infancy.   In a proportion of about  one-half, when the  disease
is developed, patients are less than twenty years of age, and in about the same
proportion the age is between thirty and fifty.  It is extremely rare after the
age of  fifty.  The number of males affected with the disease  is considerably
larger  than  of females.  There have been a few instances recorded in which
diabetes mellitus has passed into diabetes  insipidus, the sugar disappearing
from the  urine.
  The  pathology is unsettled.   The  discovery by Bernard that a puncture
in the floor of the fourth ventricle of the brain will produce polyuria without
sugar in the urine naturally directed attention to this situation as the seat of
the disease.  Cases have been observed in  which after death lesions were
found to involve this part.  There is not, however, sufficient ground  for  assum-
ing that diabetes  insipidus depends on anatomical changes  here or elsewhere
in the brain.  The  absence of all symptoms of cerebral disease, exclusive of
the polyuria, in  cases the duration of which extends over  many years, mili-
tates against this  assumption.  That the disease is neuropathic is rendered
probable by  the occurrence of polyuria as a symptom in various nervous affec-
tions.   The  production of polyuria  in animals by  division  of the splanchnic
nerve favors this view.   A  reasonable hypothesis attributes the polyuria to
the dilatation of the renal  capillaries from influences exerted through  the
vaso-motor system.  This result may be produced either by a paralytic effect
through the splanchnic nerves, or by an active  dilatation of the capillaries by
an excitation of vaso-dilator nerves.  (Vide p. 863.)   The presence of  inosite
in the  urine has been  shown to be an effect, not a cause, of the polyuria,
This principle appears in the  urine if a large quantity of fluids  be ingested
in healthy persons.
  The  polyuria in cases of diabetes  insipidus may he suspended during the
continuance of an inflammatory or febrile disease.  Excluding cases of poly-
uria as symptomatic of cerebral  or  of renal lesions, diabetes insipidus is an
extremely rare  disease.  The basis  of the diagnosis is a persistent polyuria
which  is independent of these lesions.  The disease  is to be distinguished

  1 Weil has reported the history of  a family of 91  members, extending through four
generations.  Of these, 23 had  polyuria, and in 13 it could not be determined whether
this existed or not.   This affection existed throughout life without impairment of the
general  health (Virchow's Archiv, Bd.  95, p. 70). 
DIABETES MELLITUS.
929
from polydipsia.   In the latter disease the excess of water in the urine is an
effect of the excess of liquid ingested.   If the quantity of urine exceed  the
quantity of drink, and if polyuria continue  notwithstanding a restriction of
the latter, the differential diagnosis is established.   From diabetes mellitus
the discrimination is easy.   The low specific  gravity of the  urine is distinct-
ive, but  the exclusion of that disease  is rendered  positive by the negative
result  of testing the urine for the presence of sugar.
   It is injudicious to attempt to limit the excess of the water in the urine by
diminishing the  amount of ingested liquid.  The  disease is not thereby cured,
and  not only^ is there  suffering from thirst, but, inasmuch as the polyuria
continues, serious evils may arise  from a morbid reduction of water in  the
blood.   Theoretically, it is an object of treatment  to diminish the size of
the renal capillaries.  In a case reported by  DaCosta recovery within a short
period was apparently effected by  the fluid extract of ergot in drachm doses,
increased to two drachms and given three  times daily.   This remedy  was
recommended, on the basis of experience, many years ago by  Prof. Gross.
Ergot  or ergotin has been found useful by others.  Other remedies which
are recommended are gallic acid, dilute nitric  acid, and valerian.
   The patient's strength is to be  maintained as far  as possible by tonic rem-
edies, good  alimentation, and favorable  hygienic influences.
   The disease is not in  itself  fatal, but it may occasion more or less  exhaus-
tion, and thus  increase the liability to death from associated or intercurrent
aff'ections.


                          Diabetes Mellitus.
   An increased  flow of urine or diuresis is generally a notable feature of the
affection now to be considered.  The distinctive feature, however, is the pres-
ence of grape-sugar or glucose in the urine ;  and hence the significance of the
term mellitus.   Glycosuria and melituria are  other names applied to the affec-
tion  characterized by saccharine  urine.   The affection is  far from being of
frequent occurrence, yet it is not so rare but  that cases  come under the obser-
vation of every physician.  From the number of cases which have come under
my observation in recent years I have been led to think that the disease is less
rare than formerly in this part of the world.  One reason of its apparent infre-
quency is that it is liable to be overlooked in cases which end fatally with some
intercurrent disease.
   Sugar in the urine, like albuminuria, may occur as a symptom in various
pathological connections.   It follows anaesthesia produced by the inhalation
of chloroform or ether, an epileptic or  an hysteric  paroxysm, some violent
emotion, etc.  The sugar under these circumstances is usually not abundant,
and the urine  contains it for a brief period only.  As the distinctive feature
of an individual  affection the sugar which the urine  contains is in greater or
less  abundance, and  it  continues  more or less persistently.   Even when the
aff'ection exists  the  saccharine urine is in fact  merely a symptom.  It does
not constitute the affection.   It is incidental to or  an effect of the real  dis-
ease.   The  sugar exists in the urine because it  pre-exists in the blood and is
excreted by the kidneys;  but with our present  knowledge the true seat  and
nature of the disease are  not established, and  therefore,  provisionally, it is
named as if it were a disease of the urinary system, and is included for the
sake of convenience  among  the diseases affecting this  system.
   An abnormal accumulation of sugar in the blood constitutes the morbid con-
dition called glycoh;einia.  Glycohaemia  stands in an immediate causative rela-
tion to the  presence of glucose in the urine, and glycosuria is an effect of the
glycohaemia.  The  latter  stands in a nearer  relation than the former to the
       5'J 
930          STRUCTURAL DISEASES  OF  THE KIDNEY.
pathology of diabetes mellitus.  The pathology of glycohaemia is the pathol-
ogy of the diabetic disease.   Glyc-olneinia  has been considered in Part I.
among the morbid conditions  of the blood. (Aride p. 69.)

  Anatomical Appearances.—Although the pathological anatomy of dia-
betes  mellitus is not known, certain anatomical  changes have been found with
sufficient frequency to deserve mention in this connection.   That  any of these
changes are  concerned in the production of diabetes  mellitus has  not been
proven.
  On page 71 the existence  of changes  in the central nervous  system, and
especially the observations of Dickinson  on this point, have been  considered.
Frerichs also found  dilatation of  the  vessels,  capillary  hemorrhages, and
minute myelitic fogi frequently present  in the  medulla oblongata after death
from  saccharine diabetes.
  The liver may be large, small, or of normal size, hyperaemic, anaemic, or of
normal vascularity, and the hepatic cells  fatty,  atrophic, or normal.  In  other
words, there is no anatomical basis for the current theory which refers dia-
betes  mellitus to abnormalities in the circulation or in the functions of the
liver.   The amount of glycogen in the liver of diabetics seems to be dimin-
ished  during life.
  Attention has been directed in recent years especially to alterations in the
pancreas in cases of diabetes.  In  many cases  atrophy of  the pancreas has
been  observed.  The atrophy of  the gland-structure may be combined with
increase of the interstitial connective and adipose tissue.   Whether, as has
been surmised, the cceliac plexus be involved in the pancreatic disease is not
known.  Glycosuria is occasionally present in cases of cancer and of calculous
disease of the pancreas.   It is claimed that diabetes mellitus associated with
pancreatic disease runs a particularly rapid  and severe course, and is accom-
panied often  with fatty diarrhoea.
  The kidneys of diabetic patients are often large  and hyperaemic,  probably
in consequence of their increased functional activity.  Glycogenic degenera-
tion of the epithelial cells lining the looped tubules  of Henle is a constant
change  in  diabetes mellitus  (Ehrlich).  These  tubes  occupy the boundary-
zone of the pyramids.  The affected cells are swollen and  hyaline in appear-
ance.  The presence of glycogen is  proven by the reaction  with iodine.  This
change is probably secondary to diabetes.  Chronic  diffuse  nephritis is  not a
rare complication of diabetes.
  A hyaline  degeneration of the walls of small arteries in various  parts of
the  body  has been often seen in  diabetic cases
  An excessive amount of fatty matter  in the blood, constituting  lipaemia,
is common in diabetes.
  The complications  of  diabetes  will he mentioned in connection  with the
Clinical History.

  Clinical History.—Notable increase of the urine, or polyuria, is usually
the  symptom which first awakens suspicion of the  existence of the disease.
Not only are  the acts of micturition more frequent, but the quantity of urine
passed in a given time is much greater than in  health. The urine is deficient
in color in proportion to the amount of sugar which it contains.  The appear-
ance is generally clear as well as pale.   It has frequently a sweetish odor
like that of whey.  The  presence of sugar is perceptible to the taste.   Flies
and bees are  attracted to it if  emitted on the ground.  The density exceeds
that of healthy urine in  proportion to the amount of sugar.   The specific
gravity varies between  1025 and 1074, the latter  being  an extreme of in-
creased density.  A specific gravity below 1020  is exceptional.  The  reac- 
DIARETES MELLITUS.
931
 tion is in  most cases feebly acid.   The  water of the  urine  is more  or  less
 increased ; and hence the increased quantity of urine.  The increase in the
 quantity of urine is  generally very great, and sometimes enormous.   It may
 amount to fifty pints or even more in the twenty-four  hours.  The frequent
 calls to micturate are a source of great  discomfort, and especially during the
 night they constitute a serious evil by interfering with sleep.  The action of
 the sugar on  the urethra may occasion a sense of heat and stinging pains.
 Inflammation and excoriation of the  prepuce and glans are sometimes pro-
 duced, and may lead to phimosis.   I  was led to the discovery of diabetes by
 an examination of the  urine in a case in which  the patient complained only
 of an itching sensation in the middle of the penis, there being no increase of
 urine, no thirst, and  no symptom of any  disease except that  just mentioned.
 The  urine was found to be  loaded with sugar.  In women eczema  of the
 vulva is a frequent  effect, giving rise to  distressing pruritus.  It has been
 stated  that  more liquid is  contained in the  urine in some cases  than is
 ingested.  This may be true for a limited period, but  examinations  extend-
 ing over several  days  show  that, large  as is the quantity of urine,  it falls
 short  of the amount of liquid contained in food and  drink.
   Cases differ in respect of the quantity of urine  and  the amount of sugar.
 Generally, at the beginning of  the disease  the quantity  of urine and "the
 amount of sugar are not large, but the increase of both is progressive as the
 disease advances.   Exceptionally,  the quantity of  the urine is not increased,
 although  abounding in  sugar.   This has been  true of several cases which
 have come under my observation, the patients not being under treatment,
 and for^ this  reason  the  disease is liable to be overlooked.   The quantity of
 both urine and sugar also varies at different periods of the day, being gener-
 ally largest within a  certain period after meals.  The proportion of sugar in
 the urine  varies between ? and 10 per cent., in extreme cases being 15 per
 cent.   Usually from  2 to 4 per cent, is  found.   The quantity of  sugar con-
 tained in the urine during twenty-four hours has  been known to amount to
 fifty ounces.  The quantity of sugar and of urine may be diminished by inter-
 current febrile diseases and toward a fatal termination of the disease.   Inosite
 has been found in the urine in some cases with grape-sugar, or after this had
 disappeared.
   The  daily excretion of urea in  diabetes is generally markedly increased.
 Uric  acid, although a frequent sediment in diabetic urine, is not excreted in
 abnormal amount.  In many but not in all cases of diabetes there is a notable
 excess in the excretion of ammonia by the urine.  This is associated with the
 presence of oxybutyric  acid, a substance which by oxidation gives rise  to
 diacetic acid.   Acetone  has  been  frequently found in  diabetic  urine, but
 whether it be preformed or originate from some other substance in the urine
 is uncertain.  Many refer the formation of acetone to the presence of diacetic
 acid, which is probably the substance which imparts to the urine a burgundy-
 red color upon the addition of ferric chloride (Gerhardt's reaction.  See p. 72).
 Albuminuria, although not rare, is  to be regarded as a complication.
   The urine when preserved for several days undergoes the alcoholic fermen-
 tation.  It  remains acid and is devoid of the ammoniacal odor which is emitted
 by decomposed healthy urine.  It  is rendered turbid by the development of
 the Torula cerevisi;e, or yeast-fungus.  This alcoholic fermentation imparts to
 the urine irritating properties which cause inflammation and irritation  of the
 skin with which it comes in contact.
   Emaciation is usually marked after the disease has existed for some time.
 Cases differ as regards the  rapidity of the emaciation.  In  general, it is  in
proportion  to  the  abundance of sugar in  the  urine and the duration  of the
disease, but it is affected in a greater measure by the condition of the digest- 
 932         STRUCTURAL  DISEASES OF THE KIDNEY.

 ive  organs.  It is evident that certain alimentary principles which in health
 contribute to the growth and repair of the body are lost to nutrition  in this
 disease.  The development of  other affections, especially pulmonary tubercu-
 losis, increases the emaciation.  The occurrence of diabetes is not infrequently
 preceded by embonpoint more or less excessive.
   Increase of the appetite is usually a prominent symptom.  The patient in-
 gests much more food than in health.  The abnormal appetite may amount to
 bulimia or polyphagia.   This, conjoined with progressive decrease of weight,
 should excite  suspicion  of the disease.   Exceptionally, the  appetite is  not
 increased, but, on the contrary, it may be more or less impaired.  Not infre-
 quently, in the course of the disease the appetite fluctuates, being sometimes
 greater and sometimes less than in health.   It fails as the disease approaches
 a fatal termination.
   Thirst is one of the first symptoms, occurring  as  soon as the quantity of
 urine is increased.   It is urgent in proportion to the degree of diuresis.  The
 quantity of liquid ingested is  sometimes enormous.  The necessity of drink
 during the night contributes, with the  calls to urinate, to prevent sleep.
 Dryness of the mouth is a source of considerable inconvenience.  The tongue
 is sometimes moist and coated,  and sometimes dry and reddened.  The gums
 are generally affected.   They are  softened,  and either pale or reddened, bleed-
 ing readily on pressure.   The teeth may become loosened and carious.  The
 saliva is  usually acid.
   Digestion, until the disease is far advanced or  until serious complications
 occur, generally appears to be well performed.  Dyspeptic ailments, however,
 are not uncommon.  If  vomiting occur, the vomited matter is found to con-
 tain sugar.   Sugar is  also contained in  the  feces.   Constipation is the rule,
 but income cases diarrhoea alternates with  constipation.  The dejections show
 a deficiency of  bile.
 ^  The  respiratory function  is  not disordered, save by  the pulmonary affec-
 tions with which the disease is liable to become  complicated, especially pul-
 monary  tuberculosis.   The  respirations are  somewhat fewer  than  normal
 if there be no pulmonary complication.   It is stated that the amount  of
 carbonic acid in  the expired air  is less than in health.   The breath has
 a mawkish, sweetish odor which  is quite  characteristic.   It  has been com-
 pared  to the odor of hay and of  apples.   I have recognized a patient whom
 I had examined at a clinic months before, and whose features I had entirely
 forgotten, as  soon as he came sufficiently near for the odor of his breath to
 be perceptible.   In repeated instances I have been led to suspect the disease
 by  this  peculiar  odor.   The condition  of  the gums and  teeth renders the
 breath in some  cases fetid.
   The circulation often offers no symptoms of importance.  The pulse, if at
 all affected, is oftener retarded  than accelerated, exclusive, of course, of the
 effect of complications.   I have observed capillary congestion of the'surface
 in a notable  degree.  Symptoms denoting cardiac weakness  are sometimes
 present, causing shortness of breath and tendency to syncope.  Failure of
 heart-power may occur  suddenly  and  terminate  fatally.  The temperature
 of the body is lowered, the thermometer in the axilla showing a temperature
 of 96° or 95° F.  in some cases  in  which the disease is uncomplicated.  The
 skin usually is  dry and  rough.   It is  rare for perspiration to occur except
 when pulmonary tuberculosis  becomes  developed.   Furfuraceous  desqua-
 mation of the epidermis is not uncommon.  Itching of the skin is a symptom
which  sometimes occasions much  annoyance.  Diabetics are  subject to car-
buncles, boils, and various eruptions—namely, psoriasis, lichen, eczema, and
impetigo.   Spontaneous  gangrene of the lower limbs is  an occasional event.
 1 have  known of several instances in  which  this occurred.   The gangrene 
DIABETES MELLITUS.
933
resembles gangraena senilis.   Ulcerations of the  lower  limbs without gan-
grene have  been observed.   AVounds and surgical operations often take an
unfavorable course in diabetic  patients.   In protracted  cases oedema of the
legs frequently  occurs.   Bright's disease is an occasional complication of
diabetes.
  Muscular feebleness is more or less marked and progressive.  Aside  from
the effect of complications,  the  patient  is enfeebled in proportion to the
excessive excretion of the urine,  the amount of sugar which it contains, and
the duration of the disease.   Troubles of vision are not  very infrequent.
Amblyopia, or feebleness of  vision, sometimes  occurs early, and may event-
uate as  the disease advances in confirmed amaurosis, either  complete or
incomplete.   Troubles of accommodation are not rare.  In the majority of
cases in which the vision  is affected the  defect is  slight  or  moderate.   Com-
plete amaurosis is extremely rare.  In  the cases in which amaurosis, com-
plete or incomplete, exists, the ophthalmoscope shows atrophy of the  optic
discs.   Retinitis is a ground for  suspecting that albuminuria  coexists.   The
diabetic  condition also  favors  the development of  soft cataract.  In  some
cases recovery from defect of vision occurring  in  diabetes  takes place  after
the  sugar  has  disappeared  from  the  urine.   Diminution,  and  at length
extinction, of venereal  desire  belong to  the clinical history  of the disease.
This effect  frequently occurs early in  the history of the disease,  before the
general powers of the system are much reduced.   It may be the  first symp-
tom noticed by the  patient.    It  is  not, however, a  constant symptom.  In
women the menstrual discharge  gradually diminishes and  is  at length sup-
pressed.
   Certain symptoms referable to  the nervous system  are of  great importance
in  the  history of diabetes.  The mental  condition  frequently undergoes a
marked change ;  the patients become irritable, sad, and hypochondriacal; and
the intellectual  faculties are  enfeebled.   Neuralgia, aff'ecting most frequently
the sciatic nerve  and often  occurring on both sides of the  body, is an  obsti-
nate symptom in some cases  of diabetes.   Occipital and trigeminal neuralgias
have also been repeatedly observed. Absence of the  knee-phenomenon is not
an  infrequent symptom in diabetes.
   By far the most important of  the nervous symptoms of diabetes are  those
which have been embraced under the name diabetic coma.   The coma may
follow physical  over-exertion,  mental  excitement, or some  slight  bodily ail-
ment,  such  as pharyngitis, gastritis, or bronchitis, or it  may  appear without
any apparent exciting  cause.    The advent of coma may be sudden, but
more frequently it is preceded by premonitory symptoms, of which the most
important  are headache,  nausea, and  vomiting, a sensation  of anxiety and
of  oppression, restlessness, and noisy delirium, sometimes attended with fits
of  screaming.   AVith or  without this  premonitory period of excitement and
delirium the patient sinks into  a state of somnolence deepening  into coma.
The coma is usually accompanied with a peculiar dyspnoea, without evidence
of  disease  of the lungs or air-passages, the respirations being strong, deep,
and often  noisy.  The  number of respirations is either normal  or more fre-
quently moderately increased.  The  pulse  usually  is  small  and frequent.
The temperature usually is subnormal.  A peculiarity of diabetic coma is
the marked ethereal odor of  the  breath, compared to the odor of  fruit or of
chloroform.  The urine in the great  majority  of cases presents  Gerhardt's
reaction.   The duration of the coma is generally between one  and  three days,
but it  may be  shorter  or longer.  The termination is generally, but not
necessarily, fatal.  Coma may occur  without  the characteristic  dyspnoea.
   The  most plausible explanation of  diabetic  coma  refers  this symptom  to
the presence of  some toxic substance in  the blood, but we  are ignorant as to 
 934          STRUCTURAL DISEASES OF TEE KIDNEY.

 the nature of this substance.  The fruity odor of the breath and the changes
 in the urine have led to the supposition that acetone or some kindred sub-
 stance is the toxic  agent;  but it has not been possible to  confirm  this sup-
 position. (See  p. 72.)  It is not probable  that  the  coma is  due  to  fatty
 embolism,  as has been suggested.
   Coma  may occur in diabetes from  uraemia, sudden  failure of heart-power,
 and cerebral  hemorrhage, but these cases are not identical  with the so-called
 diabetic coma.
   The course  of diabetes  is generally slow.  Its development is imper-
 ceptible, and when discovered it  had probably, in most  cases, existed  for a
 considerable  period.   It is  therefore difficult  to  fix the date of its  origin ;
 but,  dating  from the  time  when its  existence  is  known, in most  cases
 it  continues  for  many months, and not infrequently for  many years, before
 ending fatally.   Its  duration is indefinite  and variable.   Exceptionally, it
 runs rapidly to a fatal issue.  Generally in these cases the patient is cut off
 by some intercurrent  affection.   The existence  of diabetes notably impairs
 the tolerance of other diseases.   Oriesinger  found the mean duration in 225
 cases to be between two and three years.  Cases have been described under
 the name diabetes acutus in which the disease has appeared only  a  few  days
 or weeks before death.

   Causation.—In the vast majority  of cases of diabetes the age is between
 thirty and fifty years.  The  disease  occurs in infancy, youth, and advanced
 life, but instances are rare. Facts go to show that predisposition is an import-
 ant factor in the causation, and that this predisposition  may  be inherited.  Of
 36 cases  recorded, with reference to this point, by A. Flint, Jr., in 10 two or
 more cases occurred in members of the same family.  In one instance a father,
 an uncle, two sisters, two brothers, and a son of one of the sisters were affected
 with the disease.1  As regards pathogenetic influences  pertaining to climate,
 season, diet, temperament, habits of life, etc., we have  only  conjectures with-
 out any precise information.  Men are oftener affected than women.   Of the
 225 cases analyzed by Griesinger, in 172 the patients were men, and in 53
 women.
   In a  considerable—not a  large—number of instances the disease follows
 some injury  of the  head or spine or a concussion  of the  whole  body.  In
 some of these instances the glycosuria may have been only  a transient symp-
 tom, and in other instances there may be room for doubt as to any causative
 connection, considering that in a large majority of cases no  such causation is
 evident.  A constant connection  has not been established between the disease
 and cerebral lesions affecting the floor of the fourth ventricle, which  the experi-
 ments of Bernard on animals showed to stand in a causative relation  to glyco-
 suria.  Autopsical examinations in cases of diabetes mellitus have  failed  to
 discover  lesions in this  situation, and  lesions have been found  here when
 diabetes  had not existed.  No pathological  connection of  the disease  with
 any anatomical  changes  in  the  liver has been ascertained.   Syphilis and
 gout have  been assigned a share in the causation, but with what propriety
 is  uncertain.
   The disease in some cases has been attributed to violent mental  emotions.

   Diagnosis.—It is to  be  borne in mind that the fact of  sugar existing in
the urine is not alone sufficient evidence of the existence of  the disease under
 consideration.  Sugar, generally in small  quantity and for a transient period,
is  not infrequently found in the  urine in the course of various maladies.  In
  1 Journal of the American Medical Association, April 17, 1886. The "son of one of the
sisters" developed diabetes since the note appeared in the Journal. 
DIABETES MELLITUS.
935
aged persons the urine sometimes  temporarily contains a considerable amount
of sugar.  A number of instances have fallen under my observation.  I have
known much needless uneasiness to be occasioned by announcing to a patient
the discovery of a trace of sugar after an analysis of the urine.
  If diabetes exist, saccharine  urine  is more or less persistent, the amount
of sugar is unusually  large, and  generally the quantity of urine is notably
increased.  These points relating to the urine render the" diagnosis sufficiently
easy and positive.   The diagnosis is confirmed by other  symptoms belonging
to the  clinical history of the disease.  If the quantity of urine be  consider-
ably increased,  and on testing  with  the  urinometer the specific  gravity  be
found  high, sugar is probably present.  Sugar, however, is sometimes  pres-
ent in urine of low  specific gravity.  In cases of polyuria in which only
the water  of the  urine is  increased, as in  diabetes insipidus, the specific
gravity is  extremely low, sometimes but little above that of spring-water.
The fragrant odor of diabetic  urine is  characteristic,  and it froths  readily
on  agitation, the air-bubbles remaining for  some  time, but the practitioner
should not be satisfied without demonstrative proof of the presence of sugar.
Of the several methods of testing urine for sugar, one readily available is the
fermentation test.  A common  test-tube or phial containing a little ordinary
yeast is to be filled with urine, inverted and placed  in a saucer containing the
urine, care being  taken to prevent the entrance of air.   Kept at a tempera-
ture of 70° F., fermentation ensues, and the  gas formed  rises  in the tube and
displaces the urine.   The gas is shown to be carbonic acid from its failure to
support combustion.  Christison states that a cubic inch of the carbonic acid
formed in the fermentation test represents a  grain of sugar.   Of the various
other methods of  testing for sugar, the employment of Fehling's  solution is
the most convenient, and it is sufficiently  reliable.  I have found this test,
as prepared by Squibb  in two separate solutions, to remain unchanged  for a
year kept in  glass-stoppered  bottles, although used almost daily.  Bottger's
test with the subnitrate of bismuth is readily applied.   The polarization test
is probably the  most accurate,  but it is not necessary to resort  to  this for
clinical purposes.   If it  be desired to ascertain the actual amount of sugar
excreted in a given period, the volumetric method of analysis by Fehling's
test or Roberts's  differential density method may be employed.1   Examina-
tions of urine are to be repeated, in the first place, to settle the persistence of
the saccharine condition, and in the second place with reference to improve-
ment  or  otherwise.

  Prognosis.—As regards prognosis, a  distinction is to be made between
cases  in  which  the sugar disappears from the urine when the diet is free
from carbohydrates, and cases in which sugar persists during a strictly albu-
minous diet.  The former class of cases is in general more amenable to treat-
ment  and offers a  better prognosis than the latter.  The milder  cases may,
however, become  severe, and  they may terminate fatally by  some  of the
many complications to which  diabetic patients are subject.
  An early diagnosis diminishes the gravity of the prognosis.  This fact en-
forces the importance of examining  the  urine for sugar in all cases in which
there are any grounds for suspecting  its  presence ; and it is to be recollected
that sugar is sometimes persistently present when the  quantity of urine is
not much, nor even at all, increased, and when the specific gravity is not nota-
bly above the normal standard.   Examination of the urine for sugar should
not be omitted  whenever failure  of strength or  emaciation  occurs  without
apparent cause, and especially if the appetite be increased rather than dimin-
ished.  Unusual thirst,  dryness of the mouth or fauces, acidity of the saliva,
         1 Aide  Roberts, Urinary and Renal Diseases, Philadelphia, 1879. 
936          STRUCTURAL  DISEASES  OF THE  KIDNEY.

impairment of vision, obstinate neuralgia, dimininution or extinction  of vene-
real desire, dryness and itching of the skin, irritation or inflammation of the
prepuce  or glans penis, and pruritus vulvae, should  suggest the possibility
of the existence of this disease.  A certain amount of increase in the quan-
tity of urine may not attract the attention of the patient, or the patient may
not deem it a symptom of importance, and it is therefore necessary for the
physician to direct inquiries to this  point.
  The age and the weight of the body have a bearing on the prognosis. The
prognosis is in general unfavorable in proportion to the youth of the patient,
and as regards this disease corpulence is a distinct advantage.
  The existence or development of complications is of great influence in the
prognosis.  The majority of fatal cases of diabetes terminate either in phthisis
or in diabetic  coma.   According to some statistics, the most frequent  cause
of death is coma.  The phthisis is a genuine  pulmonary tuberculosis.  Other
not infrequent complications wrhich may prove fatal are—pneumonia, nephri-
tis,  carbuncles, gangrene, and cerebral hemorrhage.  The existence of diabetes
lessens the  ability to cope with affections which under other  circumstances
might  not  prove  serious.   Not  a  few  cases terminate  in  debility and
marasmus.1
  In respect of prognosis much depends on the ability and willingness of the
patient to efficiently carry out the dietetic treatment.
  Undoubtedly, the majority of cases of diabetes  mellitus terminate fatally
sooner or later.   My  experience, which has  been  considerable, has  led me,
however,  to  modify  somewhat the  views  respecting  prognosis which were
expressed in the  early editions of this work.   The disease seems to me less
formidable than  heretofore, provided proper treatment be  adopted and per-
sisted in.   Moreover, I have met with a number of cases which illustrate the
tolerance  of the disease by those who have not been aware of its  existence
and by those who refuse to submit to rigid dietetic restrictions.  In the great
majority of cases the diabetic condition may be notably ameliorated, but there
is always more or less danger of a relapse even in cases in which the  sugar has
been made to disappear and the patient has regained his usual health.

  Treatment.—The essential  treatment of diabetes mellitus is dietetic.  The
object is the exclusion, as far as possible, of  sugar  and starch  from the diet.
In proportion as this  object is effected the glycohaemia and glycosuria dimin-
ish.  Not  infrequently all  evidence  of the disease  disappears under  strict
dietetic treatment, and the patient is apparently in perfect health. Difficulties
in the way of success under this treatment arise from  the inability to carry it
out rigidly.  Patients sometimes have not sufficient strength of will to  adopt
and persevere in the  dietetic restrictions.   In  some cases this  difficulty does
not exist, but the system will not tolerate the restrictions,  and the vital func-
tions give way under the continuance of the treatment.  Complications or asso-
ciated diseases  sometimes render its adoption impracticable.
  In not a few instances the physician is  responsible for want of success with
dietetic treatment, his instructions not being given with sufficient precision.  It
will not be sufficient to say, in general terms, that saccharine and starchy arti-
cles of diet are to be avoided.   Most  patients have not sufficient knowledge
of alimentary principles to discriminate correctly the food  which is allowable.

  1 Of 2i0 fatal cases observed  and analyzed by Frerichs, the following were the causes
of death : Exhaustion, 18; phthisis, 34; pneumonia, 7 ; nephritis, 8 ; carbuncles, 6; cere-
bral hemorrhage, 10; cerebral softening, 2; cerebro-spinal meningitis, 3; other compli-
cations i caneer, etc.), 9 ;  and in all the remaining cases (153) coma diabeticum (Freriehs,
Ueber den  Diabetes, Berlin, 1884).   Most  statistics  have shown a larger proportion of
phthisical  cases; for instance, 43 per  cent, in  Griesinger's analys's. 
DIABETES MELLITUS.
937
I have known instances, for example, of diabetic patients eating freely of rve
and corn-meal bread under the belief that only wheat bread was interdicted.
It is essential that a written or printed list be furnished to patients of all the
articles which may  enter  into  the  diet  and of all  those  which  are  to  be
excluded.  Such a list is essential in order to meet another requisite for suc-
cess.   The dietetic treatment must be  made to satisfy not only the needs of
nutrition, but the desires of the patient.  This can be done only by varying
the articles of diet from  day by day, by making combinations to suit the appe-
tite, and by the  preparation of food in ways to be acceptable to the  taste.
Hence the diet-list  should be as comprehensive as  possible.
   Bread occasions more  difficulty than any other article of food.   The force
of the phrase " staff of life," as applied to  bread, is appreciated when the
attempt is made to exclude it persistently from the  diet.  Diabetic  patients
of good  resolution will  begin the dietetic treatment  with the conviction that
they  can do  very well  without  bread, but  after a  time  the desire  for  it
becomes too  imperative  to be resisted without great discomfort.  The fact,
then, is  to be accepted  that  some form of  bread  must  enter into the diet.
Different substitutes for bread  which have  been devised do not  satisfy the
want of it.   Flour consisting only of  bran, prepared after Camplin's method,
is generally tolerated but for a short time.   Patients soon have a repugnance
for it, and, as it is innutritious, there is then no advantage in persisting in its
use.  This is measurably true, also, of flour consisting of pure gluten, and of
the almond-flour recommended by Pavy.  Either a certain quantity of ordi-
nary bread must be  allowed, or  a  bread must be used containing a  diminished
proportion of starch without its entire exclusion.  A bread made by Messrs.
II. A . Hecker &  Co. of New York contains a very small proportion of starch.
This bread is light and agreeable, but it requires great care in its preparation.
Analyses made by Prof. C. A. Doremus  gave between 1 and 2] per cent, of
starch, whereas in ordinary bread the  proportion is about 55 per cent.  In a
number  of cases in  which I have advised its use patients have found it to be
a satisfactory form of bread.
   The bill of fare for diabetics is very extensive.   All  varieties of  shellfish
are allowable.  Soups of various kinds may be prepared without flour, rice,
vermicelli, or any other article which  contains starch.  Fish of every descrip-
tion may be eaten, either fresh, salted, or preserved  in  oil.  Of meats, poul-
try, and  game, there is but a single exception—namely, the livers may contain
enough sugar to warrant their exclusion.  Salads may be made of lettuce, cel-
ery, cucumber, romaine, watercress, Brussels sprouts, chicory, dandelion, young
onions, coldslaw, and olives.  Of vegetables, other than those just  named, the
list embraces spinach, cabbage,  cauliflower, string  beans, pickles, beet-tops,
sorrel, radishes, mushrooms, asparagus, truffles, artichokes, oyster-plant  or
salsify,  and tomatoes.   Eggs,  caviar, cheese of all kinds,  butter, cream in
moderation, unsweetened jellies, filberts, pecan-nuts, almonds,  butternuts and
walnuts. Brazil-nuts, and  cocoanuts are included.  Of drinks,  coffee, tea, and
cocoa without sugar, whiskey,  brandy, gin,  claret, Burgundy,  and dry sherry
are permissible.  Glycerin may be used in lieu of sugar in coffee and tea.  A
patient under my care  ate with relish custards made with glycerin instead of
 sti2;ar.  It is stated that mannite, inosite, levulose, and  inulin are forms  of
 sugar which  may  be taken without  rendering the  urine saccharine.   This
 statement needs further  confirmation based  on experimental  observation.
The  interdicted kinds  of food are—sugar,  syrups of all  kinds, and  honey,
wheat and  rye flour and corn-meal, arrowroot, sago, tapioca, oatmeal, barley,
potatoes, beets, parsnips, carrots, rhubarb, peas and  beans, chestnuts,  sweet
fruits of any kind,  chocolate, cider, most malt liquors, champagne and other
sparkling wines, all  the sweet wines, sweetened spirits, and  liqueurs.  The 
938          STRUCTURAL DISEASES  OF THE KIDNEY.
 admissible articles of diet have been conveniently arranged by Austin Flint,
 Jr., in the form of a bill of fare.1
   The very  bitter ales  may be  taken moderately   Turnips  are  considered
 by some as allowable.  Celery is  interdicted  by some, but probably without
 reason.  There  have been doubts as to tomatoes, but they are probably cor-
 rectly placed in the list of allowable articles.  The quantity of ingested fluids
 should be moderately restricted.
   For the sake of emphasis it may be repeated that success will depend on
 the pains taken  to vary,  combine, and  prepare the allowable kinds of food, so
 as to render the diet  satisfactory as regards the patient's taste, appetite, and
 digestion.  To do this will require much and constant attention on the part
 of those who have charge of the  dietary of diabetic patients.  It is difficult
 to carry  out the dietetic  treatment properly in hospitals.  Patients can rarely
 have it properly carried out in  hotels and boarding-houses.   Poverty is some-
 times a serious obstacle in the  treatment of this disease.
   Under the dietetic treatment, faithfully carried out, the sugar in the urine
 is speedily diminished.   In a considerable proportion of cases  it disappears;
 the quantity of urine decreases and often becomes normal in this regard ; the
 thirst disappears, and there may be no evidence of ill health.  Patients  have
 repeatedly declared,  even when  the urine  still  contained  some sugar, that
 were it not for the knowledge of this fact they would not  suspect the exist-
 ence  of  any malady.  Not infrequently there  is a  consciousness of better
 health than  for a  long  time before the diabetic disease was discovered.
   The return to the articles which are not in the list of those  allowable is to
 be made after a time gradually and tentatively, watching the effect upon the
 urine.  Probably in most instances an  unrestricted diet will cause a return of
 the saccharine urine if the cases  of transient diabetes, to  which reference has
 been made, be excepted.   Under these circumstances patients  cannot be con-
 sidered as cured;  but, on the other hand, the restricted  diet, with  proper
 pains, may be well tolerated indefinitely, the general health remaining excel-
 lent.  Although, therefore, the  disease be not cured (quoting the language of
 Senator), it may be made entirely harmless.
   Reference  may be  here made to the skimmed-milk treatment proposed by
 Donkin.   His method consists  in confining the  patient  strictly to skimmed
 milk, from six to eight pints being taken daily, the treatment to be continued
 for ten or twelve weeks,  after  this period other articles  of diet being grad-
 ually added  and  at  length  substituted.  That this plan  of  treatment has
 proved temporarily useful in  some instances  must be  admitted; in  most
 instances, however, it has been  not only nugatory, but hurtful  and  even
 destructive.
  As regards the employment of drugs, if there be no special symptomatic
 indications to be met  by remedies,  before any medication is employed it should
 be ascertained how much  may be effected by diet alone.
  The alkalies, first employed for  theoretical reasons, have been found to be
 useful in some cases.   Trousseau's method was to give a  drachm daily of the
 bicarbonate of soda, and to increase the doses gradually to three or even four
 drachms.  In order to avoid the evils incident to super-alkalinity of the blood
 he advised that the remedy be given only during ten consecutive days in  each
month.   I have seen  the good effect, apparently, of this treatment when there
 was  not  much restriction in diet.  The benefit which patients derive  from
treatment at  Carlsbad and  A'ichy cannot depend greatly on the alkaline
springs, for  the same benefit is  not derived  from the water when taken at
home.  The credit belongs, in a great measure, to accessory circumstances in
  1 A. Flint, Jr., " On the Treatment of Diabetes Mellitus," Journal of the Am. Med.
 Association, July 12, 1884. 
              INVOLUNTARY SEMINAL  EMISSIONS, ETC.          939

these watering-places and to the treatment in other respects.   A cure is not
to be  expected from  the  use of alkalies, and it is  seldom advisable when
patients can carry out and tolerate  strict  dietetic treatment.
   Opium causes diminution of the sugar in  the urine.   Pavy, who advocates
the opium treatment, advises,  in preference to other preparations, codeia,  giv-
ing it in doses gradually increased from a quarter of a grain  to two grains
three times daily.   The treatment relieves, but it does not effect a cure, and
it is open to objection  on the score of a liability to the formation of the opium
habit.   Opium, however, is indicated in some cases for the relief of muscular
pains,  from which diabetics not infrequently suffer, and which prevent sleep.
   Other remedies  among  the  great  number which have been  recommended
are—the carbonate of ammonia, lactic acid, cod-liver  oil, the iodide and the
bromide of potassium, iodoform, ergot, arsenic, arsenite of  bromine, carbolic
acid, salicylic acid, salicin, strychnia, jambol and sulphide of calcium.  Each
of these in certain cases is more or less useful, but  no  one of them is entitled
to be considered as a curative remedy. The late Dr. Frick of Baltimore stud-
ied the  relative effects of different  remedies in a case under his observation
for nine  months,  and the diminution of the sugar in the urine was most
marked under the use of  strychnia.   Dickinson remarks that " strychnia is,
of all  remedies, the most  constantly useful."  Some cases are notably bene-
fited by salicylic acid or  salicylate  of sodium.
   There may be  indications for  remedies without  reference to any curative
effect.   Tonics are indicated  if  the  appetite or  the  digestion be  impaired.
Anaemia, as in other pathological connections, calls for iron.  The nervous
system may be tranquillized and sleep induced by the bromides or other hyp-
notic remedies.  Ararious symptoms may require  palliative treatment,
   An  important part of the treatment of diabetes pertains  to hygienic obser-
vances.  The body should be protected against atmospherical changes and the
functions of the skin should be well maintained.  The warm bath or sponging
the body, if the  immediate effect be agreeable, is to  be recommended.  The
hydropathic pack has been found serviceable.  A change from a climate which
is cold and variable to  one uniform and warm is often highly advantageous.  A
long sea-voyage in a warm latitude has proved signally beneficial.   Exercise
in the  open air is to be advised, not exceeding so  far the limits of comfort as
to induce over-fatigue or  exhaustion. Gymnastic  exercises may sometimes
be resorted to with profit.   Last, but not least in importance, mental  relaxa-
tion and  recreation  are to be  enumerated in the  list  of regiminal  measures.
   An efficient treatment in cases  of diabetic coma has not been found.  Cam-
phor, ether, and other stimulating restoratives may be  tried.


  Involuntary Seminal Emissions—Spermatorrhoea—Impo-
                                 tence.

   Involuntary  seminal emissions, spermatorrhoea, and impotence frequently
depend on abnormal conditions which belong to surgery, but not infrequently
they fall properly w*ithin the  sphere of the  practice of medicine.  By invol-
untary seminal emissions is meant the ejaculation of semen and the venereal
orgasm without any voluntary effort, either  natural or unnatural.   Involun-
tary emissions occurring during sleep are common, taking place in connection
with erotic dreams.  Occurring after intervals of several days in persons of
continent habits, they are  physiological rather than pathological.   They de-
note simply a certain amount of functional activity of  the generative organs.
They do  not imply a morbid condition nor do they lead to any morbid  effects.
They occur especially when habitual  sexual  intercourse is  interrupted from
any cause.  Under these  circumstances  they are  manifestations of  health 
940         STRUCTURAL DISEASES OF THE KIDNEY.

rather than of disease.  The physician is warranted in giving such assurances
to patients, who are often rendered  needlessly apprehensive and unhappy by
popular works or lectures the object of which is to  excite fears for a merce-
nary purpose.
  Occurring more frequently, the emissions denote a morbid erethism  and
weakness  of the  organs  of generation.   They occur sometimes nightly, and
sometimes even repeatedly during  the same night.   They then call for reme-
dial measures,  although even under these circumstances  their morbid effects
have  been much exaggerated.  Occurring  in persons debilitated from  any
cause, they may take  place  without  erection and  with little or no venereal
excitement, the patient sometimes becoming aware of their occurrence only
by the seminal stains.   They occur sometimes during the day when the vene-
real desire is excited.   These are called diurnal in distinction from nocturnal
emissions.  A patient  stated to me that they had occurred in his case from
excitement caused by  shampooing the head in a barber-shop.  Persons who
have been addicted to  venereal excesses or to unnatural  abuse of the sexual
function are especially  subject to this morbid frequency of involuntary emis-
sions.   The  mind in such cases, particularly if the affection be attributable
to unnatural abuse, may become  greatly  depressed ;  the patient is appre-
hensive of impotence  or  fancies that he is already impotent; his attention is
absorbed with  the affection ;  he  suffers from a sense  of pollution and degra-
dation ; he believes that  his  constitution is ruined and that there is  danger
of insanity.   Patients  in the condition just sketched form an unfortunate
class  with which every practitioner is  more or less familiar.  They go from
one physician to another, and upon patients  of this class quacks prey largely.
The affection sometimes  exists in a still greater degree.   The  emissions are
diurnal as well  as nocturnal.  They are produced by anything which pro-
vokes the sexual  passion, and may take place with little or no excitement of
the external organs.
   Spermatorrhoea means, strictly, the discharge of semen without the occur-
rence of the orgasm.   It  is an affection superadded  to morbid seminal emis-
sions, the seminal secretion passing into the urethra, and sometimes into the
bladder, without the  consciousness of the patient.  In  cases  of spermator-
rhoea the semen is expelled in the acts of micturition and defecation.  Cases of
true spermatorrhoea are far  less frequent than has been  supposed.   Persons
have  been regarded as having this affection whenever a mucilaginous fluid
bearing some  resemblance to semen is discharged  from the urethra.   The
microscope affords the only trustworthy mode of  determining that the liquid
is seminal.  AVere this mode of examination  generally  employed, cases of
spermatorrhoea would  be found to be  extremely rare.   In examining the
sediment of the  morning urine  it  is to be  borne  in mind that spermatozoa
will  be likely to  be found  if sexual intercourse or a seminal emission  have
taken place during the night.   The presence of  the  spermatozoa under these
circumstances  is  not evidence of spermatorrhoea.  A'eritable spermatorrhoea
doubtless occurs, but  probably only  in  persons who are affected  with a
morbid frequency of  seminal emissions.   Muco-purulent matter escaping
from  the urethra or observed in the urine  in cases of cystitis  may give rise
in the mind of the patient to the apprehension of spermatorrhoea.  A trans-
parent viscid liquid escaping in small  quantity  from the urethra, especially
after  prolonged  erection, not infrequently occasions  much uneasiness in the
minds of persons whose attention is directed to the sexual organs with refer-
ence to spermatorrhoea, and of those who have  gonorrhoea.  This is  treated
as a  gleety  discharge  by empirics.  The  discharge  is a  secretion from the
prostate gland  and is  of no practical  importance.  It is  sometimes  of im-
portance in  a medico-legal view to determine  whether stains on linen be 
             INVOLUNTARY SEMINAL EMISSIONS, ETC.         941

caused by dried semen.   The physical  characters of suspected  stains are not
to be.relied upon, nor is  chemical  analysis reliable.   If, however, water  be
slowly added to the stains and portions be examined by the microscope, sper-
matozoa will be recognizable when the stains are seminal.
  Involuntary  seminal  emissions  and spermatorrhoea  are  frequently  asso-
ciated  with symptoms denoting various kinds of functional  disorder,  espe-
cially disturbance of the nervous system.  These  symptoms have been con-
sidered as  direct morbid  effects of seminal  losses.   More or  less general
debility is undoubtedly a result of an abnormal  discharge of  semen, but the
latter is  often incidental to disorder of the system otherwise produced; and
the disturbance of the nervous system so frequently associated with seminal
losses  is  measurably due to the mental depression and  apprehensions  which
they frequently occasion.
  In  the  treatment of seminal  emissions  the  distinction which  has been
made between their physiological and pathological character is to be kept in
view.  Occurring infrequently in a person of full health, in addition  to assur-
ances of their innocuousness it will generally suffice to advise moderation in
the use of wine  or spirits  and  stimulating articles of food, saline laxatives
occasionally, cold ablution of the genital organs at night, avoidance of  undue
warmth from the bed or bedclothes and of distension of the bladder, and that
the mind be diverted as much as possible from provocatives of sexual desire.
If these  measures do not suffice, certain remedies which appear to  exert  an
anaphrodisiac influence may be prescribed.  Remedies which may be  given
for this purpose are camphor, lupulin or the tincture of hops, conium,  bella-
donna, and the bromide of potassium.   The remedy last named has seemed
to me to be distinctly efficacious.   Marriage is always remedial  in  these
cases.
   Cases in which the emissions depend upon a morbid  erethism and weakness
of the generative organs, and cases  of spermatorrhoea, are of more importance
and the  treatment is more difficult.  The anaphrodisiac remedies  are indi-
cated, but in these cases much benefit  is derived from  tonic remedies and
an  invigorating regimen.   Quinia, small doses of strychnia or  nux vomica,
and the  preparations  of iron are  useful.  Sea-bathing or the sponge-bath
and out-of-door life or gymnastic  exercises are useful  regiminal measures.
The diet  should be nutritious, but not stimulating, and-alcoholic  stimulants
are to be  taken very  moderately or interdicted.   Everything calculated to
provoke  sexual desire  should, as  far as practicable,  be avoided.   Health-
ful mental occupation and chaste  associations  do very much toward  effect-
ing a cure.   It is obvious that to carry out the  moral  part  of the treatment
requires  on  the part of the patient a determination and perseverance  which
are often  wanting.   Taking  into  view  all the circumstances in individual
cases,  it  is sometimes judicious  to encourage or recommend  marriage.
  Attention is to be directed to  the condition of  the  urethra in  cases  of
seminal emissions and spermatorrhoea.  They often follow gonorrhoea, and are
sometimes dependent more or  less on urethral stricture.  According to  Lalle-
mand, seminal  losses often depend on an abnormal sensibility at or near the
prostatic portion of the urethra, and the  treatment in these cases requires the
use of the bougie and cauterizing applications.  The opinion of Lallemand is
held by distinguished surgeons at the present time.  For information on this
point the reader is referred to surgical works.
  Impotence means inability to perform the act of coition. The term does not
mean want of the power of procreation,  and the latter may be wanting when
there is  no incapacity for sexual intercourse.  Exclusive  of malformations
and  other  abnormal conditions of  a surgical nature, impotence, in  the first
place  mav involve absence of  sexual desire.   Different persons in  health 
942         STRUCTURAL DISEASES OF TEE  KIDNEY.

differ widely as regards the venereal propensity ; in some persons the  sexual
desire  is intense and importunate, in others it is feeble, and sometimes  it is
altogether  wanting.   The  propensity may, on the one hand, be increased by
indulgence and by fostering in various ways ideas connected with it; and on
the other hand it may be diminished and extinguished by an opposite course.
In  the  marital  relation frigidity, as regards this propensity, may depend on
personal antipathy, and hence is a not infrequent source of domestic unhap-
piness.   Absence of  sexual desire may arise  from general debility,  and is
incident to various diseases.  If  the disease  with which it is connected be
not serious nor permanent, a return of  sexual desire may be expected on
recovery of  the accustomed health.   Intense  mental  preoccupation, the
depressing  emotions,  and  exaltation  of  the  higher  sentiments  tend to
repress sexual  desire.
  As the loss of virility is generally dreaded,  physicians are often consulted
when a notable change as  regards  the venereal  propensity is experienced.
The circumstances which have led to the change  in  individual cases  are to
be  investigated, and the conclusion  with  respect to the  probability  of impo-
tence,  together  with  the treatment, is to  be  based on these circumstances.
In  a large proportion of cases the deficiency  or absence of sexual  desire is
due to  temporary causes.   Premature decline or  extinction may result, on
the one hand, from early and excessive indulgence  or  abuse of the generative
function, and on the  other hand from prolonged continence.   Under certain
circumstances aphrodisiac remedies are desired.  The remedies so called are
of doubtful efficacy.   Phosphorus, cantharides, and  nux vomica  have been
considered  as special stimulants acting on the organs of generation.  They
should  be given circumspectly.   It is sometimes useful to secure the moral
influence of the administration  of remedies supposed to have this effect.
  Impotence  may exist without loss  of sexual desire.  Temporary incapacity
proceeds from  timidity or  deficient self-confidence.   The  physician  is not
infrequently  consulted  by  persons about  to  enter upon marriage  who are
apprehensive of being  incompetent to accomplish coition.  Assurances of
capability, if it  be evident  that the apprehensions  are imaginary, may  be all
that these  cases require.   Persons who have practised masturbation in boy-
hood, and they who are  subject to  involuntary emissions during sleep, are not
infrequently led to believe that they are impotent  by  pernicious publications
or lectures designed to alarm sensitive minds;  and apprehension on the score
of ability to accomplish the act of coition creates  incapacity.   A failure to
accomplish the  act is likely to be followed by  the  conviction that impotence
exists,  and, practically, it does exist so long as this conviction continues.   In
such cases all that is requisite is that the act of coition should be undertaken
without any anxiety  as to  success.   It is useful  in  such  cases to  interdict
sexual  intercourse for a certain time, in  order to prevent  tentative efforts,
which,  if unsuccessful,  fasten the conviction  of impotence more and more
upon the mind.  If a certain period of  abstinence  be  enforced, it will be
likely to happen that the patient  is impelled  by his  desires to demonstrate
his  capacity before the period expires.   It is sometimes the case, however,
that coition is permanently prevented by fancied incapacity.  I have known
an  instance in  which this  was the probable explanation of the  absence of
sexual  intercourse during  the whole of  a married  life lasting over fifteen
years, and in  another  instance five  years had elapsed without any accomplish-
ment of the act of coition.   In both instances  seminal emissions occurred not
infrequently.   A remedy prescribed with  an  assurance  of a cure doubtless
sometimes  proves curative  by a moral effect.  In certain  cases  impotence,
with sexual desire, is a result of the erethism and weakness of the genera-
tive organs associated with seminal emissions and spermatorrhoea.  The ejacu- 
             INVOLUNTARY SEMINAL  EMISSIONS,  ETC.          943

lation and orgasm take place at the beginning of, or prior to, the act of coition.
This kind of impotence is sometimes, temporarily, a result of prolonged  con-
tinence.   The measures of treatment in such  cases  are  those  indicated by
seminal emissions and  spermatorrhoea.  Persistence in the  employment of
these measures, together with  a  proper degree  of  reserve  as  regards the
frequency of the attempts to consummate  sexual intercourse, will generally
prove successful.
  Excessive indulgence in  venery, when it does not lead to involuntary semi-
mil emissions, spermatorrhoea, or impotence, is a not infrequent  cause of ill
health.   Dyspeptic  ailments, attacks of vertigo, functional  disorder of the
heart, melancholia, and hypochondriasis are among the morbid effects of this
cause.   It is the duty of the physician to  inquire into the habits of  patients
in this regard.   The evils of excessive indulgence,  aside from  moral conse-
quences, are  greater when  it is illicit than  when it is marital; and moreover,
the former is far more likely to be  excessive.   The  limits of a healthful
indulgence doubtless vary according to constitutional vigor, but it  may be
considered as excessive if the acts of coition are repeated  several  times a
week.
  The unnatural abuse of the sexual function, or masturbation, as a cause of
involuntary seminal emissions, spermatorrhoea, and sometimes of impotence, has
been already referred to.   The effects on mind as well as body are pernicious.
It is plainly  the duty of the physician not only* to  endeavor to discover and
arrest this practice in individual cases, but to enjoin upon parents, teachers,
and  associates  the importance of watchfulness in this respect over those for
whose welfare they are to a greater or less extent responsible.  There is also
another duty of the  physician  connected with this  important topic.  Many
sensitive persons who have been addicted to self-abuse in early life suffer greatly
from the belief  that their  mental and physical powers have  been irreparably
injured.   The evils, great  as they sometimes are, are much  exaggerated by
popular works and  lectures designed to excite  fears  for a  mercenary  end.
The physician  may  often do much good by removing undue apprehensions
connected  with  the  errors of youth. 
   SECTION   SEVENTH.

FEVERS  AND OTHER  GENERAL  DISEASES,
                         CHAPTER  I.

CLASSIFICATION  AND  PATHOLOGY  OF  FEVER.—FEBRICULA.
                      —CONTINUED  FEArERS.

Classification of Fevers.—The General Pathology of Fever.—Febricula.—Typhoid Fever:
                  Anatomical Characters and Clinical History.

                     Classification of  Fevers.

    THIS concluding section will  be devoted  to fevers  and other general dis-
    eases.
   Fevers  are  distinguished as essential and symptomatic.   A symptomatic
fever  is one which is secondary to some local affection, such as  an acute in-
flammation.  The term essential  distinguishes a fever which  is not secondary
or  symptomatic, but  is primary or  idiopathic.  Local  affections may exist
in  essential fevers, but  they cannot be considered  the cause of the fever.
The essential fevers are febrile infectious  diseases.  The essential fevers are
those  which are to be considered in this  section.
   According to the  usual symptomatic  classification  of fevers we  distin-
guish—
   1. Febricula, a  form of  fever  characterized by its short duration and
mildness.
   2.  Continued fevers, which are distinguished by the  unbroken continuity
of the febrile phenomena, such  as typhoid  and typhus fevers.  Relapsing
fevers and erysipelatous fever may  be included in this class.
   3. Periodical fevers, which are distinguished  by the occurrence of  distinct
paroxysms or notable exacerbations  as regards the febrile phenomena, such
as intermittent fever, remittent fever, typho-malarial fever, yellow fever, and
dengue.
   4. Eruptive or exanthematous fevers, in which an eruption on the surface
of the body is  a prominent feature,  as in smallpox,  scarlet fever, measles,
roseola, and typhus.
   Fevers are also often classified on an etiological basis into miasmatic, con-
tagious, and miasmatic-contagious fevers, according to distinctions which have
already been defined  on page  84.   The malarial fevers are  the type of the
miasmatic forms.   Probably pneumonia, and perhaps acute articular rheuma-
tism, are also to be included in  this  category.   Contagious fevers are smallpox,
chicken-pox, scarlet fever, measles,  rbtheln, typhus fever, and relapsing fever.
As miasmatic-contagious fevers are  reckoned  typhoid fever, yellow fever, and
dengue.  Epidemic dysentery and Asiatic cholera are also to be regarded as
miasmatic contagious diseases.
  The foregoing list of fevers  does not comprehend all  that  exist.  It com-
       944 
GENERAL  PATHOLOGY  OF  FEVER.
945
  prebends however, those which from  their prevalence and  established iden-
  tity it is desirable to consider in this work.  Some of the diseases which for
  convenience have been considered in preceding sections of this work, such as
  epidemic dysentery, Asiatic cholera, cerebro-spinal meningitis,  trichinosis and
  pneumonia, might with propriety have been included in the  present section
    Ihere are certain terms in  common use which in their application to  fevers
  require a few words of explanation.   Fevers characterized  by great prostra-
  tion have been called adynamic, asthenic, or low. Fevers have been said to be
  ataxic when symptoms referable to the nervous system, such as delirium etc
  are  prominent   levers of unusually long duration have been called slow'}
  and when  the febrile  phenomena—especially  the temperature-are intense,
  he fever is said to  be high.  The initial stage of a fever extends from the
  beginning of  the disease until the full development of the fever.  The period
  of full development, or acme, of the fever is  sometimes called the fastigium.
  The fastigium is followed by the stage  of defervescence, or decline of the fever
  \Yhen the decline is rapid, occupying only a few hours  or a day  or two, the
  fever is said to terminate by  crisis.   AVhen the decline is protracted the ter-
  mination is by lysis.   These diff'erent stages of fevers, to which may be  added
  the period of convalescence, are of very unequal duration in the  different forms
  of fevers.

                    General Pathology of Fever.
   It is deemed desirable to introduce this subject in this connection, although
  properly it belongs  to  the department of  General Pathology considered 'in
  1 art I. of this work.   The general causes and the theory  of  fever are anions
  the most difficult and least understood subjects  in general pathology.1
  _ It has been proven  experimentally that various substances when injected
  into  the blood or the tissues of an animal are capable of exciting fever.   It
  has not been found possible to determine any general characters which distin-
  guish these pyrogenic substances.  It is of  especial interest  that various fer-
  ments, particularly fibrin ferment, and  many  of  the so-called ptomaines  or
  cadaveric alkaloids, possess  pyrogenic  properties.   This has  given rise to the
  supposition  that  the  fever which is  secondary  to local inflammations,  to
  necrotic foci, and to injuries  is often  due to  the  absorption  of fermentative
 substances  which are  produced  by the local disease.   Micro-organisms are
 among the most important of fever-exciting  agents, and are probably involved
 in the causation of all the essential fevers.   It  has been proven  by experi-
 ment that injuries of various  parts of  the central  nervous system, especially
 puncture of certain circumscribed regions of the brain, are followed within a
 few hours by marked elevation of temperature.   There is reason, therefore, to
 believe that fever may  be in some cases a purely nervous affection produced
 without the introduction  of any pyrogenic substance into  the blood.
   In what way is the abnormal  elevation of temperature produced in fever?
 It seems to be established, on the one hand, that an excessive amount of heat
 is produced in  fever within the body, and, on the other hand, that in propor-
 tion to this excessive production less heat is given  off from the body than in
 health.   It is well known that animal heat is the result of chemical processes,
 especially processes of  oxidation, which  are constantly going on within the
 body.  Now, it is found that  in  fever, in proportion to the amount of nour-
 ishment taken, there is an abnormally large quantity of urea  excreted by
 the urine, and  particularly that more oxygen is  absorbed  and more carbonic
 acid given off by the respiration than  in health.   These changes have  been
 observed to be  present  before  there is  any elevation of temperature, so that
  1 An important monograph on this subject  is that of H. C. AVood— Fever: A Study
in Morbid and Normal Physiology, Washington, Smithsonian Institution,  1880.
60 
946     CLASSIFICATION AND PATHOLOGY  OF FEVER, ETC.

they cannot he considered, at least  not  entirely,  as secondary to the fever.
They also indicate  an increase in the oxidizing  processes within the body,
and therefore an increase in the amount of heat produced.
  It has furthermore been rendered probable that the amount of heat given
off from the  body in fever is diminished relatively to the amount produced.
AVhen a fever is ushered in  by a chill or by chilly sensations, the arterioles
of the skin are contracted, the surface is cold, and there is an absolute diminu-
tion  in the radiation of  heat from  the body.  There is at this time the most
rapid development of pyrexia.   AVhen the surface of the body is abnormally
hot,  as it is during  the  greater part of most fevers, it is evident that more
heat must  be given off by radiation than at the  normal temperature of  the
skin ; but there seems  to be no doubt that, in proportion to the amount of
heat produced in the body, there is less heat given off in fever than would be
the case during a corresponding increased production  of heat in health, as by
severe muscular exercise.   In other words, the equilibrium which  normally
exists between the amount of heat produced and that given off is disturbed in
fever.  Perspiration, which  is an  important factor in the regulation of  the
bodily temperature,  is usually, although not always, diminished during  the
height of a fever.
  We have no positive knowledge as to how fever-producing  agents act in
causing pyrexia.   Since experiments have shown  that injury of certain parts
of the brain is followed by rapid elevation  of  temperature, which cannot be
identified with  ordinary traumatic fever, the theory has  gained wide accept-
ance that the pyrogenic agents act  primarily upon certain nervous centres.
Whether these centres be special heat-centres,  as has been surmised, or vaso-
motor or other  centres, is uncertain.
  Our knowledge of the effects of the elevation of temperature upon the vari-
ous organs and functions of the body is imperfect.  Fever is accompanied with
increased frequency of pulse and of respiration, and it has been  shown experi-
mentally that these  effects follow elevation of the temperature of the blood.
It has  not, however, been proven, nor is it indeed probable, that all of  the
circulatory and respiratory disturbances of fever are directly referable to the
elevation of temperature.  The injurious effects of the  special agents which
cause the fever must also be taken  into consideration.  There has doubtless
been a tendency to exaggerate the immediate effects of the pyrexia  as  such,
and  to disregard the action of the special agents of infection.  Parenchyma-
tous degeneration of muscular tissue, particularly of the heart, and degenera-
tion of glandular cells, are common, but by no means constant, in fevers, even
in severe forms, and are referable  probably more to the infection than to the
elevation of  temperature.  Nor is  it justifiable  to refer disturbances of the
nervous, digestive, and renal functions in fever exclusively to the elevation of
temperature.  AVe possess no satisfactory explanation of the diminution of the
chlorides in the urine in fever.  The blood-pressure  is  generally diminished
in fever.   It has been shown that many fevers are accompanied by a destruc-
tion of red blood-corpuscles.   The increased  quantity of coloring matter in
the  urine also points to this.   That fever of long  duration should cause a  loss
of weight of the body  is not strange when one considers  the  increased  con-
sumption of tissue  and the  small  amount  of nutriment ingested.
   Facts warrant the conclusion that each of the  essential fevers  has its  own
special cause; in other words, that each requires a particular causative agent
capable of producing that fever and none other.   It  is  most consistent with
our  present knowledge, if it be not logically certain, that this causative agent
is a living organism.  The unlimited reproduction of the special cause within
the  body in the infectious fevers  is a fact of  which the causation  by living
organisms alone  affords a rational explanation.   In relapsing  fever  and in 
FEBRICULA.
947
typhoid fever it  is probable  that  the  causative organisms  have been dis-
covered.


         Febricula—Ephemeral Fever—Simple  Fever.
  The term febricula, a diminutive of febris, is  perhaps the best name  to
denote a mild, short fever which is  everywhere of not infrequent occurrence.
If very short, lasting only a single day,  it is appropriately called an ephemeral
fever.   AVhen not  ephemeral the fever may continue  for a period varying
between  three and eight, even ten, days.  It  has been known by a variety of
names.   It is frequently called simple continued or simple fever.
   This fever has no known anatomical characters.   The opportunity of post-
mortem examination is seldom offered, for the disease rarely if ever of itself
ends fatally, at  least  in cold or temperate climates.  No lesions  belonging to
the fever have been found  in cases  in which, owing to complications, death
has taken place.
   The invasion  in cases of febricula is generally abrupt, hut  in  a certain
proportion of cases lassitude, loss of appetite, and  general malaise exist for
two or three clays before the fever is developed.  Irregular chilly sensations
may accompany the attack, but there is seldom a well-pronounced chill.  The
febrile movement is more or less intense; and not  infrequently  the accelera-
tion of the pulse and  heat of the  surface  are greater  than at the beginning
of typhus or typhoid  fever.   Pain in the head is a prominent symptom, the
pain  being generally frontal.  There is more or less  pain in the  loins  and
limbs.   Anorexia is  usually complete.   Constipation  is the rule,  and  the
abdominal symptoms which belong to typhoid fever are wanting.  The urine
is scanty and high-colored ;  the intelligence remains unaffected ;  and the hebe-
tude  which characterizes typhus and typhoid fever is not observed.  There
is no characteristic eruption; herpetic vesicles about the mouth sometimes
occur; and  bluish spots (tdches bleudtres), from three to eight  lines in  dia-
meter, not  elevated and not  disappearing on  pressure, have been  observed.
These occur occasionally in  typhoid fever.
   The  febrile  career  ends  suddenly after one, two, three, or more days, the
limit of the duration being ten days. Frequently with  the cessation of fever
there is  a copious perspiration.  Epistaxis and, occasionally, hemorrhage from
the uterus  and  rectum have been observed  at the end of the  fever.   The
convalescence is usually rapid, and there are no sequels.  The thermometer
indicates a sudden rise of temperature  of four or five degrees, and as rapid a
decline,  the heat passing in one or  two  days  to the  normal standard.
   This kind of fever is supposed to occur irrespective  of any special cause;
that is, ordinary causes are supposed to produce it.  It is observed to follow
over-exertion, dietetic excesses, and exposure to the sun's rays.   This view
of the causation is, however, conjectural.  It  is  probable that  certain  cases
which from their  short duration are considered as cases of febricula are in
fact  cases  of  typhoid or typhus  fever, the  disease  ending without going
throuuh  its usual  career;  in  other words, cases of ephemeral  fever may be
cases  of abortive typhoid or typhus fever.
   The diagnosis of febricula is of importance with  reference to the success
of measures employed to arrest or abridge the duration of typhoid and typhus
fever.   In  cases in which measures employed  for these ends appear to prove
successful, the question is, AVas the  disease  typhoid  or typhus  fever, or was
it a febricula?   The following  are considered as  diagnostic points:  1,  the
abrupt  development  of the  fever;  2, the  attack succeeding obvious and
ordinary causes. To these is to he added absence of diagnostic  traits belong-
in «• to the clinical history of either typhoid or typhus fever.  Cases, however, 
948    CLASSIFICATION AND PATHOLOGY OF FEVER, ETC.

occur in which it is difficult  or impossible to decide during the progress of
the fever whether it be typhoid or typhus or a febricula, and after the fever
ends whether  it have  been a febricula or an abortive or arrested typhoid or
typhus fever.
  Febricula in cold and temperate climates  is rarely, if ever, fatal, except
from an accidental complication of a serious nature.  It is said to prove fatal
not infrequently in tropical countries.
  As regards the treatment of febricula  in cold and temperate climates,
hvgienic and  palliative measures  only are  called  for.   A  saline laxative,
refrigerants, and  anodynes are the remedies  indicated.


                          Typhoid  Fever.

  The name typhoid signifies  typhus-like.   The pertinency of this  name, as
applied  to the fever to be now considered, consists in the resemblance of the
disease to typhus  fever.   It  might, therefore, seem most appropriate to con-
sider first typhus fever;  but typhoid fever prevails very extensively in this
country, and has  been known with us as common continued fever, whereas
typhus is comparatively rare, and the latter is perhaps never an indigenous
disease.  For  this reason, reversing the order which  the name  suggests, I
shall consider  first typhoid fever with reference to its anatomical characters,
clinical history, causation, diagnosis, and prognosis; afterward, typhus under
the several aspects just named ; and last, the treatment of typhoid and typhus
fever.
  The name typhoid  is open  to objection.   It is  customary to apply this
name to a condition or state  incident to many diseases, and hence has  arisen
confusion.   Of other names  which have been proposed, no one  has been
generally adopted, and probably the disease will continue to be called typhoid
fever.   This name was introduced  by Louis, whose clinical  researches were
of great value, not merely with reference to our knowledge of this disease,
but as inaugurating the true method of the study of the clinical history of all
diseases—namely, by  means of the  analysis of carefully recorded cases. The
correspondence of the  results of the researches of  Louis as regards typhoid
fever with  the results of similar researches by others in different countries
furnishes the best possible proof of the value of the method of study, and at
the same time shows  the remarkable  uniformity of the disease at different
times and places.  By German writers the disease is called abdominal typhus
or ileo-typhus.   Prof. Geo. B. AVood suggested as  an appropriate name enteric
fever.   Both  these names relate to the intestinal lesions which are  charac-
teristic  of the  disease, and they are  objectionable  because they convey the
impression  that the fever is the result of these lesions.  Murchison proposed
as the name pythogenic fever—a name which  implies that the disease is pro-
duced by putrescent matter.   It is an objection to this  name that the source
of the special cause, implied in the name, has not been  established.

  Anatomical Characters.—The characteristic  lesions of typhoid  fever
are seated in  the lymphatic  structures of  the  intestine—namely,  Peyer's
patches and the  solitary follicles.   Corresponding to the intestinal changes
are alterations  in the  mesenteric glands.  There  are also important changes
in other organs of the body, but  most of the latter changes are  common to
many infectious diseases.
  Four stages of the  morbid process in the intestine  may be distinguished:
1, the stage of congestion and  simple inflammation of the mucous membrane ;
2, the stage of medullary infiltration of the lymphatic structures ;  3, the stage
of retrograde  metamorphosis and ulceration ; 4, the stage of repair.   These 
TYPHOID FEVER.
949
stages  correspond approximately  to  certain periods of the clinical  history.
In the first week of the disease are  developed  congestion  and inflammation
of the mucous membrane of the small intestine, together with swelling of a
certain number of solitary follicles and agminated glands. In the second week
the general congestion of the mucous  membrane diminishes, and  the  swell-
ing and infiltration of the solitary  follicles and  Peyer's  patches increase.
During this week necrotic changes in the swollen follicles  and patches take
place.   The casting off of the necrotic tissue results in the formation of the
typhoid  ulcers.   In the third week  the process of ulceration is completed.
After this follows the period of repair of the ulcers, which occupies a vari-
able time.   It is to be noted that different  stages of the lesions are usually
found in the same  case.  The changes are most advanced in the small intes-
tine near the ileo-caecal valve.
   At the onset of the disease the mucous membrane of the lower part of the
small intestine is hyperaemic, swollen, softened, and coated with mucus.   At
the same time Peyer's patches and the solitary follicles of  the lower half of
the ileum  begin to enlarge.   As their enlargement increases the hyperaemia
diminishes, except in the immediate neighborhood of the swollen follicles and
patches ;  these  remain surrounded  by a  zone  of congestion.   The morbid
process is  most intense in the ileum  near the ileo-caecal valve.  In some cases
the solitary follicles of the large intestine are swollen, and they may ulcerate.
This involvement  of the large  intestine  is more common in some epidemics
than in  others.  The follicles of the jejunum may likewise become swollen,
but ulceration in this situation is rare.  According to Hoffmann,1 the disease
rarely extends higher  than nine  and a half feet above the valve.  Usually,
both Peyer's patches and the solitary follicles are involved.   Sometimes the
changes are more  marked in one of these structures than in  the  other.  In
the stage of medullary infiltration  the solitary follicles and Peyer's patches are
swollen, and project, one, two, three, or even four, lines above the plane of
the adjacent mucous membrane.   The enlarged solitary follicles preserve their
round shape and may attain the size  of a pea.   The swollen Peyerian plaques
are elliptical or long-oval in shape.   Swellings many inches in length  and in
breadth may be produced, especially near  the valve, by the confluence of
several enlarged patches.  Usually  the patches are indurated to  the  touch.
Their surface is sometimes smooth, and  sometimes it  presents an irregular,
granular aspect. The edges are generally abrupt, and sometimes they are con-
stricted near the base,  so that the patch has somewhat of a mushroom  shape.
Upon  section the  infiltrated follicles  and plaques have a grayish-red  or  a
whitish color.   The appearance on  section  frequently resembles that  of the
white matter of the brain or spinal cord, and hence the name  medullary infil-
tration which is applied to this condition.  The peritoneum corresponding to
the affected  patches  is  usually congested.  The  swelling of Peyer's patches
and of the solitary follicles is due to an increase in  the number of lymphoid
cells normally present in these structures.   In  addition to the ordinary lym-
phoid cells there are also found larger cells with a greater amount of  granu-
lar protoplasm.  Some of these large cells contain several nuclei._ The new
cells are generally  considered to be  the offspring of the pre-existing lymph-
cells of the follicles, and the whole  process is  regarded as a hyperplasia of
the lymphatic  structures.   The cellular infiltration is not confined  to  the
limits of the  solitary follicles or of Peyer's patches, but extends for  a  certain
distance into  the surrounding mucous membrane.   It  also extends  in depth
for a variable distance.  Sometimes chains of  lymphoid cells can be traced
from the follicles through the muscular coat to the subserous  tissue.
   1 Untersuchmu/en uber die Path, anatom.  Verdnderungen der Organe beim Abdominal-
typhus, Leipzig, 1869. 
950    CLASSIFICATION AND PATHOLOGY OF FEVER, ETC.

  The medullary infiltration may terminate in resolution or in ulceration.   In
the process of resolution  the swelling of the follicles gradually diminishes,
and many of the new cells undergo fatty degeneration and are absorbed.   As
a rule, this retrograde metamorphosis by degeneration and absorption occurs
in some of the swollen follicles  and plaques, while in others ulceration takes
place.   Sometimes  the individual  follicles of a Peyerian  patch soften  and
discharge their  contents.  In these patches  the intervening tissue forms a
projecting network  around the sunken follicles.  This appearance character-
izes  the so-called  reticulated patches.   A reticulated aspect of the patches
may be  clue also  to  simple degeneration and  absorption  of  the infiltrated
material in the follicles.   The most characteristic termination of the process,
however, is in the formation  of a slough, and  by the separation of the slough
the production of the typical typhoid ulcer.  The slough may occupy a whole
Peyer's patch or only portions of a patch.  It has usually a yellowish color
from imbibition  with  bile.   It may present a  hemorrhagic appearance.  The
rapidity with which the sloughing process takes place varies in different cases.
The process usually reaches its acme in the second week, but cases have been
described in which the ulcers were fully formed on  the seventh or eighth  day
of the disease.  It  must be remembered that it is by no means easy to deter-
mine in all cases the day on which the disease begins.  It may be stated here
that there is no  constant relation between the  extent of the intestinal  lesions
and the severity of the disease as denoted by  the abdominal and other symp-
toms.   The sloughing and ulceration take place earliest in the glands nearest
the ileo-caecal valve, and usually different  degrees of progress  are presented
in the  series above this point.   The necrosis  or  sloughing of  the infiltrated
glands is sometimes ascribed to arrest of the circulation from the pressure upon
the small blood-vessels exerted by the excessive production of new cells; but it
is equally probable  that it is  due to the presence of the typhoid bacilli.  The
necrosis does not usually extend beyond the boundaries of the affected Peyer-
ian patches.   Sometimes the slough separates en masse, but  more frequently
it is thrown off in  fragments, leaving at first small, irregular  losses of  sub-
stance. After the sloughing is completed ulcers take the place of the affected
solitary follicles and Peyer's patches.   These  ulcers have certain distinctive
features.   Those resulting from  necrosis of the solitary  follicles are round,
while those which  take their origin from Peyer's patches preserve the oval or
elliptical shape of these patches, the long axis of the ulcer being parallel to the
direction of the intestine.   The bottom of the  ulcer is usually smooth,  and
often presents to view the transverse muscular fibres of the intestine.  The
edges are undermined and more or less swollen and congested.  The ulcer may
extend in depth and reach the deeper layers of the  muscular coat, or its floor
may consist only of the serous membrane.  Cicatrization is the last  step in
the  series of processes.   Granulation-tissue  springs  from  the  floor of the
ulcers.   The undermined edges become united with the bottom of the ulcer.
The resulting cicatrix  is  whitish, or more   frequently pigmented,  slightly
depressed, and covered by epithelium.  The  villi and glands of the mucous
membrane, according to most writers, are  not regenerated.  It is a remarkable
fact that the cicatrices of typhoid ulcers have very little tendency to cause
stenosis of the intestinal lumen.   The process of cicatrization  usually begins
in the third week  of the  disease and continues during  convalescence.   The
time  occupied in the completion of  this process varies in different cases.  It
is sometimes unusually slow—a fact which accounts for the persistence of the
abdominal symptoms in certain cases for some  time  after  the  career of the
fever is ended.
   Perforation, of the intestine is liable to occur in one or  more of the ulcers.
According to Hoffmann, perforation occurs in  about 1 per  cent, of the cases of 
TYPHOID FEVER.
951
typhoid fever, and in about 8 per cent, of the deaths from this disease.   It is
most frequent between the third and the fifth week of the disease. It is rarelv
caused by the primary sloughing, but is due  to secondary ulceration after the
separation of the slough.   The perforation may be due to rupture of the thin
floor of an ulcer by distension of the intestine with  gas, by the contact of
feces, or by the presence of round worms.  The opening in the peritoneal coat
may be of  considerable size or it may be no  larger than a pin's point.   AVith
intestinal perforation are associated  appearances denoting  acute diffuse  peri-
tonitis, the latter being occasioned by the escape of the gaseous and  other
contents of the intestine into the peritoneal  sac.  In rare instances the  peri-
tonitis is circumscribed around the seat of perforation  by means of adhesions.
Death may occur before sufficient time has elapsed  for the  production of
inflammatory exudation.   Profuse hemorrhage may occur from the primary
sloughing or from  the secondary ulceration.
   More or less enlargement of the mesenteric glands is always associated with
the intestinal lesions.  The mesenteric glands which are in immediate relation
to the affected Peyerian and solitary glands are especially enlarged.  Their vol-
ume is often  much  increased, and not infrequently they attain to the size of a
pigeon's egg.  The enlargement is due to congestion  and to the production of
new cells resembling those normally present  in the glands.   The same  large,
granular, sometimes multinuclear, cells found in the  infiltrated follicles of the
intestine are met with in the swollen mesenteric glands.  The morbid process,
in fact, in these glands is of the same nature as that  in  the  lymphatic  struc-
tures of the  intestine.   Only in  exceptional cases does the morbid growth
which gives  rise to  the enlargement  produce  sloughing.   This process of
necrosis is, however, an occasional source of peritonitis developed in the course
of the disease.  Usually the glands  diminish in size as the process of ulcera-
tion is going on in the intestine.   The  new  cells undergo fatty degeneration.
The resulting molecular mass  in part is absorbed, and in part remains as a dry
detritus which may become infiltrated with the salts of lime.
   The spleen is enlarged, dark red in color, and softened.   It is often two or
three times the normal size, and maybe larger.  In very exceptional cases no
swelling of the spleen is found.  The enlargement is  due to congestion and
to hyperplasia of the cellular elements.   Large cells containing one or more
red blood-corpuscles or fragments of corpuscles are found in the splenic pulp
and veins.   Hemorrhagic infarctions are occasionally met with in the spleen.
Instances of  rupture of the capsule of the  spleen with  escape of blood into
the peritoneal cavity have occurred.  The result is  a  fatal peritonitis or sud-
den death.
   Typhoid fever, like other infectious  diseases, is attended by parenchymatous
degenerations.   The parts most affected are the cardiac muscle, the liver, the
kidneys, and  the glands of the stomach.  The voluntary muscles also undergo
the change.  For the description of this metamorphosis the reader is referred
to Part I. p.  53, and  to the accounts of this  degeneration in connection with
diseases of the organs named.   The degeneration is probably due to infectious
blood-changes.  Hyaline or pseudo-waxy degeneration  occurs in  voluntary
muscles.  This  change  affects only certain  muscular fibres,  not the  whole
muscle uniformly.   It  is observed most frequently in the recti abdominis, in
the adductors of the thigh, and in the diaphragm.   It may  also occur  in the
cardiac muscle.   The affected portions of muscle are pale and have a grayish
waxy lustre.  The muscular fibres are transformed  into a homogeneous, fri-
able'mass without trace of the normal transverse striatum.   This change may
lead to rupture of the muscular fibres with hemorrhage.  This  metamorphosis
is not confined to typhoid fever, but it may  occur in other diseases, and may
be produced in animals by injuries to the  muscles.  Regeneration of muscular 
  952    CLASSIFICATION AND PATHOLOGY OF FEVER,  ETC.

  fibres destroyed by parenchymatous or by hyaline metamorphosis takes place
  during convalescence.  (A'ide p. 39.)
    Changes in the lungs are present in nearly all cases of typhoid fever. Con-
  gestion and inflammation of the bronchial  mucous membrane form an almost
  constant element in the disease.   Hypostatic congestion  and the condition
  called splenization of the lungs are found in a large proportion of cases. Pul-
  monary oedema is not  uncommon.  Pneumonia, usually in the lobular, but
  sometimes in the lobar, form, is a frequent complication.  The lobular pneu-
  monia is due often to aspiration of sputum and of foreign particles.   Hemor-
  rhagic infarctions may be caused  by emboli derived from thrombi formed in
  the right cavities  in  the  heart.
    Ulcerations in the larynx are found in many cases.   These occur most fre-
  quently on the edges of the epiglottis and on the posterior wall of the larynx
  just above the vocal cords.   AVriters are not agreed  as to whether some of
  these ulcers  be specifically typhoid or not.   These  ulcers  may  extend in
  depth and cause perichondritis.  (Edema of the glottis is a rare  complication
  of typhoid fever.   Various forms of angina, catarrhal,  follicular,  croupous,
 and  ulcerative, occur.   The follicles  at the  base of  the  tongue  are often
 swollen.  Aphthous inflammation of the mouth and pharynx is not very infre-
 quent in typhoid fever.
   The  liver is usually somewhat  swollen,  pale, and  softened.   The hepatic
 cells are in a condition  of parenchymatous  degeneration.  Accumulations of
 lymphoid cells in the interlobular tissue about the branches of the portal vein
 are described by Wagner under the name of typhoid lymphomata.  The bile
 is  usually  pale yellow  and thin.   The kidneys may present  lymphomata
 similar to those in the liver.  Parenchymatous degeneration of the renal
 epithelium is the rule.   A genuine acute nephritis may occur, but it is rare.
 Hoffmann describes as a frequent occurrence proliferation and parenchyma-
 tous  degeneration of the cells in  the  acini  of the salivary glands  and pan-
 creas.  Abscess of the  parotid gland  may occur in  typhoid as well as in
 typhus  fever.
   No changes have been discovered in the central nervous system to explain
 the mental disturbance  which characterizes this disease.   There may be some
 increase  of the cerebro-spinal  fluid.   Lymphoid  cells  are  sometimes found
 around  the ganglion-cells of the  brain, but these wandering cells may be
 present in various  other conditions.                ,
   The blood in typhoid  fever, as in other infectious diseases, is poor in fibrin,
 and contains a relatively or  absolutely larger number of white blood-corpus-
 cles than normal.
  _ No disease  is accompanied by so great a number and variety of complica-
 tions as typhoid fever.   Some have already been mentioned.  Other possible
 complications or sequelae are—peritonitis without perforation, pleuritis, peri-
 carditis, endocarditis, meningitis, cerebral hemorrhage, otitis media or externa
 cystitis, epididymitis, orchitis, embolism  of arteries of  the lower  extremities
 with gangrene, embolism of the pulmonary  artery, thrombosis of the femoral
 vein with phlegmasia alba dolens,  thrombosis  of other veins, thrombosis of
 the heart, arteritis,  necrosis of bone, periostitis,  noma, gangrene of various
 parts  of the  body, bed-sores, septicaemia from bed-sores  and  other sources
 pyaemia with  abscesses  in  the  lungs,  spleen,  and other parts, erysipelas'
 furuncles, retro-pharyngeal  abscess, dysentery (during  convalescence), ab-
scess  of the  liver, suppurative nephritis, croupous or diphtheritic inflamma-
tion of the larynx and pharynx, hemorrhagic diathesis, icterus gravis, ulcer
of the cornea,  peripheral degenerative  neuritis, neuro-retinitis, inflammation
of the mucous membrane of the gall-bladder, and pyaemic or rheumatic poly-
arthritis.                                                             ^  J 
TYPHOLD FEVER.
953
   A micro-organism peculiar to  typhoid fever was discovered by Eberth in
1880, and  was further investigated, and for the first time isolated in pure
culture, by Gaffky, whose researches were published  in  1884.  Its pathoge-
nic properties were demonstrated experimentally by Fraenkel  and Simmonds
in 1885.1
   The organism  is a short, thick bacillus with rounded ends.  The average
length is about one-third of  the  diameter of a red blood-corpuscle and  three
times the breadth of the bacillus.  The individual bacilli vary considerably in
size.  According to Gaffky the bacillus forms endogenous spores, even within
the body.2  Each spore occupies one end of a bacillus.  The bacillus can be
cultivated upon  nutrient gelatin, agar-agar, potato, blood-serum, and various
other media.   It grows readily at ordinary temperatures, but even  more
rapidly at  the temperature of the  human body.   It does not form spores at
a temperature much below 70° F.  In nutrient gelatin it forms at first bluish-
white, later whitish, opaque  colonies upon the surface.   It  does not liquefy
the gelatin.   It  is aerobic, but  grows to some  extent in the depths of  the
solid culture media.  The most  characteristic growth is upon the surface of
sterilized, steamed potato, on which it grows rapidly, but in such a way as to
leave the surface of the potato almost unchanged, so that to the naked eye
no growth is apparent, or at the most a delicate pellicle may be discovered.
If, however, scrapings  from  the surface of the potato be  examined micro-
scopically, there  is found a luxuriant growth of the  bacilli.   Examined in a
drop of liquid, the living bacilli  are found to be endowed with the property
of active movement.
   The morphological  characters of the typhoid bacillus are not sufficiently
marked to  distinguish it  from other similar organisms.   For this distinction
it is necessary, as with other forms of bacteria, to take into consideration all
of the properties of the organism,  particularly its peculiar growth on potato.
AVhen all  of these properties are  considered, it is  found that the typhoid
bacillus  is  a  species distinct from any other known species of bacteria.
   The typhoid bacillus is constantly present  in the early stages of typhoid
fever in the  affected  solitary follicles  and  Peyer's  patches,  in  the swollen
mesenteric glands, and in the spleen.  It has also been found  in  the  liver,
the kidneys, and the  lungs.   It has been found  only exceptionally in  the
blood, although  it is  often found microscopically in the interior of  small
blood-vessels  in  the liver.   The bacillus is usually absent after the fourth
week of the disease, and is often not found during the fourth  week.  It may,
however, be present at a much later period.  Upon microscopical examination
the bacilli are  found in irregular clumps which stain deeply with various ani-
line dyes.   The examination  is usually  made  in sections  of the spleen  or of
the mesenteric glands,  as other organisms are usually mixed with the typical
bacillus upon the surface of  the  intestinal  lesions.   Often prolonged search
is required to discover the colonies, and sometimes the microscopical examina-
tion is negative.  Gaffky found the colonies in 27 out of 28 cases, and in  the
exceptional case  death occurred  at  the  end  of  the  fourth week.  Other
observers have been less fortunate  in their microscopical  examinations; but
even  in  the cases with  negative  microscopical  result the bacillus can  be
obtained by pure culture from the spleen unless the examination be made at
too late a stage of the  disease.3  The culture method is a much more delicate
  1 Eberth, Virchow's Archiv, 1880, Bd.  81; Gaffky, Mi.ttheil. aus  d. Kaiserl. Gesundheit-
samte  Berlin. 1884;  Fraenkel  u. Simmonds, Die  aetiologische Bedeutung  d. Typhus-
bacillus, Hamburg  u. Leipzig, 1886.                    _
  2 Other observers have failed to detect spores.  Vacuoles in the ends and sides  of the
bacillus are common.
  3 The greater  certaintv with which  the presence of typhoid bacilli can  be demon-
strated in the spleen and other organs by means of cultures than by the microscope is prob- 
954    CLASSIFICATION AND  PATHOLOGY OF FEVER, ETC.

method of demonstrating the presence of the typhoid bacilli  than the micro-
scopical examination.   It is needless to say that the typhoid bacillus has not
been found in any disease other than typhoid  fever, although many diseases
have been examined with that object  in  view.   We may conclude, therefore,
that a specific micro-organism is constantly present in the typical lesions of
tvphoid fever.
   Gaffky failed to obtain  positive results by the inoculation of  cultures of
the typhoid bacillus in inferior animals, but the experiments of Fraenkel and
Simmonds have shown that this bacillus possesses pathogenic properties.  The
majority of the mice inoculated died, and the majority of the rabbits inocu-
lated within the peritoneal cavity or by injection into the blood died.  Many
of those which  did  not die were manifestly ill.   In the organs of the  dead
animals were  found the characteristic bacilli.   The important lesions  con-
sisted in swelling of various lymphatic glands, including the solitary follicles
and Peyer's patches, and of the spleen.   It is not claimed that  the disease
produced  is identical with typhoid fever as it occurs in man.   It is not known
that the inferior animals are susceptible to typhoid fever.
   The constant presence in the characteristic lesions of typhoid fever of a
pathogenic  organism which does not  occur in any other disease or in health
hardly  admits of any other interpretation than that this organism is the
special  cause  of the disease.  The idea  that this organism is secondary to
typhoid fever, being present simply because  the disease produces favorable
conditions for its growth, is met  with insuperable difficulties.
   The typhoid  bacillus has been repeatedly demonstrated by means of cul-
tures in the stools of patients affected with typhoid fever.  This demonstration,
however,  does not always succeed.
   The discovery of  the typhoid bacillus  makes  it possible  to determine in
many cases whether the various and frequent complications of typhoid fever
be the direct  effect of the  typhoid poison or not.  The question here raised
has been  answered  in only a few instances.   It has  been found that the
abscesses  and the severe inflammations of the throat have been  caused by
the secondary invasions of other organisms.  A secondary invasion of micro-
cocci  is not uncommon in  typhoid fever.
   We  are ignorant as  to the manner in which the typhoid bacilli produce the
manifestations of the  disease.   The fact  that  the bacilli are found in small
number or not at all in the blood, taken in  connection  with the  severe con-
stitutional and nervous symptoms, suggests the possibility that they  produce
some toxic substance which is absorbed by the blood.   (The  etiological  rela-
tions  of the typhoid  bacillus  will be  further  considered under Causation.)

   Clinical  History.—Typhoid fever,  as a  rule, is developed  gradually.
After the development of the  disease  the most convenient division of stages
is into septenary periods.  The career of  the  disease will embrace the  first,
second, third,  and sometimes a fourth, fifth, sixth, or even a seventh, week.
  In a large proportion of cases patients are unable to fix  the precise date
of their ailments, so imperceptible is the beginning of  the  disease.    It is
therefore  often  not easy to  determine accurately the  duration of the  pro-
dromic period.  This period ends when the  disease is  developed.  My rule
ably owing  to the circumstance that isolated typhoid bacilli or their spores cannot be dis-
covered microscopically, or at least are readily overlooked. Reher and Fraenkel and Sim-
monds find that from the isolated organisms the characteristic colonies may develop in
the spleen after  death, so that  they advise, for microscopical purposes, preserving the
spleen for twenty-four hours after death, wrapped in a cloth wet with an antiseptic solu-
tion, before hardening in alcohol.  For one familiar with the modern methods of  culti-
vation on solid transparent media it is very easy to demonstrate the presence of the
typhoid bacillus by  means of cultivation 
TYPHOID FEVER.
955
 has been to consider the fever as established when the patient  takes  to  the
 bed. This is an arbitrary criterion, and not always accurate, but  the instances
 in which patients take to the bed before and after the full development of the
 disease will  about compensate for each other.   The first chill or chilly sensa-
 tions and an increase of the temperature  are  more correct criteria •  but in
 a large majority of cases patients do not  come under observation until  the
 fever is developed, and they often cannot recall  the first chill or chilly sensa-
 tions.   Judged by the rule just  stated,  the prodromic period varies between
 one day and ten days, and the mean duration is about  five days.  Exception-
 ally, the attack  is abrupt, the  patient taking  at once to the bed.
   The  following are the  prodromic symptoms:  Chills, more  or  less  pro-
 nounced, or chilly sensations, recurring irregularly,  sometimes followed by
 perspiration and  sometimes not; cephalalgia, the pain generally referred  to
 the frontal  region ; mental irritability,  with difficulty of concentrating the
 attention or exerting  the faculties  of the  mind; loss  of appetite, occasional
 nausea,  and sometimes slight vomiting ; epistaxis in a pretty large proportion
 of cases; pain  in the  loins  and limbs; looseness  of  the bowels or  hyper-
 catharsis if a  mild purgative be given  (the bowels may at first be consti-
 pated) ; lassitude and progressive debility until at length the patient, who up
 to this  time has kept up with more or less effort, feels compelled to take  to
 the bed.  The duration of  this period is  of importance in diagnosis.
   The symptoms which after this  period make up  the clinical  history may
 be distributed into those referable to the countenance or general aspect, the
 nervous system,  the digestive  system, the skin, the  respiratory system, the
 circulation,  the  temperature, and the urinary  system.
   Countenance  and  General Aspect.—There  is no   marked alteration  of
 the  countenance for  the first few days.  The face in the early period  of the
 disease is usually more  or  less  flushed.   Afterward the countenance  presents
 a dull or listless  expression, and in severe cases there is lack of expression  or
 an appearance of stupidity.  The latter  corresponds with the gravity of the
 disease,  and is more and more marked as the  disease continues.  These altera-
 tions of the physiognomy are dependent  on the mental condition.
   The surface presents slight or moderate capillary congestion, like that pro-
 duced by the action of cold.   This is most  marked  on  the face, especially
 on the cheeks.  Distinctly  circumscribed redness of the cheeks  is rare save
 in the cases  in which the disease is  complicated with pneumonitis.  The red-
 ness disappears on pressure, and returns more or less quickly.  In some cases
 the  hue of the surface is slightly dusky.  The capillary congestion observable
 on the face  is diffused over the body, but, next  to the face, it is most marked
 on the hands and arms.  It  is rational to consider this appearance as denoting
 paresis of the peripheral arteries.  Slight or moderate  congestion of the con-
 junctiva is not infrequently observed.
   Nervous System.—Pain in the head is more  or less  complained of during
 the first  week.   It is not always a prominent  symptom, and it never  has  the
 intensity which belongs to the pain in the first stage of acute meningitis.  It
 gradually becomes less  and less a subject  of complaint,  and usually  ceases
 during the second week.  The cephalalgia  is not  accompanied with notable
 intolerance of light  and sounds.  Pain in the back is also complained of in
 the  early part of  the disease, but this is rarely a very prominent symptom.
   Delirium  is manifested in the majority  of cases.  As a rule, it is not  mani-
 fested until  the  second week, and  sometimes not until the third or fourth
 week.   Exceptionally, it is  manifested in the first week, and even when  the
patient  first takes to the bed.   Cases differ much as  regards the degree of
delirium.  It may be slight, or, on the other hand, a very prominent  symp-
tom.  Generally, the first evidence of mental  aberration is temporary con- 
956    CLASSIFICATION AND PATHOLOGY OF FEVER, ETC.

fusion on  awakening  from sleep, the patient being unable to recall where ho
is and asking incoherent questions.  Increasing, the patient talks incoherently
and mutters like a person talking in sleep.  Efforts to get out of bed are com-
mon,  and when asked where they would go patients often say they wish to
go home.  In  most cases they are easily persuaded to lie down, but after a
few moments the effort to get up  is repeated.  If  not watched, they some-
times get up and succeed in getting on their clothes.   The delirium is always
greater during  the night, and it may be manifested only at that time.  In the
great majority of cases the delirium is of a quiet, passive kind.  It apparently
proceeds from weakness of mind, there being inability to carry on connected
trains of thought.   The  incoherent talking or muttering usually relates to
habitual pursuits. The patient is in a dreamy state, a succession of disjointed
ideas  passing through the mind.
   There are occasional exceptions to the rule regarding the kind of delirium.
It is sometimes noisy and active.   The patient shouts  and makes  strong and
persistent efforts to get up.   Constant  forcible  restraint may be  necessary.
Fixed delusions, either of the senses or ideas, during the progress of the dis-
ease are certainly rare ; but they may occur at the time of convalescence.  In
one of my cases the patient  fancied that he had become immensely rich, and
this delusion continued  for  several days after convalescence.  In  another
case, the patient being a young  woman, the delirium in convalescence  had
the character of delirium tremens.  The  delirium during the course of the
fever  is  in general marked in proportion to the intensity of the disease.   So
far as my observations go, persisting, active,  or  violent delirium, requiring
restraint,  is an  extremely unfavorable symptom.
   Patients are sometimes perfectly coherent, but not rational.  They reply to
questions at haphazard,  and no reliance is to be placed on their  statements
with respect to the  events of their illness.   In  some cases there are no mani-
festations of delirium during  the whole  course  of the disease,  but after
recovery there  is very little  recollection of anything that occurred.   The
delirium sometimes has an hysterical character, consisting in emotional mani-
festations—weeping and sobbing—the emotions being very rarely mirthful.
   Delirium, however prominent as a symptom, is  no evidence of encephalic
inflammation.   The appearances of meningitis  are not found  after death in
cases  characterized by  very active delirium,  nor is there an abnormal  amount
of congestion.
   Irrespective of delirium, the mental condition in  the second, third, or fourth
week, or later,  is characterized by hebetude, indifference,  and inanimation.
Blunted perception  is shown by various circumstances.  The patient asks for
nothing—not for drink, although the  mouth may be  dry and desiccated, or
for cliange of the position of the body.   Flies creeping  over the  face  may
occasion  little or no annoyance.  In grave cases the urine and feces may be
passed in bed, not from paralysis of the sphincters, hut through indifference
and a reluctance to  make any effort.  The special  senses  are  impaired, espe-
cially the sense  of hearing, and deafness in one or both ears is  frequently
marked.   General and special sensibility are diminished, as  a rule, in  pro-
portion to the intensity of the disease.  Frequently there is dilatation of the
pupils.
   AVakefulness is complained of during the first few  days, the patient experi-
encing discomfort from the want of refreshing sleep.   Afterward the want of
sleep may not  be appreciated, owing to  the mental  condition.  The patient,
indeed, may seem  to  doze most of the  time,  but  without  obtaining  true
sleep, being easily aroused, but soon relapsing into a pseudo-somnolent state.
This state, in which the patient  may be said to be both sleeping and wake-
ful, is  called coma-vigil, the significance of the  term  depending on the incon- 
TYPHOID FEVER.
957
 gruity of the words which it combines.   This name is also applied to a state
 occasionally observed in which the patient is unconscious with the eyes open.
 In coma-vigil or the pseudo-somnolent state, from which  the patient is readily
 aroused, the mind  is frequently occupied with a series of disconnected ideas
 or dreamy  delusions which give rise to the muttering  delirium.   This com-
 bination of stupor and delirium is expressed by the term  typho-mania.  The
 want of true sleep doubtless contributes not  only to the exhaustion, but to
 delirium and other disordered nervous phenomena,  as in delirium tremens.
   Coma-vigil and  typho-mania do not  involve a tendency to true coma; but
 in a certain proportion  of cases coma is gradually developed in the latter part
 of the career of the fever, and under these circumstances a fatal result is to
 be expected.  In a certain proportion of cases coma is sudden.  It occurs unex-
 pectedly, and in mild as well as in severe cases.  These  cases  end fatally, the
 mode  of dying  being by apnoea.   This  apoplectic coma  is often preceded by
 disturbance of the rhythm of respiration, the inspiratory act being shortened
 and quickened.
   Other symptoms referable to the nervous system, or  ataxic symptoms de-
 noting gravity  of disease, are—grasping at invisible objects  or carphologia,
 pulling up of the bedclothes or fumbling with the body-linen, visible twitch-
 ings of the  muscles of the face and of the extremities, and movements of
 the  tendonsof  the wrist perceptible  to  the touch  (the latter called subsultus
 tendiuum), rigidity of the muscles of the neck or extremities, and convulsions.
 Muscular rigidity and  convulsions are very rare, and betoken a fatal termi-
 nation.  There  is reason to believe that the pathological condition giving rise
 to convulsions with coma is frequently, if not always, uraemia.  In these cases
 the urine will be found to  be albuminous.
   Digestive System.—Anorexia is  the rule, but to  this rule there are excep-
 tions ; the appetite being sometimes preserved  throughout the disease.  Food
 is sometimes acceptable when, owing to the mental condition, it is not asked
 for.  Thirst is usually a prominent symptom until perception becomes blunted.
 Drink, although not asked for, is often  taken with avidity when given.   The
 condition of the mouth would involve a desire for  drink were the  ability to
 perceive morbid sensations not impaired.
   The  tongue generally presents morbid appearances.   It may  be simply
 furred  or frosted, but it is oftener covered  with a coating more or less thick,
 which in different cases is whitish, yellowish,  brownish, or even black.   Not
 infrequently the coatings are thrown off once or repeatedly, and the surface
 is then usually reddened.  Exfoliation of the coating or  its gradual thinning,
 the surface  being moist and of a natural color, betokens  convalescence.   The
 varied appearances of the coatings have no  special significance.  The surface
 of the tongue is sometimes reddened and  smooth  or glazed.  It sometimes
 becomes dry and hard.  This occurs in coma-vigil.  The patient breathing
 with  the  mouth open, the  surface is  desiccated.   It  sometimes  becomes
 cracked and deeply fissured.  Tremulousness  of the tongue,  as in cases of
 delirium tremens, is sometimes observed, usually preceding or accompanying
 grave  ataxic symptoms.  The tongue in some  cases at an  advanced period is
 protruded with  apparent hesitation and difficulty, and when protruded may
 not be  withdrawn,  apparently from forgetfulness.  The delay in protruding
 and withdrawing the tongue represents the weakness and slowness of the
 mental acts.
   Dark or black matter, called sordes, after  the first week  often accumulates
 upon  the teeth  and lips, especially in grave  cases.  Hemorrhage  from the
gums is an occasional symptom, occurring in mild as well as in severe cases.
Redness of  the  gums  and bleeding on  slight  pressure  are common.
   A rare complication is inflammation of one or both of the parotid  glands. 
 958     CLASSIFICATION AND PATHOLOGY OF FEVER, ETC.

 It leads to notable enlargement, and the appearance is like that of ordinary
 parotiditis or mumps; but, unlike the affection just named, in the great major-
 ity of cases suppuration takes place, and not infrequently there is more or less
 sloughing of the areolar tissue.  This complication adds  to the danger and
 retards convalescence.   It may occur at any period of the febrile career or
 during convalescence.   It is not to be regarded  as  a critical event.  The
 discharge of pus is sometimes into the meatus auditorius.   This complication
 occurs in typhus as well as in typhoid fever.  It occurred in 5  of 30 cases of
 typhus and typhoid fever which I recorded in the winter of 1849-1)0.   Prior
 to that year I had never met with an instance, and since that year I  have
 met with  a very few examples, but in  a much larger field of observation.
   Vomiting is  an occasional symptom.   Generally it is  a result of over-
 ingestion.   As regards the occurrence of this symptom, typhoid fever  is in
 striking contrast with  remittent fever.
   Diarrhoea or looseness of the bowels exists in a large majority of cases, and
 this belongs among the diagnostic symptoms of the disease.  The  dejections
 often  have a yellow,  ochre color.   They give  an alkaline reaction, but this
 is not distinctive of the disease.   Exceptionally, constipation exists, and the
 dejections may have a natural appearance throughout the disease.   The bow-
 els are often evacuated in bed, either from indifference or from paralysis of
 the  sphincter ani.  Involuntary evacuations denote gravity of disease.
   Hemorrhage from  the bowels is an important event in the clinical history
 of this disease.  It occurs in a proportion of between 5 and 8 per cent.  The
 hemorrhage may be slight, moderate, or profuse.  It may cease after a single
 occurrence, or there  may be a greater or less number  of  recurrences.   The
 loss of blood  is  sometimes the  immediate cause of death.  Statistics, how-
 ever, show that in the larger number of cases  patients recover.  Even very
 profuse hemorrhages  do not always prove fatal.   I have known the loss of
 blood to occasion complete collapse for several  hours in cases which ended in
 recovery.  The hemorrhage occurs late in the disease, and in most instances
 is from the intestinal  ulcers.  Its occurrence may be foreshadowed  by  a sud-
 den and  notable decline of the temperature of the body.   I have met with a
 case in which the decline of  the axillary temperature to 98° was for a time
 considered as evidence that the fever had ended, but within a few hours  pro-
 fuse hemorrhage from the bowels occurred and the patient died from the loss
 of blood.
   Other abdominal symptoms are—meteorism or tympanites,  tenderness or
 pain on pressure, and gurgling.  The abdomen is always resonant  from the
 presence of intestinal  gas.  Frequently there is more or less distension, and
 sometimes the tympanitic  enlargement is great.  Tenderness on pressure in
 the iliac region, especially on the  right side, is very rarely absent.   Sudden
 and  forcible pressure may be required for the  manifestation of pain if per-
 ception be much blunted.  The tenderness is often  marked, and sometimes it
 extends over the greater part of the abdomen.   Ourgling on pressure  in the
 iliac region as a sound and  as  a  tactile  sensation is a frequent svmptom.
 These  three symptoms—namely, meteorism  or  tympanites, iliac tenderness
 and  gurgling, especially the two former conjoined with diarrhoea or looseness
 and  ochre-colored  discharges—form  a group of abdominal  symptoms highly
 diagnostic  of this  form of fever.  They may, however, all  be  absent.   The
 tympanites, tenderness, and gurgling, as  regards their prominence, are not
proportionate to the amount of intestinal lesions.   By  percussion and by
palpation  over the region of the  spleen this organ is found to be  enlarged.
   Perforation of the  small—or  in rare  instances the large—intestine takes
place in a certain proportion of cases; namely, in between 8 and 10 per cent.
of fatal cases, and between 1 and 2 per cent, of all cases.  It takes place late 
TYPHOID FEVER.
959
 in the disease or during convalescence, and sometimes even after apparent
 recovery from the fever.   It  occurs  as often in mild as in severe cases.   It
 occurs  oftener in men than in  women, and is very  rare in  children.
   Perforation gives rise to  peritonitis, which is generally developed abruptly.
 The sudden occurrence of notable tenderness diffused over the  abdomen,
 abdominal pain,  increased  tympanitic  distension, rigidity of the abdominal
 walls, with marked frequency of pulse,  prostration,  haggard expression of
 countenance,  etc., point  to peritonitis from  perforation.   Replacement of
 hepatic  flatness  by tympanitic resonance  usually occurs in  perforative peri-
 tonitis,  but it may be absent,  and  this  symptom may be present without
 pneumoperitoneum.   In some cases, the perforation being quite small, the
 development of the peritonitis is gradual,  and it may be circumscribed under
 these circumstances.  Peritonitis does not invariably  denote  perforation.   It
 may be  caused by the  evacuation into the peritoneal  sac of liquefied matter
 within a mesenteric gland.  It may occur irrespective of either this cause  or
 perforation.   Probably in  most of the reputed cases of recovery after the
 occurrence of peritonitis   perforation  was  not  involved.   Peritonitis  from
 perforation is almost certainly  fatal.
   Skin.—Of  the symptoms referable  to  the  skin, the most  important  is a
 characteristic eruption.  The  eruption consists of  isolated papules, generally
 limited to  the trunk, of a rose or pink  color, called by Louis lenticular rose-
 colored  spots.   They are  slightly  elevated, and therefore  are  papulse, not
 maculae.  The elevation is  distinctly felt if  the finger be carried  lightly over
 them.   They  are slightly  oval  in form,  and are  from one  to  two lines  in
 diameter.  The redness momentarily disappears on light pressure.  The num-
 ber of papules is generally small, in the majority of cases not exceeding fifteen
 or twenty, and sometimes only four or five can be discovered.  Exceptionally,
 they are abundant over the trunk, and  the eruption sometimes extends to the
 extremities.   Fresh papules appear from  time to time during the course of
 the fever, taking the place  of  those of anterior date.  They are  to be sought
 for over the  chest  and abdomen in front and over  the back, and they are
 sometimes found exclusively  in the latter  situation.
   Dating from the time of  taking to the bed, the average time of the appear-
 ance of the eruption is about the seventh day. Papules continue to disappear
 and  to  appear during the career of the disease, and sometimes the eruption
 persists  into the  stage of convalescence.   The papules are not apparent after
 death.
   The eruption is not invariably present.  The proportion of  cases in which
 it occurs varies in different years, as my statistics show.  It appears to be
 less  frequent  in the country than in the city.  It is less frequent in children
 than in adults.   The copiousness of the eruption is no evidence of the sever-
 ity of the  fever, and on the other hand it  is as likely to be absent in mild
 as in severe cases.   A scarlet rash  occasionally precedes the characteristic
 roseolar  eruption.
  Miliary vesicles or sudamina are not infrequently observed in  the  middle
 and latter  part of the disease  on the neck, chest, and  abdomen.   This erup-
 tion is observed in various affections in which perspiration occurs.  Petechias
 or minute  ecchymoses are  occasionally observed.    These  do not denote un-
 usual gravity of the disease.   They occur in mild as well as in severe cases.
 Herpes  labialis is so rare an occurrence in  typhoid  fever that  its presence  is
 evidence against the diagnosis of this disease.
  Bluish patches (peliomata or taches blenCdres) of  irregular form, from three
to eight  lines  in  diameter, are  occasionally observed on the  abdomen, back,
and thighs.  They are not peculiar  to this disease, and are  more likely to
occur in mild than  in  severe  cases. 
960    CLASSIFICATION AND  PATHOLOGY  OF FEVER, ETC.

  Perspiration, more or less abundant and recurring more or less frequently,
is observed in about one-half of the cases, exclusively of its  occurrence at
the time of convalescence or just before death.   It occurs in about an equal
proportion of fatal cases and of  those ending in recovery.  Observation does
not show a connection  between  this symptom and any particular antecedent
events;  but, taking the  frequency of the pulse as a criterion of the gravity
of the disease, and comparing the  pulse before and after the  occurrence of
perspiration, in  the majority  of cases improvement  follows.    AVhile  this
symptom, therefore, has no bearing on the prognosis, it often betokens some
amelioration.   As a rule, during the  greater part of the  career of the fever
the skin is dry.
  Gangrene is liable to occur in  situations exposed to pressure. Spontaneous
gangrene of the extremities has  been observed, the  probable explanation
being arterial  thrombosis.   Gangrene and troublesome  ulcers are liable to
follow vesication.  The liability to bed-sores on the nates, hips,  and  shoulders
is to be  borne in mind.  These  may be prevented by changing from time to
time the position of the body,  by the use of air-pillows, etc.  Erysipelas is
an  occasional  complication of typhoid fever.
  Respiratory  System.—Cough is not a prominent symptom unless an import-
ant pulmonary complication exist,  but slight or moderate cough  is almost
invariably present, proceeding  from subacute  bronchitis.   A sibilant rale is
frequently  heard over the chest on  auscultation.
  Pneumonia is  a not  infrequent complication.  It is  rendered probable by
prominence of cough and accelerated breathing, but the proof of its existence
is afforded by the physical signs.  It is sometimes latent as regards diagnostic
symptoms, and is determinable only by physical  exploration.   Its occurrence
adds to  the danger,  but it by no  means precludes recovery.  Hypostatic con-
gestion  and oedema of the posterior portions of both lungs are incident to the
feeble circulation in the latter part of the disease.  These physical conditions
are represented by dulness  on percussion, weak respiratory  murmur, and sub-
crepitant rales.  Irrespective of  any pulmonary complication except subacute
bronchitis, the frequency of the respirations is increased, the  average  being
about 21 per  minute.
  Frequent sighing in the  early part  of the disease is a forerunner of ataxic
symptoms of  grave omen.   A spasmodic  or jerking inspiration when  pneu-
monia does not  exist is a precursor of coma.   This statement  holds good in
other forms of fever.  The importance of this symptom is enhanced by the
fact that it may sometimes be  observed when no other  symptoms denote
impending coma.   This  was true of several  cases which I have  observed.
  Epistaxis  has been  mentioned as a symptom of diagnostic value early in
the disease.  It occurs not infrequently  afterward.  Generally the hemor-
rhage is small, but occasionally it is profuse, and it may require  to be arrested
by mechanical means.   AVhen slight  or moderate it does not appear to have
any influence on the progress of the disease.  Uterine  hemorrhage is  not
uncommon.  Its  occurrence is not  limited to  the period when menstruation
should  take place.
  Pharyngitis, laryngitis, and oedema  of the glottis are occasional  complica-
tions  of typhoid fever.
  Circulation.—More or less acceleration of the pulse belongs  to the history
of the disease.   The acceleration varies considerably in different cases, and at
different periods of the disease in the  same case.   There  is a greater average
frequency in fatal cases than  in those ending in recovery.   The  danger is
usually  considerable if the  pulse for  many days exceed 120 per minute,  and
the danger is augmented in a geometrical  ratio as the frequency rises higher
than this.  The mean  frequency in cases  not proving fatal of  those which I 
TYPHOID FEVER.
961
have  analyzed was 93; and in the fatal cases, 110.  In some mild cases the
average  frequency during the whole of the disease is less than the average
frequency of health.   In  one  of my  cases the average frequency was 69.  In
these cases, however, the pulse at times  exceeds the healthy standard, hence
the pulse may at times fall below the  standard of health.  "This is not infre-
quently observed at or near the time of convalescence.  I have  noted it as
low as 64, 60, and 40.  Others have observed it to fall still  lower.  Oftener
the pulse continues more or less accelerated after  convalescence is declared.
A sudden  and  considerable increase  of  the  frequency of  the pulse  often
denotes the occurrence of some important event, such as pneumonia or peri-
tonitis.
  _ As regards characters of the pulse  other than frequency, it is quick and
vibratory, not hard or resisting.  It  denotes increased action, but not  in-
creased power, of  the ventricular systole.  It becomes feeble or compressible
in proportion  as it is  frequent.  The  force is always  notably diminished if
the frequency much exceed  120.   An unfavorable progress of the disease
toward asthenia is shown by progressive increase in frequency and diminution
of force.  Under these circumstances the first sound of the heart, on auscul-
tation over  the apex, is notably weakened and may be inappreciable.  The
form  of the pulse, as traced  by the sphygmograph, presents  the  following
characters:  a short and nearly vertical line of ascent, indicative of weakness
and quickness of the ventricular systole; a line of descent, denoting the free
passage of blood from  the  arteries in  the capillaries, and notable dicrotism.
The dicrotism of the radial artery  is sometimes appreciable by the touch.
These characters  belong to the graphic pulse also in cases of typhus and in
all affections  with which is associated the typhoid condition.
   Temperature.—More or less increase of the heat of  the body is invariable.
In general, the thermometer in the axilla shows a daily increase of tempera-
ture for the first five or six days.   This gradual rise of temperature  from
day to day during the first week is diagnostic of typhoid fever.  At the end
of this  period the temperature rises to at least 103° F.  If, in the progress
of the disease the thermometer show much increase above this, the prognosis
is unfavorable, whereas a decline of the  temperature in the morning to near
the normal standard is evidence of convalescence.  During the progress  of the
disease there is, as a rule, an oscillation of temperature between morning and
evening, the difference varying between half a degree and a degree and a half
up to the time of  convalescence, when the oscillations  become much greater,
the difference being four to five degrees, the temperature in the morning fall-
ing to the normal standard, 98°, or lower.  The difference between the morning
and evening temperature at the time  of convalescence has been observed to be
more  than nine degrees.   The  temperature in  typhoid  fever  does not always
pursue the  typical course which has been described.  The temperature may
reach its acme by the end of the third day.  Not very infrequently the course
of the temperature is of a remittent  type, and even  distinctly intermittent
types of temperature have been observed  during the first and second weeks.
A high elevation  of  temperature  in the  morning—namely,  106°  to 108°—
indicates the approach of death.  The laws of the disease as regards temper-
ature are sufficiently characteristic to render the thermometer useful in  diag-
nosis as well as in prognosis.  A sudden and considerable rise of temperature
during the progress of the disease points to the occurrence of an inflammatory
complication.  A sudden and considerable fall of temperature, other symptoms
not denoting convalescence or improvement, is unfavorable.   This  often indi-
cates hemorrhage from the bowels.  It is important, however, to note that, irre-
spective of complications, the temperature in some cases becomes increased, and
the rise  may continue for several  days;  and on the other hand a decline of
       61 
 962     CLASSIFICATION AND  PATHOLOGY OF FEVER,  ETC

 from one to two and a half degrees sometimes takes place, lasting for several
 hours, without any obvious cause and having no special significance.
   Urine.—The urine is usually scanty and of high specific gravity until  the
 approach of  convalescence, when it  becomes abundant and of a low specific
 gravity.  During the progress of the disease, as a rule, the urea  and uric acid
 are absolutely increased and the chlorides are diminished.   The coloring mat-
 ter is also more abundant than in  health.1  The presence of albumen during
 a part of the febrile career is common.   An abundance of albumen denotes
 gravity.  This symptom occurs in the middle or latter part of the disease, and
 it may continue for a period varying  between twenty-four  hours and twelve
 days.   In the  fatal  cases in which it  occurs it continues up to  the time of
 death.   In these  cases the kidneys  after death  may be found  to be simply
 congested, no deposit or structural change existing.
  A genuine acute diffuse nephritis may develop during the course of typhoid
 fever, even in the early stages.   Cases in which the  renal  symptoms pre-
 dominate have been designated as renal typhoid.  Such cases are rare, arid
 may offer considerable difficulty in diagnosis.  It is  probable that  coma and
 convulsions occurring in the progress of typhoid fever are due to uraemic
 poisoning.  I have  met with a case  in which, following a large  hemorrhage
 from  the bowels,  profuse  haematuria took place, the blood passed from the
 bladder forming clots after its emission.  The patient became much blanched
 from  the loss of blood, but he recovered.
  The urine  is sometimes retained  in cases of typhoid fever, and owing to the
 blunted  perception the bladder may become greatly  distended.   The practi-
 tioner should not omit to ascertain the condition of the bladder  by examina-
 tion of the abdomen during the progress of the disease, and resort seasonably
 to the use of the  catheter when  required.  On the other hand, the urine  is
 often passed in bed, sometimes from indifference and sometimes from  incon-
 tinence.
  In  order to determine the duration of the disease it is necessary to  fix upon
 certain  points  which shall mark the beginning  and the  end of the febrile
 career.   The time of taking to the  bed is a convenient, and in  a collection of
 cases a tolerably correct, criterion of the development of the fever.  It is dif-
 ficult to find  any one circumstance which  will  answer equally w*ell to denote
 the date of convalescence.   The career of  the fever rarely ends abruptly ; the
 termination in convalescence, like the development, being gradual.  The decision
 that a patient is convalescent is a matter of judgment, and is to be based on
 the ensemble, of symptoms.  Of 42 cases ending in recovery, analyzed with ref-
 erence to the duration of the fever, dating from the time of taking to the bed
 to the time when the improvement in all the symptoms was sufficient for the
 patients  to be considered convalescent, the average duration was sixteen days.
 The maximum  duration was twenty-eight days, and the minimum five days.
 The longest duration  in any case  under my observation was in a female hospi-
 tal patient, the disease continuing in this case without any important complica-
 tion fifty-eight days.  It is perhaps of importance to state that these cases were
 observed long before  the recent introduction in medical practice of antipyretic
 measures of treatment.  The mean duration in 75 cases observed by Murchison
 was a fraction more than twenty-four days.  This greater duration, as compared
  1 The so-called diazo-reaction, first described  by Ehrlich,  can usually be produced in
 the urine of typhoid-fever patients.   The test consists in mixing the urine with  a solu-
 tion of sulfo-diazo-benzol, and then adding ammonia, when, if the reaction is present, the
urine acquires  a red color which is followed by the precipitation of a greenish sediment.
The reaction is found chiefly, although  not  exclusively, in  febrile diseases.  Its diag-
nostic  and prognostic importance is not yet established, the results of different observers
being  contradictory (Ehrlich, Charite Annalen, Jahrg. viii., and Deutsche med. Wochca-
schrifl, 1883, No. 38). 
TYPHOID FEVER.
963
with my cases, is probably owing to the beginning being fixed at an earlier
period than the date of taking to the bed.  Of 45 fatal cases in my collection,
the mean duration was a fraction more than  fourteen days, the maximum being
twenty and the minimum nine days.  The mean duration in 12 fatal  cases ob-
served by Murchison was a fraction more than twenty-two days. The aver-
age duration of convalescence is between one and two weeks.  The return of
the axillary temperature to the normal standard—that is, complete  deferves-
cence—shows of course that the febrile career is ended. Sometimes the defer-
vescence is rapid, and the temperature quickly falls to that of health ;  but gen-
erally it is gradual, and paroxysms or exacerbations of fever, as indicated by
the thermometer, are liable to occur for some  days after the a*ppetite, mental
condition, and other symptoms denote convalescence.   The temperature may
be  kept  up by complications which persist after the career of the  fever is
ended.  A temporary fever often accompanies the change of diet from liquid
to solid animal  food.
   Relapses of typhoid fever  sometimes occur.  Many examples have fallen
under my observation.  A return of the fever may take  place after ten days
or a fortnight from the date of convalescence,  and the patient pass through a
second career, the eruption and other characteristic  symptoms being repro-
duced.   The  duration of the  second career  is usually shorter and the severity
greater than the first, but a fatal termination is rare.
   Complications which are likely to arise in the  course of typhoid fever have
been noticed in  connection  with  the anatomical appearances  and  with the
symptoms referable to different anatomical systems.  The occasional occur-
rence of thrombosis of the iliac or femoral vein on one side or on both sides is
not  rare, and is attended with swelling  and pain of the  corresponding limb.
This complication  rarely leads  to evil  consequences, but sudden death has
been known  to  occur from  an embolus detached  from the  thrombus  and
occluding the pulmonary artery.  Typhoid fever  may  be  associated  with
intermittent fever  (typho-malarial fever),  scarlatina, rubeola, diphtheria, and
perhaps with typhus.   Occasional sequels are  acute miliary  tuberculosis, pul-
monary phthisis, and subcutaneous abscesses.  Progressive emaciation and
death from inanition  have been  known to follow ; but in many  instances
nutrition  becomes  extremely active after  recovery and the patient attains
a  greater weight than  ever  before.   The  mental  powers in some  cases are
eufeebled for  a  considerable period.
                        CHAPTER  II.

                 CONTINUED  FEA'ERS (Continued).

Causation of Typhoid Fever; Diagnosis; Prognosis.-Typhus Fever: Anatomical Cha-
           racters; Clinical History; Causation; Diagnosis; Prognosis.

   THE  anatomical characters and clinical history of typhoid fever have been
    described in the preceding chapter ; and it remains to consider the causa-
tion, diagnosis, and prognosis of this disease before entering on the considera-
tion of typhus fever.

  Causation.—Typhoid fever is not restricted within any geographical lim- 
964
CONTINUED FEVERS.
 its.  It is endemic in every quarter of the globe.  It prevails, however, often
 within circumscribed districts, and  not infrequently does not extend beyond
 a few houses or even a single house.   Although it now prevails within many
 malarial regions, it  is  certain that in some  situations in  this country well-
 marked  cases of typhoid fever were hardly known so long as malarial fevers
 were rife, but the former became the common form of fever after intermit-
 tent and remittent  fever ceased to  prevail.   As  regards  the  season  of the
 year, if shows  in this latitude a decided  predilection for the autumn.1  It is
 stated that a warm, dry summer favors the occurrence of the disease in the
 following autumn.   According to Buhl and Pettenkofer, the disease prevails
 in Munich when the level of the ground-water is low, and the prevalence has
 been observed to end when  the level of  the  water has been raised  by abun-
 dant rain.  A similar  relation has not been observed in all places.
   The susceptibility to typhoid fever is greatest between the ages of fifteen
 and twenty-five, next  between ten and fifteen, and next  between twenty-five
 and thirty.  It is rare  in infancy, but not infrequent in childhood.  A  con-
 siderable proportion of cases of so-called infantile remittent fever are cases
 of typhoid fever.  The susceptibility is much diminished after sixty, but the
 disease  may develop in persons more than seventy years of age.
   Both  sexes  appear  to be about  equally liable to  the  disease.   Generally,
 persons are in good  health when attacked. Other diseases do not seem  to pre-
 dispose  to typhoid fever.  No causative influences relating to social position,
 occupation, or habits of life have been ascertained.   A certain degree of  pro-
 tective  influence against  typhoid fever seems to be exerted  by phthisis and
 other diseases attended by cachexia and severe anaemia, but this protection is
 not absolute.  A protective influence exerted  by pregnancy and lactation, if it
 exist at all, is much less than was  formerly supposed.   Typhoid fever devel-
 oped soon  after delivery is liable to be mistaken for puerperal fever.  Preg-
 nant women when attacked with  typhoid fever generally abort, but this does
 not seem to influence the prognosis  unfavorably.  The foetus is generally dead
 or dies soon after birth.   The typhoid  bacillus has been found in the  foetus,
 in which have  also, but very rarely, been found the lesions of the disease.
   New-comers  in an infected district are more likely to be attacked than those
 who have long resided  there.  As  of those who  are exposed to the typhoid-
 fever poison only a  certain number are attacked, it is evident that a certain
 degree of individual immunity exists.
   The reasons have already been given for believing that the so-called bacillus
 of typhoid fever is  the specific cause of the  disease.  Of the properties of
 this organism bearing  upon  the causation, may be mentioned its growth at
 ordinary temperatures, although best at a temperature between 85° and 100°
 F.; its  growth upon a  great variety of substances, such as vegetables, milk,
 meat-infusions, etc.; its formation of spores;  and its presence in the typhoid
 stools.   AVe may therefore infer that the typhoid  bacillus may grow readily
 under ordinary conditions outside of the body, as in the soil or in liquids  con-
 taining sufficient nutriment, and that by  the  formation of spores it may  pre-
 serve its vitality for a long time, even under  unfavorable conditions.  There
 is no evidence  that  the typhoid  bacillus exists in the exhalations  from the
 patient.
  Typhoid  fever is communicable, hut rarely if  ever in  the same way as
 the strictly  contagious diseases, such as typhus fever, smallpox, scarlet fever,

  1 Of o9S8 cases admitted during twenty-three years in the London.Fever Hospital and
analyzed by Murchison, 41 per cent, occurred in autumn, 21.3 per cent, in winter, 12.7
per cent, in spring, and 24.8 per cent, in summer.-
  Of 45 cases which I  have analyzed with reference .to this point, 16 were in October,
9 in .November, and 12 in December. 
TYPHOID FEVER.
965
and relapsing fever.   Emanations from the bodies of those affected with the
disease do not infect the surrounding atmosphere, and hence in hospital wards
the disease is not diffused by typhoid cases among patients affected with other
diseases  if care be taken  to  thoroughly disinfect the dejecta.   Physicians,
nurses, and members of families  brought into  close proximity to cases sel-
dom contract the disease in consequence.  Nevertheless, the causative germs
multiply within the bodies of typhoid patients,  and are  expelled from the
body  with the intestinal  dejections.   It is  not  necessary  to suppose that
these germs, the typhoid  bacilli,  must undergo any further  modification or
development outside of the body in order to communicate the disease.  It
is  possible to explain  the  infrequency  with which those in attendance  upon
typhoid patients contract the  disease by the fact that with ordinary care por-
tions  of  typhoid stools are not  likely to be taken into the alimentary canal,
and there is no reason to suppose that  any exhalations from the patient con-
tain the  bacillus.   AVasherwomen not infrequently contract the  disease from
washing  linen soiled with  typhoid excreta, and it is  easy to understand how
infection might take place  in this  way.
   It  is probable, however, that  the typhoid stools  are the chief source  of
infection of a locality in which the disease becomes endemic.  Instances might
be multiplied to  show that persons who have contracted typhoid fever in
one locality, then go  to another  locality and become a source of infection
for a  region in which the disease  has not hitherto  prevailed.   In the  preced-
ing editions of this work I have reported a remarkable instance of this nature.
In this instance a stranger ill with  typhoid fever came to a little settlement
called North Boston,  consisting  of nine families.  Up to this time typhoid
fever had never been known in that neighborhood.   In a few days the stranger
died,  and in a month  more than  one-half of the  population, numbering 43,
had been affected, and 10  died.   Both the symptoms and post-mortem exam-
ination showed  the disease  to  be typhoid fever.  Of the nine families, one
family escaped  which  obtained  its water from a source diff'erent from the
others, which used  a  common  well.1
   That infection with  typhoid fever often takes place from the drinking-water
cannot be doubted.   The  typhoid bacilli  have been found  in  the drinking-
water of regions where  typhoid fever was prevailing as an epidemic (Mors,
Michael).   Such water may be perfectly clear and apparently pure.  Meade
Bolton has shown that typhoid bacilli may exist in drinking-water for at least
a month, although they do not  multiply unless the water contain an  amount
of organic matter not likely to be present in any water which would  be used
for drinking  purposes.  In a number  of  instances of infection through the
water it  has  been  possible  to show some communication or leakage between a
well used  for drinking purposes  and a privy-vault, cesspool, sewer, or drain.
That such contamination,  as well  as the contamination of the soil in a similar
wav,  is an important  factor in  the causation of the disease  seems certain;
but, in accordance with our present views, we must  suppose  that no  amount
of contamination  by the  ordinary products  of decomposition is capable of
causing  typhoid fever, and that the typhoid  bacillus must always be present
when this occurs.
   Allied to epidemics traceable to the drinking-water are  epidemics referable
to the milk-supply.   A number of such  epidemics have been reported, espe-
cially in England.2   Here it is probable that the vehicle of infection is the

   1 For fuller details concernine; these cases, vide A. Flint, Clinical Reports on Continued
Fever  etc   1852 and American Journal of the Medical Sciences, July, 1845.
   2 Dr F  C Curtis in the Fourth Annual Report of the State Board of Health of JSew
York  ^ives an account of an outbreak of typhoid fever at Port Jervis in the autumn of
1883,'traceable to milk-supply. (See, also, The Lancet, Feb.  7, ISSo.) 
966
CONTINUED FEVERS.
water used  in cleansing the cans or in  diluting the milk.  As already men-
tioned, milk is a favorable  medium for the growth of the typhoid bacillus.
Boiling the  milk is the  only sure preventive.
   Some believe that the  chief source of infection is through the atmosphere
in regions in which the ground contains  the specific germ.   It is probable
that infection may take place from uncooked food, especially from fruits and
vegetables which are contaminated by the presence of the specific organism.1
   A question of importance is whether an outbreak of typhoid fever be always
referable to  the introduction of the typhoid germ derived directly or indirectly
from a person affected  with the disease, or whether the  special poison may
be generated outside of the human body.   That the former method of infec-
tion is a common one cannot be doubted, but the properties of the  typhoid
bacillus are such that it is capable of living independently  of the  animal
body, and there is therefore no apriori objection to the assumption that
typhoid fever may develop  in regions which  have never been visited by any
one affected with the disease.   It is, however, very difficult to prove the lat-
ter view, for the  typhoid germ may be transported by an individual who does
not contract the disease,  and  it is  certain that  this  germ may preserve  its
vitality for  a long time, at least for several years.2
   The early and  predominant involvement of the intestine in typhoid fever
seems to indicate that  the  infection takes  place  primarily from the alimen-
tary tract.   Even if the typhoid bacilli should be inspired, ft is not necessary
to suppose  that  the infection is through  the  respiratory organs, for  after
reaching the mouth or throat the  organisms could  be swallowed.
   The agency of bad cesspools, sewers, and privies in the causation of typhoid
fever seems  to be that here the bacilli, derived usually from typhoid  dejecta,
find suitable conditions for their growth, and that with  imperfect drainage
from these sources the surrounding soil  and neighboring  waters may become
infected with the  specific  organism.   This important agency enforces the
necessity of measures  of  prophylaxis consisting  of effective sewerage, pro-
vision against obstructions of house-drains, prevention of leakage from these
and cesspools, care that the trapping of hand-basins,  sinks, and water-closets
is complete,  and the disinfection and speedy removal of the excreta of patients
affected with the disease.3
  The interval between the introduction of the germs and the first manifesta-
tion of the  disease, or the period of incubation, is usually about two weeks.
The duration is longer than this in some instances, but probably never several
months, as has been supposed.   On the other hand, the duration sometimes
does not exceed  one or two days.4   This disease  is  one of those which are
very rarely  experienced twice ; and a person who has had the disease, as a
rule, is thereafter unaffected by the special  cause.  As already stated, how-
ever, a relapse sometimes occurs shortly after the date  of convalescence.

  Diagnosis.—Typhoid  fever is  to he discriminated from  other essential
fevers, especially  typhus, remittent, and  typho-malarial fever.  The  differ-

 _ x In Switzerland  epidemics of typhoid fever have been reported in which the infec-
tion has been  referred to eating the meat of diseased calves; but this interpretation of
the cases is not free from  doubt.
  2 According to bacteriological nomenclatures, tbe typhoid bacillus may be regarded
as a saprophyte and a potential parasite; that is, all of the conditions for its" development
are present outside of the animal body, and it may therefore exist as a saprophyte.  It
occasionally makes incursions into the human body, where it becomes a parasite.
  3 A full account of the different agencies involved or supposed to be involved in the
etiology of typhoid fever will be found in J. H. Hutchinson's article on this disease, in
Pepper's System of Practical Medicine, by American Authors, Philadelphia, 1885, vol.i.
  4 Vide Murchison, in St. Thomas's Hospital Repoi-ts, vol. ii. 
TYPHOID FEVER.
967
ential diagnosis cannot be  fully considered without anticipating  the diag-
nostic events which belong to the  clinical history of these fevers.   The dis-
crimination  is to be made  by ascertaining  the presence of more or less of
the events which are diagnostic of typhoid  fever and the  absence of events
diagnostic  of other  fevers.   The  points in the  clinical  history which are
distinctive of typhoid fever are as follows:  the gradual  development; the
absence of marked remissions; the abdominal symptoms—namely, diarrhoea
with ochre-colored dejections, tympanites, tenderness and gurgling in the right
iliac region ; the occurrence of epistaxis; and the characteristic eruption.  As
regards the  eruption,  a fact important to be  borne in  mind  is that rose-
colored papules, like those belonging  to the history of typhoid fever, are
sometimes found in other affections.   Other points to  be taken  into  account
are the autumnal season and the youth of the patient.  The foregoing points,
taken in connection with the absence of features distinctive of other fevers,
generally render the diagnosis  easy after a  certain duration  of the  disease.
In  typho-malarial fever, as  will  be seen,  the symptomatic  phenomena of
typhoid  and malarial fever are commingled in variable relative proportions
in different cases.
   Other affections with which typhoid  fever may he confounded are—cere-
bral and  cerebro-spinal  meningitis, bronchitis, pneumonitis,  acute  tubercu-
losis, and enteritis.
   Acute meningitis, as  distinguished from typhoid fever, is characterized by
more intense cephalalgia, by intolerance of light and sounds, early and active
delirium, frequently by vomiting as a prominent symptom, by rigidity of the
muscles at the back of  the  neck, sometimes by paralyses, and by somnolency
and coma succeeding the delirium.  There generally is constipation. The abdo-
men is not tympanitic, but frequently depressed, and iliac tenderness  is want-
ing.  This differential diagnosis is  required chiefly in children.
  "Subacute bronchitis  is an element of typhoid fever.  If the bronchitis be
unusually prominent and the fever  unusually mild, the latter  may  be over-
looked and  the disease considered  a primary bronchitis.  This error can only
happen in the early part of the fever;  and the duration and progressive increase
of  the disease, together with the  characteristic events of the fever, will lead
to a correction of the diagnosis.  If  the bronchitis be capillary,  owing to the
predominance of the pulmonary symptoms, this may be supposed  to be the
primary and sole disease.   An  instance has fallen  under my observation, but
capillary bronchitis as a complication is extremely rare.
   Typhoid  fever may be confounded with pneumonitis when the latter exists
as  a  complication.  The existence of pneumonitis is shown  by its  physical
signs.  The differential diagnosis  is to be  based on facts  which show the
existence of fever prior  to the occurrence  of the pneumonitis, and on the
events  characteristic of  typhoid  fever—namely, the  abdominal  symptoms
and eruption.   Cases  of primary pneumonitis in  which  the existence of
tvphoid fever  may be suspected are  cases of so-called  typhoid  pneumonitis;
that  is.  pneumonitis with  phenomena  denoting the typhoid state—namely,
low delirium, prostration, subsultus tendinum, etc.
   Acute  miliary tuberculosis has not infrequently been mistaken for typhoid
fever.  The former is to be discriminated by the notable frequency of the res-
pirations, the prominence of the cough, the occurrence of haemoptysis in some
cases, the abundance of subcrepitant rales;  by marked  lividity in some cases;
by the  presence of choroid tubercles ;  and by the absence of the  abdominal
and other characteristic  events of typhoid fever.
   Typhoid  fever may be considered as primary enteritis when the  abdominal
svniptoms are unusually prominent from the beginning.  The liability to this
error is chiefly in cases'occurring in children.  Events  other than the abdom- 
968
CONTINUED FEVERS.
inal  symptoms belonging to the history of typhoid fever are  to  be  sought
after.  Some of these are not so readily appreciated in children as in  adults,
especially those relating  to the mind, and the eruption is oftener wanting.
Hence typhoid fever in children is not infrequently called  enteritis.   AVith
due care in tracing the development and  progress of the disease  this error
of diagnosis  should generally  be  avoided.
  It is evident that  familiarity with the phenomena  and laws of typhoid
fever and of the diseases  with which it is liable to be  confounded—namely,
other fevers  and the local affections just  referred to—is an  essential  quali-
fication for accuracy in diagnosis.    This remark is of  general application
to diagnosis.
  The thermometer may be brought to bear upon the diagnosis of this  dis-
ease at an early period, before the  eruption or other distinctive features are
fully  declared.  A moderate increase of temperature daily for several suc-
cessive clays, with  an evening  exacerbation, points to typhoid fever as con-
trasted with typhus, periodical, relapsing, or an eruptive fever, assuming the
disease to be an essential fever and not  an inflammatory disease.  Aarious
circumstances, however, may occasion deviation from this gradual  increment
of fever  in typical, uncomplicated cases.
  In  some cases the disease may be overlooked in consequence of the phe-
nomena being imperfectly developed.  These cases were called by Louis cases
of " latent typhoid fever." They are called  by German writers cases  of -- typhus
ambulatorius;" and the term "walking  cases" is in use in this country.  The
patients do not take to the bed, and perhaps they continue their usual avoca-
tions.  They complain, only of  debility, loss  of appetite, and mild  diarrhoea.
Under these  circumstances death sometimes takes place from intestinal per-
foration,  profuse hemorrhage, or some grave complication, and  on post-mortem
examination the characteristic typhoid lesions of the intestine  are found.  The
only explanation of these cases to be given is that the effects of the  special
cause are concentrated on the glandular elements of the  small-intestine.
  Errors of  diagnosis  are likely to  be made in  cases  of abortive typhoid
fever,  in very  mild cases (typhus levissimus), and in  cases in  which  the
temperature-curve  has  a remittent or  possibly intermittent character.   In
children the existence of typhoid fever is doubtless often overlooked.1   Here
abdominal symptoms may be slight, particularly intestinal hemorrhages  and
peritonitis, while  severe cerebral symptoms are usually present.  In old per-
sons the course of the disease is  often irregular, pulmonary  and cerebral
symptoms frequently  being most marked.   The occurrence of eases  of typhoid
fever in which the symptoms of an acute Bright's disease appear early is rare,
but this should be borne in mind.

  Prognosis.—Of 18,612 cases aggregated  by Murchison,the mortality  was
18.62  per cent,, or 1 in  5.4.  Of  303 cases received in the Massachusetts
General  Hospital  and analyzed by James Jackson, 42 were  fatal,  being 1 in
about 7 cases, or a fraction less than  13 per cent.  Of the 73 cases which I have
analyzed, 18 were  fatal, nearly 1 in 4, or about 24 per cent.  These facts show
much variation in  the death-rate in  different  collections of cases  occurring at
different  places and periods.  That the variation is often  considerable  at  dif-
ferent seasons in the  same place, and under similar circumstances  as regards
surroundings and  treatment, is shown by the ratio of deaths  in  succ-essive
years in the Massachusetts General Hospital.2  In 1828, of 22 cases, 2 died ;
in 1829, of 25 cases, 1 died; in 1830, of 14  cases, 4 died; in 1831, of 29
  1 Henry D. Chapin, Am. Journ. of Obstetrics and of Diseases of Women and Children,
July, 1883.                                            J
  2 Report on Typhoid Fever, by James Jackson,  M. D. 
TYPHOID FEVER.
969
 ca.ses, 2 died;  in 1832, of 23  cases, 4 died ; in 1S33, of 37 cases. 6 died ;  in
 1834  of 34 cases.  6 died ; and in 1835, of 35 cases, 6 died.   Statistics show
 that the average mortality from typhoid fever in recent years is less than for-
 merly, being about 10 per cent.   This diminution in mortality may be fairly
 attributed to improved  methods  of treatment.  It is, however, evident that
 there  are wide differences in the  intrinsic tendency of the disease  to  a  fatal
 issue  at  diff'erent periods and places—a fact to be  considered in estimating
 the influence of therapeutical measures.
   As  regards age,  Murchison's statistics show the lowest rate of mortality to
 be in  cases between ten and  fifteen years, and the next lowest between "five
 and ten  years, the number of cases  analyzed at  less than five years being
 insignificant.  The highest rate at less than fifty-five years is between thirty
 and thirty-five years.  Jackson's  statistics show the death-rate to be greater
 above than  below  thirty years of age, and they show a greater mortality  in
 the cold than  in  the  warm  months.  It is a matter of common observation
 that vigorous persons  are more likely to succumb than those of  feeble consti-
 tution.
   A fatal result in a considerable proportion of cases is attributable to com-
 plications or accidents,  such  as  pneumonitis, peritonitis, and hemorrhage.
 Pre-existing disease may lead to a fatal result, as, for example, chronic dis-
 ease of the kidneys.   Unusual severity of the abdominal lesions is sometimes
 the cause of death.  In the great  majority of fatal cases the mode of dying is
 by asthenia.  Apnoea  is combined with asthenia in the cases in which sudden
 coma  precedes death.
   Coma and convulsions, probably uraemic in most cases, render the prognosis
 extremely unfavorable.  Other marked ataxic symptoms, such as carphologia,
 subsultus, etc., are ominous.    Cases characterized by active  persistent delir-
 ium usually end fatally.   The prognosis is unfavorable whenever  the pulse
 becomes  extremely frequent and  feeble and the first sound of the heart  is
 notably weakened.   The  immediate cause  of  death in these, as  in all cases
 in which  the mode of dying is by  slow asthenia, is the giving way of the
 power of the heart's  action.   Great prostration is evidence of much  danger.
 The chances of recovery may be good, notwithstanding the occurrence of
 pneumonitis limited to one lobe.   Intestinal hemorrhage is less  serious than
 has been supposed by some; recovery taking place in the majority of the cases
 in which this event occurs.  Death may be caused by gangrene or bed-sores
 in  parts exposed to continued pressure from the  weight of the body.  An
 increase of the axillary temperature above 105° denotes great danger, and a
 temperature of 106° or 107° or upward is a fatal prognostic.   On the other
 hand,  a considerable decrease  of temperature  below the  minimum  of  health
 is ominous.  In general, after the first few days of the disease, the tempera-
 ture having daily increased up to this time, the heat as shown by the ther-
 mometer  varies in the  morning between 102° and 103°, and in the evening
 between 103° and  105°.
   A favorable  prognosis may be entertained so long as ataxic symptoms are
 not marked, the adynamia is  not great, the pulse not very frequent or feeble,
 and there are no  serious complications;  but under these circumstances the
 prognosis should always be guarded, in view of the liability at any period of
 the disease to  serious complications  or accidents.   Let it be borne in mind
that sudden  coma  and perforation of intestine are  not less liable to occur
in mild than in severe cases.  The liability to perforation during  convales-
cence is to be recollected.   On the other hand, recovery may be hoped for in
cases in which the symptoms denote the utmost gravity. 
970
CONTINUED FEVERS.
                           Typhus Fever.

  The fever called typhus, known from the earliest antiquity, has received a
great variety of names.  The name typhus, introduced by Sauvages in 1750.
and now generally adopted by writers of all countries, has the negative merit
of not involving any hypothesis concerning the nature and seat of the dis-
ease.   Derived from rucpoq, denoting stupor, it relates to a feature which is
usually more or less prominent in  this disease.  In  this country, from the
fact that the disease is imported in vessels bringing emigrants from Ireland,
it has been commonly known as ship fever.
  This  fever has many features  in  common with typhoid fever.   The iden-
tity or non-identity of the two affections was once a mooted question.   They
present points of contrast amply sufficient  to show that they are distinct dis-
eases.   In considering typhus it will suffice to present the traits by which it
is distinguished from typhoid fever.

  Anatomical  Characters.—In  typhus the abdominal  lesions  which are
characteristic of typhoid fever are wanting.  The Peyerian and solitary glands
of the small intestine are either unaffected or they are simply more conspicu-
ous than usual, sometimes presenting a number of black points, giving rise to
what  has been called the shaven-beard appearance.  The mesenteric  glands
are not infiltrated as in  typhoid fever, and  are generally healthy.
  The disease has no known special anatomical characters;  that is, there are
no lesions peculiar to  the disease and constantly present.  Morbid appear-
ances in different parts are frequently found after death, but they  are due to
complications or are such as  belong to infectious diseases in general.
  The spleen is usually large, soft, and of a dark, bluish-red color.  In very
rare  instances there is no enlargement of the spleen.  The  heart is often
flabby and softened.  The blood in the heart and large vessels is unnaturally
dark and fluid, and coagula, if they exist at  all, are dark and soft. Hypostatic
congestion of the lungs, bronchitis, lobular pneumonia, and pulmonary <eclema
are very frequent,  Slight extravasation of blood into the arachnoid  cavity
occurs in a small proportion of cases.  Cerebral congestion and effusion of
serum into the ventricles of the brain, the subarachnoid space, and  the arach-
noid cavity  are  not uncommon, but  they are usually unattended  by inflam-
matory exudation.   Meningitis is  a rare  complication.   The same  paren-
chymatous  degenerations which  are  present in typhoid fever may occur in
typhus.  The kidneys are often congested.  They are  sometimes  enlarged,
and may present the appearances of an acute nephritis.  Nephritis is more
common in  tvphus* than in  typhoid fever.   Subserous ecchymoses are com-
mon.    The  granular and hyaline changes in  fibres  of voluntary muscles,
noticed as  occurring in typhoid fever, have also been  observed in typhus.

  Clinical History.—The duration of the access is shorter than in typhoid
fever, and cases  of  an abrupt invasion are not as rare.   Patients in the great
majority of  cases take to the bed on the second or third  day after the first
manifestation of illness.   The symptoms during the  development of the dis-
ease  are essentially the same  as  in typhoid fever, with  this important differ-
ence—namely, the  abdominal symptoms of typhoid fever, diarrhoea, meteor-
ism, iliac tenderness, and gurgling, are wanting.  Pain in the back and limbs
and muscular weakness are more  prominent as prodromata of typhus than
of typhoid fever.
   Countenance and General Aspect.—Capillary congestion of the face, extrem-
ities, and trunk is more marked in typhus than in typhoid fever.  It gives to
the surface, especially of the face, a dusky or dingy hue, so distinctive of 
TYPHUS FEVER.
971
typhus as compared with typhoid fever that even nurses and attendants, after
becoming conversant with the two diseases, learn to discriminate them by the
physiognomy.  The conjunctiva is more frequently and more deeply congested.
A besotted or expressionless countenance is earlier and more strongly marked.
  lfervous System.—The symptoms referable to the nervous  system which
belong to the clinical history of  typhoid  fever occur  in typhus.  Coma-vigil
and typho-mania are observed in a larger proportion of cases of typhus, they
are oftener present in  a marked degree, and  they occur earlier in the career
of the disease.   Other ataxic symptoms, such as subsultus and carphologia,
are of more frequent occurrence. Prostration is generally more  marked and is
earlier manifested.  Persistent active delirium, in my experience, has occurred
oftener in typhoid than in typhus fever.  Contraction of the pupil often accom-
panies delirium or stupor, and is sometimes extremely marked, called by Graves
the pinhole pupil.   I have observed oscillations of the eyeballs  occurring in a
marked degree, the movements  being lateral and notably rapid.  The oscil-
lations occurred whenever the patient was raised.   The cases  ended  fatally.
Coma and convulsions  occurring in typhus as in typhoid fever are  generally
attributable to uraemia.  Hyperesthesia of the surface, even when  the men-
tal perception is notably blunted, is sometimes manifested.
  Digestive, System.—The  tongue, more  frequently  than  in  typhoid fever,
becomes  covered with  a thick brown  or black coating.  It is less frequently
reddened, glazed, and fissured.  It is oftener with difficulty protruded.  Sordes
occur more frequently, earlier,  and in  greater  abundance.   As regards the
abdominal symptoms which  are highly diagnostic of typhoid fever, the  two
diseases present a striking contrast.   Diarrhoea very rarely occurs in typhus,
and if present  it is almost  invariably slight.   The stools have not the ochre
color  of those in typhoid fever.  Tympanites  is much oftener wanting, and
generally when present it is slight in  typhus.  This  statement  applies also to
iliac tenderness.   Intestinal  perforation does not occur in typhus.   Hemor-
rhage from the bowels is  one of  the rarest  of  events, exclusive of cases in
which dysentery is a  complication.
  Parotiditis is liable to  occur, and the remarks  made  with reference to
this complication in typhoid fever are equally applicable to its occurrence in
typhus.
  Skin.—A characteristic eruption occurs in a larger proportion of  cases of
typhus than of typhoid fever.   Murchison states that of 3506 cases received
at the London Fever Hospital, it was not  observed in 403, or a fraction more
than 11 per cent.  Of 05 cases which I have analyzed, it existed in  57.  It is
oftener wanting in children than in adults.  The eruption appears  earlier in
tvphus.   The average  period from the time of taking to the bed to the first
appearance of the eruption is a  little  less than three days.   The eruption in
typhus is much oftener abundant,  frequently being copious  over the extremi-
ties as well as on the trunk, and sometimes appearing on the face.
  Other  distinctive points relating to  the eruption  are as follows:  It  is a
maculated, not a papular,  eruption.  The spots become  of a  dull, dingy or
dark-red  color, and  after the  first two or three days the redness cannot read-
ily be made to disappear by pressure.  In some cases in the latter part of the
disease the spots become truly petechial.   They are smaller than the  papules
of typhoid fever.  They do not come and go like the rose papules of typhoid;
thev all appear  in  the"course of three or  four  days, and remain during the
greater part  or the whole course of the disease, sometimes even continuing
into convalescence.  They are often  apparent after  death.
  The copiousness of the'typhus eruption represents generally a correspond-
ing o-ravity of disease.   Tins statement does not hold good with respect to
the eruption in typhoid fever. 
972
CONTINUED FEVERS.
  In a certain proportion of cases of typhus intermingled with the character-
istic maculae are more or less of the rose papules which are characteristic of
typhoid fever.
  Petechiae are observed in some cases of typhus, as in cases of typhoid fever,
as well as in  various  other  diseases.   As already stated, the  characteristic
typhus-spots sometimes become petechial.   The eruption of typhus is some-
times called  a petechial  eruption.  This  is incorrect.  Petech'nx are spots
caused by minute extravasations of blood; that is, they are ecchymoses, and
these  are  not distinctive  of typhus.   Vibices are occasionally observed in
cases of typhus.  Sudamina  or miliary vesicles occur in  cases of typhus as
well as of typhoid  fever.
  The statements with  respect to  sweating and moisture of the skin in
typhoid are also  applicable to typhus  fever.
  The odor from typhus patients is stated to be characteristic.  I have  met
with persons who  declared that they were able to discriminate cases of typhus
from typhoid fever by  the sense of  smell.  I can bear testimony to an offen-
sive odor emanating from patients affected with either disease, but I have not
been able  to appreciate its value as a diagnostic symptom.
  Erysipelas sometimes occurs in typhus as in typhoid fever.   Bed-sores are
less liable to occur, in consequence of the shorter duration of typhus.   Spon-
taneous gangrene, not  produced by pressure, is an occasional event.   I have
seen a case in which gangrene of both feet took place.  The nose, penis, and
scrotum have been known to slough away.   Ulceration or  sloughing of the
cornea has been  observed.   The affection  known as noma is another serious
complication occurring sometimes, not only in children, but in adults.   These
complications occur in  hospitals among patients who prior to the disease were
suffering from innutrition.
  Respiratory System.—The account of symptoms referable to the respiratory
system in typhoid fever is mainly applicable to typhus.   The significance of
a spasmodic inspiration occurring without any pulmonary complication is the
same in the latter as in the former disease.   Cough from bronchitis is gener-
ally more prominent than  in  typhoid  fever.  Pseudo-pneumonitis—that is,
hypostatic congestion  and oedema—is more frequent,  whereas true  pneu-
monitis appears to be less frequent than in typhoid fever.   Epistaxis occurs
less frequently.  It appears to be established that the expired breath contains
more ammonia than in health.
   Circulation and Temperature.—The average frequency of the pulse in cases
of typhus is greater than in typhoid fever.  The significance of frequency and
other characters of  the pulse, and of weakness or absence of the first sound
of the heart over the apex, as representing the state of the vital forces, is not
less in typhus than  in typhoid fever.
  The temperature of the body, as determined by the thermometer, is more or
less increased, varying between 102° and 107° F. The increase of temperature
corresponds to the intensity of the disease.   A decline of temperature is coin-
cident with the occurrence of convalescence.  The defervescence in some cases
is notably rapid, but in other cases it is gradual.  At the time of convales-
cence the temperature  frequently falls below the standard of health.  As in
typhoid fever and in other essential fevers, a sudden and considerable rise of
temperature  renders probable  some inflammatory complication ; and on the
other hand a sudden  fall of  temperature below the  average range in health
denotes a serious change for the worse.  As a rule, the increase of temper-
ature daily is progressive from the beginning  of the disease to about the
fifth day,  and the daily oscillations of the morning and evening temperature
are not observed  prior to this period.  An  analysis  by Dr. Maclagan of 58
cases ending in recovery gave,  as the average temperature in the morning,  a 
TYPHUS FEVER.
973
fraction over 102°, and in the evening a fraction over 103° F.  The highest
point reached in any of these cases was a fraction over 105°.   In typhus, as
in other fevers, a fall of  temperature not infrequently denotes approaching
convalescence, prior to any appreciable improvement in the pulse and other
symptoms.
   Urine.—The urea  and uric acid  are generally increased, as in cases  of
typhoid fever.   According to Murchison, the chlorides are greatly diminished
or disappear entirelv.
   Albuminuria  is of more frequent  occurrence in typhus  than in  typhoid
fever.   Murchison found  it in 20 out of 28 cases, or a fraction more than 71
per cent.  In about one-half of the cases the amount of albumen was consid-
erable.  In most of the latter cases there was no evidence of pre-existing renal
disease.  In typhus as in typhoid fever the  early appearance of albumen in
the urine, its abundance, and its duration, denote gravity of disease.  Epithe-
lial and blood-casts are sometimes observed.
   The duration of typhus is less than that of typhoid fever.   Of 53 uncom-
plicated cases ending in recovery analyzed by Murchison, the duration varied
between eight and twenty days, the mean duration  being a fraction more than
fourteen days.  The mean duration in 10 fatal cases was fifteen days.  Of 45
cases ending in recovery which  I have analyzed, the maximum duration was
twenty-six and the minimum nine days, the mean  being fourteen days.  The
mean duration in 9 fatal  cases was ten days.   In  my cases the beginning of
the disease was reckoned  from the time of  taking to the bed.
   Relapses of typhus are extremely rare.   Examples  of this fever  having
been experienced more than once are  also very infrequent.  There are no spe-
cial sequels,, and  in the great majority of cases the health  is excellent after
recovery.   Temporary loss of the hair is a common  consequence  of  both
typhoid and typhus fever. Mental imbecility sometimes remains for a certain
period after the general condition of the body denotes recovery.
   Typhus  fever is sometimes associated with  dysentery.  Typhus and variola
have been  known  to be combined.  Probably typhus and typhoid fever  may
coexist.

   Causation.—The contagiousness of typhus is shown by the occurrence of
successive  cases in particular houses  and neighborhoods, by the number who
are attacked of persons brought into  contact with  typhus patients, especially
in hospitals, either as physicians, attendants, or fellow-patients, and by  the
importation of the disease in  localities where it did not previously exist.
Referring the reader to works on fever for the further evidence of the con-
tagiousness of typhus, I  shall subjoin  some illustrative facts falling within
my own  knowledge:
   In 1850, 1851, and 1852,1 was engaged in  the clinical study of typhus and
typhoid fever in the Buffalo Hospital of the  Sisters of Charity.  I recorded
during these years  65 cases of typhus.  Twelve Sisters of Charity were
assigned to this hospital during the period just named.  Of  these twelve sis-
ters, five contracted typhus fever.  These five sisters alone had charge of the
fever patients ; and the remaining seven sisters, performing other duties, were
not brought into  contact with the fever patients.  Thus, every sister who
nursed fever cases had an attack of  the disease.  During the last of these
years eleven patients, admitted  for  other  affections, contracted the disease,
the number of cases of typhus received during this year being  considerably
larger than during the preceding two  years.
   Typhus fever began to  prevail in certain parts of the city of New York as
an epidemic in 1861, the  disease having been imported from Ireland.   From
Jan. 1, 1861, to Nov. 1, 1864, 1428 cases were admitted into Bellevue Hospi- 
974
CONTINUED FEVERS.
tal, more than 500 cases having been received during the six months preceding
Nov.  1, 1864.   Of 22 members of the house  staff during the time above
stated, 15 contracted the fever.   Of persons employed in the hospitals  as
orderlies, watchers, etc., 16 were  attacked with  fever.  From June, 1803, to
June, 1864,  26 patients, admitted into the hospital for various affections, con-
tracted the fever.  In May, 1864, the fever patients were transferred to tents,
and no new  cases were received.  There was subsequently no development of
the disease in the hospital.
  The infectious poison  emanating from  typhus patients rarely  communi-
cates  the disease except to those who are in immediate proximity to patients.
Concentration  of the poison is  generally necessary.  Hence, the  disease is
likely to be  contracted by those who render personal attentions to patients,
and especially  by those  who are exposed  to the  atmosphere of  ill-venti-
lated  fever-wards containing a large number of cases.  A single  patient in
a spacious, well-ventilated apartment seldom communicates the disease.  All
persons at all times, moreover, are not  equally  susceptible, and hence some
contract the disease after  comparatively slight exposure, while  others  who
are much exposed  escape.   There is ng proof that the disease  is diffused
from  one house to another or from hospitals to adjoining  houses, except by
intercommunication.  Facts show that the disease may be  communicated by
fomites, but a  considerable impregnation of  articles of clothing, etc. is neces-
sary.   Exposure of infected clothing  to a  dry heat of  200° F. probably
destroys the miasm.   Some  facts appear to show that  the  disease may be
contracted by  dissecting bodies dead with typhus, but this is not certain.
The period of  the disease in  which  it is most likely to be communicated is
after  the  first week.   Facts appear to  show that  it  may be communicated
during  convalescence.
  The fact  that in the emanations from the bodies of patients  a  contagium
exists capable  of producing the disease  is distinctive  of typhus as contrasted
with typhoid fever.  There is no reason  for supposing that the infecting capa-
bility of the typhus germs depends on  any changes taking place  after they
are thrown off from the body.
  There is  considerable variation in the  estimation by different observers
of the  period  of incubation.  Probably this period  varies  considerably  in
different cases.  Murchison  has determined the average period to be about
tw*elve  days.   Exceptionally it is longer than this, but it rarely if  ever
exceeds  three  weeks.   On  the other  hand, in many cases it is  less than
twelve  days, and occasionally the symptoms begin  almost at the instant of
exposure.1   Persons have sometimes had an impression  that  they received
the poison at  a particular moment when they  were  conscious of a peculiar
sickening odor inhaled from the body of a typhus  patient.   Little or no
reliance  is to  be placed  on this impression  as evidence  of the reception of
the infection.   Probably physicians  have very many times experienced this
sickening odor without having had typhus.  Such  has been repeatedly my
experience.
  As a rule, in this country typhus fever is an imported disease and is diffused
exclusively  by contagion.  It is, however, difficult to trace all outbreaks of
the disease  to  contagion, and hence  the opinion is  held  by some  that the
special cause is sometimes produced outside of the body.   The disease some-
times appears to be developed as a consequence of overcrowding and deficient
ventilation; in  other words, the concentrated emanations from the bodies of
healthy persons apparently suffice for the generation of typhus germs.2 Out-
breaks in jails, hospitals, workhouses, ships, and unventilated tenement-houses
             1 A'ide St. Thomas's Hospital Reports, vol. ii.
             2 For facts bearing on this point, vide Murchison, op. cit. 
TYPHUS FEVER.
975
crammed with occupants are thus accounted for in some instances irrespective
of contagion.
  In  1841,  I reported  four  cases of typhus  developed  in  the Erie  county
almshouse.  They occurred during the winter months.   The wards  in this
institution were quite small  and crowded, and for the sake of warmth fire-
places, which had previously been used, had been bricked up and close stoves
substituted.  There was  an abundant eruption in all these cases, and an exam-
ination  after death in the only case  which proved  fatal showed  the absence
of the typhoid lesions.   In these cases overcrowding and w*ant of ventilation
seemed  to be important  elements in causation.1  No cases of typhus occurred
out of the almshouse, and the disease was not imported.
  Overcrowding, deficient ventilation, especially if conjoined with innutri-
tion,  are  powerful auxiliary  causes acting in  conjunction with  contagion.
The causative  influence of destitution and  starvation is  strikingly shown  by
the prevalence of typhus in Ireland in periods  of famine, and by the large
proportion of cases among those received in hospitals in which the depriva-
tions  and hardships of  poverty had been  experienced  prior to the attack
of fever.
  Typhus attacks  the two sexes in  about an  equal proportion.  Persons are
more  liable to be attacked during adult age, but children  are not exempt, and
this fever does not,  like  typhoid, spare those who  are  beyond the  middle
period  of life.  It is more hkely to  prevail in the winter and  spring  months
than  in autumn, in this respect  differing from typhoid fever.

   Diagnosis.—The remarks on the discrimination  of  typhoid  fever  from
remittent fever and several local affections will apply to typhus fever. (ATide
p. 966.)  The discrimination of typhoid and typhus fever  is to be here noticed.
The following are the more important points in this differential diagnosis: The
relatively long duration of the forming stage in typhoid, and its short duration
in typhus;  the prominence of pain in the loins and limbs and muscular pros-
tration  at an early stage of typhus; absence,  in typhus,  of the characteristic
abdominal  symptoms of typhoid—namely, diarrhoea, meteorism, iliac  tender-
ness, and gurgling—or their presence in  comparatively a slight degree; the
dusky or dingy hue of the surface in typhus; the appearance of the eruption
earlier  in  typhus,  and  the different characters of the eruption—namely, in
typhoid, papular, rose-colored, the redness disappearing on pressure; in typhus,
after two or three days, if not at first, maculated,  the color dark red,  and the
redness not disappearing on pressure.  Other distinctive points relate to the
eruption—namely, the  sparseness in typhoid  and the copiousness  in typhus;
the frequent.extension  in the latter  of the eruption over the extremities; the
persistence of the spots in typhus, and the disappearance of papules with the
production of fresh papules  in typhoid.  It is to be borne in mind  that  in
some cases of typhus  rose papules are  intermingled with the characteristic
maculae.    In  typhoid  fever  the temperature  reaches  its acme  at  a later
period  than in typhus.  The rise of temperature is more  gradual and reg-
ular in typhoid than in typhus.   In typhus the average duration of the fever
is shorter than in typhoid, and  the defervescence is more rapid.
   Corroborative diagnostic points are—the occurrence of peritonitis and hem-
orrhage from the bowels in some cases of tvphoid, and the earlier occurrence
of  delirium, coma-vigil, and other ataxic symptoms in typhus.
   If the eruption be present, typhus is generally recognized without difficulty.
The eruption is not always present,  and the diagnosis may then involve delay
and difficulty.   The prevalence of typhus and  exposure to  contagion are to
be taken  into account in doubtful cases.
                1 Vide Boston Med. and Surg. Journal, June, 1841. 
976
CONTINUED FEVERS.
   Prognosis.—Of 18,592  cases aggregated by Murchison, occurring at the
London Fever Hospital in fourteen years, at  King's College Hospital, the
Edinburgh Infirmary, and at  Glasgow, Scotland, the mortality was 18.78 per
cent., or 1 in 5.27.   This rate of mortality differs only by a small  fraction
from the rate in about the same  number of cases of typhoid fever analyzed
by Murchison.   The death-rate is found to vary at diff'erent times and places
between 9 and  25 per cent., the variations being due to differences as regards
an intrinsic tendency of the disease to a fatal result.  In epidemics of typhus,
as of other diseases, it has  been  often observed  that the fatality is greatest
at first and decreases as the number of cases diminish.   The ratio of fatality
is greater among males than females.  The fatality is less  in early life  than
subsequently.  It is greater at less than ten years of age than between ten
and twenty years.  After thirty years  of age  the fatality progressively in-
creases, and  after fifty years the proportion  of deaths is  nearly one-half.
   Of the  63 cases which  I have analyzed, 12 were fatal; that is, 1 in a  frac-
tion more than 5, or a fraction more than 18 per cent.
   A fatal  result is oftener due to the intensity of the fever—that is, occurring
irrespective of  complications—in  typhus than in  typhoid  fever.  Peritonitis,
which destroys a certain proportion of patients with typhoid  fever, does not
occur in typhus.  This is true also with  respect to intestinal hemorrhage.
Pneumonitis  is less  frequent in typhus, and there are no complications pecu-
liar to the latter.  Acute diffuse nephritis attended by uraemic symptoms is
more liable to occur in typhus than in typhoid fever.  A fatal result appears
to be oftener attributable to  feebleness of constitution, or to causes which
impair the power of resisting the disease, in  typhus than in  typhoid fever.
Of 38 cases which occurred among the members of the resident medical staff
and persons  employed in Bellevue  Hospital, 17 ended fatally, whereas of
1428  patients admitted with fever during the same period, the number of
deaths was 243, or  1  in 5.87.  This difference in the mortality in the  two
classes of  cases is the more  remarkable because the resident  physicians and
persons  employed in the  hospital were  treated  for the  disease under more
favorable  circumstances than the hospital patients.   It is difficult to account
for the greater fatality among the former class, except by supposing that liv-
ing in the hospital involved  exposure to nosocomial depressing  influences
which rendered  the system less  able  to resist the disease.
  In general, the symptoms pointing on the one hand to a favorable, and on
the other hand to an unfavorable, prognosis are the same in both typhoid and
typhus fever.
                      CHAPTER   III.

                 CONTINUED  FE\rERS  (Continued).

Treatment of Typhus and Typhoid Fevers.—Relapsing Fever; Anatomical Characters;
   Clinical History;  Causation;  Diagnosis;  Prognosis; Treatment.—Erysipelatous
   Fever.—Epidemic Fever characterized by Mild Erythematic Pharyngitis.

   THE  general  principles  of treatment in typhoid and typhus fever are
    essentially similar, and indeed  are  applicable to all the fevers.  It will
suffice  to notice  incidentally  indications pertaining  exclusively  either  to 
         TREATMENT OF TYPHUS AND TYPHOID FEVERS.     977

 typhus or typhoid fever,  without considering the treatment  of  each fever
 separately.
   It must be admitted that the known resources of therapeutics do not afford
 reliable means for the arrest of these fevers, nor even for shortening the dura-
 tion of the febrile career.   Quinia, so potential  in  arresting malarial  fevers,
 has no abortive potency in the continued fevers.  Calomel  in  doses of from
 ten to fifteen  grains repeated daily for several days has been recommended by
 Wunderlich, Liebermeister, and other German writers as shortening the course
 of typhoid  fever, diminishing  the mortality, and sometimes causing the dis-
 ease to abort.  Iodine or the iodide of potassium and carbolic acid have been
 thought to have a special influence over this fever. Liebermeister states that
 the iodide of potassium in  doses of a scruple to a drachm daily, given in more
 than two hundred cases, while it produced no appreciable effect upon any of
 the febrile phenomena,  apparently diminished the rate of mortality. That the
 mineral  acids—namely, the dilute phosphoric, hydrochloric, nitric, and nitro-
 hydrochloric—have a favorable modifying influence upon the disease there is
 abundant testimony.  In 1863 and 1864,1 instituted a comparison in the male
 fever-wards at Bellevue Flospital of  the rate of mortality during six  months
 without, and the same period with, the use of dilute sulphuric acid, eliminat-
 ing all cases in  which death took place within forty-eight hours after-admis-
 sion.   Of 70 cases treated from January 1 to July 1, 1863, without acid, the
 death-rate was 20 per cent.; of 78 cases treated with acid from July 1, 1863,
 to January  1, 1864, the death-rate was 10.25 per cent.  The treatment in the
 two collections  of cases was  the  same, exclusive of the acid.1  My observa-
 tions do not enable me to state which one of the mineral acids is  to  be pre-
 ferred.  They are generally relished  by fever patients if sufficiently diluted,
 with the addition of  syrup of orange-peel or simple syrup, and they may be
 given, not as a  medicine, but as a drink.   The death-rate, however, in the
 cases  treated with  the acid was not  below that in  307 cases treated  by Dr.
 Cotting of Boston  without drugs of  any kind.  The rate in these cases was
 10 per cent.
   Of  all  therapeutic measures, those directed toward the reduction of the
 fever take the first rank.   The modus operandi of antipyretic measures is not
 thoroughly understood, but there is  no  doubt that their efficacy consists in
 something more  than the mere reduction of the temperature, and that indi-
 cations for their  employment are to be sought not only in the height of the
 temperature, but especially in symptoms denoting severity of infection, such
 as stupor and other ataxic disturbances.
   Beduction  of  the  intensity  of the fever may be accomplished  either by
 the application of cold or by the administration of antipyretic drugs.   Currie
 a century ago pointed out the efficacy  in fever of water employed as a cold
 affusion.  The modern  revival of the use  of cold water for an antipyretic
 effect  in typhoid fever is attributable to a publication  by E. Brand in 1861.
 Bartels, Jiirgensen, and  Liebermeister are to be named  as  especially  promi-
 nent in bringing to the test of clinical  experience antipyretic measures of
 treatment,  There  is  no doubt that a remarkable reduction  in  the death-rate
 of typhoid fever has been brought about by systematic antipyretic treatment.
   The methods  of refrigeration  by cold water  now* in vogue  are the bath,
 sponging  the  body,  and  the wTet sheet with sprinkling.   The bath  is the
 method chiefly employed by German  physicians.  The following method of
 administering the bath may be recommended : The bath-tub should be drawn
 up beside the bed.   The patient should be lifted and  placed in the bath by
attendants without any  exertion on  his part and  with  as little disturbance
  1 Aide report by Dr. Irving AV. Lyon, then one of the house-physicians of Bellevue
Hospital, in American Medical Times, Feb., 1864.
       62 
978
CONTINUED  FEVERS.
as possible.   The temperature of the bath should be from 75° to 80° F., and
the patient should be removed after ten minutes from the bath and dried.  It
is not necessary to use baths at a temperature much if any below 75°, but it
may be advantageous to immerse the  patient in water of a temperature of
about 90°, and then gradually cool the water down to about 75°.   It is im-
portant to know  that the rectal temperature  sinks for half an hour after
removal from the bath.   If the  patient feels very cold after the bath and
there are  any symptoms of collapse, heat should be applied and stimulants
administered.   Generally  in  from two to three hours" the  temperature has
risen, sometimes to its former height.  It is  generally sufficient to administer
three to five baths during the day, and it  is rarely desirable to give  them
at night.  It is usually stated that a temperature of 103° or upward is an
indication for the bath, but, as has already been mentioned, other symptoms
than the  temperature  are also to be considered.   AVhen  it is apparent that
notwithstanding the temperature named the patient's  general  condition is
good and is  not suffering from the pyrexia, there is no necessity of the bath;
on  the other hand, when  there are  stupor and other symptoms to  indicate
that the system is being overpowered by the severity of the infection, then it
may be desirable to employ the bath even at  a temperature lower than 103°.
Contraindications  to the use of the bath are intestinal  hemorrhage,  perfora-
tion of the  bowel, and great  weakness of the heart's action.
   Although the bath  is the most  effectual  mode of reducing the tempera-
ture, the  method  is open to objections on the  score of inconvenience, espe-
cially in private practice,  and of the excitement of the patient which it is
apt to occasion.  Considerable judgment  is  required in its  employment to
avoid unpleasant  depressing  influences.  For these reasons  other measures
are more  commonly employed in this country.  Sponging  is the simplest
method, involving the  least inconvenience  to the patient  and others.   It
should be first employed, and in a large proportion of cases it will  suffice.
Sponging  either the whole body at once or diff'erent parts in succession with
water at a temperature not uncomfortable to the  patient for as long a period
as it is unattended by discomfort, repeating the measure as often as indicated
by a rise of  temperature, will generally prove successful.   If not  conducted
by a skilled  nurse, it  is difficult often  to have  this method properly carried
out—in part, because persons cannot appreciate that so simple a measure can
have much potency, and partly from the popular fallacy that there is danger
of " taking  cold."  The sponging should  be resorted  to  when  the  axillary
temperature is 103° and that of the rectum 102J°.  It should be continued
until the temperature in the rectum falls to 100° or 101°, and repeated when-
ever it  again rises.   A little wine or spirits should be  given if the patient
manifest chilliness.
  If this  method  prove ineffective,  the wet sheet and sprinkling may be em-
ployed.   The patient  is placed  on a cot, wrapped in a wet sheet  without any
other covering, and the body sprinkled with cold water  at  short intervals.
For  sprinkling a  common watering-pot is suitable.  This may be  continued
for half an hour or even longer, according to the effect on  the  temperature
and other  symptoms.   The thermometer must be introduced into the  rectum.
This method is to be repeated as often as the  temperature rises.   The temper-
ature will be found to fall after the patient has been transferred from the cot
to the  bed.   A cot with arrangements for the drainage of the water is con-
venient.   A sense of chilliness, feebleness of the pulse, and cyanosis contra-
indicate the continuance of the  sprinkling  and are indications for  wine or
spirit.
  AVe  possess a considerable  list of drugs  which  have  antipyretic  effects.
The  most important of these are  quinia,  salicylic  acid,  kairin, resorcin, 
         TREATMENT  OF TYPHUS AND TYPHOID  FEVERS.     979

hydrochinon, antipyrine, and  thallin.  Of antipyretic drugs,  quinia, admin-
istered in closes of 20 to 40  grains  before the  evening  exacerbation, until
recently held the first rank.   Antipyrine, however, is at  present  the  favor-
ite  drug for reducing temperature.   This  remedy  has  many advantages,
and  is attended with but few  secondary  disagreeable effects.  The taste  is
slightly bitter, but not particularly unpleasant,  It is readily soluble in water,
and  may be administered either in powder or in solution.  The  method  of
administration recommended by Filehne, who introduced the drug  into medi-
cine, is to give at first 30 grains, followed in an hour by another 30 grains,
and  at the end of another hour by 15 grains.  Striking reduction of temper-
ature is obtained by the administration of smaller doses, which are less likely
to be attended with any unpleasant effects. The fa]l in temperature is consid-
erable  and rapid.   The heart's action is usually  at the same  time increased
in force and decreased in frequency,  and  the mental state of the patient  is
improved.   In a few instances symptoms  of collapse or of notable prostration
have followed the  administration of  antipyrine.  The unpleasant secondary
effects which have been noted in some cases are vomiting, profuse perspira-
tion, and  an erythematous  eruption.  Should the drug  excite vomiting,  it
may be given  hypodermically or  preferably by  the  rectum.   The  eruption
often  resembles somewhat that of measles.  It disappears, as  a rule, soon
after the  cessation  of the drug.  The other antipyretic drugs which have
been mentioned are less commonly used, and are accompanied  by more or less
disagreeable secondary effects.
   Good results  have been obtained  by the use of veratrum viride, digitalis,
salicin, and salicylate of sodium, but these drugs are to be given  circum-
spectly and are not very commonly employed.
   A'aluable as are the antipyretic remedies in typhoid fever, there is no proof
that they exert any specific effect upon the special poison of the disease or that
they shorten the duration of tbe disease.  The injurious effects of pyrexia per
se have undoubtedly been much exaggerated.  Some late writers  have even
revived the old notion that a certain  amount of  increase of heat in the infec-
tious  diseases has a useful purpose.  Probably too  much  weight has been
assigned to the mere abstraction of excessive heat in the treatment of fevers.
The beneficial  effects of antipyretic  treatment  are manifested even more  in
the  removal of other symptoms, such as somnolence, delirium, dryness of the
tongue, weakened  heart's action,  and adynamia ; and when  such symptoms
are "not present it is not necessary to resort to vigorous  measures to reduce
temperature.
   Indications for treatment relate to  particular symptoms or events and com-
plications embraced in the clinical history of these fevers.
   In  the early part of the disease  cephalalgia claims palliative measures.
This symptom is relieved by ice-water, spirit and water,  distilled vinegar, or
cologne-water freely applied to the head, and if more efficient measures  be
required the cold douche or ice-cap may be employed.  As soon as the exist-
ence of either typhus or typhoid fever is declared the hair  should be closely
cut.  This renders the patient more comfortable and facilitates local applica-
tions.
   Insomnia is a symptom calling for treatment.   To procure sleep is desir-
able, not only for immediate comfort,  but  as a means of averting ataxic symp-
toms.   An  opiate often proves beneficial.  It may procure  refreshing sleep
in place of pseudo-somnolence or coma-vigil.   The latter condition, not denot-
ing  a  tendency to true coma, does not contraindicate the trial of opium.  Other
remedies which may be prescribed are hyoscyamus and the bromide of potas-
sium,  either separately or in combination.
   Delirum, if slight  or moderate, does not call for remedies ;  but if prominent 
980
CONTINUED  FEVERS.
as a symptom, as shown by constant talking and attempts to get out of bed,
it leads to other ataxic symptoms and to exhaustion.  Opium  in  some form,
and other anodynes, are indicated.  If these fail, the combination of antimony
in small doses with opium, as recommended  by Graves, will often prove effi-
cacious.   An eighth or a sixteenth of a grain of the tartrate of antimony and
potassa may be given  hourly or half-hourly  until the  patient becomes quiet,
unless nausea or vomiting occur, when it is  to be at once suspended.  The
remedies given for insomnia in addition to opium are appropriate.  The tinc-
ture of digitalis in half-drachm doses sometimes has a happy sedative effect
upon  the nervous system.   The wet pack—that  is, the  body wrapped in  a
wet sheet and covered with a blanket—is a soothing measure which may often
be resorted to with advantage.  It is also an  antipyretic measure, although
less  effective than continued sponging or  the wet  sheet with  sprinkling.
Insomnia, delirium, and other  symptoms denoting disorder of the nervous
system are less marked in proportion as the antipyretic treatment is effective.
This  statement is probably applicable in general to the complications and
serious events liable to occur during the course of  the disease, including per-
haps perforation of the intestine and intestinal hemorrhage.
   Nausea and vomiting seldom occur spontaneously in either typhoid or typhus
fever to an extent to call for anything more than  regulation of the ingesta.
Diarrhoea in typhoid fever may  require to be restrained, and for this end opi-
ates and  astringents, given by the mouth or rectum, may be employed. Mere
looseness of the evacuations without undue frequency does not call for treat-
ment.  On the other  hand, in typhus and sometimes in typhoid fever con-
stipation may furnish  an indication for treatment.   As a  rule, cathartics, or
even  laxative remedies, are not required for constipation.   Simple enemata
suffice and are to be preferred.  Evacuations may be delayed for two or three
days,  or even longer, without injury if there be no evidence of discomfort and
if the abdomen be not distended.  Tympanites, if  great or considerable, occa-
sions  discomfort and embarrasses respiration  by interference with the descent
of the diaphragm. Large enemata may suffice  to relieve this symptom.  Tur-
pentine should enter into the enemata.  If these fail a saline laxative  may be
given.  A stomach-tube introduced into the  rectum and  carried as far as
practicable sometimes occasions the  discharge of gas in considerable quantity.
Turpentine given by the mouth  is supposed to relieve this  symptom.   Tur-
pentine stupes to the abdomen are useful.  Charcoal given freely is sometimes
effective.  Mechanical compression by means  of a band applied over the abdo-
men sometimes affords relief.
   Two important events connected with  the abdominal lesions are liable to
occur in cases of typhoid fever—namely,  perforation of the intestine followed
by peritonitis, and intestinal hemorrhage.  The probability of  the successful
treatment of the former is almost  nil.   The  small  chance of success to be
hoped for depends on the free use of  opium  and measures to support the
powers of life.   Local depletion and  blisters are not admissible.   Peritonitis
not dependent on perforation  claims the same treatment and is not so hope-
less.   Intestinal hemorrhage if profuse involves danger.   This event calls for
haemostatic  remedies.   The  peristaltic  movements should be  arrested by
opium.  Ergotin  may be given hypodermically.  The acetate of lead, given
by the mouth, is preferable to tannic- acid or the astringent preparations of
iron, as less likely to occasion vomiting.  Cold  applications should be made to
the abdomen.  Absolute quietude is to be enforced.
   Cough, although generally existing, is seldom  sufficiently troublesome to
require palliation.  Pneumonia should not be treated with local or general
depletion, blisters, or  mercury, or with nauseant sedatives.   This, as  well as
other serious complications, contraindicates depressing measures.   The  posi- 
         TREATMENT OF TYPHUS AND TYPHOID FEVERS.     981

tion of the patient should be occasionally changed to prevent hypostatic con-
gestion of the lungs.   Epistaxis is sometimes so profuse or persisting as to
indicate local astringent remedies,  and sometimes even plugging of the ante-
rior and posterior nares.
  Coma is to be treated by sinapisms or blisters to the back of the neck, and
if dependent on uraemia by saline hydragogues if they be not contraindicated
by the  abdominal symptoms.  If contraindicated reliance must be had on
measures to produce copious perspiration.  For  the latter object the pilocar-
pine, administered hypodermically, may prove efficient.  Strong coffee is  use-
ful as a palliative of undue somnolency or semi-coma apparently due to nerv-
ous exhaustion.
  It is  important to prevent accumulation of urine  from retention, and to
resort to the  timely  use  of the  catheter if required.
  Bed-sores are  to be guarded against  by having the position of the patient
often changed and  by attention to cleanliness.   If they occur, the ulcerated
parts are to be relieved from pressure by air-cushions  and treated with  appro-
priate local applications.
  Hygienic and supporting measures constitute  a most important part of the
treatment of typhoid and typhus  fever.   Hygienic measures indicated are—
complete ventilation, cleanliness, regulation of temperature (which should be
about 60°  F.), changing frequently  the position of the body, and  the  varied
attentions involved in gq,od nursing.
  Foremost among the hygienic conditions for passing safely through the dis-
ease is an abundance of pure air.  In  private practice the  sick-room should
be large and ventilated as completely as possible.   In hospitals, fever-wards,
in addition to ample provisions for ventilation, should not  be crowded; 1500
cubic feet of  air should  be  allowed to  each bed.  The evacuations should
invariably be instantly removed.   AVhen practicable it is advisable that the
bed- and body-linen should be changed daily.
  The importance of fresh air is shown by the reduced rate of mortality when
patients are treated in sheds and  tents, as compared with  the death-rate in
even well-ventilated hospital wards.   Striking  evidence of this was afforded
by the transfer  of  fever  cases (chiefly typhus) from Bellevue Hospital to
tents on Blackwell's Island.  A  comparison of the  mortality in  520 cases
treated in tents from May 17 to November 1, 1864, with the average mortal-
ity in the Bellevue Hospital wards, shows a marked difference.   The average
death-rate  in  the  hospital wards  was 1  in  5.07 ; in the tents, 1  in  16.77,
excluding the cases in which death  took place within forty-eight hours after
admission.   Making the fullest allowance for the conjecture that the cases in
the tents were  milder than those in  the hospital wards, it  can  hardly be
doubted  that  the superior ventilation  in the tents was the means of saving
many lives.
  In a paper communicated to the New York Academy of Medicine in June,
1853, by Dr. John  IT. Griscom, an account is given  of 82 cases  of  typhus
transferred from an emigrant ship at Perth Aniboy, N. J., to wooden shanties
with sail "roofs."   The ship brought over between three and four hundred
passengers, and a number had died on the  passage.  There being no hospital
or other accommodations in the  town,  two shanties  were erected, "thirty
feet long and twenty feet wide, boarded on three sides about four feet up, and
over them old sails were  stretched."  82 fever  patients were transferred to
these shanties, of whom 12 were  in a state of insensibility when removed.
On  the night after  their removal there was a violent thunder-gust accom-
panied by torrents of rain, and the following morning the clothes of all were
saturated with water.  The medical treatment consisted " of an  occasional
laxative or enema;  vegetable acids and bitters were  liberally administered, 
982
CONTINUED FEVERS.
 together  with the free use of cold water, buttermilk, and  animal broths."
 4 sailors  who sickened after the  arrival of  the vessel were removed to an
 ordinary dwelling-house, and of these cases 2 proved  fatal.   Of the 82 cases
 treated in the shanties, not one proved fatal.1
   Fever patients should not only be allowed  to take water as freely as they
 may desire, but it should be systematically given when from the  blunted
 state of the  perception they manifest  no desire for it.  There is  reason to
 think that death is sometimes attributable to an insufficient supply of liquid.
 The importance of this should not be overlooked by the physician, inasmuch
 as it is  a popular notion that the free use of water  in fevers is hurtful.  Iced
 water is not  objectionable.  It may be  acidulated with lemon- or orange-juice
 if rendered thereby more agreeable to the patient.
   The  importance of support is based on the plain  fact that, typhus  and
 typhoid fever being self-limited diseases, if  the patient can be kept alive,
 after three, four, or more  weeks recovery will take place, provided there be
 no serious complication.  In a case of severe  uncomplicated fever the patient
 is in a  situation  not unlike  that of a person in danger of drowning  not far
 from or perhaps very near the shore.  If he drown, it is because his strength
 gives way before the shore is reached.  As a person in this situation requires
 only to be buoyed up by some support, so the fever patient in a similar emer-
 gency may  only need  supporting  measures  to live until the  disease ends.
 Death may  take place at a juncture when, could i^ have been averted a few
 days, or perchance even a single day, the period of danger might have passed.
   Supporting measures embrace tonic remedies, alcoholics, and alimentation,
 especially the two latter. Of tonic remedies, the most efficient and convenient
 of administration is quinia, which may be given in doses of two or three grains
 twice or thrice daily.
  Alimentation ranks  first in importance.  It is desirable for the patient to
 take as  much nutritious food as will be digested and assimilated.  Innutrition
 in cases of fever, as  in other affections,  enhances and adds to the morbid phe-
 nomena belonging to the disease.   Graves uttered an important truth in say-
 ing that a great object of  treatment is to prevent patients from dying from
 starvation.   In the early part of the disease there  is generally a repugnance
 to food, and  afterward, owing to the mental  state  and the condition of the
 mouth,  taste  and appetite are wanting.   Under the  latter circumstances  food
 is to be given, although not desired by the patient, and even when there  is a
 disinclination to take it.   The indifference to food  may proceed, measurably,
 from an unwillingness to be disturbed and a reluctance to make any exertion.
  The supporting diet should be in a liquid  form, embracing the  neeessary
 variety  of alimentary principles.   The animal broths, eggs, and milk, with the
 addition of some farinaceous preparation of  food,  fulfil these requirements.
 Different articles should be given in alternation and at regular intervals.  The
 intervals should be  between two and four hours  long.  It is injudicious to
 give food every half hour or hour, or after even  shorter  intervals, as is not
 infrequently  done.  The amount of food given at a time must vary according
 to circumstances, the object being to give as much as can be taken without risk
 of either vomiting, discomfort from  over-accumulation  in the stomach, or indi-
 gestion.  If  the patient be  in a condition to feel  and express  a choice for
 particular kinds of food, the preference should as  far  as practicable  be con-
 sulted.  The physician should have an oversight of the preparation of food,
lest  through  ignorance  or carelessness it be unpalatable,  innutritious,  or
improperly served.   Precise directions  and attention to the details-of dietet-
ics form an important part of the physician's  duty, not only in fevers, but in
all cases of disease in which supporting treatment  is indicated.  Of the  dif-
      1 Transactions of the New York Academy of Medicine, 1853, vol. i. part ii. 
         TREATMENT OF TYPHUS AND TYPHOID FEVERS.     983

ferent articles of food just named, milk is by far the most  valuable as enter-
ing into the fever diet,  It is taken, if not with relish, at least with less reluc-
tance than  other articles, and it has the great advantage of embracing in
proper combination all the alimentary principles required for nutrition.  The
" beef-tea,"  as it is often prepared, is little more than warm water flavored with
the meat.  The  different so-called meat extracts contain little or no nutriment.
It has been considered, indeed, that they are injurious from  the amount of
excrementitious principles entering into their composition.   Prepared in any
mode and  as carefully as possible, the essence of meat and broths are vastly
inferior in nutritive value to milk.  They should, therefore, never he relied
upon to the exclusion of  the latter.   If the same article of animal diet—for
example, beef-broth—be given day after day, the patient acquires for it after
a time an intolerable disgust,  The form should therefore be  varied, beef-, mut-
ton-, and chicken-broth  being given in alternation.  They may be rendered
more nutritious by the addition  of barley or some other farinaceous  article,
and by adding the  yolk or albumen of eggs.   It is desirable that  from one
to two quarts of milk per diem should be ingested;  but since the value of a
milk diet  in fevers has come to  be appreciated  its use has  frequently been
pushed to an injurious excess.  I have met with instances  in which an abun-
dance of hard curds was passed  from the bowels after much abdominal dis-
tress  and general disturbance.   Coffee or tea,  if acceptable to  patients, is
allowable.   It may  be made nutritious by a large addition  of milk.
   Alcoholics have entered largely into the treatment of fevers in this country
during the last thirty years.   That they have been used too freely and indis-
criminately  can hardly be doubted.   As a natural consequence, there is per-
haps at the  present  moment a tendency to undervalue  their  importance.  It
does not follow that they are never useful because in mild cases or in those
treated  under most favorable hygienic conditions  the  rate  of mortality is
small although  they were not used.   Observation of their  immediate effects
in certain cases shows their utility, often in a very striking manner.   Indis-
criminately  and excessively used, they  are not useful; but  used with proper
application  and moderation, they form an essential part  of the supporting
treatment of  fevers,  as  well as  of  all other diseases which destroy life  by
asthenia.
   The supporting effect  of  alcoholics  is directed chiefly to  the  circulation.
Hence the indications respecting their use are derived  especially from symp-
toms relating to the heart.   Feebleness of the circulation,  as denoted by the
pulse and the heart-sounds, calls for their  use, and  they are to be  given, as
regards quantity, in proportion to the degree of  feebleness  of the circulation
and  according to their effect.  The characters  of the pulse denoting feeble-
ness of the  heart's  action are smallness and compressibility, frequently com-
bined with considerable or great  frequency.   A  pulse in the  adult exceeding
120 per minute  never denotes strength, and above this number it is  feeble in
proportion  to frequency.  Above 130  the pulse always denotes a degree of
feebleness of the circulation  rendering supporting measures highly important.
The  heart-sounds also constitute a good  criterion for estimating the degree
of feebleness of the heart's action.   In proportion as the action of the heart
is  weakened, the intensity of the first sound over the apex is diminished; it
is  shortened, and in quality it resembles the second  sound.  If the heart be
notably weakened,  the  first sound  may  be inappreciable over the apex.
Stokes was  the  first to direct attention to these changes as  criteria for the
administration of alcoholics.
   Alcoholics are rarely indicated  in the early part of either t}rphus or typhoid
fever.  They  are  oftener and "earlier  indicated in typhus than  in  typhoid
fever.  Brandy or some form of spirit, and  wine, sherry or Madeira, may be 
984
CONTINUED FEVERS.
employed.   Beginning with a moderate quantity, half an  ounce of spirit or
an ounce of wine, the effect on the circulation and other symptoms should be
observed.   A good  effect is shown by increased force, with diminished fre-
quency, of the pulse, perhaps some reduction of  the temperature of the body,
diminution of delirium,  etc.   The intervals should  vary,  according to the
urgency with which this supporting measure is indicated, between six or
eight hours and each successive hour.  The quantity given at a time should
rarely exceed that just stated.  Guided by the true indications and by the
effect, alcoholics will not do harm, and will often do much  good in the treat-
ment of typhus  and typhoid fever.   I have repeatedly tried their suspension
for a few hours in cases in which they appeared to be urgently indicated, in
order to become  fully satisfied of their utility, and have found the pulse  be-
coming  more frequent, with increase of delirium and other ataxic symptoms,
until their use was resumed.   AVhile  a certain proportion of cases do well
without them, and  they  are therefore not always indicated, I cannot doubt
that I have seen not a few cases in which  life  was saved by their  employ-
ment.
   In these fevers, as in some other diseases, the tolerance of alcohol is often
notably greater  than  in  health.  A  patient may take from one to two pints
of spirit per day who in  health could not have taken one-fourth of this quan-
tity without inebriation.  The excitant or toxic effects of alcohol should never
be produced in  cases of  fever.  If these effects be produced, the indications
for alcohol are not  present or  it is  too largely given.  In extreme cases an
ounce or  even more of  spirit, given hourly, may be necessary ;  but in the
majority of the  cases in which alcoholics are indicated not more  than six or
eight ounces in the twenty-four hours are  needed.
   During convalescence alcoholics  should  be given moderately.  If  they
have been used freely during the  career of the  fever, when convalescence
begins their excitant effect may be for the first time apparent.   Frequently
malt liquors or light wines are best suited to convalescence.  Solid food should
be allowed as soon as convalescence  is declared.   The processes of digestion
and  assimilation  are usually active, and the appetite may be voracious.  The
cautions to be observed relate  to the kinds of food and the quantity taken
at one  time.  The  patient should  be restricted to plain, wholesome,  well-
cooked  articles of diet, and excess may be avoided by taking food at shorter
intervals than in health.  Convalescence from typhoid, more than from typhus
fever, requires care as regards diet, in view of the probable existence of intes-
tinal ulcerations. Gestation in  the open air may be allowed early in the stage
of convalescence, and as  soon as their strength will permit patients may walk
out of doors.  Care with respect to  much muscular exertion is important in
convalescence from typhoid fever in consequence of a liability to  intestinal
perforation.
   Measures of the  utmost importance relate to the prophylaxis of typhus
and  of typhoid fever.  It is established that by the introduction of modern
sanitary arrangements  these diseases have been made to disappear from dis-
tricts where they formerly prevailed.  These measures relate chiefly to mat-
ters  of public hygiene which are beyond the power of the individual physician
to accomplish, but which  he may do much to advance by his advice.  First in
importance in cities is a good system of sewerage and a supply of good water.
   In the prevention of typhus fever it is  important to  avoid overcrowding
and  to secure free ventilation.  Patients with typhus should not be  treated
in hospital wards with other cases.  This statement does not apply to patients
affected with typhoid fever, as there is no risk of the diffusion of the latter
among  patients.  The custom of transferring to  fever-wards with cases of
typhus  patients  affected with  typhoid  fever is objectionable in view of  the 
RELAPSING FEVER.
985
risk of  the  latter  contracting  typhus  during  convalescence.   Repeated
instances in which  this has occurred  have fallen  under my observation.
   In every case of typhoid fever the disease should, if possible, be traced to
its source, and continued  exposure of the patient and  others to the cause
should be prevented.  Careful examination for  defects or leakage in water-
closets, sinks^ stationary washstands, drains, and soil-pipes should  be  made,
and such defects  remedied.
   Drinking-water should be boiled if there he any ground for suspecting its
purity.  In order to prevent diffusion of the disease the intestinal dejections
should  be disinfected by adding a solution of the sulphate  of iron and car-
bolic acid, and they should  not be thrown into privies  or water-closets, but
buried, so as to avoid  the possibility of their infecting either drinking-water
or the atmosphere.  Articles of  clothing or bed-linen soiled by intestinal de-
jections should be at once plunged in boiling water or disinfected.


                          Relapsing Fever.
   A form of continued fever heretofore  known by a variety of names, but
now called  relapsing fever, received very little attention in this country prior
to 1870.   It  has  never been  indigenous in this  country.   In June, 1844,
15 cases were admitted  into the Philadelphia Hospital  presenting the  cha-
racters of  relapsing fever, this name, however, at that time not being in use.
These were probably the first  cases reported in this country.   The patients
were Irish immigrants, all coming over  in  the same vessel.  The cases were
observed by  Dr.  Meredith  Clymer, and  were  reported  in  his  treatise  on
fevers.1  In addition to these, so far as I know, the only cases observed  are a
few reported  by Dr. A.  Dubois in 1848,2 and 15 cases which  came under my
observation in 1850-51, an account of which is  contained  in  my Clinical
Reports  on  Continued  Fever.3  The cases reported  by Dr. Dubois and by me
were among recent Irish immigrants.   It  is highly probable  that other  cases
have occurred among immigrants which have not been  reported, and which
may have been confounded with typhus and typhoid fever. In the winter of
1809—70 the disease was imported by foreign immigrants, and it prevailed to
a considerable extent in New York during this winter and the following sum-
mer.   It prevailed  also to some extent in others  of the  large cities of this
country.   At this time the wards of  Bellevue  Hospital afforded an ample
opportunity for the  clinical study of this disease;  and my observations were
the basis of a lecture published in the spring of 1870, to which was  appended
a  statistical report  of 103  cases prepared at  my  request by Dr. Thomas J.
Moore, then one of the house-physicians of the hospital.4
   It is not long  since the distinctive features of relapsing  fever have been
pointed out and its claims to be considered as a distinct species of fever estab-
lished.   It  is by no means, however, a new disease, and  there is evidence of
its having existed from a very early period in the history of medicine.  In
modern  times it has prevailed  at different  epochs, especially in Ireland,  Scot-
land, and England.   It  prevailed  as an epidemic in Upper  Silesia, a prov-
ince of Prussia,  in 1847, and among the troops in the Crimea during the war
of France  and England with Russia.  In  1863 it  again  appeared in Russia,
and  in  1805 there was a great epidemic in St. Petersburg.   Since this date

  i FeVers, their Diagnosis, Pathology, and Treatment, by Meredith Clymer, M. D., Phila-
delphia, 1846, p. 99.'
  2 A'ide Transactions of American  Medical Association, vol. ii.
  3 A'ide Clinical Reports on Continued Fever, based on Analyses of 161/, Cases, by Austin
Flint. M. P., 1So2.
  4 A'ide New York Medical Journal, March, 1S70. 
986
CONTINUED FEVERS.
there have been several  epidemics of relapsing fever in Russia and in North
Germany, particularly its  eastern part.  Among the different  names hereto-
fore applied to the disease are the following:  Febris recurrens, typhus recur-
rens, spirillum fever, " five-day fever,"  " seven-day  fever,"  " short fever,"
"mild yellow  fever," "  famine  fever," "hunger-pest,"  The name relapsing
fever is based on one of the most striking of the peculiarities of the disease,
and involves no hypothesis ;  it is therefore to be preferred to any of the other
appellations.  The disease described by Oriesinger as bilious typhoid fever is
a severe form of relapsing fever.

   Anatomical Characters.—The lesions are those of an acute infectious
disease.  The spleen is enlarged, of  a dark-red color, and of soft consistence.
The enlargement is in many cases extreme, and resembles that which occurs
in typhoid fever.   In a  few instances rupture of the spleen has taken place.
Infarctions in this organ are not rare.  Abscesses also occur, but they are less
frequent.   The Malpighian follicles are indistinct, although often  swollen.
They are sometimes  the seat of small abscesses and of  necrotic softening.
The enlargement of the spleen is  due to congestion and hyperplasia of its
lymphoid elements.  The liver is also enlarged, and of a reddish-gray or yel-
lowish-brown  color.   It is the seat of parenchymatous and often  of fatty
degeneration.   The kidneys are  swollen, especially the cortex, and  often pre-
sent a number of small hemorrhages.   The epithelial  cells of the  cortical
tubes undergo granulo-fatty degeneration.   Ponfick observed lymphoid cells
in the interstitial tissue.   These are the changes of an acute  diffuse nephritis.
They are not present in  all cases, but they are not  rare.   There is usually a
moderate degree of inflammation of  the intestinal tract, the mucous membrane
being congested, swollen, and coated with mucus.   The solitary follicles are
somewhat enlarged.  Ponfick attributes the icterus  often present in relapsing
fever to gastro-duodenitis.   Ecchymoses are often met with  in the stomach.
Subpleural  and pericardial ecchymoses are not uncommon.  Small  hemor-
rhages have also been found in the brain.  Petechiae of the skin are present
in about 10 per cent, of the  cases.   The striated muscular substance  is the
seat of parenchymatous and of hyaline  degeneration, as in typhoid fever.
The degeneration is frequent, and of especial importance in the muscular sub-
stance of the heart. The myocardium may be affected with  a fatty degenera-
tion almost as intense as  that in phosphorus-poisoning.   This degeneration
may be  the  immediate  cause of death.    Ponfick  observed in some  cases
changes  in the marrow of the bones.  These changes were partly diffuse and
partly circumscribed.  The diffuse changes consist in the appearance  of large
cells filled with fatty granules, especially in the course of the small  arteries,
and in an increase in the number of lymphoid  elements.   Another alteration
of the marrow occasionally found is the presence  of circumscribed  foci of
necrotic  softening.   The blood is dark in  color and fluid or imperfectly coag-
ulated.   AVhen examined during life the number of white corpuscles is often
found notably increased  (1 white to 50-20 red).
  In 1873, Obermeier in Berlin discovered a spiral-shaped  bacterium in the
blood of relapsing-fever patients.  This parasitic organism is called the spiro-
chete Obermeieri,  or  the spirochaete of relapsing fever.  It belongs to the
group called spiro-bacteria (page 02).  This parasite has  been found in the
blood in no other disease.1   The spirochaetae are sometimes,  but  not  usually,
found in the blood after death, and if found, they are observed to be motion-
less.  These spiral organisms are extremely delicate, and are  readily seen only
  1 The spirochaete Obermeieri resembles the Spirochete plicatalis discovered by Cohn in
mucus from the mouth, and a spirocbpete previously discovered by Ehrenberg in water.
Similar spiral-shaped bacteria have been found elsewhere. 
RELAPSING  FEVER.
987
with the high powers of the microscope. The diameter of a spirochaete is about
that of the finest fibrils of fibrin.   Its length varies  between ten and  forty
micro-millimetres, or from  one and a half to six times the diameter of  a red
blood-corpuscle.  In a drop of blood drawn during life the spirochaetae are in
rapid motion, which resembles somewhat that of the spermatozoa,  The  para-
site has been found only in the blood, and not in the other fluids or in the organs
of the body.  It differs from most bacteria in the readiness with which  it  is
destroyed by the action of various reagents.   It is found almost invariably
during  the  febrile paroxysms, and disappears during the  intermission.   It is
occasionally found during  the intermission, especially for a  few hours  after
the crisis and for a few hours preceding the relapse.   AVe are ignorant as to
the life-history of this organism.  Attempts to cultivate it  artificially  have
failed.  AVe  do  not know  how it gains access to the body,  or in what  rela-
tion it  stands to the phenomena  of the disease.   It is held by many writers
that the spirochaete develops from spores which are present in the body  dur-
ing the intermissions.

   Clinical  History.—Under this head I shall state succinctly the symp-
tomatic features which are characteristic of this fever.  These relate to two or
more successive paroxysms of fever separated by an apyrexial period or inter-
mission.  The recurrence of the paroxysm of fever, or the relapse, is the dis-
tinctive feature  whence the name of the disease derives its significance.
   Abruptness of  invasion  characterizes  the disease.   The attack is sudden.
There is  no prodromic period.   The seizure  is almost always marked  by a
well-pronounced  chill  which is immediately  followed  by febrile movement.
Usually, the patient at once takes to the bed; but in  some cases one,  two, or
three days pass before there is this evidence of yielding to the disease. Mod-
erate perspiration occurs shortly  after the fever  begins in a considerable pro-
portion of cases.  The perspiration in  some cases is  abundant, and  it  may
recur repeatedly during the continuance of the febrile paroxysm.
   The fever attains quickly either considerable or great intensity, as denoted
by the pulse and axillary temperature.  Thus, of two cases in which the dis-
ease was developed in  Bellevue Hospital, in one the pulse on the first day was
120 and the temperature 103° ;  in the other  case the pulse on the first day
was 130 and the temperature was 103°.  During the continuance of the first
paroxysm the pulse and temperature generally denote a persistent intensity
of fever, the pulse  ranging in different cases between 100 and 140 and the
temperature  between 100° and 105°.  The oscillations are rarely great, and
those which are observed  are irregular in their  occurrence.
   The cessation of the fever is as abrupt as its invasion.   The pulse and tem-
perature quickly fall to nearly or quite the normal standard.   The transition
from high fever to complete apyrexia  takes place often in a  few hours ; and
usually this is accompanied by profuse perspiration, which continues for sev-
eral hours, and even an entire day.  Not infrequently the pulse and temper-
ature fall below  the standard of health.  I have observed the pulse to fall as
low as 54 and the temperature  as low as 05°.  In a  day or two both the
pulse and temperature rise  again  to the normal standard.   Symptoms of col-
lapse sometimes occur  soon after the fall of temperature.  They are usually
of short duration.
  The duration of the primary paroxysm in the majority  of cases is between
five and seven days.  Exceptionally, it is only two days, and it may be  four-
teen days.
  Durin"- the apyrexial period or intermission the absence of fever is  com-
plete.  It is incorrect to call this period a remission. The fever does not remit,
but it intermits.   The average duration of this period is about seven days, but 
988
CONTINUED FEVERS.
it may not exceed two  or  three days, and it  may extend  to twelve  days or
even  more.
   The relapse, like the  primary attack, is sudden.   It is generally ushered in
by chilly sensations, but not so  constantly by a well-pronounced chill as in the
case of the first paroxysm.   The fever in the relapse quickly becomes  more or
less intense.   The intensity ma)* exceed that of the first paroxysm, but in the
majority of cases it is less.  The relapse also ends suddenly, and in most cases
with profuse perspiration.
   The duration of the relapse varies between three and five days. It is some-
times, however, only twenty-four hours, and it may extend to ten days.
   It is to be borne in mind that the relapse does not  always take place.   On
the other hand, a second, a third, and  even a fourth and a fifth relapse have
been observed. In some epidemics there have  been two relapses in the major-
ity of  cases.   In others a second  relapse has been the exception.   The dura-
tion of the second intermission is eight or  nine days, and that of  the  third
paroxysm about three  days.   The  duration of the  disease  averages about
twenty-five  days, but is longer if more than  two  febrile  paroxysms occur.
In none of the cases which  I have  seen has there been more than a single
relapse.
   The foregoing points are those most highly distinctive of  relapsing fever.
It remains to notice other points  belonging to the clinical  history which  are
more  or less characteristic.
   Of symptoms referable to the digestive system, nausea and vomiting occur
sufficiently often to be  somewhat distinctive,  especially when this disease is
contrasted with typhus  and typhoid fever.  Not infrequently, these symptoms
are prominent and persistent during the febrile paroxysms. The matter vom-
ited is green  or yellow from  the  presence of bile.   The tongue is  generally
coated, and in most cases it is moist.   This moisture of the tongue in connec-
tion with high fever is somewhat  distinctive of this disease.   The  tongue
may, however,  become dry and fissured.   Herpes labialis sometimes  occurs.
A'omiting of  blood presenting the character of " black  vomit" has been  ob-
served, but it is a very rare symptom.  It is generally associated with hem-
orrhage in other situations, and it is  to be considered as an accidental event,
not as an  element of the disease.  Epistaxis is a more frequent form of hem-
orrhage, and is observed especially during a crisis.  In some epidemics  a mod-
erate diarrhoea  has been the rule, and in others  constipation.  There is nothing
characteristic as regards the condition of the bowels.   Meteorism in a  moder-
ate degree is not  uncommon.  Tenderness on pressure over the epigastric
region is frequent.  Slight  tenderness in  the iliac region  is not uncommon.
Notable tenderness exists in most cases over the liver and spleen, and enlarge-
ment of these organs  is determinable  by palpation and  percussion.   I have
not observed a craving  for food during the paroxysms, which, according to
some  writers, is distinctive of  this form of fever.   The appetite, however,
returns during the intermission,  and  the  digestion  may  be active  in  this
stage.
  The occurrence of jaundice maybe mentioned in this connection.  A dirty,
yellowish color of the skin is present in most cases, and to it has been assigned
some diagnostic value.   True jaundice occurs in a small proportion of eases,
but its infrequency in the  other  continued fevers  renders it somewhat dis-
tinctive of relapsing fever.   It is  doubtful if the statement that this event is
an element of gravity be correct.   The event is much more frequent in some
epidemics than in others.   The name  " mild yellow fever " derives  whatever
pertinency it has from the  occurrence of jaundice sometimes in  a  consider-
able  proportion of cases, and also from  the occasional occurrence of black
vomit. 
RELAPSING  FEVER.
989
  A symptom referable to the nervous and  the  muscular system  is highly
characteristic  of the  disease under  consideration.   I refer to arthritic and
muscular  pains, especially the latter.  During the first  paroxysm pains  in
the loins,  the calves of the legs, and the muscles  in other situations are gen-
erally much complained of.   They are never  wanting, although, as regards
intensity,  they differ considerably in different cases.   The muscular  pains do
not cease with the ending of the paroxysm, but they continue during the
intermission ;  they are more or less  prominent during the relapse, and they
often persist into  convalescence.  The muscles,  especially those of the calf,
are sensitive to pressure.  The pains are sometimes referred to the bones.
Ponfick thinks that this may be  explained  by the changes  in  the marrow
which  he observed.
  The mental condition perhaps, in a measure,  accounts  for the  suffering
from these  pains.   The perceptions are  not blunted in this disease, as they
are in typhus  and typhoid fever.  This is a  negative point of distinction  in
contrast with  the fevers  just named.  Another negative point is  the absence
of the delirium which characterizes typhus  and  typhoid fever.  Delirium is
by no means absent in all cases of relapsing fever; but the delirium is such
as may occur whenever there is high febrile movement, whether  the fever
be essential or symptomatic, and it is generally manifested only at night.   In
the daytime the mental faculties are generally intact.   The condition known
as coma-vigil  does not belong to the clinical history of relapsing fever.  This
statement is also  true of subsultus, carphologia, and other ataxic  symptoms
which  occur in grave cases of typhus and typhoid fever.  Deafness is  also a
rare symptom in relapsing fever.
   A distinctive point, in comparison with typhus and typhoid fever,  is the
absence of  a  characteristic  eruption.  In most  cases  there  is no  eruption.
Sudamina or miliary vesicles  are sometimes  observed at  the time when pro-
fuse perspiration  occurs, but this eruption  is incident to various  affections.
The same is true of petechial  spots which occur  in some cases  of  relapsing
fever.  Other kinds of eruption are sometimes accidentally associated.  Even
the rose  papules of typhoid fever sometimes  occur in this as they do in vari-
ous other diseases.
   The physiognomy presents nothing distinctive.  The  face  is  more or less
flushed, as in  cases of symptomatic  fever.  There is not that  degree of capil-
lary congestion, marked especially  on the  cheeks, which exists in typhoid
fever, or the dingy complexion which characterizes typhus.   The expression
of indifference, vacuity, or stupidity which is a notable  characteristic of the
fevers just  named is rarely observed in relapsing fever.
   The urine  during the paroxysms is usually concentrated,  dark in  color,
and rich in urates.  In  some epidemics  albuminuria has been a not uncom-
mon symptom.  Blood-corpuscles and hyaline casts have  also  been found,
but  in the majority of cases neither albumen nor casts are present.   Great
diminution, and  even  suppression, of  the  urine,  however,  are  sometimes
observed, uraemic coma and  convulsions  taking  place, but these  cases  are
exceedingly rare.
   It may be stated, as a point somewhat  distinctive of  relapsing fever, that
there is very  little liability to serious complications.   In this fact we have
an explanation, in part  at least, of the very small rate  of fatality from  the
disease.
   What has just been stated with respect to complications holds true as regards
sequels.   As  a rule, important sequels do not occur.   The most  frequent are
ocular affections,  particularly  iritis and  irido-choroiditis.  Otitis  media has
also been repeatedly observed, although less frequently.  Other  complica-
tions or sequels of some clinical importance  are parotiditis, laryngitis, dysen- 
990
CONTINUED FEVERS
tery, pneumonia, and acute diffuse nephritis.  Relapsing fever, when it attacks
pregnant women, always leads to miscarriage or abortion.  The mother almo-t
invariably recovers, but the  child, no  matter how near may be the end of
gestation, as a rule is either stillborn or dies shortly after  birth.  The spiro-
chaetae" have been found in the blood of the foetus.

  Diagnosis.—The diagnosis of relapsing fever is made certain  by the dis-
covery of the characteristic spirochaetae in the blood during a paroxysm of the
disease.  The cases in  which competent  observers have  failed to find the
organisms after searching for them are so very few that they may be left out
of consideration.   Other distinctive features of relapsing fever are such  as to
leave hardly any room for doubt concerning the  diagnosis after the disease
has  ended.   The  distinctive characters are—the abruptness  of the inva-
sion, the rapid increment of fever, the frequent  occurrence  of moisture on
the skin or perspiration more or less abundant without any marked abate-
ment of the fever, the  prominence of  muscular and  arthritic pains,  and  in
certain cases the occurrence of jaundice.   These are the positive points which
are diagnostic.   The fevers to be excluded are the eruptive fevers, febricula,
remittent fever, and typhus and typhoid  fever.   Scarlet fever and  measles
are readily excluded by the  absence  of the eruption  and of the characters
which are  distinctive of these fevers during the period of invasion.   Small-
pox is  excluded  after the third day by the continuance of fever and the
absence of the eruption.  It is not always practicable to decide at once that the
disease is not a febricula,  but the intensity of the fever and the notable mus-
cular pains do not belong to the latter.   Doubt, however, is soon removed by
the persistence of  the fever.   Typhoid fever is excluded by the absence of  a
prolonged access and of  the  abdominal symptoms before sufficient time has
elapsed for the appearance of the eruption, and by absence of the character-
istic mental  condition.   Typhus is excluded by the absence of the eruption,
which appears earlier than in typhoid fever, of the dusky complexion, and of
the mental condition—the latter  also being apparent  earlier than in typhoid
fever.   Remittent fever is excluded by the absence of remissions, these being
determinable by  a notable diminution  of the axillary temperature in some
cases in which they are not  distinctly denoted by the pulse.   Of course the
prevalence of relapsing fever is  taken into  account  in  arriving at the  diag-
nosis.

   Causation.—Relapsing  fever  is  undoubtedly a  communicable  disease.
This statement rests on  facts  derived from  the different sources of evi-
dence, exclusive of inoculation, which  establish the  contagiousness of other
diseases; as, for example, typhus fever.   Of those  who are attacked dur-
ing the prevalence of the disease, a large proportion are known to have been
brought into  contact with, or close  proximity to, patients  affected  with  it.
The disease is diffused in hospitals among fellow-patients and those who have
charge of the sick.  During the period in which cases  were  received in Belle-
vue Hospital after the disease began to prevail in this city—namely, between
November  14, 1869, and  February 6, 1870—twelve persons contracted the
fever  in the hospital.  These twelve persons were  especially brought into
contact with  patients affected with  the disease, and in no instance  did  it
attack one  who had not been thus  exposed.   One of the  senior assistant
physicians residing in the hospital had the disease.  The orderly in one of
my wards  contracted it, and his wife, who came to nurse  him, was attacked
by it.   The disease has often been  diffused after the importation of a case in
localities in which it did not previously exist.
   Facts, however, go to show that it is not a highly contagious disease.  Con- 
RELAPSING  FEVER.
991
siderable exposure is generally necessary.   The area of the infection appears
to be limited, and it remains to be ascertained whether it may be transported
by fomites.  Some facts cited by Murchison  render it  probable  that it may
be diffused in this way.   It is  especially  communicable when  the miasm
is derived from a number of patients in the wards of  a hospital or in  close
apartments.   The disease is not likely to be contracted from  single patients
in well-ventilated rooms.   The investigations  of the Metropolitan  Board of
Health in New York during the prevalence of the disease showed that it is dif-
fused chiefly among those living in overcrowded, ill-ventilated tenement-houses.
Of the propriety and  importance  of removing these patients  to hospitals or
wards devoted specially to  cases of this  disease there can be no doubt
   Destitution, deprivations, and especially deficient alimentation, are power-
ful auxiliary causes.   Of this fact the past history of the disease at different
times and places furnishes abundant evidence.  The significance of the names
"famine fever " and " hunger-pest" relates to this fact.   Statistics do not
show any notable  etiological influence  pertaining to age, sex, or  season
   Although its diffusion involves  generally,  and perhaps always, a contagious
principle, the history of the  disease in other countries shows that it occurs as
an epidemic, and after continuing for a  certain time it disappears completely.
Thus, in  the city of London  for  the fourteen years preceding the winter of
1868-69  there had been  no cases of the disease.  The complete disappear-
ance of the disease for so long a period tends to show the necessity of co-ope-
rating causes in conjunction with the special poison on  which  the production
of the disease  depends.  The effective means  for arresting the spread of the
disease are—thinning the  population of overcrowded  tenement-houses, dis-
persing the  occupants of  insalubrious dwellings, relieving  destitution,  espe-
cially as regards food, and promptly removing patients to hospitals devoted
to cases of relapsing fever.  An attack of this  disease does not secure exemp-
tion from subsequent attacks.   The period  of incubation in more than one-
half of the  cases in which it is determinable does not exceed  five days.  It
rarely exceeds nine days.  Occasionally, as in typhoid  and typhus fever, the
symptoms begin almost immediatel}* after the exposure.1
   That the spiral bacteria  discovered by Obermeier in  the blood during a par-
oxysm of relapsing fever have an essential  pathological connection with the
disease is universally admitted.  That they or  their spores constitute the con-
tagium, and that the phenomena  of the disease are due to their presence in
the  blood, are conclusions  vastly  more  probable  than that either are effects
of the fever or accidentally associated  with it.  That the agent of infection
is contained in the blood does not admit of doubt.  Motschutkoffsky has pro-
duced relapsing fever in human beings by inoculating them with blood taken
during a paroxysm from a patient  affected with the disease.   Koch and Carter
have produced the disease  in monkeys by inoculating them with blood from a
case of relapsing fever.  Other animals do  not  appear to be susceptible to the
disease.   Blood taken during a paroxysm only is capable  of  producing the
disease.   Nothing is known of the life-history of the spirochaete of  relapsing
fever.   It has not hitherto  been possible to  cultivate  it artificially.   It is
more probable, for various reasons, that the  spores of the spirochaete are the
usual agents of contagion  than.that the spirochaete itself is the contagium.
Nothing is  positively  known, however,  concerning these spores,  although it
has been suspected that small round glistening bodies frequently found in the
blood of relapsing-fever patients are such spores.
   In  accordance with  the germ theory, the first paroxysm of relapsing fever
is due to a brood of spjrochaetae.  Their existence terminates in about a week,
as a rule, and the first febrile paroxysm  then ends.  In a small proportion of
             1 A'ide Murchison, St.  Thomas's Hospital Reports, vol. ii. 
992
CONTINUED FEVERS.
cases the conditions required for the production of a second brood of these
organisms are wanting, and the disease then consists of a single paroxysm of
fever. In the great majority of cases, however, these conditions are not want-
ing ;  hence the germs  remaining in the body give rise to a second brood, and
there is the relapse of the fever.  In rare instances a third and a fourth brood
are produced, but in most persons the conditions therefor are extinguished after
a second paroxysm of fever.  The conditions, however, are never permanently
extinguished,  as  in cases of typhus and typhoid fever, yellow fever, small-
pox, and the other eruptive  fevers, for after a certain period they who have
had relapsing fever are again susceptible to the contagium.   The extinction
of the conditions for  the  development and  reproduction of the  spirochaetae
within the body is only  temporary.
   The contagium  is probably contained  in the breath and cutaneous exhala-
tions.  There are no facts tending to show that the intestinal dejections have
any part in the  diffusion  of the disease.

   Prognosis.—It is, at first view, remarkable that a fever of such intensity,
and prevailing especially among a class of persons whose powers of tolerance
are impaired by previous hardships and  want,  should have such a small rate
of mortality.  The mortality in different collections of cases varies between 2
and 11 per cent.   Dr. Moore, in his statistical report, states that of 103 cases
admitted into  Bellevue Hospital between November 14, 1869, and  February
6, 1870,  only 2 proved  fatal.  In some epidemics the mortality has been as
high  as  10 or 11 per cent., but as a rule it has not exceeded 2 to 4 per cent.
In epidemics with the higher rates of mortality the complications have been
many and the disease  has presented the so-called bilious type.  AVhat is the
explanation  of the low rate of mortality ?  An explanation which perhaps is
sufficient to  account for the fact has been already given—namely, the disease
is very rarely  accompanied by any serious complications.  The comparatively
greater  fatality of typhus  and typhoid  fever is due mainly to complications.
These fevers rarely kill per se;  that  is, death is not purely an effect of the
intensity of the  disease.
  Of the fatal cases of relapsing fever, the death in a certain proportion is
attributable  either to complications, such as pneumonia and dysentery, or to
antecedent affections—as, for example, disease  of the kidneys and  chronic
alcoholism—but this fever may destroy life irrespective of any important com-
plications or antecedent affection.  Several  observers have reported cases in
which sudden death occurred apparently from  syncope.  Dr. Moore's report
exemplified  this fact.   The death in one case was  sudden and  unexpected
during the night on the seventh day of the disease.   At the time of death
the primary paroxysm  seemed about to end, free perspiration  having taken
place.  Neither  coma  nor convulsions occurred, and, so far as information
could be obtained,  the dying was by syncope.  The fatty degeneration of
the heart explains, in many cases at least,  death by  syncope.
  Suppression of urine followed by uraemic coma and  convulsions is some-
times a cause of death.  This fact was exemplified  by one of  the  two fatal
cases  occurring in  Bellevue  Hospital.   These symptoms  are  due to acute
diffuse nephritis,  which is  one of the recognized complications of relapsing
fever.

  Treatment.—There are no known means which can he relied  upon for
cutting  short  this disease.   AVith  our  present knowledge there  are no
remedies which,  employed  in  the intermission,  wilj  prevent the relapse.
Quinia has been  used freely, but with no  success.  Its  inutility as a pro-
phylactic  has  been abundantly shown by  different  observers.  It  has been 
ER YSI PEL A TO US FE VER.
993
recently claimed that calomel exerts a favorable influence upon the progress
of the disease.   The treatment, with our present knowledge, must be expect-
ant, meaning by this term that it is to consist of palliative measures and those
addressed to the particular indications in individual cases.
   The intensity of the fever during the paroxysms may be lessened by spong-
ing the body with water and  by the  wet sheet.  Cold water may be taken into
the stomach freely.   Ice-cold carbonic-acid water is an acceptable and useful
drink to allay thirst.  Cephalalgia  may be relieved by cold applications to the
head.  The bowels should be  kept  open by saline laxatives. The muscular and
arthritic pains call for the use of opium, especially if it produce no unpleasant
after-effects.  Irrespective of the  pains, opiates are indicated to relieve sleep-
lessness.
   The dietetic treatment is  important, especially in the  cases in which defi-
cient alimentation has been an auxiliary cause of the disease.  In this fever,
as in other  fevers when alimentary support is indicated, milk  is the  form
of diet to be preferred; and  it is  to be borne in mind  that in this, as in most
diseases, there is never any danger of the over-appropriation of nutriment,
the only risk being in the ingestion of more food than can be digested.  It
is desirable  that during the paroxysms  one or two quarts  of  milk  should
be taken daily.  In the intermission, when the appetite returns, as much sub-
stantial food as can be digested  should be allowed ;  and the more food is
appropriated in this stage the  better is the patient enabled to  tolerate the
relapse.   Tonic remedies are indicated throughout the disease,  especially in
the intermission.  Quinia in  small doses and some preparation of iron are the
tonics to be preferred.
   If the symptoms  denote asthenia, alcoholics are indicated.   The occasional
occurrence  of death from syncope renders it important to watch carefully for
this indication.  AVhen there is  room for  supposing  that alcoholics may be
useful they should  be given tentatively, and  continued  or not according to
the  effect,  especially on the pulse and  temperature.   They are  of course
urgently  indicated  if the  symptoms denote  danger in  the direction  of
asthenia.
   Attention to the urine is important.  It is to be remembered that a cause of
death is suppression of urine.  If the urinary excretion be deficient in quan-
tity, or if, the quantity being sufficient, there be a deficiency of urea, diuretics
are indicated.  If the kidneys do  not respond to diuretics, hydragogue cathar-
tics are indicated, with a view to eliminate urea through the alimentary canal.
Active hydragogues are of  course indicated if uraemic coma or convulsions
supervene.
   It is  stated  that convalescence from relapsing  fever is notably  slow,
patients  remaining  for a long time much enfeebled, and tolerating with dif-
ficulty affections which may occur before the  recovery is complete.  This
has  not been a marked peculiarity in the cases  which  have  come under
my observation.   It is  doubtless  more likely to be marked  in  the  cases in
which there has been impairment of the vital powers from innutrition and
hardships  before the fever was contracted; and also it is more  likely to be
marked when  abundant  alimentation and  the judicious use of alcohol have
not  entered into the  treatment of the  disease.

                         Erysipelatous Fever.

   Erysipelas, considered as a local affection, belongs to surgery rather than to
medicine.   For an account of this form of  inflammation, therefore, the reader
is referred to surgical works.  It  occurs as an occasional complication  of the
continued fevers which have been considered.  A form  of continued fever dis-
63 
994
CONTINUED FEVERS.
tinct from the fevers which have been  considered is characterized by the fre-
quent occurrence of erysipelas, and hence it is called erysipelatous fever.   As
a distinct form or species of fever this is to be distinguished from erysipelas
occurring as a local affection and accompanied with more or less febrile move-
ment.  The fever in the latter is symptomatic, whereas in erysipelatous fever
it is primary or essential.   On  the other hand, erysipelatous fever is to be
distinguished  from typhus, typhoid, and  relapsing fever with erysipelas as
a complication.
  Erysipelatous fever occurs as a sporadic and as an epidemic disease.   As a
sporadic disease it is rare, and has not  been  as yet sufficiently studied  by
means of the analysis of  recorded  cases.  The  invasion is either abrupt or
there is a forming stage of variable duration.  The erysipelas may be devel-
oped within a few hours from the  attack or after the lapse of one, two, or
three days.  The  head  is oftenest  the seat of the erysipelas, but  it may be
developed  in  any part of the body.   Different parts may  be  successively
invaded.  I have  known it  to extend over the  whole  surface of the body.
The febrile movement is more or less intense.   Passive  delirium  and other
ataxic symptoms are not infrequently developed ; in other words, the typhoid
state exists.  The abdominal symptoms of typhoid fever are wanting, and the
career of the disease is shorter than that of typhoid fever.  The  symptoms
are modified,  and the disease,  as regards duration  and clanger, is  affected
materially by the degree of intensity, the extent, and the local results of the
eiysipelas.  The general principles  of treatment are the  same as in other of
the  continued fevers.   In the existing state of our knowledge of  this fever
I shall pass it by with this brief notice.   It is sometimes classed among the
eruptive fevers, but the erysipelas  is hardly to be considered as a  cutaneous
eruption.
  Epidemic erysipelatous fever I shall also notice very briefly.  It prevailed
extensively in this country between  1841 and 1846.  It was not confined to
a particular section, but prevailed in certain districts in  the New England,
Middle,  AVestern,  and Southern States.   In some localities great numbers
were affected and  the  mortality was  large.  It was commonly  known in
certain parts of the country as the  " black tongue," from an appearance  of
the tongue occasionally observed.   The medical journals of this country dur-
ing the  years just named and afterward contained many articles relating to
the prevalence of the disease in different localities.   Of these, an  article by
Drs. Hall  and Dexter, giving an account of the disease as it prevailed in
Vermont,1  and a paper  by the late Dr.  Bennett of Bridgeport,  Conn.,  are
especially deserving of notice.  The latter gives an analysis of various arti-
cles contained in different medical  journals.2
  The epidemic prevailed in isolated sections.   It did not appear to migrate
or to be transported from place to place.  Its course was " irregular and
erratic."   Dr. Bennett, however, states that it sometimes  appeared to follow
the direction of rivers, small streams, and lakes.   The attack was sometimes
sudden  and sometimes preceded by premonitions, the  latter rarely existing
longer than twenty-four hours, and  being the same as those  belonging to the
access of other fevers.  A pronounced and frequently a prolonged chill, with
or without rigor, ushered in the disease,  accompanied often by pains  in  the
extremities and in  some cases by great prostration.  Pharyngitis was at once
or speedily developed ; and this local affection was constant.   It varied much
in intensity in diff'erent cases.  Not  infrequently it was attended with great
swelling  of the tonsils, and sometimes sloughing occurred.  The  inflamma-
tion sometimes  involved the larynx, and in a  certain proportion of cases
          1 A'ide American Journal of the Medical Sciences. January, 1844.
          2 A'ide New  York Journal of Medicine, July, 1853. 
     EPIDEMIC FEVER CHARACTERIZED BY PHARYNGITIS.    995

 death was due to either laryngitis or oedema of the glottis.   The lymphatic
 glands  of the neck became more or less swollen, the swelling in some  cases
 being very great, and occasionally suppuration taking place.
   Erysipelas was far from being constant.  The frequency of its occurrence
 varied  at  different times and places.  Dr. Bennett observed it  in only  one-
 sixth of one hundred and fifty cases.   In view  of the fact  that erysipelas
 occurs  in  only  a  certain proportion of cases, the propriety  of calling the
 disease erysipelatous fever rests upon the absence of any  other and better
 name.   The erysipelas was  seated  in different parts.  It frequently led to
 suppuration, gangrene, and sloughing.  The clanger and protracted  character
 of the  disease depended on the degree, extent, and local results of the ery-
 sipelas.
   The febrile movement was more  or less intense.  Erratic pains, like those
 of neuralgia and  muscular rheumatism, were common  during the course of
 the disease.  Typhoid delirium and other ataxic symptoms occurred in severe
 cases.   Petechia  were  sometimes observed.   Abscesses without erysipelas
 occurred  in some cases.   The disease was not infrequently complicated with
 inflammation of serous membranes, as the pleura, peritoneum, and  the  cere-
 bral meninges.  Pneumonitis was  an occasional complication.
   Different cases  differed much as regards the  gravity of the disease.   In
 many cases the  disease was mild and ended in five or six days.  The severity
 and danger were generally due to the complications.  Of the cases compli-
 cated with laryngitis  or oedema of the glottis, extensive erysipelas, serous
 inflammations, or pneumonitis, a large proportion ended fatally, the  duration
 being very prolonged.
   Puerperal peritonitis  prevailed in conjunction with  this  epidemic so  uni-
 formly  as  to show a pathological relationship between these  two affections.
 The opinion was generally held that the peritonitis was caused by a virus or
 miasm carried by the obstetrician from patients affected with the epidemic dis-
 ease. Assuming this to be true in certain cases, puerperal peritonitis was by no
 means uniformly to be accounted for in this way.   A rational explanation in
 many, if  not in  all, cases is  that labor acted  as an exciting cause and deter-
 mined the situation of the local affection in those predisposed to the disease
 from the action  of  the epidemic influence.  Many, if not most, practitioners
 held that the disease was communicable.  Its contagiousness, however, cannot
 be considered as established.
   As regards treatment there was a diversity of opinion.   Some practi-
 tioners  advocated  bleeding and other of the measures  called  antiphlogistic ;
 but the majority, before the epidemic  ceased to  prevail, were convinced of
 the impropriety  of  these measures.  In view of the symptoms, the nature of
 the disease, the  tendency to suppuration and  gangrene  in the cases in which
 erysipelas  existed,  and  the other complications which were liable to occur,
 there can hardly be a question as to the propriety of measures of an  opposite
 character.   Tonic remedies, alimentation, and alcoholic stimulants—in other
 words,  supporting  measures of  treatment—were  indicated.  Mild cases
 required little or no treatment,  but  in grave cases were applicable the  prin-
 ciples which  should govern the management of  other  essential fevers with
 serious  local complications.

        Epidemic Fever characterized by Pharyngitis.

   In the winter  and spring of 1857  an epidemic fever prevailed  in the west-
ern part of the  State of New York, in the adjacent parts of Pennsylvania,
and in Canada, characterized by inflammation of the pharynx of  a mild grade
of intensity, and unaccompanied by either diphtheritic  exudation  or much 
996
PERIODICAL  FEVERS
submucous  infiltration.  I reported the results  of an analysis of  23 cases
which I observed and recorded.  A report of this epidemic, based upon notes
of 37 cases, was  at  the  same time made by Prof.  Rochester.1  The different
cases presented great uniformity as regarded the general and local symptoms.
The fever was ushered in with a chill without rigor.  The febrile  movement
in all the cases was considerable or marked.  The severity of the disease was
generally sufficient to keep the patients in bed for several days.  The lymph-
atic  glands of the neck were in most cases  moderately enlarged, but without
suppuration.  Soreness of the  throat  was not a prominent symptom, even
when the pharyngitis was marked.  There was in no case an  eruption. Vomit-
ing did not occur, and generally the bowels were constipated.  There were no
symptoms of importance referable to the pulmonary  and  nervous system.
The  duration of the  fever was between three and six clays.   It affected  per-
sons of either sex and of all ages.   The epidemic continued about two months,
reaching its acme gradually  and  gradually declining.   In no case under my
observation  did  it prove fatal.
  The disease was not scarlatina, as shown by its affecting persons  who had
had  that disease, by the fact that scarlatina did not prevail at the  time, by
the absence  of an eruption in all the  cases, by the  non-occurrence of dropsy
as a  sequel in any case, and the fact that middle-aged and aged persons were
attacked  as  well  as  children and  infants.   There were no cases of epidemic
pharyngitis with exudation or diphtheria in that part of the country.   The
fever resembled  the  mild cases of  erysipelatous fever which occurred during
the epidemic prevalence of that disease, but erysipelas was not  developed in
any case.' The cases bore a  close  analogy to those  of  influenza, except that
the local affection was seated  in the pharynx, and  not in the  Schneiderian and
bronchial mucous membrane.
  Dr. Harvey E. Brown, Assistant  Surgeon  U. S. Army, kindly communicated
to me an account of an epidemic similar to that just described which prevailed
among the United States troops stationed at  Hart's Island, Long Island Sound,
in January and February, 1866.
  Palliative measures of treatment only were indicated.
                        CHAPTER  IV.

                     PERIODICAL  FEVERS.

Intermittent Fever:  Anatomical Characters ; Clinical History; Causation ; Diagnosis;
             Prognosis; Treatment,—Pernicious Intermittent Fever.

   THE  periodical are distinguished from the continued fevers  by the occur-
    rence of febrile  paroxysms or marked  exacerbations in a regular order
of succession, thereby exemplifying a law of periodicity.  This distinction
applies  especially to  the fevers called  intermittent and remittent.   Yellow
fever is generally included  among the periodical fevers, and it belongs per-
haps more appropriately here than in  any other nosological division.  The
intermittent and remittent fevers are often  distinguished as malarial fevers.
These fevers will be  found to  present  many striking points of difference as
               1 For both reports, vide Buffalo Med. Journal, 1857. 
INTERMITTENT FEVER.
997
contrasted with the fevers which have been considered in the preceding chap-
ters.  They differ not only in the events of the clinical history, but as regards
the laws governing their causation, duration, complication, sequels, and the
extent to which  they  are controllable  by known remedies.


                        Intermittent Fever.

  An intermittent fever is characterized by  the occurrence of febrile parox-
ysms  in regular succession and by the absence of febrile movement between
the paroxysms.   The intermission is the distinctive  feature of this form of •
fever, as its name  implies.   Popularly, the  disease  is known  as " fever and
ague," "chill fever," "the shakes," and by names expressive of the locality
in which it is produced, as "swamp fever," "Panama fever," " Chagres fever,"
etc.   Although essentially the same disease, intermittent fever as ordinarily
presented in practice is unattended with danger to life, but occasionally it is
one of the most dangerous of maladies.  I shall consider first simple or ordi-
nary intermittent fever, and  afterward  the grave forms of the disease under
the head of Pernicious Intermittent  Fever.

  Anatomical  Characters.—The essential  anatomical  lesion in all forms
of malarial fever is the presence of dark pigment in the blood  and in certain
organs.  A certain  amount of this pigment  is formed in simple intermittent
fever.   The quantity of this pigment and other malarial anatomical changes
are so much greater in the more severe forms of malarial  poisoning that the
consideration of  these  changes will  be referred to the article on Remittent
Fever.   The spleen is more  or  less enlarged in  simple  intermittent fever.

  Clinical History.—The  clinical history will  embrace  an  account,  first,
of the paroxysm ;  and second, of the  intermission.
  In  the majority of cases the attack is  sudden.   In  a certain  proportion of
cases,  however,  there  are  premonitions  for  a  variable period.  The premo-
nitions are not very distinctive of this disease, consisting of pain in the head,
vawnings,  indisposition to exertion, loss of appetite, and general malaise.
Although not very  definite,: they  sometimes suffice to lead  patients who  have
been  repeatedly affected with intermittent fever to  anticipate an impending
attack.
  A paroxysm, when complete, consists of three distinct periods or stages—
namely, the cold, the hot, and the sweating stage.
   Cold Stage.—This  stage presents first a feeling of chilliness, beginning in
the loins and extending thence over the back and limbs.  The chill is more or
less intense, in some cases consisting of a slight creeping sensation of coldness
with  shiverinss,  being  in  other cases  extremely severe.   Muscular tremor,
commonly known as rigor, may or may not accompany the chill.  I have met
with a single example  of distinct  rigor without a sensation of chilliness.  Dur-
ing the  chill bristling of the hairs  over the body, or horripilation, and the
appearance familiar as " goose-skin," are often observed.   Notwithstanding
the sensation of coldness  which the patient  experiences,  and the feeling of
coldness when  the  hand  is placed on certain  parts, the thermometer in the
rectum shows an increase of the temperature of the body.  The thermometer,
however, applied to the extremities shows a decrease of  temperature  below
that of health.    The increase of the temperature of  the body begins prior to
the paroxysm.   The  sensation of coldness is sometimes  limited to a part of
the body, as the back or the  extremities.  During the rigor frequently the
teeth  chatter and the movements of the body and limbs are sufficient to shake
with considerable violence the bed on which  the patient lies. 
998
PERIODICAL  FEVERS.
  During this stage the patient frequently sighs, the pulse, which is usually
accelerated, is small and feeble, the countenance has an expression of anxiety,
the prolabia and face are pale or frequently livid, and lividity is often marked
at the roots of the nails.  The general appearance is as if the person had been
exposed to intense cold.  The circulation is sometimes completely  suspended
in the fingers, which are waxy in appearance, devoid of sensibility, and bleed
less than usual if wounded.  Other symptoms are—mental irritability, a sense
of oppression referred to the praecordia, pain in the head and limbs, and pal-
pitation.
  The duration of this stage varies between a few moments and two hours or
even longer.  The average duration may be estimated at from a half to three-
quarters  of an hour.   The transition to the next stage is sometimes abrupt,
but is generally  gradual.   Flushings of heat  are  felt, the rigor ceases, the
coldness, as  it were,  melts  away, febrile  movement is developed, and  the
cold stage  is then  ended.
  The cold stage is not infrequently wanting, the paroxysm  beginning with
the hot stage. I  have known a state of intense nervousness to take the place
of the cold stage.  Gastralgia or gastric irritability, denoted by pain or inces-
sant vomiting, is a morbid condition  which sometimes takes the place of this
stage, as well as drowsiness  or stupor and a condition resembling  hysterical
coma.  Veritable  coma is liable to occur in this stage in a form of the disease
which  will be noticed separately under the head of Pernicious  Intermittent
Fever.   In young children  convulsions  are liable to occur in the cold stage.
  Congestion of  internal  organs is  necessarily involved in  the cold stage,
inasmuch as there is less blood in the vessels of the  surface and the whole
mass  of blood is not  diminished;  but  the primary and essential morbid
condition underlies the congestion, and it is probable that the  latter  is an
effect of an active  contraction or spasm of the  peripheral  vessels,  the  blood
accumulating in the internal organs  in consequence of its being  driven from
the surface of the body.  That the congestion incident to this stage does  not
stand in a causative relation to the other stages is shown by the fact that  the
cold stage is  sometimes wanting, and that  the other stages in these  cases  are
not less marked than  when the cold stage occurs.
  Hot Stage.—This  stage is characterized by more or less intense pyrexia.
The skin becomes hot, the pulse is accelerated and full or bounding, the face
is flushed,  the cephalalgia continues, but the pain in the limbs and the prae-
cordial oppression disappear.   The axillary temperature rises  notably, usu-
ally reaching 105° or 106° F.  Thirst is usually a prominent symptom.  The
intensity of the pyrexia varies considerably in different cases.   The duration
of this stage is  between three and  eight  hours.   It is evident that in this
stage the spasm  of the vessels of the periphery which  existed  in the  cold
stage has ceased, and that,  on the contrary, the distributing vessels of  the
surface of  the body  are abundantly dilated.
  Sweating Stage.—Perspiration  appears  first on the face,  and afterward on
the trunk  and  extremities.   The pyrexia gradually abates,  and  at length
disappears.   The  heat  of the surface, cephalalgia, thirst, restlessness, etc.
cease.  The thermometer indicates a rapid defervescence, the heat falling to
the normal standard.   The  patient obtains refreshing sleep.  AVith  this stage
the paroxysm ends.   As regards the amount of sweating cases differ, it  being
sometimes profuse and sometimes slight.   The duration of the sweating stage
is variable, the average duration being three or four hours.  The sweating is
evidence that the pyrexia is about to end.   That it is the means  of bringing
the paroxysm to a close is by no means certain ; it is a sign of the approach-
ing intermission,  and it may be an effect rather than a cause of the decrease
of the pyrexia.   During and succeeding  the paroxysm, urea, uric acid, and 
INTERMITTENT FEVER.                    999
the  chlorides in the urine are increased.   The urine  is  not infrequently
albuminous,  and occasionally there is  haematuria.
   The intermission, called  also the apyrexial period, is the space of time
between  two successive paroxysms.  The period from the beginning of one
to the beginning of the next paroxysm is called  the interval  in  distinction
from the intermission.   The duration of the interval is the basis of a division
into varieties commonly known as the  diff'erent types of the disease.  Each
variety or type observes a law of periodicity in the succession of paroxysms.
There  are  three  simple types of intermittent fever—namely, the quotidian,
the  tertian, and the quartan type.  In the quotidian type the interval  is
about twenty-four hours, or the paroxysm recurs daily, as the name imports.
In the tertian type  the  interval is  about forty-eight hours,  or the paroxysm
recurs on the third day, reckoning the days on which two successive parox-
ysms take place.   In the quartan type the interval is  about seventy-two
hours, or the paroxysm recurs on the fourth day.   As a rule, the paroxysms
are  uniform  in each individual case as regards  the  occurrence of the cold
stage, the duration  of the  several stages respectively, the  severity of each,
etc., but they present considerable  diversity in different cases.  Of the three
simple types, the quotidian and tertian type are  by far the most frequent.
Examples  of the quartan type are comparatively rare.   Of 98,237 cases  of
intermittent fever in the United States army, only 1757 were of the quartan
type.1
   As regards the relative frequency of quotidian and tertian  cases, either
variety may predominate  at particular seasons.  In the  same locality the
majority of cases are at one season of the quotidian and at another season
of the tertian type.   In an aggregate of cases occurring in a series of years
the quotidian type predominates.   Of 98,237 cases in the United States army,
51,623 cases were of quotidian and 44,857 cases of tertian type.2  Cases  have
been observed  in which the paroxysm has recurred  on the fifth, sixth, sev-
enth, and eighth day, and hence  there may be a quintan, a  sextan, a heptan,
and  an octan type  of intermittent  fever.   Such  cases,  however, are among
the rare  curiosities of clinical experience.  In some cases during the contin-
uance of the disease the type changes, the quotidian succeeding the tertian, or
vice  versa ; such cases, however, are rare.
   Cases are observed occasionally in which one of the simple types is dupli-
cated ; that is, two sets of paroxysms of the same type coexist.  Thus, one
compound  type is called a  double quotidian, two paroxysms occurring  daily.
Another  compound type is a double tertian.  In a double tertian a paroxysm
occurs daily, but the paroxysms on successive days take place  at different
hours, and  may differ in various ways, whereas on alternate days they occur at
the same hour and correspond in other  respects.   Again, a tertian is doubled
or duplicated when two paroxysms occur on alternate days.  Another  com-
pound type is a double quartan.   In this type a paroxysm occurs on two suc-
cessive days, and on  the third day there is  no paroxysm.  Finally, a triple
quartan is a compound type in which a paroxysm  occurs on three successive
days, the paroxysms on these days presenting notable points of difference, but
each paroxysm  corresponding  with that which  recurs  on the fourth  day.
These compound types, except the double  tertian, are extremely rare,  and
are interesting  merely as curiosities of  clinical experience.  The double  ter-
tian  is not very  infrequent.
  Paroxysms may occur at  any hour of the day.   They rarely occur during
the night.  In a large majority of the cases of the quotidian and tertian type
the paroxysms occur before noon.   Quartans are as likely  to occur  after as
   1  A'ide Woodward, Camp Diseases of the  United States Army, Philadelphia, 1863.
   2 Ibid. 
1000
PERIODICAL  FEVERS.
 before the  middle of the day.  In  infants the type is almost uniformly quo-
 tidian.  As a rule, the successive paroxysms  recur precisely or nearly at the
 same  hour; but sometimes there is a variation from  this rule, and the varia-
 tion is in accordance with a certain law whenever the paroxysms are said to be
 either anticipating or retarding.  They are anticipating when each successive
 paroxysm recurs  earlier by the same period than  the last.   Thus, they may
 regularly anticipate half an hour, an hour  and a  half. etc.   The  paroxysms
 are retarding  when each successive  paroxysm is in  like manner  delayed.  "This
 variation in time of recurrence is generally evidence that the disease is about
 to end.
   During the intermission there is much difference  in different cases as regards
 freedom from ailments.   In  some cases the  patient complains  only of a cer-
 tain amount of debility;  the appetite and digestion are good, and there is  no
 apparent disorder  of any of the functions.  In other cases marked prostra-
 tion follows, the appetite  and digestion are more or less impaired, and various
 disturbances exist.
  _ Probably more or less enlargement of the spleen  occurs in all cases of mala-
 rial fever.  The enlargement is often sufficient for the  organ to  be readily felt
 through the abdominal  walls, constituting what is commonly known as the
 " ague cake " in districts where the disease prevails. The organ in  some cases
 becomes enormously enlarged.   A splenic tumor of large size is not very fre-
 quent. _ It  occurs in some cases when the disease has  been of short duration,
 and it is by no means developed in the  majority  of  the cases  in which the
 disease has existed for a long period.   It may continue for  a considerable
 period after the paroxysms  cease.
   Anaemia  is incident to the disease, especially if it have been of consider-
 able duration.   The pallor of the face in  cases in which the disease has been
 protracted or in which frequent relapses  have  taken place is often associated
 with a yellowish or sallow tint and  with  more or less  oedema, giving rise  to
 a characteristic facies.  These characters denote what is called  the malarial
 cachexia.  General dropsy is an  occasional concomitant or sequel.   Notable
 anasarca with  effusion into the serous cavities is sometimes incident to the
 disease, and does not, therefore, necessarily denote  either a cardiac  or a renal
 affection.  An  herpetic eruption about the mouth is a  frequent  concomitant.

   The duration of the disease is indefinite.   It not infrequently ends spon-
 taneously after  a few paroxysms, but in  many cases it continues  for weeks
 and even months, if not  arrested by curative  means.   Its indefiniteness  of
 duration is  a  striking point  of difference as contrasted with  the  continued
 fevers  ; and its self-limitation is not, as in  the latter, restricted within a certain
 period.  Another  not less striking point  of  difference relates to the liability
 to relapses.  Subsequent  attacks occur in the great majority  of cases   The
 liability to relapse remains for many years.  In some cases successive attacks
 occur regularly after a certain period, showing that  in these cases the relapses
 take place  in accordance with an intrinsic tendency;  that is, irrespective of
 external causes.   The notion was formerly entertained that  the tendency to
 relapse was  lessened if the disease were left to end of its own accord or " wear
 itself  out.   So far from  this being  true, I  believe that clinical experience
 shows  a aiminished tendency to relapse in proportion  as  the  paroxysms  are
 speedily interrupted by therapeutical  interference.   After the paroxysms
have ceased to recur, either spontaneously or from  the use of  remedies, ther-
mometry observations may show more or less increase  of the heat of the
 body at the  time when the paroxysm was to be expected.  So  lontr as these
fluctations  of temperature exist  the disease has not  completely diappeared
and relapses are liable to occur. 
INTERMITTENT FEVER.
1001
  Physicians in malarial  districts become familiar with cases which may be
called  cases of latent intermittent fever.   In these cases paroxysms are not
fully developed, but the patient complains of indefinite ailments, to which the
term bilious is frequently applied.  The appetite is impaired or lost; and there
may be nausea and  occasional vomiting, with pain in  the head, indisposition
to exertion, etc.   The tongue is frequently covered with a thin and very white
coating.   A close examination will  sometimes disclose evidence  of periodicity
in an increase of ailments at regular periods  on successive days or on alter-
nate days, and slight manifestations of the several stages of a paroxysm may
be observed.  The thermometer in the axilla  is useful as a means of diagno-
sis in these cases, showing a periodical rise of temperature when  the surface
of the body may not show increase  of heat and the pulse is  but  little accel-
erated.   In a case  under observation at Bellevue Hospital  at the time  of
writing the morning temperature  in the axilla was 105° F., the pulse being
only 80, and at evening the temperature was 100°.   Under  the free use of
quinia the  daily increase of temperature  rapidly diminished, and in a short
time  ceased.  The  prompt relief afforded  by treatment addressed  to a sus-
pected malarial condition  shows the  correctness of  the suspicion ; and this
treatment may be resorted to tentatively in cases of doubt.   The affection in
these cases is sometimes called dumb ague.  This term is also applied to par-
oxysms in which rigors are wanting.
   Intermittent fever is said to be masked in certain cases in which it is associ-
ated with other affections.  It may exist in combination with various affections,
such  as bronchitis,  pneumonitis, dysentery, etc.   The association  may render
the periodical disease irregular and  interfere with the full development of the
paroxysms.  In these cases  it is  not  correct  to apply to the  associated affec-
tions the  term  malarial, meaning  thereby that  these affections are  due to
malaria.   They  are simply  accompanied  by phenomena proceeding  from
malarial disease  existing in combination.  In malarial districts the influence
of malaria is liable to pervade all affections and it claims special measures of
treatment.  Of this  fact practitioners in these districts become fully aware.
Paroxysms of neuralgia sometimes appear to  take the place of the paroxysms
of intermittent fever, recurring with the same regularity after  intervals cor-
responding to those in the different types  of  intermittent fever, and a cure is
effected  by the remedies  which are efficacious  in the  latter disease.

   Causation.—The causation  involves a special morbific agent commonly
known as malaria.  The existence of  a  special  cause  is logically inferred
from the peculiar character of  the disease, its limitation to certain localities
called malarial, and the fact  that it is  controlled by remedies having a specific
operation.  The  production  of the  special cause was attributed to vegetable
decomposition in marshy localities and  called marsh miasm in  1717 by Lan-
cisi, an Italian writer.  This doctrine and the  name have  since been very
generally adopted ;  but  that something more than ordinary vegetable decom-
position is  requisite for its  production  is  sufficiently proven by the disease
bein«; indigenous in  certain localities, whereas in certain districts and coun-
tries" in which vegetable decomposition  must take place abundantly the dis-
ease never occurs.  Observation shows that it is produced especially in marshy
localities, but its production is not confined to such situations,  and hence  the
name  marsh miasm  is inappropriate.   The  production of the special cause
requires a temperature above 60° F.  In so-called malarial districts it is more
abundantly produced when  a dry follows a wet  period.  Turning up of  the
soil is often followed  by an increase of its production.  It  often disappears
after the  cultivation of soil for several years, so that highly malarial districts
mav after a time become free  from  malaria.  On the other hand, the  area 
1002
PERIODI< AL FEVERS.
of a malarial district is  sometimes greatly enlarged  by a gradual  extension.
During the  last twenty-five years the malarial  district near the city of New
York has extended far upward on the banks of the  Hudson River, eastward
into  the State of Connecticut, and along the banks of the Connecticut River
into  Massachusetts, periodical fevers  until lately not having been endemic in
these situations for a long period.
  The telluric source of malaria is proven by the fact of its being endemic in
certain localities.  Facts show that the morbific agent  remains near the sur-
face of the earth.   Persons sleeping in an upper story may escape when those
sleeping on a level with the ground become aff'ected.  It is more abundant in
the night-air than during the day, and hence the disease  may often be escaped
by avoiding exposure in the  evening, night, or early in the  morning.   The
special cause of this disease is not eliminated from the bodies of those affected
in such a manner that the  causation ever involves a contagium.  Facts abun-
dantly prove that the disease is not communicable from one person to another.
The malarial fevers therefore belong among those  distinguished  as  purely
miasmatic.
  Various attempts have been made to  discover  parasitic organisms in the
blood of persons affected with  malarial fever.  The  so-called ague-plants or
palmellae, which  Salisbury in  a paper published in 1866  claimed  to  be the
special cause of malarial fever, have  at present only historical interest.   The
same may be said of the bacilli which Klebs and  Tommasi-Crudeli found in
the  ground of  malarial regions, and  which they supposed to be the  special
cause of malaria.   There  is  no proof whatever that either the  palmellae of
Salisbury or the alleged  bacillus malariae of Klebs and  Tommasi-Crudeli are
in any way  concerned in the production of malaria.  Bodies which were dis-
covered in  1881 by Laveran  in  malarial blood, and which have been  more
carefully studied since 1883 by Marchiafava and Celli in Rome, deserve more
serious  consideration.1  These  bodies are found usually  within red blood-cor-
puscles, but they may exist free in the blood.  They vary in size, the average
being about one-third the size of red blood-corpuscles, but many are smaller
and  others are  larger than  this.   Many of the  bodies contain black or dark-
brown pigment-granules, and others are free from  pigment. AVhen unstained
the bodies are clear and homogeneous in appearance (with the exception, pos-
sibly, of included pigment), and so delicate that they are not readily detected.
The bodies can  be stained with fuchsin, methylene-blue and some other
aniline  dyes.   In  stained specimens the shape of the  bodies  varies,  some
being round, others elongated, crescentic, and of various other, often very
irregular, shapes.  In a drop of fresh  blood  the bodies are  endowed with
the  power  of  movement,  changing  their shape  in  a  manner  analogous to
the  amoeboid movements of white blood-corpuscles,  and even more rapidly.
Exceptionally,  movable thread-like filaments are attached to the bodies.  The
main point  in  favor of these  bodies  being living organisms is their property
of amoeboid movement.  They have been found only in  the blood of malarial
patients, and chiefly during a paroxysm of malarial fever.  They may be pres-
ent in  only  a few red corpuscles or they may be abundant.  Marchiafava and
Celli claim to have produced typical intermittent fever  by the injection into  a
  1 Laveran, Trade des  Fievres palustres, Paris, 1884; Marchiafava  and Celli,  several
articles in Fortschritte d. Medicin in 1883 and  1885. The latter authors call this supposed
parasitic organism, Plasmodium malarise.
  Councilman and Abbot in  1885 described the presence  in malarial blood of small
hyaline corpuscles, most of which contain  pigment.  These  corpuscles are probably
identical with those  found by Marchiafava  and Celli. (SSee  Councilman  and Abbot,
Am. Journ. of the Med. Sciences, 1885.)
  In the preceding edition of this book the presence  of a hyaline envelope  around
malarial pigment-granules  was mentioned. 
INTERMITTENT FEVER.
1003
vein of a person free from malarial history of malarial blood containing these
bodies, and to have afterward found similar bodies in the blood of the individ-
uals experimented upon.1  They consider these bodies to be parasitic organisms
which penetrate the red blood-corpuscles, which they partly or wholly destroy,
and in which they elaborate the characteristic malarial pigment.  If these bodies
be parasitic organisms, they are entirely diff'erent from bacteria and resemble
amoebae.  It is urged, as a point in favor of the view that the parasitic organism
of malaria is an amoeba-like organism rather than a bacterium, that quinine
exerts a much more powerful influence in arresting the vitality of the amoebae
than that of the bacteria. Attempts to cultivate  these bodies have failed.  It
has been urged, in opposition to the view that these bodies are parasitic organ-
isms, that they may be the result of some degenerative or other metamorphosis
in the red blood-corpuscles.  The possibility of such a metamorphosis cannot be
denied, but it would be without analogy in any known pathological changes.2
Should Laveran's corpuscles prove to be parasitic organisms peculiar to mala-
rial blood, the evidence for regarding them as the specific cause of the disease
would  of course be very strong.3
   The period of  incubation is indefinite.   It may be a few days only or a
few weeks, but it is not  infrequently many  months, and perhaps years may
elapse  after the reception of malaria before  its morbid effects are  manifested.
Auxiliary conditions often appear to be necessary to give efficiency to the spe-
cial cause.   An attack is liable to occur after exposure to  cold, over-exertion,
excesses in eating or drinking, etc.   The activity of the special cause is also
often awakened by the occurrence of some other affection.  The disease occurs
especially in the  spring  and  autumn, probably in consequence of the action
of auxiliary causes in  these seasons.   The vernal intermittents are in general
milder than the autumnal.
   The disease shows no preference for either sex and it affects all ages.
   If the paroxysms be caused by the development and multiplication within
the body of vegetable organisms,  it is to be  supposed that a crop  sufficient to
occasion an attack either dies or  is eliminated when the paroxysm ends, and
that from germs remaining in the system other successive  crops are produced
after definite periods of time corresponding  to the different types of the dis-
ease.  These different types  seem  to imply different varieties of the ague-
producing organism.

   Diagnosis.__In well-marked cases the diagnosis offers no difficulty.  The
type is to be determined by the duration of the intervals and a comparison
of the paroxysms.  Latent and masked intermittents are  not so easily recog-
nized • and in arriving at a positive diagnosis the effect of treatment is some-
times to be considered.   Febrile paroxysms resembling those of intermittent
fever are sometimes observed in connection  with pulmonary phthisis.  They
may present the  three  stages well marked, and recur at regular intervals.
They oftener occur in  the afternoon than in  the forenoon, whereas the reverse
obtains in intermittent fever.   The coexistence of phthisis is to be taken into
account  in making this differential diagnosis, as well as the known exposure
to malaria or otherwise.   The treatment appropriate  to  intermittent fever
will sometimes arrest  the  paroxysms connected with phthisis.   Chills  con-
nected with suppuration  in some of the internal  organs may suggest as proba-
ble  the  action  of malaria in  malarial  districts.  The irregularity of their

   1 Gerhardt had  previously produced intermittent fever by the injection into human
beings  of malarial  blood.                                       .
   •-' Unless such an  analogv exist in tbe " AA urmchen" found by (mule in frogs blood.
   3 Laveran's corpuscles have been demonstrated in malarial blood in Algiers, in Italy,
and in  this country. 
1004
PERIODICAL FEVERS.
 occurrence, the  inefficacy of treatment specially directed to a malarial affec-
 tion, and  the  discovery of the local affection will in time clear up the diag-
 nosis.  Happily, the remedies  indicated in malarial diseases are rarely hurt-
 ful  in  the cases in which intermittent fever is incorrectly supposed to exist.
 Operations on the  urinary passages, such as  catheterism and lithotrity, some-
 times produce paroxysms  resembling those  of intermittent fever.

   Prognosis.—Ordinary or simple intermittent fever as regards  immediate
 danger is not a  grave  affection.  AVhenever the disease involves  immediate
 danger, it is to be  considered as pernicious, and not therefore belonging under
 the  head of ordinary or simple intermittent fever.  An important fact  is that
 an intermittent fever at first devoid of immediate danger may become per-
 nicious.  An ordinary  or simple intermittent may prove remotely  serious, if
 it continue long or recur frequently, by inducing anaemia, general dropsy, or
 the  malarial cachexia.   The remote effects of the disease, however, are  rarely
 in themselves fatal.  Death may result from the association of intermittent
 fever with other affections.   It has been supposed that  this  disease  exerts a
 protective influence against the development of pulmonary tuberculosis.   So
 far from this being true, there is reason to believe that it promotes the  devel-
 opment of the aff'ection just named in those predisposed to it.  It is not a
 small calamity to  contract intermittent fever, on account of the liability to
 relapse and to its recurrence in connection  with other diseases.

   Treatment.—For the  cure of intermittent fever medicine possesses spe-
 cifics if any remedies be entitled  to this appellation.  This statement applies
 especially  to the  salts of quinia, of which the sulphate and the bisulphate are
 almost  universally used in this country.  The salts of quinia will promptly
 interrupt the recurrence of the paroxysms of intermittent  fever in the vast
 majority of cases.   It  is always desirable to  arrest the disease as speedily as
 possible.   Its morbid effects  are  less in proportion as it is quickly arrested
 and  the liability to  relapses is diminished.   There is no need of preparatory
 treatment.  This position was taken  by the  author in  an  article  published
 more than forty years ago.1   An experience  embracing many hundred  eases
 in different climates since the date  of that  publication has abundantly con-
 firmed  the correctness  of this position.   Aside from the  delay in arresting
 the  disease, the  measures  heretofore employed  to  prepare  the system for
 quinia or other special  remedies were injurious.   These measures were mer-
 curial cathartics, emetics, and sometimes  bleeding.   They are not indicated
 in the treatment of intermittent fever.  A consideration of no small  import-
 ance, as enforcing an immediate employment  of the abortive  treatment,  is the
 possibility of an intermittent fever, at first simple or ordinary, becoming after
 several  paroxysms  pernicious.
  AVith respect to the time of giving the antiperiodic remedy, my experience
 has  led me to the  conclusion at which  Bretonneau, Graves, Briquet, Trous-
 seau, Murchison, and others have arrived—namely, that it proves most effect-
 ive when given as near  as possible to the paroxysm which has passed.  It is
 probable that  if it  be given in the sweating  stage the chances of preventing
 the next paroxysm are greater than if the  administration  be delayed  until
 after this  stage.    As  regards  doses, the  most efficient  plan is  to give the

  1 A^ide American Journal of the  Medical Sciences^ October, 1841. This article contains
 a series of observations on  the employment of quinia in single  doses of from twentv to
forty  grains.  At that time this  treatment was novel and bold. The author believes
that he was  the first in this country to make observations with  respect to the treatment
of intermittent fever by large, single doses of quinia without preparatory measures and
given at different periods in the paroxysm. 
INTERMITTENT  FEVER.
1005
remedy so as to produce evidence of cinchonism as speedily as possible.  This
object may be  accomplished  by giving at  a single dose the quantity sup-
posed to be required.  This quantity for an adult is between ten and twenty
grains.   A dose of ten or twenty grains is generally tolerated by the stom-
ach as well as smaller doses.  An objection, however, to this  method is that
the quantity  estimated  as  sufficient may  not  be  large  enough  or  it may
be  larger  than  is required.   A preferable  method, therefore, is  to give the
remedy in smaller but not in small  doses, which are to  be repeated at inter-
vals of two or three hours until cinchonism  is produced.  The latter  is indi-
cated  by tinnitus aurium ;  and this effect is in  general  evidence  that a
sufficient quantity has been  administered.   For an adult five grains may be
given at a dose, and repeated after four hours once, twice, or thrice if neces-
sary for the  effect just  stated.  By this method of treatment in a  case  of
quotidian type the chances that another paroxysm will or will not occur are
about  even.   In a  case  of tertian  type the chances that  another will not
occur predominate.  If another paroxysm  occur the same  method of treat-
ment is to be repeated.
   As regards the form in which the  sulphate of quinia may be administered,
it is most efficient when  given in solution, its solvency being secured  by the
addition of a minim  of the aromatic  sulphuric acid for each grain  of the salt.
Owing to its greater solubility if given in pills, powders, capsules, or wafers,
the bisulphate is to  be preferred to the sulphate. If, owing to  the irritability
of the stomach, the  remedy be not retained when given  by the mouth, it may
be  given per enema.   It is  readily absorbed  from  the  intestine, and  the
opinion has been held by some that  it acts more efficiently when  thus given.
According to most  observers, however, the quantity when given by the rec-
tum should be  larger than when given by  the mouth.
   The plan of treatment just described is almost invariably successful.   If
it fail,  there is  always reason to  suspect  that the preparation of  quinia
employed is  spurious or adulterated.   A difficulty in some cases relates to
an  intolerance of the remedy.  Some persons are affected very unpleasantly
by even small doses  of a salt of quinia.  This intolerance is not infrequently
imaginary, but it is sometimes real.  In such cases small doses must be given
or some one of the remedies to be presently mentioned should be substituted.
As a rule, small doses are curative in  the cases in which the remedy is tolerated
only in  small quantities.   On the other hand, some persons are  affected by the
remedy only when full or even large  doses are given; and as a rule such per-
sons require larger doses than others.  Cinchonism is evidence that the requi-
site quantity has been given, but this need not be produced except in a slight
decree.    The coexistence of another affection does not contraindicate  the
plan of treatment which has been described.  In all cases in which inter-
mittent fever is complicated with other affections, the primary object of treat-
ment is to interrupt the  paroxysm as speedily as possible.   In children and
infants the doses are to be less than  in adults  in proportion to the age.   In
young children,  owing to the difficulty of administration  by the  mouth, the
remedy may  he  given per enema.   It may also be  employed effectively  by
inunction, an ointment containing it  being rubbed into  the axilla and groins
and over the abdomen.   I  have met with a few instances in which moderate
doses of quinia have produced menorrhagia, occurring at a period when men-
struation was not due.
  The hypodermic injection may he  resorted to in cases  of ordinary intermit-
tents when the remedy is not retained either by the stomach  or rectum.  This
mode of administration has the advantage of economy as  regards the quantity
of the remedy required, experimental observation appearing  to show that the
effect is three or four times greater when thus administered than when taken 
1006
PERIODICAL  FEVERS.
into the stomach.   The effect is  also more quickly induced.  It is, however,
in cases of pernicious intermittent that the hypodermic injection of a solution
of quinia is of special value, by reason of the certainty and promptness with
which cinchonism may be induced by this mode of administration.  In simple
intermittents the risk'of abscesses at the places where the injections are given
renders them unadvisable.   Binz  states that pure amorphous hydrochlorate
of quinia is especially well adapted for subcutaneous injection, dissolving in
an equal  weight of water, this not giving rise  to  abscesses.
   After  the paroxysms are  interrupted,  the remedy should be continued in
small doses, between four and eight grains daily, for a considerable period.  It
is desirable to  continue it for several weeks.   If anaemia exist a chalybeate
should be conjoined.   Relapses are prevented  by this  after-treatment.  The
diet should be nutritious, and a little  wine with meals is  advisable.   Cathar-
tics are to be avoided.  Given before the interruption of the paroxysms, they
conflict with that object.  If there be constipation,  it should be remedied by
mild laxatives or enemas.
   The germ theory affords a rational explanation of the specific efficacy of
quinia in  this disease.   This drug is destructive to certain low organisms, and
its efficacy is due to its action as a parasiticide.   This statement  will probably
apply to  other  remedies which have a controlling influence over the disease.
   Preparations of cinchona other than the sulphate of quinia are more or less
effective  in arresting intermittent fever.   The sulphate  of quinidia appears to
possess an antiperiodic power not less than that of the sulphate  of quinia.  It
has less  bitterness and is more soluble.   The sulphate  of cinchonia and cin-
chonidia  are much less effective.  Amorphous quinia, called quinoidia,  chin-
oidine, or the precipitated extract of bark, must  be  given in doses of double
the size of the doses of sulphate of quinia.
   There  are several succedanea  of the preparations of cinchona which .are
capable of arresting the disease.   Salicin  is successful in  a certain proportion
of cases.  Between 40 and 60 grains are to be given in an intermission. The sul-
phate of bebeerine is frequently successful, and it has been  claimed in behalf
of this remedy that it does not produce the unpleasant effects which are some-
times caused by the preparations of cinchona.   From 15 to 30  grains are to
be given in the apyrexial period.   The ferrocyanide of  iron, or Prussian  blue,
I have found an efficient antiperiodic in  doses of between 1 and 2 drachms.
Patients take it with reluctance, its appearance suggesting the idea of poison.
Strychnia and nux vomica often  succeed.   Chloride of sodium, given to the
extent of 8 or 10 drachms in the  apyrexia, effects a cure in a certain  propor-
tion of cases.  Piperine sometimes proves curative.   Many practitioners give
this remedy in combination with the preparations of cinchona. Arsenic is prob-
ably, next to the preparations of cinchona, the most reliable remedy.  Fowler's
arsenical  solution is  the form generally employed,  given in doses of  5  to 10
drops three times daily to an adult.  The muriate of ammonia, in  doses of a
drachm  in  the  intermission, appears  to exert an antiperiodic power.   Nitric
acid in doses of 8  or 10 drops continued during the  intermission and par-
oxysm, once in six hours, has been  found to be efficacious.  The  iodide of
potassium has proved successful  in some cases when the disease has  resisted
quinia.   To  the foregoing  are   to be added  the  eucalyptus  globulus and
hydrastia,  This list might be extended.   It is to be borne in mind, in  judg-
ing of the effect of remedies in this disease, that it tends intrinsically to end
after a few paroxysms in a certain proportion of cases.  All the known  reme-
dies which may be employed as  succedanea of the preparations of cinchona
are  much inferior  to the latter.  None  are to be preferred except in  some
cases in  which from an idiosyncrasy the preparations  of cinchona  are not
tolerated.   They may sometimes  come into play where  the preparations of 
INTERMITTENT FEVER.
1007
cinchona cannot be  procured, and they have  the  advantage of being less
costly  than  the latter..
  The administration of pilocarpine  at or shortly  before the beginning of
the paroxysm has been found by Dr. Gaspar Griswold to prevent or arrest
the paroxysm, and in many instances  there is  no recurrence.1   The remedy
acts with most  certainty if administered hypodermically.  The dose for hypo-
dermic use is one-fifth of a grain of  the muriate of pilocarpine dissolved  in
ten minims of  distilled water.   Given by the mouth, the dose  is one-fourth
of a grain.   For feeble  patients these doses should be somewhat reduced.
This method of treatment has sometimes succeeded in effecting a cure when
the disease had resisted other measures. The efficacy of this treatment estab-
lishes the fact that to prevent a paroxysm or to render it abortive may be
sufficient for  the cure.   A full opiate  at the beginning of the cold stage often
appears to shorten and modify the severity of the paroxysm.  It sometimes,
indeed, acts as an abortive measure, and may even effect a cure of the disease.
I have known  a sinapism applied over the whole  length  of  the spine  at
the beginning of the cold stage to arrest the  paroxysm and effect a cure.
This result  has been obtained by dry cups applied  to the spine  and by fric-
tion with the  spirits  of turpentine.   The  method of Mcintosh—namely,
bleeding in the cold  stage—was sometimes effectual, but for obvious reasons
it is not to be  recommended.  A paroxysm appears to be sometimes warded
off by taking to the  bed  before the hour when it is  expected, and keeping up
warmth of the body by bottles of hot water or other  means.  External warmth
is useful in the cold stage, and stimulants may be given internally if tolerated
by the stomach. The internal use of chloroform has been highly recommended.
Given in drachm doses (either alone, followed immediately with  cold water, or
suspended in mucilage) at the beginning of the  paroxysm, it has been found
to arrest the chill and induce a refreshing sleep, from which the patient awakens
without prostration.  The duration and severity of the paroxysm appear to be
lessened by this treatment,
   During the hot stage relief is procured by sponging the body with cold or
tepid water.  Pieces  of ice, ice-water, or carbonated water may be taken freely.
During the sweating stage comfort is promoted by wiping the body with warm
flannel and changing the linen and bedclothes.
   Anaemia and general  dropsy, occurring as sequels,  claim  tonic remedies,
into which the preparations  of  cinchona  and iron should enter, with nutri-
tious diet and  other hygienic measures calculated to restore the  strength and
invigorate the body.   Enlargement of the  spleen is to be treated with the sul-
phate of quinia or other preparations  of cinchona, and a belladonna plaster or
anodyne embrocations applied over the enlarged organ.  If these  measures
fail, the iodide  of potassium may be tried.  Faradization and the cold douche
applied to the region of the spleen have been found useful.
   The preparations  of cinchona and other antiperiodic remedies are effica-
cious as prophylactics.  Taken  in  small  doses  daily by persons exposed  to
malaria, they ward off attacks of intermittent fever and they prevent relapses.
There is no foundation for the popular notion that the prolonged use of the
sulphate of quinia in small or moderate doses is prejudicial to health.  I have
known an instance in which two or three grains had been taken daily for twenty
years, the person having found by experience that by this means he was exempt
from relapses of intermittent fever.   Other means of prophylaxis  have been
already stated in treating of the causation.
                    1 ATide N Y. Med, Journal, Aug:, 1880. 
1008
PERIODICAL  FEVERS.
                  Pernicious Intermittent Fever.

  Simple or ordinary intermittent  fever is not attended with immediate  dan-
ger; but the disease is sometimes  presented in forms more or less dangerous,
and'it may prove fatal within a few days or hours.  These  forms of the dis-
ea.se are to be considered apart from simple or ordinary intermittent fever, and
collectively they constitute a variety of the disease called pernicious, maliguant,
and congestive.  Of these names the first is commonly adopted by writers.  The
term congestive, although much used in the Southern and AVestern portions of
this country, is objectionable, as implying that the primary or essential patho-
logical state is congestion—a doctrine which probably is incorrect.
  "pernicious intermittent fever occurs in isolated cases wherever the simple or
ordinary variety of the disease prevails ; but, happily, such cases are extremely
rare.  It, however, prevails at certain epochs in malarial regions.  Of the cases
of intermittent fever which occur at these epochs, the proportion in which the
disease is pernicious is more or less large.  In some seasons the fatality from
the disease  is very great, and it constitutes one of the most formidable of
the maladies which the physician has to  encounter.   In  this country it has
prevailed chiefly in the Southern and AVestern States.   In view of the  great
danger  attendant  on pernicious intermittent fever, and of the fact that the
success of prompt and  efficient treatment  is perhaps more conspicuous in this
than in any other malady involving an equal amount of danger, the disease is
one of great importance.  It will, however, suffice to notice the symptomatic
features by which the  different forms are distinguished from simple or  ordi-
nary intermittent fever, together with the therapeutical indications.
   Different  observers agree that in many, if not in most, cases a pernicious
paroxysm is preceded  by one or more paroxysms not characterized  by any
symptoms  denoting gravity of disease; hence the vast importance, especially
whenever cases of the pernicious variety are known to have  occurred, of
resorting in  every case at once to prompt and  efficient measures to interrupt
the  paroxysms.  In a certain  proportion of cases, however, the pernicious
character of the disease is manifested in  the first paroxysm, and  death  may
take place in that  paroxysm.   Drake  states that the pernicious character is
sometimes foreshadowed by some slight anomaly in the first paroxysms,  such
as " a partial numbness or coldness of the  great toes instead of a regular chill,
or a disposition  to sleep at the  access of the paroxysm."  According to this
author, in the cases in which the pernicious character is gradually developed
the  cold stage in the early  paroxysms is  not strongly marked, the hot stage
is imperfectly developed, and in the intermissions the patient may he pursu-
ing his usual avocations.  Both patient and physician are liable to be thrown
off their guard by the  mildness of the paroxysms preceding  the one which is
pernicious.
   The symptomatic features of pernicious paroxysms vary much in different
cases; and on account of these diversities this variety of the disease may be
considered as embracing several forms.   More or less complete coma charac-
terizes  some cases, and these cases are distinguished as comatose, soporose, or
apoplectic intermittents.   Other cases are characterized by delirium preceding
coma.   The delirium is  sometimes active,  the patients requiring to he re-
strained.   Examples have fallen  under  my observation.   Epileptiform con-
vulsions occur in some cases.   Intense jaundice appears early in the so-called
icteric variety.   A form called algid is characterized by notable reduction  of
temperature, the extremities becoming cold as marble or the coldness  being
like that of a cadaver.   Profuse sweating  characterizes some  cases. A'omiting
and purging are not infrequently prominent symptoms, leading to a state  of
collapse like that in cases  of epidemic  cholera.   The secretion of urine is 
                PERNICIOUS INTERMITTENT FEVER.           1009

sometimes  suppressed, and albuminuria is not infrequent.   In  a form which
may be called  asthenic there are  great  restlessness and  prostration, with a
notably small, feeble, and irregular pulse.   The development of well-marked
febrile movement, with a full, regular pulse and heat of  skin, is evidence
that the patient will  struggle through the paroxysm.  The  danger to be
apprehended from  another paroxysm is proportionate to  the  severity of
that from  which the  patient emerges  with  safety.   If  the  latter  have
involved very  great risk, the next will be likely to prove fatal.  The  pros-
tration in the intermission is  in proportion to the severity of the paroxysm.
   Hvema.turic malarial fever, which  is one  of the most important forms of
pernicious  fever, has already been considered  (p. 924).
   The diagnosis of all the forms of pernicious intermittent fever is aided by
the fact that as a rule the dangerous paroxysm is preceded by at least one
paroxysm,  and it  may be two or  three paroxysms, devoid of any symptoms
denoting danger, and by the fact that the pernicious paroxysm occurs in
accordance with the type of the disease.   In the forms characterized by coma,
delirium, or convulsions  cerebral meningitis and uraemia are to be excluded.
The former is excluded by the absence of symptoms of cerebral inflammation
exclusive of those  just named, and  the  latter is excluded by an examination
of the urine.   Microscopical  examination may show the presence in a  drop of
blood of black pigment  and  of the peculiar  bodies described under the head
of  Causation in the preceding  article.  Enlargement of the spleen also has
diagnostic  significance.
   Of the pathology of the several forms of pernicious as  compared with sim-
ple or ordinary intermittent fever, all that can be said, with our present know-
ledge, is, that the essential morbid condition existing in the latter variety in a
degree not  involving immediate danger  exists in the former variety in such
intensity as to  prove highly dangerous.  Intermittent fever is not the  only
affection which without any essential change in the nature of the disease is in
some cases extremely mild and in other cases extremely formidable.   Scarlet
fever may be cited  as another striking example.  The difference as regards
symptomatic phenomena and gravity between pernicious  and simple  or ordi-
nary intermittent fever is not explained by lesions found after death.
   Pernicious intermittent fever is often preventable, and many lives are saved
by timely efficient treatment.  It is doubtless prevented by promptly inter-
rupting  paroxysms  before they assume  a pernicious character.   In  seasons
when pernicious cases prevail there  is much risk of lives being sacrificed by
the delay in arresting the disease incident to the employment of the so-called
preparatory measures of treatment.   In these seasons especially the  curative
treatment should be resorted to at once in all cases of intermittent fever, and
the disease should be arrested as speedily as possible.   AAHien the disease has
become pernicious there are two great objects of treatment.  One of  these is
to  carry the patient  safely through an existing paroxysm; the other is to
prevent  another paroxysm.
   AVith  reference to  the first of these objects, the indications differ according
to the differences of form which pernicious paroxysms assume and according
to the symptoms whatever may be the form.  Enfeebled  action of the heart
always calls for stimulants, alcoholic, ethereal, and aromatic, severally or col-
lectively.  In  many cases the danger of the disease is manifested chiefly by
the symptoms  referable to the circulation.   In  these cases  the all-important
indication is to strengthen the heart's action.   Coma, unaccompanied by aug-
mented force of the circulation and increased heat,  does not  call for blood-
letting.  Bloodletting has been employed in the cold stage  of pernicious par-
oxysms of intermittent fever.  That patients have recovered under this treat-
ment by no means proves that it is  devoid of danger.  It is admissible only
        04 
1010
PERIODICAL  FEVERS
when the symptoms denote active cerebral congestion.   Coldness of the sur-
face is an indication for the external  application of heat by means of warm
blankets, bottles of hot water, etc , and  for  internal  stimulants.   A'omiting
and purging are to be restrained by opiates given  by the mouth  or rectum.
Opiates are also indicated by  restlessness,  delirium,  and convulsions.    In
connection  with the latter the kidneys are to be interrogated  with reference
to the existence of uraemia.   Emetics given at the  beginning  of  the parox-
ysm, although they have been much used, are of doubtful utility, and cathar-
tics should never be given.   Chloroform in drachm  doses deserves further
trial  as a means of abridging the cold stage.   The  doses should be repeated
until the hypnotic  effect of the remedy is obtained.  Pilocarpine, administered
hypodermically, will  become an invaluable  remedy if  it prove  as  successful
in arresting a pernicious paroxysm as it is in cases of a simple intermittent
fever.
   The second object—namely, to prevent  another  paroxysm—should enter
into the treatment  before the paroxysm, attended with more or less  immediate
danger, is ended.   AVith reference to this object  nothing can take  the place
of the preparations of  cinchona.  The succedanea of these preparations are
not to be relied upon if the latter can be obtained.   The sulphate, bisulphate,
or the muriate of  quinia should be given during the paroxysm, and given in
larger doses than in cases of ordinary intermittent fever, in view of the vastly
greater importance of arresting the  disease, and because the tolerance of the
remedy is  often much greater.  It  is  to  be given during  the  paroxysm, not
for its immediate effect, but to render more sure the  prevention  of another
paroxysm.   A scruple of the sulphate of quinia may be given at once by
the mouth  to an adult, and a larger quantity if given by the rectum.   After
three or four hours, if there  be no evidence of cinchonism, the dose may be
repeated.   It  is to be continued after the patient has  emerged from the par-
oxysm in doses of  between 10 and 20  grains, the intervals between the doses
being sufficient to indicate the effect of  each dose.   Cinchonism  should  be
produced and maintained during the  intermission without reference to the
quantity required ; but to  produce  this effect the enormous closes which  have
sometimes been given are never necessary.  Promptness and boldness are im-
portant, but excessive  cinchonism is not advisable,  and it is  to be borne in
mind that permanent blindness and deafness have resulted from the  use  of
quinia in  enormous  doses.  By pursuing the plan just  stated the remedy
may be employed as freely as may be necessary to obtain to the fullest extent
its remedial influence, without incurring much r,jsk of injury from  its toxical
effect.   In  a  case in which  it was considered that the life  of the  patient
depended on the prevention of another paroxysm, 120  grains of quinia  were
given in divided doses in about twenty-four hours.  The  paroxysm was pre-
vented, but suddenly, without having  previously had symptoms of  much cin-
chonism, he became  completely blind and almost completely deaf.   As may
be imagined, great anxiety was felt; but, happily, at  the  end  of eight hours
both the blindness and deafness had disappeared, and  the patient recovered
without any further untoward symptoms.
   The administration of quinia by  means of hypodermic  injections has been
found efficient in cases of pernicious intermittent characterized by coma and
inability to swallow.   It  may be resorted to when, from irritability of the
stomach, the  remedy will  not be  retained  if given by the mouth.
   The nostrum  called AVarburg's  tincture is  highly recommended by many
East  Indian physicians in the treatment of pernicious as well as of simple
intermittent fever.
   The pernicious paroxysm  having  been  experienced,  at the  time when
another paroxysm is to  be expected, provided  the type he  known, and on 
REMITTENT FEVER.
1011
the second and  third  day if the type be not ascertained, the patient  should
be in  bed at the hour when the  recurrence  is likely to take place, and the
body  should be  kept warm by artificial heat and hot, stimulating drinks.  An
opiate will render more sure the prevention of the dreaded paroxysm.
  After the interruption of the paroxysms some one of the preparations of
cinchona should be continued in tonic doses,  with a nutritious diet and other
restorative measures.  After both the pernicious  and  simple variety of inter-
mittent fever, if the malarious  cachexia remain in spite of appropriate meas-
ures of treatment, removal to a situation without the  sphere of the malarious
influence  during the  season when  this influence is rife  is to  be  advised.
                          CHAPTER  V.

                 PEBIODICAL FEVERS (Concluded).

Simple Remittent and Typho-malarial Fever: Anatomical Characters ;  Clinical History ;
   Pathological Character and Causation ; Diagnosis; Prognosis; Treatment.—Pernicious
   Remittent Fever.—Yellow Fever: Anatomical Characters; Clinical History; Causa-
   tion ; Diagnosis ; Prognosis ; Treatment; Prevention.

A FORM  of periodical fever is distinguished by the occurrence of remis-
     sions instead of intermissions, and hence is called reneittent fever.  It is
also known as bilious remittent or bilious fever.  The term bilious is superflu-
ous, and, so far as  it  has any significance, tends to perpetuate a pathological
error.   Between simple remittent and intermittent fever there is a  close rela-
tionship.   They are mutually convertible  into each other, they undoubtedly
involve the same special cause,  and they  are controlled by the same specific
remedies.  The propriety of  recognizing  remittent as distinct from intermit-
tent fever is denied by some writers.  Bouillaud  calls it a " real nosological
superfcetation " !  There is, however, a practical convenience in considering the
two forms as separate affections, admitting that they are essentially identical.
   Remittent fever  and typhoid fever  may be associated.   Not only may the
former present typhoid phenomena or the typhoid state, but the two diseases
occur not infrequently in  combination.  This statement embodies an opinion
held for  a lon<*- time by practitioners in malarial sections of this country, and
inculcated especially by Prof. Dickson.  Dr. Drake also maintained this opin-
ion, calling the combined  affection remitto-typhous  fever.1  I have for more
than  thirty-five years advocated this opinion in  medical teaching.2   More
recently  it has  been proposed to employ a name  denoting the union of the
two aff'ections, and  the term typho-malarial fever has been introduced by Dr.
Joseph J. AVoodward.3  I shall adopt  this name,  and consider remittent and
typho-malarial fever conjointly.  The facts which show the blending of remit-
tent and  typhoid fever will  be noticed under the  heads of Pathological Cha-
racter  and Causation.

  1  A'ide The Principal Diseases of the Interior  Valley of North America, Second Series,
Philadelphia, 1854, p. 557.
  2  Aide article by the author, in the Buffalo Med, Journal, 18)7.
  3  A'ide  Outlines of the  Chief Camp Diseases of the United States Army, etc., by Joseph
Janvier AVoodward, M. D., Assistant  Surgeon U. S. Army, etc., 1863. 
1012
PERIODICAL  FEVERS.
        Simple  Remittent and Typho-malarial Fever.

  By the term simple remittent fever is meant remittent not associated with
typhoid fever and  not accompanied by symptoms of gravity entitling it to be
called  pernicious.   Pernicious remittent  fever will claim a  brief separate
notice.  Typho-malarial fever will be considered in conjunction with simple
remittent fever.

  Anatomical  Characters.—The characteristic lesion of remittent fever
consists in the presence of dark pigment-granules in the blood and in various
organs of  the body.   The parts chiefly affected are the spleen, the liver, and
the marrow of the bones.  AVhen contained in the circulating blood the  pig-
ment may be found in the blood-vessels of any part of the body.  The pres-
ence of the  pigment in the blood constitutes the condition called mclauzemia.
The pigmentation of organs is  sometimes called melanosis.  Melanaemia and
melanosis  attend remittent fever, pernicious malarial  fevers, long-continued
intermittent fever, and sometimes the malarial cachexia.  The degree of  pig-
mentation depends upon the duration and the severity of the  malarial affec-
tion.   It is therefore most intense  in connection with  the severe malarial
infection of  warm climates.
  During  a  paroxysm of malarial  fever the spleen is  enlarged  from  hyper-
aemia.   This swelling at first subsides during an intermission, but under the
influence of prolonged malarial infection the organ becomes permanently en-
larged, constituting the so-called ague-cake.   The color of the swollen spleen
varies  between dark-red or brownish- and bluish-black in  proportion to the
amount of pigment present.  The consistence is soft when the enlargement is
recent or when death has occurred during a febrile paroxysm.   If there have
been no recent attacks the consistence is firm.   The swelling at first is due to
hyperaemia ;  and subsequently there is hyperplasia of the cellular elements of
the spleen, with new formation  and thickening of its  connective-tissue frame-
work.  The pigment is in the form of granules and of larger masses, and is con-
tained chiefly within cells and within the hyaline bodies described on p. 1002.
In recent cases its color is reddish-brown, and later it becomes black. The pig-
ment is in the splenic pulp, and is also accumulated about  the blood-vessels,
especially around the veins.  It is contained  also within the  splenic  veins.
Little or no pigment is found in the Malpighian bodies in  most cases.   The
cells containing the pigment  are chiefly the lymphoid cells, which constitute
the principal cellular elements of the spleen.   Pigment is also contained in
larger  and  more granular cells, and in long  fusiform cells which are consid-
ered to be  endothelial cells  of the  veins.
  The liver in most cases is enlarged, but  in cases of long duration it may he
atrophic.  The consistence is usually more or less softened.  The organ  pre-
sents a bronze, chocolate, or slate color.  It is called the bronzed liver and the
pigment liver.   It usually is hyperaemic.  The pigment-granules are  found
both  in the interlobular tissue and within the lobules.   They are enclosed
chiefly within cells.   They exist partly within  the blood-vessels and  partly
in the  extravascular tissue.  The pigment is  chiefly found within  lymphoid
cells, but  also  in  fusiform, and  sometimes in stellate, cells.   The fusiform
cells are considered by many writers to be derived from the spleen,  as similar
cells exist there and as the same cells are found in  the blood of the splenic
and portal veins.  The melanaemic pigment does not exist within the hepatic
cells.  These cells, however, usually contain a considerable  amount of yellow-
ish-brown pigment derived from the biliary coloring matters.   According to
Kelsch, there is an increased  number of lymphoid cells in the interlobular 
       SIMPLE REMITTENT AND TYPHO-MALARIAL FEVER.   1013

tissue.  This writer also maintains  that a form of cirrhosis may be produced
by malarial affection of the liver.
  Pigment is found in the marrow of the bones, both outside of  and within
the blood-vessels.   It  is contained in lymphoid  cells.   Pigmentation of the
brain forms a marked lesion in some cases of melanaemia.   The change in
color is most evident in the gray matter, which  acquires a dark-gray or slate
color contrasting markedly with  the white matter.   AVhen  the change is
intense the  white matter  also has a dirty grayish tint and  presents  many
puneta vasculosa.  In  some severe cases capillary hemorrhages  have  been
found in  large number.  These extravasations have been attributed to plug-
ging  up of the small cerebral blood-vessels with  pigment.  In  melanamiic
brains the pigment is  present chiefly within  the small blood-vessels.   It is
also found in  the walls of the vessels and in the perivascular spaces.  The
pigment does not exist in  large  amount in the brain unless it be also present
in the circulating blood.  If pigment be present  in the  kidney, it is met with
chiefly in the glomeruli.   The accumulation of pigment in other organs than
those  named  is not great.  It  may be found  in  lymphatic glands,  in the
spinal cord, in the lungs, in the pancreas, in the skin, in mucous membranes,
etc.   In these situations it is contained within the blood-vessels.
   The characters of the pigment in the blood, the source of the pigment, and
the  relations  between the  pigmentation of organs and  the presence of pig-
ment in the blood are subjects which have been discussed in the article on
Melanaemia in Part I. (p. 78).
   After death from remittent fever more or less  congestion and inflammation
of the stomach and of the  intestine are frequently found.  The mucous mem-
brane of these parts may present ecchymoses. The solitary glands and Peyer's
patches may be swollen.   The latter often present the shaven-beard appear-
ance.
   The  same  parenchymatous and hyaline degenerations  which  have  been
described under the  head of Tvphoid Fever  have also  been found  after
death from severe malarial fevers.
   Acute  nephritis, dysentery, and  pneumonia are  rare  complications of this
disease.
   In typho-malarial  fever, in addition  to appearances characteristic of mala-
rial  disease,  the abdominal lesions which  are essentially those characteristic
of typhoid  fever are  found after  death.1

   Clinical  History.—Under this  head I shall  present a  brief sketch of
simple  remittent  fever as regards especially its distinctive features,  and
afterward of typho-malarial fever.
   Simple remittent fever  often begins  abruptly, but  in a  certain propor-
tion  of  cases  it has a brief  forming stage,  the prodromes being the  same
as those  attending  the development of other  fevers.   The febrile career
begins  with  a chill more  or less pronounced, either with or  without rigor.
During the  chill, as in the cold stage of an intermittent paroxysm, the tem-
perature of the body is actually raised, as shown by the thermometer in the
axilla.   The  attack is oftener before than after  mid-day.  Febrile movement
follows, varying in intensity in different cases, accompanied with  cephalalgia,
pain in the loins, etc.   The thermometer in the axilla shows an  increase of
temperature of between 2° and  10° above the range of health.   The febrile
movement continues unabated for six, twelve, eighteen, twenty-four, and even
forty-eight hours, and then notably subsides; the pulse falls in  frequency,
  1 AVoodward at first believed that the intestinal ulcers of typho-malarial  fever pre-
sent certain peculiarities which distinguish them from those of ordinary typhoid fever.
Extended studies led him to abandon this view. 
1014
PERIODICAL  FEVERS.
the  skin becomes moist, the patient is  comparatively comfortable, and  may
obtain refreshing sleep.  The febrile movement, however, does not disappear ;
there is not apyrexia ; and there is a remission, not  an intermission.   The
temperature in  the  remission, as compared with the exacerbation, is notably
decreased, sometimes falling nearly to the normal standard.  The remission is
likely to occur during the  night.  The degree of abatement of febrile move-
ment varies in  diff'erent  cases, sometimes approximating  to apyrexia, and
sometimes the remission being  slight.   The duration of'the remission varies
between two or  three hours and one or two days.  At the end of the remis-
sion another chill may occur, but it is often wanting, and if present is gener-
ally slight.  The febrile movement is renewed with as much  or more intensity
than before  the remission.  A series of remissions may ensue, recurring in reg-
ular succession,  and, as regards the intervals, corresponding to the quotidian,
tertian, or frequently the double tertian type of an intermittent fever.   In a
case under  my observation the double quotidian type was represented by the
remissions;  that is,  two  distinct exacerbations  occurred daily.   The remis-
sions sometimes recur irregularly.   Different cases differ as  regards the num-
ber  of  remissions.   There  may be but a  single remission, or, on the other
hand, remissions may occur regularly  through  the whole course of the dis-
ease.  The  latter is rare.  In general the remissions  cease to be distinct after
a few days, and sooner or  later the  fever becomes continuous.   The febrile
career ends during the second or third week.   It eventuates in intermittent
fever in a certain proportion of cases.   In some cases the disease is preceded
by intermittent fever, remissions taking the place of the intermissions.  Dur-
ing  the  remissions there is a  marked  abatement of the temperature of the
body, the temperature during the exacerbations being notably increased.   In
this respect  remittent fever differs from typhoid fever exclusive of the period
of defervescence in the latter disease.  The fall in temperature, as shown by
the thermometer, may denote remissions which are not rendered apparent by
the general  symptoms.
  Early in the fever nausea and vomiting generally occur, and are frequently
prominent symptoms, continuing more  or less throughout the  febrile career.
The matter  vomited  is greenish or yellowish in  color.   Pain or uneasiness
is usually referred to the region of  the stomach, and there is tenderness on
pressure over the epigastrium.  Diarrhoea, tympanites, and iliac  tenderness
are wanting.  Sordes is rarely observed.   Delirium is  rarely a  prominent
feature,  and when present it  is due to the  intensity of febrile  movement.
The urine is scanty, its coloring matter is increased, and its specific  gravity
is high.  It is rarely albuminous.   Jaundice occurs in a certain  proportion
of cases.
  If simple remittent fever be protracted, certain  symptoms  denoting the
typhoid state may appear—namely, low delirium, sordes, subsultus tendinum,
etc.   These  symptoms are not sufficient to show the union of  typhoid fever
and  remittent fever.   They are liable  to occur in all fevers and in  various
other affections.
  In  typho-malarial  fever the symptoms  distinctive of typhoid fever are
intermingled with those of periodical fever.  The symptoms referred to are
those connected with  the abdominal  lesions of  typhoid  fever—namely, diar-
rhoea, tympanites, and iliac tenderness.   These symptoms  become more or
less marked  during the second week of the career of the disease.  The cha-
racteristic eruption of typhoid fever may be observed.  The  ataxic symptoms
belonging to the  typhoid state—namely, low delirium, deafness, subsultus  ten-
dinum, etc.—occur more frequently, earlier, and in a more  marked degree than
in connection with simple remittent fever.  Enlargement and suppuration of
one or both  parotids are sometimes observed in cases of typho-malarial fever. 
       SIMPLE REMITTENT AND TYPHO-MALARIAL FEVER.  1015

This form of fever is preceded by a forming stage longer than in cases of
simple remittent fever.   The duration of  the febrile career is longer and the
gravity of the  disease is greater.  Perforation  of the intestine is liable  to
occur.   Bronchitis is a common complication, and  pneumonitis is  developed
oftener than in simple remittent fever.  Convalescence  is likely to be pro-
tracted in cases of typho-malarial fever.  Distinct malarial paroxysms often
occur during convalescence.  In different  cases of the disease the phenomena
of typhoid fever and of periodical fever  are intermingled in varying propor-
tions, in some cases the  periodical and in  other  cases the  typhoid phenomena
preponderating.  In proportion as the phenomena of the one or the other dis-
ease predominate cases will approximate, on the one hand,  to simple  remittent,
and on the other hand to typhoid fever.

   Pathological  Character and Causation.—Simple remittent fever,
as regards its essential pathological  character, does not differ from  intermit-
tent fever.   Both are  due to the special  poison  known as  malaria.  True
remittent fever  is never  contracted  elsewhere than in  malarial  situations.
The distinction between the two diseases  is nosological rather than patho-
logical.
   Typho-malarial fever is caused by the combined action of malaria and the
special cause of  typhoid fever.  Practitioners in malarial situations have
been accustomed to say that remittent becomes converted into typhoid fever.
This mode of expression is not accurate.  There is not a metamorphosis of the
one  disease into the other, but a combination of both diseases, the phenomena
of the one or of the  other disease predominating  in  different cases.  Typho-
malarial fever  is  not  a distinct type of  fever.  It is,  however, of great
importance to recognize the combination of typhoid and of malarial fever.1
   Cases of typho-malarial fever  occur in most if not in  all malarial  regions.
This fact shows that the special cause of typhoid fever is not held in abey-
ance by the prevalence of' malaria, and  produced only after  the  latter dis-
appears.  The extinction of malaria is followed by cases  of unmixed typhoid
fever, and hence it has appeared as if the  latter  follows in the wake of the
periodical  fevers.   The typho-malarial  fever  prevailed  largely among  the
United States troops in certain  situations during the recent civil  war. espe-
cially  in the Army  of the  Potomac  in  the  Peninsular  campaign of 18(52.
when  it was known as the Chickahominy fever.  It was called elsewhere dur-
ing the war camp fever.
   Simple remittent and typho-malarial fever prevail especially in the autumnal
season.  Persons of  all ages are liable to be affected with simple remittent
fever.   There  is no evidence that this fever is ever contagious, or that the
malarial poison producing it is portable.  Its occurrence affords no protection
against its recurrence.

   Diagnosis.—Simple remittent fever  is  readily discriminated from simple
intermittent fever by the occurrence of notable remissions instead of inter-
missions.  The thermometer in  the axilla may show  the occurrence of these
when  they are not distinctly manifested by symptoms aside from those relating
to the temperature of the body.   A  notable variation in temperature at differ-
ent periods of the day  in the'early part of the  disease, the mercury rising to
a high point at one period  and falling nearly within the range of health at
another period, warrants the exclusion of typhoid fever.  Exclusive of remis-
sions the differential  diagnosis involves the following points:
   The abdominal symptoms of tvphoid fever are wanting in simple remittent
   1 \Tide article by AVoodward on " Typho-malarial Fever," in  the  Transactions of the
International Medical Congress, Philadelphia, 1877, p. 305. 
1016
PERIODICAL  FEVERS.
 fever, and  in  place of these are the gastric symptoms distinctive of the lat-
 ter—namely, nausea and vomiting, with tenderness over the-epigastrium.  The
 ataxic symptoms of  the  typhoid  state are either wanting in simple remittent
 fever or they occur at a later period.  The typhoid eruption is wanting.  The
 access is much oftener abrupt  and accompanied  by a more pronounced chill.
 Paroxysms of intermittent fever are liable to occur at the close of a remittent
 fever.  Finally,  remittent fever is developed  only in malarial districts or in
 persons who have been exposed to malaria.  There can  be no question as to
 this  differential  diagnosis in cases of  disease  occurring  in a situation where
 malaria is known not to  exist  and when the patient is  known  not to have
 been within a malarial influence.
   Typho-malarial fever is discriminated, on the one hand, from simple remit-
 tent fever by the characteristic events of typhoid fever—namely, the abdomi-
 nal  symptoms, the eruption in some  cases, the  earlier  occurrence of ataxic
 phenomena, epistaxis, and occasionally intestinal perforation.  It is discrim-
 inated, on the other hand, from unmixed  typhoid fever  by the characteristic
 events of periodical  fever—namely, remissions,  gastric  symptoms, jaundice,
 and the  termination  in some cases in  intermittent fever.   The  diagnosis of
 typho-malarial fever  by means of positive  symptoms may be difficult, espe-
 cially if  the abdominal symptoms and  the eruption of typhoid be absent, as
 is frequently the case.  The  diagnosis  is to be based on the presence of more
 or less of the symptoms  belonging to  malarial and to typhoid fever, and on
 negative  facts which serve  to  exclude other fevers.

   Prognosis.—Simple remittent fever in itself does not involve  danger to
 life.  In fatal cases the termination is  due to coexisting affections.  Of course
 it is to be understood that cases of pernicious remittent fever are not included
 under the head  of simple' remittent fever.   An attack  of remittent fever
 leaves behind  it a liability to subsequent attacks of intermittent fever, and is
 liable to  be followed by the sequels of the latter disease—namely, enlarged
 spleen, anaemia, and general dropsy.   This disease differs  much in severity at
 different times and places and in different cases  at the same time and  place.
 As a rule, it is likely to be more severe in tropical than in  temperate climates.
   Typho-malarial fever is a much graver affection than simple remittent fever,
 and it is  certainly not less grave than typhoid  disconnected  from malarial
 fever.  Like the latter, the rate of mortality differs  at  different times and
 places, owing to  differences as  regards  the intrinsic tendency of the disease
 and a variety of circumstances.  Data  for determining the average death-rate
 are not available, as it  has not been customary to  separate cases of this dis-
 ease from cases,  on the one hand, of  simple remittent  fever in which the
 typhoid state  occurs, and on the  other hand of typhoid fever without the
 combined  action  of malaria.

  Treatment.—The first and leading object in  the treatment of  simple
 remittent  fever is the arrest of  the disease by antiperiodic remedies, of which
 the preparations  of cinchona are by far the most reliable, the sulphate, the
 bisulphate, and the muriate of  quinia being the preparations to be preferred.
 As soon as the  character  of  the disease is determined by the  occurrence of
 a remission, one  of these salts  of quinia should be  given  in  a  full dose__
 namely, 10 or 20  grains to an  adult.   The remedy should he continued in
 doses  of 5 or 10 grains after  intervals of from two to four hours until it pro-
duces slight deafness or  ringing in the ears, suspending the  remedy when
these manifestations of cinchonism appear.   If other preparations of cinchona
be used, they are to be given in equivalent  doses  in  the  same manner.  If
the remedy be not tolerated by the stomach, it should be given  per enema. 
PERNICIOUS REMITTENT FEVER.
1017
If cinchonism be not produced during the remission, the remedy may be con-
tinued during the exacerbation of fever.  This is preferable to waiting  for
another remission.   In a case in which  the practitioner is satisfied that a
remission  has already occurred—in  other words, whenever the diagnosis is
clear—the remedy should be given at once, notwithstanding the intensity of
the febrile movement, without waiting for a remission.  Time need not in any
case be lost in resorting to cathartics or  other measures  preparatory to  the
administration of an  antiperiodic  remedy.  In short, the  treatment is essen-
tially  the  same  as in  cases of intermittent fever.   This plan of treatment
will succeed  in a large proportion of cases in promptly arresting the disease.
   Aside from the treatment just stated, palliative measures are to be employed
according to  the indications in individual cases.  The indications will relate
to pain in the head, nausea and vomiting, vigilance and restlessness,  heat and
dryness of the skin, etc.  The same measures are  to  be  addressed  to  these
symptoms as when they are  present in  other  fevers.  It is unnecessary to
consider these measures in this connection.   The treatment during convales-
cence is the same as after other fevers, except that  a preparation of  cinchona
should be employed for some time in conjunction  with a chalybeate, as after
an  attack of intermittent fever.
   The plan of treatment which has been sketched does not embrace measures
heretofore considered important in this disease—namely,  emetics, cathartics,
bleeding,  and the use of mercury.   Emetics are contraindicated by the condi-
tion of the stomach.   Cathartics are not indicated by the disease per se.  They
are required  only to  overcome constipation, and  generally simple  enemata or
mild  laxatives will suffice for  this  object.   Bleeding is  called  for  only  by
active cerebral congestion or  intense febrile movement with augmented power
of the heart's action, the  patient being robust and  plethoric.  Under the  lat-
ter circumstances sedative remedies, saline laxatives, and cold to the surface
will generally be sufficient without  the  abstraction of blood.  The  external
use of cold water is highly useful  when the skin is  notably hot and dry. The
wet sheet may be employed,  as in cases of typhoid fever.   Opium,  given in
pretty full doses early in the disease, appears  sometimes to exert  an  effect
beyond that of a  palliative  by  inducing a more marked remission.  The
pathological  views which formerly led practitioners to employ mercury freely
in this disease are not tenable, and clinical observation affords no  ground  for
regarding this remedy as specially  indicated.
   In  typho-malarial  fever the periodic element claims the  treatment indicated
in simple  remittent fever.  The object is to  eliminate this element by means
of antiperiodic remedies.  Aside from this object, the hygienic and medicinal
measures  indicated are the same  as  in  cases of unmixed  typhoid fever.  To
discuss these measures here would he to repeat what has been  presented in
the chapter in which the treatment of typhoid fever is considered.  The reader
is therefore referred  to that chapter.
   It is highly important to recognize the existence of the  malarial element
in cases  of   typho-malarial  fever with reference to  continuing  antiperiodic
remedies throughout the course of the disease.   I have known death to occur
from  a paroxysm of intermittent fever when  the symptoms had denoted con-
valescence from the typhoid  fever, the autopsy also showing that restorative
processes  were taking  place  in the intestinal ulcers.   Probably in this case
quinia in  antiperiodic doses, continued throughout the  course of the fever,
would have  prevented the fatal  paroxysm.

                   Pernicious Remittent Fever.
   A brief notice of pernicious remittent fever will  suffice.   This fever is  dis-
tinguished as pernicious under circumstances  similar to those which constitute 
1018
PERIODICAL FEVERS.
grounds for the application of the same  term to intermittent fever—namely,
circumstances giving to the disease unusual gravity and danger.  This variety
of the disease  is also called malignant and congestive.   Pernicious remittent
fever presents the same diversities as regards symptomatic phenomena as per-
nicious intermittent fever.   In  cases in which death takes place  quickly it is
impossible to determine whether the disease be intermittent or remittent; and
a fatal result may take place before either a remission or an intermission occurs.
The occurrence of an intermission or of  a remission is the chief differential
point.   The two forms of  disease, in a pathological view, are essentially the
same,  and they claim  the same  treatment.   The  importance of pernicious
remittent fever is by no means to  be measured by this brief notice of  it  ;
but inasmuch as all  that is of practical importance in relation to  this disease
is embraced in the consideration of pernicious intermittent fever, the reader is
referred to that portion of the preceding  chapter which treats of  the latter.
  Remittent fever, especially the  pernicious variety, has received in different
parts of the world  a  variety of  names denoting its geographical relations,
such  as AValcheren  fever,  African fever, Hungarian fever, jungle fever, lake
fever,  etc.

                            Yellow Fever.
  The fever to be now considered has received a great variety of names, but
it is at this time everywhere known as yellow fever—a name tbe  significance
of which is derived from the frequent occurrence of  yellowness of the surface
of the body.   Although the name relates  to a symptom not constantly pres-
ent, and occurring occasionally in  other fevers, it has the merit of not involv-
ing any hypothesis concerning the nature or causation of the disease.

  Anatomical Characters.—The morbid appearances which are most fre-
quent  are situated  in the liver, in the stomach and intestine, and in the kid-
neys.  The liver may  be  somewhat enlarged,  but  it  generally  presents  no
marked change as regards  size.  It is pale in color rather than congested.  Its
consistence is often diminished.  The most characteristic change is the yellow
color which the organ presents in  most  (although not in all)  cases.   The
change in color may affect the whole liver or may exist in a  larger or smaller
number of scattered patches.  The abnormal coloration is due to the presence
of fat, as was proven  by Alonzo  Clark in 1853.  The fat is in the form of
large and small  drops in the  liver-cells.  According  to  some observers, fat is
found  also in the interstitial tissue.  The process  is  to be regarded as  an
acute fatty degeneration of the  liver.1  Some writers describe an actual dis-
integration of some  of the hepatic  cells  in  yellow fever.  The yellow color
may be due in part to jaundice of the liver.  The  combination of bile-stain-
ing and  of fatty metamorphosis produces the so-called saffron-colored liver.
Small  ecchymoses are often  found upon the  surface of the liver.  Schmidt
describes the occasional presence in the liver, as well  as elsewhere, of reddish-
brown  stains which he attributes to extravasations of haemoglobin.2
  The mucous membrane  of the stomach is  usually swollen,  softened, and
congested.  Small hemorrhages  are found in the mucous and submucous tis-
  ' The presence of large oil-drops is not a sufficient criterion of fattv infiltration  in
distinction from  fatty  degeneration. (Consult  Part I.  p. 53, and the article on  Fatty
Liver, p. 611.)   It is incorrect to regard the hepatic changes in yellow fever as compar-
able in degree or extent with those in acute yellow atrophy of the liver.   There is still
less ground for the assumption that the essential symptoms of yellow fever are referable
toan acute parenchymatous or fatty degeneration of the liver "(Liebermeister, Schmidt-
leinl.
  -_Schmidt, "The Pathology of Yellow Fever," New York Medical Journal, 1879, vol.
xxix. p. 128. 
YELLOW FEVER.
1019
sues.   The stomach often contains a dark, bloody fluid, which is of the same
nature as the black vomit to be described under the head of the Clinical His-
tory.   The cells of the gastric tubules undergo parenchymatous degeneration.
There may be an extensive accumulation of lymphoid cells in the submucous
and other coats of the stomach.   Changes similar to those of the stomach are
found in the upper part of the small intestine, and they may extend downward
to a variable degree.  The upper part of the intestine contains in some cases
black matter  similar to that found in the stomach.  The Peyerian and soli-
tary  glands of the intestine present no morbid  alteration.
   The kidneys usually are enlarged and the seat of parenchymatous degene-
ration.   They often  contain small  extravasations of blood.  Acute  diffuse
nephritis is a frequent accompaniment of yellow fever.  In this condition the
cortex is swollen and  presents a yellowish-white color mingled with congested
and hemorrhagic portions.  The epithelial cells of the convoluted  tubes con-
tain fatty molecules.  Red blood-corpuscles are found  in the tubes as well as
in the intertubular tissue.   Collections of emigrated  white corpuscles are
met with between the tubes.  Miliary abscesses have been seen exceptionally
in the kidneys of  those who have died of yellow  fever.
   It is a remarkable fact that in a disease so acutely infectious as yellow fever
the spleen as a rule undergoes no enlargement.  The lungs are often the seat
of hypostatic congestion.  In many cases hemorrhagic infarctions have been
found  in the lungs.  The pleura as well as  the pericardium and other serous
membranes frequently presents small  ecchymoses.  Parenchymatous and fatty
degeneration of the myocardium has been frequently seen in some epidemics.
The brain and its  membranes present nothing distinctive.  No changes have
been discovered in the blood other than those  belonging to most of the essen-
tial fevers.   The  attempts  to discover a specific  organism in the blood and
tissues  have thus  far met  with no  success.1

   Clinical  History.—An attack  of yellow fever usually is abrupt.   In a
minority of cases it is preceded for one, two,  or three days  by languor, lassi-
tude,  loss of appetite, pain in the head, and chilly sensations.  The attack is
generally denoted by a chill, with or without  rigor, the chill  in most cases
being of moderate intensity.  Fever  follows, differing in intensity in diff'erent
cases.   The temperature quickly reaches its maximum, which varies between
102° and 110° F.  The  pulse seldom exceeds 100.  The tongue is moist and
more or less coated.  Aromiting occurs in a certain proportion of cases early,
but it rarely is  a prominent symptom  until a later period.  Tenderness  on
pressure over the  epigastrium is more or less marked.   The  bowels, as  a rule,
are constipated.   Cephalalgia, the pain referred especially to the supraorbital
reo-ion, is usually present, and is sometimes intense.  Frequently pain in the
loins  and pain in the lower limbs, especially in  the calves  of the legs, is a
prominent  symptom.   This fever bears an analogy to smallpox in the fre-
quent prominence of lumbar pain.   The mind usually is clear,_but occasion-
ally delirium is manifested,  rarely violent and  active, and sometimes mirthful.
The  eyes are reddened,  irritable, watery, or tearful.  This is quite constant,
and so marked as to constitute a diagnostic feature.   Otherwise, the  organs
of sense are not disturbed.   Generally there are no pulmonary symptoms.
   The pyrexia continues for a period varying between a few hours and three
days.   Then follows either  a marked abatement or entire cessation of  fever.
A remission is said to take place ; but this term is not always accurate, inas-
much as there may be complete  apyrexia, and  in a certain proportion of cases
there  is no  return of fever.  The' condition following  the  febrile paroxysm
  1 The published observations of Freire  and of Cremona  upon this point are not of a
nature to inspire confidence in their conclusions. 
1020
PERIODICAL  FEVERS.
has been called "the state of calm."  This is reckoned  as the second  stage
of the disease, the first stage embracing the period of fever, the  latter  being
called  the "febrile period," the "stage of excitement,"  or the "paroxysm."
The first stage may be regarded as constituting the disease proper, and  what-
ever may follow as sequels of the  disease.   The  disease is then a fever with
a single paroxysm. In mild cases convalescence takes place immediately after
this  stage.
  In grave cases the cessation of fever is often deceptive.   The pains, etc.
may cease, and the patient may feel as if convalescence had begun ; but after
a period varying between a few hours and twenty-four or longer there are new
symptoms more distinctive  of the affection  than  those during the febrile par-
oxysm.  The pulse  sometimes falls below the normal frequency, and it has
been observed to fall as low as 40, and even 30, per minute.  It is sometimes
small and weak, and  sometimes vibratory.   It is always notably compressible,
and has been called a " gaseous pulse."  The surface is usually cool, especially
of the parts of the body which are exposed.   In the few cases which 1 have
noted capillary congestion of the skin existed in a marked degree.   Lividity
of the back, attributable to hypostatic congestion, is sometimes observed.
  Of the symptoms  referable to the digestive system, those most character-
istic pertain to the stomach.   A'omiting occurs, if not already present, and if
present it becomes more prominent.  In a large proportion of  fatal cases and
in a  few of the cases ending in recovery the black vomit  occurs.   This, taken
in connection with other  symptoms, is pathognomonic of the disease.   Here-
tofore there has been much discussion respecting  the nature of the vomited
matter, but it is settled that the appearances are due to blood changed by the
action of the gastric fluids.   As regards  the  gross appearances, the matter
vomited is a thin  liquid  of a reddish, brown, claret, or  blackish color, with
sediment resembling coffee-grounds.  Occasionally the liquid is  bright red,
the blood having  undergone but little  change.   Rarely it has a greenish or
yellowish tinge, from the presence of bile.  The secretion is acid, and it has
an acid  taste without bitterness.    It  is  sometimes acrid, excoriating the
throat,  tongue, and  lips.   The microscope shows the sediment  to contain
disintegrated particles of  food, mucus, epithelium, blood-pigment,  and de-
formed blood-discs,  often decolorized.   Fungus-spores are often found.  A
fluid  resembling the black vomit  may be produced artificially by adding an
acid to blood out of the body.  The bilious matter  vomited  in  some  cases
of remittent  fever presents somewhat similar  gross characters, but chemical,
microscopical, and  spectroscopical examination shows the  presence of bile and
the absence of blood-constituents.   The black  vomit in different cases of yel-
low fever is more or less abundant.  It is sometimes ejected with force, and
sometimes by an act of regurgitation rather than of vomiting.  It generally
ceases for a period of from twelve to twenty-four  hours  before death.   The
black vomit rarely occurs until after the febrile paroxysm. It occurs at vari-
able periods afterward, but generally not until  toward  the close of the dis-
ease.   Blair described a matter vomited prior to the black vomit, limpid or
slightly opalescent, which he termed the " white  vomit."  Tenderness over
the  epigastrium is more or  less marked,  and the  tenderness is sometimes
extreme.   The tongue  is frequently reddened,  dry, and cracked ;  in  some
cases it  is  moist and covered with a creamy coating, and sometimes it pre-
serves its natural  appearance.
  During the second stage  the evacuations  from  the bowels are frequently
of a  brownish, approaching to a black, appearance.   They resemble sometimes
tar or molasses.   This appearance is due to the presence of blood, so altered,
however, in its passage through the intestinal canal that its morphological
characters are not demonstrable.  Uric  acid and the triple phosphates may be 
YELLOW FEVER.
1021
found in the evacuations from the bowels.  Sometimes blood but little altered
is passed from the bowels.  Diarrhoea in this as in the first staae is rare.  The
abdomen is soft and  seldom meteorized.  The melaenic discharges  generally
precede the occurrence of black vomit, and they have been called the -• black-
vomit  stools."
   Albuminuria is of  frequent occurrence in  grave or fatal cases.   Hyaline
and granular casts, red blood-corpuscles, renal epithelium, and epithelium
from the bladder are  found in the sediment of the urine.1  A scanty secretion
of  urine or  suppression not  infrequently precedes a fatal  ending.   Uraemia
occurs in a certain  proportion of cases.   The  urine in certain  cases becomes
of  a yellow or orange color from  bile-staining, and it is sometimes bloody.
   Yellowness of the  surface of the body—whence the disease derives its
name—occurs after the febrile paroxysm.  The conjunctiva becomes yellow,
and this with the redness gives to the eye a striking and peculiar appearance.
The yellowness  of the  skin  is especially  marked on the  chest and  upper
extremities.   The jaundice is probably hepatogenous, but it is considered by
some as haematogenous.   It exists in only a certain  proportion of cases.  It
occurs in a much larger proportion of fatal than  of non-fatal cases, and, in
fact, it occurs in a  small proportion of the latter.   The yellowness continues
after death  and  into  convalescence.
   Hemorrhage in  various  situations other than the stomach, intestine, and
the kidneys or bladder, to which reference has been already made, is often a
striking  feature  of the  disease.  It occurs from the nostrils, gums, uterus,
wounds or abrasions of the skin, and sometimes from the eyes, meatus audi-
torius, finger-nails,  holes  bored  in the ears for ear-rings, etc.   Petechiae and
vibices  are sometimes observed.
   As regards symptoms  referable  to the nervous and the  muscular system,
coma and  convulsions are of occasional occurrence.  They are probably de-
pendent  on uraemia.  Delirium  is observed, but frequently the mind remains
clear.  Delirium may exist during  the fever, and disappear afterward.   Gen-
erally there is notable muscular prostration, but to this rule there are remark-
able exceptions.  Patients sometimes do not take to the bed, but keep about
their usual avocations, not thinking themselves much  ill, often a few hours
before death.  These have been called " walking eases."  Rush relates  a case
in which the patient  stood up before a glass and shaved himself on the day
of  his death.  In a case cited by Bartlett the patient, a soldier, continued to
do  duty until black vomit took place.   In another case the patient  dictated
and signed a letter a quarter of an hour before  death.   Cartwright cited an
instance  of a shoemaker who nearly finished a shoe the  day before his  death.
Fenner saw a patient quietly  reading a book  after the  black vomit had
occurred.   These  cases  exemplify a kind of cheerful  delirium,  as it was
called by La Roche, in which the  patient fancies  himself  well or but little
ill.
   The physiognomv of patients is  described by different writers with a good
deal of metaphor, but nearly all state  that it  is characteristic.  The face is
flushed.   The appearance  of the  eyes is  described by different writers as
injected, brilliant, transparent, fiery, and glassy. To the facies are applied the
following terms :  suffering, dejection, anxiety, anguish, despair, terror, stupid-
ity, vacancy, astonishment, sullenness. etc.  The diversity of these terms raises
a suspicion  that  the  peculiarity of the  physiognomy is less distinctive than
observers have generally supposed ; at all events, it appears to be difficult to
convey by  language a clear idea of the characteristic appearance.
  The duration of the disease after  the febrile  paroxysm varies between
  1  A'ide " The Urine in Yellow Fever," by Prof. J. AV. Holland, in the London Prac-
titioner, July, lb79, and  the American Practitioner, Sept., 1879. 
1022
PERIODICAL FEVERS.
 twelve hours and three or four days.  In  cases of great gravity the dura-
 tion  is brief, the disease  running rapidly to a fatal  termination.
   Writers recognize a third stage in fatal cases, called  the stage of collapse or
 the stage of exhaustion.   The collapsed  condition is denoted by prostration,
 feebleness and irregularity of the pulse, coldness of the extremities, low delir-
 ium in some cases, the intellect remaining  clear in other cases, and  mental
 indifference or apathy generally existing as in cases  of epidemic cholera,—
 these symptoms showing  tendency to death by asthenia.  Coma and convul-
 sions  sometimes occur in this stage, attributable, probably, to uraemia.  In
 some cases this  period is characterized by great  restlessness, jactitation, and
 general distress;  but in other cases the patient remains quiet and seems  free
 from  suffering.
   If death do not take place, the third stage is  the  stage of  convalescence.
 AA'hen  the disease passes to the second stage, and  presents the grave symp-
 toms  belonging to  this stage—namely, black vomit,  hemorrhage, etc.—the
 recovery is always slow,  and is frequently preceded  by fever having more or
 less of the phenomena of the typhoid state.   Relapses sometimes occur  after
 convalescence appears to be declared.
   In mild cases the disease ends in convalescence immediately following the
, paroxysm of fever.  AArhenever an epidemic  prevails  there  is a certain  pro-
 portion of cases devoid of any gravity.   In these cases a slight chill occurs,
 followed by moderate  pyrexia continuing for one or two days, and recovery
 quickly takes place.   These cases would not be recognized as cases of yellow
 fever except from the fact of their  occurrence during the prevalence of an
 epidemic.  AVhen this mild  form of the disease occurs it is not infrequently
 a matter  of doubt whether  patients have  had the disease  or not.
   More severe  cases are distinguished by the  intensity of the pyrexia.   The
 term inflammatory, often applied to  these cases, is not  correct, inasmuch as
 the intensity of the febrile movement is not due  to inflammation, but  to the
 fever per se.  Malignant cases are those characterized by black vomit  or pro-
 fuse hemorrhage in other situations, followed by collapse or exhaustion, and
 also  cases  in which coma or convulsions occur  with suppression of urine.
   The duration of the disease is variable.  Shortness of its career is a distin-
 guishing feature.  In  the shortest cases death or convalescence takes place in
 two  or three days.   According to  La Roche, the duration varies between
 three and  nine  days.  The average  duration is less  than a week.

   Causation.—The peculiar features of this disease, its limitation within cer-
 tain  geographical boundaries, and its occurrence as an epidemic, warrant the
 inference that it requires for its production a special cause.   Does the special
 cause emanate  from the  bodies of those affected with the disease? in other
 words, is the disease contagious?  This question  has given rise to much dis-
 cussion.   Aolumes have  been written by contagionists and non-contagionists
 in defence of the two  opposing doctrines.   It is  evident that the question  is
 one of great importance in its  bearing on commerce and quarantine laws, as
 well as on precautionary measures respecting exposure in visiting or attending
 upon those affected with the disease.  (For a full consideration of this  topic
 the reader is referred to works treating in  extenso of  yellow fever, and  espe-
 cially to the elaborate treatise by La Roche.)  I shall simply state the grounds
 which substantiate the non-contagiousness of the disease :
   1. The disease is confined  within certain territorial limits.   In this  respect
 it differs from most diseases the contagiousness of which is established.  Even
 in localities in which it is prevailing as an epidemic it is sometimes restricted
 to a  circumscribed area.
   2. The rise and progress of epidemics are  not consistent with its diffusion 
YELLOW FEVER.
1023
by contagion.   For example, Fenner, with great zeal and fidelity, traced the
first 30 or -10 cases in the epidemic at  New Orleans in  1853, and ascertained
that the disease broke out in different  places  among persons who could have
had no communication with each other.   Fenner investigated the origin  and
spread of the disease  in  New Orleans for twelve  years, and stated that he
never found the least proof of personal coniniunicability.  This is alike true
of epidemics in other places.1
  3.  In certain places within  the yellow-fever  zone sporadic cases occur
almost every year.  According to Fenner, a summer never  passes in which
there is not a greater or  less number of sporadic  cases in  New Orleans, but
the disease  prevails as an epidemic only in certain  years.  Were the disease
contagious it should be diffused more or less whenever  there are any cases
of it.
  4. AATien it prevails as  an epidemic  it spreads too rapidly to be diffused by
contagion.
  5. Persons going from  a district where it prevails into a district where it
does not exist,  and becoming attacked in  the latter, do not communicate the
disease.  There is abundant evidence  that this is  the rule, and  the apparent
exceptions are  so few and of such a character that it is most logical to explain
them otherwise than by the supposition of contagion.
  6. Persons brought into close  contact with  yellow-fever patients—physi-
cians,  nurses,  or other hospital  patients—do not  contract the  disease.
  7. Epidemics run a certain course as  respects duration, and  abruptly end,
in this respect  resembling epidemics of cholera.  The disease should prevail
longer and disappear more  slowly if  propagated by contagion.  Like other
epidemics, the  disease, as a rule, becomes milder by continuance.  It appears
to absorb other diseases while it continues, in  this respect resembling epidemic
cholera, and its prevalence is arrested  by cold.  These facts, especially the two
latter, are not  consistent  with the doctrine of contagion.
  8. The great majority of those who have had an extensive practical acquaint-
ance with the disease believe it to be non-contagious.
  9. Experiments  to test the question of communicability,  by inoculation, by
swallowing the black vomit, and by the utmost possible exposure, have led to
negative results.  To cite one among many experimental  observations, Dowler
gives  the following account: In  1805, Don  Cabanellos,  a  Spaniard, slept  at
night  with his  children in beds in the  lazaretto  in which  yellow-fever victims
had died.   For submitting the question of contagion to this  personal test he
was made physician to the royal household, with an annuity of twelve hundred
dollars.  A number  of galley-slaves  who accompanied  him had  one year's
imprisonment remitted.   The whole party amounted to fifty, and no one suf-
fered  any  harm.
  10.  Complete seclusion has proved  ineffectual to prevent the  disease.
  In  view of the foregoing  considerations, to which others  might be* added,
it seems certain that yellow fever is not produced by means of  a contagium.
Yellow fever, therefore, is a  purely infectious  miasmatic disease, using this
term as already defined.   (A'ide p. 85.) Another question arises in connection
with  that  of  contagion—namely, May not  the infection  be transported  in
clothing, merchandise, etc., and the disease be  in this way  imported?  Facts
have  established an affirmative answer  to this  question.    The  special cause
can in this way be  distributed by vessels, railroads, and other  conveyances.
The fact of the disease  being portable renders judicious quarantine restric-
tions  of vital  importance, but in view of its non-contagiousness the restric-
tions  need  not include the  detention of persons.
  1 A'ide article  on " Epidemiological  Conclusions and Suggestions," in Brit, and For.
Mcdico-Chirurg. Review, Oct., 1870, p.  484. 
1024
PERIODICAL  FEVERS.
   Of  the nature of the infection we  have not, as yet, demonstrative proof.
 Something, however, is known of the conditions under which it is produced.
 It  is indigenous in warm climates.  Yellow fever is rarely  developed south
 of  20° south or north of 40° north latitude.    It prevails more in the East-
 ern than in the AVestern  Hemisphere, and in  certain  parts of Kurope and
 America than in Africa.   In  the AVestern AVorld it prevails especially in the
 commercial  towns  on the Atlantic coast south of  Charleston, S.  C., on the
 Gulf of Mexico, and in the AVest India islands.  It rarely prevails in rural
 situations.   It prevails only in the summer season in other than tropical cli-
 mates,  and  in  the  latter chiefly during the hottest months.   A high temper-
 ature is essential to its causation, but in  yellow-fever  localities epidemics do
 not always  occur in the  years in which the temperature is highest.  Humid-
 ity has been supposed to favor the development of the disease, but this is not
 conclusively established.   There does not seem  to be  ground for connecting
 the causation with any known  meteorological  conditions  other than  a  high
 temperature.  As  stated by  Nott, the special cause  is  most active near the
 ground, persons on  a ground-floor being more likely to be attacked than those
 in stories above.   The miasm is more active at night than in  the daytime.
   In localities where the disease prevails often the conditions for its develop-
 ment do not uniformly exist  during the  hot seasons.   Epidemics occur  only
 in certain years.   It seems that the efficiency of the special cause is favored
 by  the  co-operation of other causes, and hence  sanitary measures—drainage,
 sewerage, removal of filth, avoidance of overcrowding, etc.—contribute to the
 prevention of yellow-fever epidemics.
  Unaeclimation is  a condition pertaining to individual susceptibility.  Natives
 of yellow-fever localities are rarely attacked.   Particular epidemics, however,
 have been characterized by a considerable number of cases among  the native
 population.   Not having  experienced the disease is another personal  con-
 dition.   The disease  having  been once experienced, the susceptibility to the
 special  cause, as a  rule, is extinguished.   The number of persons  who have
 the disease more than once is probably not greater than the number of excep-
 tions to the rule that smallpox and typhus render the  system insusceptible
 ever afterward  to  the  special  causes of these diseases.   Acclimation,  as
 regards  this  disease, is complete only when  the  disease  has been expe-
 rienced.
  The  negro race  seems to be singularly exempt  from a liability to this dis-
 ease.   Statistics show the mortality among negroes to be insignificant.  It is
 stated, however, by Fenner that the insusceptibility is not nearly so great as
 mortuary statistics  seem to show, in consequence of the fact that the disease
 in the  negro is  almost  invariably mild and not likely to  prove fatal.  The
 susceptibility is not affected  by age, persons of different ages, inclusive of
 infancy, being liable to the disease.  Statistics  show a larger proportion of
 cases atnong males than  among females.
  The special cause is destroyed by cold.  It is a matter  of  common obser-
 vation that  an epidemic is arrested by one or two hard frosts.  Epidemics,
 however, have a  self-limited  duration.   Fenner noted that  at  New Orleans
 repeatedly the disease disappeared before the  occurrence of frost.   An epi-
 demic  rarely continues longer than 60 or 70 days.   Barlow calculated the
 average  duration of yellow-fever epidemics, and finds it  to  be  58.33 days,
 being somewhat longer than  the mean duration  of  epidemics  of  cholera.
  Of the nature of the special  cause or infection, as already stated, positive
proof has not as yet been obtained ; but that the disease is produced by spe-
cific germs or organisms is as logically established as with respect to any of
the  infectious diseases the causes of which have  not been demonstrated.
 Assuming the existence of yellow-fever germs, the production of the disease 
YELLOW FEVER.
1025
 by filth or any local conditions without the presence of these germs'can only
 be considered as possible by those who  hold to the doctrine of spontaneous
 generation.   While, as  already stated, certain  obvious local conditions may
 have an  auxiliary agency, that these conditions are essential is 'disproved by
 instances in which the disease is developed in situations as healthy as possible
 in a sanitary  point of view.  The multiplication of germs  without the body,
 therefore, may take place irrespective of any apparent local causes.  The
 organisms which furnish  the  yellow-fever germs are exotic as regards most
 if not all parts of this  country.   The sporadic cases  which appear in New
 Orleans  in seasons  when  the disease  is not epidemic are probably  due  to
 germs which have  escaped destruction having been placed  under circum-
 stances  favorable for retaining  their vitality.   This has been  called the
 "laying over" or the "hibernation" of germs.  Germs attached to  cloth-
 ing or other articles under favorable  circumstances may probably retain
 their vitality and infective capability for a long period.
   The period of incubation is variable.  It varies  between two and  fifteen
 days, and in  the majority of cases it  is nearer the first than  the second of
 these  numbers.   Campbell has reported an  instance in which the period was
 nearly six weeks.1

   Diagnosis.—The access of the  disease  and the  symptoms during the
 febrile or first  stage present nothing very distinctive.  All observers agree
 that it is often difficult to  arrive at a positive diagnosis during this stage.  In
 a  considerable proportion of cases the disease at the  end  of this stage ter-
 minates  in convalescence.   These cases would not be considered as cases of
 yellow fever except during an epidemic.   The disease in these cases presents
 the characters of a febricula.   The symptoms which have  diagnostic  signifi-
 cance  are—the abruptness of the attack, pains in the back and limbs, and
 suffusion or redness of the eyes.
   In cases progressing beyond the febrile paroxysm and presenting the grave
 events which are liable  to follow, the diagnostic features are sufficiently dis-
 tinctive.   They  are—yellowness of the conjunctiva  and skin,  black  vomit,
 hemorrhages  elsewhere  than from the  stomach, epigastric  tenderness, slow-
 ness of the pulse in certain cases, coldness of the extremities, suppression
 or  a scanty secretion of urine, and  the phenomena denoting collapse.  All
 these events  are not  present  in  every case, but generally enough  of them
 exist to render  the  diagnosis  positive.   The march of the  disease to  a fatal
 is.sue from the end of the febrile paroxysm or the first stage in well-marked
 cases is peculiar, and it can hardly be  confounded with any other affection.

   Prognosis.—The mortality from yellow fever varies much in different epi-
 demics.   The range of variation  is between 10 and 75 per  cent.2  The aver-
 age mortality, according to calculations by La Roche, is 1 in 2.32.  The rate
 of  mortality differs in different periods of the same epidemics, the rule being
 a  decrease in the rate as  the epidemic  approaches  its termination.   Beniiss
 gives the  rate of mortality in private practice during the  epidemic  of 1878
 in New Orleans as 10 per  cent, among white patients  and  3 per cent,  among
 colored patients.  The mortality during the same  epidemic among hospital
 patients  was  51.7 per cent, for white and 21 per cent, for  colored patients.3
   Unfavorable prognostics are—yellowness of the surface, black vomit, great

  1 " The Yellow-Fever Germ on Coast  and  Inland," by Henry F. Campbell, M. D.,
 Trans, of  the Med. Association of Georgia, 1879.
  - DaCosta, Medical Diagnosis, Philadelphia,  1881, p. 828.
  :i S. M. Beniiss, article on " Yellow Fever" in Pepper's System of Practical Medicine, by
American Authors, Philadelphia, 1885, vol. i.
65 
1026
PERIODICAL  FEVERS.
diminution or suppression of urine, abundant hemorrhage in any situation,
coldness  of the  extremities, jactitation, hiccough, delirium, convulsions, and
coma.  Of these symptoms, black vomit and suppression of urine are almost
invariably forerunners of  death.  Coma and convulsions are fatal symptoms
dependent on uraemia.
  A favorable prognosis cannot be confidently entertained in any case of this
disease.  Unfavorable events are liable to occur when up to the time of their
occurrence the symptoms appeared  to be favorable.   Black vomit, hemor-
rhage elsewhere, and  uraemic convulsions or coma are liable to occur unex-
pectedly  in  cases which appear  to  be progressing  favorably.
  Exclusive of cases  in which  the immediate cause of death is uraemic coma,
the mode of dying is  by asthenia.

  Treatment.—With  reference  to the treatment of yellow fever, it is to be
premised that no specific remedy has been discovered.  There is no known
plan of treatment on  which  reliance can be placed to cut short the  disease.
Another  consideration to be premised is that the disease, exclusive of malig-
nant cases, tends to recovery.  Mild yellow fever is a very mild  disease, not
tending to destructive lesions of  either the solids or fluids, nor  does it tend
to continue indefinitely if not arrested, like intermittent  fever.
  A third preliminary consideration is that in  a considerable proportion of
malignant cases  the  disease  is necessarily fatal.  Hence,  a large proportion
of fatal  cases  is by no means proof of injudicious treatment.  A fourth con-
sideration is that diff'erent epidemics differ as regards the relative proportion
of mild and malignant cases.   In some epidemics most of the cases are mild,
and in others  malignant.  It follows that the ratio of  recoveries under a cer-
tain plan of treatment may be no test of the superiority of that plan.  Meas-
ures which appear to be eminently successful in one epidemic may appear to
fail in  another epidemic, the difference being due to  variations as regards the
tendency of the disease to a fatal issue.
  In cases of mild yellow  fever no active interference is required.  Quietude,
restricted diet, ventilation, and other hygienic regulations, together with such
palliative measures as particular symptoms in individual  cases may indicate,
suffice for the treatment.  The palliative  measures  embrace anodyne and
refrigerant remedies, cold applications to the head,  sponging of the body,
laxatives in some cases, etc.   It  is, however, to  be  borne in mind  that the
disease may become malignant in cases which are at first mild in  appearance.
It is impossible  always to distinguish at the outset the cases which will prove
to be mild, and hence  it is of vast importance to take every precaution to pre-
vent the development of grave symptoms.   For this end  hygienic measures
are especially  or chiefly important.   Patients should at once give up to the
disease and take to the bed.  As  complete rest of body and mind as practica-
ble is  to be enforced.  The services of a faithful and experienced nurse  are
of more  importance than medication.   Free ventilation, cleanliness, and other
sanitary  measures are not less important in this  than in other forms of fever.
   In cases characterized  by intensity  of fever during the febrile paroxysm
no  one entertains at  the  present time the  propriety of bloodletting.   Anti-
pyretic measures of treatment—namely, cold sponging and  the wet  sheet—
are rationally indicated. Data are not  as yet available for forming an opinion
as to the efficacy of these measures in  preventing the grave events of the dis-
ease and in lessening  its mortality.
   Purgatives have been  much  employed in this as in most other diseases.
Drastic or active purgatives do harm  by increasing the gastro-intestinal irri-
tation  and producing exhaustion.   Even if well borne, it is difficult to  see
what indication  they fulfil  which may not be equally met by mild laxatives 
YELLOW FEVER.
1027
or simple enemas.   The latter are indicated  by constipation.   Purgation,
except in some cases  for the  purpose of eliminating urea, is to be avoided.
Emetics, which have also been  much used, are  contraindicated by the gastric
symptoms which belong to the  history of yellow fever.
  Mercury has  been  considered as important in this disease.   Calomel in
large doses has been much used, and  it has been thought to be desirable to
produce ptyalism.  This practice has  now but few advocates.   Facts do not
warrant  the  opinion that  mercurialization  is in any sense curative, and the
testimony of most physicians who have had practical  acquaintance with this
disease is adverse to the use  of  mercury in any form.
  Measures to relieve  gastric  irritability are often  indicated.   For this end
counter-irritation over the epigastrium may be employed by means of small
blisters, dry cupping, sinapisms, and stimulating liniments.  Anodynes, given
either by the mouth or  by the hypodermic method, are indicated for this end.
Other  remedies are chloroform in small doses, prussic  acid,  and  creasote.
Ice swallowed in small pieces has been found useful  in allaying irritability of
the  stomach.   To  prevent black  vomit, and with  a  view  to arrest gastric
hemorrhage when it has occurred, the acetate of lead with opium  has been
much extolled.   AVith  reference to this  event careful attention should be
given to the ingesta.   Milk with lime-water, not given in large quantity, is
probably the best article of  diet.   If sustaining measures be not indicated,
bland liquids only should be  taken  into the  stomach.
  Hemorrhages elsewhere call  for  local styptics if the source of the hemor-
rhage be accessible, and for ergot or other haemostatics.  In a case  related to
me  by a former colleague life was apparently saved  by  the transfusion  of
blood.
  Great restlessness and vigilance call for opium or other anodyne remedies.
Deficiency of the urinary secretion is an indication for diuretic remedies if
they be tolerated by the stomach, and for measures to produce diaphoresis if
diuretics he not borne or if they prove inoperative.  If symptoms be present
denoting uraemia, the hot-air bath should be employed. Under these circum-
stances elaterium or  some other hydragogue  may be advisable if  relief be
not  procured by diaphoresis.
  Sustaining measures  are indicated in proportion  as a tendency to collapse
or death by  asthenia is denoted by  the symptoms.   The irritability of the
stomach may interfere with the sustaining treatment.  The forms of stimulus
and  nourishment are to be selected which on trial are found to be best borne.
Alcoholic stimulants may be given per enema if not  retained by the  stomach.
Two of my  colleagues in the  New  Orleans  School of Medicine,  who  had
experienced this disease in  its severe or malignant  form,  attributed  their
recovery to the free use of alcoholic stimulants.  In  one of these cases, when
a fatal  termination was regarded  as  imminent, a favorable  change  occurred
immediately  after champagne  had been given freely.

  Prevention.—Measures  for the  prevention  of  yellow fever  relate—
1st,  to the removal of  local conditions which favor the multiplication  of
the disease-germs;  2d,  to quarantine regulations;  and  3d, to disinfection.
The  first of these  three  divisions  embraces  all  that  pertains to public
and  private hygiene.   The local conditions which  are especially important
as auxiliary causes are  unknown, and therefore it  can  only be hoped that
they will be  reached by rendering sanitary measures as complete as prac-
ticable ;  but, be these measures  never so  complete,  they do not make
superfluous those of  quarantine and  disinfection.   The object of quaran-
tine  regulations is that  the  disease-germs shall not be imported.   To effect
this  object either there must  be  non-intercourse with places  in which the 
1028
ERUPTIVE FEVERS.
disease  prevails, or all  articles  of merchandise, clothing, etc. brought there-
from  must be  thoroughly disinfected.   To be efficient, quarantine regula-
tions  must include not  only  vessels from infected  parts, but inland trans-
portation  by railroads  and  other  conveyances.   There  is no  clanger of
the disease  being carried  by the living body after disinfection of  the wear-
ing apparel, or by the  bodies of the dead.   Detention of the well or the
sick is therefore a needless precaution, except to  prevent groundless popular
apprehensions.   If importation  of  the germs have taken  place,  the houses
with their surroundings  in which cases occur should be instantly  and  com-
pletely disinfected.  The object now is to "stamp out" the disease.  There
is ground for the belief  that this object may be effected if measures of dis-
infection be promptly and thoroughly carried  out.
  During the prevalence of an  epidemic  unacclimated  persons should avoid
going within the infected  area except under a sense  of duty, and  they  who
are already  within this area should  leave it unless  there  be motives for
remaining which render the risk of life  justifiable and praiseworthy.
                        CHAPTER   VI.

                      ERUPTIVE   FEVERS.

 Variola, or Smallpox: Anatomical Characters; Clinical History; Causation; Diagnosis;
   Prognosis;  Treatment.—Varioloid, or Modified Smallpox.—Vaccinia, or Cowpox.—
   Varicella, or Chicken-pox.

    THE fevers  which  remain to be considered are characterized by an erup-
     tion or exanthem, and hence they are called eruptive or exanthematous
 fevers.   The continued  fevers,  typhus  and  typhoid,  have  also  an eruption,
 but the eruption  is less constant and less  prominent than in  the eruptive
 fevers.   The eruptive fevers are variola, or  smallpox, including the modified
 form known as varioloid; varicella, commonly called chicken-pox ;  scarlatina,
 or  scarlet  fever; rubeola,  or measles; roseola, or rose-rash ;  and  rbtheln,  or
 German measles.   The  eruption in two of these fevers is moist; that  is,
 vesicular or pustular.  This is true of variola and varicella.  In the remainder
 the eruption  is dry, and  is properly an efflorescence or  rash.  To the latter
 kind of eruption the term exanthem is, strictly speaking, restricted.
  The eruptive  fevers were  formerly considered as varieties of one disease,
 and the individuality  of each was not fully settled much before the present
 century.  Each is  a distinct species of fever, having phenomena and laws
 peculiar to it and its own special cause.  All, with the exception  of roseola,
 are propagated by special  causes reproduced within the body;  that is, they
 are communicable diseases.
  The division  of the career of  the disease into stages is the same in all the
 eruptive fevers.   The  first stage is the stage of invasion or the access.  This
 stage begins with the  first manifestations of disease and ends with  the first
 appearance of the eruption.  The second stage is the stage of the eruption,
and extends  from the time when the eruption first appears to its  disappear-
ance.   This stage  is  subdivided in variola.   The stage of desquamation  or
 desiccation follows  the eruptive  stage, and  this  either  constitutes or  is fol- 
VARIOLA, OR SMALLPOX.
1020
lowed by the stage of convalescence.  The consideration of these fevers will
also  embrace  the periods  of incubation  and certain  events  liable to  occur
after the disease, or  sequels.

                       Variola, or Smallpox.

  The discovery  of vaccination by the immortal Jenner toward the close of
the eighteenth century has divested this  disease of much of  the  importance
which  it  had  in  the  two previous centuries, when it ranked  first among the
acute affections destructive of human life.  It is not, however, so rare, even
in its unmodified form, at the present day hut that cases are liable to come
under the observation of every practitioner.  The gravity and loathsomeness
of the disease, together with  its contagiousness, render  highly important an
early diagnosis and judicious management.  I shall consider  first unmodified
variola, and afterward, under a separate head, the  modified form  of the dis-
ease known as varioloid,   The latter  head will embrace the consideration of
variola  produced  by  inoculation.
   Anatomical  Characters.—The characteristic lesion of smallpox is  the
eruption.  The successive  stages of the eruption are the macule,  the papule,
the vesicle, and the pustule.   The pustule undergoes desiccation.  The macule
is a reddish, slightly-elevated spot due to congestion of a  circumscribed por-
tion of the skin.   The microscope shows  that in this stage the capillaries of
the papillae of the corium are dilated, tortuous, and  elongated.  The connect-
ive tissue of the  papillae is slightly oedematous.   The papule is due chiefly to
swelling of the epithelial cells of the rete Malpighii, and to the appearance in
the same situation of little cavities containing a clear fluid. It is  to be noted
that cavities holding  fluid  are present in the papule as well as in the vesicle;
but in the former they are  so small that the vesicular structure is not evident
to the naked eye.  The swelling of the epithelium  and the small  cavities are
present  chiefly in tbe middle layers  of  the  rete  Malpighii.   AYeigert1 has
shown that in the centre of  the pock the  lowest cells of the rete Malpighii
have undergone  a peculiar  metamorphosis, by which they are transformed
into irregularly-shaped opaque masses devoid of nuclei.  To this change he
has  given the name diphtheroid metamorphosis, as it resembles  the change
described by AVagner as occurring in  the epithelium of mucous membranes
in diphtheria.   The  metamorphosis belongs to  the  group of  the  coagulation
necroses described in  Part I. pp. 52 and  53.   AA^eigert regards this necrosis
of cells  in the rete Malpighii as the first and the characteristic effect of the
smallpox poison upon the skin.  The diphtheroid metamorphosis  affects only
a certain number of cells in  the base of the pock.
   Another alteration w*hich many of the epithelial cells undergo is the forma-
tion in their protoplasm of spaces or cavities containing a clear, serous fluid.
This alteration has  been called serous infiltration  and  vesicular or dropsical
transformation of the cells.   The cells in the upper and the middle layers of the
rete 'Malpighii are those chiefly affected.   At first a clear  ring forms around
the nucleus;  and this transparent zone  increases in size until  nearly  the
whole cell is converted into a cavity, the wall of which is formed by the outer
border of the cell.  In this vesicular transformation the  cell becomes swollen,
so that the cavity may be larger than the original cell.   The boundaries sepa-
ratin"- adjacent cell-cavities may become ruptured, so that by the coalescence
of several cavities larger  spaces with  irregular walls are formed.  In this
way many explain the formation of the vesicle  out of the papule. Accord-
in-"' to this view,  in the papule a large  number of the epithelial cells  in  the
upieer  Malpighian layers  become swollen  and transformed into cavities, the
       1 Anatomische Beitrage zur Lehre von den Pocken, Breslau, 1874, Theil i. 
1030
ERUPTIVE FEVERS.
walls of which are represented by the condensed peripheral layers of the cell.
These cavities by rupture of their walls open into each other, and when large
spaces containing a clear fluid have thus been formed the appearance is that
of the  characteristic smallpox vesicle.   The interior of the vesicle is  subdi-
vided  by a network or reticulum composed of altered epithelial cells; but
the vesicular transformation of cells  is not the sole origin of the small cavities
of the papule or of the larger spaces of the vesicle.   The serum which trans-
udes from the capillaries of the corium penetrates the epidermis, and not only
enters the cells, but also makes its way  between the cells, which are thereby
pushed apart.  Thus, spaces containing serum exist between the cells as well
as within the cells.   The extracellular accumulation of serum and the coales-
cence of intracellular cavities combine  to form the  spaces  of the smallpox
vesicle.
   The  manner  in which the  reticulum of the  smallpox vesicle is formed
has been, and is still, a matter of controversy.  The reticulum  consists of
coarse  and of fine bands  which  stretch from  the  floor to the roof of the
vesicle, and  which  interlace  in its  interior.   It is generally  admitted  that
these bands  are composed of more  or  less altered epithelial cells.  AVeigert
believes that the reticulum is formed in great part of irregular and branch-
ing masses which represent cells that have undergone the diphtheroid  meta-
morphosis or coagulation necrosis.   Cornil and Leloir  are of the opinion that
the reticulum is formed mainly by  the  borders of cells in whose substance
cavities have appeared, these borders representing the partitions between the
intracellular  cavities.   All, however, admit that  at  least some of the  bands
are composed simply of epithelial cells which have been compressed, elongated,
and displaced by the accumulation of fluid between them.
   The roof of the smallpox vesicle  is composed of the stratum corneum, the
stratum lucidum, and  often  some of the upper  cells of the rete Malpighii.
The sides of the vesicle are formed  of cells in the middle layers of the rete
Malpighii, and the  floor  of the vesicle is composed of the lowest cells of the
rete Malpighii, some of which have undergone the diphtheroid metamorphosis.
Some of the epithelial cells in  the  sides and  in the  base of the vesicle are
enlarged,  and these often contain two or more  nuclei.  There is reason to
believe that  in  these situations there is an active proliferation  of epithelial
cells.
   A characteristic appearance of the smallpox vesicle is produced by a cen-
tral depression in its roof.  This depression constitutes the so-called umbilica-
tion of  the vesicle.   Not  every smallpox  vesicle is umbilicated.   Vesicles in
the palm of the hand and in the sole of the foot are not umbilicated.  There
have been various theories as to the cause of the umbilication.  Some have
attributed it  to the existence of a sweat-gland or of  a hair-follicle in the cen-
tre of the vesicle.  The umbilication may, however,  be present in vesicles
which are not formed around hair-follicles or sudoriparous glands.  The most
plausible explanation is that which attributes the central depression to swell-
ing and proliferation of the epithelial cells in the sides of the vesicles.   The
influence of this cause is aided by  the presence of bands which pass from the
centre of  the roof to the floor of the vesicle.   These bands, the existence of
which has already been noticed, act as retinacula which hold down the central
part of the roof, while the sides of the vesicle are swollen by the enlargement
and proliferation of cells and by the accumulation of serum.
  The  smallpox vesicle is filled with serum, called, in this  situation, lymph.
The serum may  be perfectly clear, but it usually contains a few pus-cells and
some granular material and micrococci.  The pus-cells are probably emigrated
white blood-corpuscles.   A delicate  network of fibrillated fibrin is sometimes
found in the  lymph of the  vesicle.   The lymph in the vesicles becomes  more 
VARIOLA, OR SMALLPOX.
1031
and more clouded by the presence of pus-cells. By the accumulation of these
cells the vesicle  is gradually transformed into a pustule.  As the pus-cells
increase in number the reticulum  within the vesicle is destroyed, so  that the
fully-formed pustule consists  of  a  single cavity.  The destruction of the
reticulum causes the  umbilication to disappear.
  In hemorrhagic variola the vesicle becomes filled with red blood-corpuscles
instead of emigrated white corpuscles.   Between the corpuscles is a network
of fibrin.
  Pus-cells  are found in the  connective tissue of the corium, especially around
the vessels of the papillae.   These pus-cells, which are undoubtedly emigrated
white blood-corpuscles, are present in large number during the pustular stage.
The pustule may extend in depth  in consequence of suppuration of the upper
layers  of the corium.   The  cicatrices or pock-marks which follow an attack
of variola are extensive and deep in proportion  to  the extent to which the
corium is involved  in  the suppurative  process  during the pustular stage.
  During the stage of desiccation  the contents of the pustule disintegrate and
dry up.   After  the  pustule ruptures and discharges its  contents brownish
scabs are formed by the desiccation  of the pustular contents.   Beneath these
scabs the epithelium is regenerated, the new cells being  produced by prolif-
eration from the intact epithelial cells.
  In a number of cases of smallpox A\reigert observed colonies of micrococci
in blood-vessels and lymph-spaces in the corium,  as well as  similar colonies in
the vesicles.  These micrococci are to be regarded as a complication, and not
as concerned in  the causation of the disease.
  The occurrence of the variolous eruption upon the  mucous membranes of
various parts of the body will be described in  connection with the Clinical
History.  Parenchymatous degeneration of the liver, heart, and kidneys has
been observed in cases  of  smallpox.  Colonies of micrococci  are often found
in internal organs.   The formation of abscesses is rare.   The spleen is some-
times swollen.   Ecchymoses are very frequently found  in  the mucous mem-
brane of the renal pelvis and of the ureters.  In variola hemorrhagica, hemor-
rhages are  present in  the interior of the body as well as upon the surface.
They are found in the mucous membrane of the air-passages, in  the lungs, in
the mucous membrane  of  the alimentary tract, especially of the stomach and
rectum, in the uterus,  and rarely  in  the Fallopian tubes and ovaries or in the
testicles.  Punctate hemorrhages are present in the  serous  membranes and
in the  pia mater.  The complications of smallpox,  which are many, will be
noticed under the  head of Clinical History.

  Clinical History.—Differences  pertaining  to  the eruption and other
events embraced in the clinical  history in diff'erent cases  are  so great that
writers have made several varieties  of  the  disease.   The  division  into  con-
fluent  and  discrete or  distinct  variola is generally  adopted.    In  the latter
variety the  vesicles  and pustules are separate or distinct from each other.
In the former variety  coalescence of the vesicles  or pustules takes place.
In cases  in which coalescence exists to a  greater or less extent,  but not
over the  whole or the greater part of the surface  of the body, the disease
is said to be semi-confluent.   When the  eruption  has a hemorrhagic character
the disease  is called hemorrhagic variola.   A\rithout considering these varie-
ties under separate heads, I shall notice their distinctive features in  connec-
tion with the symptomatology  of  the several stages of the disease.
  Stage of Invasion.—The disease is ushered in by a chill in the great major-
ity of cases, and the chill  is usually more marked than in the other  eruptive
fevers.  In some cases a series of chills occurs, alternating with flushes of heat.
Febrile movement  follows, accompanied generally by more or less perspira- 
1032
ERUPTIVE FEVERS.
tion.   The latter is likely to  continue  or  to  recur more or less  frequently
up to the time of maturity of the eruption—a feature distinctive of this as
compared with the other eruptive fevers.  The febrile movement is known as
the primary fever.  It is often intense, the thermometer sometimes showing a
rise to 104° or 105°.  Nausea and vomiting are  often prominent symptoms
in this stage.  The tongue becomes coated.   Pain is referred to  the epigas-
trium, accompanied by tenderness on pressure, either with or without notable
nausea and vomiting.   Generally, the bowels  are constipated, but diarrhoea
is sometimes present, especially  in children.   Cephalalgia, pain in the  limbs,
and general debility are more or  less marked, as in the early part  of other
essential fevers;  but in this  fever  pain in the  loins is usually a marked
symptom and possesses diagnostic  importance.   Incomplete  paraplegia is
occasionally observed, generally disappearing with the  development of the
eruption.   Paralysis of  the bladder, giving rise to retention  of  the  urine,
sometimes exists  without paraplegia.   Convulsions often attend the  develop-
ment  of this disease in children,  and sometimes occur in adults.  Delirium is
an occasional symptom.
  If the symptoms in this stage be mild, the eruption will probably he  dis-
crete ; but if the chill  be notably marked,  the pyrexia  intense, the lumbar
pain severe, etc., it may be expected that the disease will prove to be of the
confluent variety.
  The duration of this stage, as  a  rule, is two days.  The eruption begins to
appear on the third day  after the attack.   There  are, however, exceptions to
this rule.  In some cases the eruption appears  on the second or on the fourth
day.  The duration is sometimes  extended to the fifth or sixth day, and occa-
sionally even longer.  The  eruption, if it appear on the second day, may be
expected to be confluent, and on  the  other hand in proportion as the appear-
ance of the eruption is  protracted  beyond the third day mildness  of the  dis-
ease is to be expected.   Two events relating to the skin are of  occasional
occurrence in this stage.  One of these is a cutaneous  efflorescence  or rash.
The whole or the greater part of the surface of the body may be  covered
with this erythematic  redness, resembling the appearance in scarlatina.   The
disease is liable to be mistaken for scarlatina when this occurs.  In other cases
the rash is in isolated patches, and  it may then bear a resemblance  to measles.
The patches, however, are not elevated ;  that is, they are not papular.  Small
vesicles or sudamina are sometimes observed.   The efflorescence appears  on
the second day and continues only eighteen or twenty-four hours, giving place
to the  eruption peculiar  to the  disease.
  The other  event is the appearance of petechia? and  ecchymoses.  These
may be more or less abundant.  They are sometimes very abundant, covering
both the trunk and the extremities.   In  some  cases these foreshadow subse-
quent  hemorrhages, but they  by  no means always have  this significance.
They  do not always denote severity  of the  disease, and  they are sometimes
observed in mild cases.   They continue during the greater part of the stage
of the eruption.
  Stage  of Eruption.—The  histological  structure of the different forms  of
the eruption  has  already been considered.   It remains to notice the clinical
characters of the eruption.   The  eruption, as a rule,  appears first on  the
face, especially about the lips  and chin,  and nearly at the same time on the
neck and wrists ;  next on the chest and arms ;  then over the body ;  and  last
on the  lower extremities.  Its diffusion over the whole cutaneous surface
occupies between one and three days.  Exceptionally it is first observed on the
genital  organs, chiefly in young  children, and  on the loins or nates.  It may
appear first in the  neighborhood of  a blister or sore existing in any part of
the body.  Successive changes  take place in the physical characters of the 
                       VARIOLA,  OR SMALLPOX.                  1033

eruption which in different stages of its progress represent nearly all  of the
cutanei.   At first the eruption appears in the form of small red spots or specks,
sometimes having a purplish or livid color.   It is now a maculated eruption.
The central part of the maculae becomes hard, slightly elevated, and pointed.
A change has  taken place from a maculated to a papular eruption.   In this
stage  of its  progress the eruption is not unlike that of measles, and the dis-
ease is liable to be mistaken for the latter.  The papvhv are smaller, rounder,
and harder, and lack the  crescentic or curvilinear arrangement which charac-
terizes  the  eruption of measles.   They feel  like small shot under the skin.
Next, a clear liquid becomes visible in the papulae, which now become vesic-
ulae.  This  change is  observed  twenty-four hours  after  the first appearance
of the eruption.  After twenty-four hours more—/. e. forty-eight hours from
the first appearance of the eruption—the vesicles have acquired considerable
size.   On the fifth  day of the stage of the eruption the vesicles have attained
to  nearly or quite their full development,  measuring from one-quarter  to
one-third of an inch in diameter, and are raised  two-tenths to four-tenths  of
an  inch above the level of the skin.   More or less of the vesicles present a
depression in the centre.   They are  said to be umbilicated.   This appearance
is highly characteristic, indeed almost  pathognomonic.  It is observed in  no
eruption  other than that of  variola, except in the  vaccine vesicle, and  some-
times in ecthyma.  This  umbilicated appearance  may be detected in some  of
the vesicles, often  as soon as the latter are discoverable.  The vesicles  are
multilocular, as has already been described.   They contain  an opalescent
serum.
   This is the history of the eruption up to the period when the vesicles reach
the maximum  of their development if  the eruption he discrete.  In the con-
fluent variety a diffused redness of the surface precedes the appearance  of
papules and vesicles.   This diffused redness is likely to lead to the error  of
supposing this disease to be measles.   The vesicles when they first  appear
have  not the determinate form of those in discrete  smallpox, but run together
or coalesce  to a greater or less extent.   At the end of the period for the full
development of the vesicles the face and other parts are covered with patches
of  greater or less size, in which the cuticle is uniformly raised by opalescent
serum, resembling  a blister.   The whole of the face and  the greater part  of
the cutaneous surface may  be covered  with coalescent  vesicles.
   After the full development of the vesicles there is another important change
in the eruption.  The vesicles become pustules.  In other words, suppuration
takes place.  AVith this change the external characters are altered.  The pocks
are more distended.   The reticulum is broken up.  The central depression
is lost, and the pustules become pointed.  This change from vesicles to pus-
tules is accompanied by general symptoms which show it to be an important
epoch in the clinical  history of the  disease.  Hence with this  change begins
another stage—namely,  the  suppurative stage, or the stage of maturation.
This  will claim consideration under a distinct head.  It will be observed that
of the different forms  of cutaneous eruption, all except the squamee and tuber-
cube are represented in the successive changes in the eruption of smallpox—
namely, enumerating  them in the  order of their  sequence, maculae, papulae,
vcsiculse, pustulac,  and  in the confluent eruption bullae.
   The eruption is not limited to the  skin.  Simultaneously with its  appear-
ance  on the cutaneous surface it may  be observed to a greater or less extent
on the mucous membrane of the mouth and throat.  It appears here in the
form  of round opaque spots.   As no stratum corneum exists upon the mucous
membrane, tbe formation of typical vesicles and  of pustules  does not take
place.   Little  erosions and ulcers rapidly form  in  the site of the  eruption.
The membrane surrounding  the spots is swollen  and inflamed.   The spots 
1034
ERUPTIVE FEVERS.
are observed especially on the tongue and soft palate.  They are  liable  to
occur in the larynx, trachea, and bronchi;  on the conjunctiva, leading some-
times to ulcers  and destruction of the eye ; within the nostrils, in the exter-
nal meatus auditorius, and on the prepuce or vulva.   The eruption  does not
occur upon  serous membranes, and probably not on the mucous membrane
of the stomach or intestine.   In the larynx the eruption may cause laryn-
gitis, which may prove fatal.  An instance of this kind has fallen under my
observation.
  A striking feature of the primary fever pertaining to this disease is either
a notable remission or complete apyrexia on the  appearance of the eruption.
The pulse falls  to nearly or quite the normal frequency, and the heat of the
skin is but little or not at all  above that of health ; and the thermometer  in
the axilla  shows a reduction to 100° F. or lower.   This is a  highly diagnostic
feature of smallpox, provided the  eruption be not confluent.  In the confluent
variety this feature is either wanting or is much  less  marked.  As the erup-
tion progresses  the febrile movement is gradually developed or increased.
  Stage of Suppuration.—AVith the change of the eruption  to pustules, usu-
ally on  the sixth day after the first appearance  of the eruption, there is  a
recurrence of notable increase of pyrexia, constituting what is known as the
suppurative fever or the  secondary fever.   The pulse becomes more or  less
frequent, the heat of the skin is sensibly raised, and the thermometer denotes
increase of temperature, especially in the evening  as compared with the morn-
ing. The perspirations, which up  to this epoch are likely to occur, now cease.
In  mild cases of discrete smallpox  the secondary fever  continues  only for
three  or four days;  but it continues longer in  the  confluent variety  irre-
spective of any complication.  The pyrexia is symptomatic of the affection
of the skin, and its intensity, other things being equal, is proportionate to the
degree of  cutaneous inflammation.   More or less redness  and oedema of the
skin are apparent  in the spaces between the pustules.   Tumefaction of the
face occurs, and is often considerable.  The  swelling of the eyelids is often
sufficient to close the eyes, as in cases of erysipelas.   Swelling of the hands
and feet occurs  in  severe cases, especially if the  eruption be confluent.  The
redness  and swelling are accompanied  by a burning pain,  as in erysipelas.
Salivation is a frequent symptom.  In severe cases of the confluent variety
it is often very profuse, and  accompanied with more  or less swelling of the
salivary glands.   It  is measurably or chiefly  dependent on the  eruption in
the mouth and  fauces.   It is rarely observed in  children.  In severe cases
delirium is likely to occur in this stage. The delirium is generally passive, like
that in most cases of typhoid fever, but it is  sometimes active or maniacal.
Other ataxic symptoms—namely,  subsultus, carphologia, and  coma-vigil—may
also occur, denoting always a condition of gravity.  Coma occurs  in a certain
proportion of fatal cases.  Other symptoms are due  either to  complications
or to  anomalous occurrences which will presently be noticed.   Diarrhoea  is
an occasional symptom, and is always an  unfavorable omen.   The duration
of the stage  of suppuration  is four or five days.
  Stage of Desiccation.—This stage begins on  about the twelfth day of
the disease.  The  exceptional cases  in which  it begins  much earlier or
later are very  few.    The tumefaction and redness of  the skin diminish.
The pustules, for the greatest  part, break, and the pus concretes  into a thick
scab.   Over patches in which  the eruption is  confluent there is a continuous
scabby crust.   The whole face in severe cases is covered as if  by a mask,
presenting a hideous appearance,  and the  greater portion of the surface of
the body may present a similar aspect.  The diminution of  the inflammation
and the formation of scabs are first observed  on the face, afterward on the
trunk and upper extremities, and at last on the  lower  extremities.  During 
VARIOLA, OR SMALLPOX.
1035
this stage the skin exhales a sickening characteristic odor.  In cases in which
the eruption is confluent the  stench  is extremely offensive and may  be per-
ceived at a considerable distance.  The spectacle in  this and the  preceding
stage, and the fetor, render smallpox  the  most repulsive  and loathsome of
diseases.   In mild cases the stage of desiccation is the stage of convalescence.
The scabs fall off, leaving the skin beneath unbroken, but presenting a discol-
oration  continuing for a long  time, and especially apparent when the surface
is exposed to cold;  but in severe cases the skin beneath  the scabs is excor-
iated or ulcerated, the scabs are liable to be renewed, and troublesome ulcer-
ations  sometimes follow.   More or  less  pyrexia in severe cases  continues
into the stage of desiccation.   In mild cases there may remain no permanent
traces  of  the eruption, but  in  the  great majority  of  cases there  are left
cicatrices, either  circular or linear,  wdiich   are  known as  " pitting"  or
" pock-marks."   The amount of  pitting will depend on  the abundance of the
eruption,  the size of the  pocks, and  the depth of the ulcerations.  Some of
the pocks do not break, but harden, and their contents  are absorbed.  It is
probable  that in these  the corium is not involved in the suppuration or that
the vesicles are not converted into  pustules.
   To recapitulate the relative duration of  the several stages in the majority
of cases :  The duration of the  stage of invasion is between two and four days ;
of the stage of eruption, about five clays ;  of the stage of suppuration, four or
five days ; and of the stage of desiccation, between  six and ten days—making
the duration of the disease in cases ending in recovery between seventeen and
twenty-four days.  In mild, uncomplicated cases the recovery is usually rapid,
but convalescence may be indefinitely prolonged by ulcerations of the skin and
other complications.
   Ararious complications and anomalous  events are liable to  occur in the
several stages of the disease.  Pharyngitis, dependent on the eruption within
the pharynx, is sometimes sufficient  to occasion much pain and difficulty of
deglutition.  Laryngitis, dependent on the eruption within the larynx, is of
not  infrequent occurrence.   It is denoted by huskiness of voice, or aphonia,
 with,  in  some  cases, more or less difficulty of respiration.  The laryngeal
inflammation is sometimes diphtheritic.   CEdema of the glottis is an occa-
sional accident.  Bronchitis,  also from the eruption, occurs in  a certain pro-
portion of cases.  Sometimes there  is inflammation of the  gastric or of the
intestinal mucous membrane.   This is  rarely  of  the diphtheritic  variety.
 Pneumonitis, pleuritis, and pericarditis are rare complications.  Endocarditis,
 including the  acute ulcerative  form,  has been  observed as a  complication.
 Furunculi, or  boils,  and subcutaneous abscesses are not uncommon, both as
 concomitants and  sequels.   Phlegmonous tonsillitis and suppurative inflam-
 mation of the cervical lymphatic glands and of the  salivary glands occasion-
 ally occur.  Erysipelas on the  face, neck, limbs, or body is not  very infre-
 quent.   Gangrene may occur on parts exposed to  pressure, and sometimes
 in other  parts.   Ophthalmia  is an important  complication, sometimes leading
 to permanent blindness from opacity or perforation  of the  cornea.  The
 inflammation in the  throat sometimes extends  through the Eustachian tube
 and  gives rise  to median otitis, which is  liable to eventuate in deafness.
   Hemorrhage in various situations occurs in a certain proportion of cases.
 Epistaxis is an occasional  early  symptom,  but does  not  betoken  unusual
 gravity of the disease.  Haematuria is sometimes an  early and always a grave
 symptom.   Hemorrhage occurring  at any  period of  the disease from the
 mouth, throat,  air-tubes, or  bowels,  accompanied by petechiae or vibices, and
 sometimes by an extravasation of blood  into  the pocks, characterizes certain
 malignant cases.  Hemorrhagic,  scorbutic, and black variola are names applied
 to the disease as exhibited in these cases.   The  most dangerous form of 
1036
ERUPTIVE FEVERS.
hemorrhagic smallpox is that in which an acute hemorrhagic diathesis devel-
ops in an early stage of the disease.  The disease has then been called _-))•■/•-
pura variolosa.   Death may take  place  in these cases before  any eruption
characteristic of smallpox has appeared, and then a diagnosis is possible only
from a knowledge of the etiology of the  case.   In females menstruation may
occur, and  if not irregular or profuse it  is not an untoward event.  Metror-
rhagia often occurs in  hemorrhagic cases.
  Albuminuria is a symptom of not infrequent occurrence in  severe cases.
It is probable  that  the coma which occasionally occurs is sometimes due to
uraemic poisoning dependent on acute nephritis.   Orchitis  and ovaritis are
rare complications.  Inflammation of the synovial membranes of the joints,
sometimes  with serous  and sometimes with purulent  exudation,  is also  an
infrequent  complication.  Paralysis of  the lower  extremities  and  of the
bladder has been known  to be a sequel of smallpox.   This is  due,  accord-
ing to AVestphal, to an acute  disseminated myelitis.

  Causation.—Smallpox is a highly contagious disease.   It may be  com-
municated  by  means of a virus—that is, by inoculation—and by means  of
inappreciable emanations from the body.   The disease is readily transported
by means of fomites, which may retain the contagium in an effective condi-
tion for months and even years.   A very transient and slight exposure often
suffices for the  production of the disease.   Thus,  it  is not infrequently taken
by passing in the street or meeting in public conveyances persons who either
are affected or have recently been  affected with it.  It may be contracted in
hackney-coaches which have been used for carrying patients to hospitals.  The
disease is generally supposed to be communicable in all its stages, but undoubt-
edly it is most highly so during the stages  of suppuration and desiccation.  The
contents of the vesicles and pustules and the crusts  and scabs formed  by
desiccation contain the contagium ; and it is probably  contained not only in
the emanations from  the  cutaneous surface, but in the  expired breath and
perhaps in the intestinal  excreta.  The  disease may be communicated  from
the dead body by means  not  only of a  virus, hut  by inappreciable  emana-
tions.  Thus it has been contracted in  the dissecting-room from subjects
dead with  the  disease.  It is  stated that a cadaver may retain  the virus in
a condition to  communicate the disease  for an indefinite  period—even for
several years.1  The following instance  is interesting  as  showing  the  com-
munication of  the  disease from the  dead body, death having  taken place
before the  development of the eruption : -- During  the winter of 1848-49 a
young man, a  member of  the medical class of the New York University, died
suddenly and unexpectedly  in the night  under  the care of a physician who
had not thought him seriously ill.  I  was  invited  to  the autopsy, and
observed, when the corpse was  uncovered, a few dark-red spots on the sur-
face which were supposed  to be  petechial, the  principal  symptoms of his
attack having  been gastric  with great debility, as  we  were informed.  The
coffin was  taken  home  to a New  England village  for burial, where, at the
funeral, some of the relatives approached and opened it to see the face of the
deceased before it was inhumed.  Of this number, eight were attacked with
smallpox, no other persons in  the neighborhood  being assailed."2  AArhether
the disease be  ever produced otherwise than by means  of a contagium is, and
must always  remain,  an open  question ;  for with  regard to reported cases in
which the  disease has appeared to originate spontaneously it can always be
said that there may have been some unsuspected and  untraceable exposure.
  1 A'ide Noureau Diet., art. " Contagion."
  2 Vide article by Dickson  in the American  Journal of the Medical Sciences, for July,
1862. 
                      VARIOLA,  OR SMALLPOX.                 1037

This explanation is more rational than the supposition that  the special cause
is produced de novo.
  The susceptibility to the disease  exists at all ages, but it is greatest  in
children.   Some persons are wholly  insusceptible to it, exposing themselves
as fully as possible  with impunity.   Cases  have been  observed  in which
persons have become  susceptible after having  been insusceptible  for many
years.   Unknown  causes peculiar to certain times and places co-operate with
the contagium  in  the diffusion of the disease,  so that it prevails  as an epi-
demic.  Beference in these statements is had to the production of the dis-
ease in the natural way ;  that  is, exclusive of  inoculation.  The disease  as
thus produced  is distinguished as natural smallpox.   The negro  and Indian
races are particularly susceptible to the disease.  As a rule, the occurrence
of the disease once extinguishes the susceptibility ever afterward.  Instances,
however, are not extremely infrequent of the disease having been experienced
twice, and  it has been known to occur thrice.
  Certain  interesting  facts relate to the susceptibility of the foetus in iitero.
A pregnant woman affected with the  disease may or  may not communicate
it to the foetus.  The development of the disease before birth generally causes
the death  of the  child, and  cases  have been reported of stillborn children
presenting  the different stages of the eruption.  The  death of the foetus, how-
ever, does  not always occur.  Healthy children have  been  born presenting the
evidence of having passed safely through the disease in the uterus.  In some
instances the disease has been contracted before  birth, but not developed until
several  days after birth.  Becovery has taken place under these circumstances.
The disease may be communicated to the unborn child by the mother after the
fourth month of pregnancy, and perhaps before.   Finally, the special cause
may be received into  the system of the mother and the foetus become  affected
without the mother experiencing the disease.  This fact has been observed  in
cases in which  the  susceptibility of the mother had been extinguished, either
by the disease having been experienced or by vaccination.
  The special cause of this disease remains for  a certain  period latent; that
is, there is  a period of incubation. The duration  of this period varies between
five days and nearly three weeks, the average duration probably being between
twelve and fourteen days.   Facts appear to show that the special cause of
rubeola or  of scarlatina may be  in operation simultaneously with the opera-
tion of  the special cause of variola; in other words, smallpox  may be com-
bined with either  measles or  scarlet fever.  Cases, however, exemplifying
these combinations are extremely rare.
  During  an epidemic prevalence of smallpox  cases are  sometimes observed
in which all the symptoms of  the stage of  invasion occur without  being fol-
lowed  by an eruption.  The disease appears to abort spontaneously at the
end of the stage of invasion.   These  attacks resemble febricula, but it has
been observed  that persons who have had these attacks during the preva-
lence of smallpox  are thereafter insusceptible  to the disease, although not
protected  by vaccination.   Hence it  has  been considered that the disease
sometimes  occurs without an eruption ; and writers  have  been accustomed  to
recognize as a variety of the disease variola sine variolis.
  The question as to what is  the  essential  causative principle, or the con-
tagium, is  one of  great pathological  interest.   It  was at first thought  by
AA^eio-ert and by Colin that the round bacteria or micrococci which they have
observed in lymph from the vesicles, as well as in  other  parts, represent the
contagious germs  of smallpox.  This view is  now  abandoned.

  Diagnosis.—The diagnosis of smallpox presents no difficulty after the cha-
racters of tbe eruption are fully manifested;  but it is not so easy at an early 
1038
ER UPTI1 'E FE \ rERS.
period of the stage of the eruption before the vesicles are distinct.  In seek-
ing to determine the  character of the eruption vesicles  should be looked  for,
and next their umbilicated appearance.   This appearance, it is to be borne in
mind, is almost pathognomonic.  The distinctive characters of  the papules,
as determined by the touch, are  also to  be borne in mind—namely, they are
granular, hard, and deep-seated.   The duration of the stage of invasion is to
be considered—namely, from two to three days.  The prominence of lumbar
pain  and vomiting, and  especially either a remission or a cessation of febrile
movement at the time of the appearance of the eruption, are important diag-
nostic features.   It is to be remarked that lumbar  pain is not in all cases a
prominent symptom,  so that its absence is not entitled to much weight in the
exclusion of smallpox.   An  examination of the throat and mouth should not
be omitted.   The round, whitish, or ashy spots which are characteristic of
the eruption on a mucous surface are generally apparent here as soon as, or
before, the eruption  appears on the skin.  The appearance of the cutaneous
eruption successively on the face or neck, the trunk  and upper  extremities,
and  the lower extremities is to be  recollected.
  The diagnosis cannot be made  with positiveness  prior to the stage of  the
eruption.  Pain  in the loins with febrile temperature, taken  in connection
with the absence of the symptoms which attend the access of the other erup-
tive fevers and of typhoid fever, should excite a strong suspicion of smallpox,
especially if the patient be not protected either by  vaccination or by having
once had the disease.  The exclusion of rubeola and scarlatina  by the absence
of the symptoms characteristic of the stage of invasion in these diseases is
an important step in the diagnosis prior to, and in the early part of, the stage
of eruption.  When the eruption  first appears  the  differential diagnosis lies
chiefly  between these fevers.   In rubeola the Schneiderian membrane and
air-passages, and in scarlatina the fauces, are prominently and early affected,
as will be seen in treating of these fevers. Moreover, in rubeola the stage of
invasion is longer, and in scarlatina it is shorter, than in variola.   In neither
rubeola  nor scarlatina  does  the pyrexia remit or  cease when the eruption
appears.  Other  affections liable to be confounded with smallpox are  lichen
accompanied with pyrexia and a secondary  syphilitic  eruption.   The  occa-
sional occurrence of an efflorescence and of  petechiae preceding the eruption
proper, to  which  reference has been made,  is to be  borne  in  mind.   The
difficulties  attending  the  diagnosis  of purpura variolosa have already been
mentioned.1
  The diagnostic points should he  fixed in  the memory, as, in  view of the
danger  of  the diffusion  of  the disease  by exposure before its character is
ascertained, an early diagnosis  is  immensely important.  As another induce-
ment  for being prepared  to  recognize the disease promptly it may be added
that  the ability of the physician  is  thereby  strikingly shown, while, on the
other hand, delay or failure to recognize it brings upon him popular censure.
  The attempt has sometimes been made by criminals and impostors to simu-
late the eruption of smallpox by rubbing the skin with croton oil or tartar-
emetic ointment.2

  Prognosis.—Unmodified or natural smallpox is attended with much danger
to life, the ratio of fatal cases  being as 1 to 3 or 4.  The mortality is very great

  1 Prof. Janeway calls special attention to the danger of mistaking purpura variolosa
for malignant measles, typhus fever, ulcerative endocarditis, and purpura hemorrhagica.
Other  valuable suggestions are contained in his article on "The Diagnosis of Certain
of the Infectious Diseases," Medical News, July 17,  1886.
  2 For an example vide Report of the Proceedings of the Illinois State Board of Health,
Springfield, 111., June 29, 1883. 
VARIOLA, OR SMALLPOX.
1039
in cases of the  confluent, and considerably less  in  the  discrete, variety, the
ratio  in  the latter being as  1  to  10.   The death-rate  varies between' wide
limits  in  different epidemics.  The disease  is much  more fatal  to children
than to  adults,  and is especially fatal in early infancy.  It is also extremely
fatal to  aged persons.  Death is sometimes attributable to the intensity of
the disease per  se.  Life is  then  destroyed before  the  eruption  is matured
and  without any important complication having taken  place.  Instances of
this  kind are rare.   If death take place before the stage of suppuration, it
is generally due to some important complication.   Complications which are
likely  to prove fatal are—acute  laryngitis, oedema  glottidis, pneumonitis,
acute  ulcerative endocarditis, and an  affection  of the kidneys involving
uraemia.  The latter  is to  be suspected  in  cases in which  coma  or convul-
sions occur.
   Death not attributable to complications is  generally due to inability of the
powers of  the system  to support the cutaneous affection ; hence  the danger,
other things being equal,  is proportionate to the  amount of the eruption.
Confluent  smallpox  involves  a very  extensive  suppurative  inflammation
which is  likely  to lead to a fatal  result by exhaustion.  Unfavorable prog-
nostics are—great prostration, frequency and feebleness  of the pulse, typhoid
delirium and other ataxic symptoms, absence or subsidence  of redness  and
tumefaction of  the face and extremities, cessation of  salivation, diarrhoea,
hemorrhage from  the mucous  membranes, and  extravasations on the cuta-
neous  surface.
   Death taking place during or after the stage of desiccation is attributable
to ulcerations of the  skin, boils, abscesses, erysipelatous inflammation, gan-
grene, continued diarrhoea, etc.
   In pregnant women the  disease in its severe form is likely to induce abor-
tion  or miscarriage, and under these circumstances the result is generally
fatal.

   Treatment.—The treatment of  smallpox embraces  measures having direct
reference to the eruption, and those indicated by the  phenomena of the disease
irrespective of the  eruption ; in other words, the treatment is local and general.
   The general treatment involves the same principles as do the continued fevers.
There is no special treatment.  The disease  will run  its course, and hence the
expectant plan is to be pursued.  During the stage of invasion the intensity
of the  febrile movement may  be loosened by the use of cold drinks, ice-water,
lemonade, carbonated water, allowed as freely as the  condition of the stomach
will permit, by refrigerant remedies and by sponging the surface of the body with
cold  or tepid water.   If there be hyperpyrexia the wet sheet and sprinkling
with cold water may be resorted to,  as practised in cases of typhus and typhoid
fever.   Befrigeration is not objectionable on the score of interfering with the
appearance of the eruption.  Cathartics are not indicated, but constipation
is to be removed by mild laxatives or simple enemata.  Bemedies to  relieve
nausea or vomiting and cephalalgia are frequently indicated in this stage.  It
has been claimed that the sulphites have a modifying  effect upon  the disease,
lessening its severity  and danger.   Sansom advises the sulphite of sodium in
doses of 20 or 30 grs., given every  third or fourth hour.  He also regards as
a useful remedy the sulphocarbolate of sodium, given in the same doses and
with the  same intervals.   I  have  met with practitioners of  experience who
from their observations attributed to the sulphites a favorable influence over
the disease.
   During the stage of the  eruption prior to suppuration palliative measures
are indicated  by continued nausea or vomiting, vigilance, restlessness, diar-
rhoea in some cases, etc.  The various complications which are liable to occur 
1040
ERUPTIVE  FEVERS.
will  also furnish therapeutical indications.  It is  probable that the mineral
acids are useful in this fever as well as  in  the continued fevers.   Alimenta-
tion  and supporting  measures in some cases are^ important  in  this  stage.
These measures are important in the suppurative stage and the stage of desic-
cation in proportion as the eruption  is copious and confluent and the general
symptoms  are  indicative of asthenia.   The principles which should govern
the use of  alcoholic  stimulants and  tonic remedies  in conjunction with con-
centrated  nutriment  are the same as-in all  the  essential  fevers as well as
in other diseases in which  danger in the direction of asthenia is more or less
imminent.
   All the  hygienic conditions which are so  important  in  the  treatment of
typhus  and typhoid fever are not less important  in the treatment of small-
pox ; and of these conditions the freest possible ventilation  is of especial
importance.
   The local treatment embraces measures to render  the  eruption abortive on
the face or to prevent the disfiguration caused by  pitting.  The treatment for
this  end is  called ectrotic, this term signifying to miscarry.  The ectrotic treat-
ment, extending more or less over the body, has  been supposed to be useful
by limiting the amount of cutaneous inflammation, and thereby the degree of
secondary fever and danger from  exhaustion.  Of the various ectrotic meas-
ures which have been tried, the following have  been found measurably suc-
cessful :
   1. The careful evacuation of the vesicles  by means of a fine needle.   This
plan was advocated by Rayer.  It calls for much patience  on the part of the
operator.
   2. Evacuation of the vesicles and  cauterization  by means of a fine-pointed
stick of the nitrate of silver.   This also is a very tedious operation.   It is
highly  recommended  by Arelpeau, Bretonneau, and  others.
   3. The application  of the tincture of iodine once  or twice daily by means
of a  brush while the eruption is papular.   This plan  was  introduced by Craw-
ford of  Montreal and Samuel Jackson of Northumberland, Pa.   The  effect
was  observed by Sargeant in thirty cases, the treatment  being  limited to one
side  of  the  face.  There was  but little  swelling  on the side  on  which  the
iodine was applied ;  the vesicles were flattened; and the pitting, although not
prevented,  was evidently diminished.
   4. The exclusion of light and air was recommended as an ectrotic measure
by the late Dr. Picton of New Orleans.   This is effected  by covering the face
with a  plaster  of some kind.  Covering the face  with gold-leaf, as practised
by the  Egyptians, according to Larrey, must be  useful  chiefly by excluding
light and  air.
   5. The application  of a mild mercurial ointment spread  on  cloth  has been
highly recommended by authors in diff'erent  countries.  The risk of producing
the constitutional effects of mercury is  an objection of considerable moment
to this  plan.   Mercurialization is certainly  not desirable in  smallpox.   In
view of this risk Bennett was led to substitute for the mercurial ointment
calamine saturated with olive oil,  and this application he found to be usually
effective.   Skoda and  Hebra recommend the application of compresses dipped
in a  solution of corrosive sublimate (grs. ij-iv to water gvj).  Niemeyer pre-
ferred a weaker solution (gr. j to  §vj).
   6. The application of the subnitrate of bismuth and prepared chalk in equal
parts twice daily, after smearing the  surface with sweet oil, is stated to be an
effective ectrotic measure by Hamilton of Illinois.1
   7.  Stokes advised the application of poultices over the face as the surest
method  of  preventing disfigurement.  They should be applied  at the earliest
             1  American Journal of the Medical Sciences, Oct., 1865. 
               MODIFIED SMALLPOX,  OR  VARIOLOID.          1041

period and continued to an advanced stage of the disease.  He thought lin-
seed meal  the  best article for the poultice.  It should  be spread on a soft
material, such  as French'wadding, and covered with gutta-percha paper or
oiled  silk.
  8. The application of collodion as an ectrotic application was first suggested
in a letter to  me by  the late Dr. Brinkerhoff of California.1   It  was  subse-
quently recommended by Aran of Paris.  The collodion is to be applied once
or twice daily by means  of a brush.   To be successful, the application must
be made either while the eruption is  papular or while the vesicles are quite
small.  Applied at  a later period,  it has seemed to me to increase the pitting.
In  the few cases in which I have seen this plan  tried  the application was
agreeable  to the patient.
  A solution of gutta-percha in chloroform was used by Stokes. Graves, and
AVallace.   The modus operandi of the gutta-percha is similar to that of col-
lodion, the effect being produced by the exclusion of air  and by compression.
  9.  Carbolic acid has been used with success by Lemaire and Sansom.  The
acid is to  be liquefied by alcohol, and applied by means of a camel's-hair pen-
cil brush as soon as the contents of the vesicles begin to appear puriform.
  10.  The application of cold wet cloths to the  skin is regarded by many as
an  efficient ectrotic measure.
  Aside from  ectrotic measures,  the  local treatment embraces evaporating
lotions to  abate undue heat, a weak solution of the chloride of lime as an anti-
septic and to allay pruritus, soothing unguents  in the suppurative stage, and
absorbent  powders.   If  ulcerations follow the falling off of the  scabs, they
require the same applications as ulcers occurring under other circumstances.
  It should be an object of treatment to prevent the eruption from appearing
on the conjunctival membrane.  The continued  application of compresses wet
with cold  water is advisable for this object.
  AVith a view to prevent diffusion of the disease patients should not be dis-
charged from hospital, or if treated at home allowed to  go abroad, until  the
surface is completely  free from scabs and  repeated  thorough  ablutions have
been employed.  All  articles of clothing worn  during the disease should he
left at the hospital, or in cases in private practice destroyed.   Fumigations
as a  means of destroying the contagium should not be relied upon.  Physi-
cians,  after visiting patients affected with this disease, should  not see  other
patients until after  having been sufficiently in the open air for the contagium
to be  dissipated  by free ventilation.   The hands  should be  washed  before
leaving the hospital  or  house,  and change of dress before  visiting other
patients, especially  young  children, is  to be recommended  if  not enjoined.


                 Modified  Smallpox, or Varioloid.

  Thus far, smallpox  has been considered as  produced  by infected emana-
tions  or the contagium in fomites—that is, natural smallpox—in persons
unprotected by vaccination.   Materially modified as respects  the events of
its  clinical history, and  its severity notably diminished, the disease is com-
monly known as varioloid.  This term is not to be understood as applied to
a disease essentially distinct from, although resembling, smallpox.  The name
would imply this;  but in  all cases to which the term varioloid is  correctly
applied the disease is essentially variola.
  Smallpox is modified, as a rule, in a remarkable degree when produced by
inoculation, or, as it is also called, variolation.   As a means of rendering  the
disease so mild as  to be in a great measure  divested of danger, and of pre-
venting pitting,  inoculation had  been practised from time immemorial in
                 1 Yide Buffalo Medical Journal, vol. vi., 1851.
       66 
1042
ERUPTIVE FEVERS.
China  and  Persia.   Imported into Turkey,  the practice was introduced
thence into Great  Britain by Lady Alary AVortley Montague in  1721.  It
was  not adopted in France until  1704.   In the* same year of its intro-
duction into Great  Britain a large number of  persons in Boston  and the
vicinity were  inoculated by  Zabdiel  Boylston.   Boylston was the  first to
note this important fact relating to variola produced by inoculation :  namely,
that the average period of incubation is shorter by several days than in cases
of natural smallpox.  Hence the production of  natural smallpox may be anti-
cipated and prevented  by inoculation after known exposure to the miasm of
the disease.
   The eruption in cases of inoculated smallpox or after variolation is usually
slight.  The pocks  rarely exceed one hundred.  Many of  them abort; that
is, they do not proceed  to suppuration.  The secondary  fever is  slight or
wanting.   There is  very little  constitutional disturbance and the  disease
leaves little or no pitting.  These statements are true in the main.   Excep-
tionally, when inoculation was largely practised the disease  was severe.  The
rate  of mortality was exceedingly small, varying, according to  Shattuck, in
23,000 cases in Boston  between 5 and 30 deaths  in 1000.  Transferring the
virus from persons  successively inoculated, the  disease becomes progressively
more and  more modified, until at length, as a rule to which there are excep-
tions, the eruption consists only of the pustule formed at the point of inocu-
lation, with a few pustules developed around this mother-pustule.1
   As a rule, variolation affords  complete protection ever thereafter against
smallpox.   For those who availed themselves of  it, therefore, it was  a great
blessing prior to the discovery  of  vaccination;  but  it contributed  to  the
diffusion of the  disease by multiplying the foci of contagion,  and  since  the
discovery  of vaccination  it has  ceased  to be  resorted  to  as a means of
avoiding the danger and disfigurement of natural smallpox.   Under certain
circumstances, however, the physician is not only justified  but it is his duty
to practise inoculation.    These  circumstances are the  known exposure of
persons who have  never  had the disease and  who are  unprotected  by vac-
cination, and an  inability to  obtain  the  vaccine virus.   Inoculation  should
then be resorted to  in order to  secure  the great advantages  of  modified
smallpox.   The  late  Prof. Dickson  advocated  a  restoration of the practice
of inoculation, in addition to  vaccination, with a view to test  the protective
power of the latter, and to destroy as completely  as possible all susceptibility
to the disease.2
   At the  present day in most cases of  varioloid the modification is due to
vaccination.  Vaccination does not always afford complete protection against
smallpox, but in general the disease is materially modified.
   In varioloid the primary or eruptive fever in the stage of invasion is often
as marked as in cases of natural  smallpox.   The duration of this stage may
be longer than the  average  duration  in  ordinary variola.   The eruption is
usually far less copious; a few pocks only may appear, and  the eruption may
even be limited to a single pock.   The eruption passes  more rapidly through
the successive changes, the maturation being completed in  five or  six days.
Frequently the eruption aborts to a greater or less extent.   It may stop at
the vesicular, and even  at the papular, period.   More  or less of the vesicles
dry up without breaking.  The general symptoms, as a rule, are much milder
than in most of the benign cases of  natural smallpox.   The secondary fever
is either slight or wanting, and the convalescence is speedy.   Exceptionally,
cases are severe, and the disease proves fatal  in a ratio varying  between 7 and
10 per cent.
                  1 ATide Trousseau, Cliniqne medicate, tome i.
                  2 Am. Journ, of  Medical Sciences, July, 1862. 
VACCINIA,  OR COWPOX.
1043
  Smallpox is  modified in a certain proportion of cases  spontaneously ;  that
is, irrespective of inoculation or vaccination.  Cases presenting the characters
of varioloid occurred prior to the practice of inoculation and the discovery
of vaccination.  They were, however,  rare.  Finally, modified smallpox  or
varioloid is likely to be the  form of the disease when it occurs in those who
have  before experienced  it.   In all  cases of varioloid it is  to be  borne  in
mind  that  the disease is essentially variola or smallpox, and that, however
mild may be the cases, they are capable of communicating  to persons unpro-
tected a severe and fatal form of the disease.
  The diagnosis in cases of varioloid offers difficulties which do not obtain
in cases of unmodified  smallpox.  The disease most likely  to be confounded
with varioloid  is rubeola or measles.  The different points  will be stated  in
treating  presently  of the latter disease.
  In  cases of varioloid oftener than in ordinary variola the eruption is liable
to be  preceded and accompanied  by an  efflorescence bearing considerable
resemblance to scarlatina.   Until  the  variolous  eruption  is developed the
disease may  be supposed to be scarlatina.   The occurrence of  papules  in
the midst  of  the  efflorescence and the remission  or cessation of pyrexia are
the diff'erential  points.   Moreover, an examination of the mouth  and throat
may show the characteristic eruption here before its distinctive characters
on  the skin are  apparent.   The occurrence  of a scarlatiniform  eruption
explains in some  cases  the supposed  coexistence  of  variola  or  varioloid
and scarlatina.  An eruption resembling that of varicella has been  observed
in some cases of  varioloid (variola varicelloides).
  The treatment of varioloid does not claim separate consideration.   The
same  principles are involved as in  the treatment of ordinary smallpox.   The
comparative mildness in  the great majority of cases renders active treatment
unnecessary.   Usually little is required except hygienic measures.


                       Vaccinia,  or Cowpox.

  Vaccinia and cowpox  are names of a disease  of the  cow  which,  commu-
nicated to man, destroys in the  great majority of cases for a certain period
the susceptibility to smallpox, and in the cases  in  which  it does  not offer
complete  protection against the  latter disease renders it, as a rule, mild and
devoid  of  danger.   Cowpox is transferred to  man and  from one person  to
another by the  introduction of a virus, and never at a distance by infection.
The operation for its communication is called vaccination.  For the  employ-
ment of vaccination as a means of preventing smallpox the world  is indebted
to the immortal Jenner.   The discovery was promulgated by Jenner in 1798,
after  a series of observations and experiments which had occupied his atten-
tion for twenty years.   The fruits of this transcendently important discovery
have been  the  saving of an incalculable number of lives which would other-
wise have  been destroyed by one of the most loathsome  of diseases, and the
prevention, to an extent which cannot be computed, of the disfigurement and
other distressing effects which smallpox is liable to produce when it does not
prove fatal. Of all the benefactors who have ever lived, no  one has conferred
on mankind such immense, palpable, and time-lasting  benefits. Yet outside  of
the ranks of the medical profession how many are  ignorant of the name of the
discoverer  of vaccination !  The practice of vaccination met at the  outset with
much hostility, but Jenner lived to see it triumph over all opposition, and  to
witness the beginning of beneficent results which will accumulate  from age
to age until the end of  the world.   The practice was  introduced  into this
country in 1799,  notwithstanding a bitter popular  prejudice,  by Benjamin
AAraterhouse of Boston, the first professor of medicine in Harvard  University. 
1044
ERUPTIVE FEVERS.
 Connected  with vaccinia and vaccination are questions of  great interest  and
 importance which  have given rise to  extended experimental and statistical
 researches, as well as much discussion.  They have occupied a considerable
 share  of medical literature since- the  time of Jenner.   Certain points are
 still unsettled and claim further investigation.   The scope  and  character of
 this work allow of only  a brief statement of facts and the opinions most con-
 sistent with existing knowledge, considered  with direct reference to the prac-
 tice of medicine.
   Directing attention first to the descriptive history of vaccinia  in man, on
 the third day after vaccination (the operation being usually performed on the
 arm near the insertion of the deltoid muscle) red points slightly  elevated—
 that is, small  papules—are apparent  at the  spots where the  vaccine virus  was
 inserted.  On the fourth day the papules are  more developed and reddened.
 On the fifth  day vesicles  are  discoverable.  The vesicles increase, present-
 ing an  umbilicated appearance, and on the  eighth day they attain their  full
 development,  being elevated two to three lines and measuring  one-third of
 an inch in diameter.   The vesicles, like those of smallpox, are  multilocu-
 lar, flattened at the  summits,  and contain  a transparent viscid liquid called
 the vaccine lymph.   On the seventh or eighth day a red areola is apparent,
 extending one to three inches  around the pocks, increasing in redness until
 the ninth  or  tenth day, and the contents of  the vesicles become more or
 less purulent.   At this  time  there  usually  is slight pyrexia with some local
 pain and pruritus.  The  lymphatics of the arm become swollen and the glands
 in the axilla may become enlarged and tender.   On the tenth or eleventh day
 the pyrexia subsides and the redness around the  pocks diminishes.   A dark
 spot soon appears in the  centre and  gradually extends over the whole of  the
 pocks.   The pustules desiccate, and at about the fifteenth  day they are con-
 verted  into black hard scabs, which fall off  usually at about the twenty-fifth
 clay from the date of the  vaccination.  During the progress of the vaccine affec-
 tion vesicles having the distinctive characters of vaccinia have sometimes been
 observed on other parts of the body.  It is probable that these are caused by
 the patient scratching the vesicles on the arm and carrying therefrom  lymph
 containing the virus on the finger-nails to parts  where, owing to the abrasions
 of the  skin, self-vaccination  is the result.  Experiments show that between
 the fourth and the ninth or tenth day the characteristic vesicles may be mul-
 tiplied at will by revaccinating with lymph from the vesicles produced by the
 primary vaccination.   Lichenous or vesicular  eruptions, the latter lacking
 the distinctive features  of  vaccinia, not infrequently accompany or  follow
 vaccination.   Finally, permanent  cicatrices denote the  situation of the vac-
 cine pocks.  The cicatrix, provided the  vesicle have pursued a regular  course
 and  subsequent ulceration have not occurred,  is characteristic, presenting a
 series of depressions  or pits.  The period of incubation in  vaccinia is some-
 times considerably protracted in consequence of the existence of  some other
 affection or from causes which are not apparent.
  A most important practical point connected with vaccination is the discrim-
 ination  of  veritable and complete vaccination from an  incomplete or a spu-
 rious  affection.   The development  of  vesicles of full size, the  successive
 stages,  and the  duration of the  affection,  together  with the characteristic
 appearance of the vesicles and  the cicatrices, are the criteria for determining
 this point.  Simple  sores having no  specific character may  be the result  of
 vaccination.  Incomplete vaccinia—vaccinoid, as it was termed by  Trousseau
—is denoted by the vesicles  being developed more quickly and progressing
to desiccation more rapidly, by their  swollen size  and conoidal form, and  by
the absence of cicatrices  or of the appearance distinctive of the true vaccine
cicatrix.  In view of the immense importance of a true and perfect vaccina- 
VACCINIA,  OR COWPOX.
1045
tion  to those who suppose themselves to  be protected against smallpox, the
responsibility nf performing vaccination should never be undertaken by those
not practically  familiar with vaccinia.   It is obviously far better that a per-
son should not have been vaccinated, with a knowledge of tbe fact, than that
he should incorrectly believe himself to have had veritable and complete  cow-
pox, since this belief involves  a  false security leading to exposures which
might  otherwise  be avoided.
  It is now generally believed  that cowpox is not identical with smallpox,
although  allied to it.   The virus obtained from the the cow by inoculating
with the  smallpox virus (retro-vaccination, as  it is called) is not only unre-.
liable as affording protection against  smallpox in man, but it has been found
repeatedly to communicate the  latter disease.   Vaccine virus thus  obtained
is therefore never to be employed  in vaccination.1  Experiments seem to have
confirmed  the  correctness of the  opinion held by  Jenner that an  affection
sometimes seen in horses, known as grease—called by  the French  des eaux
jambes—is identical with  cowpox, and that vaccinia in  man  may be derived
from  this  source.  As to the origin of the disease in  the cow, the view is
entertained that cowpox is a disease sui generis, and  there is no positive proof
that it is usually or necessarily  derived from any other animal.   The vaccine
lymph contains bacteria, but whether these organisms represent the contagium
of the lymph or not is a question  still undecided.   The experiments of Chau-
veau have rendered it probable  that the contagium  is a  molecular substance,
and is not dissolved in the lymph.
  Other questions, tbe importance of which is obvious,  are, AVhat degree of
protection against smallpox is afforded by cowpox ?  and, AVhat are the causes
of the protection not being universal and complete?  In a large majority of
cases vaccination  affords, for a time at  least, absolute protection against small-
pox.   In these cases  the  situation of persons vaccinated, as  regards suscep-
tibility to the latter disease, is precisely as if natural  or inoculated  smallpox
had  been experienced; but in a minority of cases the protection is only par-
tial.   The susceptibility to smallpox is not destroyed, but the  disease is mate-
rially modified, constituting what  is called varioloid.  At certain times and
places, the  causes which give rise to the  epidemic prevalence  of  smallpox
being unusually efficient, a considerable number of vaccinated  persons become
affected  with  varioloid.  Owing,  however, to  the  comparative  mildness of
varioloid, the rate of mortality is  very small, and therefore fails  to represent
the relative number of vaccinated persons who become affected with modified
smallpox.  It is to be remarked  that smallpox in a certain proportion of cases
is experienced  a second time.   From the following  statistics  it  would appear
that not much  more protection is afforded  by the occurrence of variola than by
vaccination : Of 5774  boys admitted into  the Royal  Military Asylum at Chel-
sea, England, in  forty-eight years, 1950  had, on admission, marks  of small-
pox, and 3824 either had marks of vaccination or they were at once vaccinated.
Of the  former, G.15 per 1000,  and of the latter, 7.06  per 1000, contracted
smallpox  subsequently during  their  residence in the asylum.2
  The opinion  widely prevails, and appears to be well founded, that the extent
of protection afforded  by cowpox  is less in the latter than in  the former part
of the period which has elapsed  since the discovery  of vaccination ;  that is.  a
larger proportion of vaccinated  persons have had varioloid of late years  than
heretofore, and hence  many have been led to entertain the  belief that the
vaccine virus has deteriorated in  consequence  of its  transmission from  per-
son to person.
  1 \Tide Journal of the Gynecological Society of Boston, April  and June, 1872, report of
discourse  by Dr. Henry A. Martin.
  2 Aride Reynolds's System of Medicine. 
1046
ER UPTIVE  FEIHRS.
   Another reason for the increase of varioloid among those who have been
vaccinated is, that the protective influence of vaccination diminishes after the
lapse of  a certain number of years.   A'arioloid  occurs much oftener  among
those more or  less advanced in life than among the  young.  The length of
time which has elapsed after a vaccination may  fairly be considered as enter-
in <y into  the etiology of varioloid.   The importance of  revaccination rests
upon this fact.   Revaccination after the lapse of a greater or less number of
years is  completely successful, as regards the production of the vaccine dis-
ease, in a considerable proportion of cases, and partial success, as shown by
imperfect or vaccinoid vesicles, is still  more common.  The epidemic  preva-
lence of  smallpox, embracing many cases of  varioloid among vaccinated per-
sons, has been promptly and completely arrested by universal vaccination and
revaccination.
   The importance of revaccination being admitted, the  inquiry arises, How
often should it  be resorted to?  There is no known law governing the duration
of the protective influence  of a  single vaccination.  Probably  the  duration
varies widely in diff'erent persons, and some persons are protected by one vac-
cination for life.  Some have thought that revaccinations should be practised
as often as every  three years,  and others that an interval  of twenty years or
more is allowable.  It is evidently better that the period should be needlessly
short than too long.  AVith  our present  knowledge the  propriety,  if  not
importance, of  revaccinating every five  years is to be advocated.  In case of
known exposure  or when smallpox prevails  as  an epidemic it  is proper to
revaccinate without regard to previous vaccinations.   Revaccination, in fact,
is always proper as the readiest and safest test of insusceptibility to smallpox.
   There  is ground for the  belief that the frequent occurrence  of varioloid,
and also  of unmodified smallpox, among those who suppose themselves to be
protected by having had  cowpox is due in no small measure to  imperfect or
spurious  vaccinations.  In this country vaccinators are often unqualified per-
sons.   The operation is  performed not infrequently by those who make no
pretensions to medical knowledge, and to a great extent  by irregular  practi-
tioners.  In many cases persons vaccinated are never seen after the operation,
they or their friends undertaking to judge for themselves of its success.  Hence
many persons are either wholly unprotected or but partially protected.
   A  cause of  inadequate  protection is an  insufficient  number of vaccine
vesicles.   Many have supposed that  a  single vesicle is all that is required,
and that  the only advantage of inserting the virus in more than one spot is
to diminish the risk of failure to procure a single vesicle.   In many  parts of
this country it  is not customary to  procure more than one  or  two vesicles.
Facts show that the number of vaccine-vesicles has a decided influence  on the
amount of protective influence of cowpox.   The following results  of the
analysis,  by Simon, of nearly 6000 cases of smallpox contracted after vacci-
nation, with reference to  the proportion  of deaths to the number of cicatrices,
are interesting connected with the present topic: The ratio of deaths  among
those who stated  that they had been vaccinated, but who presented no vaccine
cicatrix, was 21 %  per cent.;  among those who had one cicatrix, 7 V per cent.;
among those who  had two cicatrices, 41 per cent.; among those who had three
cicatrices, 1J per  cent.; and among those who  had four or more cicatrices,
I of 1 per cent.1   In a primary vaccination it is desirable  that from four to
six vesicles should be produced on each arm.   The  number should not be
less,  after known exposure  to  smallpox, in secondary vaccinations.    A less
number, however, may suffice when it is desired only  to test the fact of pro-
tection by previous vaccinations.
   A\ ithin the past few years an important  practical question relating to vac-
                              1 Aitken, op. cit. 
VACCINIA,  OR COWPOX.
1047
cination has arisen.  In  1866  a  case of spontaneous cowpox was discovered
at Beaugency in France.  The virus obtained from this animal was perpet-
uated, through successive inoculations in heifers conducted by Depaul  under
the sanction of the French Academy of  Medicine and with the aid of the
French government.  The virus  from  this  stock  having been imported into
this  country by Dr. Henry A. Martin of Boston in 1870,  he has kept up the
supply through a continued series of heifer vaccinations ; and since  that date
the supply has been kept up from virus  derived from this  stock in New York
and some other cities.  The terms animal and bovine virus are used  to distin-
guish that derived immediately from the heifer, that derived from the human
subject being called humanized virus.   The important  practical question  is
whether the animal virus affords greater protection against smallpox than the
humanized virus ?  That the latter has deteriorated in consequence of removes
from  the cow seems certain.   Vaccination with the long-humanized virus  is
less constantly successful in producing vaccinia than formerly ; the revaccina-
tion of persons who have been vaccinated with  this virus is oftener successful,
and a diminished protection is shown by  the  greater number of vaccinated
persons who become affected  with varioloid.  The opinion  that vaccination
with  the animal virus secures a more complete and a longer exemption from
the danger of  contracting smallpox, is shared by many, and this virus is now
extensively used in this  country instead of the humanized virus.  It remains
to be determined by the results of a long experience whether—assuming that
at the present time  the animal virus has a greater  protective power—this
power may  not become deteriorated by  distant  removes from  Beaugency
stock  in heifers, as there is reason to believe has been the case in the human
race.  This, however, is a consideration which  concerns  the future;  and a
deterioration, if it occur, would  only render it important to  take  advantage
at different periods  of other  instances of vaccinia  of spontaneous  origin1 in
the  cow, in  this way renewing  the  stock.
   Vaccinia in  man produced by the animal virus differs  in  certain respects
from the disease produced by the long-humanized virus.   The full  devel-
opment of the  vaccine pock requires a longer period; the pock continues to
increase for several days after the eighth day, this being  the period required
for the  full development of the pock after vaccination  with the long-human-
ized virus; and the pock is of larger  size.  The crusts are not formed until
the eighteenth or nineteenth day, and they remain adherent until between the
twenty-fifth and the thirty-fifth day.  The vesicle does not spontaneously rup-
ture, and the crust preserves the form of the vesicle with the umbilicated cen-
tre.  The constitutional  symptoms are more marked. In a small proportion of
cases  (1 in  50) a vesicular eruption occurs over the body, and the vesicles on
close inspection are found to  be  umbilicated.  The  development of  a roseolar
eruption after vaccination has also been observed, but this is rare.  AVith respect
to these points of difference, the disease as now produced by the animal virus
corresponds with tbe  disease as described and delineated by the earliest vac-
cino-raphers—a fact which in itself renders probable  the deterioration of the
humanized and the superiority of the animal virus.2
   Assuming that the animal  or bovine virus is equal  to the humanized in its
protective power (and at least this must be conceded), there are certain advan-
  1 The term spontaneous is here  used to distinguish it from the disease produced by
retro-vaccination. AVhether cowpox be ever in a broader sense spontaneous is an open

  2 Vide Discourse by Dr.  Martin in Journal of the Gyna-cological Society of Boston ; also,
" Practical Remarks on A'accination," bv Dr. Frank P. Foster, in Neumann's Hand-book
of Skin Diseases  translated  bv Bulkier, and in article on "A'accination" in Pepper's Sys-
tem of Practical  Medicine,  by American Authors,_ Philadelphia, 1885, vol. l.; also, Sur
le Cowpox decouvert &  Pussy, par Bousquet,  Paris. 
1048                    ERUPTIVE FEVERS.
tages which the former has over the latter.  There is far less liability to local
accidents—namely, ulcerations and erysipelas.   Dr. Martin  states that in
April, 1872, there had  been at  least 400,000 revaccinations made in this
country with the  Beaugency virus, and no case  of death, of erysipelas, or
of post-vaccine variola had been  reported among them.   Another advantage
is a more uniform success in both primary vaccinations  and revaccinations.
Another is that the supply of virus can always be made to meet the demand.
Again, an  advantage which  has  only to be named  for its  importance to be
apparent is the fact that the virus  from the heifer is incapable of communi-
cating syphilis.  Granting that the risk of syphilis is small when  humanized
virus is used, there is nevertheless a risk ; and syphilis has repeatedly been
communicated.  It is an immense advantage to eliminate all  danger in this
direction.
  Deterioration of the humanized  virus is to be added  to the  causes pre-
viously enumerated of the apparent inadequateness of vaccination to  afford
complete protection against  smallpox.  Assuming that this obstacle  may be
overcome by the use of animal  virus, the other causes are  removable; and
were  they to be entirely removed it is not improbable that the expectation
which Jenner cherished of exterminating smallpox  might be realized.   Cer-
tain it is that were all the requisites for  the  most  perfect vaccination to be
invariably  observed, and if all persons living  were  vaccinated and revacci-
nated, smallpox, if not exterminated, would be  insignificant as  regards its
prevalence and severity.   The difficulty of securing for  all mankind a pro-
tection against the disease almost  complete is not so much in the insufficiency
of the means  as in enforcing their adoption  to the fullest possible extent.
Vaccination and revaccination, in order to be universal, must be compulsory,
and authoritative measures to secure the proper and successful performance
of the operation are essential. To consider the most efficient legal provisions
to accomplish these desirable ends  would be to open up a wide field for dis-
cussion, which would  be inconsistent with the  objects of this work.  Strange
as it  may  seem, there are  persons, not without intelligence, at this day who
entertain toward vaccination  the  prejudices which Jenner had to encounter.
  It  remains  to notice some practical points  relating  to the  operation for
vaccination.  The  situation for the introduction of the vaccine virus should
always be  that usually selected—namely, on the arms near the insertion of
the deltoid muscle.  Uniformity of practice in  this respect enables physicians
and others to  ascertain without delay or doubt the fact of a previous vacci-
nation, and to judge of its  success by an examination of the cicatrices.   Thee*
vaccine lymph is to be preferred to the crust.  The lymph is  usually taken
on ivory points or pointed quills,  but the virus taken in this way to be effect-
ive  must  be recent.  AVith a view  to preservation the  lymph  may be  with-
drawn from the vesicles in glass capillary tubes which are at once sealed by
means of a spirit-lamp.   Jenner considered it a " golden rule " never to take
the virus from a  vaccine  vesicle for the  purpose of vaccination after the
efflorescence is formed around it.   A crust enclosed in wax and covered with
tin-foil retains its activity for a considerable period.
  As regards the mode of vaccinating, if dried lymph he used or lymph con-
tained in capillary  tubes it may be inserted by means of slight punctures, or
by scraping away the  epidermis, or by minute scarifications; the  latter method
being preferable.  Having made, with a common  lancet,  a number of linear
and transverse scratches, not deep  enough to cause the escape  of  more than
a drop or two of blood, the lymph is to be applied  over the scarified spots,
which should  be five  to six in number and not larger than half a dime.  If
the incisions be sufficiently delicate, the operation gives no pain, and  allowing
the spots to dry before being covered by the clothing is all that is required. 
VACCINIA,  OR COWPOX.
1049
If the crust be used, a small portion  should be dissolved, always at the time
of the operation, in a drop or two of water, and applied by means of the lancet
over the scarified spots.   This is preferable to making  punctures and intro-
ducing  small pieces of the  undissolved crust.   The latter mode is  liable to
cause sores which, aside  from the annoyance they occasion, may interfere
with the specific action  of the virus.
   The age for the performance of a primary vaccination is a point of  import-
ance.  Between the second  and the third  month of infancy is the period to
be preferred for vaccination.  Any liability to exposure  to smallpox, however,
renders the operation advisable at an earlier period.  It is desirable that the
child when vaccinated should  be in good health, but the operation should not
be delayed on  account of illness if there  be a liability to exposure to small-
pox.  If the operation prove unsuccessful, another trial should be made, and
if this fail the virus may be  introduced a third time. Some persons are insus-
ceptible to cowpox.  An  insusceptibility is to be inferred from  two or three
successive  failures  with  virus which  has proved successful in others.   The
attempt to vaccinate, however, should be repeated from time to time,  for sus-
ceptibility may afterward exist.  So long as there  is insusceptibility to cow-
pox  there  is little  danger of  smallpox being contracted.  Aside from want
of susceptibility, and exclusive of inertness of the lymph or  crust used, the
common cause of failure is undue bleeding from  the scarifications, the flow
of blood preventing the absorption of the  virus.
   Troublesome  ulcerations  occasionally follow vaccination, arising from  irri-
tation  by the friction of clothing or from an unhealthy condition of the sys-
tem.  These are to be treated like  ordinary sores.   Erysipelatous inflamma-
tion  and abscesses may occur.  These concomitants or sequels are not always
evidence of any fault in  the operation  or impurity of the matter used.  Dr.
Henry G. Piffard, however, has reported  cases in  which the  disease of the
skin known as  impetigo  contagiosa has occurred  as a  sequel of vaccination
with the virus in crusts  both animal and humanized.   The  liability to the
communication of this affection is a reason for preferring lymph to crusts for
vaccination.1  Ignorant persons sometimes attribute to vaccination  diseases
of any kind which may occur  within a few weeks or months  afterward, and to
charge the physician with having used  impure vaccine matter.  This impres-
sion may be so  rooted as not to be removable, and hence a vaccination may
very unjustly prove the occasion  for  a withdrawal of  the  confidence which
the physician had  previously possessed.   So  far  as the  imputation of com-
municating human diseases is concerned, it is avoided by using the animal
virus; and this is a recommendation  of the latter to be added to the advan-
tages already mentioned.
   After a known exposure  to smallpox, if the person exposed have not been
recently vaccinated or  if  there be  any reason  to distrust a previous vaccina-
tion, revaccination  should of course be promptly performed.  It is proper to
perform it without  reference to previous vaccinations, with a view to  test the
susceptibility and render the security as complete as possible.  It has occurred
to me repeatedly to vaccinate, under circumstances involving the utmost pos-
sible  exposure, persons who had never been vaccinated, and thereby to  pre-
vent the  occurrence of  smallpox.    In one instance an unvaccinated child
lived in the same room and  slept with a person who had contracted smallpox.
The  first operation proving unsuccessful, it was  repeated three days after-
ward with success, and the child escaped.   In another instance a patient with
measles was supposed  to have smallpox and was sent to a smallpox  hospital.
He had never been vaccinated, and vaccination was at once  performed.  The
  1 A'ide articles by Dr. Piffard in the New York Med. Journal, Nos. for June and July,
1872. 
1050
ERUPTIVE FEVERS.
vaccine disease was deferred  until the measles had run its course.  It then
became developed and smallpox did not occur.  Owing to the relatively short
duration of the period of incubation in cowpox, it anticipates the development
of smallpox.  I have  not observed the coexistence of the two affections under
these circumstances.


                    Varicella, or Chicken-pox.
   Varicella—or, as it is commonly called, chicken-pox—is an affection  quite
insignificant  as regards danger or distressing  symptoms.   It  is important
with reference, first, to the question  as  to its having pathological relations
with smallpox, and second, to its discrimination  from  modified  variola or
varioloid.
   It is an eruptive disease affecting usually children, but occasionally adults.
The  eruption is preceded  generally  by slight  constitutional  symptoms for
about twenty-four  hours.   The eruption  generally appears first on the body,
and  afterward on the head.  It usually is more abundant on the neck, body,
and  scalp than on the face.   The  eruption is frequently quite small and is
very rarely abundant.   It is  almost invariably discrete.  It is a vesicular
eruption from the  first.  The vesicles contain at first a transparent liquid,
which  afterward  becomes  opaline, but not purulent  except when they are
irritated by scratching.  Desiccation occurs between the fifth and the seventh
day.  The crusts  are granular and are rarely followed by cicatrices or pit-
ting.   Sometimes bullae of greater or less size form instead of vesicles.   New
vesicles frequently continue to appear during the first three days of the  stage
of the eruption, and even after the desiccation of  those which first appeared
has begun.   During  the  eruptive  stage  constitutional  symptoms are  slight
or wanting.  The  disease is contagious  as regards  children, but very rarely
as regards adults.    Experiments made  to  determine its  communicability
by inoculation  have  so  generally  failed  that it  is a question whether, in
the few instances in which  it  was apparently successful, the contagion may
not have been otherwise received.  The period  of incubation varies between
twelve and seventeen  days.  AVriters  have made several varieties based  upon
differences as regards  the  size  and  shape  of  the vesicles.  The ordinary
variety, in which  the  vesicles are about the size  of split peas and flattened at
the top, has been distinguished as varicella lentiformis vel lenticularis, or len-
ticular  chicken-pox.  The variety  called varicella coniformis vel conoides, or
swine-pox, is  characterized by the conoidal form  of the vesicles.   Varicella
globularis vel globata, is the name of a variety in which the vesicles are un-
usually large and are globular in form.   The different vesicles in  the  same
case not infrequently present the  characters of these three varieties.   The
division  into varieties is of not  the  least practical consequence.
   The name varicella, which is a diminutive of variola, meaning little small-
pox, implies that the  disease is essentially variolous.   It has been considered
as a  modified form of variola,  and is so considered by  some eminent teachers
and writers at the  present time.   The non-identity of the two affections is
established by the following facts : The contagium of varicella is never known
to give  rise to ordinary variola, whereas the  severest  form  of the latter dis-
ease may be derived from cases of  varioloid.  Varioloid prevails only during
the prevalence  of ordinary smallpox, but varicella not infrequently'prevails
when there are no cases of smallpox.   Araricella is very rarely communicated
to adults. This is not true of varioloid.  Araricella affords no protection against
variola, and, conversely, persons who have had smallpox contract varicella.
A'accination does not protect  against varicella, and  the latter does not inter-
fere  with the success of vaccination.  It is not settled  that varicella is ever 
                 SCARLATINA, OR SCARLET  FEVER.             1051

communicable  by inoculation.  Other points of difference, showing the non-
identity  of varicella  and varioloid, relate  to the  clinical history, and upon
these points the differential  diagnosis is  to  be based.
   Although pathologically distinct, it must be confessed that the discrimina-
tion of varicella from varioloid is not always easy.   The two affections are
liable to  be confounded.   Cases of varioloid  are not infrequently at first
considered as cases of varicella, and  vice  versa.   In view  of the great im-
portance  of making  this diff'erential diagnosis promptly and  positively, the
following diagnostic  points  claim  the  careful  attention of the  student  and
practitioner:
   The stage of invasion in  varioloid  is as long  as, or  longer  than, in cases
of ordinary smallpox—namely, from two to three  days.  The  short duration
of this  stage in varicella is  a distinctive feature.   The constitutional symp-
toms in  this stage are  often as marked in varioloid  as in cases of ordinary
smallpox.  The mildness of these symptoms in  varicella is a diagnostic point.
The vesicular  character of the eruption from  the start is  characteristic  of
varicella.  In  varioloid the vesicles are preceded by papules.   In varioloid,
as  in ordinary smallpox, the eruption appears at first and  especially on the
face. In varicella it  appears first on the body,  and is likely  to  be more abun-
dant elsewhere than on the  face.   A capital diagnostic point relates to the
central depression or the umbilicated appearance.  This is generally discover-
able  in  more or less of the vesicles  in varioloid, and it is generally, if not
invariably, wanting in varicella.  The duration of the eruptive stage is  less
in varicella than in the great majority of  cases of varioloid.   Finally, traces
of vesicles in varicella are rarely found on the mucous membrane of the mouth,
fauces, and genitalia.
   It is important, as has been urged especially  by Janeway, to trace doubtful
cases of all infectious diseases to their origin, and also to note the cases which
are transmitted by the disease in question, as these other cases may be more
distinctive in their characters.
   During the prevalence of smallpox cases of varioloid in which the eruption
is small  are often considered as cases of varicella.   The  cases of so-called
varicella in adults  when smallpox prevails are generally cases of varioloid ;
hence, one source of the diffusion of  smallpox.
   A'aricella claims no treatment.   It is important  to recognize  it only in order
to relieve apprehensions by  the assurance that  the disease is not varioloid.
                       CHAPTER   VII.

                  ERUPTIVE  FEVERS  (Continued).

Scarlatina, or Scarlet Fever: Anatomical Characters; Clinical History; Causation; Diag-
                         nosis; Prognosis; Treatment,

                   Scarlatina,  or Scarlet Fever.
   THE exanthematous fever called, from the color of the eruption, scarlatina
    or scarlet fever, is remarkable  for the wide diversity which it presents in
different cases as resards  svmptoms and fatality.  In its mildest form it is a
trivial affection, but'in its severest  form there are  few diseases more appro- 
1052
ERUPTIVE FEVERS.
priately styled malignant.  The disease has  been divided into several  vari-
eties based  on differences in  symptomatic characters  and intensity.  Three
varieties are  generally  recognized by writers—namely, scarlatina simplex,
scarlatina anginosa, and  scarlatina maligna.   AVidely  different  as are these
varieties in respect to gravity and distinctive characters, they are not  dis-
tinct diseases, and  essentially "they are identical.   A simpler division is into
mild and severe scarlatina, but it will suffice to  consider  incidentally the
events which belong to the latter, without treating of it separately.

  Anatomical Characters.—The  eruption  on the surface and  the morbid
appearances in the  throat constitute the leading anatomical characters in this
affection.   There is usually little or no trace of the eruption to be observed
after death.   The eruption is caused by hyperaemia, combined with more or
less oedematous swelling of the cutis.  In a case in which death  took place
at the height of an  intense scarlatinal eruption, Birch-Hirschfeld  observed
many lymphoid cells between the epithelial  cells of the rete Malpighii, as
well as in the superficial and  deeper  layers of the corium.    He  also saw
small  extravasations  of blood.   Fenwick  has called  attention  to  blood-
extravasations in the lumen  of the  sweat-glands.   The cutaneous affection
of scarlatina is to  be regarded as a superficial dermatitis  of mild degree.
  In the mildest form of scarlatinal sore throat the mucous membrane cover-
ing the tonsils, soft  palate, and pharynx  is reddened and  slightly swollen.
The tonsils are frequently enlarged.   A  phlegmonous inflammation  of the
parts named may occur  in severe  cases of the variety of the disease desig-
nated as scarlatina  anginosa.  The swelling is then extreme.   The  submucous
and the  mucous layers  become infiltrated with pus-cells.  Abscesses form,
especially in the tonsils.  The phlegmonous inflammation may terminate  in
destructive  ulceration or in gangrene.  The phlegmonous inflammation  may
be propagated to the connective tissue in  the  submaxillary region, and  give
rise to extensive purulent collections in this situation.  Erosion of the large
vessels has been caused by this suppurative process in the neck.   In some
epidemics diphtheritic inflammation of the throat has been a frequent attend-
ant upon scarlet fever.   The fibrinous exudation begins  on  the tonsils and
extends to the  soft palate and to the pharynx.   It has less  tendency than
primary diphtheria  to extend into the larynx.  There is much controversy as
to the  relation which this diphtheritic  affection of the throat bears to scarla-
tina.   There are three prominent views as to this  relation.   According to
one view, the diphtheritic aff'ection is anatomically the same  disease as pri-
mary diphtheria, but it  is produced by the scarlatinal poison ;  according to
a second  view, the disease, both anatomically and  etiologically, is identical
with primary diphtheria, and  it is to be regarded as a complication of  scarlet
fever;  according to the third view, scarlatinal diphtheria differs in  its anatom-
ical characters from  primary  diphtheria.   Heubner  has  attempted to prove,
from an anatomical point of view, the non-identity of scarlatinal  diphtheria
and primary diphtheria, but the differential criteria to which he calls attention
are not sufficient to distinguish anatomically one disease from the other.1  The
first of the three views  mentioned is the most probable.  The inflammatory
process may be propagated from the pharynx  along tbe Eustachian tubes to
the mucous  membrane  lining the cavity  of the middle ear.   Suppurative
  1 The points to which Heubner calls attention are: 1. The pseudo-membranous depos-
its are  much thinner in scarlatinal than in primary diphtheria, so that in the former
disease  membranes are not expectorated.  2. The  fibrin in scarlatinal diphtheria is
found between the epithelial cells and in the connective tissue of the mucosa and sub-
mucosa.  He could detect no differences between the micrococci present in scarlatinal
diphtheria and those of primary diphtheria (" Beobachtungen fiber Scharlach-Diph-
therie," Jahrbuch der  Kinderheilkunde, 1879, xiv. p. 1). 
SCARLATINA, OR SCARLET FEVER.
1053
median  otitis, with perforation  of the tympanum, and  sometimes with con-
secutive caries of bone, may thus be produced.   Swelling and inflammation
of the lymphatic glands of the neck not infrequently accompany scarlatinal
angina.   The glands may suppurate.   The mucous membrane of the larynx.
trachea, and  bronchi is sometimes inflamed.  The inflammation  in this situ-
ation is rarely accompanied by a fibrinous exudation.  Lobular pneumonia is
an occasional  complication of scarlatina.  Lobar pneumonia is less frequent,
Fenwick has observed  parenchymatous degeneration of the gastric tubules in
this  disease.   Peyer's  patches and the solitary  follicles  of the  intestine  are
often moderately swollen.   There may be found ecchymoses in the gastric
and  intestinal mucous  membrane, but they are  rarely abundant.   Dysentery
is a  rare complication  of scarlet  fever.  The  spleen has often  been found
enlarged.  Swelling of the mesenteric  glands,  as well as of other lymphatic
glands  of the body, has been observed in a number of cases.  Parenchyma-
tous degenerations of the liver, kidneys, and heart occur in scarlet fever.  In
some cases  in which  the immediate  cause  of death has been failure of  the
heart-power  fatty degeneration of the muscular substance of the heart has
been present.
   The most important sequel of scarlet fever is  acute Bright's disease. Some
regard  this occurrence as a part of the scarlatinal  process, and others, as a
complication.  The kidneys in cases of scarlatinal  nephritis  present appear-
ances which have  been described in the article on x4.cute Bright's  Disease
(p. 805).  Sometimes  small abscesses  form in the kidneys in  this disease.

   Clinical History.—The symptomatic events of  the  several  stages sepa-
rately will be first noticed, and afterward anomalous events and complications
liable to occur in either of the three stages.
   Stage of Invasion.—The attack may begin with  a chill more  or  less pro-
nounced, but not infrequently it is wanting.  Vomiting is generally an early
symptom, especially in children, with, in a certain  proportion of cases, diar-
rhoea.  The  pyrexia, as a rule, is notably greater than in  the other erup-
tive  fevers.   Epistaxis is not uncommon. Redness of the fauces  more or less
vivid may generally be observed in this  stage, either with or without a sense
of soreness and pain in swallowing.   The affection of the throat  is due to  the
efflorescence which  appears in this situation before its appearance on  the skin.
As  regards the intensity of the pyrexia, pain  in the head, prostration, and
general malaise, different cases differ widely, not including  cases of unusual
severity.  In very mild cases the symptoms are  so slight  that the patient does
not  take to the bed.
   The  average  duration  of this stage is about twenty-four hours, and  the
eruption usually appears on the second  day.   Exceptionally, it appears, on
the one hand, a few hours after the attack, and on the  other hand it may be
delayed one, two, three, or more days after the time wdien it usually appears.
A considerable delay in the appearance of the  eruption  is generally attribut-
able  to some complication.
   Stage of Eruption.—This stage in  children is sometimes ushered  in by a
transient convulsion, which at this period is not a uraemic symptom.  In its
development and diffusion over  the body the eruption  does  not  observe  the
same regularity as in smallpox and measles.  It oftener appears on  the body
and  limbs before making its appearance on the face and neck, but in  a certain
proportion of cases it appears first in the latter situations. • It is rapidly  dif-
fused, extending more  or less over the whole cutaneous surface in twenty-four
hours.   As regards the degree and extent of the efflorescence, different cases
differ much.  The  first appearance is in the form of minute dots or specks.
These coalesce, forming irregularly distributed  patches, which vary much in 
1054
ERUPTIVE  FEVERS.
 size and  shape,  having irregular or  serrated margins.  Exceptionally, the
 eruption remains punctiform ; that is, in the form of distinct maculae or spots.
 The redness is most vivid and remains longest in situations where the skin is
 delicate, as the inner surfaces of the arms and thighs and the flexures of the
 joints.   The redness is vermilion or scarlet; it is not uniform like erysipela-
 tous redness, but on close inspection the patches are seen to be studded with
 points which  are distinguished  by  a more  deeply red color.   The redness
 momentarily disappears on pressure, and white lines are produced by drawing
 a pointed hard substance—for example, a pencil—over the reddened surface.
 In  some cases the whole cutaneous surface is covered with the efflorescence,
 presenting an appearance which has been compared to that of a boiled lobster.
 Generally, on passing the fingers over  the reddened surface it is felt to be
 smooth, but in some cases there is a  sensation of  minute elevations or pap-
 ules.   These are  the papillae abnormally developed, as in the  condition  com-
 monly known  as goose-skin.  Occasionally, miliary vesicles are scattered more
 or  less abundantly over the surface.   The  integument  is slightly swollen.
 This is evident on the face and is apparent to the patient when the hands are
 closed.   The  feet are also evidently  somewhat swollen.  The eruption is
 sometimes accompanied by more or less burning and pruritus.  The eruption
 attains its maximum of intensity and diffusion on the third day after its first
 appearance.
  There is much  variation in different cases in the amount of cutaneous erup-
 tion.   It  is sometimes  slight.   This is likely to be the case when the throat
 affection is unusually severe.   The eruption  then seems  to be  concentrated
 within the throat.  Occasionally the efflorescence  on the skin  disappears
 shortly after its appearance, and afterward returns.    It fluctuates as regards
 vividness, being especially marked in febrile exacerbations, and it is generally
 more vivid toward evening than in the early part of the day.   In anomalous
 cases, which will  presently be referred to, the eruption is wanting.
  The throat  is more  or  less affected in the vast majority of cases, but  in
 some very mild  cases there is no throat affection.   If the  throat  be but
 slightly affected, there is simply redness over the tonsils, the posterior part of
 the pharynx, and  extending more or less over the soft palate, with little or no
 swelling.   The affection is  then only an efflorescence.  In  most cases, how-
 ever, there is  more or less swelling of the tonsils,  together with a white  or
 ash-colored exudation in greater or less abundance.   This  exudation is gener-
 ally not like that which characterizes diphtheritic inflammation.  It adheres
 less closely, is pultaceous, and  cannot be detached in strips.   It may receive
 a dark color from matters vomited and from the oozing of blood.   In propor-
 tion to the amount of throat affection there is pain in deglutition and the voice
 becomes nasal. The submaxillary and lymphatic glands at the angle of the
 jaw frequently are swollen and tender.  A still  greater  degree  of  throat
 affection  belongs  among the anomalous events of the disease and character-
 izes the  variety distinguished  as scarlatina anginosa.
  The tongue early in  the disease generally is coated.   AVhile  the coating
 remains, frequently the  papillae projecting through it  have the appearance of
 a number of red points, and the surface of the tongue looks as if cayenne pep-
 per or red sand had  been sprinkled over it.   This is  seen in other affections.
 Another appearance is quite distinctive of scarlet fever.   In the progress of
 the  disease the coating exfoliates, leaving the surface  of the tongue clean and
reddened ;  and, the papillae being enlarged, the appearance  is strikingly like
that of a  ripe strawberry.   The strawberry-like tongue is a  pathognomonic
 symptom, and is peculiar to this disease.  It is often  but not uniformly pres-
ent.   It is due to a condition of the mucous membrane analogous to that of
the  skin in the cases of  so-called rough as distinctive from smooth scarlatina. 
                 SCARLATINA, OR SCARLET FEVER.            1055

  The pyrexia is not diminished, but, as a rule, is increased, after the appear-
ance of the eruption.   The frequency of the pulse and the increased heat of
the skin are more marked than in any other of the essential fevers. The pulse
varies in different cases—which, although more or less severe, pursue a favor-
able course—between  100 and 130  or 140 per  minute.   In extremely  severe
cases, especially in children, it rises  still higher.   Aside from frequency, the
pulse is quick, often vibratory or thrilling, but always compressible, these cha-
racters  showing  excited action without augmented power of  the ventricular
contractions.  The sphygmograph. as in all the eruptive fevers, shows absence
of dicrotism.  The skin usually is dry. and the heat, as felt  by the hand, is
often pungent.   The thermometer in the axilla shows an increase of temper-
ature to 105° F., and  in severe cases  a still  greater increase.  It has been
known  to reach  112°  F.
   During the stage of  the eruption anorexia continues, vomiting is not uncom-
mon, constipation exists in some cases, and in some cases there is diarrhoea.
Thirst usually is urgent.   Delirium, manifested  by incoherency,  generally
exists, save  in veiy mild cases.  I have known a patient, not considered  ill
enough to require a watcher during the night, to get up and wander  out of
doors in a state of delirium.  A melancholy instance, illustrative of the import-
ance of watchfulness in the care of  patients  in the delirium of fever, occurred
many years ago at the Louisville Marine Hospital during my term of service.
A female adult  patient affected with scarlatina, but not considered  seriously
ill, had been  removed to a room by herself  in the uppermost  story  of the
hospital building,  with a view to isolation.   During  the absence of her
attendant for a few moments she precipitated  herself from the  window, and,
falling upon  the pavement, was instantly  killed.   Restlessness, jactitation,
and insomnia are likely to be more or less marked.  Albuminuria occurs in a
certain proportion  (about one-seventh) of cases during the  eruptive stage.
Transient, slight albuminuria occurs in scarlatina, as in various other affec-
tions, without denoting renal disease;  but disease of the kidneys forms  an
important  complication in certain  cases of scarlatina, and will presently  be
noticed.  The duration of the stage of eruption in the majority of cases is
between four and six  days.   It is sometimes  shorter; oftener it is prolonged
to  eight or  ten  days; and occasionally it  continues for a longer period.
   Stage of Desquamation.—The  commencement of  desquamation  marks
the beginning of  this  stage.   Desquamation frequently begins  with the
decline of  the  eruption and  prior to its  disappearance.  The degree and
extent of the desquamation are in general  proportionate to the intensity and
diffusion of  the  efflorescence.  Desquamation is  rarely wanting, save in the
cases in which  the efflorescence fails  to appear.  The cuticle is  exfoliated
either in the form of minute branny scales, called furfuraceous desquamation,
or in pieces of epidermis of greater or less size.  Occasionally  the epidermis
of the hands is detached entire and may be stripped off like a glove.  This
is  true  also of  the epidermis of  the feet.   Sometimes several  successive
exfoliations  occur.                                                 . .
   In cases  which pursue a favorable course the febrile  movement diminishes
 with the beginning of exfoliation, and gradually ceases, corresponding im-
provement taking place in other symptoms.   The defervescence is sometimes
rapid but in most cases it is gradual.   If  the disease be uncomplicated  and
 there' he no  untoward  events, convalescence is declared during the stage of
 desquamation.   The desquamative process is frequently accompanied with
 pruritus  which  in some cases is excessive.   Albuminuria occurs in  this stage
 more frequently than  in the stage  of eruption—namely, in the  proportion of
 one-fourth.   As in the stage of eruption, so in  the desquamative stage, the
 presence of albumen in the'urine may or may not be indicative of an  import- 
1056
ERUPTIVE FEVERS.
ant renal complication.  A recurrence of the eruption may take place during
the stage of desquamation.
  The duration of this stage is indefinite.  It may end in five or six days.
The desquamation is generally completed in from ten to twelve days, but
exceptionally it continues  for  several  weeks.
  The foregoing sketch of the clinical history of scarlet fever applies to cases
which  are Either mild or not extremely severe, and in which the course of
the disease is regular; that is, without  anomalous events or complications.
Certain cases are characterized by extreme gravity of  the symptoms at the
outset of the disease.   The  pulse becomes very frequent, numbering  140,
150, 160, or more per  minute.   The  thermometer  shows  notable hyper-
pyrexia. ' Great restlessness, delirium, coma, and occasionally convulsions,
are other symptoms denoting severity of  the  disease.  Death may take place
in one or two days or sometimes  even within a few hours from  the attack.
A fatal result may take place before  the  eruption appears  on the skin or any
pharyngeal redness is apparent. The disease in such cases  is truly malignant.
Cases of this description are liable to occur in certain epidemics.  The gravity
in these cases is not due to any complication, but to an unusual intensity  of
the essential morbid  conditions which  constitute  the disease.  Ataxic  or
nervous symptoms, in like manner dependent on the intensity of the disease,
are liable  to be developed at a later  period—namely, active delirium, typho-
mania, carphologia, and subsultus  tendinum.  These symptoms characterize
certain cases of severe scarlet fever.
   Convulsions,  coma,  and delirium may he developed  as  effects of  uraemia.
Disease of the  kidneys  is an important  complication in a certain proportion
of  cases.   Generally,  but  not always, in these cases  the urine is highly
albuminous. Albuminuria,  as already stated,  may not indicate any important
affection  of the kidneys if the quantity of albumen be small; and on  the
other hand grave disease of  the  kidneys may exist  without albuminuria.
The presence of casts with white or red corpuscles in the urine is more sig-
nificant of renal  disease than the  presence of  albumen.   The  danger  of
uraemia is proportionate to the scanty excretion of urine.  Clinical facts show
that scarlatina  involves a  special  tendency to  renal disease, not only  as a
sequel, but as a  concomitant.  It is a rational supposition that the lining mem-
brane of the secretory tubes of the kidneys takes on a morbid condition anal-
ogous to that of the  mucous membrane of the pharynx, constituting a local
affection which  is serious in proportion as the excretion of urea is interfered
with.  General dropsy sometimes occurs during the progress of the disease as
well as afterward.  Symptoms  pointing to uraemia, in addition to the events
already stated—namely, convulsions, coma,  and delirium—are cephalalgia,
disturbance  of  respiration  occurring without either bronchitis, pneumonia,
oedema of the lungs, or any appreciable pulmonary affection, defective vision,
vomiting, and  occasionally  diarrhoea.  These symptoms should direct atten-
tion to the urine  as  regards albuminuria, the presence of casts, and espe-
cially the deficiency of urea.  Uraemia, taking  place either as a concomitant
or a sequel of scarlet fever,  may occur without albuminuria and  without
dropsy.  Hence the  importance of  examinations of the  urine in all ca.ses,
with reference  not alone to the presence of albumen,  but of casts  and  the
quantity  of urea.
   Certain cases of severe scarlatina  are  characterized  by a great amount of
throat affection.   The name scarlatina  anginosa is  applied  to these cases.
The tonsils are  greatly swollen and covered with a muco-purulent, pultaceous
deposit. Deglutition is difficult, and liquids taken into the mouth are returned
through the  nostrils.  The inflammation may extend  to  the posterior  and
anterior nares,  and acrid pus flows from the nose, excoriating the face.  The 
                 SCARLATINA,  OR  SCARLET FEVER.            1057

breath emits an intolerable fetor in some cases.  Sometimes, but  rarely, the
inflammation extends into the larynx and bronchial tubes.   OZdema of the
glottis is  an occasional accident in adults.   The structures of tbe eye  may
become involved, and destruction of both eyes has  been known to follow.
An extension of the inflammation through  the Eustachian tube  into the
middle ear is liable to occur. I have met with a case in which the tympanum
in each ear was perforated  and the  ossicles were  discharged  through the
external meatus.   Permanent  deafness, facial paralysis, and in some cases
caries of the temporal bone, followed by circumscribed meningitis and abscess
of the brain, are effects of an extension of the local  affection to  the middle
ear.   The submaxillary and lymphatic  glands of the neck become more or
less enlarged, and sometimes suppuration takes place, constituting what have
been  called scarlatinous buboes.  I  have met with a case of extensive spha-
celation of the lips and cheeks, the patient being a child well nourished and
healthy up  to the  date of the  attack.  Gangrene and ulceration within the
throat are very  rare events.   The  local events belonging to scarlatina angi-
nosa, inclusive  of inflammation and suppuration of the glands of the neck,
may occur early in the disease, or, on the other hand, they may be developed
during  the  stage of desquamation, the symptoms having previously denoted
a  mild  form of the  disease.  A  true diphtheritic exudation in  the  fauces
characterizes certain cases.
   In cases  of so-called scarlatina  anginosa, the cutaneous  eruption may be
slight  and it is sometimes wanting.  Albuminuria  is  likely to exist in these
cases.  Uraemic phenomena are liable to occur, but, exclusive of these and of
laryngitis or oedema of  the glottis, the severity of the throat aff'ection may be
sufficient  to lead to a fatal result.
   Hemorrhages in various situations, together with  petechiae and vibices on
the  skin,  characterize certain cases.  The name hemorrhagic scarlatina has
been applied to these cases.  They are almost invariably fatal.   Haematuria
may occur in connection with renal disease, and if not accompanied by hemor-
rhage elsewhere is  not necessarily of grave omen.
   Complications other than those which have  been noticed, and of rare occur-
rence, are articular rheumatism, usually confined to  a  few joints,  vaginitis,
pleuritis or pyothorax,  pericarditis, and  endocarditis (sometimes of the acute
ulcerative form), the two latter affections being often associated with either
rheumatism or  renal disease.
   In irregular cases of  scarlatina the disease is often, but by no means always,
severe.   The only local manifestation  of  the disease may be a slight soreness
of the throat, no cutaneous eruption taking place.  In these cases the disease
has  been distinguished as scarlatina faucium and  scarlatina sine  eruptione.
Cases of the throat affection more or less severe, without any eruption on the
skin, not  infrequently occur during the prevalence of epidemics  of scarlatina.
An attack of this kind  appears, in  some cases at least, to render  the patient
thereafter insusceptible to the  disease, but it is not  uncommon for persons
who have once had scarlatina  in its regular  form to  suffer from the throat
affection when exposed to the contagium.  In cases of scarlatina sine erup-
tione the nature of the  disease  is not infrequently  overlooked. _ Another
irregularity in very mild cases consists in the  absence of any affection of the
throat,  the cutaneous affection being  more or less marked.  In  these cases
doubtless the disease sometimes exists without being  recognized or it is con-
founded with roseola.   It has been supposed  that the disease may exist with-
out  either an affection of the  throat, a cutaneous  efflorescence, or febrile
movement.   The name scarlatina latens has been applied to such cases.  The
evidence of the existence of the disease in this latent form is the occurrence
of characteristic sequels—namely, albuminuria and anasarca—in persons who
        67 
1058
ER UPTIIH  FE VERS.
 had been exposed to the contagium without presenting any of the usual phe-
 nomena of scarlatina.   The local manifestation of the disease in these cases
 is supposed to be exclusively in the kidneys.  Assuming that such cases occur
 and that this explanation be true, it is more correct to say that  the  scarlati-
 nous contagium sometimes gives  rise to acute  Bright's disease without caus-
 ing scarlet  fever.  I have referred to cases exemplifying this fact in  treating
 of acute diffuse nephritis.
    Scarlatina has various sequels.   The one which occurs most frequently has
 just been alluded to—namely, albuminuria with general dropsy.  This follows
 the disease  in a considerable proportion of cases, the proportion being found to
 vary at different times and places.  The time of its occurrence is  between ten
 and twenty days after the date of desquamation.  The symptoms are those of
 acute diffuse nephritis, an affection which has been considered in connection
 with the diseases of the urinary system.1   (Edema of the face and  lower
 extremities is first observed, and anasarca frequently follows.   Effusion takes
 place into the serous cavities if the anasarca  be considerable.  Hydrothorax
 sometimes exists to such an extent as to seriously embarrass respiration.  The
 urine is scanty ; sometimes it has  a smoky appearance, and it may be distinctly
 bloody.  It may, however, contain few or no red blood-corpuscles.  It is usu-
 ally loaded  with albumen, but cases have been reported by Bayer and others
 of dropsy  after scarlatina without albuminuria.   Epithelial,  granular, and
 hyaline casts are generally found in  the urinary sediment.   Some  red, but
 more white, blood-corpuscles are  usually present.  Blood-casts are  not fre-
 quent.   There is notable anaemia, the appetite is deficient,  the  temper is irri-
 table, and muscular  debility is  more  or less  marked.   Pyrexia,  varying in
 degree  in different cases, accompanies  these symptoms.  Uraemic coma and
 convulsions, pulmonary oedema, and oedema of the glottis are grave accidents
 incident to  the renal affection.   They occur, happily, in but a  small  propor-
 tion of  cases, and under  judicious management this affection  is rarely  fatal.
 Temporary  blindness is  a rare  event, occurring in connection with uraemic
 convulsions following this disease.  Acute nephritis after scarlet fever rarely
 ends in chronic  renal disease.   It  is more rational to consider the  renal  affec-
 tion which follows scarlatina as a  special effect of the latter than to attribute
 its production to cold or other causes operating  after the scarlatinous poison
 has ceased  to act.
   The  opinion was  held  by Graves and others that the kidnevs are  oftener
 affected after mild than after severe cases of scarlatina.  This sequel certainly
 occurs after mild cases, and sometimes when, from the absence of either the
 throat affection or of the  cutaneous eruption, scarlet fever had  not been sup-
 posed to exist.   A probable explanation, however, of its occurrence in a larger
 proportion of mild cases is afforded by the fact that of severe cases a  consid-
 erable number end fatally during the progress of the fever.   It is to be borne
 in mind that coma and convulsions may occur as sequels of scarlatina, due to
 uraemia  not  accompanied  by either albuminuria or  dropsy.   That the  renal
 affection has no  necessary connection with the eruption on  the  skin is shown
 by its occurrence in cases in which the  scarlatinous rash was wanting.
   Pleuritis,  pericarditis, and acute  articular rheumatism are occasional sequels
 as well  as concomitants of scarlet fever.  Chorea  is also  to be reckoned  among
 the occasional sequels.  External  otitis is not  uncommon.   A purulent dis-
 charge takes place from  the ears,  and sometimes there is considerable deaf-
ness.  If  the inflammation be  wholly without the  tympanum, the  deafness
will be temporary, and under judicious  management the affection may gener-
ally be  removed ; but it is liable to return from  time to time for  a consider-
able period  after recovery.
                               1 Aride p. 865. 
SCARLATINA,  OR  SCARLET FEVER.            1059
  Causation.—Tbe communicability of scarlet fever is  established by irre-
fragable  proof, and it  is probable that its causation always involves  a con-
tagium.  The contagium from mild  is as efficient as that from  severe  cases.
It is  important that  this fact be popularly known.   Many persons in this
country think that the disease in very mild cases differs essentially from that
in severe cases, and it is a common impression that the name scarlatina applies
only to the former. Physicians  should take pains to correct the error of sup-
posing that the names  scarlatina and scarlet fever indicate different  diseases.
The contagium is contained in emanations from  the  body, probably in both
the expired breath and the cutaneous exhalations ; hence  the atmosphere sur-
rounding  patients is infected.   It appears  to be certain that the disease has
been communicated by inoculating with the  serum contained in the vesicles
which sometimes appear  in  conjunction with the cutaneous efflorescence, but
such inoculation does not materially affect the duration or the severity of the
disease.  That the disease  may be communicated  by means of fomites  is
unquestionable.  The  contagium may be carried in the clothes of physicians,
nurses, and others.  The disease  is probably often diffused  in this way.   Facts
show  that the contagium  adheres  to material substances and  preserves its
morbific power for a iong period.  Persons  have been attacked on returning
to houses in  which cases have  occurred  weeks  or months previously, even
when  careful efforts  have  been made  to  remove the contagium.   Several
instances have  been recorded in  which the  scarlatinal virus  appears to have
been  transported by milk.   Scarlatina sometimes follows with notable fre-
quency surgical operations and the puerperal state.   In these cases, however,
it is  necessary to be somewhat  guarded in the diagnosis, as  an efflorescence
which has nothing to  do  with scarlatina may follow these conditions and sep-
tic fevers in general.
  The period of incubation is undoubtedly, as a rule, much  shorter in scarlatina
than in the other eruptive fevers.   Its duration, however, varies in diff'erent
cases.  Trousseau cites a case in which the attack took place within twenty-
four hours after exposure.   In  a case under my observation  the  patient, an
infant of nineteen months, was attacked twenty-fours after the first  symptom
of illness in a young girl who assisted in taking care of the child.  In another
case the duration was  forty-eight hours.  It is probable that the period rarely
exceeds six days.
  Statistics show that the  disease  occurs  most  frequently in the third and
fourth years of life—that the liability to it diminishes progressively after the
fifth year, and  becomes very small after forty.  Children less than two years
of age and infants at the breast are  not, as has been incorrectly stated,  insus-
ceptible to it.  Several  instances  of its occurrence at less than two years of age
have  come under my observation.   In one of these a child  only three  weeks
old contracted  the disease  from her mother, who was attached a  few days
after  confinement.  Cases have  been reported in which the disease was con-
tracted in utero.
  As a rule, this disease is experienced only once; hut,  making  due allow-
ance for  cases  in which  roseola  may have been  confounded with scarlatina,
the exceptions to this  rule  are  not  extremely rare.   Second or third attacks
are rarely fatal.                                           .
  Nothing is  positively  known  concerning any micro-organisms which can
be regarded as the cause of the disease.  As in the other eruptivefevers,
micrococci have repeatedly been found in various organs of the body in scar-
latina, particularly when these  are  the seat of  complications,  but ltis not
believed that these micrococci are concerned in the production of the disease.

  Diagnosis.—Attention to the following diagnostic points renders the dis- 
10(30
ERUPTIVE  FEVERS.
 crimination of this disease easy in the great majority of cases:  The short
 duration  of the stage of invasion, the intensity of the pyrexia, the  appear-
 ance of the efflorescence in the throat prior to  the cutaneous  eruption, the
 appearance of the efflorescence on the bod}* and upper extremities often before
 or simultaneously with its appearance on the neck and face, the rapid exten-
 sion of the efflorescence over the cutaneous  surface, the scarlet color of the
 efflorescence, the irregular  and serrated margins of patches of  efflorescence,
 and the persistence or increase of the pyrexia after the appearance of the efflor-
 escence on the skin.  These are positive diagnostic features belonging to the
 clinical history of scarlet fever as contrasted with smallpox  and measles.   On
 the  other hand, the two latter  eruptive fevers are excluded  by the  shorter
 period of invasion in scarlatina, pain in the loins  not marked  in this period,
 absence  of the characteristic eruption of variola in the mouth and fauces,
 the  non-occurrence of variolous  papules and vesicles with  depression  in  the
 centre, and of the remission of fever when the eruption  appears, absence of
 coryza and bronchitis, which belong to the history of rubeola, and of certain
 distinctive characters  pertaining to the eruption of rubeola,  which  will be
 stated in treating of that disease.
   The difficulties in the way of diagnosis relate, in the first place,  to  ex-
 tremely mild cases with a slight eruption  and without any aff'ection  of the
 throat.   In these cases the disease is liable  to be confounded with roseola.
 The differential points will  be noticed in  treating of the latter in the next
 chapter.   In the  second place, the diagnosis may be difficult in cases in which
 the  local manifestation  is confined to  the  throat;  that is, cases  in which the
 cutaneous efflorescence is wanting.   It must be confessed that the  diagnosis
 in some of these  cases must be,  in a measure, based on their occurrence dur-
 ing  the  prevalence of scarlatina, and  sometimes on  the occurrence of well-
 marked cases in  members of  the same family.  In  some cases  of doubt or
 error the  sequels  of, scarlatina, especially renal disease, serve either to  correct
 or establish the diagnosis.
   A highly probable diagnosis before the efflorescence appears on the skin
 may be based on a*sudden  attack  of  vomiting, with high febrile movement
 and redness of the fauces, in a subject between  three and five years of age,
 especially during  the  prevalence of scarlatina.

   Prognosis.—There is perhaps  no disease in the nosology which presents
 in different cases wider extremes  as  regards gravity  than scarlatina.   In
 malignant cases the disease is rapidly fatal.  The proportion  of these cases
 varies much at different times  and places.   The prevailing type'of the  disease
 in some seasons is mild, and in other seasons severe.  AVhether this variation
 be  due to a difference in the  contagium  or to adjunctive  influences  we are
 unable to say.  Aside from  the intensity  of the  disease, the danger depends
 on complications liable to occur in cases which, as regards the general symp-
 toms, may appear to be mild.  The symptoms which  denote imminent  danger
 from the intensity of the  disease are—excessive frequency  of the  pulse,
 hyperpyrexia, jactitation, active  delirium, and prostration ; the  mode of dying
 in these cases being by asthenia.
  The prognosis  is  unfavorable in cases in which the throat affection  is un-
 usually severe.   It is extremely unfavorable if diphtheria become  developed
 either during the progress of the disease or as a sequel.  If laryngitis ensue
 a fatal result is to be expected.   Great enlargement and suppuration  of the
 glands of the neck irrespective  of diphtheritic  inflammation  of the  fauces
denote great  danger.  If gangrene of the throat or mouth occur, recovery
is  the  exception rather than the rule.  Cases characterized by  hemorrhage
from mucous  membranes and petechiae or vibices are generally fatal. Uraemic 
SCARLATINA, OR SCARLET FEVER.
1061
coma and convulsions involve imminent danger, and uraemia may occur in cases
which as regards the general symptoms appear to be mild.  These symptoms
may be developed and  sudden death take place unexpectedly if examinations
of the urine have been omitted.  Daily examinations of the urine are highly
important.   The presence  of albumen  or casts  should always excite appre-
hension, but the immediate danger  is  proportionate to the deficiency of  urea,
The patient is by no  means safe  after albumen  has disappeared from the
urine  if casts continue to be found in  the sediment, especially if the quantity
of urine be small and the  specific gravity low.  The prognosis is extremely
unfavorable in cases of scarlet fever occurring in the puerperal state.  I have •
known a case in which the patient contracted the disease in the seventh month
cf pregnancy.  She miscarried during the period of incubation ;  parenchyma-
tous nephritis occurred as a complication and the symptoms denoted  great
danger.  She, however, recovered, and  the  child was living.

   Treatment.—Cases of mild scarlatina do not call for active  measures of
treatment.   The often-quoted saying of the English Hippocrates, that scar-
latina  is only dangerous through the officiousness of the physician, is, how-
ever, hardly true even of these cases, for be the disease never  so  mild  there
is a liability to grave complications and  sequels.   On  the other  hand, in
certain cases of severe scarlatina the malignancy of the disease renders any
treatment unavailing.  AA'ith respect to  this  disease as well as the other  erup-
tive fevers, it is to be premised that there are no known specific remedies by
means of which it may be arrested or controlled;  but the inference by no
means follows that judicious measures of treatment may not do much toward
affording relief  and diminishing the  fatality.   It is to be added that a com-
parison of different collections of cases with  reference to the  rate of mortality
under  different methods of treatment  is of little  value, on  account of the wide
diversity as regards the severity of the disease.
   Certain  measures heretofore employed in the treatment  of  scarlatina are
now regarded as opposed  by sound  reasoning and experience.  This  state-
ment  applies to bloodletting, active purgatives, mercurialization, blisters, and
emetics.  These are never indicated, and must of necessity prove hurtful.
The discovery of a remedy which will arrest the disease by destroying within
the body the special cause—in other w*ords, an  effectual parasiticide for the
specific organisms and germs on which the disease is supposed to depend—
belongs to the  future.  This  statement applies to all the  eruptive fevers.
Carbolic acid,  sodium sulphocarbolate, and the  sulphites  have  been  tried
with  an apparently beneficial effect.   I have heard testimony from physi-
cians  of experience in behalf of the usefulness of each of these remedies.
It has  not, however,  been  proved that they have a special  curative efficacy.
At the present time, therefore, the indications are  to be drawn from particu-
lar symptoms, events,  and  complications in individual cases.
   In  the  majority of  mild cases hygienic  treatment is  alone  required.  In
addition to free  ventilation,  cooling  drinks,  and  light  nourishment the
hvgienic treatment should  embrace measures to maintain  the  functions of
the skin.   In view  of the  fact that  renal  disease  as  a  complication or
sequel is  a source of danger in these  cases, attention  to the  skin is im-
portant, however mild may be the disease.  The  tepid bath once  or  twice
daily is to be recommended.  If the  bath be not practicable, the  application
of a sheet  wet with tepid  water or repeated sponging of  the  body may be
employed in its  stead.  There is reason  to believe that the more the functions
of the skin are maintained by these  measures the less is the liability  to an
affection of the kidneys either during or after the disease.   Exposure to cold
is to be avoided both  while the  disease is in progress and  in convalescence, 
1062                    ERUPTIVE FEVERS.
but care in this respect should not lead to error in the way of ventilation or
of oppressing the patient with an overplus of clothing.  A'igilance or restless-
ness, if not relieved by the use of the bath, the wet sheet, or sponging, may
indicate anodyne remedies.  Constipation  is to  be relieved by simple enemas.
Other symptoms may indicate appropriate palliative remedies.
  In some eases the leading  indication is derived  from the  intensity  of the
fever as denoted by hyperpyrexia and the frequency of the pulse.  To dimin-
ish the heat and the frequency of the heart's action is an  important object of
treatment.   This object may be most eff'ectually accomplished  by the  use of
water.   It  was in this disease that Currie was led, nearly a century  ago, to
employ cold affusions  with a happy effect.  This mode of  applying water was
strongly advocated by Trousseau, who stated that he employed  it with  highly
satisfactory results in  a large number of cases in private and hospital practice.
It is perhaps the most efficient measure to be employed for the relief  of the
active  delirium which sometimes occurs in this disease.   The apparent bold-
ness of the practice renders it frequently objectionable on the score of popular
prejudice.  Frequent  sponging of the body  secures to a  considerable  extent
the same results; but the use of the wet sheet is hardly less efficacious than
the cold affusion as practised  by Currie. Employed as an  efficient antipyretic
measure, the  wet sheet is applied over the  whole body without any  other cov-
ering, and the surface  is sprinkled with cool or cold water at short intervals in
the manner described in connection with the treatment of typhoid fever  and
insolation.   The temperature is always reduced one, two,  or more degrees by
this measure, and  it  may be repeated  as  often as the thermometer shows a
return  to great intensity of heat.  There is no occasion for fear  on the ground
of danger of repelling the eruption.   The wet pack acts efficiently as a seda-
tive and diaphoretic  measure, and it  has considerable potency as an  anti-
pyretic.  The patient, stripped of all clothing, is enveloped  in a sheet saturated
with water at about the temperature of 70° F.  and closely covered with sev-
eral blankets.  Usually after  remaining in the pack for about an  hour free
perspiration is induced.   The  pack is to be removed when this  effect occurs,
the body wiped  dry,  and  the  patient placed in bed.   The frequency  of the
pulse is often notably lessened by this measure.   The patient is tranquillized
and obtains  refreshing  sleep.   The  measure may be repeated once or twice
daily.  Its effect is so agreeable that patients often desire a repetition.  In
this disease,  as in other fevers, full doses of quinia sometimes have a notable
antipyretic effect.   Antipyrine is an  efficient and safe antipyretic.
  In malignant  cases, and whenever the  intensity of the disease involves
a tendency to death  by asthenia, the chief reliance  must be  on sustaining
measures.  Alcohol is indicated in proportion to the frequency and feebleness
of the  pulse, together with general prostration.   I have witnessed the same
striking benefit from  the free use of wine or spirits in certain  cases of scar-
latina as in cases of typhus or typhoid fever.  Alcoholics, however, are not
to be given without discrimination, and the physician is to be guided in their
use by watching their immediate apparent effects, precisely as in other essen-
tial fevers.  In children, wine-whey, milk-punch, and egg-nog are eligible forms
for the admininistration of stimulants and nourishment.
  Cases  of so-called  scarlatina anginosa in addition to sustaining treatment
call for measures  addressed to the affection of the throat.  The chlorate of
potassa is  generally  considered, and  probably with  justice,  an  important
remedy in  these  cases.   From one to two drachms  may  be  given  daily.
The  chlorine mixture is highly   recommended  by  AVatson  and   others.
Stimulating  or caustic  applications  to the pharynx are  of doubtful utility.
The difficulty of  making  them in children, and the perturbation occasioned
by making  them forcibly in spite of their resistance, are not small objections  ; 
SCARLATLNA,  OR SCARLET FEVER.
1063
but aside from.these objections it may be doubted if they produce a beneficial
effect.   Antiseptic  applications by gargling, if the patient be not too young,
by means of a sponge if the resistance be not too violent, or in the  form of
a powder by insufflation, contribute at least to comfort.  The solution of
chlorinated  soda may be used for this purpose,  diluted  with  eight or ten
parts of water.   The permanganate of potash may also be used in the propor-
tion of  half a grain of the salt to five ounces of water.   Other topical reme-
dies are alum, tannic acid, the borate  of soda, carbolic acid, and salicylic acid.
The free use of iced drinks is useful as regards the condition of the throat.
The patient may be allowed to take into the mouth small pieces of ice almost •
ad libitum;  and for young children a convenient plan is to confine pieces of
ice  in a gauze bag which may be held in the mouth.  Externally, compresses
kept wet with cold water may be applied.   It has been recommended to apply
ice  to  the  sides of the neck.   It is  customary to  paint the neck with iodine
over glandular  swellings.  If suppurative inflammation ensue, poultices or the
water-dressing  should be applied.
  Extreme  pruritus of the skin  is  in  some cases a source of much annoy-
ance, preventing sleep and increasing the constitutional disturbance.  With
reference especially to this symptom  some years ago a plan of treatment pro-
posed  by a  German physician, Schneemann, consisted  in the application of
lard to the surface of the body, the rind of bacon being used  for this  pur-
pose.   This plan was  adopted to some extent in  this country.  It relieves,
in some cases  at least, the pruritus and  diminishes the  febrile excitement.
Other  applications, however, less disagreeable, are equally efficacious.   Gly-
cerin and the rose-water ointment, glycerin and cologne-water, in the propor-
tion of one part of the former to four or five parts of the latter, or, what is
still better, vaseline or lanolin, may be substituted.
   Convulsions are generally  due to uraemia, but occurring early in  young
children they  may be  incident  to the development of the disease without
denoting a renal complication.   AVhether uraemic or otherwise, if they con-
tinue the inhalation of chloroform   is  indicated.   I have notes of cases  in
which  this  measure was  employed  with immediate relief and recovery fol-
lowed.
   Uraemic phenomena  in  addition to convulsions—namely, cephalalgia, dis-
turbance of vision, and coma—render  prompt measures  of treatment vastly
important.  Saline purgatives or elaterium are to be  employed at  once  to
eliminate urea, and diaphoresis  should, if possible, be procured by the use
of  the  hot-air  bath, the wet  sheet,  or by the hypodermic administration of
the  muriate of pilocarpine.   Vomiting and purging should always suggest
the  inquiry whether they be not due  to uraemia, and if so they are not to
be  arrested.  Albuminuria, and  especially a deficiency  of urea  in the urine,
should  lead to measures with a  view of forestalling the effects of uraemia.
Fomentations  are  to be  applied  over  the loins,  the bowels  are to be  kept
loose with  saline laxatives ; and with reference to this object it is important
to produce diaphoresis by means of  the warm bath or the wet sheet.
   Restlessness and vigilance, if not relieved by measures of treatment already
noticed, may require anodyne remedies.  The succedanea of opium are to be
preferred—namely, belladonna, hyoscyamus, etc.   If, however, these  be not
efficacious, opiates are to be given, but they should be administered cautiously
in young children.  AA'ith reference to the liability to heart-clot, Richardson
advises the carbonate of ammonia given in small doses frequently repeated.
Several writers have advocated this  remedy as having a special salutary influ-
ence in scarlatina.
   The  treatment of the sequels of scarlatina need not be here considered.  The
most frequent  of the important sequels—namely, acute diffuse nephritis—has 
1064
ERUPTLVE  FEVERS.
been considered in a former part of this work, to which the rea*der is referred.
In the treatment of pleuritis, pericarditis, rheumatism, and chorea are involved
essentially the same principles as when these affections occur in other patho-
logical connections.   External otitis is often  neglected, and it may therefore
continue, and in the end lead to impairment of hearing.  Daily cleansing of
the ear by the injection of tepid water and soap will usually prove sufficient
to effect a cure; but if the affection continue in spite of this measure, which
from  its very simplicity it is often  difficult to enforce, mild  astringent  injec-
tions  should be employed.
  I shall add a remark with reference to the prevention of renal disease as a
sequel of scarlatina.   The  occurrence of this sequel  being  generally attrib-
uted to cold, it  is common to confine patients within  doors, and  sometimes
even  to  the bed, for two  or three  weeks  after  convalescence.   Regarding,
however, the sequel  as a remnant of  scarlatina, this extreme care is unneces-
sary.  It is sufficient to observe the same precautions with regard to exposure
to cold or other morbid agencies as during convalescence from any acute affec-
tion.  Gestation out of doors has  seemed to  me to be useful even when patients
are suffering from albuminuria and  general dropsy following  scarlet fever.
  It remains to notice  the  protective influence  against scarlatina which  has
been  imputed to belladonna. Satisfactory proof of its prophylactic power
requires  that the number  of failures  shall  not be large ; and, judged by this
rule of evidence, it is extremely doubtful if there be any ground for imputing
to this remedy a prophylactic power.  It  is,  however, to be considered that
to prescribe  belladonna as  a prophylactic  is always a harmless experiment,
and it is therefore objectionable  only on the score of supererogation.   More-
over, as the popular mind has been  directed to  this question, the wishes  of
friends are often better satisfied  if the drug be prescribed.   These considera-
tions may properly influence the physician.   The following are the directions
for the use of the remedy:  " Dissolve from one to  three grains of fresh and
well-prepared extract of belladonna in an ounce of  cinnamon-water, adding a
few drops of alcohol to prevent fermentation.  Of this  solution  may be given,
two or three times a day,  one drop for each year of the child's  age, to be so
administered for two weeks or longer if the danger should continue."1   The
only reliable way of protection against the disease is to avoid the contagium.
To  do this  effectually, it  is necessary not only that persons  do  not  come
within an infecting  range of patients, but  that they avoid  those  who have
been within  this range, the houses in which there  have  been  cases, and
everything that may prove  to be fomites.   Cases occurring  in hospitals and
private houses should be  at once  isolated, and all articles  in the apartment
occupied by patients should be properly disinfected.  The best means of dis-
infecting clothing, bed-linen, carpets, tapestries,  and stuffs which cannot  be
destroyed by fire is  to subject them for two or three  hours  to  steam at a
temperature of 212° F. Removal without  the limits of the prevalence of the
disease is advisable  when it is found that cases are likely to  prove malignant
or severe.  On  the  other  hand,  if cases be pretty  uniformly mild it is to  be
considered  that  the  period  is favorable for having the  disease.  Voluntary
exposure with the intention that the disease shall be contracted is, however,
under no  circumstances to be  recommended.
1 Stille, op. cit. 
RUBEOLA, OR MEASLES.
1065
                      CHAPTER   VIII.

                  ERUPTIVE  FEVERS  (Continued).

Rubeola, or Measles: Clinical History; Causation; Diagnosis; Prognosis; Treatment,—
                         Eoseola.—Eothelu.—Dengue.

                        Rubeola, or Measles.

    RUBEOLA—so called from the red color of the eruption, called also mor-
      billi, and commonly known as the measles—is a disease of less import-
ance than the eruptive fevers which have been considered.   It is generally a
mild  and  often a trivial disease, but it is desirable to discriminate it as early
as possible from other eruptive fevers.  It is of frequent occurrence, it is
sometimes accompanied by  grave complications, it  is occasionally followed
by serious sequels, and in a certain proportion of cases the disease is intrin-
sically severe or even malignant.   Hence, rubeola  is by no means an unim-
portant disease.  By German writers  the term rubeola is used to  denote an
eruptive fever distinct from  measles, called also Rotheln,  and in this country
distinguished as German measles.
   Rubeola has no special anatomical characters exclusive of the  internal and
external  efflorescence which is most conveniently  considered as belonging
among the symptoms of the disease.  I shall  pass, therefore, at once to the
clinical history.

   Clinical History.—The career  of this disease  is subdivided, like that
of the other eruptive fevers, into  the stages of invasion, eruption, and des-
quamation, each stage claiming separate  consideration.
   Stage of Invasion.—The distinctive local  symptoms in this stage resemble
those of a common cold, or  rather an attack of influenza.   There is coryza,
with frequent sneezing and an acrid muco-serous discharge from  the nostrils.
The eyes are irritable, reddened, and watery. Epiphora is sometimes marked,
the tears excoriating the face, and  there is  more or less intolerance of  light.
Subacute laryngitis, denoted by hoarseness, frequently occurs, and the symp-
toms of  bronchitis are generally present, the cough  being dry, sonorous, and
painful.   Occasionally the pharynx  is the  seat of  subacute  inflammation.
The bronchitis, laryngitis, and coryza are due to the efflorescence which takes
place on the mucous membrane of the air-passages prior to its appearance on
the skin.   AVith these local affections, which vary much in intensity in differ-
ent cases, there is associated moderate  pyrexia,  the axillary temperature rarely
exceeding 102° F., accompanied by irregular chilly sensations and shivering,
but rarely by a distinct  chill; the appetite  is  impaired or lost, and in some
cases nausea and vomiting occur;  and pain in the head and limbs, with debil-
ity and lassitude, is in general proportionate  to the pyrexia.  The general are
often  out of proportion to the local symptoms, as in cases  of influenza.  They
are less intense than in the stage of invasion in variola and scarlatina, and in
certain cases they are slight.  Constipation  exists in some cases, and in  other
cases there is diarrhoea.   Convulsions sometimes occur in this stage, chiefly
in children.  In  general  they are not indicative of danger.  Epistaxis is in
some cases a prominent symptom.  Spasm of the glottis, or false  croup, is an
occasional  symptom in young children.  An erythematous eruption sometimes
precedes the eruption proper to the disease. 
1066
ERUPTIVE  FEVERS.
   The average duration of this stage is three or four days.   The duration is
 therefore twenty-four hours longer than  in variola, and forty-eight or more
 hours longer than in scarlatina.   Cases  are not  very infrequent  in  which
 the  duration  is five, six, or seven days, and  even longer, and  on the other
 hand it  may he  but three or two days,  and even  a  single day.
   Stage of Eruption.—A transient  convulsion  may usher  in  this stage in
 children,  but it  is  of much rarer occurrence  than in scarlet fever.   The
 efflorescence first appears on the temples and  forehead.   In a few hours it
 extends over the head and neck.   It  is gradually diffused over  the body and
 extremities, its full development occupying between thirty-six and forty-eight
 hours.  In the slowness  of the extension of the rash over the cutaneous sur-
 face this fever differs from variola and scarlatina.   The eruption is sometimes
 preceded  by a day or two by the appearance of patchy redness on the hard
 and  the soft palate.   This redness is by many interpreted as the first sign  of
 the exanthem.
   The eruption has at first an appearance of minute red dots  or specks, which
 soon  enlarge, become slightly elevated, and tend  to  range themselves in cir-
 cular or crescentic forms.  The papules resemble those in smallpox prior to
 the  appearance of vesicles,  but  they are  larger  and softer.   They bear a
 resemblance to flea-bites.   The redness  momentarily disappears on pressure.
 Increasing in number and size, they coalesce to a greater or less extent, and
 form blotches of variable dimensions with curvilinear or semilunar borders,
 contrasting in the latter respect with the irregular or serrated  patches of
 efflorescence in scarlatina.   Aside from cases in which a petechial eruption
 occurs, the eruption proper  to the disease sometimes shows not only hyper-
 aemia, but infiltrated haematin, the redness being with difficulty removed by
 pressure,  and a brownish color remaining after the eruption  has  disappeared.
 The  eruption in some cases is everywhere confluent, being uniformly diffused
 over the whole or the greater part of the cutaneous surface.  The color of the
 eruption is dull or deep red, offering a contrast to the crimson or scarlet red-
 ness of the scarlatinous efflorescence.   The portions of  skin not occupied by
 the eruption retain the normal appearance.   In proportion to the  abundance
 of the eruption there is  swelling, which is most marked on the face.   The
 eruption  is sometimes attended  with considerable  pruritus.   Occasionally
 vesicles are intermingled with  the rubeolous papules (morbilli vesiculosi vel
 miliares).  On the fourth day of the eruption it begins to fade successively
 on the face, trunk, and  extremities,  and  the stage of desquamation com-
 mences.
  During the stageof the eruption the symptoms denoting coryza, laryngitis,
 and bronchitis continue.   The bronchitis in this  stage gives rise  to a more  or
 less abundant expectoration consisting of greenish  or yellowish  sputa, which
 are frequently nummular.   Dry and  moist bronchial rales are often heard
 on auscultating the chest.   The  irritability of  the eyes  continues, and not
 infrequently  there  is conjunctivitis.  Pharyngitis  in some cases  continues,
 and  sometimes the inflammation  extends  into  the Eustachian tube,  occa-
 sioning  partial deafness.   The pyrexia does not disappear or diminish with
 the development of the eruption.  On the  first and second day  of the erup-
 tion  the  temperature of  the axilla may rise to 104°  F.  and even higher.
 From this date, in the natural course of the disease, the temperature rapidly
diminishes.   Other symptoms denoting constitutional disturbance are propor-
tionate to  the pyrexia.   The latter, save  in exceptional cases, is much less  in
degree than in scarlatina.   The tongue  is generally coated, and  not infre-
quently the elongated papillae, projecting through  the coating, present the
appearance of red points.
  Stage of Desquamation.—-This  stage may be  considered as having begun 
RUBEOLA, OR MEASLES.
1067
when the eruption begins to fade.  The duration of the stage is between four
and  eight days.  In  uncomplicated cases pursuing a favorable  course  this
stage is the  stage of convalescence.   Actual desquamation  occurs in only a
certain proportion of  cases.  It may be  more or less marked.   It is always
furfuraceous, the epidermis being exfoliated in branny scales, not in patches
or flakes.   Coincident with the decline  and disappearance of the eruption
the pyrexia diminishes and  ceases.  More or less  cough and  expectoration
are likely to continue after the cutaneous  eruption has disappeared, and per-
sisting conjunctivitis  is  not  uncommon.   Occasionally the eruption  on the
skin reappears after  having  existed  for the usual period and having disap-
peared.   Diarrhoea, usually mild,  is likely to occur in this stage.
   The career  of the  disease is thus extended  between twelve  and  sixteen
days.
   The foregoing sketch of the clinical history relates to cases in which the
disease pursues a typical course.  Anomalous cases occur, the disease in some
being very severe or malignant, and in others unusually mild.  In exceptional
cases the eruption appears first on some other part of the  body than the face.
The affections of the  Schneiderian membrane, larynx, and  bronchial tubes are
sometimes wanting.   Writers have considered  these cases as constituting a
variety of the disease, called rubeola sine catarrho.  To a certain extent, doubt-
less, cases which have been considered as of this variety have been cases of
roseola.  On the other hand, it is supposed that cases occur in which the local
manifestations are  limited to the mucous  membrane;  hence there is another
variet}*, called rubeola sine eruptione.  It must be difficult  to decide positively
that rubeola exists when the cutaneous efflorescence is wanting.  In the cases
belonging to the two varieties just named the disease  is unusually mild.   A
severe form of the disease is characterized by the occurrence of petechiae and
hemorrhage in various situations.   The phenomena of  purpura are associated
with measles in these cases.   Of this rare form of the disease the following
case is  an example:  The patient was a  man aged about twenty-five years.
The ruheolous eruption was  abundant, presenting  the characteristic  appear-
ances, but was somewhat  darker than usual.   Scattered  among  the  patches
of efflorescence over  the whole surface of the body were  petechiae varying
between the size of a pin's head and that of a split pea.   There was hemor-
rha--e from the nose and mouth.   Blood also was discharged from the bowels
and°was contained in  the urine.  The tongue and  gums were pallid except at
certain  points which were stained with  exuding blood.   Blood was effused
beneath the conjunctiva, infiltrating the whole surface of the eyeball except
the cornea.  The case terminated fatally.  This form of the disease is distin-
guished as  hemorrhagic  rubeola.   It has  been  called also  rubeola nigra,  or
black measles.
   Gangrene attacking the mouth,  and occasionally the anus,  vulva, nose,
luno-s, and larynx, sometimes occurs in connection with rubeola.   Other mor-
bid&conditions than those belonging  to the latter, it is to be presumed, must
concur  in giving rise to this  event.  It has been observed chiefly in young
children in  eleemosvnary institutions.  Aside from any such local events  or
important complications,  this disease sometimes assumes a severe form, pre-
senting the  ataxic and adynamic symptoms of  typhus or  typhoid fever, and
ending fatally from an intrinsic tendency to death.   Such cases, however, are
extremely rare.                                         #
   In the great majority of the cases in  which the disease is severe the grav-
itv is dependent on complications.  The  important complications most likely
to occur are seated in the respiratory system.   Diphtheritic laryngitis or true
croup is sometimes developed.  Capillary bronchitis is  another fatal complica-
tion liable to occur in children ; and. occurring  in children of less than three 
1068
ERUPTIVE FEVERS.
years of age, it generally destroys life.  It is more liable to occur in hospital
than in private practice.  Broncho-pneumonia  and lobar pneumonia are the
most frequent of the serious complications.  The latter in young children is
likely to prove fatal, and it is by no means devoid of danger in adults.  Pleu-
ritis is an  occasional complication, but it is far more infrequent than pneumo-
nia.   Croup, capillary bronchitis, and especially pneumonia, are not less likely
to occur as sequels than as concomitants of rubeola.
   A delay in  the appearance of the eruption is  generally an  effect of some
important complication.   The occurrence of an important complication  may
lead to a notable diminution and  sometimes to a retrocession of the eruption.
It is a popular error to  attribute the complications  to the retrocession of the
eruption ; the latter is  a  consequence, not  a  cause, of the former.  _ Irregu-
larity as  regards the  situation in which the eruption first  appears  is some-
times observed.   In rare instances the efflorescence first makes its appearance
on the lower extremities,  and extends thence over the body,  upper extremi-
ties, and head.
   After  recovery from  rubeola, pulmonary phthisis, acute tuberculosis, and
tuberculous meningitis  are observed in a proportion of  cases  not large, but
sufficient  to  show that  the system  is left  in a  condition favorable for the
development of  these affections.  Affections distinguished  as scrofulous are
liable to follow as sequels—namely,  scrofulous ophthalmia, coryza, otorrhoea,
enlargement  of  lymphatic glands, etc.    After an extensive  prevalence of
measles in any place it is  observed for some years that the mortality among
children exceeds the average mortality at other times.   The practical import-
ance of these facts is obvious.
   Nephritis is a rare complication  of measles.   Some  albuminuria, at the
height of the disease, however,  is not rare.

   Causation.—Rubeola, like scarlatina and variola, is a contagious disease.
The contagium is not only received by those brought into close proximity to
persons affected with the disease, hut it may be transported to a distance by
means of fomites.   Persons contract the  disease from the contagium adhe-
rent to the clothes of those who may have recently visited rubeolous patients.
Physicians may in this  way diffuse the disease.
   The disease may be communicated by inoculation, either with blood from
an exanthematous  patch or with the secretion  from  the eyes and  nostrils.
The  activity  of the rubeolous contagium, however, is  much less persistent
than that of the contagium of smallpox and scarlet fever.  The communica-
bility, not alone by inoculation, but by means of an infected atmosphere or
by fomites, belongs to the stage of invasion as  well as to the eruptive and
desquamative stages.
   The duration of the period of incubation varies within widely separated
limits—namely, between one day and thirty days.   In the majority of cases
the attack occurs between six and ten days after exposure.  The  duration was
within these limits in a dozen cases under my observation in which the time of
exposure could  be  definitely fixed, with a single exception in  which the dura-
tion was  fourteen days.  The  average  duration  of the  period of incubation
may be  given as ten days.  AA'hen produced by inoculation the period  of
incubation is somewhat  shorter than it  is usually when the disease occurs
naturally.
   The susceptibility to the disease  exists at all ages.   Cases  are much more
frequent  in  children than in adults, but  this is owing to the fact  that the
majority  of persons have the disease in childhood, and are generally thereby
 made insusceptible.  They who escape the disease in early life on account of
 not being exposed to the contagium are  liable  to contract it at any  subse- 
RUBEOLA,  OR  MEASLES.
1069
quent age.  The susceptibility is very slight during the first six months of
infantile life.   As  a rule,  this disease, like  scarlatina  and variola, renders
the system ever afterward insusceptible to it, but  exceptions to this rule are
not very rare.   AVell-authenticated  cases in which the disease  has occurred
three and even four times have been reported.  Prevailing in camps, schools,
hospitals, and communities  as an  epidemic, this  disease presents at  different
times a great diversity as regards mildness or severity and the tendency to
particular complications ;  in other words, the  character of diff'erent epidemics
of rubeola, as of other epidemics, is by no means uniform,  but varies much
in diff'erent seasons and  places.

   Diagnosis.—The diagnosis of rubeola after the appearance of the efflores-
cence  on the skin  is  generally unattended with difficulty.   The diagnostic
characters which have been embraced in the clinical history are sufficiently
distinctive.  The more important of these are—the long duration of the stage
of invasion ;  the affection of the air-passages ;  the appearance of the eruption
almost invariably first on the  face, and its gradual diffusion over  the  body;
the color of the eruption, its  papular character, the  softness of the  papules,
and the  tendency of the papules to  assume a  crescentic arrangement.   So far
as the eruption is concerned,  early in the eruptive stage there is some  resem-
blance to the papules of smallpox, but the differential points which have been
presented in treating of the latter  disease  should enable the  practitioner to
make  the discrimination.   In a case of rubeola in which the cutaneous efflor-
escence is not abundant and the air-passages are unaffected the disease is liable
to be confounded with roseola; but  the eruption in these two affections  differs,
and. moreover, such cases are extremely rare.   Cases in which the air-passages
are alone affected—that is, in which  there is no cutaneous efflorescence—hardly
admit of a positive diagnosis,  but such cases are  extremely rare.  Their occur-
rence  during the prevalence of rubeola in persons  known to have  been ex-
posed is the  chief  ground on which the diagnosis  is to be based.
   The diagnosis cannot be  made with positiveness prior to the appearance of
the efflorescence on the skin.   The occurrence, however, of coryza, irritability
of the eves, and bronchitis,  with pyrexia, in persons who have never had
measles at a time when the disease is prevailing, renders a diagnosis  during
the period of invasion highly probable.  The diagnosis is sometimes delayed
by the  early occurrence of complications which  interfere with the regular
course of the disease,  especially as  regards the eruption.   The appearance of
the latter, however, sooner  or later  in the great majority of cases, removes the
difficulty which may previously have existed.
   Of this fever, as of all the  eruptive fevers, the diagnosis in the negro must,
of course, be based on other points than those  relating  to the color of the
eruption.  " In  the  pure negro the eruption appears as yellowish spots slightly
elevated and giving a sensation of roughness; in the mulatto, as  a  dusky-
brown,  ill-defined; and in  the lighter shades  more distinct,  reddish-brown,
 spots, approaching  the characteristics of the eruption in the  white."

   Prognosis.—In  the majority of cases, as this disease is  ordinarily presented
in civil  practice, it is either  mild or  unattended with  danger;  but  in a cer-
tain proportion of cases  the disease is severe and dangerous.   The severity
 and clanger are due to the anomalous events and complications which have
been noticed in connection  with the clinical history.  The number of cases ren-
 dered fatal by  the  coexistence of capillary bronchitis, diphtheritic laryngitis,
pneumonitis, etc. is not inconsiderable,   the rate of mortality differs  greatly
 at different  times  and places, so  that the  statistics  of  any particular  epi-
 demic would not furnish results applicable generally to the disease.   It may 
1070
ERUPTIVE  FEVERS.
prove a serious disease in camps.  AVoodward states that of the 38,0-1 cases
contained in the official returns from the armies of the United Mates in  the
first two years of the late civil war, there were 1804 deaths.  Bartholow is of
the opinion that these figures do not express the actual  fatality due  directly
or indirectly—that  is, by complications  and sequels—to this  disease during
the war • and he estimates the  ratio  of deaths to cases  as  1 to 5.
   During the war  the  prevalence of the disease was great  among recruits,
especially those from the  country, and the sequels  or the effect upon  the
general health incapacitated a considerable proportion for remaining in  the
service   Taking into view the mortality and the enfeebled condition remain-
in- for a long time in many of the cases which did not end fatally, measles
proved to be  one of the most formidable of camp diseases.   With reference
to the efficiency of  troops  in  active service, it is desirable to isolate  cases at
once wherever they occur in camp.  Doubtless, the rate of mortality and the
disqualifying  effects of the disease were often  due to the coexistence  either
of scorbutus or malarial poisoning.

   Treatment.—In ordinary cases the disease calls for nothing hut palliative
measures and attention to hygiene. The cough may be palliated by anodynes,
and these may also be  indicated by restlessness  or vigilance;  and for the
pyrexia, if it be considerable, gentle diaphoretic  and refrigerant remedies may
be prescribed.  The object of treatment in these cases is simply to render the
patient as comfortable as possible, the  disease pursuing  a favorable course
without therapeutical interference.   It is  a widely-diffused popular notion
that saffron (Crocus sativus) is a  valuable remedy in measles, as well as in the
other eruptive fevers, given for the purpose of promoting the eruption.  There
is  little ground for  this notion, but the remedy is harmless.   Cathartics in
this as in the other eruptive fevers are not indicated, and  are likely to do
harm.   Emetics are rarely if ever indicated.  The patient should be  confined
to a room in which the temperature is  agreeable, but free ventilation should
be secured.  The air of the room in the treatment  of cases of this fever, as of
the other essential  fevers,  and, indeed, of all acute diseases, should be effect-
ually changed after  short intervals by opening the windows, protecting the
patient against draughts by covering the face as well  as the body.  The body
may  be sponged,  portions at a  time, with  tepid  or cool water.  .This may
be done without any fear of  causing the eruption to disappear prematurely.
If the degree of pyrexia call for antipyretic treatment, the wet sheet may be
resorted  to.   Refrigeration will  not render the patient more liable to pneu-
monia or other pulmonary complications.   Quinia, salicin, and antipyrine may
 also be given for an antipyretic effect.  As a protection for the eyes the room
 should be moderately darkened.
    In cases in which the disease is rendered severe by complications the treat-
 ment  will have reference to the latter.  The general principles of treatment
 in these cases are the same as when the complicating affections occur in other
 pathological connections.  It would, therefore,  be  a repetition to  consider the
 indications derived from  the different  complications.   A practical  question
 relates to the retardation, diminution, or retrocession of the eruption in some
 complicated cases.   Is it  important to resort to  active measures designed to
 promote the appearance of the  eruption?   The importance of this object of
 treatment has doubtless been much exaggerated.  Certain measures employed
 for this object, such as emetics,  active  stimulants, the  hot or vapor hath, and
 overloading the body  with clothing, are not to be  employed.   This general
 rule  may he adopted—namely, measures  should not he employed for  this
 object if, aside from the object, they are likely to be hurtful.   The tepid bath,
                1 Sanitary Memoirs of the  War, New York, 1867-69. 
ROSEOLA.
1071
 stimulating pediluvia  and sinapisms or other rubefacient applications to the
 skin, are not excluded by this rule.   It is to be considered that the compli-
 cations do not occur in consequence of the eruption being delayed  or insuf-
 ficient, or  striking in ;" and it is more probable that the latter are effects of
 the former.
   Cases  presenting ataxic or  adynamic  svmptoms, either  with or without
 complications, claim the tranquillizing and supporting measures indicated in
 other diseases with the same symptoms.
   It is important to bear in mind  the liability to scrofulous  and tuberculous
 affections after recovery from  this disease.  Patients should be placed under
 hygienic influences which will tend to invigorate the system, with a view to
 obviate  a tendency to  the development  of these affections
   Protection against this  disease  and the prevention of its  diffusion can be
 secured only by means of the  isolation of cases  and measures of disinfection.
 Children should be kept  from school and  other places in  which they are
 brought  into contact with other children whenever, from the symptoms of
 the stage of invasion, the nature of the disease  is to be suspected.   There is
 ground for the opinion that the communicahility is greater during  this sta-e
 The clothes worn by patients,  the  bedding, and the apartments should be dis-
 infected.  These protective and preventive measures are especially important
 during the prevalence  of an epidemic in  which  there is a tendency to grave
 complications.  They are  of less importance in mild epidemics, inasmuch as
 the subsequent insusceptibility which, as  a rule, the disease confers, is obvi-
 ously desirable.


                                Roseola.

   The eruptive  fever  called roseola or rose  rash, and sometimes called  false
 measles, is an affection  of very little importance, exclusive of its liability to
 be mistaken  for rubeola or scarlatina.
   The eruption  is preceded by symptoms of constitutional  disturbance for
 one or two  days.   These symptoms are—cephalalgia; loss of appetite, some-
 times  nausea and vomiting, and occasionally diarrhoea, chilly sensations, febrile
 movement,  and general malaise.   In young children convulsions may occur.
 The constitutional disturbance is  more or less marked, but it frequently is
 slight.   The affection of the throat and of the air-passages which belongs to
 the history of scarlatina and rubeola in the stage of invasion is slight or want-
 ing in roseola.
   The eruption  appears in the form of rose-colored  spots or patches which
 are  not elevated,  the  redness disappearing momentarily on pressure.   It
 appears on different parts  of the  body, not  beginning  on the head  and  ex-
 tending  over the body, as  in  rubeola.  Frequently it  appears  on  the body
 and extremities and  not on the face.   It continues for twenty-four or forty-
 eight hours  only, in a majority of cases.  It disappears without desquama-
 tion and is liable to return.  It is  sometimes  accompanied with considerable
 pruritus.   The affection has neither sequels  nor complications.   A roseolar
 eruption may, however, occur  in the course  of other affections, especially in
 the  stage of invasion in varioloid, in articular rheumatism, and in  epidemic
 cholera after reaction.   Roseola is not a grave disease.   One  attack affords
 no protection against recurrences.   It is oftener presented in females than in
males.  It prevails not  infrequently as an epidemic, chiefly during  the sum-
mer season.   Some authors  consider it to be contagious.
  Attention to the foregoing points will suffice for the discrimination of  the
affection  from  scarlatina and from rubeola.   It  does not call for treatment.
  The use of the balsam of copaiba by some persons induces an efflorescence 
1072
ERUPTIVE  FEVERS.
analogous to that of roseola, and more rarely the use of cubebs. the iodide of
potassium, turpentine, antipyrine, and the  sulphate of quinia.   A variety of
the affection belongs to the history  of syphilis.

                               Rotheln.

   The affection  called  by German  writers  rotheln and  rubeola (German
measles), and called  also  rubella,  is probably  not a new disease  in  this
country, but  it  was  formerly  confounded  with measles, with  roseola, or
with  scarlet fever.    Prof. J. Lewis Smith  studied an epidemic occurring
in New York in 1874,  and found  the  characters  which  distinguish  this
affection.   It occurs as an epidemic  and is  probably contagious.  It affects
all ages,  but especially  children.    It  differs  from  measles  in  having  a
period of invasion  rarely longer  than  a  day;  in  a  much less  degree  of
pyrexia;  in the more frequent appearance  of the eruption  first  on  the
body  and  neck;  and in the rapid  diffusion of the eruption.   The eruption,
moreover, is less elevated; the spots  are round,  or at least usually less irreg-
ular than the papules of measles, and there  is  no tendency to a crescentic
arrangement.  There is slight coryza, but the  larynx and bronchial tubes are
rarely much affected.   In some epidemics the  cervical  and to a less  extent
other lymphatic glands  are swollen.
   The color of the  eruption sometimes resembles that of scarlet fever rather
than that  of measles.  The affection  bears a close resemblance  to extremely
mild  cases  of these diseases.   In making the discrimination reliance is to be
placed on the occurrence of other cases  having the  diagnostic characters of
rotheln and the  non-prevalence  of scarlet fever  or of measles.  It is  hardly
possible to diagnosticate an isolated sporadic case of rotheln, but when a large
number of cases with similar characters occurs epidemically, the diagnosis can
generally  be made.
   It  is probable that cases of  rotheln and of roseola have been not infre-
quently supposed to be  cases of measles and scarlatina, and in this way is
perhaps to be explained  some  of the  reported instances of  the latter diseases
occurring  in the same person more than once.
   That this disease is essentially distinct from  measles and scarlet fever is
proven by its epidemic occurrence,  by  its affording no  protection against
these diseases, and by the  fact that  the latter  afford no  protection against
it.  These are sufficient grounds for recognizing a separate  special  cause.
Riitheln, like roseola,  is devoid of danger, and rarely calls for  more  than
hygienic treatment.1


                               Dengue.
   Dickson's name is  especially identified  with  the  epidemic  affection  com-
monly called dengue, an  unclassical name  of  uncertain derivation, supposed
to be synonymous  with  " dandy fever."   He was the historian of its  visita-
tion  in this  country  in  1828,  and  he contributed more largely to what is
known respecting it than  any other American writer.
   The affection  prevailed extensively in  the AVest India Islands in 1827 and
1828, and about the same time in many  parts of the Southern States of this
country.   An affection supposed to be the same prevailed  in Philadelphia in
17SII, and was described by Rush.  It was then, as since, frequently  known
as the breakbone fever.   Other epidemics supposed to be  identical  have
occurred at various periods in Egypt, India, and other parts of the  world.
  1 A  valuable article on this disease by Dr. AV. A.  Edwards was published in the Am.
Journ. of the Med.  Sciences, October, 1884. 
DENG UE.
1073
It prevails especially  in  tropical  and subtropical  countries.   An  extensive
epidemic occurred  along  the southern coast of this country  in 1880.1
  The development of the affection is either abrupt or  slow, more frequently
the former.  The symptoms attending its development are anorexia, chilly sen-
sations, but rarely a pronounced chill, languor, lassitude, and general malaise.
These symptoms exist in  some cases for only twenty-four hours, but in other
cases for several days before the affection is fully developed.
  After the access  or forming period follows a febrile stage or a paroxysm of
fever. The duration of the pyrexia varies between nine hours and three or four
days, the average duration being about thirty-six hours.  During this stage,
and sometimes during the access, acute, often excruciating, pains  in the head,
eyc^, muscles of the  neck, loins, and extremities are prominent traits of the
affection ; hence the name breakbone fever.  The joints are frequently some-
what swollen, those of the hands and feet being usually first  affected.  The
affection may then have  much resemblance to  acute  articular rheumatism.
The  pains diminish or disappear with  the  cessation of the  fever, and the
patient, who had taken to the bed at the onset of fever, is now able to sit up,
and complains  only of debility;  perhaps he returns to his  accustomed voca-
tion. In four or five days, however, the pain often returns,  with frequently a
recurrence of the  pyrexia, debility, and malaise, compelling a return to the
bed.   During the  febrile stage there are  irregular remissions.  The pyrexia
is sometimes considerable, the axillary temperature rising to 105° F. and
even higher.
   In the majority of cases an  eruption  occurs at a variable period after the
febrile paroxysm.   The  eruption presents  in different cases  a  diversity  of
characters.   It resembles in some cases very closely the efflorescence of scar-
latina.  In other cases it is not unlike the eruption of rubeola.   It  is some-
times papular,  like lichen or urticaria, and it  is sometimes  vesicular, like
sudamina or  varicella.   Erysipelas and purpura  are  occasionally observed.
Hemorrhage from  the nose, mouth, bowels,  and  uterus occurs in some cases.
Corvza and  pharyngitis  are occasional complications, and the latter  is some-
times associated with enlarged cervical glands.
   The convalescence  is often tedious, and the recovery of  strength, appetite.
etc. is likely to be  slow.  The average duration  of the disease is about eight
days. Relapses are not infrequent.  As regards incidental events and sequels,
convulsions  in  children  occasionally usher in the  attack; delirium like that
of delirium tremens has been observed to succeed protracted vigilance, and in
pregnant women miscarriage is liable to take  place.  A rheumatic condition
of  the joints, abscesses, boils, and carbuncles are  not infrequent sequels.
   The extent of prevalence of  this epidemic is remarkable.   AA'ragg  com-
putes the number of cases  at one time in  Charleston at 10,000, and during
the epidemic seven- or  eight-tenths  of the population  were  affected.   All
classes are attacked, persons of  either sex, children  and octogenarians.
   The duration of epidemics is brief, ceasing usually in six or eight weeks. Of
the special cause nothing is known.  J. AY. McLaughlin of  Austin, Texas, has
cultivated from the blood of dengue patients a micrococcus which he regards
as  the special agent of infection.2  Sufficient evidence in support of this view,
however, has not been adduced.  Dickson  regarded the affection as conta-
gious.  This opinion is opposed  by the rapid  and  almost simultaneous  diffu-
sion of the affection, by  the limitation  of its prevalence to  towns or within
a circumscribed area, and  by the short  duration of epidemics.    He  also
was  of the  opinion  that, as a rule, immunity from  subsequent attacks is

  1 J Forrest, Am. Journ, of the Med. Sciences, April, 1881.
  2 "Researches  into the Etiology  of Dengue," Journ. of the Am.  Med, Association,
June 19, 1886.
        68 
1074
DIPHTHERIA .—MILK SICKNESS.
secured when the  disease has been once experienced.   In proof  of this
opinion he stated that at Charleston, where  the disease prevailed in 1850,
only those escaped  who  had experienced it  during the epidemic of 1828.
The occurrence  of a few cases  of the disease  among  those who had it  in
1828 he accounts  for  by supposing  that after an interval of twenty-two
years the susceptibility was renewed.1   It is an  aff'ection chiefly occurring in
warm climates, and it prevails especially  in cities and  large towns.   To the
latter rule  there are, however, striking exceptions.
  This  affection, although extremely  distressing, and  presenting  not infre-
quently severe symptoms, is very rarely,  if ever, fatal.   Its apparent inten-
sity is in striking contrast to the absence of danger.
  The affection  is self-limited, and  there are no known means by which it
can be arrested or abridged.  The treatment, therefore, consists of palliative
measures.  Opiates to relieve the pains, restlessness, and vigilance are indi-
cated.   Rubefacients to the spine and  in other situations are useful.    Alco-
holic  stimulants, given  pretty freely,  have been found beneficial.  A high
temperature is an indication for antipyretic treatment.  Charles recommends
moderate  doses  of belladonna.   During  convalescence tonic remedies and
hygienic measures to  promote  appetite  and  the recovery of strength are
indicated.
                       CHAPTER  IX.

                  DIPHTHERIA.—MILK  SICKNESS.

Diphtheria: Anatomical Characters;  Clinical History; Pathological Character; Causa-
             tion ; Diagnosis;  Prognosis ; Treatment.—Milk Sickness.

                              Diphtheria.

    OF the general diseases which remain to be  considered, one of the most
     important is the  affection now commonly  known as diphtheria.  This
aff'ection has prevailed at times as an epidemic in various parts of the world
from a remote period.  It has been described by writers in different countries
and epochs under a variety of names, such as ulcus Egyptiacum vel Syriacum,
cynanche maligna, cynanche contagiosa, angina  maligna, angina gangraenosa,
morbus  sujfocans vel strangulatorius, garotillo, malignant, sore throat, epidemic
croup, etc.  In this country, until within the last thirty years, it has occurred
but rarely and to a limited extent during the present century.   It was admi-
rably described by Bard in 1789 under the name angina suffocative!.  The dis-
tinctive characters of the affection were very clearly elucidated by Bretonneau
in 1821, 1825, and 1826, who applied to it the term  diphtherite, whence orig-
inated  the  name diphtheria proposed by Trousseau.   This name, the signif-
icance of which relates to the most characteristic local event—namelyfthe
formation of a false  membrane—has, to say the least, the  negative  merit of
not involving  any hypothesis concerning the pathology  of the affection.

  Anatomical Characters.—The  characteristic lesion of diphtheria is a
                    1 Elements of Medicine, 2d ed., p. 748. 
DIPHTHERIA.
1075
pseudo-membranous inflammation of one or more of the mucous membranes
of the body, and less frequently of  parts of the skin deprived of epidermis.
  The tonsils, the pillars of the fauces, the soft palate, and the pharynx are
the parts primarily affected in the  vast majority of cases of diphtheria, and
the local  affection may be limited to these situations.   Often, however, the
process extends to the mucous membrane of surrounding parts.   The larynx
is often  involved, and  thence  the  fibrinous  exudation  may  extend to the
trachea and to the large  and medium-sized bronchi.  The pseudo-membran-
ous inflammation  not infrequently invades the nasal cavity.  The Eustachian
tube is sometimes, but rarely involved, and even the mucous membrane lining
the cavity of the middle ear exceptionally is covered by false membrane.  The
mucous membrane of the  cheeks, gums, and base of the tongue may present
patches of false membrane.  The diphtheritic  inflammation may extend  a vari-
able distance down the oesophagus.   Diphtheritic conjunctivitis occurs in some
cases, and involves considerable danger of loss or impairment of vision, chiefly
from destructive ulceration and from opacity  of the cornea.
   The parts communicating with the pharynx are not the only parts which
may he  involved  in ca*ses of diphtheria.  The lips, the stomach, the  anus,
the vulva, the vagina, and the prepuce are sometimes affected.  The mucous
membrane of the puerperal uterus is sometimes attacked.  The affection also
appears  in some  cases  on excoriated or ulcerated  parts of the skin, as on
vesicated surfaces, wounds, ulcers, and leech-bites—in short, wherever the skin
is deprived  of epidermis.  Exceptionally it may  be seated in  some one or
more of  the parts which have been  named, exclusive of the fauces, the latter
remaining unaffected.   Parts other  than those primarily affected are liable to
be invaded at any time  during the career of the disease.
   In  the majority of cases of diphtheria the  false membrane appears first on
the tonsils or the soft palate.  The pseudo-membranous exudation  is often,
although not necessarily, preceded by a simple (catarrhal) inflammation.  The
false  membrane is observed first as a grayish-white, slightly  elevated patch,
which cannot he  detached from the mucous membrane  without leaving a
bleeding surface.   The  white patches may remain  distinct, or they  may coa-
lesce and form one membrane, which covers the greater part of the tonsils,
the soft palate, and  the  pharynx.   As  the pellicular  deposit  increases in
thickness it acquires a yellowish or dirty-gray color.   Sometimes  it has a
reddish or a brown hue from admixture with blood. The membranous exu-
dation is sometimes soft and pulpy in consistence ;  but often it is firm,  almost
leather-like, and elastic, and can be  detached  in a single layer.  At  autopsies
the membrane is generally found to be softened.   In the  course of three or
four days, sometimes a  longer and sometimes a shorter period, the false mem-
brane becomes loosened from its attachment to the mucous membrane,  so that
it can he readily separated without injury to the subjacent tissue. The sepa-
ration of the membranous exudation, either  as a coherent layer or  as a soft,
disintegrated mass, leaves the subjacent mucous membrane either smooth
and intact or ulcerated.   The  mucous membrane is left in an ulcerated con-
dition chiefly in those severe cases in which  the fibrinous exudation extends
into its substance.  Ulcers may be produced  also by a suppurative process in
the mucous membrane.
   Outside of the  pseudo-membranous  exudations  the mucous  membrane is
reddened.  It usually presents ecchymoses in greater or less  number.   It is
swollen  from oedematous  infiltration and the presence of inflammatory prod-
ucts   The  tonsils especially are often  greatly enlarged.   The uvula may be
swollen to twice its normal size.  The  inflamed mucous  membrane is usually
coated with a muco-purulent secretion  which may be present upon  the  false
membranes. 
1076              DIPHTHERIA.—MILK  SICKNESS.

   The extension of the membranous exudation into the larynx is not uncom-
mon, and this is a serious event in the clinical history of the disease.  The cha-
racters of the fibrinous exudation in the larynx, the trachea, and the bronchi
are the same  in  diphtheria as  in membranous croup.  (Aride  p. 287.)  The
false membrane in the trachea and bronchi is of the typical croupous variety;
that is, it  lies loosely upon the mucous  membrane.   In most  parts of the
larynx it is also loosely attached, but on  the  epiglottis and the vocal cords
it  is usually adherent.  As a rule, the pseudo-membrane is readily separated
from  mucous  membranes covered with cylindrical  epithelium and having a
well-marked basement  membrane, whereas it  is more  adherent to mucous
membranes lined with  flat epithelium.
   The false membranes are composed of fibrillated  fibrin, epithelial cells,
leucocytes, red blood-corpuscles, and low  vegetable organisms.   The  fibril-
lated  fibrin is derived  from the fibrinogen  contained  in  the inflammatory
exudation  from the blood, the  fibrin  ferment being furnished by  necrotic
leucocytes  and tissue-cells.   The  epithelial  cells  in part  undergo coagula-
tion necrosis,  and  thereby lose their nuclei  and undergo  various  changes
in  shape.  These  necrotic  epithelial  cells may form  a coarse, glistening,
homogeneous  network, allied  both  in appearance and  in composition  to
fibrin.    The  leucocytes may  likewise undergo  coagulation  necrosis and
assume an irregular  shape and a  hyaline appearance.  The structure of
the false membrane varies  considerably according to its  situation.   Upon
mucous membranes covered with cylindrical epithelium,  as in  the  trachea,
the bronchi, and the greater  part  of the larynx,  the  pseudo-membrane is
composed chiefly of fibrillated  fibrin, containing some  epithelial cells  and  a
larger or smaller number of red and white blood-corpuscles.  Upon mucous
membranes  covered  with  laminated flat  epithelium, as upon  the tonsils,
palate, and pharynx,  a considerable part of the false membrane is made up
usually of  epithelial cells and of leucocytes which have been transformed in
the manner already described by  the process  of  coagulation  necrosis; but
here there  is  also some  fibrillated fibrin, as wrell as nucleated epithelial cells
and leucocytes.   The false membrane may be composed, in addition to the
constituents mentioned,  of the  superficial  layers of the mucous membrane
which  have undergone coagulation necrosis.
   Beneath  the false membrane the mucous membrane contains inflammatory
products—namely, serum, emigrated white blood-corpuscles, escaped red blood-
corpuscles,  and frequently fibrillated fibrin.   The walls of the blood-vessels and
other parts of  the mucous membrane frequently present a homogeneous, hya-
line appearance, variously described as hyaline degeneration, fibrinoid degen-
eration, and coagulation necrosis.
   In this connection it  is well to refer once more to distinctions which have
already been described in previous articles.   The terms croupous  exudation or
inflammation and diphtheritic exudation or inflammation are used in a purely
anatomical sense, without any necessary relation to the diseases known as croup
and diphtheria.1   A croupous exudation is a fibrinous false membrane which
rests loosely upon  the  mucous  membrane without extending into  its sub-
stance.  The primary necrosis which antedates all fibrinous inflammations of
mucous membranes involves only the epithelial covering. A diphtheritic exu-
dation  is a  fibrinous false membrane which at first is  closely adherent to the
mucous membrane,  and which is composed  wholly or in part of  necrotic por-
tions of the mucous membrane.   Here the necrosis involves not only the epi-
thelium, but also the superficial layers of the mucous membrane.  Many of
the false membranes  on the tonsils and pharynx are  closely adherent to the
  1 Thus we speak of diphtheritic inflammations  of the intestine or of the bladder
when there  is no thought of the existence of  the disease known as diphtheria. 
DIPHTHERIA.
1077
mucous membrane, and thus far they appear like diphtheritic exudations; but
upon microscopical examination it is often found that only the epithelium, and
not the mucous membrane proper, enters into the formation of the false mem-
brane.   Such  apparently diphtheritic exudations  are designated by AA'eigert
as pseudo-diphtheritic.  It  is doubtful whether anything  be gained by the
distinctions which are thus made between croupous, diphtheritic, and pseudo-
diphtheritic exudations, especially as they do not refer to any essential differ-
ences in the  nature  of the morbid  process, but only to differences in  degree.
It is necessary, however, that the reader  should  be familiar with these dis-
tinctions, as they are in common use.  Some writers call all fibrinous  inflam-
mations of mucous membranes croupous  inflammations, without distinguish-
ing different varieties.   Such a plan avoids  the manifest confusion  attending
the foregoing classification.
   As would naturally be expected, the false membranes, being exposed more
or less directly to the atmosphere, contain a variety of micro-organisms.  Inas-
much  as diphtheria is  an eminently contagious  disease, there is  reason to
believe that  it  is caused  by some form  of  micro-organism.   The  various
attempts which have been  made to discover a specific organism which can be
regarded as the  cause of the disease have not yet proved successful.  Accord-
ing to Loftier,1 whose studies in  this direction are  probably the most exact
yet made, of the different  bacteria present in the false membranes of  diph-
theria  a chain micrococcus and a short bacillus are  the  two most commonly
found.  Of these, the micrococcus is the less constant and the less patho-
genic.   Loffler attaches more importance to  the short bacillus which he has
isolated in pure culture, but even  this  is not found in  every case, and more-
over it was discovered once in the mouth of a child not affected with diphtheria ;
so that, as the matter now stands, neither Lbffler's bacillus (probably identical
with one previously  described by Klebs) nor any other form of micro-organ-
ism has been proven to be  the cause of diphtheria.
   In certain  cases of great severity portions of the mucous membrane of the
mouth  and pharynx are separated in  the form  of sloughs which undergo
decomposition and emit a foul odor.  The necrotic process  may extend into
the deeper tissues.   This  malignant form of  the disease is called gangrenous
diphtheria.   Sometimes  thick  pseudo-membranous  deposits are so  disinte-
grated and decomposed as to  give a false appearance of gangrenous  diph-
theria.
   The lymphatic glands of the neck, especially those near  the angle of the
lower jaw, are more  or less enlarged.   As a rule, the amount of enlargement
corresponds to the severity of the affection within the throat.   The glandular
affection rarely proceeds to suppuration.   A diffuse inflammation of all of the
tissues of the neck may occur, but this is not common.
   The luncs  may present  a variety of appearances, none of which are cha-
racteristic of the disease.   When death has resulted from suffocation in con-
sequence of involvement of the air-passages,  the anterior and upper parts of
the lumrs  are found to be emphysematous.   Bronchitis and  broncho-pneu-
monia are  not infrequent  complications of diphtheria.  Lobar pneumonia is
a rare complication.   The  extension of the fibrinous exudation  to the  bronchi
has already been mentioned.  (Edema glottidis may develop in the course of
diphtheria.
   When the disease has been attended with symptoms of severe blood-poison-
ing ecchymoses in  the serous membranes and parenchymatous degeneration
of°the heart, liver, kidneys, and muscles have been found after death.  Acute
fatty defeneration of the  heart and  acute myocarditis have been found  in
certain cases which terminated suddenly with  signs of paralysis of  the heart.
         1 Minheilungen aus dem Kaiserlichen  Gesundheitsamte, Bd. 2, p. 421. 
1078
DIPHTHERIA .—MILK  SICKNESS.
 The  kidneys may be the seat not only of parenchymatous degeneration, but
 also of an acute nephritis.   Oertel has found colonies of micrococci  in the
 kidney,  but they  are  accidental and  not often present.  Acute ulcerative
 endocarditis is  a  rare  complication of diphtheria.  The spleen  is not  infre-
 quently somewhat enlarged and softened.   These changes in the internal
 organs are those  which characterize acute  infectious diseases  in general.

   Clinical History.—Diphtheria presents, in different cases, such differ-
 ences as regards general and local symptoms—the latter incident especially to
 the localizations of the diphtheritic affection—that some writers have  insti-
 tuted several varieties of the disease.  AVithout adopting formally any of
 these, it will suffice to indicate the important  diversities in connection with the
 symptomatology.
   A  marked point of difference relates  to  the development of the disease.
 The  attack is  sometimes abrupt, beginning  with a chill more or less  pro-
 nounced, and followed by  considerable or marked  pyrexia, or the disease
 may begin with symptoms denoting great prostration; but not  infrequently
 the development is gradual and insidious, the patient complaining of indefinite
 ailments, and the  characteristic  affection of  the throat being discovered on
 inspection when there are few or no local symptoms pointing  to the existence
 of the disease.   After the development  of  the  disease-the symptoms are
 naturally divided  into general  and local, the  latter being referable especially
 to the parts affected with the diphtheritic  process.
   The affection  of the  fauces is  rarely accompanied by notable pain or sore-
 ness,  and hence there is a liability to overlook its existence.  The sensibility of
 the parts appears,  in some cases,  to be diminished.   Deglutition is sometimes
 painful,  but in other cases it is unattended with pain.   Incomplete paralysis
 of the muscles concerned in deglutition, which will be noticed as a sequel, is
 sometimes a  concomitant of the  disease, giving rise to more or less difficulty
 of swallowing, especially liquids.   These  may regurgitate through the nose.
 If the exudation be abundant and loose, pharyngeal rales occur with respira-
 tion,  especially  during sleep.  The breath in some cases is notably  fetid,
 suggesting the idea of gangrene  of the  throat or lungs—events  not frequent
 in the history of  the  disease.  The extension of the  false membrane  over
 more  or less of the buccal mucous surface occasions greater or  less pain in con-
 nection with the introduction of  food or drinks into the mouth, together with
 ptyalism and stiffness of the parts, involving difficulty  of articulation  and
 absence of taste.  The affection of the anterior nares is preceded and accom-
 panied by a  discharge which produces excoriation and swelling  of  the upper
 lip, limited to one  side of the lip  if one nostril only be  affected.   In other sit-
 uations accessible to view, on  a mucous surface or on  the skin,  the diphthe-
 ritic process gives  rise to more "or less pain or  soreness, and is attended  by a
 sero-purulent discharge variable  in quantity,  frequently ichorous, and  some-
 times fetid.  As a rule, the  gravity of the disease is commensurate with the
 extent of the local affection and the abundance of the exudation.  It does not
 follow from this fact that the gravity depends on the local affection.  The lat-
 ter may be a criterion, not the cause, of the former.
  The symptoms  denoting  an  invasion of the larynx are essentially  those
 which belong to the history  of fibrinous laryngitis or true croup.  These have
been  already considered.1   Cough, having more or less of the characters
known as croupous, feebleness of the voice with elevation of pitch, or aphonia,
and labored, stridulous respiration, point to this most  serious localization of
the affection.  The embarrassment of respiration maybe increased paroxysm-
ally, as in  simple  laryngitis or in true croup, by the  addition of  spasm  of
                              1 Aide p. 288. 
DIPHTHERIA.
1079
the muscles of the glottis.   Swelling of the tonsils and pharynx may be suf-
ficient to  occasion  some obstruction  to respiration without  invasion of the
larynx.  It is to be borne in mind that laryngitis may be excluded so long as
the voice remains unaffected.  Diminished respiratory murmur and embarrass-
ment of the respiratory function out of proportion to the amount of laryngeal
obstruction, with the presence of moist bronchial rales, denote an  extension
of the affection  to the bronchial tubes.
  Passing  to symptoms other than  those directly referable  to the  parts
affected with the diphtheritic process,  cases  differ  widely  as respects the
amount of  constitutional disturbance. Irrespective  of an  affection of the'
larynx, which of necessity involves great danger, cases are either mild or more
or less severe.  In some mild cases the disease is  almost trivial, patients not
taking to the bed, and perhaps not keeping within-doors; but, however mild
cases may be at the outset and during more or  less of  the career of the dis-
ease, there is always a liability to the occurrence of diphtheritic inflammation
in new situations, to  the development of  grave symptoms, and to important
sequels.   In the cases in which the disease is mild throughout its career the
local affection is confined to the fauces, or, exceptionally, to a limited space in
some other  situation.
  In cases of greater or less severity the clinical history embraces symptoms
referable to the different anatomical systems—namely, the circulatory, cutane-
ous, respiratory, digestive, nervous, and urinary.
  The pulse in  some cases becomes very frequent; in other cases  the accel-
eration is moderate, and it is sometimes slight.  In the course of the disease
the  pulse is sometimes at first more or less rapid,  afterward  suddenly falling
below the average of health.  Aside from frequency, the pulse is  soft or com-
pressible.   It is  sometimes irregular—a  symptom of unfavorable omen if it
be  independent of pre-existing  organic  disease of the heart.  Hemorrhage
from the nostrils is  not an infrequent symptom, and it  occurs  occasionally
from the throat and mouth.  Epistaxis is sometimes  so profuse as to require
mechanical  means for its arrest.   Under  these circumstances it denotes great
gravity and danger, and hemorrhage in other situations is to be  regarded as
ominous.
  The skin rarely presents  much increase of heat.  In some  cases there is no
increase  and not infrequently in the course of the disease the surface becomes
cool or cold.  The pyrexia,  as a rule, is less than in most other acute diseases.
The temperature may, however,  be high.   Petechial spots or ecchymoses are
sometimes observed,  occurring generally in connection with hemorrhage from
mucous  surfaces.   In grave  cases the skin presents an anaemic  aspect even
when hemorrhage has not  occurred.   In  the  cases in which  the  air-passages
become affected there is more or less lividity of the surface, especially marked
on  the face and prolabia.  The disease has no characteristic  eruption.   Bose-
spots are sometimes observed and other forms of eruption—namely, erythema
nodosum, urticaria, and sudamina—but these are accidental.
   The symptoms referable to  the respiratory system are  due  to fibrinous
inflammation of the  larynx, trachea, and the  bronchial tubes.  These have
been already referred to among the symptoms incident to the  local affections
characteristic of the disease.  If life continue sufficiently long, false membrane
in these cases is expectorated, sometimes in the form of  hollow tubes like mac-
aroni, but  generally in  patches of irregular size  and shape.
   The desire for food is generally either  notably diminished or  lost.   Aside
from pain  and difficulty in deglutition or the  suffering  caused  by food and
drinks when the mouth is affected, there  is often an invincible repugnance to
nourishment, so that in children, if given at all, it must be  forcibly adminis-
tered.  Atomiting is  a  frequent, and  in  some cases  a prominent,  symptom. 
1080
DIPHTHERIA.—MILK SICKNESS.
This, as well as  anorexia, is serious on account of the interference with  ali-
mentation.   Diarrhoea is not uncommon,  and is a  symptom of bad omen.  In
the cases in which the diphtheritic affection extends into the  oesophagus false
membrane is expelled by vomiting in the form of ribbons, provided death do
not take place before the exfoliation is completed.
  In the majority of cases the mind  is  unaffected.   Slight  passive delirium
occasionally occurs, and sometimes the delirium is active.  The latter  denotes
great gravity of the disease.  Convulsions and coma are rare, but both are of
occasional occurrence.   Convulsions have been observed at all periods of  the
disease, and coma is the forerunner of a fatal termination.  It is probable that
coma and convulsions, occurring in this disease, are generally due to uraemia.
  Albuminuria is a frequent symptom.   The proportion of cases in which it
occurs  is variable.   It varies considerably at different  times and places.  Gen-
erally,  the albumen contained in the urine is small in  amount, but it is some-
times abundant.  In the cases in which it is abundant the diphtheritic exuda-
tion is generally large and the swelling of the glands of the neck  is unusually
great.  General dropsy in connection with albuminuria  is  rare; it has, how-
ever, been observed in a small  number of cases.   There may be evidences of
the development of acute Bright's disease, in which  case  casts  and  usually
some red and white blood-corpuscles will be found in the urinary sediment.
Haematuria has been observed in cases presenting the symptoms of purpura
or the hemorrhagic diathesis.   As in the other febrile diseases, the urine con-
tains a larger amount of urea than in health—a fact showing  an increased
waste of the tissues.
  The  duration of the disease is between one and two weeks.  In fatal cases  the
duration may fall short of a week, death  sometimes taking  place within forty-
eight hours.  On the other hand, the illness may continue for  an indefinite
period  beyond the maximum duration of the career of the disease, owing to
consecutive affections or sequels.
  Aside from the characteristic diphtheritic  affections which  are properly
components of the disease, complications  are  rare and accidental.    Pneu-
monitis is  occasionally  developed, and the affection  of the  kidneys,  giving
rise to an  abundance of albumen in the  urine,  and sometimes to  general
dropsy, is perhaps to be regarded as a complication.   The disease, however,
may be associated  with other  diseases.    Its  concurrence  with scarlatina,
measles, and smallpox has been  repeatedly  observed.   Painful swelling and
redness of the joints, like that  in acute rheumatism, is a rare complication.
  The sequels of this disease form an important  part of the clinical history.
Anaemia and general debility are likely to persist for a  considerable  period.
Feebleness of the  action of the heart sometimes exists to such a degree as
to  lead to sudden death from syncope.
  Paralysis affecting more or less  the voluntary  and  sometimes the involun-
tary muscles is a characteristic  sequel.   The  muscles of the soft palate  and
pharynx are oftenest affected, and paralysis here  generally precedes its occur-
rence elsewhere.   The  palatine  muscles are sometimes affected  during  the
course of the disease, but generally not  until after a  period  varying between
one week and four weeks from the date of convalescence.   In a slight or mod-
erate degree the paralysis in this situation is denoted by a nasal intonation  and
by  a certain amount of difficulty in deglutition and the regurgitation of liquids
through the nostrils.  In a greater degree  and associated with paralysis of
the oesophagus—which is happily rare—there is very great difficulty in swal-
lowing, and it may be even necessary to introduce aliment  by means of  the
stomach-tube.  Under these circumstances sudden death has been caused by
the passage of aliment into the larynx.   On inspection the soft palate is seen
to be relaxed and immovable.  There often is anaesthesia of the mucous mem- 
DIPHTHERIA.
1081
brane of the throat.  The paralysis affects the reflex  action,  so that the pal-
ate remains motionless when irritated with a pointed instrument,  The exist-
ence of paralysis  in this situation is indicated  by a nasal intonation of the
voice, and  sometimes by a snoring sound in respiration.  The  paralysis in
some cases affects  the tongue and muscles of the face, so that articulation is
difficult and the patient may be unable to  perform the  acts of suction and
whistling.   The act of gargling is also difficult or impossible.
   The paralysis is sometimes limited to the  muscles of the palate,  pharynx,
and mouth, but not infrequently it extends to other muscles.   Exceptionally,
the paralysis is manifested primarily or solely elsewhere than in the throat.
Paralysis of one or more of the laryngeal muscles, either unilateral or bilat-
eral, and associated often with anaesthesia of  the laryngeal mucous membrane,
may occur.  Paralysis  of the  muscles of accommodation of the eye is  not
uncommon, causing defective power of adjustment in the eye for distant or
near objects.   This disorder is generally bilateral, but  it is often more marked
in one eye  than in the other.  Other muscles of the  eye may be paralyzed,
not infrequently causing  strabismus.   Amblyopia  and  transitory amaurosis
occasionally occur.  There is reason to believe that the amaurosis is some-
times attributable to uraemia.   Disordered vision is in some cases the first  of
the paralytic sequels, and  the paralysis is sometimes limited to the organs  of
sight.   The other special senses—namely,  taste,  smell, and hearing—are
sometimes  affected, but rarely  as compared with  the sense  of sight.
   Paralysis  of the extremities is not a rare form  of diphtheritic paralysis.
Certain muscles only or all of the muscles of an extremity may be involved.
The lower limbs are  most likely to be affected, and paralysis here generally
takes precedence  of its  occurrence in the  upper extremities.   The  paralysis
is developed gradually, and is often preceded or attended by subjective sensa-
tions of tingling,  numbness, and coldness.   The loss of power over-the mus-
cles may be complete or there may be different degrees of paresis.  The par-
alysis  sometimes  assumes the form of paraplegia, sometimes of hemiplegia,
or one of the upper extremities may be paralyzed in connection with paraple-
gia, or the  upper  limb on  one side  and the  lower  limb on the  opposite side
may be alone affected.  Trousseau observed the paralysis to affect the different
extremities successively and recurrently.  Finally, the paralysis  is sometimes
general—that  is,  all  of the extremities are  paralyzed—and  in  addition  the
paralysis may involve the muscles of  the face, the throat, mouth, neck, and
trunk, and certain of the involuntary  muscles.  Cases in which the paralysis
is so extensive are extremely rare.
   The  paralysis is of the  atrophic variety.   The paralyzed  muscles  are
relaxed and may present the reaction of degeneration.  The knee-phenomenon
or  patellar tendon reflex  is usually  abolished, and  this often  occurs after
an attack  of diphtheria, even  when no paralysis  is  developed.
   Acute ataxia,  generally  of  the lower  extremities, has been repeatedly
observed as a sequel of diphtheria, without paralysis.
   In connection with the paralysis of the extremities the sensibility of the
affected parts,  when tested objectively, is often intact; but it  may be notably
diminished  both as regards the sense of pain  and touch.   Exceptionally, there
is hyperesthesia  of the integuments.
   The paralysis sometimes affects the  intercostal muscles and the diaphragm,
living rise  to  dyspnoea and  involving  danger from inability  to  carry on the
respiratory acts.   The muscles concerned in defecation are  sometimes para-
lyzed, causing either retention of, or inability to retain, the feces.  In like man-
ner, the paralysis may affect the bladder, causing retention and incontinence of
urine.   Notable impairment or loss of virile power may be mentioned as one
of the rare sequels of dipththeria. 
1082              DIPHTHERIA.—MILK SICKNESS.

  As regards the frequency of the  paralytic sequels, a nasal intonation  of
the voice and more or less impairment of deglutition are common, but par-
alysis elsewhere occurs iu a  minority of cases.  These sequels take place in
cases of mild as well as of severe  diphtheria.
  In cases of diphtheritic paralysis lesions have  been found in the central
nervous system, in the spinal nerve-roots, and in the peripheral nerves.   The
anatomical basis of the paralysis does not seem to be the same in all cases.
In several cases which have been carefully investigated the lesions of a  mul-
tiple degenerative neuritis (p. 785) have been found.   The  characters of the
paralysis, particularly the usually rapid recovery,  are in favor of the periph-
eral  nature  of  the  lesion in many cases.

  Pathological Character.—Diphtheria is a general disease or an essen-
tial fever.  The pyrexia and constitutional symptoms are not merely symp-
tomatic of the inflammation involved in the local diphtheritic affections.   Two
views are held as regards the relation between the  local lesion and the consti-
tutional affection.   According to one view, the special poison of diphtheria
first enters the blood, and the pseudo-membranous  inflammation of the throat
or of other parts is secondary to the general disease, having to the latter a  rela-
tion like that of the characteristic local affections of the skin and mucous mem-
branes in the eruptive fevers.   According to the other view, the special poison.
consisting,  probably, of some micro-organism,  enters the  circulation at the
seat of the  local affection, which is  caused by the invasion of the  parasite.
It is probable that both  modes of invasion occur.
  A question which has occasioned much discussion  and concerning which
opinions differ is, whether diphtheria  and membranous croup be distinct dis-
eases.   Regarded from a clinical point of view, it seems to me clear that this
question is to be answered in the affirmative.  There is, moreover, nothing in
the pathology of these diseases opposed  to this view.  It is established  both
experimentally  and clinically that pseudo-membranous inflammations of the
throat may be  produced by  a variety of causes,  such as inhalation of hot
vapors,  the swallowing of corrosive  poisons, traumatism, and the special poi-
sons  of various  infectious  diseases, particularly  scarlatina, smallpox,  and
measles.  There is no ground for the assumption that aside from these causes
the diphtheritic virus  is the only one capable of causing  pseudo-membranous
laryngitis.   So  far as known,  the pseudo-membranous exudations produced by
these various causes are anatomically identical, there being nothing as  yet
demonstrated which distinguishes the exudations of diphtheria.  In addition
to the pseudo-membranous laryngitis which is produced by the special poison
of diphtheria (diphtheritic croup), the author recognizes a pseudo-membran-
ous laryngitis which has been described in a previous article as true or mem-
branous croup.   The  latter affection is distinguished  from diphtheria by the
following circumstances: In true croup the exudation occurs primarily in the
larynx,  or, if the tonsils and pharynx be  coincidently  involved, the exudation
does not extend  to the nares  or the oesophagus, nor does  it occur in other sit-
uations.  A considerable enlargement of the cervical glands does not occur.
Albuminuria is not a  symptom.   The pyrexia and other general symptoms
are  purely symptomatic of the local  inflammation.  The disease is  sporadic,
not epidemic.   It  affects children almost exclusively.  It is never followed
by  paralytic affections.  There is no evidence of its contagiousness.   The
relative distinctive features of the two diseases are epitomized by saying that
diphtheria is a general  disease or an essential fever, whereas the so-called  true
croup belongs among the local diseases.
  A diphtheritic affection  of the throat  occurs as an element of scarlatina,
and  the two diseases may exist in combination.  The  combination of the two 
DIPHTHERIA.
1083
diseases  is the probable explanation of reported  instances in which patients
with scarlet fever apparently communicated diphtheria, and vice versa.   The
following instance came under my observation : The patient, a boy aged four
years, had well-marked diphtheria and no eruption.  After convalescence he
became affected with complete hemiplegia and general dropsy, the urine denot-
ing acute  diffuse nephritis.   During his convalescence a sister  was  attacked
with scarlet fever, the efflorescence being abundant.  The boy had the sequels
of both  scarlatina  and diphtheria, following what appeared to be purely an
attack of the latter, and he communicated to his sister the former and not the
latter disease.

   Causation.—Diphtheria is eminently an epidemic disease.  Sporadic cases,
however, occur, and  of late  years in large cities the disease is  never wholly
extinguished.  Diphtheria is a contagious disease.   Evidence of this is found
in instances in which the disease has followed the  accidental introduction of
some of the diphtheritic exudation into  the mouth, nostrils, eyes, or wounds
of the skin.  Many such instances have occurred among physicians in attend-
ance  upon diphtheritic patients.  These  cases prove that the contagium  is
present  in the diphtheritic  exudation.   It is true that Trousseau and  Peter
failed  to produce the  disease in themselves by voluntary inoculation, but  a
similar immunity in individuals exists toward many diseases the contagious-
ness of which is acknowledged.  In this regard positive evidence outweighs any
number of negative facts.  The experimental inoculations of animals with diph-
theritic exudation has  not yielded decisive results.1  Further evidence of the
contagiousness of diphtheria is afforded by the introduction of the disease into
situations where it had not previously existed by  patients coming from  situ-
ations in which  it  was prevailing.   There are some instances recorded of the
special poison being transported by individuals who do not themselves become
infected with the disease, but such cases  are rare.  The contagium of diphthe-
ria often adheres tenaciously to localities where it  has once gained a  foothold.
Thus the disease has been contracted by those occupying rooms where  many
months  before there  has been a patient affected  with diphtheria.   Observa-
tions have been reported which  show the possibility of  the transmission of
the  diphtheritic  poison by  means of milk.'-
   Defective sewerage, imperfect ventilation, overcrowding, and other unsan-
itary conditions  favor  in  no small degree the development of the disease  in
both its  sporadic and epidemic form.   It is probable that this effect is pro-
duced,  not by the  spontaneous generation of the diphtheritic contagium, but
by a favorable influence upon the multiplication of the disease-germs outside
of the body or by increasing the susceptibility of the persons exposed thereto.
Diphtheria, however, is not infrequent under the best hygienic surroundings.
   Sporadic cases occur under circumstances which seem to render  it impos-
sible that the special germ of diphtheria had been introduced from  without;
but a similar apparently spontaneous development of other contagious diseases
occurs, so that these instances cannot overthrow the general belief in the con-
tagiousness of diphtheria.  Still, it remains true that it is often impossible to
trace the source  of infection in cases of  diphtheria.
   The  susceptibility  to  diphtheria is not equal at all periods  of life.   This
susceptibility is greatest between two  and seven  years  of age.   After this

   1 Some experimenters have succeeded  in producing a  pseudo-membranous inflamma-
tion of mucous membrane bv inoculation with diphtheritic exudations; but  the results
of the  careful experiments of Curtis  and Satterthwaite, and those of H. C A\ood and
Formad, are opposed to  the doctrine that diphtheria can be produced in animals by
inoculation.                           .                  .....
   2 Aide article by Hart in  Proc. of International Med. Congress ot 1881. 
1084
DIPHTHERIA.—MILK SICKNESS.
   period the susceptibility progressively diminishes, but it exists in considerable
   degree even in adults.  During the first year of life diphtheria is rare.   Cir-
   cumstances pertaining  to sex, social position, occupation, etc.  do not appear
   to be connected with the causation.  Diphtheria occurs at all seasons of the
   year, but it is  most frequent during cold, moist, and changeable weather, per-
   haps  because  then ordinary inflammations of the  throat are most common,
   and these may increase the readiness with which the diphtheritic virus gains
   entrance to  the system.  One attack of diphtheria does not protect against
   subsequent attacks.  The period of incubation is generally between two  and
   eight days;  it may, however, be longer.
      Some persons are much more susceptible to diphtheria than others.   It is
   often impossible to explain to what this increased  susceptibility is due,  but
   sometimes it is associated with chronic  enlargement of the tonsils or with a
   tendency to simple, catarrhal inflammations of the  throat.
      Epidemics of diphtheria are irregular in their occurrence.  It is a remark-
   able fact that they were scarcely known in America from the time of the epi-
   demic in 1771, described by Bard, to about 1856, and since the latter date they
   have occurred in all parts of the continent.   The disease is often limited in its
   prevalence in particular sections to  a circumscribed  area.  For example, it has
   been observed to be restricted to a few houses or a single house or to a narrow
   strip of land on the banks of a stream.   The  special  cause seems to require
   auxiliary causes, at present unknown, which are peculiar to certain localities.
      Epidemics  differ as regards certain features of the disease and the rate of
   fatality.   In  some  epidemics there is an unusual tendency  to an invasion of
   the larynx, and the amount of exudation in  other situations is  unusually
   large in the majority of cases.   In  other epidemics the local affection is con-
   fined to the fauces, as the rule, and the  disease is generally  mild.   In respect
  , to variations at different times and places, diphtheria resembles other epidemic
/  diseases.
      As has already  been mentioned, nothing is positively  known  as to the
   nature of the special cause of  diphtheria.  There is some basis for the view
   that we include under the  general name of diphtheria diseases dependent upon
   diff'erent causes.   It is not probable that the diphtheritic inflammations of
   the throat which are often secondary to various infectious  diseases, particu-
   larly scarlatina, but also to measles, smallpox, typhoid fever, and erysipelas,
   are caused, as  a rule, by the same infectious  agent which  produces primary
   diphtheria.  There are also  some  writers  who hold the opinion  that  even
   primary diphtheria may be produced by various special  causes, with corre-
   sponding differences in anatomical and clinical characteristics ;  but this view
   is far from proven.

     Diagnosis.—It  is important to  define clearly the  comprehensiveness of
   the term diphtheria in respect to diagnosis.  Some physicians are accustomed
   during an epidemic to  consider cases of simple or follicular  pharyngitis as
   cases of diphtheria. This  is sanctioned by writers who recognize as a variety
   of the disease  " catarrhal diphtheria;" that is, diphtheria without the local
   diphtheritic characteristics.    It is perhaps a  rational supposition that the
   sp'ecial cause may give  rise to  a pharyngeal  inflammation and pyrexia with-
   out fibrinous  exudation ;  but, however rational, this  is only  a  supposition.
   On the  other  hand, it  is  well  known that pharyngitis without  diphtheritic
   characters is  a common affection.  False statistics in regard  to death-rate,
   and erroneous  conclusions respecting the effect of treatment, can be avoided
   only by recognizing as an essential criterion  the  local diphtheritic charac-
   teristics.   Adopting this  rule, the  diagnosis  cannot be positive prior to  the
   membranous  exudation, which  may be  preceded   for  a variable  period by 
DIPHTHERIA.
1085
pyrexia and other general  symptoms.   These,  from their violence, may mis-
lead, unless an examination of the throat be made.   Thus, I have known an
attack with high fever and delirium shortly after confinement to be mistaken
for a time  for puerperal fever.   AVhen it is an intercurrent disease in the
course of  another fever, it is liable for some time to be overlooked.  In a case
related to me by a medical friend, there being  notable abdominal tenderness
and  great prostration, the disease for twenty-four hours  was supposed to be
acute peritonitis.
   The diagnosis is easy when the local  manifestations have taken place.  The
only liability to error is in confounding with the diphtheritic affection  pharyn-
gitis or tonsillitis with a deposit of mucus or an abundant follicular secretion.
The appearance in some  cases resembles that of a true exudation.  The dis-
tinctive points are the following:  A deposit of mucus or of follicular secretion
is generally limited to, or especially marked over, the tonsils ; it can he wiped
off, but is not removable in strips ;  it  may be seen to dip  into the follicular
depressions ; and it is often thrown off within twenty-four or thirty-six hours.
On the other hand,  a diphtheritic  exudation  has the characters  of  a  false
membrane ; it generally  extends more or less over the soft palate and uvula ;
if removed it comes away  in strips; and it is  never exfoliated in thirty-six
hours.

   Prognosis.—The proportions of  deaths in collections of cases reported by
different  observers present much variation.   This  is measurably due to the
fact that, irrespective of treatment, the fatality in  different epidemics varies
within widely-separated  limits.   The variations in statistics are also due in a
measure to the error of confounding with diphtheria pharyngitis or tonsillitis
with follicular secretion, and the error of applying the name diphtheria to all
cases* of  sore  throat occurring  during an epidemic.  AA'ithout attempting,
therefore, to express the average death-rate in figures, it must suffice to say
that it is sometimes very large and sometimes  comparatively small.
   The danger is, first, from an invasion of the  larynx. Of the cases in which
the  air-passages become involved  the vast majority end fatally.   The prog-
nosis in these cases is always exceedingly unfavorable.   Apnoea either causes
or contributes  largely to the fatal result whenever  the larynx becomes
involved.   The patient  cannot he considered  as secure  against diphtheritic
laryngitis so long as the career of the disease continues, but the danger  from
this source progressively diminishes after the first w*eck.
   The  danger is, second, from asthenia or exhaustion.   The violence of the
disease may destroy life within forty-eight  hours from the date of the attack,
or perhaps even  at an  earlier period.   In these cases the disease  is truly
called malignant.  Using  the language of metaphor for the want of precise
knowledge  of  the general  conditions on  which the fatality in these cases
depends, the vital powers are said to be overwhelmed with the force of the
disease ; but in the larger proportion of the cases in which  the disease proves
fatal by asthenia the powers of life are gradually exhausted, and death takes
place in the second week.  In the cases in  which the larynx is unaffected the
prognosis is always unfavorable  if the diphtheritic membrane extend  from
the"fauces into the posterior and anterior nares, if it pervade extensively the
buccal membrane, or if it exist abundantly in other situations.  The septic
and  gangrenous forms of diphtheria offer an especially unfavorable prognosis.
Other unfavorable  prognostics  are—frequent vomiting, diarrhoea,  copious
epistaxis  or hemorrhage  in other situations, great frequency, irregularity, or
feebleness of the pulse, coldness of the surface, abundance of albumen in the
urine,  convulsions, delirium, and coma.
   A fact  important to  be borne in mind is the liability to  sudden, fatal syn- 
1086
DIPHTHERIA.—MILK  SICKNESS.
cope in this disease.  It may occur in cases which, as regards the general
symptoms, do  not  present  an appearance  of great gravity.  It generally
follows  some unusual  exertion, as in getting out of bed ; and it has been
known to  occur even during convalescence.   It is  probable that  in some of
the cases in which a fatal result occurs suddenly or unexpectedly the death is
occasioned by the formation of a thrombus in the right cavities of the heart,
It may also be  referable  to parenchymatous degeneration of the heart.
   The paralytic affections which  are  liable  to supervene  do  not, in general,
involve danger.   The danger incident to these affections  relates  to innutrition
in the cases in  which deglutition is extremely difficult or  impossible,  and to
apnoea when the  respiratory muscles are involved in the paralysis.

   Treatment.—AATith reference to therapeutical indications it  is convenient
to divide cases  into  those with and  those without a diphtheritic affection of
the larynx.  The treatment of cases in which the larynx does not  become
affected will be considered  first.   The indications in  these  cases relate to
the general condition  and to the local affection.
   It is obvious  that views which relate to the pathological connection between
the pharyngeal affection  and the general condition must  have  great influence
upon the  rational indications as regards local treatment.  If the disease be
produced  by bacterial germs or organisms, which, received into  the mouth or
nostrils, find a habitat  generally in the  mucous membrane of  the  throat, and
that generated here are broods of parasites which migrate into adjacent parts
and into the blood, it is a reasonable supposition that local treatment  is first
in importance.  According to  this view, the object is to destroy the parasites
as early, quickly, and effectually as possible.   There is sufficient probability
of the correctness of this view to dictate  the propriety of making trial  of
different  articles and   methods  with  reference to  a  parasiticidal   effect.
Another view  renders local  treatment rationally  important—namely, that
which  attributes  the general  symptoms, in a greater or less  degree,  to the
absorption of septic matter,  not accepting the theory that the morbific agency
of this  matter  is due to  a specific diphtheritic organism.  According to this
view, it is a reasonable  supposition that to prevent septicaemia  is an important
object of  local  treatment.   Rational  considerations, however, no matter how
strongly they may seem  to  be supported by morbid anatomy, together with
accepted  doctrines  of  etiology and  pathology, are  never sufficient  for the
establishment of  therapeutical rules  without the results  of  clinical experi-
ence.  Making proper allowance for the variableness of the disease in  differ-
ent epidemics, we have not,  at present, sufficient clinical  daf a for determining
the relative value of the different kinds of either the  local  or the general
treatment of diphtheria,  and we lack the important standpoint for deciding
upon the influence, collectively, of all kinds of treatment—namely, the mor-
tality when the disease  is  allowed to pursue its course unaffected  by  any
therapeutical measures.
   Caustic  and  irritating applications to the  throat—namely, the  nitrate of
silver, hydrochloric acid, the sulphate of copper,  and the strong solutions of
the pernitrate or  persulphate of iron—have heretofore been in vogue.   They
are still employed by some practitioners, and their use is sanctioned by some
standard authors.  They are  objected to on the following rational grounds:
Impairing the  continuity of tissue facilitates  the  entrance of organisms or
septic matter into the system ; and  observation teaches  that secondary diph-
theritic exudation is liable to occur in any situation on the mucous surface or
skin in which there is abrasion ;  as, for example,  after the  application of a
blister.   Many physicians have testified to the apparent hurtfulness of these
applications.  On the other hand, testimony of their usefulness is not want- 
DIPHTHERIA.
1087
ing.   A medical  friend of much experience is convinced that by the prompt
and  thorough application of nitric acid, if  the part primarily affected can be
seen and reached, the progress of the disease may with certainty be arrested.
He claims that want of success can  only be explained by lack of thorough-
ness in  the application.  It should be made by bringing into contact  over the
whole of  the  affected  part either lint or several thicknesses of linen cloth
holding the acid, with sufficient pressure for the acid to penetrate the exuda-
tion  and act upon the underlying tissue.
   Cauterizing applications have of late years, to a  great extent, given place
to those supposed to be useful by means of a disinfectant or antiseptic effect.
Bemedies applied for this effect are carbolic acid, salicylic acid, permanganate
of potassa,  chloral hydrate,  sulphite  of soda, benzoate of  soda, subsulphate
of iron, bromine, oil of turpentine, and the chlorate of potassa.  Two or more
of these are sometimes combined.  The applications in a liquid form may be
made by means of a probang, a camel's-hair brush, or a spray-producer.  The
latter is preferable, especially in children.   The salicylic acid is conveniently
applied in the form of a dry  powder combined with bismuth, or  it may be
used in the form  of a solution of salicylate of sodium (7 parts to 100 of water).
The chlorate of potassa may be taken dry into the mouth, combined with pul-
verized sugar. It is to be remembered that the absorption of large quantities
of chlorate of potassa is often  attended with danger.   The applications are to
be made by means of injections into the nostrils if the exudation be seated in
the Schneiderian membrane.    AA'hatever be the disinfecting or antiseptic arti-
cles employed, they should not be concentrated sufficiently to cause local irri-
tation, and they should be repeated at short intervals.  Oertel advises a spray
from a solution  of the chlorate of  potassa and salicylic acid, with, in severe
cases, the addition of the  permanganate of potassa, to be continued for a quar-
ter  of  an hour  and  repeated every  hour  or even  every  half  hour.  The
thorough cleansing of the affected parts  by gargling or injections with tepid
water holding some disinfectant in solution  is an  important part of the local
treatment.  Oertel attaches  much importance to  the promotion of suppura-
tion, and  advises for this  end the frequent inhalation of hot steam.   A'arious
solutions  have been used as  local applications with the view of dissolving the
false membrane.   For this purpose lime-water, lactic acid, pepsin, trypsin, and
papayotin have been employed, but  it is uncertain  whether they exert any
decidedly favorable influence.   AVhen there is much fever swallowing bits of
ice is grateful to the patient.
   The degree of efficacy  to  be attributed to local treatment, and  the partic-
ular applications to be preferred, are to be  settled  by further  clinical experi-
ence.   Physicians  differ as to  the importance of  topical  applications and as
regards preferences among those which are in use.   In view  of the deficiency
of data for exact conclusions the opinions  of individual observers will  have
weight  in proportion to  their opportunities  for observation  and  the confi-
dence placed  in  their opinions.
   AVith reference to the general treatment,  if the germ theory be adopted  it
is a legitimate purpose of clinical observation to discover a remedy to  be taken
into  the system for a parasiticidal effect,   Several remedies are supposed to
have this  effect.   Some physicians attribute to the  sulphites efficacy in this
way, given in  full doses after short intervals.   Twenty or thirty grains of the
sulphite of sodium may be repeated every two or three hours.  The sulpho-
carbolate  of sodium, in doses of a scruple  to an adult every hour or two, in
the practice of a  medical friend of much experience, has seemed to him to be
signally useful.   This remedy, improperly prepared,  is sometimes  extremely
offensive to the taste, but, properly prepared and given with an agreeable syrup,
it is not repulsive.  The benzoate of sodium, given hourly in doses aggregating 
1088              DIPHTHERIA.—MILK SICKNESS.

in twenty-four hours between fifteen and twenty-five grammes, has been used
with apparent benefit in Germany, but it has no special efficacy.  It is claimed
by Di\ E. AAr. Chapman, on the basis of clinical experience, that alcohol, given
early and as largely as can be borne without symptoms of alcoholism, acts as
an antidote, and that, conjoined with quinia, it is an effective  curative agent.
Calomel, corrosive sublimate, and other  preparations of mercury, given in fre-
quently-repeated doses, are recommended for their germicide effects, and have
apparently proved useful.  Pilocarpine has been administered internally with
the idea that by inducing abundant secretion it aids in the detachment of the
false membrane, but the favorable  results  at  first reported as following the
use of this remedy have not been confirmed by subsequent experience.  AVe
may hope that for this disease and for other infectious diseases remedies may
be discovered which will have  a  controlling influence, like that of  quinia  in
the malarial fevers ;  but at present we know of no drug  which  exerts a
specific curative influence  over diphtheria.
   Aside from remedies for a special controlling influence, in view of  the fact
that if the larynx be not affected the danger is chiefly from asthenia, the great
object of  treatment is support.  Much importance belongs to alcohol  as the
most efficient factor in the supporting treatment.   The principles which should
govern its employment are the  same as in the essential fevers and in other dis-
eases tending to destroy life by asthenia.   These principles need not here be
repeated.   In this disease, as  in the essential fevers, there  is  sometimes a
notably increased tolerance of alcoholics.   Jenner cites a case in which two
drachms of brandy were given hourly with advantage to a child three years
of ao-e.  In a case of great severity which came under my observation half an
ounce  of brandy was given hourly, the  patient being thirteen years of  age,
without any  excitant effect, the case ending in recovery.   In  the use of alco-
holics  the physician is to be guided by the indications and by  carefully watch-
ing the immediate effects.  Alimentation is an essential part of the treatment.
The diet should be concentrated and highly nutritious, and it should embrace
the necessary variety of alimentary principles.  Milk meets pre-eminently these
requirements.  A serious difficulty in the treatment often arises from  the invin-
cible repugnance to nutriment, and sometimes from the persistence  of vomit-
ing.  Owing to the difficulty of alimentation in some cases, and sometimes a
want of  appreciation of its importance, death takes place from innutrition.
Of tonic remedies, the sulphate of  quinia  and the tincture  of the chloride
of iron are very useful.
   The measures heretofore known as antiphlogistics—namely, bloodletting,
general or local, purgation, emetics, and nauseants—are rationally contraindi-
cated by the simple fact that the danger is  not from the inflammatory mani-
festations of the  disease,  but from  the  general condition  which  tends  to
destroy life  by asthenia.  Clinical experience has abundantly shown these
measures to  be injurious.   Blisters  and other counter-irritant measures are
not  to be  employed, occasioning, as they are likely to  do, new foci of diph-
theritic inflammation.
   Symptoms incidental to the disease claim palliative  treatment.   Vomiting
is to be relieved by bismuth, creasote, hydrocyanic acid, etc.   Diarrhoea calls
for opium and astringents.   Anodynes—that is, opium or its succedanea, the
bromides, or the chloral hydrate—are often indicated by restlessness and vigil-
ance.  Hemorrhage indicates the use of haemostatics topically and internally.
   The treatment of  cases in which diphtheritic laryngitis becomes developed
involves the  same general  principles as that of cases without the  laryngeal
affection ; hut, in  addition, measures are indicated to hasten the separation
of the false membrane  within the larynx, precisely as in cases of  laryngitis
with false  membrane disconnected from diphtheria ; that is, in cases of  spo- 
MILK SICKNESS.
1089
radic or primary so-called true croup.  The most efficient of the measures for
this end is the inhalation of warm vapor or steam.  AA'ith reference to  this
measure and other  points relating to the treatment directed to the laryngeal
affection the reader is referred to the article on  Laryngitis with  Fibrinous
Exudation.1
  The rules with respect  to  tracheotomy when the danger from laryngeal
obstruction  is imminent are the same as in cases of primary croup.   There is
undoubtedly less hope of success  from surgical interference than in the latter
affection.   AVith reference to  the propriety or importance of the  operation,
however, the simple question  is,  Are lives ever  saved  by it?   This question
is undoubtedly to  be  answered in the affirmative.   The question, How many
lives are saved? is of less importance in its  practical bearing.  If lives be
ever saved by tracheotomy in diphtheria, a practitioner is reprehensible if he
allow a patient to die  from laryngeal obstruction without opening the trachea.
The patient is entitled to the chance of being saved by the operation, how-
ever small that chance may  be.
  The method of treating laryngeal stenosis by passing a tube into  the larynx
(intubation) has been practised with considerable success by Dr. O'Dwyer of
New York, and has been recently  advocated by him.  Other practitioners have
in general bad less favorable results in employing this method  than those
obtained by Dr. O'Dwyer.  Experience is not yet sufficient to determine the
value of intubation of the larynx in cases of diphtheria and croup.
  The propriety of precautions  against contagion has been  already referred
to.   Patients affected with the  disease  should  be at once isolated.  AATien-
ever practicable, the removal, especially of children between three  and twelve
years of  age, from an infected house or district is advisable.  Thorough dis-
infection  of the  dejections, of all articles which have  been in contact  with
patients, and of  the  apartments  which they have occupied is to be enjoined.
Auxiliary causes are to be sought after in defective sewerage or drainage, over-
crowding, want of ventilation, etc., and these removed if discovered.
  The diphtheritic paralyses may be treated by  massage, by the employment
of  the  galvanic  current, and by hypodermic injections of small doses of
strychnine.

                            Milk  Sickness.

  During the  early decades of this century the disease known in  the lower
animals as  the trembles, and in human beings as the milk sickness, prevailed
extensively in many of the frontier settlements of what were then the A\rest-
ern and South-western States of this country.   The disease  has gradually
receded before the advances of improved agriculture, but it still retains a  foot-
hold in certain districts  where  it has been  endemic.  The States in which
the disease has  most frequently been  observed  are  Indiana, Illinois, Ohio,
Kentucky, Tennessee, Missouri,  and Michigan ; but cases have occurred in
AA'estern  Pennsylvania,  Virginia, Alabama, Georgia,  and North  and South
Carolina.   The disease is not known to have  occurred east of  the  Alleghany
Mountains,  west of the Great American Desert, or in the countries of the Old
AA'orld.  The descriptions of the disease, coming as they do in great part  from
recently-settled regions where medical science has not reached a high develop-
ment are very imperfect.  Notwithstanding the doubt which has been cast  upon
the very existence of the disease as a specific affection by some authors, and
the little attention which it has  received in medical literature, there is  suffi-
cient evidence for the recognition of a peculiar and specific disease which has
received the names already mentioned.
                                1 A'ide p. 291.
       69 
1090
DIPHTHERIA.—MILK SICKNESS.
  The name milk sickness is based upon the belief that the disease is com-
municated to man by the use of the milk of  cows affected with the trembles.
This name is objectionable, on the  ground that there is evidence of commu-
nicability also by the use of the flesh of animals  thus affected.
  The disease affects primarily herbivorous animals, especially cattle,and less fre-
quently horses, sheep, goats, and wild animals.  Unweaned calves, lambs, and
colts are especially liable to the disease.  Animals giving milk do not manifest
the characteristic symptoms so soon as those  which are not giving milk.
  The leading symptoms  of trembles occurring in cattle are at first languor,
indisposition to  exercise, and abstinence from food, and then, when the dis-
ease is  fully  developed, weakness, so  that  the  animal is  unable to stand
upright; trembling,  thirst, obstinate constipation, a lustreless and congested
condition of the eyes, coolness of the  surface   of  the  body,  and labored
respiration.   Convulsions  may  occur.    Most writers mention  a peculiarly
offensive odor of the  breath.   Mild  cases occur, but generally,  if  the
symptoms be  well marked, death  takes place  within a few hours or a few
days  after the first manifestations  of the disease.  A predisposing  cause of
an" attack often is fatigue.   Exercise  is  sometimes  employed to determine
whether the disease exist in a latent or prodromic stage.  Thus, cattle-deal-
ers in milk-sick  districts often chase the animals for a  while in order to test
their freedom  from trembles.
  The disease is most common in late summer and autumn, but it may occur
in the winter.   It is more common  in warm, dry seasons than in wet seasons.
It occurs only in certain localities, which  are  often  quite narrowly circum-
scribed.  The special cause may exist in a certain tract of  land on a farm,
and be  absent from  the land immediately adjoining.  AVild  and unimproved
lands, especially those which are densely timbered, seem to be  the favorite
situations for the special  poison,  while open prairies and  fields which are
freely exposed to the  sun are  not favorable for  its  development.  Cultiva-
tion of the soil causes the disease to disappear.   The disease has not been
observed to originate in regions where it did not previously exist, whereas,
on  the  other  hand, it has disappeared from the endemic  regions after their
subjection  to  cultivation.   It is the general opinion of the farmers in the
infected districts that the animals do not contract  the disease during the
daytime, but  only when they are  allowed to remain out during the  night.
So  far  as is known,  no  special quality of the soil characterizes*the infected
regions.
  It is  not disputed  that the trembles is due  to some special poison which is
present in the ground, but we have no knowledge as to  the nature  of this
poison.   The idea that the poison is a mineral substance has received no  sup-
port in facts,  and is now generally abandoned.   The prevalent view is  that
the disease is  caused by the ingestion of some poisonous vegetable.  A num-
ber of vegetables have been accused, such as certain poisonous Umbellifere,
the Eupatorium ageratoides,  the   Rhus  toxicodendron, and certain  fungi.
Although there is  no  evidence that any of  these  plants causes the disease,
the theory  of a vegetable poison  is  not without  considerable  probability.
There are  also, especially  of late  years, advocates  of the  theory that the
trembles is  caused by a special  micro-organism, and Phillips claims to have
found  a spirillum in the blood.  Graff found that the  flesh of  a dog  which
had been poisoned  by feeding him with meat from cows affected with the
trembles was no less poisonous than the cow's  flesh. This  experiment is an
argument in favor of the multiplication of the poison within the body.   It
is, however, desirable that these experiments should be repeated before any
conclusions are drawn from them.
  In all regions where the trembles prevails  among cattle an apparently iden- 
MILK SICKNESS.
1091
tical disease, called the milk sickness, occurs in human beings.  It is gener-
ally admitted that milk sickness is caused by ingesting either the milk or the
flesh of animals affected with the trembles.   As has already been mentioned,
the milk may contain the special poison even when the cow presents no mani-
festations of the disease, these being warded off, apparently, by the excretion
of the poison  through the mammary gland.  Butter and cheese made  from
the infected milk are also poisonous, and hence the opinion of physicians in
milk-sick districts is probably correct that cases of this disease must occur in
cities, but  that  its  true nature is not recognized by the medical attendants.
Young  children are said to be less liable to the  disease than  adults.  It has
not been proven whether or not the special poison be destroyed by boiling the
infected milk or by cooking the meat.
   The period  of incubation  is variable, being sometimes  one or two  days,
sometimes several  days, and, according  to  some writers, occasionally several
weeks.   The first manifestations of the disease often follow some special  exer-
tion.   The premonitory symptoms, which may be of short duration or may last
for several  days, are malaise, lassitude, fatigue after  slight exertion, pain in
the head and limbs, anorexia, and  slight nausea.   As  these symptoms become
more pronounced, extreme nausea and vomiting supervene, accompanied by
intense thirst, obstinate constipation, and a burning pain in the  epigastrium.
The temperature of the surface, particularly of the extremities, is below the
normal, and the internal temperature is not  usually much elevated.  The skin
is dry,  and the  abdomen is  retracted, with little if any tenderness  on  pres-
sure.  The pulsations of the abdominal aorta are prominent.  Intestinal per-
istole seems to be wholly suspended.   The tongue is swollen and flabby, pre-
senting the impressions of the teeth, and when protruded is tremulous.   At
first moist and thickly coated, the tongue may later become red, dry, and fis-
sured.  The breath is offensive, and it emits an  odor  which nearly all writers
speak of as indescribable but  characteristic, so  that  by means of this  pecu-
liar  fetor the disease can be recognized.   The urine is diminished  in quan-
tity, and sometimes its secretion is even  suspended.   The pulse varies in fre-
quency, but it is always weak and  compressible.   The action  of  the heart is
often labored, without any corresponding change apparent in the pulse at the
wrist.   The eves are often suffused with blood.  The mental  state is at first
one of restlessness and irritability, and later one of hebetude and indifference,
passing toward a fatal termination into somnolence and coma.  Convulsions
sometimes occur.   A'omiting continues  until from extreme exhaustion it  is
replaced by only a  feeble retching.  The vomited  material, consisting at first
of the  ordinary contents of the  stomach,  later  contains mucus, sometimes
tinged with blood.   It may be frothy, but it rarely contains much bile. In the
later stages the  color of the vomit  is said to sometimes resemble water colored
with indigo-blue.  Black vomit, due to hemorrhage, is a rare occurrence.  The
patient may sink into a typhoid state with low, muttering delirium.  Death,
if it occur, is  from  asthenia.
   The duration of the disease is variable. There are mild cases which hardly
pass beyond the premonitory stage.   On the other hand, there  are cases in
which the  symptoms develop rapidly and with great intensity, a fatal termi-
nation occurring within two or three days of the onset.  More frequently the
duration of fatal cases  is between  five and fourteen days.   Chronic cases last-
in"- for  several weeks have been described.
   It is difficult to form an estimate of the prognosis from the existing data.
The writers of the  early part of this  century state that the majority of  those
affected  die, whereas  more  recent authors give  a comparatively favorable
prognosis.   Perhaps this more favorable result is due to improved  methods
of treatment.   Recovery is  slow. 
1092
A R TIC ULAR RHE UMA TISM.
  Nothing is  positively known concerning the pathology of milk  sickness.
The symptoms suggest  an intense gastritis, but in tbe few recorded autopsies
mention  is made only of redness of tbe mucous membrane  and  contraction
of the stomach.  The intestinal canal  has been found markedly  contracted.
AVith the exception of these alterations, the results of post-mortem examina-
tion have generally been negative.
  The objects to be sought in the prophylaxis of milk sickness  are apparent
from  the account which has  been given of its etiology.   The former treat-
ment  of  the disease consisted in bleeding, drastic cathartics, and blisters.  The
modern treatment has  substituted,  and  with beneficial results,  the use  of
stimulants and restoratives.   Notwithstanding some contradictory testimony,
it is probable, in view of the  extreme irritability of the stomach,  that opium
judiciously administered is useful.  Quinine is highly recommended by some
writers.  Alcoholic stimulants are  now freely employed in this disease.  Coun-
ter-irritation to the  epigastric region, as by a mustard-plaster, may be tried.
While the older practitioners thought that the leading indication was to open
the bowels, there  are now some physicians who are  opposed to the  administra-
tion  of cathartics, on the  ground that  they increase the  irritability  of the
stomach and do not accomplish their purpose.  Enemata may be employed
as the least disturbing of the cathartic remedies.   Agents to allay vomiting,
such  as bits of ice, carbonic-acid  water, and creasote,  should be given.  The
diet should be chiefly liquid and easily digestible.1
                          CHAPTEE  X.

ACUTE, SUBACUTE, AND CHBONIC ARTICULAR  RHEUMATISM.

Acute Articular  Eheumatism: Clinical  History; Pathological  Character;  Causation;
  Diagnosis;  Prognosis;  Treatment.—Subacute and Chronic Articular Rheumatism.

   THE  term rheumatism is used to  denote a constitutional disease character-
    ized by certain local  manifestations seated in  the articulations and  the
fibrous  tissues  in  other parts.   The term has also been  applied to neuralgic
and other affections supposed to  arise from the constitutional morbid condi-
tion existing in the ordinary form of the disease.   I shall consider first, acute
articular rheumatism, or rheumatic fever; and second, subacute and chronic artic-
ular  rheumatism.   The affection known as muscular rheumatism has been con-
sidered  in connection  with diseases of the nervous  system under  the  name
Myalgia.  The disease called gout is in certain respects  analogous to  rheu-
matism, although presenting essential points  of difference.   After having
considered the forms  of rheumatism just named,  I shall consider, in  the

  1 The  following are among the articles which describe this disease: Hirsch, Handb. d.
Historisch-Geog. Pathologie, Bd. 2; Drake, A Memoir on the  Disease called by the  People
the Trembles and the Sick Stomach or Milk  Sickness, Louisville, 1841; Graff, "On the Milk
Sickness of the AVest," American Journ.  of the Med. Sciences, April, 1841; " Report on
Milk Sickness,"  Trans, of the Kentucky State Medical Society, 1868; Beach, " Milk Sick-
ness," The Journal of the American Med, Assoc, July 28, 1883; Fulton, Philadelphia Med.
and Surg. Reporter, Apr. 12, 1884.  A thorough monographic treatment of the subject is
much to be desired. 
ACUTE ARTICULAR RHEUMATISM.
1093
next chapter, gout and rheumatoid or deforming arthritis, often  called rheu-
matic gout.

      Acute Articular  Rheumatism—Rheumatic  Fever.

   Acute articular rheumatism,  as  the  name  imports, involves an affection
of the articulations  or  joints.   The affected  joints present the phenomena
of inflammation, and the affection is also called acute  rheumatic arthritis or
polyarthritis.   Opportunity is rarely offered to study the morbid appearances
within the joints in cases of acute articular rheumatism.  Often when symp- •
toms referable  to  the joints have been  well marked during life little change
is to be found  in  these  structures  after death.  It may be supposed  that in
these cases the condition is one chiefly of hyperaemia and oedema.  In many
cases, however, the articular cavity contains  an increased  amount  of fluid,
which is  more or less turbid  from  admixture with pus-cells.   The  synovial
membrane may be reddened from hyperaemia and thickened from serous infil-
tration.   In  some cases  flocculi of fibrin have  been  found within the articular
cavity.  Much of the swelling about the joints during life is due to inflam-
matory oedema of the tissues surrounding the affected parts.   The quantity
of fibrin or of fibrin-factors in the  blood is notably increased.  In the course
of the disease certain  internal  organs  are liable  to become  inflamed.  The
inflammation is generally seated in the fibro-serous tissues, and especially in
the endocardium  and pericardium.  In a pathological view the endocarditis,
 pericarditis,  and other  internal  inflammations which occur  in cases  of acute
 articular rheumatism are local manifestations  of the disease, like the arthritic
 affections, but it is most convenient to  consider  them  in the light of compli-
 cations.

    Clinical History.—Acute articular rheumatism, in the majority of cases,
 beo-ins with a sudden  attack, and in nearly one-half  of the  cases in which
 the attack is  sudden it takes place at  night.   In  a small proportion of cases
 pyrexia precedes  the local manifestations for  a period varying between a few
 hours and one or two  davs;  hence one reason for the name rheumatic fever
 instead of acute  rheumatism.   In most cases, however, the  fever  and  the
 local  manifestations are simultaneous  in  their occurrence.   Sometimes pain
 and  soreness of  the joints,  together  with  indefinite ailments, precede  the
 development of the disease  for a  variable period.
    The development of the disease  is denoted by an affection of one or more
 of the articulations.  The larger  joints (knee, shoulder,  or  elbow)  are first
 affected in the great majority of  cases.  The local phenomena are pain, ten-
 derness increased heat, swelling, and  redness of the  skin.   The pain  differs
 in intensity in different cases, but.  as a rule, it is  not intense so long as the
 parts are perfectly quiet.  Pain is especially excited by movements of the
 affected joints.  In severe cases the slightest motion is  insupportable, and even
  iarrin"- the bed  or room occasions suffering.   Pressure over the joints  is
 nainful   Owino-  to the pain  occasioned by movements, the patient maintains
 as long as possible  a fixed position.  Changes  of  the decubitus often cause
 extreme suffering.   Swelling is most apparent in joints not covered with
 muscle-namely, the knee, wrist,  elbow, ankle, and the smaller joints of the
 hands and feet.   It is less  apparent  in the hip and shoulder,   lhe swelling
 is due in part, to a morbid increase of liquid within the synovial cavity, and
 in part to serous effusion into the surrounding structures  The redness  is
 due to an erythema in the  form of patches or zones which do not present
 well-defined borders.   The redness, like  the swelling, is not  apparent oyer
 the hip and shoulder, but only over joints that are comparatively superficial. 
1094
ARTICULAR RHEUMATISM.
The swelling and the redness are, in general, proportionate  to  the  acuteness
of the rheumatism.
  In some cases several joints  are affected either simultaneously or in quick
succession (polyarthritis) ; but in other cases the affection is limited to a single
joint  for a greater or  less period (monanhritis).  In  the course of the dis-
ease, in most cases, various joints  are successively affected,  and frequently a
greater or less number of joints are  affected at the same time.   It is a pecu-
liarity of the rheumatic inflammation to leave one or more joints abruptly,
the focal  phenomena  sometimes disappearing within a few hours, and  to
attack as abruptly other joints.  Cases differ as regards the number of joints
affected in the course of the disease.  In some cases few or no joints escape,
and in other  cases  the rheumatic  inflammation remains limited to a few
joints or even to a single joint.  The fibrous tissues elsewhere than  within
and around the joints, and exclusive of the visceral organs, are liable to  be
attacked.   Thus, those of the dorsum of the hand and of the instep, the  liga-
ments of the neck and back,  and the sclerotic  tunic of the eye  are sometimes
involved.   The sheaths of the tendons and the bursae are liable to rheumatic
inflammation.
   The disease is extremely variable as regards the number of joints affected,
either simultaneously or successively, the order  in  which they  are attacked,
etc., yet the local manifestations  are governed by an  important pathological
]aw—namely, the law  of parallelism.   Corresponding joints  are often affected
together, and when this is not the case the different affected joints are either
on one side of the  body, or  joints on the two  sides which are analogous—
namely, the knee and  elbow, wrist and ankle, hip and  shoulder—are  affected
in combination.   In  an analysis of 21 cases with reference to this point, out
of 88 instances in  which  either a joint was affected singly or more or less
 joints affected in combination, there was  but a single violation  of  the law
of parallelism.1   This  disease, therefore, is eminently one of the bilateral  or
symmetrical diseases.   As respects the relative liability of the different joints
to become affected, the analysis just referred to showed the order to be as
follows: The  knee, ankle, wrist,  shoulder, hip, elbow,  phalangeal  joints, first
 of the hands and second of the feet, and the maxillary joint.
   Acute articular rheumatism is always accompanied by more or less pyrexia.
 In addition to the fact that  the  pyrexia sometimes precedes the local mani-
 festation, a reason for the propriety of regarding the  disease as an essential
 fever is to be found in the fact that the pyrexia is not  in  proportion to  the
 number of joints affected or to the intensity of the rheumatic inflammation, as
 denoted by pain, soreness, heat, etc.   The pulse rarely exceeds 100 per min-
 ute.  The axillary temperature in different cases varies between 102° and 110° F.
 Sweating is generally a symptom more or less prominent, occurring especially
 at night.   The sweat  emits a notably sour odor.  In connection with profuse
 sweating, sudamina  or miliary vesicles  not infrequently appear on the  neck
 and trunk.   The appetite is either lost  or greatly impaired.   Thirst is  more
 or less urgent.   The  tongue is frosted or coated.  The saliva becomes  acid.
 Generally the  bowels  are constipated, but exceptionally  there is diarrhoea.
 The urine is diminished in quantity ; its specific gravity is high, owing chiefly
 to a  decrease of  water; the  coloring matter is increased, and  on  cooling  the
 urates are deposited in abundance.   Owing  to the increase of the  pigment
 of the urine the deposit is usually of a reddish color.   The deposit of
 this  lateritious  sediment does not  show an  increase of the amount of uric
 acid  in the  urine,  but only the  diminution  of water.   Quantitative analy-
 ses of the urine have  shown the quantity of  uric acid not  to be greater than
   1 "Analysis of Twenty-one Cases of Articular Rheumatism," by the author, Buffalo
 Medical Journal, March,  1854. 
ACUTE ARTICULAR RHEUMATISM.
1095
in health.  The chlorides are sometimes deficient, and occasionally the  urine
is slightly albuminous.   Pain in the head is not common.  The intellect, as
a rule, is not  disturbed, but mild delirium  is sometimes  observed.  In gen-
eral the strength is well preserved.  Sleeplessness is usually a source of  dis-
comfort and more or less prostration, sleep being prevented by pain on change
of position and by the perspirations.
   An important feature of the disease is its tendency to invade certain of the
structures of  the heart.   Endocarditis occurs in a considerable proportion of
cases.   It is,  however,  less frequent  than has heretofore been supposed, as
already explained in treating of that affection.  The inflammation, as a rule,
is limited to the membrane lining the left cavities of the  heart, and it affects
especially the portion of this membrane situated upon  the mitral valve.  In
a large proportion  of the cases  of valvular lesions  of the heart,  especially
mitral lesions, their  point of  departure is rheumatic endocarditis.   As  a
rule, the endocarditis is simple  and  devoid of immediate danger;  but in a
small proportion of cases the endocarditis is of the fatal variety distinguished
as ulcerative  or malignant.  Pericarditis occurs less frequently.  As a rule,
when  pericarditis becomes  developed  endocarditis coexists.   For a consider-
ation of these affections, as developed in rheumatism, the reader is referred
to  the section devoted   to diseases affecting the circulatory system.  It may
be repeated here that pericarditis, and probably endocarditis, sometimes pre-
cede the local manifestations elsewhere.   It is convenient to speak of  these
affections as  complications,  but, properly speaking, they are  to  be  reckoned
among the  local manifestations  of the disease; that is, they are dependent
on the same determining cause  to which the affection of the joints is  to be
referred.   The structures of the heart are liable to become  involved in pro-
portion to the acuteness of the rheumatism.   They may become involved at
any time in  the course of the  disease; but  the  liability is greatest  in the
 early and middle periods.  They are  more likely to occur the younger the
 patient.  They occur rarely in patients more than  forty years  of age.  Acute
 dilatation of  the heart may occur as  in other febrile diseases attended with
 marked debility.  A murmur of temporary duration, referable to acute dila-
 tation of the  right ventricle, may occur, as has been pointed out by Sibson.
 Examination   of the blood by  means  of the haemacytometer has shown in
 some  cases a notable  diminution of red blood-corpuscles.
   In a small  number of cases of acute articular rheumatism important  symp-
 toms develop which are described under the names of cerebral rheumatism and
 rheumatic hyperpyrexia.  Under the  name cerebral rheumatism cases have
 been described which  present  symptoms referable to different pathological
 conditions, some without and  some with  demonstrable  lesions of the  brain.
 The  most important group of  cerebral symptoms, and  the  one  commonly
 understood as cerebral   rheumatism, is that which is generally associated with
 very high temperature.  It is by no means certain that the high temperature
 itself is the cause of these grave symptoms.  It is at least not improbable that
 the same cause which,  acting upon the thermic centre in the brain, produces
 hyperpyrexia, acts also upon other parts of the brain, producing various dis-
 turbances of  the cerebral functions.   The  nervous symptoms may appear at
 the onset of  the disease,  but  more  frequently they develop  at some later
 period.  They are  ushered  in by rise of temperature, restlessness, disturbed
 sleep, and headache.   Delirium, often violent, but sometimes of a low, mutter-
 insr character, makes its appearance.   Muscular twitchings, and even tonic or
 clonic spasms, are  not  infrequent.   The pulse becomes feeble and very fre-
 quent : a state of semi-consciousness or stupor with great prostration ensues;
 the face becomes cyanosed; and the temperature rises higher and higher, reach-
 ino- sometimes an elevation of 110° or even higher.  In the majority of cases 
1096
ARTICULAR RHEUMATISM.
death takes place  during coma.  In some cases recovery sets in  even after
the appearance of very grave  symptoms.   In fatal cases no lesions  of  the
brain or of the meninges can usually be  found.   The symptoms seem to
be referable to  some profound  infection  or  intoxication which acts upon  the
thermic and other nervous centres.
  Purulent meningitis may occur as a complication of rheumatism, but this is
very rare.  More frequent, however, is the  occurrence of cerebral  embolism
resulting from endocarditis.   Uraemia with  its attendant nervous phenomena
is  a  rare complication of rheumatism.
  A pathological relationship is supposed to exist between chorea  and rheu-
matism.  These two affections, however, are not often associated.  There is
little ground for the assumption that they involve in their causation the same
specific causative agent.
  Insanity, especially melancholia, has been observed as a rare  complication
or sequel of acute rheumatism.  The  prognosis in  these cases is  generally
favorable.  Sometimes marked hysterical symptoms develop during an attack
of rheumatism.
  In addition to sudamina or miliaria already mentioned, urticaria, erythema
nodosum, especially on the lower  extremities, and herpes  labialis, occasionally
occur in  the course of the disease.   The skin is sometimes the seat  of pur-
pura and more  or less diffuse hemorrhagic extravasation.  In the  centre of
urticarial papules in some instances there  are petechial spots (urticaria hemor-
rhagica).   The prognosis is grave in the  rare  cases of a general hemorrhagic
diathesis (hemorrhage from mucous  surfaces, etc.) occurring  in acute  rheu-
matism.  In these cases there are usually severe constitutional symptoms and
high fever.
  The development  of small subcutaneous, firm, movable nodosities during
or after an attack of acute rheumatism has been noted as an exceptional occur-
rence by several observers.1  These  nodosities, which, save some  tenderness
on pressure, are generally painless, are attached to the tendons, fasciae, perios-
teum, etc.  They persist from a few  hours, or usually a  few days, to  several
months.  They are unattended by marked local or constitutional symptoms.
They are composed of  granulation-tissue.
   Of complications of acute rheumatism other than those which have received
consideration, the  following may  be  mentioned, all of which are infrequent:
pharyngitis, bronchitis, pneumonitis, peritonitis, nephritis, myocarditis, embo-
lism of other than cerebral arteries, phlebitis, suppurative arthritis, erysip-
elas, pyaemia, and paralysis and atrophy  of  muscles  in the neighborhood of
the affected joints.
   The duration of acute articular  rheumatism varies greatly.  The disease
ends by self-limitation, but the  minimum and the  maximum of duration  are
widely apart.   These statements have reference to the  course of the disease
when left to itself; that  is, no active measures of  treatment being  employed.
In 1862, I  observed at  Bellevue Hospital  13 cases which were allowed to
pursue their course  uninfluenced by therapeutical interference, some pallia-
tive  measures being alone employed.   I  am not aware that prior to this date
any one had undertaken to study in this way the  natural history of  the  dis-
ease.   I reported the 13  cases in the American Journal of the Medical Sci-
ences for July, 1803, entitling my article  "A  Contribution toward the Natural
History of Articular Rheumatism."  In making an analysis, in 18f>4,  of 24
cases which I had  recorded, I was impressed with the importance  of obtain-
ing a knowledge of the natural history of the disease as the point of  departure
for the study of therapeutical measures.   AVith reference to this point in  my
  1 Barlow and AVarner, Trans. International Med. Congr., London, vol. iv., 1881 ; Troi-
sier, " Les Nodosites  rhumatismales sous-cutane"es," Union medic, 1884. 
ACUTE  ARTICULAR  RHEUMATISM.            1097
report of the analysis I used the following words : "At the present moment
we cannot answer the question, AVhat are the intrinsic tendencies of articular
rheumatism as respects its continuance, its complications, and its remote con-
sequences in  the organism ?  AVere we able to answer this question by an
appeal to facts. w*e  should then have a criterion by which to estimate  the
favorable or unfavorable influences of different methods of treatment pursued
in a  series of  cases ; as it is, in bringing statistical information to bear on the
therapeutics of the disease we can only study the immediate effects of differ-
ent remedies  and institute comparisons  in this point of view, and also with
reference to the duration of the  disease, etc. in  different series of cases treated
by  different  methods." x  In  my "  Contribution to the Natural History  of
Articular Rheumatism," published in 1863, I premised a report in  full of  all
the cases (13) by the following  account of my plan of study: " On entering
on duty  at Bellevue. Hospital in August, 1862, I resolved to treat with only
palliative measures the cases of articular rheumatism which should be received
into my  wards, so long as circumstances might lead me to conclude  that  by
continuing this plan no injustice was  done to the patients, whose  relief was
of course paramount to any  other object.  The cases thus treated progressed
so satisfactorily that I found no ground  for  a discontinuance of the plan.
The last of the cases, in fact, was the only one in which any important com-
plication occurred.  Some of the  cases were recorded by  myself, and  the
remainder by my  clinical assistant, Dr. Shiverick."  .  . . .  " The reported
cases were treated throughout the whole course of the disease with only pal-
liative measures.  These measures consisted of opium  in some form given in
small or moderate doses, the application generally of dry flannel to the affected
joints, and the external use of either the soap-and-opium liniment or the tinc-
ture  of  aconite.   But to secure the moral effect of a remedy given specially
for the  disease a 'placebo' was given, consisting, in nearly all the cases, of
the tincture of quassia very largely diluted.   This was given regularly, and
became well known in my wards as the ' placeboic remedy' for  rheumatism.
The favorable progress of the  cases was  such as to secure for the remedy
generally the entire confidence of the patients.  I may add that  all the cases
were brought before the medical class in attendance during the winter."
   Of these 13 cases-an endocardial murmur existed in 11, but  the murmur
was limited to the base of the heart in all  but 3 cases.   Moreover, all the
patients hut  2 were  women ; and  in women affected  with articular  rheu-
matism a systolic basic murmur is the rule with few exceptions, the murmur
being generally of haemic origin.   In only one case was pericarditis devel-
oped.  In this case the pericarditis occurred immediately after the patient's
admission.   Pneumonia occurred subsequently.  The patient, however, recov-
ered. 2
   The duration  in  these  cases  respectively, from the date of attack to con-
valescence, excluding the case in which pericarditis and pneumonitis occurred,
was as follows: In 3 cases, less than fifteen days ;  in  1 case, between fifteen
and twenty days ; in 3 cases, between twenty and twenty-five days ;  in 3 cases,
between twenty-five and thirty  days ;  and in the remaining 2 cases, forty-five
and fifty-six  days.  The mean  duration was a fraction less than  twenty-six
days.                                           .              .
   These cases establish  the fact  that  acute  articular rheumatism belongs
among the self-limited diseases.   Two years after  the  publication of  my
report in 1863—namely,  in 1865—a communication by Dr. Henry G. Sutton,
embracing  a  tabulated" report of 41  cases  treated chiefly  with mint-water,

  1 Aide Bvffalo Medical Journal, March, 1854, vol. ix. p. 557. _
  2 Vide "A'Contribution toward the Natural History of Articular Rheumatism, by
the author, American Journal of the Medical Sciences, July, 1863. 
1098
ARTICULAR RHEUM. 1TISM.
appeared in  Guys Hospital Reports.  22 were males, and  19 were  females.
The average duration from admission to the cessation of pain, the skin being
cool and no relapse taking place, was in the male cases 13.5 days, and in the
female cases 15.5 days.   The  average  number of days in hospital was for
males 27.6 days, and for females 26.3 days.  The duration  prior to admission
into hospital in many of  the  cases was considerable, the  longest being six
weeks.  Pericarditis became  developed in  4 cases, and pleurisy in  5  cases.
In a second  report by Dr. Sutton of cases  treated in the same manner, in a
subsequent  volume of Guys Hospital Reports, the average duration to con-
valescence was nine  days;  and in  a third  report of 25 cases  in the Trans.
Royal Med.-Chirurg. Society, 1869, the average  duration  was ten days.1
  The illness  of patients affected with rheumatism may be indefinitely pro-
longed by pericarditis and pleuritis ; but  of the cases which  I analyzed in
1854, embracing 5 cases of endocarditis and  1 case of endo-pericarditis, differ-
ent methods of treatment  being employed, the minimum duration was seven
days,  the maximum twenty-six days, and the average duration a fraction more
than sixteen days.
  A peculiarity of rheumatism is that it does not pursue a steady, continuous
march from  the beginning to the end, but its course is often marked by nota-
ble fluctuations as regards  the general and local  symptoms.  Not infrequently,
after  a few days the affected joints are nearly free  from pain,  soreness, etc.,
the febrile movement subsides, and convalescence appears to be near at hand,
when  suddenly the local manifestations and the pyrexia  are  renewed with
perhaps as  much or even  more  intensity than before.  This  may  occur
repeatedly during the course  of the  disease.

  Pathological  Character.—There  have been various theories as to the
pathological character of  rheumatism,  none of  which  has  gained general
acceptance.  That the disease involves the entrance of some morbid principle
into the blood is generally admitted, and is a reasonable supposition in  view
of the  clinical and  anatomical characteristics  of acute rheumatism.   The
opinion has  been prevalent that this morbid  principle  is  uric acid or lactic
acid;  but  examinations of  the blood have failed to reveal any excess of these
acids, and their agency in  the causation of  rheumatism-is now generally dis-
credited.  The theory advocated  by J. K. Mitchell,  that  acute  articular
rheumatism  is dependent upon some affection of the nervous system, has not
met with favor.  There is a growing belief that acute rheumatism belongs to
the class of  infectious diseases, and is  caused  by the presence of a specific
micro-organism.  The course  and the  symptoms  of  the  disease can be
explained  better upon this supposition than upon any other which has  been
suggested.  The occasional endemic and epidemic occurrence of acute rheu-
matism is  in favor also of its dependence upon some specific infectious agent,

  Causation.—Rheumatism is one of the diseases supposed to he frequently,
if not  generally, caused by suppression of the functions of the skin, and attrib-
uted especially to the action of cold upon the surface of the body.  This  view
of the causation has but little foundation.  It is true that patients are likely to
refer  the disease to cold, but  they  often fix upon some particular exposure
under the belief  that this agency is of course involved, for it is a popular
notion that  rheumatism generally  proceeds from cold.   A careful  interroga-
tion will show in  many, if not most, cases  that the statement  has  little to
support it;  and how often is exposure to cold  not followed by rheumatism !
That the causation may involve the agency of cold is not to  be denied in fofo ;
  l In  Dr. Sutton's communications there is no  reference to my report in the Amer
Journ. of the Med. Sciences, 1863. 
ACUTE  ARTICULAR  RHEUMATISM.
1099
but the  considerations which are to follow render it probable that cold acts
only as  an  exciting  or  accessory cause.
  A special predisposition is requisite ; in other words, the disease involves a
rheumatic diathesis.   This predisposition or diathesis may be congenital and
inherited or it may  be acquired.   There are persons congenitally liable to
tbe disease.  This is  shown by the occurrence of the disease in early life, and
by its recurrence more or less frequently in  the majority of the persons who
are once attacked by  it.  Statistics establish  conclusively the hereditary trans-
mission of this predisposition.  It is a matter of common  observation that the
disease prevails among the different members of certain families.
  Age has a decided  influence in the causation.   It occurs very rarely at less
than five years of age.   It may, however, occur in infancy.  I have met with
a case in which it occurred at one year of age, aortic lesions and hypertrophy
of the heart existing  at the age of two years.  In the majority of the cases of
a primary attack patients  are  between fifteen and thirty years of  age.   If a
person have not experienced one or more attacks before the age last named,
the liability to the disease afterward diminishes and becomes quite small after
the age  of fifty.   The number of males  attacked  by this disease exceeds the
number  of  females, but the difference is not great.  External influences per-
taining  to season play  a  small  part in the causation.   The disease prevails
most in  humid, changeable climates.   It  is a disease of  frequent  occurrence
in all climates within the temperate zone,  but is  comparatively rare in  trop-
ical and frigid latitudes.
   Accepting  the parasitic doctrine,  an  essential  causative factor, acting  in
conjunction with a special predisposition, is a specific micro-organism.   This
is a  logical conclusion, but the demonstrative  proof has not as yet  been
obtained.
   The predisposition or susceptibility is not destroyed after the  disease has
once occurred, as in  cases of certain other infectious diseases.   In a consider-
able proportion of  cases recurrences take place.
   Acute articular  rheumatism may occur as a complication of various dis-
eases ; but it  is not  probable that the articular affections which occur  some-
times as complications or sequels of scarlatina, gonorrhoea, syphilis, diphtheria,
puerperal fever, dysentery, purpura, and some other diseases are in most cases
etiologically identical with primary acute articular rheumatism.

   Diagnosis.—The  disease is to be discriminated  from gout.  For the dif-
ferential points the reader is referred to the chapter treating of the latter dis-
ease.  In  general, the diagnostic features of acute articular rheumatism are
so obvious that the disease is at once recognized.  The chief difficulty in diag-
nosis, exclusive of the discrimination from gout, relates to cases in which the
rheumatic affection is confined to a single joint.   The problem in  these cases
is to distinguish  rheumatism from a  purely local  affection of the joint; that
is. synovitis or simple acute arthritis.   The following are the points in this dif-
ferential diagnosis :  The fixedness of the inflammation in a single joint from
the  first in  the  latter, whereas  in  articular rheumatism it  is rare that the
mobility of the disease is  not to  some  extent  manifested ;  the existence of
pyrexia in some  cases of  articular  rheumatism prior to  the  affection of the
 bunt;  the want of  correspondence  between  the  degree  of pyrexia and the
local phenomena in rheumatic cases; the long duration of the local affection
in cases not rheumatic, and in certain cases the swelling and redness  being
greater  than in rheumatic cases ; the rapid disappearance of the local affection
often in cases of  rheumatism,  and the speedy  recovery of the use of the
affected joint, the  disappearance and recovery being more  slow in cases not
rheumatic ; the occurrence of endocarditis or pericarditis in a certain propor- 
1100
ARTICULAR RHEUMATISM.
tion of rheumatic cases.  The age of the patient and the previous occurrence
of rheumatism are points to be taken  into account.
  Cases of  pyaemia in which  a purulent effusion takes  place into  certain
joints  are sometimes mistaken for cases of rheumatism.   Attention to the
antecedent and concomitant circumstances should prevent this error.  Puru-
lent collections within the joints in cases of puerperal fever are embraced in
this catetrory.  The so-called gonorrhoeal rheumatism is generally monarthritic,
and the association  with gonorrhoea or gleet points  to  the  character of the
affection.

  Prognosis.—This disease is rarely fatal, and the immediate danger to life
is small.   AVhen death takes place during the career of the disease it is due to
complications, including under this head pericarditis; but  the majority of
cases in which pericarditis occurs  do not  end fatally.  Active delirium, con-
vulsions, and coma  denote  imminent danger, but it has been seen that these
are extremely infrequent events. Pulmonary complications may prove serious.
A source of danger  in some instances is intense hyperpyrexia.   The develop-
ment of the hemorrhagic diathesis, with hemorrhages into the skin and from
mucous membranes, is  a grave complication.
  The disease, aside from the complications just referred to and the suffering
attending it, is serious in view of the liability to endocarditis which may lay
the foundation  for  incurable  and  grave lesions of the  heart.  The immedi-
ate danger from  simple rheumatic endocarditis is slight;  and the lesions re-
sulting from this affection rarely occasion inconvenience until after the lapse
of several years.    Grave  cardiac lesions  do not  invariably  follow rheu-
matic endocarditis, and in some cases  there remains  no evidence of any per-
manent injury from that disease.  An endocardial murmur sometimes disap-
pears.  Ulcerative endocarditis is  an  occasional  event, giving rise to fatal
pyaemia.
  The liability to embolism is to be mentioned. Emboli may be derived from
the left side of the heart, consisting of fibrinous masses formed  in connection
with endocarditis, or a clot  may form in the right side of the heart and cause
plugging of the pulmonary  artery.   Sudden death during the course of acute
rheumatism is sometimes caused by pulmonary embolism.   An example has
fallen under  my observation.
  Acute articular  rheumatism seldom ends in the chronic form of the affec-
tion.

  Treatment.—There are few diseases in the nosology the  treatment of
which, during the last half  century, has undergone such mutations as that of
acute articular rheumatism. Among the measures more or less in vogue dur-
ing the period just named are the following : Bleeding, general and local;
mercurialization;  colchicum carried to the extent of  producing vomiting and
purging; nitrate of potassa, an ounce or more given daily;  opium in large
doses ; large doses of quinia; and the use of the veratrum viride.   Cases in
which reliance has been chiefly placed  on each of these measures have pur-
sued a favorable course and the treatment has seemed to be successful.  AY ant
of knowledge of the natural history of the disease—that is, the  history based
on the observation of cases in which the disease has been allowed to pursue
its course under favorable hygienic circumstances uninfluenced by therapeu-
tical  interference—has heretofore rendered it difficult to judge of the effect of
different methods of treatment.  My report of 13 cases, and the report by Dr.
Sutton of a  larger  number, treated  with only palliative  remedies, show an
intrinsic tendency in the disease to end within a shorter period and with a lc^s
degree of liability to  complications than  have been hitherto generally sup- 
ACUTE  ARTICULAR  RHEUMATISM.             1101
posed.  Hence it may be reasonably concluded that the influence of different
methods of treatment over the duration of the disease and the occurrence of
complications has  been much over-estimated.  Each of the measures  above
enumerated probably is, to a certain extent, useful in certain  cases;  but a
special  controlling influence over the disease is exerted by none, and clinical
observation has shown the development of endocarditis, pericarditis, and other
complications under treatment by each of them.   It is not worth while, there-
fore, to discuss  their merits and demerits severally, inasmuch  as few if any
practitioners now  rely upon  any one of  them.
   Before the introduction of the salicylate treatment the practitioners of this
country generally  relied  upon the alkaline  treatment,  first  systematically
employed  by AVright  in  1847, and afterward, on a larger  scale, by Garrod
and  Fuller.   The bicarbonate of potassa, the bicarbonate of soda,  the tar-
trate of potassa and soda, and the citrate of potassa are the remedies usually
employed.  Garrod's report of 50  cases treated  with alkalies, largely given,
showed  an average duration of six or seven days; and in no case after the
patient had been under the  influence  of this treatment for forty-eight hours
was  any affection of the heart developed.  It would, however, be an erroneous
inference that cardiac complications  never occur after  the  patient is  fairly
under the influence of this treatment.  I have notes of several cases in  which
pericarditis was developed when alkalies had been freely given, the urine
having been rendered alkaline;  but that the liability to these  complications
is lessened by this  treatment must be admitted.  Moreover, this  treatment
seems to exert some influence in abridging the duration of the disease. Fuller
claimed for the alkaline treatment, efficiently pursued, the power of lessening
the febrile movement, relieving the arthritic inflammation, abridging the dura-
tion of the disease, and preventing endocarditis and pericarditis.  AVith refer-
ence to the latter, which is manifestly the great object of treatment, he  stated
in 1862 that his experience embraced, up to that time, 194 cases, and that " in
no single instance has any heart affection occurred after the patient has been
under treatment for twenty-four hours."   The analysis by Dickinson of cases
treated with  alkalies  and of cases treated by  different remedies affords con-
clusive evidence of the usefulness of the alkaline treatment as regards dimin-
ishing  the liability to cardiac complications.   His  statistics show that a
" partial  alkaline  treatment" is useless.  To be effectual the  alkalies  must
be given  sufficiently  to  render  the urine alkaline.1
   To secure as quickly as possible protection against cardiac  affection-- the
alkali selected should be given at once  in large doses and repeated at short
intervals until  the  urine  gives  an alkaline reaction.  One or two  drachms
of the bicarbonate of either potassa or soda may be given every three or four
hours.   To  render it more grateful to the palate and stomach, citric acid or
lemon-juice  may he added to each dose; which is to be taken during efferves-
cence.  This quantity is generally well borne, and the urine, as a rule,  is ren-
dered alkaline in twenty-four hours.   I have given, without inconvenience to
the patient, the dose just stated every two hours, and produced alkalinity of
the urine  in twelve hours.  The quantity of the  alkaline  remedy shouM be
much diminished  as soon as the urine is  alkaline, the doses  afterward being
repeated only once  or twice in the twenty-four hours.  To secure more diuretic
effect than is produced by the alkaline remedy alone, the acetate, nitrate, or
bitartrate of potassa, the acetate  of  ammonia, or small doses of colchicum
may be added.  The tartrate of potassa and soda, which is much used  as an
alkaline remedy in  this disease, is inferior to the bicarbonate of potassa or
soda, because it must be given for a longer period before alkalinity  of the
urine is produced.  It is well adapted to maintain an alkaline condition of
   1 A'ide article by Dr. AVm. H. Dickinson in Trans. Med. and Chirurg. Society, 1862. 
1102
ARTICULAR RHEUMATISM.
 the urine after this condition has been produced by the bicarbonate of potassa
 or soda.
   The  remedy which is now chiefly relied upon in the treatment of acute
 rheumatism  is salicylic acid or the salicylate of sodium.  This drug,  which
 was first introduced  as a  remedy for  rheumatism in 1875, exerts over  this
 disease a specific controlling influence  analogous, in some but not in all  fea-
 tures, to that of  quinia over malarial fever.   Salicylic acid may be given in
 the form of the  powder enclosed in capsules in doses of 8 grains repeated
 every hour until ten  or fifteen doses have been taken, or until  ringing in
 the ears, the first symptom of salicyl  intoxication, has been produced.  Sa-
 licylate of sodium  may be given  in  10-20-grain doses repeated  every hour
 until eight to twelve doses have been administered or  ringing  in  the ears is
 produced.   Another  method is to administer at the beginning a single large
 dose of 60 to 80 grains of salicylate of sodium.   This dose need be repeated
 only once or twice during the day.   In general, the  quantity of salicylate of
 sodium should not exceed  1£ to 2 drachms during the twenty-four hours.
   The employment of salicylic acid or of salicylate of sodium in  large doses
 is liable to lead to the symptoms of salicyl-poisoning.  These symptoms  are
 tinnitus aurium,  nausea, vomiting, partial deafness, disturbed vision,  vertigo,
 headache,  shivering, rapid  deep respiration, and delirium.  The intensity of
 the toxic effects  is generally in proportion to the amount of the drug which
 has been taken, but  some  persons have a special  susceptibility to the action
 of this  remedy and develop toxic symptoms after only moderate doses.  As a
 rule, the unpleasant symptoms subside rapidly after the discontinuance of  the
 remedy.  A  very few  instances have been reported in which the fatal termi-
 nation has been  attributed to  the action of salicylic  acid, particularly upon
 the heart, but it is not certain that this has been the correct explanation.
   In consequence of the unpleasant symptoms  sometimes attending the  use
 of salicylic acid  or  its sodium  salt, it has  been proposed to substitute  for
 these salicin  and  the oil of wintergreen.   Salicin is  undoubtedly a beneficial
 remedy in acute  rheumatism, but  it has not  been proven that it exerts so
 powerful  an influence over  the  disease as  salicylic  acid.   Maclagan, who
 introduced the salicin treatment of rheumatism, administers 20 to 40 grains,
 at  first  hourly, and then every two hours as the symptoms begin to improve.
 He continues the drug in scruple doses three  to  four times daily for a week
 or more.  The treatment with large doses is to be resumed whenever pyrexia
 and acute arthritic symptoms return.
   The oil  of wintergreen,  which is  essentially a methyl-salicylate, has been
 recommended by Dr.  F. P. Kinnicutt as an  efficient substitute for salicylic
 acid and as devoid of its toxic properties.1   Kinnicutt gives 10 to 15 minims
 of  the oil every two hours  until eight doses have been taken.   The oil may
 be taken in milk or in  capsules.
   The efficacy of the  salicylate treatment of rheumatism is most apparent
 in acute cases with considerable  fever  and  severe  pain.   In such cases,
 within twelve hours after the beginning of the treatment the fever and  the
 acute arthritic symptoms often  subside.   The cases of acute rheumatism  are
 exceptional in  which  some relief  is not obtained by the  employment of  the
 salicyl compounds, but there are cases in which this  treatment  proves  in-
 effectual, and recourse must be had to  other measures.
   In two respects  the expectations held of the advantages of this treatment have
met with disappointment.  The salicylate  treatment does not  prevent relapses.
Even the continuance of moderate doses of salicylic acid or its substitutes
after the  subsidence of an acute attack  does  not prevent the occurrence of
other attacks.  For this reason, while most writers recommend the continu-
                   1 New York Medical Record, Nov. 4, 1882. 
ACUTE  ARTICULAR RHEUMATISM.             1103
ance of moderate doses after the cessation of the acute symptoms, there are
some who withhold  the drug until  the  first symptoms of a renewed attack
make their appearance.  By the latter method, it is claimed, the patient does
not acquire repugnance for the  drug, unpleasant symptoms are avoided, and
the results obtained are equally favorable with those of the continued admin-
istration of the remedy.
   The salicylate treatment does not prevent the heart complications of rheu-
matism, except in so far as it shortens the duration of the disease.   For this
reason this treatment should not supersede the full alkaline treatment.  In
order to prevent these complications, alkalies are to be given not less prompt-
ly and freely than they were  before the introduction of the salicylate treat-
ment.   The best results are obtained by the combination of the salicylate and
the alkaline treatment.
   Antipyrine is an  efficacious  remedy in many cases of acute rheumatism.
By the administration of  15-grain  doses hourly the  pyrexia  and acute ar-
thritic symptoms have been observed to subside in a manner  similar to that
after the use of salicylic acid.   Not more than  two drachms should be given
during twenty-four  hours.  Neither heart complications nor relapses are pre-
vented by antipyrine.
   Intense  hyperpyrexia claims more prompt and  efficient treatment  than
by salicin  or salicylic acid.   The  antipyretic  measures employed  in  other
fevers are indicated—namely,  large doses of quinia or of antipyrine, and
cold sponging, the  cold  bath, or the wet sheet.  The  arthritic affections do
not contraindicate these measures.   The following case is cited in illustration
of their efficacy : A young woman  was attacked with acute rheumatism in
the seventh month of pregnancy.   A mitral systolic  murmur  denoted endo-
carditis.    The  axillary  temperature rose to 109° F.   She miscarried, the
labor being brief and easy.  She was treated with quinia in large doses, alka-
lies, and sponging the whole body with cold water.   The latter  was employed
constantly during the hyperpyrexia.   These measures proved efficient and the
patient recovered.
   The palliative treatment embraces opiates or other anodynes for the relief
of pain, restlessness, and  inability to sleep.  Thirst may be relieved by the
free use of water or lemonade.  Lemon-juice given in large quantity is one
of the remedies for  this disease in vogue within late years.   It is, in fact, an
alkaline remedy, but taken  in sufficient quantity to render the  urine  alkaline
the stomach often rebels against it, and the alkaline carbonates are to be pre-
ferred.
   The affected  joints claim local measures  of  treatment.   The application
of cloths saturated with  an alkaline and opiate solution, as recommended by
Fuller, is useful.  Fuller's  solution  consists of  from 4 to 6 drachms of the
carbonate of soda or potassa, dissolved in a mixture of an ounce of Battley's
solution (for which laudanum may be substituted), 2 ounces of glycerin, and
9 ounces of rose-water.  The soap-and-opium liniment is a good local appli-
cation.  A liniment containing chloroform has  been found useful.   I have
found  the  tincture of aconite  applied to  the parts to afford  marked relief.
Some practitioners  prefer  to envelop  the joints with dry flannel or cotton.
In the choice  of local applications  the  sensations  of  the  patient may serve
as a guide.  Extension of  the limbs by means of an apparatus for that pur-
pose, or simply a cord, pulley,  and  weight, in order to diminish the pressure
of the articulated surfaces upon each other, affords marked relief.  The appli-
cation of pasteboard splints lined with cotton and confined by a firm bandage
has been found not only to relieve  pain, but to promote  the  disappearance
of the inflammation.  Any measure which has  the latter effect lessens the
pyrexia, for, assuming the disease to be an essential fever, the pyrexia is in 
1104                ARTICULAR RHEUMATISM.
part symptomatic of the arthritis.  Cold  applications  to  the  affected joints,
and even the ice-bag, are recommended by German authors.   Much relief is
afforded in some cases by what may be termed methodic friction.  Using some
lubricating embrocation, the friction at  first over the affected joints, if they
be extremely tender, must be as light as possible to avoid giving pain.   The
force of  the friction, however, may be gradually increased, until  at length
the patient  is sometimes able to bear without suffering as much pressure  as
can conveniently be made.   Methodic friction, gradually  increased up  to  as
much pressure with  the  hands  as can  be  borne without  pain, leaves the
affected joints more comfortable for several hours, and the operation may be
repeated  once or twice daily.
  It is important, in order to avoid relapses, that the patient should not  leave
the bed and should not make unnecessary exertion until some  time—if possi-
ble a week—has elapsed after all acute symptoms have subsided.
  The treatment of rheumatic endocarditis and pericarditis  has been already
considered.   Pleuritis and pneumonitis are to be treated according to the
indications in individual cases, as when they occur in other pathological con-
nections.   The indications  pertaining to active delirium, convulsions, and
coma are derived from  the pathological  conditions with which these events
may be associated—namely,  hyperpyrexia,  cerebral meningitis, or uraemia.
  DaCosta has reported 30 cases  treated with the bromide of ammonium in
doses of 15  or 20 grains  every three  hours.   Of these cases, in 23 there
was  no  cardiac  complication when this  treatment was begun, and in  none
of the 23 cases was any cardiac  complication  subsequently developed.  The
mean duration of the disease was 22.5 days.1   Senator has made some obser-
vations on the treatment with benzoic acid.   Giving  2£ to  3 drachms  of
the acid, or from 3 to nearly 4 drachms of the benzoate of  soda, during the
twenty-four hours, the disease was apparently shortened.  This result I have
observed in a few cases.  Its efficacy is vastly inferior to that of salicin and
salicylic acid.   Trimethylamine,  employed largely  in this disease by Arvena-
rius  of St. Petersburg a quarter of a century ago,  has more recently been
employed with success  by Lagrange  and Dujardin-Beaumetz in France.2


        Subacute and  Chronic Articular Rheumatism.

  The terms subacute and chronic rheumatism are applied not alone to cases
having the distinctive features of the  disease just considered, save acuteness,
but to affections resembling articular rheumatism only in their situations, and
also to persistent  pains in different parts of  the body supposed  to  involve a
rheumatic diathesis.  I shall notice under this heading true  articular rheu-
matism in so mild a form as to be distinguished as subacute, and the chronic
form, involving, as  there is reason to suppose, a constitutional  condition, if
not identical with, allied to, that  in the  acute disease.    The  affection called
rheumatoid  arthritis will be noticed  after gout has been considered.
  Subacute  rheumatism  may have  all the characters  of the  acute disease,
minus intensity.  It is  then  the same  disease in a  mild  form.  There is a
liability to the cardiac complications, although it is much  less  than  when the
disease is acute.  The treatment  is the same, with modifications which are
suggested by the want of acuteness of  the symptoms.   The  alkaline  reme-
dies  are indicated  as protective against cardiac complications.
  Both  acute  and subacute  articular  rheumatism may end in a chronic
arthritic  disease.   The essential constitutional affection in  these cases may
not continue, but  there remains  an affection  of one or more of the joints
               1 Vide Pennsylvania Hospital Reports, 1869, vol. ii.
               2 Vide National Dispensatory,  1879. 
      SUBACUTE AND CHRONIC ARTICULAR  RHEUMATISM.   1105

previously involved.  The arthritic affection is perhaps a sequel of the  rheu-
matic disease, rather than the latter persisting in  a  chronic form.
  In most cases of chronic rheumatism the disease is subacute from the first.
It depends doubtless upon an  internal  determining cause.   If it cannot be
affirmed that this cause  is identical wnth that in acute articular rheumatism,
a relationship between the two  diseases may fairly  be inferred.
   Cases of chronic rheumatism are frequently met  with in medical  practice.
The patients are  generally in middle  or advanced life.   A  greater or less
number of joints may be affected.  The  affection  remains fixed in certain
joints ; that is, it does not shift from joint to joint, as in cases of acute rheu-
matism.  The affected  joints are tender, painful  to the  touch, sometimes
swollen from intra-articular effusion ; their temperature is more or less raised,
and the surface may he reddened.  Motion is painful, especially at first after
periods of rest.   A grating sensation  and sound often accompany the first
movements  after these periods.   The local symptoms vary much in degree at
different times, and patients often observe a connection between an increase
of  these symptoms and certain  atmospherical conditions.   They often  say
that their sensations  enable them not only to judge of existing conditions,
especially as regards moisture, but to foretell changes which are soon to take
place.
   Pyrexia is wanting except when there is an  exacerbation as regards  the
local  symptoms.   The digestive  and nutritive functions may be but little or
not at all affected.  There is no liability to  cardiac complications  or to  dis-
ease  of internal  organs other than the heart.
   The  diagnosis involves discrimination from  rheumatoid  arthritis,  which
will be considered in the next chapter.   In the  latter  occur anatomical
changes, dislocations, and distortions which do not  belong  to the history of
chronic rheumatism.  Subacute or chronic synovitis, not  rheumatic, is to be
excluded.   The  points to be considered in differentiating  the  latter from
rheumatoid arthritis are those  which have  been stated  in  connection with
the diagnosis of  acute articular rheumatism.  AVhenever chronic rheumatism
has been preceded by the acute  disease, this fact has of course an important
bearing on the diagnosis.
   Chronic rheumatism is devoid of immediate danger, but it persists in many
cases indefinitely, and in  not a few instances during  life.   Ankylosis of the
affected joints sometimes takes place.  Notable atrophy of muscles may be a
result  of their  inaction  when the  disease interferes greatly with  muscular
movements, or possibly the  result of  some  nervous  disorder.
   In cases of chronic rheumatism the treatment so important in the acute
disease is less effective.   Alkalies are of comparatively little service.  Salicin
or salicylic acid has little controlling influence.  A great variety of remedies
with reference  to a constitutional effect have had  advocates.   Observing
proper care not to do harm by medication, trial should be made of different
remedies.  Of these may be mentioned the preparations of guaiacum—namely,
the simple tincture, the ammoniated tincture, the mixture or the compound
decoction of sarsaparilla into which guaiacum enters—the  bichloride of mer-
cury, iodide of potassium in large doses, colchicum in small  or moderate doses,
the hvdrochlorate of ammonia, sulphur, and  arsenic.
   The local treatment  is important.  Benefit may be  obtained  from  flying
blisters or  the application of the tincture  of iodine.  Methodic  friction or
shampooing, as described in connection with the acute form of the disease, and
stimulating embrocations are often  of much utility.   Counter-irritation by
"firing" has been recommended.  Palliation of pain may frequently be  pro-
cured °by the application of the tincture of  aconite or the  veratria  ointment.
The treatment has reference to two objects—namely, the removal of, first, the
70 
1106
GOUT.—RHEUMATOID ARTHRITIS.
inflammatory condition, and second, the effects of the inflammation.  In order
to prevent stiffness and ankylosis passive motion  is advisable so  soon as the
inflammatory  condition subsides.
   Rendering the affected joints immovable by means of pasteboard  splints
and bandaging should be tried.  The immobility, however, should be contin-
ued for only a few days at a time, and in the intervals passive movements may
be important to prevent ankylosis.  Local douches with  either cold or warm
water, or with each in alternation, may prove of service.  Electricity, especially
the constant current, has been found serviceable.
   External measures acting upon the entire surface are perhaps, in certain
cases, not less  useful than internal remedies.  Reference is had to the simple
tepid  bath, the alkaline bath, the Turkish bath, the sulphur vapor-bath, and
hydropathic packing.  The resources of  treatment should not  be  considered
as exhausted without a fair trial of these measures.
   Measures having reference to improvement of the general health and the
invigoration of the system form an essential part of the treatment, embracing
tonic  remedies, with attention to diet, clothing,  exercise, etc.   It  is unneces-
sary to go into  details which are essentially the same in  the treatment of many
chronic affections.   Change from a  cold, changeable, and humid  climate to
one mild, uniform, and dry often proves the most effective measure which can
be adopted. The mineral springs are frequently resorted to with advantage
by persons suffering from chronic rheumatism.   Of the different waters, the
alkaline, sulphurous, saline, and chalybeate are each useful in certain cases.
Doubtless, however, much of the benefit derived from  watering-places is due
to the various  incidental hygienic influences.
                        CHAPTER   XI.

                 GOUT.—RHEUMATOID ARTHRITIS.

Gout: Anatomical  Characters ; Clinical History ; Pathological Character ;  Causation ;
            Diagnosis ;  Prognosis; Treatment.—Rheumatoid Arthritis.

                                 Gout.

   THE disease called gout has been thought to be  allied to articular rheu-
    matism, and the two affections have even been considered to be identical.
As will be seen,  however, they are shown to be essentially distinct forms of
disease  by points of contrast  pertaining to morbid anatomy, clinical history,
pathological character, and causation.   The name gout or its synonym in dif-
ferent  languages  is universally applied to the  disease to  be now considered.
The name is derived from gut fa, a  drop, and is  supposed to refer to the drop-
ping of some morbid fluid into the joints.
  Gout occurs as an acute, a subacute, and a chronic affection. AArriters have
made other varieties, such as irregular and misplaced gout.  As the subacute
form is not always  chronic, it is  convenient  to  consider this form when of
brief duration and the acute  form  under one head.   The term transient gout
will embrace the acute and subacute  form, the latter ending too  soon to be
considered as  chronic.   Persistent or chronic gout will embrace all cases in
which  the disease is protracted. 
GOUT.
1107
  Anatomical Characters.—The most distinctive anatomical character of
gout consists  in the deposit within the tissues of crystalline urates, chiefly
urate of sodium. Mingled with the urate of sodium have been found in small
quantity other salts, as urate of calcium and of magnesium and carbonate and
phosphate of calcium.  The urate of sodium is in the form of acicular crystals,
with which  may be mingled amorphous granular matter.  With few excep-
tions the urates are deposited first in the joints, and in the majority of cases
first in the metatarso-phalangeal articulation of one of the  great toes.  In  the
course of the disease other joints become affected.  At first the disease mani-
fests a preference for the small joints of the foot and hand, but subsequently
(and in rare cases primarily) larger joints, as the knee and elbow, may become
involved.   The  urate deposit seems to  form a white, chalk-like incrustation
upon the free  surfaces of the articular cartilages.  Careful examination, how-
ever, shows that the deposit is in the substance of the  cartilage.  Usually
only the superficial layers of the cartilage contain the deposit.  Upon micro-
scopical examination are found acicular crystals arranged in little  clusters
which radiate from a centre.  The centre of a cluster is often  a cartilage-cell,
but the crystals are deposited in the basement-substance as well.  The depo-
sition of urates in the joints may occur either with or without paroxysms of
articular gout.   Garrod has shown that a single paroxysm of gout suffices to
cause a certain amount of the urate deposit in the affected joint.
  Urate concretions are often found in the synovial membranes and the artic-
ular ligaments.  These gouty concretions are called tophi or chalk-stones. Tophi
consist of needle-shaped  crystals of urate of sodium, mingled with granular
matter and animal  substance.   Their consistence is usually compared to that
of mortar.
  Although the urate deposit is often  associated with acute transitory inflam-
mation in and about the joints, it is  sometimes though less frequently com-
bined with destructive  inflammatory and degenerative changes in the joints.
The stiffness of the joints observed during  life is due more to the affection of
the ligaments than  to the alterations of the cartilage.  Fibrous ankylosis may
occur.   There  may be erosion  of the articular cartilages.   These changes,
combined with tophaceous nodules, and sometimes subluxation of the joints,
may give rise in chronic gout to striking deformities, which are observed most
frequently in the hands.
  The deposits  of  urates may  be found not only in the ligaments and carti-
lages, but also  in  various  other situations,  of  which the most frequently
affected are the  perichondrium, the periosteum,  the  periarticular connective
tissue, the tendons and their sheaths, the bursal sacs, the kidneys, the skin, and
the cartilages of the external ear.   Tophaceous masses occurring in the exter-
nal ear, varying  in size from that of a pin's head to that of a split pea, are often
of great assistance in diagnosis.   Among the rare situations for gouty deposits
may be mentioned the spongy texture  of bone, the small laryngeal cartilages,
the tarsal cartilage, and the sclerotic  coat of the eye, the outer sheaths of
vessels  and of nerves,  the endocardium, and the dura mater.   In general,
those tissues are most liable to be affected  which are possessed  of little vas-
cularity, but tbe gouty  deposit  has been found in such vascular structures as
the skin and  the muscles.  Tophi, especially those seated  subcutaneously,
may lead to the formation of abscesses, which burst and discharge pus min-
gled with chalky material.  In this way or by  simple  necrosis  of the skin
over the  tophi  sluggish  ulcers are  formed which  have little tendency to
repair.                                                       #
  The  interesting discovery has been made by Ebstein that the tissues which
are the  seat of urate deposits in gout are in the condition of coagulation necro-
sis.  According to  Ebstein, this coagulation necrosis precedes the deposition 
1108
GOUT—RHEUMATOID  ARTHRITIS.
of urates, and is caused by the abnormal chemical constitution of the blood.
The  fixation of urates  in  the tissues, according to this view,  is due to the
acidity of the necrotic tissues, leading to the formation of the insoluble acid
urates out  of  the  neutral urates, which are in excess  in the  circulating
blood.  An  area  of reactive inflammation exists  around the foci  of coagu-
lation necrosis.
  Todd and Garrod have  established the fact that gout is one  of the causes
of the small granular kidney.   The diseased kidney presents  the  gross and
the microscopical  changes  which have already been described as characteristic
of this  form of chronic Bright's disease (p. 878).   The  gouty kidney is the
seat  of urate deposits, chiefly in the pyramids, where they appear as whitish
streaks  and points.  The  morbid deposit is found both within and between
the tubes.  The  gouty kidney may develop without the  occurrence  at any
time  of articular symptoms,  although at the autopsy urates are found in the
articular cartilages.  Gout is  an occasional cause of waxy degeneration.  Con-
cretions of urate  of sodium have been found in the renal calices and pelvis.
  It has been shown by Garrod that the blood in gout  contains an excess  of
uric  acid, which  is present in the  form of urate of sodium.  According to
this  author, no appreciable excess of uric  acid  is present in the  intervals
between the early attacks of gout, but in chronic gout  the blood is continu-
ously rich in uric  acid.  The accumulation of uric  acid in the blood constitutes
the condition called uricsemia or lithaemia, which has  been considered in Part
I. of this work.
  The gouty dyscrasia  is frequently  associated  with  various anatomical
changes  other  than those  which have  been described.   These lesions, how-
ever, are generally  without special peculiarities by which they can be recog-
nized as gouty  in origin.
  Patients  with gout are especially liable to chronic inflammations, of which
the most  common  are chronic gastritis, chronic enteritis, chronic bronchitis,
and  chronic endarteritis (atheroma).   Fatty liver  and,  according to some
authors, cirrhosis of the liver may be an effect of gout.  Various  cutaneous
diseases, especially  eczema, are ascribed to gout.  Cardiac lesions are common
in chronic gout.   They are most frequently secondary  to chronic  nephritis,
but  fatty heart and chronic endocarditis and myocarditis may  occur in  gout
without this association.   Gouty patients have a tendency to  the  formation
of renal calculus and  to  chronic inflammations of the  bladder, urethra, and
prostate  gland.   Gout and diabetes mellitus are sometimes combined, or one
may  be a sequel  of the other.

  Clinical History.—Transient gout and persistent  gout require  separate
consideration as regards their clinical history.  Having considered these forms
of the disease,  I  shall notice irregular and misplaced gout.
   Transient Gout.—Under this  head are to be  embraced all cases in which
the  disease  is  of short duration ;  that  is, the duration not sufficiently pro-
longed  for  the disease to be  regarded  as  chronic.   In this form  of the
disease  the  patient is said to have an attack or  fit of gout.  The  disease is
generally acute,  but sometimes it is subacute.
  The seizure is  generally sudden, occurring, as a rule, during the  night, and
in the majority of cases  after  midnight.   In a certain  proportion  of cases
the seizure  occurs without premonitions ; and the patient may have retired to
bed feeling as well as usual.  In some cases, however, there are prodromic phe-
nomena  consisting of cardialgia, gastric  flatulency, eructations,  and other
dyspeptic ailments, together with  inability  to  exert  the mental  faculties,
irritability of mind, and depression of spirits.  These phenomena are not suf-
ficiently significant to  lead to the expectation of an  attack of gout if one or 
GOUT.
1109
more  attacks  have not been  already  experienced, hut in  persons  who are
subjects of the disease they may denote an impending seizure.  Observations
have shown that for several clays preceding a gouty paroxysm there is a nota-
ble diminution of uric acid in the urine.
   The seizure is marked by  pain, which in the great majority of cases  is
seated in the metatarso-phalangeal joint of one of the great toes.   The pain
soon becomes more or less intense, and frequently it is excruciating, being com-
pared by patients to pain caused by the  gnawing of an animal, a dislocation
of the bone, a nail driven  into  the joint, tearing  of the parts with pincers,
etc.   Such comparisons express only intensity of suffering,  for it is not to be
supposed that patients have actually experienced  the  pain  produced by the
various causes mentioned.   A  sense of throbbing in the  part accompanies
the pain.   More or less pyrexia is developed, preceded  by shivering.  These
symptoms  continue for several  hours, and then the  pain  and fever subside.
The patient is comparatively comfortable and obtains some sleep.   The relief
is usually accompanied by slight perspiration.  In the mean  time, the affected
joint becomes swollen, the skin is  reddened and shining, the subcutaneous
veins are distended,  the heat is  raised, and there is exquisite  tenderness
to  the touch.  These appearances  are  observed  after the severe pain has
abated.
   In  some cases only a  single paroxysm of severe pain is experienced, but
much  oftener the  seizure  is renewed  on the following  night, and on succes-
sive nights for a  variable  period.  The  local affection may remain in the
joint affected  at the first  seizure, or  the affection may be transferred from
this joint to the corresponding joint of the opposite foot.   In some cases the
inner side of the foot, the  instep,  or the heel becomes  affected, and the affec-
tion may extend to the larger joints and to the small joints of the upper
extremities.   This extension of the local manifestations of  the disease rarely
occurs until after several attacks, and it occurs especially in cases of chronic
gout.  After recovery from transient gout  there  is often a feeling of better
general health than  before its occurrence, the  patient being relieved of
indefinite ailments which  previously  existed.
   During the continuance of transient gout the symptoms other than those
referable  to  the  part or parts affected vary considerably in  different cases.
Pyrexia  is more  or less marked in proportion to the  acuteness of the local
manifestations.  The fever appears  to be symptomatic, and, as a rule, it is less
than  in  cases of  acute articular rheumatism.   The  appetite is frequently
impaired or lost, but  in  some cases it is preserved.   Dyspeptic ailments are
sometimes present and  sometimes  absent.   The urine is  generally scanty,
hiuh-colored,  and  deposits a  lateritious sediment on  cooling.  The excre-
tion of uric acid  is  lessened.  The bowels  are generally  constipated.
   Cases  also differ much as regards the  local symptoms.   The affection may
be called acute when the pain is severe, the swelling, redness, etc. are marked,
these local symptoms being accompanied by a corresponding amount of fever.
On the other hand, the affection  is subacute when the pain is  notably less
severe, the other local symptoms are less marked, and  fever is either  slight
or wanting.   As regards the  seizures of pain, which  occur usually at night,
they are in some  cases  paroxysmal, the pain passing off in the day, but  in
other cases more or less severity of pain continues during the day as well as at
nicht; in other words, remissions occur instead of intermissions.   The local
symptoms gradually decline as the fit or attack  passes off.  OZdema of the
part or parts is more or  less marked at the decline of the local affection, with
frequently pruritus, and in the majority of  cases furfuraceous desquamation
of the epidermis.   The local symptoms just named are diagnostic of gout as
contrasted with rheumatism.   Cramp  affecting the muscles of the leg, the 
1110
G 0 UT—RIIE UMA TO ID AR THRITIS.
 thigh, and  other  parts  of the body is a symptom more or less marked in a
 considerable number of cases.
   The duration of transient gout varies between a few days and several weeks.
 In the majority of cases  the paroxysms recur  nightly for at least a week.
 Generally, the paroxysms or exacerbations are less and less severe in propor-
 tion to the duration of the attack.   If  the disease  continue  for more than
 three or four weeks it is to be considered as persistent or chronic.   An attack
 of acute or subacute gout, especially the latter, may eventuate in the persist-
 ent or chronic  form of the disease, or, having continued for a variable period,
 the disease for the time  ceases, recurring at longer or shorter intervals in the
 vast majority of cases.
   Persistent or  Chronic  Gout.—Gout, beginning as either  an acute or sub-
 acute affection, in a certain proportion of cases continues as a chronic affection
 for many weeks, months, and even  years.  Generally, this persisting or chronic
 form of the disease is preceded by the occurrence of many transient attacks
 recurring after intervals which become shorter and shorter, until at length, as
 it were, they run together.   AVhen the disease is persistent it has not contin-
 uously a uniform severity, but  remissions occur from time  to time, and not
 infrequently intercurrent acute attacks  take place.
   In the persistent or chronic form the local symptoms which characterize the
 acute affection—namely, intense pain, heat, and redness—are either slight or
 wanting.   There is little or no fever.  Disorders of the  digestive  system are
 often present and the general health is more  or less  impaired.  In this form
 the  joints  are  liable to become  stiffened, ankylosed,  and  deformed from
 the  abundance of  the  gouty  deposit.    Chalk-like  concretions  may occur
 within and around the small  joints of the hands.   In some cases  collections
 of semi-solid matter are felt near the surface,  and if they be opened the mat-
 ter may he  pressed  out.  Sometimes collections of  considerable  size open
 spontaneously.   The solid concretions, or chalk-stones, sometimes  make their
 appearance  through the skin.  The  gouty matter may be deposited in  the
 bursae mucosae  in  the neighborhood of joints.   In a certain  proportion of
 cases—the number, happily, not large—the hands and  feet become perma-
 nently distorted and crippled, the fingers sometimes presenting an appearance
 compared by Sydenham to that  of a bunch of parsnips.  Nodules of  the
 deposit are frequently seen on  the  helix of  the ear, sometimes also on  the
 eyelids, and occasionally on  the  face.
   In chronic as in acute gout the  predilection of the disease, as regards  the
 seat of the local manifestation, is for the joints of the great toe. An affection
 of other joints occurs primarily in a  small proportion of cases.  After  the
 great toes,  the order in which  parts are liable to become implicated, according
 to Garrod, is as follows :  The heels and ankles, the knees, the smaller articula™
 tions of the hands, the elbows, and lastly the shoulders and hips.   There are,
 however, many exceptions to this order  of  sequence.  A blow, sprain, or
 other injury may determine the seat of the local affection.   A point of dif-
 ference in  different  cases pertains to the  number  of joints which  become
 affected.
   In some  cases the local manifestations of the disease, however long it may
persist or frequently recur, remain  concentrated on a few joints;  in  other
cases a large number of joints are  implicated ; and, again, in some cases differ-
ent joints are affected in  successive attacks.  If the same and a few joints be
always affected, and if the disease either persist or recur frequently, permanent
changesin  the affected joints are more likely to occur.  Another point of dif-
ference in different cases  relates to the palpable changes in  the affected joints.
Some  gouty  patients escape ankylosis and nodosities, although  they suffer
from the disease more or less throughout their  lives, whereas in other cases 
GOUT.
1111
the hands and feet become deformed and crippled after a comparatively short          •
duration of the disease.
  Irregular and Misplaced Gout.—It is an old doctrine that local manifestations
of gout are liable to be seated in the different visceral organs—namely, the stom-
ach, intestines, lungs, heart, liver, kidneys, and brain.  Disorders referable to
these viscera preceding the ordinary manifestations of gout have been considered
as gouty, and it has been supposed that gouty disorders of viscera may occur
without any affections of the joints either accompanying  or ensuing.  In such
cases gout is  said to be  irregular and  misplaced.  Anomalous and latent gout
are other terms  applied to these cases.  Sometimes during an attack of gout ■
the affection of the joint  or joints suddenly disappears, and symptoms denoting
an aff'ection of some internal organ supervene.   In these cases a transference
or metastasis of the gouty manifestations is supposed to  take place, and  the
name  retrocedent gout is employed to express such an  occurrence.    These
notions are probably, in  a measure, well founded, but  it is difficult with  our
present knowledge to say how far they are to  be accepted as correct.  The
difficulty consists in the  inability to determine whether antecedent, coexistent,
or consecutive affections in certain  cases of gout are not  associated merely by
coincidence. It has  doubtless been too much the custom to consider all affec-
tions occurring in persons subject  to gout as of a  gouty character, and  the
gouty diathesis is often considered to exist on insufficient data.  Making, how-
ever, due allowance for error, it can scarcely be doubted that the constitutional
morbid condition which constitutes the disease in cases of gout may determine
disorders, sometimes of  a grave character, in  organs more important  to  life
than those in which the  local manifestations are usually seated.  Evidence of
a pathological connection of these disorders with gout is  afforded by complete
relief following the development of a gouty affection  of the joints, by their
occurrence immediately after a gouty affection of the joints has been apparently
suppressed, by the absence of any other  appreciable causes  explaining their
occurrence, and by the  indefinite  or anomalous character of the disorders.
   Disorders of the stomach and intestine attributed to gout are neuralgic pain
or spasm, flatulent dyspepsia, and persistent vomiting, accompanied with more
or less  prostration, diarrhoea, and in some cases symptoms denoting enteritis.
   Disturbed action of the heart is not uncommon in gouty patients.  It some-
times  occurs in an alarming degree, hut it may be doubted if a purely func-
tional  disturbance occurring in this connection ever prove  fatal.  Valvular
lesions and enlargement of the heart often exist in persons affected with chronic
gout, being usually  associated with chronic Bright's disease.  The want of a
tendency to acute endocarditis and pericarditis is one of the points distinguish-
ing  gout from rheumatism.
   Cough, asthmatic dyspnoea, and bronchitis  are attributed to gout.   Spas-
modic affections of muscles or cramp in various situations, neuralgia affecting
the  branches  of the fifth  pair, the sciatic nerve, and other nervous  trunks,
paroxysmal headache and hysteria, are  to be  added to the list.
   Delirium and fatal coma are among the disorders imputed to  gout.   These
svmptoms may be due to uraemia or to meningitis, which may or may  not be
dependent on gout.
   The deposit of the urate of sodium in the uriniferous tubes in cases of gout
has  been stated under the head of  the morbid anatomy.   It  is not difficult to
understand that this deposit  may accumulate and form renal calculi.  Clinical
observation shows that gouty persons are liable to the formation of renal cal-
culi and to paroxysms of pain caused by the passage of the stones along the
ureter  or renal colic.   It has  been established that the contracted  kidney
may be due to gout.  The coexistence of renal disease  in certain cases  may
account for the occurrence of some events which have been heretofore consid- 
 1112             GOUT—RHEUMATOID  ARTHRITIS.

 ered as being specially connected with gout—namely, vomiting and purging,
 headache, neuralgia  in different situations, delirium, convulsions, and coma.
 The  existence of renal disease is to be ascertained by means  of the  urinary
 changes which have been already considered.   The urine presents the charac-
 ters distinctive of the small granular kidneys.   It usually is clear and abun-
 dant, and it deposits but little sediment.  The amount of albumen in the urine
 may be  slight, but in some cases it is considerable.   Casts  are usually not
 abundant, and they may be absent.  Slight albuminuria in the course of gout
 is not necessarily indicative of Bright's disease.
   Cystitis and urethritis  have been attributed to gout, but the  existence of
 any special pathological  connection may be doubted.   Certain  affections of
 the  skin, particularly  eczema, are common in persons subject to gout.  Graves
 called attention to the habit of grinding the teeth as peculiar to cases of gout,
 The  habit proceeds from an uneasy sensation in the  teeth, which is in  this
 way  momentarily relieved.
   A small amount of sugar may he found occasionally in the urine of gouty
 patients.   The association of gout and of diabetes mellitus in  some cases has
 been already referred to.   This association has led to the idea that the vices
 of nutrition which are  the causes of  these diseases  are in a measure allied,
 but  we are wholly in  the dark as to the fundamental disorders of nutrition in
 both of these diseases.

   Pathological Character.—The researches of  Garrod  show  that  the
 pathology of this  disease  involves  a particular  morbid  condition  of  the
 blood—namely, an abnormal  accumulation  of  uric  acid, uricaemia (lithee-
 mia).1  The blood in health contains  only a trace of uric acid.   In 47 cases
 of gout an analysis of the blood-serum by Garrod  showed a notable  increase
 of this constituent.   Garrod has also shown  that during an attack  of acute
 gout the uric acid in the urine is  notably  diminished.   It is apparently
 increased, since a  deposit of the urates in more or less abundance when  the
 urine  cools is common ;  but the increase is only apparent, the deposit being
 due  to the scanty quantity of urine.  In chronic gout the quantity of uric
 acid excreted by the kidneys is habitually below the average in health. Gar-
 rod has found the  uric acid in excess in the blood in cases of lead-poisoning.
   From  the facts just  stated, taken  in connection with the deposit of  the
 urate of  sodium within or around the joints, it is rationally concluded that the
 local manifestations of gout are effects  of the uricaemia;  hut it is evident
 that the uricaemia  is itself  an effect,  and the primary perversions underlie  the
 excess of uric acid in the blood.  Either this principle is produced in  too
 great abundance, or,  without being unduly  produced,  it accumulates as  a
 result of  insufficient excretion by the  kidneys.   Probably both  explanations
 are involved.   Direct observation, at all events, shows deficient excretion,
 since the amount in the urine is less than in health.   Garrod  entertains  the
 opinion that the  deposit of uric acid  in the form of the urates takes place
 within and around the joints in consequence of diminished alkalinity of  the
 blood; whereas Ebstein considers the  primary effect of the abnormal condi-
 tion  of the blood to be the production of coagulation necrosis, which is  fol-
 lowed  by the deposit of  urates.
   In  treating of rheumatism it has been stated that  an examination of  the
blood in that disease with reference to the amount of uric acid shows this
principle not to be in  excess.  Here is a capital point of difference between
gout and rheumatism  as regards pathological character.  The  clinical history
of gout has afforded  several striking points of contrast between the two dis-
eases.  These points will be reproduced under the head of Diagnosis.  Other
                            1 A'ide Part I. p. 75. 
GOUT.                             1113
points of contrast will be presented under the head of Causation.  The indi-
viduality of each disease is therefore sufficiently established.

   Causation.—Gout is a diathetic disease, and the diathesis in a certain pro-
portion of cases is congenital and inherited.  It is a matter of common obser-
vation that certain families are  predisposed to this disease, and it is sometimes
transmitted successively through a  series of generations.  Scudamore's statis-
tics  showed that of  523 patients affected with gout, in 309  the disease had
existed in either the parents  or grandparents.  Of 80 cases reported to  a
commission of the French Academy, in 34 the disease had been transmitted,
and  Garrod states  that in the cases  which he  has  observed an hereditary
predisposition  existed  in  50  per  cent.   The diathesis,  however, is by no
means invariably  inherited; in a certain proportion of cases  it is  acquired;
and  on the other hand the disease is  not always transmitted to offspring.
There are causes, then, which may produce it in those in whom there is no
reason to  suppose  a congenital  predisposition, and  in  those  predisposed by
inheritance other  causes may  be  required for  its development,
   A causative influence relates to  age.   It occurs very rarely before the age
of puberty.   Of 515 cases analyzed by Scudamore with reference to age, in
only  5 did the disease occur in  persons less than eighteen ;  in 142 cases the
ages  at the time of  the development or first occurrence of the  disease  were
between twenty and thirty years;  in 194 cases, between thirty and forty ;  in
118 cases, between forty and fifty ;  in 38, between fifty and sixty ; and in only
10  cases between sixty and sixty-six years.  The liability  thus diminishes
progressively  after fifty, and the  development of the  disease is as  rare, if
not more  so,  after  seventy  as before  puberty.   In the  cases  in which   it
appears before the age of twenty-five it generally is inherited.  In the causa-
tive  influence relating to age there is a point of contrast to  rheumatism, the
latter  disease   affecting  by preference young subjects.
   A very marked difference exists between the two  sexes in the liability to
gout.  Gout—at least articular  gout—is much more common  in men than
in women.  Here is  another point of difference  from rheumatism, the latter
occurring  scarcely less frequently in females than  in males.
   Dietetic and regiminal habits lead to the acquirement of the diathesis,
and  co-operate with a  congenital  predisposition in  producing  the  disease.
To the habitual use  of wine  or malt liquors the disease is in  many cases
chiefly attributable, and, on the  other hand, the  use of distilled spirits seems
to exert no influence in its production.   Gout prevails in countries in  which
wine  and malt liquors are largely used, whereas in  countries in which the
use of spirits predominates the disease  is relatively rare.   It is compara-
tively rare in   Scotland, Bussia, Poland, Denmark, and in this country, prob-
ably in a great measure for the reason just stated.   It is proverbially preva-
lent  among those of the opulent class of society who are addicted to luxu-
rious habits;  but  doubtless the  habitual indulgence in the pleasures of the
table, exclusive of the use of fermented liquors, contributes largely in this
class  to  the production of the disease.   Physical indolence also enters into
the causation.  The  agency of malt liquors alone  is strikingly shown by
the frequent occurrence of the disease among a  class of  laborers in  London
employed to raise ballast from the bottom of the Thames, who are accustomed
to drink  two  or three gallons of  porter daily.   According  to  Budd, gout
is quite common among this class.  The lighter wines are less  likely to pro-
duce  the disease than the stronger  varieties—namely, sherry, madeira, and
port—and this is true of malt liquors.   There is little reason to suppose that
cider  tends to produce it.  It is evident from the facts just stated  that the
causative agent in  fermented liquors is  not exclusively  alcohol.  Ascribing 
1114             GOUT—RHEUMATOID ARTHRITIS.
to the use of wine and malt liquors, to high living in other respects, and to
indulgence in luxurious ease a due causative influence, the disease is  some-
times developed irrespective of these causes.  Examples are occasionally met
with among laborers accustomed to a plain diet and neither wine-drinkers nor
beer-drinkers.  My clinical records contain notes of  several such cases.   Gout
developed  in individuals  of the  poorer  classes  often  pursues an  atypical
course,  and the acute paroxysms  may be absent.
   Various causes  may determine  the occurrence of an attack of gout; that
is they may act as exciting causes.   Attacks are sometimes attributable to
prolonged  intellectual exertion, anxiety of mind,  bodily fatigue, exposure to
cold, acts of excessive indulgence  in eating or drinking, etc. ; but in  not a
few instances the disease occurs without any appreciable exciting cause.  Ihe
disease  is  rarer in tropical than in  temperate climates.   Attacks are  more
likely to occur  in  the spring and  autumn than at other seasons of the>  year
Garrod  adduces facts which show that impregnation of the system with lead
is among the causative agencies.   Of  51  male hospital patients, 16  were
either  painters, plumbers, or workers  in lead.   This connection has  been
noted by other observers.   The fact  that  in cases of lead-poisoning  the uric
acid is found in excess in  the blood  has already been  stated.

   Diagnosis.—The  difficulties in  the way of the  diagnosis of articular gout
relate to its discrimination from rheumatism and the affection called rheuma-
toid arthritis.  The  distinctive features  of the latter will be presented in
treating of that affection, and the differential diagnosis of gout and rheuma-
tism only will be here considered.  The  points involved  in  this differential
diagnosis embrace facts  relating  to  anatomical characters, clinical  history,
pathological  character, and causation which have been presented under these
respective  heads.
   Distinctive Features relating to Anatomical Characters.—Under this  head
reference is had to the morbid changes within and around the affected joints.
A distinctive anatomical  change in  gout  is the deposit of a morbid product
abounding in the urate of  sodium, the gouty or tophaceous matter, either in
collections of a semi-solid consistence or in hard concretions commonly called
chalk-stones.  These are never present in  rheumatism and are pathognomonic
of gout.  The deposit, however, in a situation and in sufficient quantity  to be
ascertained during life occurs  in  only a certain  proportion of cases, and
chiefly  in  chronic gout.
   Distinctive Features relating to Clinical History.—In the great majority of
cases the primary  local affection is seated in the metatarso-phalangeal  joint
of one  of  the great  toes.   The larger joints are affected subsequently, if at
all.  The local manifestations tend to the smaller joints of the toes and hands.
In acute cases  the pain is more intense  than in  acute rheumatism, and the
tenderness is greater.  Pain occurs in paroxysms or in marked exacerbations.
QEdema, pruritus, desquamation of the cuticle, and enlargement of the  veins
are distinctive of gout.  Febrile movement is less marked than in acute  rheu-
matism, and is apparently symptomatic,  whereas  in rheumatism the  fever is
essential  as well as  symptomatic.   Acute endocarditis and pericarditis  are
very rarely, if ever, developed  in the course of the disease.  The deposit of
small collections of the urate of sodium on the helix of  the ear is of  frequent
occurrence in  cases  of gout, and serves to establish the diagnosis.   They
should  always  be sought for.
   Distinctive  Features relating  to  Pathological Character.—The uric acid in
the blood is morbidly increased. This may be ascertained by obtaining serum
either from  a  small  quantity  of  blood  or by means of a small blister, and
resorting to what Garrod  calls the " uric-acid thread experiment."  The mode 
GOUT.
1115
of performing this experiment, as described by Garrod, is as follows :  -- Take
one  or two fluidrachms of the serum of the blood and put  it into a flat-
tened glass dish or capsule.  To this  add ordinary strong acetic  acid in the
proportion of six  minims to  each  fluidrachm of serum, which  causes  the
evolution of a few bubbles of gas.   AYhen the fluids are well mixed  intro-
duce one or two  ultimate  fibres, about an inch  in  length, from a piece  of
unwashed linen  fabric, which should be depressed by means of a small rod. as
a probe or the point of a pencil.   The glass should then be set aside in a cool
place until the serum is quite set and almost dry.  Should uric acid be pres-
ent in the serum in more than  a small amount, it will crystallize, and during
its crystallization will be attracted to the thread and assume forms not unlike
those presented by sugar-candy upon a string.   To observe this,  the glass
containing the dried serum should be placed under a linear magnifying power
of about fifty or sixty, procured with an inch  object-glass and low eye-piece;
or a single lens of  one-sixth of an  inch  focus answers perfectly.  To ensure
perfect success the glasses should  be  broad and flat; the acetic acid  should
be neither very  strong nor too  weak ;  the glass should not be  disturbed dur-
ing the drying of  the serum ; the temperature should be that of an ordinary
sitting-room ;  and the glass should be protected from dust.''1
  For  a diagnosis  the  thread experiment,  according  to Garrod, suffices.
Crystals of uric acid do  not form  and  adhere to the thread in  the blood-
serum in health.   The uric acid  of the  blood is  not morbidly increased in
rheumatism.
  Distinctive Features relating  to Causation.—Gout occurs very rarely before
puberty, and it occurs generally between thirty and fifty years of age.  Bheu-
matism affects especially young subjects.  Gout is oftener hereditary than rheu-
matism.  It rarely affects women.   The use of fermented liquors and habits
of luxury as regards diet and exercise exert an agency in producing gout which
is not exerted to the same extent in the causation of rheumatism.  The poorer
classes  are as  liable to rheumatism as are the rich, if not more so ; the reverse
being true of  gout.
  To determine  the existence of the diathesis  prior to the arthritic manifesta-
tions of the dfsease, and to recognize the irregular or misplaced manifestations
of gout, are objects of diagnosis  involving not a little difficulty and  doubt.
Certain  symptoms  should excite strong suspicion  of the constitutional gouty
condition if they occur within the periods of life most favorable for the devel-
opment  of the disease  and in a person  of a  gouty family whose  habits  of
life  are such  as will co-operate with an  innate predisposition.  Among  the
symptoms referred to are those which  belong to dyspepsia,  with  a  scanty
secretion of urine  which  deposits  the urates, and the liability to gravel or
attacks of renal  colic.  If with these  symptoms an examination of the blood-
serum show a morbid  excess of uric  acid,  the development of an attack of
gout may be predicted with  considerable confidence.  The diagnosis of dis-
orders of internal  organs imputed to gout—or, to use a term which  has been
applied to these cases, of " visceral gout"—must rest mainly on their occur-
rence in proximity to attacks  of gout,  either preceding, accompanying, or
following the  sudden  cessation of well-marked gouty  manifestations.

  Prognosis.—The immediate danger to life  from gout  is slight.  If it ever,
per se, prove fatal, it is by its irregular or so-called misplaced  manifestations;
and  in  many, if not most, of the  cases in which death is imputed  to gouty
affections of vital organs it is probable, as already intimated, that these^affec-
tions do not strictly belong  to  gout, but are to be regarded as coexisting or
intercurrent affections.   The prognosis becomes grave if the small  granular
         1 This account from Garrod's work has been somewhat condensed. 
1116
G 0 UT.—RHE UMA TOID  ARTHRITIS.
 kidney be developed in the course of gout.  It is an error to suppose that
 gout is salutary as regards the duration  of life.  Frequently-recurring attacks
 of transient gout and the persistence of the disease in a chronic form  impair
 the constitutional powers, diminish  the  ability of the system to resist other
 diseases,  and thus  shorten  life.  It is  a  serious  disease in certain  chronic
 cases in  which it  leads to deformity and  rigidity of  the  affected  joints.   It
 has been a favorite notion  that the  liability to gout lessens the  liability to
 other diseases.   There is little  foundation for this  notion, and, on the con-
 trary, there is ground for the  belief that if gout do  not tend to produce
 other diseases it favors their inroads upon the  system.
   A tendency to recurrence  is a law  of  the disease.   It is extremely rare for
 a  single attack only to occur. If life  be  not cut off by some other disease, fre-
 quent attacks are almost invariably experienced, and the disease may become
 chronic.  The diathesis is thus rarely if ever extinguished.

   Treatment.—Ararious  therapeutical  measures heretofore considered  as
 having  a  curative influence over gout are now rarely employed.   Their dis-
 use has resulted  from the clinical study of their  effects  and from  improved
 pathological views.   Among the measures referred to are embraced bloodletting,
 emetics, mercurialization, and continued  or often-repeated purgation.   These
 measures are now regarded as contraindicated in both the transient and the
 persistent form  of gout.   Other measures, long more or less in  vogue, are
 still prized in the treatment of this disease.  In the latter list are colchicum
 and alkaline remedies.  The indications  for treatment  during attacks of tran-
 sient gout, during  the  intervals between these  attacks, and in cases of per-
 sistent  or chronic gout respectively  claim  separate consideration.
   Treatment during Attacks  of Transient Gout.—The  great  Sydenham, him-
 self for more than  thirty years a sufferer  from this  disease, was led to con-
 clude that an  attack should not be interfered with. Regarding it as an  effort
 of nature to get rid of  a noxious material,  he believed it to be undesirable  to
 arrest or  abridge it.  The propriety  of  non-interference was also  advocated
 by Trousseau.  _ Few physicians, however, would  feel satisfied  to  fold  their
 hands and await the cessation of the disease, and  still fewer p'atients would
 be content to forego measures to alleviate their  sufferings.   Nor is this line
 of conduct consistent with either reason or experience.   Transient gout is a
 self-limited^ affection.  It is  probably rarely, if  ever, arrested, and it might
 not be advisable  to arrest it were this  practicable.  Perhaps its duration  is
 not often abridged  by  therapeutical  interference  ; hut its severity may  be
 lessened and the  suffering connected with it may  be materially mitigated  by
 measures  which, if judiciously employed, will not  do  harm.  This is a mild
 expression of  the resources of medicine  in  cases of transient gout.
   Colchicum is  an ancient remedy for gout, assuming the hermodactylus of
 the Grecian and  Arabian physicians  to  have been this drug.  It  has  been
 not less prized by the majority of physicians in modern times.   Most if not
 all of the various secret  nostrums for  gout which have  commended  them-
 selves to popular  favor owe their efficacy chiefly to this remedy.   Its  special
 power of  controlling the inflammatory phenomena of  the  disease is undoubt-
 ed.   Our knowledge of the  value of this remedy is derived  wholly  from
 experience.   Its special mode of operation cannot be  explained.  A rational
 object of  treatment, deduced from the pathological character of gout,  so far
 as it is at present known, is the elimination of uric acid;  but the researches
 of Garrod show that this remedy does not  increase the amount of  uric acid
excreted by the kidneys,  nor does  it in all cases increase  the  quantity  of
urine.   It may be  here added that other rational objects of treatment are
prevention of  an undue formation of uric  acid or its undue  accumulation in 
GOUT.
1117
the blood, and neutralization of this acid, or keeping it in a state of solution
in the blood until it is eliminated through  some of the natural emunctories.
   In an acute attack of gout,  colchicum may be given at  first in a tolerably
full dose; that is, half a drachm or a drachm of the wine, or an equivalent
dose of the tincture or acetic extract.   It should afterward be  continued
in small doses.  It is never judicious to carry its use to  the extent of pro-
ducing  vomiting or purging.  Carried to  this extent, it is objectionable on
account of its depressing influence, although relief of the gouty inflammation
be procured.   Its special  influence is independent of its operation as an
emetic or a cathartic.  An  emetic of any kind  is not indicated  unless  the
attack occur  soon after  a  full meal  and  there be  reason to suppose  that
the stomach is overloaded with undigested  food.   If constipation exist, a free
evacuation by means of a saline purgative is desirable.  A saline purgative
is also appropriate as a depletory measure if the patient be robust or of a  full
habit and  the fever  be high.   The purgation  should be effected  by salines
rather than by the colchicum.  Some physicians regard  salicylic acid  and
salicylate of sodium  as beneficial  in acute attacks  of gout;  but  the favor-
able influence of these drugs is far  inferior in this disease to  that exerted in
rheumatism.
   Alkaline remedies are  rationally indicated with a  view of promoting  the
solubility of uric acid.  For this end the salts of potassium and of lithium are
to be preferred to those of sodium, the urate of potassium and the urate of lith-
ium being more soluble than the urate of sodium.  Moreover, these salts have a
diuretic action, and thus contribute to another rational object of treatment—
namely, the elimination of uric acid  by the kidneys.  The  bicarbonate of
potassa may be selected,  and the acetate  and the bitartrate  are appropriate.
The alkaline remedy may be given  in conjunction with the colchicum.   The
phosphate of  ammonia was introduced as a remedy in gout some years since
by Buckler of Baltimore, its efficacy being supposed  to consist in its form-
ing a  soluble  salt, readily  eliminated, by  the  combination of uric acid  and
ammonia, the phosphoric acid  combining with the soda  and  forming another
soluble salt,   Ten grains may  be given three or  four times daily.   This rem-
edy, however, is better suited  to the chronic form  of the disease or to the
intervals between attacks of transient gout.   This remark will also apply to
the benzoic acid, which is supposed to be  useful by converting the uric  into
hippuric acid.
   The carbonate of lithia, introduced  as a remedy by Garrod, has  proved to
be of much value.1   The urate of  lithia is highly soluble, and the remedy in
small doses acts efficiently  as a diuretic.   It is a remedy which produces no
unpleasant consequences, although continued  for a considerable  period.  It
may be given in five-grain doses three times daily.   An efficient and agree-
able mode of administration is to give it largely diluted in carbonated water.
The citrate of lithia has the advantage of greater solubility in water than the
carbonate.
   During the paroxysms of pain opiates may be given moderately if they be
well borne.   If they occasion unpleasant effects, the succedanea of opium
must be relied upon—namely, hyoscyamus, belladonna, and aconite.  From its
action upon the skin the  Dover's powder is an  eligible form of opiate.   The
inconveniences  of opium given by the mouth may sometimes be avoided by
the hypodermic method  of administration.
   As regards local treatment,  the affected joints may he covered  with cotton
over  which oiled silk should  be applied.  In addition, relief is  sometimes
afforded by applications containing opium, belladonna, or aconite, singly or
   1 This remedy was suggested as  a remedy for gout, on theoretical grounds, by Buckler
in 1853. 
1118
GOUT—RHEUMATOID  ARTHRITIS.
 combined.   Chloroform as a local application has been recommended.   Trous-
 seau highly recommended tobacco fumigations, not during the parox3rsms,
 but in the intermissions, with a view to diminish the suffering when the pain
 returns.
   The diet for a few days  should be considerably restricted, animal food being
 excluded.   Should  the  attack continue, however, it is important, as in other
 diseases, to provide  against the evils of innutrition.   A nutritious but unstiru-
 ulating diet should be  directed,  embracing  milk, farinaceous articles, eggs,
 fowl, and  fish.
   Treatment in the Intervals between Attacks of Transient Gout.—The ends of
 treatment  between the  attacks  are—the prevention  of  the recurrence of the
 disease, the prolongation of the intervals, and the diminution of the severity of
 attacks.   The  immediate rational objects are—prevention of the undue pro-
 duction of uric acid, its elimination by the natural emunctories, and the pro-
 motion of  its solubility in  the blood.   AVith reference to the latter objects, it
 is to be borne in mind that  the uric acid probably  has been accumulating in the
 blood for some time before gouty manifestations occur, and that probably the
 deposit of  the  urates within and around joints precedes, for a greater  or less
 period, the  inflammatory phenomena  which  belong to an attack or  fit  of  the
 gout.
   Removal of the known causes of gout  is an essential part of the treat-
 ment.   AVine and malt liquors, especially the  stronger kinds, are to be inter-
 dicted.   If the use of alcoholics be desirable  or allowable, spirits  should be
 substituted.  Gin is to be preferred on account of its diuretic tendency.  The
 diet should be plain,  wholesome, and restricted to an amount required for nutri-
 tion.  A certain amount  of bodily exercise is an important part of the hygienic
 management.   Travelling,  a long sea-voyage, and a  sojourn  in a tropical  cli-
 mate are in some cases advisable.  All  exciting  causes  are, as far as practi-
 cable,  to be avoided.
   If dyspeptic  or other symptoms render it probable that an attack  is im-
 pending, remedies with a view to prophylaxis are indicated.  Alkalies should
 be given in  small doses, largely diluted.   They should be continued for a
 short time, then intermitted, and  afterward resumed if the indications con-
 tinue or return.  The  salts of potassa  are  to be preferred to those of soda.
 The carbonate  of lithia may also  be given.  If the  near approach  of an
 attack be strongly suspected, colchicum in small doses  may be resorted  to.
 There  is reason to believe  that this remedy sometimes wards off an impend-
 ing attack.
   These remarks have reference to the treatment directed especially to gout.
 Disorders of any kind  not of a gouty character  of course claim appropriate
 treatment.
   Treatment of Persistent  or  Chronic Gout.—The removal of causes  which
 produce or  promote the gouty diathesis, and of exciting causes, ranks first
 in importance.    This is a sine qua non in the  treatment.  In addition, in
 obstinate  cases,  when circumstances  permit, travelling, a  sea-voyage, and
 residence in  a  tropical climate  may  be recommended  as likely to  effect a
 salutary constitutional change.  Hygienic  is doubtless  vastly more import-
 ed than medicinal treatment, but remedies  are undoubtedly of much utility.
   Alkalies, the carbonate of  lithia, and other diuretics are indicated precisely
 as in  the intervals between  attacks  of  transient gout when the symptoms
denote an impending attack.  It is important to  bear in mind the injunction
to give alkaline remedies in small doses,  largely diluted,  and to intermit their
use after they have been continued for a short time.   This injunction is also
applicable to the  carbonate of lithia and other diuretic remedies.  Exacerba-
tions of the  disease, which are liable to occur  from time to  time,  may  be 
GOUT.
1119
treated with  colchicum in small doses, its effects upon the alimentary canal
and  circulation  being carefully watched.   Other remedies, of the value of
which in certain  cases there is abundance of testimony,  are the iodide of
potassium, guaiacum, and  the  phosphate of ammonia.  Perhaps  the benzoic
acid is to be  added.  Fraxinus excelsior (European ash) is said to have efficacy
" administered in an infusion with thirty grains of the leaves in half a pint of
water, strained  and sweetened, and  taken twice or thrice daily." 1
   The most important point in the treatment of the  gouty diathesis  is the
regulation of the diet.   It has been generally held that the diet of  gouty
individuals  should consist largely of farinaceous food.  It has been custom-
ary  to withhold to a great  extent  animal food, which is rich in nitrogen.
This selection of a diet chiefly vegetable is based upon the assumption that
the  formation of  uric acid,  which it is  desired  to restrict,  is increased by
highly nitrogenous food.   Clinical experience, however, has  shown, as has
been pointed out  especially  by Draper,2 that saccharine and amylaceous arti-
cles of food  are in  general not so well  tolerated by gouty patients as  is ani-
mal food.  Draper, therefore, recommends in gout a diet similar to that suit-
able for diabetes mellitus—namely, one  composed mainl}* of animal food,
fatty substances, and vegetables which do not contain much sugar or starch.
The experience, however,  of many physicians is in favor of a predominantly
vegetable diet.
   It is important that food should not be taken in excess;  and still, it should
never be inadequate to nutrition, either  as regards quantity, kind, or variety.
The articles of food which  are to be especially recommended in the  treat-
ment of gout are lean meats, fish, soups, eggs, milk, bread,  and green and
succulent vegetables, such as tomatoes, cauliflower, cabbage, and the different
kinds  of salads.  If well borne, fatty food may be taken.  Saccharine sub-
stances,  especially pastry, starchy vegetables, particularly  potatoes, and acid
substances are to be avoided.   Ripe fruits may be taken in moderate  quan-
tity.   Alcoholics, particularly the heavy wines  and malt  liquors, are  to be
interdicted.  Pure water  should  he  taken freely, especially whenever  there
are gouty premonitions, in order to hold in solution in the blood the uric acid
and to promote  its elimination.   The sparkling  table-waters  are  likely to be
taken more freely than simple water, and they are  therefore useful.   Active
exercise  in the open air is a  means only second  in  importance to the regula-
tion of the diet.  The function of the skin should be kept  active also by fre-
quent bathing and friction.
   To relieve stiffness and soreness of the joints methodic friction or sham-
pooing is highly useful, provided undue  violence be not used.   Small blisters
from time to time  are recommended.   Collections of soft gouty matter—or
"gouty abscesses," as they have been called—if near the surface may be punc-
tured  and the  creamy matter  gently pressed  out.   Occasionally ulceration
follows, which is troublesome, but leads  to no evil results.   Deformities, nodo-
sities,  and ankylosis due to chalk-stones  and structural changes are effects of
the disease which do not admit of removal.
   Different mineral waters have  been much  resorted  to in the treatment of
gout, particularly the Arichy water.   Of the utility of the latter and of other
springs there is  much difference of opinion among those who have given more
or less attention to an investigation of their effects. The A'ichy water is alka-
line, its alkalinity being due to the bicarbonate of soda.   The imported and
the  artificial water are used  to a  considerable extent  in  this country ; but
springs which owe whatever therapeutical value they possess  to  other saline
ingredients, such as the sulphate of soda  or of magnesia, the chloride of sodium
     1 National Dispensatory, 1879.
     2 Article "Gout" in System of Practical Medicine, by American Authors, vol. ii. 
1120             GOUT—RHEUMATOID ARTHRITIS.

or of calcium, the chalybeate and the sulphur springs, are severally advocated
as useful  in cases of  gout.   The Carlsbad  springs are  much  resorted to by
gouty patients.  It is difficult to eliminate the beneficial  influence of hygienic
circumstances connected with a residence at watering-places, and thus arrive
at a fair judgment of the therapeutic value of the water.   For the  discussion
of this question the reader is referred to other works.1
   The treatment of irregular and misplaced gout involves indications derived
from the character and seat of the disorders; in other words, from  the symp-
toms in individual cases.  If gout have retroceded local measures to solicit its
return are indicated.  For this end warm and stimulating applications are to
be made to the part or parts in which the regular manifestations have  been
seated.

          Rheumatoid Arthritis—Deforming Arthritis.

   This disease has received  a variety of names,  of which may be mentioned
rheumatic gout, nodosity of the joints (Haygarth), chronic rheumatic arthritis
(Adams), nodular rheumatism, dry arthritis,  proliferating arthritis,  chronic
osteo-arthritis, arthritis pauperum, and malum senile articulorum.   AVhen the
affection attacks the hip-joint it has  been called malum coxae  senile.   AVhen
the vertebral articulations are affected it is called spondylitis deformans.  The
term rheumatic gout is much used by practitioners to  designate this  disease,
but it is objectionable.  It implies that  the disease is a combination of rheu-
matism and gout.  Rheumatism and gout  very rarely occur conjointly.  It
is quite certain that the disease under consideration has no relation with gout,
and  it is  probable that it differs in its nature from rheumatism.  The names
which have been placed at the head of this article seem to he the most appro-
priate  of  those  which have  been suggested.  Garrod introduced  the name
rheumatoid arthritis.  Arthritis deformans  is  the name chiefly used by  Ger-
man writers.
   Some writers make  no distinction between rheumatoid arthritis and chronic
rheumatism.   It must be admitted that it is impossible  to draw  a  sharp dis-
tinction between these affections.  Indeed, we have very  little positive know-
ledge concerning the etiology and pathology of many chronic affections  of
the joints.  It is  probable  that  under  the  names chronic rheumatism and
rheumatoid arthritis  are  embraced a number of essentially distinct diseases,
but  we have  no insight into the real nature  of these  diseases.   Anatomically,
those cases are usually designated as chronic rheumatism in which the exten-
sive osseous  formations  and  deformities  which characterize  rheumatoid
arthritis are wanting, but it will not infrequently happen that a case which
has been considered as one of chronic rheumatism takes on the characteristics
of rheumatoid arthritis.
   The anatomical  characters of rheumatoid arthritis are  as follows  :
Early in the case there  may be an accumulation within the  affected joints
of clear  or  slightly  turbid  fluid which  in the progress of  the  disease is
absorbed.   Fluid effusion, however, does not necessarily  occur  at any period
of tiie disease, and as a rule  upon post-mortem examination the cavities of the
joints are found so dry that the disease has received the name of dry arthritis
(arthritis  sicca).  Important changes occur  in all the structures which  com-
pose the joints.   The articular cartilages are absorbed, especially their cen-
tral  parts, where  opposing  cartilaginous  surfaces come into contact.  The
ends of the bones, being denuded of cartilage, come into  contact,  and acquire
  1 For a discussion of mineral waters in general in gout, and the relative value of dif-
ferent European springs, vide Garrod, The Nature and Treatment of Gou{ and Rheu-
matic Gout, London,  1859. 
RHEUMATOID ARTHRITIS.
1121
a hard, smooth, polished appearance in consequence of the friction to which
they are  subjected.   This condition of bone  is called  eburnation.  Around
the margin of the articulation  there is a new-growth, in nodular masses, of
cartilage and of bone.   In this way the articular extremities of the bones
become enlarged by the formation of a rough, irregular, bony and cartilagin-
ous ring  which surrounds the eburnated surfaces.  After  the  disappearance
of the cartilage the process of absorption may invade the articular ends of the
bones.  Thus, when the hip-joint is aff'ected, not only the head, but a consid-
erable portion of the neck, of  the  femur may be  absorbed.  In consequence
of the thickened condition of the end  of the bone from the marginal osseous
growths, the appearance is often as if  the eroded head of the femur had been
pushed down nearer to the shaft.   Irregular bony outgrowths or  nodosities
are formed around the sockets. The sockets are sometimes widened and some-
times deepened and  contracted.    Dislocations  may have  occurred and  new
sockets have been formed.   The synovial  membranes and the ligaments of
the joints are also affected.   The little polypoid or villous outgrowths which
are normally present to a certain extent upon the inner surface of the synovial
membrane often  become greatly increased  in number  and size,  so that the
inner surface of the thickened membrane may acquire a shaggy  appearance,
especially where it extends for a short distance over the articular  extremities.
To these hypertrophied  synovial villi  the  name dendritic  vegetations of the
synovial membrane is sometimes applied.  Some of these hypertrophied villi
may become changed into cartilaginous or  even into osseous nodules, which
are often connected by narrow  pedicles with the inner surface of the synovial
membrane.  The pedicles sometimes rupture, so that the bony or cartilaginous
nodules are detached and exist as foreign bodies in the articular cavity.  The
ligaments may also become thickened.  Plates of cartilage and of bone may
develop in these thickened ligaments.  An ossifying periostitis exists to some
extent around the ends of the bones.  Osseous  ankylosis is said never  to
occur in arthritis deformans, but the  joints may be rendered immovable by
the thickened condition of the  ligaments and by the new bony growths.  The
interarticular  cartilages are  generally destroyed, and also the round ligament
of the hip and the long tendon of the biceps brachii when  the joints in which
they  are situated are  affected.  The disused  muscles are atrophied.   The
atrophy  is said to be sometimes  greater than can be accounted  for by the
disuse of the limbs, so that some writers consider that a neuropathic element
is involved.
   The microscopical examination of the cartilage in this disease shows a prolif-
eration of the cartilage-cells and a breaking up of the  basement-substance into
fibrils. The spaces enclosed by the capsules of the cartilage-cells become greatly
enlarged, especially in a  vertical direction.   These enlarged spaces contain
proliferating cartilage-cells.  The intercellular substance is thus  reduced  in
amount.   According to Cornil  and  Banvier, the capsules on the  surface rup-
ture into the articular cavities, into which the  cartilage-cells  are  discharged.
The intercellular substance between the ruptured capsules projects for a time
in the form of little villi from the surface of the cartilage, to which they give
a filamentous, velvety appearance.   In the progress  of the disease the fila-
ments are destroyed and  the cartilage-spaces are gradually opened until the
whole central  part of the  cartilage is removed.  At the periphery the articular
cartilage is covered by synovial membrane.   Here the cartilage-spaces filled
with cells do not rupture, but the  proliferative process results in the forma-
tion of new cartilage, instead of in absorption.  This new cartilage may undergo
ossification.1  The so-called chalky deposit of gout is wanting, but rheumatoid
  1 According to Ziegler, cartilaginous and fibrous nodules develop in the bone beneath
the cartilage.  These nodules may be converted into cysts.  A rarefying  ostitis occurs,
       71 
1122             GOUT—RHEUMATOID ARTHRITIS.

arthritis may occur in persons who have this deposit as an effect of attacks of
gout which have previously occurred.

  The disease is  usually, from the first and  during its  course, subacute.
Sometimes the  local  and general  symptoms  denote a certain  degree  of
acuteness  causing a resemblance  to  acute rheumatism.   A  sudden  inva-
sion successively of different joints, however, does  not take  place as in the
latter affection, and there is  no liability to pericarditis  or to  endocarditis.
  The development and the progress of the disease are  slow.   The  smaller
 joints may be first affected, and subsequently the larger joints, or the reverse
of this may obtain.   A feature of the disease is its progressive  character as
regards increase of  the anatomical changes in the joints affected and exten-
sion to other joints.   It may, however, remain stationary, in both  these
respects, for  a long time.  Pyrexia, except at times,  is  wanting, and  there
may be but  little'constitutional disturbance.   The appetite, digestion, and
nutrition  are  sometimes hut little affected.  The affected joints are painful,
especially on  motion.
  A particular deformity of the fingers is characteristic—namely,  a lateral
deflection in the ulnar direction.   The toes sometimes present also this  pecu-
liarity.   The situation and motions of the thumb generally are unaffected.
  In the progress of the disease the anatomical changes lead to  permanent
extension or^flexion of parts, dislocations, nodulations,  and notable distor-
tions.   Extending,  as  it  sometimes does, over all  the  joints of the  body
(polyarthritis deformans), the trunk is  bent and rigid, the  neck is  immov-
able, the jaws are more or less fixed, the limbs are distorted, the muscles are
attenuated from disuse, and  the patient presents a most distressing spectacle
of utter helplessness.  Between this picture of  extreme progress and the early
 appearances of the disease there is every degree of  gradation.
  The disease may occur at all ages, but in the majority of cases patients
 are  in middle life,  and much oftener  women  than men.  It occurs in the
 poorer classes of  society and among those who suffer from hardships, expos-
 ure, and deprivations;  but it is by no means confined to these.   Persons are
 rarely affected when in full  health and vigor.   Its victims are those whose
 constitutions  are  broken down by various circumstances affecting body and
 mind.  Large hospitals in which  chronic  cases are  received are seldom with-
 out examples of this disease in  the* different stages of  its progress.
   More  than forty  years  ago Prof. J.  K. Mitchell  maintained that diseases
 of  the joints resulted from  affections  of the spinal  cord.   More recently
 attention has been  directed  by Remak, Benedikt, AVeir  Mitchell,  Charcot,
 and others to morbid conditions of  the cord and injuries of nerves as giving
 rise to arthritic  affections.  On the basis of facts exemplifying this patholog-
 ical connection, together with the symmetrical occurrence  of the joint affec-
 tions and apparent etiological  relations in  some instances,  the theory that
 rheumatoid arthritis is of nervous origin  is not irrational.   This theory  is
 supported by the  well-known occurrence of trophic disturbances of  the mus-
 cles as effects of diseases or injuries of  the cords and nerves.
   Different varieties of arthritis deformans can be distinguished.  In one group
 of  cases (the polyarticular) the affection begins primarily in the small  joints
 of  the hand and foot, where it  either remains or extends subsequently  to the
 larger joints,  as the knee, elbow, shoulder, and hip.   In other cases  the large
 joints are first  affected,  and here there is often a tendency in the disease  to
 confine itself to a  single joint, especially to the hip-joint  or the  shoulder-
 resulting in enlargement of the medullary spaces and absorption of the bony trabecule.
 Ziegler observed  changes which he interprets as proliferation of the bone-cells ( FV-
 chow's Archiv, 1877,  Bd. 70). 
RHEUMATOID ARTHRITIS.
1123
joint (monarticular form).  In  some cases the vertebral column, and often
at the same  time the pelvic  articulations and  the hip, are solely involved
(spondylitis deformans).  Charcot considers  that the affection characterized
by nodosities of the small joints, particularly the distal phalangeal joints of
the hand, should be separated from other forms of deforming arthritis.  He
proposes for  the last variety the name Heberden's  rheumatism or nodosities,
from the author who first accurately described them.   AVhether these are to
be regarded as varieties of the same morbid process or as different diseases is
uncertain ; but at present they are most conveniently grouped under the same
heading.
  The diagnosis involves discrimination from rheumatism and gout.  From
chronic rheumatism it is not readily discriminated prior to the occurrence of
its  deforming effects, especially if the affection have not been  preceded by
acute rheumatism.  These  effects constitute the diagnostic criterion.   It is
distinguished from gout  by the larger  joints being primarily affected in a
certain  proportion of cases; by the smaller joints of the hands being affected
without a previous affection of the toes; by the absence of the paroxysms or
exacerbations which  are characteristic of gouty attacks; by the absence of
the  chalk-like deposit and of  an excess of uric acid in the blood;  and by its
occurrence in a certain proportion of cases in young subjects and especially
in women.
   Although  not involving  immediate danger to life, rheumatoid  arthritis is
a hopeless disease  as regards recovery.   All that can be hoped  for is  a  cer-
tain measure of improvement, non-progression, and indefinite tolerance.
   The  first object of treatment is the improvement of the general health.
Tonic remedies, long continued and varied from time to time, in conjunction
with a nutritious diet and  other hygienic measures calculated to invigorate
the  system,  are  to  be employed  for this object.  Bemedies which have a
special  influence in cases of  rheumatism and gout—namely, alkalies, colchi-
cum, and salicin or the salicylic acid—are unavailing in this affection.  All
depressing remedies  are  contraindicated.  Iodine in the form of either the
iodide of iron or the iodide of potassium, guaiacum, and arsenic appear to be
useful in certain cases.  Cod-liver oil may be given in conjunction with tonics
if there be a tendency to waste.  Chalybeates are especially indicated if the
patient be anaemic.  AYarm baths  are recommended by many writers.   The
alkaline mineral waters and  those which-act  powerfully upon the bowels or
kidneys are  hurtful.   On the other hand, chalybeate  and tonic waters  may
prove beneficial.
   Local measures of treatment are important.   Leeching or  cupping and
severe  counter-irritation  are  not indicated.  Small blisters and  the applica-
tion of iodine may be useful  if there be effusion within the joints.   Rest is
indicated while effusion exists or when the symptoms  denote  inflammation;
and afterward passive motion,  friction,  warm douches, shampooing, and the
constant current constitute the most important part of the treatment. 
1124          SCORE UTUS.-P URP URA.-HYEMOPIIILIA.





                      CHAPTER   XII.

            SCORBUTUS.—PURPURA.—HAEMOPHILIA.

Scorbutus, or Scurvy: Anatomical Characters; Clinical History; Pathological Character;
   Causation; Diagnosis; Prognosis; Prevention;  Treatment.—Purpura (Simplex,  Pur-
   pura Rheumatica, and Purpura Haemorrhagica.—Hemophilia.

   THIS concluding  chapter  will he  devoted to three affections which, as
    regards symptomatic events, are closely allied  to  each  other—namely,
scorbutus, or scurvy,purpura, and haemophilia.  The first of these  affections is
of interest and importance  especially in view of  the  fact that our knowledge
of its pathology and causation, although by no means complete,  is sufficient
to serve as a basis of effective treatment, and has  rendered the disease  pre-
ventable.

                      Scorbutus, or Scurvy.
   This disease  appears to have been know*n  to the ancients,  but  it began to
prevail frequently and extensively when, with improvements in  navigation,
long voyages were undertaken, and hence it was called  sea-scurvy.  During
the last five or six centuries  it has been pre-eminently the disease destruc-
tive to life in armies, navies, and exploring or emigrating expeditions by land
and by water.   Notwithstanding that it has been  rendered preventable by our
knowledge of its pathology and causation, it has prevailed largely and proved
greatly destructive to life within the present century.   Hammond states that
at Council Bluffs in  1820 nearly the entire garrison  was attacked, and many
died; and the efficiency of the United States forces  in the Florida and the
Mexican AVars was very materially lessened by its  occurrence.1   It prevailed
enormously in the English and French armies in the Crimean campaign.  It
contributed not inconsiderably to the mortality of our armies in  the late Civil
AATar.  The inconsistency  between these facts and the existing state of  know-
ledge is in part to be explained bythe inability  always to  secure the  means
of prevention  in  military operations; but it is  in a greater measure to be
accounted for by a  censurable ignorance or neglect of these  means.
   There has been of late  years great success  in  preventing scurvy in the
naval services of the chief nations of the world.   According  to AAfales,2 in
1881, out  of 82,629 cases of disease in the chief naval services  of the  world,
there  were only ?A cases  of scurvy—a ratio  of 41  per 1000.   The statistics
of the mercantile marine are less favorable.

   Anatomical Characters.—It is probable that the primary and essential
morbid changes relate  to the blood.   Our present knowledge, however, does
not enable us to state  in what consist the changes  peculiar to the disease.
Observers differ as regards  the appearances as well as the results of chemical
and microscopical examinations.   The color has been found sometimes darker
and sometimes lighter than that of normal blood.   The blood in the  heart-
cavities and vessels has been in some instances fluid and in other instances

  1 "Report on Scurvy,"  United States Sanitary Commission, by AVilliam A. Hammond
M. D., 1862.
  2 Article  "Scurvy," in A  System of Practical Medicine, by American Authors, vol. ii.
p. 168. 
SCORBUTUS.
1125
coagulated.   The blood-corpuscles  have been considered  by some observers
diminished in number, and by others unaffected in this regard.  No uniform
changes in the form or  constituents have been determined.   It  is not estab-
lished that a deficiency of potassa is a constant feature.  Contradictory results
have been obtained respecting the white corpuscles, the quantity of fibrin, and
the proportion of albumen.   In short, quoting Immerman, " If we take a gen-
eral survey of the total analyses made of the blood of scurvy patients up to
this time, we can hardly avoid a feeling of dissatisfaction.   From the various
and contradictory statements by different authors, we obtain but one,  and that
a decidedly negative result—namely, that the condition of the blood of scurvy
patients, so far as we understand it at the present time, shows no peculiarities
which might not occur as well in other pathological processes."
   Extravasations of blood are found within and beneath the skin, where they
are apparent before death, and between the fibres of muscles.  The gums are
swollen, ulcerated, and sometimes sloughing.   A bloody serum is often found
in the joints, associated  sometimes with intra-articular ulcerations.  A sero-
sanguinolent liquid, often in considerable or large quantity, together with
inflammatory products in a  certain  proportion of cases, is contained in the
pericardial and pleural cavities.   The  spleen is often enlarged and softened.
Parenchymatous and fatty degenerations of the heart, muscles,  liver,  and
kidneys have been found.  The kidneys may be infiltrated  with  blood  and
inflamed.   Ecchymoses are observed in many internal situations—namely, on
the serous membranes, the  bronchial  mucous membrane, within  the  whole
tract of the  alimentary canal, and  in the urinary passages.   The  extravasa-
tions  are evidently  secondary to,  and  dependent upon,  the morbid  blood-
changes.  The mode, however, in which the  latter give rise to the former is
not clearly understood.   Either  the blood is so altered that it escapes from
the vessels, or the  nutrition  of the walls of the vessels is impaired, so that
they do not offer adequate resistance to  the  pressure of the  blood, or, again,
paralysis affecting the vaso-motor nerves may be a pathological element.  It
is not impossible that each of these conditions enters  into the mechanism.

   Clinical  History.—The symptomatic events which are characteristic of
the disease  are preceded by general weakness and  lassitude.   Patients are
listless, apathetic, and indisposed to either mental or physical exertion.   The
appetite fails and  pallor of the surface is  marked.   These symptoms pro-
gressively increase.  The more characteristic events are swelling and spongi-
ness of the  gums, which bleed  either spontaneously or  on  slight pressure,
hemorrhage from the mucous surfaces in other situations, and extravasation
of blood within and beneath  the skin.   The fungous appearance of the gums
is chiefly  marked around the teeth.  It is less marked in situations where the
teeth are  wanting.   The teeth may become  loose, and they sometimes either
fall out or can he easily removed. "The  prolabia  are notably pale, presenting
a  striking contrast to the redness  of the gums.  Hemorrhages are  frequent
from the different outlets—namely, the nostrils, mouth, vagina, and intestinal
canal.   It is  rare from the  bronchial  tubes.  The ecchymoses apparent on
the cutaneous surface are either in the form of petechiae or of patches of vari-
able size; and generally these forms are conjoined.   They are either limited
to or most abundant on the  trunk and  lower extremities.  The  ecchymoses
undergo the same successive alterations in  color as when due to contusions.
A  slight bruise suffices  to produce them in  any part of the surface  of  the
bodv.C  They  occur sometimes beneath the conjunctiva and within the globe
of the eves ; into the joints,  between the muscles, in the serous cavities, occa-
sionally  between the meninges of  the  brain, and beneath  the  periosteum.
Fetor of the  breath is usually a marked symptom. 
1126         SCORB UTUS.—PURPURA.—HEMOPHILIA.

  The skin is dry and rough, compared by Larrey to that of a plucked fowl.
The ankles are often oedematous, and  some oedema of the face is not infre-
quent.  The patient complains of pain in the loins and in the extremities,
especially the lower limbs.   The muscles of the lower limbs are swollen and
hard.   Palpitation  and dyspnoea  are  excited  by slight exertion.    Haemic
murmurs are heard over the heart.  Pain  referred to the chest is  not un-
common.  The bowels are in some cases constipated, in other cases loose, or
looseness may  succeed constipation in the progress of the disease in the same
case.   The urine is diminished in quantity.   The excretion of urea  and of
chlorides is  diminished.  The excretion of potash, either absolutely  or rela-
tively to that  of soda, is  increased.  The phosphates are also increased in
quantity.   The  specific gravity is  usually higher than normal, and the color
is more intense.  The urine often is albuminous.   There is absence of pyrexia
except as symptomatic of  an inflammatory complication.   The pulse is some-
times  slower than in health, but  it becomes rapid on any exertion.  It is
always soft and compressible.   The temperature of  the  body is somewhat
lowered.  The spirits are depressed.   The  patient frequently longs for fresh
vegetables and fruit.
  These symptoms are more  or less  marked.   In extreme cases or in an
advanced stage of the disease the prostration is great.   Slight exertion occa-
sions syncope.   The patient may fall into a state of collapse.   This is likely to
follow abundant hemorrhage.   Old ulcers and cicatrices  sometimes  reopen,
and  bones which  had been fractured and  united may  become  separated.
 Ulcerations  occur within  the mouth and  over the ecchymoses on  the skin.
AVeakness of  vision, day-blindness, and night-blindness are not uncommon.
Inability to sleep  is common, but generally the mental faculties,  although
weakened, remain intact.    In  cases which are comparatively mild  general
debility, mental  depression, pain in the back and lower limbs, together with
the  other symptoms, are more or less marked, but not excessive; and asso-
ciated with these  symptoms are spongy  swelling of  the  gums  and  ecchy-
moses beneath the  skin.
  Scorbutus may exist as the  sole affection, but it is frequently combined
with  other diseases.  It may be  combined  with  dysentery, and the latter
affection is  then called scorbutic dysentery.   It may coexist with typhus  and
with  typhoid fever.  It may be accidentally associated with a variety of dis-
eases which are liable  to  mask  the scorbutic affection.  The recognition of
its coexistence with other diseases is of great importance with  reference to
appropriate  treatment.
  Secondary affections or true complications which are likely to occur are
lobar  pneumonia, pulmonary hemorrhagic infarctions, pulmonary gangrene,
pericarditis  and pleuritis  with  bloody effusion, and acute diffuse nephritis.

  Pathological Character.—The essential characteristic blood-change in
this  affection  is not as yet determined.   There  is doubtless a deficiency as
regards certain of the constituents of the  blood, but the particular deficiency
which belongs specially to the affection is  a matter of question.  Garrod con-
siders that the special deficiency relates  to  the  salts of potassa.   That this
deficiency enters into the  pathological  condition is probable, but that it con-
stitutes the pathological condition exclusively or chiefly in all cases  may be
doubted, in  view of the  fact that  supplying the salts of potassa, although
highly useful, is not always the most effective method of treatment. AYith
our present knowledge we must be content with saying that  owing to incom-
plete nutritive supplies the constitution of the blood is impaired, giving rise
to certain ascertained  morbid changes common to this and other affections,
and  causing other changes, not yet ascertained, which are peculiar  to  this 
SCORBUTUS.
1127
disease.  It is noteworthy that the phenomena  of scurvy are not produced
by prolonged abstinence from food. This fact goes  to show that the unknown
blood-change in this disease is of a special character.
  A view which has been recently advanced is  that scurvy is an infectious
disease caused by a  specific micro-organism.  This view, however,  has not
received any substantial support from the study of the disease.

  Causation.—Scurvy  is a dietetic  disease.  It is the  broadest expression
of the causation to say that the  disease is clue to the want of  certain ali-
mentary supplies.  A less comprehensive but probably correct statement is to
say that the disease is caused by an  insufficiency of nutritive principles con-
tained in vegetable food.  For a long time the disease was attributed to the
free use of  salted meat.  It is, however, certain that the disease is  not pro-
duced by this diet, except in so far as it displaces other articles of food contain-
ing principles necessary for the  normal constitution of the blood ;  and scurvy
has  repeatedly been  developed  when  the diet has been too much restricted
to fresh meat.   Garrod's theory of the pathological character of the disease
involves the conclusion that it is  attributable to a diet wanting the requisite
quantity of the salts of potassa, these salts being abundant in vegetable food.
Admitting a deficient supply of the salts of potassa to be  an  important ele-
ment  in the causation, other elements are involved.  The dietetic principles,
the  deficiency of which  causes this disease, are  abundant in  various  articles
of food distinguished as antiscorbutic, experience having shown that they
prevent the development of the  disease.
   Although causes relating to diet are essential to the  production of the dis-
ease, other  causes act powerfully as auxiliaries.  Among  the auxiliary causes
are exposure to cold and wet, overcrowding, deficient ventilation, and depress-
ing moral influences. The disease is oftener developed during the winter than
during the  summer.  I have known an instance in which the disease appeared
to be produced by great and prolonged mental depression, but  probably in
this instance, from an utter indifference to food, dietetic causes were involved.
The disease is oftener developed in the aged than in young persons, and the
cause of the disease will act more speedily in persons in whom the constitu-
tion has been  impaired by  previous  disease, by injurious  medication, and by
excesses of any kind.  There  is  reason to believe that the morbid condition
of the blood which exists in scurvy is not infrequently produced, to an extent
falling short of that requisite to give rise to the  striking manifestations of the
disease, by an undue restriction of the diet to a few  articles of food, either
from poverty or false notions of dietetics.   It is important for the physician
to recognize this fact in medical practice.

   Diagnosis.—In view of the striking symptomatic features of  this disease,
and of the fact that generally a  greater or less number of  persons  become
affected under circumstances which  sufficiently account  for its development,
the  diagnosis is easy, provided the characters of the disease be marked.  In
isolated cases the  diagnosis involves discrimination  from purpura haemor-
rhagica.  This differential diagnosis will  be considered  in  treating  of the
latter affection.
   The morbid condition of the blood peculiar to scurvy  may exist to  a
greater or  less extent when the  most striking  symptomatic features of the
disease  are  not present—namely, the subcutaneous ecchymoses  and  hemor-
rhages from mucous outlets.  Under these circumstances the disease may be
overlooked.    Thus,  Hammond, AVoodward, and  others  state that  in cases
called  in army sick-reports cases of general debility the  disease  is not infre-
quently incipient or not fully-developed  scorbutus.   The pain  in the back 
1128         SCORR UTUS.—PURPURA.—HEMOPHILIA.
 and  muscles of the lower  limbs may lead the practitioner for a time  to
 consider the disease as muscular rheumatism or myalgia.  AVhen associated
 with other diseases, such as dysentery and the essential fevers, it is liable  to
 be overlooked.  The appearance of the  gums is highly important with refer-
 ence to the diagnosis in the cases  in which petechiae or vibices are wanting;
 and when, from the appearance of the  gums  and other symptoms, the scor-
 butic condition is  suspected, an investigation of the diet may lead to the
 knowledge of facts which will tend to settle the diagnosis.  This investigation
 is  important, not only in army  or  naval practice and in public institutions,
 but in private cases in which  the symptoms point to  scurvy.  It is to be
 added that in children before dentition and in  aged persons who have lost
 their  teeth  the characteristic appearances  of the gums may  be  wanting.
 They are also wanting  in  rare  instances irrespective of these circumstances.

   Prognosis.—In cases of scurvy in which the ecchymoses are many and
 large, or in which hemorrhage from the mucous outlets is profuse, the danger
 to  life is  great.   Life  may be destroyed by rapid hemorrhagic effusion into
 the pleural or pericardial cavities.  Meningeal hemorrhage  is  sometimes the
 immediate cause of death.  Sudden death  sometimes occurs from syncope
 induced by muscular exertion.   If the causes which have produced the  dis-
 ease  continue in operation, it proves fatal  in a large  proportion of cases.
 Before the pathology and causation were  as well understood  as  now  the
 mortality from this disease among  soldiers and  seamen was often very large.
 Associated with other diseases,  it contributes indirectly to' their  fatal termi-
 nation, and it stands in the way of recovery from wounds and surgical ope-
 rations which otherwise would  not prove serious.
   Promptly  recognized and judiciously  treated, the disease may be expected
 to end in  recovery in a large  proportion of cases.   It has no definite dura-
 tion.   It  continues for a longer or shorter period, according to the extent to
 which it  has advanced, the amount and situations of hemorrhagic extrava-
 sation, the previous condition of the patient, etc.   The recovery is  usually
 gradual, not  infrequently tedious, and the system is likely to remain  debili-
 tated  for  a long time.

   Prevention.—The disease may be  prevented by a diet  embracing the
 requisite variety of alimentary  principles, and this 'is secured by a proper
 variety of animal and vegetable food.   AVith the knowledge of this fact, and
 with due attention to its practical application, scurvy should never occur except
 under circumstances which render  the means of its  prevention unavailable.
 Its occurrence is always an occasion for reproach when  articles of food  con-
 taining adequate supplies for the healthful constitution of the blood  can be
 obtained.   It is chiefly in military campaigns and lon»  sea-voyages that there
 are difficulties in  the  way of prevention.   These  difficulties, however, may
 generally  be  met by providing antiscorbutic articles of diet ;  and with 'refer-
 ence to these difficulties the knowledge of the various articles  which may
 furnish the needed alimentary principles  is of vast importance.  The preven-
 tion of this disease  has been made practicable under all circumstances by the
 preservation of meats, vegetables, and fruits in hermetically-sealed cans
  Lemon-juice or lime-juice has  long been known as a most valuable antiscor-
 butic.  Experience has abundantly shown that one or two 'ounces per diem of
 the fresh juice will prove an effectual preventive against scurvy during verv
 long voyages without fresh provisions.   For convenience of  transportation,
 the juice can be reduced in  bulk  by evaporation.  Orange-juice is  also an
 effectual antiscorbutic.   Pure citric acid, although it appears to be useful  is
not a substitute for the fresh juice of the fruit.  One of the most efficient'of 
SCORBUTUS.
1129
antiscorbutic vegetables is the  potato.  It is  most efficient when eaten raw.
Pickles, onions, raw cabbage or sauerkraut, the water-cress, and other of the
Cruciferse, are to be reckoned among the valuable  antiscorbutic  vegetables.
Green corn, green  apples, and most  of the esculent  fruits  are preventives.
They are  more so  unripe than  ripe.   Spruce  and birch  beer and yeast are
antiscorbutics.   Many vegetables which  do not enter much  into ordinary
diet may  often  be  used  as  antiscorbutics in  military campaigns  when the
articles which have been named are not to be obtained.  Among the vege-
tables now referred to which experience has shown to be effectual in the pre-
vention of scurvy are the sorrel (Rumex acetosella), lamb's quarters (Cheno-
pjodium album), the bulb of the wild artichoke, a  species of cactus known
as the Agave Americana  or maguey,  indigenous  in  Texas, California, and
Mexico, the prickly pear  (Cactus opuntii), and the dandelion  (Leontodon
taraxacum).
   AVales  suggests  that " in the event of the occurrence of scurvy and the
exhaustion of the fresh-vegetable stores, various quickly-growing vegetables,
such as mustard, radishes, turnips, and cresses, could  be cultivated on  ship-
board if  seeds are  provided."1
   That the antiscorbutic virtue of certain vegetables and fruits depends, to a
greater or less extent,  on  the presence of the salts of potassa is  altogether
probable.   These salts, isolated, are useful in the prevention as well as in the
treatment, hut experience has shown that they cannot take the place of anti-
scorbutic  articles of diet.
   Finally, in addition to dietetic means,  attention to ventilation and cleanli-
ness, avoidance of  unnecessary exposure and physical exertion, and measures
of a nature to produce  cheerfulness, constitute an  important part of the
prophylaxis.

   Treatment.—The dietetic means of prevention constitute an essential part
of the treatment.    The juice of  lemons, oranges, and other fruits should be
taken freely, but of course not to  such an  extent as to produce disorder of the
stomach.   The antiscorbutic vegetables and fruits should enter into the diet
as abundantly as the digestive powers permit, in conjunction with meat, milk,
and farinaceous  food.    Bemedies to improve the appetite and  strengthen
digestion  are indicated—namely, quinia, salicin, the bitter infusions or tinc-
tures, the mineral  acids, and chalybeate preparations.  The salts  of potassa
are  useful.  The  bitartrate or the citrate may be selected.  AA'ine, spirits, or
cider in  small quantities, if an agreeable  cordial  effect be produced, will be
useful.   In short,  the chief objects of treatment are  the assimilation of ali-
mentary  principles needed for the healthy constitution of the  blood and the
invigoration of the system.
   Particular symptoms or disorders claim appropriate measures  in addition
to those  having reference to  the  objects just stated.   Constipation is to be
relieved by mild laxatives or simple enemas, and, on the other hand, diarrhoea
is to be controlled  by anodyne and astringent remedies.   The dryness of the
skin indicates sponging with tepid water or the tepid bath.  Pain in the back
and limbs may be  alleviated by friction with anodyne and mildly-stimulating
liniments.  Stiffness of the joints, which sometimes occurs, is to be prevented
or removed by passive movements.   The condition  of the  mouth  calls for
astringent collutories.  Ulcerations in the  mouth  or on the  skin are to be
treated locally on  general principles.  Hemorrhage from the different outlets
is to be restrained  by haemostatic remedies.
   It is hardly  necessary to add  that the scorbutic condition,  when  asso-
ciated with  dysentery, typhus or typhoid fever, or with any disease, claims
                                  1 Loc. cit. 
1130         SCORB UTUS.—PURPURA.—HEMOPHILIA.

the same dietetic and other measures  of treatment as does scorbutus exist-
ing alone.

 Purpura  Simplex,  Purpura  Rheumatica, and  Purpura
       Haemorrhagica  (Morbus  Maculosus Werlhofii).

  The term purpura is applied to circumscribed extravasations of blood into
the skin.  Purpuric spots are bright-red, livid, or dark  purplish-red in color,
do not disappear on pressure, and are unattended by itching or other signs of
local irritation.  Small extravasations of blood, from the size of a pin-point
to  that  of a  finger-nail, are called  petechiae.   Larger  extravasations are
called ecchymoses.   If the hemorrhages  take  the form of lines or broad
stripes, they are called vibices.   The purpuric  spots generally  are not ele-
vated, but they sometimes  appear as small papules around  the  hair-follicles
(purpura papulosa, lichen lividus), or as wheal-like nodules (purpura urti-
cans), or rarely there  are formed bullae  containing blood (purpura bullosa).
The  extravasated  blood  undergoes  the usual  changes of color,  becoming
brown, green, and yellow.
  Purpura may be due to a great variety of  causes.  It is customary to dis-
tinguish between secondary  or symptomatic purpura and primary  or idiopathic
purpura; but it is probable that in many cases  so-called idiopathic purpura
is really symptomatic of some underlying morbid condition.
  The following may be mentioned as the leading  causes of secondary pur-
pura : injury, including  the bites of insects;  passive congestion; various
drugs, such as iodide  of potassium, phosphorus, copaiba balsam, ergot,  chlo-
ral hydrate, and mercury ; snake-bites; embolism or thrombosis of cutaneous
vessels ; cachexiae, as tuberculosis, cancer, Bright's disease, and cirrhosis of the
liver; profound anaemia, as pernicious anaemia and leucocythaemia ; diseases of
the nervous system; infectious diseases, as smallpox, typhus fever, and typhoid
fever; acute ulcerative endocarditis, measles, scarlet fever, acute articular rheu-
matism, malaria, cholera, yellow fever, cerebro-spinal meningitis, and icterus
gravis;  and, finally, scorbutus.  Purpura may be accidentally present in the
course of any disease.
  Purpura is distinguished  as primary or idiopathic when it is not dependent
upon any other disease.  As has already  been mentioned, there is some doubt
whether even in these cases  the purpura be not symptomatic, but with our
present  knowledge it is  convenient  to  treat of purpura  as  sometimes an
idiopathic disease.
  Idiopathic  or primary purpura is usually subdivided into  three varieties—
namely, purpura simplex, purpura rheumatica,  and purpura haemorrhagica,
or morbus maculosus AATerlhofii.   No  sharp lines of distinction can be drawn
between these varieties.  They merge  into  each  other by every  grade of
transition, so  that it  is often  difficult  to  classify  cases according to these
subdivisions.
  Purpura, simplex is the mildest form of idiopathic purpura.   Hemorrhage
occurs only in the skin, and not from  mucous membranes.   Purpura simplex
occurs both in the robust and in  the  debilitated.  The  purpura  may be pre-
ceded or accompanied by languor, loss of appetite, aching of the  limbs, and
slight fever, or there  may be no constitutional disturbance  whatever.   Pur-
puric spots occupy chiefly the lower extremities, or they may extend to the
trunk and upper extremities, and in rare instances to the face. Only a single
crop of purpuric patches may develop, in which case recovery takes placedn
between ten  and fourteen days, or the disease may be prolonged for several
weeks by the appearance of  successive crops.   Even in mild cases of purpura,
hemorrhages from  mucous surfaces, particularly haematuria, may occur, thus 
PURPURA.
1131
showing the close relationship which exists between the different varieties of
the disease.  Purpura simplex is  not  uncommon  in elderly  persons.  It is
then called purpura senilis.
  Purpura rheumatica—or, as it is also called, q^liosis rheumatica—is charac-
terized by the combination with purpura of rheumatic pains in the joints, and
sometimes with actual inflammation of  the joints.  There are often moderate
fever, debility, and gastric disturbances.   The joint affection may precede or
accompany the purpura, or it may disappear when the purpuric eruption occurs.
The duration is generally between ten days and three weeks, hut relapses are
common, especially when the patient walks too soon.  Rheumatic purpura is
most common in males between twenty and thirty years of age.  The  affec-
tion of the joints is  etiologically distinct from acute articular rheumatism.
Joint affections are common in all forms of primary purpura, and in general
in diseases characterized by a hemorrhagic diathesis.   The propriety, there-
fore, of distinguishing rheumatic purpura as a separate variety of the disease
is questionable.  The occurrence of hemorrhages from mucous membranes in
some cases which have been classified  as  rheumatic purpura shows the rela-
tionship of this to the following variety of idiopathic purpura.
  Purpura haemorrhagica is not an appropriate  name for  the variety of pur-
pura now to be described, as every kind of purpura is  hemorrhagic.   The
name morbus maculosus Werlhofii, or AA7erlhof 's disease, is the one adopted by
German and many English writers.  This variety of purpura is  characterized
especially by the occurrence of hemorrhages, often  profuse, from mucous sur-
faces.  The hemorrhages in the skin usually are larger and greater in number
than in purpura simplex.  Constitutional symptoms are more marked and the
prognosis is graver.   The disease is somewhat more frequent in  females than
in males.  It develops oftenest between fifteen and thirty years of age.  It
may occur in previously healthy individuals, but it is more common in those
whose  constitution  is enfeebled by disease  or bad hygienic  surroundings.
Pregnancy and the puerperal state have been thought to aid in the causation.
  The first manifestation of morbus maculosus  AVerlhofii  may be the appear-
ance of purpuric spots in the skin, or, less frequently, hemorrhage from some
mucous surface.  Often, however,  there  are vague premonitory symptoms,
such as  malaise, anorexia,  vomiting, pains  in  the muscles, and even  slight
fever.  Pain and swelling of the joints  may  occur  as an  early  symptom.
Hemorrhages occur  from the nose, mouth,  throat, stomach, intestine, and
urinary organs.  Bronchial and pulmonary hemorrhages are rare.  In severe
cases hemorrhages take place into serous cavities, and even into  the substance
of internal organs.   Petechiae and ecchymoses can be detected in the visible
mucous membranes.   As in  all  forms  of  purpura, hemorrhages are liable to
occur in parts of the skin  subjected to pressure  or injury.   In distinction
from scurvy, the gums are not swollen  and inflamed.  Constitutional disturb-
ance may be slight or even  wanting, but often  it is marked.   There may be
fever, which  is usually moderate, but is sometimes high.   The  patient  some-
times sinks into a typhoid state.  There may be diarrhoea, colicky pains, and
other severe  gastric and intestinal symptoms.  Endocarditis and acute hem-
orrhagic  nephritis  are occasional complications.  There sometimes is  acute
splenic tumor.  Perforative peritonitis has been  known to occur.   Symp-
toms of anaemia, such as vertigo, weakness, functional cardiac disorders, and
oedema, develop in proportion to the loss  of blood.  Hemorrhage may occur
into the brain or its meninges.  Death  may result from loss of blood or from
grave constitutional disorder, marked especially  by typhoid symptoms or from
some complication.
  The duration of the disease is usually between two and four  weeks,  but it
may be protracted  for many months.   The prognosis in general is favorable, 
 11 o2         SCORBUTUS.—PURPURA.—HEMOPHILIA.

 but it is necessary  to  be  cautious in expressing a positive opinion on  this
 point, as even in apparently mild cases grave symptoms may develop.  As has
 already been remarked, there are cases representing every grade of transition
 from the mildest purpura simplex to the most severe purpura haemorrhagica.
   The diagnosis from scorbutus is based  especially upon  the  absence  of
 swelling of the gums and of ulcerative inflammations  elsewhere, by the lack
 of the cachexia which antedates and  accompanies scurvy, by the absence of
 the  dietetic causation of scurvy,  and by  the  comparative  inefficacy of the
 dietetic regimen, which, as a rule,  promptly relieves the symptoms of scurvy.
 According full force to these points of difference, it must be admitted that
 they do not establish conclusively  the non-identity of purpura haemorrhagica
 and  scorbutus, nor do they always suffice to enable the practitioner to make
 with positivencss the  differential  diagnosis.
   Nothing  is known as to the essential  cause  of purpura haemorrhagica.
 Changes have been  surmised to exist  in  the walls of the  blood-vessels, in
 the  composition of the blood,  and in the nervous system,  but none have
 been demonstrated which can fairly be considered causative.   Infection has
 also been suggested as a cause.
   The objects of treatment in cases of purpura haemorrhagica  are—the res-
 toration of the normal constitution of  the blood, increase of the vital powers,
 and  arrest or  restraint of hemorrhage.   AVith reference to these  objects the
 diet should be nutritious and varied, and digestion is  to  be  aided by tonic
 remedies, together with wine or spirits in small  quantity if the immediate
 effect be  good.  In view of the difficulty in  always discriminating purpura
 from scorbutus, and of there being ground for supposing  that the same mor-
 bid  condition  of the  blood  exists in  both affections,  the treatment should
 embrace the dietetic and other  measures which experience has shown to be
 useful in cases of scorbutus.  Of tonic remedies,  the dilute sulphuric acid is
 especially recommended.   This  remedy has  the  advantage  of  being  agree-
 able to the taste if added to a proper  quantity of water and syrup.   It may
 be given in  doses of from five to fifteen drops  every two  hours.   Quinia  is
 often combined with the sulphuric acid.  Haemostatics are to be given with
 reference to the hemorrhage.  Ergot or ergotin has been highly recommended.
 The gallic acid, the muriated tincture  of  iron, and the acetate  of  lead are
 remedies which may be employed.  The oil  of turpentine has  been recom-
 mended as a  valuable remedy  in  this affection.   It is important that the
 patient should preserve  the recumbent  posture in bed,  avoiding all unneces-
 sary  exertion.


                            Haemophilia.
   Haemophilia, or  haematophilia, is a congenital  and  usually an hereditary
 affection,  characterized  by a tendency to immoderate bleeding, traumatic
 or spontaneous, and  often  associated  with  swelling of the joints.  Persons
 with  this diathesis  are  called "bleeders."   No other  disease illustrates in
 so striking a manner transmission by inheritance.  The  diathesis has been
 traced through successive generations of the same family for more than two
 hundred  years.  Males  are far  more liable to the disease than females the
 ratio  being  as 11  of the former to 1  one of the latter.1  The diathesis  is
 transmitted, however, far more  frequently through  the female  members  of
 bleeder families than through the male members.   The daughters of a bleeder
family, even when not themselves bleeders, transmit the diathesis to their sons.
 A son of a bleeder family, if himself a bleeder, should he live to beget children

*£*!&££ j^rSssF Duun'717 ™ males and 63 females iAmerican Jm- 
HAEMOPHILIA.
1133
more frequently transmits the disease to his grandsons, through his daughters,
than directly to his own children.   The male members of a bleeder family, if
not themselves bleeders, rarely transmit the disease to their descendants.   It
rarely happens that all of the members of a family are bleeders.  It is uncer-
tain whether the diathesis ever dies out in a family, although it may pass over
one or more generations.  It has been noted that the females of bleeder fam-
ilies are very fertile.   In 12 such families  there were 120 children (AVachs-
muth).
   Haemophilia may develop, as it were spontaneously, in individuals coming
from  a  healthy family  stock.  Such persons may become the starting-points
of new bleeder families.  Even  in these spontaneous cases the diathesis seems
to be  congenital.  Probably  in a considerable number of the apparently spon-
taneous cases a full knowledge of the ancestral history would reveal  trans-
mission by heredity.
   A larger number of instances  of haemophilia have been reported  among
the Anglo-Germanic nations  than among other races.1  The affection has been
repeatedly observed in Jews.   It seems  to be  more  common in  cold, moist
climates than  in warm climates.   Although a large proportion of bleeders
have been  blondes, with fair,  delicate skin and prominent superficial veins, it is
not likely that any such constitutional peculiarity  is  involved in the etiology
of haemophilia.
   The essential causes  of haemophilia  are wdiolly unknown.   It is reasonable
to suppose that abnormal constitution  of the vascular walls and deficient coag-
ulability of the blood are involved in  the  causation,  but we have no positive
data upon  which to base these  suppositions.  No morbid changes  have been
found, with any uniformity,  after death from haemophilia.  An abnormal thin-
ness of the arterial walls has been noted in several cases.  It is possible that
there are  defects pertaining to the fibrin-factors  or  to  the  blood-plates, but
these have not been ascertained.
   There is usually nothing indicative  of either this diathesis or aught abnor-
mal prior to the occurrence of a hemorrhage, which is with difficulty, if at all,
controlled.   The diathesis is sometimes manifested immediately after birth by
profuse and sometimes uncontrollable bleeding from the umbilicus.   More
frequently, the affection is made apparent at a later date, but during the first
few years'  of life.   It  is exceptional  for the diathesis  not  to be discovered
until" after the second  dentition.  Persons  having this  diathesis continue to
lose blood from an insignificant wound, such as that produced by a  puncture,
a slight cut, a leech-bite, or  the extraction of a tooth, all efforts to  arrest the
hemorrhage proving ineffectual until syncope occurs,  which may prove fatal,
and if not fatal the loss of  blood induces a notable degree of anaemia.  The
hemorrhagic diathesis  also  leads to extravasation of blood,  often extensive,
within and beneath the integument, resulting from slight contusions.   Hem-
orrhage is  also likely to occur from the nose and the gums, and less frequently
the stomach, the intestine, and the urinary passages.  Hemorrhages into inter-
nal organs which are removed from any external mechanical influences are very
rare, if indeed they occur at all.  In females, in whom the diathesis is gener-
ally less marked than in males, the menstrual flow usually is profuse and post-
partum hemorrhage is  abundant.
   As in other diseases with a  hemorrhagic diathesis, there  is a tendency to
swelling of the joints,  most  frequently the knee-joint, particularly after some
injury.   The swelling  seems to be  due to hemorrhage into the joint.   Neur-
algia, especially of the trigeminus,  is  not infrequent.
  1 A full account of the American literature on this subject will be found in the article
bv Dunn above  cited, and in the article on " Haemophilia," by Osier, in A System of
Practical Medicine, by American  Authors,  Philadelphia, 1885, vol. m. 
1134          SCORB UTUS.—PURPURA .—HEMOPHILIA.

  All degrees of the haemophilic  diathesis may exist, from  the rudimentary
form, in which there is  simply a tendency to  excessive but  not  dangerous
hemorrhage after a wound, to the fully-developed form which has been de-
scribed.  Children affected in a marked degree with this diathesis rarely live
to  adult age, but in some instances  the  diathesis diminishes  or ceases after
childhood;  and if it continue in a moderate or slight degree  it may not inter-
fere with longevity.
  The prophylactic treatment is the most important  in the management of
haemophilia.  AVounds are of course to be avoided as far as  possible.   The
diathesis constitutes an insuperable objection to all surgical operations which
are  not unavoidable.   Teeth should never be extracted.  The operation of
circumcision should not be permitted. Araccination should be performed with
great care.   Leeches should never be  applied to " bleeders."   Measures should
be employed  to invigorate the system, such as a  nutritious  diet, out-of-door
life, frequent bathing, and tonic remedies.   The marriage of female members
of bleeder  families  and that of  male members who are bleeders should be
prohibited.   AVhen hemorrhage occurs, either from wounds or  spontaneously,
local measures to arrest the flow of blood are to be resorted to if practicable,
and haemostatic remedies are to be given internally. 
INDEX.
                  A.

Abortive measures of treatment, 106
Abscess, fecal, 482, 485
     of brain, 715 (vide Encephalitis).
     of heart, 324
     of kidnev, 896
     of liver, 417, 471, 480
     of lungs, 82, 179
     of spleen, 638
     of stomach, 416
     perinephritic, 908
     perityphlitic, 483
     retro-pharyngeal, 399
     subphrenic, 145
     tropical, 593
Abscesses, in heart, 82, 323
     metastatic,  32, 79, 81, 179, 320,  321,
       328
     multiple, in  pyaemia, 81, 82
     pyaemic, in lungs, 179
Acephalocysts, 276, 619
Acetonemia, 72
Acetone, 72
     in diabetic urine, 72, 931, 934
Acetonuria, 72
Acholia, 78,  609
Achroiocythaemia, 60, 371
Actinomyces, 47, 93
Actinomycosis, 47
Addison's disease, 389
     anatomical characters, 389
     causation, 394
     clinical history, 392
     diagnosis, 394
     pathological characters, 391
     prognosis, 394
     treatment, 395
Ague and fever, 997
     cake, 1000, 1012
     dumb, 1001
Air, inhalation of compressed, 65, 66
     swallowing of, 444
Akinesia, 773
Akinesis, 773
Alalia, 653
Albumen, increase and diminution of, in
      blood, 20, 63
Albuminuria, acute, 20, 8G8
    after scarlatina, 97, 1055-58
    in acute  Bright's disease, 868, 869
    in acote  interstitial nephritis, 897
    in chronic  Bright's  disease, 64, 881,
      S82, 887,  889,  890
Albuminuria in congestion of kidnev, 863,
       864.
Alcoholism or alcoholismus, 85, 853
    causation, 854
    clinical history, 854
    diagnosis, M56
    prognosis, 855
    treatment, 856
Allopathy, 107
Ammoniaemia, 74, 75
Amygdalin, 85
Amyloid degeneration, 55 (vide Degenera-
       tion, waxy).
Amyotrophic affections, spinal, 754,758,760
Anaematosis, 367
Anaemia, acute and chronic, 20, 60, 61
    benign, 367
    causes of, 62
    cerebral, 62, 74, 648
    collateral, 25
    idiopathic or essential, 62, 381
        symptoms  and signs of, 62, 63
        treatment of, 62,  63
    local, 25, 60
    lymphatic, 381
    of spinal cord and its meninges, 687
    pernicious or idiopathic, 62, 384
        anatomical characters, 385-87
        causation, 384
        clinical history, 387
        diagnosis,  387
        prognosis,  388
        treatment, 388
    secondary, changes in, 61
    simple or benign,  62,  63, 367
        clinical history, 368
        diagnosis, 368
        prognosis,  369
        treatment,  63, 369
    splenic, 380
Anaesthesia, 772
Analeptic treatment, 106
Analgesia,  772
Anasarca, 32, 150, 870
Anatomical characters of  disease, 20
Anatomy, morbid, 20, 111
Anchylostoma duodenale,  94, 385, 570
Aneurism,  of heart-valves, 316, 321,  326
        cardiac, acute, 324
    of pulmonary vessels, 187
    partial, of heart, 323
    thoracic, 361
        anatomical characters, 361
                            1135 
1136
INDEX
Aneurism, thoracic, clinical history, 362
         diagnosis, 364
         prognosis, 364
         treatment, 364
Aneurisms, miliary,  in  cerebral  hemor-
           rhage,  659, 661, 728
         in tuberculous cavities, 187
Angina, 278
     Ludovici, 405
     pectoris, 358
         clinical history, 358
         diagnosis, 360
         pathological characters, 359
         prognosis, 359
         treatment, 360
Anhydraemia, 64, 68
Ankle-clonus, 732, 759
Anthracosis of lung, 180
Antidotes  to  corrosive and acrid poisons,
       411
Antiscorbutics, 1128
Aorta, aneurism of, 361
Aphasia, 299, 653, 680
     amnesic, 654,  680
     ataxic, 654, 680
     in cerebral embolism and thrombosis,
       653
     in cerebral hemorrhage, 666
     in cerebritis, 716
     in hemiplegia, 654
     sensory, 680
Aphemia, 653
Aphonia, 279, 299, 653, 675, 720
Aplasia, 51
Apnoea, 66, 105, 222, 224.  225
     mode of dying by, 105
Apoplexy, congestive, 646, 684
     from cerebral  hemorrhage, 662
     from embolism and thrombosis, 652
     meningeal, 682, 691
     prevention of, 671
     pulmonary, 266
     spinal, 688
Appendix  vermiformis, inflammation  and
       perforation  of, 483
Argyll-Robertson pupil, 744
Arterio-capillary fibrosis, 880
Arteritis,  659
Arthritis deformans, 1120
     pauperum, 1120
     proliferating,  1120
     rheumatic, acute, 1093
     rheumatoid, 1120
     simple acute, 1099
Arthropathy, 20
Ascaris alata,  563
     lumbricoides,  94,  560, 623
     vermicularis, 562
Ascites,  32,  585,   587 [vide  Hydroperi-
       toneum).
Asphyxia, 67
     cause of dyspnoea in, 67
     symptoms of, 67
Aspiration in empyema, 142, 143
     in thoracentesis, 137,  138
Aspirator,  Dieulafoy's, 139
 Aspirator, Flint's, 138. 139
 Asthenia, mode of dying by,  105
     nervous, 781, 907
 Asthma, 244
     asphyxia in, 67
     causation,  87, 247
     clinical history, 244
     diagnosis, 250
     hay, 246, 248
     pathological character, 244, 246
     prognosis; 251
     thymic, 296
     treatment, 251
 Ataxia, locomotor, 742
     anatomical  characters, 743
     causation, 747
     clinical history, 744
     diagnosis, 746
     pathological character, 743
     prognosis, 746
     treatment, 747
Atelectasis, 174, 224
     acquired, 175, 224, 225, 232
     congenital, 175,  178
Atheroma of arteries, 659
Athetosis, 677, 821
Atrophy, 50
     acute yellow, of liver. 606
     brown, of heart, 51, 57
        of liver, 624
     causation of, 50
     facial, progressive,  unilateral, 757
     fatty, 54
     granular, of kidney, 51, 878, 882
     neurotrophic, 51
     numerical, 51
     of lungs, 287
     of stomach, 438
     progressive  muscular, 51,  753
        anatomical characters, 754
        clinical history, 754
        causation, 757
        pathological character, 753
        treatment, 757
     red, of liver, 329, 625
     senile, 50
     simple, 51
Aura epileptica, 823, 830


                  B.
Bacillus, 90
     anthracis, 92
        relation to  malignant pustule  or
          splenic fever, 92
     malariae, 1002
     tuberculosis, 47, 48, 49, 195
        Koch's discovery of,  47
        lesions  due to, 48, 184, 187, 188
        multiplication of, 48
        staining of,  48, 199, 200
Bacteria, Cohn's classification  of, 90, 91
     action of, 93
     colonies of,  90
     in acute ulcerative endocarditis, 321
     in diphtheria, 1077 
INDEX.
1137
Bacteria in variola, 91, 1031
    pathogenic properties of, 89, 91
    power of reproduction, of, 90
    relation  to putrefaction, of, 91
Barometric pressure, effects of changes of,
       66
Basedow's disease, 356
Basilar meningitis, 698 (vide  Meningitis,
       tuberculous).
Bile-passages, diseases affecting, 628
Bilirubin, 57, 77
Black tongue, 280, 994
Blood, alteration in the gases of, 65-68
    changes  in the albumen,Jat, and inor-
       ganic  salts of, 68, 69
    deficiency of oxygen in, 67, 68
    excess of carbonic acid in, 67, 68
    increase  and diminution  of albumen
       in, 68
    increase  and diminution of water in,
       60, 63, 64
    increase of oxygen in, 65, 66
    source of corpuscles of, 61
    transfusion of, 59, 1027
    urea in,  73
Bloodletting  in pleuritis  and other acute
       inflammations,  124, 167,  223, 227
Blue  line, on gums, in lead-poisoning,  527,
       795
Brain, abscess of, 715  (vide Encephalitis).
    anaemia  of, 648
    carcinoma of, 723
    congestion of, 644
    embolism and thrombosis of, 650
    functional diseases of, 767
    hemorrhage in, 659
    induration of, 717
    inflammation and abscess of, 715 (vide
       Encephalitis).
    inflammatory and structural  diseases
       of, 715
    sclerosis, diffuse, of, 717
    softening of, 717
    tubercle of, 723
    tumors of, 722
Break-bone fever, 1072 (vide Dengue).
Bright's disease of the kidneys, acute, 865
         anatomical characters, 866
         causation, 871
         clinical  history, 867
         diagnosis, 871
         pathological character, 869
         prognosis, 871
         treatment, 872
    chronic  forms of, 873.
         anatomical characters, 875.
         cassation, 887
         classification  of, 873
         clinical history, 880
         diagnosis, 889
         pathological character, 887
         prognosis, 891
         treatment, 892
Bronchiectasis, 187, 214, 230, 237-239
Bronchitis, 19, 218
72
Bronchitis, acute, affecting the large bron-
           chial tubes, 218, 219
         anatomical characters, 219
         causation, 220
         clinical history, 219
         diagnosis, 221
         in young children, 224.
         pathological character, 220
         prognosis, 222
         treatment, 222
    affecting  the  small  bronchial  tubes,
       218, 225
    chronic, 218, 230
         anatomical characters, 230
         causation, 232
         clinical history, 231
         diagnosis, 232
         prognosis, 232
         treatment, 233
    circumscribed, 218, 230
    fetid, 230, 231
    subacute, 219, 223
Broncho-pneumonitis,  174, 225, 256
Bronchorrhagia, 20, 261
Bronchorrhoea, 20, 231, 273
Bronzed-skin disease, 389
Brown atrophy of the heart, 51, 57
Brown induration of lungs, 181, 329, 330
Buboes, scarlatinous, 1057
Buffy coat, 65
Bulbar paralvsis, acute or apoplectiform,
       695, 722, 760
    chronic, 675,719 (vide Paralysis, glosso-
       labio-laryngeal).
Bulimia, 452

                   C.
Cachexia, 88
    carcinomatous, 45, 432
    malarial, 78, 1000
    tuberculous, 88
Caecitis, 483
Caecum,  inflammation and perforation of,
           482
         anatomical characters, 483
         causes of, 483
         treatment, 483
    inflammation and perforation of ver-
       miform appendix of, 485
    painful tumor of, 485
    perforation of, 483
Caisson disease, 66
Calcareous degeneration, 57, 201, 214
Calcification or cretefaction, 57, 201, 214
Calculi, biliary, 530
         passage of, 531
    intestinal, 496
    pancreatic, 643
    pulmonary, 202
    renal,  passage of, along ureter, 905
         composition of, 906
Cancer (vide Carcinoma), 20, 43, 44.
    cells, 44, 45
Capsules, suprarenal, disease  of,  389 (vide
       Addison's disease).
Caput Medusae, 602 
1138
INDEX.
Carcinoma, 20, 43, 44
    colloid, 44, 45
    encephaloid, 44
    gastric, 429 (vide Cancer of stomach)
    genesis of, 45
    laryngeal, 301
    local origin of, 45
    medullary, 44
    melanotic, 44, 45
    metastases in, 45
    of brain,  723
    of intestine, 495
    of kidney, 45, 914
         anatomical characters, 914
         clinical  history, 916
         diagnosis, 916
         prognosis, 917
         treatment, 918
    of larynx, 301
    of liver, 615
    of lung, 274
    of oesophagus, 403
    of pancreas, 642
    of peritoneum, 586
    of spleen, 640
    of stomach, 429
         anatomical characters, 429
         causation, 431
         clinical  history, 431, 455
         diagnosis, 431
         prognosis, 433
         treatment, 434
    origin of  cells in, 45
    scirrhous, 44
    simplex,  44
    stroma of, 44
    type of secondary, 45
    varieties  of, 44
    within the chest, 274
    within the cranium, 723
Cardialgia, 361, 443.
Carnification of lungs, 117
Carotids, ligation of, in epileptic convul-
       sion, 834
Carpliololgia, 957, 969, 971
Cams, 768
Casts of renal tubes, in renal congestion,
       863, 864
    in acute nephritis, 867, 868, 870.
    in   chronic  nephritis, 876-879,  881,
       882,  889
    in diphtheria, 1080
    in haemoglobinuria. 922, 923, 925
    in relapsing fever, 989
    in scarlet fever, 1056,  1058
    in suppurative nephritis, 897
    in typhus fever, 973
    in uraemia. 72
    in variola,' 1032, 1039
    in vellow fever, 1021
Catalepsv,  844
Catarrh,*219
    autumnal, 248
    dry, 231
    intestinal, 490
    senile, 225
 Catarrh, suffocative, 225
     summer, 248
 Catarrhal inflammation, 37
 Catarrhus asstivus, 248
     autumnalis, 248
 Causes of disease, 83-89,  111
     accessory or co-operating, 87, 102
     exciting, 87
     external or extrinsic, 83
     internal or intrinsic,  83
     mental, 84
     mycotic, 83 (vide Bacteria).
     ordinary, 84
     predisposing,  87
     primary, 86
     secondary, 86
     special  or specific, 84
     traumatic, 86
 Cells, reproduction of, 38"
     segmentation  of, 38
     serous infiltration of,  in  variola, 1029
     specialization of, 38
     vesicular or dropsical  transformation
       of, in variola, 1029
 Cephalalgia, 810
     treatment of, 812.
 Cerebellum, diseases of, 673
 Cerebral diseases,  644
     topical  diagnosis of,  672 (vide  Local-
       ization of cerebral  disease).
 Cerebritis, 715  (vide Encephalitis).
     diffused interstitial, 739
 Cervicodynia, 809
 Cestoda, 93,  563
 Chalicosis pulmonum, 180
 Chest, new growths within the, 274
 Chicken-pox, 1050 (vide A'aricellaJ.
 Chlorosis, 370
     Egyptian, 385, 571
     tropical, 385,  571
 Choked  disk, in  tuberculous  meningitis,
       701
 Cholaemia, 77, 631
     hepatogenous, 77, 631
 Cholecystitis, 629
\ Cholera, epidemic, or Asiatic, 88, 542.
          anatomical characters, 543
          bacteria  in,  90,  92, 543, 546, 549,
            552, 553
          causation, 88, 90
          clinical history,  545
          diagnosis, 553
          pathological character, 548
          prognosis, 554
          prophylaxis, 554
          treatment, 556
     asphyxia, 547
     cyanosis, 547
     drv, 526
     infantum, 512, 539
     morbus, 535
     nostras, 535
     sicca, 526, 546
     spasmodic, 547
     sporadic, 535
          causation, 537 
INDEX.                                1139
Cholera, sporadic, clinical history, 535
         diagnosis, 537
         pathological character, 536
         prognosis, 536, 538
         treatment, 538
Cholerine, 545
Cholesteatoma, within cranium, 723
Cholesteraemia, 77, 78, 589, 609
Chorea, 813
         causation, 814
         clinical  history,  813
         pathological character, 814, 1096
         treatment, 815
     festinans vel procursiva, 817
     gravidarum, 814
     major, 814
     oscillatoria,  817
     saltatorea, 816
     scriptorum, 818
Chthonophagia, 453
Chylopoietic system,  diseases of, 396
Chylous ascites, 34, 588
Chyluria, 94, 925
Circulation, disturbances  of,  25
     cerebral and spinal, 644
Circulatory system, diseases of, 303
Cirrhosis of kidney, 878, 882
     biliary, 604, 634
     of liver, 599 (vide Hepatitis).
         hypertrophic, 604
     of lung, 186, 214
     of stomach, 418
Clergyman's sore throat, 400
Clinical history of disease, 96, 111
Cloudy  swelling,  53 (vide  Degeneration,
       parenchymatous).
Coagula, ante-mortem, 29, 350
     post-mortem, 29, 350
Coagulation of  blood  in cavities of  the
       heart, 29, 323, 326, 350
     in blood-vessels,  28-30
Coagulation necrosis, 25, 31,  48, 51
     essential conditions for, 52
     in acute Bright's disease, 867
     in atheroma, 52
     in diphtheria, 52, 1076
     in dysentery, 467
     in embolic infarction, 31, 52
     in gout, 1107
     in inflammation, 37
     in laryngitis, 288
     in pneumorrhagia, 266
     in relapsing  fever, 52, 986
     in septicaemia, 80
     in tubercle, 48, 52, 186
     in tumors, 52
     in typhoid fever, 52
     in ulcerative endocarditis, 320
     in variola, 52, 1029
     in waxy degenerations, 52
Coat, buffy, 65
Colic, from copper, 529
     from lead, 101, 524, 770
         causation, 525
         clinical  history,  524
         diagnosis, 526
Colic from lead, prognosis, 525
        treatment, 527
    hepatic, 520, 530
    intestinal, 520
        causation, 522
        clinical history, 521
        diagnosis, 521
        pathological character, 522
        prognosis, 528
        treatment, 523
    painter's, 524
    renal, and nephrolithiasis, 520, 905
Colica pictonum, 524
Colitis, 486
Collapse of  pulmonary  lobules,  174,  175,
      178
Colloid  cancer, 44
    degeneration, 55
    material, 55
Colotomy, in intestinal obstruction, 505
Columns,  posterior, sclerosis of, 742
Coma, 768
    in acute yellow atrophy, 608
    in alcoholism, 853
    in ammoniaemia, 74, 75
    in catalepsy, 844
    in cerebellar disease, 673
    in cerebral hemorrhage, 662
    in cerebral hyperaemia, 646
    in cholaemia, 77
    in diabetes, 72, 933,  936
    in diphtheria, 1080
    in delirium tremens, 853
    in embolism and thrombosis, 652, 653,
      657, 659
    in encephalitis, 716
    in epilepsy, 824
    in hysteria, 837, 838
    in insolation, 683
    in intermittent fever, 998,  1008
    in meningeal hemorrhage, 682
    in meningitis, 695, 698, 701, 708
    in pachymeningitis,  692
    in poliomyelitis, acute anterior, 749
    in scarlatina, 1056, 1063
    in tumors,  intracranial, 726
    in typhoid fever, 957, 960, 962, 981
    in typhus fever, 971, 981
    in uraemia, 72, 839,  868, 884, 889, 890,
          989
        treatment of. 893
    in variola,  1034, 1039
    in yellow fever, 1021, 1022, 1026
    vigil, 956,  971, 1034
Comma bacillus, in cholera, 90, 543,  546,
      549
Complication, definition  of, 86
Congestion, active,  26
    hypostatic, 26
    of brain, 644
    of cord, 687
    of liver, 624, 636
    of lungs, 181
    passive, 26
    renal, active, 862
        passive, 863 
1140                                INI

Conservatism in treatment of disease, 104
Constipation, 516
    causation, 517
    clinical history, 517
    pathological character, 516
    treatment,  518
Consumption, pulmonary, 184 (vide Phthi-
      sis, pulmonary).
    galloping,  185, 194
Contagion, definition of, 84
Contagium, 84
    fixed, 84
    vivum, 85, 89
    volatile, 84
Convulsions (vide references under Coma).
Cor bovinum, 343
Cor villosum, 304
Cord, spinal (vide Spinal cord).
Coronary arteries,  embolism of, 32
Corpora amylacea, 56, 719, 735, 740, 743
Coryza, 219, 223, 248
Costiveness, 516
Cough, nervous, 298
Countenance, Hippocratic, 100
Cow-pox, 1043  (vide Vaccinia).
Cramp, 818
    writer's, 818 (vide Chorea scriptorum).
Cranium, tumors within, 722
Cretefaction, 57
Croup, false, 278, 283, 287
    membranous, 287 (vide Laryngitis with
      exudation).
    spasmodic, 296
    true, 278, 283, 287, 1082  (vide Laryn-
      gitis with exudation).
Croupous inflammation, 37
    exudation, 37
Crusta inflammatoria, 65
Cry, cephalic, 700
Culture,  pure, of micro-organisms, 89
Curative measures of treatment, 106, 109
Cyanosis, 67, 226,  238, 239, 245
Cynanche, 278
    contagiosa, 1074
    maligna, 1074
Cysticerci,  94, 563
    cellulosae, 94,  565
Cystinuria, 907
Cvsts, apoplectic, of brain, 661
    renal,  878, 879,  910
    varieties of, 41


                   D.
Dance, St. A'itus's, 813  (vide Chorea).
Degeneration, 53
    albuminous or parenchymatous, 53
    amyloid, waxy, or lardaceous, 55
    calcareous, 57
    cheesy, in  tubercle, 48, 214
    colloid, 55
    cystic, of kidnev, 910
    fatty, 53, 54
         general, 54
         in anaemia, 61
         in carcinomata, 46
Degeneration, fatty, in emphysema, 236
         local, 54
         of heart, 54, 346
    fibroid, in tubercles, 214
    granular, 53
    hyaline,  53, 56, 1076
         in tubercle, 48,  214
    mucoid,  55
    parenchymatous, 53
         causes of, 53, 80
         in diphtheria, 1077
         in malarial fevers, 1013
         in scarlatina, 1053
         in variola, 1031
         of gastric tubules, 53, 438
         of heart,  53, 54, 80,  347, 349
         of kidney, 53, 54, 80
         of liver, 53, 54, 80
         of muscles, 53, 54
    reaction  of,  730, 733
    secondary to cerebral hemorrhage, 661
    spinal, 729,  735
    waxy, of gastric tubules, 440
         in malarial fevers, 1013
         of intestines, 55, 56, 496
         of kidnevs, 55, 56, 876, 890
         of liver, 55, 605, 613
         of spleen, 55, 56, 640
         of stomach, 55,  438
Delirium ebriosum, 856 (vide Alcoholism).
    hysterical, 837
    in Bright's disease, 72, 885
    in typhoid fever, 956-
    tremens,  853
    vigilans, 855
Dementia paralytica, 775 (vide Paralysis,
      general cerebral).
Dengue,  1072
Dermalgia, 807
Diabetes, acutus  and acutissimus, 934
    insipidus, 862, 927
    mellitus, 69, 862, 929
         causation, 70, 929, 934
         clinical history, 929
         coma in, 72, 933, 936
         diagnosis, 934
         pathological character, 930
         prognosis, 935
         treatment, 936
Diagnosis, definition of, 21, 97, 111
    consideration  of, 97
    differential, 99
    by exclusion,  98, 99
Diapedesis, 27, 3l
Diarrhoea, 509
    acute, 486
    bilious, 509
    causation, 510, 512
    choleraic, 545
    clinical history, 509
    colliquative, 513
    crapulous, 512
    dysenteric, 510
    fatty, 510, 642
    lienteric, 510
    serous, 509 
INDEX.                                1141
Diarrhoea, treatment, 511, 513
    tubular. 487
    typhoid, 509, 955, 958
    stercoraceous, 509
Diathesis, 88,  101
    hemorrhagic,  1126
    tuberculous, 194, 195, 198, 205
Diathetic diseases, 88
Diazo-reaction, in  typhoid fever, 962
Digestive or  chylopoietic system, diseases
      of, 396
Digestive ulcer of stomach, 421
Dilatation of stomach, 419,  428, 434
Diphtheria, 1074
         anatomical characters, 1074
         bacteria in, 91
         causation, 1083
         clinical history, 1078
         cloudy swelling in, 53, 1076
         coagulation necrosis in, 52, 1076
         diagnosis, 1084
         pathological character, 1082
         prognosis, 1084, 1085
         treatment, 1086
    paralysis following, 97, 403, 1080
Diphtheritic exudation, 37
Diplegia facialis, 791
Dipsomania, 452, 454, 854
Dirt-eating, 453
Disease, definition of, 22
    art and nature in cure of, 109
    Basedow's or Graves's,  356
    bronzed skin, 389
    caisson, 66
    clinical and natural history of, 96, 111
    course of, 97
    diagnosis of, 97, 111
         differential, of, 99
    Duchenne's, 742
    duration  of, 113
    dynamic, 20
    elementary forms of,  114
    extinction of susceptibility to, 88
    functional, definition of, 20
    germ theory of, 89, 101
    Hodgkin's, 380   (vide Pseudo-leuco-
      cythaemia).
    individuality  of, how determined, 112
    insusceptibility to,  88
    intuitive perception of, 99
    laws of, 98, 109, 113
    Meniere's, 770
    mental influence on, 108
    micro-organisms, proof of  their causa-
      tion of, 89
    pathology of, 111
    prevention of, 112
    recovery,  tendency of, to, 104
    self-limitation of, 104, 113
    stages of, 96
    Thomsen's, 819
    treatment of, 102, 110, 112
    trichinal, 568
    uniformity of laws of, 109
    vagabond's, 394
    Werlhof's, 1131
Diseases, acute, definition of, 112
    anatomical characters of, 111
    aspects, different, under  which  they
      are to be considered, 111
    causation of, 83, 111
    cerebral, localization of, 672
    chronic, definition of, 112
    classification of, 113
    complicating, 86
    deuteropathic, 86
    diathetic, 88
    endemic, 88
    epidemic, 88
    functional, 111
    general, 113, 944
    infectious contagious, 84, 85
         miasmatic, 84, 85
    intercurrent, 86
    local, 113, 114
    miasmatic contagious, 85
    nomenclature of, 19
    pandemic, 88
    pathology of, 111
    portable, 89
    primary, 86
    protopathic,  86
    secondary, 86
    self-limited, 113
    spontaneous, 86
    surgical, 114
Disinfection, and disinfecting agencies, 101,
      106
Distoma hepaticum, 94, 623
    lanceolatum, 94, 623
Dorsodynia, 183, 805
Dropsy, 32, 113
    cachectic, 33
    cardiac, 33, 331
    general, 32, 215
    hydraemic, 33
    in acute Bright's disease, 870
    in chronic Bright's disease, 880, 890
    in hydraemia, 64
    in uraemia, 72
    local, 32
    mechanical, 33
    peritoneal, 32, 587
    renal,  33, 870, 880, 887
    scarlatinous, 97, 1056
Duchenne's disease, 742 (vide Ataxia, loco-
      motor).
Ductus communis choledochus,  inflamma-
      tion of, 628
Duodenitis, 405, 420, 487
Duodenum, ulceration of, 420, 493
Dura mater, hematoma of, 681-691
Dying, different modes of, 105
Dynamic morbid changes, 20
Dyscrasiae,  58, 88
Dysentery,  acute, 463
    acute sporadic,  clinical history, 467
         causation, 470
         diagnosis, 470
         pathological character, 464, 469
         prognosis, 467, 470
         treatment,  471 
1142                                INDEX.
Dysentery, anatomical characters of acute
      simple, 464
    anatomical characters of diphtheritic,
      466
    catarrhal, 464
    chronic, 478
         anatomical characters, 479
         clinical  history, 480
         diagnosis, 481
         prognosis,  481
         treatment, 481
    croupous, 466
    diphtheritic, 464, 466
    epidemic, 464,  474
         anatomical characters, 474
         causation,  476
         clinical history, 474
         treatment, 476
    fibrinous, 466
    follicular, 465,  479
    malignant, 476
    pylephlebitis from,  627
    scorbutic, 475, 478
    stools in, 468, 480
    ulcers of, 479
Dyspepsia, acute, 411, 413, 441
    chronic, 442
         causation, 442, 447
         clinical history, 443
         pathological characters,  446
         treatment, 448


                   E.
Ecchymosis, 27
Echinococcus, 94, 563
    of kidney, 911
    of liver, 618
         anatomical characters, 618
         clinical history, 619
         diagnosis, 620
         pathological character, 618
         prognosis,  621
         treatment,  621
    of lung, 275
    multilocular, 622
Ecstasy, 845
Ectopia renis, 918
Electricity in paralysis,  670
    in Addison's disease, 395
    in angina pectoris, 361
    in cephalalgia,  812
    in chorea, 816
    in diagnosis of  paralyses, 732
    in exophthalmic goitre, 358
    in functional paralysis, 775
    in lead  paralysis, 796
    in myalgia, 810
    in neuralgia, 800
    in neuritis, 785,786
    in neuroses, 818
    in paralysis agitans, 821
    in peripheral paralysis, 787
    in poliomyelitis anterior, 751, 753
    in   progressive  muscular  atrophy,
      757
Electro-muscular sensibility and  contrac-
       tility, 772-774
Embolism,' 28, 30, 650
     capillary, 32
     of brain, 659
Embolism and thrombosis, cerebral, 28, 650
         anatomical characters, 651
         clinical history, 652
         diagnosis, 655
         pathological character, 31, 651
         prognosis, 657
         treatment, 658
     in pyaemia, 82
     in ulcerative endocarditis, 319, 321, 329
     of arteries in the  medulla oblongata,
       32
     of coronary arteries, 32
     of mesenteric arteries, 494, 495
     of pulmonary  artery, 32, 82, 179, 205,
       350
Embolus, 30,  650
     air, 30, 32
     bland, 30, 32
     fat,  30, 32, 68
     infectious, 32, 82, 179
         in pyaemia, 82
     mycotic, 29
     pigment,  30
Emissions, involuntary seminal, 939
Emphysema, 235
     acute. 235
     idiopathic, 235
     interlobular or interstitial, 235
     of lungs,  235
         anatomical characters, 236
         causation, 239
         clinical history, 237
         diagnosis, 241
         pathological character, 238
         prognosis, 243
         treatment, 243
     senile, 237, 242
     vesicular   235   (vide Emphysema  of
       lungs).
Emprosthotonos, 846
Empyema, 112, 117, 140.
     causation, 140
     cystidis felleae, 630
     diagnosis, 141
     prognosis, 141
     treatment, 142
Emulsin, 85
Encephalitis, 715
     anatomical characters, 715
     causation, 715
     clinical history, 716
     prognosis, 716
     treatment, 716
Encephalopathy, definition of, 20
     saturnine, 525, 770
Enchondroma, 43
Endarteritis, 186
     deformans, 659
     in chronic Bright's  disease, 875
     obliterans, 186, 660
Endemic diseases, 88 
INDEX.
1143
Endocarditis, 303, 307, 315
        anatomical characters, 315
        causation, 317
        clinical  history, 316
        diagnosis, 318
        pathological character, 317
        prognosis, 319
        treatment, 319
        bacteria in,  91.
    bacteritic, 320
    diphtheritic, 320
    embolism, cerebral, in, 650
    malignant, 315,  320
    mycotic, in pyaemia, 82, 320
    papillary, 316
    puerperal, 320
    pvaemic, 82, 320
    rheumatic, 307,  1093, 1095
    septic, 320
    simple, 315
    ulcerative, acute, 315, 320
        anatomical  characters, 320
        causation, 91, 'Al'l
        clinical  history, 322
        diagnosis, 322
        pathological character, 322
        prognosis, 322
        treatment, 323
Endopericarditis, 317
Enteralgia, 20, 524
    from  lead,  524 (vide Colic, from lead).
Enteritis,  acute, 487
        anatomical  characters, 488
        causation, 489
        clinical  history, 488
        diagnosis, 489
        pathological character, 488
        prognosis, 490.
        treatment, 490.
    chronic, 490
    membranous, 487
    polyposa, 479
    septicaemic, 80
    subacute, 490.
    varieties of, 487
Enteroliths, 496
    obstruction of intestine by, 506
Enterorrhcea, 20, 510, 536
Enterorrhagia, 20, 514, 602, 958, 980
    clinical history, 516
    etiology, 515
    prognosis, 516
    treatment, 516
Ependymitis, granular or chronic, 714
Epidemic diseases, 88
Epilepsia gravior, 823
    niitior, 822
Epilepsy,  822
    causation, 825
    clinical history, 823
    diagnosis, 827
    hemiplegia in, 777
    in cortical lesions, 680
    pathological character, 825
    prognosis, 828
    spinal, 737
Epilepsy, treatment, S31.
Epileptiform convulsions, 822
Epileptoid  attacks, 823, 829
Epithelioma, 43
    of stomach, 429
Erythromelalgia, 773
Erysipelas, 993
    epidemic, 280
    micro-organisms causing, 89, 91
    streptococcus in, 91
Etiology, 21, 83, 111
Excrementitious principles,  accumulation'
       of, in blood,  65, 72
Expectant  treatment of disease,  104
Exudation, 33, 35
    adhesive, 37
    catarrhal, 37, 1075
    croupous, 37, 1074
    diphtheritic, 37, 1074
    fibrinous, 36
    hemorrhagic, 36, 37
    inflammatory, 35
    mucous, 37
    plastic, 37
    pseudo-diphtheritic, 1077
    purulent, 36
    serous, 36
Eyeballs, prominence  of, and enlargement
       of thyroid  body, associated  with
       functional disorder of  the heart,
       356.

                   F.
Facies Hippocratica, 100
Fat, increase and diminution of, in blood,
       68
Fatty degeneration, 53, 54
    emboli, 32
    infiltration, 53, 54
    metamorphosis, 53
Febricula,  944, 947
Fecal abscess, 482
Fever, definition of, 18, 945
    abdominal tvphus, 948
    African, 1018
    and ague, 997
    bilious, or bilious remittent, 1011
    break-bone, 1072
    camp, 1015
    causes of, 946
    Chagres, 997
    cerebro-spinal, 707
    Chickahominy, 1015
    congestive, 1008
    continued, common, 944, 947, 948
         simple, 947
    dandy, 1072
    enteric, 948
    ephemeral, 947
    epidemic,  characterized  by  pharyn-
       gitis, 995
    erysipelatous, 993
         epidemic,  994
    famine, 986, 991
    five-day, 986 
1144
INDEX.
Fever, gastric, 412, 441
    heat, 683
    hectic, in phthisis pulmonalis, 190
         in pyelitis, 899
    Hungarian, 1018
    ileo-typhus, 948
    intermittent, 997
         anatomical characters, 997
         causation, 1001
         clinical history,  997
         diagnosis, 1003
         melanaemia  in, 78
         prognosis, 1004
         relapses of, 1000
         stages of, 997
         treatment, 1004
    intermittent, compound types of, 999
         bilious, 1001
         congestive, 1008
         latent, 1001
         malignant, 1008
         masked, 1001
         pernicious, 1008
            algid, 1008
            apoplectic, 1008
            asthenic, 1009
            comatose, 1008
            haematuric,  1009
            icteric,  1008
            melanaemia  in, 78
            quinia,  in, 106, 1004, 1010
            soporose, 1008
            treatment of, 1009
        prophylaxis of, 1007
        quartan, 999
        quotidian, 999
        tertian,  999
            tvpes of, 999, 1003
   jail, 970
   jungle,  1018
   lake, 1018
   lung, 164
   Panama, 997
   pathology of, 945
   pneumonic, 152,  164
   puerperal, 81
   pyaemic, 82
   pythogenic, 948
   relapsing, 985
        anatomical characters, 986
        causation,  89, 990.
        clinical  history, 987
        coagulation necrosis in, 52, 986
        diagnosis, 990
        prognosis,  992
        spirochete  Obermeieri  in, 89, 92
          93, 986, 990
        treatment, 992
   remittent, bilious, 1011
        pernicious, 1017
   remittent, simple, and typho-malarial,
          1012
        anatomical characters, 1012
        causation, 88, 1015
        clinical history, 1013
        diagnosis, 1015
 Fever, remittent,  pathological  character,
       1015
         prognosis, 1016
         quinia, use of, in, 1016
         treatment, 1016
     rheumatic, 1093
     scarlet, 1051
     septicaemic, 81
     seven-dav, 986
     ship, 970
     short, 986
     simple, 947
     splenic, due to micro-organisms, 89
         bacilli anthracis in, 92
     spotted, 707
     suppurative or secondarv, in variola,
       1034
     swamp, 88, 997
     symptoms of, 946
     thermal, 683
     typhoid, 948
         abortive, 968
         anatomical characters, 948
         bacillus of, 92, 950, 953, 964
         bacteria in, 90-92, 950, 953, 964
         causation, 963
         clinical history, 954
         complications, 952, 963
         diagnosis, 966
         latent, 968
         prevention of, 966, 984
         prognosis, 968
         treatment, 976
     typhoid  and typhus,  non-identity  of,
       98, 99, 970
     typho-malarial, 963, 1011  (vide Fever,
       remittent typho-malarial).
     typhus, 970
         anatomical characters, 970
         causation, 973
         clinical history, 970
         diagnosis, 975
         prevention of, 984
         prognosis, 976
         recurrens, 986
         treatment, 976
     AValcheren, 1018
     worm, 560
     yellow, 1018
         anatomical characters, 1018
         causation, 88, 89, 1022
         clinical history, 1019
         diagnosis, 1025
         prevention of, 1027
         prognosis, 1022, 1025
         treatment, 1026
Fevers and other general diseases, 944
Fevers, adynamic, 945
     asthenic, 945
     ataxic, 945
     causes of, 946
     chlorides in blood, and urine  in, 69
     classification of, 944
     contagious, 944
     continued,  944
     eruptive, 112, 944, 1028 
INDEX.
1145
 Fevers, essential, 113, 944
      exanthematous, 944
      fastigium of, 945
      high, 945
      low, 945
      lysis of, 945
      malarial, 997
      miasmatic,  944
      miasmatic contagious, 944
      micro-organisms in, 945
      pathology, general, of, 945
      periodical, 944, 996.
      slow, 945
 Fibrin, coagulation of, within vessels,
            29
          within  heart, 28
      decrease of, 64
      morbid increase of, in blood, 64
      origin of, 28, 52, 64
 Fibrin ferment,  28, 52
      in transudations, 34
 Fibrinogen, 34, 52
 Fibrino-plastin,  28, 52
 Fiiaria sanguinis hominis, 94, 589, 922,
 Fingers, bulbous or clubbed, 193
 Foot-clonus, 732
 Flux, bloody, 474
 Fluxion, definition of, 26
 Fomites, 89, 974, 1036, 1059
 Formations, new, 38
 Friedreich's disease, 748
 Functional morbid changes, 20, 111
 Fungi, varieties of, 93


                    G.
 Gall-bladder, cancer of, 630
     dilatation of, 629
     inflammation of, 629
 Gall-stones, passage of, 530
     clinical history, 531
     diagnosis, 531
     prognosis, 533
     treatment, 533
 Gangrene, dry, 51, 52 (vide Necrosis).
     moist, 51, 52
     of lungs, 231, 268
         anatomical characters, 268
         causation, 268
         clinical history, 269
         diagnosis, 270
         prognosis, 270
         treatment, 270
     senile, 52
Gastralgia, acute, 20, 460
     chronic, 461
Gastrectasia, 434
     anatomical characters, 434
     clinical history, 436
     diagnosis, 437
     prognosis, 437
     treatment, 438
Gastric carcinoma, 429
     anatomical characters, 429, 435
     diagnosis, 431
     etiology, 431
28,
926
 Gastric carcinoma, prognosis, 433
     symptoms, 431, 455
     treatment, 434
     tubules, degeneration of, 438
          anatomical characters, 438
          causation, 438
          clinical history, 440
     ulcer, 421 (vide Ulcer, gastric).
 Gastritis, acute, 405
          anatomical characters, 406
          causation, 408
          clinical history, 408
          diagnosis, 409
          pathological character, 408
          prognosis, 409
          treatment, 409
     chronic, 413
          interstitial, 418
             anatomical  characters, 418
             causation, 420
             clinical history, 419
             diagnosis, 420
             treatment, 420
     phlegmonous, 416
          anatomical characters, 416
          causation, 417
          clinical history,  417
          diagnosis, 417
          metastatic, 417
          prognosis, 418
          treatment, 418
     polyposa, 414
     subacute, 411, 442
     toxic, 407, 410
     uraemic, 412
 Gastro-duodenitis, 420, 628, 633
 Gastrodynia, 460
 Gastromalacia, 421
 Gastrorrhagia, 20, 455, 602, 626
 Gastrorrhoea, 20, 536
 Gastro-enteralgia, 524
 Genito-urinary system, diseases of,  862
 Germ theory of disease, 89, 101
     conditions necessary to demonstration
       of, 89
     how  supported  by effects  of  quinia,
       1006
 Glanders, 47
     cause of, 85
     micro-organisms causing, 89, 92
 Glioma, 43
     brush or spider cells  in, 43
     in brain, 722
 Globules  of blood, changes  in conforma-
      tion and composition  of, 60, 65
     migration of white, 34
     regeneration of red, 61
     source of red, 61
Globus  hystericus, 837
Glomerulo-nephritis, 866, 875
Glosso-pharyngeal nerve, paralysis of, 792
Glottis, oedema of, 294, 405
        anatomical character, 294
        causation, 294
        clinical history, 295
     spasm of, 296, 363 
1146
INDEX.
Glycohaemia, 69, 929
Glvcosuria,  69, 929  (vide Diabetes melli-
      tus).
    causes of, 69, 70, 642, 934
Goitre, exophthalmic, 356
Gout, 75, 113, 1106
        anatomical characters, 1107
        causation, 76, 87, 1118
        clinical historv, 1108
        diagnosis, 1099, 1114
        pathological characters, 1112
        prognosis, 1115
        treatment, 1116
    anomalous, 1111
    chronic or persistent, 1110
    irregular or misplaced, 1111
    kidneys in, 76, 878, 887
    latent, 1111
    retrocedent, 1111
    rheumatic, 1120
    tophi in, 76, 1107
    transient, 1108
    uric  acid in  blood  in,  75, 84, 1108,
       1112
Granulation tissue, 39
    new blood-vessels in, 39
Graphospasms, 818
Gravel, 76, 906
Graves's disease, 356
Growths,  morbid, 38 (vide Tumors).
Gumma, 46
    in brain, 723
    in cord, 761
    in heart-wall, 324, 349
    in intestine, 492
    in liver, 605
    in lungs, 276
    in pharynx, 401
Gums, blue  discoloration of, in lead-poison-
       ing, 527
    in scorbutus, 1125

                  H.
Haematemesis, 455
Haematinuria, 862, 922
Haematoblasts, 61
Haematoidin, 28, 57
Haematoma, 27
    of dura mater, 681, 691
    of the peritoneum, 584
Haemato-myelitis,  688, 734, 737
Haemato-myelus, 688
Haematophilia, 1132
Haematopoietic system, diseases of, 366
Haematorrhachis, 688
Haematuria, 20
    endemic, 921
    renal, 899, 900, 911, 913, 917, 920
Haemoglobinaemia, 922
    malarial, 924
Haemoglobin, 65, 67, 71
Haemoglobinuria,  862, 922
     paroxysmal, 923
Haemopericardium, 313
Hcemophthisis, 367, 385
Haemophilia, 1132
Haemoptysis, 261, 269
    in bronchitis, 229
    in phthisis  pulmonalis, 189, 192, 201,
      204, 215
    in pneumorrhagia, 267
    in miliary tuberculosis, 217
    with cardiac valvular lesions, 330
Hay asthma, 246, 248
Hay fever, 248
Headache, 810
    in uraemia, 72, 884, 889
    sick, 442, 811
Health, definition of, 22
Heart, atrophy of, 346
    abscess in, in pyaemia, 82
        in infarction,  323
        in myocarditis, 323
    aneurism of, in myocarditis, 323
    brown, 51
    dilatation of, 324,  329, 340, 342, 1095
    enlargement of, with valvular  lesions,
           325, 337
        without valvular lesions, 344, 879
    fatty degeneration of, 346,  390
    functional disorder of, 352
        causation, 354, 446
        diagnosis, 354
        treatment, 355
    functional disorder of, associated with
           enlargement of  thyroid  body
           and  prominence  of  eyeballs,
           356
        pathological character, 357
        treatment, 357
    gummata in, 349
    hypertrophv and dilatation of, in ne-
           phritis, 876, 886, 887, 890
        clinical history of, 342, 345
    infarctions in, 31,  323
    murmurs, 334 et seq.
    new growths and parasites in, 349
    obesity of, 346
    parasites in, 349
    parenchymatous  degeneration of, 347,
       349
    partial aneurism of, 323
    red, 51
    rupture of, 323, 324, 350
    syphilitic disease of, 324
    thrombosis  of, 323, 326, 350
    tubercles in, 216, 349
     valvular lesions of, with enlargement,
           325, 337
         anatomical characters, 325
         causation, 334
         clinical history, 330, 338
         diagnosis, 334
         pathological character, 333
         prognosis, 338
         treatment, 339
 Heart-beats, diminished frequency of 353
 Heart-clot, 28, 165, 316, 321, 323
 Heart-sounds, reduplication of, 353
 Heat of body, in disease, 100 
INDEX
1147
 Helminthi, intestinal, 93, 559 (vide AVorms,
       intestinal).
 Hematoma, of dura mater, 681, 691
 Hemianaesthesia, crossed, 674
     from lesions of corpora striata, 677
 Hemianopsia,  from  disease  of  the  optic
       thalami, 676
     from cortical lesions, 681, 716
     from  disease  of  the corpora striata,
       677
 Hemiathetosis, 821
 Hemichorea, 676, 679, 813, 822
 Hemicrania, 802, 810
 Hemiopia, 678, 681
 Hemiplegia, 777, 778
     double, 669, 776
     emotional, 777, 778
     infantile spastic, 718
     in cerebral embolism  and thrombosis,
       653
     in cerebral hemorrhage, 662, 664
     in epilepsy, 824
     in insolation, 684, 777
     in lesions of cortex, 679
     in meningeal hemorrhage, 682
 Hemoptysis (vide Haemoptysis).
 Hemorrhage by diapedesis, 27
     by rhexis, 27
     cerebral, 659
         anatomical characters, 659
         causation, 659, 667
         clinical history,  662
         diagnosis, 667
         pathological character, 659
         prognosis, 668
         treatment, 669
     meningeal, 681
     pulmonary, 20, 261, 269, 280
         relations of, to phthisis, 262, 263,
           264
         treatment of, 264, 268
     punctate, 27
     spinal, 6SS
     spontaneous, 659
Hemorrhagic diathesis, 27, 1132
Hemorrhagic  extravasation,  changes  :
       27
Hemorrhagic infarction, 27, 31
     in cardiac disease, 330
     in pyaemia, 82
Hepar mobile, 624
Hepatic colic, 530
Hepatitis, chronic interstitial,  599
         anatomical characters, 599
         causation, 602
         clinical history, 601
         diagnosis, 603
         prognosis,  604
         treatment, 604
    suppurative, 593
        anatomical characters, 593
        causation, 594, 59(5
        clinical history, 595
        diagnosis, 597
        prognosis, 598
        treatment, 598
 Hepatitis, syphilitic, 605
 Hernia, diaphragmatic, 503
     duodeno-jejunal, 503
     strangulated within abdomen, 502
 Heterologous, definition of the term, 41
 Hippocratic countenance, 100
 Histology, morbid, 20
 Hodgkin's  disease,  380 (vide  Pseudo-leu-
       cocythaemia).
 Homoeopathy, 107
 Homologous, definition of the  term, 41
 Hum, venous, in anaemia,  63, 368
 Hyaline degeneration,  53, 56
     in tubercle, 48
 Hydatids, 94
     in the kidneys,  899, 911
     in the liver, 618
     in the lungs, 275
     in the spleen, 641
 Hydraemia, 60, 63, 68
     cause of oedema in, 64
     three forms of, 63
 Hydrencephaloid affection, 649, 659, 768
 Hydrocephalus, 20, 32, 33, 713
     acute, 698, 714
 Hydromyelus, 761
 Hydronephrosis, 901
     anatomical characters, 902
     causation, 902
     clinical  history, 903
     diagnosis, 904
     prognosis, 904
     treatment, 904
 Hydropericardium, 20,  32, 313
 Hydro-peritoneum, 20,  32, 33, 587
     causation, 587, 616
     clinical  history, 589
     diagnosis, 590
     fluid of,  588
     prognosis, 590
     treatment, 591
 Hydrophobia, 849 (vide Rabies).
 Hydrops cystidis felleae, 32, 629
     adiposus, 588
     chylosus, 34, 588
 Hydrorrhachis, 713
 Hydrothorax, 20, 32, 150
 Hvgienic treatment of disease, 104, 106,
       112
 Hypalbuminosis,  63
 Hyperaemia,  active, 26
     active cerebral, 645
     cerebral, 644
         anatomical characters, 645
         causation, 645
     collateral or compensatory, 26
     functional, 26
     mechanical, 26
     of kidneys, 862
     of liver,  624
     of lungs, 181
     of spinal cord and its meninges, 687
     passive, 26
     passive cerebral, 645, 647
     venous, 26
Hyperalbuminosis, 64 
1148
INDEX.
Hyperinosis, 64
Hyperplasia, 40
Hypertrophy, 40
    numerical, 40
    of heart, 342
         in  chronic Bright's disease,  876,
           879
    simple or true, 40
Hypinosis, 64
Hypnotism, 845
Hypochondriasis, 859
Hypodermic  injections  of  morphia, in
      neuralgia and other affections, 799
    injections of quinia, in malarial fevers,
           1006, 1010
         in neuralgia, 801
    syringe, in diagnosis, 136
Hypoglossus nerve, paralysis of, 792
Hypostasis,  26
Hysteria, 836
    causation, 841
    clinical history, 836
    diagnosis, 838
    pathological character, 841
    prognosis, 842
    treatment, 842
Hysterical coma, 838
    condition, 836
    convulsions, 837
    cough, 837
    delirium, 837
Hystero-epilepsy, 843


                    I.
Icterus, 77,113, 628, 631  (vide Jaundice).
    gravis,  78, 602,  604, 606
    haematogenous,  77, 631, 923
    hemorrhagic, 606
    hepatogenous, 77, 631
Ileo-colitis,  486
Ileus, idiopathic, 496, 508
Impotence,  939, 941
Inanition, 458
Incision, free, for empyema, 142
    for pleuritis with pneumothorax,  147
Incubation of disease, definition of, 97
Indican, in intestinal obstruction, 500
Indications, causal, 107
    classification of therapeutical,  107
    pathological, 107
    symptomatic,  107
Indigestion, 441
Induration, brown  or pigment, of lungs,
       181
Infarction, anaemic or white, 31, 650
    cardiac, 31
    cerebral, 31, 650
    coagulation necrosis in, 52
    embolic, 31, 650
    gastric, 31
    hemorrhagic, 27, 31, 82, 179, 266
    intestinal, 494
    renal, 31
     retinal, 31
    shape of, 31
Infarction, splenic, 31
Infection, definition of, 84
Infectious tumors, 42, 46
Infectious nature of tubercle, 49
Infiltration, 53
    albuminous, 53
    fatty, 53, 54
         of heart, 346, 390
         of muscle, 55
Inflammation, 18,  19, 34
    catarrhal, 37
    Cohnheim's theory of, 34
    croupous, 37
    diphtheritic, 37
    fixed cells in, 36
    Hunter's theory of, 34
    parenchymatous, 37
    phenomena of, 35
    products of, 36
    source of pus in, 36
    terminations of, 37, 57
    treatment of acute, 124
    use of opium in, 127
    A'irchow's theory of,  84
Influenza, 88, 219, 228, 399
Inhalations  of oxygen and  warm  vapor,
      227, 228
Inoculation, to prevent variola, 1041
Insolation, 682
    anatomical characters, 683
    causation, 684
    cerebral congestion in, 646
    clinical history, 683
    diagnosis, 685
    hemiplegia in, 777
    pathological characters, 683
    prognosis, 685
    treatment, 685
Insufficiency, relative, of  heart-valves, 326
Insufflation, 235
Intestine, carcinoma of, 495
    compression and stricture of, 496, 504
    functional affections of, 509
    hemorrhage into, 20, 514, 602
         in  tvphoid  fever, 951,  958, 969,
           980
    infarction in, 31
    inflammatory diseases of, 463
    intussusception or   invagination  of,
           469, 497
         anatomical characters, 497
         causation, 498
         clinical history,  499
         diagnosis, 499
         laparotomy in, 501
         prognosis, 497, 498, 500
         treatment, 500
    new growths in, 495
    obstruction of, 496
         from enteroliths, 496, 506
         from feces, 496,  506
         from foreign  bodies, 496, 506, 533
    perforation of, in  typhoid fever, 950
       958, 980
    rotation or twisting of, 496, 502
    rupture of, in  obstruction, 505 
INDEX.
1149
Intestine, Simon's  method of  exploring,
      505
    stricture and compression of, 496, 504
    structural affections of, 491
    tuberculosis of, in phthisis, 193
    twisting of, 496, 502
    ulcers of, 491
    waxy degeneration of, 55, 496
Intussusception, 497
Intubation of larynx, in diphtheria, 1089
Irritation, spinal, 668, 782
Ischaemia, local, 25, 60


                   J.
Jaundice, 77, 113, 628, 631
         clinical history,  632
         diagnosis, 634
         pathological characters, 632
         prognosis, 634
         treatment, 634
    fatal, 606
    haematogenous, 77, 631
    hepatogenous, 77, 631
    malignant, 606


                   K.
Kak-ke, 785
Kidney, abscess of, 896
    atrophy, granular, of, 51, 878,  882
    carcinoma of, 45,  914
         anatomical characters,  914
         clinical history,  916
         diagnosis, 916
         prognosis, 917
         treatment, 918
     cirrhosis of, 878,  882
     congestion of, active, 862
         passive,  863
     degeneration of, cvstic, 910
         fatty,  54, 61,  864
         parenchymatous, 864
         waxy, 55
     echinococci in, 911
     fibroid, 878, 882
    floating, 918
    gouty, 878, 879, 882,  887, 889
    granular, small, 878, 882
    hydatids in, 911
    induration, cyanotic, of, 863
    inflammation,   acute,  of,  865  (vide
           Nephritis,  acute diffuse).
         acute  interstitial or suppurative,
           of,  896 (vide  Nephritis, acute
           interstitial or suppurative).
         chronic  diffuse,  of, 873 (vide Ne-
           phritis, chronic diffuse).
    large, without waxv degeneration, 875,
           890
         with waxy degeneration, 876, 888
    large red,  875
    large white, 875
    movable, 918
    new growths in, 911
    small granular, 878, 882, 890
Kidney, spirit, 88S
    surgical, 896
    tuberculosis of, 216, 912
    wandering, 918
    waxv degeneration of, 55, 876, 890
Knee-jerk, 731, 1081


                   L.
Lactic acid in rheumatism, 317, 319
Laparotomy in intestinal  obstruction, 501,
       504
Laryngismus stridulus, 296
Laryngitis, acute simple, 278, 279
        anatomical characters, 279
        causation, 280
        clinical history, 279
        diagnosis, 281
        pathological character, 280
        prognosis, 281
        treatment, 281
    chronic, 192, 201, 204, 283
    subacute, 283
    syphilitic, 284
    with fibrinous exudation, 287
        causation, 289
        clinical  history, 288
        diagnosis, 290, 10S2
        pathological character, 289
        prognosis, 291
        treatment, 291
Laryngoscope, 287, 302
Laryngotomy,  in  cases of thoracic aneur-
       ism, 365
Larynx, diseases  of, 277
    fistulous orifice within, 301
    morbid growths within, 301
    paralysis of,  279, 288, 298
    spasm of, 279, 288, 289, 296, 850
    topical applications within, 286
Lead colic, 524 (vide Colic from lead).
    encephalopathy,  525, 770
    enteralgia, 101, 524
    paralysis, 101, 525, 527, 794
    poisoning by, 85, 101, 524
Leprosy, 47, 92
Leptomeningitis, 691, 693  (vide Meningitis,
       acute cerebral).
Lesions, definition of, 20
Leucocytes, 36
Leucocythaemia or leukaemia,  65, 372
    causation, 379
    clinical history, 376
    diagnosis, 378
    hemorrhagic tendency in, 27, 375, 377,
       660
    pathological  character, 372, 639
    prognosis, 378
    treatment, 379
Leucocytosis, 65,  372
Leucomyelitis, chronic posterior, 742
Leukaemia, 65
Lime-metastases,  57
Lipaemia,  68, 930
Lipoma, 43
Lithaemia, 75, 1108, 1112 
1150
INDEX.
Lithiasis, 906
Lithiuria, 908
Liver, abscess of, 593 (vide Hepatitis, sup-
           purative).
        in pya-mia, 82
    acute yellow atrophy of, 606
        anatomical characters, 606
        causation,  609
        clinical history, 607
        diagnosis,  609
        pathological changes, 608
        prognosis,  610
        treatment,  610
    amyloid, 613
    atrophy of, 623
        brown,  of,  624
        red, of,  329, 625
    bronzed, 1012
    cancer of, 615
        anatomical characters, 615
        clinical hislory, 616
        diagnosis,  617
        treatment,  617
    changes in position and shape of, 624
    cirrhosis of, 415, 599, 1013
    cirrhosis, hypertrophic, of, 604
    congestion of, 624, 636
    diseases of, 593
    fatty, 54, 611, 1018
    functional affections of, 636
    gin, 603
    hydatids in, 618 (vide Echinococcus of
       the.liver).
    hypertrophy of, 623
    lardaceous or  waxy, 613  (vide Liver,
       waxy).
    new growths in, 617
    nutmeg, 329, 625
    parenchymatous degeneration of, 613
    pigmentary deposit in, 623, 1012
    pulsating, 332
    syphilitic disease of, 605
    torpor of, 637
    tuberculosis of, 216, 618
     wandering,  624
    waxy or lardaceous, 55, 605, 613
         anatomical characters, 613
         causation, 614
         diagnosis,  614
         pathological characters, 613
         prognosis, 615
         treatment, 615
     whiskey, 603
 Localization of  cerebral disease, 672
     in cerebellum, 673
     in centrum ovale, 678
     in corpora quadrigemina, 675
     in corpora striata, 676
     in cortex cerebri, 654, 678
     in crura cerebelli, 673
     in medulla oblongata, 674
     in pedunculi cerebri, 675
     in pons ATarolii, 674
     in thalami  optici, 675
 Locomotor ataxia,  742
 Lockjaw, 845
Lotura carninm, 468, 474
Lumbago, 805
Lumbodynia, 809
Lumbricoid worms, 94, 560
Lung, carnified, 117
    carcinoma of, 215
    cirrhosis of, 214
    senile atrophy of, 237
Lungs,  diseases of,  115 (vide  Pulmonary
      diseases).
    brown or pigment induration of, 181
    hyperaemia of, 181
    splenization of, 182
Lymph, 33
Lymphadenoma, 42
Lymphangitis in pyaemia, 82
Lymphoma, 42, 381
Lympho-sarcoma, 42
    malignant, 381
    of lung, 274
Lysis, 158,  945
                  M.

Macrocytes, 60, 386
Magnetic sleep, 845
Main en griffe, lob
Mal, haul or grand, 823
    petit, 823
Malacia, 452
Malaria, 1001
Malignant tumors, 41
Malingerers, 99
Malingering, 99
Malum coxae senile, 1120
Mania-a-potu, 854, 856
Marrow of bone, in anaemia, 61
    in leucocythaemia, 373,  374
    in melanaemia,  78
    in pseudo-leucocythaemia, 382
    in pernicious anaemia, 386
    in regeneration of red corpuscles,  61
Masturbation, 943
Measles, 1065 (vide Rubeola).
    false, 1071 (vide Roseola).
    German, 1072 (vide  Rotheln).
Meckel's diverticulum, 502
Medicine, definition of,  17
    conservative, 104
    departments, different,  of,  17
    preventive, 101
    principles and practice of, 18, 19, 22,
       102
    progressive character of, 108
Medulla oblongata, embolism of arteries of,
       32
    apnoea in diseases of, 105
    glvcosuria in diseases of, 70
Megrim, 811
Melaena, 456,  514
Melanaemia, 78, 1012
     pathological effects  of,  79
     pigment, seat of, in, 78, 1012
         source of, in, 57, 78, 79
Melanin, 58
Melanosis, 1012
Melasma supra-renale, 389 
INDEX.                               1151
Melituria, 929 (vide Diabetes mellitus).
Meniere's disease, 770
Meninges of brain and  spinal  cord, dis-
      eases of, 690
Meningitis,  basilar, 698 (vide Tuberculous
      meningitis).
    cerebral, acute, 691, 693
         anatomical characters, 693
         causation, 695
         clinical history,  694
         diagnosis, 695
         pathological characters, 693
         prognosis, 696
         treatment, 696
    cerebral, chronic, 697
    gummatous, 723
    cerebro-spinal, 707
         anatomical characters, 707
         causation, 711
         clinical history,  708
         diagnosis, 711
         pathological character, 710
         prognosis, 712
         treatment, 712
    spinal,  acute, 702
         anatomical characters, 703
         clinical history,  703
         diagnosis, 704
         etiology, 703
         pathological characters, 703
         treatment, 704
    spinal,  chronic, 704
    tuberculous, 194, 698
         anatomical characters, 698
         clinical history,  700
         diagnosis, 701
         pathological characters, 699
         treatment, 702
Meningo-myelitis, 703, 734
Mental influences, in the  treatment of dis-
      ease,  108
Mesmeric or magnetic sleep, 845
Metamorphosis, diphtheroid, 1029, 1030
    fatty, 53
         causes of,  54
Metastases,  lime, 57
Miasm, 84,  88
    marsh,  84, 1001
Micrococci,  90, 92
    in diphtheria, 1077
    in pyaemia, 81, 82
    in variola, 1030, 1031
Microcytes,  60, 386
Mierocvthaemia, 60
Migraine, 802
Milk  sickness, 1089
    treatment, 1092
Mind, disorders of, 767
    management of, in disease, 108
Monoplegia in cortical diseases, 679
Morbilli, 1065 (vide Rubeola).
Morbid growths (vide New growths).
Morbus coxae senile, 1120
    haemorrhagicus maculosus, 1131
Motor oculi communis, paralysis of, 665,
          675, 788
Motor oculi externus, paralysis of, 789
Movements, muscular, anomalous, 816
    compelled, 673, 724
Mucin, 55
Mucus, 231
Mumps, 403 (vide Parotiditis).
Murmurs, anaemic,  63, 336
    aortic, 318, 335
    bellows, 63, 307
    cardiac—friction, 307
    cardiac—pleural friction, 308
    cardiac—pulmonary, 335
    endocardial, 307, 318, 334
    exocardial, 307
    haemic, 63," 336
    inorganic, 63, 336
    mitral, 318, 334
    pericardial, 307
    pulmonic, 318, 336
    tricuspid, 215,  336
    venous, 63
Muscles, fatty degeneration of, 54, 61
    abscesses in, in pyaemia,  82
    atrophy of, in  cerebral hemorrhage,
      666
         in progressive hemorrhage, 753
Myalgia, 807
Myelitis, acute, 734
         anatomical characters, 735
         causation,  738
         clinical history, 736
         pathological character, 735
         prognosis,  737
         treatment, 738
    ascending, 734
    central, 734
    chronic, 735, 738
    cortical, 734
    descending, 734
    diffuse, 734
    pressure, 760
    transverse, 734
    varieties of, 734
Myocarditis, 303, 323
    chronic interstitial, 323
    fibrous, 323
    gummatous, 324
    indurative, 323
    interstitial, acute, 324
    parenchymatous, 324
    suppurative, 324
Myoma,  48
Myxoma, 20, 42


                   N.

Necrosis, 51
    anaemic, 31, 52
    bacteria in, 51
    causation of, 51
    coagulation, 25, 31, 48. 51
         in acute Bright's disease, 867
         in diphtheria, 52, 1076
         in dysentery, 467
         in endocarditis, ulcerative, 320
         in variola, 52, 1029, 1030 
1152
INDEX.
Necrosis, simple, 51
    with decomposition, 51
Needles, evils of their use in thoracentesis,
      139
Nematoda, 93, 563, 568
Neoplasms, 38 (vide New growths).
Nephritis, acute diffuse, 865
        anatomical characters, 866
        causation, 870
        clinical history, 867
        diagnosis, 871
        pathological character, 869
        prognosis, 871
        treatment, 872
    acute interstitial, or suppurative, 896
        anatomical characters, 896
        causation, 896, 897
        clinical history, 897
        diagnosis, 898
        prognosis, 898
        treatment, 898
    after scarlatina, 1053, 1055, 1058
    chronic diffuse, 873
        anatomical characters, 875
        causation, 887
        classification of its varieties, 873
        clinical history, 880
        diagnosis, 889
        pathological characters, 887
        prognosis, 891
        treatment, 892
Nephrolithiasis, 905
Nephro-phthisis, 912
Nervous system, diseases of, 644, 783
Neuralgia, 796
        causation, 798
        clinical history, 797
        diagnosis, 799
        treatment, 799
    cervico-brachial, 804
    cervico-occipital, 804
    crural, 805
    cutaneous, 807
    dorso-intercostal, 183, 805
    epileptiform, 803
    lumbo-abdominal, 805
    muscular, 807
    sciatic, 805
    trifacial, 802
Neurasthenia, 781
Neuritis, 784
    ascending, 784
    circumscribed, 784
    descending, 784
    multiple, 785
Neuroma, 43
Neuroses,  644, 781, 813
New formations, pathological, 38
New growths, 38
    in the brain, 722
    in the chest, 274
    in the heart, 349
    in the kidney, 911 et seq.
    in the larynx, 301
    in the liver, 617
    in the lungs, 274
 New  growths in the spleen, 641
    in the thorax, 274
 Noma, in typhus fever, 972
 Nomenclature of disease, 19
 Nosology, 113
 Nymphomania, in rabies, 850


                   o.

 Obesity,  54
 Obstipation, 516
 Obstruction of bowels, 496
 (Edema, 32, 113, 150
    cardiac, 33, 331
    collateral, 166, 271, 294
    of the glottis, 33, 105, 294
    pulmonary, acute, 32, 271
         anatomical characters, 271
         causation, 271
         symptoms, 273
         treatment, 273
    pulmonary, collateral, 271
 (Esophagus, inflammatory and other affec-
      tions of, 402
 Oil-emboli, 30
 Oligaemia, 60, 61, 367, 385
 Oligochromaemia,  60, 371
 Oligocythaemia, 60, 367, 385
 Opisthotonos,  703, 709, 838, 846
 Orchitis, variolous, 1035
 Orthopnoea, 151, 226
 Ossification, 57
 Osteoma, 43
 Ovarian  cyst, diagnosis of, from hydroperi-
      toneum, 591
Oxaluria, 20, 76, 907, 908
Oxygen,  causes reducing its amount in the
      blood, 67
Oxyuris  vermicularis, 94, 562


                   P.
 Pachymeningitis, 691
    cervical, hypertrophic,  706, 761
    externa, (591
    haemorrhagica, 681
    interna, 691
 Palliative treatment, 106
 Palsy, wasting or creeping,  753
    shaking, 820
 Pancreas, affections of, 641
    calculi in, 643
    cancer of, 642
    diarrhoea,fatty, in diseases of, 510, 642
    enlargement of, 642
    fatty disease of, 642
    inflammation of, 641
 Pancreatitis, 641,  642
    hemorrhagic, 643
 Papilloma, 48
 Paracentesis, from necessity, 141
    in ascites, 592, 627
    in empyema,  142
    in pericarditis. 313, 314
    in pleuritis, 137
 Paralysis, 772 
INDEX.
11;
Paralysis, acute ascending, 780
    acute bulbar, 695, 722, 760
    agitans, 820
    alcoholic, 854
    alternating, 664,  674
    Bell's, 790
    bulbar, acute, 675, 722, 760
    bulbar, chronic, 675, 719
         anatomical characters, 719
         causation, 721
         clinical history, 720
         pathological character, 719
         prognosis, 720
         treatment, 721
    cerebral, general, of insane, 775
    crossed, 604, 674, 675
    from  arsenic,  copper, mercury,  and
      phosphorus, 796
    from Bright's disease,  884
    from cerebral embolism and throm-
      bosis, 653
    from cerebral hemorrhage, 662
    from chorea, 814
    from commotion, 774
    from compression of spinal cord, 762
    from cranial tumors, 724
    from diphtheria,  787, 1078
    from encephalitis, 716
    from hysteria, 837
    from insolation, 684
    from lead, 525, 527, 794
    from locomotor ataxia, 746
    from meningitis,  694, 701, 703, 709
    from myelitis, 736
    from neuritis, multiple, 786
    from paralysis agitans, 820
    from poliomyelitis anterior, 749, 752
    from primary lateral sclerosis, 758
    from spinal  hemorrhage, 689
    from variola, 1036
    glosso-labio-laryngeal,  719  (vide Bul-
      bar paralysis, chronic).
    hemiplegic, 653, 662
    infantile, spinal, 51, 748
    Landry's, 780
    local, of other than  cranial  nerves,
      798
    mimetic, 790
    myo-pathic, 773
    myo-sclerotic, 763
    neuropathic, 773
    of cervical sympathetic nerve, 794
    of eighth cranial  nerve, 792
    of fifth cranial nerve, 788
    of fourth cranial nerve, 788
    of laryngeal muscles, 279, 288, 298
    of motor  portion of seventh  cranial
     nerve, 790
    of ninth cranial nerve, 792
    of sixth cranial nerve,  789
    of the insane, 775
    of third cranial nerve,  665, 675, 788
    paraplegic, 688, 762, 779, 796
    peripheral, 773, 786
   pseudo-hypertropliic or myo-sclerotic,
     763
 Paralysis  reflex, 774, 779
     spastic cerebral, of children, 718
     spinal, chronic atrophic, 752
         general, 776
         of children and  adults, 734, 748,
           752 (vide  Poliomyelitis, acute
           anterior).
         spasmodic, 758
         spastic, 730, 741,  75S
 Paraphasia, 653
 Paraplegia, 688, 762, 779,  796, 1081
     alcoholic, 854
     reflex, 779
 Parasites,  animal, 93
     vegetable, 89
 Parenchymatous degeneration (vide Degen-
       eration ).
 Paresis, 773, 775
 Parotiditis, 403
     in typhoid fever, 405
 Pathogenesis, 20
 Pathological anatomy, scope of general, 25
     new formations, 38
 Pathology, definition of, 18, 22
     general and special, 18, 25, 111
     medical and surgical,  19
     relationship to  physiology, 22
     special, introduction to, 102, 111
 Pathophobia, 859
 Pentastomum, 93, 623
 Perforation, of intestine, in typhoid  fever,
       576
 Periarteritis, 186, 660
 Peribronchitis, in phthisis, 185, 186
 Pericarditis,  acute,  303
         anatomical characters,  304
         causation,  306
         clinical history, 305
         diagnosis, 307
         pathological character, 306
         prognosis,  309
         treatment, 310
     chronic, 312
     in  rheumatism, 305,  306,  307,  309,
       1093, 1095
     in Bright's disease, 86, 305, 309
     pneumo-, 314
     purulent, 304, 306,  324
     rheumatic, 305-307, 309, 1094, 1095
Perichondritis, laryngeal, 284
Perihepatitis, 20, 582
Perinephritis, 20, 908
Peritoneum, diseases of, 572
Peritonitis, acute diffuse, 19, 573
         anatomical characters, 573
         causation, 576
         clinical history, 574
         diagnosis, 576
         pathological character,  575
         prognosis, 578
         treatment,  106, 579
    cancerous, 583,  616
    chronic, 583
         anatomical characters, 583
         clinical history, 586
         diagnosis, 586
73 
1154
INDEX.
Peritonitis, chronic, treatment, 587
        varieties of, 583
    hemorrhagic, 584
    proliferative, 584
    serous, 583
    tuberculous, 190, 193, 585
Perityphlitis, or perityphlitic abscess, 483,
     * 485
Perspiration, elimination of urea by, 873
Pertussis, 254
    causation, 257
    clinical history, 254
    diagnosis, 258
    pathological character, 257
    prognosis, 258
    treatment, 258
Pharyngeal, retro- abscess, 399
Pharyngitis, 398
    acute, 398
    chronic, 399
    epidemic, 398, 995
    exanthematous, 399
    erysipelatous, 399
    follicular, 399
    gangrenous, 399
    phlegmonous, 399
    pseudo-membranous or fibrous, 399
    subacute, 399
    syphilitic, 400
    tuberculous, 400
Phlebitis, portal, 424, 626
Phleboliths, 29
Phlegmasia alba dolens, 30
Phosphuria, 908
Phthisis, pulmonary, 184
        anatomical characters, 184
        causation,  184, 195
        clinical history, 189
        diagnosis,  198^ 201, 215
        pathological character, 194
        prognosis,  201, 215
        treatment, 205, 216
     acute,  185, 194
     clinical history of first stage, 189
        of second stage, 191
     coal miner's, 180, 214
     complications of, 193
     curability of, 202
     fibroid, 186, 214
     florida, 185, 194
     laryngeal, 284
     methods of cure of, 189
     pathology of, 194
     pneumothorax in, 192, 204
     renal,  912
     sputa of, 189, 191, 192, 200, 216
     stages of, 188
     stone-cutter's, 180,  214
Physician, definition of, 17
     mien and manners of, 108
Physiology, definition  of, 22, 23
Pica, 452
Pigment, derivation of, 57, 78, 79
Pigment induration of  lung, 181
Pigmentation, 57
Pin-worm, 94
Plethora, 58
    causes of, 59
    hyclraemic,  produced by transfusion, 59
Pleuritis, acute, 19, 115
        anatomical characters, 115
        causation, 120
        clinical history, 117, 131
        diagnosis, 121
        pathological character, 120
        prognosis, 123
        treatment, 124
    chronic,  117, 132, 186, 189
        anatomical characters, 132
        causation, 134
        clinical history, 132
        diagnosis, 136
        pathological character, 134
        prognosis, 134
        relations to tuberculosis, 133-136
        treatment, 137
    circumscribed, 117, 149, 154
    diaphragmatic or phrenic, 150
    drv, 116
    in'Bright's disease, 86,  133, 134
    paracentesis in, 137, 150
    sicca, 116
    suppurative, 140 (vide Empyema).
    varieties of, 131
    with pneumothorax, 143
        anatomical characters, 143
        causation, 144, 235
        clinical history, 144
        diagnosis, 145
        prognosis, 146
        treatment, 147
Pleurodynia, 183, 809
Pleuro-pneumonitis, 154
Pleurosthotonos, 846
Pneumonic fever, 152
Pneumo-haemothorax, 143
Pneumo-hydrothorax, 112,  143, 204
Pneumonitis or pneumonia, 19,  151
    acute lobar, 152
        anatomical characters,  152
        causation, 160, 164
        clinical history, 156
        diagnosis, 162
        pathological character, 164
        prognosis, 164-167
        treatment, 103, 167-172
    acute circumscribed, 201
    broncho-, 174
    caseous  or tuberculous, 87, 176, 185,
       214
    catarrhal,  174
    croupous,  152
    deglutition, 177, 178
    embolic, 178
    heart-thrombus in, 165
    hypostatic, 181, 182
    interstitial, 18(5,  214
    in young children, 172-174
    lobular,  174, 224
         anatomical characters, 175
         causation, 177
         clinical history,  176 
INDEX.                                1155
  Pneumonitis lobular, diagnosis, 177
          suppurative, 178
          treatment, 178
      typhoid, 159
  Pneumokoniosis, 180
  Pneumo-pericarditis, 314
  Pneumo-pericardium, 20, 314
  Pneumo-pyothorax, 143
      simulated  by abscess  between liver
        and diaphragm, 145
  Pneumorrhagia, 261, 266, 339
  Pneumothorax, 20, 147
      anatomical characters, 147
      case of, 148
      causation,  148
      clinical history, 148
      prognosis,  149
      treatment,  149
  Poikilocytosis,  60
  Poisons, definition of, 85
      antidotes for corrosive and acrid, 411
  Poliomyelitis, anterior,  734
      acute, 748
         anatomical characters, 748
         causation, 751
         clinical history, 749
         degeneration, reaction of, in, 750
         diagnosis, 751
      acute, in adults, 752
      chronic, 752
      subacute, 752
 Polyarthritis, rheumatic, 1093, 1094
 Polvaemia, 59
 Polvcvthaeniia,  59
 PolVdipsia, 452, 454, 929
 Polyphagia, 452, 932
 Polypus, cardiac, 321, 326, 350
     nasal,  in asthma, 247
 Polyuria,  927
     in Bright's disease,  882
     in diabetes, 930
 Portability of disease, 89
 Portal thrombosis,  30, 626
 Predisposition,  definition of, 87
     acquired, 87
     congenital,  87
     inherited, 88
 Prescribing, simplicity in, 107
 Preventive or prophylactic treatment, 105
 Priapism,  in leucocythaemia, 377
 Proctitis, 486
 Prodromes of disease, definition of, 97, 111
 Profession, the medical,  definition of, 17
         province of, 107
 Prognosis,  definition of, 21, 99, 112
     consideration of, 100, 112
 Prognostics, unfavorable, 100
 Proliferation, atrophic, 51
 Prophylactic treatment, 112
 Prophylaxis, definition of, 21, 101, 105, 112
     consideration of, 105, 112
 Prosopalgia, 802
 Protozoa, 90, 93
 Psammoma, 723
Pseudo-leucocythaemia, or Hodgkin's dis-
       ease, 380
 Pseudo-leucocythaemia, anatomical charac-
        ters, 380
      causation, 383
      clinical history, 382
      diagnosis, 383
      prognosis, 384
      treatment, 384
 Ptomaines, 80
      in fevers, 945
      produced by bacteria, 93
 Ptomainaemia, 80
 Pulmonary apoplexy, 266
      carcinoma, 274
      congestion, 181
      diseases, 115
      echinococci, 295
      gangrene, 268
      hemorrhage, 20, 261
      hydatids, 275
      lympho-sarcoma, 274
      new growths, 274
      oedema, 271, 275
      phthisis, 184
      sarcoma, 274
      syphilis, 276
      tuberculosis,  184 (vide  Phthisis, pul-
           monary).
          acute miliary, 49, 194, 216
 Pulse, after bloodletting, 126
     collapsing, 332
      jerking, 332
     of fatty heart, 347
 Pupil, pin-hole, in typhus fever, 971
 Purpura haemorrhagica, 27, 1131
     rheumatica,  1131
     simplex, 1130
 Pus,  characters of, 36, 231
     composition  of,  36
     source of, inflammation, 36
 Putrefaction,  relation of bacterium  termo
       to, 80
     ptomaines in, 80
 Pyaemia, 20, 79, 81
     causation, 81
     clinical history, 82
     infectious emboli, from thrombi,  in 32
     micrococci in, 81
     multiple abscesses in, 32, 81, 82
     thrombosis in, 82
 Pyelitis, 898
     anatomical characters, 898
     causation, 899
     clinical history,  899
    diagnosis, 900
    prognosis, 901
    treatment, 901
 Pyelo-nephritis, 896
 Pyle-phlebitis, adhesive and suppurative,
      424, 626
 Pyle-thrombosis, 30,  626
 Pylorus, hypertrophic stenosis of, 418, 419
    stricture of, 423, 430, 435
 Pyonephrosis, 898, 901, 913
Pj'o-pericardium, 313
Pyothorax, 140 (vide Empyema),
Pyrosis, 443 
115(5
INDEX.
                   Q.
Quinia, hypodermic injection of, in mala-
      rial  fever, 1006,'1016
    in neuralgia, 801
Quinsy, 396, 397

                   R.

Rabies canina, 849
    causation, 85, 849
    clinical history, 849, 852
    diagnosis, 851
    prognosis, 850
    treatment, 851
Ray-fungus, 47
Reaction of degeneration  in  cerebral par-
      alysis, 774
    in amyotrophic lateral sclerosis, 760
    in chronic bulbar paralysis, 730, 733
    in lead paralysis, 795
    in myelitis, 737
    in neuritis,  784, 787
    in peripheral paralysis, 787
    in poliomyelitis anterior, 750, 752
    in progressive muscular  atrophy, 756
    in spinal paralysis, 730, 733
Reflexes in acute ascending paralysis, 780
    in cerebral  hemorrhage,  664
    in cerebral  and spinal paralysis, 774
    in chorea, 814
    in compression of spinal cord,  762
    in diphtheria, 1081
    in neuritis,  multiple, 786
    in peripheral paralysis, 787
    in spastic paralysis, 731
    in spinal diseases, 731
         ankle,  732
         cutaneous, 731, 737, 746, 750, 752
         patellar, 731, 744, 746
         tendon, 731, 741, 750, 759, 760
Regeneration, 39
    fibrillated connective tissue in, 39
    of epithelium, 39
    of muscle, 39
    of nerve-fibre,  40
Regurgitation, gastric, 443
Relapsing fever, 985
Respiration, Cheyne-Stokes,  347, 701
    in chronic Bright's disease, 884
     in meningitis,  694
    in tubercular meningitis, 701
Respiratory centre, asphyxia from inter-
            ferences  with, 67
         system, diseases of, 115
Restorative treatment, 106
Retention cysts, 41, 878, 879
Retinitis albuminurica, 879,  884
Rheumatism, acute  articular, 113, 1093
         causation, 1098
         clinical history,  1093
         diagnosis, 1099
         pathological character, 1098
         prognosis, 1100
         treatment, 1100
     articular, chronic, 1104
         subacute,  1104
Rheumatism, cerebral, 1095
    gonorrhoeal, 1100
    muscular, 807 (vide Myalgia).
Risus sardonicus, 817, 846
Rose-cold, 248
Roseola, 1071
Rose-rash, 1071
Rotheln, 1072
Rubeola, 1065
         causation, 1068
         clinical history, 1065
         diagnosis, 1069
         prognosis, 1069
         treatment, 1070
    hemorrhagic,  1067
    nigra, 1067
    sine catarrho, 1067
    sine eruptione, 1067


                   S.

Sago spleen, 640
Salaam convulsions, 817
Sanitary measures of treatment, 106
Sapraemia, 80
Sarcinae ventriculi, in cancer of stomach,
       431
    in dilatation of stomach, 436
    in dyspepsia,  452
Sarcoma, 20, 42
    myeloid, 42
    of brain, 722
    of liver, 617
    of lung, 274
    varieties of, 42
Satyriasis, in rabies, 850
Scanning speech,  in cerebro-spinal sclero-
       sis, 741
Scapulodynia, 809
Scarlatina, 1051
         anatomical characters, 1052
         causation, 89, 1059
         clinical history,  1053
         diagnosis, 1059
         prognosis, 1060
         treatment, 1061
    anginosa, 1052, 1054, 1056, 1057, 1062
    diphtheria in, 1052, 1057
    faucium, 1057
    hemorrhagic, 1057
    latens, 1057
    maligna, 1052, 1056, 1060
    rheumatica, 1072
    simplex, 1052
    sine eruptione, 1057
Schizomycetes, 47, 90
    Cohn's classification of, 90
Scleroderma, 764
Sclerema, 764
Sclerose en plaques disseminees, 739
Sclerosis, amyotrophic  lateral, 754,  758,
       760
    cerebro-spinal, 739
         clinical history,  741
         diagnosis, 742
         pathological anatomy, 739 
INDEX.
1157
 Sclerosis, cerebro-spinal, prognosis, 742
         treatment, 742
     disseminated, of cord, 739
     multiple, or insular, 739 (vide Sclero-
            sis, cerebro-spinal).
     muscular, 763
     of lung, 214
     posterior spinal, 742 (vide Locomotor
            ataxia).
     primary lateral, 758
 Scorbutus, 1124
     anatomical characters, 1124
     causation, 1127
     clinical history, 1125
     diagnosis, 1127
     pathological character, 1126
     prognosis, 1128
     prevention,  1128
     treatment, 1129
 Scrofula, 50
     chronic inflammations in, 50
 Scurvy, 1124 (vide Scorbutus).
 Scybala, 468, 480
 Semeiology, definition of, 21, 94
 Seminal emissions, involuntary, 939
 Septicaemia, 20, 79
     bacteria in,  80
     causes of, 80
     clinical history, 80
     morbid anatomy, 80
     ptomaines causing, 80
     treatment, 81
 Sequelae of disease, 97
 Sickness, milk, 1089
 Siderosis of lung, 180
 Signs, definition of, 95
 Sleep, mesmeric or magnetic, 845
 Smallpox, 1029 (vide Variola).
     natural, 1037, 1041
 Softening, of brain, 651
     puriform or simple, of thrombi, 29
 Somnambulism, 845
 Sopor, 768
 Sordes, in typhoid fever, 957, 971
 Sore throat, clergyman's, 400
 Spasm, es.sential or idiopathic, of  the mus-
       cles of the extremities, 818
     local, 816
     of glottis, 304
 Specialists,  18
 Specialties, advantages  and disadvantages
       of, 18
 Speech, loss of, after apoplexy, 653
     lesions of cortical centre of, 680
 Spermatorrhoea, 939
 Sphygmograph, trace of, in aortic valvular
      lesions, 332
     in mitral valvular lesions, 331
     in thoracic aneurism,  363
Spina bifida, 714
Spinal cord, anaemia of, 687
     compression  of, 761
         clinical  history, 762
         morbid anatomy,  761
         prognosis, 763
         treatment, 763
 Spinal cord, congestion of, 687
     degeneration, ascending and descend-
       ing, of, 729, 735
     functional diseases of, 767
     hemorrhage within, 688
     hyperaemia of, 687
     inflammatory and  structural  diseases
       of, 728
     tumors of, 761
 Spinal apoplexy,  688
     irritation, 688, 782
     meningitis, 702
 Spirilli, 90
 Spirillum Obermeieri, 89, 986
     in relapsing fever, 89, 986
 Spirochaete, 90, 92, 986
     Obermeieri  in relapsing fever, 89, 92,
       986
 Spleen, affections of, 637
     abscess of, 638
     cancer of, 640
     congestion of. 637, 638
     enlargement  of,  638, 1000
     extravasations in, 640
     hydatids of, 641
     infarction of,  31, 638
     inflammation of, 639
     removal of, 641
     sago, 640
     syphilitic disease of, 641
     tuberculous disease of, 216, 646
     tumor, acute, of, 638
     wandering, 641
     waxy degeneration of, 55, 640
 Splenic fever, 89 (vide Fever, splenic).
 Splenization of lung, 182, 271
 Sputa, nummular, 192
 Status epilepticus, 824
 Stomach, abscess of, 416
     atrophy of, 438, 439
     carcinoma of, 429
     cirrhosis of, 418
     degeneration  of tubules  of,  418, 438
     dilatation  of,  419, 423, 434 (vide Gas-
       trectasia).
     fibroid degeneration of, 418
     functional affections of, 441
     hemorrhage into, 424, 426,  455
     induration of, 418
     inflammation of, 405 (vide Gastritis).
     inflammatory diseases of, 405
     insufficiency of, 436
     sclerosis of, 418
     softening of, 421
     structural affections of, 421
     suppurative inflammation of, 41(5
     tumors of, 429
     ulcer of, 421 (vide Ulcer, gastric).
     waxy degeneration of, 55, 438
Strongylus gigas, 94,  899
Strychnia, effects  of, contrasted with tet-
      anus, 847
St. Vitus's dance, 813 (vide Chorea).
Subsultus tendinum, in typhoid fever, 957,
      969, 971
Suffocation, 67 
1158
INDEX.
Sugar, abnormal accumulation of, in blood,
      69, 70
    presence of, in urine, 69, 70, 929
    tests for, in urine, 935
Summer complaint, 512, 539
Sunstroke, (582 (vide Insolation).
Suprarenal capsules,  disease of, 389 (vide
      Addison's disease).
Sustaining treatment, 106
Swelling,  cloudy,  53  (vide Degeneration,
      parenchymatous).
Symptomatology, definition of,  21, 94
Symptoms, 94
    diagnostic, 95, 98
    objective, 95
    pathognomonic, 94, 98
    precursory, 97, 111
    prodromal, 97, 111
    subjective, 95
Synovitis, 1099
Syringe,  Flint's  modification  of  David-
       son's, for aspiration, 138, 139
Syringomyelia, 714, 761
Syringomyelus, 713, 761
Svphilis of brain, 726
     of  heart, 324, 349
     of  larynx, 284
     of  liver, 605
     of  lungs, 276
     of  spleen, 641
T.
Tabes dorsalis, 743 (vide Locomotor ataxia)
Tdches bleuatres, 959
Tachycardia, 352, 356
Taenia solium, 564
    lata, 564
    mediocanellata, 564
    saginata, 564
Taeniae or tape-Avorms. 94, 563
    clinical history, 565
    diagnosis, 565
    habitat, 565
    natural history, 563, 618
    treatment, 566
Tenesmus, 469
    gastric, 412
    laryngeal, 279
    of bladder, 905
Tetanus, 845
         clinical history, 845
         diagnosis, 847
         prognosis, 846
         treatment, 848
     idiopathic, 845
    traumatic, 845
Tetany or tetanilla, 818
Therapeutical indications, classification of,
       107
     measures, classification of, 105
Therapeutics, general and special, 21, 102
Thoracentesis, in empyema, 142
     in hydrothorax,  151
     in pleuritis,  137, 147
     in pneumothorax, 149
Thrombosis, 28, 650 _
    capillarv, of brain, 659
    cerebral,  650  (vide  Embolism, cere-
       bral).
    of cerebral sinus, 658
    of heart,  165, 316,  321, 323, 350
    portal, 30, 626
Thrombus, 28, 650
    ante-mortem, 350
    bland, 29
    canalization of, 29
    infectious, 30
    marantic, 28, 330,  351, 658
    occluding, 28
    organization of a,  29
    parietal,  28
    softening of a, 29
    white, red, mixed, 28, 351
 Tic douloureux, 802
Tinnitus aurium, 837, 1005
Tissues, active alterations in, 38, 46
    passive alterations in, 50
Tongue, strawberrv-like, in scarlatina, 1054
Tonsillitis, 396
    follicular, 396
Tophi, 76, 1107
Tormina, 469.
Torticollis, rheumatic,  804, 808
 Torulae cerevisiae, in cancer of stomach, 431
     in diabetic urine, 931
     in dilatation of stomach, 436
 Toxicology, 85
 Trachea, affections of,  277
 Tracheotomy, in aphonia, nervous, 300
     in diphtheria, 1089
     in laryngeal growths, morbid, 301
     in laryngitis, 280, 283, 286, 293
     in oedema of glottis, 296
 Trance, 845
 Transfusion of blood, 59, 389, 457, 1027
     of salt solution in anaemia. 62
 Transudation, 33
 Treatment, abortive, 106
     analeptic or restorative, 106
     antiperiodic, 107
     antiphlogistic, 107
     antipyretic, 107
     curative, 106, 109
     ectrotic, 1040
     expectant, 104, 108
     hygienic, 104, 106, 112
     palliative, 106
     preventive or prophylactic, 105, 112
     supporting or sustaining, 106
 Treatment of diseases, classification of ob-
       jects of, 105, 107
 Trembling, mercurial, 796, 821
     senile, 819
 Tremor, 816, 819
      mercurial, 796, 821
      senile, 819
      shaking, 741
 Trichina spiralis, 94,  568
 Trichiniasis, 568
 Trichinosis,  568
 Trichophyton tonsurans, 93 
INDEX.
1159
  Tricocephalus dispar, 94, 562
  Trifacial nerve, paralysis of, 788
      neuralgia of, 802
  Trismus, 845
  Tubercle, 47, 185, 186, 214, 216
      bacilli of, 47-49, 92
      coagulation necrosis, in, 48, 52
      giant-cells, in, 48
      in kidneys, 216, 912
      infiltrated, 49, 185
      inoculation with, 49
      lymphadenoid or giant-celled, 48
      non-vascularity of, 48
      obsolete, 202
      origin of cells in, 48
      pneumonic, 185
      structure of,  48, 49, 185, 216
      within cranium, 723
  Tuberculosis, acute miliary, 49, 194, 216
          general, 49, 216
      genito-urinary,  912
      pulmonary, 184 (vide Phthisis, pulmo-
        nary).
      renal," 912
      specific virus in, 47-49
      sputa of, 187, 189, 192, 195, 200, 215
  Tubules, gastric, degeneration of, 438
  Tumors, 41
      benign, definition of, 41
      causation of, 41
      classification of, 41
      coagulation necrosis, in, 52
      fatty, 43
      fibrous, 43
      glandular, 43
      gliomatous, 43
      heterologous,  41
      homologous,  41
      infectious, 42, 46, 92
      intracranial,  722
          anatomical  characters, 722
          clinical history, 724
          pathological characters, 723
          prognosis, 726
          treatment, 726
     intraspinal, 761
     intrathoracic, 274
     local origin of malignant, 41
     lymphomatous, 42
     malignant, 41
     myxomatous, 42
     mixed, 41
     osseous, 43
     sarcomatous, 42
     syphilitic, 46
     varieties of, 41-43
     vascular, 43
     waxy, 56
Tussis hysterica,  298
Tympanites, in dyspepsia, 443
     in typhoid  fever, 958
Typhlitis, 482, 909
Typhlo-enteritis, 482
Typhoid fever, 948 (vide Fever, typhoid).
Typho-malarial fever,  1011  (vide  Fever,
      typho-malarial).
 Typho-mania, 957, 971
 Typhus fever, 970 (vide Fever, typhus).


                   U.
 Ulcer, duodenal, 420
     gastric, 421
         anatomical characters, 421
         causation, 424
         clinical history, 425
         diagnosis, 426
         pathogenesis, 424, 426
         prognosis, 427
         treatment, 428
 Ulcers, duodenal, 420, 493, 576
     intestinal, 187, 491
         anatomical characters, 492
         clinical history, 493
     laryngeal, 288
     syphilitic, 492
     tuberculous, 491
     typhoid, of intestine, 491, 504, 950
 Umbilication of variolous vesicle, 1030,1033
 Uraemia, 20, 72
     carbonate of ammonia in, 74
     clinical history of, 72
     composition  of blood in, 73, 74
     in Bright's disease,  868, 870,  886, 887,
       890
     in cystic degeneration of kidneys, 911
     in diphtheria, 1080
     in relapsing  fever, 989, 992
     in rheumatism, 1096
     in scarlatina, 1056, 1058, 1061
     in typhoid fever, 957, 962, 981
     in tvphus fever, 971, 981
     in variola, 1032, 1039
     in yellow fever, 1021, 1026
     symptoms of, 72
     theories of, 73-75
     urine, composition of, in, 72, 73
     without retention of urea in blood, 74
Uricaemia,  75, 1108, 1112
     causes of, 75, 76
     deposits of urates in, 76, 1108
     urine in, 76
Urine, condition of, in acute nephritis, 868
     in chronic nephritis, 881, 889,  890, 891
     in chyluria, 925
     in congestion, renal, 863, 864
     in cystic degeneration of kidneys, 911
     in diabetes insipidus, 927
    in diabetes mellitus, 931
    in diphtheria, 1080
    in hydronephrosis, 904
    in haematuria, renal, 921
    in haematuria, endemic, 922
    in haemoglobinuria, 923, 924, 925
    in intermittent fever, 999, 1008
    in milk sickness, 1091
    in nephritis, suppurative, 897
    in perinephritic abscess, 909
    in relapsing fever, 989,  993
    in remittent fever, 1014
    in renal cancer, 917
    in renal colic, 905 
1160
INDEX
Urine, in renal cystic degeneration, 911
    in renal parenchymatous degeneration,
      865
    in renal tuberculosis, 913
    in rheumatism, 1094
    in scarlatina, 1058, 1061
    in scorbutus, 1126
    in septicaemia, 81
    in typhoid fever, 982
    in typhus fever, 973
    in uraemia, 72
    in yellow fever, 1021, 1025
    tests for sugar in, 935
A'accination, 1043
    operation for,  1048
\Taccinia, 1043, 1047
ATaccinoid, 1044
A'agabonds' disease, 394
ATalvular cardiac lesions, 325
         aortic, 327, 3:^8
         mitral, 827
         pulmonic, 328
         tricuspid, 828
    clinical history of, 330
ATaricella,  1050
    differential diagnosis of, from variola,
       1050
    varieties of, 1050
Variola, 1029
         anatomical characters, 1029
         causation, 89, 1036
         clinical history, 1031
         confluent, 1031
         diagnosis, 1037
         discrete, 1031
         prognosis, 1038
         treatment, 1039
     coagulation necrosis in, 52, 1029
     differential diagnosis of, from  scarla-
       tina, rubeola, and roseola, 1037
     hemorrhagic, 1035
     sine variolis,  1037
     varieties of, 1031, 1035, 1043
 A^ariolation, 1041
 Varioloid, 1041, 1045
 A'cgetations, in endocarditis, 316, 321
 A'enesection,  in acute inflammations, 124,
       167
     in bronchorrhagia, 264
     in cerebral hemorrhage, 669
     in cerebral congestion, 647
     in insolation, 686
     in laryngitis, 281, 291
     in meningitis, 696, 704, 713
     in nephritis,  872
     in pericarditis, 310
     in  pernicious  malarial  fever, 1009,
       1017
     in poliomyelitis anterior,  751
     in pulmonary oedema, 273 ^^____
     in thoracic aneurism, 364~"7\c T*' L'
 A'enom, definition of, Sir  ■: 0 >
A'enous hum, 63. 368
Vermes, 93, 559
Vermiform appendix of caecum, inflamma-
      tion and perforation of, 485
A'ermis cucurbitinus, 564
A'ertigo, 770
    epileptic, 823
    stomachal, 772
A^irchow, cell theory of, 34
Alms, definition of,  83, 84
Vomicae,  187, 189, 200, 202, 214, 268, 270,
       274, 276
A'omiting, in dyspepsia, 445
ATulnerability, definition of, 88

                  W.
Water, employment of,  in pleuritis and
       pneumonitis,  129, 168, 169
         in scarlatina, 1062
         in typhus and typhoid fever, 978
     increase and diminution of, in blood,
       60, 63, 64
AVater-brash, 443
AVaxy degeneration, 55
     of intestine, 55
     of kidney, 55
     of liver, 55
     of spleen, 55
AVerlhof's disease, 1132
Whooping cough, 254 (vide Pertussis).
Wind-sucking, 444
Word-blindness, 654, 680
AVord-deafness,  680
Worms, intestinal, 93, 559
     anchylostoma duodenale, 94, 560, 570
     ascaris lumbricoides, 94, 560
     lumbricoid, 94, 560
     oxyuris vermicularis, 94, 560, 562
     pin-, 94, 5(52
     seat-, 94, 562
     tape- (vide Taeniae),94,  560, 563
     thread-, 94, 562
     trichinae, 94, 560, 568
     tricocephalus dispar, 94, 560, 562
 Wrist-drop, 101, 794
 Writer's cramp, 818

                    X.

 Xanthine calculi, 907

                    Y.

 Yellow fever, 1018  (vide Fever, yellow).

                    Z.

 Zoogloea. 90
     in diphtheria,  1078
     in endocarditis, acute  ulcerative, 321
     in hepatitis, suppurative, 594
     in pyaemia, 82
     in suppurative nephritis, 896
I     in typhoid  fever, 953
\- ,   in variola,  1031
I Zymogenous bacteria, 91 
           LEA  BROTHERS   <fc  CO.'S

                         (Late HENRY C. LEA'S SON & CO.)

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professions of  the two great English speaking peoples, and in laying before them a period-
ical which must be universally recognized as marking a new era  in medical progress.
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sides of  the Atlantic, they feel themselves warranted,  by the expectation of a large in-
crease in circulation, in maintaining  the present very  moderate subscription price, not-
withstanding the greatly augmented expenditure entailed by the  change.
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THE MEDICAL  NEWS VISITING  LIST FOR 1887.
  Containing Calendar for two years.  Obstetric diagrams.  Scheme of Dentition.  Tables
of weights and measures and comparative  scales.   Instructions for examining  the  urine.
List of disinfectants.  Table of eruptive  fevers.   Lists of remedies  not generally used,
and Incompatibles, Poisons and Antidotes.  Artificial respiration. Table of doses, prepared
to accord with the last revision  of the U. S. Pharmacopoeia, an extended table of Diseases
and  their remedies, and directions for Ligation of Arteries.  Handsomely bound in limp
Morocco, with tuck and pencil and rubber.  Preparing.
     Issuecl towards the  close of 1885 as an experiment, the large edition of The Medical
News Visiting List for  1886 was rapidly exhausted.  The great favor thus shown has
placed this venture upon a permanent basis, and the profession may therefore look in due
time for The List for 1887, in full confidence that it will contain such new features as may,
trom time to time, prove  themselves desirable and possible.   In response to numerous
complaints and  requests,  The List will in future be issued in several  different sizes to
accommodate all the records of practices varying from thirty to ninety patients per  week.
THE  MEDICAL  NEWS PHYSICIANS' LEDGER.
    Containing 400 pages of fine linen " ledger " paper, ruled so that all the accounts of a
large practice may be conveniently kept in it, either by single or double entry, for a long
period.   Strongly bound  in leather, with  cloth sides, and  with a patent flexible back,
which  permits it to  lie  perfectly flat when opened  at any place.  Price, $5.00. Also
a small special lot of same Ledger, with 300 pages.  Price,  $4.00.


HARTSHORNE, HENRY, A.  M.,  M.  D., LL. D.9
      Lately Professor of Hygiene in the University of Pennsylvania.
    A Conspectus of the Medical Sciences; Containing Handbooks on Anatomy,
Physiology, Chemistry, Materia  Medica, Practice of  Medicine, Surgery and Obstetrics.
Second edition,  thoroughly revised  and  greatly improved.  In  one large royal 12mo.
volume of 1028 pages, with 477 illustrations.  Cloth, $4.25;  leather, $5.00.
                                           industry  and energy of its able editor.—Boston
                                           Medical and Surgical Journal, Sept. 3,1874.
                                            We can say with the strictest truth that it is the
                                           best work of the  kind  with which we are ac-
                                           quainted.  It embodies in a condensed form all
                                           recent contributions to practical medicine, and is
                                           therefore useful to every busy practitioner through-
                                           out our country, besides being admirably adapted
                                           to the use of students of  medicine.  The book is
                                           faithfully and ably executed.—Charleston Medical
                                           Journal, April, 1875.
  The object of this manual is to afford a conven-
ient work of reference to students during the brief
moments at their command while  in attendance
upon medical lectures. It is a favorable sign that
it has been found necessary, in a  short space of
time, to issue a new and carefully revised edition.
The illustrations are  very numerous and unusu-
ally clear, and each part seems to  have received
its due share of attention.  We can  conceive such
a work to be useful, not only to students, but to
practitioners as well.  It reflects credit upon  the
NEILL,  JOHN, M. L>.,  and  SMITH, F. G.,  M. D.,
   Late Surgeon to the Penna. Hospital.          Prof, of the Institutes of Med. in the Univ. of Penna.
    An Analytical  Compendium  of the Various Branches of Medical
Science, for the use and examination of Students.  A new edition, revised and improved.
In one large royal 12mo. volume of 974 pages, with 374 woodcuts. Cloth, $4; leather, $4.75.

LUDLOW,  J. L., M. D.,
       Consulting Physician to the Philadelphia Hospital, etc.
    A Manual of Examinations upon Anatomy, Physiology, Surgery, Practice of
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics.  To which
is added a Medical Formulary.  3d edition, thoroughly revised, and greatly enlarged.  In
one 12mo. volume of 816 pages, with 370 illustrations.  Cloth, $3.25; leather, $3.75.
    The arrangement of this volume in the form of question and answer renders it espe-
cially suitable for the office examination of students, and for those preparing for graduation. 
4           Lea Brothers & Co.'s Publications—Dictionaries.
 DUNGLISON, ROBLEY,  M.D.,
       Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia.
     MEDICAL  LEXICON; A Dictionary of Medical Science: Containing
a concise Explanation of the various Subjects and Terms of Anatomy,  Physiology, Pathol-
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris-
prudence and Dentistry, Notices of Climate and of  Mineral Waters, Formulae for Officinal,
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms,
and  the French and other Synonymes, so as to constitute a French as well  as an English
Medical Lexicon.  Edited by  Richard  J. Dunglison,  M. D.  In  one very large and
handsome royal octavo volume of 1139 pages. Cloth, $6.50;  leather,  raised bands,  $7.50;
very handsome half Russia, raised bands, $8.
     The object of the author, from the outset, has not been to make the work a mere lexi-
con or dictionary of terms, but to afford under each word a condensed view of its various
medical relations, and thus to render the work  an epitome of the existing condition of
medical science.  Starting with this view, the immense demand which has existed for tbe
work has enabled him,  in repeated revisions, to augment its completeness and usefulness,
until at length it has attained the position of a recognized and standard authority wherever
the language is spoken.  Special pains have been  taken in the preparation of the present
edition to maintain  this enviable  reputation.  The additions to  the vocabulary are more
numerous than in any previous revision, and particular attention has been bestowed on the
accentuation, which will be found marked on every  word.  The typographical arrangement
has been greatly improved, rendering reference much more easy, and  every  care has been
taken with the mechanical execution.  The volume now contains the matter of at least
four ordinary octavos.
  About the first book purchased by the medical
student is the Medical Dictionary.  The  lexicon
explanatory of technical terms is simply a sine qua
non.  In a science so extensive and with such col-
laterals as medicine, it is as much a necessity also
to the practising physician.  To meet the wants of
students and most physicians the dictionary must
be condensed while comprehensive, and practical
while perspicacious.  It was because Dunglison's
met these indications that it became at once the
dictionary of general use wherever medicine was
studied in  the English language.  In no former
revision have the alterations and additions been
bo great.  The chief terms have been set in black
letter, while the derivatives  follow in small caps;
an arrangement which greatly facilitates reference.
—Cincinnati Lancet ana Clinic, Jan. 10,1874.
  A  book of which  every American ought to  be
proud.  Whrn the  learned  author of the work
passed away, probably all of us feared lest the book
should  not maintain its place  in the advancing
science whose terms it defines.  Fortunately, Dr.
Richard J. Dunglison, having assisted his father in
the revision of several editions of the work, and
having  been, therefore, trained in the methods
and imbued with the spirit of the book, has been
able to  edit it as a work of the kind should  be
edited—to carry it on steadily, without jar or inter-
ruption, along the grooves of thought it has trav-
elled during its lifetime.  To show the magnitude
of the task which Dr. Dunglison has assumed and
carried  through, it is only necessary to state that
more than six thousand new subjects have been
added in the present edition.—Philadelphia Medical
Times, Jan. 3,1874.
  It has the rare merit that it certainly has no rival
in the English language for accuracy and extent of
references.—London Medical Gazette.
 HOBLYN, RICHARD  D., M. D.
     A Dictionary of the Terms  Used in Medicine  and the  Collateral
 Sciences.  Revised, with numerous additions, by  Isaac Hays, M. D., late editor  of
 Ihe American Journal of the Medical Sciences.  In one large royal 12mo. volume of 520
 double-columned pages.   Cloth, $1.50; leather, $2.00.

 £*££«$£$* £253!*i0D8 weha™, and ought always to be upon the student's table-Severn


 STUDENTS' SERIES OF MANUALS.
     A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine
 and Surgery, written by eminent Teachers  or Examiners,  and issued in pocket-size
 12mo. volumes of 300-540 pages, richly illustrated and at a low price.   The following voh
 umes  are now ready:  Treves' Manual  of Surgery, by various writers, in three volumes;
 Bells Comparative Physiology  and Anatomy, Gould's Surgical Diagnosis, Robertson's
 Physiological Physm■. Bruce's Materia Medica and Therapeutics, Power'sHuman Physi-
 ology , Clabke and Lockwood's Dissect Manual, Ralee's  Clinical CherntTyT^yi'
 Surgical Applied Anatomy, Pepper's Surgical Pathology, and Klein's Elements ofHisSlofy
 The following are m press:  Bellamy's Operative Surgery, Pepper's  Forensic MedS
 and Curnow's  Medical Applied Anatomy.   For separate notices see index on l^t page!


 SERIES OF CLINICAL MANUALS.
     In arranging for this Series it has been the design of the publishers to provide the
profession with a collection of authoritative  monographs on  important  cliniSl  subiects
in a cheap and portable form.  The volumes will contain  about 550 pages  and will  £
freely  .1 ustrated  by chromo-lithographs and woodcuts.   The   followin| voihmls  ar^
now ready:  Owen on Surgical Diseases of Children, Morris on Surgical Diseases of 7hl
Kidney  Pick on Fractures and Dislocations, Butlin on the Tongue, Treves on Intestinal
 Obstruction, and  Savage on Insanity and Allied Neuroses.  The following are in TrK
preparation:  Hutchinson on Syphilis, Bryant on the Ereast, Broadbent on the PulJ
Lucas on Diseases of the Urethra, Marsh on  Diseases of the Joints,  and Ball on t^
Rectum,  and Anus.  For separate  notices see index on last page.                       e 
Lea Brothers  & Co.'s Publications—Anatomy.             5
GRAY, HENRY,  F. R. S.,
      Lecturer on Anatomy at St. George's Hospital, London.

    Anatomy, Descriptive and Surgical.  The Drawings by H. V. Carter, M. D.,
and Dr. Westmacott.  The dissections jointly by the Author and Dr. Carter.   With
an Introduction on General Anatomy and Development by T. Holmes, M. A., Surgeon to
St. George's Hospital.  Edited by T. Pickering Pick, F.  R. C. S., Surgeon to and Lecturer
on Anatomy at St. George's  Hospital, London, Examiner in Anatomy, Royal  College of
Surgeons of England.  A new American from the tenth enlarged and improved London
edition.  To which  is added the second American from  the  latest English  edition of
Landmarks,  Medical and  Surgical, by  Luther Holden,  F.R.C.S.,  author  of
" Human Osteology,"  " A  Manual of Dissections," etc.  In one  imperial octavo volume
of 1023 pages, with  564 large and  elaborate engravings on wood.  Cloth, $6.00; leather,
$7.00; very handsome half Russia, raised bands, $7.50.
    This work covers a more extended range of subjects  than is  customary in the ordinary
text-books, giving not only the details necessary for the student, but also the application to
those details to the practice  of medicine  and surgery.   It thus  forms both a guide for the
learner and an admirable work of reference for the active practitioner.  The engravings
form  a special  feature in the work, many of them  being the size  of  nature, nearly all
original, and having the names of  the  various  parts printed on the  body of the cut, in
place of figures of reference with descriptions at the foot.  They thus form a complete and
splendid series, which will greatly  assist the student in forming a clear idea of  Anatomy,
and will also serve to  refresh the memory of those who may  find in the exigencies of
 Sractice the necessity of recalling the details of the  dissecting-room.  Combining, as it
 oes, a complete Atlas of Anatomy  with a  thorough treatise on systematic, descriptive
and applied Anatomy, the work will be found of great service to  all physicians who receive
students in their  offices, relieving both  preceptor and  pupil of much labor in laying the
groundwork of a thorough medical education.
  Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden,
has been appended to the present edition as it was to the previous one.  This work gives
in a clear, condensed and systematic way all the information by which the practitioner can
determine  from the external surface of the body the position of internal parts.  Thus
complete, the work, it is believed, will fu™ush all the assistance  that can be rendered by
type and illustration in anatomical study.
  This well-known work comes to us as the latest
American from the tenth English edition.  As its
title indicates, it has passed through many hands
and has received many additions and revisions.
The work is not susceptible of more improvement.
Taking it all in all, its size, manner of make-up,
its character and illustrations, its general accur-
acy of description, its practical aim, and  its per-
spicuity of style, it is the Anatomy best adapted to
the wants of the student and practitioner.—Mt "
  There is probably no work used so universally
by physicians and medical  students as this one.
It is deserving of the confidence that they repose
in it.  If the present edition is compared with that
issued two years ago, one  will  readily see how
much it has been improved in that time.  Many
pages have been added to the text, especially in
those parts that treat of histology, and many new
                                         cuts have been introduced and old ones modified.
e wants of the student and practitioner.—Medical j —Journal of the American Medical Association, Sept.
Record, Sept. 15,1883.            ______________11,1883.

      Also for sale separate—

HOLDEN,  LUTHER,  F. R.  C. S.,
      Surgeon to St. Bartholomew's and the Foundling Hospitals, London.
    Landmarks, Medical and  Surgical.  Second American from the latest revised
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the  Phila-
delphia School of Anatomy.   In one handsome 12mo. volume of 148 pages.  Cloth, $1.00.
  This little book is all that can be desired within
its scope, and its contents will be found simply in-
valuable to the young surgeon or physician, since
they bring before him such data as he requires at
every examination of a patient. It is written in
language  so clear and concise that  one  ought
almost to learn it by heart. It teaches diagnosis by
external examination, ocular and palpable, of the
body, with such anatomical and physiological facts
as directly bear on the subject. It is eminently
the student's and young practitioner's book.—Phy-
sician and  Surgeon, Nov. 1881.
  The study of these Landmarks by both  physi-
cians and surgeons is much to be encouraged.  It
inevitably leads to a progressive education of both
the eye and the touch, by which the recognition of
disease or the localization of injuries is vastly as-
sisted. One thoroughly familiar with the facts here
taught is capable of a degree of accuracy and a
confidence of certainty which is otherwise unat-
tainable. We cordially recommend the Landmarks
to the attention  of every physician who has not
yet provided himself with a copy of this useful,
practical guide to the correct  placing of all the
anatomical parts and organs.—Canada Medical and
Surgical Journal,  Dec. 1881.
WILSON, ERASMUS, F. R.  S.
    A  System  of  Human  Anatomy, General  and Special.   Edited by  W. H.
Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of
Ohio.  In  one large and handsome  octavo volume of 616 pages, with 397 illustrations.
Cloth, $4.00; leather, $5.00.  ______________________*_

CLELAND,  JOHN, M. D., F. R. S.,
      Professor of Anatomy and Physiology in Queen's College, Galway.
    A  Directory for the Dissection  of the Human Body.   In one 12mo.
volume of 178 pages.  Cloth, $1.25. 
6             Lea Brothers & Co.'s  Publications—Anatomy.
ALLEN,  HARRISON,  M. D„
       Professor of Physiology in the University of Pennsylvania.
     A System of  Human Anatomy, Including Its Medical and Surgical
Relations.  For the  use  of Practitioners and  Students of Medicine.   With an Intro-
ductory  Section on Histology.  By E. O.  Shakespeare,  M.  D.,  Ophthalmologist to
the Philadelphia Hospital.   Comprising 813  double-columned  quarto pages, with 380
illustrations on 109 full page lithographic plates, many of  which are in colors, and 241
engravings in the text.   In six Sections, each  in  a portfolio.   Section I. Histology.
Section ft.  Bones and Joints.   Section III.  Muscles  and  Fascije.   Section IV.
Arteries, Veins and  Lymphatics.   Section V. Nervous  System.   Section VI.
Organs  of Sense,  of  Digestion  and  Genito-Urinary  Organs, Embryology,
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations,
and General and Clinical Indexes.  Price per Section, $3.50; also bound in one
volume, cloth, $23.00; very handsome half Russia,  raised bands  and open back, $25.00.
For sale by subscription only.   Apply to the Publishers.
                             Extract from Introduction.
    It is the design of this book to present the facts of human anatomy in the manner best
suited to the requirements of the student and the practitioner of medicine.  The author
believes that such a book is needed, inasmuch as no treatise,  as far as he knows, contains, in
addition to the text descriptive of the subject, a systematic presentation of such anatomical
facts as can be applied to practice.
     A. book which will be at once accurate in statement and concise in terms; which will be
an acceptable expression of the present state of the science of anatomy; which will exclude
nothing that can be made applicable to the medical  art, and which will thus embrace all
of surgical importance, while omitting nothing of value to clinical medicine,—would appear
to have an excuse for  existence in a country where most surgeons are general practitioners,
and where there are few general practitioners who have no interest in surgery.
  It is to be considered a study of applied anatomy
in its widest sense—a systematic  presentation of
such anatomical facts as can be  applied to  the
practice of medicine as well as of surgeiy.  Our
author is  concise, accurate and practical in  his
statements, and succeeds  admirably in infusing
an interest into the study of what is generally con-
sidered a dry subject.  The department of Histol-
ogy is  treated in a masterly manner, and  the
ground is travelled over by one thoroughly famil-
iar with it.  The illustrations are made with great
care, and are simply superb.  There is as much
of practical application of anatomical points to
the every-day wants of the medical clinician as
to those of the operating surgeon.  In fact, few
general practitioners will read the work without a
feeling of surprised gratification that so many
points, concerning which they  may never have
thought before are so well presented for their con-
sideration. It is a work which is destined to be
the best of its  kind in  any  language.—Medical
Record, Nov. 25,1882.
CLARKE, W. B., F.R. C.S. & LOCKWOOD, C. B., F.R. C.S.
       Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London.
    The Dissector's  Manual.  In one pocket-size 12mo. volume of 396 pa-res, with
49 illustrations.  Limp cloth, red edges, $1.50.  See Students' Series of Manuals, page 4.
  This is a very excellent manual for the use of the
student who desires to learn anatomy. The meth-
ods of demonstration seem to us very satisfactory.
There are many woodcuts which, for the most
part, are good and instructive.  The book is neat
and convenient.  We are glad to recommend it.—
Boston Medical and Surgical Journal, Jan. 17,1884.
TREVES,  FREDERICK,  F. R. C. 8.,
      Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital.
  %  Surgical Applied Anatomy.  In one pocket-size 12mo. volume of 540 pages
with  61 illustrations.  Limp cloth, red  edges, $2.00.   See Students' Series  of  Manuals,
page 4.
  He has produced a work which will command a
larger circle of readers than the class for which it
was written.  This union  of a thorough, practical
acquaintance with these  fundamental branches,
quickened by daily use as a teacher and practi-
tioner, has enabled our author to prepare a work
which it would be a most difficult task to excel.—
The American Practitioner Feb. 1884.
 CURNOW, JOHN, M. D.,  F. R. C. P.,
       Professor of Anatomy at King's College, Physician at King's College Hospital.

QM  Me/di,C>ae ^PPA^d A?atomy-  In  one  pocket-size  12mo. volume.  Preparing.
See Students' Series of Manuals, page 4.                                          F    y

BELLAMY, EDWARD, F. R. C.  S.,
      Senior Assistant-Surgeon to the Charing-Cross Hospital, London.

    The Student's Guide to Surgical  Anatomy:  Being a  Description of the
most Important Surgical Regions of the Human Body, and intended as an Introduction to
operative Surgery.  In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25

H^S£SI25?£'?  HANDBOOK  OF  ANATOMY I HORNER'S SPECIAL ANATOMY AND m«Tr>T
  tVnNo3n«P^Ii°,L0GY-, S^ond  edition, revised.    OGY.  Eighth edition, extensively rev^a^H
  In one royal 12mo volume of 310 pages, with 220    modified.  In two octavo volumes of  1007 5 and
  woodcuts.  Cloth, 81.75.                      |   with 320 woodcuts.  Cloth, $6m      °°7 pa8es' 
Lea Brothers & Co.'s Publications—Physics, Physiol., Anat.      7
DRAPER,  JOHN C,  M. D., LL. D.,
       Professor of Chemistry in the University of the City of New York.
     Medical Physics.  A Text-book for Students and Practitioners of Medicine.   In
one octavo volume of 734 pages, with 376 woodcuts, mostly original.  Cloth, $4.
                                    From 'the Preface.
     The fact that a knowledge of Physics is indispensable to a thorough understanding of
Medicine has not been as fully realized in this country as in Europe, where the admirable
works of Desplats and Gariel, of Robertson and of numerous German writers constitute a
branch of educational literature to which we can show no parallel.  A full appreciation
of this the author trusts will be sufficient justification for placing in book form  the sub-
stance of his lectures  on this department of science, delivered during many years at  the
University of the City of New York.
     Broadly speaking, this work  aims to impart  a  knowledge  of the relations  existing
between Physics  and Medicine in their latest state of development, and to embody in  the
pursuit of this object  whatever experience the author has gained during a long period of
teaching this special branch of applied science.
  This elegant and useful work bears ample testi-
mony to the learning and good judgment of the
author.  He has fitted his work admirably to the
exigencies of  the  situation by  presenting the
reader with brief, clear and simple statements of
such propositions as he is by necessity required to
master.   The subject  matter  is  well arranged,
liberally illustrated  and carefully indexed.  That
it will take rank at once among the text-books is
certain, and it is to be hoped that it will find a
place  upon the  shelf of the practical physician,
where, as a book of reference, it will be found
useful and  agreeable.—Louisville  Medical News,
September 26, 1885.
  Certainly we have no text-book as full as the ex-
cellent one he  has  prepared.  It  begins with a
statement of the properties of matter and energy.
After these the special departments of physics are
explained, acoustics, optics, heat, electricity and
magnetism, closing with a section on electro-
biology. The applications of all thesf • to physiology
and medicine are kept constantly  in view. The
text is  amply  illustrated and the many difficult
points of the subject are brought forward with re-
markable clearness and ability.—Medical and Surg-
ical Reporter, July 18,1885.
 That this work will greatly  facilitate the  study
of medical physics is apparent upon even a mere
cursory examination.   It is marked by that scien-
tific accuracy  which  always characterizes  Dr.
Draper's writings.  Its  peculiar value lies in the
fact that it is written from the standpoint of the
medical man.  Hence  much is omitted that ap-
pears in a mere treatise on physical science, while
much is inserted of peculiar value  to the  physi-
cian.—Medical Record, August 22,1885.
ROBERTSON,  J.  McGREGOR,  M. A., M. B.,
       Muirhead Demonstrator of Physiology, University of Glasgow.
    Physiological Physics.   In one  12mo. volume of 537 pages, with  219 illustra-
tions.  Limp cloth, $2.00.  See Students' Series of Manuals, page 4.
                                             ments.  It will be found of great value to  the
  The title of this work sufficiently explains the
nature of its contents.  It is designed as a man-
ual  for the student of medicine, an auxiliary to
his,text-book in physiology, and it woul d be particu-
larly useful  as a guide to his laboratory experi-
practitioner.  It is a carefully prepared book of
reference, concise and accurate, and as such we
heartily recommend it.—Journal of the American
Medical Association, Dec. 6,1884.
DALTON,  JOHN C,  M. D.,
       Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York.
     Doctrines of the Circulation of the Blood.   A History of Physiological
Opinion and Discovery in regard to the Circulation of the Blood.   In  one handsome
12mo.  volume of 293 pages.  Cloth, $2.
  Dr. Dalton's work is the fruit of the deep research
of a cultured mind, and to the busy practitioner it
cannot fail to be a source of instruction.  It will
inspire him with a feeling of gratitute and admir-
ation for those plodding workers of olden times,
who laid the foundation of the magnificent temple
of medical science as it now stands.—New Orleans
Medical and Surgical Journal, Aug. 1885.
  In the progress of physiological study no fact
revolutionized the theories of teachers, than the
discovery of the circulation of the blood.  This
explains the extraordinary interest it has to all
medical historians. The volume before us is one
of three or four which have been written within a
few years by American physicians.  It is in several
respects the most complete. The volume, though
small in size, is one of the most creditable con-
tributions from an American pen to medical history
was of greater moment, none more completely | that has appeared.—Med. & Surg. Rep., Dec. 6,1884

BELL,  F. JEFFREY,  M. A.,
       Professor of Comparative Anatomy at King's College, London.
    Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages,
with 229 illustrations. Limp cloth, $2.00.   See Students' Series of Manuals, page 4.
  The manual is preeminently a student's book-
clear and  simple in language and arrangement.
It is well and abundantly illustrated, and is read-
able and interesting.  On the whole we consider
                          page'

it the best work in  existence in the English
language to place in  the hands of the medical
student.—Bristol Medico-Chirurgical Journal, Mar.,
1886.
ELLIS,  GEORGE  VINER,
       Emeritus Professor of Anatomy in University College, London.
     Demonstrations  of Anatomy.   Being a  Guide  to the Knowledge  of  the
Human Body by Dissection.  From the eighth and revised London edition.  In one very
handsome octavo volume of 716 pages, with 249 illustrations.  Cloth, $4.25;  leather, $5.25.

ROBERTS,  JOHN B.,  A.  M.9 M. D.,
       Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic and Coll. for Graduates in Medicine.
     The Compend of Anatomy.  For use in the dissecting-room and in preparing
for examinations.   In one 16mo. volume of 196 pages.   Limp cloth, 75 cents. 
8     Lea Brothers & Co.'s  Publications—Physiology, Chemistry.
DALTON, JOHN C, M. D.,
       Professor of Physiology in the College of Physicians and Surgeons, New  York, etc.
     A Treatise on  Human Physiology.    Designed  for the use of Students and
Practitioners of Medicine.  Seventh edition, thoroughly revised and rewritten.  In one
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth,
$5.00; leather,  $6.00;  very handsome half Russia, raised bands, $6.50
  The merits of Professor Dalton's text-book, his
smooth and pleasing style, the remarkable clear-
ness of his descriptions, which leave not a chapter
obscure, his cautious judgment and the general
correctness of his facts, are perfectly known. They
have made his  text-book  the one most familiar
to American students.—Med. Record, March 4,1882.
  Certainly no physiological work has ever issued
from the press that presented its subject-matter in
a clearer and more attractive  light.  Almost every
page bears evidence  of the  exhaustive revision
that has taken place.  The material is placed in a
more compact form, yet its delightful charm is re-
tained, and no subject is thrown into obscurity.
Altogether this edition is far in advance of any
previous one, and will tend to keep the profession
posted as to  the most recent additions to our
physiological knowledge.—Michigan 3Iedical News,
April, 1882.
  One can scarcely open a college catalogue that
does not  have mention of Dalton's Physiology as
the recommended text or consultation-book.  For
American students we would unreservedly recom-
mend Dr. Dalton's work.- Va. Med. Monthly,Ju\y,'S2.
FOSTER, MICHAEL, M.  D.,  F. R. S.,
       Prelector in Physiology and Fellow of Trinity College, Cambridge, England.
     Text-Book  of Physiology.  Third American from the fourth English edition,
with notes and additions by E. T. Reichert, M. D.   In one handsome royal 12mo. volum'
of 908  pages, with 271 illustrations.  Cloth, $3.25; leather, $3.75.  Just ready
  Dr. Foster's work  upon  physiology is so well-
known as a text-book in this country, thatitneeds
but  little  to be said in regard to  it.  There is
scarcely a medical  college in the United States
where  it is not in the hands of the students.  The
author, more than any othei writer with whom
we are acquainted,  seems to  understand what
portions of the science are essential for students
to know and what may be passed over by them aa
not important.  From the beginning to the end,
physiology is taught in a systematic manner.  To
this third American edition numerous additions,
corrections and alterations have been made, so
that in its present form the usefulness of the book
will be found to be much increased.—Cincinnati
Medical News, July 1885.
POWER, HENRY,  M. B.,  F. R.  C.  S.,
      Examiner in Physiology, Royal College of Surgeons of England.
    Human Physiology.   In one handsome pocket-size 12mo. volume of 396 pages.
with 47 illustrations.  Cloth, $1.50.  See Students' Series of Manuals, page 3.
  The prominent character of this work is that of
judicious condensation, in which an able and suc-
cessful effort appears to have been made by its
accomplished author to teach the greatest number
of facts in the fewest possible words.  The result
is a specimen of concentrated intellectual pabu-
lum  seldom  surpassed, which ought to be care-
fully ingested and  digested by every practitioner
who desires to keep  himself well informed upon
this  most progressive  of the  medical sciences.
The volume is one which we cordially recommend
to every one of our readers.—The American Jour-
nal of the Medical Sciences, October, 1884.
  This  little work  is deserving of the  highest
praise, and we can hardly conceive how the main
facts of this science could have been more clearly
or concisely stated.  The price of the work is such
as to place it within the reach of all, while the ex-
cellence of its text will certainly secure for it most
favorable commendation —Cincinnati Lancet and
Clinic, Feb. 16,1884.
CARPENTER,  WM. B., M. D., F. R. S., F. G. S., F. L. S.,
       Registrar to the University of London, etc.
     Principles of Human Physiology.  Edited by Henry Power, M. B., Lond.,
F. R. C. S., Examiner in Natural Sciences, University of Oxford.  A new American from the
eighth revised and enlarged edition, with notes and additions by Francis G. Smith, M. D.,
late Professor of the  Institutes of Medicine in the University of Pennsylvania.  In one
very large  and handsome  octavo  volume of 1083 pages, with  two  plates and 373  illus-
trations.  Cloth, $5.50; leather, $6.50;  half Russia, $7.


SIMON,   W., Ph.  D., M. D.,
       Professor of Chemistry and Toxicology in the College of Physicians and  Surgeons, Baltimore, and
       Professor of Chemistry in the Maryland College of Pharmacy.

     Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners
in Chemistry.  A Text-book, specially adapted for Students of  Pharmacy and Medicine.
In  one  8vo.yol.  of^ 410 pp., with  16  woodcuts  and 7 plates,  mostly of  actual deposits,
with colors illustrating 56  of the  most  important chemical reactions.  Cloth,  $3 00- also
without  plates, cloth,  $2.50.
  This book supplies a want long felt by students
of medicine and pharmacy, and is a concise but
thorough treatise on the subject. The  long expe-
rience  of the author as  a teacher in  schools of
medicine and  pharmacy is conspicuous in the
perfect adaptation of the work to the special needs
of the  student of these  branches.  The colored
plates, beautifully executed, illustrating precipi-
tates of various reactions, form a novel and valu-
able feature of the book, and cannot fail to be ap-
preciated by both student and teachpr as a  help
over the  hard places of  the science.—Maryland
Medical Journal, Nov. 22,1884.
    Wohler's  Outlines of Organic Chemistry.  Edited by Fittig.  Translated
by Ira Remsen, M. D., Ph. D.  In one 12mo. volume of 550 pages.   Cloth, $3.
GALLOWAY'S QUALITATIVE ANALYSIS.
LEHMANN'S MANUAL OF CHEMICAL PHYS-
  IOLOGY.  In one octavo volume of 327 pages,
  with 41 illustrations.  Cloth, $2.25.
CARPENTER'S PRIZE ESSAY ON THE USE AND
  Abuse of Alcoholic Liquors in Health *m> Djs.
  ease. With explanations of scientific word- Small
  12mo.  178 pages.  Cloth, 60 cents. 
Lea  Brothers  &  Co.'s Publications—Chemistry.            9
FOWNES,  GEORGE, Ph. D.
    A  Manual  of  Elementary  Chemistry;  Theoretical and Practical.  Em-
bodying AVatts' Physical  Inorganic Chemistry.   New American edition. In  one large
royal 12mo. volume of 1061 pages, with 168 illustrations on wood and a colored plate
Cloth, $2.75; leather, $3.25.
  Fownes' Chemistry  has been  a standard text-
book upon chemistry for many years.  Its merits
are very fully known by chemists and physicians
everywhere in this country and in England.  As
the science has advanced by the making of new
discoveries, the work has been revised so as to
keep  it abreast of the times.   It has steadily
maintained its position as a text book with medi-
cal students. In this work are treated fully: Heat,
Light and Electricity, including Magnetism.  The
influence exerted by  these forces in chemical
action upon health and disease, etc., is of the most
important kind, and  should be familiar to every
medical  practitioner.   We can commend  the
work  as one of the  very best text-books  upon
chemistry extant.—Cincinnati Medical News, Oc-
tober, 1885.
  Of all the works on chemistry intended for the
use of  medical  students, Fownes' Chemistry is
perhaps the most widely used.  Its popularity is
based upon its excellence.  This last edition con-
tains all of  the  material found in the previous,
and it is  also enriched by the addition of Watts'
Physical ami Inorganic Chemistry.  All of the mat-
ter is brought to the present standpoint of chemi-
cal knowledge.  We may safely predict for this
work a continuance of the fame and favor it enjoys
among  medical  students.—New Orleans Medical
and Surgical Journal, March, 1886.
FRANKLAND,E.,D.  C.L.,F.R.S.,&JAPP,F.R.,F.I. C,
Professor of Chemistry in the Normal School
          of Science, London.
Assist. Prof, of Chemistry in the Normal
     School of Science, London.
    Inorganic Chemistry.   In one handsome octavo volume of 677 pages with 51
woodcuts and 2 lithographic plates.   Cloth, $3.75 ;  leather, $4.75.
  This work should supersede other works of its
class in the medical colleges.  It is certainly better
adapted than any work upon chemistry.with which
we are acquainted, to impart that clear and full
knowledge of the science which students of med-
icine should have. Physicians who feel that their
chemical knowledge is behind the times, would
do well to devote some of their leisure time to the
study of this work.  The descriptions and demon-
strations are made so plain that there is no diffi-
culty in understanding them.—Cincinnati Medical
News, January, 1886.
ATTFIELD, JOHN,  Ph. D.,
       Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc.

    Chemistry,  General,  Medical and Pharmaceutical;  Including the Chem-
istry of the  U. S. Pharmacopoeia.  A Manual of the General Principles of the Science,
and their  Application to Medicine and Pharmacy.  A new  American, from the tenth
English edition, specially revised by the Author.  In one handsome royal  12mo. volume
of 728 pages, with 87 illustrations.  Cloth,  $2.50;  leather, $3.00.
                                             to put himself in the student's place and to appre-
                                             ciate his state of mind.—American Chemical Jour-
                                             nal, April, 1884.
                                              It is a book on which too much praise cannot be
                                             bestowed.  As a text-book for medical schools it
  A text-book which passes through ten editions
in sixteen years must have good qualities. This
remark is certainly applicable to Attfield's Chem-
istry, a book which is so well known that it is
hardly necessary to do more than note the appear-
ance of this new and improved edition. It seems,
however, desirable to point out that feature of the
book which, in all probability, has made it so
popular.  There can be little doubt that it is its
thoroughly  practical  character, the  expression
being used in its best sense.  The author  under-
stands what the student ought to learn, and is able
is unsurpassable in the present state of chemical
science, and having been prepared with a special
view towards medicine and pharmacy, it is alike
indispensable to all persons engaged in those de-
partments of science.  It includes the  whole
chemistry of the last Pharmacopoeia.—Pacific Medi-
cal and Surgical Journal, Jan. 1884.
BLOXAM,  CHARLES L.,
       Professor of Chemistry in King's College, London.

     Chemistry, Inorganic  and Organic.   New American from the fifth Lon-
don edition,  thoroughly revised  and much  improved.   In one very handsome octavo
volume of 727 pages, with 292 illustrations.   Cloth, $3.75; leather, $4.75.
  Comment from us on this standard work is al-
most superfluous.  It differs widely in scope and
aim from that of Attfield, and in its way is equally
beyond criticism.  It adopts the most direct meth-
ods in stating the principles, hypotheses and facts
of the science.  Its language is so terse and lucid,
and its arrangement of matter so logical in se-
quence that  the student never has  occasion  to
complain that chemistry is a hard study.  Much
attention is paid to experimental illustrations of
chemical  principles and  phenomena,  and the
mode of conducting these experiments.  The book
maintains the position it has always held as one of
the best manuals of general chemistry In the Eng-
lish language.—Detroit Lancet, Feb. 1884.
REMSEN, IRA, M.  D., Ph.  D.,
       Professor of Chemistry in the Johns Hopkins University, Baltimore.
    Principles of Theoretical Chemistry, with special reference to the Constitu-
tion of Chemical Compounds.  Second and revised edition.  In one handsome royal 12mo.
volume of 240 pages.  Cloth, $1.75.
  That in so  few  years  a second edition  has
been  called  for indicates  that many chemical
teachers  have been found ready to endorse  its
plan and to  adopt its methods.   In  this edition
a considerable proportion  of the book has  been
rewritten, much new matter  has been added
and  the  whole has  been brought up to date.
We earnestly commend this book to every student
of chemistry.  The high reputation of the author
assures its accuracy in all matters of fact, and its
judicious conservatism in matters of theory, com-
bined with the fulness with which, in a small
compass, the present attitude of chemical science
towards the constitution of compounds is con-
sidered, gives it a value much beyond that accorded
to the average  text-books of the day.—American
Journal of Science, March, 1884. 
10           Lea Brothers  &  Co.'s Publications—Chemistry-
CHARLES, T.  CRANSTOUN, M. D.,  F. C. S.,  M. S.,
       Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast.
    The  Elements of Physiological  and Pathological Chemistry.   A
Handbook for Medical  Students and Practitioners.   Containing a general account of
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and
Excretions of the  Body in Health and in Disease.  Together with the methods for pre-
paring or separating their chief constituents, as also for their examination in detail, and
an outline syllabus of a practical course of instruction for students.  In one handsome octavo
volume of 463 pages,  with 38 woodcuts and 1 colored plate.   Cloth, $3.50.
                                              Dr. Charles' manual admirably fulfils  its inten-
                                            tion of giving his readers on the one hand a sum-
                                            mary, comprehensive but remarkably compact, of
                                            the mass of facts in the sciences which have be-
                                            come indispensable to the physician ; and, on the
                                            other hand, of a system of practical directions so
                                            minute that analyses often considered formidable
                                            may  be  pursued by  any intelligent  person.—
                                            Archives of Medicine, Dec. 1884.
  The work is thoroughly trustworthy,  and ip
formed throughout by a genuine scientific spirit.
The author deals with the chemistry of the diges-
tive secretions in  a systematic manner, which
leaves nothing to be desired, and in  reality sup-
plies a want in English literature.  The book ap-
pears to us to be at  once full and systematic, and
to show a just appreciation of the relative import-
ance of the  various subjects dealt with.—British
Medical Journal, November 29,18S4._____________
HOFFMANN, F.,  A.M., Ph.D.,  &  POWER  F.B., Ph.D.,
      Public Analyst to the State of New York.     Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy.
    A Manual of Chemical Analysis, as applied to the Examination of Medicinal
Chemicals and their Preparations.   Being a Guide for the Determination of their Identity
and Quality,  and for the Detection of Impurities and Adulterations.  For the  use of
Pharmacists, Physicians, Druggists and  Manufacturing Chemists, and Pharmaceutical and
Medical Students.   Third edition, entirely rewritten and much enlarged.   In one very
handsome octavo volume of 621 pages, with 179 illustrations.  Cloth, $4.25.
                                            tion of them singularly explicit.  Moreover, it is
                                            exceptionally free from typographical errors.  We
                                            have no hesitation in recommending it to those
  We congratulate the author on the appearance
 of the third edition of this work, published for the
 first time in this country also.  It is admirable and
 the  information it undertakes to supply is both
■ extensive and trustworthy.  The selection of pro-
 cesses for determining the purity of the substan-
 ces of which it treats is excellent and the descrip-
who are engaged either in the manufacture or the
testing of medicinal chemicals.—London Pharma-
ceutical Journal and Transactions, 1883.
CLOWES, FRANK, D. Se.,  London,
      Senior Science-Master at the High School, Newcastle-under-Lyme, etc.
    An Elementary  Treatise on Practical  Chemistry  and  Qualitative
Inorganic  Analysis.  Specially adapted for use in the Laboratories of Schools and
Colleges and  by Beginners.  Third American from the fourth and revised English edition.
In one very handsome  royal  12mo. volume of 387  pages, with 55 illustrations.   Cloth,
$2.50.
  The style is clear, the language terse and vigor-
ous.  Beginning with a list of apparatus necessary
for chemical work, he gradually unfolds the sub-
ject from its simpler to its more complex divisions.
It is the most readable book of the kind we have
yet seen, and is without  doubt a  systematic,
intelligible and fully equipped laboratory guide
and text book.—Medical Record, July 18,1885.
  We  may simply repeat the  favorable opinion
which we expressed after the examination of the
previous edition of this work. It is practical in its
aims, and accurate and concise in its statements.
—American Journal of Pharmacy, August, 1885.
RALFE,  CHARLES H.,  M. D.,  F. R. C. P.,
      Assistant Physician at the London Hospital.
    Clinical Chemistry.  In one  pocket-size  12mo. volume of 314  pages, with 16
               Limp cloth, red edges, $1.50.  See Students' Series of Manuals, page 4.
illustrations
  This is one of the most instructive little works
that we have met with in a long time. The author
is a physician and physiologist, as well as a chem-
ist, consequently the book is unqualifiedly prac-
     elling the physician just what he ought to
know, of the applications  of chemistry in medi-
tical, telling
cine.  Dr. Ralfe is thoroughly acquainted with the
latest contributions to his science, and it is quite
refreshing to find the subject dealt with so clearly
and simply, yet in such evident harmony with the
modern  scientific methods and spirit.—Medical
Record, February 2,1884.
CLASSEN,  ALEXANDER,
      Professor in the Royal Polytechnic School, Aix-la-Chapelle.
    Elementary Quantitative Analysis.  Translated, with notes and additions, by
Edgar F. Smith. Ph. D., Assistant Professor of Chemistry in the Towne Scientific School,
University of Penna.  In one 12mo. volume of 324 pages, with 36 illust.  Cloth, $2.00.
  It is probably the best manual of an elementary
nature extant insomuch as its methods are the
best.  It teaches by examples, commencing with
single  determinations,  followed by separations,
and then advancing to the analysis of minerals and
such products as are met with in applied chemis-
try. It is an indispensable book for students in
chemistry.—Boston Journal of Chemistry, Oct. 1878.
GREENE,  WILLIAM H., M.  D.,
      Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania.
    A Manual of Medical Chemistry.  For the use of Students. Based upon Bow-
    's Medical Chemistry.  In one 12mo. volume of 310  pages, with 74 illus.  Cloth $1.75.
                                            the recognition of compounds due to pathological
                                            conditions.  ™°  -w».£«™. -«■ —i~JL,1 ^'"gicai
man
  It is a concise manual of three hundred pages,
giving an excellent summary of the best methods
of analyzing the liquids and solids of the body, both
for the estimation of their normal constituents and
           The  detection of poisons is treated
with sufficient fulness for the purpose of the stu-
dent or practitioner.—Boston Jl. of Chem., June '80 
Lea  Brothers  &  Co.'s Publications—Pharm., Mat. Med., Therap. 11
BRUNTON,  T. LAUDER, M.D., D.Sc., F.R.S., F.R.C.P.,
       Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc.
    A Text-book of Pharmacology, Therapeutics  and Materia Medica;
Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs.
In  one handsome octavo volume  of 1033 pages, with  188 illustrations.   Cloth, $5.50;
leather, $6.50.   Just ready.
  It is a scientific treatise worthy to be ranked with
the highest productions in physiology, either in
our own or any other language.  Everything is
practical, the dry, hard facts of physiology being
pressed into service and applied to the treatment
of the commonest complaints.  The information
is so systematically arranged that it is available
for immediate use.   The index is so carefully
compiled that a reference to any special point is
at once obtainable.  Dr. Brunton is never satisfied
with vague generalities, but gives clear and pre-
cise directions for prescribing the various drugs
and preparations.  We congratulate students on
being at last placed in possession of a scientific
treatise of enormous practical importance.—The
London Lancet, June 27,1885.
  Dr. Brunton has been building up the material
for this volume through sixteen years of steady
labor, and the result proves that this long toil was
well directed. He has produced a work of singu-
lar merit, every page of which is marked by the
results of original research, judiciously analyzed.
We are not saying too much in  pronouncing this
treatise the most complete and valuable in ourown
or any other language on the topic to which it is
devoted.  The arrangement is eminently scientific.
The author is equally satisfactory in all his details,
and his work is certainly destined to rank as one
of the most important additions to medical litera-
ture of the period.—Medical and Surgical Reporter,
Oct. 17,1885.
PARRISH, EDWARD,
       Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy.
    A Treatise on Pharmacy: designed  as  a  Text-book for the Student, and as a
Guide for  the Physician and Pharmaceutist.  With many Formulae and Prescriptions.
Fifth edition, thoroughly revised, by  Thomas S. Wiegand, Ph. G.   In one handsome
octavo volume of 1093  pages, with  256 illustrations.  Cloth, $5; leather,
  No thoroughgoing pharmacist will fail to possess
himself of so useful a guide to practice, and no
physician who properly estimates the value of an
accurate knowledge of the remedial agents em-
ployed by  him in daily practice, so far as their
miscibility, compatibility and most effective meth-
ods of combination are concerned,  can afford to
leave this work out of the list of their works of
reference.   The country  practitioner, who must
always be in a measure his own pharmacist, will
find  it indispensable.—Louisville Medical  Neivs,
March 29, 1884.
  This well-known work presents itself now based
upon the  recently revised new  Pharmacopoeia.
Each page bears evidence of the  care bestowed
upon it, and conveys valuable information from
the rich store of the editor's experience.  In fact,
all that relates  to practical pharmacy—apparatus,
processes and dispensing—has been arranged and
described with  clearness in its various aspects, so
as to afford aid and advice alike to the student and
to the  practical pharmacist.  The work is judi-
ciously illustrated with good woodcuts—American
Journal of Pharmacy, January, 1884.
  There is nothing to equal Parrish's Pharmacy
in this or any  other language.—London Pharma-
ceutical Journal.
HERMANN, Dr. L.,
       Professor of Physiology in the University of Zurich.
    Experimental Pharmacology.  A Handbook of Methods for Determining the
Physiological Actions  of Drugs.  Translated, with  the Author's permission, and  with
extensive additions, by Robert Meade Smith, M. D., Demonstrator of Physiology in the
University of Pennsylvania.   In one handsome  12mo.  volume of  199  pages, with  32
illustrations.  Cloth, $1.50.________________________

MAISCH, JOHNM., Phar. D.,
       Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy.
    A Manual of Organic Materia Medica;  Being a Guide to Materia Medica of
the Vegetable and Animal  Kingdoms.  For the  use of Students, Druggists, Pharmacists
and Physicians.   New (second) edition.   In one handsome royal  12mo. volume of 526
pages, with 242 illustrations.  Cloth, $3.00
  This work contains the substance,—the practical
"kernel of the nut" picked out, so that the stu-
dent has no superfluous labor.  He can confidently
accept what this work places before him, without
any fear that the gist of the matter is not in  it.
Another merit is that the drugs are placed before
him in such a manner as to simplify very much
the study of them, enabling the mind to grasp
them more readily.  The illustrations are most
excellent, being very true to nature, and are alone
worth the price of the book to the student.  To the
practical physician and pharmacist it is a valuable
work for handy reference and for keeping fresh
in the memory the knowledge of materia medica
and botany already acquired.  We can and do
heartily recommend it.—Medical and Surgical Re-
porter, Feb. 14,1885.
BRUCE, J.  MITCHELL,  M. D.,  F. R. C. P.,
       Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London.
     Materia  Medica and Therapeutics.   An Introduction to Rational  Treat-
ment.   In one pocket-size 12mo. volume of 555 pages.   Limp cloth, $1.50.  See Students'
Series of Manuals, page 4.________________________i

GRIFFITH, ROBERT EGLESFIELD,  M. D.
     A  Universal Formulary,  containing the Methods  of Preparing and  Adminis-
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut-
ists.  Third  edition, thoroughly revised, with numerous additions,  by John M. Maisoh,
Phar. D. Professor of Materia Medica and Botany in the Philadelphia College  of Pharmacy.
In one octavo volume of  775 pages, with 38 illustrations.  Cloth, $4.50; leather, $5.50. 
12      Lea Brothers  & Co.'s Publications—Mat. Med., Therap.
 STILLE, A.,  M.D.,LL.D.,  & MAISCH, J. M.,Phar.D.,
       Professor Emeritus of the Theory and Prac-             Prof, of Mat. Med. and Botany in Phila.
       tice of Medicine and of Clinical Medicine             College of Pharmacy, Sec'y to the Ameri-
       in the University of Pennsylvania.                   can Pharmaceutical Association.
     The National Dispensatory: Containing the Natural History, Chemistry, Phar-
 macy, Actions and Uses  of Medicines, including those recognized in the Pharmacopoeias of
 the United States, Great Britain and Germany,  with numerous references to the French
 Codex.   Third edition,  thoroughly revised and greatly enlarged.   In one magnificent
 imperial  octavo  volume of  1767  pages,  with 311  fine  engravings.    Cloth,  $7.25;
 leather, $8.00; half Russia, open back, $9.00.  With Denison's  " Ready Reference Index "
 $1.00 in addition to price in any of above styles of binding.
     In the present revision the authors have labored incessantly with the view of making
 the  third edition of The National Dispensatory an even more complete represen-
 tative of the pharmaceutical and therapeutic science of 1884 than its first edition was of
 that of 1879.  For this, ample  material  has been afforded not only by the new United
 States Pharmacopoeia, but by those of Germany and France, which have recently appeared
 and have been incorporated in the Dispensatory, together with a large number of new non-
 officinal remedies.  It is thus  rendered  the representative of the  most advanced state of
 American, English, French and German pharmacology and therapeutics.  The vast amount
 of new and important material thus introduced may be gathered  from the fact that the
 additions to this edition amount in themselves to the matter of an ordinary full-sized octavo
 volume, rendering the work larger by twenty-five per cent,  than the last edition.  The
 Therapeutic Index (a feature peculiar to this work),  so suggestive and convenient to the
 practitioner,  contains 1600 more references than the last  edition—the General Index
 3700 more, making the total number of  references 22,390, while the  list  of illustrations
 has been increased by 80.  Every effort has  been made  to prevent undue enlargement of
 the volume by having in it nothing that could be regarded as superfluous, yet  care  has
 been taken that nothing should be omitted which a pharmacist or physician could expect
 to find in it.
     The appearance of the work has been delayed by nearly a year in consequence of the
determination of  the authors that it should attain as near an approach to absolute ac-
curacy as is humanly possible.  With  this view an elaborate and  laborious series of
 examinations and tests have been made to verify or correct the statements of the Pharma-
copoeia, and very numerous corrections have been found necessary.   It has thus been  ren-
dered indispensable to all who consult the Pharmacopoeia.
    The work is therefore presented in the full  expectation that  it  will  maintain  the
position universally accorded to it as the standard authority in  all  matters pertaining to
its subject, as registering the furthest advance of  the  science  of the  day, and as embody-
ing in a shape for convenient reference the recorded  results  of human experience in the
laboratory, in the dispensing room, and at the bed-side.
                                          up to date. The work has been very well done, a
                                          large number of extra-pharmacopoeial  remedies
                                          having beenadded to those mentioned in previous
                                          editions.—London Lancet, Nov. 22,1884.
                                            Its completeness as to subjects, the comprehen-
                                          siveness of its descriptive language, the thorough-
                                          ness of the treatment of  the topics, its brevity not
                                          sacrificing the desirable  features of  information
                                          for which such a work is needed, make this vol-
                                          ume a marvel of excellence.—Pharmaceutical Re-
                                          cord, Aug. 15,1884.
  Comprehensive in scope, vast in design  and
splendid in execution, The National Dispensatory
may be justly regarded as the most importantwork
of its kind extant.—Louisville Medical Neivs, Dec.
6,1884.
  We have much pleasure in recording the appear-
ance of a third edition of this excellent work of
reference.  It is an admirable abstract of all that
relates to chemistry, pharmacy, materia medica,
pharmacology  and  therapeutics.  It may be re-
garded as embodying the Pharmacopoeias of the
civilized nations of the world, all being brought
FARQUHARSON, ROBERT, M. D.,
      Lecturer on Materia Medica at St. Mary's Hospital Medical Scl
    A Guide to Therapeutics and Materia Medica.   Third American edition
specially revised by the Author.  Enlarged  and adapted to the U. S. Pharmacopoeia by
Frank Woodbury, M. D.  In one handsome 12mo. volume of 524 pages.  Cloth $2.25.
  Dr. Farquharson's Therapeutics is constructed ; umned pages—one side containing the rec'oenized
upon a plan which brings before the reader all the ' ^h,rC;^i^„°oi „„*,•---1^-----"."?."" I,"v'8nf?ea
which they must  p^^fuL  The^ doublet | l£ZZbX^% 2*5%. jltrlTZIX?

EDES, ROBERT T., 31.  D.,
      Jackson Professor of Clinical Medicine in Harvard University, Medical Department.
    A Text-Book of Materia Medica and Therapeutics. In one octavo volume
of about 600 pages, with illustrations.   Preparing.

STILLE, ALFRED,  M.  D., LL. D.,
      Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna.
    Therapeutics and Materia Medica.  A Systematic Treatise on the Action and
Uses of Medicinal  Agents, including  their Description and History.  Fourth  edition
revised and enlarged.   In two large and handsome octavo volumes, containing 193fi mtfJ
Cloth, $10.00; leather, $12.00;  very handsome half Russia, raised bands, $13 00.      g 
Lea Brothers & Co.'s Publications—Pathol., Histol.            13
COATS,  JOSEPH,  M.  D., F.  F. P. S.,
       Pathologist to the Glasgow Western Infirmary.
     A Treatise on Pathology.   In one very handsome octavo volume of 829 pages,
with 339 beautiful illustrations.  Cloth, $5.50; leather, $6.50.
  The work before us treats the subject of Path-
ology more extensively than it is usually treated
in similar works.  Medical students as well as
physicians, who desire a work for study  or refer-
ence, that treats  the  subjects  in the various de-
partments in a very thorough manner, but without
prolixity, will certainly give this one the prefer-
ence to any with which we are acquainted. It sets
forth the most recent discoveries, exhibits, in an
interesting manner, the changes from a normal
condition effected in structures by disease, and
points out the characteristics of various morbid
agencies, so that they can be easily recognized. But,
not limited to morbid anatomy.it explains fully how
the functions of organs are disturbed by abnormal
conditions.  There is nothing belonging to its de-
partment of medicine that is not as fully elucidated
as our present knowledge will admit,—Cincinnati
Medical News, Oct. 1883.
GREEN,  T.  HENRY,  M.  D.,
       Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London.
    Pathology and Morbid Anatomy.   Fifth American from the sixth revised
and enlarged English edition.   In one very handsome octavo volume of 482 pages, with
150 fine engravings.  Cloth, $2.50.
  The fact that this well-known treatise has  so
rapidly reached its sixth edition is a strong evi-
dence of its popularity.  The author is to be  con-
 fratulated upon the thoroughness with which he
 as prepared this work. It is thoroughly abreast
with all the most recent advances in pathology.
No work in the English language is so admirably
adapted to the wants of the student and practi-
tioner as this, and we would recommend it most
earnestly to every one.—Nashville Journal of Medi-
cine and Surgery, Nov. 1884.
WOODHEAD,  G.  SIMS,  M.  D., F.  R.  C. P. E.,
       Demonstrator of Pathology in the University of Edinburgh.
    Practical Pathology.  A Manual  for Students  and Practitioners.  In one beau-
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations.  Cloth, $6.00.
  It forms a real guide for the student and practi-
tioner who  is thoroughly in earnest in his  en-
deavor to see for himself and do for himself.  To
the laboratory student it will be a helpful com-
panion, and all those who may wish to familiarize
themselves with modern methods of examining
morbid tissues  are  strongly urged  to  provide
themselves with this  manual.   The numerous
drawings are not fancied  pictures,  or  merely
schematic diagrams, but they represent faithfully
the actual images seen under  the  microscope.
The author merits all praise for having produced
a valuable work.—Medical Record, May 31,1884.
SCHAFER, EDWARD  A., F.  R. S.,
       Assistant Professor of Physiology in University College, London.
     The  Essentials  of  Histology.   In one  octavo volume  of 246  pages,  with
281 illustrations.   Cloth, $2.25.  Just ready.
  This admirable work is a cheering example of
well-won success, earned by the faithful and dili-
gent pursuit of excellence in presentation of this
essential foundation of all true  medical  science.
Since this new work of Professor Schafer's will
doubtless be speedily placed upon the list of text-
books required in every medical college, we feel
that it needs no further recommendation at our
hands.—Am. Jour, of the Med. Sciences, Jan. 1886.
  This short volume might be called a companion
book to Green's Pathology, and fills the same place
in histology the latter occupies in pathology. This
book is so short, clear and satisfactory, as to invite
perusal, and repay any time spent in doing so. We
think the book deserving of the highest praise.
—New Orleans Medical ana Surgical Journal, Dee.
1885.
CORNIL,  V.,         and        RANTIER,  L.,
       Prof, in the Faculty of Med. of Paris.             Prof, in the College of France.
     A Manual of Pathological Histology.  Translated, with notes and additions,
by  E. O. Shakespeare, M. D., Pathologist and Ophthalmic Surgeon  to  Philadelphia
Hospital, and by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in
the University of Pennsylvania.  In one very handsome octavo volume of 800 pages, with
360 illustrations.  Cloth, $5.50 ; leather, $6.50; half Russia, raised bands, $7.

KLEIN,  E.,  M. D., F. R. S.,
     Joint Lecturer on General Anat. and Phys. in the Med.  School of St. Bartholomew's  Hosp., London.
     Elements of Histology. In one pocket-size 12mo. volume  of 360 pages, with 181
illus.  Limp cloth, red edges, $1.50.  See Students' Series of Manuals, page 4.
  Although an elementary work, it is by no means The illustrations are numerous and excellent. We
superficial or incomplete, for the author presents commend Dr. Klein's Elements most heartily to
In concise language nearly all the fundamental facts the student.—Medical Record, Dec. 1,1883.
regarding  the  microscopic structure of tissues.
PEPPER,  A.  J, M. B.,  M. S., F. R. C. S.,
       Surgeon and Lecturer at St. Mary's Hospital, London.
     Surgical Pathology.  In one pocket-size  12mo. volume of 511  pages, with 81
illustrations. Limp cloth, red edges, $2.00.   See Students' Series of Manuals, page 4.
  It is not pretentious, but it will serve exceed-
ingly well as a book of reference.  It embodies a
great deal of matter, extending over  the whole
field of surgical pathology.  Its form is practical,
itB  language is clear, and  the  information set
forth  is  well-arranged,  well-indexed  and  well-
illustrated.  The  student will find in it nothing
that  is unnecessary.  The list of subjects covers
the whole range of surgery.  The book supplies a
very manifest want and  should meet witn suc-
cess.—New York Medical Journal, May 31,1884. 
14        Lea Brothers & Co.'s Publications—Practice  of  Med.
FLINT,  AUSTIN, M.  D.,
   Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y.

     A Treatise on the Principles and Practice of  Medicine.   Designed for
the use of Students and Practitioners of Medicine.  With an Appendix on the Researches
of Koch, and  their  bearing on  the Etiology,  Patliology, Diagnosis and  Treatment  of
Phthisis.  Fifth edition, revised and largely rewritten  In one large and closely-printed
octavo volume of 1160 pages.  Cloth, $5.50; leather, $6.50; half Russia, $7.

     Koch's discovery  of the bacillus of tubercle gives promise of being the greatest
boon ever conferred by science on humanity, surpassing even vaccination in  its benefits  to
mankind.  In the appendix  to his  work, Professor Flint deals with the subject  from a
practical standpoint, discussing  its bearings on the  etiology, pathology, diagnosis, prog-
nosis and treatment of pulmonary phthisis.   Thus enlarged and  completed, this  standard
work will be more than ever a necessity to  the physician who duly  appreciates the re-
sponsibility of his calling.
  A well-known writer and lecturer on medicine
recently expressed an opinion, in the highest de-
gree complimentary of the admirable treatise of
Dr. Flint, and in eulogizing it, he described it ac-
curately as "readable and reliable." No text-book
is more calculated to enchain the interest of the
student, and none better classifies tne multitudi-
nous subjects included in it.  It has already so far
won its way in England, that no inconsiderable
number of men use it alone in the study of pure
medicine; and we can say of it that it is in every
way adapted to serve, not only as a complete guide,
but also as an ample instructor in the science ana
practice of medicine.  The style of Dr. Flint is
always polished and engaging.  The work abounds
in perspicuous explanation, and is a most valuable
text-book of medicine.—London Medical News.
  This work is so widely known and accepted as
the best American text-book of the practice of
medicine that it would seem hardly worth while to
give this, the fifth edition, anything more than a
passing notice.  But even the most cursory exami-
nation shows that it is, practically, much more
than a revised edition; it is, in fact, rather a new
work throughout.  This treatise will undoubtedly
continue to hold the first place in the estimation
of American physicians and students. No one of
our medical writers approaches Professor Flint in
clearness of diction, breadth of view, and, what we
regard of transcendent importance,  rational esti-
mate of  the value of remedial agents. It is thor-
oughly practical, therefore pre-eminently the book
for American readers.—St. Louis Clin. Rec, Mar. '81.
HARTSHORNE,  HENRY, M.  D., LL. D.,
       Lately Professor of Hygiene in the University of Pennsylvania.

    Essentials  of the Principles  and Practice of  Medicine.   A  Handbook
for Students and Practitioners.   Fifth edition, thoroughly revised and rewritten.   In one
royal 12mo. volume of 669 pages, with 144 illustrations.  Cloth, $2.75; half bound, $3.00.
  Within the compass of 600 pages it treats of the
history of  medicine, general pathology, general
symptomatology, and physical diagnosis (including
laryngoscope, ophthalmoscope, etc.), general ther-
apeutics, nosology, and special pathology and prac-
tice. There is a wonderful amount of information
contained in  this  work, and  it is one of the best
of its kind that we have seen.—Glasgow Medical
Journal, Nov. 1882.
  An indispensable book.  No work ever exhibited
a better average of actual practical treatment than
this one; and probably not one writer in our day
had a better opportunity than Dr. Hartshorne for
condensing all the views of eminent practitioners
into a 12mo.  The numerous illustrations will  be
very useful to students especially.  These essen-
tials, as the name suggests, are  not intended to
supersede the text-books of Flint and Bartholow,
but they are the most valuable in affording the
means to see at a glance the whole literature of any
disease, and the most valuable treatment.—Chicago
Medical Journal and Examiner, April, 1882.
BRISTOWE, JOHN SYER, M.  D., F. R. C. P.,
       Physician and Joint Lecturer on Medicine at St. Thomas' Hospital, London.
    A Treatise on the Practice of Medicine.  Second American edition, revised
by the Author.  Edited, with additions, by James H. Hutchinson, M.D., physician to the
r\fUlS7t A«ia ,H°lpitaL in 0ne handsome octav° volume of 1085 pages, with illustrations.
Uloth, 3)5.00; leather, $6.00; very handsome half Russia, raised bands, $6.50.
  The reader will find every conceivable subject
connected with the practice of medicine ably pre-
sented, in  a style  at once clear, interesting and
concise. The  additions made by Dr. Hutchinson
are appropriate and practical, and greatly add to
its usefulness to American readers.—Buffalo Med-
ical and Surgical Journal, March, 1880.
 WATSON,  SIR  THOMAS,  M. D.,
       Late Physician in Ordinary to the Queen.

t   3i!CtUftuST,0nrtfeJ??'mciples  and Practice  of Physic.  A new American
from  the fifth English edition.   Edited, with  additions, and 190 illustrations, byfiSS
Hartshorne A. M, M. D, late Professor of Hygiene in the University of Pennsylvania
In two large octavo volumes of  1840 pages.   Cloth, $9.00; leather, $11.00         W*1*-
LECTURES ON THE STUDY OF FEVER. By
  A. Hudson, M. D., M.  R.  I. A.  In one octavo
  volume of 308 pages.  Cloth, $2.50.
STOKES' LECTURES ON  FEVER.  Edited by
  John William Moore, M. D., F. K. Q. C. P.  In
  one octavo volume of 280 pages.  Cloth, 82.00.
A TREATISE ON FEVER.  By Robert D. Lyons
  K. C. C.  In one 8vo. vol. of 354 pp. Cloth, $2*2&'
LA ROCHE ON YELLOW FEVER, considered in
  its  Historical,  Pathological,  Etiological  and
  Therapeutical Relations.  In two large and hand
  some octavo volumes of 1468 pp.  Cloth $7 00
    A CENTURY  OF  AMERICAN MEDICINE, 1776-1876.  By  Drs E H Cia™*  tt  t
Bkjelow, S. D. Gross,  T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 page's  C?otn', fi£. 
Lea Brothers & Co.'s Publications—Systems of Med.        15
For Sale by Subscription Only.
A  System   of   Practical   Medicine.
                      BY AMERICAN AUTHORS.
        Edited by WILLIAM  PEPPER, M. D.,  LL. D.,
   PROVOST AND PROFESSOR OF THE THEORY AND  PRACTICE OF MEDICINE AND OF
              CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA,

assisted by Louis Starr,  M. D., Clinical Professor  of the  Diseases of Children in  the

                     Hospital of the University of  Pennsylvania.

In five imperial octavo volumes, containing about 1100 pages each, with illustrations.  Price per
    volume, cloth, $5;  leather, $6 ; half Russia, raised bands and open back, $7.  Volumes
      I, II, III. and IV., containing 4315 pages and  140 illustrations, are now ready.
              Volume V, containing about 1200 pages, will be ready in June.
     In this great work American medicine will be for the first time represented  by its
worthiest teachers, and presented in the full development of the practical utility which is its
preeminent characteristic.  The most able men—from the East and the West, from the
North and the South, from  all the prominent centres of education, and from all the
hospitals which afford  special  opportunities  for study  and practice—have  united  in
generous rivalry to bring together this vast aggregate of specialized experience.
     The distinguished editor has so  apportioned  the work  that each author has had
assigned to him the subject which  he is peculiarly fitted to discuss, and in which his views
will be  accepted  as the latest expression of scientific and practical knowledge.   The
practitioner will therefore find these volumes a complete, authoritative and unfailing work
of reference, to which he may at all times turn with full certainty of finding what he needs
in its most recent aspect,  whether he seeks information on the general  principles of medi-
cine, or minute guidance  in the treatment of special disease.  So wide  is the scope of the
work that, with the exception of midwifery and matters strictly surgical, it embraces the
whole domain of medicine, including the departments for which the physician is accustomed
to rely on special  treatises, such as diseases of women and children, of the genito-urinary
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology
and otology.  Moreover, authors have inserted  the  formulas which they have found most
efficient  in the  treatment of  the  various  affections.  It may thus be truly regarded as a
Complete Library of Practical Medicine, and the general practitioner possessing it
may feel secure that he will require little  else in the daily round of professional duties.
     In spite of every effort  to condense the  vast  amount of practical information fur-
nished, it has been impossible to present it in less than 5 large octavo volumes, containing
about 5500  beautifully printed pages, and embodying the matter of  about 15 ordinary
octavos.   Illustrations are introduced wherever requisite to elucidate the text.
     A  detailed  prospectus of the work will be  sent to any  address on application  to the
publishers.
                                           pie, etc., it is peculiarly adapted to  the wants
                                           of  American  practitioners of  medicine,  and  it
                                           seems to us that every one of them would  desire
                                           to have it. It  has been truly called a "Complete
                                           Library of Practical  Medicine," and the general
                                           practitioner will require little else in his round
                                           of professional duties.—Cincinnati Medical News,
                                           March, 1886.
                                             Each of the volumes is  provided with a most
                                           copious index, and the work altogether promises
                                           to be one which will add much  to the medical
                                           literature of the present century, and reflect great
                                           credit upon the scholarship and practical acumen
                                           of its authors.— The London Lancet, Oct. 3, 1885.
                                             The Editor tells us  in his preface that he feels
                                           that the  time has come  for the presentation
                                           of the  whole  field of  practical  medicine as it
                                           is  actually taught and practised by  American
                                           physicians. We quite  agree that an  extensive
                                           and systematic treatise by American physicians is
                                           a good thing for physicians.  Race, temperament
                                           and climatic  conditions  give  undoubtedly  a
                                           peculiar physiognomy  to  many diseases, and
                                           develop special modes of dietetic and medicinal
                                           treatment.  We welcome the appearance  of  an
                                           " American System of Medicine" therefore.  The
                                           present work is a most thorough, satisfactory and
                                           creditable one.—Medical Record, Nov. 7,1885."
  This magnificent work has filled us with feel-
ings of warm admiration.  It  is adorned with a
galaxy of famous names, many of them familiar
to the European student as representative of the
best work  done in  scientific medicine in the
Western Continent, and the articles are therefore
to be regarded as coming from the highest au-
thorities on the particular subjects of which they
treat.  We would offer our congratulations on the
excellence of the System of Medicine, and in ex-
pressing our high opinion of  the work we have
only to add our hearty wish that it may be read as
much in this country as it deserves.—-Edinburgh
Medical Journal, February, 1886.
  The third volume of this great work, which at-
tained a merited popularity immediately on the
issue of the first volume, is in no way inferior to
its predecessors.  This  "System of Medicine by
American Authors" is a monument to American
medicine.—Journal of American Medical Associa-
tion, December 5,1885.
  We consider it one of the  grandest works on
Practical Medicine in the English language. It is
a work of which the profession of this country can
feel  proud.  Written exclusively by  American
physicians who are acquainted with all the varie-
ties of climate in the United States, the character
of the soil, the manners and customs of the peo- 
16       Lea  Brothers & Co.'s Publications—Clinical Med., etc.
FOTHERGILL, J. M.,  M. D., Edin., M. R. C. P., Loud.,
      Physician to the City of London Hospital for Diseases of the Chest.
    The Practitioner's Handbook of Treatment; Or, The Principles of Thera-
peutics. New edition.  In one octavo volume df about 700 pages.  Cloth, $3.75.  Shortly.

                      From the Preface to the Previous Edition.
    This work is not an imperfect Practice of Physic, but an attempt of original character
to explain the rationale of our therapeutic measures.  First  the physiology of each sub-
ject is given, then the pathology is reviewed, so far as they bear on the treatment; next
the action of remedies is examined;  after which their  practical application in concrete
prescriptions is furnished.  It is designed to furnish to  the practitioner reasons for  the
faith which is in him;  and is a work on medical tactics for the bedside rather than  the
examination table.__________________________

REYNOLDS,  J. RUSSELL, M. D.,
      Professor of the Principles and Practice of Medicine in  University College, London.
    A System of Medicine.  With notes and  additions by  Henry Hartshorne,
A. M., M. D.,late Professor of Hygiene in the University of Pennsylvania. ^ In three large
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra-
tions.  Price per volume, cloth, $5.00; sheep, $6.00; very handsome half Russia, raised bands,
$6.50.  Per  set, cloth, $15; leather, $18; half  Russia,  $19.50.  Sold only by subscription.
  For conciseness and comprehensiveness in the thin index can fully appreciate.—Michigan Medical
treatment of all the subjects embraced under the
head of "Practice of Medicine," there is no work
in the English language, or in any other language,
for that matter, which equals, much less excels,
Reynolds' System. Each volume contains a com-
plete index—a feature which those who may have
encyclopaedic works on medicine not containing
News, June 10, 1880.
  There is no medical work which we have in
times past  more  frequently  and  fully consulted
when perplexed by doubts as to treatment, or by
having  unusual or apparently inexplicable symp-
toms presented to us  than  Reynolds' System of
Medicine.—Am. Journ. of Med.  Sci., January, 1830.
STILLE, ALFRED, M. D., LL. D.,
      Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna.
    Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat-
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. Just ready.
  This timely little work is full of the learning
and good judgment which marks all that comes
from the pen of its distinguished author. What
he has to say on  treatment is characterized by
his usual caution and his well-known preference
for a rational system.  Altogether, the monograph
is one that will have an excellent influence on the
professional mind.—Medical and Surgical Reporter.
August 1,1885.
FINLAYSON, JAMES,  M. D., Editor,
      Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc.
    Clinical Diagnosis.  A Handbook for Students and Practitioners of Medicine.
With Chapters by Prof. Gairdner on the  Physiognomy of Disease; Prof. Stephens on
Diseases  of the Female Organs; Dr. Robertson  on Insanity; Dr. Gemmell on Physical
Diagnosis;  Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor
on Case-taking, Family History and Symptoms of Disorder in the Various Systems.   New
edition.  In  one handsome 12mo. volume  of 600  pages, with  about 100 illustrations.
Preparing.

BROADBENT,  W.  H.,  M. D.,  F. R. C. P.,
      Physician to and Lecturer on Medicine at St. Mary's Hospital.
    The Pulse. In one 12mo. volume.  Preparing. See Series of Clinical Manuals, page 4.

FENWICK, SAMUEL,  M. D.,
      Assistant Physician to the London Hospital.
    The Student's Guide to Medical Diagnosis.   From the third revised and
enlarged English edition.  In one very handsome royal 12mo. volume of 328 pages, with
87 illustrations on wood.  Cloth, $2.25.

HABERSHON, S.  O.,  M.  D.,
      Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital, London.

    On  the Diseases of the Abdomen;   Comprising those of the Stomach, and
other parts of the Alimentary Canal, Oesophagus, Caecum, Intestines and Peritoneum. Second
American from third enlarged and revised English  edition.  In one handsome  octavo
volume of 554 pages, with illustrations.   Cloth, $3.50.

TANNER, THOMAS HAWKES, M. D.
    A Manual of Clinical Medicine and Physical Diagnosis. Third American
from the second London edition.   Revised  and  enlarged by Tilbury Fox,  M. D
In one small  12mo. volume  of 362 pages, with illustrations.  Cloth, $1.50. 
Lea Brothers &  Co.'s Publications—Hygiene, Electr., Pract.     17
RICHARDSON, B. W., M.A., M.D., LL. D., F.R.S., F.S.A.
       Fellow of the Royal College of Physicians, London.

    Preventive Medicine.   In one octavo volume of 729 pages.   Cloth, $4;  leather,
$5; very handsome half Russia, raised bands, $5.50.
  Dr. Richardson has succeeded in producing a
work which is elevated in conception, comprehen-
sive in scope, scientific in character, systematic in
arrangement, and which is written in a clear, con-
cise and pleasant manner.  He evinces the happy
faculty or extracting the pith of what is known on
the subject, and of presenting it in a most simple,
intelligent and practical form. There is perhaps
no similar work written for the general public
that contains such a complete, reliable and instruc-
tive collection of data upon the diseases common
to the race, their origins, causes, and the measures
for their prevention.  The descriptions of diseases
are clear, chaste and scholarly; the discussion of
the question of disease is comprehensive, masterly
and fully abreast with the latest and best knowl-
edge on the subject, and the preventive measures
advised are accurate, explicit and reliable.—The
American Journal of the Medical Sciences, April, 1884.
  This is a book that will surely find a place on the
table of  every  progressive physician. To the
medical profession, whose duty is quite as much to
prevent as to cure disease, the book will be a boon.
—Boston Medical and Surgical Journal, Mar. 6,1884.
  The treatise contains a vast amount of solid, valu-
able hygienic information.—Medical and Surgical
Reporter, Feb. 23,1884.
BARTHOLOW, ROBERTS, A. M., M. D., LL. D.,

       Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc.

    Medical Electricity.   A  Practical  Treatise on the Applications of Electricity
to Medicine and Surgery.  New (third) edition.  In one very handsome octavo volume of
300 pages, with about 125 illustrations.  Preparing.
    A notice of the previous edition is appended.

  A most excellent work, addressed by a practi-
tioner to his fellow-practitioners, and thereforo
thoroughly practical.  The  work now  before us
has the exceptional merit of clearly pointing out
where the benefits to be derived from electricity
must come. It contains all and everything that
the practitioner needs in order to understand in-
telligently the nature and laws of the agent he  is
making use of, and for its  proper application in
practice.  In a condensed, practical form, it pre-
sents to the physician all that he would wish to
remember after perusing a whole library on medical
electricity, including the results of the latest in-
vestigations. It is the book for the practitioner,
and the necessity for a second edition proves that
it has been  appreciated by the profession.—Physi-
cian and Surgeon, Dec. 1882.
THE  YEAR-BOOK OF  TREATMENT  FOR  1885.
    A  Comprehensive and Critical Review  for  Practitioners of Medi-
cine.  In one 12mo.  volume of 320 pages, bound in limp cloth, $1.25.  Just  ready.
  One strong feature of the book is that treatment
comes in  for a greater  share of attention than
pathology, and this gives to it a practical nature—
because, what the practitioner wants to know is
not a theory or a scientific explanation, but what
is the best thing for him to  do in certain emer-
 Sencies, or how he can improve his treatment.
 [e can learn by consulting the Year-Book of Treat-
ment what has been  done all over the world  by
the best practitioners in medicine and surgery, in
every department and in every specialty.  As the
book is arranged in sections, there can be little
difficulty  in finding out what may  be required;
and as the descriptions of the  newer methods of
operation are very full, even new operations can
be tried.—Provincial Medical Journal, March 1, '86.
THE  YEAR-BOOK OF  TREATMENT FOR  1884.

     Similar to that of 1885 above.
  It is a complete account of the more important
advances made  in the treatment of disease.  Ex-
treme pains have been taken to explain clearly in
the fewest possible words  the views of each
writer, and the  details of each subject.   One of
the principle points about the book is its practical,
yet concise language.  Each editor has well per-
formed his duty, and we can say with truth that
it is a volume well worth buying for frequent use.
— Virginia Medical Monthly, March, 1885.
  In a few moments the busy practitioner can re-
fresh his mind  as  to the  principal advances  in
treatment for a year past. This kind of work is
peculiarly useful at the present time, when current
literature is teeming with innumerable so-called
advances, of which the practitioner has not time
to determine  the value.  Here he has, collected
from many sources, a rlsuml of the theories and
facts which are new, either entirely or in part, the
decision as to their novelty being made by those
who by  wide  reading and long experience are
fully competent to render such  a verdict.—Ameri-
can Journal of the Medical Sciences, April, 1885.
SCHREIBER,  DR. JOSEPH.

    A  Manual of Treatment  by Massage  and  Methodical  Muscle  Ex-
ercise.   Translated by Walter Mendelson, M. D., of New York.  In one handsome
octavo volume of about 300 pages, with about 125 fine engravings.  Preparing.
BTURGES' INTRODUCTION TO THE STUDY
  OF CLINICAL MEDICINE.  Being a Guide to
  the Investigation of Disease. In one handsome
  12mo. volume of 127 pages.   Cloth, $1.25.
DAVIS" CLINICAL  LECTURES ON VARIOUS
  IMPORTANT  DISEASES.  By N. S. Davis,
  M. D. Edited by Frank H. Davis, M. D. Second
  edition.  12mo. 287 pages.  Cloth, $1.75.

TODD'S CLINICAL  LECTURES ON CERTAIN
  ACUTE  DISEASES.  In one octavo volume of
  320 pages.  Cloth, $2.50.
PAVY'S TREATISE ON THE FUNCTION OF DI-
  GESTION; its Disorders and their Treatment.
  From the second London edition.  In one octavo
  volume of 238 pages.  Cloth, $2.00.
BARLOW'S MANUAL OF THE PRACTICE OF
  MEDICINE.  With  additions by D. F. Condib,
  M. D.  1 vol. 8vo., pp. 603.  Cloth, $2.50.
CHAMBERS' MANUAL OF DIET AND REGIMEN
  IN HEALTH AND  SICKNESS. In one hand-
  some octavo volume  of 302 pp.  Cloth, 82.75.
HOLLAND'S MEDICAL NOTES  AND REFLEC-
  TIONS.  1 vol. 8vo., pp. 493.  Cloth, $3.50. 
18      Lea Brothers & Co.'s Publications—Throat, Lungs, Heart.
FLINT,  AUSTIN, M. D.,
      Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y.
    A Manual  of Auscultation and Percussion; Of the Physical Diagnosis of
Diseases of the Lungs and Heart, and of Thoracic Aneurism.  Fourth  edition.  In one
handsome royal 12mo. volume of 278 pages, with 14 illustrations. Cloth, $1.75.  Just ready.
 The  student  needs a first-class text-book in  percussion to private classes, composed of medical
which  the subject is fully explained for him to  students and practitioners.  The fact that within
study.  Dr. Flint's work is just such  a book. It  a little more than two years a large edition of this
contains the substance  of the lessons which the  manual has been exhausted, is proof of the ia.**or
author has for  many years given in  connection  with which it has been  regarded by  the medical
W'.th practical  instruction in auscultation  and  profession.—Cincinnati Medical News,  Feb. 1886.
                             BY THE SAME A UTHOR.
    Physical Exploration of the Lungs by Means  of Auscultation and
Percussion.  Three lectures delivered before the Philadelphia County Medical Society,
1882-83.   In one handsome small 12mo. volume of 83 pages.  Cloth, $1.00.

    A Practical Treatise on the Physical Exploration of  the Chest and
the Diagnosis of Diseases Affecting the Respiratory Organs.  Second and
revised edition. In one handsome octavo volume of 591 pages.  Cloth, $4.50.

    Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and
Complications,  Fatality and Prognosis, Treatment and Physical Diag-
nosis ; In a series of Clinical Studies.   In one handsome octavo volume of 442 pages.
Cloth, $3.50.                           ----
    A Practical Treatise on the Diagnosis, Pathology and  Treatment of
Diseases of the Heart.  Second revised and enlarged edition.   In one octavo volume
of 550 pages, with a plate.  Cloth, $4.

    Essays on Conservative Medicine and Kindred Topics.  In one very hand-
some  royal 12mo. volume of 210 pages.  Cloth,  $1.38.
COHEN, J. SOLIS, M. D.,
      Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College.
    Diseases of the Throat and Nasal Passages.   A Guide to the Diagnosis and
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares.   Third
edition, thoroughly revised and rewritten, with a large number of new illustrations.  In
one very handsome octavo volume. Preparing.
SELLER,  CARL, M.  D.,
      Lecturer on Laryngoscopy in the University of Pennsylvania.
    A Handbook of Diagnosis and Treatment of Diseases of the Throat,
Nose and Naso-Pharynx.   Second  edition.  In one handsome royal 12mo. volume
of 294 pages, with 77 illustrations. Cloth, $1.75.
  It is one of the best of the practical text-books
on this subject with which we are acquainted. The
present edition has been increased in size, but its
eminently practical character has  been  main-
tained.  Many new  illustrations have also been
introduced, a case-record sheet has been added,
and there are a valuable bibliography and a good
index of the whole. For any one who wishes to
make himself familiar with the practical manage-
ment of cases of throat and nose disease, the book
will be found of great value.—New  York Medical
Journal, June 9,1883.
BROWNE, LENNOX,  F. R.  C.  S., Edin.,
      Senior Surgeon to the Central London Throat and Ear Hospital, etc.
    The  Throat and its Diseases.  Second American from the second English edi-
tion, thoroughly revised.  With 100 typical illustrations in colors and 50 wood engravings
designed and executed by the Author.  In one very handsome imperial octavo volume of
about 350  pages.   Preparing.

GROSS,  S.  D., M.D., LL.D., D.C.L. Oxon.,  LL.D.  Cantab.
    A Practical Treatise on Foreign Bodies in  the Air-passaees.  In one
octavo volume of 452 pages, with 59 illustrations.  Cloth, $2.75.
FULLER ON DISEASES OF THE LUNGS AND
  AIR-PASSAGES.  Their Pathology, Physical Di-
  agnosis, Symptoms and Treatment. From the
  second and revised English edition.  In one
  octavo volume of 475 pages.  Cloth, $3.50.
SLADE ON DIPHTHERIA; its Nature and Treat-
  ment, with an account of the History of its Pre-
  valence in various Countries. Second and revised
  edition. In one 12mo. vol., pp. 158. Cloth, $1.25.
WALSHE ON THE DISEASES OF THE HEART
  AND GREAT VESSELS.  Third American edi-
  tion. In 1 vol. 8vo., 416 pp.  Cloth, $3.00.
SMITH ON CONSUMPTION; its Early and Reme-
  diable Stages.  1 vol. 8vo., pp. 253. Cloth $2 25
LA ROCHE ON PNEUMONIA.  1 vol. 8vo of4«JO
  pages.  Cloth, $3.00.                 '
WILLIAMS ON PULMONARY CONSUMPTION-
  its Nature, Varieties and Treatment.   With an
  analysis of one thousand cases to exemplify its
  duration.  In one 8vo. vol. of 303 pp.  Cloth fto v»
JONES' CLINICAL OBSERVATIONS ON FTTNT
  TIONAL NERVOUS DISORDERS. Second Am
  erican edition. In one handsome octavo volume
  of 340 pages.  Cloth, $3.26.            volume 
Lea  Brothers & Co.'s Publications—Nerv. and Ment. Dis., etc.   19
ROSS, JAMES, 31.D., F.R. C.P.,  LL.D.,
       Senior Assistant Physician to the Manchester Royal Infirmary.

    A  Handbook  on Diseases  of  the Nervous  System.   In one  octavo
volume of 725 pages, with 1S4 illustrations.  Cloth, $4.50; leather, $5.50.  Just ready.
  Dr. Ross' reputation as  a neurologist is so well ' able.  The descriptions are always graphic__some-
established that anything we can say will scarcely j times  almost  photographic.  The  treatment  is
add to it.  This work is a condensation of his large | always  as definite as circumstances will  permit
treatise, intended for the use of students aid for
the "busy practitioner."   As coming from  Dr.
Ross' pen the work can scarcely be less than au-
thoritative. It is besides, clear, succinct and read-
The work is altogether good—too good we fear for
the success of his larger work.—The Bristol Med-
ico-Chirurgical Journal, March, 1880.
MITCHELL,  S.  WEIR,  M.  D.,
      Physician to Orthopcedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc.
    Lectures on  Diseases of the Nervous  System;  Especially  in Women,
Second edition.   In one 12mo. volume of 288 pages.  Cloth, $1.75.
  No work in our language develops or displays
more features of that many-sided affection, hys-
teria, or gives clearer directions for its differen-
tiation, or sounder  suggestions  relative  to its
teachings  the  stamp of authority all over the
realm ot medicine.  The work, although written
by a specialist, has no exclusive character, and
the general practitioner above all others will find
its perusal profitable, since it deals with diseases
which he frequently  encounters and must essay
to treat.—American Practitioner, August, 1885.
general management and treatment.  The book
is particularly valuable in  that it represents  in
the main the author's own clinical studies, which
have been so extensive and fruitful as to give his


HAMILTON,  ALLAN McLANE, 31. D.,
      Attending Physician at the Hospital for Epileptics and Paralytics, BlackweWs Island, N. Y.

    Nervous Diseases; Their Description and Treatment.  Second edition, thoroughly
    ;ed and rewritten. Tn one netavn vnlnmpnf ftQS*  nno-ce with 7*> illiict-raf^nc  ni^+1^ «/i
revised and rewritten.  In one octavo volume of 598 pages, with 72 illustrations.  Cloth,
  When the first edition of this good book appeared
we gave it our emphatic endorsement, and the
present edition enhances our appreciation of the
book and  its author'as a safe guide to students of
clinical neurology.   One of the best and most
critical of English neurological journals, Brain, has
characterized this book as the best of its kind in
any language, which is a handsome endorsement
from an exalted source.  The improvements in the
new edition, and the additions to it, will justify its
purchase even by those who possess the old.—
Alienist and Neurologist, April, 1882.
TUKE, DANIEL HACK,  M. D.,
       Joint Author of The Manual of Psychological Medicine, etc.
    Illustrations of the Influence of the Mind upon the Body in Health
and  Disease.   Designed  to  elucidate  the Action  of the Imagination.   New edition.
Thoroughly revised and rewritten.   In one handsome octavo  volume of 467 pages, with
two colored plates.  Cloth, $3.00.
                                            method of interpretation.  Guided by an enlight-
                                            ened  deduction, the  author has reclaimed for
                                            science a most interesting domain in psychology,
                                            previously abandoned to charlatans and empirics.
                                            This book, well conceived and well written, must
                                            commend itself to  every thoughtful understand-
has he adhered to a physiological and rational j ing.—New York Medical Journal, September 6,1884.

CLOUSTON,  THOMAS S., 31. D.,  F. R. C. P., L. R. C. S.,
       Lecturer on Mental Diseases in the University of Edinburgh.
    Clinical Lectures on Mental Diseases.  With an Appendix,  containing  an
Abstract of the Statutes of the United States and of the Several States and  Territories re-
lating to the Custody of the Insane.   By Chakles F. Folsom, M. D., Assistant Professor
of Mental Diseases, Med. Dep. of Harvard Univ.  In one handsome octavo volume of 541
pages, with eight lithographic plates, four of which are beautifully colored.  Cloth,  $4.
  The practitioner  as well as the student will ac- 1 the general practitioner in guiding him to a diag-
  It is impossible to peruse these interesting chap-
ters without being convinced of the author's per-
fect sincerity, impartiality, and thorough mental
grasp.   Dr. Tuke  has exhibited  the  requisite
amount of scientific address on all occasions, and
the more intricate the phenomenathe more firmly
cept the plain, practical teaching of the author as a
forward step in the literature of insanity.  It is
refreshing to find a physician  of Dr. Clouston's
experience  and high reputation giving the bed-
side notes upon which nis experience  has  been
founded and his mature judgment  established.
Such clinical observations cannot but be useful to
nosis and indicating the treatment, especially in
many obscure and doubtful cases  of mental dis-
ease.  To the American reader Dr. Folsom's Ap-
pendix adds  greatly to the value of the work, and
will make it a desirable addition to every library.
—American Psychological Journal, July, 1884.
108 pages.
■. Folsom's Abstract may also be obtained separately in one octavo volume of
 Cloth, $1.50.
SAVAGE,  GEORGE H.,  31. D.,
       Lecturer on Mental Diseases at Guy's Hospital, London.
     Insanity and  Allied  Neuroses, Practical  and Clinical.   In one 12mo.
of 551 pages, with 18 illus.  Cloth, $2.00.  See Series of Clinical Manuals, page 4.

PLAYFAIR,  W.  S.,  M.  D.,  F. R. C.  P.,
     The Systematic Treatment of Nerve  Prostration and Hysteria.
one handsome small 12mo. volume of 97 pages.  Cloth,  $1.00.

     Blandford on Insanity and its  Treatment:  Lectures on  the Treatment,
Medical and Legal, of iDsane Patients.  In one very handsome octavo volume.
vol.
In 
20             Lea  Brothers & Co.'s  Publications—Surgery.
ASHHURST,  JOHN,  Jr., M.  D.,
       Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia.
    The Principles and Practice of Surgery.   New (fourth) edition, enlarged
and revised.   In one large and handsome octavo volume of 1114 pages, with 597 illustra-
tions.  Cloth, $6 ; leather, $7 ; half Kussia, $7.50.
                                             Every advance in surgery worth notice, chroni-
                                            cled in recent literature, has been suitably recog-
                                            nized and noted in its proper place.  Suffice it to
  As with Erichsen so with Ashhurst, its position
fn professional favor is established, and one has
now but to notice the changes, if any, in theory
and practice, that are apparent in the present
as compared with the preceding edition, published
three years ago.  The work has been brought well
up to date, and is larger and better illustrated than
before, and its author may rest assured that it will
certainly have a  "continuance of the favor with
which  it has heretofore  been received."— The
American Journal of the Medical Sciences, Jan. 1886.
say, we regard Ashhurst's Surgery, as now  pre-
sented in the fourth edition, as  the best single
volume on surgery published in the English lan-
guage, valuable alike to the student and the prac-
titioner, to the one as a text-book, to the other as
a manual of practical surgery.  With pleasure we
give this  volume our endorsement in full.—New
Orleans Medical and Surgical Journal, Jan., 1886.
GROSS,  S.  D.,  M.  D.,  LL.  D.,  D.  C.  L.  Oxon,,  LL.  D.
          Cantab.,
      Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia.
    A System of Surgery:  Pathological,  Diagnostic,  Therapeutic and  Operative.
Sixth edition, thoroughly  revised and greatly improved.  In two large and  beautifully-
printed imperial octavo volumes containing 2382  pages, illustrated by 1623  engravings.
Strongly bound in leather, raised bands, $15; half Russia, raised bands, $16.
                                             His System of Surgery, which, since its first edi-
                                            tion in 1859, has been a standard work  in this
                                            country as well  as  in America,  in  "the whole
                                            domain of surgery," tells how earnest and labori-
                                            ous and wise a surgeon  he was. how thoroughly
                                            he appreciated the work done by men in other
                                            countries, and how much he contributed to pro-
                                            mote the science and practice of surgery in his
                                            own.  There has been no man to whom America
                                            is so much indebted in this respect as the Nestor
                                            of surgery.—British Medical Journal, May 10,1884.
  Dr. Gross' System of Surgery has long been the
standard work on that subject for  students and
practitioners.—London Lancet, May 10,1884.
  The work as a whole needs no commendation.
Many years ago it earned  for itself the enviable
reputation of the leading American  work on sur-
gery, and it is still capable  of maintaining that
standard.  A considerable amount of new material
has been introduced, and altogether the distin-
 fuished author has reason to be satisfied that he
 as placed the work fully abreast of the state of
our knowledge.—Med. Record, Nov. 18,1882.
GOULD,  A.  PEARCE,  M.  S., M. B., F.  R.  C. S„
      Assistant Surgeon to Middlesex Hospital.
    Elements  of Surgical Diagnosis.   In one pocket-size 12mo. volume of 589
pages.   Cloth,  $2.00.  See Students' Series of Manuals, page 4.
  This book will be found to be a  most useful
guide for  the  hard-worked  practitioner.  Mr.
Gould's style is eminently clear and precise, and
we can cordially recommend the manual as being
the outcome of the efforts of an honest and thor-
oughly practical surgeon.— The Medical News, Jan.
24,1885.
  This is a capital little book, written by a prac-
tical man on a very practical subject.  The topics
are very systematically and succinctly arranged,
are tersely presented, and the points of diagnosis
very intelligently discussed. It will  be found to
be of the greatest amount of help both to  teacher
and student.—Medical Record, Feb. 28,1885.
GIBNEY, V. P.,  M.  D.,
      Surgeon to the Orthopaedic Hospital, New York, etc.
    Orthopaedic Surgery.  For the use of Practitioners and Students.  In one hand-
some octavo volume, profusely illustrated.   Preparing.


DRUITT, ROBERT,  M.  R.  C. S., etc.

T   The Principles and  Practice  of  Modern  Surgery.  From the eighth
I^ondon edition.  In one 8vo. volume of 687 pages, with 432 illus.  Cloth, $4; leather^ $5.

ROBERTS, JOHN B.,  A. M.,  M. D.,
      Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy

*nA Tb^?rinci^?TS ^nd Practice of Modern Surgery.  For the use of Students
and Practitioners of Medicine and Surgery.   In one very handsome octavo volume of about
500 pages, with many illustrations.  Preparing.

BELLAMY,  EDWARD,  F. R.  C. S.,
      Surgeon and Lecturer on Surgery at Charing Cross Hospital, London.
    Operative  Surgery.  Shortly.  See Students' Series of  Manuals, page 4.

                                            MILLER'S PRINCIPLES OF SURGERY. Fourth
                                             American from the third Edinburgh edition   Tn
                                             Clo^Rm" °f 638 Page8' With 34° illustrat'ion£

                                            MILLER'S PRACTICE OF SURGERY.  Fourth
                                             and revised American from the last Edinburgh
                                             ?£-tl,?n-i In.one lal?e 8vo- ▼«!• of 682 pagesw£h
                                             364 illustrations. Cloth, $3.75       J^ses, with
SARGENT ON BANDAGING and OTHER OPERA-
  TIONS  OF MINOR  SURGERY.  New edition,
  with a Chapter on military surgery.  One 12mo.
  volume  of 383 pages, with 187 cuts. Cloth, $1.75.

PIRRIE'S PRINCIPLES AND  PRACTICE  OF
  SURGERY.  Edited  by John Neill, M. D.  In
  one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75.

SKEY'S OPERATIVE SURGERY. In one vol. 8vo.
  of 661 pages, with 81 woodcuts.  Cloth, $3.25. 
Lea  Brothers  &  Co.'s Publications—Surgery.            21
ERICHSEN, JOHN E., F.  R.  S.,  F. R.  C.  S.,
       Professor of Surgery in University College, London, etc.
     The Science and Art of Surgery; Being a Treatise on Surgical Injuries, Dis-
eases and Operations.   From the eighth and enlarged English edition.  In two large and
beautiful octavo   volumes  of 2316 pages,  illustrated with 984  engravings on wood.
Cloth, $9; leather, raised bands, $11;  half  Eussia, raised bands, $12.
  In noticing the eighth  edition of this  well-
known work, it would appear superfluous to say
more than that it has, like its predecessors, been
brought fully up to the times, and is  in  conse-
quence one of the best treatises upon surgery that
has ever been penned by one man.  We  have  al-
ways regarded "The Science and Art of  Surgery"
as one of the best  surgical text-books in  the
English language, and this  eighth edition only
confirms  our previous opinion.  We take  great
pleasure in cordially commending it to  our read-
ers.— The Medical News, April 11,1885.
  After being  before the  profession  for thirty
years  and maintaining during that period a re-
putation as a leading work on surgery, there is not
much to be said in the way of comment or criti-
cism.  That it still holds its own goes without say-
ing.  The author infuses into it his large experi-
ence and ripe judgment.  Wedded to no school,
committed to  no theory, biassed by no hobby, he
imparts an honest personality in his observations,
and his teachings are the rulings of an impartial
judge. Such men are always safe guides, and their
works stand the  tests of  time and experience.
Such an  author is Erichsen, and such a work is his
Surgery.—Medical Record, Feb. 21,1885.
BRYANT,  THOMAS, F.  R.  C. S.,
      Surgeon and Lecturer on Surgery at Guy's Hospital, London.
    The Practice of Surgery.  Fourth American from the fourth and revised Eng-
lish edition.   In one large and very handsome imperial octavo volume of 1040 pages, with
727 illustrations.  Cloth, $6.50;  leather, $7.50; half Russia, $8.00.
  The treatise takes in the whole field of surgery,
that of the eye, the ear, the female organs, ortho-
paedics,  venereal diseases, and military surgery.
as well as more common and general topics.  All
of these are treated with clearness  and with
sufficient fulness to suit all practical  purposes.
The illustrations are numerous and well printed.
We  do not doubt that this new edition will con
tinue to maintain the popularity of this standard
work.—Medical and Surgical Reporter, Feb. 14, '85.
  This most magnificent work upon surgery has
reached  a fourth edition in this country, showing
the high appreciation in which it is held by the
American profession.  It  comes fresh  from the
pen of the author.  That it is the very best work
on  surgery  for  medical  students we think
there can be no doubt.  The author seems to have
understood just what a student needs, and has
prepared the work accordingly.—Cincinnati Medical
News, January, 1885.
                               By the same Author.
    Diseases of the Breast.  In one 12mo. volume.  Preparing. See Series of Clinical
Manuals, page 4.

TREVES,  FREDERICK,  F. R. C. S.,
       Hunterian Professor at the Royal College of Surgeons of England.
    A Manual  of  Surgery.  In  Treatises by Various Authors.  In three 12mo.
volumes, containing 1866  pages, with 213 engravings.  Price per volume, cloth, $2.  See
Students' Series of Manuals, page 4.
    These volumes afford in a  compact and portable form a complete view of the clinical
aspects of modern surgery as understood and practised by  thirty-three leading British
surgeons._________________

BUTLIN,  HENRY T.,  F. R.  C.  S.,
       Assistant Surgeon to St. Bartholomew's Hospital, London.
    Diseases  of  the Tongue.  In one 12mo. volume of 456 pages, with 8 colored
plates and 3 woodcuts.  Cloth,  $3.50.  See Series of Clinical Manuals, page 4.
  This  book,  the latest  issue of  the "Clinical
Manuals  for  Practitioners   and  Students  of
Medicine,"  is a  model  of its  kind.   It is
specially welcome, all the more so, since the text
is  really  illustrated  by a sufficient  number of
admirably executed colored plates. The work has
been written by one whose opportunities have
peculiarly fitted him for the task, since he teaches
not only from a clinical but from a pathological
standpoint.  We heartily commend the  book to
our readers.—The Medical News, October 17,1885.
ESMARCH,  Dr.  FRIEDRICH,
       Professor of Surgery at the University of Kiel, etc.
     Early  Aid in Injuries  and Accidents.  Five Ambulance Lectures.  Trans-
lated by H.  R.  H. Princess Christian.  In one handsome small  12mo. volume  of 109
pages,  with 24 illustrations.   Cloth, 75 cents.

TREVES,  FREDERICK, F. R. C. S.,
       Surgeon to and Lecturer on Surgery at the London Hospital.
     Intestinal  Obstruction.  In one pocket-size 12mo. volume of 522 pages, with 60
illustrations. Limp cloth, blue edges, $2.00.  See Series of  Clinical  Manuals, page 4.
  A standard  work  on  a subject that has not  been
so comprehensively treated by any contemporary
English writer.  Its completeness renders a full
review  difficult, since every chapter deserves mi-
nute attention, and it is impossible to do thorough
justice to the author in a few paragraphs.  Intes-
tinal Obstruction is  a  work that will prove  of
equal value to the practitioner, the student, the
pathologist, the physician and the  operating sur-
geon.—British Medical Journal, Jan. 31,1885.
BALL,  CHARLES B.,  M.  Ch., Dub., F. R. C. S. E.,
       Surgeon and Teacher at Sir P. Dun's Hospital, Dublin.
    Diseases of the  Rectum and Anus.  In one  12mo. volume of 550  pages.
Preparing.   See Series of Clinical Manuals,  page 4. 
22    Lea  Brothers & Co.'s Publications—Surgery, Frac, Disloc.
HOLMES, TI3IOTHY, 31.  A.,
      Surgeon and Lecturer on Surgery at St. George's Hospital, London.
    A System of Surgery; Theoretical and Practical.   IN TREATISES BY
VARIOUS AUTHORS.  American edition, thoroughly revised and re-edited
by  John  H. Packard, M. D., Surgeon to the Episcopal  and St. Joseph's Hospitals,
Philadelphia, assisted by a corps of thirty-three of the most  eminent American surgeons.
In  three  large  and very handsome imperial  octavo volumes containing  3137 double-
columned pages, with  979 illustrations on wood and 13  lithographic plates, beautifully
colored.  Price per volume, cloth, $6.00; leather, $7.00;  half Russia, $7.50.  Per set, cloth,
$18.00;  leather, $21.00; half Russia, $22.50.  Sold only by subscription.

HAMILTON, FRANK H.,  M. D., LL. D.,
      Surgeon to Bellevue Hospital, New York.
    A Practical Treatise on  Fractures  and Dislocations.  Seventh edition,
thoroughly revised  and much improved.  In  one very handsome  octavo volume of 998
pages, with 379  illustrations. Cloth, $5.50; leather,  $6.50;  very handsome half Russia,
open back, $7.00.
  It is about twenty-five years ago since the first
edition of this great work appeared. The edition
now issued is the seventh, and this fact alone is
enough to testify to the excellence of it in all par-
ticulars.  Books upon special subjects do not
usually command  extended sale, but this one is
without a rival in any language.  It is essentially
a practical treatise, and it gathers within its covers
almost everything valuable that has been written
about fractures and dislocations. The principles
and methods of treatment are very fully given.
The book is so well known that it does not require
any lengthened review.  We can only say  that it
is still unapproaehed as a treatise, and that it is a
proof of the zeal and industry and great ability of
its distinguished author.— The  Dublin Journal of
Medical Science, Feb. 1886.
  With its first appearance in 1859, this work took
rank among the classics  in medical literature,
and has ever since  been quoted by surgeons the
world over as an authority upon the topics of
which it treats.  The surgeon, if one can be found
who does not already know the work, will find it
scientific, forcible and scholarly in text, exhaustive
in detail, and ever marked by a spirit of wise con-
servatism.—Louisville Medical News, Jan. 10,1885.
STIMSON, LEWIS A., B. A., M. D.,
      Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Curator
      to Bellevue Hospital, Surgeon to the Presbyterian Hospital, New York, etc.

    A Manual of Operative Surgery.   New (second) edition.  In one very hand-
some  royal 12mo. volume of 503 pages, with 342 illustrations.   Cloth, $2.50.  Just ready.
                                           of the practical parts of surgery.  The text will be
                                           found to represent in an entirely satisfactory man-
                                           ner the latest expressions of surgical science on
                                           its operative methods.—Medical and Surgical Re-
                                           porter, Dec. 19, 1885.
  Such works as this are sure "to find large popa
arity when carefully prepared.  This is certainly
the case with the  volume  of Dr. Stimson. It is
judiciously condensed, omitting nothing of much
importance,  and embracing  a complete synopsis
                             By the same Author.

    A Practical Treatise on Fractures.  In one very handsome octavo volume of
598 pages, with 360 beautiful illustrations.   Cloth, $4.75; leather, $5.75.
  The author has given to the medical profession
in this treatise on fractures what is likely to be-
come a standard work on the subject. It is certainly
not surpassed by any work written in the English,
or, for that  matter, any other language.  The au-
thor tells us in a short, concise and comprehensive
manner, all that is known about his subject.  There
is nothing scanty or superficial about it, as in most
other treatises; on the contrary,everything is thor-
ough. The chapters on repair of fractures and their
treatment show him not only to be a profound stu-
dent, but likewise apractical surgeon and patholo-
gist.  His mode of treatment of the different fract-
ures is eminently sound and practical. We consider
this work one of the best on fractures ;  and it will
be welcomed not only as a text-book, but also by
the surgeon in full practice.—N.  O. Medical and
Surgical Journal, March, 1883.
S3IITH,  STEPHEN,  M.  D.,
       Visiting Surgeon to Bellevue and St. Vincent't Hospitals, N. Y.
    A  Manual of  Operative  Surgery.  New (second)  and thoroughly revised
edition.  In one very handsome octavo  volume, profusely illustrated.  In press.

            EXTRACT  FROM THE PREFACE TO THE SECOND EDITION.
    This work was first published in 1879, and although there have been repeated large
issues since that date, there has been no change whatever in the text  until the present
which  must therefore be regarded as the second  and only revised edition.  To make the
work a proper exponent of the present state of Operative Surgery has required a complete
revision of nearly the entire text.   This has been carefully performed, and the author has
the satisfaction of believing that the work now embraces the latest advances in the field
ot new operations,  and that the details of the most approved  antiseptic methods have
been placed in  such a light  that  they may be easily mastered and  utilized  by every
practitioner.                                                                         J

MARSH, HOWARD,  F.  R. C. S.,
      Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London.
    Diseases  of the Joints.  In one 12mo. volume. Preparing.  See Series of Clinical
Manuals, page 4.

PICK, T.  PICKERING, F. R.  C. S.,
      Surgeon to and Lecturer on Surgery at St. George's Hospital, London.

    Fractures and  Dislocations.  In  one 12mo. volume  of  530  pages,  with 93
illustrations.   Limp cloth, 2.00.  Just ready.  See Series of Clinical Manuals, page 4. 
Lea Brothers & Co.'s Publications—Otal., Ophtlial.
23
BURNETT,  CHARLES H.,  A. 31.,  31.  D.,
       Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society.
    The Ear,  Its Anatomy, Physiology and Diseases.   A Practical Treatise
for the use of Medical Students and Practitioners. New (second) edition. In one handsome
octavo volume of 580 pages, with 107 illustrations.  Cloth, $4.00; leather, $5.00.
                                            carried out, and much new matter added. Dr.
  We note with pleasure the appearance of a second
edition of this valuable work.  When it first came
out it was accepted by the  profession as one of
the standard works on modern aural surgery in
the English language; and in his second edition
Dr. Burnett has fully  maintained his reputation,
for the book is replete with  valuable information
and suggestions.  The revision has been carefully
Burnett's work must be regarded as a very valua-
ble  contribution to aural surgery,  not only on
account of its comprehensiveness, but because it
contains the results of the careful personal observa-
tion and experience of this eminent aural surgeon.
—London Lancet, Feb. 21,1885.
POLITZER, ADA3I,
      Imperial-Royal Prof, of Aural Therap. in the Univ. of Vienna.

    A Text-Book  of the Ear and its Diseases.  Translated, at the Author's re-
quest, by James Patterson Cassells,  M. D., M. R. C. S.  In one handsome octavo  vol-
ume of 800 pages, with 257 original illustrations.  Cloth, $5.50.
  The work itself we do not hesitate to pronounce
the best upon the subject of aural  diseases which
has ever appeared, systematic without being too
diffuse on  obsolete subjects, and eminently prac-
tical in every sense.  The anatomical descriptions
of each separate division of the ear are admirable,
and profusely illustrated by woodcuts.  They are
followed immediately by tne pnysiology of the
section, and this again by the pathological physi-
ology, an arrangement which serves to keep up the
interest of the student by showing the direct ap-
plication of what has preceded to the  study of dis-
ease.  The whole work can be recommended as a
reliable guide to the student, and an efficient aid
to the practitioner in his treatment.—Boston Med-
ical and Surgical Journal, June 7,1883.
JULER, HENRY E.,  F. R.  C.  S.,
       Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp.; late Clinical Ass't, Moorfields, London.
    A Handbook of Ophthalmic Science and Practice.   In one handsome
octavo volume of 460 pages, with 125 woodcuts,  27  colored  plates, selections  from  the
Test-types of Jaeger and Snellen,  and Holmgren's Color-blindness Test.   Cloth, $4.50;
leather, $5.50.
  This work is  distinguished by the great num-
ber of colored plates which  appear in it for illus-
trating various pathological conditions.  They are
very beautiful in appearance,  and have been
executed with great care as to accuracy.  An ex-
amination of the work shows it to be one of high
standing, one that will be regarded as an authority
among ophthalmologists.  The treatment recom-
mended is such as  the author has  learned from
actual experience to be the best.—Cincinnati Medi-
cal News, Dec. 1884.
  It presents to the  student concise descriptions
and typical illustrations  of  all important  eye
affections,  placed in juxtaposition,  so as to be
grasped  at a glance.  Beyond a doubt it is the
best illustrated handbook  of ophthalmic science
which has  ever  appeared. Then, what is  still
better, these illustrations are nearly all original.
We have examined this entire work with great
care, and it represents the commonly accepted
views of advanced ophthalmologists. We can most
heartily commend this book to all medical  stu-
dents, practitioners  and  specialists. — Detroit
Lancet, Jan. 1885.
NORRIS, WM. F., M. D., and  OLIVER,  CHAS. A., M. D.
       Clin. Prof, of Ophthalmology in Univ. of Pa.
    A Text-Book of Ophthalmology.   In one octavo volume of about 500 pages,
with illustrations.  Preparing.

WELLS, J. SOELBERG, F. R. C.  S.,
       Professor of Ophthalmology in King's College Hospital, London, etc.
    A Treatise on  Diseases of the Eye.  New (fifth) American  from the third
London edition.  Thoroughly revised, with copious additions, by L. Webster Fox, M. D.
In one large octavo volume of about 850 pages, with  about 275 illustrations on wood, six
colored plates, and selections from the Test-types of Jaeger and Snellen.  Preparing.

NETTLESHIP, EDWARD, F. R. C. S.,
       Ophthalmic Surg, and Lect. on Ophth. Surg, at St. Thomas' Hospital, London.
    The Student's Guide to Diseases of the Eye. Second edition. With a chap-
ter on the  Detection of Color-Blindness, by William Thomson, M. D, Ophthalmologist
to the Jefferson Medical  College.   In one royal  12mo. volume of  416 pages, with  138
illustrations.  Cloth, $2.00.

BROWNE, EDGAR A.,
       Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skm Diseases.
    HOW to Use the Ophthalmoscope.   Being Elementary Instructions in Oph-
thalmoscopy, arranged for the use of Students.   In one small royal 12mo. volume of 116
pages, with 35 illustrations.   Cloth, $1.00.________
LAWSON ON INJURIES TO THE EYE, ORBIT
  AND EYELIDS: Their Immediate and Remote
  Vffpoti   8 vo 404 pp., 92 illus.  Cloth, $3.50.__
LAURENCE AND MOON'S HANDY BOOK  OF
  OPHTHALMIC SURGERY, for the use of Prac-
  titioners.  Second edition.  In one octavo vol-
  ume of 227 pages, with 65 illust.  Cloth, $2.75.
CARTER'S PRACTICAL TREATISE ON DISEAS-
  ES OF THE EYE.  Edited by John Geeen, M. D.
  In one handsome octavo volume. 
24      Lea Brothers & Co.'s Publications—Urin. Dis.,Dent.
ROBERTS,  WILLIAM, M. D.,
      Lecturer on Medicine in the Manchester School of Medicine, etc.
    A Practical Treatise on Urinary and Renal Diseases, including Uri-
nary  Deposits.   Fourth American  from the fourth London edition.   In one  hand-
some octavo volume of 609 pages, with 81  illustrations.  Cloth, $3.50.
                                             The peculiar value and finish of the book are in
                                           a measure derived from its resolute maintenance
                                           of a clinical and practical character.  It is  an un-
  The previous editions of this book have made it
bo familiar to and so highly esteemed by the med-
ical public, that little more is  necessary than a
mere announcement of the  appearance of this,
their successor. But it  is pleasant to be able to
say that, good as those were, this  is still better.
In fact, we think it may be said to be the best book
in print on the subject of which it treats.— The
American Journalof the Medical Sciences.—Jan. 1886.
  Among the numerous works on renal and uri-
nary diseases  now in circulation, perhaps Dr.
Roberts' has the best claim to be regarded as
"standard."  The present edition shows evidence
of having been carefully revised, and appears to
be well up to the times.  Dr.  Roberts'  book is an
eminently useful and practical one, and we con-
gratulate the author oh its deserved  popularity
with the profession.—Chicago Medical Journal and
Examiner, February, 1886.
rivalled  exposition of everything  which relates
directly  or indirectly to the diagnosis, prognosis
and treatment of urinary diseases, and possesses
a completeness not found elsewhere in our lan-
guage in its account of the different affections.—
The Manchester Medical Chronicle, July, 1885.
  The work is practical in its character, and is
regarded as an authority in the diseases which it
treats.  There is certainly  no work that more
fully sets forth the progress that has been made
than this one of Dr. RoDerts, and that more fully
meets the wants of the  physician in  explaining
the best methods of  treatment.  We  have  no
hesitation in recommending it to our subscribers.
—Cincinnati Medical News, June, 1885.
PURDY,   CHARLES  W., M. D.
    Bright's Disease and Allied Disorders.
with illustrations.   Cloth, $2.  Just ready.
In one octavo volume of 288 pages,
MORRIS, HENRY, M. B.,  F. R.  C. S.,
      Surgeon to and Lecturer on Surgery at Middlesex Hospital, London.
    Surgical Diseases of the  Kidney.  In one 12mo. volume of 554 pages, with
40 woodcuts, and 6 colored plates.  Just ready.  Limp cloth, $2.25.  See Series of Clinical
Manuals, page 4.
  In this manual we have a distinct addition to
surgical  literature, which  gives information not
elsewhere to be met with in a single work.  Such
a book was distinctly required, and  Mr. Morris
has very diligently and ably performed  the task
he took in hand.  It is a full and trustworthy
book of reference, both for students  and prac-
titioners in search of guidance.  The illustraiions
in the text and  the chromo-lithographs are beau-
tifully executed.—The London Lancet,Feb. 26,1886.
See  Series
 LUCAS,  CLEMENT, M. B., B. S., F. R. C. S.,
       Senior Assistant Surgeon to Guy's Hospital, London.
     Diseases of the Urethra.   In one  12mo. volume.   Preparing.
 of Clinical Manuals, page 4.

 THOMPSON, SIR HENRY,
       Surgeon and Professor of Clinical Surgery to University College Hospital, London.
     Lectures on Diseases of the Urinary Organs.  Second American from the
 third English edition.  In one 8vo. volume of 203 pp., with 25 illustrations.   Cloth, $2.25.

                              By the Same  Author.
     On the  Pathology and  Treatment of Stricture of the Urethra and
 Urinary Pistulse.  From the third English  edition.  In one octavo volume of 359
 pages, with 47 cuts and 3 plates.  Cloth, $3.50.

 AN AMERICAN  SYSTEM  OF DENTISTRY.
 ttt   A sys\em of Dentistry, in Treatises by Various Authors.  Edited by
 Wilbur I. Litch M D, D. D. S., Professor of Prosthetic Dentistry, Materia Medica and
 Iherapeutics  in  the  Pennsylvania College of Dental Surgery.  In three very  handsome
 octavo volumes of about 800 pages  each; richly illustrated.  Per volume, cloth, $6;  leather
$7;  half Morocco, gilt top, $8.  Volume I., just ready.   For sale by subscription only.

 COLEMAN, A.,  L. R. C.  P.,  F. R. C. S., Exam.  L. D. S.f
       Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp  London
 a  ri]Ta^ual of  .Dental Surgery and Pathology. Thoroughly  revised  and
adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M D
  i     ' ??iL°f ^y^Qgya* the Philadelphia Dental College.  In one handsome octavo
volume of 412 pages, with 331 illustrations.  Cloth, $3.25.
  This volume  presents a highly  creditable ap-
pearance, and deserves to rank among the most
important of recent contributions to dental litera-
ture. Mr. Coleman has presented his methods of
practice, for the mcst part, in a plain and concise
manner, and the work of the American editor has
been conscientiously performed.  He  has  evi-
BASHAM  ON RENAL DISEASES:  A Clinical
  Guide  to their Diagnosis and  Treatment. In
dently labored to present his convictions of the
best modes of practice for the instruction of those
commencing a professional career, and he has
faithfully endeavored to teach to others all that he
has acquired by his own observation and experi-
ence.  The book deserves a place in the library of
every dentist.—Dental Cosmos, May, 1882.
one 12mo. vol. of 304 pages, with 21 illustrations
Cloth, $2.00. 
Lea Brothers  & Co.'s Publications—Venereal, Impotence.      25
BUMSTEAD, F.  J.,         and          TAYLOR,  R.  W.,
             M. D.,  LL. D.,                               A. M.,  M. D.,
       Late Professor of Venereal Diseases           Surgeon to Charity Hospital, New York, Prof, of
       at  the College  of Physicians  and           Venereal and Skin Diseases in the  University of
       Surgeons, New York, etc.                     Vermont, Pres. of the Am. Dermatological Ass'n.
    The Pathology  and Treatment of Venereal Diseases.   Including the
results of recent investigations upon the subject.  Fifth edition, revised and  largely re-
written,  by Dr. Taylor.   In one  large and handsome octavo volume of 898 pages with
139 illustrations, and thirteen chromo-lithographic figures.  Cloth, $4.75; leather, $5.75;
very handsome half Russia, $6.25.
  It is a splendid record of honest labor, wide
research, just comparison, careful scrutiny and
original experience, which will always be held as
a high credit to American medical literature. This
is not only the best work in the English language
upon the subjects of which it treats, but also one
which has no equa. in other tongues for its clear,
comprehensive and  practical  handling  of  its
themes.—American Journal of the Medical Sciences,
Jan, 1884.
  It is certainly the best single treatise on vene-
real in our own and probably the best in any lan-
guage.—Boston Medical and Surgical Journal, April
3,1884.
  The character of this standard work is so well
known that it would be superfluous here to pass in
review its general or special points of excellence.
The verdict of the profession has been passed; it
has been accepted as the most thorough and com-
plete exposition of the pathology and treatment of
venereal diseases in the language. Admirable as a
model of clear description, an exponent of sound
pathological doctrine, and a guide for rational and
successful treatment, it is an ornament to the medi-
cal literature of this country.  The additions made
to the present edition are eminently judicious,
from the standpoint of practical utility.— Journal of
Cutaneous and Venereal  Diseases, Jan. i884.
CORNIL, V.,
      Professor to the Faculty of Medicine of Paris, and Physician to the Lour cine Hospital.
    Syphilis, its Morbid Anatomy,  Diagnosis  and Treatment.   Specially
revised  by the Author, and  translated with  notes and additions by J. Henry C. Simes,
M. D., Demonstrator of Pathological  Histology in the University of Pennsylvania, and
J.William White, M. D.,  Lecturer on Venereal Diseases and Demonstrator of Surgery
in the University  of  Pennsylvania.  In one handsome octavo volume of 461 pages, with
84 very beautiful illustrations.  Cloth, $3.75.
  The anatomical and histological characters of the
hard and soft sore are admirably described.  The
multiform cutaneous manifestations of the disease
are dealt with  histologically in a masterly way, as
we should indeed expect  them to be, and the
accompanying illustrations are executed carefully
and well.  The various nervous lesions which are
the recognized outcome of the syphilitic dyscrasia
are treated with car  and consideration. Syphilitic
epilepsy, paralysis, cerebral  syphilis and locomotor
ataxia are subjects full of interest; and nowhere in
the whole volume is the clinical experience of the
author or the wide acquaintance of the translators
with medical literature more evident.  The anat-
omy, the histology, the pathology and the clinical
features of syphilis are represented in this work in
their best, most practical  and most instructive
form, and no one will rise from its perusal without
the feeling that his grasp of the wide and impor-
tant subject on which it treats is  a stronger and
surer one.—The London Practitioner, Jan. 1882.
ataxia are suojecis iuh 01 interest; auu nowiieie m

HUTCHINSON,  JONATHAN, F. R. S.,  F. R. C. S.,
       Consulting Surgeon to the London Hospital.
    Syphilis.  In one 12mo. volume.  Preparing.  See Series of Clinical Manuals, page 4.

GROSS,  SAMUEL  W.,  A. M.,  M.  D.,
  Professor of the Principles of Surgery and of Clinical Surgery in  the Jefferson Medical College of Phila.
    A Practical Treatise on  Impotence, Sterility, and Allied Disorders
Of the Male Sexual Organs.  Second edition, thoroughly revised.  In one very hand-
some  octavo volume of 168 pages, with 16 illustrations.  Cloth, $1.50.
  The author of this monograph is a man of posi-
tive convictions and vigorous style. This is justi-
fied by his experience and by his study, which has
gone hand in hand with his experience. In regard
to the various organic and functional disorders of
the male generative apparatus, he has had ex-
ceptional opportunities for observation,  and his
book shows that he has not neglected to compare
his own views with those of other authors. The
result is awork which can be safely recommended
to both physicians and surgeons as a guide in the
treatment of the disturbances it refers to. It is
the best treatise on the subject with which we are
acquainted.—The Medical News, Sept. 1,1883.
GROSS, S. D., M.  D.,  LL.  D., D. C. L., etc.
    A Practical  Treatise  on  the Diseases, Injuries  and Malformations
of the  Urinary  Bladder, the  Prostate Gland  and  the  Urethra.  Third
edition, thoroughly  revised by Samuel W. Gross, M. D.  In one octavo volume of 574
pages, with 170 illustrations.  Cloth, $4.50.

CULLERIER, A., & BUMSTEAD, F. J., M.D., LL.D.,
Surgeon to the Hdpital du Midi.
Late Professor of Venereal Diseases in the College of Physicians
and Surgeons, New  York.
    An Atlas of Venereal Diseases.  Translated and edited by Freeman J. Bum-
STEAD M. D.   In one imperial 4to. volume of 328 pages, double-columns, with 26 plates,
containing about 150 figures, beautifully colored, many of them the size of life.   Strongly
bound in cloth, $17.00.  A specimen of the plates and text sent by mail, on receipt of 25 cts.

tttt t  r>N qVPHTLIS AND LOCALCONTAGIOUS ! FORMS OF   LOCAL  DISEASE  AFFECTING
  rnqORDFRSIn one 8vo vol. of 479 p. Cloth, 83.25.  PRINCIPALLY THE ORGANS OF  GENERA-
LEE'S LECTURES ON SYPHILIS AND SOME \ TION.  In one 8vo. vol. of 248 pages. Cloth, $2.25. 
26        Lea  Brothers & Co.'s Publications—Diseases of Skin.
HYDE,  J.  NEVINS,  A. 31.,  31.  D.,
       Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago.
     A Practical Treatise on Diseases of the Skin.  For the use of Students and
Practitioners.  In one handsome octavo volume of 570 pages, with 66 beautiful  and elab-
orate illustrations.  Cloth, $4.25; leather, $5.25.
  The author has given the student and practi-
tioner a work admirably adapted to the wants of
each.  We can heartily commend the book as a
valuable addition to our literature and a reliable
guide to students and practitioners in their studies
and practice.—Am. Journ. of Med. Sci., July, 1883.
  Especially to be praised are  the practical sug-
gestions as  to what may be called the  common-
sense treatment of eczema. It is quite impossible
to exaggerate the judiciousness with which the
formulte for the external treatment of eczema are
selected, and what is of equal importance, the full
and clear instructions for their use.—London Medi-
cal Times and Gazette, July 28,1883.
  The work of Dr. Hyde will be awarded a high
position.   The student of medicine will find it
peculiarly adapted to his wants. Notwithstanding
the extent of the subject to which  it is devoted,
yet it is limited to a single and not very large vol-
ume, without omitting  a proper discussion of the
topics.   The conciseness of the volume, and the
setting forth of only what can be held as facts will
also make it acceptable to general practitioners.
—Cincinnati Medical News, Feb. 1883.
  The aim of the author has been to present to his
readers  a work not only expounding  the most
modern conceptions of his subject, but presenting
what is of standard value.  He has more especially
devoted its pages to the treatment of disease, and
by his detailed descriptions of therapeutic meas-
ures has adapted them to the needs of the physi-
cian in active practice.  In dealing  with  these
questions the author leaves nothing to the pre-
sumed knowledge of the reader, but enters thor-
oughly into the most minute description, so that
one is not only told what should be done under
given conditions but how to do it as well.  It is
therefore in  the best sense  "a practical treatise."
That it is  comprehensive, a glance at the index
will show.—Maryland Medical Journal, July 7,1883.
  Professor Hyde  has long  been known as one of
the most intelligent and enthusiastic  representa-
tives of dermatology in  the  west.  His numerous
contributions to the literature of this specialty
have gained for him a favorable recognition as a
careful, conscientious and original observer.  The
remarkable advances made  in our knowledge of
diseases of the skin, especially from  the stand-
point of pathological  histology  and  improved
methods of treatment,  necessitate  a  revision of
the older text-books at short intervals in order to
bring them up to the standard demanded by the
march of science.  This last contribution of  Dr.
Hyde is an effort in this direction.  He has at-
tempted, as he informs us, the task of presenting
in a condensed form the results of the latest ob-
servation and experience. A careful examination
of the work convinces us that he has accomplished
his task with painstaking fidelity and with a cred-
itable result.—Journal of Cutaneous  and Venereal1
Diseases, June, 1883.
FOX,  T.,  M.D., F.R. C. P., and FOX, T. C, B.A., 3I.R. C.S.,
   Physician to the Department for Skin Diseases,           Physician for Diseases of the Skin to the
        University College Hospital, London.                   Westminster Hospital, London.

    An Epitome of Skin Diseases.   "With Formula?.   For Students and Prac-
titioners.   Third  edition, revised and enlarged.  In  one very handsome  12mo.  volume
of 238 pages.   Cloth, $1.25.
  The third edition of this convenient handbook
calls for notice owing to the revision and expansion
which it has undergone. The arrangement of skin
diseases in alphabetical order, which is the method
of classification adopted in this work, becomes a
positive advantage to  the student.   The book is
one which we can strongly recommend, not only
to students but also to practitioners who require a
compendious summary  of the present state of
dermatology.—British Medical Journal, July 2,1883.
  We cordially recommend Fox's Epitome to those
whose  time  is limited  and who wish  a  handy
manual to lie upon the table for instant reference.
Its alphabetical arrangement is suited to this use,.
for all one has to know is the name of the disease,
and here are its description and the appropriate
treatment at hand and ready for instant applica-
tion.  The present edition has been very carefully
revised and a number of new diseases are  de-
scribed, while most  of the  recent  additions  to
dermal therapeutics find mention, and the formu-
lary at the end of the book has been considerably
augmented.—The Medical News, December, 1883.
MORRIS,  MALCOLM,  F.  R. C. S.,
       Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, London.
    Skin Diseases; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor-
bid Anatomy and Treatment.   A Manual for Students  and Practitioners.   In one 12mo
volume of 316 pages, with illustrations.  .Cloth, SRI 75
  To physicians who would like to know something
about skin diseases, so that when a patient pre-
sents himself for relief they can make a correct
diagnosis and prescribe a rational treatment, we
unhesitatingly recommend this little book of Dr.
Morris.  The affections of the skin are described
in a terse, lucid manner, and their several charac-
teristics so plainly set forth that diagnosis will be
easy.  The treatment in each case is such as the
experience of the mosteminent dermatologists ad-
vises.—Cincinnati Medical News, April, 1880.
  This is emphatically a learner's book;  for we
can safely say, that in the  whole range of medical
literature there is no book of a like scope which
    1.75.

for  clearness of expression and methodical ar-
rangement is better adapted to promote a rational
conception of dermatology—a branch confessedly
difficult and perplexing to the beginner.—St. Louis
Courier of Medicine, April, 1880.
  The writer has certainly given in a small compass
a large amount of well-compiled  information, and
his little book compares favorably with any other
which has emanated from England, while in many
 Eoints he has emancipated himself from the stub-
 ornly adhered to errors of others of his country-
men.  There is certainly excellent material in the
book which will well repay perusal.—Boston  Med
and Surg. Journ., March, 1880.
WILSON,  ERAS3IUS, F. R. S.
    The Student's Book of Cutaneous Medicine and Diseases of the Skin
In one handsome small octavo volume of 535 pages.  Cloth, $3.50.

HILLIER,   THOMAS, M.  D.,
       Physician to the Skin Department of University College, London.
    Handbook  of  Skin Diseases;  for Students and Practitioners.  Second Ameri
can edition.   In one 12mo. volume of 353 pages, with plates.  Cloth, $2.25. 
Lea Brothers & Co.'s Publications—Dis. of AVomen.         27
AN AMERICAN SYSTEM  OF  GYNECOLOGY.
     A System of Gynaecology, in Treatises  by Various Authors. Edited
by  Matthew  D. Mann, M. D., Professor of  Obstetrics  and Gynaecology in the Uni-
versity of Buffalo, N. Y.   In two handsome octavo volumes, richly illustrated.   In  active
preparation.
                              LIST OF CONTRIBUTORS.
WILLIAM H. BAKER, M. D.,
FORDYCE BARKER, M. D.,
ROBERT  BATTEY, M. D.,
SAMUEL  C. BUSEY, M. D.,
HENRY F. CAMPBELL, M. D.,
HENRY C. COE, M. D.,
E. C. DUDLEY, M. D.,
GEORGE  J.  ENGELMANN, M. D.,
HENRY F. GARRIGUES, M. D.,
WILLIAM GOODELL, M. D.,
EGBERT  H. GRANDIN,  M. D.,
SAMUEL W. GROSS, M.  D.,
JAMES B. HUNTER, M.  D.,
A. REEVES JACKSON, M. D.,
EDWARD W. JENKS, M. D.,
WILLIAM T. LUSK, M. D.,
MATTHEW D. MANN, M. D.,
ROBERT B. MAURY,  M. D.,
PAUL F. MUNDE, M. D.,
C. D. PALMER, M. D.,
WILLIAM M. POLK, M. D.,
THADDEUS A. REAMY, M. D.,
A. D. ROCKWELL, M. D.,
ALEX. J. C. SKENE, M. D.,
R. STANSBURY SUTTON, A. M., M. D.,
T. GAILLARD THOMAS, M. D.,
ELY VAN DE WARKER, M. D.,
W. GILL WYLIE, M. D.
THOMAS, T. GAILLARD,  M. D.,
      Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y.
    A Practical Treatise on the Diseases of Women.  Fifth edition, thoroughly
revised and rewritten.   In one  large and handsome octavo volume of 810 pages, with 266
illustrations.  Cloth, $5.00; leather, $6.00;  very handsome half Eussia, raised bands, $6.50.
  The words which follow "fifth edition" are in
this case no mere formal announcement.  The
alterations and additions which have been made are
both numerous and important.  The  attraction
and the permanent character of this book lie in
the clearness and truth of the clinical descriptions
of diseases; the fertility of the author in thera-
peutic resources and the fulness with which the
details  of treatment are described; the  definite
character of the teaching; and last, but not least,
the evident candor which pervades it. We would
also particularize the fulness with which the his-
tory of the subject is gone into, which makes the
book additionally interesting and gives it value as
a work  of reference.—London  Medical Times and
Gazette, July 30,1881.
  The determination of the  author to keep his
book foremost in the rank of works on gynaecology
is most gratifying.  Recognizing the fact that this
can only be accomplished by frequent and thor-
ough revision, he has spared no pains to make the
present edition  more desirable even than the pre-
vious one.  As a book of reference for the busy
practitioner it is unequalled.—Boston Medical and
Surgical Journal, April 7,1880.
  It has been enlarged and carefully revised. It is
a condensed encyclopaedia of gynaecological medi-
cine.   The style of arrangement, the masterly
manner in which each subject is treated, and the
honest  convictions derived from probably the
largest  clinical experience in that specialty of any
in this country, all serve to commend it in the
highest terms to the practitioner.—Nashville Jour.
of Med.  and Surg., Jan. 1881.
  That the previous editions of the treatise of Dr.
Thomas were thought worthy of translation into
German, French, Italian and Spanish, is enough
to give it the stamp of genuine merit.  At home it
has made its way into the library of every obstet-
rician and gynaecologist as a safe guide to practice.
No small number of additions  have been made to
the present edition to make it correspond to re-
cent improvements in treatment.—Pacific Medical
and Surgical Journal, Jan. 1881.
EDIS, ARTHUR W., M. D., Lond., F.R. C.P., M.R. C.S.,
       Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital.
    The Diseases  of Women.   Including  their  Pathology, Causation, Symptoms,
Diagnosis and Treatment.  A  Manual for  Students and Practitioners.  In one handsome
octavo volume of 576 pages, with 148 illustrations.  Cloth, $3.00;  leather, $4.00.
  It is a pleasure to read a book so thoroughly
good as this one.  The special qualities which are
conspicuous  are  thoroughness  in  covering  the
whole  ground, clearness of description and con-
ciseness of statement.  Another marked feature of
the book is the attention paid  to the details of
many minor surgical operations and procedures,
as, for  instance, the use of  tents, application of
leeches, and use of  hot water injections.  These
are among the more common methods of treat-
ment, and yet very little is  said about them in
many of the text-books.  The book  is one to be
warmly recommended especially to students and
general practitioners, who need a concise but com-
plete resumi of the whole subject. Specialists, too,
will find many useful hints in its pages.—Boston
Med. and Surg. Journ., March 2,1882.
  The greatest pains  have been taken with the
sections relating to treatment.  A liberal selection
of remedies is given  for each morbid condition,
the strength, mode of application and other details
being fully explained.  The descriptions of gynae-
cological  manipulations  and operations  are full,
clear and practical.  Much care has also been be-
stowed on the parts of the book which deal with
diagnosis—we  note especially the pages  dealing
with  the  differentiation,  one from another, of the
different kinds of abdominal tumors. The prac-
titioner will therefore  find in this book the kind
of knowledge he most needs in his daily work, and
he will be pleased with the clearness and fulness
of the information there given.—The Practitioner,
Feb. 1882.
BARNES, ROBERT, M. D., F. R. C. P.,
       Obstetric Physician to St. Thomas' Hospital, London, etc.
     A Clinical Exposition of the Medical and Surgical Diseases of Women.
In one handsome octavo volume, with numerous illustrations.  New edition.  Preparing.

WEST,  CHARLES, M. D.
     Lectures  on the Diseases of Women.  Third American from the third Lon-
don  edition.  In one octavo volume of 543 pages.  Cloth, $3.75; leather, $4.75. 
28      Lea Brothers & Co.'s Publications—Dis. of Women, Midwfy.
EMMET,  THOMAS  ADDIS,  31.  D.,  LL.  D.,
      Surgeon to the Woman's Hospital, New York, etc.

    The Principles and Practice of Gynaecology; For the use of Students and
Practitioners of Medicine.  New (third) edition, thoroughly revised.   In one large and very
handsome octavo volume of 880 pages, with 150  illustrations.  Cloth, $5; leather, $6;
very handsome half  Russia, raised bands, $6.50.
  We are in doubt whether to  congratulate the l once a credit to its  author and to American med-
author more than the profession upon the appear- ical literature. We repeat that it is a book to  be
ance of the third edition of this well-known work. I studied, and one that is  indispensable to every
Embodying, as it does, the life-long experience of | practitioner giving any attention to gynaeco|ogy.—
one who  has conspicuously distinguished himself American Journal of the Medical Sciences, April, 1885.
                                             The time has passed when Emmet's Gynaecology
                                           was to be regarded as a book for a single country
                                           or for a single generation.  It has always been his
                                           aim to popularize gynaecology, to bring it within
                                           easy reach of the general  practitioner.  The orig-
                                           inality of the ideas, aside  from the perfect con-
                                           fidence which we feel in the author's statements,
                                           compels our admiration  and  respect.  We may
                                           well take an honest pride in  Dr. Emmet's  work
                                           and feel that his book can hold its own against the
                                           criticism of two continents.  It represents all that
                                           is most earnest and most thoughtful in American
                                           gynaecology.  Emmet's  work will  continue  to
                                           reflect the individuality, the sterling integrity and
                                           the kindly heart of its honored author long after
                                           smaller  books  have been  forgotten.—American
                                           Journal  of Obstetrics, May, 1885.
as a bold and successful operator, and who has
devoted  so much attention  to the  specialty, we
feel sure the profession will not fail to appreciate
the privilege thus offered them of perusing the
views and practice of the author. His earnestness
of purpose and conscientiousness  are manifest.
He gives not only his individual experience but
endeavors to represent the actual state of gynae-
cological  science and art.—British Medical Jour-
nal, >lay 16,1885.
  No jot or tittle of the high praise bestowed upon
the first  edition is abated.  It  is still a book of
marked personality, one based upon large clinical
experience, containing large  and valuable  ad-
ditions to our knowledge, evidently written not
only with honesty of purpose, but with a conscien-
tious sense of responsibility, and a book that is at
DUNCAN, J. MATTHEWS, M.D., LL. D., F. R. S. E., etc.
    Clinical Lectures on the Diseases of Women;  Delivered  in Saint  Bar-
tholomew's Hospital.   In one handsome octavo volume of 175 pages.  Cloth, $1.50.
  They are in every  way worthy of their author ; j rule, adequately handled in the text-books; others
indeed, we look upon them as among the most i of them, while hearing upon topics that are usually
valuable of his contributions. They  are all upon  treated of at length in such works, yet bear such a
matters of great interest to the general practitioner,  stamp of individuality that they  deserve to be
Some of them deal with subjects that are not, as a | widely read.—N. Y. Medical Journal, March, 1880.

MAY,  CHARLES  H.,  M. D.
       Late House Surgeon to Mount Sinai Hospital, New York.
    A Manual of the Diseases of Women.  Being a concise and  systematic  expo-
sition of the theory and practice of gynaecology.   In one 12mo. volume of  342 pages.
Cloth, $1.75.            1-6/6.                                   f 5
  Medical students will find this work adapted to
their wants.  Also practitioners of medicine will
find it exceedingly convenient to consult for the
purpose of refreshing their minds upon the lead-
ing points of "a gynaecological subject.  By syste-
matic condensation, the omission of disputed ques-
tions, and the presentation only of accepted views,
it constitutes a very satisfactory exposition of the
leading principles of gynaecology as they are un-
derstood at the present time.—Cincinnati Medical
News, Nov. 1885.
HODGE, HUGHL., M.  D.,
      Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania.
    On Diseases Peculiar to Women;  Including Displacements of the  Uterus.
Second  edition, revised and enlarged.  In one beautifully printed octavo volume of 519
pages, witli original illustrations.  Cloth, $4.50.

                              By the Same Author.

    The Principles and  Practice of Obstetrics.   Illustrated with large litho-
graphic plates containing 159  figures from original photographs, and with numerous wood-
cuts.  In one large  quarto volume of 542 double-columned pages.   Strongly bound  in
cloth  $14.00.  Specimens of the plates and letter-press will be forwarded to any  address
free by mail, on receipt of six cents in postage stamps.

RAMSBOTHAM, FRANCIS H.,  M. D.
    The Principles  and  Practice  of  Obstetric Medicine and  Surgery •
In reference to the Process of Parturition.   A new and enlarged edition, thoroughly revised
by the Author.   With additions by W. V. Keating, M. D., Professor of Obstetrics etc
m the  Jefferson Medical College of Philadelphia.   In one large and  handsome imperial
octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain-
ing in all nearly 200  beautiful figures.  Strongly bound in leather, with raised  bands $7

WINCKEL, F.
    A  Complete Treatise on the Pathology and Treatment of Childbed
*or btudents and Practitioners.  Translated, with the consent of the Author, from the
second German edition, by J.  E. Chadwick, M. D.  Octavo 484 pages.  Cloth, $4 00
ASHWELL'S practical  treatise on the
  DISEASES PECULIAR TO WOMEN.  Third
  American from the third and revised London
  edition.  In one 8vo. vol., pp. 520.  Cloth. $3.50.
CHURCHILL  ON  THE PUERPERAL FEVER
 AND OTHER DISEASES PECULIAR TO WO-
 MEN.  In one 8vo. vol. of 464 pages.  Cloth 82 BO,
MEIGS ON THE NATURE, SIGNS AND TREAT
 MENT OF CHILDBED FEVER.  In one 8vo
 volume of 346 pages.  Cloth, $2.00. 
Lea  Brothers &  Co.'s Publications—Midwifery.
29
BARNES,  ROBERT,  M. D.,  and  FANCOURT,  M. D.,
       Phys. to the General Lying-in Hosp., Land.           Obstetric Phys. to St. Thomas' Hosp., Lond.
    A System  of Obstetric Medicine and Surgery, Theoretical and Clin-
ical.  For the Student and the Practitioner.  The Section on Embryology contributed by
Prof.  Milnes  Marshall.    In one handsome octavo volume of 872 pages,  with  231 illus-
trations.  Cloth, $5;  leather, $6.   Just ready.
  This system will be eagerly sought for, not only
on account of its intrinsic merit, but also because
the reputation which the elder Barnes, in particu-
lar, has secured, carries with it the conviction that
any book emanating from him is necessarily sound
in teaching and conservative  in practice. It is in-
deed eminently fitting that a man who has done so
much towards systematizing the obstetric art, who
for so many years has been widely known as a capa-
ble teacher and trusted accoucheur, should embody
within a single treatise  the system which he has
taught and in practice tested, and which is the oufc-
come of a lifetime of earnest labor, careful obser-
vation and deep study.  The result of this arrange-
ment is the production of a work which rises above
criticism and which in no respect need yield the
palm to any obstetrical treatise hitherto published.
—American Journal of Obstetrics, Feb. 1886.
PLAYFAIR,  W.  S.,  M.  D., F.  R. C.  P.,
       Professor of Obstetric Medicine in King's College, London, etc.
    A Treatise on the  Science and  Practice of Midwifery.  New (fourth)
American, from the fifth English edition.   Edited, with additions, by Robert P. Har-
ris, M. D.   In one handsome octavo volume of 654 pages, with 3 plates and 201 engrav-
ings  Cloth, $4; leather, $5; half Russia, $5.50.
  This  still remains a favorite in  America, not  j for students have very much to boast of in  this
only because the author is recognized as a safe
guide and eminently progressive man, but also as
sparing no effort to make each successive edition
a faithful mirror of the latest and best practice.
A work  so frequently noticed  as the present
requires no further review.  We believe that this
edition is  simply the forerunner of many others,
and that the  demand will  keep pace with  the
supply.—American Journal of Obstetrics, Nov.  1885.
  Since its first publication, only eight  years ago,
it has rapidly become  the  favorite  text-book, to
the practical exclusion  of  all others. A  large
measure of its popularity is due to the clear and
easy style in which it is written.  Few  text-books
respect.—Medical Record.
  In the short time that this excellent and highly
esteemed work has been before the profession it
has reached a fourth edition in this country and a
fifth one in England.  This fact alone speaks in
high praise of it, and it seems to us that scarcely
more need be said of it in the way of endorsement
of its value.  As a text book for students and for
the uses of the general  practitioner there is no
work on obstetrics  superior to the work of Dr.
Playfair.  Its teachings are practical, written in
plain language, and afford a correct understanding
of the art  of midwifery.  No one can be  disap-
pointed in it.—Cincinnati Medical News, June, 1885.
BARKER, FORDYCE, A. M.,  M. D.,  LL. D. Edin.,
       Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College^
       New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc.
    Obstetrical and Clinical Essays.  In one handsome  12mo. volume of about
300 pages.  Preparing.     _________________________

KING,  A.  F. A.,  M. D.,
       Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer-
       sity, Washington, D. C, and in the University of Vermont, etc.
    A Manual of Obstetrics.  Second edition.  In one very handsome 12mo. volume
of 331 pages, with 59 illustrations.   Cloth, $2.00.
  It must be acknowledged that this is just what
it pretends to be—a sound guide, a portable epit-
ome, a work in which only indispensable matter
has been presented, leaving out all padding and
chaff, and one in which the student will findpure
wheat or condensed nutriment.—New Orleans Med-
ical and Surgical Journal, May, 1884.
  In a series of short paragraphs and by a con-
densed style of compo3ition, the writer has pre-
sented a great deal of what it is well that every
obstetrician should know and be ready to practice
or prescribe. The fact that the demand  for the
volume has been  such as to exhaust the first
edition in a little over  a year and a half  speaks
well for its popularity.—American Journal  of the
Medical Sciences, April, 1884.
BARNES,  FANCOURT,  M. D.,
       Obstetric Physician to St. Thomas' Hospital, London.
    A Manual of Midwifery for Midwives and Medical Students.  In one
royal 12mo. volume of 197 pages, with 50 illustrations.   Cloth, $1.25.

PARVIN,  THEOPHILUS,  M. D., LL. D.,
       Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College.
    A Treatise  on Midwifery.   In one very  handsome octavo volume of about 5501
pages, witli numerous illustrations.  Preparing.

PARRY, JOHN S.,  M.  D.,
       Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia.
    Extra - Uterine Pregnancy: Its Clinical History,  Diagnosis,  Prognosis and
Treatment.  In one handsome octavo volume oi 272 pages.  Cloth, $2.50.

TANNER, THOMAS HAWKES, M. D.
    On the Signs and Diseases of  Pregnancy.   First American from the second
English  edition.   Octavo, 490 pages, with 4 colored plates and 16 woodcuts.  Cloth, $4.25. 
30       Lea Brothers & Co.'s Publications—Midwfy., Dis. Childn.
LEISHMAN,  WILLIA3I, 31. D.,
       Regius Professor of Midwifery in the University of Glasgow, etc.

    A System of Midwifery, Including the Diseases of Pregnancy and the
Puerperal State.  Third American edition, revised  by the Author, with additions by
John S. Parry, M. D, Obstetrician to the Philadelphia Hospital, etc.   In one large and
very handsome octavo volume of 740 pages, with 205 illustrations.  Cloth, $4.50; leather,
$5.50; very handsome half Russia, raised bands, $6.00.
  The author is broad in his teachings, and dis-
cusses briefly the comparative anatomy of the pel-
vis and the mobility of the pelvic articulations.
The  second chapter  is devoted  especially to
the study of the  pelvis, while  in the third  the i must prove admirably adapted  Complete in all its
female organs  of  generation  are  introduced. ! parts, essentially modern in its teachings, and with
The structure and development of the ovum are  J
admirably described. Then  follow chapters upon
the various subjects embraced in the study of mid-
wifery. The descriptions throughout the work are
plain and pleasing.  It is sufficient to state that in
this, the last edition of this well-known work, every
recent advancement in this field has been brought
forward.—Physician and Surgeon, Jan. 1880.
  To the  American student the work  before us
demonstrations noted for clearness and precision,
it will gain in favor and be recognized as a work
of standard merit.  The work cannot fail to be
popular and  is  cordially recommended.—N. O.
Med. and Surg. Journ., March. 1880.
LANDIS, HENRY G., A.  M., 31.  D.,

       Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O.

     The  Management  of  Labor,  and  of the  Lying-in Period.   In one
handsome  12mo. volume of 334 pages, with 28 illustrations.  Cloth, $1.75.  Just ready.
  This is a book we  can  heartily  recommend. | and has consistently  excluded  from  this little
The author  goes much more practically into the , work everything that is not of practical use in the
details of the management of labor than most ] lying-in room.  We think that if it is as widely
text-books,  and  is so  readable throughout as to I read  as it deserves, it will  do much to improve
tempt any one who should happen to commence | obstetric practice in general.—New Orleans Medi-
the book to read it through.  The author pre-  cal and Surgical Journal, Mar. 1880.
supposes a  theoretical knowledge of obstetrics, ]


SMITH, J. LEWIS, 31. D.,
       Clinical Professor of Diseases of Cliildren in the Bellevue Hospital Medical College, N. Y.
     A Treatise on the Diseases of  Infancy  and Childhood.  New (sixth)
■edition,  thoroughly revised   and  rewritten.  In one  handsome octavo volume  of 867
pages, with 40 illustrations.  Cloth, $4.50; leather, $5.50 ;  half Russia, $6.00.  Just  read
  No better  work on children's diseases could be
placed in the hands of the student, containing, as
it does, a very complete account of the symptoms
and  pathology of the diseases of early life, and
possessing  the  further  advantage, in  which it
stands alone amongst other works on its subject,
of recommending treatment in accordance with
the most recent therapeutical views.—British and
Foreign Medico-Chirurgical Review.
  Among American medical  text-books  which
have become classic, Smith on Children may be
ranked with the foremost.  The author has con-
tinuously kept in view the eminently practical
character of his work, which made it so popular
in former editions.  A very commendable feature
is the increasing space devoted to therapeutics, in
which the author, besides drawing on his own
rich  mine of clinical experience, gives  in addi-
tion,  the most improved forms of treatment as
gleaned from the  works of others.—Cincinnati
Lancet and Clinic,  Feb. 27,1886.
KEATING, JOHNM., 31. D.,
       Lecturer on the Diseases of Children at the University of Pennsylvania, etc.
     The Mother's Guide in the Management and Feeding of Infants.  In
one handsome 12mo. volume of 118 pages.  Cloth, $1.00.
  Works like this one will aid the physician im- | successfully instructed the mother in such details
mensely, for it saves the time he is constantly giv- | of the treatment of her child as devolve upon her
ing his patients in instructing them on the sub- | He  has studiously omitted giving prescriptions'
jects here dwelt  upon  so thoroughly and prac- ] and instructs the mother  when to call upon the
tically.  Dr. Keating  has written a practical book, : doctor, as his duties are totally distinct from hers
ha:.- carefully avoided unnecessary repetition, and J —American Journal of Obstetrics, October, 1881.

OWEN,  EDMUND, M.  B., F.  R. C. S.,
       Surgeon to the Children's Hospital, Great Or?nond St., London.

     Surgical  Diseases of Children.  In one 12mo. volume of 525  pages with  4
«hromo-lithographic plates and 85 woodcuts.   Just  ready.  Cloth, $2.  See Series of Clin-
ical Manuals, page 4.
  One is immediately struck on reading this book I honestly  recommended to both students and
with its agreeable style and the evidence it every-  practitioners.   It is  full of sound  information

amhor ^VSt^^e*^** £ I PleaSant'y ^n^AMaU ***"»' Ma^ 18*--

WEST, CHARLES, M. D.,
      Physician to the Hospital for Sick Children, London, etc.

     Lectures on the Diseases of Infancy  and Childhood.  Fifth American
from 6th English edition.  In one octavo volume of 686 pages.  Cloth, $4.50; leather, $5.50.

                              By the Same Author.

     On Some Disorders of the  Nervous System in Childhood.  In one small
12mo. volume of 127  pages.  Cloth, $1.00.

CONDIE'S  PRACTICAL TREATISE  ON  THE I vised and augmented. In one octavo volume nf
  DISEASES OF CHILDREN. Sixth edition, re- | 779 pages.  Cloth, $5.25; leather, 86.25. 
Lea Brothers & Co.'s Publications—Med. Juris., Miscel.      31
TIDY, CHARLES MEYMOTT,  M. B., F.  C. S.,
       Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc.
    Legal Medicine.  Volcme II.   Legitimacy and  Paternity, Pregnancy, Abor-
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth,  Infanticide, Asphyxia,
Drowning, Hanging, Strangulation, Suffocation.   Making a very handsome imperial oc-
tavo volume of 529 pages.  Cloth, $6.00; leather, $7.00.
    Volume I.   Containing  664  imperial  octavo pages, with  two beautiful  colored
plates.  Cloth, $6.00;  leather, $7.00.
  The satisfaction expressed with the first portion
of this  work is in no wise lessened by a perusal of
the second volume. We find it characterized by
the same fulness of detail  and  clearness of ex-
pression which we had occasion so highly to com-
mend in our former notice, and which render it so
valuable to  the  medical  jurist.  The copious
tables of cases appended to each division of the
subject, must have cost the author a prodigious
amount of labor and research, but they constitute
one of the most valuable features of the book,
especially for reference in medico-legal trials.—
American Journal of the Medical Sciences, April, 1884.
TAYLOR, ALFRED S., M. D.,
       Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London.

    A Manual of Medical Jurisprudence.  Eighth American from the tenth Lon-
don edition, thoroughly revised and rewritten.  Edited by John J. Reese, M. D., Professor
of Medical Jurisprudence and  Toxicology in  the University of Pennsylvania.  In  one
large octavo volume of 937 pages, with 70 illustrations.  Cloth, $5.00;  leather, $6.00; half
Russia, raised bands, $6.50.
  The American editions of this standard manual
have for a long time laid claim to the attention of
the profession in this country; and  the eighth
comes before us as embodying the latest thoughts
and emendations of Dr.  Taylor upon  the subject
to which he devoted his life with an assiduity and
success which  made him facile princeps among
English writers on medical jurisprudence.  Both
the author and the book have made a mark too
deep to be affected by criticism,  whether  it be
censure or praise. In this case, however, we should
only have to seek for laudatory terms.—American
Journal of the Medical Sciences, Jan. 1881.
  This celebrated work has been the standard au-
thority in its department for thirty-seven years,
both in England and America, in  both the profes-
sions which it concerns, and  it is improbable that
it will be superseded in many years.  The work is
simply indispensable to every physician, and nearly
so to every liberally-educated lawyer, and  we
heartily commend the present edition to both pro-
fessions.—Albany Law Journal, March 26,1881.
                               By the Same Author.
    The Principles and Practice of Medical Jurisprudence.  Third  edition.
In two handsome octavo volumes, containing 1416 pages, with 188 illustrations.  Cloth, $10;
leather, $12.  Just ready.
  For years Dr. Taylor was the highest authority
in England upon the subject to which he gave
especial attention.  His experience was vast, his
judgment excellent, and his skill beyond cavil. It
is therefore well that the work of one who, as Dr.
Stevenson  says, had an "enormous grasp of all
matters connected with the subject," should be
brought up to the present day and continued in
its authoritative position.  To accomplish this re-
sult Dr. Stevenson has subjected it to most careful
editing, bringing it well up to the times.—Ameri-
can Journal of the Medical Sciences, Jan. 1884.
                               By the Same Author.
    Poisons in Relation to Medical Jurisprudence and Medicine.  Third
American, from the third and revised English edition.  In one large octavo volume of 788
pages.  Cloth, $5.50; leather, $6.50.

PEPPER,  AUGUSTUS J., M. S.,  M. B.,  F. R. C. S.,
       Examiner in Forensic Medicine at the University of London.
    Forensic Medicine. In one pocket-size  12mo. volume.  Preparing.  See Students'
Series of Manuals, page 4.______________________

LEA, HENRY C.
    Superstition and Force: Essays on The Wager of Law, The Wager of
Battle, The Ordeal and Torture.  Third revised and enlarged edition.  In  one
handsome royal 12mo. volume of 552 pages. Cloth, $2.50.
  This valuable work is in reality a history of civ-
ilization as interpreted by the progress of jurispru-
dence. . .  In "Superstition and Force" we have a
philosophic survey of the long period intervening
between primitive barbarity and civilized enlight-
enment.  There is not a  chapter in the work that
should not be most carefully studied; and however
well versed the reader may be in the science of
jurisprudence, he will find much in Mr. Lea's vol-
ume of which he was previously ignorant.  The
book is a valuable addition to the literature of so-
cial science.— Westminster Review, Jan. 1880.
                          By the Same Author.
Studies in Church History.  The Rise of the Temporal Power—Ben-
efit of Clergy—Excommunication
octavo volume of  605 pages.  Cloth, $2.50.
  The author is pre-eminently a scholar.  He takes
up every topic allied with the leading theme, and
traces it out to the  minutest detail with a wealth
of knowledge  and impartiality of treatment that
compel admiration.   The amount of information
compressed into the book is extraordinary.  In no
other single volume is the development of the
New edition.   In one very handsome royal
Just ready.
 primitive church traced with so much clearness,
 and with so definite a perception of complex or
 conflicting sources.  The fifty pages on the growth
 of the papacy, for instance, are admirable for con-
 ciseness and  freedom from prejudice.—Boston
 Traveller, May 3,1883. 
  Allen's Anatomy      ....
  American Journal of the Medical Sciences
  American System of Gynaecology .
  American System of Practical Medicine
  An American System of Dentistry
  *Ashhurst's Surgery  .
  Ash well on Diseases of Women
  A ttfield's Chemistry
  Ball on the  Rectum and Anus
  Barker's Obstetrical and Clinical Essays,
  Barlow's Practice of Medicine
  Barnes' Midwifery
  ♦Barnes on  Diseases of Women
  Barnes' System of Obstetric Medicine
  Bartholow on Electricity
  Basham on Renal Diseases  .
  Bell's Comparative Pliysiology and Anatomy
  Bellamy's Operative Surgery
  Bellamy's Surgical Anatomy
  Blandford on Insanity
  Bloxam's Chemistry
  *Bristowe's Practice of Medicine
  Broadbent on the Pulse
  Browne on the Ophthalmoscope
  Browne on the Throat
  Brace's Materia Medica and  Therapeutics
  Brunton's Materia Medica and Therapeutics
  Bryant on the Breast ....
  *Bryant's Practice of Surgery
  ♦Bumstead on Venereal Diseases  .
  *Burnett on the Ear    ....
  Butlin on the Tongue  ....
  Carpenter on the Use and Abuse of Alcohol
  ♦Carpenter's Human Physiology  .
  Carter on the Eye      ....
  Century of American Medicine
  Chambers on Diet and Regimen
  Charles' Physiological and Pathological Chem
  Churchill on Puerperal Fever
  Clarke and Loekwood's Dissectors' Manual
  Classen's Quantitative Analysis
  Cleland's Dissector    ....
  Clouston on  Insanity  ....
  Clowes' Practical Chemistry
  Coats' Pathology       ....
  Cohen on the Throat  ....
  Coleman's Dental Surgery  .    .
  Condie on Diseases of Children
  Cornil on Syphilis     ....
  ♦Cornil and Ranvier's Pathological Histology
  Cullerier's Atlas of Venereal  Diseases
  Curnow's Medical Anatomy
  Dalton on the Circulation
  ♦Dalton's HumanPhysiology
  Davis' Clinical Lectures
  Draper's Medical Physics
  Druitt's Modern Surgery
 Duncan on Diseases of women
 ♦Dunglison's Medical Dictionary  .
 Edes' Materia Medica and Therapeutics
 Edis on Diseases of Women .
 Ellis'Demonstrations of Anatomy
 Emmet's Gynaecology
 ♦Erichsen's System of Surgery
 Esmarch's Early Aid in Injuries and Accld'ts
 Farquharson's Therapeutics and Mat. Med.
 Fenwick's Medical Diagnosis
 Finlayson's Clinical Diagnosis
 Flint on Auscultation and Percussion
 Flint on Phthisis      ....
 Elint on Physical Exploration of the Lungs
 Flint on Respiratory Organs
 Flint on the Heart     ....
 Flint's Essays
 ♦Flint's Practice of Medicine      .    '
 Folsom's Laws of TJ. S. on Custody of Insane
 Foster's Physiology
 ♦Fothergilfs Handbook of Treatment  .
 Fownes' Elementary Chemistry   .
 Fox on Diseases of the Skin .
 Frankland and Japp's Inorganic Chemistry
 Fuller on the Lungs and Air Passages  .
 Galloway's Analysis  ....
 Gibney's Orthopaedic Surgery
 Gould's Surgical Diagnosis  .
 ♦Gray's Anatomy  .        .
 Greene's Medical Chemistry .
 Green's Pathology and Morbid Anatomy'
 Griffith's Universal Formulary
 Gross on Foreign Bodies in Air-Passages
 Gross on Impotence and Sterility  .
 Gross on Urinary Organs
 ♦Gross'System of Surgery  ,
 Habershon on the Abdomen
 ♦Hamilton on Fractures and Dislocations
 Hamilton on Nervous Diseases
 Hartshorne's Anatomy and Physiology .
 Hartshorne's Conspectus of theMed. Sciences
 Hartshorne's Essentials of Medicine
 Hermann's Experimental Pharmacology
 Hill on Syphilis  .     .
 Hillier's Handbook of Skin Diseases    '
 Hoblyn's Medical Dictionary
 Hodge on Women
 Hodge's Obstetrics     .
 Hoffmann and Power's Chemical Analysis
 Holden's Landmarks  .
Holland's Medical Notes and'Reflections"
*Holmes' System of Surgery
Horner's Anatomv and Hist«
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 Hudson on Fever    ....
 Hutchinson on Syphilis
 Hyde on the Diseases of the Ski u  .
 Jones (C. Handheld) on Nervous Disorders
 Juler's Ophthalmic Science and Practice
 Keating on Infants
 King's Manual of Obstetrics .
 Klein's Histology
 Landis on Labor
 La Roche on Pneumonia, Malaria, etc.
 La Roche on Yellow Fever  .
 Laurence and  Moon's Ophthalmic Surgery
 Lawson on the Eye, Orbit and Eyelid
 Lea's Studies in Church History
 Lea's Superstition and Force
 Lee on Syphilis
 Lehmann's Chemical Physiology  .
 ♦Leishman's Midwifery
 Lucas on Diseases of the Urethra  .
 Ludlow's Manual of Examinations
 Lyons on Fever ....
 Maisch's Organic Materia Medica  .
 Marsh on the Joints
 May on Diseases of Women .
 Medical News
 Medical News Visiting List .
 Medical News Physicians' Ledger .
 Meigs on Childbed Fever
 Miller's Practice of Surgery .
 Miller's Principles of Surgery
 Mitchell's Nervous Diseases of Women
 Morris on Diseases of the Kidney  .
 Morris on Skin Diseases
 Neill and Smith's Compendium of Med.
 Nettleship on Diseases of the Eye  .
 Norris and Oliver on the Eye
 Owen on Diseases of Children
 *Parrish's Practical Pharmacy
 Parry on Extra-Uterine Pregnancy
 Parvin's Midwifery
Pavy on Digestion and its Disorders
Pepper's System of Medicine
Pepper's Forensic Medicine .
Pepper'sJ5urgical Pathology
Scl.
13 ' Pick on Fractures and Dislocations
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    Pirrie's System of Surgery  .
    Playfair on Nerve Prostration and Hysteria
    ♦Playfair's Midwifery  .
    Politzer on the Ear and its Diseases
    Power's Human Physiology .
    Purdy on Bright's Disease and Allied Affections
    Ralfe's Clinical Chemistry
    Ramsbotham on Parturition
    Remsen's Theoretical Chemistry
    ♦Reynolds' System of Medicine
    Richardson's Preventive Medicine
    Roberts on Urinary Diseases
    Roberts' Compend of Anatomy
    Roberts' Principles and Practice of Surgery
    Robertson's Physiological Physics
    Ross on Nervous Diseases
    Sargent's Minor and Military Surgery
    Savage on Insanity, including Hysteria
    Schafer's Essentials of  Histology,
    Schreiber on Massage  .
    Seller on the Throat, Nose and Nnso-Pharynx
    Series of Clinical Manuals  .
    Simon's Manual of Chemistry
    Skey's Operative Surgery
    Slade on Diphtheria
    Smith (Edward) on Consumption
    ♦Smith (J. Lewis) on Children
    Smith's Operative Surgery  .
    Stllle on Cholera
    *Still6 & Maisch's National Dispensatory
    *Still6's Therapeutics and Materia Medica
    Stimson on Fractures  .
16  Stimson's Operative Surgery
 n  Stokes on Fever .
    Students' Series of Manuals
    Sturges' Clinical Medicine  .
    Tanner on Signs and Diseases of Pregnancy
    Tanner's Manual of Clinical Medicine
    Taylor on Poisons
    ♦Taylor's Medical Jurisprudence  '.
    Taylor's Prin. and Prac. of Med. Jurisprudence
    ♦Thomas on Diseases of Women   .
    Thompson on Stricture
    Thompson on Urinary Organs
    Tidy's Legal Medicine.
   Todd on A cute Diseases
   Treves' Manual of Surgery  ,
   Treves' Surgical Applied Anatomy
   Treves on Intestinal Obstruction   .
   Tukeon the Influence of Mind on the Body
   Visiting List, The Medical News
   Walshe on the Heart .
   Watson's Practice of Physic
   ♦Wells on the Eye
   West on Diseases of Childhood
   West on Diseases of Women
   West on Nervous Disorders in Childhood
   Williams on Consumption  .
   Wilson's Handbook of Cutaneous Medicine
   Wilson's Human Anatomy  .
   Winckel on Pathol, and Treatment of Childbed
   Wohler's Organic Chemistry
   Woodhead's Practical Pathologv  .
   Year-Books of Treatment for 1*884 and 1
s Anatomy and Histology .

                Books marked  * are also bound in half Russia.

      LEA  BROTHERS  &  CO.,  Philadelphia
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